LIVING COMMUNITY OF ST JOSEPH
Non profit - Corporation
96 Beds
BENEDICTINE HEALTH SYSTEM
Data: November 2025
Trust Grade
60/100
#94 of 479 in MO
Photo by Benedictine Living Community-St. Joseph
Photo by Benedictine Living Community-St. Joseph
Photo by Benedictine Living Community-St. Joseph
1 / 10 photos
Last Inspection: January 2025
Within standard 12-15 month inspection cycle. Federal law requires annual inspections.
Overview
Families researching Living Community of St. Joseph in Saint Joseph, Missouri, will find that it has a Trust Grade of C+, indicating it is slightly above average but not exceptional. The facility ranks #94 out of 479 in the state, placing it in the top half of Missouri nursing homes, and it is the best option among six local facilities in Buchanan County. The facility is improving, with the number of reported issues decreasing from 16 in 2023 to 7 in 2025. Staffing is a significant strength, as it has a perfect 5-star rating with a turnover rate of 53%, which is lower than the state average. Although there have been no fines, there are concerning incidents, such as a resident who fell and fractured a hip due to inadequate assistance during a transfer, and another resident experienced a delay in medical treatment because staff did not promptly notify a physician of a change in their condition. Overall, while there are notable strengths in staffing and improvement trends, families should be aware of the serious care issues highlighted in the inspector findings.
- Trust Score
- C+
- In Missouri
- #94/479
- Safety Record
- Moderate
- Inspections
- Getting Better
- Staff Stability ⚠ Watch
- 53% turnover. Above average. Higher turnover means staff may not know residents' routines.
- Penalties ✓ Good
- No fines on record. Clean compliance history, better than most Missouri facilities.
- Skilled Nurses ✓ Good
- Each resident gets 56 minutes of Registered Nurse (RN) attention daily — more than average for Missouri. RNs are trained to catch health problems early.
- Violations ⚠ Watch
- 36 deficiencies on record. Higher than average. Multiple issues found across inspections.
60/100
Top 19%
Needs review
16 → 7 violations
★★★★☆
4.0
Overall Rating
★★★★★
5.0
Staff Levels
★★★☆☆
3.0
Care Quality
★★★☆☆
3.0
Inspection Score
↔
Stable
2023: 16 issues
2025: 7 issues
The Good
-
5-Star Staffing Rating · Excellent nurse staffing levels
-
Full Sprinkler Coverage · Fire safety systems throughout facility
-
No fines on record
Facility shows strength in staffing levels, fire safety.
The Bad
Staff Turnover: 53%
Near Missouri avg (46%)
Higher turnover may affect care consistency
Chain: BENEDICTINE HEALTH SYSTEM
Part of a multi-facility chain
Ask about local staffing decisions and management
The Ugly 36 deficiencies on record
2 actual harm
Apr 2025
1 deficiency
1 Harm
SERIOUS
(G)
📢 Someone Reported This
A family member, employee, or ombudsman was alarmed enough to file a formal complaint
Actual Harm - a resident was hurt due to facility failures
Accident Prevention
(Tag F0689)
A resident was harmed · This affected 1 resident
Based on interview and record review, the facility failed ensure one of 6 sampled residents (Resident #1) received adequate assistance and supervision to prevent accidents when the facility staff tran...
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Based on interview and record review, the facility failed ensure one of 6 sampled residents (Resident #1) received adequate assistance and supervision to prevent accidents when the facility staff transferred the resident to a standing position without a gait belt. The resident ambulated to the restroom, notified staff that he/she felt dizzy, the staff member left the resident alone to go obtain a gait belt and the reisdent fell. The resident fractured his/her left hip and required surgery. The facility census was 77.
Review of the facility policy titled, Integrated Fall Management Policy, dated 8/24/17, showed:
-Fall Risk assessments are to be completed quarterly and upon significant change of condition;
-Identify other risk factors in the Minimum Data Set (MDS) to identify additional risk factors and interventions;
-Residents at risk for falls have an individualized resident centered care plan developed based upon the fall risk assessment;
-Include other professionals to assess or intervene regarding fall risk prevention;
-Residents are provided education, regarding her/his fall risk and interventions to reduce falls based on the fall risk assessment;
-Completed fall risk assessments are maintained in the resident's medical record.
Review of the facility policy titled, Transfer Belt (Gait Belt) Placement Education Document, dated 2009, showed when transferring a resident, staff should always apply belt over clothing around waist with buckle in front.
Review of CNA A's orientation training packet, showed CNA A was trained on 2/08/25 for safe transfers and gait belt use by the facility for competency and facility policy.
1. Review of Resident #1's Face Sheet, dated 3/31/25., showed:
-New admission to the facility;
-Diagnoses included: Right lung cancer, high blood pressure, and a post-surgical wound left groin for clot removal.
Review of the Resident's baseline care plan, dated 3/31/25, showed:
- Resident's goals was not to sustain a fall with an injury;
-The care plan did not identify the resident's activity level.
-He/She was at risk for falls due to atherosclerosis of extremities;
-Educate resident on the prevention and reduction of fall precautions;
-No transfer or ambulatory status was care planned;
-He/She was to receive PT/OT services to maintain highest functional ability;
- The care plan did not address use of a walker or a gait belt for resident's mobility.
-The care plan did not address how much staff assistance the resident required for mobility needs.
Review of the Fall Risk Assessment, dated 3/31/25., showed:
-The resident uses a front wheeled walker;
- The resident's pain and wounds required the need for staff to assist with transfers.
- The resident needs one staff person for transfer assistance with a gait belt and a second person for hygiene, equipment and clothing management recommended;
- The resident was assessed as not being at risk for falls.
Review of the Resident's documented Activities of Daily Living (ADL) and transfers document dated 4/6/25 at 3:33 P.M., showed the Resident required extensive assistance with transfers by staff to assist with ADLs.
Review of the Resident's nursing progress notes on 4/6/25 at 12:55 P.M., showed:
-Nursing staff transferred Resident in the bathroom with a walker, resident fell in bathroom. Resident went to turn and reach for the grab bar, but turned wrong and fell.
- Resident fell to the floor with feet out in front of him/her and resident hit head against the bathroom wall;
-The resident denied pain to his/her head but stated left hip pain was at a level 5 out of 10 on the pain scale, with 10 being the worst pain.
-Emergency Medical Services (EMS) arrived to transfer the resident to the emergency room (ER).
Record Review of the facility's fall event report, dated 4/6/25 at 6:08 P.M., showed:
- The report was completed by LPN A;
- The fall was witnessed by CNA A;
-The Resident was transferred without the use of a gait belt by CNA A;
-CNA A left the resident's side to grab a gait belt, and the resident lost balance and fell;
-The resident complained of a pain level 7 (out of 10) for head and hip pain;
-The resident complained of dizziness, lightheadedness, headache, and nausea vomiting.
-The resident was sent to the hospital for evaluation of injuries;
-The hospital provided an updated to LPN A that the reisdent sustained a left hip fracture injury.
Review of the Resident's hospital records dated 4/6/25, showed:
-He/She fell when left unassisted, and had sustained an injury at the facility;
-He/she had left hip pain;
-X-ray dated 4/6/25 resulted in a fracture of left femur;
-Surgical intervention was completed on 4/8/25 to repair the fracture.
During a interview on 4/23/25 at 5:30 P.M., Certified Nurses Aide (CNA) A said:
- He/she transferred the reisdent from the bed to the standing position without a gait belt;
-After he/she assisted the resident up off the bed, the resident immediately began walking towards the restroom before he/she could put a gait belt on the resident;
-The gait belt was next to the resident's bed.
-He/She heard the resident say he/she was dizzy;
-CNA A told the resident to hold onto the bar and not move;
-He/She left the resident standing in the bathroom alone holding on to the pull bar while she retrieved the gait belt;
-As soon as CNA A took three steps to reach gait belt, the resident fell trying to turn him/herself in order to sit on the toilet.
-The resident landed with his/her head against the wall.
-The resident said he/she was in pain.
-He/She knew he/she was supposed to use a gait belt when transferring the resident but did not use it;
-He/She had been trained on transfers and resident safety with transfers.
During an interview on 4/23/25 at 11:59 A.M., Licensed Practical Nurse (LPN) A said:
-He/she was asked to go to the resident's room and assess the reisdent after the fell;
-He/she said the resident was not wearing a gait belt and was already sitting in a wheelchair; -He/she did not know who transferred the resident up off the floor into the wheelchair.
-He/she observed the resident being transferred with a gait belt from the wheelchair to the bed by 2 nursing staff members;
-He/she assessed the resident and the resident did not appear to be in pain, but did complain of dizziness;
-He/she assessed the resident's legs and the resident reported pain at a level of 5.
- The reisdent denied any head pain;
-There was no visible defects observed in the resident's skin integrity, and no leg rotation or shortening of the leg was observed;
-Vital signs were monitored by LPN B;
-Neurological nursing assessments were completed by LPN B.
During an interview on 4/23/25 at 12:10 P.M., Registered Nurse (RN) A said all staff are to use gait belts when assisting residents to ambulate.
During an interview on 4/24/25 at 4:44 P.M., Family Member (FM) A said:
-He/she was in the room and witnessed the aide leave the resident unattended and the then the resident fell;
-The residents fall could have been prevented if the resident was not left standing alone;
-The resident was in pain and needed to be seen in the ER;
-The resident had surgery to repair his/her broken hip and required additional surgery on his/her hip due to complications.
During an interview on 4/23/25 at 10:55 A.M., Physical Therapist (PT) A said:
-It is facility policy for staff to use gait belts when transferring residents, for the resident's safety.
-He/She would expect that staff use a gait belt on the resident for staff assisted transfers and ambulation.
During an interview on 4/23/25 at 1:00 P.M., The Administrator said:
-She expects Activities of Daily living to be documented on every resident's care plan;
-All employees are educated on how to perform safe transfers and how to assist with ambulation;
-Gait belt use is an expectation for all staff.
During an interview on 4/23/25 at 1:45 P.M., The Director of Nursing (DON) said:
-She expects Activities of Daily living to be on each resident's care plan;
-All nursing staff are educated on how to assist residents on ambulation and transfers;
-All nursing staff are expected to use gait belts for transfers and ambulation;
-All nursing staff are expected to stay with residents if the reisdent needs assistance from staff;
-CNA A did not follow the facility policy regarding when to use gait belts, which resulted in the resident's fall.
MO252397
Jan 2025
6 deficiencies
CONCERN
(D)
Potential for Harm - no one hurt, but risky conditions existed
Assessment Accuracy
(Tag F0641)
Could have caused harm · This affected 1 resident
Based on observation, interview, record review, facility policy review, and review of the Resident Assessment Instrument (RAI) Manual, the facility failed to ensure one of 25 sampled residents (Reside...
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Based on observation, interview, record review, facility policy review, and review of the Resident Assessment Instrument (RAI) Manual, the facility failed to ensure one of 25 sampled residents (Resident (R) 21) residents had an accurate Minimum Data Set (MDS) assessment. This had the potential to cause the resident to have unmet care needs. The facility census was 80.
Findings include:
Review of R21's Face Sheet, found under the Profile tab in the electronic medical record (EMR), indicated an admission date of 09/07/18 with diagnoses of dementia, anxiety disorder, major depressive disorder, and Alzheimer's disease.
Review of the RAI Manual, dated 10/01/19, indicated, . It is important to note here that information obtained should cover the same observation period as specified by the Minimum Data Set (MDS) items on the assessment and should be validated for accuracy (what the resident's actual status was during that observation period) by the IDT completing the assessment.
Review of the facility's undated policy titled Comprehensive Assessments and Care Planning, provided by the facility, indicated, . provide a comprehensive person-centered interdisciplinary care assessment of the residents' condition, in order to develop consistent quality care that will attain or maintain the highest practicable physical, mental and psychological functioning possible, a facility must make a comprehensive assessment of a resident's needs, using the RAI specific by the State . The assessment must accurately reflect the resident's status, and each person who completes a portion of the assessment must sign and certify the accuracy of that portion of the assessment .
Review of R21's Elopement Risk assessment, dated 08/24/24 and located under the Assessments tab of the EMR, revealed that R21 wandered with no rational purpose and attempted to open doors and was a high elopement risk.
Review of R21's quarterly Minimum Data Set (MDS), with an assessment reference date (ARD) of 08/27/24, recorded R21 did not exhibit the behavior of wandering.
Review of R21's annual MDS, with an ARD of 11/27/24 and found under the Assessments tab in the EMR, indicated R21 had a BIMS score of four of 15, which indicated R21 was severely cognitively impaired. It was recorded that R21 did not exhibit wandering.
Review of R21's Care Plan, with a revision date of 12/02/24 and found under the Care Plan tab of the EMR, indicated a plan for Behavioral Symptoms with a start date of 04/21/23. The plan indicated that R21 . exhibited wandering with no rational purpose, seemingly oblivious to needs or safety. Approaches indicated to, . check double doors if alarm goes off to make sure I do not get off unit, monitor every shift if 'Wander Guard' is in place, to place [R21] in a secure environment, and to provide comfort measure for basic needs (e.g. Pain, hunger, toileting, too hot/cold, etc.) .
Review of R21's Care Plan, with a revision date of 12/02/24 and found under the Care Plan of tab of the EMR, indicated a plan for Cognitive Loss/Dementia with a start date of 06/05/24. The plan indicated that R21 wanders on the hall of floor, may call out and ask where she is, what she should be doing, or how she got here. Reorient resident to the best of ability. Approaches indicated to place a green sign outside R21's room to help identify her room, to check the Wander Guard functionally each week, change the battery annually, check every shift for proper placement, distract from wandering by offering pleasant diversions, structured activities, food, conversation, television or book and help finding her room.
During an observation on 01/01/25 at 2:53 PM, R21 ambulated in the hallway slowly using her walker and stopped to talk to a staff member. The staff member led R21 to her room. An observation on 01/01/25 at 3:06 PM revealed R21 ambulated out of her room using her walker into the hallway. A staff member met R21 and walked with her back to her room. An observation on 01/01/25 at 3:19 PM revealed R21 ambulated out of her room using her walker into the hallway, then walked up to staff member and spoke to the staff member. R21 then turned and went back to her room. An observation on 01/01/25 at 3:22 PM revealed R21 ambulated out of her room using her walker into the hallway, walked slowly and approached a staff member and began talking. R21 then walked using her walker and entered the dining area on her unit and seated herself at a table.
During an interview on 01/02/25 at 10:35 AM, MDS Coordinator (MDSC)2 stated that social services completed the behavioral and wandering section of the MDS. When asked who was responsible for signing off on the accuracy of the MDS, she stated that the MDS Coordinators were.
During an interview on 01/02/25 at 10:45 AM, Social Services Director (SSD)1 stated that it was her responsibility to complete the behavioral and wandering section of the MDS. She stated that she accepted the responsibility that nothing was entered on this section for R21. SSD1 stated that she did not know the resident wandered and that she should have asked more questions at team meetings regarding the resident. The SSD stated that she should have dug into it more.
In an interview on 01/02/25 at 5:57 PM, the Director of Nursing (DON) stated that the reason the MDS assessment did not indicate that R21 was wandering was because wandering did not trigger in the look back period. The DON stated that her expectation would be that the MDS Coordinators and other staff members responsible for completing portions of the assessments would review progress notes, elopement risks, and review care plans during the completion of the assessment.
CONCERN
(D)
Potential for Harm - no one hurt, but risky conditions existed
Medication Errors
(Tag F0758)
Could have caused harm · This affected 1 resident
**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on interview, record review, and policy review, the facility failed to have an end date for an as needed (PRN) psychotropi...
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**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on interview, record review, and policy review, the facility failed to have an end date for an as needed (PRN) psychotropic medication for two of six residents (Resident (R) 16 and R282) reviewed for unnecessary medications out of a total sample of 25. The failure had the potential for residents to receive psychotropic medications without ongoing assessment by a physician or practitioner for continued appropriateness. The facility census was 80.
Findings include:
Review of the facility's Psychotropic Medication Use policy, reviewed on 09/07/23, revealed, . Psychotropic drug is any drug that affects brain activities associated with mental processes and behavior . PRN orders for psychotropic drugs are limited to 14 days. If the medical provider believes that it is appropriate for the PRN order to be extended beyond 14 days, the medical provider should document their rationale in the resident's medical record and indicate the duration for the PRN order .
1. Review of R16's Resident Face Sheet, located in the Face Sheet tab of the electronic medical record (EMR), revealed R16 was admitted to the facility on [DATE] with diagnoses that included anxiety with depression.
Review of R16's [Hospital] DC [Discharge] Summary, dated 12/02/24 and located in the admission Documents portion of the Resident Documents tab of the EMR, revealed an order upon discharge from the hospital to continue alprazolam (an anti-anxiety medication) 0.5 milligrams (mg) in the morning, at noon, and at bedtime PRN for anxiety.
Review of R16's Orders tab of the EMR revealed an order dated 12/02/24 for alprazolam 0.5mg every eight hours PRN for anxiety. There was no end date for the PRN anti-anxiety medication until it was added on 12/31/24.
Review of the facility's December SNF [skilled nursing facility] Review, completed by the pharmacist, revealed R16's medications were reviewed on 12/03/24, without mention of the alprazolam.
Review of R16's admission Minimum Data Set (MDS), with an Assessment Reference Date (ARD) of 12/08/24 and located in the RAI tab of the EMR, revealed R16 scored 15 out of 15 on her Brief Interview for Mental Status (BIMS), which indicated she was cognitively intact.
During an interview on 01/01/25 at 11:10 AM, R16 reported she took the PRN alprazolam frequently at night to help her settle for the night and into the next morning.
2. Review of R282's Resident Face Sheet, located in the Face Sheet tab of the EMR, revealed R282 was admitted to the facility on [DATE]with diagnoses that included pneumonia and chronic respiratory failure.
Review of R282's [Hospital] DC Summary, dated 12/06/24 and located in the admission Documents portion of the Resident Documents tab of the EMR, revealed an order upon discharge from the hospital to start taking hydroxyzine pamoate (an antihistamine medication which can be used to help control anxiety) 50mg every six hours if needed for anxiety for up to 10 days.
Review of R282's Orders tab of the EMR revealed an order dated 12/06/24 for hydroxyzine pamoate 50mg every six hours PRN for anxiety. The order had no end date.
Review of the facility's December SNF Review, completed by the pharmacist, revealed R282's medications were reviewed on 12/07/24, without mention of the hydroxyzine.
Review of R282's admission MDS, with an ARD of 12/12/24 and located in the RAI tab of the EMR, revealed R282 scored 14 out of 15 on his BIMS, which indicated he was cognitively intact.
During an interview on 12/31/24 at 8:30 AM, R282 reported he did not think he had used the PRN hydroxyzine.
During an interview on 01/01/25 at 11:23 AM, Licensed Practical Nurse (LPN) 2 stated PRN psychotropic medications or medications used as an anti-anxiety medication needed an end date. LPN2 stated she thought the end date was 14 days from the start of the medication.
During an interview on 01/01/25 at 2:35 PM, LPN1 stated she believed scheduled psychotropic medications had an end date but PRN psychotropic medications did not have end dates.
During a concurrent interview on 01/01/25 at 3:19 PM, with LPN Infection Preventionist (IP) and Registered Nurse, Clinical Manager (CM) 2, the IP stated if a PRN psychotropic medication was not needed, the facility checked with the provider about discontinuing it. The IP stated the pharmacist reviewed medications and rounded with the nurse practitioner, seeing residents weekly. The IP was uncertain what the regulatory requirement was regarding end dates for PRN psychotropic medications. CM2 stated she reviewed medication orders for newly admitted residents as did the pharmacist. CM2 stated the nurse practitioner or doctor set the end dates for PRN psychotropic medications. CM2 was unsure what the regulatory requirement was regarding end dates for PRN psychotropic medications.
During an interview on 01/01/25 at 3:35 PM, the Director of Nursing (DON) reported she expected nurses to enter an end date of 14 days for PRN psychotropic medication orders, and after 14 days, the doctor could renew the order or discontinue the medication if it was not used. The DON stated consequences of not having an end date included falls, oversedation, and polypharmacy. The DON stated that R282 had not used his PRN hydroxyzine, so the facility would check on discontinuing it. The DON stated that since R16 used her PRN alprazolam frequently, hers was renewed for 14 days.
CONCERN
(D)
Potential for Harm - no one hurt, but risky conditions existed
Medical Records
(Tag F0842)
Could have caused harm · This affected 1 resident
**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on interview, record review, and policy review, the facility failed to ensure the medical record was accurate and complete...
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**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on interview, record review, and policy review, the facility failed to ensure the medical record was accurate and complete for one out of 25 sampled residents (Resident (R) 37). R37's record did not include the updated Preadmission Screening and Resident Review (PASRR) Level 1 form, and R37 was documented with a serious mental illness diagnosis of bipolar disease that was not accurate. This created the potential for R37 to experience the stigma associated with mental illness and for staff and medical providers not to have full and accurate information about R37's mental health condition. The facility census was 80.
Review of the facility's admission Prescreening for Individuals with Mental Retardation or Mental Illness policy, dated 2021, revealed, Missouri law mandates preadmission screening for all individuals with mental illness (MI) or mental retardation (MR) who apply to long term care facility . The policy indicated if the resident had a serious mental illness diagnosis, a referral would be made to the designated state agency titled COMRU. COMRU would determine whether a PASRR Level 2 screening would be required, and this should be completed prior to the resident's admission to the facility.
Review of the facility's Charting and Documentation in the Medical Record policy, dated 2023, revealed the purpose was, To ensure objective, accurate, timely and clinically complete information in the individual resident medical record . The medical record facilitates communication between the interdisciplinary team regarding the resident's condition and response to care .
Review of R37's annual Minimum Data Set (MDS), with an Assessment Reference Date (ARD) of 12/04/24 and located in the electronic medical record (EMR) under the RAI [Resident Assessment Instrument] tab, revealed R37 was admitted to the facility on [DATE] and had a Brief Interview for Mental Status (BIMS) score of 15 out of 15, which indicated the resident was cognitively intact. It was recorded that R37 did not have a serious mental illness.
Review of R37's Physician Order Report, dated 02/22/21 - 03/22/21 and provided by the facility, revealed documentation that R37 had a diagnosis of bipolar disorder.
Review of R37's EMR revealed it did not have the most current PASRR Level 1 located within the record. Review of R37's PASRR Level 1, dated 02/16/21 and provided by the facility, revealed documentation R37 did not have a serious mental illness. The diagnosis of bipolar disorder was not identified. The PASRR Level 2, therefore, did not trigger to be completed and was not completed or found in the medical record.
Review of the undated CCD [Continuity of Care Document], located in the EMR under the Resident tab and reviewed on 12/31/24, revealed a diagnosis of bipolar disorder, current episode hypomanic, initiated on 07/31/23.
Review of R37's Care Plan, dated 07/12/24 and located in the EMR under the RAI tab, revealed a problem of Behavioral Symptoms, I have serious mental illness bipolar disorder, current episode hypomanic .
Review of all the Progress Notes, from 01/01/2023 - 12/31/24 and located in the EMR under the Resident tab, revealed only one entry with documentation of bipolar disorder.
Review of R37's IDT [Interdisciplinary] Psych Medication Note, dated 02/22/24 and located in the EMR under the Progress Notes tab, revealed, . Resident remains on Trazodone 150 mg [milligrams] at HS [hour of sleep] depression . Olanzapine [antipsychotic medication] 2.5 mg at HS, 5 mg [milligrams] at noon, Bipolar .
Review of R37's medical record revealed additional conflicting information regarding whether R37 had a diagnosis of bipolar disorder. The Physician Order Report, dated 02/22/21 - 03/22/21 and provided by the facility, revealed R37 had a diagnosis of bipolar disorder; however, the current Physician Order Report, dated 12/02/24 - 01/02/25 and located in the EMR under the Orders tab under the heading of Diagnoses, did not document bipolar disorder.
Review of R37's comprehensive MDS assessments, provided by the facility and from admission through the survey (admission MDS with an ARD of 02/24/21, annual MDS with an ARD of 02/08/22, annual MDS with an ARD of 12/21/22, and annual MDS with an ARD of 12/04/23), reviewed no documentation that R37 had a serious mental illness.
Review of the untitled Discontinued Diagnoses Report, from admission through 01/02/25 and provided by the facility, revealed the diagnosis of bipolar disorder was first added on 02/18/21 and was discontinued on 10/27/22. The diagnosis of bipolar disorder was added a second time on 07/31/23 and was discontinued during the survey on 01/01/25.
During an interview on 12/31/24 at 3:55 PM, the Administrator stated the PASRR Level 1 completed on 02/16/21 did not document presence of a serious mental illness. The Administrator stated if serious mental illness and/or a psychiatric stay or other indicator had been documented on the PASRR Level 1 form, the form would have been sent to the state agency COMRU (Central Office Medical Review Unit) to make the decision whether a PASRR Level 2 was needed.
During an interview on 01/01/25 at 3:44 PM, the Director of Nursing (DON) stated she was not sure how the diagnosis of bipolar disease got added to the CCD/Face Sheet document. The DON stated the resident's attending Physician did not document bipolar disorder in the Physician Notes and neither did the Psychiatrist. The DON stated after the issue was brought to her attention during survey, she called R37's psychiatry physician group, and they reviewed R37's information and instructed the DON to discontinue the bipolar diagnosis from R37's record, which had been done.
Review of R37's Nurse's Note, dated 01/01/25 and located in the EMR under the Progress Notes tab, revealed, Writer spoke to [Psychiatrist's name] resident's psychiatrist regarding bipolar diagnosis not found on recent past psych visits. [Psychiatrist's name] stated dc [discontinue] bipolar disorder and use major depressive disorder diagnosis. Bipolar diagnosis dc'd [discontinued] per MD [Medical Doctor] order. Call out to [family Member] to let her know Bipolar diagnosis was removed and keep Major Depressive Disorder. [Family Member] stated, 'Good, I have been telling them for years she is not Bipolar .
Review on 01/02/25 of the undated CCD in the EMR under the Resident tab showed the diagnosis of bipolar disorder had been deleted.
During an interview on 01/02/25 at 2:35 PM, the Administrator stated the bipolar diagnosis was first noted on 03/11/21 by the Nurse Practitioner (NP). The Administrator verified inconsistent documentation in the record regarding the bipolar disorder diagnosis. The Administrator stated R37 had several admissions in and out of the hospital since she was originally admitted to the facility. The Administrator stated an additional PASRR Level 1 form was found that identified serious mental illness with the diagnosis of bipolar disorder. The Administrator stated this PASRR Level 1 had not been in R37's EMR.
Review of R37's PASRR Level 1, dated 02/16/24 and provided by the Administrator on 01/02/25 at 2:35 PM, revealed R37 had received intensive psychiatric treatment for a diagnosis of bipolar. This PASRR Level 1 had been referred to COMRU to determine whether a PASRR Level 2 was needed.
An attempt to interview R37 was made on 01/02/24 at 11:40 AM; however, the resident was sleeping and was not available for interview.
CONCERN
(E)
Potential for Harm - no one hurt, but risky conditions existed
Deficiency F0554
(Tag F0554)
Could have caused harm · This affected multiple residents
**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** 2. Review of R23's undated Face Sheet, located in the EMR under the Resident tab, revealed R23 was admitted to the facility on [...
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**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** 2. Review of R23's undated Face Sheet, located in the EMR under the Resident tab, revealed R23 was admitted to the facility on [DATE] with diagnoses that included chronic obstructive pulmonary disease (COPD) and chronic respiratory failure.
Review of R23's annual MDS, with an ARD of 08/06/24 and located under the RAI tab of the EMR, revealed R23's cognition was intact with a BIMS score of 15 out of 15.
Review of R23's Observation Detail List Report [Self Administration of Medication Assessment], dated 11/04/24 and located in the EMR under the Document tab, revealed that R23 wanted to self-administer some medications. The report read, List of medications resident would like to self-administer - Nebulizer treatments, Advair Diskus inhaler nasal spray, Icy Hot - resident keeps vials at bedside and has order to self-administer. The Observation Detail List Report indicated R23 was appropriate to self-administer medications, and she was able to name the dosage, frequency, and reason for each medication, tell the time and state when each medication was due, and could read the label and identify each medication. It was recorded R23 was able to pour pills out of the bottle and properly dispense inhalers and nebulizers. It was recorded the appropriate medications for the resident to self-administer were, Nebulizer treatments, nasal spray and icy hot.
Review of R23's Care Plan, dated 11/10/24 and located in the EMR under the RAI tab, revealed a problem of, I may self-administer nebulizer treatments, medication will be kept in the med [medication] cart. The goal was, Resident will safely demonstrate to the staff that she can complete this task. The approach was Staff will educate resident on the use of this medication, and keep it safely locked in the medication cart.
Review of R23's Care Plan, dated 11/10/24 and located in the EMR under the RAI tab, revealed a problem of, Self-administration, Resident has a physicians' order to keep the following medications at bedside and self-administer: Resident has been assessed by Interdisciplinary care plan team to be capable of self-administration. Resident demonstrates ability to: Follow simple directions. Remember directions consistently. Read prescription labels adequately. Identify medications by appearance. The goal was, Resident will take medications safely and as Prescribed. Resident will demonstrate ability to take medications at correct dose, route, and time. Resident will verbalize and demonstrate understanding of: What each medication is supposed to do. What foods, drinks and other medications should be avoided while taking each medication. What the possible side effects are, and what should be done if they occur. Approaches in pertinent part were, Assess residents' ability to self-administer Ipratropium Bromide [medication treating breathing problems] 0.5 mg and Albuterol Sulfate [bronchodilator relaxing muscles in the airways] 3 mg, Cool Therapy Roll on Pain reliever, and Zinc 50 mg, 1 cap PO [orally], every other day, Albuterol Inhaler with admission, quarterly, with each assessment, and as needed .
Review of R23's Physician Order Report, dated 12/02/24 - 01/02/25 and located in the EMR under the Orders tab, revealed current Physician's Orders for self-administration of medications for R23 as follows:
Resident is ok to self-administer medications and keep locked in bedside drawer/key when not in room, initiated on 11/10/23.
Cough drops (kept at bedside whenever [family member] will bring) Special Instructions: as needed for cough/throat lozenges, initiated on 07/04/24.
May self-administer nebulizer treatments, initiated on 10/03/24.
Medicated body Powder (menthol) [OTC - over the counter] powder; 0.15%; amt [amount] small amount; topical, Special Instructions: Resident keeps at bedside in locked cabinet, may self-administer, initiated 12/30/24.
Neosporin (neo-bac-polym) (neomycin-bacitracin-polymyxin) [OTC] ointment; 3.5 mg [milligrams] - 400 unit - 5,000 unit/gram; amt: small amount; topical, Special Instructions: Resident and family request to keep at bedside. Order to keep at bedside and may self-administer, initiated on 12/30/24.
Voltaren Arthritis Pain (diclofenac sodium) [OTC] gel; 1/5; amt: 2 gms [grams]; topical, Special Instructions: apply to shoulder and neck pain: PRN [as needed] pain. May keep at bedside, in locked cabinet, initiated on 12/30/24.
During an interview on 12/30/24 at 11:02 AM, R23 stated that on this morning, while she was out of her room, the staff had come into her room and removed Tums and other medications/lotions from a locked drawer in her bedside table. R23 stated she was upset about the medications being removed and not being informed. R23 stated she was going to ask the nurse about it.
During an observation on 12/30/24 at 11:05 AM, CM1 spoke to R23 and told her she had removed R23's medications because R23 did not have orders for the medications.
During an interview on 12/31/24 at 2:56 PM, CM1 stated she told Family Member (F)1 to stop bringing in medications for R23. CM1 stated she had removed an unlabeled bottle of Tums from R23's beside table on 12/30/24 when R23 was out of the room. CM1 stated R23 had physician's orders to self-administer medicated powder, an inhaler (there was no order for the inhaler), and her nebulizer. CM1 stated physician orders were required for R23 to be able to self-administer medications. CM1 verified the cough drops and throat spray had been removed and stated the nursing staff would have to get orders for self-administration (R23 had a current order for self-administration of the cough drops).
During an interview on 01/01/25 at 8:36 AM, R23 stated the nursing staff had returned the medicated powder but not the Tums, throat/cough lozenges (she had an order to self-administer cough drops) and throat spray that were removed from the locked drawer in her bedside table. R23 stated she wanted these items returned to her. R23 stated she currently self-administered her nebulizer and inhaler by herself (there was no order for self-administration of the inhaler). R23 stated she knew when and how to take the medications that had been removed (Tums, cough drops, and throat spray). R23 stated the facility was holding the confiscated medications for F1 to come and pick up.
During a Resident Council meeting on 01/01/25 at 2:00 PM, R23 stated, The unit manager [CM1] came in on Monday and took all the medications that I keep in my room on my table. I've had them for a long time. Why is it a problem now? R23 stated the medications were removed from her room without her knowledge and when she was not in her room.
During an interview on 01/02/25 at 11:21 AM, F1 stated she brought the Tums to R23 because R23 had indigestion and Tums helped. F1 stated family had brought in throat spray and lozenges/cough drops which were also beneficial to R23. F1 stated the facility staff had not contacted her about the medications that had been confiscated on 12/30/24.
During an interview on 01/02/25 at 11:36 AM, R23 identified the medications she kept at her bedside as, Tums, Coricidin 10 cream, body powder, cough drops, and throat spray. Only the body powder was returned to me.
During an interview on 01/02/25 at 12:10 PM, CM1 stated, I only took a cup with what may have been Tums, but I can't assume they were Tums, they were not in the original bottle. I don't know where the other medications are. I'll have to call the [family member] to bring in more. CM1 was asked if she had entered R23's room without the resident present to remove the Tums. CM1 stated, Yes.
During an interview on 01/02/25 at 1:38 PM, Licensed Practical Nurse (LPN) 4 stated R23 self-administered her nebulizer and she could have cough drops at bedside. LPN4 stated nursing staff administered the inhaler as needed. LPN4 stated R23 could not have medicated powders or creams at bedside (R23 had a current order for self-administration of Neosporin and medicated body powder). LPN4 stated nursing staff administered Voltaren Gel (R23 had a current order to self-administer the Voltaren Gel).
Based on observation, interview and record review the facility failed to ensure two of 25 sample residents (Resident (R) 54 and R23) reviewed for self-administration of medications were permitted to exercise their resident rights. Specifically, the facility failed to ensure medications were not left at the bedside of R54 who was not assessed to be able to self-administer medications safely; and the facility failed to ensure R23, who desired to self-administer medications and was assessed to be safe to do so was permitted to. The facility census was 80.
Findings include:
Review of the facility's Self-Administration of Medications policy, dated 08/31/23, revealed the purpose was, To enhance resident independence to self-administer medications. The policy indicated, . Residents have the right to self-administer medications if the interdisciplinary team has determined it is clinically appropriate and safe . The nursing associates will assess each resident's mental and physical abilities to determine whether self-administering medications is clinically appropriate for the resident .
1. Review of R54's Face Sheet, located in the electronic medical record (EMR) under the Dashboard tab, revealed R54 was admitted on [DATE] with diagnoses that included unspecified dementia, unspecified severity, with mood disturbance.
Review of R54's admission Minimum Data Set (MDS), with an assessment reference date (ARD) of 10/23/24 and located under the RAI (Resident Assessment Instrument) tab in the EMR, revealed R54 had a Brief Interview for Mental Status (BIMS) score of 12 out of 15, which indicated R54 was moderately cognitively impaired.
During an interview on 01/02/25 at 11:19 AM, R54 was observed to have a medication cup on his overbed table. The medication cup contained three pills. R54 stated, Those were left about an hour ago. I don't know what they are. I just have to take them. The medications left at the bedside were confirmed by the MDS Coordinator (MDSC1) on 01/02/25 at 11:22 AM. At 11:24 AM, the Certified Medication Technician (CMT1) entered R54's room and stated, I never leave them. I don't know why I did. CMT1 revealed, as entered on the Medication Administration Record (MAR) dated 01/2025, that the medications were aspirin, Gemtesa, senna, and vitamin D3. CMT1 stated, The vitamin D3 was not in the cup. CMT1 did not look for the medication, ask R54 if he had taken the medication, or look to see if it was in the trash directly under the overbed table where the medications had been placed or dropped on the floor.
Review of R54's MAR for 01/02/25 revealed the medications were signed as administered at 10:25 AM.
Review of R54's EMR Assessments tab revealed no assessment to determine if R54 could self-administer medication. Review of R54's Orders tab of the EMR revealed no physician's order to self-administer medications.
In an interview on 01/02/25 at 12:10 PM, the Director of Nursing (DON) and Clinical Manager (CM)1 confirmed they were aware of the medications left at the bedside of R54. The DON stated, That should not have happened.
CONCERN
(E)
Potential for Harm - no one hurt, but risky conditions existed
Investigate Abuse
(Tag F0610)
Could have caused harm · This affected multiple residents
**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on interviews, record review, and facility policy review, the facility failed to conduct a thorough investigation of an al...
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**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on interviews, record review, and facility policy review, the facility failed to conduct a thorough investigation of an allegation of verbal abuse by a staff member for two of two residents (Resident (R) 26 and R32) reviewed for abuse out of a total sample of 25. This failure created the potential for abuse of other residents. The facility census was 80.
Findings include:
Review of the facility's Abuse Prevention Plan, dated 07/21/22, revealed, Any person with the knowledge or suspicion of suspected abuse, neglect, misappropriation of resident property, and/or financial exploitation must report immediately, without fear of reprisal and/or retaliation . Any allegations involving abuse, neglect, misappropriation of resident property and/or financial exploitation will be investigated . Measures will be taken to identify the source of the alleged abuse and prevent future incidents. Investigative packets will be utilized to systematically direct the team through the investigative process. Any evidence gathered will be handled with caution to ensure no tampering, destruction or alteration occurs . Identify and interview all who might have knowledge of the incident including the alleged victim, perpetrator, witnesses, or others who may have had related contact with the alleged perpetrator, related to the incident in question. The focus of the investigation is to determine the extent, cause and future prevention with thorough documentation of the investigative process .
Review of R26's Face Sheet, located under the Dashboard tab in the electronic medical record (EMR), revealed R26 was admitted to the facility on [DATE] and passed away on 12/29/24. R26 had diagnoses that included dementia.
Review of R26's annual Minimum Data Set (MDS), with an assessment reference date (ARD) of 11/24/24, revealed a Brief Interview for Mental Status (BIMS) score of six out of 15, which indicated R26 was severely cognitively impaired. R26 was noted to require one to two staff members to assist with activities of daily living (ADL) needs.
Review of R32's Face Sheet, located under the Dashboard tab in the EMR, revealed R32 was admitted on [DATE] with diagnoses that included congestive heart failure.
Review of R32's annual MDS, with an ARD of 12/10/24, revealed a BIMS score of 13 out of 15, which indicated R32 was cognitively intact.
Review of the monthly Resident Council Minutes, dated 02/23/24 at 11:00 AM and provided by the Wellness/Activity Director (AD), revealed, . [R32] stated that on the 19th the nurse aide was inside his room on his roommate's side and was yelling at him. [R32] stated that he asked her to talk to him when she was done and he then asked her why she was yelling at his roommate [R26] and the nurse responded back that his roommate was not listening to her. [R32] stated that he does not sleep well at night when this stuff is going on .
Review of the facility's investigation of the allegation, provided by the Director of Nursing (DON), revealed Fefiuary [sic] 23,2024 AT approximately 2:45pm. [AD] came into writer's office to review council meeting nursing concerns. One of the concerns was Resident [32] stated an agency aide on Monday who worked was yelling at his roommate [R26] calling him 'dumbass' and other things [R32] stated he could not repeat. [R32] stated he went over to speak to the aide telling her she should not speak to [R26] that way and wanted his shower. [R32] stated he was told by the aide it was not his business and if he contlnued [sic] to complain the aide would wait to give him his shower until last. Resident [32] did not get a shower until the next day when [Certified Medication Technician (CMT)1] gave him a shower first th ing [sic] .
The facility's summary of the investigation recorded to refer to [Former Social Service Coordinator] notes for R32's interview. The notes were not contained in the investigative documentation and were not located by the DON; therefore, they were not reviewed. R26 was identified as not interviewable.
An interview with R32, contained within the summary, read, [R32] told her the aide who worked days on Monday had been yelling and speaking aggressively to [R26]. When she asked what he meant by that, [R32] further stated that he stopped the aide on the way out of the room and told her she had no business talking to [R26] that way as he isn't capable of defending himself. [R32] also stated that the aide told him to mind his own business and let her do her job. The aide began to yell at him and he told her to leave his room and not come back.
There was no documented evidence contained in the investigative documentation that the allegation of verbal abuse was investigated. There was no documentation that R26 was assessed. There was no documentation that other residents were interviewed. There was no documentation that non-interviewable residents cared for by the Certified Nurse Aide (CNA) were assessed. There was no documented evidence that the CNA was interviewed. It was recorded that the facility notified the employment agency that the identified CNA was not allowed to return to work in the facility.
During an interview on 01/02/25 at 8:30 AM, R32 stated that he remembered what he reported in February 2024. R32 stated, I don't remember her name. My issues with the CNA were not addressed, not about me. I told her don't you speak to him [R26] like that, get out of this room and don't you ever come back in this room again or I'll call the police. R32 stated he did not remember the CNA's name but did remember the CNA yelling at his roommate (R26).
During an interview on 01/02/24 at 6:00 PM, the DON was asked why the allegation was not investigated. The DON did not say why the allegation involving R32 and R26 were not investigated. The DON stated, I'm still looking for more paperwork. No additional information was provided as of exit on 01/02/25 at 7:30 PM.
CONCERN
(E)
Potential for Harm - no one hurt, but risky conditions existed
Accident Prevention
(Tag F0689)
Could have caused harm · This affected multiple residents
**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, interview, record review and policy review, the facility failed to ensure two of 25 sampled residents (Res...
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**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, interview, record review and policy review, the facility failed to ensure two of 25 sampled residents (Residents (R)37 and R21) were provided with sufficient supervision and assistive devices to prevent accidents. R37 experienced a fall in which she fell forward out of the bed onto the floor on 09/20/24. There was a lack of interventions implemented in response to the fall and seven days later, R37 experienced another fall onto the floor. R37 sustained injuries including abrasions to her knees, a nosebleed, bleeding gums, bruise to her right cheek, and experienced hip and knee pain. R21 wandered through out the First-Floor [NAME] unit and into residents' rooms, including the rooms of R37 and R32, putting herself and other residents at risk of injuries. R21 wandered at night into residents' rooms when there was less staffing on the unit to supervise her and when she had the potential to startle residents who were sleeping. The facility census was 80.
Findings include:
Review of the facility's Integrated Fall Management policy, dated 09/2023, revealed the purpose of the policy was, Fall risk assessment, identification and implementation of appropriate interventions as necessary, to maintain resident safety, prevent falls and reduce further injury from falls . Residents at risk for falls have an individualized resident centered care plan developed. Care plan interventions are based on the finding of the fall risk assessment .
1. Review of R37's Face Sheet, located under the Resident tab of the electronic medical record (EMR) revealed R37 was admitted to the facility on [DATE] with diagnoses that included muscle weakness, need for assistance with personal care, muscle wasting and atrophy, acute and chronic respiratory failure, sleep apnea, adjustment insomnia, and end stage renal disease with dependence on renal dialysis.
Review of R37's Care Plan, dated 02/26/21 and located in the EMR under the RAI [Resident Assessment Instrument] tab, revealed a problem of Falls, I am at risk for falls due to decreased cognition, bipolar-psychotropic & antidepressants medication use, DM [diabetes mellitus], neuropathy. The goal was, I will be free of injuries due to falls in the next 90 days. The approaches in total were:
Keep my frequency used personal items within reach, initiated on 06/12/21.
Assessed for proper Hoyer sling size, which is large, and what is being used initiated on 06/04/21.
Increased staff supervision with intensity based on my need initiated on 02/26/21.
Comprehensive medication review by pharmacist assess for polypharmacy and medications that increase the fall risk as needed initiated on 02/26/21.
Review of R37's quarterly Minimum Data Set (MDS), with an assessment reference date (ARD) of 09/07/24 and located in the electronic medical record (EMR) under the RAI [Resident Assessment Instrument] tab, revealed R37 was admitted to the facility on [DATE] and was unimpaired in cognition with a Brief Interview for Mental Status (BIMS) score of 15 out of 15. It was recorded R37 required substantial/maximal assistance with toileting hygiene and lower body dressing, was independent for rolling left to right, going from sitting to lying, and lying to sitting on the side of the bed. It was recorded that R37 was dependent for chair to bed transfers, had not walked during the assessment period, and had not experienced any falls since the previous MDS assessment.
Review of R37's Nurse's Note, dated 09/20/24 at 2:15 AM and located in the EMR under the Progress Notes tab, revealed, . CNA [Certified Nursing Assistant] heard resident table fall and resident crying, attended immediately and saw resident lying in [sic] the floor. This writer was notified by CNA and attended as well. Resident was seen on right side lying position, facing the nightstand, feet were almost under the bed. When asked what she was doing and how she fell, the resident said she was sitting on the edge of her bed as she used to and fell asleep. Table was pushed, as she drops to her knees and fell completely. Physical assessment done, noted with abrasion on both knees. Resident claims her hips hurt but does not think she had fracture, just sore as verbalized. Res [resident] denies hitting her head claiming her face is the one that hit the floor, no bruise noted on face. Notified resource and came assess with the writer. Resident was able to move her legs and hand grips were equal. Neuro assessment done and recorded. Vital signs WNL [within normal limits]. No bruise nor other discoloration noted on hip and back, no visible fracture. Resident was able to roll over by herself while placing the Hoyer pad underneath to lift her. Transferred her back to bed safely with Hoyer Lift. Advised to refrain from sitting on edge of bed specially when she is sleepy, resident acknowledged. Safety measures ensured, kept her things within reach and reminded to call for any assistance needed .
Review of the Event Report (fall investigation), dated 09/20/24 and provided by the facility, revealed R37 was in bed prior to fall that occurred at 3:15 AM. R37 was documented as being alert and oriented, not being able to ambulate (walk), complaining of mild pain to her hips. R37's range of motion (ROM) was normal, she was alert and without any changes to her mental status. Under the section Interventions - Immediate measures taken, the assessment was blank. Under the section Possible Contributing Factors, the assessment was blank. R37's physician and family were notified on 09/20/24 at 8:07 AM. There was no documentation of what the resident was doing prior to the fall. Registered Nurse (RN)1 was the nurse on duty and completed the Event Report.
Review of R37's Care Plan, located under the RAI tab of the EMR, revealed no documented evidence that any interventions were identified and implemented in relation to the fall on 09/20/24.
Review of R37's Nurse's Note, dated 09/27/24 at 11:30 PM and located in the EMR under the Progress Notes tab, revealed, . Writer and CNA heard a noise coming from resident room followed by a cry for help. Went to resident room immediately and saw resident sitting on the floor, her head under her bedside table. When asked what happened, she said she is trying to lay down on the bed but instead of going backwards, she slipped and eventually fell forward. Resident noted with nosebleed and bleeding on her front gums as a result of hitting the table in front of her, she also claims her Rt [right] eye was hit, light bruise noted on Rt cheek, no redness nor bleeding noted on rt eye. Ice pack applied on nose and mouth and instructed to lean forward while applying ice pack. Instructed to gurgle as well to wash blood in the mouth. Bleeding stopped after around 5 minutes of ice application. She also c/o [complained of] pain on L [left] knee that was hurt during the fall. Able to move upper and lower extremities with good ROM. Neuro vitals signs checked. Transferred to bed safely with Hoyer lift. Advised to refrain dangling her legs and to keep her whole body in the bed when sleeping, resident agrees and shows understanding. Tried to reach her [family member] to update but to no avail, left VM [voice message] instead including call back number .
Review of R37's Event Report, dated 09/27/24 and provided by the facility, revealed the fall occurred at 11:30 PM. The fall was unwitnessed. R37 fell forward out of the bed onto the floor. R37 was assessed, ROM completed, and neuro checks were initiated. The physician was notified on 09/28/24 at 1:53 AM and the family on 09/28/24 at 12:53 AM. There was no documentation of immediate measures being implemented, and the pattern of the resident falling forward out of the bed onto the floor was not identified. RN1 was the nurse on duty when the fall occurred and had filled out the Event Report.
Review of R37's Care Plan, dated 10/02/24 and located in the EMR under the RAI tab, revealed a problem of, Resident is at risk for falls due to lack of safety awareness. The goal was, Resident will be free of falls. Interventions in total were:
-Keep frequently used items within reach, initiated on 12/06/24.
-Keep my call light within reach while I'm in my room, initiated on 12/06/24.
-Increased staff supervision with intensity based on resident need, initiated on 10/02/24.
-Resident had two falls due to falling asleep at side of bed. Staff will get recliner for resident's room for her to sit in and resident will be educated not to sit on edge of bed, dated 10/02/24.
Review of R37's Interdisciplinary Note, dated 10/02/24 and located in the EMR under the Progress Notes tab, revealed, IDT [interdisciplinary team] met to discuss falls on 9/20/24 and 9/27/24. Staff to encourage [R37] to sit in a recliner and not on the side of her bed.
Review of a Work Order, dated 11/13/24 and provided by the facility, revealed R37 needed the rocker chair in her room replaced with a regular recliner. The work order was documented as being completed on 11/18/24.
Review of the annual Minimum Data Set (MDS) with an ARD of 12/04/24 in the EMR under the RAI tab revealed R37 continued to be unimpaired in cognition with a BIMS score of 15 out of 15.
During an interview on 12/30/24 at 3:13 PM, R37 stated she had fallen a couple times a few months ago. R37 stated she fell asleep when she was sitting up on the edge of the bed, fell forward out of the bed, and landed on the floor when each of the falls occurred. R37 stated she hit her face and had a bloody nose. R37 stated she did not know what interventions were added by staff to prevent falls. R37 stated she tried to lay down when she was getting tired and falling asleep. R37 stated that recently she had fallen backward when she was sitting up in bed and had fallen asleep instead of falling forward. She stated when this occurred, she landed on the mattress and had not injured herself. R37 stated she was supposed to have a recliner chair in her room, but she had not been provided with one. R37 was observed to have an upright cushioned chair that did not recline. The chair had an ottoman that pulled out for propping her feet up.
During an interview on 01/02/25 at 9:10 AM, RN1 stated she had been working the night shift and was R37's nurse when the falls occurred on 09/20/24 and on 09/27/24. RN1 stated for the first fall on 09/20/24, R37 fell while going to sleep. RN1 stated she was at the nursing station at the time of the fall, and both she and the CNA heard a noise so they went to the rooms on that side and found R37 on the floor. RN1 stated R37 had said she fell asleep and fell out of bed onto the floor but was okay. RN1 stated R37 tended to sleep on the edge of the bed, and R37 told her she was sitting up and fell asleep while she was sitting. RN1 stated R37's bedside table was there with everything in reach at the time of the fall. RN1 stated the resource nurse came and assisted with assessing the resident. RN1 stated the intervention she implemented was educating R37 to lay back whenever it was nighttime. RN1 stated the staff made rounds and kept things R37 might need near her. RN1 stated that the fall on 09/27/24 was the same story on how it happened, with R37 falling forward again out of bed. RN1 stated the intervention was to continue to do rounds. RN1 stated on the night shift, she had two halls (First Floor South and West) that she covered with one CNA on each hall. RN1 stated someone should be on the hall and checking residents every hour or so. RN1 stated she advised R37 to sit in a chair if she wanted to. RN1 stated R37 had a chair in her room but she preferred to sit on the bed. RN1 stated R37 was cooperative and she did not have any problems caring for her.
During an interview on 01/02/25 at 9:49 AM, the Environmental Services Director stated R37 wanted a reclining lift chair, but nursing approval was needed for that. The Environmental Services Director stated he was not able to provide a chair that electronically lifted residents up. The Environmental Services Director stated the chair currently in R37's room was the one he had placed in there when completing the work order on 11/18/24. He showed the surveyor the chair which was an upright sitting chair with an ottoman that pulled out; the chair did not recline. The Environmental Services Director stated R37 previously had a rocking chair in her room that he had to remove due to the facility's policy that no rocking chairs were allowed for safety reasons.
During an interview on 01/02/25 at 1:27 PM, CNA1 stated R37 required staff assistance with some ADLs, was dependent on staff for transfers, and was unable to stand or walk. CNA1 stated she was not aware of R37 being at risk for falls. CNA1 stated there was a CNA cheat sheet that was available that provided information such as fall risk and interventions needed.
During an interview on 01/02/25 at 1:41 PM, Licensed Practical Nurse (LPN) 4 stated R37 tended to sit on the side of her bed which put her at risk of falling due to going to sleep while she was sitting up. LPN4 stated she was not aware of any interventions to address the fall risk from sitting on the edge of the bed and going to sleep. LPN4 stated she had been informed that R37 did not sleep much at night; however, she slept a lot during the day.
During an interview on 01/02/25 at 5:14 PM, the Director of Nursing (DON) and Clinical Manager (CM) 1 were interviewed and stated an IDT meeting was held daily, and in the meeting, falls were reviewed. The DON stated the Pharmacist reviewed R37's medications on 10/15/24 (two weeks after the second fall occurred on 09/27/24). The DON stated R37 was encouraged to lay down when she was tired and had been sleeping more. The DON stated therapy staff reviewed R37 on 09/27/24; however, she was at her baseline and they did not initiate therapy. They stated R37 tended to sit on the edge of the bed with her legs dangling and they wanted R37 to elevate her legs, and the family did not have the funds to purchase a recliner. They stated R37 did not want to sit in the chair that was currently located in her room.
2. Review of R21's Face Sheet, found under the Profile Tab in the EMR, indicated an admission date of 09/07/18 with diagnoses of dementia, anxiety disorder, major depressive disorder, and Alzheimer's disease.
Review of R21's Elopement Risk assessment, dated 08/24/24 and located under the Assessments tab of the EMR, revealed that R21 wandered with no rational purpose and attempted to open doors and was a high elopement risk.
Review of R21's quarterly MDS, with an ARD of 08/27/24, recorded R21 did not exhibit the behavior of wandering.
Review of R21's Assessments, found under the Assessment tab of the EMR, indicated that a quarterly Elopement Risk assessment for November 2024 had not been completed.
Review of R21's annual MDS, with an ARD of 11/27/24 and found under the Assessments tab in the EMR, indicated R21 had a BIMS score of four of 15, which indicated R21 was severely cognitively impaired. It was recorded that R21 did not exhibit wandering.
Review of R21's Care Plan, with a revision date of 12/02/24 and found under the Care Plan tab of the EMR, indicated a plan for Behavioral Symptoms with a start date of 04/21/23. The plan indicated that R21 . exhibited wandering with no rational purpose, seemingly oblivious to needs or safety. Approaches indicated to, . check double doors if alarm goes off to make sure I do not get off unit, monitor every shift if 'Wander Guard' is in place, to place [R21] in a secure environment, and to provide comfort measure for basic needs (e.g. Pain, hunger, toileting, too hot/cold, etc.) .
Review of R21's Care Plan, with a revision date of 12/02/24 and found under the Care Plan of tab of the EMR, indicated a plan for Cognitive Loss/Dementia with a start date of 06/05/24. The plan indicated that R21 wanders on the hall of floor, may call out and ask where she is, what she should be doing, or how she got here. Reorient resident to the best of ability. Approaches indicated to place a green sign outside R21's room to help identify her room, to check the Wander Guard functionally each week, change the battery annually, check every shift for proper placement, distract from wandering by offering pleasant diversions, structured activities, food, conversation, television or book and help finding her room.
During an observation on 12/31/24 at 2:36 PM, R21 was observed wandering up and down the hall and come and ask LPN3 and the surveyor where she was supposed to go and what she should do.
During an observation on 01/01/25 at 8:46 AM, R21 was wandering in the hall near her room and was redirected by staff to her room.
During an observation on 01/01/25 at 2:53 PM, R21 ambulated in the hallway slowly using her walker and stopped to talk to a staff member. The staff member led R21 to her room. An observation on 01/01/25 at 3:06 PM revealed R21 ambulated out of her room using her walker into the hallway. A staff member met R21 and walked with her back to her room. An observation on 01/01/25 at 3:19 PM revealed R21 ambulated out of her room using her walker into the hallway, then walked up to staff member and spoke to the staff member. R21 then turned and went back to her room. An observation on 01/01/25 at 3:22 PM revealed R21 ambulated out of her room using her walker into the hallway, walked slowly and approached a staff member and began talking. R21 then walked using her walker and entered the dining area on her unit and seated herself at a table.
a. Review of R32's undated Face Sheet, located in the EMR under the Resident tab, revealed R32 was admitted to the facility on [DATE].
Review of R32's quarterly MDS, with an ARD of 12/08/24 and located in the EMR under the RAI tab, revealed R32 had a BIMS score of 15 out of 15, which indicated the resident was cognitively intact.
During an interview on 12/30/24 at 2:31 PM, R32 stated R21 was lost, and she came in and used his bathroom quite a bit. R32 stated, One time she was sitting on my stool and I had to pee. R32 stated that between 2:00 - 3:00 AM, R21 was up and hunting for the bathroom and came into his room, which was right next to hers. R32 stated R21 had come into his room without clothing on. R32 stated he could usually get R21 to leave his room but he had used the call light before for staff to come and get her. R32 stated R21 came into his room several times per day.
During a subsequent interview on 01/01/25 at 8:48 AM, R32 stated, Everyone knows she [R21] has been in my bathroom. R32 stated R21 was confused and was not aware of what she was doing and that she would not hurt anyone; however, R32 stated he felt uncomfortable and thought it was against the law for him to see R21 undressed. R32 stated he felt like he was in trouble when R21, who was not dressed, came into his room during the night.
During an interview on 12/31/24 at 2:34 PM, LPN3 stated R21 wandered in the unit and had a Wanderguard (wrist or ankle band alert system to alarm and lock monitored doors for wander-prone residents) to prevent her from leaving. LPN3 stated R21 was very confused and the staff kept an eye on her, redirected her, and did room checks to keep track of her whereabouts. LPN3 stated she did not work nights and had not heard of R21 wandering into other residents' rooms.
During an interview on 12/31/24 at 3:01 PM, CM1 stated she was not aware of R21 wandering into other residents' rooms.
During an interview on 01/02/25 at 9:10 AM, RN1 stated she routinely worked night shift on the hall where R21, R32, and R37 resided. RN1 stated R21 wandered at night. RN1 stated R21 got up around midnight to go to the bathroom and came out to the nursing station and asked staff, Where am I? Where is my room? RN1 stated she and the CNAs oriented R21 and put her back to bed. RN1 stated R21 often tried to go into one of the rooms right next to hers during night shift, and they redirected her out of the room.
During an interview on 01/02/25 at 1:27 PM, CNA1, who worked day shift, stated R21 wandered and this was not a new behavior. CNA1 stated R21 occasionally went into other residents' rooms. CNA1 stated yesterday she observed R21 wandering into a resident's room that was not her own or that of R32 or R37. CNA1 stated residents, mostly R32, let her know if R21 was wandering into their rooms. CNA1 stated she had notified the nurse on duty when residents told her R21 wandered into their rooms. CNA1 stated R32 had notified her twice of R21 coming into his room and she had passed the information to the nurse on duty.
b. Review of R37's annual MDS, with an ARD of 12/04/24 and located in the EMR under the RAI tab, revealed R37 was admitted to the facility on [DATE] and had a BIMS score of 15 out of 15, which indicated the resident was cognitively intact.
During an interview on 12/30/24 at 3:30 PM, R37 stated R21 had dementia, was confused, and frequently wandered into her room. R37 stated R21's room was right next door to hers, which was confirmed by observation. R37 stated R21 came into her room three to five times a day, did not know where she was, and stated she wanted to go home. R37 stated she asked R21 to leave which she generally did; however, if she did not leave, R37 stated she pushed the call light for staff to come and get her out.
During an interview on 01/02/25 at 5:27 PM, CM1 and the Director of Nursing (DON) stated night shift staff consisted of one nurse and two CNAs to cover First Floor South and First Floor [NAME] halls, each hall with 16 residents, and the night shift nurse was responsible for the medication pass on both units which occurred until 10:00 PM - 11:00 PM. They verified there could be times when there were no staff on the hallway on either side of the First Floor if the nurse was on the other side and the CNA on the hall was in a room with a resident. Both stated R21 had dementia, and it was common for her to be up early in the morning around 4:30 AM. They stated the facility did not have a memory care unit and they could not meet the needs of residents with significant wandering and had discharged residents to memory units when necessary. The DON stated the staff and residents had not reported that R21 was wandering into residents' rooms.
Mar 2023
16 deficiencies
CONCERN
(E)
Potential for Harm - no one hurt, but risky conditions existed
Deficiency F0567
(Tag F0567)
Could have caused harm · This affected multiple residents
**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on record review and interview, the facility failed to hold residents' monies separate from facility money when they did n...
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**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on record review and interview, the facility failed to hold residents' monies separate from facility money when they did not reimburse residents and/or their responsible parties after the residents were discharged , which affected six residents (Residents #994, #995, #996, #997, #998, and #999). The facility census was 95.
Review of facility policy, Refunds - Credit Balances, dated [DATE], showed:
-Purpose: To prevent fraud, waste, and abuse and manage reimbursement;
-Policy: All credit balances will be reviewed within 30 days from being identified. Under the Patient Protection and Affordable Care Act, Title VI entitled Transparency and Program Integrity section 6402; overpayments from Federal payers must be refunded within 60 days after the date on which the overpayment was identified. Federal payers include Medicare A and B, Medicaid, Veterans Association, Medicare Advantage or any other payer under title XVIII and XIX;
-Private Pay - For residents who have discharged and have a credit balance, complete the eSource Request for Refund if, all other payer balances is zero. If there is a balance under another payer, refund amounts up to the outstanding balance owed under the other payer are allowed;
-Resident Liability- If the resident expired, contact the county regarding disbursement location. If the resident discharges, refund the resident.
1. Review of the facility's Payer Aging Report (A/R) Credit Balance Summary, dated [DATE], showed:
-Resident #994, discharged on [DATE], had a negative balance of -7.77;
-Resident #995, discharged on [DATE], had a negative balance of -14.20;
-Resident #996, discharged on [DATE], had a negative balance of -1420.00;
-Resident #997, discharged on [DATE], had a negative balance of -5,565.00;
-Resident #998, discharged on [DATE], had a negative balance of -4,000.00;
-Resident #999, discharged on [DATE], had a negative balance of -1,375.00.
During an interview on [DATE] at 8:41 A.M., the Business Office Manager said:
-He/she started four months ago;
-He/she did not know how long the facility held funds;
-Resident #994 discharged and had a new balance this month;
-Resident #995's check was issued for the wrong amount; the correct amount was being processed;
-He/she did not know why Resident #996's funds were not refunded;
-Resident #997 passed away on [DATE]; he/she did not know why funds had not been processed;
-Resident #998 expired on [DATE]. The refund request was submitted to corporate on [DATE];
-Resident #999 expired on [DATE]; he/she did not know if a refund request had been made;
-Refund requests are initiated at the corporate office level;
-The refund process was led by corporate office who reviewed account credits and started the refund process;
During an interview on [DATE] at 10:57 A.M., the Director of Revenue Cycle Management said:
-Resident #995 was due a $14.20 refund. Corporate needed to issue a credit back and the refund request had not been made by the Business Office Manager
-Resident #996 had a credit of $1420.00; The refund was in the final approval process;
-Resident #997 had a credit of $5,565; The refund needed approved by the Executive Director first;
-Resident #998 had a $4,000 credit; the refund request was entered on [DATE] but had not been approved by the Executive Director yet;
-The Executive Director did not sign off on any refunds during February;
-Resident #999 had a $1375 credit; the refund request was made on [DATE] and was waiting for Executive Director approval;
-Resident funds should be returned in thirty days.
During an interview on [DATE] at 11:15 A.M., the Executive Director said:
-Resident funds should be returned within thirty days;
-He/she was not aware funds had not been processed within thirty days;
-He/she received emails of resident reimbursements for approval;
-He/she was not aware of any unapproved reimbursements;
-He/she was not aware of any reimbursements that had not been approved.
During an interview on [DATE] 02:25 P.M., the Administrator said:
-Funds should be returned to a resident within 30 days of discharge or expiration from facility;
-He/she was aware of accounts that are beyond thirty days.
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 the record review and interview, the facility staff failed to check the Certified Nurses' Assistant (CNA) Registry for all staff to ensure they did not have a Federal Indicator (a marker give...
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Based on the record review and interview, the facility staff failed to check the Certified Nurses' Assistant (CNA) Registry for all staff to ensure they did not have a Federal Indicator (a marker given by the federal government to individuals who have committed abuse/neglect). This affected four of ten sampled staff (Cook A, Housekeeper A, Physical Therapy Assistant, Culinary Services Aide F). The facility census was 95.
Review of the facility policy, Abuse Prevention Plan, dated 7/21/22, showed:
-All potential employees will be screened during the hiring and re-hiring process for a history of abuse, neglect, financial exploitation, misappropriation of resident property, or mistreatment of a vulnerable adult;
-Inquiries will be made into the state licensing authorities or Nursing Assistant Registry;
-The facility will prohibit employment of individuals with a disciplinary action in effect against their professional license by a state licensure body as a result of a guilty finding of abuse, neglect, exploitation, mistreatment of residents, or misappropriation of resident property.
1. Review of [NAME] A's employee file showed:
-Hired on 12/5/2022;
-No CNA Registry check found.
2. Review of Housekeeper A's employee file showed:
-Hired on 2/20/23;
-No CNA Registry check found.
3. Review of Physical Therapy Assistant's employee file showed:
-Hired on 3/21/14;
-No CNA Registry check found.
4. Review of Culinary Services Aide F showed:
-Hired on 4/3/22;
-No CNA Registry check found.
During an interview on 2/28/23 at 3:54 P.M., the Administrator said he/she did not know non-nursing staff had to be checked on the nurse aide registry.
During an interview on 3/2/23 at 9:38 A.M., the Human Resources Manager said:
-Nurse aide registry checks should be completed twice a year or quarterly.
-He/she completed registry checks in January;
-He/she was not aware that CNA registry checks should be completed on all employees upon hire.
CONCERN
(E)
Potential for Harm - no one hurt, but risky conditions existed
Comprehensive Assessments
(Tag F0636)
Could have caused harm · This affected multiple residents
**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on interview and record review, the facility failed to ensure they completed and submitted to Centers for Medicare and Med...
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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 they completed and submitted to Centers for Medicare and Medicaid (CMS) comprehensive Minimum Data Set (MDS, a federally mandated assessment completed by staff) according to the required timeframes. This affected two of 19 sampled residents (Residents #28 and #84). The facility census was 95.
Review of the facility's Comprehensive Assessments and Care Planning policy, dated 2017, showed:
- A facility must conduct a comprehensive assessment of a resident as follows:
a. Within 14 calendar days after admission, excluding readmissions in which there is no significant change in the resident's physical or mental condition.
b. Within 14 days after the facility determines, or should have determined, that there has been a significant change in the resident's physical or mental condition.
- Within seven days after a facility completes a resident's assessment:
a. A facility must enter the MDS information into a computer.
b. A facility must be capable of transmitting to the State information for each resident contained in the MDS in a format that conforms to standard record layouts and data dictionaries, and that passes standardized edits defined by CMS and the State.
- A facility must electronically transmit, at least monthly, encoded, accurate, complete MDS data to the State for all assessments conducted during the previous month, including the following:
a. admission assessment
b. Annual Assessment
c. Significant change in status assessment
- MDS will be completed by each department by day seven after the Assessment Reference Date (ARD, the last day of the observation period the assessment covers).
- Annual MDS process must be completed no later than 366 days from the full MDS and not more than 92 days from the third quarterly MDS.
- Significant Change MDS process must be completed 14 days from the time a significant change is identified.
1. Review on 2/28/23 of Resident #84's facility MDS records showed the facility completed the following assessments:
- Significant change in condition MDS assessment was dated 11/11/22. gave me.
- Alert noting the MDS was still In Process.
- Last completed and submitted comprehensive MDS was a Significant Change assessment dated [DATE].
Review on 2/28/23 of the resident's MDS record in the Centers for Medicare and Medicaid's reporting system (ASPEN) showed:
- Significant change in condition MDS assessment was dated 11/11/22.
- Last completed and submitted comprehensive MDS was a significant change in condition assessment dated [DATE].
2. Review on 2/28/23 of Resident #28's MDS facility record showed:
- Quarterly MDS assessment dated [DATE].
- Alert noting that the MDS was still In Process.
- Last completed and submitted comprehensive MDS was a Significant Change assessment dated [DATE].
Review on 2/28/23 of Resident #28's MDS record in ASPEN showed:
-Quarterly MDS assessment dated [DATE].
-Last completed and submitted comprehensive MDS was a significant change in condiction assessment dated [DATE].
3. During an interview on 3/6/23 at 2:00 P.M., the MDS Coordinator said:
- He/she has worked in the MDS Coordinator position since August 2022.
- He/she was responsible for completing and submitting MDS assessments.
- MDS assessments should be completed and submitted in a timely manner, according to the appropriate time line.
- admission MDS should be completed within 14 days of a resident's admission. On Annual and Significant Change in condition MDS assessments, staff have seven days to conduct the assessment then seven days to enter the information into the MDS, which she then submitted.
- She knew some of the MDS assessments were late and have not been submitted. They were just late.
During an interview on 3/6/23 at 2:57 P.M., the Director of Nursing (DON) said:
- The MDS team was responsible for completing and submitting MDS assessments.
- She knew they had late MDS assessments that had not been submitted.
- Several of the MDS team members had been out with health issues. There was also confusion in regards to what the corporate office wanted in regards to who was responsible for completing and submitted MDS assessments.
During an interview on 3/6/23 at 3:54 P.M., the Administrator said:
- The Clinical Reimbursement Nurse was also the MDS Coordinator and was responsible for completing and submitting MDS assessments.
- She expected staff to complete and submit MDS assessments on time.
- She knew they had MDS assessments that were late and not submitted.
CONCERN
(E)
Potential for Harm - no one hurt, but risky conditions existed
Deficiency F0638
(Tag F0638)
Could have caused harm · This affected multiple residents
**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on interview and record review, the facility failed to ensure they completed, submitted to Centers for Medicare and Medica...
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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 they completed, submitted to Centers for Medicare and Medicaid (CMS) and they accepted the Minimum Data Set (MDS, a federally mandated assessment completed by staff) on a quarterly basis. This affected six of 19 sampled residents (Residents #28, #68, #75 #84, #87, and #227). The facility census was 95.
Review of the facility's Comprehensive Assessments and Care Planning policy, dated 2017, showed:
- A facility must conduct a comprehensive assessment of a resident as follows:
c. Using the quarterly review instrument specified by the State and approved by Center for Medicare and Medicaid (CMS) not less frequently than once every 3 months.
- Within seven days after a faciltiy completes a resident's assessment:
a. A facility must enter the MDS information into a computer.
b. A facility must be capable of transmitting to the State information for each resident contained in the MDS in a format that conforms to standard record layouts and data dictionaries, and that passes standardized edits defined by CMS and the State.
- A facility must electronically transmit, at least monthly, encoded, accurate, complete MDS data to the State for all assessments conducted during the previous month, including the following:
f. Quarterly Review
- MDS will be completed by each department by day seven after the Assessment Reference Date (ARD, the last day of the observation period the assessment covers).
- Quarterly MDS is due within 92 days of the last Quarterly or Full MDS.
1. Review on 2/28/23 of Resident #84's facility MDS record showed:
- Significant change in condition MDS assessment dated [DATE].
- Alert noting the MDS was In Process.
- Last completed and submitted comprehensive MDS was a Significant Change assessment dated [DATE].
Review on 2/28/23 of the resident's MDS record in the Centers for Medicare and Medicaid's centralized reporting system (ASPEN) showed:
-Significant change in condition MDS assessment was dated 11/11/22.
-Last completed and submitted comprehensive MDS was a significant change in condition assessment dated [DATE].
-There is one missing Quarterly assessment.
2. Review on 2/28/23 of Resident #68's MDS record showed:
-Quarterly MDS assessment dated [DATE].
-Alert noting that the MDS was In Process.
-Last completed and submitted MDS was an admission assessment dated [DATE].
Review on 2/28/23 of the resident's MDS record in ASPEN showed:
-Quarterly MDS assessment dated [DATE].
-Last completed and submitted MDS was an admission assessment dated [DATE].
-There is one missing Quarterly assessment.
3. Review on 2/28/23 of Resident #227's MDS record showed:
-Quarterly MDS assessment dated [DATE].
-Alert noting that the MDS was In Process.
-Last completed and submitted MDS was a Quarterly assessment dated [DATE].
Review on 2/28/23 of the resident's MDS record in ASPEN showed:
-Quarterly MDS assessment dated [DATE].
-Last completed and submitted MDS was a Quarterly assessment dated [DATE].
-There is one missing Quarterly assessment.
4. Review on 2/28/23 of Resident #87's MDS record showed:
-Quarterly MDS assessment dated [DATE].
-Alert noting that the MDS was In Process.
-Last completed and submitted MDS was a Quarterly assessment dated [DATE].
Review on 2/28/23 of the resident's MDS record in ASPEN showed:
-Quarterly MDS assessment dated [DATE].
-Last completed and submitted MDS was a Quarterly assessment dated [DATE].
-There is one missing Quarterly assessment.
5. Review on 2/28/23 of Resident #28's MDS record showed:
-Quarterly MDS assessment dated [DATE].
-Alert noting that the MDS was In Process.
Review on 2/28/23 of the resident's MDS record in ASPEN showed:
-Quarterly MDS assessment dated [DATE].
-There is one missing Quarterly assessment.
6. Review on 2/28/23 of Resident #75's MDS record showed:
-Quarterly MDS assessment dated [DATE].
-Alert noting that the MDS was In Process.
-Last completed and submitted MDS was a Significant Change assessment dated [DATE].
Review on 2/28/23 of the resident's MDS record in ASPEN showed:
-Quarterly MDS assessment dated [DATE].
-Last completed and submitted MDS was a Significant Change assessment dated [DATE].
-There are 2 missing Quarterly assessments.
7. During an interview on 3/6/23 at 2:00 P.M., the MDS Coordinator said:
- She has worked in the MDS Coordinator position since August 2022.
- She is responsible for completing and submitting MDS assessments.
- MDS assessments should be completed and submitted in a timely manner, according to the appropriate time line.
-Staff have seven days to conduct the quarterly assessments then seven days to enter the information into the MDS, which they then submit.
- She knew they had late MDS assessments that had not been submitted. They were late.
During an interview on 3/6/23 at 2:57 P.M., the Director of Nursing (DON) said:
- The MDS team was responsible for completing and submitting MDS assessments.
- She knew MDS assessments were late and had not been submitted.
- Several of the MDS team members had been out with health issues. There was also confusion in regards to what the corporate office wanted in regards to who was responsible for completing and submitted MDS assessments.
During an interview on 3/6/23 at 3:54 P.M., the Administrator said:
- The Clinical Reimbursement Nurse was also the MDS Coordinator and was responsible for completing and submitting MDS assessments.
- She expected staff to complete and submit MDS assessments on time.
- She knew they had late MDS assessments that not been submitted.
CONCERN
(E)
Potential for Harm - no one hurt, but risky conditions existed
MDS Data Transmission
(Tag F0640)
Could have caused harm · This affected multiple residents
**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on interview and record review, the facility failed to ensure they completed and transmitted to Centers for Medicare and M...
Read full inspector narrative →
**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on interview and record review, the facility failed to ensure they completed and transmitted to Centers for Medicare and Medicaid (CMS) and they accepted the Minimum Data Set (MDS, a federally mandated assessment completed by staff) according to the required timeframes. This affected six of 19 sampled residents (Residents #28, #68, #75, #84, #87, and #227). The facility census was 95.
Review of the facility's Comprehensive Assessments and Care Planning policy, dated 2017, showed:
- A facility must conduct a comprehensive assessment of a resident as follows:
a. Within 14 calendar days after admission, excluding readmissions in which there is no significant change in the resident's physical or mental condition.
b. Within 14 days after the facility determines, or should have determined, that there has been a significant change int he resident's physical or mental condition.
c. Using the quarterly review instrument specified by the State and approved by Center for Medicare and Medicaid (CMS) not less frequently than once every three months.
d. Not less than once every 12 months.
- Within seven days after a faciltiy completes a resident's assessment:
a. A facility must enter the MDS information into a computer.
b. A facility must be capable of transmitting to the State information for each resident contained in the MDS in a format that conforms to standard record layouts and data dictionaries, and that passes standardized edits defined by CMS and the State.
- A facility must electronically transmit, at least monthly, encoded, accurate, complete MDS data to the State for all assessments conducted during the previous month, including the following:
a. admission assessment
b. Annual Assessment
c. Significant change in status assessment
f. Quarterly Review
- MDS will be completed by each department by day seven after the Assessment Reference Date (ARD, the last day of the observation period the assessment covers).
- Quarterly MDS is due within 92 days of the last Quarterly or Full MDS.
- Annual MDS process must be completed no later than 366 days from the Full MDS and not more than 92 days from the third Quarterly MDS.
- Significant Change MDS process must be completed 14 days from the time a significant change is identified.
1. Review on 2/28/23 of Resident #84's MDS record showed:
-Significant Change MDS assessment was dated 11/11/22.
-Alert noting that the MDS was In Process.
-Last completed and submitted comprehensive MDS was a Significant Change assessment dated [DATE].
Review on 2/28/23 of the resident's MDS record in CMS' centralized reporting system (ASPEN) showed:
-Significant Change MDS assessment was dated 11/11/22.
-Last completed and submitted MDS was a Significant Change assessment dated [DATE].
-There is one missing Quarterly assessment.
2. Review on 2/28/23 of Resident #68's MDS record showed:
-Quarterly MDS assessment dated [DATE].
-Alert noting that the MDS was In Process.
-Last completed and submitted MDS was an admission assessment dated [DATE].
Review on 2/28/23 of the resident's MDS record in ASPEN showed:
-Quarterly MDS assessment dated [DATE].
-Last completed and submitted MDS was an admission assessment dated [DATE].
-There is one missing Quarterly assessment.
3. Review on 2/28/23 of Resident #227's MDS record showed:
-Quarterly MDS assessment dated [DATE].
-Alert noting that the MDS was In Process.
-Last completed and submitted MDS was a Quarterly assessment dated [DATE].
Review on 2/28/23 of the resident's MDS record in ASPEN showed:
-Quarterly MDS assessment dated [DATE].
-Last completed and submitted MDS was an Quarterly assessment dated [DATE].
-There is one missing Quarterly assessment.
4. Review on 2/28/23 of Resident #87's MDS record showed:
-Quarterly MDS assessment dated [DATE].
-Alert noting that the MDS was In Process.
-Last completed and submitted MDS was a Quarterly assessment dated [DATE].
Review on 2/28/23 of the resident's MDS record in ASPEN showed:
-Quarterly MDS assessment dated [DATE].
-Last completed and submitted MDS was a Quarterly assessment dated [DATE].
-There is one missing Quarterly assessment.
5. Review on 2/28/23 of Resident #28's MDS record showed:
-Quarterly MDS assessment dated [DATE].
-Alert noting that the MDS was In Process.
-Last completed and submitted comprehensive MDS was a Significant Change assessment dated [DATE].
Review on 2/28/23 of the resident's MDS record in ASPEN showed:
-Quarterly MDS assessment dated [DATE].
-Last completed and submitted MDS was a Significant Change assessment dated [DATE].
-There is one missing Quarterly assessment.
6. Review on 2/28/23 of Resident #75's MDS record showed:
-Quarterly MDS assessment dated [DATE].
-Alert noting that the MDS was In Process.
-Last completed and submitted MDS was a Significant Change assessment dated [DATE].
Review on 2/28/23 of the resident's MDS record in ASPEN showed:
-Quarterly MDS assessment dated [DATE].
-Last completed and submitted MDS was a Significant Change assessment dated [DATE].
-There are two missing Quarterly assessments.
7. During an interview on 3/6/23 at 2:00 P.M., the MDS Coordinator said:
-He/she has worked in the MDs Coordinator position since August 2022.
-He/she is responsible for completing and submitting MDS assessments.
-MDS assessments should be completed and submitted in a timely manner, according to the appropriate time line.
-admission MDS should be completed within 14 days of a resident's admission. On Quarterly, Annual and Significant Change MDS assessments, staff have 7 days to conduct the assessment and then 7 days to enter the information into the MDS, which is then submitted.
-He/she is aware that there are MDS assessments that are late and have not been submitted. When asked why this was, he/she said it was becuase they were late.
During an interview on 3/6/23 at 2:57 P.M., the Director of Nursing (DON) said:
-The MDS team is responsible for completing and submitting MDS assessments.
-He/she is aware that there are MDS assessments that are late and not been submitted.
-Several of the MDS team members have been out with health issues. There was also confusion in regards to what the corporate office wanted in regards to who was responsible for completing and submitted MDS assessments.
During an interview on 3/6/23 at 3:54 P.M., the Administrator said:
-The Clinical Reimbursement Nurse is also the MDS Coordinator. He/she is responsible for completing and submitting MDS assessments.
-It is his/her expectation that MDS assessments are completed and submitted on time.
-He/she is aware there are MDS assessments that are late and not been submitted. There is an action plan in place with the corporate office and the corporate team is assisting in getting the MDS assessments up to date.
CONCERN
(E)
Potential for Harm - no one hurt, but risky conditions existed
Comprehensive Care Plan
(Tag F0656)
Could have caused harm · This affected multiple residents
**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** 3. Review of Resident #120's face sheet shows:
- admitted to facility on 12/31/22;
- Diagnoses include morbid (severe) obesity w...
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**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** 3. Review of Resident #120's face sheet shows:
- admitted to facility on 12/31/22;
- Diagnoses include morbid (severe) obesity with alveolar hypoventilation (rare disorder in which a person does not take enough breaths per minute), septic pulmonary embolism (unusual condition characterized by the implantation of infected thrombi into the pulmonary vasculature from a variety of infectious sources, resulting in a parenchymal infection with high morbidity and death) with acute cor pulmonale (a condition that causes the right side of the heart to fail).
Review of resident's admission MDS dated [DATE], showed:
- BIMS score of 12.
- Diagnoses include pneumonia, chronic obstructive pulmonary disease (COPD, a chronic inflammatory lung disease that causes obstructed airflow from the lungs);
- Required extensive assistance with bed mobility, dressing, and personal hygiene; activity did not occur for walking in room/corridor, locomotion on/off unit, total dependence on staff for toilet use and bathing;
- Required a wheelchair for assistance.
- Received oxygen therapy.
Review of resident's undated care plan showed staff did not include any interventions to address the use of oxygen.
4. Review of Resident #382's admission MDS, dated [DATE], showed:
- admitted to facility 2/1/23;
- Cognitively intact;
- Diagnoses include septicemia (disease caused by the spread of bacteria and their toxins in the bloodstream), Diabetes Mellitus (disease in which the body does not control the amount of glucose in the blood and the kidneys make a large amount of urine), aphasia (disorder that affects how you communicate), stroke, hemiplegia (condition caused by a brain injury that results in a varying degree of weakness, stiffness and lack of control in one side of the body), traumatic brain injury (brain dysfunction caused by an outside force, usually a violent blow to the head), malnutrition, respiratory failure (a serious condition making it difficult to breathe on your own);
- Total dependence upon staff for bed mobility, transfer, dressing, eating, toilet use, personal hygiene and bathing;
- Direct care staff did not believe he/she was capable of increased independence in some activities of daily living (ADL).
- Nutrition received via feeding tube.
Review of the resident's baseline care plan summary, dated 2/1/23, showed:
- admitted for encephalopathy (a broad term for any brain disease that alters brain function or structure; causes include infection, tumor, and stroke);
- Unable to speak; non-verbal;
- Dependent on staff for all ADLs; used a peg tube for eating;
- Nothing by mouth; Isosource at 60 ml/hour continuous; flush with 150 cc water every four hours;
- Frequent oral care; suction machine at bedside.
Review of resident's undated care plan showed it did not address his/her nutritional status, ADL function, falls, skin, pain, mood, cognitive loss, medications, therapy services, communication, dehydration or special treatments.
5. During an interview on 3/6/23 1:16 P.M., the Clinical Reimbursement Coordinator said:
- He/she is responsible for developing and updating care plans.
- Clinical managers are also responsible for updating care plans.
- Baseline care plans should be in the chart within the first 48 hours.
- Comprehensive care plans should be completed within 7 days after the MDS is completed.
- Care plans should be updated quarterly, significant change, annually and as needed.
- He/she is aware that there are care plans that are late and have not been updated.
During an interview on 3/6/23 at 3:54 P.M., the Administrator said:
- The MDS Coordinator and nursing floor staff are responsible for creating and updating comprehensive care plans.
- Comprehensive care plans should be in place 21 days from admission. They should be updated quarterly, significant changes, annuals and as needed.
- It is his/her expectation that comprehensive care plan are in place, updated and correct.
2. Review of Resident #89's significant change in condition MDS, dated [DATE], showed:
- He/she understood others and made him/herself understood.
- Score of 10 on the Brief Interview for Mental Status (BIMS, a structured evaluation aimed at evaluating aspects of cognition in elderly patients). This score indicates moderately impaired cognition.
- He/she required extensive assistance from staff with ADLs, including dressing, bathing, and personal hygiene.
- Two Stage 2 pressure ulcers (partial thickness skin loss involving epidermis, dermis, or both. The ulcer is superficial and presents clinically as an abrasion, blister, or shallow crater).
- Diagnoses included stroke (damage to the brain from interruption of its blood supply), pneumonia (infection that inflames air sacs in one or both lungs, which may fill with fluid), and Diabetes Mellitus Type 2 (a chronic condition that affects the way the body processes blood sugar).
Review of the resident's progress notes showed:
-12/27/22 admitted to hospital for shortness of air. Diagnosed at hospital with pneumonia after chest xray done.
-1/3/23 Returned to facility with orders for oxygen as needed and antibiotics.
-1/26/23 Skin assessment completed. No issues noted.
-2/28/23 at 4:05 P.M.: Rash noted to under the resident's left breast on 2/27/23.
Review of the resident's comprehensive care plan, dated 1/23/23, showed:
- No care plan interventions addressing skin break down or rash under breast.
- No care plan interventions addressing respiratory needs, including oxygen as needed.
Based on observation, record review and interviews, the facility failed to assure staff used the residents' comprehensive assessments to develop and implement a comprehensive person-centered plan of care consistent with the resident rights that includes measurable objectives and timeframes to meet the resident's medical, nursing, and mental and psychosocial needs for four of 19 sampled residents (Resident #55, #89, #120 and #382). The facility census was 95.
Review of the facility provided Comprehensive Care Plan Workload document, dated 9/1/22, showed:
- The Minimum Data Set (MDS: a mandated assessment tool completed by the facility) Coordinator will use the Baseline Care Plan to build a Comprehensive Care Plan.
Review of the Comprehensive Assessments and Care Planning policy, dated 2017, showed:
- Purpose: To provide a comprehensive person-centered interdisciplinary care assessment of the resident's condition, in order to develop consistent quality care that will attain or maintain the highest practicable physicial, mental and psychological functioning possible, a facility must make a comprehensive assessment of a resident's needs.
- A facility should use the results of the assessment to develop, review, and revise the resident's person-centered comprehensive plan of care.
- All person-centered care plan interventions will be implemented by qualified personnel. Interventions may be communicated through the electronic health record, resident profile, assignment sheets, and/or verbal communication.
1. Review of Resident #55's quarterly Minimum Data Set (MDS), a federally mandated assessment instrument completed by staff, dated 11/3/22, showed:
- Staff did not complete the Brief Interview of Mental Status (BIMS) or indicate if the resident had any long- or short-term memory issues;
- Extensive assistance to total dependence on staff for Activities of Daily Living (ADLs: activities related to personal care that include: bathing/ showering, dressing, getting in/ out of bed or a chair, walking, using the toilet, and eating.)
- Functional limitation in range of motion (ROM: the normal range of movement of a joint) of the upper extremity including shoulder, elbow, wrist or hand.
- Diagnoses of Alzheimer's dementia (a progressive disease that destroys memory and other important mental functions.), adult failure to thrive (a syndrome of weight loss, decreased appetite, poor nutrition, and inactivity, often accompanied by dehydration, depressive symptoms, and impaired immune function), and transischemic attack (a temporary blockage of blood to the brain with symptoms like a stroke, that may have lasting effects of weakness, decreased mobility and cognitive issues).
Review of the physician order sheet dated February 2022 showed an order dated 9/24/21, to place a rolled washcloth in the resident's left hand to help with contractures.
Review of the resident's comprehensive care plan, dated 8/3/21, showed:
- Alterations in self care: need for assistance with ADLs;
- Hospice care.
- Impaired visual function.
- Nutritional risk.
- Risk for falls.
- Behavioral symptoms: refusal of care
- Staff did not include any interventions for the resident's contractures and the need for him/her to have a rolled washcloth in his/her left hand.
Observation during the annual survey showed:
- 3/1/23 at 3:55 P.M the resident had no washcloth in his/her left hand;
- 3/2/23 at 9:02 A.M. the resident had no washcloth in his/her left hand;
- 3/2/23 at 11:31 A.M. the resident sat up at the nurses' station, with no washcloth in his/her left hand. The resident was able to open his/her first finger and thumb. He/she was unable to straighten fingers #3-5. The resident was asked to open hand, he/she shook his/her head no. The resident was then asked if his/her hand hurt and resident shook his/her head no. Then the resident was asked if it hurt to open his/her hand, and the resident nodded his/her head yes.
During an interview on 3/2/23 at 11:17A.M., Certified Nurse Aide (CNA) A who also worked as the restorative nursing aide (RA), said:
- The resident is not currently on his/her RA caseload.
- He/she worked the floor sometimes and helped the resident eat, and move his/her arms.
- He/she did not know about a hand roll for this resident.
- He/she would use the care plan to know what care to provide each resident.
During an interview on 3/2/23 at 11:37 A.M., Licensed Practical Nurse (LPN) D said
- He/she believed hospice staff may apply the washcloth to the resident's hand two to three times per week.
- He/she and staff did not apply the hand roll.
- He/she did not know the resident had an order for staff to place a rolled washcloth to the reisdent's hand.
During an interview on 3/2/23 at 3:39 P.M., CNA D said:
- The care plan was how he/she knew what care to provide residents.
During an interview on 3/6/23 at 2:57 P.M., the Director of Nursing (DON) said:
- The resident should have a washcloth in his/her hand.
- The resident removed the washcloth at times.
- The MDS Coordinator completed the care plans.
- Charge Nurses on the floor can add information to the care plan as needed.
CONCERN
(E)
Potential for Harm - no one hurt, but risky conditions existed
Deficiency F0657
(Tag F0657)
Could have caused harm · This affected multiple residents
Based on observations, interviews and record reviews, the facility failed to review and revise the comprehensive care plan to address residents who have had a significant change in health care status ...
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Based on observations, interviews and record reviews, the facility failed to review and revise the comprehensive care plan to address residents who have had a significant change in health care status and dependent upon staff to carry out their activities of daily living for one sampled resident (Resident #95) out of 19 sampled residents. The facility census was 95.
Review of the facility's undated policy for care plans showed:
- Its purpose is to provide a comprehensive person-centered interdisciplinary care assessment of the resident's condition, in order to develop consistent care that will attain or maintain the highest practicable physical, mental and psychological functioning possible, a facility must make a comprehensive assessment of a resident's needs using the resident assessment instrument (a tool to help care providers develop individualized care plans based on assessments of residents' strengths, limitations, and preferences) (RAI) specified by the State.
- The assessment must accurately reflect the resident's status.
- A facility must conduct a comprehensive assessment of a resident within fourteen days after the facility determines, or should have determined, there has been a significant change in the resident's physical or mental condition.
- A facility should use the results of the assessment to develop, review and revise the resident's person-centered comprehensive care plan.
1. Review of resident #95's admission Minimum Data Set (MDS), a federally mandated assessment instrument completed by staff, dated 7/6/22 showed:
- admitted to facility on 6/29/22.
- Brief Interview of Mental Status (an assessment used to measure cognitive impairment) BIMS of 7
- Set up help only with bathing; independent with walking; limited assistance with bed mobility; and supervision with transfers, dressing, toilet use and personal hygiene.
- Diagnosis included hypertension and bipolar disorder (a mental health condition that causes extreme fluctuation in thinking, mood and behavior).
Review of resident's significant change MDS, completed by staff, dated 12/16/22 showed:
- He/she was readmitted back to facility on 12/10/22.
- He/she was unable to complete cognitive assessment.
- Diagnosis included hypertension, septicemia (blood poisoning by bacteria), wound infection and respiratory failure.
- Extensive assist with bed mobility, dressing, eating, personal hygiene; two plus person assist with transfers; activity did not occur for walking in room, corridor or on/off unit or toilet use; total dependence upon staff for bathing.
- Wheelchair for assistance.
- Receiving oxygen therapy and hospice care.
Review of resident's care plan, last reviewed and revised on 1/24/23, showed:
- Problem Start Date: 7/13/22;
- Category: Activities of Daily Living (ADL) Functional/Rehabilitation Potential - He/she has some self-care deficits with ADL (bathing, grooming, oral cares, ambulation, transferring, mobility, vision, bowel and bladder related to cognitive and health status). Edited 1/24/23
- Goals:
- Long Term Goal Target Date 3/22/23: He/she will maintain his/her current abilities through review period - edited 12/22/22.
Approach
- Start Date 7/13/22: He/she requires staff oversight to ensure his/her needs are met. He/she can dress themselves, toilet themselves, feed themselves, provide personal hygiene, transfer and ambulate independently. He/she requires staff assist of 1 to assist with bathing - edited 8/23/22.
- Start Date 7/13/22: Offer to assist him/her with cares as indicated to promote his/her safety and that his/her needs are met. Report to charge nurse and/or physician if changes noted in his/her usual behavior and self-care abilities - edited 8/23/22.
- Start Date 7/13/22: He/she is usually continent and takes his/herself to the bathroom, but will not always remember to verbally ask for assistance if needed. Make checks on me throughout shift. He/she wears pull ups for protection.
Review of resident's shower sheets showed:
- 2/6/23: bed bath given. Nothing documented resident was shaved.
- 2/16/23: bed bath given, nails clipped and hair washed. Nothing documented resident was shaved.
- 2/23/23: Shower not given. Note documented resident's daughter said hospice would do Friday.
- 2/27/23: Bed bath, hair washed. Nothing documented resident was shaved.
- 3/2/23: Complete bed bath given, hair washed, face shaved.
Review of resident's progress notes showed:
- Documentation bed baths were given on 2/16/23 and 2/20/23.
- No documentation on resident being shaved.
During observation on 2/28/23 at 9:51 A.M., showed:
- He/she laying in bed and observed with chin hairs.
- Signage above bed states resident has sensitive skin and not to dry shave.
During an interview on 2/28/23 at 2:37 P.M., the resident's representative said:
- Resident was able to walk and talk when admitted to facility but developed sore on his/her foot.
- Resident then developed pressure sore on his/her bottom and has since had a decline in health and is now on hospice care.
During an interview on 3/6/23 at 1:16 P.M. RN Clinical Reimbursement Coordinator said:
- She is responsible for developing and updating care plans.
- Clinical managers are also responsible for updating care plans.
- Comprehensive care plans should be completed within seven days after the MDS is completed.
- Care plans should be updated quarterly, during significant changes, annually and as needed.
- She is aware there are care plans that are late and have not been updated.
During an interview on 3/6/23 at 2:57 P.M., the Director of Nursing (DON) said:
- MDS team is responsible for care plans.
- MDS/care plan staff are under the administrator. Several staff have been out with health issues and there was some confusion in regards to what the corporate office wanted.
- MDS staff are responsible for comprehensive care plan.
- Floor nurses are responsible to keep update/add to care plan.
- Care plan should be updated after unusual event, change of crucial medication (diuretic), infection, etc., quarterly, significant changes, admittance and annually.
- Printed care plan is in blue book that floor staff write updates in those, then MDS picks them up and updates in computer.
During an interview on 3/6/23 at 3:54 P.M., the Administrator said:
- The Clinical Research Nurse and nursing staff are responsible for creating an updating care plans.
- Comprehensive care plans should be in place in twenty-one days from admission. They should be updated quarterly, during significant changes and as needed.
- Expectations are for care plans to be in place and correct.
CONCERN
(E)
Potential for Harm - no one hurt, but risky conditions existed
Deficiency F0658
(Tag F0658)
Could have caused harm · This affected multiple residents
**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, interview and record review, record review, the facility staff failed to ensure they provided care and tre...
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**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, interview and record review, record review, the facility staff failed to ensure they provided care and treatment in accordance with professional standards of practice for two of 19 sampled residents (Resident #41 and #78) when staff failed to label and date a dermal patch for Resident #41 and failed to clarify a physician's order for scheduled nasal spray for Resident #78. The facility census was 95.
Review of the facility's undated Physician Service Policy, showed:
- All physician's orders will be followed as prescribed;
- If physician's orders are not followed the reason shall be recorded in the resident's medical record.
Review of the facility's Transdermal Drug Delivery System (patch) Policy, revised, August, 2014 showed:
- Remove the old patch;
- Label patch with date and nurses initials;
- Apply new patch firmly to skin.
1. Review of Resident #41's quarterly Minimum Data Set (MDS) a federally mandated assessment instrument completed by facility staff, dated 10/14/22, showed:
- Cognitively intact;
- Assist of two staff members with bed mobility and transfers;
- On pain control regiment;
- Diagnoses included: anemia, arthritis, highblood pressure.
Review of the resident's undated care plan showed the resident experienced pain.
Review of the resident's Physician Order Sheet (POS), dated 2/2/23 through 3/2/23, showed:
- Start date: 2/27/23 - Lidocaine (a patch applied to the skin used to treat pain) adhesive patch, medicated, 4%, apply one patch daily to mid back, put on in the A.M. for 12 hours, then remove at night.
Review of the resident's Medication Administration Record (MAR) dated 2/2/23 through 3/2/23, showed:
- Start date: 2/27/23 - Lidocaine (a patch applied to the skin used to treat pain) adhesive patch, medicated, 4%, apply one patch daily to mid back, put on in the A.M. for 12 hours, then remove at night.
- Initials of the staff that applied the patch on 2/28/23, at 10:00 A.M.;
- Initials of the staff that removed the patch on 2/28/23, at 10:00 P.M.
Observation and interview on 2/28/23 at 10:38 A.M., showed and the resident said:
- The resident had a patch on the middle of his/her back with no date or initials;
- The resident said the nursing staff applies the patch in the morning for his/her back pain and the nursing staff are supposed to take the patch off 12 hours later before he/she goes to bed:
- The resident said the patch was not taken off last night.
Observation and interview on 3/1/23 at 9:18 A.M., showed and the resident said:
- The resident in bed with a patch on his/her middle back;
- The patch did not have a date or initials on it;
- The resident said the staff did not take the patch off last night.
Observation on 3/1/23 at 9:42 A.M., showed:
- Registered Nurse (RN) B removed a lidocaine patch, 4%, out of the medication cart and cut the top off the package;
- The nurse removed the old patch from the resident's back that had no date or initials on it;
- The nurse applied a new patch to the resident's back;
- The nurse did not write his/her initials, or the time on the new patch.
During an interview on 3/2/23 at 03:22 P.M., RN B said:
- Staff should apply the resident's patch in morning, take it off at night and should add the date, time and the initials of the staff who applied the patch;
- He/she said she forgot to date, time and initial the resident's patch on 3/1/23.
3. Review of Resident #78's admission MDS dated [DATE] showed:
- Moderate cognitive impairment;
- Assist of one staff member for bed mobility;
- Assist of two staff members with transfers;
- Oxygen therapy;
- Diagnoses included: respiratory failure, pneumonia, and hyperlipodemia (high cholesterol).
Review of the undated resident's care plan showed staff did not address the resident's use of nasal spray, inhalers and oxygen.
Review of Resident #78's POS, dated 2/2/23 through 3/2/23, showed:
- Start date: 12/21/22 - saline nasal spray (used to treat dry nasal passages) 0.65%, use for dry nose due to oxygen use, give two sprays four times a day;
- The order for the saline nasal spray did not specify how many sprays to each nostril.
Observation on 3/1/23 at 10:33 A.M., showed:
- RN B administered one spray of the saline nose spray in the resident's right nostril and did not hold the left nostril closed;
- RN B attempted to administer a spray in the left nostril but the medication came out as two drops instead of a spray and ran down the resident's face;
- No other attempt were made to administer the nose spray.
During an interview on 3/2/23 at 03:22 P.M., RN B said:
- The physician should have been notified when the order for the residents nasal spray did not specify how many sprays to given in each nostril.
During an interview on 3/6/23 at 2:57 P.M., the Director of Nursing (DON) said:
-When a dermal patch is applied it must be labeled with the date, time and the initials of the staff member who applied it;
-The old patch should be removed by the nurse as ordered by the physician;
-Nasal sprays should be given per the facility policy;
-If a physician's order is vague the physician should be called to clarify the order.
CONCERN
(E)
Potential for Harm - no one hurt, but risky conditions existed
ADL Care
(Tag F0677)
Could have caused harm · This affected multiple residents
**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, interview, and record review, the facility failed to provide the necessary care and services to maintain g...
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**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, interview, and record review, the facility failed to provide the necessary care and services to maintain good personal hygiene for two of 19 sampled residents (Resident #39 and #95) who required assistance to perform activities of daily living. The facility census was 95.
Review of the undated facility policy for activities of daily living showed:
- The purpose is to provide residents with care, treatment and services appropriate to maintain or improve their ability to carry out activities of daily living (ADLs).
- Residents unable to carry out ADLs independently will receive the services necessary to maintain grooming and personal hygiene.
- Care and services will be provided for residents who are unable to carry out ADLs independently with the consent of the resident and in accordance with the plan of care, including appropriate support and assistant with hygiene (bathing and grooming).
- If resident refuses care, associates will approach at a different time, or having another associate speak with the resident as needed.
- The resident's response to interventions will be documented, monitored, evaluated and revised as appropriate.
1. Review of Resident #39's face sheet showed:
- readmitted [DATE].
- Diagnoses include post traumatic seizures, need for assistance with personal care, other reduced mobility, epilepsy (brain disorder that causes reoccuring, unprovoked seizures), muscle wasting and atrophy (thinning or loss of muscle tissue), difficulty in walking and encephalopathy (damage or disease that affects the brain).
Review of resident's annual Minimum Data Set (MDS), a federally mandated assessment instrument completed by staff, dated 2/10/23, showed:
- Brief Interview of Mental Status (BIMS) score of 10, which indicated moderate cognitive impairment;
- No rejection of activities of daily living (ADL) care;
- Limited assist for bed mobility, transfers, dressing, toilet use, and hygiene with one person physical limited assist and physical help in part of bathing activity.
- Always incontinent for urinary output;
- Diagnosis of osteoporosis (a medical condition in which the bones become brittle and fragile from loss of tissue).
Review of resident shower sheets showed:
- 2/4/23: resident refused;
- 2/8/23: shower given - no documentation as to whether resident shaved.
Review of progress notes showed:
- 2/11/23 Resident received shower today no new skin issues noted.
Reivew of resident's shower sheets showed:
- 2/11/23: shower given - no documentation as to whether resident shaved;
- 2/15/23: shower given - no documentation as to whether resident shaved;
- 2/25/23: shower given - no documentation as to whether resident shaved.
Observation and interview on 2/27/23 at 3:38 P.M., showed and the resident said:
- He/she was observed with quarter inch chin hairs.
- He/she did not know he/she had them and would like them removed.
Review of progress notes showed:
- 3/1/23 Resident received shower today from floor CNA, no new skin issues noted.
Observation on 3/1/23 at 3:20 P.M., showed the resident observed with chin hairs.
Review of resident shower sheets showed:
- 3/1/23: shower given - no documentation on shower sheet to show resident shaved
2. Review of Resident #95's significant change in condition MDS, dated [DATE], showed:
- readmitted back to facility on 12/10/22;
- Unable to complete cognitive assessment; staff did not indicate if the resident had short- or long-term memory loss;
- Diagnoses included hypertension, septicemia (blood poisoning by bacteria), wound infection and respiratory failure.
- Extensive assist with bed mobility, dressing, eating, personal hygiene; two plus person assist with transfers; activity did not occur for walking in room, corridor or on/off unit or toilet use; total dependence upon staff for bathing.
- Wheelchair for assistance.
- Received oxygen therapy and hospice care.
Review of resident's care plan, last reviewed and revised on 1/24/23 showed, it was not updated to reflect the significant change in activities of daily living.
Review of resident's shower sheets showed:
- 2/6/23: bed bath given. staff did not document to indicate they shaved the resident;
- 2/16/23: bed bath given, staff documented they clipped the resident's nails and washed his/her hair but did not document they saved him/her.
- 2/23/23: Shower not given. staff noted the resident's daughter told them hospice would provide a shower on Friday;
- 2/27/23: Bed bath, hair washed. Staff did not document they shaved the resident.
Observation on 2/28/23 at 9:51 A.M., showed:
- He/she laying in bed; the resident had hair on his/her chin long enough to be observed when standing about 3 feet away;
- A sign hung above the resident's bed which directed staff to not dry shave the resident as he/she had sensitive skin;
During an interview on 2/28/23 at 2:37 P.M., the resident's representative said:
- Resident was able to walk and talk when he/she admitted to facility but developed a pressure ulcer on his/her foot.
- The resident then developed a pressure ulcer on his/her bottom and has since had a decline in health and is now on hospice care.
- He/she had to put up signs in the residents room to direct staff not to dry shave the resident due to his/her sensitive skin.
. During an interview on 3/2/23 at 9:25 A.M., Certified Nursing Aide (CNA) D said:
- The facility had one shower aide who covered both the first and second floor.
- Staff are expected to provide reidents with two showers per week; if they are on hospice, they get up to four showers a week.
- He/she does not always depend on shower aides to give baths as he/she cannot guarantee showers will get done.
- He/she has not been told by a resident recently they did not get a bath.
- They fill out shower sheets and can write on shower sheets if residents were shaved, etc., but then he/she will pass that information on to the nurse as CNAs are unable to chart in their electronic medical record (EMR). If nursing does not get time to chart it, there can be communication errors on what was done.
- After the shower sheets are filled out, they sign and give them to the nurse for them to review and sign. They then go to the Director of Nursing (DON).
- For females, it is a dignity thing. If he/she noticed chin hair on female residents, he/she will shave them.
- He/she recently had to shave Resident #90 and Resident #95.
During an interview on 3/2/23 at 11:15 A.M., Licensed Practical Nurse (LPN) B said:
- Everyone is responsible for resident showers including CNAs, nurses and shower aides.
- They only have one shower aid for the first and second floor.
- If shower aides are unavailable, CNAs do them.
- Staff fill out a shower sheets after every bath/shower.
- Once completed, they give to the nurse, they sign it and make a note in progress notes and then put in folder for the Clinical Resource Manager and then the Director of Nursing will upload them into the resident's medical record.
- They have a shower schedule and residents get showers two times a week.
- If a resident is on hospice, they will get two additional showers a week.
During an interview on 3/2/23 at 12:17 P.M., LPN C said:
- CNAs give residents baths two times a week.
- Staff fill out shower sheets and if female residents needed shaved, they will document it on shower sheets.
- Female residents should be asked if they want shaved.
- When shower sheets are done, CNAs will put them on the desk for them to be reviewed by nursing. Depending on how the day is going, he/she will document it in the resident's progress notes.
- Shower sheets are then put in a folder for the resource manager after they are signed.
- He/she would not know if a female resident had chin hairs unless they were able to see them.
During an interview on 3/2/23 at 12:38 P.M., CNA E said:
- Shower aides normally give showers but they do not have one on the lower level.
- Any nurse or CNA can give a resident a shower.
- Shower sheets are filled out and then those are given to the nurse to review and sign. They are then given to the resource nurse.
- They document any redness, bruising, rashes, scratches, document grooming, nail care and document if females were shaved.
- Residents receive showers twice a week.
- Every now again will have a few female residents who refuse showers and they will document on the shower sheets they refused.
- If residents get sponge bathes, he/she tries to shave the female residents if she can see chin hair.
CONCERN
(E)
Potential for Harm - no one hurt, but risky conditions existed
Tube Feeding
(Tag F0693)
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 date and time enteral feeding bag (bags that are used ...
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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 date and time enteral feeding bag (bags that are used with feeding pumps) to ensure residents receiving nutrition via feeding tube (a medical device used to provide nutrition to people who cannot obtain nutrition by mouth, are unable to swallow safely, or need nutritional supplementation) are not receiving spoiled formula, for one resident (Resident #382) out of nineteen sampled residents. The facility census was 95.
Review of the undated facility policy for Monitoring Residents Receiving Enteral Feedings (a form of nutrition that is delivered into the digestive system as a liquid) showed:
- The nutritional status of resident's who receive enteral nutrition/feedings will be evaluated and monitored on an ongoing basis by the Dietitian/designee to assure their nutritional needs are being met.
- Procedure: A resident who obtains nutrition per an enteral feeding will receive appropriate treatment and services to prevent complications and to restore if possible, oral intake; the nursing department is responsible for the administration of enteral feedings and all feeding equipment.
- The policy did not address dating/timing the feeding bag.
1. Review of Resident #382's admission Minimum Data Set (MDS), a federally mandated assessment instrument completed by staff, dated 2/4/23, showed:
- admitted to facility 2/1/23;
- Cognitively intact;
- Diagnoses include septicemia (disease caused by the spread of bacteria and their toxins in the bloodstream), Diabetes Mellitus (disease in which the body does not control the amount of glucose in the blood and the kidneys make a large amount of urine), aphasia (disorder that affects how you communicate), stroke, hemiplegia (condition caused by a brain injury that results in a varying degree of weakness, stiffness and lack of control in one side of the body), traumatic brain injury (brain dysfunction caused by an outside force, usually a violent blow to the head), malnutrition, respiratory failure (a serious condition making it difficult to breathe on your own);
- Total dependence upon staff for bed mobility, transfer, dressing, eating, toilet use, personal hygiene and bathing;
- Direct care staff did not believe he/she was capable of increased independence in some activities of daily living (ADL).
- Nutrition received via feeding tube.
Review of the resident's baseline care plan summary, dated 2/1/23, showed:
- admitted for encephalopathy (a broad term for any brain disease that alters brain function or structure; causes include infection, tumor, and stroke);
- Unable to speak; non-verbal;
- Dependent on staff for all ADLs; used a peg tube for eating;
- Nothing by mouth; Isosource at 60 ml/hour continuous; flush with 150 cc water every four hours;
- Frequent oral care; suction machine at bedside.
Review of resident's current physician orders sheet (POS) showed:
- Order dated 2/23/23: Isosource (a formula intended for the dietary management of malnourished or at risk of malnutrition patients) 1.5, 60 milliliters (ml) per hour continuous via peg tube (a tube inserted through the wall of the abdomen directly into the stomach) every shift.
- Order dated 2/27/23: 150 cubic centimeter (cc) water flushes to peg tube every four hours (12:00 A.M., 4:00 A.M., 8:00 A.M., 12:00 P.M., 4:00 P.M. and 8:00 P.M.)
Review of residents nutrition assessment dated [DATE] showed:
- admitted related to metabolic encephalopathy due to sepsis, UTI, respiratory failure with history of brain aneurysm, DM.
- Diet nothing by mouth (NPO) with g-tube feeding - Isosource 1.5 at 60 mls continous ith 150 ml's water flush every 4 hours to provide: 2160kcals, 98 grams protein and 2000 ml's fluid to meet estimated needs.
- Eating ability: total assistance.
Review of resident's undated care plan showed staff did not address anything related to his/her nutrition or he/she receiving enteral feeding via feeding tube.
Review of resident's progress notes showed:
- 2/15/23 at 1:37 P.M.: NPO receiving tube feeding at 60 cc/hr with 100 cc water every 4 hour per tube.
- 2/14/23 at 6:28 P.M.: NPO receiving tube feeding at 60 cc/hr with 100 cc water every 4 hour per tube.
- 2/13/23 at 5:16 P.M.: NPO receiving tube feeding at 60 cc/hr with 100 cc water every 4 hour per tube.
- 2/13/23 at 12:34 P.M.: NPO receiving tube feeding at 60 cc/hr with 100 cc water every 4 hour per tube.
- 2/12/23 at 3:45 P.M.: NPO receiving tube feeding at 60 cc/hr with 100 cc water every 4 hour per tube.
- 2/11/23 at 10:31 A.M.: NPO receiving tube feeding at 60 cc/hr with 100 cc water every 4 hour per tube.
- 2/10/23 at 1:52 P.M.: NPO receiving tube feeding at 60 cc/hr with 100 cc water every 4 hour per tube.
- 2/9/23 at 7:39 P.M.: NPO receiving tube feeding at 60 cc/hr with 100 cc water every 4 hour per tube.
- 2/8/23 at 11:08 A.M.: NPO receiving tube feeding at 60 cc/hr with 100 cc water every 4 hour per tube.
- 2/7/23 at 8:58 P.M.: NPO receiving tube feeding at 60 cc/hr with 100 cc water every 4 hour per tube.
Observation during the survey showed:
- On 2/28/23 at 2:14 P.M., the resident had a feeding tube. He/she receiving 60 milliliters per hour via enteral feeding. A bag of Isosource hung from the pump without any date or time to indicate when staff hung the bag.
- On 3/1/23 at 3:25 P.M., a bag of Isosource hung from the pump without any date or time to indicate when staff hung the bag; the pump ran at 60 ml/hour and had 450 ml remaining;
- On 3/2/23 at 12:14 P.M., a bag of Isosource hung from the pump without any date or time to indicate when staff hung the bag.
Review of the Isosource manufactuerer's usage showed, once opened, consume within twenty-four hours.
During an interview on 3/2/23 at 11:15 A.M., Licensed Practical Nurse (LPN) B said:
- Nursing staff administered feedings for residents who had peg tubes.
- Staff should add a date and time to feeding begs when they hang them on the pumps for residents who had peg tubes.
- He/she did not know how long a bag of Isosource was good for.
During an interview on 3/2/23 at 11:45 A.M., Licensed Practical Nurse (LPN) B said:
- He/she got clarification and the Isosource bag is only good for twenty-four hours.
During an interview on 3/2/23 at 12:17 P.M., LPN C said:
- Nursing staff hang the enternal feedings.
- Staff should add the date and time they hang the bags
- He/she believed it is policy.
During an interview on 3/2/23 at 1:15 P.M., Registered Nurse (RN) A said:
- LPN/RN provided any needed care for residents with a peg tube;
- He/she will verify physicians order and check when in the room that it is working properly.
- Staff should add the date and time to the bags when they hang them as they are only good for 24 hours.
During an interview on 3/6/23 at 2:57 P.M., the Director of Nursing (DON) said:
- The charge nurse is responsible or evaluation, changings and monitoring residents who require tube feedings.
- Staff should be dating and timing the enternal feeding bags.
- Adverse effect could be the resident getting spoiled formula if it is not dated.
CONCERN
(E)
Potential for Harm - no one hurt, but risky conditions existed
Respiratory Care
(Tag F0695)
Could have caused harm · This affected multiple residents
**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observations, interviews and record review, the facility failed to ensure staff provided proper respiratory care for fo...
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**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observations, interviews and record review, the facility failed to ensure staff provided proper respiratory care for four of 19 sampled residents (Residents #1, #78, #95 and #120) when staff failed to properly clean oxygen concentrator filters and when staff failed to follow orders for oxygen therapy. The facility census was 95.
Review of the facility's undated physician service policy showed:
- All physicians' orders will be followed as prescribed;
- If physicians' orders are not followed the reason shall be recorded in the resident's medical record.
Review of the facility's oxygen therapy policy, dated 6/12/04, showed:
- Oxygen therapy is initiated per a physician's order;
- A specific order for liter flow must be ordered by the physician;
- Adjust the liter flow according to physician's order;
- Document the oxygen setting in the medical record.
Review of the facility's cleaning of oxygen equipment policy, dated June 2017, showed:
- It is the policy of the facility to adhere to standards of practice that ensure safe environment for the residents who receive oxygen;
- Clean filters with warm water and let dry before place them back in the machine;
- Check with the service technician as to the frequency in which the filters need to be cleaned.
1. Review of Resident #95's significant change Minimum Data Set (MDS), a federally mandated assessment instrument completed by staff, dated 12/16/22 showed:
- Staff indicate the resident could not answer questions for a Brief Interview for Mental Status (BIMS) but did not indicate if the resident suffered from short or long-term memory loss.
- Diagnoses included hypertension (high blood pressure) and respiratory failure (a condition in which your blood does not have enough oxygen or has to much carbon dioxide);
- Extensive assist with bed mobility, dressing, eating, personal hygiene; required two plus person staff assistance with transfers; activity did not occur for walking in room, corridor or on/off unit or toilet use; total dependence upon staff for bathing;
- Wheelchair for assistance.
- Receiving oxygen therapy and hospice care.
Review of the resident's care plan, last reviewed and revised on 1/24/23, showed:
- Problem Start Date 7/13/2022 - Special treatment: He/she has the following special treatments/procedures: As needed (PRN) oxygen therapy as ordered for shortness of air or saturations (sats, a test that measures the amount of oxygen being carried by red blood cells) below 90%; refer to physician orders sheet (POS).
- Goal: His/her shortness of air to be managed with treatments/procedures as ordered as evidenced by signs/symptoms or verbal statement related to relief of shortness of air (SOA)and/or oxygen (O2) sats below 90%.
- Approaches: Assess/check O2 sats every shift and administer O2 via nasal cannula at 2 liters per minute (LPM) PRN for shortness of air or O2 sats below 90%.
Review of the resident's POS showed:
- Order dated 6/29/22: O2 2LPM per nasal cannula PRN SOA or sats below 90%. Check O2 sats every shift PRN;
- Order dated 6/29/22: Oxygen concentrator remove and wash filter weekly, once a day on Monday 11:00 P.M. - 7:00 P.M.;
- Order dated 12/10/22: Admit to intermediate care facility (long term care facility that provides nursing and supportive care to residents on a non-continous skilled nursing basis under physicians direction); level of care with hospice.
- Order dated 12/10/22: admission blood pressure, pulse, respirations, temperature and O2 sats once a day on Sunday 12:30 P.M.
Review of the resident's medication administration record (MAR, a written or electronic record of medication ordered and administered to a resident) for February 2023 showed:
- No documented entries for O2 2 liters/min per nasal cannula PRN SOA or sats below 90%. Check O2 sats every shift.
- 2/6/23, 2/13/23, 2/20/23 and 2/27/23 staff signed to indicate they removed and washed the oxygen concentrators filters.
Review of resident's vital signs report for February 2023 showed:
- 2/1/23 at 10:51 P.M. O2 sat at 97% with liter flow at 2.5 LPM;
- 2/2/23 at 9:40 P.M. O2 sat at 98% with liter flow at 2.5 LPM;
- 2/7/23 at 1:16 A.M. O2 sat at 96% with liter flow at 2.5 LPM;
- 2/08/23 at 1:02 A.M. O2 sat at 98% with liter flow at 3 LPM;
- 2/11/23 at 1:32 P.M. O2 sat at 94% with liter flow at 3 LPM;
- 2/13/23 at 9:13 A.M. O2 sat at 94% with liter flow at 3 LPM;
- 2/15/23 at 10:36 A.M. O2 sat at 91% with liter flow at 3 LPM;
- 2/18/23 at 1:25 A.M. O2 sat at 94% with liter flow at 3 LPM;
- 2/19/23 at 11:35 A.M. O2 sat at 99% with liter flow 3 LPM;
- 2/20/23 at 10:11 P.M. O2 sat at 98% with liter flow at 3 LPM;
- 2/22/23 at 5:06 A.M. O2 sat at 98% with liter flow at 3 LPM;
- 2/22/23 at 2:00 P.M. O2 sat at 97% with liter flow at 4 LPM;
- 2/23/23 at 11:37 A.M. O2 sat at 97% with liter flow at 3 LPM;
- 2/24/23 at 12:19 P.M. O2 sat at 93% with liter flow at 3 LPM;
- 2/28/23 at 12:52 P.M. O2 sat at 94% with liter flow at 3 LPM.
Review of resident's progress notes shows no entries related to changes in oxygen level.
- 2/24/23 at 11:00 A.M. O2 on at 2L;
- 2/24/23 at 1:00 P.M. O2 on at 2L;
- 2/24/23 at 3:00 P.M. O2 on at 2L;
- 2/24/23 at 5:18 P.M. O2 on at 2L;
- 2/24/23 at 6:56 P.M. O2 on at 2L;
- 2/26/23 at 8:00 A.M. O2 on at 2L;
- 2/26/23 at 9:00 A.M. O2 on at 2L;
- 2/26/23 at 11:00 A.M. O2 on at 2L;
- 2/26/23 at 1:00 P.M. O2 on at 2L;
- 2/26/23 at 3:00 P.M. O2 on at 2L;
- 2/26/23 at 5:00 P.M. O2 on at 2L;
- 2/26/23 at 6:42 P.M. O2 on at 2L;
- 3/1/23 at 8:00 A.M. Resident had oxygen via nasal canula on 2L;
- 3/1/23 at 10:00 A.M. Resident had oxygen via nasal canula on 2L;
- 3/1/23 at 12:00 P.M. Resident has O2 on at 2L via nasal cannula;
- 3/1/23 at 2:09 P.M. O2 on at 2L;
- 3/1/23 at 4:00 P.M. O2 on 2L;
- 3/1/23 at 6:00 P.M. O2 on 2L.
Observation during the survey showed:
- 2/28/23 at 9:40 A.M., he/she had on oxygen, with the oxygen concentrator set to 4.5 liters.
- 3/1/23 at 3:18 P.M., his/her oxygen concentrator set at 3.5 liters.
- 3/2/23 at 9:04 A.M. the oxygen concentratorset at 3.5 liters. The filter on the concentrator was caked with dirt and debris.
- The concentrator had a green tag with a date of 11/29/22 of when it was last cleaned.
2. Review of Resident #120's face sheet showed:
- admitted to facility on 12/31/2022
- Diagnoses include morbid (severe) obesity with alveolar hypoventilation (rare disorder in which a person does not take enough breaths per minute), septic pulmonary embolism (unusual condition characterized by the implantation of infected thrombi into the pulmonary vasculature from a variety of infectious sources, resulting in a parenchymal infection with high morbidity and death) with acute cor pulmonale (a condition that causes the right side of the heart to fail).
Review of resident's admission MDS, dated [DATE] showed:
- Brief interview for mental status (BIMS) score of 12;
- Diagnoses include pneumonia, chronic obstructive pulmonary disease (COPD a chronic inflammatory lung disease that causes obstructed airflow from the lungs).
- Resident required extensive assistance with bed mobility, dressing, and personal hygiene; activity did not occur for walking in room/corridor, locomotion on/off unit; total dependence on staff for toilet use and bathing;
- Resident required a wheelchair for assistance;
- Received oxygen therapy.
Review of the resident's baseline care plan, dated 12/31/22, showed he/she needed oxygen at 4 L continuous.
Review of the resident's care plan last updated on 1/2/23, showed staff did not included any interventions for the use of continous oxygen therapy.
Review of the resident's current February 2023 POS showed:
- Order dated 12/31/22: O2 at 2L/min per nasal canula - check O2 stats and ensure O2 is on at all times;
- Order dated 12/31/22: Oxygen concentrator: Remove and wash filter weekly. Once a day on Monday 11:00 P.M. to 7:00 A.M.
- Order dated 1/13/23: Hospice to evaluate and treat.
Review of the resident's treatment administration record ( TAR, a record detailing what treatment was administered to a resident by a facility) for the month of February 2023 showed:
- 2/1/23 O2 sat at 95% with liter flow at 3 LPM.
- 2/4/23 O2 sat at 96% with liter flow at 3 LPM.
- 2/5/23 O2 sat on 1st shift 94% with liter flow at 3 and 2nd shift 98% with liter flow at 3 LPM.
- 2/6/23 O2 sat at 97% with liter flow at 3 LPM.
- 2/7/23 O2 sat at 96% with liter flow at 3 LPM.
- 2/9/23 O2 sat at 97% with liter flow at 3 LPM.
- 2/15/23 O2 sat at 95% with liter flow at 3LPM.
- 2/18/23 O2 sat at 96% with liter flow at 3 LPM.
- 2/19/23 O2 sat on 1st shift at 95% with liter flow at 3 and 2nd shift at 95% with liter flow at 3 LPM.
- 2/20/23 O2 sat at 96% with liter flow at 3 LPM.
- 2/23/23 O2 sat at 98% with liter flow at 3 LPM.
- 2/27/23 O2 sat at 98% with liter flow at 3 LPM.
Review of residents vital signs report for the month of February 2023 showed:
- 2/7/23 at 1:22 A.M. O2 sat at 97% with liter flow at 3 LPM.
- 2/8/23 at 1:37 A.M. O2 sat at 97% with liter flow at 3 LPM.
- 2/9/23 at 10:55 P.M. O2 sat at 96% with liter flow at 3 LPM.
- 2/10/23 at 12:35 A.M. O2 sat at 97% with liter flow at 3 LPM.
- 2/11/23 at 11:56 P.M. O2 sat at 97% with liter flow at 3 LPM.
- 2/19/23 at 12:32 P.M. O2 sat at 95% with liter flow at 3 LPM.
- 2/20/23 at 1:43 P.M. O2 sat at 96% with liter flow at 3 LPM.
- 2/22/23 at 5:05 A.M. O2 sat at 98% with liter flow at 4 LPM.
- 2/23/23 at 11:56 A.M. O2 sat at 98% with liter flow 3 LPM.
- 2/26/23 at 10:16 A.M. O2 sat at 98% with liter flow at 3 LPM.
- 2/28/23 at 2:44 P.M. O2 sat at 96% with liter flow at 3 LPM.
- 3/3/23 at 7:43 P.M. O2 sat at 96% with liter flow at 3 LPM.
Review of resident's progress notes showed staff did not document any entries related to changes in oxygen levels.
Observation during the annual survey showed:
- 2/28/23 at 11:30 A.M., the resident used oxgen through a concentrator set at 3.5 L;
- 3/1/23 at 3:16 P.M. the resident used oxgen through a concentrator set at 3.5 L;
- 3/2/23 at 9:08 A.M. the resident used oxgen through a concentrator set at 3.5 L; the filter on the concentrator was caked with dirt and debris; the concentrator had a green tag indicating it had last been cleaned on 10/13/21.
3. Review of Resident #1's quarterly MDS dated [DATE], showed:
- Cognitively intact;
- Supervision of staff for transfers;
- Oxygen therapy;
- Diagnoses included: respiratory failure and anemia.
Review of the resident's undated careplan showed staff did not address the resident's oxygen therapy.
Review of the resident's POS, dated 2/2/23 through 3/2/23, showed:
- No order to change the filter on the resident's oxygen concentrator.
Observation on 3/1/23 at 9:12 A.M., showed the filter on the resident's oxygen concentrator caked with dust and dirt.
4. Review of Resident #78's admission MDS dated [DATE] showed:
- Moderate cognitive impairment;
- Assist of two staff members with transfers;
- Oxygen therapy;
- Diagnoses included: respiratory failure and pneumonia.
Review of the resident's undated care plan showed staff did not address the resident's use oxygen.
Review of the resident's POS, dated 2/2/23 through 3/2/23, showed:
- Start date: 2/13/23 - oxygen concentrator: remove and wash filter weekly once a day on Monday.
Observation on 3/1/23 at 9:33 A.M., showed the filter on the resident's oxygen concentrator was caked with dust and dirty.
During an interview on 3/2/23 at 9:18 A.M., Housekeeper B said:
- He/she did not do anything with the oxygen machines
During an interview on 3/2/23 at 9:25 A.M., Certified Nursing Aide (CNA) D said:
- Housekeeping cleans the filter if they are dirty.
- CNAs do not change them out, not sure who does.
- He/she will let maintenance know if the oxygen concentrator was fogged over, not working or beeping and will find a replacement in the meantime.
- He/she called housekeeping to let them know if it needed cleaned.
- He/she will put in a work order if he/she noticed it had not been taken care of.
- Housekeeping or maintenance can clean the oxygen machines.
- Staff can call the front desk for them to put in a work order, can put it in TELS (electronic work order software program designed for senior living with integrated asset management, life safety and maintenance solutions) or contact maintenance supervisor.
- CNAs and nurses are the eyes and ears and always check oxygen to make sure it is on the right setting.
- CNAs can only adjust when nurses give permission.
- Nurses can only adjust if they get physician order.
- He/she would notify nurse if resident appears confused or skin color is not normal.
- Adverse effects for dirty filter could be the resident could get used to higher level of oxygen and when trying to adjust back down to lower setting, could cause problems with their body.
- He/she would check with a nurse if a resident were to ask for their oxygen level to be raised and would not adjust without asking.
- He/she checks O2 levels anytime they are in a resident's room.
During an interview on 3/2/23 at 11:15 A.M., and 11:45 A.M., Licensed Practical Nurse (LPN) B said:
- Nursing staff are responsible for O2 levels, not CNAs.
- CNAs should not touch oxygen levels as it is considered a medication.
- Expectations would be for CNAs to report to nursing if there are concerns with settings.
- O2 settings should be checked every time CNAs or nursing staff are in the resident's room. This includes when they do checks, during med pass and answering call lights.
- Nursing staff are to clean machines once a week on Sundays.
- He/she is not sure who is responsible for cleaning filters.
- If a filter is observed dirty, it should be reported to nursing.
- Adverse effects for a dirty filter could cause the oxygen machine to clog up or stop working, or the resident is breathing in bacteria as it is unable to filter out everything going in.
- He/she got clarification on the oxygen filter; tt should be cleaned monthly by night shift.
During an interview on 3/2/23 at 12:17 P.M., LPN C said:
- CNAs gets vitals, pulse and saturations.
- Nurses check oxygen levels once a shift unless a resident is having difficulty breathing.
- He/she would check oxygen concentrator to see if it was working properly, check the resident's pulse, saturations then notifythe physician if the resident said they were having difficulty breathing.
- He/she would not contact the physician right away and would tend to the resident's needs first and raise oxygen liters. He/she would then call the physician as the physician is not going to say no.
- CNAs should not adjust oxygen levels and should notify the nurse.
- Filters should be cleaned weekly. Night shift is usually responsible for cleaning filters but it is now on the MAR since the new Director of Nursing DON took over. This is to let everyone know whether it has been done or not.
- Oxygen filters should never be dirty.
- Adverse effect for a dirty filter could cause the machine to malfunction and the resident would be breathing in dirt and bacteria from the air which could cause an infection.
During an interview on 3/2/23 at 12:38 P.M., CNA E said:
- All CNAs and nursing staff are responsible for checking residents' oxygen liters on the concentrators
- CNAs should not adjust oxygen levels and should check with the nurse.
- Night shift usually checks machine and cleans filters.
- Day shift should be checking filters too.
- Adverse effects for dirty filters could cause the resident to get an infection or respiratory sickness because they are breathing in bacteria. Could also cause the machine to malfunction.
- Could not remember what could happen if a resident's concentrator malfunctioned.
During an interview on 3/2/23 at 1:15 P.M., Registered Nurse (RN) A said:
- Nurses should monitor oxygen levels on oxygen machines but if a CNA notices it at a different level from before, such as it is now at a 4 but was at previously at a 2, they should reach out to a LPN or RN to verify order change.
- CNAs or other staff other than nursing should not touch or adjust oxygen levels.
- Staff should monitor/check at least once a shift.
- Adverse effects if oxygen level is adjusted to more than what is ordered could cause resident to end up in hospital with significant needs. If it is set to low, can cause hypoxia or lack of O2 which could ultimately be fatal.
- LPN/RNs should clean filters weekly. The supervisor's role is to ensure that it is being done.
- Adverse effects for dirty filter could cause resident not to get good oxygen, dust and bacteria particles could get in oxygen causing respiratory infection or residents could suffer an allergic reaction if they have allergies to certain things.
- If a resident's oxygen is set to a higher level than ordered, they could become dependent upon it and would need to be weaned down. Would need to do an assessment as they do a gradual reduction.
During an interview on 3/2/23 at 2:30 P.M., the Maintenance Supervisor said:
- Staff can call the front desk who will then put in a work order in their TELS system. The work orders then go this computer or to an application (app) he has access to on his phone.
- Nurses can also put work orders in through TELS.
- Not everyone uses TELS, sometimes staff will just call.
- They quit cleaning the filters since COVID and just replace them twice a year unless they get dirty before.
- When residents leave, housekeeping brings the concentrator to maintenance for them to clean/sterilize.
- They do not clean the filters or oxygen machines unless there is a work order or a resident leaves.
- Housekeeping will keep an eye out if the machines are dirty.
- He/she does not currently have a work order for Resident #95 or Resident #120's filter.
- They check filters monthly but do not always replace. They do not wash, just will replace them.
- He/she confirmed after seeing Resident #95's filter, it was dirty and would be changing it out.
- He/she did not get to observe Resident #120's filter as staff were providing care.
- Nursing should be checking the filters.
- He/she hardly ever gets any work orders for the filters. Only gets notified when a resident leaves.
- Housekeeper brought two oxygen concentrators downstairs yesterday that were filthy.
- He/she checked work orders for today and confirmed no current work orders for Resident #95 and #120's filters.
During an interview on 3/2/23 at 3:22 P.M., RN B said the filters on the oxygen concentrators should not be caked with dust and should be changed one time a month.
During an interview on 3/6/23 at 2:57 P.M., the Director of Nursing (DON) said:
- Saturations should be maintained above 90%.
- Hospice residents vary depending upon comfort level.
- Can titrate up to 4 liters for hospice residents; an example order is for 2 liters.
- Staff may put it higher, then call physician to get order.
- Should be documented in progress notes.
- Adverse effects would depend on what the disease process is. Residents could become dependent upon that level. Would have to titrate back down to level.
- Hospice patients depend upon comfort.
- Night staff change oxygen filters monthly.
- Adverse effects for dirty oxygen filters is not enough oxygen getting to the resident causing a low oxygen rate. It could cause malfunction in the machine.
- If filter is being signed as being cleaned, it should not be caked in dirt.
CONCERN
(E)
Potential for Harm - no one hurt, but risky conditions existed
Unnecessary Medications
(Tag F0759)
Could have caused harm · This affected multiple residents
Based on observation, interview and record review, the facility failed to ensure staff administered medications with a medication error rate of less than 5%. Facility staff made six medication errors ...
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Based on observation, interview and record review, the facility failed to ensure staff administered medications with a medication error rate of less than 5%. Facility staff made six medication errors out of 25 opportunities for error, resulting in a medication error rate of 32%. This affected three residents sampled for medication administration (Residents #1, #41, and #78). The facility census was 95.
Review of the facility's Medication Administration Procedures Policy, dated December 2017, showed:
- Oral Medication Administration:
o Wash hands when beginning a medication pass;
o Avoid touching the tablet or capsule unless wearing gloves.
- Eye Drop Administration:
o With gloved finger, gently pull down lower eyelid to form a pouch while instructing the resident to look up;
o Instruct resident to close eye;
o When eye is closed, use one finger to compress the tear duct in the inner corner of the eye for 1 to 2 minutes.
- Nasal Spray Administration:
o Instruct resident to hold head in an upright position, slightly tilted forward;
o Use finger of the other hand to close the nostril that is not receiving medication by gently pressing the side of the nostril;
o Press spray firmly and quickly to administer spray.
The facility did not provide the requested policy for administration of bronchodialator and steroid inhalers.
1. Review of the facility's Transdermal Drug Delivery System (patch) Policy, revised August 2014, showed:
- Remove the old patch;
- Label patch with date and nurses initials;
- Apply new patch firmly to skin.
Review of the Lidocaine adhesive patch, medicated, 4% manufacturer's guidelines, dated September, 2022, showed:
- Open pouch and remove one patch;
- Apply 1 patch at a time to affected area;
- Remove patch from the skin after 12-hour application.
Review of Resident #41's physician order sheet (POS), dated 2/2/23 through 3/2/23, showed:
- Start date: 2/2723 - Lidocaine (a patch applied to the skin used to treat pain) adhesive patch, medicated, 4%, apply one patch daily to mid back, put on in the morning for 12 hours, then remove at night.
Review of the resident's medication administration record (MAR), dated 2/2/23 through 3/2/23, showed:
- Lidocaine adhesive patch, medicated, 4% percent, apply one patch daily to mid back, put on in the morning for 12 hours then remove after at night;
- Initials of the staff that applied the patch on 2/28/23, at 10:00 A.M.;
- Initials of the staff that removed the patch on 2/28/23, at 10:00 P.M.
Observation and interview on 2/28/23 at 10:38 A.M., showed and the resident said:
- Certified Nurses' Aide (CNA) F moved the pad underneath the resident as the resident grabbed the side rail;
-The resident grimaced while grabbing the side rail;
-The resident said his/her back was hurting;
-The resident had a patch on the middle of his/her back with no date or initials;
-The resident said the nursing staff applies the patch in the morning for his/her back pain and the nursing staff are supposed to take the patch off 12 hours later before he/she goes to bed:
-The resident said no one removed the patch last night.
Observation and interview on 3/1/23 at 9:18 A.M., showed:
- The resident in bed with a patch on his/her middle back;
- The patch did not have a date or initials on it;
- The resident said the staff did not take the patch off last night.
Observation on 3/1/23 at 9:42 A.M., showed Registered Nurse (RN) B did the following:
- The nurse removed a lidocaine patch out of the medication cart and cut the top off the package;
- The nurse took the patch to the resident's room;
- The nurse removed the old patch from the resident's back that had no date or initials on it;
- The nurse applied a new patch to the resident's back;
- The nurse did not write his/her initials, or the time on the new patch.
During an interview on 3/2/23 at 3:22 P.M., RN B said:
- The resident's patch is to be applied in morning and taken off at night and should have the date, time and the initials of the staff who applied the patch;
- He/she forgot to date, time and initial the resident's patch on 3/1/23.
2. Review of the Combigen eye drops manufacturer's guidelines, dated June 2022, showed:
- Pull down lower eyelid to form pouch;
- When eye is closed use one finger to compress the tear duct in the inner canthus of the eye for 2 minutes.
Review of Resident #1's POS, dated 2/2/23 through 3/2/23, showed:
- Start date: 7/5/22 - Combigen (used to treat eye conditions that cause blindness) eye drops, 0.2 - 0.5%, give one drop in left eye two times a day.
Review of the resident's MAR, dated 2/2/23 through 3/2/23, showed: Combigen eye drops, 0.2 - 0.5%, give one drop in left eye two times a day.
Observation on 3/1/23 at 9:59 A.M., showed RN B instilled one drop in the left eye and he/she did not apply lacrimal pressure to the left eye.
During an interview on 3/2/23 at 3:22 P.M., RN B said he/she forgot to apply lacrimal pressure to the resident's left eye after administering the Combigen eye drop.
3. Review of the Saline Nose spray 0.65% manufacturer's guidelines dated June, 2021 showed:
- Hold head in an upright position:
- Use finger to press the nostril that is not receiving the medication to close the nostril.
Review of the Combivent inhaler manufacturer's guidelines, dated May 2022, showed:
- Rinse mouth out after using the inhaler and spit the water out;
- If other inhalers are used, wait at least one minute between each medication.
Review of the Symbicort inhaler manufacturer's guidelines, dated July 2022, showed:
- Wait five minutes in between other inhalers;
- Rinse mouth out after using the inhaler and spit the water out.
Review of Resident #78's POS, dated 2/2/23 through 3/2/23, showed:
- Start date: 11/14/22 - probiotic (used to balance intestinal health) 3 billion colony forming units, give on capsule once daily;
- Start date: 12/21/22 - saline nasal spray (used to treat dry nasal passages) 0.65%, use for dry nose due to oxygen use, give two sprays four times a day; did not specify how many sprays to each nostril;
- Start date: 1/20/23 - Combivent Respimat mist (used to treat lung conditions) 20 - 100 micrograms (mcg), inhale two puffs twice a day;
- Start date: 1/20/23 - Symbicort (used to treat used to treat lung conditions) 80 - 4.5 mcg, inhale two puffs twice a day.
Review of the resident's MAR, dated 2/2/23 through 3/2/23, showed:
- Probiotic, three billion colony-forming units, give on capsule once daily;
- Saline nasal spray 0.65%, use for dry nose due to oxygen use, give two sprays four times a day; did not indicate how many sprays to spray in each nostril;
- Combivent Respimat mist 20 - 100 mcg, inhale two puffs twice a day;
- Symbicort 80 -4.5 mcg, inhale two puffs twice a day.
Observation on 3/1/23 at 10:33 A.M., showed:
- RN B opened a bottle of probiotic and poured one capsule into the medicine cup;
- The directions on the bottle of read: 1 billion colony-forming units per serving size of two capsules, give two capsules daily;
- The order on the MAR read 3 billion colony-forming units, give one capsule once daily;
- The nurse gave two capsules to the resident for a total of only 2 billion colony-foring units;
- The nurse administered one spray of the saline nose spray in the resident's right nostril and did no hold the left nostril closed;
- The nurse attempted to administer a spray in the left nostril but the medication came out as two drops instead of a spray and ran down the resident's face;
- No other attempt were made to administer the nose spray;
- The nurse gave two puffs of the Combivent inhaler to the resident;
- The resident did not rinse his/her mouth out after receiving the Combivent inhaler;
- The nurse gave two puffs of the Symbicort inhaler immediately after giving the Combivent inhaler;
- The nurse did not instruct the resident to rinse with water and spit after the Symbicort inhaler was given.
During an interview on 3/2/23 at 3:22 P.M., RN B said:
- The left nostril should be closed when administering the resident's nasal spray in the right nostril;
- He/she should ensure that a spray is coming out of bottle of nose spray and not drops if spray is what is ordered by the physician;
- He/she should wait at least one minute after giving the resident the Combivent inhaler before giving him/her the the Symbicort inhaler;
- He/she should instruct the resident to rinse after each inhaler;
- If an order is not specific, staff should call the physician for clarification;
- The physician should have been notified when the order for the resident's nasal spray did not specify how many sprays to given in each nostril;
- He/she should have doubled check the label on the probiotic to make sure it matched the POS and the MAR.
4. During an interview on 3/6/23, at 2:57 P.M., the Director of Nursing (DON) said:
- When a dermal patch is applied it must be labeled with the date, time and the initials of the staff member who applied it;
- The old patch should be removed by the nurse as ordered by the physician;
- Nasal sprays should be given per the facility policy;
- If a physician's order is vague the physician should be called to clarify the order;
- Lacrimal pressure should be applied when giving eye drops;
- There should be a wait time between inhalers and the resident should rinse their mouth out with water after taking a steroid inhaler.
CONCERN
(E)
Potential for Harm - no one hurt, but risky conditions existed
Deficiency F0761
(Tag F0761)
Could have caused harm · This affected multiple residents
**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observations, interviews, and record review, the facility failed to store drugs and biologicals in a locked storage are...
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**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observations, interviews, and record review, the facility failed to store drugs and biologicals in a locked storage area to ensure drugs and biologicals were inaccessible to residents when medications were found in four residents' (Residents #1, #5, #15, and #78) rooms with no physicians' orders and failed to discard expired medications when expired medications were found in the rooms of three residents (Residents #1, #15 and #78). The facility census was 95.
Review of the facility's policy, storage of medication in the facility, dated August 2014, showed:
- It is the policy of the facility to ensure proper and safe storage of medications;
- Outdated and contaminated medications are to be immediately removed from inventories;
-No expired medication will be administered to residents.
1. Review of Resident #1's physician's order sheet (POS), dated 2/2/23 through 3/2/23, showed:
- Start date: 1/10/22 - Alpha [NAME] skin oil (used to treat dry skin), use after bathing on Tuesdays and Fridays;
- No order to keep at bedside was found.
Observation and interview on 3/1/23 at 8:52 A.M., of the resident's room showed:
- A bottle of Alpha [NAME] skin oil labeled with the resident's name and expiration date of 1/7/23 setting on the bedside table;
-The resident said the staff apply it to his/her arms and legs two times a week after his/her shower.
2. Review of Resident #5's POS, dated 2/2/23 through 3/2/23, showed:
- Start date: 1/17/22 - Ketoconazole shampoo 2% (used to treat dry scalp) use twice a week on Tuesdays and Fridays;
- No order to keep at bedside was found.
Observation and interview on 3/1/23 at 9:05 A.M., of the resident's room showed:
- A bottle of Ketoconazole shampoo 2% labeled with the resident's name setting on the bedside table next to the resident;
- The resident said the staff use the shampoo on his/her hair on shower days dry scalp, two times a week during his/her bath.
3. Review of Resident #78's POS, dated 2/2/23 through 3/2/23, showed no order for hydrogen peroxide 3%.
Observation and interview on 3/1/23 at 9:33 A.M., of the resident's room showed:
- A bottle of hydrogen peroxide 3%, setting on the night stand with an expiration date of July 2015;
- The resident said the last time he/she used it was to soak his/her right toe yesterday.
4. Review of Resident #15's POS, dated 2/2/23 through 3/2/23, showed:
- No order for Refresh eye drops (used to treat dry eye);
- No order for Biofreeze (topical cream used to treat pain).
Observation and interview on 3/1/23 at 9:51 A.M., of the resident's room showed:
- A bottle of Refresh eye drops on the night stand next the resident's bed;
- Bottle of Biofreeze on the night stand next the resident's bed;
- The resident said he/she used the eye drops and the Biofreeze when he/she needed them.
5. During an interview on 3/2/23 at 3:22 P.M., Registered Nurse (RN) B said:
- Residents should not have access to expired medications.
- Residents should not have medications left at their bedside without a physician's order;
- He/she did not know why the expired medications where in the residents' rooms;
- He/she did not know why medications were in the residents' rooms with no physician's order;
- The nurses are responsible for making sure there are no expired medications in the rooms;
- He/she did not know there were medications in the resident's rooms that did not have orders to be at the bedside.
During an interview of 3/6/23, at 2:57 P.M., the Director of Nursing (DON) said:
- A resident with medication at the bedside should have a physician's order for the medication to be at the bedside;
- Residents should not have access to expired medications;
- Medications without a bedside order should be secured away from resident access.
CONCERN
(E)
Potential for Harm - no one hurt, but risky conditions existed
Deficiency F0804
(Tag F0804)
Could have caused harm · This affected multiple residents
**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation and interviews, the facility failed to ensure staff served food to the residents that was palatable, attrac...
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**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation and interviews, the facility failed to ensure staff served food to the residents that was palatable, attractive, and served at a safe and appetizing temperature to the residents when hot food was not served at an appetizing temperature to eight of nineteen sampled residents (Resident #30, #73, #88, #89, #91, #229, #232, and #284). The facility had a census of 95.
Review of the facility policy, Maintaining Proper Food Temperature during Food Service, dated 2012, included the following:
-Food will be maintained at proper hot and cold temperatures prior to and during meal service to assure food quality and tastiness/palatability as well as food safety;
-Temperature of hot food will be 135 degrees or higher during tray assembly;
-Temperatures of cold food foods will be 41 degrees Fahrenheit or less during tray assembly;
-Temperatures will be taken and recorded for all hot and cold items at all meals. Temperatures will be recorded;
-Heating food in the steam table was prohibited. Heating food to proper temperature was accomplished by direct heat (i.e. stove, oven, and steamer) and food was then transferred to the preheated steam table not more than 30 minutes before meal service.
1. Review of Resident #88's admission MDS dated [DATE], showed he/she was cognitively intact with a BIMS of 15.
During an interview on 2/28/23 at 10:25 A.M., Resident #88 said his/her food was usually cold.
2. Review of Resident #91's quarterly Minimum Data Set (MDS) a federally mandated assessment, dated 2/16/23, showed he/she was cognitively intact with a Brief Interview for Mental Status (BIMS) score of 15.
During an interview on 2/28/23 at 10:43 A.M., Resident #91 said his/her food was always cold when staff served it to him/her.
During an interview during meal service on 2/28/23 at 1:18 P.M. Resident #91 said his/her food was cold.
3. Review of Resident #232's admission MDS, dated [DATE], showed he/she was cognitively intact with a BIMS of 15.
During an interview on 2/28/23 at 12:15 P.M., Resident #232 said food can be cold when staff served it.
4. Review of Resident #30's prior assessment MDS, dated [DATE], showed he/she was cognitively intact with a BIMS of 15.
During an interview on 2/28/23 at 12:45 P.M., Resident #30 said his/her food was usually cold when served.
5. Review of Resident #89's MDS significant change assessment, dated 1/16/23 showed he/she
has moderately impaired cognition with BIMS of 10
During an interview on 2/28/23 at 4:00 P.M. Resident #89 said his/her foods have been cold.
6. Review of Resident #73's admission MDS assessment, dated 10/6/22 showed he/she was cognitively intact with a BIMS score of 14.
During an interview on 3/1/23 at 8:48 A.M. Resident #73 said his/her food was cold.
7. Review of Resident #229's MDS entry tracking record dated 2/26/23 showed no BIMS was completed.
During an interview on 3/1/23 at 9:39 A.M. Resident #229 said his/her food was not good and it was cold.
Observation of Culinary Services Aide B on the second floor west hall kitchenette on 2/27/23 at 1:04 P.M. showed a microwaved puree meal package was removed and served with no temperature taken.
Observation of Culinary Services Aide B the second floor south hall kitchenette on 2/27/23 at 1:33 P.M. showed no food temperatures taken on the steam table for the vegetables, potatoes, and gravy.
Observation of first floor meal service on 2/28/23 showed:
-12:00 P.M. lunch cart arrived to first floor west;
-Food temperatures taken from steam table, mashed potatoes read 115 degrees; mashed potatoes stirred by Culinary Assistant Supervisor and retested at 122.5 degrees; Mashed potatoes returned to kitchen to be reheated;
-12:00 P.M. Culinary Services Aide A cut up turkey for first plate to be served while temperature checking remaining food items;
-12:28 P.M. reheated mashed potatoes arrive from kitchen, temperature checked at 164.8 degrees;
-1:18 P.M. Food placed on south steam table; Temperature check showed pork chop at 129 degrees, Supervisor advised Culinary Service Aide A to microwave;
-Culinary Services Aide A loaded all pork chops onto plate and microwaved for thirty seconds, retemped at 115 degrees;
-Supervisor advised Culinary Services Aide A to split up the pork chops onto two plates and took over reheating of pork chops for sixty seconds;
-1:34 P.M. Reheated pork chops on first plate with temperature of 161 degrees and second plate 147 degrees;
-1:45 P.M. Resident #284 stated pork chop was dry, he/she offered the alternative meat of turkey;
-During meal service Culinary Services Aide advised she had forgotten a resident's chicken noodle soup, Culinary Assistant Supervisor contacted the kitchen via cell phone to have [NAME] A bring soup to first floor south;
-1:52 P.M. Additional turkey arrived from the kitchen, temperature of 112 degrees;
-1:54 P.M. Sliced turkey warmed up in microwave, temperature of 127.5 degrees;
-1:57 P.M. Reheated turkey taken out of microwave for second time, temperature of 142.2 degrees;
-2:01 P.M. Chicken noodle soup arrived from kitchen, temperature of 139 degrees;
-2:11 P.M. Last tray served on south hall, meal service time was posted at 12:45 P.M.;
Observation at the end of the meal service on 2/28/23 at 2:15 P.M. staff provided a test tray as the last meal prepared and obtained the following temperatures:
-Pork chop, 104 degrees;
-Minced and moist turkey, 107.2 degrees;
-Pork chop was dry and hard to chew.
Observation on beginning of meal service of first floor south hall meal service on 3/2/23 at 1:21 P.M. showed no temperatures taken after food placed on the steam table.
Observation and interview on 3/2/23 of the lower level rehab showed and Resident #229 said:
-He/she told the therapist his/her food at lunch was cold.
- The toast was always cold and hard. He/she did not like the eggs. He/she said they did not taste like normal eggs.
During an interview on 2/27 at 10:33 A.M., the Culinary Assistant Supervisor said:
-There have been no recent complaints from residents on food being cold;
-Facility obtained lids for steam tables to help keep heat in;
-Food was served to ten kitchenettes in the facility, six of those were in the nursing home.
During an interview on 2/28/23 at 11:03 A.M. the Culinary Services Director said:
-He/she expected temperatures to be done when cooking food and when Culinary Services Aides get to the floor.
-Temperature checks should occur on both west and south halls when food was on the steam tables.
During an interview on 02/28/23 at 11:25 AM, [NAME] A said he/she temperature checked foods from the warmer and before it went out on carts.
During an interview on 3/2/23 at 11:28 A.M., Certified Nurses Assistant (CNA) A said:
-He/she had resident complaints of food not being hot;
During an interview on 3/2/23 at 11:38 A.M., CNA B said:
-There have been temperature complaints from residents stating food was not warm enough;
-Soup was often a complaint regarding temperature issues;
During an interview on 3/2/23 at 11:47 A.M., CNA C said:
-There had been some residents complain about food temperatures;
During an interview with 03/02/23 02:04 P.M., Culinary Services Aide C said:
-Hot food service temperature should be between 140 and 160 degrees.
During an interview on 3/2/23 at 02:07 P.M., Culinary Services Aide B said:
-Food temperatures were completed upon arrival to the west and south kitchenettes prior to the start of food service.
During an interview on 3/2/23 at 2:14 P.M., Culinary Services Aide D said:
-Food temperature checks were completed right before food service occurred;
-He/she had received complaints about the food temperatures;
-He/she was provided a guideline for food temperatures as part of his/her food safety training;
-Hot food must be 140 degrees or higher; cold food should be between 35 and 40 degrees.
During an interview on 3/2/23 at 2:18 P.M. Culinary Services Aide E said:
-He/she took food temperatures right before food was served on west kitchenette and then again before food service at south kitchenette;
-Serving temperatures on hot food should be between 160 and 180 degrees, he/she was not sure on serving temperatures of cold food;
-He/she documented temperatures in a paper in folder at each kitchenette.
During an interview on 03/02/23 02:25 P.M., the Administrator said:
-He/she had received complaints of food being served cold;
-The facility kitchen served meals with a neighborhood concept, which was different from other nursing facilities;
-Hot food should be served hot, cold food should be served cold.
CONCERN
(E)
Potential for Harm - no one hurt, but risky conditions existed
Deficiency F0809
(Tag F0809)
Could have caused harm · This affected multiple residents
**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observations, interviews, and record review, the facility failed to serve meals according to scheduled meal times. This...
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**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observations, interviews, and record review, the facility failed to serve meals according to scheduled meal times. This affected five of nineteen sampled residents (Resident #2, #12, #30, #88, and #232) This had potential to impact all residents residing in the community. The facility census was 95.
The facility did not provide a policy on meal times.
1. Review of the signs posted in the main dining rooms on each floor showed:
-West hallway kitchenettes;
-Breakfast 7:30 A.M.
-Lunch 12:00 P.M.
-Dinner 5:30 P.M.
-South hallway kitchenettes;
-Breakfast 8:15 A.M.
-Lunch 12:45 P.M.
-Dinner at 6:15 P.M.
2. Observation of lunch service on the second floor on 2/27/23 showed:
-Cold food loaded onto food carts 11:39 A.M.;
-Hot food loaded onto food carts at 12:07 P.M.;
-Food carts leaving kitchen to provide meal service 12:16 P.M.;
-The lunch cart arrived to the west kitchenette at 12:20 P.M.;
-The first tray was served at 12:30 P.M., thirty minutes after posted start time;
-The last tray was served at 1:04 P.M., one hour and four minutes after posted start time;
-The lunch cart arrived to the south hallway at 1:12 P.M., twenty seven minutes after posted start time;
-The first tray served at 1:33 P.M., forty three minutes after posted start time.
During an interview and observation on 2/28/23 at 11:51 A.M. Culinary Services A stated
-He/she served 16 residents on the first floor west hall and 15 residents on the first floor south hall;
-He/she then began loading the black food cart in the kitchen.
Observation of the lunch service on first floor on 2/28/23 showed:
-The lunch cart arrived to the west kitchenette at 12:00 P.M.;
-Mashed potatoes had to be returned to kitchen to be reheated due to low temperature; mashed potatoes arrived back at 12:28 P.M.;
-The first tray was served at 12:35 P.M., thirty five minutes past posted meal service time;
-Salads were made in the kitchenette, Culinary Service Aide A measured out lettuce, added cheese, added tomato;
-During meal service, staff forgot resident's divided plate; supervisor returned to the kitchen to get it;
-Ran out of drinking glasses during meal service; supervisor returned to kitchen to get them;
-The last tray was served at 1:06 P.M., one hour and six minutes past posted meal service time;
-The lunch cart arrived to the south hallway at 1:15 P.M., thirty minutes past posted meal service time;
-The first tray was served at 1:36 P.M., forty six minutes past posted meal service time;
-Culinary Services Aide A advised supervisor that he/she was short on turkey to complete meal service;
-1:45 P.M. Resident #284 stated the pork chop was dry, staff offered him/her the alternative meat of turkey;
-During meal service Culinary Services Aide advised she had forgot a resident's chicken noodle soup, Culinary Assistant Supervisor contacted the kitchen via cell phone to have [NAME] A bring soup to first floor south;
-1:52 P.M. Additional turkey arrived from the kitchen and had to be warmed up in the microwave
-1:56 P.M. CNA H notified dietary staff he/she was out of silverware and needed more to complete meal service;
-2:02 P.M. They ran out of white serving plates, Culinary Service Aide A located thin plastic plates to continue meal service;
-2:05 P.M. Additional silverware arrived via Culinary Assistant Supervisor;
-The last tray was served to south hallway at 2:11 P.M., one hour and twenty six minutes past posted meal service time
Observation of the lunch service on the first floor on 3/2/23 showed:
-Lunch was still being served at 12:44 P.M. on west hallway; forty-four minutes past posted meal start time;
-The first tray on south hall was served at 1:26 P.M., forty-one minutes past posted meal start time.
3. Review of Resident #12's admission Minimum Data Set (MDS), a federally mandated assessment dated [DATE] showed he/she was cognitively intact with a Brief Interview Mental Status (BIMS) of 15
During an interview on 2/28/23 at 10:01 A.M., Resident #12 said:
-Lunch was as late as 2:30 P.M. and dinner was late as 7:30 P.M.
-He/she has a hard time falling asleep after a meal that late
4. Review of Resident #2's admission MDS dated [DATE] showed he/she is cognitively intact with a BIMS of 14.
During an interview on 2/28/23 at 10:10 A.M., Resident #2 said:
-Meal service was as late as 2:00 P.M. for lunch and 7:00 P.M. for dinner.
-He/she has a hard time settling down and falling asleep after eating that late
5. Review of Resident #88's admission MDS dated [DATE], showed he/she is cognitively intact with a BIMS of 15.
During an interview on 2/28/23 at 10:25 A.M., Resident #88 said:
-Meals were at least half an hour late, but were up to an hour or more late
6. Review of Resident #232's admission MDS, dated [DATE], showed he/she was cognitively intact with a BIMS of 15.
During an interview on 2/28/23 at 12:15 P.M., Resident #232 said:
-Meals were frequently late
7. Review of Resident #30's prior assessment MDS, dated [DATE], showed he/she was cognitively intact with a BIMS of 15.
During an interview on 2/28/23 at 12:45 P.M., Resident #30 said:
-Meals were always late
During an interview on 2/27/23 at 10:33 A.M., the Culinary Assistant Supervisor said:
-Meal service times are 7:30 A.M., 12:00 P.M., and 5:00 P.M.;
-They serve meals to ten kitchenettes in the facility.
During an interview on 3/2/23 at 11:28 A.M., Certified Nurses Assistant (CNA) A said:
-Has observed staff run out of food during meal service and ask another floor to bring stuff down.
During an interview on 3/2/23 at 11:34 A.M., Licensed Practical Nurse (LPN) A said:
-Meals are sometimes served late; usually five to ten minutes;
-He/she is aware some residents want food served super hot;
-He/she has observed dietary staff forget items from kitchen, staff will leave station to run down to basement to obtain items or sometimes call kitchen for assistance.
During an interview on 3/2/23 at 11:38 A.M., Certified Nurse Aide (CNA) B said meals are occasionally served late in the evenings around 6:30 P.M. or 7:00 P.M.
During an interview on 3/2/23 at 11:46 A.M., CNA C said food had been served ten to fifteen minutes late.
During an interview on 3/2/23 at 12:04 P.M. Culinary Service Director said:
-He/she expects staff to contact kitchen when items are forgotten, item will be brought to floor for aides;
-Kitchenettes are restocked after dishes washed at each meal.
During an interview on 03/02/23 at 2:25 P.M., Administrator said:
-He/she had complaints about food being served late;
-He/she expected food to be served within thirty minutes of posted meal service times;
-The facility had been following a neighborhood concept for meal service.
CONCERN
(E)
Potential for Harm - no one hurt, but risky conditions existed
Food Safety
(Tag F0812)
Could have caused harm · This affected multiple residents
**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, record review, and interviews, the facility failed to store, prepare, and serve food in accordance to prof...
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**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, record review, and interviews, the facility failed to store, prepare, and serve food in accordance to professional standards of food service safety when staff failed to fully date opened items, utilize proper hand washing, and failed to ensure all areas of the kitchen and food storage areas remained clean (dry food storage, walk through cooler, food prep counter, and food transport carts). The facility census was 95.
1. Review of the facility policy, Food Storage-Perishable, dated 2017, included:
-All storage that takes place in refrigerated and freezer areas will be maintained in a clean, sanitary condition;
-All food items must be stored on shelving or drainage racks that allow the entire floor to be completely cleaned;
-To facilitate floor cleaning, the lower shelf in walk-in coolers and freezers should be a minimum of six inches above the floor;
-Refrigerators and freezers should be kept clean. Spills should be wiped up immediately;
-All prepared food stored in the refrigerator units should be in covered, seamless containers or otherwise suitably protected with used by date. Containers should be arranged so that free circulation of air is allowed at all times. Storage of large quantities of food in oversized containers should be avoided;
Observation of the kitchen food storage on 2/27/23 at 10:33 A.M., showed:
-Gelatin mix laying on floor of dry storage;
-Food condiment packets laying on floor of dry storage;
-Dented can of tomato soup dated 1/13 on shelf with other soups;
-Undated and uncovered brownies in the refrigerator;
-Undated flat of blueberry muffins with two muffins missing out of the package in the refrigerator;
-Undated and opened container of ginger;
-Undated package of opened dinner rolls;
-Two undated and opened hamburger bun packages with holes in top of package and twist tie still on closure of both bags. First bag had one bun missing, second bag had four hamburger buns remaining. Both packages exposed to air;
-Two undated and opened packages of marble sour dough rye bread with three fourths of package used;
-Undated package of sliced smoked ham lunch meat sat on top of whipped topping container;
-Undated and unlabeled white sliced cheese in plastic container covered with saran wrap;
-Undated hard boiled eggs;
-Undated sliced turkey lunch meat;
-Undated and opened caramel syrup container;
-Undated ham lunch meat on top shelf;
-Undated green grapes in container;
-Undated and opened bag of lettuce;
-Undated container of chopped ham;
-Case of sour cream sitting on the floor of the walk in cooler dated 2/24;
-Undated and opened box of fudge bars in the freezer;
-Three undated containers of strawberries in the walk in cooler;
-Pancake mix dated 1/19 wrapped in Saran wrap on top of ice machine;
-Container of croutons dated 2/13 resting on top of ice machine;
During an interview on 2/27/23 at 10:33 A.M., the Culinary Assistant Supervisor said dates were written on food when items were delivered off truck.
During an interview on 2/28/23 at 11:07 A.M., the Culinary Services Director said:
-Dented cans were disposed of by facility or returned to the manufacturer;
-Staff knew not to cook with dented cans;
-Every item should to be labeled with name and date when opened and placed in the container;
-Food should never be stored on the floor.
During an interview on 3/2/23 at 02:07 P.M., Culinary Services Aide B said:
-Food should be labeled and dated when it was opened;
-He/she did not know when food should be discarded.
During an interview on 3/2/23 at 2:14 P.M., Culinary Services Aide D said:
-Food should be labeled when opened;
-Food without labels or dates should be thrown out.
During an interview on 3/2/23 at 2:18 P.M., Culinary Services Aide E said:
-Food should be labeled right before it is opened by sticking a label on it;
-Food cannot be stored on the floor.
During an interview on 03/02/23 02:25 P.M., the Administrator said opened food should be labeled and dated.
2. Review of facility policy titled, Culinary Department Sanitation Monitoring, dated 2019, showed:
-It is policy of the Culinary Department to maintain a sanitary food service operation, which includes cleanliness of equipment, the department and the personnel. Sanitary and proper food handling techniques shall be used at all times;
-Culinary Services Director is responsible for monitoring the Culinary Department on a regular basis to assure department is operated and maintained in a sanitary manner;
-Culinary Services Director/designee will accomplish on monthly basis using Sanitation Checklist;
-Areas included in inspections [NAME] include: storage areas, refrigerator/freezer units, equipment/utensils, food preparation areas, dishwashing area, kitchenette serving areas outside main kitchen;
Observation of the kitchen on 2/27/23 at 10:52 A.M., showed:
-Water, broken glasses, and coffee mugs in a basin under the handwashing sink on the floor;
-Spilled milk in the middle of the kitchen floor;
-Two bags of trash sitting on the floor by the water hose;
-Dry storage room floor was sticky;
-An opened can of pop on a shelf in the dry storage room;
-Food crumbs, crackers, and packages of condiments on the floor of the dry storage room;
-A sticky food substance on the wall of the walk through cooler;
-Food debris and cheese on the metal serving table;
-Top of ice machine was dirty/dusty;
-Walk in freezer had cardboard and crumbs laying the floor;
-Cart in walk in freezer had food particles and red jelly like substance;
-Food warmer carts had food particles on lower tray;
-Refrigerator handle was sticky.
Observation on 2/27/23 at 11:39 A.M., showed food loaded onto food warmer carts for transport; cart had not been wiped clean from food crumbs and residue observed on cart shelves.
During an interview on 2/28/23 at 11:07 A.M., the Culinary Services Director said:
-Everything is cleaned after first shift;
-Everything in the kitchen should be scrubbed and mopped each evening;
-Staff mop out coolers and freezers weekly, and they are swept daily;
Observation on 3/2/23 at 2:11 P.M., showed two bags of trash on the kitchen floor.
During an interview on 3/2/23 at 2:18 P.M., Culinary Services Aide E said:
-He/she had a cleaning list and was expected to initial items completed on cleaning list;
-Sani-bucket should be used to wash down surfaces before and after meal service at kitchenettes;
-Sani-buckets are refilled during every shift.
3.) Review of the facility's policy, Handwashing Procedure, dated 2012, showed:
-The hands of those who prepare and serve food must be clean at all times in order to safeguard the health of those who are dependent on this service. Hands must be washed frequently, thoroughly, and according to proper procedure.
Observation on 2/27/23 at 11:30 A.M., showed:
-Four Culinary Service Aides returned to the kitchen from taking a break; only one of the four culinary service aides washed hands upon return to kitchen;
-Culinary Service Aide A and B did not wash hands along with a male aide.
Observation of Culinary Service Aide B on 2/27/23 at 11:31 A.M. showed:
-He/she opened a new can of applesauce and poured into a container;
-He/she touched the trash can with bare hands; he/she did not wash his/her hands;
-He/she opened a new can of applesauce;
-He/she touched the trash can with bare hands; he/she did not wash his/her hands;
-He/she pulled out his/her phone from his/her pocket to look at the date and labeled the top of the container;
-He/she grabbed boiled eggs out of the package;
-He/she touched the trash can and did not wash his/her hands;
-He/she continued to place eggs in a zip lock package with bare hands.
Observation of Culinary Staff Aide B on 2/27/23 at 11:54 A.M., showed:
-He/she removed trash from the trash can and took the trash out the back door;
-He/she placed a new trash bag in the container;
-He/she did not wash his/her hands;
-He/she put on gloves;
-He/she began loading items onto meal warmer cart;
-He/she touched his/her face mask several times and did not wash his/her hands.
During an interview on 2/27/23 at 12:11 P.M., the Culinary Assistant Supervisor said:
-He/she expected staff to wash hands in between each job, when staff walked away from an area in the kitchen, and after touching their faces.
Observation of Culinary Staff Aide B on 2/27/23 at 12:29 P.M., showed:
-He/she washing hands for first time since observation began in kitchen at 11:30 A.M., food preparation has already been completed and all food containers have been moved to steam table;
-He/she applied gloves;
-He/she touched his/her nose and face with his/her gloves and did not wash hands or change gloves.
During an interview on 2/28/23 at 11:07 A.M., Culinary Services Director said:
-He/she expected staff to wash hands any time they leave their station;
-Staff should wash hands when returning from breaks;
Observation of Culinary Staff Aide B on 2/28/23 at 11:29 A.M., showed:
-He/she returned from break and did not wash his/her hands;
-He/she touched the trash can, did not wash his/her hands, and returned to sealing a pudding container;
-He/she touched his/her nose, grabbed food items and placed food on the mobile food warmer cart.
During an interview with 03/02/23 02:04 P.M., Culinary Services Aide C said:
-He/she could not recall any food safety training;
-He/she should wash hands every time he/she changed gloves, touched something, or touched the trash can;
During an interview on 3/2/23 at 02:07 P.M., Culinary Services Aide B said:
-Staff should wash hands every time staff touch the trash can, switch positions, put gloves on, or have contact with food;
During an interview on 3/2/23 at 2:14 P.M., Culinary Services Aide D said:
-He/she has worked in the kitchen for four months;
-He/she should wash hands upon arrival to kitchen then every five minutes;
-He/she should wash hands after touching the trash can;
During an interview on 3/2/23 at 2:18 P.M., with Culinary Services Aide E said:
-He/she has worked in the facility for a month and half;
-He/she should wash hands between stations and after any contact between surfaces;
During an interview on 03/02/23 02:25 P.M., the Administrator said:
-Handwashing should occur before food is served, in between touching food, and/or between other items they have gotten out;
Feb 2020
13 deficiencies
1 Harm
SERIOUS
(G)
Actual Harm - a resident was hurt due to facility failures
Quality of Care
(Tag F0684)
A resident was harmed · This affected 1 resident
**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, interviews and record reviews, the facility failed to assure staff provided the necessary care and service...
Read full inspector narrative →
**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, interviews and record reviews, the facility failed to assure staff provided the necessary care and services to attain or maintain the highest practicable physical, mental, or psychosocial well-being for one resident (Resident #31). Staff failed to notify the physician of the resident's change in mental and physical status in a timely manner. This failure resulted in a delay in medical treatment. The facility census was 90.
Review of the undated facility policy for Change in Condition showed:
-Purpose to provide care and services based upon the current needs of the resident under the direction of the attending provider. To inform the resident or resident representative and attending provider when a significant change in resident condition occurs;
-When a significant change in the resident's physical, mental, or psychosocial status is identified by the licensed nurse, or when there is a need to alter treatment significantly, the licensed nursing associate consults with the attending provider and notify the resident or resident representative;
-The Licensed nursing associate will assess significant change in the resident's condition noted through direct observation, interview or report from other staff;
-Obtain a set of vital signs and repeat as needed or ordered;
-Conduct a symptom review and assessment, as condition warrants;
-Notify the attending provider of the change in condition and implement orders for treatment and appropriate monitor as directed. If unable to contact the physician, contact the Medical Director;
-Notify the resident or the resident representative;
-Document symptom(s), assessment, observations, resident or resident representative notification and the medical provider notification;
-Monitor and provide treatment as ordered by the attending provider;
-Update the care plan as appropriate.
1. Review of Resident 31's hospital history and physician dated 12/9/19 showed:
-The resident has diagnosis of hypertension (HTN), atrial fibrillation and cerebral vascular disease. He/she has been up and about, exceptionally active and the main caregiver for the spouse at home. He/she was brought to the emergency room due to agitation and confusion and was found to have an acute cerebellar bleed (Cerebellar hemorrhage is a form of intracranial hemorrhage and is most frequently seen in the setting of poorly controlled hypertension). The resident is alert and will follow all commands without difficulty. He/she complains of a headache and dizziness.
Review of the baseline care plan dated 12/19/19 showed:
-Goal to discharge to the community;
-Alert and oriented;
-Receives physical therapy and occupational therapy;
-Safety - nothing marked for any history of falls or at risk for falls;
-Assistance of one staff member for bed mobility, transfers, walking, toileting and bathing.
Review of the fall risk assessment dated [DATE] showed the resident was at low risk for falls.
Review of the care plan for return to community dated 12/24/19 showed:
-Goal to return to home.
Review of the admission Minimum Data Set (MDS), a federally mandated assessment instrument completed by staff dated 12/25/19 showed:
-admitted to the facility on [DATE];
-Alert and oriented and able to answer questions appropriately;
-Extensive assistance of one person for Activities of Daily Living (ADL's);
-No pain;
-History of falls;
-Diagnosis of atrial fibrillation (irregular heartbeat), coronary artery disease (CAD) (narrowing or blockage of the coronary arteries), HTN, cerebral vascular accident (CVA - stroke), anxiety, depression and subdural hematoma (is a type of bleeding in which a collection of blood gathers between the inner layers of the brain).;
-Discharge plan to return home.
Review of the physician's progress notes dated 1/2/20 showed:
-The resident continues with some headache issues, and nausea and dizziness, particularly with any type of standing.
Review of the nurses notes dated 1/3/20 at 12:42 P.M. showed:
-At 12:30 P.M. went into the residents room to give him/her medications, he/she was trying to talk, but was not making any sense. His/her words were jumbled and slow and slurred. A neurological assessment was completed and it was determined that the primary care physician should be called. His/her left arm was flaccid (a part of the body soft and hanging loosely or limply) and he/she could not squeeze the nurses hand. His/her responses to questions were extremely delayed. Orders were received to send the resident to the emergency room (ER) for evaluation.
Review of the resident's ER medical records dated 1/3/20 showed:
-The resident comes into the ER for a stroke alert. The facility states that the resident was having left sided drooping of the face and speech. The resident had a brain bleed on 12/9/19. The resident was recently discharged from the hospital for a stroke and had speech deficits since. yesterday then the resident's family spoke with the neurologist, everything was fine, but today the nursing home staff noticed left sided weakness and facial droop. The resident was admitted to the hospital about two to three weeks ago for intracranial hemorrhage. The resident was transferred to the nursing home and evaluated as an outpatient with no significant deficits. The resident was evaluated by the nursing staff today at the facility and they were concerned about an acute stroke. On presentation, however, the family indicates the resident is completely at baseline mental status and the resident neurological exam has not changed. The resident was noted to have mild neglect on the left side, which the family indicates is unchanged from previous. The resident was discharged back to the nursing home with orders to return if worse.
Review of the nurses notes dated 1/3/20 at 4:30 P.M. showed:
-The resident returned from the ER, he/she is leaned over on his/her left side in the wheelchair, the left arm remains flaccid, speech is still scattered and delayed responses noted. He/she is extremely weak.
Review of the care plan for ADL functional/Rehabilitation Potential dated 1/3/20 showed:
-The resident is at risk for deterioration in ADLs;
-Goal: The resident will not deteriorate in ADLs as evidenced by maintaining the ability to assist in his/her own care;
-Approaches: Assess the resident for deterioration and eliminate the risk factors, if possible; document and report any deterioration in status to the physician.
Review of the care plan for falls dated 1/3/20 showed:
-The resident is at risk for falls;
-Goal to remain free from injury;
-Approaches: Encourage the resident to assume a standing position slowly; encourage the resident use environmental devices such as hand grips and hand rails; give reminders not to ambulate or transfer without assistance; keep the bed in the lowest positron with the brakes locked.
Review of the care plan for psychotropic (relating to or denoting drugs that affect a person's mental state) drug use dated 1/3/20 showed:
-The resident received antiquity medication related to anxiety;
-Goal: The resident will not exhibit drowsiness/over-sedation, delayed reaction, impaired cognition/behavior, disturbed balance, gait or positioning ability, drug dependence, sleep disturbances, rash, blurred vision or anticholinergic symptoms (Side effects of anticholinergic medications include dry mouth and related dental problems, blurred vision, tendency toward overheating (hyperpyrexia), and in some cases, dementia-like symptoms.);
-Approaches: monitor the resident's mood and response to medications.
Review of the nurses notes dated 1/14/20 showed:
-The resident out to see the physician to be evaluated due to decline in condition. The resident is alert to self only, transfers with assistance of two and a mechanical lift, is incontinent of bowel and bladder and needs assistance with eating.
Review of the physician progress note dated 1/14/20 showed:
-Seen for follow up on issues of HTN, cerebellar bleed and atrial fibrillation. He/she has had an extensive workup over the last week failing to reveal any other new issues. The size of the bleed and swelling in the brain are less. At the same time, he/she is not doing as well and the family is concerned. Speech maybe is worse, not getting up and is just not doing as well. No report of headaches and the nausea is resolved. Still has some dizziness and balance issues;
-Impressions and plan: Insomnia and perhaps depression contributing to the issues. Give Remeron (an antidepressant with a side effect of dizziness) and consult with psychiatrist.
Review of the nurses notes dated 1/16/20 through 1/21/20 showed the resident to have increased anxiety, tearfulness and restlessness. Required assistance of two staff members and mechanical lift for transfers and was incontinent of bowel and bladder.
Review of the nurses notes dated 1/21/20 showed:
-No acute confusion or decline in cognition noted. Continues to have frequent episodes of increased anxiety.
Review of the nurses notes dated 1/26/20 signed by Registered Nurse (RN) B showed:
-Resident has improved from one week ago. Appetite increased, able to make his/her needs known. Able to feed him/herself.
Review of the Medication Administration Record (MAR) dated 2/1/20 showed:
-Lorazepam (used to treat anxiety disorders) 0.5 milligrams (mgs) and one half tablet every 12 hours as needed (PRN). Documented as given one time a day from 2/1/20 through 2/7/20. Discontinued on 2/7/20
-Acetaminophen 325 mg, give two tables every four hours. Documented as given at 6:00 A.M., 2:00 P.M. and 10:00 P.M. with a pain level of no pain to mild pain.
-Remeron 15 mg at bedtime.
Review of the therapy notes dated 2/5/20 showed:
-The resident is now using a walker for stand and pivot transfers to and from the toilet. Educated the nursing staff.
Review of the nurses notes dated 2/6/20 showed:
-The resident had extreme anxiety throughout this shift, the resident was found in the room crying out, yelling, throwing things, screaming and hyperventilating. Physician notified.
Review of the nurses notes dated 2/7/20 showed:
-Follow up to physician notification of resident behavior on 2/6/20 with orders to give Lorazepam .05 mg one half tablet every 12 hours.
Review of the MAR dated 2/11/20 showed an order for:
-Lorazepam 0.5 mg, give one half tablet two times a day with a start date of 2/11/20.
Review of the nurses notes dated 2/9/20 at 3:33 A.M. signed by Licensed Practical Nurse (LPN) G showed:
-The resident slept at long intervals. As needed analgesic and anti-anxiety medication given per the residents request. Uses call light when in need of assistance. Required assistance with transfer to and from the wheelchair.
Review of the nurses notes dated 2/10/20 at 4:26 A.M. signed by LPN G showed:
-The resident called for assistance approximately 10 minutes after lying in bed and wanted to get up. The resident stayed up for approximately 20 minutes then requested to go back to bed. The resident was tearful.
Review of the nurses notes dated 2/12/20 at 5:44 P.M. signed by RN B showed:
-The resident is agitated throughout the day calling out and crying for staff. The resident will press the call light but will cry out before staff is able to respond. After providing care, the resident cried for staff to come back numerous times and stated his/her head was hurting. Administered prn Acetaminophen.
Review of the nurse notes dated 2/13/20 at 7:25 A.M. signed by LPN G showed:
-The resident slept very little. The resident rested in bed approximately from 7:30 P.M. to 9:00 P.M. The resident then started to yell out and crying. This nurse sat with the resident for a while then the resident began to yell out and crying. This behavior continued throughout the night. The resident complained of a headache.
Review of the speech therapy notes dated 2/13/20 at 1:24 P.M. showed:
-The residents behavior appears to be attention seeking/control. The resident also not speaking in a normal tone but whiny and immature syntax and low volume.
Review of the nurses notes dated 2/13/20 at 4:38 P.M. signed by RN B showed:
-Spoke with nurse at the physician's office regarding the resident's behaviors. Orders were received from the on call physician to increase the Lorazepam to 1 mg two times a day prn and 1 mg at bedtime for anxiety.
Review of the nurses notes dated 2/13/20 at 7:40 P.M. signed by LPN G showed:
-The Certified Nurse Aide (CNA) was assisting the resident to the toilet and the resident fell to the floor. The resident obtained a skin tear to the right shin. Responsible party notified of the fall and skin tear.
Review of the nurses notes dated 2/13/20 at 10:00 P.M. signed by LPN G showed:
-The resident had been yelling and crying out loud since this nurse came on duty. The CNA and the nurse had checked on the resident multiple times. The nurse found the resident attempting to throw his/her legs off the bed. The resident had been wet. The CNA attended to his/her needs. The CNA then found the resident on the floor with his/her head under the bed. There was massive amounts of blood on the resident, the floor and the wall. The bed was moved enough to get to the resident. The residents head was cleaned and the resident had a contusion to his/her left eye brow and possible on the left side of the hair line. The CNA called for additional staff for assistance. Another nurse contacted emergency services and the resident was transported to the hospital ER.
Review of the nurses notes dated 2/13/20 at 10:00 P.M. signed by RN C showed:
-Called to the residents room and noted the resident on the floor lying on his/her back with his/her head toward the foot of the bed. The resident was yelling out incoherently with massive amounts of blood noted from head onto the floor and nearby wall. Unable to visualize the head wound due to massive blood to area. Emergency services called.
Review of the nurses notes dated 2/13/20 at 10:10 P.M. signed by RN C showed:
-Emergency services at the facility and transported the hospital.
Review of the Emergency Medical Services (EMS) report dated 2/13/20 at 11:06 P.M. showed:
-Dispatched to the facility. Upon arrival the resident was laying on the floor with the nursing home staff at the resident's side. The resident had injured his/her head and forearm. The staff does not know how the resident was injured, possibly from a fall from the bed. There is a large amount of blood on the floor. The resident was also incontinent of both urine and stool. The resident had a laceration on his/her head. Information was vague from the staff. The bleeding was nearly controlled at the time of arrival. The resident had bled an inordinate amount. The resident's mental state made evaluation difficult.
Review of the nurses notes dated 2/14/20 at 2:40 A.M. signed by LPN G showed:
-The resident was admitted to the hospital with a brain bleed and a stroke.
Review of the hospital emergency room report dated 2/13/20 at 11:40 P.M. showed:
-The resident presents in the emergency room after a fall. Staff found the resident on the floor and report they were unsure of how long he/she laid on the floor;
-CT (A computerized tomography (CT) scan combines a series of X-ray images taken from different angles around your body and uses computer processing to create cross-sectional images (slices) of the bones, blood vessels and soft tissues inside your body. CT scan images provide more-detailed information than plain X-rays do.) showed scatted small subdural hematoma over the left frontal part of the brain. Contusion to the anterior left frontal lobe of the brain. New stroke noted in the right part of the brain with cerebral edema. The resident was admitted to the hospital.
During an interview on 2/26/20 at 8:30 A.M. LPN G said:
-He/she had worked on 2/9/20 and the resident was restless, but able to have a conversation about his/her family and current events;
-When he/she came back to work on 2/11/20 the resident was a different person, he/she was very restless, no longer able to carry on a conversation, was agitated and complained of a headache;
-The primary care physician was not available, the on call physician had ordered Lorazepam to be given at bedtime;
-On 2/13/20 the resident had two falls. The first fall occurred around 7:30 P.M. when CNA J had tried to transfer the resident to the toilet and was lowered to the floor;
-The resident could not bear weight;
-The resident got a skin tear to the left lower leg;
-CNA J put the resident to bed after the fall, the resident was very restless, throwing his/her leg over the side of the bed, screaming out. He/she tried to check on the resident as much as he/she could. CNA J was busy laying other resident down;
-At around 9:30 P.M. or 9:45 P.M., CNA J yelled for him/her to come to the resident's room;
-When he/she entered the resident's room, the resident was laying on his/her back on the floor with his/her head at the foot of the bed, partially under the bed;
-There was a lot of blood on the floor and on the walls;
-The resident's bed was about a foot off the floor and there were no fall mats beside the bed, the resident had half rails at the head of the bed;
-He/she moved the bed away from the resident's head and had CNA J call for the other staff;
-The resident was yelling out, but would respond to his/her name;
-He/she is unsure of how long the resident was on the floor before CNA J found him/her;
-Another nurse called for an ambulance and the resident was transferred to the hospital.
During an interview on 2/26/20 at 9:30 A.M. RN B said:
-He/she took care of the resident on 2/12/20 and 2/13/20;
-The resident had complained of increased nausea and a headache on 2/12/20;
-He/she received an order from the neurologist for medication for the nausea and the resident's Tylenol prn order was changed to be given scheduled;
-He/she had noted a behavior change in the resident;
-The resident was more agitated and confused, the resident would yell out and was very anxious and impulsive, he/she would try to get out of bed;
-The resident complained of a headache and was given Acetaminophen as ordered;
-He/she would put a cool compress to the resident's head for comfort;
-He/she did not know what else to do;
-He/she contacted the primary care physician regarding the change in the resident's mental status and received an order from the on call physician to give Lorazepam 0.5 mg in the morning and 1 mg at bedtime;
-The primary care physician was not available to give an update on the change in the resident's mental status;
-He/she did not think to call the Medical Director when the primary care physician was not available.
During an interview on 2/26/20 at 10:30 A.M. the Director of Therapy said:
-The resident was receiving physical, occupational and speech therapy due to the brain bleed and stroke;
-The resident was progressing physically in therapy and was able to be transferred by one staff member;
-On 2/13/20 the nursing staff requested a speech evaluation due to an increase in -behaviors, would yell out and become very anxious;
-The speech therapist recommended the nursing staff contact the primary care physician.
During an interview on 2/26/20 at 11:30 A.M. the Director of Nursing said:
-The resident was admitted to the facility in December of 2019 from a spontaneous brain bleed and stroke. The resident was improving physically and mentally and had a goal to return to home;
-The first part of January 2020, the resident showed a physical decline and was seen by the primary care physician and at the hospital. The CT of the head showed that the brain bleed was dissipating but the swelling remained. The resident returned to the facility and began showing progress again in therapy;
-A few days before 2/13/20, the resident had an increase in agitation, anxiety, very restless and a decline mentally;
-The primary care physician was called regarding the change in condition, but did not return the facilities calls;
-On 2/13/20 RN B contacted the physician on call and received an order to increase the Lorazepam;
-She was notified on 2/13/20 around 7:30 P.M. of the residents fall in the bathroom and again at 10:00 P.M. of the resident being found on the floor and sent to the hospital;
-She did not notify the Medical Director of the resident's change in mental status when the primary care physician was not available;
-She did not think to send to the resident to the emergency room for the change in mental status when the primary care physician was not available;
-She should have contacted the Medical Director.
During an interview on 2/27/20 at 9:10 A.M. CNA J said:
-He/she took care of the resident on 2/13/20;
-The resident was having a lot of behaviors. He/she was very impulsive and would attempt to throw him/herself off the bed. He/she would try to stand up and fall back onto the bed;
-He/she was transferring the resident from the wheelchair to the toilet around 7:30 P.M. with a gait belt, when the resident said that he/she could not stand and that he/she was going to fall. He/she lowered the resident to the floor and call for the nurse;
-The resident was assisted by him/herself and another CNA back into the wheelchair and he/she laid the resident in the bed;
-The bed was about a foot off the floor with no fall mats beside the bed, there were half rails at the top of the bed;
-About an hour and half to two hours later, he/she went by the residents room and saw the resident on the floor;
-The resident's head was at the foot of the bed;
-There was a lot of blood around the resident's head;
-He/she called for the nurse.
During an interview on 2/27/20 at 9:30 A.M. Physician A said:
-He/she expects the nursing staff to notify the primary care physician of any changes in the resident's mental and/or physical status;
-When the primary care physician is not available, then the nursing staff should contact him/her;
-He/she was contacted when the primary care physician was not available when the resident showed a change in status;
-He/she would expect to send a resident to the hospital when there is a significant change in status;
-He/she would have expected the nursing staff to have sent the resident to the hospital emergency room when they noted the significant change in status and the primary care physician was not available.
MO166761 and MO166727
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 observation, interview and record review, the facility failed to ensure staff provided written notices of transfer or d...
Read full inspector narrative →
**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, interview and record review, the facility failed to ensure staff provided written notices of transfer or discharge to residents or their responsible parties and the reasons for the transfer in writing in a language they understood. This affected two of 18 sampled residents (Resident #92 and #31). The facility census was 90.
1. Review of Resident #92's discharge Minimum Data Set (MDS) assessment, a federally mandated assessment completed by facility staff dated 11/27/19, showed:
- admission date was 10/13/19.
- discharge date of 11/27/19.
- Discharge was planned; return not anticipated.
2. Review of the resident's medical record showed:
-The facility discharged the resident to his/her own home with Home Health Services per the resident's physician's order.
- Staff did not document that a discharge letter was presented to the resident or the resident's representative prior to discharge.
3. Review of Resident #31's discharge MDS dated [DATE] showed:
--admitted to the facility on [DATE];
-discharged from the facility on 2/23/20;
-Discharge was not planned; return anticipated.
Review of the medical record showed:
-The resident was discharged to the hosptial on 2/13/20;
-Staff did not document that a discharge letter was presented to the resident or the resident's representative.
4. During an interview on 2/27/20, at 10:48 A.M., the administrator said she was not aware the facility was required to provide a discharge letter to the resident or the resident's representative when they discharged , therefore, they were not providing the letters.
CONCERN
(D)
Potential for Harm - no one hurt, but risky conditions existed
Comprehensive Care Plan
(Tag F0656)
Could have caused harm · This affected 1 resident
**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on interviews and record review, the facility failed to develop a comprehensive person-centered care plan that included ob...
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**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on interviews and record review, the facility failed to develop a comprehensive person-centered care plan that included objectives to meet a residents' medical, nursing, and mental and psychosocial needs identified in the comprehensive assessment. This affect two residents (Resident #63 and #74). The facility census was 90.
Review of facility policy, Resident/Family Participation in Care Planning, dated 2017, showed:
-Care planning includes both the initial decisions about care and treatment and the decisions about changes in care and treatment.
Review of facility policy, Comprehensive Assessments and Care Planning, dated 2017, showed:
-Purpose: to provide a comprehensive person-centered interdisciplinary care assessment of the residents' condition, in order to develop consistent quality care that will attain or maintain the highest practicable physical, mental and psychological functioning possible.
-The baseline care plan reflects goals and objectives, and includes interventions that address his or her current needs.
-A facility should use the results of the assessment to develop, review and revise the care plan.
1. Review of Resident #74's significant change Minimum Data Set (a federally mandated assessment completed by facility staff), dated 1/18/20, showed:
-Receives dialysis.
-Diagnoses include: end-stage renal disease.
During an interview, on 02/24/20 at 1:00 P.M., Resident #74 and family member said:
-He/she receives hemodialysis offsite Monday, Wednesday, and Friday and the facility handles the transportation to and from the dialysis facility.
Review of the POS (physician order sheet) showed:
-01/12/20: Dialysis Mon/Wed/[NAME].
Review of the care plan showed:
-No documentation of dialysis.
2. Review of Resident #63's significant change MDS, dated [DATE], showed:
-Not on hospice.
-Diagnoses included: stroke, dementia, and alzheimer's disease.
Review of the POS showed:
-05/29/19: Admit to hospice.
-01/22/20: discharged from hospice and referred to the Serious Illness Management program.
Review of nurses notes showed:
-01/30/20: Notify hospice to readmit.
Review of the care plan showed:
-No documentation of hospice or the cares coordinated between the two providers.
During an interview on 02/25/20, at 09:30 P.M., Licensed Practical Nurse (LPN) C said:
- Resident #63 is currently on hospice.
During an interview on 02/27/20, at 11:51 A.M., the MDS and Care Plan Coordinator said:
-Dialysis should be care planned.
-Hospice should be care planned to show the coordination of cares between hospice and the facility staff.
During an interview on 02/27/20, at 02:18 P.M., the Director of Nursing said:
-Care plans should include dialysis.
-He/she was unsure if hospice is care planned, but that the mds/care plan coordinator is responsible for the care plans.
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 observations, interviews, and record reviews, the facility failed to implement measures to treat and prevent pressure u...
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**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observations, interviews, and record reviews, the facility failed to implement measures to treat and prevent pressure ulcers (PU) , (injuries to skin and underlying tissue resulting from prolonged pressure on the skin) when staff did not asses and document a new PU and implement measures to promote healing and ensure treatment was provided when direct care staff identified a skin change for one of 18 sampled residents (Resident #47). The facility census was 90.
1. Review of the facility's policy titled Prevention and Treatment of Skin Breakdown dated 2018, showed:
- Definitions: PU, refers to localized damage to the skin and/or underlying tissue usually over a bony prominence or related to a medical or other device;
- Stage I PU: Non-blanchable erythema (reddening of the skin) of intact skin;
- Stage II PU: Partial-thickness skin loss with exposed dermis (the inner layer of the two main layers of the skin);
- Stage III PU: Full-thickness skin loss;
- Stage IV PU: Full-thickness skin and tissue loss;
- Unstageable PU: Obscured full-thickness skin and tissue loss;
- An unstageable PU appears as full-thickness skin and tissue loss in which the extent of tissue damage cannot be confirmed because it is obscured by slough (a form of non-viable tissue) or eschar (dead tissue).
2. Review of the Resident #47's admission Braden (tool to assess risk of PU) assessment dated [DATE], showed:
-No unhealed PU;
-Skin pale;
-Skin tears;
-Surgical wounds;
-Bed mobility: extensive assistance;
-Friction and shearing problem: requires moderate to maximum assist with moving;
- Skin turgor (refers to the skin's elasticity and how quickly your skin returns to its normal and is only moderately accurate at detecting hydration levels, the skin's elasticity) poor;
-Edema (swelling)
-Elastic stockings (assist with swelling);
-Elevate edematous/affected extremities;
-Degree of physical activity: Chair fast ability to walk is severely limited or nonexistent;
-Mobility: ability to change and control body position very limited;
-Nutrition: probably inadequate;
-Muscle wasting;
-Sensory perception ability to respond manfully to pressure-related discomfort slightly limited, responds to verbal commands but can not always communicate needs/discomfort or has some sensory impairment that limits ability to feel pain/discomfort in 1-2 extremities;
-Decreased range of motion;
- Surgical wound care;
- Pressure reduction devices for bed and chair;
-Turning/repositioning program;
-Occupational and physical therapy;
-Skin tear present on admission to left elbow. Right hip has two incisions with dressings that are draining;
-Braden score of 13 which indicates moderate risk for skin breakdown.
Review of resident's admission Minimum Data Set (MDS), a federally mandated assessment instrument completed by facility staff, dated 1/13/20, showed staff assessed the resident as follows:
-Moderate cognitive impairment;
-Extensive staff assistance of two staff for bed mobility, dressing, and transfers;
-No unhealed PU;
-Diagnoses included hip fracture and cancer.
Review of the resident's physician order sheet (POS) dated February 2020, showed:
-admitted to the facility on [DATE];
-Start date 1/8/20, asses skin every hour of sleep (HS) for breakdown and redness especially bony prominence's and dependent areas;
- Start date 2/20/20, cleanse right heel with wound cleanser pat dry, apply cavilon barrier (helps to protect intact or damaged skin from irritation) film to surrounding intact tissue apply tegaderm (non-adherent dressing) foam border once daily;
-Start date 2/26/20, at 1:01 P.M., wound clinic referral.
Review of the resident's nurses' notes dated 2/13/20, at 1:34, showed Certified Nurse Aide (CNA) A documented the following:
-Therapy staff assisted resident with his/her shower no skin issues noted by therapy staff.
Review of the resident's nurses' notes dated 2/17/20, at 2:36 P.M., showed CNA A documented the following:
- Assisted resident with shower nurse notified of shower and skin issues.
Review of the resident's nurses' notes dated 2/17/20, at 7:13 P.M., showed Licensed Practical Nurse (LPN) A documented the following:
-Resident is alert and oriented and able to make needs known requires assistance with activities of daily living and transfers. Continues to be followed by therapy without problem noted. No documentation of the reported new skin issue.
Review of the resident's care plan updated on 2/20/20, showed:
- Unstageable PU to right heel related to decreased activity and mobility secondary to right hip fracture post surgical repair;
-Inspect skin daily for redness or breakdown especially bony prominence and dependent areas;
-Wound care per physician orders.
Review of the resident's Wound Management note dated 2/20/20 at 2:00 A.M., showed staff documented the following:
-Wound type: Unstageable PU to right heel slough and /or eschar;
-Length 2 centimeters (cm);
-Width 3.5 cm;
-No depth;
-Exudate (drainage), color serosanguineous (pale to pink thin and watery);
-Necrotic tissue;
-No odor;
-Irregular wound edges macerated (occurs when skin is in contact with moisture for too long).
Review of the Resident's weekly Braden dated 2/20/20, showed:
-New unstageable PU injury to right heel;
-Unhealed PU;
-Most severe tissue type for any PU: Eschar;
-Skin and PU treatments: PU care;
-Applications of ointments/medications other than to feet;
-Physician update;
-Skin tears;
-Bed mobility: limited assistance;
-Friction and shearing: Problem requires moderate to maximum assist in moving;
-Skin turgor poor;
-Edema;
-Elastic stockings;
-Elevate edematous/affected extremities;
-Degree of physical activity: Chair fast ability to walk is severely limited or nonexistent;
-Mobility: ability to change and control body position slightly limited;
-Nutrition: adequate;
-Sensory perception ability to respond meaningfully to pressure-related discomfort slightly limited responds to verbal commands but can not always communicate needs/discomfort or has some sensory impairment that limits ability to feel pain/discomfort in 1-2 extremities;
-Pressure reduction devices for bed and chair;
-Braden score of 15 which indicates at risk for skin breakdown.
Review of the resident's nurses' notes for February 2020, showed staff documented the following:
-2/24/20, at 2:19 P.M., wound noted to right heel measures larger than previous measurement. Resident is a diabetic and has established care with podiatry (specializes in treatment of disorders of the foot, ankle, and lower extremity) plan to contact office as he/she has an upcoming appointment to determine if the physician would like to assess the resident sooner;
-2/24/20, at 2:30 P.M., Referral to wound clinic due to resident's PU being open with drainage, previous scheduled appointment with podiatry unchanged.
During an interview on 2/27/20, at 10:59 A.M., CNA A said the following:
-Staff are expected to asses residents' skin while cares are being provided;
-If the observation is during a resident's shower staff should chart their findings on a shower sheet, report their findings to the charge nurse, give the shower sheet to the nurse, and document the issue;
-On 2/17/20, he/she assisted the resident with a shower;
-The resident's right heel was reddened and he/she reported this to LPN A.
During an interview on 2/27/20, at 11:10 A.M., LPN A said the following:
-All staff are expected to asses residents' skin while cares are being provided;
-When a new PU identified nursing staff are expected to contact the resource nurse and he/she will stage the PU, measure, document the findings, and obtain orders for wound care;
-He/she was the nurse in charge on 2/17/20, and does not recall CNA A informing him/her that Resident # 47's heel was reddened;
-He/she did not recall CNA A providing him/her with the resident's shower sheet with a newly identified skin change.
During an Interview on 2/27/20, at 11:29 A.M., Certified Occupational Therapy Assistant (COTA) A said the following:
-He/she assisted the resident with a shower on 2/13/20, and he/she had no skin breakdown.
During an Interview on 2/27/20, at 1:20 P.M., Registered Nurse (RN) B said:
-He/she is the facility's wound care nurse;
-He/she does weekly measurements of residents' with wounds;
-Resident # 47 developed an unstageable PU to his/her right heel after he/she was admitted to the facility;
-Staff should have identified a change in the resident's skin prior to 2/20/20, when staff identified an unstageable PU to the resident's right heel;
- A darkened area on a wound is indicative of eschar and is considered unstageable.
During an interview on 2/27/20, at 2:15 P.M., the Director of Nursing (DON) said:
-All staff are expected to asses residents' skin while cares are being provided;
-If a new PU is identified by an LPN they are expected to contact the resource nurse and he/she will stage the PU, measure, document the findings, and ensure orders are obtained for wound care;
-On 2/17/20, when CNA A identified the resident's heel being reddened the above measures should have been implemented.
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 provide appropriate care and services to one of 18 sampled residents (Resident #14) with a percutaneous endoscopic gastrostomy...
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Based on observation, interview and record review, the facility failed to provide appropriate care and services to one of 18 sampled residents (Resident #14) with a percutaneous endoscopic gastrostomy (PEG) ( a tube that is placed directly into the stomach through an abdominal wall incision for administration of food, fluids, and medications) when staff did not follow their policy to check for placement by checking gastric residual volume (GVR) (a technique to determine how the resident is tolerating the enteral feeding) prior to medication administration, and failed to administer medications in a way that would prevent the PEG tube from becoming clogged. The facility census was 90.
1. Review of the facility's undated policy titled PEG tube, showed:
-Inspect PEG tube prior to medication administration or beginning of feeding process;
-Prior to medication administration or start of feeding, check GVR if any push back into tube;
-If there are any concerns or questions regarding the tube placement, or complaints of pain, notify the provider for further instruction before proceeding with treatment;
-The policy did not include the administration of medication through a PEG tube.
Review of the facility's undated policy titled nasogastric tube (NG tube) (a special tube that carries food and medicine to the stomach through the nose) showed:
-Objective: To safely administer medications;
-The resident's head of the bed should be elevated to semi-Fowlers (position is a position in which a patient, typically in a hospital or nursing home in positioned on their back with the head and trunk raised to between 15 and 45 degrees);
-Remove plunger from 60 milliliter (ml) syringe and connect to clamped tubing if clamp present;
-Administer approximately 30 ml of water prior to receiving medications, then administer one at a time, flushing tube with 5 ml water after each medication and approximately 15-30 ml of water after all medication is given;
-The policy did not include how staff should prepare and administer medications that require crushing.
2. Review of Resident #14's care plan, revised 12/7/19, showed:
-Asses feedings tube placement, patency, and residual every shift and before/after administration of any fluids or medications;
- Monitor medications.
Review of Resident #14's admission Minimum Data Set (MDS), a federally mandated assessment instrument completed by facility staff, dated 12/13/19, showed staff assessed the resident as follows:
- Rarely understood;
- Extensive assistance of two staff for bed mobility, dressing, and transfers;
- Receives 51% or more of his/her nutrition through a tube;
- Diagnoses included cerebrovascular accident (CVA) (medical term for a stroke) and aphasia (impairment of language).
Review of the resident's physicians' order sheet (POS), dated February 2020, showed:
-Keppra (seizure medication) liquid 500 milligrams (mg)/ 5 ml administer 10 ml per gastric tube twice daily;
- Atorvastatin (medication used to improve cholesterol levels and decrease risk for heart attack and stroke) tablet 80 mg per gastric tube twice daily;
-Potassium chloride (mineral supplement used to treat or prevent low amounts of potassium in the blood) liquid 20 milliequivalent (meq)/15 ml administer 15 ml per gastric tube twice daily;
-Flush with 50 ml of water before and after medication administrations;
-Flush PEG tube with 100 ml of water every six hours;
-IsoSource (nutritionally-complete, calorically-dense tube feeding formula), 1.5 at 50 ml/hour continuous tube feeding.
Observation and interview on 2/25/20, at 3:10 P.M., showed Licensed Practical Nurse (LPN) A did and said the following:
- Informed the resident that he/she planned to administer his/her medications;
-Prepared the resident's Atorvastatin 80 mg crushing the tablet and poured the crushed tablet into a medication cup, did not add water to the medication cup to make a slurry (semi-liquid mixture);
-Prepared the resident's liquid Keppra 10 ml in a medication cup;
-Prepared the resident's liquid Potassium chloride 15 ml in a medication cup;
-Obtained a 60 ml syringe and pulled the plunger inside the 60 ml syringe back to 50 ml which was near the end of the syringe;
-Opened the resident's PEG tube and inserted the 60 ml syringe into the end of the tube and gently pushed the plunger all the way injecting air to checked placement of the PEG tube as he/she used auscultation with his/her stethoscope;
-He/she did not pull the plunger back to check the resident's gastric residual volume (GRV) (refers to the volume of fluid remaining in the stomach at a point in time during enteral nutrition feeding);
-As he/she removed the 60 ml syringe from the resident's PEG tube air exited the tube making a gastric noise;
- Pulled the plunger from the 60 ml syringe and put the tip of the 60 ml syringe into the PEG tube, held the syringe above the stomach, and slowly poured 50 ml of water from a graduate (container used for measuring) into the 60 ml syringe allowing the water to flow into the resident's stomach via gravity;
- After pouring 50 ml of water into the syringe he/she poured the medication cup that contained the resident's Potassium chloride 15 ml into the 60 ml syringe;
- Poured 10 ml of water to flush the PEG tube then he/she poured the resident's crushed Atorvastatin 80 mg tablet into the tube;
-Immediately the contents in the 60 ml syringe stopped running in via gravity;
-LPN A said the tube is clogged;
-Rubbed the PEG tube between his/her fingers attempting to unclog the PEG tube;
-Said he/she should have added water to the medication cup that contained the resident's crushed Atorvastatin 80 mg;
-Removed the 60 ml syringe from the PEG tube and inserted the plunger into the syringe;
- Inserted the 60 ml syringe into the PEG and put the tip of the 60 ml syringe into the PEG tube, held the syringe above the stomach, with the plunger pulled back about half way;
-Pushed the plunger in the 60 ml syringe several times and said the resident's PEG tube remains to be clogged;
-Rubbed the PEG tube between his/her fingers attempting to unclog the PEG tube;
-Shook the 60 ml syringe back and forth that remained connected to the resident's PEG tube;
-Again pushed the plunger two more times and said the PEG tube is now unclogged;
-Poured 10 ml of water to flush the PEG tube then poured the resident's Keppra 10 ml into the syringe;
-Poured 50 ml of water from the graduate into the syringe then removed the 60 ml syringe from the PEG tube and closed the resident's PEG tube;
- Gathered supplies, removed his/her gloves, washed his/her hands, and exited the resident's room.
During an interview on 2/25/20 at 3:40 P.M., LPN A said:
-It is acceptable to inject 50 cc of air when checking for placement;
-Checking Placement also includes checking for GVR;
-The PEG tube became clogged because he/she did not make a slurry with the resident's Atorvastatin 80 mg.
During an interview on 2/27/20, at 2:15 P.M., the Director of Nursing (DON) said:
- PEG tube placement should be verified using auscultation with a stethoscope prior to administering medication, water flushes, and supplements;
-This is done by pulling the plunger back to no more than 20 ml and staff should gently introduce a small amount of air using a 60 ml syringe;
-Checking placement also includes checking for GVR;
- Staff check GVR to determine how the resident is tolerating the enteral feeding (feeding administered through the gastrointestinal tract);
-When administering medications that are not in a liquid form staff should crush the medication and then add some water to the cup to prevent the medication from clogging the tube;
- Give medications only by gravity, and staff should not force with plunger.
CONCERN
(D)
Potential for Harm - no one hurt, but risky conditions existed
Unnecessary Medications
(Tag F0759)
Could have caused harm · This affected 1 resident
Review of www.humalog.com, showed:
-Humalog (a fast acting insulin used to control blood sugars) kwikpen should be primed with two units. Failure to do so could result in too much or too little insuli...
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Review of www.humalog.com, showed:
-Humalog (a fast acting insulin used to control blood sugars) kwikpen should be primed with two units. Failure to do so could result in too much or too little insulin. Turn the dose knob to 2 units; hold the pen with the needle pointing up. Tap the cartridge holder gently to collect air bubbles at the top. Continue holding the pen with the needle pointing up. Push the dose knob in until it stops and 0 is seen in the dose window. Hold the dose knob in and count to 5 slowly. There should be insulin at the tip of the needle.
Review of Resident #8's February 2020 POS showed:
-Humalog KwikPen (insulin lispro) 10 units subcutaneously with meals.
Observation and interview on 02/25/20 at 01:35 P.M., showed and LPN E said:
-Did not prime the kwikpen with two units prior to dialing the pen to ten units and administering the dose to the resident.
-She did not know the insulin pen should be primed first.
During an interview on 2/27/20, at 2:15 P.M., the Director of Nursing (DON) said:
- Staff should hold a Forteo pen against the skin for five to ten seconds to ensure the correct dose is delivered.
-Insulin pens should be primed with two units prior to administering the dose.
Based on observation, interview and record review, the facility failed to ensure staff administered medications with a medication error rate of less than 5%. Facility staff made two medication errors out of 25 opportunities for error, resulting in a medication error rate of 8%. This affected two residents (Resident #4 and #8). The facility census was 90.
Review of facility policy, Insulin Pen Injection, dated 3/2012, showed the following on how to prime the pen needle prior to performing the injection:
-Dial 2 units;
-Point pen up;
-Tap cartridge holder to collect air at tip;
-Push the dose knob in until it stops and you see O in the dose window;
-Hold the dose knob in and count to 5 slowly;
-Prime the pen needle so that liquid flows from the pen. Insulin should appear from the tip of the needle. If not re-prime. If you do not see a drop of insulin after 6 times do not use the insulin pen.
Review of the website, https://www.forteo (medication to help to form new bone, increase bone mineral density and bone strength ) .com, showed
-Inject Forteo one time each day in your thigh or abdomen (lower stomach area);
-The Forteo delivery device has enough medicine for 28 days;
-It is set to give a 20 microgram (mcg) dose of medicine each day;
-Inject the medication by inserting the needle into the skin and push the dose knob all the way in and continue to hold the dose knob in and slowly count to 5 before removing the needle.
Review of Resident # 4's February 2020 physician's order sheet (POS) showed:
-Forteo 20 mcg administer 20 mcg subcutaneous ( under the skin) preset injection syringe once daily.
Observation on 2/25/20, at 3:21 P.M., showed Licensed Practical Nurse (LPN) A did the following as the resident sat in his/her chair:
-Informed the resident that he/she planned to administer his/her Forteo injection;
-Attached the needle to the resident's Forteo 20 mcg pen and administered Forteo 20 mcg subcutaneous and did not hold the needle in the skin for 5 seconds and immediately withdrew the needle.
During an interview on 2/25/20, at 4:00 P.M., (LPN) A said:
-It is not necessary to hold the needle in the skin for five seconds after administering Forteo;
-He/she was not aware that the manufacture guidelines for Forteo require the needle to be left in the skin for five to ten seconds after the insulin is administered to ensure the accurate dose is delivered.
CONCERN
(E)
Potential for Harm - no one hurt, but risky conditions existed
Deficiency F0572
(Tag F0572)
Could have caused harm · This affected multiple residents
Based on interview and record review the facility failed to annually inform residents of their rights. The facility census was 90.
1. Review of the facility Resident's Rights and Notification of Resi...
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Based on interview and record review the facility failed to annually inform residents of their rights. The facility census was 90.
1. Review of the facility Resident's Rights and Notification of Resident Rights policy copyright 2017, showed:
- Social Services (SS) was responsible for the policy implementation.
- The facility was to ensure residents are notified of their rights.
2. During a group meeting on 2/25/20 at 2:02 P.M., residents reported staff are not reviewing resident rights with them annually.
During interviews on 2/26/20 at 3:56 P.M. and 2/27/20 at 9:18 A.M., SS staff SS A and SS B said the only time they review resident's rights with the resident's is upon admission. They never review resident's rights with the resident's after that time. They do not go over resident's rights at care plan meetings. They are unaware of regulatory requirements to inform each resident of their rights at least annually.
During an interview on 2/27/20 at 9:20 A.M., Activity staff A said he/she only reviews resident rights with the limited number of residents who attend resident council. He/she does not know who is responsible to review resident rights with other residents' in the facility.
During an interview on 2/27/20 at 7:22 A.M., the Administrator said she was unaware that SS staff were only reviewing resident rights at admission. Staff were to review resident rights with residents and resident family at admission, at each quarterly care plan conference and at least annually.
CONCERN
(E)
Potential for Harm - no one hurt, but risky conditions existed
Deficiency F0604
(Tag F0604)
Could have caused harm · This affected multiple residents
**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, interview and record review the facility failed to provide safety for residents when, staff did not follow...
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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 safety for residents when, staff did not follow their bed rail use policy by not assessing resident's for bed rail use and/or did not provide bed rail protectors for legacy beds and/or did not restrain bed rails to prevent resident access for residents (Resident #141, Resident #145, Resident #146, Resident #17, Resident #147 and Resident #79 ) . The facility census was 90.
1. Review of the facility bed rail policy showed undated guidelines issued by the United States Food and Drug Administration (FDA) titled What Systems do Dimensional Guidelines Reference? for entrapment to all existing bed systems in the field, commonly referred to in eldercare as legacy beds, showed:
- The Seven Zones of Bed Entrapment included Zone 1, Within the Rail: Any open space between the perimeters of the rail can present a risk of head entrapment. FDA recommended space was less than four and three-fourths inches.
- Zone 1 Solutions included mesh side (bed) rail protectors could be added to help reduce potential entrapment areas. Mesh bed rail protectors fit snugly over rails to cover gaps.
Review of the facility Restraint/Adaptive Equipment Use report dated, 4/2019 included:
- Observation date and completed date;
- Bed rails;
- Medical symptoms requiring side rails;
- Reason for bed rail usage;
- Types of bed rails to be used;
- Frequency of use;
- Does device meet the definition of physical restraint?;
- If device is assessed to be a restraint, was appropriate provider order obtained?;
- Care plan action taken.
2. Review of Resident #141's Physician Order Sheet (POS) showed:
- He/she admitted to the facility 2/17/20;
- No order for bed rails.
Observation and interview on 2/24/20 at 1:25 P.M., showed:
- Resident #141 said today, staff put his/her bed rails down and braced them so he/she cannot use them. He/she does not know why suddenly he/she is not allowed to use bed rails.
- Observation showed bilateral bed rails tied down with zip ties to the resident's bed frame.
Review of the facility Restraints/Adaptive Equipment use report for the resident showed a completion date 2/25/20 for bilateral bed rail consent.
Review of General Orders for the resident showed a 2/25/20 nursing order for bilateral side rails.
Observation and interview on 2/25/20 at 8:50 P.M., showed:
- Bilateral bed rails up and accessible to the resident with mesh protectors.
- The resident said he/she used the bed rails that were on his/her bed since he/she admitted to the facility on [DATE]. On 2/24/20, staff took the bed rails away. On 2/25/20, staff had him/her sign forms to put the rails back up. Staff added mesh protectors over the rails that were not on the rails when he/she used them previously.
During an interview on 2/26/20 at 2:06 P.M., Physical Therapist (PT) A said:
- The bed rails were left up on the resident's bed from a previous resident. Staff should have tied the bed rails down prior to the resident moving into the room to prevent the resident from having access to them.
- The resident should have been assessed for the rails prior to using them. The resident used the bed rails since admit to the facility on 2/17/20 until 2/24/20, without staff assessing for safe bed rail use.
- It was not until 2/25/20, that staff completed a bed rail safety assessment.
- The mesh covers over the bed rails are required due to the space between the bed rail bars being too big creating a safety risk.
During an interview on 2/26/20 at 2:25 P.M., the Director of Therapy said:
- The resident was admitted on [DATE]. The legacy bed rails were not removed prior to his/her admit. The resident had access to the rails for a week without staff assessing the resident for bed rail safety. The bed rails should have had mesh protectors on them during this time but did not. The protectors were required due to the space between the bed rails posing a potential resident safety hazard. Staff should have assessed the resident for bed rail use before he/she ever used them.
- Nursing did not notify therapy to do a bed rail assessment for the resident until 2/25/20.
- Nursing staff did not complete a consent to use bed rail form for the resident until 2/25/20.
- A lack of communication between therapy and nursing staff prevented the rails from being assessed before the resident used them.
3. Review of Resident #145's POS showed:
- He/she admitted to the facility on [DATE].
- No order for bed rails.
Review of the resident's care plan dated 2/18/20, showed:
- Diagnoses included dementia.
- No care plan for a bed rail.
No bed rail assessment completed by staff.
Observation on 2/26/20 at 5:22 P.M., showed the resident in bed with one legacy bed rail up without a mesh cover.
4. Review of Resident #146's POS, showed he/she admitted to the facility 2/21/20.
Observation and interview on 2/26/20 at 5:43 P.M., showed:
- The resident lying in bed with one legacy bed rail up without a mesh cover.
- The resident said the nurse recommended he/she use the rail.
5. Review of Resident #17's POS showed:
- He/she admitted to the facility on [DATE].
- No order for a bed rail.
Review of the resident's care plan showed:
- No plan for a bed rail.
No bed rail assessment completed by staff.
Observation and interview on 2/26/20 at 5:45 P.M., showed:
- One legacy bed rail up without a mesh cover.
- The resident said the rail cover got pulled up one day and just never got put back down. He/she used the bed controls on the bed rail and sometimes used the rail to get out of bed.
6. Review of Resident #147's POS, showed:
- He/she admitted to the facility on [DATE].
- No order for bed rails.
Review of the resident's care plan dated 2/24/20, showed:
- Avoid use of restraints.
- No plan for bed rails.
During observation and interview on 2/26/20 at 5:50 P.M., showed:
- One legacy bed rail up on the resident's bed.
- The resident said one of the staff put the rail up for him/her. The rail was kept up most of the time.
No bed rail assessment completed by staff.
7. Review of Resident #79's POS showed:
- He/she admitted the facility on 1/31/20.
- No order for a bed rail.
Review of the resident's care plan showed:
- Diagnoses of altered mental status.
- No plan for a bed rail.
Observation and interview on 2/26/20 at 6:00 P.M., showed:
- The resident in bed with one legacy bed rail up without a mesh cover.
- The resident said the rail was up most of the time. Staff help him/her with the rail.
8. During an interview on 2/26/20 at 2:25 P.M., the Director of Therapy said:
- The facility used legacy beds with bed rails that were unqualified for safe use by residents. Maintenance staff were to cover the rails with mesh protectors when the bed rails were in use. Maintenance and nursing staff determined which bed rails required the mesh protectors. When a resident who used legacy bed rails discharged from the facility, maintenance staff were to zip tie the rails down to prevent accessibility.
- Physical therapy conducts a movement assessment and administrative nursing staff used a bed rail assessment to determine if bed rails are an enabler or a restraint. If it is determined that the rails are a restraint then the resident cannot use them.
- At times, staff miss removing the bed rails between one resident discharging and a new resident admitting, leaving the rails accessible to resident's who have not been assessed for bed rail safety or determination if it is an enabler or restraint.
During an interview on 2/26/20 at 3:18 P.M., the Maintenance Supervisor (MS) said:
- The facility used mesh covers on legacy bed rails to prevent risk of resident entrapment. Nursing and physical therapy staff were to let the maintenance staff know if a resident needed bed rails. If the bed is a legacy bed, nursing and physical therapy staff put the mesh covers on the bed rails.
- Maintenance staff used zip ties to tie down bed rails when not assessed for safe use for a resident by nursing and therapy.
- When a resident discharged from the facility, nursing staff were to inform maintenance staff to zip tie the bed rails down in order to prevent it from getting missed before a new resident was admitted . He/she was not aware of any bed rails being missed. It was unsafe to leave bed rails accessible to resident's who were not assessed for safe bed rail use.
During an interview on 2/26/20 at 4:18 P.M., Unit Coordinator (UC) A said:
- Resident bed rail use is determined between administrative nursing staff and therapy staff.
- Bed rails are never used as a restraint only as an enabler.
- Staff determine resident bed rail use by physically assessing the resident. The assessment is documented in the resident care plan. A nurse makes an order for resident bed rail use.
- All of the legacy beds are required to have a mesh covers for safety as without them residents could get their heads through the bed rail openings.
- Residents are required to sign a bed rail consent form to show they are aware that there is a possibility of their head getting through the bed rail opening and to show they understand the benefit of the rail.
- Staff do not know how bed rails that have not been assessed for a resident safe use become accessible to residents. They do not know if family are putting them up or if the rails are not strapped down prior to residents admitting to the facility. Part of the problem could be due to some of the bed rails having bed controls on them that residents want to access in order to reposition. Staff do not take the bed rails completely off the bed due to needing the controls on the rails in order to raise and lower the beds. Staff explain to the residents that the bed rails are not to be up unless they assess them to determine that they need the rails.
- He/she did not know when the MS determines to strap down the bed rails. He/she did not know how this is communicated to the MS.
- The communication system between staff regarding the bed rails was poor. He/she did not know the system and should. He/she thought the MS should be notified to strap down the bed rails when a resident discharges to prevent the bed rails from being accessible to newly admitted residents.
During an interview on 2/27/20 at 11:00 A.M., the Director of Nursing (DON) said the legacy beds used by the facility have an open space between the perimeters of the bed rail that is bigger than the FDA guidelines for Zone 1 of The Seven Zones of Bed Entrapment allow.
During an interview on 2/27/20 at 7:22 A.M., the Administrator said if residents need bed rails for bed mobility they need to be assessed for bed rail use, then a decision made. The assessment should happen upon admission. The nurse who is handling the resident's admission should be part of the bed rail assessment. Only cognitively appropriate residents should have bed rails. Staff should follow the bed rail policy.
CONCERN
(E)
Potential for Harm - no one hurt, but risky conditions existed
Deficiency F0658
(Tag F0658)
Could have caused harm · This affected multiple residents
Review of Resident #85's admission MDS assessment, dated 2/10/20, showed:
-No cognitive impairment.
-Required limited assistance with Activities of Daily Living.
-Diagnoses included: type 2 diabetes. ...
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Review of Resident #85's admission MDS assessment, dated 2/10/20, showed:
-No cognitive impairment.
-Required limited assistance with Activities of Daily Living.
-Diagnoses included: type 2 diabetes.
During an interview on 2/24/20, at 10:10 A.M., the resident said:
-Last weekend his/her blood sugar bottomed out, he/she asked a nurse to check his/her blood sugar, it was 44, the nurse gave him/her a glass of juice.
-He/she waited a while and could tell the juice was not working, he/she went back to the nurse to tell her the juice had not worked because he/she still felt shaky and light headed and asked her to retake his/her blood sugar, the nurse told her she had to wait an hour to have blood sugar rechecked, and the nurse never followed up with her.
-He/she felt scared because he/she could have went into diabetic coma and it made him/her angry because he/she knew there was an issue and the nurse refused to help his/her.
Review of the resident's progress notes showed staff documented the following:
-On 2/15/20, at 03:03 AM patient complained of feeling strange and very clammy. Blood sugar was taken and results were 44. Juice was given as well as crackers and peanut butter. A cool cloth was placed around her neck. Patient feels much better and has gone on to bed. Will continue to monitor.
-No additional progress notes showing staff documented continued monitoring the resident's blood glucose level reading or condition.
-Staff did not document that anyone had notified the resident's physician of the hypoglycemic blood glucose level.
Review of the resident's vital signs records dated February 202 showed:
-No documentation of the resident blood glucose level reading on 2/15/20 at 3:03 AM on and no documentation to indicate staff rechecked the resident's blood glucose levels every 15 minutes until hypoglycemia was resolved.
-Staff documented a blood glucose level reading at 2/14/20 at 9:49 PM at 168 ml/dl and a reading on 2/15/20 at 8:04 AM at 237 ml/dl.
During an interview on 2/27/20, at 2:15 P.M., the Director of Nursing (DON) said:
-Physician orders should be followed;
-Daily dressing changes should be done as ordered by the physician;
-She expects staff to follow their protocols and is a resident's blood sugar is less than 60 mg/dL staff should recheck the resident's blood sugar every fifteen minutes and notify the resident's physician;
-Resident's on insulin are at risk for hypoglycemia (a condition caused by low blood glucose (blood sugar) levels that can be life threatening if not treated);
- Glucagon comes as a solution (liquid) in a prefilled syringe and an auto-injector device to inject subcutaneously (just under the skin), and is used for treatment to treat very low blood sugar);
-Resident's who are on insulin should also have an order for Glucagon.
Review of Resident #49's annual Minimum Data Set (MDS), a federally mandated assessment, dated 1/8/20, showed staff assessed the resident as follows:
- Cognitively intact;
- Supervision for activities of daily living (ADLs);
- Diagnoses of heart failure, and chronic obstructive pulmonary disease (COPD, a chronic inflammatory lung disease that causes obstructed airflow from the lungs), and respiratory failure;
-Hospice care;
-Required oxygen therapy.
Review of the resident's care plan, last updated on 1/16/20, showed:
-Physician ordered oxygen therapy;
-Staff assistance with applying maintaining and removing oxygen when needed;
-Requires oxygen therapy at all times;
-Change oxygen tank when needed;
-At risk for acute respiratory infection related to lung disease.
Review of the physicians' order sheets (POS), dated February 2020, showed the following orders:
- Start date 11/11/19, oxygen at 2 liters (L) per minute via nasal cannula may increase to 4 L with exertion;
-Monitor oxygen cannula in place four times daily.
-Diagnosis included chronic COPD.
Observation on 2/24/20, at 11:05 A.M., showed the resident in his/her wheelchair in the hallway with a nasal cannula attached to his/her face. He/she had a portable oxygen tank attached to his/her wheelchair.
Observation on 2/24/20, at 11:15 A.M., showed the resident in his/her wheelchair in the hallway with a nasal cannula attached to his/her face. He/she had a portable oxygen tank attached to his/her wheelchair and appeared to be in distress. He/she stated I can not breath and was waving his/her arms. The resident was breathing through pursed lips (works by moving oxygen into your lungs and carbon dioxide out of your lungs and relieving shortness of breath).
Observation on 2/24/20, at 11:16 A.M., Certified Medication Technician(CMT) A informed the resident that he/she would check his/her pulse oximeter (an electronic device that measures the saturation of oxygen carried in your red blood cells) and he/she left the resident to obtain the pulse oximeter.
Observation on 2/24/20, at 11:18 A.M., showed CMT A checked the residents pulse oximeter by attaching the device to the resident's finger. The resident's oxygen saturation ( normal reading is typically between 95 and 100 percent) (%), read 64 percent (%) and the resident's lips had a bluish tint (symptom is called cyanosis generally due to a lack of oxygen in the blood). CMT A called for Licensed Practical Nurse (LPN) B. LPN B immediately discovered the oxygen tank on the back of the resident's chair was not turned on. The portable oxygen tank was then turned on at 4 L. The pulse oximeter remained on the resident's finger as the resident continued to breath through pursed lips. The resident's oxygen saturation started to increase and within a few minutes his/her saturation reached 96%. The resident's lips were no longer cyanotic and the resident was no longer breathing with pursed lips.
During an interview on 2/24/20, at 11:30 A.M., the resident said:
-It is terrible to not be able to breathe;
- It is so frightening to not get air.
Observation on 2/24/20, at 11:35 A.M., showed staff pushed the resident to the dinning room.
Review of the resident's nurses' notes dated 2/24/20, showed LPN B documented the following:
-At 10:08 A.M., Resident's lower leg continues to be red, swollen, and tender to touch;
-No documentation of the incident related to the resident's oxygen tank not being turned on;
-No documentation that the physician was notified of the incident.
During an interview on 2/24/20, at 4:00 P.M., LPN B said:
-He/she did not document the incident and or notify the resident's physician because it was not necessary.
During an interview on 2/25/20, at 9:50 A.M., the Director of Nursing (DON) said:
- Staff are expected to set the resident's prescribed oxygen flow rate as listed on the POS on the portable oxygen tank;
- Staff are expected to administer oxygen as ordered by the resident's physician;
-She was not informed that the resident's oxygen saturation was 64%;
-LPN B should have notified her, the physician, and the resident's family;
-LPN B should have done a head to toe assessment including a full set of vitals and documented his/her findings.
Based on observation, record review and interview, the facility failed to assure they provided care and treatment in accordance with professional standards of quality when staff failed to follow physician's orders for one of 18 sampled residents (Resident #47) and failed to follow their policy for one resident ( Resident # 85 ) who had a diagnosis of diabetes and staff failed to notify the resident's physician when the resident's blood sugar was 44, and failed to recheck the resident's blood sugar every fifteen minutes as the policy directed; and facility staff failed to provide necessary respiratory care failed to administer oxygen at the prescribed flow rate, when staff failed to ensure they had the portable oxygen tank turned on. This affected one additionally sampled resident (Resident #43). The facility census was 90.
Review of the facility's policy titled Standing Orders dated 2018, showed:
-Purpose: To provide guidance for nurses when a resident has a slight change of condition;
-Standing orders will be utilized by nursing associates to treat minor changes in condition;
-These orders may be used to treat minor changes in condition that occur, with the understanding that once a standing house order is utilized, the primary provider will be notified;
- Anytime the standing orders are updated, the primary provider will be given a new version to approve and sign off on;
-The policy did not address following physicians' orders.
Review of the facility's Hypoglycemia Protocol for Adults, dated November 2011, showed:
-Moderate hypoglycemia was defined as blood glucose level reading less than 60 milligrams per deciliter (ml/dl).
-If blood sugar level reading is less 60 ml/dl, retest blood glucose in 15 minutes, repeat treatment and retest every 15 minutes until hypoglycemia is resolved.
Review of the facility's policy titled Oxygen Therapy, dated 2017, showed:
Purpose: Oxygen therapy is provided to residents in a safe manner as identified by a prescribed provider. Oxygen therapy is available to residents in need of services to assist in supporting their respiratory needs;
-Administration of the oxygen therapy is completed by nursing associates;
-Document assessment of resident oxygen status, tolerance, vital signs, and respiratory status in medical record as necessary;
-Follow manufacture recommendations for safe handling, cleaning, humidification, storage, and dispensing, maintenance of equipment in accordance with the manufacturer specifications and consistent with federal, state, and local laws and regulations.
Review of Resident #47's admission Minimum Data Set (MDS), a federally mandated assessment instrument completed by facility staff, dated 1/13/20, showed staff assessed the resident as follows:
-Moderate cognitive impairment;
-Extensive staff assistance of two staff for bed mobility, dressing, and transfers;
-Diagnoses included hip fracture and cancer.
Review of the resident's physicians' order sheet (POS) dated February 2020, showed:
-Start date 2/18/20, cleanse right third digit (finger) with normal saline or wound cleanser pat dry apply cavilon barrier (helps to protect intact or damaged skin from irritation) secure with tegaderm (non-adherent dressing) foam adhesive dressing daily and as needed for protection.
Review of the resident's care plan updated on 2/20/20, showed:
-Wound care per physician orders.
Observation and interview on 2/25/20, at 2:30 P.M., the resident did and said:
-He/she had a blister from his/her wheelchair;
-The dressing to the resident's right third digit was dated 2/24/20.
Observation on 2/26/20, at 7:30 A.M., showed the dressing to the resident's right third digit was dated 2/24/20.
During an interview on 2/26/20, at 8:00 A.M., Licensed Practical Nurse (LPN) A said:
-The resident self propels in his/her wheelchair and he/she has a blister on his/her right third digit;
-He/she was the charge nurse on 2/25/20, and he/she forgot to do the resident's dressing change on 2/25/20.
Review of the resident's nurses' notes dated 2/26/20, at 9:31 A. M., showed LPN A documented the following:
- This writer omitted dressing change on 2/25/20, physician made aware of incident.
Observation on 2/26/20, at 10:40 A.M., showed LPN A did and said the following:
-Informed the resident that he/she planned to change the dressing to his/her right hand;
-LPN A removed the dressing resident's right third digit that was dated 2/24/20;
-The open area was approximately the size of a dime, reddened, and very macerated (occurs when skin is in contact with moisture for too long);
-Said the dressing may have gotten wet.
During an interview on 2/26/20, at 10:57 A.M., LPN A said:
-The resident self propels in his/her wheelchair and the open area is a blister that had popped;
-Physician orders should be followed;
-Said he/she notified the resident's physician that the dressing change was not done.
CONCERN
(E)
Potential for Harm - no one hurt, but risky conditions existed
Accident Prevention
(Tag F0689)
Could have caused harm · This affected multiple residents
Based on observation, interview and record review the facility failed to ensure resident safety, when staff stored unsecured oxygen in one resident (Resident # 143)'s closet. The facility census was 9...
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Based on observation, interview and record review the facility failed to ensure resident safety, when staff stored unsecured oxygen in one resident (Resident # 143)'s closet. The facility census was 90.
1. Review of the facility Oxygen Use Safety Precautions dated 12/2002, showed:
- There are procedures for the safe use of oxygen therapy.
- Oxygen tanks are to be securely anchored when stored. Oxygen tanks not in use will be returned to the oxygen closet and placed in appropriate carrier.
- All residents and visitors will be informed of restrictions when oxygen is initiated.
2. Review of the Physical Therapy Daily Treatment Note for Resident #143, showed Physical Therapist Assistant (PTA) A documented that on 2/24/20 at 3:21 P.M., he/she was working with the resident on education of oxygen tank.
Observation and interview on 2/25/20 at 4:00 P.M., showed:
- Family Member (FM) B said on 2/23/20, he/she brought oxygen tanks from home to the facility as requested by PTA A. PTA A planned to use the tanks during therapy sessions with the resident. PTA A had FM B store the tanks in the resident's closet. PTA A did not inform him/her on oxygen storage safety.
- Observation showed two canisters of oxygen laying sideways in a plastic bag in the resident's closet.
During an interview on 2/27/20 at 9:39 A.M., PTA A said he/she asked FM B to bring in two two-hour oxygen tanks to allow him/her to work with the resident on use of the tanks. FM A brought the tanks in the weekend prior to 2/24/20 and stored them in the resident's closet. On 2/24/20, he/she got the tanks out of the closet for use during a therapy session and then placed them back in the closet. He/she did not inform other staff that the tanks were stored in the closet. At the time, he/she did not think about it being a safety risk. Storing oxygen tanks in the closet was a potential safety risk for residents, visitors and staff. He/she did not know where he/she should store resident personal oxygen tanks.
During an interview on 2/27/20 at 11:00 A.M., the Maintenance Supervisor said that it was unsafe for oxygen to be stored unsecured in a resident's closet. All staff should know that oxygen is to be stored and secured in designated locked oxygen storage closets.
During an interview on 2/27/20 at 7:22 A.M., the Administrator said staff should report when oxygen is brought into the facility by resident's family in order for staff to assure it is secured for resident, resident family and staff safety.
CONCERN
(E)
Potential for Harm - no one hurt, but risky conditions existed
Deficiency F0761
(Tag F0761)
Could have caused harm · This affected multiple residents
**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Review of Resident #16's significant minimum data set, (MDS, a federally mandated assessment completed by staff), dated 12/6/19,...
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**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Review of Resident #16's significant minimum data set, (MDS, a federally mandated assessment completed by staff), dated 12/6/19, showed:
-Moderately impaired cognitive status;
-Always incontinent of bowel;
-Diagnosis include: Alzheimer's Disease, dementia, palliative care, toxic encephalopathy (a neurologic disorder that can cause confusion, attention deficits, seizures, and coma), spinal stenosis (abnormal narrowing of the spinal canal that causes pressure on the spinal cord), and chronic kidney disease.
Review of Resident #39's admission MDS, dated [DATE], showed:
-Cognitively intact;
-Diagnoses include: anxiety;
-Received anxiety medication daily for the last seven days.
Review of Resident #50's annual MDS, dated [DATE], showed:
-Cognitively intact;
-Diagnoses include: paraplegia and lung disease;
-Receives scheduled pain medication and as needed (PRN) pain medication.
Review of Resident #291's entry MDS tracking showed admission on [DATE] with no full MDS submission.
Observation and interview of the first floor south medication cart on 02/25/20 at 09:25 A.M., showed and Licensed Practical Nurse (LPN) E said:
-Resident #291's two tablets of hydrocodone/acetaminophen (pain medication) 5 milligrams (mg)-325 mg; use by 2/16/20.
-Resident #50's 25 tablets of tramadol (pain medication) 25 mg scheduled twice a day (BID) as needed (prn); expired 1/28/20.
-Resident #50's 16 tablets of allergy 4 mg scheduled four times a day (QID) prn; expired 2/4/20.
-Resident #16's 30 tablets of hyoscyamine (used to control symptoms associated with gastrointestinal disorders) sublingual 0.125 mg scheduled once every 4 hours prn; expired 12/7/19.
-He/she said it is the nurses' responsibility to check for expired medications on every shift.
Observation and interview of the first floor west medication cart on 02/25/20 at 10:43 A.M., showed and LPN D said:
-Resident #39's five individual pill packets of hydroxyzine (used to treat allergies and anxiety) 25 mg QID prn; four packets showed a use by date of 2/10/20 and the other packet showed a use by date of 2/6/20.
-He/she said expired medications are checked for every shift.
-He/she said expired medications should be removed and destroyed.
During an interview on 2/27/20, at 2:15 P.M., the Director of Nursing (DON) said:
- Medications should be dated when opened, because the expiration date of medications can change once opened.
- Expired medications should be removed from use;
- Expired medications should be checked for at least monthly.
Based on observation, interview and record review, the facility failed to discard outdated medications for four residents (Residents #16, #39,#50, and #291), failed to date multi-dose bottles of medications which included Ativan (anti-anxiety medication) and a vial of tuberculin (used for a skin test performed by injecting a small amount of the tuberculin under the skin on the lower part of the arm) and a multi-dose injectable syringe of Forteo ( medication to help to form new bone, increase bone mineral density and bone strength ) when opened and failed to not store a multi-dose bottle of discontinued Ativan for two additionally sampled residents ( Resident #52 and #4) . The facility census was 90.
Review of the facility policy, Expiration Dating, updated 05/13/15, showed:
-It is the responsibility of nurses who administer medications to monitor the expiration dates of the medications. All expired medications will be disposed of per facility policy.
Review of the facility policy, Destruction of Medications by Facility, updated 05/13/15, showed:
-All discontinued and expired medications shall be disposed of and documented appropriately by the facility nursing staff;
-The facility will place all discontinued or out-dated medications in a designated, secure location, to be used only for discontinued and/or expired medications.
Review of the facility policy, Administering Medications, dated 2018, showed:
-Check expiration dates prior to administering medications.
-Ensure multi-dose containers have the date opened identified on the container.
Review of the undated Physician Online Reference for Ativan Intensol (used to treat anxiety and often used during end of life) showed:
-Staff should discard 90 days after opening the bottle and store between 36 to 46 degrees Fahrenheit (F).
Review of the website, https://www.cdc.gov/infectionsafety/providers.com, showed:
-If a multi-dose vial (typically contains an antimicrobial preservative to help prevent the growth of bacteria) that has been opened or accessed (e.g., needle-punctured), should be dated and discarded within 28 days unless the manufacturer specifies a different (shorter or longer) date for that opened vial, Centers for Disease Control and Prevention (CDC).
Review of the website, https://www.forteo.com, showed
-Inject Forteo one time each day in your thigh or abdomen (lower stomach area);
-The Forteo delivery device has enough medicine for 28 days;
-It is set to give a 20 microgram (mcg) dose of medicine each day.
Review of Resident # 52's February 2020 physicians' order sheet (POS) showed:
-No active order for Ativan.
Observation on 2/25/20, at 2:40 P.M., of the facility's refrigerator that contained residents' medications located in the [NAME] medication room showed:
- Resident # 52's opened bottle of Ativan with no date to indicate when the bottle was originally opened, with a fill date of 10/22/19.
Observation on 2/25/20, at 2:45 P.M., of the facility's refrigerator that contained residents' medications located in the [NAME] medication room showed:
- A multi dose vial of tuberculin with no date to indicate when the vial was originally opened.
Review of Resident #4's February 2020 POS showed:
-Forteo 20 mcg administer 20 mcg subcutaneous ( under the skin) preset injection syringe once daily keep refrigerated.
Observation on 2/25/20, at 2:50 P.M., of the facility's refrigerator that contained residents' medications located in the [NAME] medication room showed:
-Resident #4's Forteo injection pen with no date to indicate when the medication was originally opened with a fill date of 12/27/19.
During an interview on 2/25/20 at 2:55 P.M., Licensed Practical Nurse (LPN) A said:
- All medications should be dated when opened;
-The vial of tuberculin is used for residents' tuberculin tests.
CONCERN
(E)
Potential for Harm - no one hurt, but risky conditions existed
Deficiency F0809
(Tag F0809)
Could have caused harm · This affected multiple residents
**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on interviews and record review, the facility failed to ensure residents were offered a bedtime snack. This affected seven...
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**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on interviews and record review, the facility failed to ensure residents were offered a bedtime snack. This affected seven residents (Resident #1, 29, 30, 37, 50, 141 and #144). The facility census was 90.
1. Review of undated facility policy, Between Meal Nourishments/Bedtime (HS) Snacks showed:
-Nursing staff will offer and provide a nourishing snack at bedtime (HS).
-Nursing will record the intake of between meal and bedtime (HS) snacks according to facility procedure.
-The facility must have a record of residents who are refusing snacks.
2. During a group interview on 02/25/20 at 2:02 P.M., the residents stated:
-Bedtime snacks are not offered.
3. During an interview on 02/25/20 at 9:15 P.M., Certified Nurses Aide (CNA) E said:
-Bedtime snacks are offered by 7:45 P.M.
During an interview on 02/25/20 at 09:30 P.M., Licensed Practical Nurse (LPN) C said:
-Bedtime snacks are offered by 7:45 P.M.
-Many residents do not want one as some are still eating dinner at 7:30 P.M.
During an interview on 2/25/20 at 8:22 P.M., CNA G said:
- He/she offered residents a bedtime snack at 7:45 P.M
- None of the residents on his/her hall accepted a snack tonight.
- He/she did not tell the residents what snacks were available.
- He/she did not show residents the snacks in order to choose one.
During an interview on 2/25/20 at 8:30 P.M., CNA H said:
- He/she offers bedtime snacks after supper between 7:00 P.M. and 7:30 P.M
- He/she has already offered residents a bedtime snack.
During an interview CNA I said he/she is agency staff. This is the second night he/she has worked at the facility. He/she was responsible to provide care assistance for 16 rooms on his/her hall. He/she was not trained to pass bedtime snacks to the residents on his/her hall.
During an interview on 2/25/20 at 9:15 P.M., LPN F said he/she thought CNA's delivered bedtime snacks too close to supper time. He/she did not think that residents would be as interested in a snack when they just finished eating supper.
4. During an interview on 02/25/20 at 8:15 P.M., Resident #30 said:
-He/She was not offered a bedtime snack.
Review of Resident #30's bedtime snack intake record showed:
-No documentation of bedtime snack intakes since 11/30/19.
5. During an interview on 02/25/20 at 08:30 P.M., Resident #50 and family member said:
-He/she did not receive a bedtime snack.
-He/she did not know what a HS (bedtime) snack was.
Review of Resident #50's bedtime snack intake record showed:
- No documentation of bedtime snack intakes since 11/30/19.
6. Review of Resident #29's quarterly Minimum Data Set (MDS), a federally mandated assessment completed by facility staff), dated 12/24/19, showed:
-Cognitively intact;
-Diagnoses include: diabetes.
During an interview on 02/25/20 at 09:05 P.M., Resident #29 said:
-He/she did not receive a bedtime snack.
Review of Resident #29's bedtime snack intake record showed:
-No documentation of bedtime snack intakes since 12/23/19.
7. During an interview on 02/26/20 at 11:20 A.M., Resident #37 said:
-He/she did not receive a bedtime snack last night.
-Bedtime snacks are not offered.
Review of Resident #37's bedtime snack intake record showed:
-No documentation of bedtime snack intakes since 11/30/19.
8. Review of Resident #144's Physician's Order Sheet (POS) showed he/she admitted to the facility on [DATE].
Review of Resident #144's bedtime snack intake record showed no documentation of snack intakes for 2/10/20 through 2/15/20, 2/17/20 through 2/19/20, 2/21/20 and 2/24/20.
During an interview on 2/25/20 at 8:30 P.M., CNA H said:
-The resident's Family Member (FM) A comes every night for most of the evening. He/she already offered the resident a bedtime snack.
During an interview on 2/25/20 at 8:41 P.M., Resident #144 and FM A said:
-FM A visits the resident regularly in the evenings and arrives about 7:00 P.M Staff never offer the resident a bedtime snack. Staff did not offer a bedtime snack tonight.
9. Review of Resident #1's POS showed he/she admitted to the facility on [DATE].
Review of Resident #1's bedtime snack intake record showed no documentation of snack intakes for 2/7/20 through 2/8/20, 2/10/20 through 2/15/20, 2/17/20 through 2/19/20, 2/21/20 and 2/24/20.
During an interview on 2/25/20 at 8:47 P.M., the resident said staff never offer him/her a bedtime snack.
10. Review of Resident #141 POS showed he/she admitted to the facility on [DATE].
Review of the resident's bedtime snack intake record showed no documentation of snack intakes for 2/18/20 through 2/19/20, 2/21/20 or 2/24/20.
During an interview on 2/25/20 at 8:50 P.M., the resident said staff do not offer him/her a bedtime snack.
11. During an interview on 2/27/20 at 7:22 A.M., the Administrator said:
- Staff were to offer bedtime snacks in the evening. Staff should go room to room and ask each resident if they would like a snack during water rounds at 7:30 P.M. to 8:00 P.M The staff should let residents know that the facility has a variety of snacks and what that includes.
- Agency staff should be trained to offer and pass snacks.
During an interview on 02/27/20 at 02:18 P.M., the Director of Nursing said:
-HS snacks should be offered before bed and documented.
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 on observation, interview and record review, the facility failed to ensure staff provided care in a manner to prevent i...
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**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on on observation, interview and record review, the facility failed to ensure staff provided care in a manner to prevent infection or the possibility of infection when staff failed to change gloves and wash their hands between dirty and clean tasks during incontinent care and failed to change gloves and wash hands when providing wound care for three of 18 sampled residents (Residents #77, #47 and #20). Additionally, staff failed to follow their policy when staff did not clean the insulin pen prior to attaching the needle. This affected two additionally sampled residents (Resident #8 and #29). The facility census was 90.
Review of the facility policy, Hand Hygiene, dated September 2017, showed:
-By following proper hand hygiene practices, associates will reduce the spread of potentially deadly germs, as well as reduce the risk of healthcare provider colonization caused by germs acquired from the residents;
-Times to perform hand hygiene are, but not limited to;
-Before and after direct resident contact;
-Before and after assisting a resident with cares;
-Before and after changing a dressing;
-Upon and after coming in contact with a resident's intact skin, such as when taking vitals or after assisting with lifting;
-Before and after assisting a resident with toileting;
-After handling soiled equipment or utensils;
-After removing gloves.
Review of the facility policy, Living Community Saint [NAME] (LCSJ) Insulin Pen Injection, dated March 2012, showed:
-Swab the rubber seal end of the insulin pen with alcohol wipe prior to placing the pen needle.
-After administration, dispose of the needle, trash, and gloves, and wash hands.
1. Review of Resident #77's significant change in condition Minimum Data Set (MDS), dated [DATE], showed:
-Severe cognitive impairment;
-Extensive assistance of two staff for bed mobility, dressing, hygiene and totally dependent on staff for toileteing needs;
-Always incontinent of bowel and bladder.
Review of resident's care plan updated 2/11/20, showed:
-Trimethoprim (antibiotic) 100 milligrams (mg) orally once daily at bedtime for recurrent urinary tract infections (UTI)'s;
-Apply barrier cream with antifungal (creams and medicines are used to treat fungal infections of the skin) to buttock twice daily.
Observation on 2/24/20, at 10:37 A.M., showed Certified Nurse Aide (CNA) C, CNA D, and Licensed Practical Nurse (LPN) B provided incontinent care as the resident lay in bed and they did the following:
-All three staff applied clean gloves without washing their hands prior to putting on clean gloves;
-CNA C obtained a wash basin and filled it with water and wash cloths;
-CNA C and CNA D opened the resident's soiled brief;
-CNA C used several wash cloths and cleansed the resident's frontal perineal skin folds;
-CNA C did not remove his/her gloves and wash his/her hands and with dirty gloves he/she assisted CNA D to roll the resident onto his/her side;
-CNA D used the resident's disposable brief to wipe the resident's buttock removing a moderate amount of fecal material then he/she discarded the soiled brief;
-CNA D did not remove his/her gloves and wash his/her hands after discarding the brief that contained fecal material;
-CNA C used several wash cloths to cleanse the resident's buttock and rectal areas removing fecal material;
-CNA C removed his/her gloves as they contained fecal material and he/she washed his/her hands and applied clean gloves;
-LPN B applied moisture barrier to the resident's buttock, he/she did not remove his/her gloves and wash his/her hands after applying the moisture barrier cream;
-With dirty gloves LPN B and CNA D assisted the resident to roll back and forth as they secured a clean brief, placed the mechanical lift seat under the resident, and dressed the resident;
-With the same gloves CNA D assisted CNA C to used the mechanical lift and both staff transferred the resident to his/her wheelchair with the lift;
-With dirty gloves CNA D obtained the resident's hair brush and hair detangler spray then he/she brushed the resident's hair;
-LPN B removed his/her gloves used hand sanitizer and exited the resident's room;
-CNA D removed his/her gloves and used hand sanitizer;
- CNA D and CNA C assisted the resident with his/her jacket;
-Staff then gathered supplies, bagged the trash, and CNA C removed his/her gloves, and both staff exited the room without washing their hands or using hand sanitizer.
During an interview on 2/24/20, at 3:47 P.M., CNA C and CNA D said:
-Staff should wash their hands and change gloves between dirty and clean tasks;
-Staff should not touch clean items with dirty hands;
-Staff should always wash their hands after glove removal.
During an interview on 2/24/20, at 4:00 P.M., LPN B said:
-Staff should remove their gloves and wash their hands after applying moisture barrier cream to a resident's buttock;
-Staff should not touch clean items with dirty hands.
2. Review of Resident #47's admission MDS dated [DATE], showed staff assessed the resident as follows:
- Moderate cognitive impairment;
- Extensive staff assistance of two staff for bed mobility, toileting, dressing, and transfers;
-Frequently incontinent of bowel staff did not include urinary continence;
-Diagnoses included hip fracture, cancer, and urinary tract infection (UTI).
Review of the resident's care plan updated on 2/20/20, showed:
-At risk for PU due to moisture from bowel and bladder incontinence;
-Urinary incontinence related to UTI;
-Provide incontinence care after each incontinent episode;
-Wound care per physician orders.
Review of the resident's POS dated February 2020, showed:
-Start date 2/18/20, cleanse right third digit (finger) with normal saline or wound cleanser pat dry apply cavilon barrier (helps to protect intact or damaged skin from irritation) secure with tegaderm (non-adherent dressing) foam adhesive dressing daily and as needed for protection;
-Diagnosis included chronic kidney disease and UTI.
Observation on 2/26/20, at 7:30 A.M., CNA A and CNA F entered the resident's room to answer his/her bathroom call light and did the following:
-Both staff used hand sanitizer and applied clean gloves;
-Applied a gait belt and assisted the resident to stand up from the commode;
-CNA F used two disposable wipes and cleaned the resident's frontal perinea skin folds;
-With the used disposable wipes in his/her hand CNA F attempted to pull up the resident's pants;
-CNA A instructed CNA F to not pull up the resident's pants because they needed to clean his/her buttock and rectal area;
-CNA F attempted to reach around the resident and with the same disposable wipes used for the resident's frontal perinea skin folds he/she attempted to wipe the resident's buttock with the disposable wipes ;
-CNA A said stop and he/she obtained several disposable wipes and wiped the resident's buttock and rectal area removing fecal material;
-CNA A did not remove his/her gloves and wash his/her hands and with dirty gloves both staff assisted the resident to pull up his/her pants;
-With dirty gloves both assisted the resident to his/her wheelchair using the gait belt;
-CNA F removed the gait belt from around the resident's waist with dirty gloves and pushed the resident in his/her wheelchair out of the bathroom;
-Both staff removed their gloves and used hand sanitizer as they exited the room.
Observation on 2/26/20, at 10:30 A.M., showed LPN A prepared the treatment cart in the hall and did the following:
-Washed his/her hands and applied clean gloves;
-Placed a disposable barrier on the top of the treatment cart and placed dressing supplies on the barrier;
-Removed his/her gloves did not wash his/her hands opened the treatment cart drawer to obtain scissors and placed them on the barrier;
-Reached into his/her pocket and obtained a marker and placed the marker on the barrier;
-Locked the treatment cart and pushed the cart down the hall to the resident's room.
Observation on 2/26/20, at 10:40 A.M., showed LPN A and CNA A did and said the following:
-Both staff entered the resident's room and LPN A pushed the treatment cart that he/she prepared in the hall prior to entering the resident's room;
-The top of the treatment cart contained a paper barrier with dressing supplies;
-LPN A informed the resident that he/she planned to change the dressing to his/her right hand;
-LPN A placed a disposable barrier in the resident's lap and he/she removed the dressing to the resident's right third digit;
-Picked up the scissors from the top of the treatment cart and cut the dressing off the resident's right hand;
-Placed the scissors on top of the treatment cart not on the disposable barrier;
-Removed the dressing and discarded it in the trash removed his/her gloves and washed his/her hands and put on clean gloves;
-Poured normal saline over the open area then used gauze to clean the wound;
-Did not remove his/her gloves and wash his/her hands after cleansing the wound; -With dirty gloves obtained the cavilon barrier from the top of the treatment cart opened the package of cavilon barrier applying it around the open area;
-The open area was approximately the size of a dime, reddened, and very macerated (occurs when skin is in contact with moisture for too long);
-LPN A removed his/her gloves and said he/she did not have any hand sanitizer on the treatment cart;
-Applied clean gloves without washing his/her hands;
-Obtained the foam adhesive dressing from the top of the treatment cart and covered the open area then secured it with a tegaderm;
-Removed his/her gloves did not wash his/her hands and with dirty hands opened the drawers of the treatment cart to obtain tape;
-With dirty hands used tape to secure the dressing;
-Used the marker from the top of the treatment cart and wrote the date on the dressing;
-Folded the disposable barrier that lay on the top of the treatment cart and discarded it into the trash;
-With dirty hands used the marker and wrote the date on the bottle of normal saline then he/she opened and placed the bottle of normal saline into the treatment cart;
-LPN A did not wash his/her hands prior to exiting the resident's room and exited the resident's room pushing the treatment cart down the hall.
During an interview on 2/26/20, at 10:57 A.M., LPN A said:
-After glove removal staff should use hand sanitizer or wash their hands;
-Staff should ensure they have hand sanitizer available when they plan to do a treatment;
-After cleansing a wound staff should remove their gloves and sanitize before applying clean gloves;
-Staff should not touch clean items with dirty hands;
-Contaminated dressing supplies should not be returned to the treatment cart.
3. Review of Resident #20's quarterly MDS dated [DATE], showed staff assessed the resident as follows:
- Severe cognitive impairment;
- Extensive staff assistance of two staff for bed mobility, dressing, and toileting;
-Always incontinent of bowel and bladder;
-Diagnoses included dementia.
Review of the resident's care plan updated on 12/16/19, showed:
-Provide incontinence care after each incontinent episode.
Observation on 2/25/20, at 1:03 P.M., showed CNA B and CNA C provided incontinent care as the resident lay in bed and they did the following:
-Neither staff washed their hands or used hand sanitizer upon entering the room;
-CNA C obtained a wash basin and filled it with water and wash cloths;
-Both staff pulled the resident's pants down with their bare hands;
-CNA C used hand sanitizer and applied clean gloves;
-CNA B did not wash his/her hands or use hand sanitizer before applying clean gloves;
-CNA B opened the resident's wet brief;
-CNA B used several wash cloths and cleansed the resident's frontal perinea skin folds removing fecal material;
-CNA B did not remove his/her gloves and wash his/her hands and with dirty gloves he/she assisted CNA C to roll the resident onto his/her side;
-CNA B used several wash cloths to cleanse the resident's buttock and rectal areas removing fecal material;
-CNA B removed his/her gloves used hand sanitizer and applied clean gloves;
-Both staff secured a clean brief on the resident;
-Both gathered supplies, bagged the trash, and both staff removed their gloves used hand sanitizer and exited the resident's room.
During an interview on 2/27/20, at 2:15 P.M., the Director of Nursing (DON) said:
- Staff should wash their hands all the time; this includes upon entering and prior to exiting a resident's room, after providing care, going from a dirty site to clean site, and after glove removal;
- Staff should wash their hands and change gloves between dirty and clean tasks;
-Cleaning a wound is considered a dirty task;
- Staff should not touch clean items with dirty hands;
- When staff touch clean items with dirty hands the item is then considered contaminated.
4. Review of Resident #29's quarterly Minimum Data Set (MDS), a federally mandated assessment completed by facility staff), dated 12/24/19, showed:
-Cognitively intact;
-Required one staff assist for activities of daily living;
-Diagnoses include: depression, heart failure, diabetes, Coronary Artery Disease (damage or disease in the heart's major blood vessels), and Peripheral Artery Disease (narrowed blood vessels reduce blood flow to limbs).
Observation and interview on 02/25/20 at 12:48 P.M., showed and Licensed Practical Nurse (LPN) D said:
-LPN D administered Resident #29's dose of Novolog (fast-acting insulin used to treat blood sugar levels) via flexpen, discarded trash items, discarded the needle in the sharps container, removed gloves, did not wash her hands, applied new gloves, cleaned the flexpen, and removed gloves.
-He/she said she should have performed hand hygiene between glove changes.
5. Review of Resident #8's quarterly MDS, dated [DATE], showed:
-Severe cognitive impairment; did not make daily decisions;
-Requires at least two staff assist for bed mobility and transfers;
-Diagnoses include: diabetes, stroke, dementia, anxiety and depression.
Observation and interview on 02/25/20 at 01:35 P.M., showed and LPN E said:
-LPN E opened the medication cart, retrieved Resident #8's Humalog (fast-acting insulin used to treat blood sugar levels) kwikpen, opened the cap, opened a new needle and attached the needle to the kwikpen.
-LPN E did not clean the rubber seal on the kwikpen with an alcohol wipe prior to attaching the needle.
-He/she said she should have cleaned the rubber seal end with an alcohol wipe prior to attaching the needle.
During an interview on 02/27/20 at 02:18 P.M., the Director of Nursing said:
-Staff should clean the rubber seal on insulin pens with alcohol prior to attaching needles.
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
- "Can I speak with families of current residents?"
- "What's your RN coverage like on weekends and overnight?"
Our Honest Assessment
Strengths
- • No fines on record. Clean compliance history, better than most Missouri facilities.
Concerns
- • 36 deficiencies on record, including 2 serious (caused harm) violations. Ask about corrective actions taken.
Bottom line: Mixed indicators with Trust Score of 60/100. Visit in person and ask pointed questions.
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About This Facility
What is Living Community Of St Joseph's CMS Rating?
CMS assigns LIVING COMMUNITY OF ST JOSEPH an overall rating of 4 out of 5 stars, which is considered above average nationally. Within Missouri, this rating places the facility higher than 99% of the state's 100 nursing homes. This rating reflects solid performance across the metrics CMS uses to evaluate nursing home quality.
How is Living Community Of St Joseph Staffed?
CMS rates LIVING COMMUNITY OF ST JOSEPH's staffing level at 5 out of 5 stars, which is much above average compared to other nursing homes. Staff turnover is 53%, compared to the Missouri average of 46%.
What Have Inspectors Found at Living Community Of St Joseph?
State health inspectors documented 36 deficiencies at LIVING COMMUNITY OF ST JOSEPH during 2020 to 2025. These included: 2 that caused actual resident harm and 34 with potential for harm. Deficiencies causing actual harm indicate documented cases where residents experienced negative health consequences.
Who Owns and Operates Living Community Of St Joseph?
LIVING COMMUNITY OF ST JOSEPH is owned by a non-profit organization. Non-profit facilities reinvest revenue into operations rather than distributing to shareholders. The facility is operated by BENEDICTINE HEALTH SYSTEM, a chain that manages multiple nursing homes. With 96 certified beds and approximately 78 residents (about 81% occupancy), it is a smaller facility located in SAINT JOSEPH, Missouri.
How Does Living Community Of St Joseph Compare to Other Missouri Nursing Homes?
Compared to the 100 nursing homes in Missouri, LIVING COMMUNITY OF ST JOSEPH's overall rating (4 stars) is above the state average of 2.5, staff turnover (53%) is near the state average of 46%, and health inspection rating (3 stars) is at the national benchmark.
What Should Families Ask When Visiting Living Community Of St Joseph?
Based on this facility's data, families visiting should ask: "Can I visit during a mealtime to observe dining assistance and food quality?" "How do you handle medical emergencies, and what is your hospital transfer rate?" "Can I speak with family members of current residents about their experience?"
Is Living Community Of St Joseph Safe?
Based on CMS inspection data, LIVING COMMUNITY OF ST JOSEPH has a clean safety record: no substantiated abuse findings (meaning no confirmed cases of resident harm), no Immediate Jeopardy citations (the most serious violation level indicating risk of serious injury or death), and is not on the Special Focus Facility watch list (a federal program monitoring the lowest-performing 1% of nursing homes). The facility has a 4-star overall rating and ranks #1 of 100 nursing homes in Missouri. While no facility is perfect, families should still ask about staff-to-resident ratios and recent inspection results during their visit.
Do Nurses at Living Community Of St Joseph Stick Around?
LIVING COMMUNITY OF ST JOSEPH has a staff turnover rate of 53%, which is 7 percentage points above the Missouri average of 46%. Moderate turnover is common in nursing homes, but families should still ask about staff tenure and how the facility maintains care continuity when employees leave.
Was Living Community Of St Joseph Ever Fined?
LIVING COMMUNITY OF ST JOSEPH has no federal fines on record. CMS issues fines when nursing homes fail to meet care standards or don't correct problems found during inspections. The absence of fines suggests the facility has either maintained compliance or corrected any issues before penalties were assessed. This is a positive indicator, though families should still review recent inspection reports for the full picture.
Is Living Community Of St Joseph on Any Federal Watch List?
LIVING COMMUNITY OF ST JOSEPH 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.