BEAUVAIS REHAB AND HEALTHCARE CENTER
For profit - Limited Liability company
184 Beds
AMA HOLDINGS
Data: November 2025
1 Immediate Jeopardy citation
Trust Grade
0/100
#229 of 479 in MO
Photo by Beauvais Rehab and Healthcare Center
Photo by Beauvais Rehab and Healthcare Center
Photo by Beauvais Rehab and Healthcare Center
1 / 5 photos
Last Inspection: March 2025
Within standard 12-15 month inspection cycle. Federal law requires annual inspections.
Overview
Beauvais Rehab and Healthcare Center has received a Trust Grade of F, indicating significant concerns about the quality of care provided. In Missouri, it ranks #229 out of 479 facilities, which places it in the top half, but the low grade raises serious questions. The facility is currently experiencing a worsening trend, with issues increasing from 2 in 2024 to 22 in 2025. Staffing is a mixed bag, with a 56% turnover rate that is slightly below the state average, but the overall staffing rating is only 2 out of 5 stars. There are concerning fines of $91,045, which are higher than 79% of other facilities in Missouri, indicating repeated compliance problems. Notably, there have been serious incidents, such as a resident with dementia eloping from the facility multiple times without staff knowledge, posing a significant safety risk. Additionally, the facility has failed to adequately manage residents with pressure injuries, neglecting to follow their own wound care policies for at least two residents. Overall, while there are some strengths like slightly better turnover rates, the numerous deficiencies and critical incidents suggest families should carefully consider their options.
- Trust Score
- F
- In Missouri
- #229/479
- Safety Record
- High Risk
- Inspections
- Getting Worse
- Staff Stability ⚠ Watch
- 56% turnover. Above average. Higher turnover means staff may not know residents' routines.
- Penalties ○ Average
- $91,045 in fines. Higher than 65% of Missouri facilities. Some compliance issues.
- Skilled Nurses ⚠ Watch
- Each resident gets only 22 minutes of Registered Nurse (RN) attention daily — below average for Missouri. Fewer RN minutes means fewer trained eyes watching for problems.
- Violations ⚠ Watch
- 76 deficiencies on record. Higher than average. Multiple issues found across inspections.
0/100
Top 47%
Review needed
2 → 22 violations
★★☆☆☆
2.0
Overall Rating
★★☆☆☆
2.0
Staff Levels
★★☆☆☆
2.0
Care Quality
★★☆☆☆
2.0
Inspection Score
↔
Stable
2024: 2 issues
2025: 22 issues
The Good
-
Full Sprinkler Coverage · Fire safety systems throughout facility
-
No fines on record
Facility shows strength in fire safety.
The Bad
2-Star Overall Rating
Near Missouri average (2.5)
Below average - review inspection findings carefully
Staff Turnover: 56%
Near Missouri avg (46%)
Frequent staff changes - ask about care continuity
Federal Fines: $91,045
Well above median ($33,413)
Moderate penalties - review what triggered them
Chain: AMA HOLDINGS
Part of a multi-facility chain
Ask about local staffing decisions and management
Staff turnover is elevated (56%)
8 points above Missouri average of 48%
The Ugly 76 deficiencies on record
1 life-threatening 5 actual harm
Jun 2025
3 deficiencies
CONCERN
(D)
📢 Someone Reported This
A family member, employee, or ombudsman was alarmed enough to file a formal complaint
Potential for Harm - no one hurt, but risky conditions existed
Free from Abuse/Neglect
(Tag F0600)
Could have caused harm · This affected 1 resident
**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on interview and record review, the facility failed to protect one resident's right (Resident #2) to be free from physical...
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**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on interview and record review, the facility failed to protect one resident's right (Resident #2) to be free from physical abuse when his/her roommate (Resident #3), who had a history of aggressive behaviors, punched him/her in the face, then displayed a sharp knife and threatened to kill him/her. The sample was 7. The census was 140.
The facility was notified of past non-compliance on 6/6/25. Facility staff immediately intervened, notified administration, separated the residents, and provided assessment and services to the involved residents. Staff were in-serviced on abuse and neglect prevention. The deficiency was corrected on 5/23/25.
Review of the facility's abuse prevention and prohibition program revised 10/24/22, showed:
-Each resident has the right to be free from mistreatment, neglect and abuse. The facility has zero-tolerance for abuse and neglect. Staff must not permit anyone to engage in verbal, mental, sexual, or physical abuse, neglect, mistreatment, or misappropriation of resident property;
-The facility screens for potentially abusive residents during the pre-admission process;
-The facility promptly and thoroughly investigates reports of resident abuse, mistreatment, neglect, injuries of an unknown source, or criminal acts;
-The facility ensures protection of residents during abuse investigations;
-The presence of a mental disorder or cognitive impairment does not automatically preclude a resident from engaging in deliberate or non-accidental behavior.
Review of Resident #2's quarterly Minimum Data Set (MDS), a federally mandated assessment instrument completed by facility staff, dated 4/15/25, showed:
-Cognitively intact;
-Diagnoses included bipolar disorder (a mood disorder characterized by extreme mood swings, ranging from periods of intense elation or irritability (mania) to periods of deep sadness or hopelessness (depression)), anxiety disorder and schizoaffective disorder (a mental illness characterized by a combination of symptoms from both schizophrenia and a mood disorder such as depression or mania).
Review of the resident's progress notes, dated 5/22/25 at 11:45 P.M., showed the resident was verbally and physically aggressive. Staff separated residents immediately. A head-to-toe skin assessment was completed. A pain assessment was completed. The resident was given one to one time with staff to deescalate/vent and verbalize feelings. A room search was completed. The police were called. The resident was placed on one to one to ensure protective oversight. Physician and family notified of altercation.
Review of the resident's skin observation, dated 5/22/25 at 10:40 P.M., showed moderate swelling to his/her right eye. He/She refused an x-ray.
Review of the resident's progress notes, showed:
-On 5/23/25 at 9:55 A.M., a psychosocial assessment was completed on the resident. No signs or symptoms of distress;
-On 5/24/25 at 10:08 A.M., the interdisciplinary team met on 5/23/25 to discuss altercation between residents. New interventions put in place.
During an interview on 6/3/25 at 10:00 A.M., Resident #2 said he/she was on a one to one observation. The staff member was sitting in the hallway with the door closed. Resident #3 pulled his/her bed next to Resident #2's bed. Resident #3 accused Resident #2 of moving his/her pillow. Resident #2 said he/she did not move the pillow. Resident #3 said Fuck you! I'm a gangster. Don't disrespect me. I'll kill you. Resident #3 punched Resident #2 in the face. Resident #3 pulled out a pocket knife with a black handle and sharp, silver blade. The aide entered the room and yelled He/She has a knife. He/She left the room to get help, then came back. Staff separated the residents. The facility called the police.
Review of Resident #3's quarterly MDS dated [DATE], showed:
-Moderate cognitive impairment;
-Diagnoses included adjustment disorder (a person experiences emotional or behavioral symptoms after a stressful life event, change, or loss, and the symptoms are more intense than what would be expected for the event), cocaine dependency, other stimulant abuse, schizoaffective disorder, and major depressive disorder.
Review of the resident's progress notes, dated 5/22/25 at 11:45 P.M., showed the resident was verbally and physically aggressive. Staff separated residents immediately. A head-to-toe skin assessment was completed. A pain assessment was completed. The resident was given one to one time with staff to deescalate/vent and verbalize feelings. A room search was completed. The police were called. The resident was placed on one to one to ensure protective oversight. Physician and family notified of altercation.
Review of the facility's investigation, dated 5/22/25, showed:
-Summary: Staff responded to an altercation at 10:30 P.M. Resident #3 said he/she moved his/her bed next to Resident #2's bed. Resident #3 was upset about Resident # 2's pillow overlapping on his/her bed. Resident #3 got out of bed, walked around to Resident # 2's bed and was verbally and physically aggressive towards him/her. An altercation occurred. Staff separated the residents. A room search was completed, and contraband was removed from room. Police were called and both residents remained on one to one to ensure protective oversight. Head to toe skin assessments and pain assessments completed on both residents;
-Interventions: Immediate separation of residents, de-escalation of situation, psych visit from facility physician requested, police contacted, continuation of enhanced observation, psychosocial follow-up completed, staff in-servicing: abuse/neglect, residents' rights, de-escalation, one to one monitoring and nurse practitioner assessment.
Review of the resident's hospital discharge paperwork dated 5/23/25, time unknown, showed the resident was transported to the hospital by the police. The resident said he/she resided in a transitional home and had an altercation with his/her roommate. The resident fell on his/her back during the altercation. The police told him/her, he/she should go somewhere else until the boss arrived at the facility. X-rays completed with no notable findings. The resident was discharged back to the facility.
Review of the resident's progress notes, showed:
-On 5/23/25 at 9:58 A.M., a psychosocial assessment was completed on the resident. No signs or symptoms of distress;
-On 5/24/25 at 10:17 A.M., the interdisciplinary team met on 5/23/25 to discuss altercation between residents. New interventions put in place.
Review of the resident's care plan, in use during the survey and revised on 5/25/25, showed:
-Focus: The resident had potential to be verbally aggressive toward staff and residents (initiated 4/11/15). On 5/20/25 the resident was verbally aggressive with facility administrator. On 5/22/25 altercation with another resident;
-Goal: The resident will verbalize understanding of need to control verbally abusive behavior;
-Interventions: Administer medications as ordered. Monitor/document for side effects and effectiveness. Analyze key times, places, circumstances, triggers, and what de-escalates behavior and document. Assess and anticipate resident's needs: food, thirst. toileting needs, comfort level, body positioning, pain etc. Assess resident's understanding of the situation. Allow time for the resident to express self and feelings towards the situation. Give the resident as many choices as possible about care and activities. Psychiatric/Psychogeriatric consult as indicated. When the resident becomes agitated: Intervene before agitation escalates; Guide away from source of distress; Engage calmly in conversation; If response is aggressive, staff to walk calmly away, and approach later.
Review of Certified Nursing Assistant (CNA) C's written statement, dated 5/22/25 (time unknown), showed he/she sat outside the residents' room on the 200 hall. He/She heard Resident #2 and Resident #3 fussing at each other. He/She went in the room, and they were fighting. He/She ran down the hall to get help.
During an interview on 6/4/25 at 7:54 A.M., CNA B said he/she has worked as needed (PRN) at the facility for two years. On 5/21/25, he/she was assigned to one to one with Resident #3. Another CNA was on one to one with Resident #2. Both CNAs were sitting in the hallway with the door closed. Resident #2 was in bed. Resident #3 went out to smoke and returned to his/her room. Around 10:00 P.M., he/she heard the residents arguing. The CNA on one to one with Resident #2 opened the door and Resident #3 was standing over Resident #2 with a hunting knife in his/her hand. He/She opened the door and yelled down the hall for assistance. Resident #2 fell on top of Resident #3 when staff tried to separate them. The Certified Medical Technician (CMT) took Resident #3 to the dining room. Staff did not find the knife. The police were called and took Resident #3 to the hospital. He/She was only in-serviced on abuse/neglect.
During an interview on 6/4/25 at 11:44 A.M., the Administrator said Resident #3 was verbally and physically aggressive prior to the altercation. After the incident, Resident #3 went to the hospital. When staff cleaned out the resident's room they found the knife. It was a pocket knife. The tip was broken, and it did not appear to be new. Resident #3 came back to the facility the next day. He/She was placed on a one to one observation. He/She started yelling and beating on the glass. The police were called, and he/she was arrested for assault.
MO00254863
CONCERN
(D)
📢 Someone Reported This
A family member, employee, or ombudsman was alarmed enough to file a formal complaint
Potential for Harm - no one hurt, but risky conditions existed
Quality of Care
(Tag F0684)
Could have caused harm · This affected 1 resident
**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, interview and record review, the facility failed to follow up with the facility's primary care physician a...
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 follow up with the facility's primary care physician and/or the resident's Veteran's Affairs (VA) physician to get medication orders after finding filled prescription bottles in the resident's room after he/she returned from an appointment for one out of three sampled residents (Resident #6). Additionally, the facility failed to provide care consistent with professional standards of practice when staff sat in the hallway, outside the residents' room, with the door closed during one-to-one observation. The residents (Resident #2 and Resident #3) had a physical altercation inside their room and Resident #3 displayed a knife and threatened to kill Resident #2. The sample was 7. The census was 140.
Review of the facility's Physician Order policy, dated 10/24/22, showed:
-Purpose: To ensure that all physician orders are complete and accurate;
-The Medical Records Department will verify that physician orders are complete, accurate and clarified as necessary;
-Whenever possible the Licensed Nurse receiving the order will be responsible for documenting and implementing the order;
-Documentation pertaining to physician orders will be maintained in the resident's medical record.
Review of the facility's Enhanced Supervision policy, undated, showed:
-To initiate enhanced supervision when there is a reasonable assumption that the resident has tried to harm themselves, harm others, expresses suicidal thoughts or intent, or resident has had increased behaviors;
-The facility considers enhanced supervision as a means to enhance the oversight of the resident;
-Facility staff are educated on the types of enhanced supervision which may include but not limited to the following:
-One to one Observation: Staff member will be scheduled to keep resident within line of sight.
1. Review of Resident #6's significant change Minimum Data Set (MDS), a federally mandated assessment instrument completed by facility staff, dated 4/5/25, showed:
-Cognitively intact;
-Preadmission Screening and Resident Review (PASRR, used to identify individuals who may have serious mental illness (SMI), intellectual disability (ID), developmental disability (DD) or related condition (RC)) showed mental retardation;
-No behaviors noted;
-Diagnoses included stroke, hemiplegia (complete or sever loss of strength on one side of the body) or hemiparesis (mild weakness on one side of the body) affecting right side of body, traumatic brain injury (TBI, brain injury affecting cognitive physical or psychosocial functions) and needed assistance for personal care.
Review of the resident's care plan, undated, showed:
-Problem: At risk for impaired cognitive function related to history of cerebral infarction and history of TBI;
-Interventions included: Administer medications as ordered; Ask simple yes/no question in order to determine the resident's needs; Use task segmentation to support short term memory deficits. Break tasks into one step at a time.
Review of the resident's progress notes, dated 3/2/25 through 6/3/25, showed:
-On 5/27/25, at 5:11 P.M., the resident had a physician appointment scheduled for 5/28/25 at 10:40 A.M.;
-There was no documentation found showing the resident went to the appointment, when he/she returned from the appointment and if there were any new orders.
During an interview on 6/3/25 at 9:25 A.M., the resident said:
-He/She had medication from his/her last appointment at the VA and a facility staff person took the filled medication bottles from his/her room;
-He/She had not received the medications from the nurses and could not understand why;
-He/She kept asking the nursing staff for the medications that his/her VA physician prescribed but they would not administer the medications to the resident;
-He/She did not know why;
-He/She was constantly itchy, uncomfortable and believed it was due to missing medications;
-He/She showed the prescription documents which corresponded to the medications the facility staff removed from his/her room.
Review of the prescription documents, showed:
-An order dated 5/28/25, for Diphenhydramine (Benadryl, antihistamine) 25 milligram (mg) capsule (cap), take one at night as needed;
-An order dated 5/28/25, for Prednisone (decreases inflammation) 10 mg tablets. Take four tablets for seven days; Take two tablets for two days; Take one tablet one day. Start on 5/28/25.
Review of the resident's physician order sheet, dated 6/3/25, showed:
-An order dated 5/14/25, for acetaminophen extra strength (Tylenol, pain and fever reducer) 500 mg, give two tablets every six hours as needed for pain/discomfort/elevated temperature;
-No orders for Diphenhydramine 25 mg or Prednisone 10 mg.
Review of the resident's progress notes, dated 3/2/25 through 6/3/25, showed:
-No documentation the facility staff found filled prescription bottles in the resident's room and removed them;
-No documentation the facility tried to notify the primary care physician (PCP) or VA physician to obtain new orders for the Prednisone 10 mg or Diphenhydramine 25 mg capsules.
Observation on 6/4/25 at 8:19 A.M., showed:
-The resident was getting help with dressing from Certified Nursing Assistant (CNA) D;
-The resident had several small areas of reddened skin on his/her back and shoulders.
During an interview on 6/4/25 at 8:36 A.M., Licensed Practical Nurse (LPN) G said:
-If residents come in to the facility with medications from home, the hospital or the VA, nursing staff were instructed to remove the medications from the resident's room because the facility can not verify what is actually in the medication bottles, medications are only administered by the facility so they could verify what the resident actually took which reduced the risk of overdose;
-The medications were then stored in the medication room and were destroyed by the Assistant Director of Nursing (ADON).
Observation on 6/4/25 at 8:40 A.M., of the medication room for the hall in which the resident resided, showed:
-There were no medications bottles from other pharmacies found for the resident;
-LPN G was not aware of any stored medications from other pharmacies for the resident.
During an interview on 6/4/25 at 8:48 A.M., Certified Medication Technician (CMT) E said:
-He/She was responsible for passing medications to the resident today and had not passed any medications to the resident yet;
-The resident complained of feeling uncomfortable and asks for acetaminophen extra strength every morning and the CMT administers the medication as ordered;
-CMT E pulled up the medications scheduled for administration to the resident during the A.M. medication pass and showed there were no orders for Prednisone;
-He/She was not aware the resident had an order for Prednisone.
During an interview on 6/4/25 at 9:05 A.M. and at 9:15 A.M., ADON F said:
-When residents admit with filled prescriptions from the hospital, home, or VA, nursing staff are instructed to remove the medications from the residents room for their safety;
-All outside medications are taken to the medication room to get destroyed if they are not able to send the medications home with the residents' family or return unopened bubble packs to the pharmacy for credit to the residents' account. The medications are then reordered from the facility pharmacy and administered to residents by staff;
-She tells residents their outside medications will get destroyed by the facility and hopes her nursing staff explains the same to the residents;
-She was aware the resident came back with two bottles of medications from the VA and they were removed from the resident's room;
-She explained to the resident they had to remove them from his/her possession for his/her safety but would use the medications and administer them to the resident as prescribed;
-She gave the two medication bottles to LPN G and asked the LPN to put in the appropriate orders for the Diphenhydramine and Prednisone;
-She expected LPN G to get the orders and put them in the resident's electronic medical health record (EMHR);
-She tried to call the resident's physician at the VA twice on the day she received the two medication bottles and could not get through;
-She asked the resident for the corresponding paperwork from the VA physician and the resident never got back to her.
During an interview on 6/4/25 at 9:15 A.M. and at 9:27 A.M., LPN G said:
-A CNA gave him/her two medication bottles (Diphenhydramine and Prednisone) after the CNA had found them in the resident's room;
-LPN G did not put an order for the medications because he/she did not have the corresponding paperwork from the resident's VA appointment;
-He/She asked the resident for the corresponding paperwork to the medications and the resident said he/she would get them from the VA to clarify the orders;
-LPN G did not call the resident's physician from the VA;
-The resident never got back to LPN G with the appropriate paperwork;
-LPN G could not tell when the prescription bottles were filled by the pharmacy, saying they could be a year old;
-LPN G pulled the two medication bottles filled by the VA for the resident, one for Diphenhydramine 25 mg and the other for Prednisone 10 mg, and could not located the fill date on the prescription bottles;
-The Surveyor showed LPN G the fill date on both medication bottles and the LPN confirmed they were both filled by the VA pharmacy on 5/28/25;
-He/She should have documented in the resident's progress notes when the medication bottles were found in the resident's room, what the prescription was on the bottles, contacted either the facility PCP or VA physician to get the appropriate orders, and if there was no response from either physician, he/she should have included that in the progress note and reported it to on-coming nursing staff so they could follow up;
-The resident was at risk of suffering complications related to delayed treatment of Prednisone, including but not limited to increased inflammatory response and respiratory depression and was at risk of feeling uncomfortable and itchy with delayed administration of the Diphenhydramine.
During an interview on 6/4/25 at 9:22 A.M., ADON F said:
-She asked the resident if she could look at the corresponding paperwork to the two medications (Diphenhydramine and Prednisone);
-The resident showed ADON F the corresponding paperwork that was in the resident's room which had the orders for both medications;
-The resident shrugged his/her shoulders when ADON F asked if the resident remembered her asking for the paperwork sometime last week;
-ADON F did not think to call the facility PCP to verify the orders once she had possession of the two medication bottles;
-She should have documented in the resident's progress notes when the medication bottles were found in the resident's room, what the prescription was on the bottles, noted the time and results of her calling the resident's VA physician, contacted the facility PCP and if there was no response from either physician, he/she should have included that in the progress note and reported it to on-coming nursing staff so they could follow up.
During an interview on 6/4/25 at 1:31 P.M., the Director of Nursing (DON) said:
-She expected nursing staff to have knowledge of and to follow facility policies;
-If residents came to the facility with filled prescriptions from the VA, she expected nursing to remove the medications from the residents' possession for safety;
-She expected nursing staff to follow up with the residents' VA physician to clarify orders and if they were not available, to notify the facility PCP of the situation, noting the prescription and the order on the prescription bottle, get new orders, including to use the medication from the VA until it was empty and then order more from the facility pharmacy if needed;
-She expected nursing staff to continue to try to follow up with the VA physician for continuity of care and to ensure the plan of care was followed;
-She expected nursing staff to document everything in a progress note in the resident's EMHR, including what medications were found and removed from the resident's room, who they tried to contact and the results of the conversation, including any new orders;
-She expected nursing staff to document in progress notes if they were not able to clarify order with the VA physician or facility PCP, including that they reported the same to the oncoming nurse so they could follow up on the situation;
-She also expected nursing staff to inform management of the situation immediately so they could ensure it was followed up on and the resident received their medications as per plan of care;
-It was not appropriate to depend on or ask a resident to get the corresponding paperwork to medications as residents were not always cognitively able to perform the task and it was the nurses responsibility to do so, not the residents;
-It was not appropriate to wait several days to clarify an order from a physician. It was actual non-compliance as nursing staff were not following plan of care or attempting to follow physician orders;
-Delaying treatment could put the resident at risk for several different health complications depending on what why the medication was prescribed;
-It was not appropriate to destroy any outside medications residents brought in from home, the hospital, or other facility's as medications were very expensive and pharmacies may not fill the prescription again as it was too soon since it was last filled.
2. Review of Resident #2's quarterly MDS, dated [DATE], showed:
-Cognitively intact;
-Diagnoses included bipolar disorder, anxiety disorder and schizoaffective disorder (a mental illness characterized by a combination of symptoms from both schizophrenia and a mood disorder such as depression or mania).
Review of Resident #3's quarterly MDS dated [DATE], showed:
-Moderate cognitive impairment;
-Diagnoses included adjustment disorder (a person experiences emotional or behavioral symptoms after a stressful life event, change, or loss, and the symptoms are more intense than what would be expected for the event), cocaine dependency, other stimulant abuse, schizoaffective disorder, and major depressive disorder.
During an interview on 6/4/25 at 11:44 A.M., the Administrator said on 5/21/25, Resident #2 was on one to one for smoking in his/her room. Resident #3 was on one to one for aggressive/erratic behaviors.
Review of the facility's investigation dated 5/22/25, showed:
-Staff responded to an altercation at 10:30 P.M. Resident #3 said he/she moved his/her bed next to Resident #2's bed. Resident #3 was upset about Resident # 2's pillow overlapping on his/her bed. Resident # 3 got out of bed, walked around to Resident # 2's bed and was verbally and physically aggressive towards him/her. An altercation occurred. Staff separated the residents;
-Staff in-serviced on one-to-one observations.
During an interview on 6/3/25 at 10:00 A.M., Resident #2 said he/she was on a one to one. The staff member was sitting in the hallway with the door closed. Resident #3 pulled his/her bed next to Resident #2's bed. Resident #3 accused Resident #2 of moving his/her pillow. Resident #2 said he/she did not move the pillow. Resident #3 said Fuck you! I'm a gangster. Don't disrespect me. I'll kill you. Resident #3 punched Resident #2 in the eye. Resident #3 pulled out a pocket knife. The knife had a black handle and sharp, silver blade. Resident #3 said he would stab Resident #2. The aide entered the room and yelled (He/She) has a knife. He/She left the room to get help, then came back. Staff separated the residents.
Review of CNA C's written statement dated, 5/22/25 (time unknown), showed he/she sat outside the residents' room on the 200 hall. He/She heard Resident #2 and Resident #3 fussing at each other. He/She went in the room, and they were fighting.
During an interview on 6/4/25 at 7:54 A.M., CNA B said on 5/21/25, he/she was assigned to one to one with Resident #3. Another CNA was on one to one with Resident #2. Both CNAs were sitting in the hallway with the door closed. The residents were on one to one for smoking, therefore, staff did not have to be inside the resident's room. The residents have the right to close their doors. He/She does not like to sit in the resident's room because they have mice. He/She was only in-serviced on abuse/neglect.
During an interview on 6/6/24 at 10:10 A.M., ADON A said staff should be within arm's length of the resident during a one to one. It is not appropriate for staff to sit in the hallway, with the resident's door closed.
During an interview on 6/4/25 at 1:59 P.M., the DON said staff should always be with the resident during a one to one. They should document what the resident is doing. It is never appropriate for staff to sit in the hallway, with the door closed during a one to one. Staff are supposed to be within arm's length of the resident.
During an interview on 6/4/25 at 11:44 A.M., the Administrator said during the one to one, staff are supposed to be within eye sight or arm's length of the resident. It is not appropriate to sit in the hallway with the door closed.
MO00254863
CONCERN
(D)
📢 Someone Reported This
A family member, employee, or ombudsman was alarmed enough to file a formal complaint
Potential for Harm - no one hurt, but risky conditions existed
Deficiency F0740
(Tag F0740)
Could have caused harm · This affected 1 resident
**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on interview and record review, the facility failed to provide a behavioral management program for one resident (Resident ...
Read full inspector narrative →
**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on interview and record review, the facility failed to provide a behavioral management program for one resident (Resident #3) who frequently yelled, cursed and threatened residents and staff members, and used illicit substances. The resident's behaviors escalated, and he/she punched his/her roommate in the face, displayed a knife and threatened to kill him/her. Additionally, staff did not complete a Pre-admission admission Screening and Resident Review (PASRR) (a federally mandated screening process for individuals with serious mental illness (SMI), intellectual disability/developmental disability (IDD/DD), and/or related condition who apply for or reside in a Medicaid Certified bed in a nursing facility regardless of payment source) when it was determined the resident would be admitted to the facility for long-term care. The sample was 7. The census was 140.
Review of the facility's Behavior Management policy, undated, showed:
-Purpose: To ensure facility staff performs a timely and appropriate assessment of the resident's behavioral symptoms and implement appropriate interventions before and after the resident begins taking psychotherapeutic medications. The facility is responsible for providing behavioral health care and services that create an environment that promotes emotional and psychosocial well being meet each resident's needs and include individualized approaches to care;
- The concept of behavior management is an interdisciplinary process. The key components of this process are:
-Identifying residents whose behaviors may pose a risk to self or others;
-Developing individual and practical care strategies based on assessed needs;
-Implementing the behavior management program;
-Ongoing assessment, monitoring, and evaluation of the effectiveness of the behavior management program including the effectiveness of psychoactive drugs.
-When a resident exhibits adverse behavioral symptoms (crying, yelling, hitting, biting, etc.), licensed nursing staff will document the behaviors in the medical record, noting the time the behavior(s) occur, prior events, possible causal factors and interventions attempted;
-Upon observing the adverse behavioral symptom, staff will do the following as indicated:
-Ensure the safety of the resident as well as all other residents;
-Document notification of the Attending Physician;
-Document notification of the resident's family and/or responsible party about the change in behaviors and the Attending Physician's response;
-Document the incident on the 24 hour report.
-The Charge Nurse will assign a staff member(s) to monitor/shadow the resident as needed;
-Such monitoring is for the protection of the resident as well as all others, and is not meant to restrict their movement or mobility;
-Nursing staff will continue to monitor the resident's behavior to determine what event(s), if any, precipitated the behavior and document the following information as indicated:
-Date and time of behavior;
-Location of resident when the behavior occurred;
-Description of the behavior (what the resident said or did and if the behavior intensified);
-Non-verbal cues (darting eyes may indicate anxiety or fear, crossed arms may signal withdrawal or fear, and tears may indicate sadness, frustration or fear);
-What seemed to cause the behavior;
-Any interventions used and their effect;
-In assessing the resident for potential causal factors, licensed nursing staff will consider the following factors and document their findings in the medical record:
-Physical conditions (pain or discomfort, hunger or thirst, fatigue, toileting needs, incontinence);
-Environmental conditions (inappropriate room temperature, noise, overcrowding);
-Psychosocial or emotional stressors (change in resident's customary routine, loneliness, frustration, fear of the unknown, possible abuse by staff or other residents, incompatibility with roommate, inability to communicate needs, lack of support system, loss of control due to changes in physical condition, financial concerns);
-Medical conditions that require treatment (diabetes mellitus, heart disease, chronic obstructive pulmonary disease (COPD), infection, constipation, recent stroke, arthritis);
-Mental health conditions, which may contribute to resident's behavior (consider if the resident could be cheeking medications. If a dose adjustment is necessary due to a change in a medical condition, or there has been an increase in the resident's hallucinations and/or delusions).
Review of Resident #3's history and physical assessment, dated 1/23/25, showed:
-admitted to the hospital on [DATE] for shortness of breath;
-He/She smoked 8-9 cigarettes per day;
-admitted to using cocaine prior to arrival at hospital;
-Urinalysis was positive for cocaine.
Review of the resident's social history and initial assessment, dated 2/5/25 at 9:06 A.M., showed:
-Reason for admission: Long term care/rehab;
-History of drug abuse, blank;
-History of smoking, blank;
-Anticipated length of stay: Long-term.
Review of the resident's care plan, in use during the survey, showed:
-Focus: The resident was a smoker;
-Goal: The resident will not suffer injury from unsafe smoking practices;
-Intervention: Instruct resident about smoking risks and hazards and about available smoking cessation aids. Instruct resident about the facility policy on smoking: locations, times, safety concerns. Notify the charge nurse immediately if it is suspected resident has violated facility smoking policy. The resident can smoke unsupervised. The resident's smoking supplies are stored by staff;
-Focus: The resident used oxygen therapy as needed due to congestive heart failure (CHF) and COPD;
-Goal: The resident will have no signs and symptoms of poor oxygen absorption;
-Intervention: Change resident's position every two hours to facilitate lung secretion movement and drainage;
-No documented discharge planning.
Review of the resident's progress notes, showed:
-On 2/16/25 at 12:08 P.M., the nurse practitioner noted the resident was seen for an initial evaluation following an acute admission [DATE] - 02/03/2025) for acute CHF/COPD
exacerbation. He/She presented to the emergency room with shortness of breath, non-productive cough, and substernal chest pain. He/She reported cocaine use the day before. He/She had multiple admissions 7/24/24, 8/24/24, 9/24/24, 12/24/24 for similar concerns;
-On 2/19/25 at 2:42 P.M., the Administrator counseled the resident on smoking in his/her room. The resident was informed he/she would be terminated immediately if it happened again. The resident verbalized an understanding. At 2:50 P.M., the social worker talked to resident about smoking in the facility and in his/her room. Social Services informed the resident he/she would be immediately discharged from the facility if he/she did it again. The resident verbalized understanding.
Review of the resident's psychiatric notes, dated 2/19/25, showed:
-Chief complaint: They don't want to help. I asked them to get me in rehab;
-Review of symptoms: Depressed, anxious and irritable;
-Feelings: Expressed feelings of helplessness/hopelessness;
-Judgement: Poor insight/judgement;
-Dangerousness assessment: Danger to self;
-Recommendation: Not a good fit for the facility;
-Resident made aware if he/she continued to smoke in his/her room, he/she would be discharged ;
-The social worker said the resident refused to complete the rehab program.
Review of the medical record, showed no documented psychiatric visits for March or April, 2025.
Review of the Resident #3's quarterly Minimum Data Set (MDS), a federally mandated assessment instrument completed by facility staff, dated 2/28/25, showed:
-admitted [DATE];
-Moderate cognitive impairment;
-Little to no interest in doing things;
-Felt down, depressed, or hopeless;
-Trouble falling asleep;
-Tired and little energy;
-Poor appetite;
-Trouble concentrating on things;
-No behaviors exhibited;
-Diagnoses included CHF, COPD, adjustment disorder (a person experiences emotional or behavioral symptoms after a stressful life event, change, or loss, and the symptoms are more intense than what would be expected for the event), cocaine dependency, other stimulant abuse, schizoaffective disorder (a mental illness characterized by a combination of symptoms from both schizophrenia and a mood disorder such as depression or mania), and major depressive disorder;
-No antipsychotic medications.
Review of the resident's progress notes, showed:
-On 3/20/25 at 2:30 P.M., social services reviewed the smoking policy with the resident and explained the importance of smoking in designated areas;
-On 3/24/25 (late entry) 8:30 A.M., social services reviewed the smoking policy with the resident and explained the importance of smoking in designated areas;
-On 4/10/25 at 12:40 P.M., the resident used foul language towards dietary staff, in the dining room. Social services informed the resident if the behavior continued, he/she could not eat in the dining room.
Review of the resident's care plan, in use during the survey, showed:
-Focus: The resident had potential to be verbally aggressive toward staff and residents (initiated 4/11/15);
-Goal: The resident will verbalize understanding of need to control verbally abusive behavior;
-Interventions: Administer medications as ordered. Monitor/document for side effects and effectiveness. Analyze key times, places, circumstances, triggers, and what de-escalates behavior and document. Assess and anticipate resident's needs: food, thirst, toileting needs, comfort level, body positioning, pain etc. Assess resident's understanding of the situation. Allow time for the resident to express self and feelings towards the situation. Give the resident as many choices as possible about care and activities. Psychiatric/Psychogeriatric consult as indicated. When the resident becomes agitated: Intervene before agitation escalates; Guide away from source of distress; Engage calmly in conversation; If response is aggressive, staff to walk calmly away, and approach later.
Review of the resident's progress notes, showed:
-On 4/16/25 at 4:06 P.M., social services reviewed the smoking policy with the resident and explained the importance of smoking in designated areas;
-On 5/20/25 at 3:16 P.M., the Administrator noted, the resident voiced disapproval regarding an incident with another resident. The resident was caught taking inappropriate pictures of a female staff member and resident. The resident was aggressive. He/She walked around the Administrator's desk, pointed his/her finger in the Administrator's face and said, I will kick your ass. The Administrator tried to redirect the resident. The resident became irate and approached the Administrator briskly with clenched fists.
Review of the resident's psychiatric note, dated 5/21/25 (time unknown), showed:
-Chief complaint: They moved me down the hall and I don't like that. I want to get out of here;
-Review of symptoms: The resident was anxious and notably pissed off;
-Interview behaviors: Uncooperative, irritable, negative, hostile and aggressive;
-Mood: He/She was angry and tried to control it;
-Feelings: Negative feelings evident with hopelessness/helpless;
-Insight/judgement: The psychiatrist was notified this date of the resident threatening violence and sexual actions towards residents and staff;
-Dangerousness assessment: The resident was a danger to others;
-Recommendation: Discharge the resident and request police intervention for threats of dangerousness.
Review of the resident's record, showed no laboratory work was completed.
Review of the resident's progress notes, dated 5/22/25 at 11:45 P.M., showed the resident was verbally and physically aggressive. Staff separated residents immediately. A head-to-toe skin assessment was completed. A pain assessment was completed. The resident was given one to one time with staff to deescalate/vent and verbalize feelings. A room search was completed. The police were called. The resident was placed on one to one to ensure protective oversight. Physician and family notified of altercation.
During an interview on 5/23/25 at 2:35 P.M., the Administrator reported the resident had a history of homelessness and incarceration. He/She had been displaying pen behaviors (slang for behaviors often displayed by people who have served time in prison). The resident had an altercation with his/her roommate. He/She was discharged from the hospital back to the facility at 9:00 A.M. The resident was throwing stuff and cornered the Administrator. The police returned to the facility. The police found a crack pipe (used to smoke crack cocaine) with residue, alcohol bottles and cans with holes in them (used to smoke illegal substances). The resident was arrested.
Review of the facility's discharge letter, dated 5/23/25, showed:
-The facility could not meet the resident's needs;
-The resident's presence was a danger to the health and safety of others in the facility;
-The resident became irate with a staff member and threw a full urinal- filled with urine into the charge nurse's face. The resident was alert and oriented and showed no regard for what transpired.
During an interview on 6/6/24 at 10:10 A.M., the Assistant Director of Nursing (ADON) A said he/she has worked at the facility for three years. He/She assisted with the 200 hall. He/She did not approve referrals. He/She greeted the residents upon arrival to the facility. The resident was admitted for rehab/long-term care. The ADONs read the history and physical prior to admission. He/She was not aware of the resident's substance use. The resident's behaviors were in and out. At baseline the resident was pleasant. His/Her behaviors started two to three weeks after admission. The resident had to be redirected about smoking in his/her room. Staff would give the resident space to calm down. Sometimes he/she would apologize for the behavior. The psychiatrist was in the building often. He/She is not sure if the resident had regularly scheduled visits with the psychiatrist. The resident was placed on one to one observation after the incident with the Administrator. ADON A thinks the interventions the facility put in place worked.
During an interview on 6/4/25 at 11:37 A.M., the social worker said the resident was alert and oriented. He/She signed in and out of the building. He/She was admitted due to homelessness. He/She had a substance abuse issue. The nursing department was responsible for addressing his/her substance use issues. The social worker thinks the resident was placed on a one to one after he/she tried to attack the Administrator. The resident was verbally aggressive towards staff prior to the incident. He/She was not present for the resident-to-resident altercation. The police were called, and the resident was escorted to the hospital. The resident returned to the facility and the police were called again. The resident was arrested. He/She thinks the resident was seeing a psychiatrist. She did not know if a PASRR was completed for the resident. Someone from corporate does the referrals.
During an interview on 6/4/25 at 1:59 P.M., the Director of Nursing said she has been at the facility for five days. When Resident #3 displayed verbal and physical aggression, the resident's physician and family should have been notified. They should have looked at the resident's meds and adjusted if needed. She would have put the resident on one to one observation and obtained labs. If a resident is using illicit drugs something should have been put in place. The social worker and the nursing department should have worked together to find resources. The substance use issue should have been addressed during the admission assessment. It should have been on the resident's care plan.
During an interview on 6/4/25 at 11:44 A.M., the Administrator said he did not know why the resident was admitted to the facility. He did not see the referral. He was not aware the resident was actively using cocaine. The police found drug paraphernalia. He assumed a PASRR was completed for the resident. The facility was trying to find placement for the resident and then everything kicked off. After the resident tried to attack him, he just avoided the resident. It was hard to put interventions in place for the resident, because he/she was non-compliant. The resident was placed on a one to one. He tried to get a psych evaluation, but the resident was very aggressive towards the psychiatrist. The psychiatrist wanted the resident discharged from the facility. The Administrator did not want to discharge the resident to a homeless shelter.
MO00254863
Mar 2025
19 deficiencies
CONCERN
(D)
📢 Someone Reported This
A family member, employee, or ombudsman was alarmed enough to file a formal complaint
Potential for Harm - no one hurt, but risky conditions existed
Safe Environment
(Tag F0584)
Could have caused harm · This affected 1 resident
**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, record review, interview, and facility policy review, the facility failed to ensure the fifth-floor shower...
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**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, record review, interview, and facility policy review, the facility failed to ensure the fifth-floor shower room was cleaned as required for one of one resident (Resident (R) 109) reviewed for the environment out of a total sample of 48. This failure had the potential to affect the resident's health and ability to utilize the shower area. The facility census was 136.
Findings include:
Review of the facility's policy titled, Housekeeping- Restroom and Showers, revised 10/24/22, revealed . Showers . Scrub bathtubs and showers .
Review of R109's admission Record, located under the Profile tab of the electronic medical record (EMR), revealed the resident was admitted on [DATE]. Diagnoses included displaced fracture, chronic obstructive pulmonary disease, chronic respiratory failure, and emphysema.
Review of R109's quarterly Minimum Data Set (MDS), with an Assessment Reference Date (ARD) of 01/02/25 and located under the MDS tab of the EMR, revealed R109 had a Brief Interview for Mental Status (BIMS) score of 13 out of 15, which indicated the resident was cognitively intact.
During an interview on 03/17/25 at 2:09 PM, R109 stated he wished there were better places to take showers because the shower was not clean.
During an observation and interview on 03/17/25 at 2:25 PM with the Certified Nurse Aide (CNA) 1, the shower area had orange-colored stains on the lower sides of the standing shower tiles and within the shower grout. CNA1 stated the Housekeepers should have been cleaning the area.
During an observation and interview on 03/17/25 at 2:31 PM, the Maintenance Director (MD) stated the orange area was probably soap scum. He stated he did not see why the orange areas could not be removed.
During an observation and interview on 03/17/25 at 2:37 PM, Housekeeper (HSK) 1 observed the orange area and stated she did not usually work on the fifth floor. She stated they normally cleaned the shower rooms.
During an observation and interview on 03/17/25 at 2:40 PM, Housekeeping Manager (HSKM) stated the shower was supposed to be cleaned every day. She sprayed the orange area and while wiping, it was coming off. She confirmed the area was improving as she sprayed with a chemical and wiped. She stated there was no documentation of the shower rooms being cleaned. She stated it was supposed to be cleaned every day. She confirmed it had been a while since it had been deep cleaned.
MO00248617
MO00251444
CONCERN
(D)
Potential for Harm - no one hurt, but risky conditions existed
Deficiency F0637
(Tag F0637)
Could have caused harm · This affected 1 resident
**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on record review, staff interview, and facility policy, the facility failed to complete a significant change Minimum Data ...
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**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on record review, staff interview, and facility policy, the facility failed to complete a significant change Minimum Data Set (MDS) within 14 days of change for one of 10 residents (Resident (R) 23) reviewed for significant change assessments out of a total sample of 48. R10 showed a severe weight loss of 11.28% in six months and declined in mobility status that impacted more than one area of the resident's health status. This failure had the potential to cause further decline in the resident's status without further intervention by staff, interdisciplinary review, or revision of the care plan. The facility census was 136.
Findings include:
Review of the facility's policy titled, RAI Process, revised 10/24/22, indicated, . Purpose: To ensure that the Resident Assessment Instrument (RAI) is used, in accordance with specified format and timeframes, in conducting comprehensive assessments as part of an ongoing process through which the facility identifies each resident's preferences and goals of care, functional and health status, strengths and needs, as well as offering guidance for further assessment once problems have been identified . Policy: I. The Facility will utilize the Resident Assessment Instrument (RAI) process as the basis for the accurate assessment for each resident's functional capacity and health status, as outlined in the CMS RAI MDS 3.0 Manual .
Review of R23's undated admission Record, located under the Profile tab of the electronic medical record (EMR), revealed R23 was admitted to the facility on [DATE] with diagnoses that included Alzheimer's disease, anxiety disorder, insomnia, mood disorders, dysphagia, dementia, and depression.
Review of R23's annual MDS, with an assessment reference date (ARD) of 12/02/24 and located under the MDS tab of the EMR revealed R23 had not normally used a wheelchair in the last 7 days.
Review of R23's quarterly MDS, with an ARD of 02/27/25 and located under the MDS tab of the EMR, revealed R23 had a change and had normally used a wheelchair in the last 7 days.
Review of R23's Weights, located in the EMR under the --- tab, revealed R23 weighed 133.0 pounds (lbs) on 08/07/24 and 118.0 lbs on 02/20/25. This constituted an 11.28% severe weight loss in six months.
Review of R23's Progress Notes, dated 2/28/2025 at 11:32 AM and located under the Progress Notes tab of the EMR, revealed, . SIGNIFICANT WEIGHT LOSS NUTRITION NOTE: weight: 118# 2/20/25, BMI 22.3; +2.3% in 1 month, -11.3% in 6 months. Diet: mechanical soft, super cereal with breakfast, milk/chocolate milk with meals, Magic Cup with lunch. Eats meals in SCU dining room. Ambulates ad lib. Staff reported intake varies and refuses to be fed. Order for weekly weights to follow trend. Receiving supercereal with breakfast, milk/chocolate milk with meals, and Magic Cup with lunch to help increase nutritional intake. Current weight indicates some weight gain x 1 month. Will continue to follow and intervene further prn [as needed].
Review of R23's MDS tab of the EMR revealed no documented evidence a significant change assessment was completed when it was noted the resident had a major decline in nutritional status and a decline in mobility. It was recorded a quarterly MDS, with an ARD of 02/27/25 was completed.
During an interview on 03/19/25 at 5:30 PM, the MDS Coordinator (MDSC) stated We have IDT meetings to discuss residents. I would do the significant change assessment within 8 days. Significant change would include significant permanent changes in ADLs [activities of daily living], insurance status changes for hospice, significant weight, mood, and behavior changes. The MDSC stated she was unsure if changes in two care areas were required to qualify for a significant change MDS.
During an interview on 03/20/25 at 10:34 AM, the MDSC stated, The weight on 02/20/25 was not within 180 days of the August weight taken on 08/07/25 and was not in compliance per CMS guidelines and therefore does not count. Since the weight taken in August was greater than 180 days, we cannot use it for a significant weight loss.
CONCERN
(D)
Potential for Harm - no one hurt, but risky conditions existed
Assessment Accuracy
(Tag F0641)
Could have caused harm · This affected 1 resident
**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on record review, interview, and policy review, the facility failed to ensure Minimum Data Set (MDS) assessments were comp...
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**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on record review, interview, and policy review, the facility failed to ensure Minimum Data Set (MDS) assessments were completed accurately for two of 48 residents (Resident (R) R23 and R136) whose records were reviewed. This had the potential to cause unmet care needs for the residents. The facility census was 136.
Findings include:
Review of the facility's policy titled, Assessment and Management of Resident Weights, revised 10/24/22, indicated, . V. Significant Weight Change Management: A. Significant weight changes will be reviewed by the Director of Nursing Services or designated licensed nurse. Significant weight changes are: i. 5% in one (1) month, ii. 7.5% in three (3) months, iii. 10% in six (6) months .
Review of the facility's policy titled, RAI Process, revised 10/24/22, indicated, . Purpose: To ensure that the Resident Assessment Instrument (RAI) is used, in accordance with specified format and timeframes, in conducting comprehensive assessments as part of an ongoing process through which the facility identifies each resident's preferences and goals of care, functional and health status, strengths and needs, as well as offering guidance for further assessment once problems have been identified . Policy: I. The Facility will utilize the Resident Assessment Instrument (RAI) process as the basis for the accurate assessment for each resident's functional capacity and health status, as outlined in the CMS RAI MDS 3.0 Manual .1. Review of R23's admission Record,, located under the Profile tab of the EMR, revealed R23 was admitted to the facility on [DATE] with diagnoses that included Alzheimer's disease, anxiety disorder, insomnia, mood disorders, dysphagia, dementia, and depression.
Review of R23's Weights, located under the Wts/Vitals tab of the EMR, revealed:
On 08/07/24, the weight was 133.0 pounds (Lbs).
On 01/09/25, the weight was 115.4 Lbs.
On 02/02/25, the weight was 118.0 Lbs.
Review of R23's Progress Notes, dated 01/20/2025 at 9:24 AM, revealed, . SIGNIFICANT WEIGHT LOSS NUTRITION NOTE: weight: 115.4# 1/9/25, BMI 21.8; essentially stable x 1 month, -6.2% in 3 months, -14.3% in 6 months .
Review of R23's Progress Notes, dated 02/28/2025 at 11:32 AM, revealed, . SIGNIFICANT WEIGHT LOSS NUTRITION NOTE: weight: 118# 2/20/25, BMI 22.3; +2.3% in 1 month, -11.3% in 6 months .
Review of R23's quarterly MDS, with an ARD of 02/27/25 and located under the MDS tab of the EMR, revealed the resident was coded to have no weight loss of 5% or more in the last month or 10% or more in the last six months.
During an interview on 03/19/25 at 10:34 AM, the MDSC stated, the weight on 02/20/25 for R23 was not within 180 days of the August weight taken on 08/07/25 and was not in compliance per CMS guidelines and therefore did not count. She stated, Since the weight taken in August was greater than 180 days [old], we cannot use it for a significant weight loss.
2. Review of R136's admission Record, located under the Profile tab of the EMR,, revealed R136 was admitted to the facility on [DATE] with diagnoses that included congestive heart failure and chronic kidney disease stage 3. The resident was discharged on 12/30/24 to home.
Review of R136's Order Summary, located under the Orders tab of the EMR, revealed an order dated 12/27/24 to Discharge home 12/28/24 with all belongings including meds.
Review of R136's Progress Notes, located under the Prog Notes tab of the EMR, revealed no documentation regarding R136's discharge.
Review of R136's Discharge MDS, with an ARD of 12/30/24, located under the MDS tab of the EMR, revealed the resident was coded to have discharged to short-term general hospital.
During an interview on 03/19/25 at 5:30 PM, the MDSC stated she was unable to provide an explanation for the discrepancy regarding the discharge status of R136 and stated, The discharge assessment information would have been taken from the [EMR].
During a subsequent interview on 03/20/25 at 10:40 AM, the MDSC stated, [R136] was discharged home and the discharge MDS has been modified.
CONCERN
(D)
Potential for Harm - no one hurt, but risky conditions existed
PASARR Coordination
(Tag F0644)
Could have caused harm · This affected 1 resident
**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on record review, interviews, and facility policy review, the facility failed to ensure Pre-admission Screening and Reside...
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**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on record review, interviews, and facility policy review, the facility failed to ensure Pre-admission Screening and Resident Review (PASARR) level one was updated with a new diagnosis after admission for one of two residents (Resident (R) 91) reviewed for PASARR out of a total sample of 48. This failure had the potential to affect the resident's need for any potential additional services. The facility census was 136.
Findings include:
Review of the facility's policy titled, Pre-admission Screening and Resident Review (PASRR), revised 07/27/23, revealed, . The facility also conducts Level 1 screen for current residents who have a mental illness or intellectual disability and experience a significant change in their condition based on MDS [Minimum Data Set] 3.0 guidelines . A negative PASRR Level 1 screen permits admission to proceed and ends the PASRR process unless a possible serious mental disorder or intellectual ability arises later .
Review of R91's admission Record, located under the Profile tab of the electronic medical record (EMR), revealed the resident was admitted on [DATE]. It was recorded that a diagnosis of mood disorder was added on 12/06/23.
Review of R91'sLevel One PASARR, located under the Misc section of the EMR and dated 08/02/23, revealed under the section Does the individual have a current, suspected, or history of a Major Mental Illness as defined by the Diagnostic & Statistical Manual of Mental Disorders (DSM) current edition? There was no documented evidence that R91's PASARR had been updated to include the diagnosis of mood disorder when it was added on 12/06/23.
During an interview on 03/19/25 at 9:56 AM, the Social Services Director (SSD) stated she did not do anything regarding PASARRs.
During an interview on 03/19/25 at 10:06 AM, the Business Office Manager (BOM) stated she did not do anything regarding the PASARR. She stated the Regional BOM (RBOM) oversaw the PASARR. The BOM called the RBOM, and the RBOM stated the facility usually sent her any changes. The RBOM stated that for a new diagnosis, they would do a duplicate PASARR to add the new diagnosis. She stated it would have been the MDS Coordinator (MDSC) who would have updated her.
During an interview on 03/19/25 at 10:41 AM with the Administrator, Interim Director of Nursing (DON), and MDSC, the MDSC stated she did not update the BOM when R91 received the diagnosis of mood disorder. She stated she only updated the diagnosis in the EMR. She stated no one had ever asked her to do anything different. The Interim Director of Nursing (DON) stated she was unsure of who oversaw sending updates to the RBOM. The Administrator stated he thought it would be between Social Services or the BOM.
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 record review and interview, the facility failed to develop and implement a care plan for a resident's hospice services...
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**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on record review and interview, the facility failed to develop and implement a care plan for a resident's hospice services for one of one resident (Resident (R) 57) reviewed for hospice out of a total sample of 48. This had the potential to cause unmet care needs. The facility census was 136.
Findings include:
Review of R57's Face Sheet, located in the Profile tab of the EMR, revealed R57 was admitted to the facility on [DATE].
Review of R57's Physician Orders, located under the Orders tab in the EMR and dated 02/07/25, revealed an order for hospice services.
Review of R57's Care Plan, located under the Care Plan tab of the EMR and dated 02/07/25, revealed there was no evidence R57 had a care plan developed for hospice services.
During an interview on 03/19/25 at 5:29 PM, the MDS Coordinator (MDSC) stated the facility missed developing a care plan for hospice services for R57. She stated updating the care plan to include hospice was missed since the payor type was not updated.
During an interview on 03/20/25 at 5:42 PM, the Director of Nursing (DON) stated that a care plan should have been implemented for hospice services.
CONCERN
(D)
Potential for Harm - no one hurt, but risky conditions existed
Quality of Care
(Tag F0684)
Could have caused harm · This affected 1 resident
**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, interview, and record review, the facility failed to ensure staff followed physician orders for the use of...
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**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, interview, and record review, the facility failed to ensure staff followed physician orders for the use of a helmet related to fall safety for one of one resident (Resident (R) 2) reviewed for Helmet use out of a total sample of 48. This had the potential to increase R2's risk of injury with any fall. The facility census was 136.
Findings include:
Review of R2's Face Sheet, located under the Profile tab of the electronic medical record (EMR), revealed the resident was admitted to the facility on [DATE] and readmitted on [DATE] with diagnoses which included Parkinson's with dyskinesia, functional quadriplegia, mood disorder, schizoaffective, paranoid schizophrenia, vascular dementia, intellectual disabilities, and other seizures.
Review of R2's quarterly Minimum Data Set (MDS), with an Assessment Reference Date (ARD) of 01/08/25 and located under the MDS tab of the EMR, revealed the facility assessed the resident to have a Brief Interview for Mental Status (BIMS) score of six out of 15, which indicated severe cognitive impairment.
Review of R2's Care Plan, revised 11/29/24 and located under the Care Plan tab of the EMR, revealed R2 wore a helmet for fall safety. It was documented the resident often refused to wear the helmet.
Review of R2's Physician Orders, dated 03/20/25 and located under the Orders tab of the EMR, revealed an order dated 11/21/24 for R2 to have a helmet on to prevent major injuries due to continuous falls and to document all refusals in the progress notes.
Review of R2's Nurses Notes, dated March 2025 and located under the Prog (Progress) Notes tab of the EMR, revealed no documentation staff offered the helmet to R2 or that he refused to wear the helmet.
During observations of R2 on 03/18/25 at 2:35 PM, 03/18/25 at 3:30 PM, 03/19/25 at 5:45 AM, and 03/19/25 at 8:20 AM, R2 did not have a helmet on.
During an observation and interview on 03/19/25 at 6:04 AM, Licensed Practical Nurse (LPN)8 stated she just documented No on the treatment record (TAR) when R2 was not wearing the helmet. She stated he had not been wearing the helmet. LPN8 stated she did not know she was supposed to document any refusals in the electronic medical record, LPN8 stated R2 did not have a helmet in his room. She stated she was not sure what happened to it.
During an observation and interview on 03/19/25 at 7:28 AM, Certified Nurse Aide (CNA)2 stated he was unsure if R2 was supposed to wear a helmet. He stated he had heard the resident's family talking about it. He stated he had not seen the helmet. CNA2 went into R2's room and checked the room and the closet, but was unable to find a helmet. He stated he thought the family took it home and never brought it back, but he did not notify a nurse.
During an interview on 03/20/25 at 5:44 PM, the Director of Nursing (DON) stated she expected staff to follow physician orders. She stated if there was an issue or concern, staff should have contacted the physician and staff should have attempted to locate the helmet.
CONCERN
(D)
Potential for Harm - no one hurt, but risky conditions existed
Deficiency F0685
(Tag F0685)
Could have caused harm · This affected 1 resident
**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on record review, staff interview, and facility policy review, the facility failed to ensure vision services related to ca...
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**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on record review, staff interview, and facility policy review, the facility failed to ensure vision services related to cataract surgery provided for one of two residents (Resident (R) R16) reviewed for vision and hearing services out of a total sample of 48. R16 had a failed appointment for cataract surgery in May of 2024 and the facility failed to reschedule the appointment. This failure had the potential to prevent R16 from living in the highest practicable physical well-being. The facility census was 136.
Findings include:
Review of the facility's undated policy titled, Care and Services, revealed, Residents are provided with the necessary care and services to maintain the highest practicable physical, mental, and social well-being level of in an environment that enhances quality of life in the scope of a long-term care facility. Care and services are provided in a manner that consistently enhances self-esteem and self-worth.
Review of R16's admission Record, located under the Profile tab of the electronic medical record (EMR), revealed R16 was admitted to the facility on [DATE] with diagnoses that included other specified cataract.
Review of R16's Minimum Data Set (MDS), with an Assessment Reference Date (ARD) of 01/19/24 and located under the MDS tab of the EMR, indicated R16 had a Brief Interview for Mental Status (BIMS) score of 15 out of 15, which indicated R16 was cognitively intact. The assessment indicated R16's vision was adequate without the use of corrective lenses.
Review of R16's Care Plan, dated 02/27/23 and located under the Care Plan tab of the EMR, revealed R16 had cataracts, and interventions included, Arrange consultation with eye doctor PRN [as needed].
Review of eye surgery appointment letter located under the Misc (miscellaneous) tab of the EMR revealed R16 was to have laser eye surgery on the right eye on 03/05/24, with post-operative follow-up visits scheduled for 03/07/24 and 03/12/24 respectively.
Review of R16's Progress Notes, dated 03/05/24 and found under the Progress Notes tab of the EMR, revealed in part, the resident returned from her eye appointment, did not have cataract surgery done, needs to reschedule because the resident stated the facility needed to send a Hoyer lift machine with her.
During an interview on 03/18/25 at 9:39 AM, R16 stated she should have had cataract surgery a year ago, but the facility did not send her again after it did not work out the first time.
During an interview on 03/19/25 at 1:25 PM, the 4th floor Unit stated she was not employed at the facility in March of 2024, but was able to find out that R16 needed a Hoyer lift in order to be placed in the chair for surgery at the surgery center in order to undergo the cataract surgery. She stated the surgery center did not have a Hoyer (a mechanical device that allows a person to be lifted and transferred with minimum physical effort) lift or the capacity to lift her into the chair, and the surgery was canceled. When asked why the issue was never revisited and the surgery attempted since last year, she stated she did not know.
During an interview on 03/20/25 at 7:30 PM, the Director of Nursing (DON) stated she did not know why the facility did not attempt to reschedule R16's cataract surgery since it was canceled the previous year on 03/05/24.
CONCERN
(D)
Potential for Harm - no one hurt, but risky conditions existed
Accident Prevention
(Tag F0689)
Could have caused harm · This affected 1 resident
**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, interview, record review, and facility policy review, the facility failed to ensure one of four residents ...
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**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, interview, record review, and facility policy review, the facility failed to ensure one of four residents (Resident (R) R2) reviewed for smoking out of a total sample of 48 did not smoke inside the facility. R2, who was assessed to need supervision while smoking locked himself in his bathroom and smoked. The facility census was 136.
Findings include:
Review of a facility policy titled, Smoking by Residents, revised April 2024, indicated, . Smoking is not allowed anywhere inside the facility . Residents will be allowed to smoke in designated smoking area(s) only . It may be necessary to counsel patients or responsible parties who violate the smoking policy. Violation of this policy may compromise the safety of all residents and staff due to potential negative consequences that can occur. For this reason, any violations will result in the following actions:
1. First Offense - Written warning and counseling session with the understanding that continued violation will result in further action.
2. Second Offense - The Facility will notify your attending physician and a care conference will occur to discuss further consequences, which may include discharge to a more appropriate setting.
3. Third Offense - Due to the safety risks posed to Facility Staff and other residents including harboring flammable materials and paraphernalia around medical equipment, the Facility may initiate discharge based on resident safety concerns consistent with state and
federal law .
Review of R2's Face Sheet located under the Profile tab of the EMR, revealed the resident was admitted to the facility on [DATE] and readmitted on [DATE] with diagnoses which included Parkinson's with dyskinesia, functional quadriplegia, mood disorder, schizoaffective, paranoid schizophrenia, vascular dementia, intellectual disabilities, and other seizures.
Review of R2's quarterly MDS, with an ARD of 01/08/25 and located under the MDS tab of the EMR,, revealed R2 had a BIMS score of six out of 15, which indicated severe cognitive impairment.
Review of R2's Care Plan, revised 02/06/24 and located under the Care Plan tab of the EMR, revealed, . Potential for safety hazard, injury related to smoking . Interventions in place were to wear a smoking apron during supervised smoking, smoking only in designated areas, smoking supplies to be stored by staff, to notify charge nurse of violation of facility protocol, and direct supervision by staff when smoking.
Review of Progress Note, dated 03/11/25 at 9:02 AM, located under the Prog Notes tab of the EMR, and written by LPN2 revealed, . Resident was observed smoking in his room with his bathroom door locked resident was educated on how important it is to not smoke in his room for safety reason will notify SW [Social Worker] about resident behavior .
During an observation on 03/18/24 at 3:30 PM, R2 was observed in the outside smoking area. Staff placed a smoking apron on the resident and provided him with a cigarette. Staff lit the cigarette for R2. Staff then provided R2 with another cigarette. R2 smoked the first cigarette and attempted to light the second cigarette with the lit butt of the first cigarette. Staff took the lit butt from the resident and lit the second cigarette.
During an interview on 03/19/25 at 7:28 AM, CNA2 stated that on 03/11/25 he noticed R2's call light was on, and he went into the resident's room, and he observed the resident's bathroom door was closed and locked. He stated he knocked on the bathroom door, and he could smell smoke, but the resident would not open the door. CNA2 stated he had to leave the room and get maintenance to get the master key to unlock the door, but by the time maintenance got back, R2 had unlocked the door. CNA2 stated he could smell the smoke, but he was unable to find the lighter or cigarette. He stated R2 would get cigarettes from other residents. He stated they were supposed to be changing R2's bathroom doorknob to one that did not lock, but it had not been done yet. CNA2 stated he was unsure why the doorknob had not been changed.
During an interview on 03/19/25 at 9:52 AM, LPN2 stated that on 03/11/25, CNA2 told her he was knocking on R2's bathroom door because it was locked and CNA2 had reported he believed R2 had been smoking in the bathroom. LPN2 stated CNA2 went to get the Maintenance Director (MD) and they both went to the resident's room. LPN2 stated she was not aware prior to that day that the bathroom door locked from the inside. She stated CNA2 told them they took the lock off the door. LPN2 stated she did not report to management because it was reported to maintenance, and she believed they would fix it. She stated that no residents should have smoking paraphernalia on them or in their rooms.
During an interview on 03/19/25 at 10:07 AM, the MD stated he was not aware of an issue with the bathroom door in R2's room and was not asked to do anything with the doorknob until this morning. The MD stated he was still waiting to get clarification on what needs to be done with doorknob.
During an interview on 03/20/25 at 5:44 PM, the Director of Nursing (DON) stated the lock on the resident's door was a safety lock. She stated it could be opened with any key, but they could have done a better job educating staff to ensure they knew how to unlock the door. She stated she was unsure what other changes were made to R2's plan of care after he was caught in the bathroom smoking. She stated she was not aware that R2 did not have a smoking assessment completed prior to 03/11/25, but she would have expected that one was completed prior to allowing the resident to smoke.
CONCERN
(D)
Potential for Harm - no one hurt, but risky conditions existed
Respiratory Care
(Tag F0695)
Could have caused harm · This affected 1 resident
**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, record review, and interview, the facility failed to ensure one of one resident (Resident (R)51), reviewed...
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**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, record review, and interview, the facility failed to ensure one of one resident (Resident (R)51), reviewed for oxygen administration out of a total sample of 48, received oxygen per nasal cannula according to the physician's order. This failure had the potential for the resident to receive increased oxygen causing hyperoxia (cells, tissues and organs are exposed to an excess supply of oxygen.) The facility census was 136.
Findings include:
Review of R51's admission Record, located in the Profile tab of the electronic medical record (EMR), revealed R51 was readmitted to the facility on [DATE] with diagnoses that included chronic respiratory failure with hypoxia.
Review of R51's Physician Orders, dated 01/29/21 and located under the Orders, tab in the EMR, revealed R51 was to receive oxygen at two Liters per Minute (LPM) via nasal cannula as needed for shortness of breath.
Review of R51's Care Plan, dated 01/10/23 and located under the Care Plan tab of the EMR,, revealed a focus of Pulmonary Hygiene/Respiratory. Interventions included administering oxygen per physician orders.
Review of R51's quarterly Minimum Data Set (MDS), with an Assessment Reference Date (ARD) of 01/22/25 and located under the MDS tab of the EMR, revealed R51 had a Brief Interview for Mental Status (BIMS) score of 15 out of 15, which indicated no cognitive impairment. It was recorded R51 received oxygen therapy.
Review of R51's Medication Administration Record (MAR), dated 03/2025 and located under the Records tab in the EMR, revealed no documented oxygen use on 03/17/25, 03/18/25 and 03/19/25.
During observations on 03/17/25 at 9:25 AM, 03/18/25 at 11:45 AM, and 03/19/24 at 6:15 AM R51 was lying in bed with a nasal cannula on and oxygen flowing at three LPM. R51 stated he wore his oxygen continuously.
During an interview on 03/19/25 at 6:16 AM, Licensed Practical Nurse (LPN)8 confirmed R51 was wearing his nasal cannula and the oxygen flow was set at three LPM. LPN8 stated she was unable to answer why there was no documentation on the MAR about R51 being on oxygen. LPN8 stated she just assumed R51 was on oxygen continuously and she did not know what his correct LPM should have been. LPN8 stated she did not look at the LPM this morning and only obtained his blood oxygen saturation level. LPN8 stated she was unaware that he was on three LPM because she did not pay attention. She stated staff should be checking the LPM and the saturation and documenting on the MAR.
During an interview on 03/20/25 at 5:29 PM, the Director of Nursing (DON) stated there should be some documentation on the MAR when a resident was placed on oxygen and they should be checking every shift to ensure the correct LPM.
CONCERN
(D)
Potential for Harm - no one hurt, but risky conditions existed
Medication Errors
(Tag F0758)
Could have caused harm · This affected 1 resident
**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on interview and record review, the facility failed to monitor target behaviors for the use of psychotropic medications fo...
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**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on interview and record review, the facility failed to monitor target behaviors for the use of psychotropic medications for one of five residents (Resident (R) 42) reviewed for unnecessary medications out of a total sample of 48. This had the potential to cause R42 to receive unnecessary medications. The facility census was 136.
Findings include:
Review of R42's Resident Face Sheet, located under the Continuity of Care (CCD) tab of the electronic medical record (EMR), indicated the resident was re-admitted to the facility on [DATE] with diagnoses including mood disorder, anxiety disorder, schizophrenia, and major depression.
Review of R42's quarterly Minimum Data Set (MDS), with an Assessment Reference Date (ARD) of 02/01/25 and located under the MDS tab of the EMR, revealed R42 had a Brief Interview for Mental Status (BIMS) score of 13 out of 15, which indicated no cognitive impairment. The resident was coded as receiving antipsychotic, antidepressant, and antianxiety medications.
Review of R42's Physician Order Report, dated 03/20/25 and found under the Orders tab of the EMR, indicated R42 was to receive alprazolam (an antianxiety medication) 0.25 milligrams (mg) once daily, alprazolam 0.50mg twice daily, buspirone (an antianxiety medication) 15mg twice daily, and Seroquel (an antipsychotic medication) 300mg at bedtime. Further review revealed no documented evidence of target behaviors associated with the medications.
Review of R42's Medication Administration Record (MAR), dated February and March 2025 and found in the EMR under the Orders tab, revealed no documented evidence to show which specific behaviors were associated with the administration of the resident's psychotropic medications and required routine monitoring.
During an interview on 03/20/25 at 10:06 AM, Licensed Practical Nurse (LPN)2 stated she was not aware of what targeted behaviors related to any of the resident's psychotropic medications. She stated R42 did not have any behaviors. LPN2 stated no one had told her of a time span to monitor a resident for target behaviors before letting the physician know. She stated staff were not monitoring behaviors or documenting them. She stated she was not sure what behaviors they should be monitoring for.
During an interview on 03/20/25 at 5:37 PM, the Director of Nursing (DON) stated there should be an order to monitor target behaviors along with side effects. She stated staff should be documenting behaviors to indicate the need for prescribed medications.
CONCERN
(D)
Potential for Harm - no one hurt, but risky conditions existed
Deficiency F0883
(Tag F0883)
Could have caused harm · This affected 1 resident
**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on interview, record review, and facility policy review, the facility failed to offer pneumococcal vaccines for two of sev...
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**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on interview, record review, and facility policy review, the facility failed to offer pneumococcal vaccines for two of seven residents (Resident (R) 92 and R95) reviewed for pneumonia vaccinations out of a total sample of 48. This practice had the potential to increase the risk for these residents to contract pneumonia. The facility census was 136.
Findings include:
Review of the policy titled, Pneumococcal Disease Prevention, implemented 09/01/23 revealed, . Pneumococcal vaccines are recommended for the following classifications of residents: A. All adults [AGE] years of age and older . Anyone 2 through [AGE] years of age who has a long-term health problem such as: heart disease, lung disease, sickle cell disease, diabetes, alcoholism, cirrhosis, leaks of cerebrospinal fluid or cochlear implant . Anyone 2 through [AGE] years of age who has a disease or condition that lowers the body's resistance to infection, such as: Hodgkin's disease; lymphoma or leukemia; kidney failure; multiple myeloma; nephrotic syndrome; HIV Infection or AIDS; damaged spleen, or no spleen; organ transplant . Anyone 2 through [AGE] years of age who Is taking a drug or treatment that lowers the body's resistance to Infection, such as: long-term steroids, certain cancer drugs, radiation therapy .
1. Review of R92's quarterly Minimum Data Set (MDS), with an Assessment Reference Date (ARD) of 01/13/25 and located under the MDS tab of the electronic medical record (EMR), revealed R92 was admitted to the facility on [DATE] with diagnoses that included essential (primary) hypertension, chronic kidney disease, type 2 diabetes mellitus and anemia. It was recorded R92 had a Brief Interview for Mental Status (BIMS) score of 14 out of 15, which indicated R92 was cognitively intact. Review of MDS revealed R92 was admitted at the age of 65.
Review of R92's admission Agreement, located under the MISC (Miscellaneous) tab of the EMR, revealed R92 signed the agreement electronically on 11/21/23 and also signed a consent to receive the pneumococcal vaccination on 11/21/23 as follows:
Pneumococcal Vaccine Informed Consent __
I hereby give the Center permission to administer pneumococcal vaccination series. PPSV23 is recommended for:
All adults [AGE] years of age and older,
Anyone 2 through [AGE] years of age with certain long term health problems,
Anyone 2 through [AGE] years of age with a weakened immune system,
Adults 19 through [AGE] years of age who smoke cigarettes or have asthma.
Review R92's Immunization Record, located under the Immunization tab of the EMR, revealed no indication that R92 had received any pneumococcal vaccine.
2. Review of R95's quarterly MDS, with an ARD of 03/04/25 and located under the MDS tab of the EMR, revealed R95 was admitted to the facility on [DATE] with diagnoses that included orthostatic hypotension, alcohol dependence with alcohol-induced mood disorder, and mild cognitive impairment. It was recorded R95 had a BIMS score of 15 out of 15, which indicated R95 was cognitively intact.
Review of R95's admission Agreement, located under the MISC tab of the EMR, revealed R95 signed the agreement electronically on 08/11/23 and also signed a consent to receive the pneumococcal vaccination on 08/11/23 as follows:
Pneumococcal Vaccine Informed Consent __
I hereby give the Center permission to administer pneumococcal vaccination series. PPSV23 is recommended for:
All adults [AGE] years of age and older,
Anyone 2 through [AGE] years of age with certain long term health problems,
Anyone 2 through [AGE] years of age with a weakened immune system,
Adults 19 through [AGE] years of age who smoke cigarettes or have asthma.
Review R95's Immunization Record, located under the Immunization tab of the EMR, revealed no indication that R95 received the Pneumococcal Prevnar 20 on 03/19/25.
During an interview on 03/18/25 at 3:37 PM, the Assistant Director of Nursing/Infection Preventionist (ADON)4 stated R95 had declined the pneumococcal vaccine. When informed that R95 had consented to the vaccine, but never received it, ADON4 stated she will look into it.
During an interview on 03/20/25 at 6:18 PM, the Director of Nursing (DON) stated it was her expectation that R92 and R95 should have received the vaccines they consented to on admission.
CONCERN
(E)
Potential for Harm - no one hurt, but risky conditions existed
Deficiency F0583
(Tag F0583)
Could have caused harm · This affected multiple residents
Based on observation, interview, and facility policy review, the facility failed to ensure medical records containing personal health information (PHI) were not accessible to 27 of 27 residents and/or...
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Based on observation, interview, and facility policy review, the facility failed to ensure medical records containing personal health information (PHI) were not accessible to 27 of 27 residents and/or visitors who resided on the secure unit. This failure had the potential to allow inappropriate access to resident records. The facility census was 136.
Findings include:
Review of the facility's policy titled, General Provisions- Medical Records Manual-General, revised 10/24/22, revealed, Active records are to be located in an area not accessible to unauthorized persons.
Review of the facility's policy titled, Resident Rights, revised 05/01/23, indicated, . State and federal laws guarantee certain basic rights to all residents in this Facility. These rights include, but are not limited to, a resident's right to . Privacy and confidentiality.
Review of the facility's policy titled, Confidentiality of Information and Personal Privacy, revised 10/01/17, indicated, . The facility will safeguard the personal privacy and confidentiality of all resident personal and medical records . Access to resident personal and medical records will be limited to authorized staff and business associates .During an observation on 03/19/25 at 7:39 AM, Certified Medication Technician (CMT) 6 administered medications to R38 in R38's room. The medication cart was located in the dining room. CMT6 left R38's electronic medical records (EMR) open which contained confidential and private medical information visible to any resident or visitor in the dining room. Multiple residents were in the dining room waiting for breakfast.
During an observation on 03/19/25 at 7:42 AM, CMT6 administered medications to R123 in R123's room. The medication cart was located in the hallway outside of R123's room. CMT6 left R123's EMR open which contained confidential and private medical information visible to any resident or visitor in the hallway outside of R123's room. Residents were observed walking down the hallway.
During an observation on 03/19/25 at 7:53 AM, CMT6 left the medication cart that was located in the dining room. CMT6 left the EMR for all residents on the hall open which contained confidential and private medical information visible to any resident or visitor in the dining room. There were 27 residents located on this hall.
During an interview on 03/19/25 at 08:16 AM, CMT6 stated, I didn't realize I was leaving the screen open.
During an interview on 03/20/25 at 5:33 PM, the Director of Nursing (DON) stated, The [EMR] screen should be locked when the nurse walks away from the medication cart. There would be privacy concerns if the screen was left open.
CONCERN
(E)
📢 Someone Reported This
A family member, employee, or ombudsman was alarmed enough to file a formal complaint
Potential for Harm - no one hurt, but risky conditions existed
Deficiency F0725
(Tag F0725)
Could have caused harm · This affected multiple residents
**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, record review, interview, and facility policy review, the facility failed to ensure adequate staffing on t...
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**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, record review, interview, and facility policy review, the facility failed to ensure adequate staffing on the fifth floor for four of 18 residents (Resident (R) 138, R97, R75, and R89) reviewed for staffing concerns out of a total sample of 48. This failure had the potential to affect quality resident care. The facility census was 136.
Findings include:
Review of the facility's policy titled, Nursing Department- Staffing, Scheduling & Postings, revised 10/24/22, revealed, . The facility will employ sufficient nursing staff as determined by resident assessments and individual plans of care .
1. Review of R138's admission Record, located under the Profile tab of the electronic medical record (EMR), revealed the resident was admitted on [DATE]. Diagnosis included acute respiratory failure.
Review of R138's quarterly Minimum Data Set (MDS), with an Assessment Reference Date (ARD) of 03/12/25 and located under the MDS tab of the EMR, revealed R138 had a Brief Interview for Mental Status (BIMS) score of 13 out of 15, which indicated the resident was cognitively intact.
During an interview on 03/17/25 at 11:39 AM, R138 stated the call light response times were long and could be 40 minutes. She stated they did not come, and she could not breathe. She stated it was taking a long time for a call light response this day and she was blind.
During an observation on 03/17/25 at 11:59 AM, R138's call light was on and a staff member (Certified Medication Technician (CMT) 1) on the floor was noted to be talking on the phone through earbuds.
During an interview on 03/17/25 at 12:05 PM, CMT1 was seated in the corner and stated she worked at the facility about once a week. She stated she was on break but was going to pass trays once they arrived.
During an observation on 03/17/25 at 12:08 PM, the trays arrived on the floor. CMT1 remained talking on the phone and started to pass trays. R138's call remained on. At 12:16 PM, the call light was answered by a different unidentified staff member. The call light was observed to be on from 11:59 AM through 12:16 PM.
2. Review of R97's admission Record, located under the Profile tab of the EMR, revealed the resident was admitted on [DATE]. Diagnoses included cognitive communication deficit, schizoaffective disorder, mood disorder, neurocognitive disorder with Lewy bodies, Parkinson's disease, dementia, depression, and other seizures.
Review of R97's quarterly MDS, with an ARD of 01/09/25 and located under the MDS tab of EMR, revealed the resident had a BIMS score of 15 out of 15, which indicated the resident was cognitively intact.
During an interview on 03/17/25 at 10:19 AM, R97 stated there were not enough staff on the fifth floor, and there were no staff available on the weekends.
Review of R75's admission Record, located under the Profile tab of the EMR, revealed the resident was admitted on [DATE]. Diagnoses included bipolar disorder, paranoid schizophrenia, anxiety, and the history of falling.
Review of R75's quarterly MDS, with an ARD of 02/24/25 and located under the MDS tab of the EMR, revealed the resident had a BIMS score of 14 out of 15, which indicated the resident was cognitively intact.
During an interview on 03/17/25 at 10:48 AM, R75 stated they did not have staff at night and the call lights were not answered.
Review of R89's admission Record, located under the Profile tab of the EMR, revealed the resident was admitted on [DATE]. Diagnoses included anxiety, schizophrenia, difficulty in walking, and repeated falls.
Review of R89's quarterly MDS, with an ARD of 02/19/25 and located under the MDS tab of the EMR, revealed the resident had a BIMS score of 11 out of 15, which indicated the resident was moderately cognitively impaired.
During an interview on 03/17/25 at 12:11 PM, R89 stated there were not enough staff on the fifth floor.
During an interview on 03/19/25 at 5:15 AM, CMT15 stated there were not enough staff on the fifth floor at night. She stated she was usually the only staff on the floor from 11:00 PM- 7:00 AM She stated there was one resident on the floor who had seizures.
Review of the February 2025 staffing sheets, provided by the facility, revealed the fifth floor (500-hall) had only one staff member, either a CMT or a Licensed Practical Nurse (LPN) on the floor for the 11:00 PM- 7:00 AM shift on the following nights: 02/14/25; 02/15/25; 02/16/25; 02/17/25; 02/18/25; 02/19/25; 02/20/25; 02/23/25; 02/24/25; 02/26/25; 02/27/25. There was no Certified Nurse Aide (CNA) on those shifts. (Eleven nights with one staff member (CMT or an LPN) on the floor)
Review of the March 2025 staffing sheets, provided by the facility, revealed the fifth floor (500-hall) had only one staff member, either a CMT or LPN, for the 11:00 PM- 7:00 AM shift on the following nights: 03/01/25; 03/02/25; 03/03/25; 03/05/25; 03/10/25; 03/11/25; 03/16/25. There was no CNA on those shifts. (Seven nights with one staff member (CMT or LPN) on the floor)
Review of the March 2025 staffing sheets, provided by the facility, revealed the fifth floor (500-hall) had no CMT or Licensed Practical Nurse (LPN) coverage for the 11:00 PM- 7:00 AM shift on the following nights: 03/09/25; 03/14/25. The floor was staff with only one CNA.
During an interview on 03/20/25 at 10:46 AM, the Scheduler stated she had been in this position for two years. She stated her expectation was to have at least one CMT and one CNA on nights for the fifth floor. She stated the CMT preferred to work by herself. The Scheduler stated the staff were supposed to call off at least two hours before their shift, but they had been calling off less than one hour, at times. She stated they did not tolerate staff talking on their phones during their shifts. She confirmed the missing coverage displayed on the staffing sheets and stated it was due to call-offs.
During an interview on 03/20/25 at 12:21 PM, the interim Director of Nursing (DON) stated that for nights, staffing was tricky. She stated that ideally, they should have a nurse and a CNA. She stated if that pattern was not available, then a CMT and the nurse from 400-hall would cover the nursing duties. She confirmed she was aware of a staffing concern. She stated phone usage had been a struggle on the floor and that earbuds were not allowed.
M00247452
MO00248617
MO00250713
MO00251444
CONCERN
(E)
📢 Someone Reported This
A family member, employee, or ombudsman was alarmed enough to file a formal complaint
Potential for Harm - no one hurt, but risky conditions existed
Deficiency F0727
(Tag F0727)
Could have caused harm · This affected multiple residents
Based on interview, facility documentation, and facility policy review, the facility failed to ensure eight hours of Registered Nurse (RN) coverage every day of the week for 136 of 136 census resident...
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Based on interview, facility documentation, and facility policy review, the facility failed to ensure eight hours of Registered Nurse (RN) coverage every day of the week for 136 of 136 census residents. This failure had the potential to affect the safety of resident care. The facility census was 136.
Findings include:
Review of the facility's policy titled, Nursing Department-Staffing, Scheduling & Postings, revised 10/24/22, revealed, . The facility must use the services of a registered nurse for at least 8 consecutive hours a day, 7 days per week, unless a waiver applies .
Review of the January 2025 staffing sheets, provided by the facility, revealed there was no RN coverage on 01/02/25, 01/09/25, 01/18/25, 01/23/25, 01/27/25, and 01/30/25.
Review of the February 2025 staffing sheets, provided by the facility, revealed there was no RN coverage on 02/01/25, 02/06/25, 02/10/25, 02/13/25, 02/15/25, 02/20/25, 02/24/25, and 02/27/25.
Review of the March 2025 staffing sheets, provided by the facility, revealed there was no RN coverage on 03/01/25, 03/02/25, 03/10/25, 03/15/25, and 03/16/25.
During an interview on 03/20/25 at 10:46 AM, the Scheduler stated they had some staff currently transitioning to be an RN. She confirmed the lack of RN coverage in the building and stated it was difficult to get RNs. She stated the only RN working in a management role was the Director of Nursing (DON). She also confirmed there was no RN coverage due to call-offs.
During an interview on 03/20/25 at 12:21 PM, the interim DON confirmed the lack of RN coverage in the facility. She stated if anything in the facility required an RN then she would handle it.
M00247452
MO00248617
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 observation, interview, and policy review, the facility failed to ensure medications were labeled with open and discard...
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**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, interview, and policy review, the facility failed to ensure medications were labeled with open and discard dates, individual insulin syringes were labeled with the resident's name, and expired medications were disposed of and not made available on the medication cart for 4 of 4 medication carts reviewed. This had the potential to cause medication errors, adverse medication reactions, and residents to receive suboptimal therapeutic actions of medications. The facility census was 136.
Findings:
Review of the facility's policy titled, Storage of Medication, dated 01/2024 revealed, . Medications and biologicals are stored properly, following the manufacturer or provider pharmacy recommendations, to keep their integrity and to support safe, effective drug administration. The medication supply shall be accessible only to licensed nursing personnel, pharmacy personnel, or staff members lawfully authorized to administer medications . Outdated, contaminated, discontinued or deteriorated medications and those in containers that are cracked, soiled, or without secure closures are immediately removed from stock, disposed of according to procedures for medication disposal . and reordered from the pharmacy . if a current order exists .
The following observations were made during reviews of medication carts throughout the facility:
1. During a medication administration observation on 03/18/25 at 12:53 PM on the 4th floor with Registered Nurse (RN)1, RN1 administered insulin with HumaLOG KwikPen Subcutaneous Solution Peninjector 100 UNIT/ML (Insulin Lispro) insulin pen for R71. The insulin pen was not labeled with open or discard dates.
During an interview on 03/18/25 at 12:55 PM, RN1 acknowledged the pen did not have an open date or discard date. When asked how many days after opening before the pen must be discarded, she stated she thought it was 30 days, but was unsure and would ask her supervisor.
During a follow-up interview on 03/18/25 at 1:07 PM, RN1 stated her supervisor had confirmed the insulin pen must be discarded 28 days after first use.
2. During a review of the medication cart on the 5th floor on 03/20/25 at 11:07 AM with Licensed Practical Nurse (LPN) 6, the following were observed:
a. Novolin N NPH (insulin isophane human) Suspension 100 units/ml vial, received date 12/28/24, with no open or discard dates for R40.
b. Insulin Lispro Injection Solution 100 UNIT/ML (Insulin Lispro) vial received date 11/01/24 with no open or discard dates for R111.
c. Basaglar Kwikpen received date 02/27/25 labeled with R138's name, with no open or discard dates.
d. Insulin Aspart 100 units per ml pen NovoLOG Pen received date 01/3/25. No open or discard dates for R110.
e. Lantus Solostar subcutaneous solution (insulin glargine) received date 03/10/25 with no open or discard dates for R106.
f. Lantus Pen with no patient label, no open or discard date.
g. Lyumjev KwikPen Subcutaneous Solution Pen-injector 100 UNIT/ML (Insulin Lispro-aabc) with an open date of 2/19/25 was on its 29th day, for R75.
h. Basaglar Kwik pen insulin glargine subcutaneous solution pen-injector 100 unit/ml (insulin glargine) no open or discard received date 3/15/25 for R97.
i. HumaLOG KwikPen Subcutaneous Solution Pen-injector 100 UNIT/ML (Insulin Lispro) received date 12/24/24 for R106. The insulin pen cap had a sticker with a handwritten date 03/15/25 and the first name of R138.
j. HumaLOG KwikPen Subcutaneous Solution Pen-injector 100 UNIT/ML (Insulin Lispro) for R138 received date 02/27/25 with no open or discard date. This item was stored in the same bin and was identical in appearance to R106's insulin pen.
k. Vial of insulin lispro 100 units/ml received date 8/13/24. Open date 12/09/24 for R106. The discard date would have been 01/06/25, 28 days after the open date of 12/09/24.
During an interview on 03/20/25 at 11:33 AM, LPN6 stated, They put the top on the wrong pen, but it is the same medication. The Assistant Director of Nursing/Infection Preventionist (ADON) 4 and the Assistant Director of Nursing/Unit Manager (ADON) 1 joined the conversation on 03/20/25 at 11:35. ADON4 acknowledged the handwritten name of R138 on the cap of R106's single person use insulin syringe could potentially cause a medication error and stated that as a nurse, she would be looking at the pharmacy's printed label, not the handwritten name on the cap. She stated, You read labels, not caps. ADON4 further stated R138 was in the hospital and was unsure of when the two medications were open and when they should be discarded. When asked when the insulin pen for R106 was opened, ADON1 stated it looked like 03/15/25, but was not sure since the open date sticker on R106's medication had R138's handwritten name on it. ADON4 stated the insulin syringes and vials should be labeled with open and discard dates once opened and the seal is broken and that she would discard the medications immediately.
3. The following observations were made in the 4th floor cart with Certified Medication Aide (CMT)2 on 03/20/25 at 12:37 PM:
a. Ketorolac eye drops for R24 labeled as open on 01/15/25. No discard date.
b. For R87 prednisolone eye drops, no open or discard date.
c. Dorzolamide eye drops for R84. Marked opened on 01/16/25.
d. Ciprofloxacin Dexamethasone Eye Drops for R107 open 02/08/25, no open or discard date.
During an interview on 03/20/25 at 12:42 PM, CMT2 stated she did not know how long it was before the medications must be discarded after opening and did not know why they were not labeled with open and discard dates.
4. Observations during review of the medication cart on the 2nd floor with CMT3 on 03/20/25 at 12:52 PM revealed:
a. Latanoprost eyedrops for R5 with no open or discard dates.
b. Atropine 1% eyedrops for R13 with no open or discard dates.
c. Latanoprost 0.005% for R339, no open and discard dates.
d. Insulin pen Lispro opened on 10/30/24 labeled with the name of a resident deceased on [DATE]. The pen cap was handwritten with the name of a resident that had been discharged from the facility on 02/12/25.
e. Atropine 1% eye drops for R8. No open or discard dates.
During an interview on 03/20/25 at 12:43 PM, CMT3 stated she had been gone for 12 days and all the eyedrops were in the medication cart when she returned to work. She stated she had no idea where some of the residents were and that some were no longer on the second floor, including R339 and R8.
5. The following observations were made of the 1st floor medication cart on 03/20/25 at 1:04 PM with CMT7:
a. For R4, prednisolone 1%, no open or discard date.
b. For R25 Polymyxin eye drops labeled for use for 7 days. Receive date 02/21/25. no open or discard date.
c. For R18 Brimonidine 0.2 eye drops no open or discard date.
d. For R65 latanoprost eyedrops expired 11/2/24.
e. For R53 Tobramycin eye drops labeled for use for 5 days, received date 2/4/24. No open or discard dates.
f. For R65 Dorzolamide eye drops opened 10/1/24 no discard date.
g. For R51 sublingual Nitroglycerin expired on 10/01/24.
h. For R18 Brimonidine 0.2 eye drops expired 09/12/24.
i. For R25 Olopatadine eye drops expired 07/11/24.
j. For R65 Brimonidine 0.2 eye drops expired 10/12/24.
k. For R51 sublingual Nitroglycerin 0.4 mg expired 11/20/22.
l. For R4 Prednisolone expired 08/01/24.
During an interview on 03/20/25 at 1:15 PM, CMT7 stated she did not know she had to label eyedrops with date opened and did not know how long it was before they were discarded.
During an interview on 03/20/25 at 2:08 PM, ADON4 stated the time limits for eyedrops vary, but they should be labeled with the date opened. ADON4 stated it was her expectation that staff should call pharmacy if they are unsure of duration after opening. She stated some eyedrops are different, and if they are antibiotics, staff should follow the order. ADON4 stated some insulins are good for 30 days, and some are good for 28 days. ADON4 stated staff should follow directions and consult the pharmacy. ADON4 stated it was her expectation that expired and outdated medications should be discarded.
During an interview on 03/20/25 at 6:04 PM, the Director of Nursing (DON) stated the standard of care is that insulin pens are good for 28 days, and insulins should be dated the day they are open. The DON stated that expired medications should be discarded, and medications of residents who have been discharged should be removed from the cart and discarded.
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, interview, and sampling of a meal test tray, the facility failed to ensure food prepared by the facility w...
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**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, interview, and sampling of a meal test tray, the facility failed to ensure food prepared by the facility was palatable for seven of seven residents (Resident (R) 42, R129, R77, R99, R109, R96, and R132) reviewed for palatability out of a total sample of 48. As a result of this deficient practice the residents had the potential for poor nutrition and weight loss. The facility census was 136.
Findings include:
1. Review of R42's quarterly Minimum Data Set (MDS), with an Assessment Reference Date (ARD) of 02/01/25 and located under the MDS tab of the EMR, revealed R42 had a Brief Interview for Mental Status (BIMS) score of 13 out of 15, which indicated no cognitive impairment
During an interview on 03/17/25 at 11:48 AM, R42 stated the food did not taste good, and trying to get an alternative was almost impossible.
2. Review of R129's admission MDS, with an ARD of 02/14/25 and located under the MDS tab of the EMR, revealed R129 had a BIMS score of 14 out of 15 which indicated no cognitive impairment.
During an interview on 03/17/25 at 11:48 AM, R129 stated the food was awful, and she did not like it. She stated she did not eat what they served a lot because of it.
3. Review of R77's modification admission MDS, with an ARD of 01/18/25 and located under the MDS tab of the EMR, revealed R77 had a BIMS score of 14 out of 15, which indicated no cognitive impairment.
During an interview on 03/20/25 at 12:30 PM, R77 stated the French dip sandwich was bland and had no flavor. He stated the food's flavor was usually not good.
4. Review of R99's admission Record, located under the Profile tab of the EMR, revealed the resident was admitted on [DATE]. Diagnosis included moderate protein-calorie malnutrition.
Review of R99's quarterly MDS, with an ARD of 01/03/25 and located under the MDS tab of the EMR, revealed the resident had a BIMS score of 15 out of 15, which indicated the resident was cognitively intact.
During an interview on 03/17/25 at 2:06 PM, R99 stated he did not like the meat and vegetables provided.
5. Review of R109's admission Record, located under the Profile tab of the EMR, revealed the resident was admitted on [DATE]. Diagnosis included obstruction pulmonary disease.
Review of R109's quarterly MDS, with an ARD of 01/02/25 and located under the MDS tab of the EMR, revealed the resident had a BIMS score of 13 out of 15, which indicated the resident was cognitively intact.
During an interview on 03/17/25 at 2:09 PM, R109 stated breakfast was cold, and the food was inedible. He stated they had to eat what they gave them, and it was so greasy. He stated he was weak because he could not eat the food and had to buy his own. He stated he was running out of money and felt like he was going to die because the food was so bad.
6. Review of R96's admission Record, located under the Profile tab of the EMR, revealed the resident was admitted on [DATE]. Diagnosis included moderate protein-calorie malnutrition.
Review of R96's annual MDS, with an ARD of 02/20/25 and located under the MDS tab of the EMR, revealed the resident had a BIMS score of 13 out of 15 which indicated the resident was cognitively intact.
During an interview on 03/17/25 at 2:22 PM, R96 stated the food needed improvement.
7. Review of R132's admission Record, located under the Profile tab of the EMR, revealed the resident was admitted on [DATE]. Diagnosis included chronic obstructive pulmonary disease.
Review of R132's quarterly MDS, with an ARD of 02/28/25 and located under the MDS of the EMR, revealed the resident had a BIMS score of 11 out of 15, which indicated the resident was moderately cognitively impaired.
During an interview on 03/17/25 at 10:10 AM, R132 stated he could not tell if there was a menu, because they served the same food all the time.
On 03/20/25, a test tray left the kitchen at 12:00 PM on a cart carrying 49 trays. The last tray was passed at 12:50 PM. The temperatures were taken of the foods on the test tray. The beef dip meat was 110 degrees Fahrenheit (F) and the tater tots measured 110 degrees F.
During an interview on 3/20/25 at 4:42 PM, the Dietary Manger (DM) stated she had heard there were resident complaints about the food. She stated some residents asked for more seasoning in the food, but salt and pepper were available on request. She stated the younger residents seemed to be the ones who had more concerns. The DM stated they asked for specific seasonings that the facility did not offer.
During an interview on 03/20/25 at 5:33 PM, the Director of Nursing stated she expected that residents would be served food they enjoyed.
CONCERN
(E)
Potential for Harm - no one hurt, but risky conditions existed
Infection Control
(Tag F0880)
Could have caused harm · This affected multiple residents
2. During medication administration observation on 03/18/25 at 1:07 PM with Certified Medical Technician (CMT)5, CMT5 entered R41's room, gave R41 oral medications in a cup, and exited R41's room with...
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2. During medication administration observation on 03/18/25 at 1:07 PM with Certified Medical Technician (CMT)5, CMT5 entered R41's room, gave R41 oral medications in a cup, and exited R41's room without performing hand hygiene. CMT5 returned to her medication cart, touched her computer, dipped her hands in her pocket to retrieve medication cart keys, and opened the medication cart, touching the contents without performing hand hygiene.
On 03/18/25 at 1:24 PM CMT5 administered eye drops to R24. On 03/18/25 at 1:31 PM, CMT5 accidentally dropped the eyedrops lid on floor. CMT5 picked up the lid and screwed it back on. When asked, CMT5 confirmed she should have cleaned the lid before putting it back on.
During medication administration observation on 03/19/25 at 7:33 AM with Licensed Practical Nurse (LPN)5, LPN5 applied a pair of gloves and administered an insulin injection on R92. LPN5 removed the gloves and failed to perform hand hygiene before touching her computer, pocket, keys, and medication cart. LPN returned R92's insulin vial to the medication cart.
At 7:36 AM, without performing hand hygiene, LPN5 applied another pair of gloves and wiped off the glucometer. LPN5 removed her gloves and did not perform hand hygiene.
During an interview on 03/19/25 7:38 AM, LPN5 acknowledged she had changed gloves several times without performing hand hygiene between glove changes.
During an observation with CMT2 on 03/19/25 at 8:26 AM, CMT administered a Spiriva inhaler to R106 without applying gloves. CMT2 had a cup of water which she stated was for R106 to rinse and spit after using the inhaler. At 8:26 AM, R106 rinsed his mouth with water and spat it out in a cup and gave the cup back to CMT2 who received it with her bare hand. CMT2 discarded the cup and returned to her medication cart without performing hand hygiene and touched her computer and medication cart.
During an interview with CMT2 on 03/19/25 at 8:33 AM, CMT2 confirmed that she could have been exposed to R106's fluids and should have worn gloves and performed hand hygiene.
During an interview on 03/19/25 at 11:07 AM, the Assistant Director of Nursing (ADON)1 stated staff should perform hand hygiene before entering residents' rooms, should wash their hands before and after applying gloves, and that CMT2 should have been wearing gloves during administration of the inhaler for R106.
Based on observation, interview, record review, and review of facility policies, the facility failed to deliver meal trays in a manner to prevent cross-contamination for seven of 48 sampled residents (Resident (R) 5, R8, R80, R117, R76, R93, and R91) reviewed for infection control, and administer medications in a manner to prevent cross-contamination for four of four residents (R41, R24, R92, and R106) observed during the medication pass observation. These failures could promote the spread of multi-drug-resistant organisms (MDROs) throughout the facility. The facility census was 136.
Findings include:
Review of the facility's policy titled, Hand Hygiene, dated 10/24/22, revealed . Facility Staff are trained and regularly in-serviced on the importance of hand hygiene in preventing the transmission of healthcare-associated infections . Staff follow the hand hygiene procedures to help prevent the spread of infections to other staff, residents, and visitors . Hand hygiene products and supplies (sinks, soap, towels, alcohol-based hand rub, etc.) are readily accessible and convenient for staff use to encourage compliance with hand hygiene policy . Facility Staff, visitors, and volunteers must perform hand hygiene procedures in the following circumstances . In between glove changes . Hand hygiene is always the final step after removing and disposing of personal protective equipment. VII. The use of gloves does not replace hand hygiene procedures .
Review of the facility's policy titled, Personal Protective Equipment - Using Gloves, revised September 2010 revealed, . When to Use Gloves 1. When touching excretions, secretions, blood, body fluids, mucous membranes, or non-intact skin; 2. When the employee's hands have any cuts, scrapes, wounds, chapped skin, dermatitis, etc.; 3.When cleaning up spills or splashes of blood or body fluids;3.When cleaning potentially contaminated items; and 5. Whenever in doubt .
1. During an observation of the noon meal tray delivery on 03/17/25 beginning at 12:06 PM, Certified Nurse Aide (CNA) 5 pushed the lunch tray cart containing Styrofoam cups and a pitcher of lemonade down hallway 200 and stopped near R5's room. CNA5 poured a cup of lemonade and delivered it to R5's bedside table. CNA5 pushed the bedside table in front of R5. CNA5 exited the room and did not perform hand hygiene. CNA12 followed CNA5 down the hallway pushing the lunch tray cart containing plates of food covered with plastic wrap labeled with each resident's name. CNA12 sorted through plates of food until finding R5's plate. CNA12 picked up a fork from the pile of forks on top of cart and delivered it to R5's bedside table. CNA12 moved R5's personal items and cup of lemonade on bedside table to make more room for her meal set up. CNA12 exited the room and did not perform hand hygiene.
At 12:09 PM, CNA5 poured a cup of lemonade and delivered it to R8's bedside table. CNA5 pushed the bedside table in front of R8. CNA5 exited the room and did not perform hand hygiene. CNA12 sorted through plates of food until finding R8's plate. CNA12 picked up a fork from the pile of forks on top of cart and delivered it to R8's bedside table. CNA12 moved R8's personal items and cup of lemonade on bedside table to make more room for her meal set up. CNA12 exited the room and did not perform hand hygiene.
At 12:11 PM, CNA5 poured a cup of lemonade and delivered it to R80's bedside table. CNA5 moved the bedside table in front of R80. CNA5 exited the room and did not perform hand hygiene. CNA12 sorted through plates of food until finding R80's plate. CNA12 picked up a fork from the pile of forks on top of cart and delivered it to R80's bedside table. CNA12 moved R80's personal items and cup of lemonade on bedside table to make more room for his meal set up. CNA12 exited the room and did not perform hand hygiene.
At 12:14 PM, CNA5 poured a cup of lemonade and delivered it to R117's bedside table. CNA5 pushed the bedside table in front of R117. CNA5 exited the room and did not perform hand hygiene. CNA12 sorted through plates of food until finding R117's plate. CNA12 picked up a fork from the pile of forks on top of cart and delivered it to R117's bedside table. CNA12 moved R117's personal items and cup of lemonade on bedside table to make more room for his meal set up. CNA12 exited the room and did not perform hand hygiene.
At 12:16 PM, CNA5 poured a cup of lemonade and delivered it to R76's bedside table. CNA5 pushed the bedside table in front of R76. CNA5 exited the room and did not perform hand hygiene. CNA12 sorted through plates of food until finding R76's plate. CNA12 picked up a fork from the pile of forks on top of cart and delivered it to R76's bedside table. CNA12 moved R76's personal items and cup of lemonade on bedside table to make more room for his meal set up. CNA12 exited the room and did not perform hand hygiene.
At 12:18 PM, CNA5 picked up R93's and R91's plates and two forks from the pile of forks on top of cart. CNA5 stacked the plates with both still covered in plastic wrap on top of another. CNA5 pushed R93's bedside table in front of R93 and moved his personal items on bedside table to make more room for his meal set up. CNA5 removed the plate stacked on top of the other plate and delivered it to R91, setting the plate on R91's bedside table. CNA5 pushed the bedside table in front of R91 and moved his personal items on his bedside table to make more room for his meal set up. CNA5 exited the room and did not perform hand hygiene. CNA12 poured two cups of lemonade and delivered them to R93 and R91's bedside tables. CNA12 exited the room and did not perform hand hygiene.
During the continuous observation of the noon meal tray delivery on 03/17/25 from 12:06 PM through 12:18 PM, CNA5 and CNA12 were observed delivering meal trays and drinks to eight residents. The CNAs touched overbed tables and personal belongings with each delivery. The CNAs did not perform hand hygiene during this continuous observation
During an interview on 03/17/25 at 12:30 PM, CNA5 stated, Yes, I sanitized my hands, I have it right here in my pocket and use it in between each resident. CNA5 was not able to show the hand sanitizer from her pocket. CNA5 stated, It's missing now, but I only passed two trays down on that hall. When I go into their rooms I wash my hands every single time. I washed my hands when I went back to my hall.
During an interview on 03/17/25 at 12:32 PM, CNA12 stated, I'm sorry. I didn't know you were supposed to hand sanitize in between each resident. I was just trying to hurry and get them passed. No, I didn't use hand sanitizer in between passing trays. I'm sorry, but I will do it next time.
During an interview on 03/17/25 at 1:12 PM, Assistant Director of Nursing and Infection Preventionist (ADON 4) stated, All the staff know they are required to do hand hygiene before resident care, in between residents, and after residents. We do in-services annually and have the upcoming annual skills fair check-off coming up next month. We do in-services quarterly and monthly as well and always cover infection control in them. We're always going around and doing reminders weekly and daily sometimes so that it's just always in their mind that they need to do it.
During an interview on 3/19/25 at 8:41 AM, the Director of Nursing (DON) stated, We are continually doing ongoing education and training on infection control. Staff know to use hand hygiene before, during, and after resident care or whenever they touch any of the resident's personal items. We have a skills fair check-off scheduled for the first week of April for all staff. But we constantly give reminders weekly if not daily sometimes.
During an interview on 3/19/25 at 8:42 AM, the Administrator stated, Staff know they should perform hand hygiene, and I will be making sure they all get reeducated again.
CONCERN
(F)
Potential for Harm - no one hurt, but risky conditions existed
Deficiency F0726
(Tag F0726)
Could have caused harm · This affected most or all residents
**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on staff interview and record review, the facility failed to ensure competencies were completed for Certified Medication T...
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**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on staff interview and record review, the facility failed to ensure competencies were completed for Certified Medication Technician (CMT) staff to safely administer medications to residents for 10 (CMT2, CMT3, CMT4, CMT6, CMT8, CMT9, CMT10, CMT11, CMT12, and CMT14) of 10 CMT personnel reviewed. The facility census was 136.
Findings include:
During an observation on 03/19/25 at 7:34 AM, CMT6 was observed at his medication cart. Multiple medication cups were sitting on top of the cart. Each cup contained medications for different residents. CMT13 looked at the surveyor and then stacked the medication cups, placed them in the medication cart, and locked the cart.
During an interview on 03/19/25 at 7:39 AM, CMT6 stated he/she knew it was not policy to prepare the residents' medications in advance. He/She stated he/she had signed the medications as being administered when he/she placed the medications into the medication cups.
Review of ten CMT personnel files revealed the file for CMT2, CMT3, CMT4, CMT6, CMT8, CMT9, CMT10, CMT11, CMT12, and CMT14 revealed no documented evidence of medication administration competency checks for the CMTs.
During an interview on 03/20/25 at 8:46 PM, the Director of Nursing (DON) stated the onboarding of CMTs included new employee orientation, validated certifications, and background screening. The DON stated CMTs were not required to have medication administration competency completed upon hire. She stated, It is assumed that the CMT has the training when they complete their certification. They are given 3 days of orientation with another CMT or nurse for medication pass. As the DON, it is my job to oversee clinical services here at [NAME].
CONCERN
(F)
Potential for Harm - no one hurt, but risky conditions existed
Deficiency F0847
(Tag F0847)
Could have caused harm · This affected most or all residents
**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on record review, and interview, the facility failed to ensure binding arbitration agreements were explained in a form and...
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**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on record review, and interview, the facility failed to ensure binding arbitration agreements were explained in a form and manner that residents understood and that the resident or their representative acknowledged that they understood the agreement for three of three residents (Resident (R) 92, R95, and R189) reviewed for binding arbitration agreements out of a total sample of 48. The facility census was 136.
Findings:
1. Review of R92's quarterly Minimum Data Set (MDS), with an Assessment Reference Date (ARD) of 01/13/25 and located under the MDS tab of the electronic medical record (EMR), revealed R92 was admitted to the facility on [DATE] with diagnoses that included essential (primary) hypertension, chronic kidney disease, stage 3 type 2 diabetes mellitus and anemia. It was recorded R92 had a Brief Interview for Mental Status (BIMS) score of 14 out of 15, which indicated R92 was cognitively intact.
Review of R92's admission Agreement, located under the MISC (Miscellaneous) tab of the EMR, revealed R92 signed a binding arbitration agreement electronically on 11/21/23.
R92's signature was appended to the binding arbitration agreement under the following verbiage:
By signing below, the Resident/Resident Representative and the Facility agree to the terms of this Arbitration Agreement: The signature panel failed to include the provision that the residents understood the agreement before signing the agreement.
During an interview on 03/20/25 at 5:58 PM, R92 stated she did not know what a binding arbitration agreement was and did not recall signing one.
2. Review of R95's quarterly MDS, with an ARD of 03/04/25 and located under the MDS tab of the EMR, revealed R95 was admitted to the facility on [DATE] with diagnoses that included orthostatic hypotension, alcohol dependence with alcohol-induced mood disorder, and mild cognitive impairment. It was recorded R 95 had a BIMS score of 15 out of 15, which indicated R95 was cognitively intact.
Review of R95's admission Agreement, located under the MISC tab of the EMR, revealed R95 signed a binding arbitration agreement electronically on 08/11/23.
R95's signature was appended to the binding arbitration agreement under the following verbiage:
By signing below, the Resident/Resident Representative and the Facility agree to the terms of this Arbitration Agreement: The signature panel failed to include the provision that the residents understood the agreement before signing the agreement.
R95 was unavailable for interview.
3. Review of R189's entrance tracking MDS, located in the EMR under the MDS tab and with an ARD of 02/28/25, revealed R189 was admitted to the facility on [DATE] with diagnoses that included chronic diastolic (congestive) heart failure, unspecified severe protein-calorie malnutrition, and anxiety disorder due to known physiological condition.
Review of R189's admission Agreement, located under the MISC tab of the EMR, revealed R92 signed a binding arbitration agreement electronically on 02/20/25.
R189's signature in the binding arbitration agreement was appended to the following verbiage:
By signing below, the Resident/Resident Representative and the Facility agree to the terms of this Arbitration Agreement: The signature panel failed to include the provision that the residents understood the agreement before signing the agreement.
During an interview with R189 on 03/20/25 at 6:00 PM R189 stated, No, I did not sign it. I don't know what that is.
During an interview on 03/19/25 at 4:41 PM, the Administrator stated he had been in the position for two years and was not the person responsible for presenting and explaining binding arbitration agreements to residents and their representatives, but the people responsible were not available. When asked what an arbitration agreement was, the Administrator stated it had something to do with legal or financial and he knew nothing about them.
During a telephone interview with 03/19/25 at 4:57 PM, the regional director of business development (RDBD) stated arbitration was, if there were to be a lawsuit, the attorneys would meet behind closed doors and reach an agreement agreeable to those involved. The RDBD was unaware the facility had any current arbitration agreements. The RDBD was asked if she had ever been responsible for explaining the contents of an arbitration agreement to a prospective resident before they signed. She stated she had. The RDBD was asked if she explained to the residents that they were giving up the constitutional right to a trial, and that they had a right to a neutral venue and neutral arbitrator. She stated she did not know that. The RDBD was asked if she explained that residents have a right to rescind the agreement, she stated they had 30 days to rescind. The RDBD was asked if she was aware the residents have to sign that they understand as well as agree with the agreement. She stated she did not know that and that the current arbitration the facility had to be updated.
Feb 2024
2 deficiencies
CONCERN
(D)
📢 Someone Reported This
A family member, employee, or ombudsman was alarmed enough to file a formal complaint
Potential for Harm - no one hurt, but risky conditions existed
Quality of Care
(Tag F0684)
Could have caused harm · This affected 1 resident
**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on interview and record review, the facility failed to provide services to promote the highest practicable physical well-b...
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**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on interview and record review, the facility failed to provide services to promote the highest practicable physical well-being for two of seven sampled residents (Residents #2 and #1). One resident's resistance to repositioning and transfers due to a stiff painful knee from osteoarthritis (a degenerative joint disease which causes tissues in the joint to break down over time) experienced recurring issues with moisture associated skin damage (MASD, inflammation and erosion of the skin). Nursing staff also failed to consistently carry out physician's orders to get the resident out of bed for meals to improve intake as well as a need for pressure relief (Resident #2). Another resident resisting staff attempts to open and clean his/her contracted (a condition of shortening and hardening of muscles, tendons or other tissue, often leading to deformity and rigidity of joints) hand resulted in hand hygiene deficits (Resident #1). The census was 137.
Review of the facility policy titled, Pain Management, revised 10/24/22, showed the purpose of the policy was to ensure accurate assessment and management of a resident's pain. A licensed nurse was to assess residents for pain on admission and routinely as indicated by the resident's health and functional status. Facility staff was responsible for helping the resident attain or maintain their highest level of well-being while working to prevent or manage the resident's pain. The licensed nurse will administer pain medication as ordered and document medication administered on the Medication Administration Record (MAR). The licensed nurse will assess the resident for pain and document results on the MAR each shift using the 1-10 pain scale. The shift pain score will indicate the highest pain level that occurred on that shift. If there is a new onset of pain, if the pain has changed in nature, or the pain has not been relieved with current medication, the licensed nurse will notify the attending physician for a review of medications. The Interdisciplinary Team (IDT) Committee will review the resident's pain assessment. The licensed nurse will notify the resident/responsible party regarding new pain medication orders. Nursing staff will implement timely interventions to reduce the increase in severity of pain. The nursing staff will attempt to become familiar with cognitive, cultural, familial or gender-specific influences on the resident's ability or willingness to verbalize pain. Nursing staff will also use non-pharmacological interventions by adjusting the resident's environment to reduce pain. The licensed nurse will document the resident's pain and response to interventions in the medical record on the weekly summary and as indicated on the progress notes. The licensed nurse will update the care plan for pain management with any change in treatment or medication.
Review of the facility's policy titled, Physician Orders, 10/24/22, showed the purpose was to ensure that all physician orders are complete and accurate. Whenever possible, the licensed nurse receiving the order will be responsible for documenting and implementing the order.
1. Review of Resident #2's quarterly Minimum Data Set (MDS), a federally mandated assessment instrument completed by facility staff, dated 10/26/23, showed the following:
-Severe cognitive impairment;
-Diagnoses included osteoarthritis unspecified site, pain in right knee, progressive neurological conditions, Alzheimer's disease (brain disorder that slowly destroys memory and thinking skills and eventually, the ability to carry out the simplest tasks), other specified disorders of muscle shoulder region, abnormalities of gait and mobility, anemia and high blood pressure;
-Wheelchair mobility;
-Mechanically altered diet;
-Weight: 127 pounds, height 63 inches;
-No weight loss of 5% or more in the last month or loss of 10% or more in the last six months;
-Always incontinent of bowel and bladder;
-No unhealed pressure ulcers;
-Required substantial/maximal assistance with eating, oral hygiene, dressing, personal hygiene, bed mobility;
-Dependent on full performance by staff of toileting hygiene, shower/bathing and transfers.
Review of the resident's undated physician's orders, showed the following:
-6/2/20, snack at bedtime (HS) for hypoglycemia (low blood sugar);
-6/28/20, assess pain level every shift for pain monitoring;
-11/3/20, weekly skin assessment every night shift every Thursday for skin monitoring. Please document assessment in progress notes. Notify MD/Nurse Practitioner (NP)/ Family/Director of Nurses (DON) of any skin changes/abnormalities;
-4/2/21, acetaminophen, give 650 mg every 6 hours as needed (PRN) for pain/headache/temp greater than 100 Fahrenheit;
-5/19/22, admit to Palliative Services, Dx (diagnosis): Alzheimer's disease;
-12/19/22, add snacks between meals and at HS;
-5/22/23, Ready Care three times a day for weight management 120 cubic centimeters (cc) health shakes;
-6/19/23, nurse please make sure resident is up for all meals;
-7/3/23, Lidocaine external gel 4% (used to prevent and treat chronic pain), apply to right knee topically 1 time a day related to unspecified osteoarthritis unspecified site;
-7/3/23, remove Lidocaine patch 4% at HS.
Review of the resident's undated weight summary, showed on 10/1/23 at 9:39 P.M., the resident weighed 132.0 lbs. On 11/1/23, the resident weighed 130 lbs.
Review of the resident's shower sheets/skin condition reports, showed the following:
-11/2/23, shower and skin check done. None of the descriptors for the skin condition were selected and the diagram was blank;
-11/6/23, open area to coccyx (tailbone). Additional notes: order for coccyx;
-11/9/23, open area to coccyx.
Review of the resident's progress notes, dated 11/9/23 at 11:44 A.M., showed the following order administration note at 11:44 A.M., acetaminophen 650 mg tablet given at 10:00 A.M. for right knee pain. At 4:05 P.M., the PRN administration was effective.
Review of the resident's shower sheets/skin condition reports, showed the following:
-11/13/23, showed abnormal skin with open area to coccyx;
-11/16/23, area to coccyx selected on diagram. Skin condition descriptors unchecked;
-11/20/23, red area to right buttock. Skin condition descriptors unchecked. Note: orders in place;
-11/23/23, right buttock marked with an x. Skin condition descriptors unchecked;
-11/27/23, right buttock marked with an x. Skin condition descriptors unchecked. Note: red area right (R) butt.
Review of the resident's weekly skin observation, dated 11/29/23, showed skin issues on the right buttock: red area, calmoseptine (multipurpose moister barrier that protects and helps heal skin irritation) applied.
Review of the resident's shower sheets/skin condition reports, dated 11/30/23, showed there was a red area on the resident's right buttock.
Review of the resident's shower sheets/skin condition report, dated 12/4/23 and 12/7/23, showed shower and skin check done. None of the descriptors for the skin condition were selected and the diagram was blank.
Review of the resident's undated weight summary, dated 12/10/23 at 11:05 A.M., showed the resident weighed 127.4 lbs.
Review of the resident's shower sheets/skin condition report, dated 12/14/23 and 12/18/23, showed shower and skin check done. None of the descriptors for the skin condition were selected and the diagram was blank.
Review of the resident's physician progress note, dated 12/18/23, showed his/her right buttock wound was healed.
Review of the resident's undated physician's orders, showed an order dated 12/18/23, for Ensure two times a day as a supplement. There was also an order dated 12/28/23, which showed the resident was at risk for malnutrition. Interventions included: Registered Dietitian (RD) to monitor, labs PRN, as well as monitoring of weights and medications.
Review of the resident's shower sheets/skin condition report, dated 12/21/23, 12/25/23, 12/28/23 showed shower and skin checks were done. None of the descriptors for the skin condition were selected and the diagram was blank.
Review of the resident's undated care plan, showed the following:
-Resident has limited physical mobility/activities of daily living (ADL) self-care deficit related to weakness and osteoarthritis;
-Extensive assistance required with bed mobility, eating and dressing;
-The resident requires total assistance with bathing, personal hygiene, toileting, and locomotion;
-He/she is resistive to care and has a history of refusing assistance with transfers related to dementia;
-He/she has a communication problem. Weak or absent voice;
-Anticipate and meet the resident's needs;
-Impaired cognitive function related to Alzheimer's disease;
-Monitor/document physical/nonverbal indicators of discomfort or distress and follow-up PRN;
-The resident has a nutritional problem or potential nutritional problem and is at risk for malnutrition;
-He/she is at risk for generalized pain;
-Monitor/record/report to nurse the resident's complaints of pain or requests for pain treatment;
-Notify physician if interventions are unsuccessful or if current complaint is a significant change from the resident's past experience of pain;
-The resident has potential/actual impairment to skin integrity.
Review of the resident's weekly skin observations, dated 1/2/24 and 1/5/24, showed the skin of his/her right and left buttocks had blanchable redness (red skin which turns white when pressed with a fingertip, then immediately turns red again when the pressure is removed).
During an interview on 1/16/24 at 1:15 P.M., the Assistant Director of Rehab (ADR) said when she first started working at the facility in November of last year, staff were not getting the resident up. The resident complained about pain but needed to be up in his/her wheelchair for social interactions and brain stimulation. Staff getting the resident up at least three days a week would help with contractures, positioning and skin breakdown from pressure.
During an interview on 1/11/24 at 4:24 P.M., Certified Nurse Aide (CNA) A said the resident allowed staff to get him/her out of bed, but complained about knee pain. He/She was not good with staff repositioning, because the stiffness of his/her right knee bothered him/her. Sometimes, the resident could feed him/herself, but often needed help and other than dessert or snacks, he/she would not eat regular food in bed.
During an interview on 1/11/24 at 3:32 P.M., Nurse C said when he/she started working at the facility in December of last year, staff were not getting the resident out of bed. So, Nurse C made sure staff got him/her up into a wheelchair. The resident refused showers a lot, complaining the water was too cold.
During an interview on 1/11/24 at 4:04 P.M., CNA D said staffing issues made it challenging to get residents out of bed daily. Residents frequently refused showers because the water did not get warm. Another issue with ADL care was the fact that supplies like soap, briefs and towels were always low.
During an interview on 1/26/24 at 10:05 A.M., the DON said her Assistant Directors of Nursing (ADONs) had reported in clinical meetings about having to go to Resident #2's floor and have conversations with the resident's family member in the evening about the resident being in bed and not up for the meal, the ADONs subsequently going and having staff get the resident out of bed. After this surveyor requested copies of the resident's shower sheets, the DON saw the documented blanchable redness on the resident's buttocks and spoke with the Wound Nurse. According to the Wound Nurse, the resident had a history of recurring breakdown in that area which would heal and go away. The resident had really dry skin and did not like to get out of bed. He/She had to be encouraged to get out of bed. Staff had to stay on top of rotating the resident in bed. A combination of dry skin and pressure were responsible for the blanchable redness on the resident's buttocks.
During an interview on 1/24/24 at 12:20 P.M., Physician B said he/she had issued an order for staff to get the resident up for all three meals each day, after the resident's family phoned Physician B six months ago with concerns about staff not getting the resident up for meals. The resident ate much better, when he/she staff got him/her up for meals. Also, getting the resident up for meals helped with preventing skin breakdown from pressure. The blanchable redness on the resident's buttocks was due to a combination of prolonged exposure to moisture and pressure.
2. Review of Resident #1's quarterly MDS, dated [DATE], showed the following:
-Moderate cognitive impairment;
-Diagnoses including hemiplegia, malnutrition, encephalopathy (disease, damage, or malfunction of the brain), muscle weakness (generalized), dysphagia oropharyngeal phase (difficulty in either the oral or throat phases of swallowing, such as in chewing, initiating the swallow, or propelling the bolus through the throat to the esophagus- the muscular tube connecting the throat and stomach), unspecified abdominal pain, difficulty in walking not elsewhere classified, fractures and other multiple trauma, subluxation of C7/T1 cervical vertebrae subsequent encounter (partial dislocation of the segment of the spine connecting the neck with the upper back), anemia, high blood pressure, aphasia (loss of ability to understand or use words correctly, caused by brain damage) and cerebrovascular disease (CVA, stroke);
-Required substantial/maximal assistance with eating, oral hygiene, dressing and mobility;
-Dependent on full performance by staff of showers/bathing, putting on/removing footwear, chair/bed-to-chair transfers, wheelchair mobility.
Review of the resident's undated physician's orders, showed the following:
-1/4/24, pain assessment every shift;
-1/8/24, acetaminophen Oral Tablet 325 mg, give 2 tablets via gastrostomy tube, (g-tube, a tube inserted through the belly that delivers nutrition directly to the stomach) every 6 hours PRN for pain-moderate;
-1/9/24, weekly skin checks every evening shift every Monday. Please document assessment in progress notes. Notify MD/NP/Family/DON of any changes/abnormalities;
-1/8/24, Lidocane external patch 5%, apply to lower back two times a day for pain, on at 9:00 AM off at 9:00 PM.
Review of the resident's undated care plan, showed the following:
-The resident has an ADL self-care performance deficit;
-He/She requires extensive assistance with bathing/showering, personal hygiene/oral care, bed mobility, and dressing;
-The resident has limited physical mobility related to contractures/CVA;
-He/She has impaired cognitive function;
-The resident has a communication problem. He/She can make his/her needs known;
-He/She has chronic pain;
-Evaluate the effectiveness of pain interventions. Review for compliance, alleviating of symptoms, dosing schedules and resident satisfaction with results, impact on functional ability and impact on cognition;
-Monitor/record pain characteristics. Quality (e.g. sharp, burning). Severity (1-10 scale), anatomical location, onset, duration (e.g. continuous, intermittent), aggravating factors, relieving factors;
-Monitor/record/report to nurse any signs/symptoms of non-verbal pain;
-Monitor/record/report to nurse resident's complaints of pain or requests for pain treatment;
-Notify physician if interventions are unsuccessful or if current complaint is a significant change from the resident's past experience of pain.
Review of the resident's therapy screen/referral form, signed 1/16/24, showed the following:
-Decreased range-of-motion (ROM)/contracture: LLE (hand);
-Need for splint/orthotic/prosthetic: has palm protector;
-Pain/edema: resident complaints of pain at times;
-Decline in ADLs: requires max assistance per staff;
-The resident would benefit from therapy services to address ADL function, contracture/splint, pain, transfers.
Review of the resident's Occupational Therapist (OT) evaluation and plan of treatment, signed 1/18/24, showed the start of care was on 1/18/24. Diagnoses included contracture of left hand, contracture of left elbow, encephalopathy and muscle weakness (generalized). A new goal was completion of hygiene and grooming tasks such as cleaning his/her left hand. His/Her baseline was total dependence without attempts to initiate.
Review of the resident's OT treatment encounter notes, dated 1/29/24, showed the following:
-Precautions/contraindications: contractures upper and lower extremity;
-Warm water soak of L hand/wrist/digits in preparation for stretching and hand hygiene. Pain with stretching of distal phalangeal joint (connects the bones at the tips of the fingers) and proximal inter-phalangeal (the first joint of the finger between the first two bones of the finger) joints.
-Pain limits the following functional activities: stretching of joints in left hand;
-Pain at rest: 3/10;
-Pain with movement: 5/10;
-Frequency: other (during stretching and warm soak);
-Location: L hand/wrist;
-Pain description/type: N/A (not applicable).
During an interview on 1/11/24 at 3:32 P.M., Nurse C said the resident's left hand was contracted due to a stroke. Staff had not been instructed to place a rolled towel or orthotic carrot in the resident's hand. The resident would not always allow staff to open the resident's hand and clean it. A lot of the time, he/she said, stop messing with me or don't do that.
During an interview on 1/16/24 at 1:15 P.M., the ADR said the resident had a contracted hand which he/she did not usually allow anyone to mess with it. Staff were not keeping a rolled towel or orthotic carrot in the resident's hand. The therapy department had evaluated him/her a couple of weeks prior to the interview and began treating it with warm water soaks and electrical muscle stimulation (stimulates muscle contractions and strengthens tissue, particularly muscles which have become shortened, weakened or atrophied due to injury or disease). They need to get the hand open, so that he/she could at least wear a palm protector.
During an interview on 1/26/24 at 10:05 A.M., the DON said she was unaware the resident was not allowing staff to clean his/her contracted hand. If the resident was refusing care due to pain, then she expected staff to notify her if the pain was new or out of the ordinary.
During an interview on 1/24/24 at 12:20 P.M., Physician B said the resident had left-sided hemiplegia. The muscles on that side of his/her body did not work well and his/her left hand was paralyzed. Physician B was concerned about a buildup of moisture in the resident's closed left hand leading to infection, so Physician B asked staff if they washed the resident's hand and was told the resident was refusing. Physician B instructed them to use alcohol to clean the resident's hand. Staff did not report the refusals were due to the pain caused when they opened the resident's hand. The resident had orders for pain medication. Physician B expected staff to let him/her know if the resident was experiencing breakthrough pain.
3. During an interview on 1/26/24 at 12:13 P.M., the Administrator said his expectation was that nursing staff follow nursing standards of care in accordance with facility policy, as long as the resident was in agreement with it.
MO00229385
MO00229867
MO00229879
CONCERN
(D)
📢 Someone Reported This
A family member, employee, or ombudsman was alarmed enough to file a formal complaint
Potential for Harm - no one hurt, but risky conditions existed
Deficiency F0697
(Tag F0697)
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 adequately address the pain of one of seven sampled re...
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 adequately address the pain of one of seven sampled residents (Resident #3). The facility failed to assess, monitor and implement interventions to adequately address breakthrough pain (a sudden and brief flare-up of pain from a chronic condition like arthritis which breaks through doses of administered pain medication) which impacted the provision of rehabilitation services and assistance with activities of daily living (ADLs). Nursing staff also failed to consistently carry out physician's orders for a neurological assessment to secure Botox treatments to relax the resident's tightly contracted joints. The census was 137.
Review of the facility policy titled, Pain Management, revised 10/24/22, showed the purpose of the policy was to ensure accurate assessment and management of a resident's pain. A licensed nurse was to assess residents for pain on admission and routinely as indicated by the resident's health and functional status. Facility staff was responsible for helping the resident attain or maintain their highest level of well-being while working to prevent or manage the resident's pain. The licensed nurse will administer pain medication as ordered and document medication administered on the Medication Administration Record (MAR). The licensed nurse will assess the resident for pain and document results on the MAR each shift using the 1-10 pain scale. The shift pain score will indicate the highest pain level that occurred on that shift. If there is a new onset of pain, if the pain has changed in nature, or the pain has not been relieved with current medication, the licensed nurse will notify the attending physician for a review of medications. The Interdisciplinary Team (IDT) Committee will review the resident's pain assessment. The licensed nurse will notify the resident/responsible party regarding new pain medication orders. Nursing staff will implement timely interventions to reduce the increase in severity of pain. The nursing staff will attempt to become familiar with cognitive, cultural, familial or gender-specific influences on the resident's ability or willingness to verbalize pain. Nursing staff will also use non-pharmacological interventions by adjusting the resident's environment to reduce pain. The licensed nurse will document the resident's pain and response to interventions in the medical record on the weekly summary and as indicated on the progress notes. The licensed nurse will update the care plan for pain management with any change in treatment or medication.
Review of the facility's policy titled, Physician Orders, 10/24/22, showed the purpose was to ensure that all physician orders are complete and accurate. Whenever possible, the licensed nurse receiving the order will be responsible for documenting and implementing the order.
Review of Resident #3's quarterly Minimum Data Set (MDS), a federally mandated assessment instrument completed by facility staff, dated 8/15/23, showed the following:
-Cognitively intact;
-Diagnoses included chronic pain, low back pain, osteoarthritis unspecified site, pain in left hip, unspecified orthopedic conditions (medical conditions that affect the bones, joints, muscles, tendons and ligaments), spinal stenosis lumbar region with neurogenic claudication (condition resulting from spinal nerve compression from narrowing of the spinal canal exerting pressure on the nerve roots of the lumbar spine resulting in symptoms such as pain, weakness or heaviness in the legs, tingling and cramping), sciatica left side (pain affecting the back, hip and outer side of the leg caused by compression of a spinal nerve root in the lower back), hemiplegia (total paralysis of the arm, leg, and trunk on the same side of the body) and hemiparesis (weakness on one side of the body), malnutrition, need for assistance with personal care, high blood pressure;
-Manual wheelchair mobility;
-Required substantial/maximal assistance with eating, oral hygiene, dressing, and bed mobility;
-Dependent on full performance by staff of toileting and personal hygiene, bathing, tub/shower transfers;
-Moderate pain;
-Scheduled pain medication regimen in the last five days;
-No as needed (PRN) pain medications received in the last five days.
Review of the resident's undated physician's orders, showed the following:
-5/10/22, assess pain level every shift;
-11/14/22, tramadol HCL (hydrochloride) tablet 50 milligrams (mg), give 1 tablet two times a day for pain;
-1/18/23, Tylenol Extra Strength Tablet 500 mg, give 1 tablet every 4 hours PRN for elevated temperature/mild pain;
-5/31/23, turn and reposition frequently with siderails for safety and mobility;
-8/14/23, Cyclobenzaprine HCL (muscle relaxant) 5 mg, give 1 tablet two times daily;
-11/27/23, neurologist consult for cerebral vascular accident (CVA, stroke) with hemiplegia with newer contraction;
-12/8/23, Biofreeze Cool the Pain External Gel 4%, apply bilateral upper extremities (BUE) and bilateral lower extremities (BLE) topically every 8 hours PRN for pain/discomfort;
-1/8/24, occupational therapy (OT) clarification order: treat 4 times per week/4 weeks for skilled OT therapy.
Review of the resident's healthcare provider visit note, dated 9/11/23, showed the following:
-Verbal pain scale: 4;
-Description of pain: aching;
-What eases the pain: position change and medication;
-Pain notes: resident has chronic left hip pain described as severe ache. Takes tramadol routinely which relieves the pain;
-Plan: resident has a history of osteoarthritis in the left hip. He/She has pain with transfers and movement. No redness or swelling noted to joints. Continue routine tramadol. Call with any change in condition any redness or swelling in joints. Encourage him/her to ask for PRN Tylenol for breakthrough pain. Contingency pain: consider scheduled Norco (a combination of acetaminophen and hydrocodone for relief of moderate to severe pain) three times daily if pain persists or worsens and discontinue tramadol.
Review of the resident's progress notes, showed the following:
-10/13/23 at 7:42 A.M. and 10/30/23 at 4:53 P.M., the resident's lower back and right hip hurt really bad;
-11/27/23 7:29 P.M., physician in to see the resident. New orders written for neurologist consult for CVA with left hemiplegia and newer contraction, add Ensure plus (nutritional shake) twice daily (BID), keep Ensure 1 three times daily with meals.
Review of the resident's care plan, revised 12/15/23, showed the following:
-The resident has chronic pain related to low back;
-Anticipate his/her need for pain relief and respond immediately to any complaint of pain;
-Evaluate the effectiveness of pain interventions;
-Monitor/record/report to the nurse any signs or symptoms of non-verbal pain;
-Notify the physician if interventions are unsuccessful or if current complaint is a significant change from resident's past experience of pain.
Review of the resident's December 2023 MAR showed Diclofenac Sodium Gel 1% was administered on 12/1 for a pain level of 3 at 9:00 P.M. Tylenol Extra Strength 500 mg administered on 12/7 for a pain level of 8. The resident's pain level was rated at 5 on the nights of 12/16, 12/17, 12/21 and 12/28 as well as on the evening of 12/28. Tramadol HCL tablet 50 mg was administered on the following dates:
-Pain level of 2 in the AM on 12/10;
-Pain level of 4 in the AM and PM on 12/30 and 12/31;
-Pain level of 5 in the AM on 12/1, 12/4, 12/6, 12/8, 12/11-12/13, 12/15, 12/18, 12/20, 12/22, 12/27, 12/29;
-Pain level of 5 in the AM and PM on 12/5, 12/7, 12/14, 12/19, 12/21, 12/28;
-Pain level of 8 in the PM on 12/16.
Review of the resident's progress notes, dated 12/18/23 at 4:16 P.M., showed the physician was in to see the resident this shift and stated the resident needs a neurology consult for possible Botox injections for contractures to be scheduled ASAP.
Review of the resident's physical therapy (PT) recertification/progress report, dated 12/28/23, showed severe joint contracture in left (L) hip and knee rendered the resident bedbound. BLE orthotics pending. No orthotic being used on the left hand to promote extension of fingers. The resident had a palm protector, but lost it or it was not being put on. Precautions/contraindications: Late effect CVA with L hemiplegia, left lower extremity (LLE) sciatica, significant LLE contractures, risk for skin breakdown.
Review of the resident's January 2024 MAR, showed the resident's pain level on the night of 1/9 was rated at 5. Tramadol HCL tablet 50 mg was administered on the following dates:
-Pain level of 5 in the AM on 1/2, 1/3, 1/5, 1/8 and 1/10;
-Pain level of 5 in the AM and PM on 1/1, 1/4 and 1/9.
Review of the resident's PT treatment encounter note, dated 1/24/24, showed the following:
-Pain with movement: 7/10;
-Location: BLE hips and LLE knee;
-Pain description/type: shooting and sharp;
-Pain limits the following functional activities: bending and extension;
-What relieves pain: remaining still;
-What exacerbates pain: bending, prolonged activity.
Review of the resident's PT Discharge summary, dated [DATE], showed the resident would benefit from additional skilled PT upon arrival of LE orthotics.
Observation on 1/9/24 at 11:00 A.M., 1:00 P.M. and 3:11 P.M. and 1/20/24 at 10:15 A.M. and 2:10 P.M., showed the resident lay in bed with his/her right hand gripping the bed rail and the extended right arm propping the resident up on his/her left side, with the left leg bent and his/her foot up near the right hip. No wedges were underneath the resident. No pillow was placed between his/her legs.
During an interview on 1/9/24 at 11:00 A.M., the resident said lying in bed with his/her right hand gripping the bed rail and the right arm propping the resident up on the left side with his/her left leg bent and his/her foot up near the right hip was the only way he/she could comfortably lie in bed due to left hip pain. Lying flat in bed caused him/her joint pain. The resident said he/she experienced joint pain all the time in his/her left hip, flank, and knee. During PT sessions, the therapist told him/her to breathe deeply and work through the pain, but the pain was too intense. The resident's pain medications were not potent enough; they only helped with mild spasms not the severe spasms of pain he/she experienced. He/She never got to see a neurologist.
During an interview on 1/11/24 at 4:24 P.M., Certified Nurse Aide (CNA) A said the resident always complained of arm and leg pain. CNA A could tell by the resident's facial expressions, he/she was uncomfortable sitting up in a wheelchair. When staff tried to change the resident's adult brief or clothing, moving him/her caused joint pain. The resident was only comfortable in bed, when using his/her right hand on the bedrail to push up onto the left side with the left leg bent behind the right leg. Whenever CNA A attempted to move the resident's right hand from the bedrail and reposition him/her, the resident said Ow, ow don't move it. Just leave it be. The resident was in pain a lot. His/Her medications just quieted down the pain.
During an interview on 1/16/24 at 1:15 P.M., the Assistant Director of Rehab (ADR) said she was aware the resident laid in a contorted position in bed, with his/her left foot and leg underneath his/her bottom. To aid with comfortable positioning, the ADR would like staff to use the wedges provided by the therapy department and apply the palm protector which the resident had in his/her room. Staff should also place a pillow between the resident's knees and bottom. The resident experienced a lot of joint pain. The therapy department was working on obtaining a hip abduction device to halt the rotation of the resident's left hip. The resident also had an issue with a contracted left knee which made it uncomfortable to straighten that leg. Therapy staff allowed gravity to help straighten it. A few times, therapy staff had nursing administer the resident's pain medications prior to his/her therapy session. They tried to work around the resident's scheduled afternoon pain medications, going to nursing one hour prior to the session and requesting the pain medications be administered. Botox injections would be really good for the resident, who had a lot of tone (tension/resistance to movement) in his/her muscles, which made the muscles feel like they were closing or tight. Botox was used for severe contractures, to help the muscles relax.
During an interview on 1/26/24 at 10:05 A.M., the Director of Nurses (DON) said physician's orders in November and December of last year for the resident to be seen by a neurologist were not carried out due to transportation issues, which were not specific to the resident. There had been issues with transport drivers not showing up. There had also been instances of the transporter canceling medical appointments without notifying the nursing department. When a resident missed a medical appointment, the DON's expectation was that a nurse either notified the DON or physician as soon as the appointment was missed, the nurse became aware that it would be missed or there would be a delay in carrying out the order to schedule the appointment. As for the resident's issues with pain, CNAs were expected to report breakthrough pain to the nurse. Once the nurse became aware of it, then he/she was expected to notify the resident's physician or make a note of it which the DON would subsequently see. If the DON saw a lot of documented pain scores or PRN pain medication being administered repeatedly, it was an indication the physician should be asked about ordering routine pain medication or non-pharmaceutical measures should be explored. The DON did not know if staff employed wedges to assist the resident with comfortable positioning in bed. If therapy had provided wedges for the resident's positioning in bed, then therapy orders would have been given to the restorative aides, along with a program on use of the wedges. There was nothing in physician's orders regarding wedges for the resident and she did not see any documentation of a program for use of wedges with the resident.
During an interview on 1/24/24 at 12:20 P.M., Physician B said the resident experienced pain due to a left-sided contraction. Physician B ordered a consult with a neurologist who could administer Botox injections to release the resident's joint tightness, ease his/her painful muscle spasms and help the resident lie flat. Last year, when Physician B learned staff had not carried out the order he/she issued in November, he/she reissued the order in December. Staff never reported any transportation issues, they just said they were working on it. If transportation issues prevented a resident from keeping medical appointments, then the physician expected staff to let him/her know so other transportation arrangements could be made.
During an interview on 1/26/24 at 12:13 P.M., the Administrator said the facility has contracts with transportation companies as well as a facility driver. The only way a medical appointment got cancelled was if a transportation company driver did not show up. In those situations, the facility driver is used as a failsafe, to ensure the resident still made it to his/her appointment. The residents normally waited up front in the facility to be picked up for appointments. If the driver was a no show, then whichever staff person became aware of the no-show: the resident's nurse, the Administrator, Social Services Worker or IDT member was responsible for following up and to ensure nursing was aware. His expectation was that a nurse would then inform the physician that the driver did not show up and reschedule the appointment. The transporter should not cancel resident medical appointments, because they are not clinical staff. Only the nursing staff should cancel medical appointments. In regard to pain issues, the Administrator's expectation was that nursing staff follow nursing standards of care in accordance with facility policy, as long as the resident was in agreement with it.
Nov 2023
15 deficiencies
CONCERN
(D)
Potential for Harm - no one hurt, but risky conditions existed
Resident Rights
(Tag F0550)
Could have caused harm · This affected 1 resident
Based on observation, interview, record review, and facility policy review, the facility failed to conceal the urine collection bag for a resident's indwelling urinary catheter to maintain dignity for...
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Based on observation, interview, record review, and facility policy review, the facility failed to conceal the urine collection bag for a resident's indwelling urinary catheter to maintain dignity for 1 (Resident #90) of 3 sampled residents reviewed for urinary catheter management.
Findings included:
Review of a facility policy titled, Privacy and Dignity, revised 06/2020, revealed, Purpose: To ensure that care and services provided by the facility promote and/or enhance privacy, dignity, and overall quality of life. Policy: The facility promotes resident care in a manner and an environment that maintains or enhances dignity and respect, in full recognition of each resident's individuality.
Review of a facility policy titled, Catheter - Care of, revised 06/2020, revealed, III. Proper Techniques for Urinary Catheter Maintenance. Further review of the policy revealed F. Collection bags and IV. The resident's privacy and dignity will be protected by placing a cover over drainage bag when the resident is out of bed.
Review of an admission Record revealed the facility admitted Resident #90 on 01/29/2022 with diagnoses that included other obstructive and reflux uropathy, dementia, chronic kidney disease, and adult failure to thrive.
Review of a quarterly Minimum Data Set (MDS), with an Assessment Reference Date (ARD) of 09/26/2023, revealed Resident #90 had a Brief Interview for Mental Status (BIMS) score of 5, which indicated the resident had severely impaired cognition. Further review of the MDS revealed the resident required extensive assistance with bed mobility, transfers, toilet use, personal hygiene, and bathing. Per the MDS, Resident #90 had an indwelling catheter.
Review of an Order Summary Report revealed Resident #90 had a physician's order dated 07/28/2023 for a 16 French urinary catheter.
On 11/06/2023 at 11:27 AM, Resident #90 was observed lying in bed, with a urinary catheter drainage bag hanging from the left side of the bed and facing the door. The urinary catheter drainage bag lacked a privacy cover. The catheter bag contained urine and was visible from the hallway outside the resident's room.
During an observation and interview on 11/06/2023 at 11:28 AM, Certified Nursing Assistant (CNA) #7 acknowledged Resident #90's catheter drainage bag was without a privacy cover and visible to others from the resident's doorway. She stated she would get a privacy cover and place it over the catheter bag, identifying the situation as a dignity issue. She stated she expected to respect a resident's right to dignity by covering the catheter drainage bag.
On 11/07/2023 at 8:05 AM, Resident #90 was observed lying in bed with a urinary catheter drainage bag hanging from the left side of the bed, facing the door, with a privacy cover on the catheter drainage bag. However, the privacy only covered three-fourths of the catheter drainage bag. The catheter bag contained urine and was visible from the hallway outside the resident's room.
During an interview on 11/08/2023 at 9:13 AM, CNA #8 stated a urinary catheter drainage bag should always be placed in a privacy cover to maintain the resident's dignity. She stated that the facility had various sizes of privacy covers and Resident #90 needed a different size than the one placed, which did not completely cover the drainage bag. She stated the nurses informed them to keep a catheter bag covered, noting it was the responsibility of the nurses and CNAs. She stated she expected the privacy cover to fully cover the drainage bag. She stated she expected to respect a resident's right to dignity by ensuring the catheter drainage bag was always covered.
During an interview on 11/08/2023 at 9:17 AM, Assistant Director of Nursing (ADON) #9 stated the nurses and CNAs were responsible for ensuring a resident's urinary catheter drainage bag was covered. She stated the facility had various sizes of privacy covers depending on the size of the drainage bag, which she noted should cover the entire collection bag. She stated the drainage bag should be kept in a privacy cover to maintain the resident's dignity.
During an interview on 11/09/2023 at 9:13 AM, the Director of Nursing (DON) stated it was the nursing staff's responsibility to ensure a urinary catheter bag was always covered. She stated all staff should be checking during rounds to ensure a urinary catheter bag had a privacy cover to maintain the resident's dignity.
During an interview on 11/09/2023 at 11:01 AM, the Administrator stated nurses and CNAs were responsible for ensuring a privacy cover was maintained on urinary catheter drainage bags, which he noted staff should be checking throughout the day. He stated he expected urinary catheter drainage bags to be covered to maintain a resident's dignity.
CONCERN
(D)
Potential for Harm - no one hurt, but risky conditions existed
Deficiency F0553
(Tag F0553)
Could have caused harm · This affected 1 resident
Based on record review, interviews, and facility policy review, the facility failed to invite the resident or resident RP to participate in the care planning process for 1 (Resident #79) of 25 residen...
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Based on record review, interviews, and facility policy review, the facility failed to invite the resident or resident RP to participate in the care planning process for 1 (Resident #79) of 25 residents whose care plans were reviewed.
Findings included:
A review of a facility policy titled Care Planning, revised in June 2020, revealed, The facility will invite the resident, if capable, and their family to care planning meetings and use its best efforts to schedule care planning meetings at times convenient for the resident and family.
A review of Resident #79's admission Record revealed the facility admitted the resident on 11/19/2020 with diagnoses that included dementia, diabetes, and chronic diastolic heart failure.
A review of Resident #79's quarterly Minimum Data Set (MDS), with an Assessment Reference Date (ARD) of 09/14/2023, revealed Resident #79 had a Brief Interview for Mental Status (BIMS) score of 12, which indicated the resident had moderate cognitive impairment.
A review of Resident #79's care plan revealed there had been revisions made on 06/15/2023, but there was no indication that the resident or responsible party had participated in a care plan meeting.
A review of Resident #79's Care Plan Conference Note dated 03/24/2021, 03/16/2022, and 10/04/2022 revealed care plan meetings had been held with the Interdisciplinary Team (IDT) and with the family of Resident #79. There were no additional notes available.
A review of Resident #79's MDS assessment schedule revealed the following assessments had been completed since October 2022:
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12/06/2022: Quarterly
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01/17/2023: Annual
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04/12/2023: Quarterly
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05/23/2023: Quarterly
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06/01/2023: Significant Change
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06/22/2023: Quarterly
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09/14/2023: Quarterly
During an interview on 11/06/2023 at 11:36 AM, Resident #79 stated they had not been invited to attend a care plan meeting since their initial admission into the facility.
During an interview on 11/07/2023 at 2:00 PM, Responsible Party (RP) #5 stated they had not participated in a care plan meeting with Resident #79 recently and were not sure why. RP #5 stated the last care plan meeting they participated in was in October of 2022, and all care plan meetings should have included them or the resident's other family member.
During an interview on 11/08/2023 at 9:12 AM, the MDS Coordinator stated she provided the resident assessment calendar to the Social Services Director (SSD), and the SSD used the calendar to schedule the care plan meetings. The MDS Coordinator stated care plan meetings should be held within the first 72 hours of a resident's admission, quarterly/annual assessments (3-4 times per year), and as needed. The MDS Coordinator stated she had not received any complaints that Resident #79 had not had a care plan meeting since October 2022.
During an interview on 11/07/2023 at 9:51 AM, the SSD stated she coordinated all care plan meetings based off the assessment schedule provided by the MDS Coordinator. She stated she notified residents of care plan meetings verbally and notified their RPs via telephone. She confirmed that since there were no care plan meeting notes since 10/04/2022, that would have been the last care plan meeting held. She stated if a care plan meeting had been held, it would have been documented in the progress notes. She stated meetings should have been scheduled at all annual and quarterly MDS assessments. The SSD revealed a care plan meeting was not held with Resident #79 and their RP since October 2022 because she was covering multiple departments at one time.
During an interview on 11/08/2023 at 1:27 PM, the Director of Nursing (DON) stated care plan meetings were held within 72 hours of admission, quarterly, and as needed. She stated Resident #79 should have had care plan meetings held around the time of the resident's January, April, June, and September quarterly assessments. The DON stated she was unaware that the care plan meetings had not been held with Resident #79 and their RP.
During an interview on 11/08/2023 at 1:48 PM, the Administrator stated his expectation was for all residents to have care plan meetings scheduled and held.
CONCERN
(D)
📢 Someone Reported This
A family member, employee, or ombudsman was alarmed enough to file a formal complaint
Potential for Harm - no one hurt, but risky conditions existed
Notification of Changes
(Tag F0580)
Could have caused harm · This affected 1 resident
Based on observations, interviews, record review, and facility policy review, the facility failed to notify the physician when there was a need to alter treatment for 1 (Resident #100) of 3 residents ...
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Based on observations, interviews, record review, and facility policy review, the facility failed to notify the physician when there was a need to alter treatment for 1 (Resident #100) of 3 residents reviewed for skin concerns.
Findings included:
A review of a facility policy titled Change in a Resident's Condition or Status, revised in February 2021, revealed, Our facility promptly notifies the resident, his or her attending physician, and the resident representative of changes in the resident's medical/mental condition and/or status (e.g., changes in level of care, billing/payments, resident rights, etc.). The policy revealed, 1. The nurse will notify the resident's attending physician or physician on call when there has been a(an): d. significant change in the resident's physical/emotional/mental condition. e. need to alter the resident's medical treatment significantly. The policy further revealed, 2. A 'significant change' of condition is a major decline or improvement in the resident's status that: a. will not normally resolve itself without intervention by staff or by implementing standard disease-related clinical interventions (is not 'self-limiting'). Further review of the policy revealed, 5. Except in medical emergencies, notifications will be made within twenty-four (24) hours of a change occurring in the resident's medical/mental condition or status.
A review of Resident #100's admission Record revealed the facility admitted Resident #100 on 03/23/2023 with diagnoses that included chronic heart disease, type 2 diabetes mellitus (DM II), need for assistance with personal care, and dementia.
A review of Resident #100's quarterly Minimum Data Set (MDS), with an Assessment Reference Date (ARD) of 10/11/2023, revealed a Staff Assessment of Mental Status (SAMS) that indicated the resident had short- and long-term memory problems and moderately impaired cognitive skills for daily decision making. The MDS revealed the resident required partial/moderate assistance with personal hygiene, dressing, positioning, and transfers and required maximum assistance with showers/bathing. The MDS revealed Resident #100 had no open lesions and was not receiving ointments/medications nor nonsurgical dressings.
A review of a care plan focus area for Resident #100 dated 03/24/2023 revealed the resident had diabetes. Interventions directed staff to check the resident's body for breaks in the skin and treat them promptly as ordered by the resident's physician.
During a telephone interview on 11/08/2023 at 8:53 AM, the Responsible Party (RP) for Resident #100 stated that during a visit on 10/21/2023, they noticed the resident had a rash. The RP stated when they told the nursing staff about the rash, the nursing staff said they would get a cream for them to apply to the resident. The RP stated that during their visit on 10/28/2023, the rash had spread to the resident's legs, and the resident was itching like crazy. The RP stated they told the nurse on shift, who handed the RP a cream and instructed them to apply it to the resident. The RP stated the nurse did not assess or evaluate the resident's skin. The RP stated they believed staff did not follow up with the resident's physician regarding the rash since the RP identified the rash on 10/21/2023.
During an observation and interview on 11/09/2023 at 7:43 AM, an observation of Resident #100's skin with Certified Nurse Aide (CNA) #35 revealed CNA #35 lifted the resident's shirt, exposing the skin on the resident's back and sides. The resident had red scabbing and a rash on their left side from their underarm to their hip, then across the lower back along the pant line. CNA #35 stated Resident #100 had a red rash on their back for about a month, which was not new. She stated the nurse had been giving her creams and lotions to put on the area, but the CNA was unsure what specific creams and lotions they were. She stated the rash area should have been documented on the bath sheets and skin assessments. She stated she told the nurse when it appeared a month ago but could not recall which nurse she told.
A review of Resident #100's Progress Notes for the timeframe from 09/29/2023 through 11/03/2023 revealed no documented skin concerns and no documented evidence the resident's physician was notified of the resident's rash.
A review of Resident #100's physician's Order Summary Report revealed an order dated 10/07/2023 for A&D ointment to feet. There was no documented evidence treatment had been ordered for a rash or itching.
During a telephone interview on 11/09/2023 at 9:38 AM, Resident #100's Primary Care Physician (PCP) stated she had received no calls from the facility nurses about Resident #100 having a rash or any skin concerns. She stated she last saw Resident #100 on 10/30/2023 but did not do a skin assessment during the visit, and the nursing staff brought no concerns about the resident's skin to her attention during the visit. She stated the resident was confused at baseline and did not appear itchy or uncomfortable during her last visit. The PCP further stated that the facility nurses had not requested anti-itch creams for Resident #100. She stated the nurses should always call her first to inform her of a resident's condition before applying any creams or ointments to the resident.
During an observation and interview on 11/09/2023 at 11:09 AM, an observation of Resident #100's skin in their room with the Assistant Director of Nursing/Infection Preventionist (ADON/IP) revealed the resident had a red rash that extended around both sides, covering their breasts, stomach, and back. Resident #100 told the ADON/IP that their back itched and their skin hurt. In an interview with the ADON/IP during the observation, the ADON/IP stated the red rash was not present on 11/07/2023 and stated that since it was so bright red, she had doubts about it being there for a month.
During an interview on 11/09/2023 at 2:13 PM, the Director of Nursing (DON) stated if a CNA noticed a skin abnormality, they should report it to the nurse immediately, who would then call the physician and the DON and follow any orders received. She stated nothing should be administered to the resident before the physician was consulted about the resident's presentation.
During an interview on 11/09/2023 at 4:28 PM, the Administrator stated any open area, bruise, or anything out of the ordinary should be reported to the nurse immediately. The nurse should document the condition of the resident's skin and call the physician for orders.
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
Based on interviews, record reviews, and facility policy review, the facility failed to ensure resident care plans were comprehensive for 1 (Resident #128) of 3 residents reviewed for care plans.
Find...
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Based on interviews, record reviews, and facility policy review, the facility failed to ensure resident care plans were comprehensive for 1 (Resident #128) of 3 residents reviewed for care plans.
Findings included:
A review of a facility policy titled Care Planning, last revised in June 2020, revealed, A comprehensive person-centered Care Plan will be developed for each resident. The Care Plan will include measurable objectives and timetables to meet a resident's medical, nursing, mental and psychological needs. The policy further revealed, Each resident's Comprehensive Care Plan will describe the following: A. Services that are to be furnished to attain or maintain the resident's highest practicable physical, mental, and psychological well-being.
A review of Resident #128's admission Record revealed the facility admitted the resident on 08/28/2023 with a diagnosis of unspecified dementia without behavioral disturbance, psychotic disturbance, mood disturbance, and anxiety.
A review of Resident #128's 5-day Minimum Data Set (MDS) with an Assessment Reference Date (ARD) of 09/05/2023 revealed Resident #128 had a Brief Interview for Mental Status (BIMS) score of 15, which indicated the resident was cognitively intact. The MDS revealed the resident required limited assistance from one staff member with bed mobility, transfers, dressing, and personal hygiene. The MDS revealed Resident #128 had an active diagnosis of non-Alzheimer's dementia.
A review of Resident #128's care plan revealed no interventions regarding dementia care until after the surveyor's inquiry. The care plan revealed a focus area with an initiation date of 11/09/2023 that indicated the resident had impaired cognitive function related to dementia. Interventions directed staff to administer medications as ordered, ask simple yes/no questions, cue the resident, reorient the resident, supervise the resident as needed, keep the resident's routine consistent, and try to provide consistent caregivers as much as possible.
During an interview on 11/09/2023 at 1:14 PM, Licensed Practical Nurse (LPN) #6 stated the nurse initiated the care plans during the admission process. LPN #6 did not know who completed the care plan. LPN # 6 stated that the Director of Nursing (DON) may have completed the care plan. LPN #6 stated the care plans were used to identify the problems and goals of the residents. LPN #6 stated she was not aware Resident #128 had a diagnosis of dementia. LPN #6 stated the goals and treatment for dementia would be documented in the care plan. LPN #6 stated they only started the care plan, and the Registered Nurse (RN) would finish implementing the care plan.
During an interview on 11/09/2023 at 2:21 PM, the MDS Coordinator stated that significant diagnosis, dementia care, and everything that staff would need to know to care for the resident should be listed on the care plan. She stated the care plan was created within 72 hours of admission, then she reviewed the care plan after two weeks, and the care plan was reviewed again when the resident had an assessment. The MDS Coordinator stated things that came up in the morning meetings were also added.
During an interview on 11/09/2023 at 3:08 PM, the Regional Nurse Consultant (RNC) stated if the residents were not located on the dementia unit, their care plan may not address dementia care. The RNC stated if the residents were not displaying symptoms of dementia, the care plan would not include dementia care treatment. The RNC stated the care plan would be specific to the needs identified at the time, and if it was not an active diagnosis, there would not be a care plan.
During an interview on 11/09/2023 at 4:00 PM, the Administrator stated he expected the resident's diagnosis to be included in the care plan.
CONCERN
(D)
Potential for Harm - no one hurt, but risky conditions existed
ADL Care
(Tag F0677)
Could have caused harm · This affected 1 resident
Based on observation, interview, record review, and facility policy review, the facility failed to provide services necessary to maintain good grooming and personal hygiene for 1 (Resident #111) of 9 ...
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Based on observation, interview, record review, and facility policy review, the facility failed to provide services necessary to maintain good grooming and personal hygiene for 1 (Resident #111) of 9 sampled residents reviewed for activities of daily living (ADL) care.
Findings included:
Review of a facility policy titled, Activities of Daily Living (ADL), Supporting, revised in March 2018, revealed Residents will be provided with care, treatment and services as appropriate to maintain or improve their ability to carry out activities of daily living (ADLs). The policy revealed, Appropriate care and services will be provided for residents who are unable to carry out ADLs independently, with consent of the resident and in accordance to the plan of care, including appropriate support and assistance with: Hygiene (bathing, dressing, grooming, and oral care.
Review of Resident #111's admission Record, revealed the facility admitted the resident on 06/12/2023 with diagnoses that included diabetes mellitus, cervical disc degeneration, sciatica, and other chronic pain.
Review of Resident #111's quarterly Minimum Data Set (MDS), with an Assessment Reference Date (ARD) of 09/21/2023, revealed Resident #111 had a Brief Interview for Mental Status (BIMS) score of 15, which indicated the resident had intact cognition. The MDS revealed the resident required extensive assistance from staff with personal hygiene and required physical assistance from staff with parts of bathing. The MDS revealed the resident did not reject assistance from staff when they provided care to the resident.
Review of Resident #111's care plan revealed a focus statement, with an initiation date of 06/23/2023, that revealed the resident had an ADL self-care performance deficit. The care plan contained interventions directing staff to provide extensive assistance with the resident's personal hygiene.
On 11/06/2023 at 10:51 AM, Resident #111 was observed in bed with all fingernails measuring approximately three-fourths to one inch in length with a brown dirty substance underneath the nails. The resident's beard was approximately one-and-a-half to two inches long.
During an interview on 11/06/2023 at 10:51 AM, Resident #111 stated their fingernails had not been cut since admission to the facility. The resident stated they informed staff their fingernails were too long and the resident wanted them to be cut. Resident #111 stated their facial hair had been shaved one time since admission. The resident said they did not like facial hair and wanted their facial hair cut.
On 11/07/2023 at 6:35 AM, Resident #111 was observed in bed with all fingernails measuring approximately three-fourths to one inch in length with a brown dirty substance underneath the nails. The resident's beard was approximately one-and-a-half to two inches long.
On 11/08/2023 at 9:35 AM, Resident #111 was observed in bed with long fingernails. Resident #111 had a clean-shaven face.
During an interview on 11/08/2023 at 9:35 AM, Resident #111 said Certified Nurse Aide (CNA) #16 shaved their face the day before.
During an interview on 11/08/2023 at 9:40 AM, Assistant Director of Nursing (ADON) #9 stated the CNAs could not cut Resident #111's fingernails, but could clean them. She stated Resident #111's fingernails were long and dirty and needed to be cut. She said she expected residents' nails to be trimmed and clean. She stated CNA #16 cut Resident #111's long facial hair the day prior and said CNAs were responsible for shaving residents as part of providing assistance with daily hygiene.
During an interview on 11/08/2023 at 12:32 PM, CNA #16 indicated he provided care to Resident #111. He stated he cut Resident #111's facial hair the day prior, noting it was long and should have been cut prior to that day. He stated he observed the day prior that Resident #111 had long nails, but said he could not cut the resident's fingernails because Resident #111 had diabetes. He stated he could, however, clean the resident's nails and should have done so previously. He stated he expected residents to receive proper grooming care and maintain good hygiene.
During an interview on 11/08/2023 at 4:12 PM, CNA #17 stated Resident #111's nails were very long and had dirty substances underneath them. CNA #17 said he could not cut the resident's nails, but noted he could clean them.
During an interview on 11/08/2023 at 4:15 PM in Resident #111's room, Licensed Practical Nurse (LPN) #18 stated the resident's fingernails were very long and the LPN would ensure they were cut.
During an interview on 11/09/2023 at 9:23 AM, the Director of Nursing (DON) stated she had not paid attention to residents' fingernails or facial hair when making rounds. She stated she made rounds frequently and assumed nail care was being completed. She indicated nurses were responsible for cutting Resident #111's fingernails because the resident was diabetic. She indicated ADON #9 was the manager on Resident #111's floor and should delegate tasks and follow up to ensure care was provided. She stated that shaving and cleaning residents' fingernails were daily responsibilities of CNAs. She stated she expected residents to receive grooming and good personal hygiene daily and expected residents' fingernails to be cut and cleaned.
During an interview on 11/09/2023 at 11:04 AM, the Administrator stated nurses were responsible for cutting Resident #111's fingernails, noting CNAs were responsible for cleaning underneath the fingernails and shaving the resident. He said he had not seen Resident #111. He stated he expected residents to be groomed and for good personal hygiene to be maintained.
CONCERN
(D)
📢 Someone Reported This
A family member, employee, or ombudsman was alarmed enough to file a formal complaint
Potential for Harm - no one hurt, but risky conditions existed
Deficiency F0679
(Tag F0679)
Could have caused harm · This affected 1 resident
Based on observations, interviews, record review, and facility policy review, the facility failed to consistently provide a program of meaningful activities in accordance with the resident's needs, in...
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Based on observations, interviews, record review, and facility policy review, the facility failed to consistently provide a program of meaningful activities in accordance with the resident's needs, interests, and preferences as identified in the resident's assessment to enhance quality of life for 1 (Resident #43) of 3 residents reviewed for activities.
Findings included:
A review of a facility policy titled Activities Program, revised June 2020, revealed, Purpose: to encourage residents to participate in activities to make life more meaningful, to stimulate and support physical and mental capabilities to the fullest extent, and to enable the resident to maintain the highest attainable social, physical, and emotional functioning. The policy revealed II. A variety of activities should be offered on a daily basis, which includes weekends and evenings. III. Activities are developed for individual, small group, and large group participation. The procedure revealed C. The facility will provide equipment and supplies for independent and group activities, and for residents who have special needs. Further review revealed A. The activity department will maintain accurate records of each resident's participation in group, independent, and room visit involvement. Participation will be documented on a daily basis.
A review of Resident #43's admission Record revealed the facility admitted the resident on 05/20/2022 with diagnoses that included vascular dementia, major depressive disorder, generalized anxiety disorder, and drug-induced tremor.
A review of Resident #43's annual Minimum Data Set (MDS), with an Assessment Reference Date (ARD) of 05/09/2023, revealed Resident #43 had a Brief Interview for Mental Status (BIMS) score of 9, which indicated the resident had moderate cognitive impairment. The MDS revealed during the resident interview for activity preferences the resident indicated the following activities were very important: having books, newspapers, and magazines to read, keeping up with the news, doing things with groups of people, doing favorite activities, going outside to get fresh air when the weather is good, and participate in religious services or practices. The MDS revealed Resident #43 required limited assistance from staff with transfers and required staff supervision with locomotion on and off the unit. The MDS revealed the resident used a wheelchair for mobility.
A review of Resident #43's care plan, initiated on 05/21/2022, revealed the resident depended on staff to meet emotional, intellectual, physical, and social needs. The care plan revealed staff were to honor the resident's right to choose programs of their liking, including self-directed, non-organized activities. Interventions directed staff to introduce the resident to residents with similar backgrounds and interests, encourage/facilitate interaction, invite the resident to scheduled activities, provide the resident with the activities calendar, and notify the resident of any changes to the calendar of activities. A review of Resident #43's care plan initiated on 08/24/2023 revealed Resident #43 was an elopement risk/wanderer with poor safety awareness, aimlessly wandered, had a diagnosis of vascular dementia, and required a secured unit (dementia unit) for oversight of care. Interventions directed staff to distract the resident from wandering by offering pleasant diversion, structured activities, food, conversation, television, and books.
A review of the activity calendars for February 2023, October 2023, and November 2023 revealed breakfast was scheduled as an activity every day at 8:30 AM. Further review revealed structured activities were scheduled at 10:00 AM and 1:00 PM daily, which consisted of Bible study, movie day, leisure time, and games, and were repeated throughout the month. The calendars revealed the last scheduled activity of the day was scheduled for 1:45 PM and was listed as Smoke Break.
A review of Resident #43's admission Activity Assessment dated 05/20/2022 revealed the resident liked to listen to music, keep up with the latest news, and attend group and religious activities.
A review of Resident #43's Task: Activities-1-1 revealed no documentation Resident #43 participated in one-to-one activities for the last 30 days.
A review of Resident #43's Task: Activities-Group Activities revealed no documentation Resident #43 participated in group activities for the last 30 days.
A review of a Concern/Grievance Report dated 06/23/2023 revealed staff concerns that no activities were being done on the unit (secured dementia care unit) and there was not enough activity staff for the whole building.
During an interview on 11/06/2023 at 11:36 AM, Certified Nurse Aide (CNA) #35 stated activities rarely came back to the secured dementia unit to do activities with the residents. She stated they had to buy supplies with their own money to do activities with the residents. CNA #35 stated the activities department did not have consistent programmed or scheduled activities for the residents on the dementia unit.
During an interview on 11/06/2023 at 11:37 AM, CNA #36 stated the activities department provided little for residents who resided on the secured unit. She stated staff tried to do activities with the residents on the secured unit when not providing direct care.
During an observation on 11/06/2023 at 1:04 PM, Resident #43 was wandering the secured unit. The posted activity calendar in the secured unit showed a Connect 4 game was scheduled for 1:00 PM; however, observation revealed no Connect 4 game was available, and no structured activity was provided.
During an observation on 11/07/2023 from 10:01 AM to 10:31 AM, Resident #43 was wandering the secured unit. Additional residents were observed sitting in chairs and not engaged in activities. A review of the posted activity calendar for 11/07/2023 showed Bible study was scheduled for 10:00 AM.
During an observation on 11/08/2023 from 10:02 AM to 10:30 AM, Resident #43 was observed in the secured dementia unit sitting in a chair in the main sitting area and talking to themself. The posted activity calendar in the secured unit for 11/08/2023 at 10:00 AM was Bible study; however, no bible study or other structured activity was observed.
During an interview on 11/08/2023 at 12:55 PM, CNA #35 stated Bible study scheduled for 10:00 AM was held only for residents not residing on the secured unit. She stated that for 11/06/2023, 11/07/2023, and 11/08/2023, she worked in the secured unit, and the activities department did not do any activities with the residents. CNA #35 stated the activities department did not get residents from the secured unit for activities that were held off the secured unit. She stated she could not leave the secured unit to take residents to activities because they all required supervision. CNA #35 stated Resident #43 wandered a lot on the secured unit and watched television in their room. She stated Resident #43, and the other residents were never offered activities. CNA #35 stated the activity department was responsible for all activities, and the activities department posted the activity calendar but did not do the posted activities. CNA #35 stated she did not think breakfast or smoking was an appropriate activity for the activity calendar because nothing was happening at those times. She stated Resident #43 would participate in activities if offered. CNA #35 stated activities should be scheduled, offered, and meet the needs of the residents.
During an interview on 11/08/2023 at 1:12 PM, CNA #36 stated residents on the dementia unit were not consistently offered activities that other residents were offered, and the activities department might come to do an activity once a week for a few minutes. She stated that so far this week, the activities department has not provided activities with any resident on the secured unit. CNA #36 stated Resident #43 would participate in activities, but activities were not provided on the secured unit, and Resident #43 was not invited to activities off the unit. CNA #36 stated Resident #43 constantly wandered, was an elopement risk, and was not safe to leave the secured unit. She stated she had previously bought activities to do with the residents on the secured unit because the activities department did not do activities with them. CNA #36 stated that activities should be structured and meaningful and meet the needs of the residents.
Observation of Resident #43 on 11/08/2023 at 1:20 PM showed the resident sitting in the secured unit and not engaged in an activity. A review of the posted activity calendar in the secured unit showed a movie day was scheduled for 1:00 PM. Continued observation revealed no activities occurring.
During an interview on 11/08/2023 at 1:49 PM, the Social Service Director (SSD) stated she had received a grievance in June 2023 from CNA #40 about the lack of activities on the secured unit. She stated she went to the unit after the grievance was filed and observed no activities occurring on the unit. The SSD stated she thought the activity department had lost staff. She stated the posted activities of breakfast and smoking on the activity calendar were inappropriate.
During an interview on 11/08/2023 at 2:29 PM, CNA #40 stated she had been employed by the facility for approximately 11 months and worked mostly on the secured unit. She stated she filed a grievance in June 2023 about the lack of activities for residents on the secured unit. She stated she talked to the Activity Director (AD) and Activity Assistant (AA) #47 about the lack of activities on the secured unit and was told they were doing activities. CNA #40 stated no activities had occurred this week, and she did not think breakfast and smoking were appropriate activities. CNA #40 stated that most of the residents, including Resident #43, would participate in a group activity if offered. She stated most of the residents on the secured unit were at risk of eloping or had behaviors and could not leave the secured unit.
During an interview on 11/08/2023 at 3:05 PM, AA #47 stated he had worked as an activity assistant for approximately a year. He stated he, along with the AD and another activity assistant, created and placed the monthly calendars throughout the facility. AA #47 stated the activity calendar had not changed since he started. AA #47 stated he and the AD completed activity assessments on admission to determine what activities each resident liked and preferred. He stated the activities department did both group and individual activities with residents. He stated the activities department did not have a chance to perform activities with residents on the secured unit each day. AA #47 stated he thought breakfast was an activity but could not describe how. He also stated smoking was an activity but could not describe how it was an activity for residents who did not smoke. AA #47 stated that the scheduled Bible study listed on the activity calendar was held in the chapel and not on the secured unit; therefore, no religious activities were held on the secured unit. He stated the movie day scheduled on 11/08/2023 and weekly at 1:00 PM occurred in the main dining room, not on the secured unit. He stated the facility did not have a Connect 4 game, so the activity did not occur on 11/06/2023 at 1:00 PM, as listed on the calendar. AA #47 stated the scheduled card design activity on 11/07/2023 was not performed with the residents on the secured unit. AA #47 stated bingo was not held on the secured unit, and those residents were not able to participate. He stated the residents on the secured unit were at risk for elopement, so most of them were not able to leave the secured unit and were not able to participate in activities that occurred outside of the unit. AA #47 revealed he was responsible for activities on the secured unit and stated he did not have activity participation documentation for Resident #43. He stated Resident #43 liked to sing and attend church activities, but that was not offered this week. AA #47 stated he thought the facility needed planned, meaningful activities based on each resident's assessment and preferences and expected residents to receive planned and meaningful activities.
During an interview on 11/08/2023 at 3:34 PM, the AD stated she had worked in her current position for approximately a year. She stated the activity calendar was completed as a team with AA #47 and another activity assistant. She stated she paid for some activity supplies out of her own money because the facility would not buy enough supplies. The AD stated that when a resident was admitted , she completed an activity assessment to see what activities they liked and preferred. The AD stated she very seldom went on the secured unit to perform activities, and it was AA #47's responsibility to provide activities on the secured unit. She stated most of the residents who resided on the secured unit were not able to come off the unit to do activities scheduled off the unit. The AD stated the activity calendar had not changed since she started. The AD stated CNA #40 submitted a grievance about activities on the secured unit, but the AD thought the activities department was doing well. She stated the activity department had approximately seven activity aides until June or July 2023, and currently, there was not enough activity staff to complete all activities. The AD stated she expected residents to receive a planned and meaningful activity program based on their assessments.
During an interview on 11/09/2023 at 8:17 AM, Licensed Practical Nurse (LPN) #49 stated that she normally worked the secured unit, and that the activity department rarely did activities with residents on the secured dementia unit. She stated she did not think breakfast and smoking scheduled on the activities calendar were appropriate. LPN #49 stated the listed scheduled activities on the calendar were held outside of the dementia unit, and most residents on the secured unit could not leave the unit because they were an elopement risk or had behaviors. She stated Resident #43 was more alert and oriented than appeared, and they would participate in any activity if offered. LPN #49 stated she expected planned and meaningful activities, but that was not happening on the dementia unit.
During an interview on 11/09/2023 at 9:42 AM, the Director of Nursing (DON) stated the facility had an activity department, an Activities Director, and several activity assistants. She stated the AD discussed activities of the day in the morning meeting. The DON stated she did not think breakfast and smoking should be on the activity calendar unless held as a group and an actual activity was provided. She stated she rarely looked at the activity calendar because she was in a clinical position. The DON stated the CNAs on the secured unit would play music and provide activities when they had time; however, the activity department was responsible for the activities in the facility. She stated Resident #43 would have to be monitored if the resident came off the secured unit because they were an elopement risk. The DON stated the facility may occasionally have activities on the secured unit but not consistently. The DON was unaware that the secured unit's scheduled activities were not done this week. The DON stated she expected an ongoing activity program based on residents' assessments, interests, and abilities, and the facility lacked appropriate activities for residents on the dementia unit.
During an interview on 11/09/2023 at 11:10 AM, the Administrator stated he and the AD were responsible for activities; however, the AD was responsible for the activities scheduled on the calendar. He stated the activity department did more than what was on the calendar and should take credit for what they did by updating it. The Administrator stated he spent hundreds of dollars on supplies for activities each month, so he expected every resident to be offered meaningful activities daily based on their assessments. The Administrator stated the three staff members currently working in the activity department were sufficient, and no one had brought concerns to him about the activities in the secured dementia unit.
CONCERN
(D)
📢 Someone Reported This
A family member, employee, or ombudsman was alarmed enough to file a formal complaint
Potential for Harm - no one hurt, but risky conditions existed
Quality of Care
(Tag F0684)
Could have caused harm · This affected 1 resident
Based on observations, interviews, record review, and facility policy review, the facility failed to ensure a rash for 1 (Resident #100) of 3 residents reviewed for skin concerns were assessed and rec...
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Based on observations, interviews, record review, and facility policy review, the facility failed to ensure a rash for 1 (Resident #100) of 3 residents reviewed for skin concerns were assessed and received treatment.
Findings included:
A review of a facility policy titled Care and Services, revised in June 2020, revealed, Purpose: To ensure through an interdisciplinary team (IDT) process, that all residents receive the necessary care and services based on an individualized comprehensive assessment process. Further review revealed, Policy: Residents are provided with the necessary care and services to maintain the highest practicable physical, mental, and social well-being level of in an environment that enhances quality of life in the scope of a long-term care facility. Care and services are provided in a manner that consistently enhances self-esteem and self-worth.
A review of Resident #100's admission Record revealed the facility admitted Resident #100 on 03/23/2023 with diagnoses that included chronic heart disease, type 2 diabetes mellitus (DM II), need for assistance with personal care, and dementia.
A review of Resident #100's quarterly Minimum Data Set (MDS), with an Assessment Reference Date (ARD) of 10/11/2023, revealed a Staff Assessment of Mental Status (SAMS) that indicated the resident had short- and long-term memory problems and moderately impaired cognitive skills for daily decision making. The MDS revealed the resident required partial/moderate assistance with personal hygiene, dressing, positioning, and transfers and required maximum assistance with showers/bathing. The MDS revealed Resident #100 had no open lesions and was not receiving ointments/medications nor nonsurgical dressings.
A review of a care plan focus area for Resident #100 dated 03/24/2023 revealed the resident had diabetes. Interventions directed staff to check the resident's body for breaks in the skin and treat them promptly as ordered by the resident's physician.
During an interview on 11/07/2023 at 10:26 AM, Resident #100 stated they had an itchy rash recently, believing they had it since the previous Christmas. The resident stated their skin was not bothering them at the moment.
During a telephone interview on 11/08/2023 at 8:53 AM, the Responsible Party (RP) for Resident #100 stated they visited Resident #100 weekly. They stated that during a visit on 10/21/2023, they noticed the resident had a rash. The RP stated when they told the nursing staff about the rash, the nursing staff said they would get a cream for them to apply to the resident. The RP stated that during their visit on 10/28/2023, the rash had spread to the resident's legs, and the resident was itching like crazy. The RP stated they told the nurse on shift, who handed the RP a cream and instructed them to apply it to the resident. The RP stated the nurse did not assess or evaluate the resident's skin.
During an interview on 11/08/2023 at 9:40 AM, Resident #100 stated they were not itchy that morning and had no rash on their arms or legs. The resident pulled up the shirt sleeve to the left arm, revealing a red, open area on the interior forearm.
During an observation and interview on 11/09/2023 at 7:43 AM, an observation of Resident #100's skin with Certified Nurse Aide (CNA) #35 revealed CNA #35 lifted the resident's shirt, exposing the skin on the resident's back and sides. The resident had red scabbing and a rash on their left side from their underarm to their hip, then across the lower back along the pant line. Resident #100 stated their skin felt better today than it had in a while. Resident #100 stated their skin used to hurt and was itchy, but not today. CNA #35 stated Resident #100 had a red rash on their back for about a month, which was not new. She stated the nurse had been giving her creams and lotions to put on the area, but the CNA was unsure what specific creams and lotions they were. She stated the rash area should have been documented on the bath sheets and skin assessments. She stated she told the nurse when it appeared a month ago but could not recall which nurse she told.
A review of Resident #100's Weekly Skin Observations dated 10/06/2023, 10/13/2023, 10/20/2023, 10/27/2023, and 11/03/2023 revealed the Assistant Director of Nursing (ADON) documented that the resident's skin was warm, dry, and scaly, with normal color and turgor, and no new or existing skin concerns were noted. According to the assessments, A&D ointment was being applied to the resident's feet.
A review of Resident #100's Progress Notes for the timeframe from 09/29/2023 through 11/03/2023 revealed no documented skin concerns nor documented skin assessments on 10/21/2023 and 10/28/2023, when the RP identified and reported a rash.
A review of Resident #100's Shower Sheet/Skin Condition Reports dated 10/03/2023, 10/06/2023, 10/10/2023, 10/13/2023, 10/17/2023, 10/20/2023, 10/24/2023, and 10/27/2023 revealed the instructions were This sheet is to be completed by the Nursing Assistant for each resident scheduled for a shower or whenever an abnormal area is observed. If an abnormal area is identified, the nursing assistant also fills out the Stop and Watch Tool (SAW) and reports it to the nurse, the nurse will visually assess the area. These sheets must be signed [sic] the nursing assistant and the nurse as appropriate and returned to the DON [Director of Nursing] or designee. Check the appropriate box and circle the affected area(s) to indicate the location of any abnormal skin condition checked. Abnormal skin areas should be identified even when not newly identified. A review of the reports revealed options to check included Normal, Abnormal, Open area, and Other: List below. The reports revealed that a CNA and a nurse signed each report, and nothing was documented/marked on any of the skin reports.
During a telephone interview on 11/09/2023 at 9:38 AM, Resident #100's Primary Care Physician (PCP) stated she had received no calls from the facility nurses about Resident #100 having a rash or any skin concerns. She stated she last saw Resident #100 on 10/30/2023 but did not do a skin assessment during the visit, and the nursing staff brought no concerns about the resident's skin to her attention during the visit. She stated the resident was confused at baseline and did not appear itchy or uncomfortable during her last visit. The PCP further stated that the facility nurses had not requested anti-itch creams for Resident #100. She stated the nurses should always call her first to inform her of a resident's condition before applying any creams or ointments to the resident.
During an interview on 11/09/2023 at 10:21 PM, Licensed Practical Nurse (LPN) #43 stated nurses completed weekly skin checks and documented any new or existing skin concerns such as blisters, open sores, and anything abnormal. LPN #43 stated she was familiar with Resident #100 and knew of no rash on the resident's upper body in October 2023 or any other time. She stated no CNA had brought anything to her about a rash on the resident.
During an interview on 11/09/2023 at 10:46 AM, the Assistant Director of Nursing/Infection Preventionist (ADON/IP) stated skin assessments should be completed weekly by the nurses and should cover the resident's skin from head to toe. She stated if the CNAs noted any changes to the resident's skin, the changes should be reported immediately to the nurse, who would forward the concern to the ADON/IP so she could join the nurse during an assessment. She stated she completed most of the skin assessments on the unit where Resident #100 resided, so nothing slipped through the cracks. She stated the resident had some dry, flakey skin, and the CNAs applied lotion on the resident's skin. She stated she last saw the resident's skin the day before yesterday, 11/07/2023. The ADON/IP stated the resident had a mole or two on their back but no rash.
During an observation and interview on 11/09/2023 at 11:09 AM, an observation of Resident #100's skin in their room with the ADON/IP revealed the resident had a red rash that extended around both sides, covering their breasts, stomach, and back. Resident #100 told the ADON/IP that their back itched and their skin hurt. In an interview with the ADON/IP during the observation, the ADON/IP stated the red rash was not present on 11/07/2023 and stated that since it was so bright red, she had doubts about it being there for a month.
During an interview on 11/09/2023 at 2:13 PM, the DON stated nursing staff should be completing skin assessments weekly and CNAs should complete bathing sheets. She stated any new skin abnormality, bruise, or dry skin should be documented. She stated if a CNA noticed a skin abnormality, they should report it to the nurse immediately, who would then call the physician and the DON and follow any orders received. The DON stated the bath sheets should include the skin condition at the time of the bath and indicate whether the skin was intact and in normal presentation. She stated leaving the bathing sheet blank revealed no information about the condition of the resident's skin and left everything up to interpretation. The DON stated she had no knowledge of skin assessments not being completed for residents and did not recall Resident #100 having a skin concern.
During an interview on 11/09/2023 at 4:28 PM, the Administrator stated he expected skin assessments to be completed and accurate. He stated that a licensed nurse completed weekly skin assessments, and the CNAs filled out bathing sheets. He stated any open area, bruise, or anything out of the ordinary should be reported to the nurse immediately, and the nurse should document the condition of the resident's skin and call the physician for orders. The Administrator stated the nurses could reach out to the DON for guidance regarding how assessments should be completed and their frequency, which should be weekly. He stated he had no knowledge of any concerns regarding skin assessments not being completed. He stated he recalled Resident #100's name but no specifics about the resident.
CONCERN
(D)
📢 Someone Reported This
A family member, employee, or ombudsman was alarmed enough to file a formal complaint
Potential for Harm - no one hurt, but risky conditions existed
Deficiency F0697
(Tag F0697)
Could have caused harm · This affected 1 resident
**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on interviews, record reviews, and facility document and policy review, the facility failed to ensure 1 (Resident #538) of...
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**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on interviews, record reviews, and facility document and policy review, the facility failed to ensure 1 (Resident #538) of 3 residents reviewed for pain management received pain medication as ordered by the physician.
Findings included:
A review of a facility policy titled Pain Management, revised in June 2020, revealed, A. A licensed Nurse will assess for pain upon admission. The Licensed Nurse will complete a Pain Assessment located in Point Click Care (PCC) [electronic health record] for residents identified as having pain within 8 hours of admission. The policy revealed for pain management, A. The Licensed Nurse will administer pain medication as ordered and document medication on the Medication Administration Record (MAR) and D. Nurse staff will implement timely interventions to reduce the increase in severity of pain.
A review of Resident #538's admission Record revealed the facility admitted the resident on 10/02/2023 and discharged the resident on 10/03/2023. Resident #538's diagnoses included a displaced fracture of the medial condyle of the right femur (the inside part of the knee) and was injured in a motor vehicle accident.
A review of Resident #538's discharge Minimum Data Set (MDS), with an Assessment Reference Date (ARD) of 10/03/2023, revealed the resident was admitted from a hospital and was discharged to a hospital on [DATE]. The MDS revealed a pain assessment was not required for the discharge MDS.
A review of Resident #538's hospital Prescription form dated 09/25/2023 revealed an order for hydrocodone-acetaminophen (Norco, a narcotic pain medication) 5 milligrams (mg)-325 mg tablet, one tablet by mouth every four hours as needed for pain.
A review of Resident #538's physician's Order Summary Report for the facility revealed an order for staff to conduct a pain assessment each shift, beginning 10/02/2023. The report revealed an order dated 10/02/2023 for hydrocodone-acetaminophen 5 mg-325 mg tablet, one tablet by mouth every four hours as needed for pain.
A review of Resident #538's admission Report Sheet dated 10/02/2023 revealed that before admission to the facility, the hospital last administered pain medication to the resident at 9:00 AM, and the resident's pain was 5 (on a scale of 0 to 10, with 10 being the worst possible pain).
A review of Resident #538's Progress Notes revealed an admission Assessment was completed on 10/02/2023 at 3:58 PM. The admission Assessment revealed Resident #538 was admitted from the hospital on [DATE] at 3:45 PM. LPN #10 documented that Resident #538 is able to report pain at this time.
A review of Resident #538's Progress Notes dated 10/02/2023 at 4:41 PM revealed LPN #10 documented Resident #538's pain level was a 9 on the numerical pain scale. The note revealed all medication orders were in and sent to the pharmacy.
A review of Resident #538's Progress Notes dated 10/02/2023 at 5:18 PM revealed medication orders and the prescription for Norco were faxed to the pharmacy that day.
A review of Resident #538's Medication Administration Record (MAR) for October 2023 revealed that on 10/02/2023 at 10:00 PM, the resident's pain level was 5 on the numerical pain scale. There was no documented evidence that hydrocodone-acetaminophen (Norco) was listed on the MAR, nor any documented evidence the medication was administered.
During an interview on 11/09/2023 at 8:31 AM, Licensed Practical Nurse (LPN) #10 stated she completed Resident #538's admission assessment. LPN #10 stated Resident #538 had requested pain medication; however, no pain medication was available to give the resident. LPN #10 stated the facility had issues contacting the pharmacy to fill the prescription for the resident's pain medication. LPN #10 stated she notified Assistant Director of Nursing (ADON) #11 that medication was needed. LPN #10 stated she gave Resident #538 a Tylenol; however, there was no documented evidence the medication was ordered nor administered. LPN #10 revealed she did not have access to the facility's emergency medication kit and did not know whether pain medications were located in the kit. LPN #10 stated only nurse managers were allowed to utilize the emergency medication kit.
During an interview on 11/09/2023 at 8:52 AM, ADON #11 stated Resident #538 was admitted to the facility without medications; however, hydrocodone was located in the emergency medication kit. ADON #11 stated the nurse must call the pharmacy to get a code and access the kit. ADON #11 stated nurse managers were not required to access the kit before administering the pain medication if the resident needed medication. ADON #11 stated as long as the facility had a prescription, the nurse could access the emergency kit.
At 9:08 AM on 11/09/2023, ADON #11 provided a list of medications kept in the emergency medication kit. A review of the EKIT [Emergency Kit] Contents list revealed hydrocodone-acetaminophen 5mg-325 mg was listed as being kept in the emergency drug kit.
During an interview on 11/09/2023 at 1:41 PM, the Director of Nursing (DON) stated when a resident was newly admitted with pain, the resident's pain should be managed. The DON stated the nurses had access to the medication emergency kit and should have retrieved the medication from the emergency medication kit on 10/02/2023 and provided the medication timely.
CONCERN
(D)
Potential for Harm - no one hurt, but risky conditions existed
Medication Errors
(Tag F0758)
Could have caused harm · This affected 1 resident
Based on interviews, record reviews, facility document and policy review, the facility failed to ensure a resident receiving antipsychotic medication had an appropriate diagnosis for continued use for...
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Based on interviews, record reviews, facility document and policy review, the facility failed to ensure a resident receiving antipsychotic medication had an appropriate diagnosis for continued use for 1 (Resident #128) of 6 residents reviewed for antipsychotic medications:
Findings included:
A review of a facility policy titled Psychotherapeutic Drug Management, revised in June 2020, revealed, The psychotherapeutic medication order will include the following information: i. Informed consent from resident and/or surrogate decision maker for each drug and for each increase in dosage as per state guidelines. ii. Diagnosis for the medication. Further review of the policy revealed, H. The Attending physician will respond to any irregularities reported by the pharmacist as described in section VI (D) by reviewing the irregularities and documenting in the resident's medical record that the irregularity has been reviewed, and what, if any, action has been taken to address it. i. If no action has been taken, the attending physician must document his/her rationale. ii. Documentation by the Attending Physician must occur within 30 days of issuance of the pharmacist's report, unless the irregularity is an emergent issue requiring immediate action.
A review of Resident #128's admission Record revealed the facility admitted the resident on 08/28/2023 with a diagnosis that included unspecified dementia without behavioral disturbance, psychotic disturbance, mood disturbance, and anxiety. A diagnosis of schizophrenia was added on 11/07/2023 after surveyor inquiry.
A review of Resident #128's 5-day Minimum Data Set (MDS), with an Assessment Reference Date (ARD) of 09/05/2023, revealed Resident #128 had a Brief Interview for Mental Status (BIMS) score of 15, which indicated the resident was cognitively intact. The MDS revealed Resident #128 received antipsychotic medications daily during the seven-day lookback period.
A review of Resident #128's care plan revealed a focus area with an initiation date of 09/12/2023 and a revised date of 11/09/2023 that indicated Resident #128 used psychotropic medication for depression and schizophrenia. The interventions directed staff to administer psychotropic medication as ordered by the physician, monitor for side effects and effectiveness every shift, document and report any adverse reactions, and monitor/record the occurrence of target behavior symptoms per facility protocol.
A review of Resident #128's Order Summary Report revealed an order with a start date of 08/28/2023 for olanzapine (antipsychotic) oral tablet disintegrating 5 milligrams (mg) with instructions to give 2.5 mg by mouth two times a day for antipsychotic related to other schizophrenia.
A review of Resident #128's Medication Administration Record (MAR) for the timeframe from 11/01/2023 through 11/06/2023 revealed staff documented that Resident #128 received olanzapine oral tablet disintegrating 2.5 mg two times daily.
A review of a document titled Note to Attending Physician/Prescriber dated 09/14/2023 and signed by the Pharmacy Consultant for Resident #128 revealed the resident was receiving the antipsychotic olanzapine and indicated an antipsychotic should only be used for a list of conditions/diagnoses (included on the form). Schizophrenia had been checked on the document, and the document had been signed and dated 11/07/2023 after the surveyor's inquiry.
During an interview on 11/08/2023 at 10:10 AM, the Pharmacy Consultant stated she completed Resident #128's pharmacy review requesting an appropriate diagnosis for the use of the antipsychotic medication olanzapine, and it was still pending in her system. She stated it was still awaiting an appropriate diagnosis.
During an interview on 11/07/2023 at 2:39 PM, the Director of Nursing (DON) stated the pharmacy consultant had completed the pharmacy review in September, indicating that Resident #128 needed an appropriate diagnosis for continued use of the medication olanzapine. The DON stated Attending Physician #9 had not checked the mail at the facility where the pharmacy recommendation was located. She stated they were usually very quick getting the recommendations back in the same day, but this recommendation had fell through the cracks.
During an interview on 11/08/2023 at 10:52 AM, the Attending Physician #9 stated they were a new provider for the facility, and they had no idea where the pharmacy recommendations were going. Attending Physician #9 indicated they received pharmacy recommendations and addressed them.
During an interview on 11/09/2023 at 4:00 PM, the Administrator stated he expected the clinical team to review pharmacy recommendations.
CONCERN
(D)
📢 Someone Reported This
A family member, employee, or ombudsman was alarmed enough to file a formal complaint
Potential for Harm - no one hurt, but risky conditions existed
Medical Records
(Tag F0842)
Could have caused harm · This affected 1 resident
Based on interviews and record review, the facility failed to maintain medical records that were complete and readily accessible for 1 (Resident #70) of 2 residents reviewed for hospitalizations.
Find...
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Based on interviews and record review, the facility failed to maintain medical records that were complete and readily accessible for 1 (Resident #70) of 2 residents reviewed for hospitalizations.
Findings included:
During an interview on 11/09/2023 at 3:15 PM, the Regional Nurse Consultant stated the facility did not have a specific policy related to obtaining hospital discharge paperwork for residents who returned from the hospital.
A review of Resident #70's admission Record revealed the facility admitted the resident on 09/25/2023 with a diagnosis that included type 2 diabetes mellitus without complications.
A review of Resident #70's admission Minimum Data Set (MDS), with an Assessment Reference Date (ARD) of 10/08/2023, revealed Resident #70 had a Brief Interview for Mental Status (BIMS) score of 13, indicating the resident was cognitively intact. The MDS revealed the resident had an active diagnosis of diabetes mellitus and received insulin daily during the seven-day lookback period.
A review of a care plan focus area for Resident #70, revised on 09/29/2023, revealed the resident had a diagnosis of diabetes mellitus with interventions that directed staff to monitor, document, and report hyperglycemia.
A review of Resident #70's physician's orders revealed an order dated 10/24/2023 that instructed staff to send the resident to the local hospital emergency room for an evaluation and treatment of high blood sugar.
A review of Resident #70's Progress Notes revealed a Transfer to Hospital Summary note dated 10/24/2023 that indicated an ambulance came to transfer the resident to the hospital for high blood sugar with two emergency medical technicians present. Further review of Resident #70's Progress Notes revealed no documentation of when the resident returned from the hospital.
During an interview on 11/08/2023 at 4:20 PM, Resident #70 stated they thought they were gone for about a week when they went to the hospital and said they were brought back by an ambulance. Resident #70 stated that they could not recall the date they returned to the facility.
During an interview on 11/07/2023 at 1:10 PM, Assistant Director of Nursing (ADON) #11 stated Licensed Practical Nurse (LPN) #44 was the nurse working with Resident #70 on 10/24/2023. She stated the nurse contacted the doctor regarding Resident #70's high blood glucose level, and transportation arrived to take the resident to the hospital; however, ADON #11 believed the doctor decided the resident would not go to the hospital.
During an interview on 11/07/2023 at 3:35 PM, LPN #44 stated Resident #70 had a high blood sugar level on 10/24/2023 when she had performed a routine blood sugar check, and she notified the resident's doctor via phone call. LPN #44 stated the doctor instructed her to give an extra ten units of rapid-acting insulin and reassess the resident's blood glucose in twenty minutes. She stated that upon reassessment, the resident's blood sugar level was still high, so she called the doctor back and was instructed to call for an ambulance. LPN #44 stated the resident was sent to the hospital and returned the next day. LPN #44 stated she looked on her computer for documentation from the day the resident returned and could not find any notes from the return or documentation from the hospital on file. She stated she was not working at the facility the day the resident came back to the facility. LPN #44 stated that a return-from-hospital note should be present. She stated she could not locate any new orders or documentation from Resident #70's hospital visit. LPN #44 stated usually, the hospital would send paperwork back with the resident and said if a resident came back from the hospital without paperwork, the nurse should call the hospital to request discharge paperwork.
During a follow-up interview on 11/07/2023 at 3:56 PM, ADON #11 stated they may have access to the hospital's medical records, but if not, they could call the hospital and request a summary of the visit.
During an interview on 11/08/2023 at 10:46 AM, the ADON/Infection Preventionist (IP) stated she had no information regarding Resident #70's return from the hospital. The ADON/IP stated she would talk to the social worker because she had asked the social worker about Resident #70's hospital visit yesterday (11/07/2023).
During an interview on 11/09/2023 at 8:13 AM with the HRD, he referenced the staff schedule from 10/25/2023 and said the nurse working on the unit that day was the ADON/IP.
During an interview on 11/08/2023 at 10:56 AM, the Director of Nursing (DON) stated the facility did not have access to the hospital medical records system. She stated she left yesterday before learning the resident had actually gone to the hospital. The DON stated she would start working on trying to locate the hospital records.
During an interview on 11/08/2023 at 2:41 PM, the Regional Nurse Consultant stated the Regional Director of Business Development had been asked to look into the referral system to see if there was anything more specific to Resident #70's hospital visit. She stated that sometimes the hospital would send a summary of the visit, but typically, they had to request paperwork from the hospital. The Regional Nurse Consultant stated the report they had requested and received from the hospital today (11/08/2023) was a discharge summary report documenting Resident #70 was seen and needed a follow-up visit, but nothing more specific. She stated she was almost positive that Resident #70 returned the same day they left. She stated that when a resident returned from the hospital, there should be a progress note entered by the admitting nurse documenting the resident's return and any new orders or changes. The Regional Nurse Consultant stated she would like staff members to get a report from someone when the resident returned to the facility but said the hospital is bad about calling report. She stated they had had to make an official request with the hospital medical records department to get discharge paperwork in the past and said this would be the next step in the case of Resident #70.
During an interview on 11/08/2023 at 3:34 PM, the Human Resources Director (HRD) stated the nurse who worked the night shift on 10/24/2023 into the morning of 10/25/2023 was the LPN Supervisor.
During an interview on 11/08/2023 at 3:46 PM, the LPN Supervisor stated Resident #70 went to the hospital before she came to work at 11:00 PM on 10/24/2023, and she did not remember the resident coming back to the facility during her shift, which ended at 7:00 AM on 10/25/2023. She stated she worked the next night on 10/25/2023, from 11:00 PM to 7:00 AM, and said Resident #70 was already back when she came to work.
During an interview on 11/09/2023 at 8:35 AM, the Director of Clinical and Reimbursement Services provided documentation that she said was requested from the hospital and was received the previous night (11/08/2023). The documentation indicated that the hospital attempted to call the resident regarding post-hospital discharge medication reconciliation. The documentation contained minimal information pertaining to Resident #70's visit on 10/24/2023 and indicated the resident was discharged to the facility sometime before 8:19 AM on 10/25/2023 per a note entered by a social worker at the hospital.
During an interview on 11/09/2023 at 8:48 AM, the DON stated she expected a note to be documented when a resident left the facility and when they came back. She stated there should be a report called or paperwork sent back with the resident. The DON stated it had been an issue in the past where they were not getting what they needed when someone returned from the hospital. She stated she would expect the nurse to initiate a call to the hospital if a resident returned to the facility with no paperwork and no report was called by the hospital. The DON stated she did not know why the nurse or ADON did not call the hospital to get a summary of the hospital visit or some kind of report.
During an interview on 11/09/2023 at 9:19 AM, the Administrator stated hospital discharge paperwork should be sent with the resident, or a report should be called when a resident returns to the facility from the hospital. He stated the nurse on the unit, the ADON for the unit, or the DON should call to confirm any new orders and get a summary of the visit and hospital discharge paperwork. The Administrator stated he was not sure why the staff did not call to obtain hospital discharge paperwork for Resident #70.
CONCERN
(D)
Potential for Harm - no one hurt, but risky conditions existed
Infection Control
(Tag F0880)
Could have caused harm · This affected 1 resident
**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observations, interviews, record review, and facility policy review, the facility failed to
ensure two staff members w...
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**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observations, interviews, record review, and facility policy review, the facility failed to
ensure two staff members wore appropriate personal protective equipment (PPE) to prevent the spread of infection when caring for 1 resident who was COVID-19 positive (Resident #187) of 4 residents sampled for infection control.
Findings included:
A review of a facility policy titled Resident Isolation - Categories of Transmission-Based Precautions, revised 10/24/2022, revealed, I. Transmission-based precautions are used whenever measures more stringent than standard precautions are needed to prevent or control the spread of infection. A. The facility will initiate transmission-based precautions for a constellation of new symptoms consistent with a communicable disease. These transmission-based precautions may be adjusted or discontinued when additional clinical information becomes available (e.g., confirmatory laboratory results. The policy revealed IIII. Contact Precautions. A. Contact precautions are implemented for residents known or suspected to be infected or colonized with microorganisms that are transmitted by direct contact with the resident or indirect contact with environmental surfaces or resident-care items in the resident's environment. i. Examples of infections requiring Contact Precautions included, but are not limited to: p. COVID-19. The policy further indicated, IV. Droplet Precautions. A. Droplet precautions are implemented for a resident who is documented or is suspected of being infected with microorganisms transmitted by droplets (large-particle droplets [larger than 5 microns in size] that can be generated by the individual coughing, sneezing, talking, or by the performance of procedures such as suctioning). i. Examples of infections requiring droplet precautions include, but are not limited to: h. COVID-19. According to the policy, C. Gloves and Handwashing i. As outlined under Policy No. - IC - 23 standard Precautions, gloves (clean, nonsterile) are worn when entering the room. iii. Gloves are removed before leaving the room and hands are washed immediately with an anti-microbial agent or a waterless anti-septic agent. iv. After gloves are removed and hands are washed, the potentially contaminated environmental surfaces or items in the resident's room are not touched. D. Gown i. As outlined in Policy No. - IC - 22 Standard Precautions, a (clean, nonsterile) gown is worn for interactions that may involve contact with the resident or potentially contaminated items in the resident's environment. ii. The gown is removed, and hand hygiene is performed before leaving the resident's environment. Further review revealed, E. A mask is worn when working upon entry to the room.
During an interview on 11/08/2023 at 1:58 PM, the Infection Preventionist (IP) stated that staff should wear full PPE, including a gown, gloves, KN-95 mask, and face shield or goggles, to walk into a resident's room who was COVID-19 positive because they never knew if they had to touch something when they got in the room or had to help the resident. The IP stated she expected the mask to be changed when they left the room of a resident who was COVID-19 positive and to close the door. She stated the risk of not following the procedures was spreading or catching COVID-19.
A review of Resident #187's demographic sheet revealed the facility admitted the resident on 10/19/2023. The resident was discharged to the hospital on [DATE] and was readmitted to the facility on [DATE].
A review of Resident #187's hospital Summary of Care, dated 11/03/2023, indicated Resident #187's diagnoses from the hospital included pneumonia due to COVID-19.
A review of Resident #187's admission Minimum Data Set (MDS), with an Assessment Reference Date (ARD) of 10/26/2023, revealed Resident #187 had a Brief Interview for Mental Status (BIMS) score of 00, which indicated the resident had severe cognitive impairment. The MDS revealed the resident required setup or clean-up assistance from staff with eating.
An observation and interview on the isolation unit on 11/06/2023 at 11:48 AM revealed that one resident room was occupied by Resident #187. The door to the room displayed a sign that read, Transmission Based Droplet-Contact Precautions. Perform hand hygiene upon entering and before exiting room. Respirator (N95) when entering room. Gown when entering room. Gloves when entering room. Wear eye protection (face shield or Goggles). Keep Door Closed. The door to Resident #187's room was open. The observation revealed Nursing Assistant (NA) #53 delivered Resident #187's lunch to the room. NA #53 was observed wearing gloves and a surgical mask upon entering the room. NA #53 made space on the resident's bedside table for the plate and removed the gloves before exiting the room. The NA left the surgical mask on, and the door open upon exiting the room. During an interview, NA #53 stated she had received COVID-19 and PPE training. She stated if she touched Resident #187 for care, she should wear gloves, a gown, a face shield, and an N-95 mask; however, she stated she was not required to wear the PPE when delivering a meal to the resident.
An observation and interview on 11/07/2023 at 7:43 AM revealed NA #54 entered Resident #187's room with a breakfast plate, wearing a KN-95 mask and gloves. She removed the gloves upon exiting the room but continued to wear the same mask and left the room door open. NA #54 stated she received COVID-19 and PPE training and was aware that a gown, gloves, mask, and face shield should be worn when entering the resident's room. She stated that she just did not wear the items and really did not think the resident had COVID-19.
During an interview on 11/07/2023 at 11:25 AM, the Director of Nursing (DON) stated any time staff went to a resident's room who was COVID-19 positive, they should wear the PPE that was listed on the door, and the door should be closed. The DON stated that both NA #53 and NA #54 were incorrect and should have worn PPE when entering the room.
During an interview on 11/09/2023 at 9:47 AM, the Administrator stated he expected NA #53 and NA #54 to wear appropriate PPE even when staff was not providing direct care, and the resident's door should be closed.
CONCERN
(E)
Potential for Harm - no one hurt, but risky conditions existed
Deficiency F0925
(Tag F0925)
Could have caused harm · This affected multiple residents
**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observations, interviews, facility document and policy review, the facility failed to maintain an effective pest contro...
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**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observations, interviews, facility document and policy review, the facility failed to maintain an effective pest control program, as evidenced by mice sightings on 3 (Unit 100, 200, and 500) of 5 units.
Findings included:
A review of a facility policy titled Pest Control, revised in August 2020, revealed, The Facility maintains an ongoing pest control program to ensure the building and grounds are kept free of insects, rodents, and other pests. The policy further revealed, As authorized by the Administrator, the Company will carry out any pest control actions needed to rid the Facility and its grounds of any environmental pests.
During an observation on 11/09/2023 at 7:04 AM in room [ROOM NUMBER], a mouse was observed running from under the bed to under the air conditioner unit.
During an observation and interview on 11/06/2023 at 11:59 AM, a mouse was observed in room [ROOM NUMBER] under Resident #21's bed behind their headboard. Resident #21 stated they heard mice and only saw them after they were caught in a trap. A mouse trap was observed next to the nightstand.
During an interview on 11/07/2023 at 2:33 PM, Resident #98 in room [ROOM NUMBER] stated they had seen a mouse in their room about three weeks ago. Resident #98 stated they had reported it to the nursing staff, and mouse traps were put down in their room.
During an interview on 11/07/2023 at 2:12 PM, Certified Medication Technician (CMT) #12, who worked on the 200 Unit, stated she had seen mice in the facility from time to time and last saw one about a month ago.
During an interview on 11/07/2023 at 2:27 PM, Restorative Aide (RA) #13 stated she had seen mice in the past and observed a dead mouse in a trap on the second floor when she was weighing a resident. RA #13 stated she picked up the mouse with the mouse trap and threw it away.
A review of a pest control document titled Summary of Service with a service date of 10/26/2023 revealed targeted pests included mice. The document indicated that 20 rodent/insect glueboards were placed. Recommendations included:
-Cracks or damage to the wall allowing pest access. Please repair to prevent pest entry.
-Woodpile is too close to the foundation. Please move to prevent attracting pests to the structure.
-Door gap/damage noted in the common areas that allow pest access. Please repair to prevent pest entry.
-Trees/vegetation touching the building. Trim to prevent pest entry to the structure.
During an interview on 11/07/2023 at 11:30 AM, the Maintenance Director stated the Pest Control Specialist (PCS) visited the facility weekly to put down mouse traps. The Maintenance Director stated the PCS went through all the rooms, and if holes were found, the Maintenance Director patched them up. The Maintenance Director stated that the mice issue had always been a problem and worsened due to Coronavirus (COVID) when residents ate more in their rooms.
During an interview on 11/08/2023 at 9:14 AM, the PCS stated she had been servicing the facility for over a year and visited weekly. The PCS revealed that mice on the 200 hall (unit) were due to residents eating in their rooms and the meal trays being picked up late. She stated she felt that was the biggest challenge.
An observation of the facility exterior and an interview with the Maintenance Director were conducted on 11/09/2023 at 10:00 AM. The observation revealed a disorderly pile of pallets about four feet tall with weeds grown completely through them next to the dumpster. A brush pile was approximately 15 feet from the building and approximately 2 feet tall, 8 feet wide, and 20 feet long. Tree limbs were noted touching the back of the special care unit, and a second tree was touching the side and over the roof of the special care unit. The Maintenance Director stated he had cut one back that was blocking the camera and had been told to cut some others back because mice could walk across the limbs and into the building, but he had not yet cut them back. He stated that when the PCS came out to the building, she would leave what she found with items to address, and he tried to correct them. The Maintenance Director stated some items could not be completed, such as the brush pile in the back, because it would take two dump trucks to remove that. He stated getting rid of that would not help because the mice were born inside the building and had never been outside. He further stated they were not catching anything in the bait traps near the brush pile; therefore, the mice were not coming out of the brush pile. He revealed that the biggest issue was residents eating in their rooms. He stated he had worked at the facility since 2006, and mice were always an issue.
During an interview on 11/09/2023 at 11:54 AM, the Director of Nursing (DON) stated that if staff saw mice or bugs, she expected staff to report the activity to her, the Administrator, or Maintenance. She stated there were also pest-sighting logs on each of the halls for staff to record observations. The DON stated she expected there to be control over pest/rodents but could not provide an acceptable number of observations.
During an interview on 11/09/2023 at 12:00 PM, the Administrator expected staff to record all observations of pests in the pest-sighting logs on the halls and to report all mice activity to Maintenance. The Administrator stated Maintenance would call the pest control company, and he expected Maintenance to follow all recommendations from the PCS. The Administrator stated that he expected there to be control over pests/rodents, and mice should not be seen at all. He stated he felt the issue had started due to residents being isolated and eating in their rooms during COVID.
CONCERN
(F)
Potential for Harm - no one hurt, but risky conditions existed
Food Safety
(Tag F0812)
Could have caused harm · This affected most or all residents
Based on observations, interviews, and facility policy review, the facility failed to ensure food storage/preparation items were maintained in a clean and sanitary condition to ensure food safety for ...
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Based on observations, interviews, and facility policy review, the facility failed to ensure food storage/preparation items were maintained in a clean and sanitary condition to ensure food safety for 123 of 125 residents who received nourishment from the kitchen.
Findings included:
A review of a facility policy titled Equipment Operation and Sanitation, revised in December 2020, revealed, A. All equipment must be thoroughly washed and sanitized between uses in different food preparation tasks. The policy further revealed e. All items washed and sanitized will be air-dried.
An observation of the kitchen conducted on 11/06/2023 at 10:24 AM revealed four coffee carafes, eight half-size pans, seven moon-size pans, and three quarter-size pans stacked together on a shelf with leftover moisture present (referred to as wet nesting).
A second observation of the kitchen conducted on 11/07/2023 at 11:22 AM revealed nine quarter-size pans and 11 half-size pans stacked together on a shelf with leftover moisture present.
During an interview on 11/06/2023 at 10:37 AM, the Dietary Manager (DM) stated that all dishes in the kitchen should be air-dried after they were cleaned and before use.
An observation of the kitchen conducted on 11/06/2023 at 10:19 AM revealed the following items in the stand-up refrigerator had been opened but not dated: a one-gallon jar of Thousand Island salad dressing, a one-gallon jar of French salad dressing, one pitcher of Italian salad dressing, and a one-gallon jar of Asian Italian salad dressing.
During an interview on 11/06/2023 at 11:08 AM, the DM stated that whoever opened an item in the kitchen was supposed to date that item. She stated the salad dressings should have been dated.
An observation of the kitchen conducted on 11/06/2023 at 10:30 AM revealed the top and bottom convection ovens had a thick, black substance inside the ovens on the bottom where the bake element was located. The glass doors to the ovens were covered with a brown substance.
During an interview on 11/06/2023 at 10:33 AM, the Dietary Aide (DA) stated the convection ovens were cleaned thirty days ago but were supposed to be cleaned twice weekly. The DA stated he did not clean the convection ovens within the last month due to there not being enough dietary staff; however, he stated all other kitchen tasks could be completed without an issue.
During an interview on 11/08/2023 at 12:47 PM, the DM stated the DA was responsible for cleaning the kitchen equipment, and she could not provide a reason why the convection ovens were not cleaned. She stated the DA was supposed to clean the ovens every three weeks or when soiled. She stated the DA was scheduled to clean every Tuesday and Wednesday; however, when she could not fill the open day shift positions for dishwasher and dietary aide on Tuesdays and Wednesdays, the DA would get pulled to those positions instead of cleaning.
During an interview on 11/08/2023 at 1:54 PM, the Administrator stated he expected that all opened food items should be dated and rotated, and that wet nesting was not allowed. He further stated there should be a cleaning schedule for all kitchen equipment and that he had never heard there were not enough staff to clean the equipment.
CONCERN
(F)
Potential for Harm - no one hurt, but risky conditions existed
Garbage Disposal
(Tag F0814)
Could have caused harm · This affected most or all residents
Based on observation, interviews, and facility policy review, the facility failed to keep the area surrounding the dumpsters free of debris for 2 (dumpsters) of 2 dumpsters observed.
Findings included...
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Based on observation, interviews, and facility policy review, the facility failed to keep the area surrounding the dumpsters free of debris for 2 (dumpsters) of 2 dumpsters observed.
Findings included:
A review of a facility policy titled Food-Related Garbage and Rubbish Disposal, revised in December 2008, revealed, 7. Outside dumpsters provided by garbage pick up services will be kept closed and free of surrounding litter.
During an observation of the dumpster area with the Dietary Manager (DM) on 11/06/2023 at 11:11 AM, one bag of trash was found on the left side of the back dumpster. Multiple bags of trash were found under the back dumpster, and debris was found on either side of both dumpsters. Debris items included pieces of paper, cardboard boxes, face masks, a wicker basket, and plastic gloves. Both top doors to the back dumpster were open. The DM stated the housekeeping department was responsible for maintaining the area and that trash was picked up every other day. She stated the trash should have been picked up over the weekend, but it appeared that it had not been. The DM stated the top doors to the back dumpster could not be closed because the dumpster was jammed up against the wooden fence behind it.
During an interview on 11/07/2023 at 11:30 AM, the Maintenance Director stated he had received an email from corporate that the waste company was changed on 11/01/2023, and that was the reason the trash had not been cleared on 11/05/2023.
During an interview on 11/09/2023 at 11:31 AM, the Housekeeping/Laundry Manager stated that Dietary, Maintenance, and Housekeeping maintained the dumpster area together. She stated that when each department disposed of trash, they should pick up around the dumpsters and close the doors to the dumpsters.
During an interview on 11/08/2023 at 2:21 PM, the Administrator stated the surrounding area around the dumpsters should be clean. He stated a new vendor was contracted recently, and they had delivered the new dumpsters too close together, so the lids could not be closed.
MINOR
(C)
Minor Issue - procedural, no safety impact
Staffing Information
(Tag F0732)
Minor procedural issue · This affected most or all residents
Based on observations, interviews, facility document and policy review, the facility failed to post nurse staffing information in an area highly visible to residents and visitors within two hours of t...
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Based on observations, interviews, facility document and policy review, the facility failed to post nurse staffing information in an area highly visible to residents and visitors within two hours of the start of shift on 3 of 4 days of the survey.
Findings included:
A review of a facility policy titled Postings Direct Care Daily Staffing Numbers, revised in August 2006, revealed, Our facility will post on a daily basis for each shift, the number of nursing personnel responsible for providing care to residents. The policy revealed, Within two (2) hours of the beginning of each shift, the number of Licensed Nurses (RNs [Registered Nurse], LPNs [Licensed Practical Nurse], and LVNs [Licensed Vocational Nurse]) and the number of unlicensed nursing personnel (CNAs [Certified Nurse Aide]) directly responsible for resident care will be posted in a prominent location (accessible to residents and visitors) and in a clear and readable format.
An observation on 11/06/2023 at 10:06 AM revealed that the nurse staffing information was not posted at the front desk in the facility's lobby.
An observation on 11/08/2023 at 9:37 AM revealed that the nurse staffing information was not posted at the front desk in the facility's lobby.
An observation on 11/08/2023 at 11:31 AM revealed that the nurse staffing information was not posted at the front desk in the facility's lobby.
An observation on 11/09/2023 at 12:42 PM revealed the nurse staffing information was not posted at the front desk in the facility's lobby.
During an interview on 11/08/2023 at 3:45 PM, the Staffing Coordinator stated she printed daily nursing schedules, which included nurse staffing information, every night, and the next morning, she delivered a copy to each unit and a copy to the front desk for their binder. She believed she did not have to post daily staffing hours at the front desk since the daily nursing schedules were printed with the staffing hours at the bottom of the sheet. She stated she was unfamiliar with the regulation specifics regarding posting nurse staffing information in a highly visible area for residents and visitors to see.
During an interview on 11/09/2023 at 2:13 PM, the Director of Nursing (DON) stated she started as DON in May 2023. She stated the daily nursing staff hours should be posted daily. She stated she was unfamiliar with how or where the nursing hours should be posted.
During an interview on 11/09/2023 at 1:48 PM, the Regional Director of Operations stated nurse staffing information should be posted behind the front desk in the lobby. He stated the nurse staffing information should be posted daily in a place visible to residents and visitors.
During an interview on 11/09/2023 at 4:28 PM, the Administrator stated nursing staff hours should be posted where it could be seen. He stated no concerns had been brought to him about the hours not being posted.
Sept 2023
2 deficiencies
1 Harm
SERIOUS
(G)
📢 Someone Reported This
A family member, employee, or ombudsman was alarmed enough to file a formal complaint
Actual Harm - a resident was hurt due to facility failures
Pressure Ulcer Prevention
(Tag F0686)
A resident was harmed · This affected 1 resident
**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** See Event ID LTWZ12.
Based on observation, interview and record review, the facility failed to ensure residents received care co...
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**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** See Event ID LTWZ12.
Based on observation, interview and record review, the facility failed to ensure residents received care consistent with professional standards and followed their Wound Management-Nursing Care policy to identify, document, monitor, notify physicians and promptly initiate physician's orders to treat pressure injuries/ulcers (injury to the skin and underlying tissue caused by pressure or friction) for two of six residents sampled with actual pressure injuries and/or at risk of developing pressure injuries (Residents #21 and #22). The census was 133.
Review of the facility Wound Management-Nursing Care policy, last revised 06/2020, showed:
-Purpose: To provide a system for the treatment and management of residents with wounds including pressure and non-pressure injury;
-Policy: A resident who has a wound will receive necessary treatment and services to promote healing, prevent infection and prevent new pressure injuries from developing;
-Definitions: -Pressure Injury: Any lesion caused by unrelieved pressure that results in damage to the underlying tissue. Although friction and shear are not primary causes of pressure injury, friction and shear are important contributing factors to the development of pressure injuries. Pressure injuries usually occur over bony prominences and are graded or staged to classify the degree of tissue damage observed;
-Assessment: A licensed nurse will perform a skin assessment upon admission, readmission, weekly, and as needed for each resident;
-Upon identification of a new wound the licensed nurse will:
-Measure the wound (length, width, depth);
-Initiate a wound monitoring record sheet;
-Implement a wound treatment per physician's order;
-An assessment of care needs for pressure injury and wound management will be made with emphasis on, but not limited to:
-Identifying risk factors;
-Treatment;
-Mechanical offloading and pressure reducing devices;
-Reducing skin friction, sheer, and moisture;
-Nutritional status;
-Evaluating and modifying interventions for a resident with an existing pressure ulcer/pressure injury;
-Wound Management:
-The attending physician will be notified to advice on appropriate treatment promptly;
-The licensed nurse will notify the responsible party of the presence of a pressure injury
-A licensed nurse will develop a care plan for the resident based on recommendations from dietary, rehabilitation and the attending physician;
-Per attending physician order, the nursing staff will initiate treatment and utilize interventions for pressure redistribution and wound management;
-The attending physician and interdisciplinary team will be notified of:
-New pressure injuries or wounds;
-Pressure injuries or wounds that do not respond to treatment;
-Pressure injuries or wounds that worsen or increase in size;
-Complaints of increased pain;
-Signs of ulcer sepsis (infection in the bloodstream), presence of exudates (drainage), odor or necrosis (dead tissue) if not already noted by the attending physician;
-Documentation: New pressure injuries or wounds will be documented on the 24 hour log;
Wound documentation will occur at a minimum of weekly until the wound is healed;
-Documentation Will Include:
-Location of wound;
-Length, width, and depth measurements recorded in centimeters (cm);
-Direction and length of tunneling and undermining (if applicable);
-Appearance of the wound base;
-Drainage amount and characteristics including color, consistency, and odor;
-Appearance of wound edges;
-Description of the peri-wound (skin surrounding the wound) or evaluation of the skin adjacent to the wound;
-Presence of pain;
-Interdisciplinary team will document discussion and recommendations for:
-Pressure injuries and wounds that do not respond to treatment;
-Complaints of increased pain, discomfort or decrease in mobility by a resident;
-Signs of ulcer sepsis, presence of exudates, odor or necrosis;
-Residents refusing treatment;
-Licensed nurses will document effectiveness of current treatment in the resident's medical record on a weekly basis;
-Document notifications following a change in the resident's skin condition;
-Update the resident's care plan as necessary.
1. Review of Resident #21's facility admission Record, showed an admission date of 3/4/22.
Review of the resident's physician order sheet (POS), dated 7/2023, showed the following:
-Diagnoses of weakness, arthritis and difficulty walking;
-Weekly skin assessment every Monday on night shift;
-Apply zinc oxide ointment 10% (topical ointment used to treat or prevent minor skin irritations such as diaper rash) cleanse coccyx (tailbone) with soap and water, apply thin layer to coccyx every day and evening shift.
Review of the resident's treatment administration records (TAR), dated 7/2023, showed the following:
-Weekly skin assessment every Monday night;
-No skin assessment documentation for 7/10 and 7/31/23;
-Cleanse coccyx with soap and water, apply zinc oxide ointment twice a day;
-No documentation of administered treatment on 7/6/23.
Review of the facility's Pressure Injury report, dated 7/16/23 through 7/23/23, showed no documentation regarding the resident.
Review of the resident's Shower Sheet/Skin Condition report (a form completed by CNAs), showed the following:
-Directions: The sheet is to be completed by the Nurse's Assistant for each resident scheduled for a shower or whenever an abnormal area is observed. The sheets must be signed by the nursing assistant, the nurse and returned to the Director of Nursing (DON) or designee;
-Shower Sheet/Skin Condition report dated 7/18/23, showed no abnormal skin issues;
-All reports were signed by the certified nurse aides (CNA) and nurse.
Review of the resident's nurse's notes, showed the following:
-7/18/23 at 6:12 A.M.: Weekly skin observations, completed by the Charge Nurse, showed: skin color was normal, skin temperature was dry and warm, skin turgor normal. No skin issues present, no new skin concerns noted;
-7/18/23 at 9:35 P.M.: Called to room by CNA, noted two pressure ulcers to the coccyx. Measured: 3 cm by 3 cm and 1 cm by 1.5 cm. Areas were tan in color with some blackened area. Areas cleaned with wound cleaner and applied calcium alginate (a fibrous absorbent dressing) and dry dressing. The physician was notified, verified treatment order and gave order for Wound Nurse to follow up. Assistant Director of Nurses (ADON) was notified. He/she was to notify resident's family and the Wound Nurse in the morning.
Review of the resident's POS, dated 07/2023, showed an order dated 7/18/23, to clean pressure ulcer to coccyx with wound care solution (wound cleaner), cover with calcium alginate and dry dressing.
Review of the resident's TAR, dated 7/2023, showed the following:
-Weekly skin assessment every Monday night;
-No order to cleanse the coccyx with wound care solution, cover with calcium alginate and dry dressing.
Review of the resident's nurse's notes, dated 7/19/23 and 7/20/23, showed no documentation the staff notified the family of the pressure ulcers or notified the Wound Nurse of the physician's order for follow up.
Review of the resident's Shower Sheet/Skin Condition report dated 7/21/23, completed by the CNA, showed the following:
-7/21/23: Blank, no documentation regarding the pressure ulcer on the coccyx;
-Signed by CNA and Charge Nurse.
Review of the facility's Pressure Ulcer report, dated 7/23/23-7/29/23, showed the following:
-Facility acquired: Yes;
-Site: Right Buttock/Coccyx;
-Stage: Unstageable (full-thickness pressure injuries in which the base is obscured by slough (yellow or white tissue that adheres to the ulcer bed in strings or thick clumps, or is mucinous) may be present but does not obscure the depth of tissue loss. May include undermining and tunneling (passageways underneath the surface of the skin)) and/or eschar (hard, black dead skin);
-Size: 4.6 cm by 4.8 cm;
-Depth: 2 cm;
-Odor: No;
-Drainage: Yes;
-Treatment: Santyl (ointment is used to remove damaged tissue from chronic skin ulcers)/Bactroban (topical antibiotic) apply calcium alginate and cover with foam dressing;
-Notes: Refer to wound company.
Review of the resident's nurses' notes, showed the following:
-7/23/23 at 9:13 P.M.: Consent from resident for outside wound care company and hospice. Family notified;
-7/24/23 at 10:44 A.M.: Skin/Wound Note completed by the wound nurse showed the following: Notified by CNA of pressure ulcer to the resident's coccyx. Assessment showed an unstageable pressure ulcer to the coccyx which measured 4.6 cm by 4.8 cm by 2 cm depth. Moderate amount of purulent drainage with malodor (strong odor). Wound bed has 51-75% of slough and 1 to 25% eschar with no granulation (new healing tissue) present. Periwound (skin surrounding the wound) was friable (bleeds with very gentle touch). Treatment orders in place. Resident referred to Wound Care Company. Call placed to the resident's physician, awaiting call back;
7/24/23 at 11:46 A.M.: Weekly Skin Observation: Skin issues present. Unstageable pressure ulcer to the coccyx;
-No documentation the resident's physician returned call on 7/24 or 7/25/23.
Review of the resident's Shower Sheet/Skin Condition report dated 7/25/23 at 11:46 A.M., completed by the CNA, showed the following:
-Marked with a check mark: Change in color (red, bluish, pale, gray) and open area;
-Anatomical drawing: A circle drawn on buttocks;
-Signed by the CNA and Charge Nurse.
Review of the resident's nurses' notes, showed the following:
-7/25/23 at 7:00 P.M.: Weekly Skin Observation: Skin issues present;
-7/26/23 at 1:10 P.M.: Wound nurse spoke with resident's physician regarding possible soft tissue infection to coccyx pressure ulcer. New order received for Doxycycline (antibiotic used to treat infections) 100 milligrams (mg) twice a day for 10 days. First dose pulled from the emergency kit and administered. DON notified;
-No further documentation regarding the coccyx pressure ulcer until 7/31/23.
Review of the resident's 7/2023 POS, provided by the facility during the onsite on 9/21/23, showed no documentation regarding the order for Doxycycline 100 mg twice a day.
Review of the resident's 7/2023 Medication Administration Record (MAR), showed the following:
-Doxycycline 100 mg by mouth two times per day for ten days;
-Staff documented as administered twice a day on 7/26/23 through 7/31/23.
Review of the resident's 7/2023 TAR, showed the following:
-7/26/23: Mupirocin (Bactroban) ointment 2% mix with Santyl, and apply nickel thick to the wound bed up to the periwound edges;
-Staff documented as complete on 7/26 through 7/31/23.
Review of the resident's 7/2023 POS, showed no order for Mupirocin Ointment 2% mix with Santyl, apply nickel thick to the wound bed up to the periwound edges.
Review of the resident's Shower Sheet/Skin Condition report dated 7/28/23 at 10:15 A.M., completed by the CNA, showed the following:
-Marked with a check mark: Shower and skin check;
-Anatomical drawing: a circle drawn on the buttocks;
-Signed by the CNA and Charge Nurse.
Review of the resident's Wound Care Company progress notes, dated 7/31/23, showed the following:
-Chief Complaint: Seen for evaluation and management of wounds;
-Note: Doxycycline 100 mg by mouth twice a day for ten days started on 7/26/23 through 8/5/23;
-Sacrum and coccyx x-ray's negative for osteomyelitis (inflammation of the bone caused by infection);
-Discussed the importance of repositioning, off loading and keeping wounds clean and dry;
-Stage IV (Full thickness tissue loss with exposed bone, tendon or muscle. Slough or eschar may be present on some or parts of the wound bed. Often includes undermining and tunneling) pressure ulcer positive for bacteria;
-Coccyx debrided (removal of dead, damaged, or infected tissue);
-Recommend medicating resident with pain medication prior to visit to make resident more comfortable;
-Wound assessment: Coccyx was an acute Stage IV unhealed pressure injury pressure ulcer. Pressure ulcer measurements post debridement: 9.5 cm by 7 cm by 2 cm depth, bone exposed. Moderate amount of sero-sanguinous drainage which has a strong odor. Undermining (erosion under the wound edge margins which results in more extensive damage under the skin). Pain level of a five out of 10. Wound bed: 26-50% granulation, 26-50% slough and 1-25% epithelialization, no eschar;
-Wound orders: Cleanse pressure ulcer with soap and water, pat dry, protect peri-wound with skin protectant (Skin Prep: solution used before applying wound dressing. provides a protective barrier) and apply Santyl and Bactroban nickel thick to entire wound bed daily.
Review of the resident's nurse's notes, showed the following:
-7/31/23 at 12:58 P.M.: Skin/Wound Note completed by the Wound Nurse;
-Rounds with Wound Company;
-Stage IV pressure ulcer to coccyx, measured 9.5 cm by 7 cm by 2 cm depth;
-Moderate amount of serous sanguineous drainage (bright red blood and clear yellow liquid) with strong malodor noted;
-Wound bed had 26-50% granulation, 26-50% slough and 1-25% epithelialization (a process of covering wound), no eschar;
-Periwound was friable, scarred and moist with red skin tone and signs and symptoms of infection;
-Treatment orders in place;
-Resident advised of progress and expressed understanding.
Review of the resident's Significant Change Minimum Data Set (MDS), a federally mandated assessment instrument completed by facility staff , dated 8/1/23, showed the following:
-Diagnoses of malnutrition, arthritis and anemia (a problem of not having enough healthy red blood cells or hemoglobin to carry oxygen to the body's tissues);
-Short/Long term memory loss;
-Extensive staff assistance for bed mobility, transfers, dressing, eating and personal hygiene;
-Total staff assistance for toilet use and bathing;
-Risk for pressure ulcers: Yes;
-Unhealed pressure ulcers: No;
-Current number of unhealed pressure ulcers: None.
Review of the resident's nurses' notes, showed the following:
-8/1/23 at 1:13 P.M.: Weekly skin observation. No skin issues present. No new skin issues. Refer to full assessment for more information;
-8/1/23 at 5:29 P.M.: Nutrition/Dietary note: Very poor oral intake. Significant weight loss in last 30 days. New Unstageable pressure ulcer to coccyx with drainage and odor. Multiple nutrition interventions in place to support weight and skin integrity;
-8/1/23 at 7:00 P.M.: New order for Morphine Sulfate (an opioid indicated for the management of pain not responsive to non-narcotic pain medication) oral solution: 20 mg/5 ml as needed for pain;
-8/2/23 at 5:48 P.M.: New order for Levofloxacin (antibiotic) 750 mg by mouth once a day for soft tissue infection for seven days;
-8/6/23 at 9:26 A.M.: Resident remained on hospice care. Nonverbal indicators of pain when turned and positioned and during wound care, as needed pain medication administered.
Review of the facility's Pressure Ulcer Report, dated 8/6/23-8/12/23, showed the following:
-Facility acquired: Yes;
-Site: Right Buttock/Coccyx;
-Stage: Unstageable;
-Size: 4.6 cm by 4.8 cm;
-Depth: 2 cm;
-Odor: No;
-Drainage: Yes;
-Treatment: Santyl/Bactroban apply calcium alginate and cover with foam dressing;
-Notes: Refer to wound company.
Review of the resident's Wound Care Company progress notes, dated 8/07/23, showed the following:
-Chief Complaint: Seen for evaluation and management of wounds;
-Notes: Wounds debrided. Discussed the importance of repositioning, off loading and keeping wounds clean and dry. DON updated on plan of care;
-Wound assessment: Measurements: 9.5 cm by 7 cm by 2 cm depth, bone and adipose tissue (connective tissue that extends throughout the body) exposed;
-Moderate amount of sero-sanguinous drainage which had a strong odor;
-Undermining noted at 12:00;
-Pain level of a five out of 10;
-Wound bed: 26-50% granulation, 26-50% slough and 1-25% epithelialization, no eschar;
-Quality of tissue deteriorated compared to the conclusion of previous visit;
-Wound orders: Cleanse pressure ulcer with soap and water, pat dry, protect peri-wound with skin protectant and apply Santyl and Bactroban nickel thick to entire wound bed daily.
Review of the resident's care plan, dated 8/10/23, showed the following:
-Problem: Resident had ADL (activities of daily living) self-care performance deficit due to weakness, decreased cognition and disease process;
-Intervention: Bathing/Shower assist of staff. Personal hygiene per staff. Skin inspection to observe redness, open area, scratches, cuts, bruises and report to the nurse;
-Problem: Resident had the potential/actual impairment to skin integrity;
-Intervention: Educate resident, family and caregivers of causative factors and measures to prevent skin injury. Encourage good nutrition and hydration in order to promote healthier skin. Follow facility protocols for treatment of injury. Use a draw sheet or lifting device to move resident. Use caution during transfers and bed mobility to prevent injury to arms, legs and hands against any sharp or hard surface.
Review of the resident's Wound Care Company progress notes, dated 8/14/23, showed the following:
-Chief Complaint: Seen for evaluation and management of wounds;
-Notes: Coccyx negative for bacteria. Wound debrided. Discussed the importance of repositioning, off loading and keeping wounds clean and dry.;
-Wound assessment: Measurements: 7.5 cm by 8 cm by 3 cm depth, bone and adipose tissue exposed. Moderate amount of sero-sanguineous drainage which has a strong odor. Undermining noted at 12:00. Pain level of a five out of 10;
-Wound bed: 51% bright red granulation (new connective tissue), 1-25% slough and 1-25% epithelialization, no eschar;
-Quality of tissue improved in comparison to previous visit;
-Wound orders: Cleanse pressure ulcer with saline, pat dry, protect peri-wound (area surrounding wound) with skin protectant, and apply Santyl nickel thick to entire wound bed, apply calcium alginate and cover with sacral silicone dressing (specialized wound dressing) daily. Discontinue Bactroban ointment.
Observation of a skin assessment on 9/12/23 at 10:58 A.M., showed the resident lay in bed on a low air loss mattress. CNA W removed the resident's covers and soiled incontinence brief. CNA W and ADON E turned the resident to the right side, revealing a dressing to the coccyx dated 9/12/23. After personal care was provided, ADON E removed the dressing which revealed a large pressure ulcer. The wound bed was red in color with no odor. The pressure ulcer measured 8.5 cm by 8.9 cm. ADON E cleaned the pressure ulcer with wound cleaner, applied Skin Prep to periwound area, Santyl and calcium alginate to the wound bed and covered with a dry dressing.
During an interview on 9/18/23 at 4:23 P.M., CNA S said he/she worked the evening shift and had taken care of the resident. He/She said CNA X found the pressure ulcer a few months ago when it began as a reddened spot. He/She reported it to the charge nurse and was instructed to apply a thick white cream. The reddened area began to get worse and changed to a sore. He/She continued to apply the cream to the sore because he/she hoped the sore would get better.
During an interview on 9/15/23 at 9:30 A.M., CNA F said he/she worked on the day shift and had taken care of the resident. The first time he/she saw the resident's pressure ulcer was approximately a week ago. He/she helped to position the resident while the nurse changed the dressing. The pressure ulcer was like a large circle at the time. He/She doesn't remember when the pressure ulcer started or what it looked like. When he/she found an open area to a resident's skin he/she reported it to the nurse.
During an interview on 9/18/23 at 4:14 P.M., Nurse R said he/she worked the night shift and had taken care of the resident. The resident required total care from the staff. He/She didn't recall whether he/she worked the night the pressure ulcer was found. He/She completed skin assessments as scheduled on the night shift. Staff for the most part would report changes in the residents' skin. Some of the staff wouldn't report changes and they had to be reminded to do so. He/She had staff who he/she trusted to report changes. Occasionally he/she would ask staff whom he/she trusts, about the resident's skin after they had completed their rounds and documented this on the resident's skin assessment. He/She didn't do that all the time, only when certain staff members worked. He/She didn't recall staff reporting any problems with the resident's skin and didn't recall when the pressure ulcer developed on the resident's coccyx.
During an interview on 9/19/23 at 1:10 P.M., Nurse T said he/she worked on the evening shift and had taken care of the resident. Staff reported the pressure ulcer to the resident's coccyx. He/She recalled the pressure ulcer had slough and blacked areas. After he/she assessed the wound he/she called the physician for a treatment order. He/She reported the information to the ADON, who said he/she would notify the Wound Nurse and family the next day. The facility had assigned shifts for skin assessments to be completed. When staff found an open area they were to report it to the nurse. The nurse was to assess the area, notify the physician for a treatment order and notify the ADON and Wound Nurse. He/she didn't know why the 7/18/23 treatment order wasn't on the TAR.
During an interview on 9/14/23 at 10:24 A.M., Nurse Q said he/she worked the day shift and had taken care of the resident. He/She didn't remember when the resident developed the pressure ulcer. The facility had a Wound Nurse who did the treatments daily. The prior Wound Nurse wanted the nurse to call the physician for an order for the resident to be seen by the Wound Nurse. Once the order was obtained the Wound nurse would assess the wound and call the physician for a treatment order. The current policy was when a wound was found, the nurse assessed the wound, called the physician for treatment orders and notified the Wound Nurse of the new order. They were to also notify the ADON. The Wound Nurse did the treatments daily. The nurse would do the treatment on the days when the Wound Nurse wasn't working or if the dressing became soiled.
During an interview on 9/14/23 at 12:38 P.M., ADON E said he/she was unaware the treatment order for calcium alginate and dry dressing, dated 7/18/23, was not on the TAR. He/She expected staff to report any changes in the resident's skin. The nurse should assess the area, call the physician for an order and notify the ADON and the Wound Nurse.
During an interview on 9/14/23 at 12:38 P.M., the DON said she was not aware the resident's treatment for calcium alginate and dry dressing ordered 7/18/23, was not on the TAR. She would have expected the nurse to make sure the order was on the TAR. She said a treatment order was obtained on 7/24/23 for a change in the resident's pressure ulcer but wasn't started until 7/26/23. Mistakes were made by the former Wound Nurse who no longer worked at the facility.
During an interview on 9/14/23 at 1:19 P.M., the Regional Nurse Consultant said, the nurse failed to push the correct tab in the computer when transcribing the 7/18/23 order for the calcium alginate and dry dressing. That error caused the treatment order not to be on the TAR. The resident received a treatment of zinc oxide to his/her buttocks during the time of the order. She was unable to show the resident received the treatment that was ordered by the physician. In addition she said staff called the physician on 7/24/23 and obtained a new treatment order. No response was received as to why the treatment was not started until 7/26/23.
2. Review of Resident #22's annual MDS, dated [DATE], showed:
-Adequate hearing;
-Speech Clarity: Clear speech, distinct intelligible words;
-Makes Self Understood: Understood;
-Ability to Understand Others: Understands, clear comprehension;
-Extensive assistance of one person required for bed mobility, transfers, walking in room/corridor, dressing, toilet use, personal hygiene and bathing;
-Always incontinent of bowel and bladder;
-Diagnoses of malnutrition or at risk of malnutrition, anxiety and depression;
-At risk of developing pressure ulcers?: Yes;
-Unhealed pressure ulcers?: No.
Review of the resident's care plan, showed:
Focus:
-11/11/22: Focus: Resident had an activity of daily living self-care performance deficit related to spinal stenosis (the space inside the backbone is too small placing pressure on the spinal cord and nerves). Intervention: Extensive assistance required for bathing/showering, bed mobility, dressing, personal hygiene, toilet use and transfers;
-1/2/23: Focus: Resident was incontinent of bowel and bladder. Intervention: Keep skin clean and dry. Use lotion on dry skin;
-1/2/23: Focus: Resident had a nutritional problem or potential nutritional problem and had a diagnosis of malnutrition with interventions in place. Intervention: Provide, serve diet as ordered;
-8/30/23: Focus: Resident had actual skin impairment to skin integrity. Stage III pressure injury (Full thickness tissue loss. Subcutaneous fat may be visible but bone, tendon or muscle is not exposed. Slough may be present but does not obscure the depth of tissue loss. May include undermining and tunneling (passageways underneath the surface of the skin)) to right hip. Interventions: Monitor/document location, size and treatment of skin injury. Report abnormalities. Failure to heal, signs and symptoms of infection to physician. Clean perineal area (buttocks/genitalia) with each incontinence episode.
Review of the POS, showed:
-An order dated 12/16/22: Weekly skin assessment every evening shift every Monday;
-An order dated 8/25/23: Wound Care Company to evaluation and treat;
-No dressing order to the right hip from 8/15/23 through 8/22/23, per Nurse P's progress note dated 8/15/23 at 6:11 P.M.;
-An order dated 9/8/23: Right Posterior Hip: Apply collagen powder (a protein used to heal wounds) to wound bed. Apply Hydrogel (promotes a moist healing environment in wounds) on top of powder on wound bed. Cover with silicone bordered foam (provides gentle adhesion, highly breathable absorbent film) daily and as necessary;
-An order dated 9/18/23: Right Posterior Hip: Apply collagen powder to wound bed. Apply Hydrogen on top of powder on wound bed. Apply calcium alginate to wound base. Cover with silicone bordered foam daily and as necessary;
-An order dated: 9/14/23, Coccyx: Apply collagen powder to wound bed. Apply hydrogel on top of powder on wound bed. Cover with silicone bordered foam daily and as necessary. Every day shift.
Review of the resident's assessment tab on 9/13/23, and located in the electronic heath care record, showed no Braden Scale (an assessment used to determine a resident's probability of developing a pressure injury) on file.
Review of the facility's weekly Pressure Injury Report, dated 8/6/23 through 8/12/23, showed no documentation regarding the resident.
Review of the resident's Weekly Skin Observation form, dated 8/7/23 at 10:34 P.M., showed:
-Observations:
-Skin Color: Normal;
-Skin Temperatures: Dry;
-Skin Turgor (refers to the elasticity or firmness of the skin): Normal;
-Skin Issues: No.
Review of the resident's Shower Sheet/Skin Condition report, dated 8/9/23, showed:
-Shower and skin check, normal, dry skin (scalp);
-No documentation about a pressure injury to the right hip/trochanter.
Review of the resident's progress notes, showed:
-8/14/23 at 7:51 A.M., completed by Nurse P: Upon skin assessment, noticed a quarter size open area to the resident's right hip area. Unit manager made aware of new open area. This nurse cleaned area and applied a dry dressing;
-8/14/23 at 8:03 P.M., completed by Nurse P: Call out to physician to make aware of new open area found on the right hip. Message left awaiting call back for orders.
Review of the residents Weekly Skin Observation form, dated 8/14/23 at 7:49 P.M., and completed by Nurse P, showed:
Observations:
-Skin Color: Normal;
-Skin Temperatures: Dry;
-Skin Turgor: Normal;
-Skin Issues: Yes;
-Site: Right trochanter/hip, quarter sized open area;
-Notes: Area cleaned and placed dry dressing.
Review of the facility's weekly Pressure Injury Report, dated 8/13/23 through 8/19/23, showed:
-Facility Acquired: Yes;
-Right posterior hip/trochanter;
-Stage II pressure injury (Partial thickness loss of dermis (skin) presenting as a shallow open ulcer with a red or pink wound bed, without slough. May also present as an intact or open/ruptured blister.);
-Measurement: 3.0 cm by 2.0 cm by 0.2 cm;
-Drainage: No;
-Treatment: Calcium alginate with silicone border foam;
-No other pressure injuries noted.
Review of the resident's progress notes, showed:
-8/15/23 at 6:11 P.M., completed by Nurse P: Representative from physician's office returned call (from 8/14/23 at 8:03 P.M.) and said the physician said to put a dressing on the wound (right hip/trochanter). No specific order given. Wound Nurse made aware of wound on resident as well;
-There was no clarification documented about what type of dressing/treatment or when and/or how often it should be appli
CONCERN
(D)
📢 Someone Reported This
A family member, employee, or ombudsman was alarmed enough to file a formal complaint
Potential for Harm - no one hurt, but risky conditions existed
Deficiency F0687
(Tag F0687)
Could have caused harm · This affected 1 resident
See Event ID LTWZ12
Based on observation, interview and record review, the facility failed to ensure proper treatment and care to maintain good foot health for two of 6 sampled residents. The resident...
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See Event ID LTWZ12
Based on observation, interview and record review, the facility failed to ensure proper treatment and care to maintain good foot health for two of 6 sampled residents. The residents' feet were extremely dry with large areas of skin that flaked and peeled (Residents #21 and #22). The census was 133.
1. Review of Resident #21's significant change Minimum Data Set (MDS), a federally mandated assessment instrument completed by facility staff, dated 8/1/23, showed the following:
-Short/Long term memory loss;
-Required extensive staff assistance for bed mobility, transfers, dressing, eating and personal hygiene;
-Required total staff assistance for toilet use and bathing;
-Diagnoses of malnutrition, arthritis and anemia;
-No foot problems documented.
Review of the resident's care plan, dated 8/10/23, showed the following:
-Problem: Resident has activities of daily living (ADL) self-care performance deficit due to weakness, decreased cognition and disease process;
-Intervention: Bathing/Shower assist of staff. Personal hygiene per staff. Skin inspection to observe redness, open area, scratches, cuts, bruises and report to the nurse;
-Problem: Resident has the potential/actual impairment to skin integrity;
-Intervention: Educate resident, family and caregivers of causative factors and measures to prevent skin injury. Encourage good nutrition and hydration in order to promote healthier skin. Follow facility protocols for treatment of injury. Us a draw sheet or lifting device to move resident. Use caution during transfers and bed mobility to prevent injury to arms, legs and hands against any sharp or hard surface.
Observation on 9/12/23 at 10:58 A.M., showed the resident lay in bed on a low air loss mattress. After washing his/her hands and applying gloves, Certified Nurse Aide (CNA) W removed the resident's covers. On the mattress at the foot of the bed was a large amount of flaky dry skin. The resident's feet were very dry, with large areas of dry peeling skin. The Assistant Director of Nurses (ADON) E applied ointment to the resident's feet.
During an interview on 9/12/23 at 10:58 A.M., CNA W said he/she was not the resident's caregiver today and was assisting the ADON with the skin assessment. He/She said ointment should be applied during care.
During an interview on 9/15/23 at 9:30 A.M., CNA F said the resident has a history of dry flaky skin. He/She applied lotion to the resident's body and feet when he/she provides care.
2. Review of Resident #22's annual Minimum Data Set (MDS), a federally mandated assessment instrument completed by facility staff, dated 7/27/23, showed:
-Makes Self Understood: Understood;
-Ability to Understand Others: Understands - clear comprehension;
-Extensive assistance of one person required for dressing, toilet use, personal hygiene and bathing;
-Diagnoses of malnutrition or at risk of malnutrition, anxiety and depression.
Review of the resident's care plan, showed:
-Focus: 11/11/22: Resident has an activity of daily living self-care performance deficit related to spinal stenosis (the space inside the backbone is too small placing pressure on the spinal cord and nerves);
-Interventions: Extensive assistance required for bathing/showering, bed mobility, dressing, personal hygiene, toilet use and transfers; Keep skin clean and dry. Use lotion on dry skin.
Observation on 9/13/23 at 11:23 A.M., showed the resident lay in bed for a skin assessment. When CNA N removed the resident's socks, dry, flaky skin cells came off the resident's feet and out of his/her socks.
3. During an interview on 9/15/23 at 9:00 A.M., CNA O said if a resident's skin was dry and flaky, then the facility has plenty of lotion to use and it should be applied.
4. During an interview on 9/15/23 at 9:05 A.M., Nurse A said if a resident has dry, flaky skin, the skin should be washed and lotion should be applied.
5. During an interview on 9/15/23 at 11:45 A.M., ADON E said she expected staff to apply lotion or ointment to the resident's body and feet when providing care.
6. During an interview on 9/15/23 at 11:50 A.M., the Director of Nurses said she expected staff to apply lotion or ointment to the resident's body and feet. Staff should report to the Charge Nurse any concerns regarding resident's skin including flaky skin.
Jul 2023
3 deficiencies
1 IJ
CRITICAL
(J)
📢 Someone Reported This
A family member, employee, or ombudsman was alarmed enough to file a formal complaint
Immediate Jeopardy (IJ) - the most serious Medicare violation
Accident Prevention
(Tag F0689)
Someone could have died · This affected 1 resident
**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on interview and record review, the facility failed to provide protective oversight for one resident who resided on a secu...
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**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on interview and record review, the facility failed to provide protective oversight for one resident who resided on a secured unit and whose diagnoses included dementia, from elopement (Resident #1). The resident left the facility, without staff knowledge on 7/8/23 or 7/9/23. Emergency Medical Services (EMS) took the resident to an emergency room on 7/9/23, and he/she was released to his/her family member, who took the resident back to the facility. On 7/9/23, the facility assessed the resident as at high risk to wander. Insufficient measures were implemented to prevent another elopement. On 7/10/23, the resident again left the facility without staff knowledge. Staff and physician interviews showed the resident was at risk due to his/her physical and mental health status, combined with the current weather conditions. The census on the secured care unit (SCU) was 26. The sample was 6. The census was 134.
The administrator was informed on 7/14/23 of an Immediate Jeopardy (IJ), which began on 7/8/23. The IJ was removed on 7/18/23 as confirmed by surveyor on-site verification.
Review of the facility's wandering and elopement policy, revised 8/2020, showed:
-Policy: The facility will identify residents at risk for elopement and minimize any possible injury as a result of elopement;
-Procedure:
-1. The licensed nurse, in collaboration with the Interdisciplinary Team (IDT), will assess residents upon admission, readmission, quarterly, and upon identification of significant change in condition;
-2. The resident's risk for elopement and preventative interventions will be documented in the resident's medial record, and will be reviewed and re-evaluated by the IDT upon admission, readmission, quarterly, and upon identification of significant change in condition;
-3. IDT may consider interventions listed in elopement risk reduction approaches for residents identified to be at risk for elopement;
-4. Residents with a history of wandering or who IDT have assessed to be at risk for wandering or elopement will have a photograph maintained in their medical record and the elopement/wandering risk binder;
-5. Facility staff will reinforce proper procedures for leaving the facility for residents assessed to be at risk for elopement;
-6. If facility staff observes a resident leaving the premises without having followed proper procedures, he/she may:
-a. Try to prevent the departure in a courteous manner;
-b. Get help from other facility staff in the immediate vicinity, if necessary; and;
-c. Direct another facility staff member to inform the charge nurse or Director of Nursing (DON) that a resident is trying to leave the premises;
-7. Response to resident elopement:
-a. The facility staff member who finds that a resident is missing will alert facility staff;
-b. The charge nurse will call code pink and organize a search. Facility staff will search areas of the facility, including common areas, bathrooms, showers, outside areas, etcetera;
-c. If the resident cannot be located, the charge nurse will notify:
-1. Administrator/designee;
-2. DON/designee;
-3. Attending physician;
-4. Responsible party;
-5. Regional leadership of clinical and operations;
-6. Senior [NAME] President (VP) of operations;
-7. Senior VP of clinical;
-d. The Administrator/designee will contact law enforcement and provide them with the following information:
-1. The resident name, description (hair and eye color, complexion, weight, height, clothing, distinguishing marks, etcetera), addresses and telephone number of residents previous residence and family members;
-2. The resident's mental status and pertinent medical conditions;
-e. The Administrator/designee will continue to work with law enforcement and the responsible party until the resident is located;
-f. The licensed nurse most familiar with the incident will document in the resident's medical record how the elopement occurred;
-g. The facility will make necessary reports to state agencies;
-8. Return of the resident:
-a. When an individual who departed without following proper procedures returns to the facility, the DON or licensed nurse should:
-1. Examine the resident for any possible injuries;
-2. Notify the attending physician; and;
-3. Notify the resident's responsible party;
-b. The licensed nurse will initiate or update the resident's care plan and implement immediate interventions(s) to prevent further wandering/elopement by the resident;
-c. The IDT, with input from the licensed nurse, will conduct a thorough review of the elopement, document its findings in the IDT notes, and update the care plan to prevent a recurrence;
-d. The quality assessment and assurance committee will review all instances of elopement.
During an interview on 7/18/23 at 10:29 P.M., the Administrator said the facility did not have policies on the following:
-Continuity of care;
-Staff responding to door alarms in the facility;
-Increased monitoring for 1:1, 15 minute checks, or hourly checks.
Review of the Resident #1's annual MDS, dated [DATE], showed:
-Severe cognitive impairment;
-No moods or behaviors;
-Wandering behavior not exhibited;
-Resident stated it was very important to go outside to get fresh air when the weather is good;
-Required limited assistance with one person physical assist for bed mobility, dressing, toilet use, and personal hygiene;
-Required supervision with one person physical assist for transfer, locomotion on and off the unit;
-Not steady, but able to stabilize without human assistance with moving from seated to standing position, moving on and off toilet, and surface-to-surface transfer;
-No mobility devices used;
-No wandering or elopement alarm;
-Diagnoses of bradycardia (heart beats very slow), high blood pressure, diabetes mellitus, difficulty in walking, muscle weakness, other lack of coordination, need for assistance with personal care, hypokalemia (low levels of potassium in the blood), alcohol abuse, dementia, anxiety disorder, unspecified mood disorder and depression.
Review of the resident's care plan, in use during the survey, viewed on 7/12/23 at 9:13 A.M., showed:
-Focus: Resident is an elopement risk/wanderer related to dementia. Resident resides on memory unit, date initiated 4/28/22, revision on 4/28/22;
-Goal: Resident's safety will be maintained through the review date, date initiated 4/28/22, revision on 6/26/23, target date 10/8/23;
-Interventions:
-Distract the resident from wandering by offering pleasant diversions, structured activities, food, conversation, television, book, date initiated 10/4/22, revision on 11/1/22;
-Identify pattern of wandering: Is wandering purposeful, aimless, or escapist? Is the resident looking for something? Does it indicate the need for more exercise? Intervene as appropriate, date initiated 10/4/22, revision on 11/1/22;
-Monitor for fatigue and weight loss, date initiated 4/28/22;
-Provide structured activities: toileting, walking inside and outside, reorientation strategies including signs, pictures and memory boxes, date initiated 10/4/22;
-Focus: Resident has a behavior problem. Resident has been noted to be exit-seeking, verbally aggressive and resistant to care. Resident has dementia and resides on the memory unit. Resident will refuse skin assessments at times, date initiated 4/28/22, revision on 12/14/22;
-Goal: Resident will have fewer episodes of 3 times a week by date, date initiated 4/28/22, revision on 6/26/23, target date 10/8/23;
-Interventions:
-Administer medications as ordered. Monitor and document for side effects and effectiveness, date initiated 4/28/22;
-Anticipate and meet resident's needs, date initiated 4/28/22, revision on 11/1/22;
-Explain all procedures to resident before starting and allow the resident to adjust to changes, date initiated 6/13/22, revision on 11/1/22;
-Focus: Resident has impaired cognitive function/communication related to dementia, date initiated 4/28/22, revision on 4/17/23;
-Goal: The resident will maintain current level of cognitive function through the review date, date initiated 10/4/22, revision date on 6/26/23, target date 10/8/23;
-Interventions:
-Administer medications as ordered. Monitor and document for side effects and effectiveness, date initiated 5/2/22;
-Communicate with resident/family/caregivers regarding the resident's capabilities and needs, date initiated 10/4/22, revision on 11/1/22;
-Discuss concerns about confusion, disease process, nursing home placement with resident/family/caregivers, date initiated 10/4/22, revision on 11/1/22;
-Keep resident's routine consistent and try to provide consistent care givers as much as possible in order to decrease confusion, date initiated 10/4/22, revision on 11/1/22;
-Monitor/document/report as needed (PRN) any changes in cognitive function, date initiated 10/4/22.
During an interview on 7/17/23 at 1:21 P.M., Certified Nurse Aide (CNA) E said he/she worked on Saturday 7/8/23 and the resident was upset when he/she left that day because he/she could not get out of the SCU. CNA E said he/she was sitting next to the front door on the SCU to make sure the resident couldn't get out. CNA E had to tell the resident the door was locked. On Saturday, the resident was saying that he/she needed to get to work. CNA E left the facility around 2:50 P.M. and he/she made sure to check the front door to the SCU locked all the way. CNA E said it was like the magnets on the door were not sticking. At different times, CNA E noticed the door would not lock and it appeared the magnet was not sticking so it would take a while for the door to latch. The problem with the door was reported to the Maintenance Assistant on Friday, 7/7/23. CNA E reported the door was not latching properly and informed the Maintenance Assistant the door was not locking at times. The Maintenance Assistant told CNA E that someone was coming to look at the door. He did not say when or who was coming to look at the door.
Review of Fire Department EMS patient care record, dated 7/9/23 at 8:36 A.M., showed the following:
-EMS was alerted by the Police Department (PD) at 8:10 A.M. EMS arrived on the scene at 8:28 AM.;
-The resident was found inside of a store looking for his/her wallet;
-The resident was confused;
-The resident was transported to the hospital;
-The family member was called and alerted to the resident's location;
-The family member stated the resident should have been at the facility.
Review of hospital records, dated 7/9/23, showed the following:
-At 8:50 A.M., the resident was admitted to the hospital emergency department (ED);
-At 9:03 A.M., mental status was altered and he/she had a guardian. An elopement band (used to activate an alarm at exit doors and elevators) was placed on the resident due to the risk of elopement;
-At 10:30 A.M., the attending physician assessed the resident. EMS stated the resident had escaped from the facility. The resident's guardian was on the way to pick the resident up from the ED and return the resident to the facility. The resident knew he/she was in the hospital and stated the year was 2018;
-At 10:30 A.M., the resident was discharged from the ED in to the care of his/her guardian. The resident was transported via private car back to the facility;
-The discharge diagnosis included dementia and delirium. The clinical impression was wandering associated with a mental disorder.
During an interview on 7/12/23 at 9:57 A.M., Durable Power or Attorney (DPOA) A said the resident was found at a grocery store located 3.2 miles away from the facility on Sunday morning 7/9/23, by the fire department and was brought to the hospital. The hospital called DPOA B and informed DPOA B the resident was at the hospital. DPOA B went to the hospital and picked up the resident and brought the resident back to the facility on 7/9/23. DPOA A said the facility was not aware the resident was not at the facility and was unsure if the resident got out of the facility on Saturday 7/8/23 or Sunday 7/9/23. DPOA A said the facility did not notify either DPOA A or B the resident was missing on Saturday or Sunday.
During an interview on 7/14/23 at 7:47 A.M., DPOA B said he/she received a phone call from the fire department the morning of 7/9/23, informing DPOA B the resident was found at a grocery store. DPOA B asked the fire department what the resident was doing at the grocery store that is located 3.2 miles away from the facility the resident resides in. The facility did not call and notify him/her that the resident was missing from the facility. The fire department said they were going to have the resident taken to a hospital to be checked out and gave DPOA B the name of the hospital. DPOA B arrived at the hospital and the resident told DPOA B that he/she got out of the door and it was tricky. DPOA B said the hospital examined the resident and said he/she looked fine and the DPOA B drove the resident back to the facility. After arriving to the facility around 11:30 A.M. to 12:00 P.M. the DPOA B told the receptionist that he/she was there bringing back the resident because he/she had got out of the facility and told the receptionist he/she needed to speak with someone. Three staff members came to speak to DPOA B and the resident. DPOA B does not remember the staff member's name but one of them was a nurse. The staff said they did not know when or how the resident got out of the facility. They did not know if the resident got out of the facility in the middle of the night on 7/8/23, Saturday night or if the resident got out this morning. They asked the resident what time he/she left the facility and asked if the resident went out the front door of the facility. At the time they were asking the resident if he/she went out the front door of the facility, the resident was in the lobby reception area and could visualize the front door the staff were referring to. The resident told the staff that he/she went out a different door, not the front door but would not tell them which door he/she exited out of. The staff told the resident not to leave the facility again and told the resident if he/she wanted to go for a walk, just to let them know. The staff assured DPOA B the resident would not elope from the facility again. The three staff members brought DPOA B and the resident back to the SCU and the resident began to cry because he/she was upset that he/she worried DPOA B. DPOA B asked the resident to stop crying and told the resident that DPOA B was alright. The resident told DPOA B he/she was tired after his/her long walk. The staff assured DPOA B the resident would not elope again and DPOA B left the facility.
Review of the resident's EMR, showed:
- Wandering risk assessment, dated 7/9/23, showed, the resident score of 13 (high risk to wander).
- No documentation of the resident's elopement from the building on 7/9/23;
- No documentation of the resident returning to the facility on 7/9/23 or any interventions put into place after the elopement on 7/9/23.
Review of the resident's care plan in use during the survey, viewed on 7/12/23 at 9:13 A.M., showed no updates to the care plan after the resident eloped and was returned on 7/9/23.
Review of the facility's investigation of the elopement on 7/9/23, undated, showed the following:
-In a written statement, signed on 7/9/23, no time noted, CNA G said he/she worked on the resident's assigned hall on 7/8/23 during the 3:00 P.M. to 11:00 P.M. shift. The resident was acting a bit upset when CNA G arrived on his/her shift. Staff reported the resident was looking for his/her keys, saying he/she needed them to go to work. Dinner was served around 4:30 P.M. and the resident ate his/her dinner in his/her room. CNA G also worked the 11:00 P.M. to 7:00 A.M. shift, stating he/she was very busy and did not notice if the resident was gone when he/she went to help other residents to bed. CNA G also did not hear any alarms during his/her shifts;
-In a written statement, undated, CNA E said he/she arrived for his/her shift at 7:00 A.M. (no date was noted). CNA E made rounds of all the rooms and brought residents to the dining room. When he/she went to get the resident from his/her room, CNA E found the resident was not there. CNA E began checking every room for the resident and could not locate the resident;
-An undated interview with Receptionist H, showed the receptionist worked on 7/8/23 from 11:00 P.M. until 7:00 A.M. He/She said he/she only left the receptionist desk one time at approximately 12:00 or 12:15 A.M. Receptionist H said while he/she was away from the desk there was a CNA sitting on the couch. Receptionist H did not say he/she asked the CNA to watch the desk while he/she was away or if the CNA knew the receptionist left the desk unattended. Receptionist H said around 1:00 A.M., he/she called a fellow employee, told them the employee door was open by the time clock and asked the employee to shut the door. There was no information found in the interview of how long the receptionist was away from his/her desk, or how the receptionist knew the employee door by the time clock was open or if the door was ever closed by the other employee.
During an interview on 7/17/23 at 1:21 P.M., CNA E said he/she worked on 7/9/23, Sunday morning. CNA E brought residents to the dining room for breakfast and when he/she went to get the resident, the resident was not in his/her room. CNA E thought maybe the resident was in a different resident's bathroom. CNA E went to the dining room and asked the resident's roommate if he/she had seen the resident and the resident's roommate said he/she had not seen the resident all night. CNA I then called the Assistant Director of Nurses (ADON) to inform her the resident was missing. CNA E went through the whole building and there were no alarms going off in the facility. CNA E said he/she did not receive any report from the night shift, CNA G. CNA E said CNA G was headed out of the facility when CNA E was walking into the SCU. CNA E said CNA G was the only staff member working on the SCU on 7/8/23, Saturday night. When DPOA B brought the resident back to the facility on Sunday 7/9/23, CNA E asked the resident what happened and the resident said all he/she could remember was a person told him/her that he/she couldn't leave and before he/she knew it, he/she was gone. The resident said he/she was confused and the resident said he/she didn't know where he/she was at. CNA E said the resident was not placed on any special checks after the resident was returned from the elopement on 7/9/23.
During an interview on 7/14/23 at 6:31 A.M., CNA I said on Sunday morning 7/9/23, while passing breakfast trays, CNA E said he/she could not find the resident. CNA I said at that time, both CNAs searched the SCU and were unable to locate the resident. CNA I said no alarms were sounding at any time prior to CNA E noticing the resident was missing. CNA I said he/she contacted the ADON and the Staffing Coordinator to inform them they could not find the resident. CNA I said the resident disappeared sometime during the night shift on Saturday 7/8/23. CNA I said he/she did not get report from the previous shift on Sunday morning. CNA I said CNA G was the only staff member working on the SCU on Saturday night 7/8/23. CNA I said the resident's roommate said the resident was gone last night. CNA I said the resident was always making comments that he/she needs to get his/her keys and he/she has to go to the post office and get some stamps. The resident would also make comments about needing to go to work and that he/she is going to be late. The resident was always going to the front door and staff would tell the resident the door is closed. CNA I said there have been issues with the front door going onto the SCU unit. CNA I said sometimes it worked and sometimes it didn't. CNA I said they would say they fixed it but the door would sometimes not latch. CNA I said after entering the code, the light on the keypad turns green and then the red light comes on after about 10 seconds. CNA I said sometimes you could push on the door and it would open. CNA I said the door has been like that for a long time and everyone is aware of the door not latching, anyone can go and just push on it without entering the code and exit the SCU. CNA I said the ADON, DON, Administrator, Charge Nurses, Maintenance, Housekeeping, and Dietary all know about the door. You would think the door was locked and it wouldn't be locked. CNA I said Maintenance has worked on the door but it still was not latching.
During an interview on 7/13/23 at 8:23 A.M., the Maintenance Assistant said a while back there was a problem with the door going into the SCU, as it was not locking. They called the company that worked on the doors to come out and repair it. He/She was unsure when that occurred. The Maintenance Assistant said he/she was at the facility on Sunday 7/9/23 when the staff noticed the resident was missing. The Maintenance Assistant said he/she had to show the DON and other staff the door alarms were set and the alarms were working correctly in the facility. He/She also said the door to the SCU was working correctly, latching when shut and only able to open when entering the correct code.
During an interview on 7/13/23 at 9:13 A.M., the Maintenance Director said he/she was called to the facility on Sunday 7/9/23 because a resident had eloped. He/She was called in around 10:30 A.M., to make sure the doors were working properly. He/She clocked in at the facility at 11:00 A.M. on Sunday.
During an interview on 7/14/23 at 8:53 A.M., Certified Medication Technician (CMT) L said he/she gave the resident his/her medication on 7/9/23, Sunday afternoon around 1:30 P.M. after the resident returned from the elopement. CMT L said he/she left the SCU after passing medication on the SCU and went to a different hall to pass medication. CMT L said the resident was not on 1:1 monitoring on Sunday 7/9/23 or Monday 7/10/23. CMT L said the resident was moving around like normal on his/her own. CMT L said he/she has heard other staff talk about the door going onto the SCU and it would sometimes open without having to enter the code. CMT L said the light on the keypad will sometimes be green like someone has entered the code when nobody has entered the code and the door will open if you push on it.
During an interview on 7/13/23 at 11:04 A.M., the ADON said any resident with a score on the wandering risk assessment that shows a high risk to wander, has a history of exit seeking or wandering, has a BIMS of 8 or below, and has a medical diagnosis of dementia or Alzheimer's should be on the SCU. The ADON said all residents on the SCU are at risk for elopement. The ADON said he/she was very familiar with the resident. The resident has dementia and some days the resident will get up and say he/she is going to work. The resident knows his/her name and birthday. The resident would frequently pack his/her bag and wander in other residents' rooms. The ADON said interventions staff would use for the resident included if the resident was up and wandering, staff would redirect the resident and ask him/her if he/she needed to use the restroom or if he/she was looking for his/her room. The ADON said the minimum amount of time he/she expected staff to make rounds on the residents on the SCU should be every 30 to 45 minutes. The normal standard rounding time is every two hours but he/she expected the staff to round on the residents on the SCU every 30 to 45 minutes. The ADON expected more frequent rounding to be completed on the SCU because a lot of the residents wander and the staff need to ensure the residents have not wandered into another resident's room. Normal staffing for the SCU is two CNAs every shift, a Certified Medication Technician (CMT) or nurse who is dedicated only to the SCU every shift. There are three staff members assigned to the SCU at all times. The nurse or CMT who is scheduled on the SCU is not shared with any other halls. The ADON said the resident has not been able to get off the SCU unattended in the past at this facility. The ADON said if a resident gets off the SCU unattended in the building, staff should call a code pink, and a CNA or staff member should stand at the door of the SCU to make sure no other residents are getting out at that time. The other CNA will be checking the census against the residents on the SCU and the CMT/nurse calls the DON or Administrator to inform them of the code pink. A picture is brought to the nurse on the other floors to show the other staff what the resident looks like. The other staff on the other floors are checking the census on the halls and searching for the missing resident. The receptionist look to see what residents are currently out of the building, and the receptionist will be monitoring the front door to ensure nobody enters or exits during that time. If resident is not located, management that has reported to the building will begin to search outside the building and other management will start doing the investigation. The management inside the building working on investigation will be calling the resident family and the doctor to notify them of the missing resident. The other management will be searching outside the facility building. If the resident is not located outside the facility building part of the management team will expand the search past the facility grounds. The ADON expected documentation in a progress note if a resident is exit seeking and expected to be notified immediately. If a resident succeeded in exiting the SCU the ADON expected the nurse to make a progress note on what happened and that the responsible party and physician was notified. The ADON said the resident had eloped from a sister facility and had also eloped on 7/9/23. The ADON said she received a phone call from CNA I on Sunday 7/9/23 around 8:30 A.M. to 8:40 A.M. CNA I told the ADON that he/she could not locate the resident. The ADON instructed CNA I to call a code pink. The ADON arrive at the facility around 9:00 A.M. on 7/9/23 and the DON and the on call nurse were at the facility. When the ADON came upstairs from searching the basement around 11:00 A.M., DPOA B was at the facility with the resident in the front lobby. DPOA B said the resident was found at a grocery store located 3.2 miles away from the facility. The resident was attempting to purchase food and did not have any money. A firefighter was at the grocery store and notified EMS. When EMS arrived they took the resident to a hospital and the hospital notified DPOA B the resident was at the hospital. The physician was notified the resident was returned to the facility and the ADON requested to give the resident his/her morning medication that was missed because the resident was missing and the physician agreed to give the resident his/her morning medications at that time. The ADON said it was determined that the last time the resident was seen was on Saturday at 11:00 P.M. by CNA I. The ADON expected there to be a nursing progress note when a resident is returned after an elopement. The nursing progress note should include when the physician was notified, if the physician has any new orders, such as labs that would need to be drawn, what the resident is doing at that time and the condition of the resident. The nursing progress note should paint a picture of what happened from the charge nurse from the time the resident was noted missing, when the code pink was called, everything that took place including notifications, and when and how the resident returned to the facility. The ADON said she did not know why there were no nursing progress notes for the resident's elopement on 7/9/23. The ADON said after the resident returned on Sunday 7/9/23, the resident was placed on 1:1 monitoring. The ADON said CNA I provided the 1:1 monitoring on 7/9/23 from 11:00 A.M. until 3:00 P.M. Then CNA G came in and took over the 1:1 monitoring from 3:15 P.M. until 9:45 P.M. CNA J provided 1:1 monitoring from 11:30 P.M. until 6:15 A.M.
Review of the facility's Enhanced Supervision Monitoring Tool, dated 7/9/23, showed the following:
-The form had time slots in 15 minute intervals, starting at 6:30 A.M. and ending at 6:15 A.M., with two corresponding columns for documentation; one marked location/activity/behavior and the other for staff initials;
-The resident's name was listed on the form;
-Reason for monitoring was fi
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
Pressure Ulcer Prevention
(Tag F0686)
A resident was harmed · This affected 1 resident
**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY**
Based on observation, interview and record review, the facility failed to ensure residents received care consistent with profes...
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**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY**
Based on observation, interview and record review, the facility failed to ensure residents received care consistent with professional standards and followed their Wound Management-Nursing Care policy to identify, document, monitor, notify physicians and promptly initiate physician's orders to treat pressure injuries/ulcers (injury to the skin and underlying tissue caused by pressure or friction) for two of six residents sampled with actual pressure injuries and/or at risk of developing pressure injuries (Residents #21 and #22). The census was 133.
Review of the facility Wound Management-Nursing Care policy, last revised 06/2020, showed:
-Purpose: To provide a system for the treatment and management of residents with wounds including pressure and non-pressure injury;
-Policy: A resident who has a wound will receive necessary treatment and services to promote healing, prevent infection and prevent new pressure injuries from developing;
-Definitions: -Pressure Injury: Any lesion caused by unrelieved pressure that results in damage to the underlying tissue. Although friction and shear are not primary causes of pressure injury, friction and shear are important contributing factors to the development of pressure injuries. Pressure injuries usually occur over bony prominences and are graded or staged to classify the degree of tissue damage observed;
-Assessment: A licensed nurse will perform a skin assessment upon admission, readmission, weekly, and as needed for each resident;
-Upon identification of a new wound the licensed nurse will:
-Measure the wound (length, width, depth);
-Initiate a wound monitoring record sheet;
-Implement a wound treatment per physician's order;
-An assessment of care needs for pressure injury and wound management will be made with emphasis on, but not limited to:
-Identifying risk factors;
-Treatment;
-Mechanical offloading and pressure reducing devices;
-Reducing skin friction, sheer, and moisture;
-Nutritional status;
-Evaluating and modifying interventions for a resident with an existing pressure ulcer/pressure injury;
-Wound Management:
-The attending physician will be notified to advice on appropriate treatment promptly;
-The licensed nurse will notify the responsible party of the presence of a pressure injury
-A licensed nurse will develop a care plan for the resident based on recommendations from dietary, rehabilitation and the attending physician;
-Per attending physician order, the nursing staff will initiate treatment and utilize interventions for pressure redistribution and wound management;
-The attending physician and interdisciplinary team will be notified of:
-New pressure injuries or wounds;
-Pressure injuries or wounds that do not respond to treatment;
-Pressure injuries or wounds that worsen or increase in size;
-Complaints of increased pain;
-Signs of ulcer sepsis (infection in the bloodstream), presence of exudates (drainage), odor or necrosis (dead tissue) if not already noted by the attending physician;
-Documentation: New pressure injuries or wounds will be documented on the 24 hour log;
Wound documentation will occur at a minimum of weekly until the wound is healed;
-Documentation Will Include:
-Location of wound;
-Length, width, and depth measurements recorded in centimeters (cm);
-Direction and length of tunneling and undermining (if applicable);
-Appearance of the wound base;
-Drainage amount and characteristics including color, consistency, and odor;
-Appearance of wound edges;
-Description of the peri-wound (skin surrounding the wound) or evaluation of the skin adjacent to the wound;
-Presence of pain;
-Interdisciplinary team will document discussion and recommendations for:
-Pressure injuries and wounds that do not respond to treatment;
-Complaints of increased pain, discomfort or decrease in mobility by a resident;
-Signs of ulcer sepsis, presence of exudates, odor or necrosis;
-Residents refusing treatment;
-Licensed nurses will document effectiveness of current treatment in the resident's medical record on a weekly basis;
-Document notifications following a change in the resident's skin condition;
-Update the resident's care plan as necessary.
1. Review of Resident #21's facility admission Record, showed an admission date of 3/4/22.
Review of the resident's physician order sheet (POS), dated 7/2023, showed the following:
-Diagnoses of weakness, arthritis and difficulty walking;
-Weekly skin assessment every Monday on night shift;
-Apply zinc oxide ointment 10% (topical ointment used to treat or prevent minor skin irritations such as diaper rash) cleanse coccyx (tailbone) with soap and water, apply thin layer to coccyx every day and evening shift.
Review of the resident's treatment administration records (TAR), dated 7/2023, showed the following:
-Weekly skin assessment every Monday night;
-No skin assessment documentation for 7/10 and 7/31/23;
-Cleanse coccyx with soap and water, apply zinc oxide ointment twice a day;
-No documentation of administered treatment on 7/6/23.
Review of the facility's Pressure Injury report, dated 7/16/23 through 7/23/23, showed no documentation regarding the resident.
Review of the resident's Shower Sheet/Skin Condition report (a form completed by CNAs), showed the following:
-Directions: The sheet is to be completed by the Nurse's Assistant for each resident scheduled for a shower or whenever an abnormal area is observed. The sheets must be signed by the nursing assistant, the nurse and returned to the Director of Nursing (DON) or designee;
-Shower Sheet/Skin Condition report dated 7/18/23, showed no abnormal skin issues;
-All reports were signed by the certified nurse aides (CNA) and nurse.
Review of the resident's nurse's notes, showed the following:
-7/18/23 at 6:12 A.M.: Weekly skin observations, completed by the Charge Nurse, showed: skin color was normal, skin temperature was dry and warm, skin turgor normal. No skin issues present, no new skin concerns noted;
-7/18/23 at 9:35 P.M.: Called to room by CNA, noted two pressure ulcers to the coccyx. Measured: 3 cm by 3 cm and 1 cm by 1.5 cm. Areas were tan in color with some blackened area. Areas cleaned with wound cleaner and applied calcium alginate (a fibrous absorbent dressing) and dry dressing. The physician was notified, verified treatment order and gave order for Wound Nurse to follow up. Assistant Director of Nurses (ADON) was notified. He/she was to notify resident's family and the Wound Nurse in the morning.
Review of the resident's POS, dated 07/2023, showed an order dated 7/18/23, to clean pressure ulcer to coccyx with wound care solution (wound cleaner), cover with calcium alginate and dry dressing.
Review of the resident's TAR, dated 7/2023, showed the following:
-Weekly skin assessment every Monday night;
-No order to cleanse the coccyx with wound care solution, cover with calcium alginate and dry dressing.
Review of the resident's nurse's notes, dated 7/19/23 and 7/20/23, showed no documentation the staff notified the family of the pressure ulcers or notified the Wound Nurse of the physician's order for follow up.
Review of the resident's Shower Sheet/Skin Condition report dated 7/21/23, completed by the CNA, showed the following:
-7/21/23: Blank, no documentation regarding the pressure ulcer on the coccyx;
-Signed by CNA and Charge Nurse.
Review of the facility's Pressure Ulcer report, dated 7/23/23-7/29/23, showed the following:
-Facility acquired: Yes;
-Site: Right Buttock/Coccyx;
-Stage: Unstageable (full-thickness pressure injuries in which the base is obscured by slough (yellow or white tissue that adheres to the ulcer bed in strings or thick clumps, or is mucinous) may be present but does not obscure the depth of tissue loss. May include undermining and tunneling (passageways underneath the surface of the skin)) and/or eschar (hard, black dead skin);
-Size: 4.6 cm by 4.8 cm;
-Depth: 2 cm;
-Odor: No;
-Drainage: Yes;
-Treatment: Santyl (ointment is used to remove damaged tissue from chronic skin ulcers)/Bactroban (topical antibiotic) apply calcium alginate and cover with foam dressing;
-Notes: Refer to wound company.
Review of the resident's nurses' notes, showed the following:
-7/23/23 at 9:13 P.M.: Consent from resident for outside wound care company and hospice. Family notified;
-7/24/23 at 10:44 A.M.: Skin/Wound Note completed by the wound nurse showed the following: Notified by CNA of pressure ulcer to the resident's coccyx. Assessment showed an unstageable pressure ulcer to the coccyx which measured 4.6 cm by 4.8 cm by 2 cm depth. Moderate amount of purulent drainage with malodor (strong odor). Wound bed has 51-75% of slough and 1 to 25% eschar with no granulation (new healing tissue) present. Periwound (skin surrounding the wound) was friable (bleeds with very gentle touch). Treatment orders in place. Resident referred to Wound Care Company. Call placed to the resident's physician, awaiting call back;
7/24/23 at 11:46 A.M.: Weekly Skin Observation: Skin issues present. Unstageable pressure ulcer to the coccyx;
-No documentation the resident's physician returned call on 7/24 or 7/25/23.
Review of the resident's Shower Sheet/Skin Condition report dated 7/25/23 at 11:46 A.M., completed by the CNA, showed the following:
-Marked with a check mark: Change in color (red, bluish, pale, gray) and open area;
-Anatomical drawing: A circle drawn on buttocks;
-Signed by the CNA and Charge Nurse.
Review of the resident's nurses' notes, showed the following:
-7/25/23 at 7:00 P.M.: Weekly Skin Observation: Skin issues present;
-7/26/23 at 1:10 P.M.: Wound nurse spoke with resident's physician regarding possible soft tissue infection to coccyx pressure ulcer. New order received for Doxycycline (antibiotic used to treat infections) 100 milligrams (mg) twice a day for 10 days. First dose pulled from the emergency kit and administered. DON notified;
-No further documentation regarding the coccyx pressure ulcer until 7/31/23.
Review of the resident's 7/2023 POS, provided by the facility during the onsite on 9/21/23, showed no documentation regarding the order for Doxycycline 100 mg twice a day.
Review of the resident's 7/2023 Medication Administration Record (MAR), showed the following:
-Doxycycline 100 mg by mouth two times per day for ten days;
-Staff documented as administered twice a day on 7/26/23 through 7/31/23.
Review of the resident's 7/2023 TAR, showed the following:
-7/26/23: Mupirocin (Bactroban) ointment 2% mix with Santyl, and apply nickel thick to the wound bed up to the periwound edges;
-Staff documented as complete on 7/26 through 7/31/23.
Review of the resident's 7/2023 POS, showed no order for Mupirocin Ointment 2% mix with Santyl, apply nickel thick to the wound bed up to the periwound edges.
Review of the resident's Shower Sheet/Skin Condition report dated 7/28/23 at 10:15 A.M., completed by the CNA, showed the following:
-Marked with a check mark: Shower and skin check;
-Anatomical drawing: a circle drawn on the buttocks;
-Signed by the CNA and Charge Nurse.
Review of the resident's Wound Care Company progress notes, dated 7/31/23, showed the following:
-Chief Complaint: Seen for evaluation and management of wounds;
-Note: Doxycycline 100 mg by mouth twice a day for ten days started on 7/26/23 through 8/5/23;
-Sacrum and coccyx x-ray's negative for osteomyelitis (inflammation of the bone caused by infection);
-Discussed the importance of repositioning, off loading and keeping wounds clean and dry;
-Stage IV (Full thickness tissue loss with exposed bone, tendon or muscle. Slough or eschar may be present on some or parts of the wound bed. Often includes undermining and tunneling) pressure ulcer positive for bacteria;
-Coccyx debrided (removal of dead, damaged, or infected tissue);
-Recommend medicating resident with pain medication prior to visit to make resident more comfortable;
-Wound assessment: Coccyx was an acute Stage IV unhealed pressure injury pressure ulcer. Pressure ulcer measurements post debridement: 9.5 cm by 7 cm by 2 cm depth, bone exposed. Moderate amount of sero-sanguinous drainage which has a strong odor. Undermining (erosion under the wound edge margins which results in more extensive damage under the skin). Pain level of a five out of 10. Wound bed: 26-50% granulation, 26-50% slough and 1-25% epithelialization, no eschar;
-Wound orders: Cleanse pressure ulcer with soap and water, pat dry, protect peri-wound with skin protectant (Skin Prep: solution used before applying wound dressing. provides a protective barrier) and apply Santyl and Bactroban nickel thick to entire wound bed daily.
Review of the resident's nurse's notes, showed the following:
-7/31/23 at 12:58 P.M.: Skin/Wound Note completed by the Wound Nurse;
-Rounds with Wound Company;
-Stage IV pressure ulcer to coccyx, measured 9.5 cm by 7 cm by 2 cm depth;
-Moderate amount of serous sanguineous drainage (bright red blood and clear yellow liquid) with strong malodor noted;
-Wound bed had 26-50% granulation, 26-50% slough and 1-25% epithelialization (a process of covering wound), no eschar;
-Periwound was friable, scarred and moist with red skin tone and signs and symptoms of infection;
-Treatment orders in place;
-Resident advised of progress and expressed understanding.
Review of the resident's Significant Change Minimum Data Set (MDS), a federally mandated assessment instrument completed by facility staff , dated 8/1/23, showed the following:
-Diagnoses of malnutrition, arthritis and anemia (a problem of not having enough healthy red blood cells or hemoglobin to carry oxygen to the body's tissues);
-Short/Long term memory loss;
-Extensive staff assistance for bed mobility, transfers, dressing, eating and personal hygiene;
-Total staff assistance for toilet use and bathing;
-Risk for pressure ulcers: Yes;
-Unhealed pressure ulcers: No;
-Current number of unhealed pressure ulcers: None.
Review of the resident's nurses' notes, showed the following:
-8/1/23 at 1:13 P.M.: Weekly skin observation. No skin issues present. No new skin issues. Refer to full assessment for more information;
-8/1/23 at 5:29 P.M.: Nutrition/Dietary note: Very poor oral intake. Significant weight loss in last 30 days. New Unstageable pressure ulcer to coccyx with drainage and odor. Multiple nutrition interventions in place to support weight and skin integrity;
-8/1/23 at 7:00 P.M.: New order for Morphine Sulfate (an opioid indicated for the management of pain not responsive to non-narcotic pain medication) oral solution: 20 mg/5 ml as needed for pain;
-8/2/23 at 5:48 P.M.: New order for Levofloxacin (antibiotic) 750 mg by mouth once a day for soft tissue infection for seven days;
-8/6/23 at 9:26 A.M.: Resident remained on hospice care. Nonverbal indicators of pain when turned and positioned and during wound care, as needed pain medication administered.
Review of the facility's Pressure Ulcer Report, dated 8/6/23-8/12/23, showed the following:
-Facility acquired: Yes;
-Site: Right Buttock/Coccyx;
-Stage: Unstageable;
-Size: 4.6 cm by 4.8 cm;
-Depth: 2 cm;
-Odor: No;
-Drainage: Yes;
-Treatment: Santyl/Bactroban apply calcium alginate and cover with foam dressing;
-Notes: Refer to wound company.
Review of the resident's Wound Care Company progress notes, dated 8/07/23, showed the following:
-Chief Complaint: Seen for evaluation and management of wounds;
-Notes: Wounds debrided. Discussed the importance of repositioning, off loading and keeping wounds clean and dry. DON updated on plan of care;
-Wound assessment: Measurements: 9.5 cm by 7 cm by 2 cm depth, bone and adipose tissue (connective tissue that extends throughout the body) exposed;
-Moderate amount of sero-sanguinous drainage which had a strong odor;
-Undermining noted at 12:00;
-Pain level of a five out of 10;
-Wound bed: 26-50% granulation, 26-50% slough and 1-25% epithelialization, no eschar;
-Quality of tissue deteriorated compared to the conclusion of previous visit;
-Wound orders: Cleanse pressure ulcer with soap and water, pat dry, protect peri-wound with skin protectant and apply Santyl and Bactroban nickel thick to entire wound bed daily.
Review of the resident's care plan, dated 8/10/23, showed the following:
-Problem: Resident had ADL (activities of daily living) self-care performance deficit due to weakness, decreased cognition and disease process;
-Intervention: Bathing/Shower assist of staff. Personal hygiene per staff. Skin inspection to observe redness, open area, scratches, cuts, bruises and report to the nurse;
-Problem: Resident had the potential/actual impairment to skin integrity;
-Intervention: Educate resident, family and caregivers of causative factors and measures to prevent skin injury. Encourage good nutrition and hydration in order to promote healthier skin. Follow facility protocols for treatment of injury. Use a draw sheet or lifting device to move resident. Use caution during transfers and bed mobility to prevent injury to arms, legs and hands against any sharp or hard surface.
Review of the resident's Wound Care Company progress notes, dated 8/14/23, showed the following:
-Chief Complaint: Seen for evaluation and management of wounds;
-Notes: Coccyx negative for bacteria. Wound debrided. Discussed the importance of repositioning, off loading and keeping wounds clean and dry.;
-Wound assessment: Measurements: 7.5 cm by 8 cm by 3 cm depth, bone and adipose tissue exposed. Moderate amount of sero-sanguineous drainage which has a strong odor. Undermining noted at 12:00. Pain level of a five out of 10;
-Wound bed: 51% bright red granulation (new connective tissue), 1-25% slough and 1-25% epithelialization, no eschar;
-Quality of tissue improved in comparison to previous visit;
-Wound orders: Cleanse pressure ulcer with saline, pat dry, protect peri-wound (area surrounding wound) with skin protectant, and apply Santyl nickel thick to entire wound bed, apply calcium alginate and cover with sacral silicone dressing (specialized wound dressing) daily. Discontinue Bactroban ointment.
Observation of a skin assessment on 9/12/23 at 10:58 A.M., showed the resident lay in bed on a low air loss mattress. CNA W removed the resident's covers and soiled incontinence brief. CNA W and ADON E turned the resident to the right side, revealing a dressing to the coccyx dated 9/12/23. After personal care was provided, ADON E removed the dressing which revealed a large pressure ulcer. The wound bed was red in color with no odor. The pressure ulcer measured 8.5 cm by 8.9 cm. ADON E cleaned the pressure ulcer with wound cleaner, applied Skin Prep to periwound area, Santyl and calcium alginate to the wound bed and covered with a dry dressing.
During an interview on 9/18/23 at 4:23 P.M., CNA S said he/she worked the evening shift and had taken care of the resident. He/She said CNA X found the pressure ulcer a few months ago when it began as a reddened spot. He/She reported it to the charge nurse and was instructed to apply a thick white cream. The reddened area began to get worse and changed to a sore. He/She continued to apply the cream to the sore because he/she hoped the sore would get better.
During an interview on 9/15/23 at 9:30 A.M., CNA F said he/she worked on the day shift and had taken care of the resident. The first time he/she saw the resident's pressure ulcer was approximately a week ago. He/she helped to position the resident while the nurse changed the dressing. The pressure ulcer was like a large circle at the time. He/She doesn't remember when the pressure ulcer started or what it looked like. When he/she found an open area to a resident's skin he/she reported it to the nurse.
During an interview on 9/18/23 at 4:14 P.M., Nurse R said he/she worked the night shift and had taken care of the resident. The resident required total care from the staff. He/She didn't recall whether he/she worked the night the pressure ulcer was found. He/She completed skin assessments as scheduled on the night shift. Staff for the most part would report changes in the residents' skin. Some of the staff wouldn't report changes and they had to be reminded to do so. He/She had staff who he/she trusted to report changes. Occasionally he/she would ask staff whom he/she trusts, about the resident's skin after they had completed their rounds and documented this on the resident's skin assessment. He/She didn't do that all the time, only when certain staff members worked. He/She didn't recall staff reporting any problems with the resident's skin and didn't recall when the pressure ulcer developed on the resident's coccyx.
During an interview on 9/19/23 at 1:10 P.M., Nurse T said he/she worked on the evening shift and had taken care of the resident. Staff reported the pressure ulcer to the resident's coccyx. He/She recalled the pressure ulcer had slough and blacked areas. After he/she assessed the wound he/she called the physician for a treatment order. He/She reported the information to the ADON, who said he/she would notify the Wound Nurse and family the next day. The facility had assigned shifts for skin assessments to be completed. When staff found an open area they were to report it to the nurse. The nurse was to assess the area, notify the physician for a treatment order and notify the ADON and Wound Nurse. He/she didn't know why the 7/18/23 treatment order wasn't on the TAR.
During an interview on 9/14/23 at 10:24 A.M., Nurse Q said he/she worked the day shift and had taken care of the resident. He/She didn't remember when the resident developed the pressure ulcer. The facility had a Wound Nurse who did the treatments daily. The prior Wound Nurse wanted the nurse to call the physician for an order for the resident to be seen by the Wound Nurse. Once the order was obtained the Wound nurse would assess the wound and call the physician for a treatment order. The current policy was when a wound was found, the nurse assessed the wound, called the physician for treatment orders and notified the Wound Nurse of the new order. They were to also notify the ADON. The Wound Nurse did the treatments daily. The nurse would do the treatment on the days when the Wound Nurse wasn't working or if the dressing became soiled.
During an interview on 9/14/23 at 12:38 P.M., ADON E said he/she was unaware the treatment order for calcium alginate and dry dressing, dated 7/18/23, was not on the TAR. He/She expected staff to report any changes in the resident's skin. The nurse should assess the area, call the physician for an order and notify the ADON and the Wound Nurse.
During an interview on 9/14/23 at 12:38 P.M., the DON said she was not aware the resident's treatment for calcium alginate and dry dressing ordered 7/18/23, was not on the TAR. She would have expected the nurse to make sure the order was on the TAR. She said a treatment order was obtained on 7/24/23 for a change in the resident's pressure ulcer but wasn't started until 7/26/23. Mistakes were made by the former Wound Nurse who no longer worked at the facility.
During an interview on 9/14/23 at 1:19 P.M., the Regional Nurse Consultant said, the nurse failed to push the correct tab in the computer when transcribing the 7/18/23 order for the calcium alginate and dry dressing. That error caused the treatment order not to be on the TAR. The resident received a treatment of zinc oxide to his/her buttocks during the time of the order. She was unable to show the resident received the treatment that was ordered by the physician. In addition she said staff called the physician on 7/24/23 and obtained a new treatment order. No response was received as to why the treatment was not started until 7/26/23.
2. Review of Resident #22's annual MDS, dated [DATE], showed:
-Adequate hearing;
-Speech Clarity: Clear speech, distinct intelligible words;
-Makes Self Understood: Understood;
-Ability to Understand Others: Understands, clear comprehension;
-Extensive assistance of one person required for bed mobility, transfers, walking in room/corridor, dressing, toilet use, personal hygiene and bathing;
-Always incontinent of bowel and bladder;
-Diagnoses of malnutrition or at risk of malnutrition, anxiety and depression;
-At risk of developing pressure ulcers?: Yes;
-Unhealed pressure ulcers?: No.
Review of the resident's care plan, showed:
Focus:
-11/11/22: Focus: Resident had an activity of daily living self-care performance deficit related to spinal stenosis (the space inside the backbone is too small placing pressure on the spinal cord and nerves). Intervention: Extensive assistance required for bathing/showering, bed mobility, dressing, personal hygiene, toilet use and transfers;
-1/2/23: Focus: Resident was incontinent of bowel and bladder. Intervention: Keep skin clean and dry. Use lotion on dry skin;
-1/2/23: Focus: Resident had a nutritional problem or potential nutritional problem and had a diagnosis of malnutrition with interventions in place. Intervention: Provide, serve diet as ordered;
-8/30/23: Focus: Resident had actual skin impairment to skin integrity. Stage III pressure injury (Full thickness tissue loss. Subcutaneous fat may be visible but bone, tendon or muscle is not exposed. Slough may be present but does not obscure the depth of tissue loss. May include undermining and tunneling (passageways underneath the surface of the skin)) to right hip. Interventions: Monitor/document location, size and treatment of skin injury. Report abnormalities. Failure to heal, signs and symptoms of infection to physician. Clean perineal area (buttocks/genitalia) with each incontinence episode.
Review of the POS, showed:
-An order dated 12/16/22: Weekly skin assessment every evening shift every Monday;
-An order dated 8/25/23: Wound Care Company to evaluation and treat;
-No dressing order to the right hip from 8/15/23 through 8/22/23, per Nurse P's progress note dated 8/15/23 at 6:11 P.M.;
-An order dated 9/8/23: Right Posterior Hip: Apply collagen powder (a protein used to heal wounds) to wound bed. Apply Hydrogel (promotes a moist healing environment in wounds) on top of powder on wound bed. Cover with silicone bordered foam (provides gentle adhesion, highly breathable absorbent film) daily and as necessary;
-An order dated 9/18/23: Right Posterior Hip: Apply collagen powder to wound bed. Apply Hydrogen on top of powder on wound bed. Apply calcium alginate to wound base. Cover with silicone bordered foam daily and as necessary;
-An order dated: 9/14/23, Coccyx: Apply collagen powder to wound bed. Apply hydrogel on top of powder on wound bed. Cover with silicone bordered foam daily and as necessary. Every day shift.
Review of the resident's assessment tab on 9/13/23, and located in the electronic heath care record, showed no Braden Scale (an assessment used to determine a resident's probability of developing a pressure injury) on file.
Review of the facility's weekly Pressure Injury Report, dated 8/6/23 through 8/12/23, showed no documentation regarding the resident.
Review of the resident's Weekly Skin Observation form, dated 8/7/23 at 10:34 P.M., showed:
-Observations:
-Skin Color: Normal;
-Skin Temperatures: Dry;
-Skin Turgor (refers to the elasticity or firmness of the skin): Normal;
-Skin Issues: No.
Review of the resident's Shower Sheet/Skin Condition report, dated 8/9/23, showed:
-Shower and skin check, normal, dry skin (scalp);
-No documentation about a pressure injury to the right hip/trochanter.
Review of the resident's progress notes, showed:
-8/14/23 at 7:51 A.M., completed by Nurse P: Upon skin assessment, noticed a quarter size open area to the resident's right hip area. Unit manager made aware of new open area. This nurse cleaned area and applied a dry dressing;
-8/14/23 at 8:03 P.M., completed by Nurse P: Call out to physician to make aware of new open area found on the right hip. Message left awaiting call back for orders.
Review of the residents Weekly Skin Observation form, dated 8/14/23 at 7:49 P.M., and completed by Nurse P, showed:
Observations:
-Skin Color: Normal;
-Skin Temperatures: Dry;
-Skin Turgor: Normal;
-Skin Issues: Yes;
-Site: Right trochanter/hip, quarter sized open area;
-Notes: Area cleaned and placed dry dressing.
Review of the facility's weekly Pressure Injury Report, dated 8/13/23 through 8/19/23, showed:
-Facility Acquired: Yes;
-Right posterior hip/trochanter;
-Stage II pressure injury (Partial thickness loss of dermis (skin) presenting as a shallow open ulcer with a red or pink wound bed, without slough. May also present as an intact or open/ruptured blister.);
-Measurement: 3.0 cm by 2.0 cm by 0.2 cm;
-Drainage: No;
-Treatment: Calcium alginate with silicone border foam;
-No other pressure injuries noted.
Review of the resident's progress notes, showed:
-8/15/23 at 6:11 P.M., completed by Nurse P: Representative from physician's office returned call (from 8/14/23 at 8:03 P.M.) and said the physician said to put a dressing on the wound (right hip/trochanter). No specific order given. Wound Nurse made aware of wound on resident as well;
-There was no clarification documented about what type of dressing/treatment or when and/or how often it should be applied/changed;
CONCERN
(D)
📢 Someone Reported This
A family member, employee, or ombudsman was alarmed enough to file a formal complaint
Potential for Harm - no one hurt, but risky conditions existed
Deficiency F0687
(Tag F0687)
Could have caused harm · This affected 1 resident
Based on observation, interview and record review, the facility failed to ensure proper treatment and care to maintain good foot health for two of 6 sampled residents. The residents' feet were extreme...
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Based on observation, interview and record review, the facility failed to ensure proper treatment and care to maintain good foot health for two of 6 sampled residents. The residents' feet were extremely dry with large areas of skin that flaked and peeled (Residents #21 and #22). The census was 133.
1. Review of Resident #21's significant change Minimum Data Set (MDS), a federally mandated assessment instrument completed by facility staff, dated 8/1/23, showed the following:
-Short/Long term memory loss;
-Required extensive staff assistance for bed mobility, transfers, dressing, eating and personal hygiene;
-Required total staff assistance for toilet use and bathing;
-Diagnoses of malnutrition, arthritis and anemia;
-No foot problems documented.
Review of the resident's care plan, dated 8/10/23, showed the following:
-Problem: Resident has activities of daily living (ADL) self-care performance deficit due to weakness, decreased cognition and disease process;
-Intervention: Bathing/Shower assist of staff. Personal hygiene per staff. Skin inspection to observe redness, open area, scratches, cuts, bruises and report to the nurse;
-Problem: Resident has the potential/actual impairment to skin integrity;
-Intervention: Educate resident, family and caregivers of causative factors and measures to prevent skin injury. Encourage good nutrition and hydration in order to promote healthier skin. Follow facility protocols for treatment of injury. Us a draw sheet or lifting device to move resident. Use caution during transfers and bed mobility to prevent injury to arms, legs and hands against any sharp or hard surface.
Observation on 9/12/23 at 10:58 A.M., showed the resident lay in bed on a low air loss mattress. After washing his/her hands and applying gloves, Certified Nurse Aide (CNA) W removed the resident's covers. On the mattress at the foot of the bed was a large amount of flaky dry skin. The resident's feet were very dry, with large areas of dry peeling skin. The Assistant Director of Nurses (ADON) E applied ointment to the resident's feet.
During an interview on 9/12/23 at 10:58 A.M., CNA W said he/she was not the resident's caregiver today and was assisting the ADON with the skin assessment. He/She said ointment should be applied during care.
During an interview on 9/15/23 at 9:30 A.M., CNA F said the resident has a history of dry flaky skin. He/She applied lotion to the resident's body and feet when he/she provides care.
2. Review of Resident #22's annual Minimum Data Set (MDS), a federally mandated assessment instrument completed by facility staff, dated 7/27/23, showed:
-Makes Self Understood: Understood;
-Ability to Understand Others: Understands - clear comprehension;
-Extensive assistance of one person required for dressing, toilet use, personal hygiene and bathing;
-Diagnoses of malnutrition or at risk of malnutrition, anxiety and depression.
Review of the resident's care plan, showed:
-Focus: 11/11/22: Resident has an activity of daily living self-care performance deficit related to spinal stenosis (the space inside the backbone is too small placing pressure on the spinal cord and nerves);
-Interventions: Extensive assistance required for bathing/showering, bed mobility, dressing, personal hygiene, toilet use and transfers; Keep skin clean and dry. Use lotion on dry skin.
Observation on 9/13/23 at 11:23 A.M., showed the resident lay in bed for a skin assessment. When CNA N removed the resident's socks, dry, flaky skin cells came off the resident's feet and out of his/her socks.
3. During an interview on 9/15/23 at 9:00 A.M., CNA O said if a resident's skin was dry and flaky, then the facility has plenty of lotion to use and it should be applied.
4. During an interview on 9/15/23 at 9:05 A.M., Nurse A said if a resident has dry, flaky skin, the skin should be washed and lotion should be applied.
5. During an interview on 9/15/23 at 11:45 A.M., ADON E said she expected staff to apply lotion or ointment to the resident's body and feet when providing care.
6. During an interview on 9/15/23 at 11:50 A.M., the Director of Nurses said she expected staff to apply lotion or ointment to the resident's body and feet. Staff should report to the Charge Nurse any concerns regarding resident's skin including flaky skin.
May 2023
1 deficiency
CONCERN
(E)
📢 Someone Reported This
A family member, employee, or ombudsman was alarmed enough to file a formal complaint
Potential for Harm - no one hurt, but risky conditions existed
Deficiency F0919
(Tag F0919)
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 a functioning call light system with working a...
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**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, interview and record review, the facility failed to provide a functioning call light system with working audio and visual components to all 25 residents on the 100 South hall. The facility failed to provide alternative or assistive devices to dependent residents on the hall when it was determined the call light system was not working and needed repairs. The census was 141.
Review of the facility's Communication-Call System policy, revised on 10/24/22, showed:
i. The Facility will provide a call system to enable residents to alert the nursing staff from their beds and toileting/bathing facilities;
iii. Should the primary call system become inoperable for any reason, the facility shall provide a bell for each resident room. Additionally, resident safety check rounds shall be conducted at least hourly and documented until the primary call system is operable again;
vi. If call bell is defective, it will be reported immediately to maintenance and replaced immediately;
vii. Call bells located within resident bathrooms are considered emergency calls due to the potential for falls and injury and must be answered promptly;
viii. An adaptive call bell (e.g. flat pad call cord, hand bell, etc.) will be provided to a resident per the resident's needs.
1. Observation of the facility's first floor south residents' hall on 5/11/23 between 11:08 A.M. and 11:51 A.M., showed no resident call lights functioning. Staff had not provided an assistive device or alternate communication device to any of the residents to alert staff of the need for care.
2. Review of Resident #1's medical record, showed diagnoses included: Upper respiratory tract infection, gastrostomy (an opening into the stomach from the abdominal wall, made surgically for the introduction of food), morbid obesity, and osteoarthritis (a condition in which joint cartilage breaks down resulting in bone-on-bone contact and wear).
Review of the resident's quarterly Minimum Data Set (MDS), a federally mandated assessment instrument completed by facility staff, dated 2/16/23, showed:
-A BIMS (Brief Interview for Mental Status) score of 15 out of a possible 15, indicating cognitively intact decision making;
-One person assistance required for bed mobility;
-Extensive, two-person assistance required for transfers;
-Wheelchair used for locomotion;
-Extensive, one-person assistance required for locomotion on and off the unit;
-Extensive, one-person assistance required with dressing, toilet use and personal hygiene.
Review of the resident's care plan, in use at the time of survey, showed:
-The resident has an activities of daily living (ADL) care deficit related to his/her obesity. Interventions included: Extensive assistance during bathing or showering, extensive assistance with dressing, extensive assistance with toileting, extensive assistance with transfers, and extensive assistance with personal hygiene;
-The resident is at risk for falls while residing in the facility. Interventions included: Anticipating and meeting the resident's needs, ensure the resident is wearing appropriate footwear when out of bed, ensuring the resident's call light is in reach and encouraging the resident to use it when he/she needed staff assistance.
During an interview on 5/11/23 at 11:08 A.M. the resident said the call lights on the whole floor had been non-functioning since 5/6/23, and there had been no increase in nursing staff rounding until 5/11/23, when the survey team arrived onsite. On the evening of 5/10/23, the resident had trouble breathing due to a chronic respiratory issue, and needed staff assistance. As the resident's call light was not working, the resident was forced to call the facility's front desk and then be transferred to the floor's nurse's station in order to receive help. The resident said it took 20 to 30 minutes before an aide arrived to help. The resident was not given any alternative communication devices in lieu of the non-functioning call light system. The resident said he/she feels unsafe at the facility if his/her room does not have a functioning call light, as a medical emergency could happen with little to no warning and he/she would not be able to receive timely assessment and treatment.
Observation on 5/11/23 at 11:08 A.M., showed the resident pressed his/her call light. The call light did not light up at the resident's door and did not alarm audibly at the nurse's station.
3. Review of Resident #4's medical record showed diagnoses included: Chronic osteoarthritis, unspecified reduced mobility, chronic heart failure and obesity.
Review of the resident's quarterly MDS dated [DATE], showed:
-A BIMS score of 15, indicating cognitively intact decision making;
-Two-person assistance required with bed mobility;
-Extensive, two-person assist with transfers;
-Wheelchair use required for locomotion;
-Extensive, one-person assistance required with locomotion on and off the unit;
-Extensive, two-person assistance required with dressing;
-Extensive, one-person assistance required with toilet use and personal hygiene.
Review of the resident's care plan, in use at the time of survey, showed:
-The resident has an ADL care deficit related to his/her obesity and limited physical mobility. Interventions included: Extensive assistance during bathing or showering, extensive assistance with dressing, extensive assistance with toileting, extensive assistance with transfers, and extensive assistance with personal hygiene;
-The resident is at risk for falls while residing in the facility. Interventions included: Anticipating and meeting the resident's needs, ensure the resident is wearing appropriate footwear when out of bed, ensuring the resident's call light is in reach and encouraging the resident to use it when he/she needed staff assistance;
-The resident is incontinent of bowel and bladder. Interventions included directions for staff to check the resident for incontinence every two hours and as needed and monitor for signs and symptoms of a urinary tract infection (an infection that happens when bacteria enter the urethra and infect the urinary tract).
During an interview on 5/11/23 at 11:18 A.M., the resident said call lights for the entire resident floor had been out since 5/6/23, and he/she had seen no increase in nursing staff rounding since that time. The resident said he/she had gone from 5/7/23 at around 5:00 A.M. until 5/8/23 at 7:30 A.M. without being provided incontinence care when his/her call light was not functioning properly. The resident was not given any assistive or communication devices to alert staff of his/her care needs.
Observation on 5/11/23 at 11:18 A.M. showed the resident pressed his/her call light. The call light did not light up at the resident's door and did not alarm audibly at the nurse's station.
4. Review of Resident #6's medical record, showed:
-Diagnoses included spinal stenosis (a condition caused when the spaces in the spine narrow and create pressure on the spinal cord and nerves), end stage renal disease (a medical condition in which a person's kidneys cease functioning on a permanent basis leading to the need for a regular course of long-term dialysis or a kidney transplant to maintain life), and repeated falls.
Review of the resident's quarterly MDS, dated [DATE] showed:
-A BIMS score of 15, indicating cognitively intact decision making;
-One-person assistance required with bed mobility;
-Extensive, one-person assistance required with transfers;
-Wheelchair use required for locomotion;
-Extensive, one-person assistance required with locomotion on and off the unit;
-Extensive, one-person assistance required with dressing, toilet use and personal hygiene.
Review of the resident's care plan, in use at the time of survey, showed:
-The resident has an ADL care deficit and limited physical mobility. Interventions included: Extensive assistance during bathing or showering, extensive assistance with dressing, extensive assistance with toileting, extensive assistance with transfers, and extensive assistance with personal hygiene;
-The resident is at risk for falls while residing in the facility. Interventions included: Anticipating and meeting the resident's needs, ensure the resident is wearing appropriate footwear when out of bed, ensuring the resident's call light is in reach and encouraging the resident to use it when he/she needed staff assistance;
-The resident is incontinent of bowel and bladder. Interventions included directions for staff to check the resident for incontinence every two hours and as needed and to monitor for constipation.
During an interview on 5/11/23 at 11:29 A.M., the resident said his/her call light had been out since 5/6/23. At that time on 5/6/23, the resident reported the call light being out to staff, and the facility Maintenance Director came in to tell him/her a transformer had blown, impacting the power source of the call lights on the floor. The resident said he/she overheard the correct parts had not been delivered on Monday, 5/8/23, as expected, and the issue had not yet been fixed at the time of the interview. The resident was not given any assistive or communication devices to alert staff of his/her care needs.
Observation on 5/11/23 at 11:29 A.M., showed the resident pressed his/her call light. The call light did not light up at the resident's door and did not alarm audibly at the nurse's station.
5. Review of Resident #8's medical record, showed diagnoses included: Cerebral infarction (a condition caused by a blockage of oxygen to the brain), generalized muscle weakness, paralytic gait, occlusion (blockage) and stenosis (narrowing) of the bilateral carotid arteries (large arteries of the heart that pump blood to the vital organs), and repeated falls.
Review of the resident's quarterly MDS, dated [DATE], showed:
-A BIMS score of 13, indicating cognitively intact decision making;
-Two-person assistance required with bed mobility;
-Extensive, two-person assistance required with transfers;
-Wheelchair use required for locomotion;
-Extensive, two-person assistance required with locomotion on and off the unit;
-Extensive, two-person assistance required with dressing, toilet use and personal hygiene.
Review of the resident's care plan, in use at the time of survey, showed:
-The resident has an ADL care deficit and limited physical mobility. Interventions included: Extensive assistance during bathing or showering, extensive assistance with dressing, extensive assistance with toileting, extensive assistance with transfers, and extensive assistance with personal hygiene;
-The resident is at risk for falls while residing in the facility. Interventions included: Anticipating and meeting the resident's needs, ensure the resident is wearing appropriate footwear when out of bed, ensuring the resident's call light is in reach and encouraging the resident to use it when he/she needed staff assistance;
-The resident is incontinent of bowel and bladder. Interventions included directions for staff to check the resident for incontinence every two hours, and monitor for signs and symptoms of a urinary tract infection.
During an interview on 5/11/23 at 11:47 A.M., the resident said his/her call light had been out since the weekend (5/6-5/7/23), and he/she had only been getting his/her incontinence briefs changed once daily. The resident said he/she felt as if the facility didn't care about him/her, and became tearful and was unable to continue the interview. The resident was not given any assistive or communication devices to alert staff of his/her care needs.
Observation on 5/11/23 at 11:47 A.M. showed the resident pressed his/her call light. The call light did not light up at the resident's door and did not alarm audibly at the nurse's station.
6. During an interview on 5/11/23 at 12:18 P.M. the facility Maintenance Director said he was unaware of the call lights being out until he was notified of the issue this morning. The Maintenance Director went to a supplier this morning for a new transformer (a passive component that transfers electrical power from one electrical circuit to another) to replace the blown one that was causing call lights to be down. After the transformer had been replaced, the resident floor's call lights began functioning normally.
7. During an interview on 5/11/23 at 10:10 A.M. the Administrator said last week, maintenance had notified him of call lights not functioning properly, and maintenance staff were working on fixing the problem. When asked if any resident call lights were out, resulting in residents being unable to contact staff for care or assistance, the Administrator stated I don't know. The Administrator said yesterday, 5/10/23, a family member for a resident on the 100 hall notified him that the call light in that room was not working properly. The Maintenance Director told the Administrator he had looked at it and said it needed a new power source. The Administrator was unable to say if that call light power source had been replaced.
During an interview on 5/11/23 at 1:10 P.M. the Administrator said call lights on the first floor residents' hall were never reported to him as not working, but he was told the lights were intermittent. He said the Maintenance Director let him know earlier today that call lights were not working at all and had begun repairs. The Administrator said if call lights were not working, he would expect floor staff to let him know so the issue could be addressed. The Administrator would expect staff to increase rounding on the floor if call lights were not working.
MO00218269
Apr 2023
6 deficiencies
1 Harm
SERIOUS
(G)
📢 Someone Reported This
A family member, employee, or ombudsman was alarmed enough to file a formal complaint
Actual Harm - a resident was hurt due to facility failures
Deficiency F0692
(Tag F0692)
A resident was harmed · This affected 1 resident
**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, interview, and record review, the facility failed to adequately support the nutritional status of one resi...
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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 adequately support the nutritional status of one resident who experienced a weight loss of 25.70% in four months by not notifying the physician to obtain orders for the Registered Dietician (RD) recommendations and the facility failed to follow their policy by not having the resident re-weighed (Resident #2). The facility also failed to follow physician orders in providing a therapeutic diet and liquids for one resident who experienced a weight loss of 6.5% in two months (Resident #10) and for one resident who experienced a weight loss of 5.6% in two months (Resident #4). The sample size was 14. The census was 138.
Review of the facility's Nutritional (Impaired)/Unplanned Weight Loss, policy, revised September 2017, showed:
-Assessment and Recognition:
-The nursing staff will monitor and document the weight and dietary intake of residents in a format which permits comparisons over time;
-The staff will report to the physician significant weight gains or losses or any abrupt or persistent change in baseline appetite or food intake.
-Cause and identification:
-The physician will review for medical causes of weight gain, anorexia and weight loss before ordering interventions;
-For individuals with recent or rapid weight gain or loss (for example, more than a pound a day), the staff and will review for possible fluid and electrolyte imbalance as a cause;
-Treatments:
-The staff and physician will identify pertinent interventions based on identified causes and overall resident condition, prognosis, and wishes.
-The physician will authorize appropriate interventions, as indicated;
-Treatment and management:
-The physician will document if cause-specific interventions could not be identified or are not feasible;
-The staff and physician will review and consider existing dietary restrictions and modified consistency diets;
-A pertinent assessment and meaningful review of possible medical and non-medical causes of altered nutritional status should precede the use of such medications.
-Monitoring:
-The physician and staff will monitor nutritional status, an individual's response to interventions, and possible complications of such interventions (for example, additional weight gain or loss, nausea, or vomiting);
-When medical conditions or medication-related adverse consequences are causing or contributing to altered nutritional status, the physician and staff will collaborate in adjusting interventions, taking into account the status of those causes and the resident responses, goals, wishes, prognosis, and complications.
Review of the facility's Assessment and Management of Residents Weights policy, revised June 2020, showed:
-Purpose: To ensure that each resident maintains acceptable parameters of weight and nutritional status, such as body weight and protein levels, unless the resident's clinical condition demonstrates that this is not possible based on the resident's comprehensive assessment. To ensure that a resident receives a therapeutic diet when there is a nutritional problem;
-Policy: Weights are obtained upon admission and/or re-admission, then weekly for four weeks and monthly thereafter. Additional weights may be obtained at the discretion of the licensed nurse or the interdisciplinary team (IDT);
-Procedure:
-A licensed nurse or designee will weigh residents;
-Admissions and re-admissions will be weighed on the shift they arrive;
-Hospital weight will not serve as admission or re-admission weight;
-Adaptive or assistive equipment used during measurement will be documented;
-If the weight is less than or greater than 5 pounds from the previous weight, immediately re-weigh and have a licensed nurse verify the accuracy of the weight;
-Weights will be entered into the clinical record on that shift;
-Significant Weight Change Management:
-Significant weight changes will be reviewed by the designated licensed nurse;
-Significant weight changes are: 5% in one month, 7.5 % in three months, and 10% in six months;
-The licensed nurse will: Report weight change in the medical record and on the 24-Hour Report; Notify the physician and dietitian of significant weight changes; and document notification in the nurses notes;
-The RD will: Complete a nutritional assessment on all residents with a significant weight change; Document the nutritional assessment and weight management recommendations in the medical record; The licensed nurse will notify the physician of the dietitian's recommendations and notify the family/health care decision maker of the weight change, as indicated; If the physician does not implement the dietitian's recommendations they will document the rationale for non-implementation in the medical record; The licensed nurse will document physician's refusal and communicate this information to the Director of Nursing Services (DNS) for follow-up on the 24 Hour Report; Residents with significant weight change will be weighed at least weekly and discussed at the Resident at Risk or other clinical meeting to determine possible causes of weight gain or loss including goals for care; The IDT care plan will be updated to reflect individualized goals and approaches for managing the weight change.
1. Review of the Resident #2's quarterly Minimum Data Set (MDS), a federally mandated assessment instrument completed by facility staff, dated 1/24/23, showed:
-Severe cognitive impairment;
-Rejected care daily;
-Dependent on facility staff for transfers, dressing, and personal hygiene;
-Required extensive assist from facility staff for bed mobility, eating, and toilet use;
-Diagnoses included: cancer, coronary artery disease (CAD, damage or disease in the heart's major blood vessels), heart failure (inability of the heart to pump blood through the body), hypertension (high blood pressure), high cholesterol, aphasia (inability to speak), hemiplegia (weakness to one side of the body) or hemiparesis (numbness to one side of the body), malnutrition (protein or calorie) or at risk for malnutrition, anxiety, depression and chronic obstructive pulmonary disease (COPD, constriction of the airways in the lungs making it difficult to breathe);
-No or unknown weight loss or weight gain.
Review of the resident's weights showed:
-On 10/5/22: 143.5 lbs;
-No weights recorded for November, 2022, December, 2022 and January, 2023.
Review of the resident's lab results, dated 12/6/22, showed a blood urea nitrogen (BUN, a blood test that reflects kidney function and hydration) of 7 mg/deciliter (dl) (normal range is 7-26) and a Creatinine level (a blood test that reflects how well your kidneys are filtering waste products) of 0.9 mg/dl (normal range is 0.71 - 1.16).
Review of the resident's care plan, initiated 1/31/23, showed:
-Focus: The resident has a nutritional problem or potential nutritional problem and is at risk for malnutrition with interventions in place; He/She is on an altered diet and in non-compliant with diet;
-Plan: RD to evaluate and make dietary recommendations as needed (PRN); Weight per facility protocol;
-Focus: The resident is frequently resistant to care and vital signs (VS, blood pressure, pulse, respiratory rate and temperature) being obtained; The resident will strike staff, yell out and kick at staff; The resident will refuse medications and treatments at times;
-Plan: If the resident resists activities of daily living (ADL), reassure the resident and leave and return 5-10 minutes later and try again;
Review of the resident's RD note, dated 2/28/23 at 1:34 P.M., showed the resident continues on a regular mechanical soft diet, intake fair. Available weight is from October, 2022, 143.5 lbs. and body mass index (BMI, a calculation to determine a healthy weight) low at 17.7 (a normal BMI is 18.5 to 24.9). Resident appears very thin, observed bony prominences (area in which the bone is close to the skin) in shoulder and temporal (temples of the head) regions. Recommend Ensure Plus (a nutritional supplement) three times daily (TID) with meals. Obtain weight. Provide two glasses water at each meal.
Review of the resident's weights showed:
-No weights recorded for February 2023;
-On 3/8/23: 105.9 lbs. The residnet was not reweighed as directed by the policy;
-No further weights were documented.
Review of the resident's physician order sheets (POS), dated March 2023 and April 2023, did not show an order for the Ensure Plus three times daily or for staff to provide two glasses of water at each meal.
Review of the resident's progress notes showed:
-No documentation the resident refused for his/her weight to be obtained or the resident's physician was notified of his/her weight loss, dietary recommendations, or any refusals of weights;
-On 4/3/23 at 9:44 A.M., the resident was sent to the hospital due to a noticeable change in condition, alert and oriented to self, vital signs blood pressure 84/48 (BP, normal 120/80), respirations 21 (normal 12-18) pulse 66 (normal 60-100), oxygen saturation 77% (normal 95-100 %). This writer was unable to arouse the resident at bedside, oxygen therapy initiated, 911 activated, physician and responsible party (RP) notified. The resident has been transferred to the hospital.
Review of the resident's hospital progress notes, dated 4/3/23, showed the resident presented to the emergency room and appeared severely cachectic (loss of body weight and muscle mass). Diagnosis included pneumonia and kidney failure.
Review of the resident's hospital lab results, dated 4/3/23, showed a BUN of 86 mg/dl (indicator of dehydration) and a Creatinine level of 3.16 mg/dl.
During an interview on 4/27/23 at approximately 11:00 A.M., Certified Nursing Assistant (CNA) E, said the resident did not like the food at the facility and he/she would only eat snacks and soda. He/She never saw the resident drink water. CNA E noticed a decline in the resident's weight over the last month or two.
During an interview on 4/28/23 at 8:45 A.M., Certified Medication Technician (CMT) C said the resident never received nutritional supplements. The resident was a picky eater and had to be fed because he/she had contracted hands. The resident only liked certain staff members and would usually be more receptive with care when those staff members took care of him/her. CMT C had noticed the resident was getting really thin over the last month before he/she passed away. If staff noticed the resident was having issues with weight loss, the nurse should be notified. If a resident refuses care, the staff member should try again later or get another staff member to try.
During interviews on 4/28/23 at 8:35 A.M. and 8:50 A.M., Nurse B said the CMTs give the nutritional supplements. The dietician progress notes are reviewed by the nurse and if there are recommendations for the resident, the physician is called and orders are placed in the computer. The dietician recommendations should be addressed immediately with the physician. Nurse B said he/she had taken care of the resident frequently. He/She noticed the resident was losing weight, because his/her face looked sunken in and he/she wasn't eating as much. He/She did not like the facility food and would frequently eat snacks. The resident was non-compliant with the mechanical soft diet. Nurse B had notified the physician of the resident's recent decline. He/She thought he/she had documented the notification. The physician is to be notified anytime the resident refuses any weights, care or medications.
During an interview on 4/28/23 at 12:05 P.M., RD K said the resident was severely underweight. The resident's BMI was 14.9 based off of the 3/8/23 weight of 105.9 lbs. The resident should have been reweighed. The resident should have received the Ensure supplements as recommended.
During an interview on 4/28/23 at 1:18 P.M., the facility's Medical Director's Nurse Practitioner (NP) G said he/she saw the resident on 2/3/23 and 3/2/23 and did not recall if the resident appeared malnourished. He/She does not recall if he/she was notified of the resident's weight loss or refusal of weights. NP G expected staff to follow their policy regarding weights and could not make any assumptions on when the dietary recommendations should be implemented.
During an interview on 4/28/23 at 2:07 P.M., the Administrator and the Regional Nurse Consultant said the resident would refuse to be weighed and would fight with staff. When the resident refuses weights, the physician or their representative is expected to be notified with documentation in the progress notes that the physician was notified.
2. Review of Resident #10's quarterly MDS, dated [DATE], showed:
-Severe cognitive impairment;
-Required extensive assist from staff with bed mobility, transfers, dressing, eating, toilet use and personal hygiene;
-Diagnosis included: anemia (a lack of red blood cells in the blood), diabetes, dementia, malnutrition (protein or calorie) or at risk for malnutrition, and COPD;
-No or unknown weight loss or weight gain.
-No rejection of care.
Review of the resident's care plan, in use at the time of survey, showed:
-Focus: The resident has a potential nutritional problem and has a diagnosis of malnutrition with interventions in place; The resident eats and gets nutrition and fluids through his/her feeding tube;
-Interventions: Monitor/record/report to the physician PRN signs and symptoms of malnutrition; emaciation (the state of being abnormally thin), cachexia, muscle wasting, significant weight loss: 3 lbs in one week, greater than 5% in 1 month, greater than 7.5% in 3 months, greater than 10% in 6 months; Provide, serve diet as ordered; Monitor intake and record every meal. RD to evaluate and make diet change recommendations PRN; Weigh per facility protocol.
Review of the resident's weights, showed:
-On 3/8/23: 113.4 lbs;
-On 4/6/23: 108.0 lbs;
-On 4/10/23: 101.2 lbs.
Review of the resident's lab results, dated 3/16/23, showed the resdient's BUN level was 38mg/dl (indicates Dehydration).
Review of the resident's POS, dated 4/1/23 through 4/27/23, showed:
-An order dated, 2/28/23, for enteral feed (tube feeding) order, Glucerna 1.2 (a type of diabetic tube feeding) at 45 milliliters (mls) and a water flush 150 mls every four hours.
-An order dated, 3/1/23, for pureed diet (a diet that all foods have a soft pudding like consistency) with honey consistency liquids;
Review of the resident's progress notes, dated 4/17/23 at 12:08 P.M., showed the RD documented in the resident's tube feeding and wound review: 4/6/23, weight: 108 lbs; 4/10/23, weight: 101.2 lbs; significant loss of 6.8 lbs (6.3%) in less than a week. However question accuracy of weights. Appears usual weight is 106 - 110 lbs in past 6 months. BMI is 17.4, underweight. The resident is at high nutritional risk. History of severe protein-calorie malnutrition. Ideal body weight (IBW) is 120 lbs. The resident has six to seven wounds (coccyx (tailbone area), left buttock, left and right heels, right outer ankle) requiring increased calories and protein to promote healing. Current tube feeding: Glucerna 1.2 at 45 mls per hour.
Observation on 4/28/23 at 8:53 A.M., showed the resident was weighed by two facility staff members with the use of a Hoyer lift (a mechanical lift used to transfer or reposition the resident) and the resident's weight showed: 105.6 lbs.
Observation on 4/26/23 at 12:10 P.M., 4/27/23 at 8:05 A.M. and 8:35 A.M. and on 4/28/23 at 8:53 A.M., showed the resident lay in bed with a tube feeding pump located next to his/her bed with Glucerna 1.2 at 45 mls with a water flush bag infusing into the resident's feeding tube. No meal tray or liquids to drink were brought into the resident's room to assist him/her with eating. The resident was able to make eye contact, but could not speak. The resident appeared thin and had dry skin on his/her arms and legs. Dressings to the resident's feet were observed.
During an interview on 4/28/23 at 8:22 A.M., Nurse P said the resident could eat a pureed diet and required assistance with feeding. They usually fed the resident during breakfast and lunch on his/her shift.
Observation on 4/28/23 at 8:24 A.M., showed no breakfast plate on the cart for the resident. CNA E said the resident did not have a breakfast tray.
During an interview on 4/27/23 at approximately 8:35 A.M., CNA E said when he/she initially starts working with a resident and notices the resident is on tube feeding and gets a tray, he/she would clarify with the nurse if the resident is to be eating in addition to the tube feeding. CNA E had never given the resident a tray to eat since he/she had been working with the resident.
During an interview on 4/27/23 at 9:38 A.M., Licensed Practical Nurse (LPN) F said he/she was surprised the resident was still on tube feeding, because he/she eats a lot when staff sit down and assist the resident with eating and drinking. The resident will comment on how good the food is.
During an interview on 4/28/23 at 12:00 P.M., CNA E said he/she passed lunch trays on the unit and there was not a tray for the resident. The resident can eat a pureed diet, but he/she had not fed the resident. He/She worked on the unit the previous day and today and did not provide a tray or feed the resident. The resident did not receive breakfast or lunch on 4/27/23 or 4/28/23.
3. Review of Resident #4's quarterly MDS, dated 3/12 23, showed:
-Cognitively intact;
-Total dependence of staff for bed mobility, transfers, dressing, toilets use and personal hygiene;
-Diagnoses included spinal cord dysfunction, quadriplegia (paralysis of all four limbs), malnutrition (protein or calorie) or at risk for malnutrition, anxiety and depression;
-Weight loss or weight gain: No or unknown.
-No rejection of care.
Review of the resident's care plan, in use at the time of survey, showed:
-Focus: The resident has a potential nutritional problem and has a diagnosis of malnutrition with interventions in place;
-Interventions: Provide, serve diet as ordered; Monitor intake and record every meal; RD to evaluate and make diet change recommendations PRN; Weigh per facility protocol.
Review of the resident's POS, dated 4/1/23 through 4/27/23, showed:
-An order, dated 7/28/22, for regular diet, ice cream with lunch daily, whole milk only with breakfast.
-An order, dated 10/21/22, for Ensure plus, TID, for nutritional support.
Review of the resident's weights, showed:
-On 3/2/23: 142 lb.;
-On 4/7/23: 138.5 lbs.
Review of the resident's RD progress note, dated 4/28/23 at 12:24 P.M., weight today 134 lbs, a decrease in 8 lbs and 5.6 % in two months, BMI 19.3. Diet order regular diet. The resident required full assistance with all meals and fluids. Intake varies 25-100%. Order noted for Ensure TID.
Observation on 4/28/23 at 9:40 A.M., showed the resident was weighed by two facility staff members with the use of a Hoyer lift and the resident's weight showed: 134.0 lbs.
During an interview on 4/28/23 at approximately 1:40 P.M., the resident said he/she can feed him/herself finger foods, but the staff will step in if he/she required help eating. He/She said he/she only receives 2% milk, not whole milk and never receives ice cream. The resident gets supplements but didn't really like them.
4. During an interview on 4/28/23 at 8:35 A.M, Nurse B said the nursing staff can review the RD notes in the computer that will have the recommendations. Sometimes they are told by the ADON and DON about the RD recommendations but not all the time. Nursing should then call the physician once the recommendations are received. He/She was not sure of the timeline on when the recommendations need to be followed through.
5. During an interview on 4/28/23 at 9:27 A.M., Restorative Aide J said he/she obtains weights monthly along with other nursing staff and places all weights in the computer. Staff are to reweigh the resident if a discrepancy in the weight has occurred and would inform the nurse, Assistant Director of Nursing (ADON) or the Director of Nursing (DON).
6. During an interview on 4/28/23 at approximately 11:00 A.M., the Dietary Manager said he/she receives the report from the RD that has the dietary recommendations on it. He/She then passes the report onto the DON or ADON.
7. During an interview on 4/28/23 at 12:05 P.M., RD K said his/her recommendations are in a report format and sent to the dietary manager and then they are distributed to the ADON and DON for review. The recommendations are expected to be implemented immediately. RD K expected staff to provide a meal tray with liquids and assist with feeding the residents. RD K expected weights to be completed monthly. Nursing staff should also review the dietician notes in the computer. A monthly weight meeting would be beneficial to keep track of the weights of the residents, because he/she is not always notified when a weight issue has occurred with the residents.
8. During an interview on 4/28/23 at approximately 12:45 P.M., the Medical Director's NP H said staff are expected to follow physician orders and follow the facility weight policy. The RD recommendations are expected to be implemented within 14 days of receiving them. Dietary recommendations are usually not considered emergent. The facility will usually send the dietary recommendations by e-mail or place them in the provider's incoming mailbox. The ADON and DON will review the weights and the dietary recommendations and sometimes will call him/her if a notable concern is determined.
9. During an interview on 4/28/23 at 2:07 P.M., the Administrator and the Regional Nurse Consultant said staff are expected to follow physician orders, provide a meal tray and to assist the resident with the meal. Dietary recommendations are to be implemented within 14 days of receiving them. The facility is working on a better process of communication between dietary services and nursing staff. The RD, ADON and DON are responsible to review the recommendations and the resident weights. Staff are expected to follow the weight policy. The residents are to be weighed monthly or as needed and the physician is to be notified if a weight loss or weight gain has been determined. A weight loss can be determined by reviewing the resident's medical record and making sure the resident is not on dialysis and has not had a recent hospitalization that may affect the resident's weight.
MO00216659
CONCERN
(D)
📢 Someone Reported This
A family member, employee, or ombudsman was alarmed enough to file a formal complaint
Potential for Harm - no one hurt, but risky conditions existed
Resident Rights
(Tag F0550)
Could have caused harm · This affected 1 resident
**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation and interview, the facility failed to ensure staff respected the personal dignity of one resident (Resident...
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**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation and interview, the facility failed to ensure staff respected the personal dignity of one resident (Resident #12), after the resident was left exposed in his/her bedroom. Staff and other residents passed the resident's room as he/she lay in bed undressed. In addition, staff was observed in the dining room clipping the fingernails of a resident while other residents were present during a meal service. The sample size was 14. The census was 138.
Review of the facility's Resident Rights policy, revised 12/2016, showed:
-Policy Statement: Employees shall treat all residents with kindness, respect and dignity;
-Policy Interpretation and Implementations;
-Federal and state laws guarantee certain basic rights to all residents of this facility. These rights include the resident's right to;
-A dignified existence;
-Be treated with respect, kindness and dignity;
-Privacy and confidentiality.
1. Review of Resident #12's annual Minimum Data Set (MDS), a federally mandated assessment instrument completed by facility staff, dated 3/4/23, showed:
-Severe cognitive impairment;
-Exhibited no behaviors such as disrobing in public;
-Rejection of care occurred daily;
-Required extensive assistance of one staff for dressing;
-Diagnoses included high blood pressure, heart disease and depression.
Review of the resident's care plan, revised 3/16/23, showed:
-Focus: The resident has an Activities of Daily Living (ADL) self-care deficit related to limited mobility, range of motion and bilateral above the knee amputation;
-Goal: The resident will maintain current level of function through the review date;
-Interventions: Allow sufficient time for dressing and undressing. Allow the resident to choose simple comfortable clothes that enhances the ability to dress self. Extensive assist with dressing.
Observation on 4/27/23 at 6:21 A.M., showed the resident lay in bed on his/her back. The resident was undressed and visible from the hallway. One resident sat in his/her wheelchair brushing his/her hair outside of the resident's doorway. At 6:24 A.M., two staff members passed the resident's room.
Observation on 4/27/23 at 6:40 A.M., 7:34 A.M. and 8:00 A.M., showed the resident lay in bed on his/her back with no clothing on and visible from the hallway. He/She was trying to cover his/her genitals with his/her hand. Multiple staff members and residents passed the resident's room.
2. Observation on 4/27/23 at 12:43 P.M., showed approximately 10 residents in the dining room, eating lunch. Physical Therapist (PT) D sat at a dinner table with one resident and clipped the resident's nails, while Resident #14 sat at the same dinner table with his/her head on the table asleep. The clipped nails landed on the table and floor. At 12:44 P.M., the Dietary Manager (DM) arrived in the dining area. When asked about the staff clipping nails at the dinner table, the DM approached PT D and told him/her not to cut nails in the dining room. PT D continued to cut the resident's nails. The DM left to get other staff. The Director of Therapy arrived at 12:45 P.M. and told PT D to stop clipping the resident's nails in the dining room.
Review of Resident #14's quarterly (MDS), dated [DATE], showed the resident was cognitively intact.
During an attempted interview on 4/27/23 at 12:46 P.M. and 4/28/23 at approximately 11:52 A.M., the resident was asleep.
During an interview on 4/27/23 at 12:50 P.M., the DM said PT D should not have clipped the resident's fingernails while at the dining table and it was disgusting.
During an interview on 4/27/23 at 12:51 P.M., the Director of Therapy said PT D should not have clipped a resident's fingernails during a meal service.
During an interview on 4/27/23 at approximately 1:00 P.M., the Regional Nurse Consultant (RNC) said PT D was in-serviced on 4/27/23 at 12:55 P.M. PT D clipping a resident's nails during a meal service was not appropriate.
During an interview on 4/28/23 at 2:08 P.M., the Administrator and the RNC said staff should not have clipped a resident's nails during a meal service and it was unacceptable.
CONCERN
(D)
📢 Someone Reported This
A family member, employee, or ombudsman was alarmed enough to file a formal complaint
Potential for Harm - no one hurt, but risky conditions existed
Deficiency F0558
(Tag F0558)
Could have caused harm · This affected 1 resident
**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, interview and record review, the facility failed to ensure resident needs were met by failing to set up a ...
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**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, interview and record review, the facility failed to ensure resident needs were met by failing to set up a meal for one resident (Resident #7) who required the assistance of staff for supervision and set up with meals. The sample size was 14. The census was 138.
Review of the facility's Activities of Daily Living (ADL), Supporting policy, revised March, 2018, showed:
-Policy Statement: Residents will be provided with care, treatment and services as appropriate to maintain or improve their ability to carry out activities of daily living (ADLs). Residents who are unable to carry out activities of daily living independently will receive the services necessary to maintain good nutrition, grooming and personal and oral hygiene;
-Policy Interpretation and Implementation;
-Appropriate 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 assistance with;
-Dining (meals and snacks);
-A resident's ability to perform ADLs will be measured using clinical tools, including the Minimum Data Set (MDS, a federally mandated assessment instrument completed by facility staff), functional decline or improvement will be evaluated in reference to the assessment reference date and the following MDS definitions:
-Supervision: Oversight, encouragement or cueing provided three or more times during the last seven days;
-Interventions to improve or minimize a resident's functional abilities will be in accordance with the resident's assessed needs, preferences, stated goals and recognized standards of practice.
Review of Resident #7's quarterly MDS, dated [DATE], showed:
-Cognitively intact;
-Exhibited no behaviors;
-Required supervision and set up only with eating;
-Diagnoses included high blood pressure, neurogenic bladder (urinary conditions in people who lack bladder control due to a brain, spinal cord or nerve condition), anxiety and depression.
Review of the resident's care plan, revised 1/24/23, showed:
-Focus: The resident has an ADL self-care performance deficit related to musculoskeletal impairment and pain to shoulders;
-Goal: The resident will maintain current level of function in ADLs through the review date;
-Interventions: Supervision with set up assist.
Observation on 4/27/23 at 12:00 P.M., showed Certified Nursing Assistant (CNA) N delivered the resident's lunch tray to his/her room. The resident asked CNA N if he/she would return to cut the resident's meat. CNA N told the resident he/she would return. At 12:14 P.M., CNA N passed the resident's room without a knife and did not enter the resident's room.
During an interview on 4/27/23 at 12:20 P.M., the resident said he/she was waiting on CNA N to return to cut his/her meat. He/She could not cut meat on his/her own because his/her hands were contracted. He/She often needs assistance with meal set up and does not receive it. The resident could not eat the meal unless the meat was cut into pieces. At 12:38 P.M. a staff member entered the resident's room and asked if he/she was finished with lunch. The resident told the staff member he/she could not eat the meal because the meat was not cut. The staff member took the tray. The resident said he/she never got the chance to eat the meal because CNA N failed to return.
During an interview on 4/28/23 at 2:08 P.M., the Administrator and Regional Nurse Consultant said the resident required set up with meals and staff should have cut the resident's meat, as requested.
MO00216745
CONCERN
(D)
📢 Someone Reported This
A family member, employee, or ombudsman was alarmed enough to file a formal complaint
Potential for Harm - no one hurt, but risky conditions existed
Deficiency F0658
(Tag F0658)
Could have caused harm · This affected 1 resident
Based on observation, interview and record review, the facility failed to ensure services provided met professional standards of practice by not following physician orders for administering one reside...
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Based on observation, interview and record review, the facility failed to ensure services provided met professional standards of practice by not following physician orders for administering one resident's intravenous (IV) antibiotic for seven doses and not changing the resident's peripherally inserted central catheter (PICC, a long flexible tube that is inserted in the arm for long term medication use) dressing weekly (Resident #3). The sample was 14. The census was 138.
Review of the facility's Nursing Documentation policy, revised June, 2020, showed:
Purpose: To provide documentation of resident status and care given by nursing staff;
Policy: Nursing documentation will be concise, clear, pertinent, accurate and evidence based. Narrative charting, as outlined in specific policies and procedures, will be used for initial treatments or procedures. Documentation for subsequent and/or routine care and procedures may be completed by exception. Checklists, flow charts, and other documentation tools will be used as appropriate;
Procedure: Nursing documentation: Medication Administration Records (MAR) and Treatment Administration Records (TAR) are completed with each medication or treatment completed; Documentation will be completed by the end of the assigned shift.
Review of Resident #3's admission Minimum Data Set (MDS), a federally mandated assessment instrument completed by facility staff , dated 3/27/23, showed:
-An admission date of 3/27/23;
-Cognitively intact;
-Independent with all activities of daily living (ADL);
-No rejection of care;
-Receiving IV medications.
Review of the resident's face sheet, showed his/her diagnoses included stroke, diabetes and endocarditis (an infection of the heart's inner lining and heart valves).
Review the resident's care plan, in use at the time of survey, showed:
Focus: The resident is on IV medications for endocarditis;
Plan: Observe and change dressing; Record observations of the site per orders;
Focus: The resident is on antibiotics for endocarditis;
Plan: Administer antibiotic medications as ordered by the physician.
Review of the resident's physician order sheets (POS), dated 3/27/23, showed:
-An order, dated 3/27/23, for Vancomycin (antibiotic) 750 milligrams (mg) IV, twice daily, stop date 4/25/23;
-No PICC line dressing change orders were documented.
Review of the resident's MAR, dated 3/27/23 through 3/31/23, showed:
-Two out of eight opportunities, Vancomycin 750 mg IV with no documentation the medication was administered;
Review of the resident's MAR, dated 4/1/23 through 4/26/23, showed:
-Five out of 50 opportunities, Vancomycin 750 mg IV with no documentation the medication was administered.
Review of the resident's progress notes did not show documentation of the reason the Vancomycin had not been administered.
During observation and interview on 4/26/23 at 9:25 A.M., the resident said he/she missed his/her first two doses of antibiotic when he/she was admitted and some doses throughout his/her admission. The resident's PICC line dressing to his/her right arm had a date of 3/30/23.
During an interview on 4/27/23 at 11:45 A.M., Nurse B said the blank boxes on the MAR mean the medication was not given. If any medication is not given for any reason, there should be a progress note showing why the medication was not given and the physician, Assistant Director of Nursing (ADON) or Director of Nursing (DON) should also be notified. The PICC line dressing should be changed per the physician orders.
During an interview on 4/28/23 at 2:07 P.M., the Administrator and the Regional Nurse Consultant said a blank box on the MAR meant the medication was not given and documentation of why the medication was not given is expected to be completed in the progress notes. PICC dressings are to be changed weekly.
MO00216986
MO00216736
MO00216882
MO00216745
CONCERN
(E)
📢 Someone Reported This
A family member, employee, or ombudsman was alarmed enough to file a formal complaint
Potential for Harm - no one hurt, but risky conditions existed
ADL Care
(Tag F0677)
Could have caused harm · This affected multiple residents
**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, interview and record review, the facility failed to ensure residents received the necessary services to ma...
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**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, interview and record review, the facility failed to ensure residents received the necessary services to maintain good personal hygiene for three of 14 sample residents who were left soiled for an extended period of time (Residents #7, #10 and #11). The census was 138.
Review of the facility's Activities of Daily Living (ADL), Supporting policy, revised March, 2018, showed:
-Policy Statement: Residents will be provided with care, treatment and services as appropriate to maintain or improve their ability to carry out ADLs. Residents who are unable to carry out activities of daily living independently will receive the services necessary to maintain good nutrition, grooming and personal and oral hygiene;
-Policy Interpretation and Implementation;
-Appropriate 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 assistance with;
-Hygiene (bathing, dressing, grooming and oral care);
-Elimination (toileting).
1. Review of Resident #7's quarterly Minimum Data Set (MDS), a federally mandated assessment instrument completed by facility staff, dated 1/12/23, showed:
-Cognitively intact;
-Exhibited no behaviors;
-Required extensive assistance of two staff for toilet use;
-Required extensive assistance of one staff for personal hygiene;
-Always incontinent of bladder;
-Frequently incontinent of bowel;
-Diagnoses included high blood pressure, neurogenic bladder (urinary conditions in people who lack bladder control due to a brain, spinal cord or nerve condition), anxiety and depression.
Review of the resident's care plan, revised 1/24/23, showed:
-Focus: The resident has an ADL self-care performance deficit related to musculoskeletal impairment and pain to shoulders;
-Goal: The resident will maintain current level of function in ADLs through the review date;
-Interventions: Extensive assistance for personal hygiene and toileting.
During an interview on 4/26/23 at 11:30 A.M., the resident said he/she was waiting to take a shower. At 9:00 A.M., he/she pressed the call light to be changed. The Certified Nursing Assistant (CNA) answered and told the resident to wait until his/her shower to be changed. The CNA told the resident, It wasn't (his/her) assignment. The resident said staff always said that and would turn off the call light. He/She was currently sitting in urine. The resident pressed the call light again and had been waiting for over an hour.
Observation on 4/26/23 at 11:31 A.M., showed the resident lay in bed. The smell of urine was present in the resident's room and his/her bedding appeared wet. At 11:41 A.M., CNA E entered the resident's room and told the resident he/she was not assigned to the resident and his/her assigned CNA was providing showers to other residents. The assigned CNA would get to the resident as soon as possible. CNA E left the resident's room. At 11:54 A.M., CNA I entered the resident's room and told the resident he/she was providing showers to other residents. The resident told the CNA he/she was wet, and needed to be changed.
Observation on 4/26/23 at 12:10 P.M., showed CNA I assisted the resident to his/her side. Under the resident was a pink disposable bed pad and brief saturated with urine.
2. Review of Resident #10's quarterly MDS, dated [DATE], showed:
-Severe cognitive impairment;
-Exhibited no behaviors;
-Required extensive assistance of one staff for toileting and personal hygiene;
-Frequently incontinent of bladder;
-Always incontinent of bowel;
-Diagnoses included anemia, dementia, malnutrition and depression.
Review of the resident's care plan, revised on 2/23/23, showed:
-Focus: The resident has an ADL self-care performance deficit related to confusion and dementia;
-Goal: The resident will maintain current level of function in ADLs through the review date;
-Interventions: Extensive assistance for personal hygiene and toilet use.
Observation on 4/27/23 at 6:30 A.M., 7:40 A.M., and 8:40 A.M., showed the resident lay in bed on his/her back with a ring of yellow urine on the mattress sheet and blue bed pad. The resident also had an odor of urine. At 8:55 A.M., Registered Nurse (RN) O went into the resident's room to answer the resident's roommate's question but did not check on Resident #10. At 9:50 A.M., RN O and CNA N assisted the resident to his/her side. Located under the resident, was the resident's mattress sheet with a yellow ring of urine. His/her blue bed pad, pink disposable bed pad and brief were saturated with urine.
During an interview on 4/47/23 at 10:00 A.M., CNA N said it was obvious the resident was left wet all night. He/She will come to work in the morning and all the residents are soaked with urine and stool from the overnight shift not changing the residents. The residents should be checked on every two hours.
3. Review of Resident #11's quarterly MDS, dated [DATE], showed:
-Cognitively intact;
-Exhibited no behaviors;
-Required extensive assistance of one staff for personal hygiene;
-Diagnoses included stroke, cancer, heart failure and depression.
Review of the resident's care plan, revised 12/15/22, showed:
-Focus: The resident has ADL self-care performance deficits related to cognitive impairment and left hemiplegia;
-Goal: The resident will maintain current level of function through the review date;
-Interventions: Extensive assistance for personal hygiene. Total assistance for toilet use.
Observation and interview on 4/27/23 at 6:40 A.M., and 7:34 A.M., showed the resident lay in bed on his/her back with dried emesis (vomit) on his/her face, gown and sheet. The resident also had a ring of yellow urine on the bed pad and had an odor of urine. The resident said he/she had vomited about 6:00 A.M. and the staff member cleaned his/her face off but did not change his/her brief. He/She then vomited again after the staff member left the room. The resident said his/her brief was not changed all night. On 4/27/23 at 8:05 A.M., CNA E and CMT M went into the resident's room. The resident was turned to his/her side. Located under the resident,was the resident's blue bed pad, a disposable pink incontinent pad and brief saturated with urine.
4. During an interview on 4/28/23 at 12:08 P.M., CNA L said usually there were two CNAs and one shower aide assigned to a unit. Resident rounds are done every two hours and as needed. If a resident was wet, staff should change them immediately.
5. During an interview on 4/28/23 at 8:38 A.M., Nurse B said Residents #7, #10 and #11 were unable to perform ADL care on their own and required staff assistance. Residents should be checked every two hours and as needed. If a resident was wet, staff should change the resident immediately.
6. During an interview on 4/28/23 at 2:08 P.M., the Administrator and the Regional Nurse Consultant said residents should be checked every two hours and as needed. Checking a resident consisted of ensuring they were adequately groomed and dry. The residents should not have been left in urine or emesis.
MO00216736
MO00216882
MO00217162
CONCERN
(E)
📢 Someone Reported This
A family member, employee, or ombudsman was alarmed enough to file a formal complaint
Potential for Harm - no one hurt, but risky conditions existed
Deficiency F0727
(Tag F0727)
Could have caused harm · This affected multiple residents
Based on interview and record review, the facility failed to hire, maintain or designate a Registered Nurse (RN) to serve as the Director of Nursing (DON) on a full time basis. The facility maintained...
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Based on interview and record review, the facility failed to hire, maintain or designate a Registered Nurse (RN) to serve as the Director of Nursing (DON) on a full time basis. The facility maintained a census of greater than 60 residents. This deficiency had the potential to affect all residents. The census was 138.
Review of the facility's undated list of Department Heads, provided on 4/26/23, showed no DON employed within the facility.
During an interview on 4/28/23 at 9:49 A.M., Certified Nursing Assistant (CNA) A said they had not had a DON in about two weeks. The facility had not had a consistent DON over the last year.
During an interview on 4/28/23 at 8:38 A.M., Nurse B said the facility had not had a DON in about two weeks, or a consistent DON for about two months.
During an interview on 4/28/23 at 2:03 P.M., the Administrator and Regional Nurse Consultant said the last DON hired, left the position to work as a floor nurse at the facility. The facility has not had a consistent DON over the last three months.
MO00216882
Feb 2023
2 deficiencies
CONCERN
(E)
📢 Someone Reported This
A family member, employee, or ombudsman was alarmed enough to file a formal complaint
Potential for Harm - no one hurt, but risky conditions existed
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 staff failed to obtain written authorization from the resident and/or his/her...
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**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on record review and interview, the facility staff failed to obtain written authorization from the resident and/or his/her financial guardian for money withdrawn for nine residents (Resident #1, #3, #5, #6, #7, #8, #10, #13 and #15) out of a sample of 12. Also, the facility staff failed to withdraw the correct monthly surplus for room and board which did not allow the resident/financial guardian the right to manage all of his/her financial affairs for seven sampled residents (Resident #1, #5, #8, #10, #12, #15 and #23). The facility census was 126.
1. Record review of the facility maintained Resident Trust Statement for the period [DATE] through [DATE], showed the following withdrawals from Resident #1's account:
Date Amount Description
[DATE] $200.00 Personal Needs
[DATE] $150.00 Personal Needs
[DATE] $59.00 Personal Needs
Record review on [DATE] of the facility maintained paperwork for Resident #1's Resident Trust Statement, showed no written authorization by Resident #1 and/or his/her financial guardian for the withdrawals.
Record review showed Resident #1 expired on [DATE].
2. Record review of the facility maintained Resident Trust Statement for the period [DATE] through [DATE], showed the following withdrawal from Resident #3's account:
Date Amount Description
[DATE] $1,500.00 Personal Needs
Record review on [DATE] of the facility maintained paperwork for Resident #3's Resident Trust Statement, showed no written authorization by Resident #3 and/or his/her financial Responsible Party for the withdrawal.
During an interview on [DATE] at 3:47 P.M., Resident #3's Financial Responsible Party said the Social Services staff asked if he/she would like to donate $1,500.00 from Resident #3's Resident Trust account for a Christmas party for the residents. Resident #3's Financial Responsible Party said he/she gave verbal authorization but he/she does not remember giving written authorization for the [DATE] withdrawal.
3. Record review of the facility maintained Resident Trust Statement for the period [DATE] through [DATE], showed the following withdrawals from Resident #5's account:
Date Amount Description
[DATE] $100.00 Personal Needs
[DATE] $100.00 Personal Needs
[DATE] $70.00 Personal Needs
[DATE] $100.00 Personal Needs
[DATE] $150.00 Personal Needs
[DATE] $1,000.00 Personal Needs
[DATE] $50.00 Personal Needs
[DATE] $300.00 Personal Needs
Record review on [DATE] of the facility maintained paperwork for Resident #5's Resident Trust Statement, showed no written authorization by Resident #5 for the withdrawals.
During an interview on [DATE] at 4:04 P.M., Resident #5 said he/she did not withdraw $300.00 nor $1,000.00. Resident #5 also said he/she may have withdrawn up to $100.00 but did not very often and did not withdraw money twice in one day on [DATE]. Resident #5 said he/she had a feeling that money was being taken from his/her account but did not say anything because the previous former Business Office Manager (BOM) would tell Resident #5 that he/she would take care of the resident.
4. Record review of the facility maintained Resident Trust Statement for the period [DATE] through [DATE], showed the following withdrawals from Resident #6's account:
Date Amount Description
[DATE] $25.00 Personal Needs
[DATE] $25.00 Personal Needs
[DATE] $25.00 Personal Needs
Record review on [DATE] of the facility maintained paperwork for Resident #6's Resident Trust Statement, showed no written authorization by Resident #6 for the withdrawals.
5. Record review of the facility maintained Resident Trust Statement for the period [DATE] through [DATE], showed the following withdrawals from Resident #7's account:
Date Amount Description
[DATE] $700.00 Personal Needs
[DATE] $100.00 Personal Needs
Record review on [DATE] of the facility maintained paperwork for Resident #7's Resident Trust Statement, showed no written authorization by Resident #7 for the withdrawals.
During an interview on [DATE] at 4:06 P.M., Resident #7 said he/she did remember withdrawing $700.00 in 10/2022 and $100.00 in 01/2023 but did not remember signing anything.
6. Record review of the facility maintained Resident Trust Statement for the period [DATE] through [DATE], showed the following withdrawals from Resident #8's account:
Date Amount Description
[DATE] $700.00 Personal Needs
[DATE] $220.00 Personal Needs
[DATE] $200.00 Personal Needs
[DATE] $150.00 Personal Needs
[DATE] $85.00 Personal Needs
Record review on [DATE] of the facility maintained paperwork for Resident #8's Resident Trust Statement, showed no written authorization by Resident #8 for the withdrawals.
During an interview on [DATE] at 3:40 P.M., Resident #8 said he/she does remember withdrawing the listed money from the account, but does not remember giving written authorization for the withdrawals.
7. Record review of the facility maintained Resident Trust Statement for the period [DATE] through [DATE], showed the following withdrawals from Resident #10's account:
Date Amount Description
[DATE] $100.00 Personal Needs
[DATE] $162.91 Personal Needs
[DATE] $300.00 Personal Needs
Record review on [DATE] of the facility maintained paperwork for Resident #10's Resident Trust Statement, showed no written authorization by Resident #10 for the withdrawals.
During an interview on [DATE] at 3:50 P.M., Resident #10 said he/she did withdraw the [DATE] and [DATE] amounts but did not sign anything. Resident #10 said he/she did not withdraw $300.00 on [DATE].
8. Record review of the facility maintained Resident Trust Statement for the period [DATE] through [DATE], showed the following withdrawals from Resident #13's account:
Date Amount Description
[DATE] $35.00 Personal Needs
[DATE] $500.00 Personal Needs
Record review on [DATE] of the facility maintained paperwork for Resident #13's Resident Trust Statement, showed no written authorization by Resident #13 and/or his/her financial responsible party for the withdrawals.
During an interview on [DATE] at 1:45 P.M., Resident #13's Financial Responsible Party said the Activity Director called and asked him/her if he/she would like to donate $500.00 from Resident #13's Resident Trust account for a Christmas party for the residents. Resident #13's Financial Responsible Party said he/she gave verbal authorization but does not remember giving written authorization for the [DATE] withdrawal.
9. Record review of the facility maintained Resident Trust Statement for the period [DATE] through [DATE], showed the following withdrawal from Resident #15's account:
Date Amount Description
[DATE] $5.00 Personal Needs
Record review on [DATE] of the facility maintained paperwork for Resident #15's Resident Trust Statement, showed no written authorization by Resident #15 and/or his/her financial responsible party for the withdrawal.
10. During an interview on [DATE] at 2:08 P.M., the Regional Business Office Manager said receipts could not be located for any resident fund withdrawals.
11. Record review of the facility maintained Resident Trust Statement for the period [DATE] through [DATE], showed the incorrect withdrawals from Resident #1's account for room & board:
Date Month Amount Withdrawn
[DATE] 06/2022 $1,417.00
[DATE] 07/2022 $1,417.00
[DATE] 08/2022 $1,417.00
[DATE] 09/2022 $1,417.00
[DATE] 10/2022 $1,417.00
[DATE] 11/2022 $1,417.00
Record review on [DATE] of the Medicaid Category History Screen provided by Missouri HealthNet Division on [DATE] and the Cost Settlement Summary Report (CSSR) provided on [DATE], showed Resident #1's Care Cost Surplus amount for room & board should be $0 for 06/2022, $1,318.00 for 07/2022, $186.40 for 08/22, $745.60 for 09/22, $186.40 for 10/2022 and $0 for 11/22 - 01/23.
12. Record review of the facility maintained Resident Trust Statement for the period [DATE] through [DATE], showed the incorrect withdrawals from Resident #5's account for room & board:
Date Month Amount Withdrawn
[DATE] 06/2022 $851.00
[DATE] 07/2022 $851.00
[DATE] 08/2022 $851.00
[DATE] 09/2022 $851.00
[DATE] 10/2022 $851.00
[DATE] 11/2022 $851.00
Record review on [DATE] of the Medicaid Category History Screen provided by Missouri HealthNet Division on [DATE] and the CSSR provided on [DATE], showed Resident #5's Care Cost Surplus amount for room & board should be $283.00 for 06/2022 - 11/2022, excluding 07/2022 which should be $0 and 12/2022 for $620.00.
13. Record review of the facility maintained Resident Trust Statement for the period [DATE] through [DATE], showed the incorrect withdrawals from Resident #8's account for room & board:
Date Month Amount Withdrawn
[DATE] 07/2022 $4,500.00
[DATE] 07/2022 $1,322.00
[DATE] 0102022 $1,322.00
[DATE] 11/2022 $1,322.00
Record review on [DATE] of the Medicaid Category History Screen provided by Missouri HealthNet Division on [DATE] and the CSSR provided on [DATE], showed Resident #8's Care Cost Surplus amount for room & board should be $2,027.33 for 07/2022 and $0 for 10/2022 and 11/2022.
14. Record review of the facility maintained Resident Trust Statement for the period [DATE] through [DATE], showed the incorrect withdrawals from Resident #10's account for room & board:
Date Month Amount Withdrawn
[DATE] 06/2022 $983.00
[DATE] 07/2022 $983.00
[DATE] 08/2022 $983.00
[DATE] 09/2022 $983.00
[DATE] 10/2022 $983.00
[DATE] 11/2022 $983.00
[DATE] 12/2022 $983.00
[DATE] 01/2023 $1,110.00
Record review on [DATE] of the Medicaid Category History Screen provided by Missouri HealthNet Division on [DATE] and the CSSR provided on [DATE], showed Resident #10's Care Cost Surplus amount for room & board should be $914.23 for 06/2022 - 10/2022, and $0 for 11/2022 - 01/2023.
15. Record review of the facility maintained Resident Trust Statement for the period [DATE] through [DATE], showed the incorrect withdrawals from Resident #12's account for room & board:
Date Month Amount Withdrawn
[DATE] 06/2022 $1,149.00
[DATE] 07/2022 $1,149.00
[DATE] 08/2022 $1,149.00
[DATE] 09/2022 $1,149.00
[DATE] 10/2022 $1,149.00
[DATE] 11/2022 $1,149.00
[DATE] 12/2022 $1,149.00
[DATE] 01/2023 $1,253.00
Record review on [DATE] of the Medicaid Category History Screen provided by Missouri HealthNet Division on [DATE] and the CSSR provided on [DATE], showed Resident #12's Care Cost Surplus amount for room & board should be $1,067.00 for 06/2022 - 01/2023.
16. Record review of the facility maintained Resident Trust Statement for the period [DATE] through [DATE], showed the incorrect withdrawals from Resident #15's account for room & board:
Date Month Amount Withdrawn
[DATE] 06/2022 $955.00
[DATE] 08/2022 $955.00
Record review on [DATE] of the Medicaid Category History Screen provided by Missouri HealthNet Division on [DATE] and the CSSR provided on [DATE], showed Resident #15's Care Cost Surplus amount for room & board should be $874.01 for 06/2022 and $0 for 08/2022.
17. Record review of the facility maintained Room & Board Statements for the period [DATE] through [DATE], showed Resident #23 was charged the incorrect amount for room & board for 08/2022 in the amount of $762.00.
Record review on [DATE] of the Medicaid Category History Screen provided by Missouri HealthNet Division on [DATE] and the CSSR provided on [DATE], showed Resident #23's Care Cost Surplus amount for room & board should be $760.00 for 08/2022 through 01/2023.
18. During an interview on [DATE] at 10:36 A.M., the Regional Business Office Manager said the systems do not match for room & board balances and the amount withdrawn from the Resident Trust Account. This has been brought to the corporate level but he/she has not received a response regarding why there is a difference.
#MO00212729
CONCERN
(E)
📢 Someone Reported This
A family member, employee, or ombudsman was alarmed enough to file a formal complaint
Potential for Harm - no one hurt, but risky conditions existed
Deficiency F0602
(Tag F0602)
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 ensure seven residents (Residents #5, #10, #22, #23, #24, #25 and #...
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**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on record review and interview, the facility failed to ensure seven residents (Residents #5, #10, #22, #23, #24, #25 and #26) were free from misappropriation of resident property when the former Business Office Manager withdrew resident funds to use for his/her personal use. The facility census was 126.
1. Record review of the facility maintained Resident Trust Statement for the period 06/01/22 through 02/10/23, showed the following withdrawals from Resident #5's account:
Date Amount Description
06/06/22 $100.00 Personal Needs
06/10/22 $100.00 Personal Needs
06/21/22 $100.00 Personal Needs
06/21/22 $150.00 Personal Needs
06/27/22 $1,000.00 Personal Needs
07/26/22 $300.00 Personal Needs
Record review of the facility maintained paperwork for Resident #5's Resident Trust Statement, showed no written authorization for the listed withdrawals by Resident #5.
During an interview on 02/21/23 at 4:04 P.M., Resident #5 said he/she did not withdraw $300.00 nor $1,000.00. Resident #5 also said he/she may have withdrawn up to $100.00 but did not very often and did not withdraw money twice in one day on 06/21/22. Resident #5 said he/she had a feeling that money was being taken from his/her account but did not say anything because the former Business Office Manager (BOM) would tell Resident #5 the former BOM would take care of him/her.
2. Record review of the facility maintained Resident Trust Statement for the period 06/01/22 through 02/10/23, showed the following withdrawal from Resident #10's account:
Date Amount Description
09/29/22 $300.00 Personal Needs
Record review of the facility maintained paperwork for Resident #10's Resident Trust Statement, showed no written authorization for the withdrawal by Resident #10.
During an interview on 02/10/23 at 3:50 P.M., Resident #10 said he/she did not withdraw $300.00.
3. Record review of the facility maintained Room & Board Statements 09/01/22 through 01/31/23, showed there had been no payments made for Resident #22's room & board.
Record review of cash receipts provided by the Regional Business Office Manager on 02/10/23, showed Resident #22's spouse made cash payments, received by the former BOM, in the following amounts:
Date
Amount
12/14/22
$1,376.00
01/11/23
$1,400.00
During an interview on 03/03/23 at 11:31 A.M., Resident #22's family member said Resident #22's spouse is incapacitated and unable to speak. The family member said Resident #22's spouse did make cash payments to the facility and said he/she did not trust the former BOM. The former BOM would ask Resident #22's spouse to go to the bank to get cash for Resident #22's room & board.
4. Record review of the facility maintained Room & Board Statements 09/01/22 through 01/31/23, showed there had been no payments made for Resident #23's room & board.
Record review of cash receipts provided by the Regional Business Office Manager on 02/10/23, showed Resident #23's family member made cash payments, received by the former BOM, in the following amounts:
Date Amount
11/09/22 $1,550.00
11/09/22 $2,100.00
12/09/22 $1,000.00
Record review of an email string dated 01/11/23 at 2:41 P.M., shows an email from the former BOM to Resident #23's family member stating Please don't pay the statement they are trying to make you pay. When I wrote the therapy charges. Review shows the email stops after the word charges.
During an interview on 02/28/23 at 11:34 A.M., Resident #23's family member said he/she made cash payments to the former BOM because the former BOM called and asked for cash payments for Resident #23's room & board. Additionally, Resident #23's family member said the former BOM told him/her if you bring me X amount of dollars in cash I will wipe off the balance due for room & board and work with the physical therapy charges for Resident #23. The former BOM also asked Resident #23's family member not to tell anyone so the former BOM would not get into trouble.
5. Record review of the facility maintained Room & Board Statements 09/01/22 through 01/31/23, showed there had been only one payment made for Resident #24's room & board on 12/09/22 in the amount of $500.00.
Record review of cash receipts provided by the Regional Business Office Manager on 02/10/23, showed Resident #24's Financial Power of Attorney made cash payments, received by the former BOM, in the following amounts:
Date Amount
07/20/22 $1,500.00
08/04/22 $600.00
10/04/22 $700.00
11/03/22 $700.00
12/02/22 $600.00
01/04/23 $700.00
Record review showed the payment on 12/02/22 in the amount of $600.00 was recorded as a $500.00 payment, which was $100.00 less than what was received by the former BOM.
During an interview on 02/28/23 at 9:17 A.M., Resident #24's Financial Power of Attorney (POA) said previous room & board payments were made using money orders until the former BOM called multiple times asking for cash to be brought for the room & board payments. The former BOM asked Resident #24's Financial POA to stay in the car when he/she arrived at the facility and the former BOM would come out to the car with a file and write a receipt. The Financial POA did not know he/she should be getting room & board statements until the facility called him/her about not receiving any payments. The Financial POA also said he/she made a payment in 09/2022 but was still looking for the receipt.
6. Record review of the facility maintained Room & Board Statements 09/01/22 through 01/31/23, showed there had been only one payment made for Resident #25's room & board on 12/14/22 in the amount of $794.00 by check #190.
Record review of cash receipts provided by the Regional Business Office Manager on 02/10/23, showed Resident #25's family member made cash payments, received by the former BOM, in the following amounts:
Date Amount
10/12/22 $700.00
11/14/22 $794.00
During an interview on 02/28/23 at 9:34 A.M., Resident #25's family member said he/she gave cash payments directly to the former BOM for 10/2022 and 11/2022 and then started paying room & board by check starting in 12/2022.
7. During an interview on 02/22/23 at 2:59 P.M., the former BOM said:
-He/she did receive cash from residents' families and he/she did not deposit the cash into the room & board account but deposited the cash into another facility account at a different bank that was used to obtain cash for residents.
-His/her name and the previous Administrator were the only names on the other facility bank account.
8. Record review of the facility maintained admission Record showed Resident #26's admission date as 05/06/22.
Record review of the resident's quarterly Minimum Data Set (MDS), a federally mandated assessment instrument, dated 01/25/23, showed staff assessed the resident as:
- No cognitive impairment (scored 15 out of 15 on the Brief Interview for Mental Status (BIMS));
- Does not have signs/symptoms of delirium;
- Does not have behaviors.
Record review of the facility maintained Room & Board Statements, dated 09/01/22 through 01/31/23, showed there had been no payment(s) made for Resident #26's room & board.
Record review of an email dated 03/14/23 at 11:29 A.M., showed the Regional BOM said Resident #26 was on skilled services through 08/14/22 and Resident #26 did not owe any surplus (room and board) for 05/06/22 through 08/14/22.
Record review of ATM Withdrawal Receipts provided by the Regional Business Office Manager on 02/10/23 and Direct Express Debit Card (the account to which the resident's monthly Social Security benefit is deposited) Monthly Account Statements provided by Resident #26 on 03/13/23, showed Resident #26's debit card was used for ATM withdrawals on the following dates/timeframes in the following amounts.
Date Amount Location
06/11/22
$504.00
[NAME], IL
06/11/22
$500.00
[NAME], IL
06/11/22
$500.00
[NAME], IL
06/11/22
$0.85
[NAME], IL
06/13/22
$1,000.00
[NAME] Manor
06/13/22
$2,000.00
[NAME] Manor
06/15/22
$504.00
East St. Louis, IL
06/15/22
$0.85
East St. Louis, IL
06/15/22
$504.00
East St. Louis, IL
06/15/22
$0.85
East St. Louis, IL
06/16/22
$500.00
Fairview Heights, IL
06/16/22
$0.85
Fairview Heights, IL
06/16/22
$40.00
Fairview Heights, IL
06/16/22
$0.85
Fairview Heights, IL
06/16/22
$400.00
Fariview Heights, IL
06/16/22
$0.85
Fairview Heights, IL
06/21/22
$500.00
Fairview Heights, IL
06/21/22
$0.85
Fairview Heights, IL
06/21/22
$500.00
Fairview Heights, IL
06/21/22
$0.85
Fairview Heights, IL
06/21/22
$460.00
Fairview Heights, IL
06/21/22
$0.85
Fairview Heights, IL
06/22/22
$504.00
[NAME], IL
06/22/22
$0.85
[NAME], IL
06/22/22
$484.00
[NAME], IL
06/22/22
$0.85
[NAME], IL
06/24/22
$504.00
East St. Louis, IL
06/24/22
$0.85
East St. Louis, IL
06/24/22
$504.00
East St. Louis, IL
06/24/22
$0.85
East St. Louis, IL
07/20/22
$500.00
[NAME], IL
07/20/22
$500.00
[NAME], IL
07/20/22
$0.85
[NAME], IL
07/20/22
$500.00
[NAME], IL
07/20/22
$0.85
[NAME], IL
07/21/22
$504.00
[NAME], IL
07/21/22
$0.85
[NAME], IL
07/21/22
$504.00
[NAME], IL
07/21/22
$0.85
[NAME], IL
08/16/22
$500.00
Fairview Heights, IL
08/16/22
$500.00
Fairview Heights, IL
08/16/22
$0.85
Fairview Heights, IL
08/17/22
$500.00
[NAME], IL
08/17/22
$0.85
[NAME], IL
08/17/22
$500.00
[NAME], IL
08/17/22
$0.85
[NAME], IL
08/18/22
$504.00
[NAME], IL
08/18/22
$0.85
[NAME], IL
08/18/22
$504.00
[NAME], IL
08/18/22
$0.85
[NAME], IL
08/18/22
$504.00
[NAME], IL
08/18/22
$0.85
[NAME], IL
08/23/22
$504.00
[NAME], IL
08/23/22
$0.85
[NAME], IL
08/23/22
$504.00
[NAME], IL
08/23/22
$0.85
[NAME], IL
09/22/22 $500.00 Fairview Heights, IL
09/22/22 $500.00 Fairview Heights, IL
09/22/22 $0.85
Fairview Heights, IL
09/22/22 $500.00 Fairview Heights, IL
09/22/22 $0.85
Fairview Heights, IL
09/23/22 $500.00 Fairview Heights, IL
09/23/22 $0.85
Fairview Heights, IL
09/23/22 $460.00 Fairview Heights, IL
09/23/22 $0.85 Fairview Heights, IL
10/19/22 $500.00 Fairview Heights, IL
10/19/22 $500.00 Fairview Heights, IL
10/19/22 $0.85
Fariview Heights, IL
10/19/22 $500.00 Fairview Heights, IL
10/19/22 $0.85
Fariview Heights, IL
10/20/22 $504.00
East St. Louis, IL
10/20/22 $0.85 East St. Louis, IL
10/20/22 $184.00
East St. Louis, IL
10/20/22 $0.85 East St. Louis, IL
11/16/22 $500.00 [NAME], IL
11/16/22 $500.00 [NAME], IL
11/16/22 $0.85
[NAME], IL
11/17/22 $500.00 [NAME], IL
11/17/22 $0.85
[NAME], IL
11/17/22 $500.00 [NAME], IL
11/17/22 $0.85
[NAME], IL
12/21/22 $504.00
East St. Louis, IL
12/21/22 $504.00
East St. Louis, IL
12/21/22
$0.85
East St. Louis, IL
12/23/22
$600.00
[NAME], IL
12/23/22
$0.85
[NAME], IL
12/23/22
$600.00
[NAME], IL
12/23/22
$0.85
[NAME], IL
01/18/23 $800.00 Fairview Heights, IL
01/18/23 $800.00 Fairview Heights, IL
01/18/23 $0.85
Fairview Heights, IL
01/20/23
$780.00 Fairview Heights, IL
01/20/23
$0.85
Fairview Heights, IL
Record review of the Direct Express Monthly Account Statement for 05/2022 showed an ending balance in the amount of $10,745.75 as of 05/31/22. Record review also showed a Social Security monthly deposit in the amount of $2,174.00 for 06/2022 through 12/2022 and $2,363.00 for 01/2023.
Record review of the Direct Express Monthly Account Statement for 01/2023 showed an ending balance in the amount of $119.90 as of 01/31/23.
During an interview on 02/10/23 at 4:00 P.M., Resident #26 said:
-His/her Direct Express debit card was held in a lock box in the office after he/she was admitted to the facility.
-He/she did authorize for one month's room and board to be withdrawn ($2,124.00), but did not authorize the former BOM to make all of the withdrawals with his/her debit card.
-He/she was not given any cash from the withdrawals.
-Staff told him/her the debit card was lost and a new one was opened.
During an interview on 02/22/23 at 2:59 P.M., the former BOM said:
-Resident #26 asked him/her to withdraw money for one month's room & board from Resident #26's debit card account.
-He/She withdrew the money for room & board for Resident #26.
-The debit card was lost around two to three months ago and was shut off.
-He/she gave Resident #26 all of the cash that was withdrawn so that Resident #26 could open a new account at a bank.
During an interview on 03/13/23 at 2:24 P.M., Resident #26 said:
-The former BOM came to his/her room holding the Direct Express debit card in 06/2022 and asked how much money was in the account. The former BOM then used his/her personal cell phone and called the bank to check the balance in Resident #26's Direct Express account. The former BOM did not ask Resident #26 if he/she wanted the former BOM to call to check the balance in the account. He/she heard the person on the phone say the balance was $10,7XX. The former BOM said there was too much money in the account for Resident #26 to get help with medical expenses and Resident #26 could only have $4,000 in the account. The former BOM said it would be best to continue to keep his/her debit card in the locked safe in the office.
-The resident did give the personal identification number for the debit card to the former BOM to withdraw the one month's room and board in 06/2022.
-He/she asked the former BOM if he/she had any money in the Direct Express debit account multiple times since he/she was admitted and the former BOM gave a different excuse for why he/she needed to know each time. The last time the resident asked for money the former BOM said there was no money in the account. He/she asked how there was no money in the account and the former BOM said he/she would check on it, but the resident did not receive a response.
-He/she felt threatened by the former BOM since he/she could not get out of bed.
-He/she overheard the former BOM telling his/her roommate the roommate could have more than a $50.00 monthly allowance and did not have to pay as much to the facility. Resident #26 thought this was not right and spoke with the Regional BOM about this in November or December of 2022. The resident also informed the Regional BOM at the same time that his/her debit card was supposed to be in the safe in the office, but he/she wondered if the debit card was missing because the former BOM kept giving him/her excuses. The Regional BOM told Resident #26 he/she would check on the card.
-The Regional BOM told Resident #26 he/she checked with the BOM and the BOM said the debit card was missing.
-He/she did get a new debit card on 01/24/23 but did not apply for one.
During an interview on 03/13/23 at 4:55 P.M., the former BOM said:
-He/she started withdrawing money from Resident #26's debit card in 06/2022 and did withdraw all of the withdrawals in [NAME], IL, Fairview Heights, IL and East St. Louis, IL because Resident #26 asked him/her to pay for Resident #26's room and board.
-He/she did give cash to Resident #26 and Resident #26 would hide the money under his/her bed in an envelope. He/she said he/she saw the envelope with cash under Resident #26's bed.
-Resident #26 would give money to his/her son.
-Resident #26 took the cash to another bank to open a new account in December of 2022.
During an interview on 03/13/23 at 5:26 P.M., Resident #26 said:
-In December of 2022 the former BOM came into his/her room with $1,000. He/she did not want the money but the former BOM insisted he/she take the money to buy clothes.
-The withdrawals on 06/13/22 in the amounts of $1,000 and $2,000 showed the money went to the facility for his/her for room & board.
-He/she did open an account at a different bank using a check from a Social Security Backpay in 12/2022, when the check was almost ready to expire.
-The former BOM asked him/her numerous times how much the Social Security check was for but he/she did not tell the former BOM.
-He/she did not receive any cash from the former BOM besides the $1,000 in 12/2022.
-He/she did not keep cash under his/her bed in an envelope, as that would be stupid since that's the first place people look for money.
Record review of an email dated 03/14/23 at 10:34 A.M., the Social Security Representative Payee Coordinator said Resident #26 did receive a Social Security backpay check in the same amount Resident #26 indicated on 12/21/21.
Record review of the Application for Employment dated 01/31/22 shows the former BOM lives in [NAME], IL.
#MO00212729
Dec 2022
2 deficiencies
CONCERN
(D)
📢 Someone Reported This
A family member, employee, or ombudsman was alarmed enough to file a formal complaint
Potential for Harm - no one hurt, but risky conditions existed
Deficiency F0658
(Tag F0658)
Could have caused harm · This affected 1 resident
**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** See F658 cited under Event ID# 45YC13
This deficiency is uncorrected. For previous examples, refer to the Statements of Deficien...
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**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** See F658 cited under Event ID# 45YC13
This deficiency is uncorrected. For previous examples, refer to the Statements of Deficiencies dated 08/19/22 and 10/7/22.
Based on interview and record review, the facility failed to ensure staff completed and documented completion of medications and treatments as ordered by the physician for four residents (Residents #44, #7, #42, and #35). The sample size was 25. The census was 114.
Review of the facility's Monitoring of Medication Administration policy, dated January 2020, showed:
-The consultant pharmacist evaluates medication administration to verify that the resident has received medications in accordance with the prescriber's orders and nursing care center policy. Procedures, personnel, and techniques are monitored, and intervention is provided when necessary. Medication administration monitoring includes, but is not limited to, medication pass observations, which are conducted by the consultant pharmacist or other designated nursing care center or pharmacy personnel;
-The consultant pharmacist, designated nursing staff or pharmacy designee, performs quality assurance evaluations to determine that:
-Medications are administered at the frequency and times indicated in the prescriber orders;
-Refusal or inability of the resident to take medications is evaluated, documented and responded to appropriately;
-Administration of medications is documented, including the frequency and reason for administration of as needed (PRN) medications.
1. Review of Resident #44's admission Minimum Data Set (MDS), a federally mandated assessment instrument completed by facility staff, dated 10/27/22, showed:
-Cognitively intact;
-Extensive assistance with bed mobility, transfers, dressing, toilet use and personal hygiene;
-Supervision with eating;
-Always incontinent of bladder and occasionally incontinent of bowel;
-Diagnoses included: anemia (decrease in the number of red blood cells), high blood pressure, psychotic disorder and peripheral vascular disease (PVD, poor circulation).
Review of the resident's electronic physician order sheet (ePOS), showed:
-An order dated 8/4/22, [NAME]-castor oil ointment (used to promote healing and treat certain types of pressure ulcers and wounds). Apply to affected area topically twice a day;
-An order dated 8/5/22, clipidogrel bisulfate (blood thinner) 75 milligrams (mg). One tablet by mouth daily;
- An order dated 8/5/22, pantoprazole 40 mg. One tablet by mouth twice a day for acid reflux;
-An order dated, 8/5/22, Senna S (stool softener) 8-6.50 mg. Two tablets by mouth twice a day for prevention;
- An order dated 8/5/22, Ready Care (high calorie and high protein nutritional drink) 60 milliliters (ml). 60 ml by mouth four times a day;
- An order dated 8/5/22, eucerin cream (lotion for very dry and sensitive skin). Apply to anterior right leg topically one time a day with dressing change/wound;
- An order dated 8/18/22, Ferrous Sulfate (iron supplement) 325 mg. One tablet by mouth three times a day related to anemia;
-An order dated 9/23/22, Lidocaine (used to treat pain) patch 4%. Apply patch to bilateral knees topically one time a day for pain;
-An order dated 10/13/22, right anterior knee skin prep (liquid dressing to protect wounds). Skin prep every Monday and Thursday;
-An order dated 11/7/22, Catheter (a sterile tube inserted into the bladder to drain urine) care every shift;
-An order dated 11/9/22, Wound care left anterior lower leg. Change every three days or as needed;
-An order dated 11/9/22, Wound care right anterior knee. Change every three days or as needed;
-An order dated 11/9/22, Wound care right lateral lower leg. Change every three days or as needed;
-An order dated 11/9/22 to 12/1/22, left medial ankle skin prep. Skin prep every day;
-An order dated 11/24/22, left medial ankle skin prep. Skin prep every day;
-An order dated 11/30/22, Singulair (allergy medication) 10 mg. One tablet by mouth at bedtime;
Review of the resident's Medication Administration Record (MAR) and Treatment Administration Record (TAR), showed the following missed doses:
-[NAME]-castor oil ointment. 9:00 A.M. treatment on 11/16/22, 11/17/22, and 12/5/22. 9:00 P.M. treatment on 11/16/22;
-Clipidogrel bisulfate 75 mg. 11/19/22 dose;
-Pantoprazole 40 mg. 9:00 P.M. dose on 11/16/22;
-Senna S 8-6.50 mg. 9:00 P.M. dose on 11/16/22;
-Ferrous sulfate 325 mg. 12:00 P.M. dose on 11/19/22;
-Ready care 60 cc. 1:00 P.M. dose on 11/19/22 and 12/5/22. 9:00 P.M. dose on 11/16/22;
-Eucerin cream. Treatments on 11/16/22, 11/17/22, and 12/5/22;
-Lidocaine patch 4%. Application on 11/16/22;
-Right anterior knee skin prep. Treatment on 12/1/22;
-Catheter care every shift. Day 11/16/22, 12/1/22, and 12/3/22. Night 11/19/22;
-Wound care left anterior lower leg treatments on 11/27/22 and 12/3/22;
-Wound care right anterior knee treatments on 11/27/22 and 12/3/22;
-Wound care right lateral lower leg treatments on 11/27/22 and 12/3/22;
-Left medial ankle skin prep treatments on 11/27/22 and 12/1/22;
-Left medial ankle skin prep treatments on 11/27/22, 12/1/22, and 12/3/22;
-Singulair 10 mg. Dose on 11/30/22 and 12/1/22;
-No documentation to show staff notified the physician or the reason for the missed doses or treatments.
2. Review of Resident #7's quarterly MDS, dated [DATE], showed:
-Cognitively intact;
-Extensive assistance with bed mobility, dressing and personal hygiene;
-Total dependence with eating, transfers and toilet use;
-Urinary catheter (a sterile tube inserted into the bladder to drain urine) and always incontinent of bowel;
-Diagnoses included: neurogenic bladder (the bladder does not empty properly due to a neurological condition), quadriplegia (paralysis of all four limbs), malnutrition, anxiety and depression.
Review of the resident's care plan, dated 6/30/22, showed:
-Focus: Resident has an activites of daily living (ADL) self-care performance deficit due to activity intolerance;
-Interventions: Bed mobility, totally dependent on one staff person for repositioning and turning in bed every two hours and as necessary. Transfer, totally dependent on two staff for transferring;
-Focus: Supra-pubic catheter (a surgically created connection between the urinary bladder and the skin, used to drain urine from the bladder in individuals with obstruction of normal urinary flow), high risk for infections;
-Interventions: Empty catheter bag every shift and as needed (PRN).
Review of the resident's physician's orders, showed:
-An order, dated 7/28/22, for supra-pubic catheter output every shift, check and record every shift.
Review of the resident's TAR, showed:
-An order, dated 7/28/22, for supra-pubic catheter output every shift, check and record every shift;
-Staff failed to document output on the day and night shift of 11/17/22, and on the day shift of 11/19 and 11/29/22.
3. Review of Resident #42's admission MDS, dated [DATE], showed:
-Moderate cognitive impairment;
-Extensive assistance with bed mobility, dressing, toileting and personal hygiene;
-Limited assistance with eating;
-Total dependence with transfer;
-Catheter and frequently incontinent of bowel;
-Diagnoses included: end stage renal disease (ESRD), diabetes, manic depression and malnutrition.
Review of the resident's medical record, showed the resident was discharged on 11/20/22.
Review of the resident's ePOS, showed:
-An order, dated 9/29/22, Gabapentin (used to treat nerve pain) 300 mg. Take one tab three times a day for pain;
-An order dated, 9/30/22, Mirtazapine (used to treat depression and anxiety) 15 mg. Take one take by mouth at bedtime for insomnia;
-An order, dated 9/30/22, Apixaban (anticoagulant) 5 mg. Take two tablets by mouth twice a day;
-An order, dated 9/30/22, Propranolol (treats high blood pressure) 10 mg. Take one tablet by mouth twice a day for high blood pressure;
-An order, dated 9/30/22, Senna (stool softener) 8.6 mg. Take two tablets twice a day for constipation;
-An order, dated 9/30/22, Sodium Zirconium (used to treat high potassium) 10 gram (gm) packet. Take one packet by mouth every 24 hours for high potassium;
-An order, dated 11/16/22, Glucerna (diabetic supplement). Drink one three times a day for supplement.
-An order dated, 11/16/22, ProMod (liquid protein that provides concentrated source of protein) twice a day for supplement 30 ml per dietician;
-An order dated, 10/17/22, Catheter care every shift.
Review of the resident's POS for the wound treatments, dated 11/2/22, showed:
-Left buttock cleanse with soap and water and pat dry. Apply calcium alginate and gentamycin. Cover with sacral silicone border gauze (multi-layer absorbent dressing. Change daily and as needed if dressing becomes soiled, loose, or dislodge every day shift for wound treatment;
-Coccyx (tailbone) cleanse with soap and water and pat dry. Apply calcium alginate and gentamycin. Cover with sacral silicone border gauze. Change daily and as needed if dressing becomes soiled, loose, or dislodged every day shift for wound treatment;
-Right buttock cleanse with soap and water and pat dry. Apply Calcium Alginate and Gentamycin. Cover with sacral silicone border gauze. Change daily and as needed if dressing becomes soiled, loose, or dislodged every day shift for wound treatment;
-Left lateral plantar foot cleanse with saline and pat dry. Apply calcium alginate. Apply 3 inch conforming gauze. Loosely wrap. Change daily and as needed if dressing becomes loose, soiled, or dislodged.
Review of the resident's November 2022 MAR and TAR, showed the following missed doses and treatments:
-Gabapentin 300 mg. 10:00 P.M. dose on 11/16 and 11/19;
-Mirtazapine 15 mg. 9:00 P.M. dose on 11/16 and 11/19;
-Apixaban 10 mg. 9:00 P.M. dose on 11/16 and 11/19;
-Propranolol 10 mg. 9:00 P.M. dose on 11/16 and 11/19;
-Senna 17.2 mg. 9:00 P.M. dose on 11/16 and 11/19;
-Sodium zirconium 10 gm. 9:00 P.M. dose on 11/16 and 11/19;
-Glucerna supplement. 9:00 A.M. and 1:00 P.M. dose on 11/17, 11/18, and 11/19. 9:00 P.M. dose on 11/16, 11/17, 11/18, and 11/19;
-Promod 30 ml protein supplement. 9:00 A.M. dose on 11/16, 11/17, 11/18, and 11/19. 5:00 P.M. dose on 11/17, 11/18, and 11/19;
-Treatment to left buttock left blank on 11/15 and 11/17;
-Treatment to coccyx left blank on 11/15 and 11/17;
-Treatment to right buttock left blank on 11/15 and 11/17;
-Treatment to left lateral plantar foot left blank on 11/15 and 11/17;
-No documentation to show staff notified the physician or the reason for the missed doses or treatments.
4. Review of Resident #35's admission MDS, dated [DATE], showed:
-Severe cognitive impairment;
-Extensive assistance with bed mobility, transfers, dressing, toilet use, personal hygiene and eating;
-Continent of bladder and frequently incontinent of bowel;
-Diagnoses included: acid reflux, wound infection, diabetes and stroke.
Review of the resident's medical record, showed the resident was discharged on 11/20/22.
Review of the resident's ePOS, showed:
-An order dated 11/17/22, Linezolid (antibiotic) 600 mg. One tablet by mouth twice a day for three days;
- An order dated 11/17/22, Vancomycin (antibiotic) 250 mg/5 ml. 2.5 ml by mouth twice a day for ten days;
- An order dated 11/17/22, Capsaicin cream (treats minor aches/pains of muscles and joints) 0.075%. Apply to bilateral lower extremities twice a day;
- An order dated 11/17/22, Collagenase ointment (removes damaged tissue from chronic skin ulcers and severely burned areas) 250 unit/gm. Apply to sacrum and hip ulcer twice a day;
- An order dated 11/17/22, Micatin cream (anti-fungal) 2%. Apply topically to affected area twice a day.
Review of the resident's MAR and TAR, showed the following missed doses and treatments:
-Linezolid 600 mg. 9:00 P.M. dose on 11/17/22;
-Vancomycin 2.5 ml. 9:00 P.M. dose on 11/17/22;
-Capsaicin cream 0.075%. 9:00 A.M. treatment on 11/17/22;
-Collagenase ointment 250 unit/gm. 9:00 A.M. treatment on 11/17/22;
-Micatin cream 2%. 9:00 A.M. treatment on 11/17/22;
-No documentation to show staff notified the physician or the reason for the missed doses or treatments.
5. During an interview on 12/8/22 at 4:49 PM, the Director of Nursing (DON) said if something is not documented, it indicates it was not done, a hole or blank is an order that was not completed. There should be a note if medication was not given, if medication was not administered, they need to contact the physician immediately.
During an interview on 12/7/22 at 2:30 P.M., Licensed Practice Nurse (LPN) M said the nurses and certified medical technicians (CMTs) should document if a medication is not given and then report it to a nurse or the charge nurse so medication can be reordered. If they are unable to get a medication, then staff should reach out to the physician.
During an interview on 12/8/22 at 4:50 P.M., the administrator said if it was not documented then it was not done. If the physician's order was not followed then the order is not completed. There should be a note if a dose was not given or treatment not done. The physician should be notified immediately if a dose is missed or there if a problem, to get further instructions. Then the family should be notified and documentation should be completed.
MO00208206
MO00209639
MO00209700
MO00210424
CONCERN
(E)
📢 Someone Reported This
A family member, employee, or ombudsman was alarmed enough to file a formal complaint
Potential for Harm - no one hurt, but risky conditions existed
ADL Care
(Tag F0677)
Could have caused harm · This affected multiple residents
**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** See F677 cited under Event ID# 45YC13.
Based on observation, interview and record review, the facility failed to provide adequat...
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**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** See F677 cited under Event ID# 45YC13.
Based on observation, interview and record review, the facility failed to provide adequate personal care to two residents (Residents #36 and #7) who required total staff assistance for meals and personal hygiene. The sample size was 51. The census was 114.
1. Review of Resident #36's quarterly Minimum Data Set (MDS), a federally mandated assessment instrument completed by facility staff, dated 11/20/22, showed:
-Cognitively intact;
-One staff assistance for eating;
-Diagnoses included heart failure, kidney disease, stroke and depression.
Review of the resident's care plan, dated 1/27/21 and revised on 3/9/22, showed:
-Focus: Bladder incontinence;
-Intervention: Clean perineal area (area between the legs and the buttocks area) with each incontinence episode;
-No direction for staff regarding meal assistance.
Observation and interview on 12/7/22 at 11:43 A.M., showed the resident in his/her room, seated on his/her bed. The head of the bed was elevated. The resident's lunch tray sat on the bedside table positioned adjacent to the bed. The meal appeared untouched and the drinks were full. The resident said no one has been in here to help me. The resident began crying, and said, No one will feed me.
During an interview on 12/7/22 at 12:17 P.M., Licensed Practical Nurse (LPN) C said the resident was set up only for meals.
During an interview on 12/7/22 at 2:04 P.M., Certified Medication Technician (CMT) N said the resident needed assistance with his/her meals. He/she said the resident does okay if he/she has something to eat like a cookie, but otherwise, needed assistance.
Observation and interview on 12/7/22 at 1:40 P.M., showed Resident #36 sat up in bed. The resident called out for help. The resident's food tray was sitting next to him/her on his/her bedside table. It appeared untouched and out of reach for the resident. CMT N was outside the resident's room, in the hallway with the medication cart. CMT N continued to pass medications. During an interview, CMT N said lunch trays came to the floor and were passed out to residents a little after 12:00 P.M. today.
Observation on 12/7/22 at 1:55 P.M., showed Certified Nurse Aide (CNA) J entered the resident's room and washed his/her hands. The CNA pulled the resident's privacy curtain and moved the bedside table, with the resident's untouched lunch tray, further away from the resident. While CNA J wet a washcloth, the resident asked the surveyor, Can you warm up my food?
Observation on 12/7/22 at 2:00 P.M., showed CNA J provided perineal care. He/she placed the used towel on the bedside table next to the food. He/she put ointment between the resident's legs, then put the open packet of ointment on the bedside table next to the resident's food. CNA J placed a clean brief on the resident and then positioned the resident. CNA J took the towel off the bedside table and gathered the trash before he/she left the room. He/she returned to the resident's room and moved the bedside table closer to the resident. The resident sat up and looked at food then the CNA. CNA J did not ask the resident why he/she did not eat or ask if he/she needed assistance. CNA J left the room and continued down the hall with the linen cart.
Observation on 12/7/22 at approximately 2:10 P.M., showed a dietary staff member brought a new lunch tray for the resident. He/she sat new tray next to the old tray. The resident looked at both trays.
Observation and interview on 12/7/22 at 2:37 P.M., showed the resident's old food was taken out of the room by dietary staff. The new tray sat covered by a lid on the bedside table. CNA J was asked if he/she knew that resident had not eaten and a new tray sat in there. He/she said no, because he/she was in different room. CNA J was asked if the resident can feed himself/herself. CNA J yelled loudly that he/she can feed themselves, which is why no one helped him/her. CNA J then entered the resident's room and was overheard asking the resident if he/she was ready to eat.
During an interview on 12/8/22 at 4:50 P.M., the Director of Nursing (DON) said when CNAs are handing out the trays, they should know if the resident needs assistance. If assistance is needed, they should set them up and position the resident. If an hour has passed between serving and assistance, it is an hour too long. Within 15 minutes they should check if the residents are eating and if there is a problem. Staff provide a service, they should be assisting. Placing soiled items next to trays is an infection control issue and should not be done.
2. Review of Resident #7's quarterly MDS, dated [DATE], showed:
-Cognitively intact;
-One staff assistance for eating;
-Diagnoses included quadriplegia (paralysis of all four limbs or of the entire body below the neck) and malnutrition.
Review of the resident's care plan, dated 6/30/22, showed no direction for staff regarding meal assistance.
Observation on the 100 hall on 12/5/22 at 12:30 P.M., showed the resident sat in bed. His/her lunch tray sat in front of him/her. The tray appeared untouched and the drinks were full.
Observation on 12/5/22 at 12:50 P.M., showed Dietary Aide O removed the dirty hall trays from the hallway and wheeled the cart down the hall. The resident's lunch tray remained in his/her room untouched.
Observation on 12/5/22 at 12:55 P.M., showed the resident remained in the same position in bed. His/her lunch tray sat on the bedside table, positioned over his/her lap. His/her meal appeared untouched, his/her drinks were full. The resident said someone was supposed to return and help him/her eat his/her meal, but did not know their name. He/she said his/her meal had been sitting in front of him/her for over twenty minutes.
During an interview on 12/5/22 at 1:03 P.M., CMT N said the CNA who was supposed to be assisting residents with their meals was somewhere on the hall.
During an interview on 12/5/22 at 1:20 P.M., CNA I said he/she was from an agency and this was his/her first time at the facility. CNA I said he/she assumed because the trays were gone, someone had helped the resident eat. CNA I then walked down the hall, without checking on the resident.
Observation and interview on 12/5/22 at 1:30 P.M., showed the resident's lunch tray remained on his/her bedside table and appeared untouched. He/she said no one had come in to help him/her eat.
Observation on 12/5/22 at 1:35 P.M., showed CNA I and CNA J entered the resident's room. CNA J noticed the untouched food that sat in front of the resident when he/she went to move the bedside table. The resident said he/she had waited to eat and was told by another CNA that he/she would return and help the resident.
Review of the resident's care plan, dated 6/30/22, showed:
-Focus: Resident has an activities of daily living (ADL) self-care performance deficit due to activity intolerance;
-Interventions: Bed mobility, totally dependent on one staff person for repositioning and turning in bed every two hours and as necessary. Transfer, totally dependent on two staff for transferring;
-Focus: Bowel incontinence;
-Interventions: Encourage resident to sit on toilet to evacuate bowels if possible;
-Focus: Potential/actual impairment to skin. Avoid scratching and keep hands and body parts from excessive moisture;
-Interventions: Keep skin clean and dry. Use lotion on dry skin. Encourage good nutrition and hydration in order to promote healthier skin;
-Focus: Suprapubic catheter (a sterile tube inserted into the bladder through the abdominal wall to drain urine), high risk for infections;
-Interventions: Empty Catheter bag every shift and as needed (PRN).
During an interview on 12/5/22 at 12:55 P.M., the resident said the administrator had been in that morning to discuss concerns. He/she told the administrator he/she had a bowel movement and needed to be cleaned up. The resident said he/she still sat in feces.
During an interview on 12/5/22 at 1:30 P.M. the resident said he/she was still sitting in feces, which was beginning to itch. He/she needed care to be provided. The surveyor then requested staff assist the resident with both his/her meal and peri care.
Observation on 12/5/22 at 1:35 P.M., showed CNA I and CNA J entered the room to provide perineal care. The resident's suprapubic catheter site was observed along with feces that covered the entire inside of the front pubic area and on the resident's genitalia.
During an interview on 12/7/22 at 10:45 A.M., the resident said he/she is unable care for him/herself and staff do not adequate provide care. He/she said he/she just wants to be cared for, he/she feels his/her needs are dismissed and his/her needs don't matter.
During an interview on 12/8/22 at 4:50 P.M., the Director of Nursing (DON) said when CNAs are handing out the trays, they should know if the resident needs assistance. If assistance is needed, they should set them up and position the resident. If an hour has passed between serving and assistance, it is an hour too long. Within 15 minutes they should check if the residents are eating and if there is a problem. Staff provide a service, they should be assisting. Leaving a resident sitting in feces is unacceptable.
MO00208062
MO00208206
MO00209639
MO00209700
MO00210018
MO00210407
MO00210424
MO00210795
Mar 2020
21 deficiencies
2 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, interview and record review, the facility failed to ensure that residents receive treatment and care in ac...
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 that residents receive treatment and care in accordance with professional standards of practice for four residents (#138, #141, #135, and #143), of six residents investigated for non-pressure wounds and wound care when the facility failed to assess and treat wounds per facility policy and standards of practice. Resident #138 had a delay in treatment orders after admission. The facility failed to routinely apply the ordered treatments and assess the wounds. The resident had a change in level of swelling and wound drainage and the facility failed to timely notify the physician after identifying the change. The resident had a change in mental status after several days of increased swelling, drainage and pain; and was sent to the hospital. The resident required surgical debridement (removal of dead tissue) of a right heel wound and a below the knee amputation (BKA) of the left lower extremity due to the condition of the wounds. The sample was 29. The census was 143.
Review of the facility's Facility Assessment Tool, updated 2/25/20, showed:
-Purpose: To determine what recourses are necessary to care for residents competently during both day-to-day operations and emergencies. Use this assessment to make decisions about your direct care staff needs, as well as your capabilities to provide services to the residents in your facility. Using a competency-based approach focuses on ensuring that each resident is provided care that allows the resident to maintain or attain their highest practicable physical, mental and psychosocial well-being;
-Services and care offered based on resident needs: Pressure injury prevention and care, skin care, wound care.
Review of the facility's Skin Ulcer-Wound Policy, dated 8/15/18, showed:
-All caregivers are responsible for preventing, caring for and providing treatment for skin ulcerations;
-Purpose: To identify at risk residents for potential breakdown or ulcerations, to prevent breakdown of tissue or ulcerations and to provide treatment that promotes prevention of ulcerations and healing of existing ulcerations;
-Definition: For the purpose of this policy, a skin ulcer (wound) is defined as any open area of the skin regardless of origin. It may also include an area of discoloration that is not open if the nurse identifies an area of concern that may potentially ulcerate and then confirms suspicion with a provider (physician/nurse practitioner/physician assistant/midlevel) for diagnosis;
-Assessment:
-Licensed staff will, upon admission, perform a head to toe body audit within 2 hours of admission. The findings will be documented in the resident's clinical record. Any items not documented in the admission assessment form will be charted in the nurse's notes;
-Licensed staff will complete a head to toe skin assessment weekly and as needed. The skin assessment will be documented on a skin assessment form and become part of the resident's clinical record. Any unusual findings will be documented on the form with a follow-up note in the nurse's notes further describing the area of concern;
-Treatment protocols:
-Consult wound care providers when appropriate;
-Until wound care providers can assess and order treatment, the following techniques may be employed:
-Follow standard precautions and good hand hygiene techniques;
-For non-open areas of concern or areas covered with stable eschar (dry dead tissue), apply skin prep (protective barrier wipe) daily and use preventative measures. On areas where skin prep is not appropriate (i.e. buttocks, etc.) moisture barrier cream is adequate. Skin prep may also be used for un-ruptured serous fluid (clear drainage) or blood-filled blisters;
-For all other open areas, the treatment is determined based on tissue type and drainage;
-All orders must be approved by a physician within 24 hours of discovering the open area or change in treatment;
-Assessment protocols:
-Nurses may not diagnose, just describe;
-Measurements must be completed weekly;
-At the time a skin issue is discovered, it must be measured. Wounds are three dimensional; therefore length, width and depth must be documented if using measuring instrument. It is acceptable to measure using common household objects (i.e. dime size, quarter size, half dollar) until actual measurements can be obtained per facility protocol;
-Length of wound should always be measured in head to toe alignment. Width should always be measured in hip to hip or side to side alignment. Depth should always be the deepest part of the wound in perpendicular alignment;
-If a reddened area is identified, the nurse should assess if the area is blanching (when skin color fades when pressure is applied and returns when pressure is released). If it is no blanching, then it should be captured on the licensed body audit report.
1. Review of the facility's Notification Changes in Condition policy, revised 1/28/20, showed:
-It is the responsibility of licensed staff to contact the physician and the resident's responsible party whenever there is a change in the resident's physical, mental or psychosocial status;
-Acute change in condition: A sudden, clinically important deviation from a resident's baseline in physical, cognitive, behavioral or functional status that, without intervention, may result in complications or death;
-Upon identification of any change in condition, licensed nursing personnel will contact the resident's attending physician/on-call physician/practitioner to notify him/her of the change. Acute changes in condition should occur immediately upon recognition;
-All notification should be preceded by an appropriate physical, mental or psychosocial assessment to enable the physician to make adequate and appropriate treatment and/or transfer decisions;
-All notifications should be documented and should include:
-The date and time of the notification;
-The name of the individual contacted;
-The specific reason for the notification;
-And any specific responses that were given by the person contacted;
-All changes in condition require follow-up assessment and documentation of resident condition which should include, at a minimum: Vital signs, pain, orientation, any change from baseline status, and status of any pending labs/diagnostics.
Review of Resident #138's admission Minimum Data Set (MDS), a federally mandated assessment instrument completed by facility staff, showed:
-admitted [DATE] from an acute hospital;
-Clear speech, understood and understands;
-Moderately impaired cognition;
-Rejection of care: Behavior not exhibited;
-Limited assistance required for dressing;
-Supervision required for personal hygiene;
-Diagnoses included: Peripheral vascular disease (PVD, is a blood circulation disorder that causes the blood vessels outside of your heart and brain to narrow), septicemia (sepsis, systemic infection of the blood) diabetes and high cholesterol;
-Infection of the foot;
-Application of nonsurgical dressings other than to feet
-Applications of dressings to feet.
Review of the resident's care plan, in use while a resident at the facility, showed:
-Focus: The resident has PVD:
-Goal: Remain free of complications;
-Interventions: Elevate legs when sitting or sleeping. Monitor extremities for signs and symptoms of injury, infection or ulcers. Monitor/document/report as needed any signs and symptoms of skin problems related to PVD: Redness, swelling, blistering, itching, burning, bruises, cuts or other skin lesions;
-Focus: The resident has diabetes:
-Goal: Have no complications related to diabetes;
-Interventions: Refer to podiatrist/foot care nurse to monitor/document foot care needs and to cut long nails;
-Focus: The resident has infection of the (specify):
-Goal: Be free from complications related to infection;
-Interventions: (blank);
-Focus: The resident has potential/actual impairment to skin integrity:
-Goal: The resident will maintain intact skin. Skin breakdown will show to be improved;
-Interventions: Avoid scratching and keep hands and body parts from excessive moisture. Educate of causative factors and measures to prevent skin injury. Monitor/document location, size and treatment of skin injury. Report abnormalities, failure to heal, signs and symptoms of infection, maceration (softness as a result from excess moisture), etc. to the physician. Treatment per physician orders. Weekly treatment documentation.
Review of the resident's diagnoses list, showed:
-Cellulitis (infection of the skin), acute infection, diagnosis on admission;
-Cellulitis of the right lower limb, acute infection, diagnosis on admission;
-Osteomyelitis (inflammation of the bone caused by infection), diagnosis on admission;
-Non-pressure chronic ulcer of right heel and mid foot with necrosis (dead tissue) of bone, history diagnosis;
-Sepsis, history diagnosis;
-Local infection of the skin and subcutaneous tissue (lower layer of the skin), history diagnosis;
-PVD, diagnosis on admission;
-Diabetes, diagnosis on admission.
Review of the resident's progress notes, showed:
-On 2/6/20 at 10:58 P.M., the resident admitted for observation/assessment of condition. The resident is alert and oriented to person, place, time and situation. The resident has no changes in mood or behavior noted. The resident has no notable changes in skin integrity. The following wounds are currently being treated: Coccyx (tailbone area), left buttocks. (No documentation of a treatment to the left or right lower extremities). Edema (swelling) both lower extremities 1+ (based on the edema scale, used to determine the severity of the edema. 1+ has 2 millimeter (mm) depression or barely visible that disappears rapidly and is the lowest severity grade. The edema scale goes up to 4+);
-On 2/7/20 at 5:30 A.M., admission assessment: Skin issues present, refer to assessment for more information.
Review of the resident's Nursing admission Assessment, dated 2/7/20 at 5:30 A.M., showed:
-Date and approximate time of arrival: 2/6/20 at 5:20 P.M.;
-Skin condition:
-Top of left foot, red circle area, weeping (draining fluid) noted;
-Right toes, missing some great toe.
Review of the resident's progress notes, dated 2/7/20 at 10:05 P.M. through 2/11/20 at 6:52 A.M., showed:
-On 2/7/20 at 10:05 P.M., there are no wounds currently noted. Edema 1+ both lower extremities. Infection details: (blank);
-On 2/8/20 at 7:50 P.M., the resident has notable changes in skin integrity. The following wounds are currently being treated: left buttocks. Edema 1+ both lower extremities. Infection details: Cellulitis;
-On 2/9/20 at 1:54 A.M., the resident has notable changes in skin integrity. The following wounds are currently being treated: left buttocks. Edema 1+ both lower extremities. Infection details: Cellulitis;
-On 2/9/20 at 1:30 P.M., the resident has notable changes in skin integrity. The following wounds are currently being treated: Both lower extremity dressing changed per treatment order. Edema 3+ (5-6 mm depression) both lower extremities and arms. Infection details: Cellulitis;
-On 2/9/20 at 10:00 P.M., the resident has notable changes in skin integrity. The following wounds are being treated: Left buttocks. Edema 3+ both lower extremities and feet. Infection details: Osteomyelitis;
-On 2/10/20 at 2:12 A.M., the resident has notable changes in skin integrity. The following wounds are being treated: Left buttocks. Edema 3+ both lower extremities and feet. Infection details: Cellulitis;
-On 2/10/20 at 2:49 P.M., the resident has no notable changes in skin integrity. There are no wounds currently noted. Both lower extremity feet dressings changed per treatment order. Edema present, both feet. Infection details: Osteomyelitis;
-On 2/11/20 at 6:52 A.M., resident alert, pleasant, skin with dressing;
-No further documentation of the wounds to the lower extremities, documentation the physician was notified of the wounds, increased edema, or descriptions/measurements of the wounds.
Review of the resident's electronic physician order sheet (ePOS), showed:
-An order dated 2/6/20, for acetaminophen (Tylenol) 325 milligram (mg) every 4 hours as needed for pain;
-An order dated 2/11/20 at 7:00 A.M., cleanse area to left anterior (front side) foot with wound cleanser, pat dry, apply triple antibiotic ointment (TAO) and ABD pad (absorbing dressing), wrap with Kerlix (gauze wrap) and secure with tape daily;
-An order dated 2/11/20 at 7:00 A.M., cleanse area to right lower extremity with wound cleanser, pat dry, apply ABD pads, wrap with Kerlix and secure with tape daily, every day shift for third spacing drainage (occurs when too much fluid moves from the intravascular space (blood vessels) into the interstitial or third space-the nonfunctional area between cells. This can cause potentially serious problems such as edema);
-An order dated 2/12/20, for weekly skin assessments;
-No treatment order for the lower extremities prior to 2/11/20.
Review of the resident's treatment administration record (TAR), for February 2020, showed:
-An order dated 2/11/20 at 7:00 A.M., cleanse area to left anterior foot with wound cleanser, pat dry, apply TAO and ABD pad, wrap with Kerlix and secure with tape daily:
-Documented as not administered, see progress note, on 2/11/20 and 2/18/20;
-Not documented as refused or administered on 2/12, 2/13, 2/15, 2/20 and 2/21/20;
-An order dated 2/11/20 at 7:00 A.M., cleanse area to right lower extremity with wound cleanser, pat dry, apply ABD pads, wrap with Kerlix and secure with tape daily, every day shift for third spacing (occurs when too much fluid moves from the intravascular space (blood vessels) into the interstitial or third space-the nonfunctional area between cells. This can cause potentially serious problems such as edema, reduced cardiac output, and low blood pressure);
-Documented as refused on 2/11/20;
-Not documented as refused or administered on 2/12, 2/13, 2/15, 2/20 and 2/21/20;
-Documented as not administered, see progress note, on 2/18/20;
-No documentation of any treatment orders for the left lower or right lower extremity prior to 2/11/20.
Review of the facility's wound reports, dated 2/12/20, 2/28/20 and undated and identified by the director of nursing (DON) as dated 2/21/20, showed the resident not listed on the wound report for any wounds. No tracking of wound progress, measurements or treatments.
Review of the resident's progress notes, dated 2/11/20 at 5:32 P.M. through 2/12/20 at 11:07 P.M., showed:
-On 2/11/20 at 5:32 P.M., orders administration note: Cleanse area to left anterior foot with wound cleanser, pat dry, apply TAO and ABD pads, wrapped with Kerlix and secure with tape daily. Refused, resident stated every time I get ready to do something, someone comes in;
-On 2/11/20 at 10:58 P.M., the resident has no notable changes in skin integrity. The following wounds are currently being treated: left buttocks. Edema 3+ both lower extremities and feet. Infection details: Cellulitis;
-On 2/12/20 at 10:25 A.M., weeping edema to both lower extremities;
-On 2/12/20 at 10:45 P.M., the resident has no notable changes in skin integrity. There are no wounds currently noted. Edema 3+ both lower extremities and feet. Infection details: Cellulitis;
-On 2/12/20 at 11:07 P.M., weekly skin observation. Skin color is normal. Skin temperature is dry and warm. Skin issues present. Refer to assessment for more information.
Review of the resident's weekly skin observation, dated 2/12/20 at 11:07 P.M., showed:
-Skin condition: Reddened area top of left foot. On antibiotic therapy.
Review of the resident's progress notes, dated 2/13/20 at 2:43 A.M. through 2/19/20 at 3:35 P.M., showed:
-On 2/13/20 at 2:43 A.M., the resident has no notable changes in skin integrity. There are no wounds currently noted. Edema 3+ both lower extremities and feet. Infection details: Cellulitis. Additional comments: Resident is on antibiotics related to cellulitis to both lower extremities and feet;
-On 2/13/20 at 10:07 P.M., the resident has no notable changes in skin integrity. There are no wounds currently noted. Edema 3+ both lower extremities and feet. Infection details: Cellulitis. Additional comments: Resident completed antibiotics;
-On 2/17/20 at 11:30 A.M., infection note: On antibiotic for cellulitis, noted weeping edema to both lower extremities;
-On 2/17/20 at 5:15 P.M., acetaminophen administration for pain;
-On 2/17/20 at 7:20 P.M., infection note: On antibiotic for cellulitis, noted significant weeping and edema to both lower extremities;
-On 2/17/20 at 9:15 P.M., acetaminophen administration for pain;
-On 2/18/20 at 5:07 A.M., weeping edema to both lower extremities;
-On 2/18/20 at 3:04 P.M., cleanse are to left anterior foot. Resident declined wound care today;
-On 2/18/20 at 3:05 P.M., cleanse area to right lower extremity. Resident declined wound care today;
-On 2/18/20 at 4:03 P.M., acetaminophen administration for pain. Resident complained of throbbing pain in feet;
-On 2/18/20 at 5:50 P.M., acetaminophen administration for pain;
-On 2/19/20 at 3:35 P.M., weekly skin observation: Skin issues present. Refer to assessment for more information.
Review of the resident's Weekly Skin Observation, dated 2/19/20 at 3:35 P.M., showed:
-Reddened area great toe/antibiotic therapy.
Review of the resident's progress notes, dated 2/19/20 at 7:47 P.M. through 2/23/20 at 4:00 P.M., showed:
-On 2/19/20 at 7:47 P.M., roommate called nursing staff to room stating the resident is on the floor. Upon arrival to room, the resident was lying on the floor stating he/she tried to stand up and fell on the floor. DON, physician and facility supervisor informed;
-On 2/19/20 at 11:02 P.M., weekly skin observation: No skin issues present;
-On 2/22/20 at 1:37 P.M., edema 4+ (8 mm depression, or a very deep indentation, the most severe type of edema) weeping to both lower extremities. Dressings changed;
-On 2/22/20 at 9:38 P.M., edema 4+ weeping to both lower extremities. Dressing changed;
-On 2/23/20 at 3:00 P.M., resident has signs and symptoms of altered mental status and weakness noted. Very poor appetite this shift. Resident asking for juice and water with juice and water sitting on table within reach of resident. Resident appears very weak. Unable to sit on side of bed without falling to side. Edema and drainage to both lower extremities seems to be getting worse, legs wrapped x2 this shift and draining continues to come though wraps, on bed and floor. Drainage is yellow and very foul smelling. Toes to right leg have dark discoloration noted. Verbal, but not making sense (less sense than normal). Family at bedside stating that the resident is not responding to them the way that the resident normally does. Call placed to physician, notified of assessment and change in condition noted. New orders noted to send to hospital. Call placed to ambulance for non-emergency transfer;
-On 2/23/20 at 4:00 P.M., ambulance arrived.
Further review of the resident's ePOS, showed an order dated 2/23/20, send resident to hospital.
Review of the resident's hospital surgical report, dated 2/23/20, showed:
-Date of surgery 2/23/20;
-Preoperative diagnosis: Left lower extremity critical limb ischemia (insufficient supply of blood) and wet gangrene (moist gangrene may occur in the toes, feet, or legs after a crushing injury or as a result of some other factor that causes blood flow to the area to suddenly stop);
-Surgery/procedure performed: Left lower extremity below-knee guillotine amputation (open or guillotine amputation is often required when infection is present and there is a need for free drainage from the operative site. A second surgical procedure involving stump (or residual limb) revision or closure is needed after the guillotine procedure. This is done only after the infection has been eliminated);
-Findings: Grossly ischemic left lower leg that appeared unsalvageable, left great toe completely dusky/black, desquamation (sheading of skin) and dependent blood pooling the into soft tissues of the left foot and lower leg up to mid-calf. Left lower leg cool to the touch and pale with moderate soft tissue edema. Sluggish bleeding from amputation site, muscle dusky but appeared viable;
-Indications for surgery/procedure: The resident arrived to the hospital emergency department with altered mental status from a nursing facility. He/she was brought to the hospital by a family member who was concerned about the care that the resident was receiving at the nursing facility and noted acute changes to the left lower extremity. On arrival, the resident was found to have significant ischemic changes to the left foot and lower leg up to the mid-calf including a completely black left great toe, pallor (paleness) of the lower leg and desquamation. The patient was unable to provide medical history due to altered mental status and was admitted to the intensive care unit with an urgent surgical consult. Due to the appearance of the left lower extremity and concerns for critical limb ischemia, urgent surgical intervention was discussed with family, involving a left lower extremity below-knee guillotine amputation.
Review of the resident's hospital surgical report, dated 2/26/20, showed:
-Date of surgery: 2/26/20;
-Preoperative diagnosis: Left lower extremity ischemia;
-Surgery/procedure performed: Right foot wound debridement (removal of dead tissue). Revision of left lower extremity amputation, left knee disarticulation (amputation of a limb through a joint, without cutting of bone);
-Findings: Ischemic changes of left lower extremity below the knee stump that appears unsalvageable;
-Indication for surgery/procedure: Left lower extremity ischemia, sepsis/shock;
-Condition at discharge: Critical.
During an interview on 3/16/20 at 12:09 P.M., with the DON, Administrator, and nurse practitioner, the DON said care plans should be complete. The DON and nurse practitioner said if a resident is admitted with a wound, treatment orders should be obtained on admission. Staff should follow the wound policy and document assessments of wounds. Changes in wounds should be reported to the physician. Treatments should be applied as ordered.
2. Review of Resident #141's quarterly MDS, dated [DATE], showed:
-Cognitively intact;
-Extensive assistance required for bed mobility, dressing, toilet use and personal hygiene;
-Diagnoses included paraplegia (impairment or loss of motor or sensory function in areas of the body) and anxiety disorder;
-Other ulcer, wounds and skin problems: No.
Review of the resident's care plan, dated 11/1/18, showed:
-Focus: Open area noted to left buttock non-pressure related. Updated 2/26/20: The wound seems to be deteriorating as he/she continues to spend long periods of time in his/her wheelchair. Skin is also staying moist due to constant sweating on bottom, fold and creases;
-Goal: Wound will exhibit signs of healing and/or be healed without any signs/symptoms of infection;
-Interventions: Administer treatments as ordered and monitor for effectiveness. Follow facility policies/protocols for the prevention/treatment of skin breakdown. Weekly treatment documentation to include measurement of each area of skin breakdown's width, length, depth, type of tissue and exudate (drainage).
Review of the resident's medical record, showed:
-An order dated 11/10/19, for skin prep wipes to left gluteal (buttocks) two times day;
-The order not documented as completed as ordered or refused, 11 of 62 opportunities in December 2019;
-An order dated 12/5/19, for skin prep to left buttocks daily;
-The order not documented as completed as ordered or refused, six of 27 opportunities in December 2019;
-A weekly skin observation, dated 12/9/19: left buttocks, treatment in place;
-A weekly wound observation tool, dated 12/10/19: Left buttocks moisture associated skin damage (MASD) measured 1.8 x 2 x 0.1;
-A weekly skin observation, dated 12/16/19: Left gluteal fold, skin prep and cream applied;
-A weekly wound observation tool, dated 12/17/19: Left buttocks MASD measured 1.8 x 2 x 0.1;
-A weekly skin observation, dated 12/23/19: Left gluteal fold open area;
-A weekly wound observation tool, dated 12/24/19: Left buttocks MASD measured 2 x 1.8 x 0.1;
-A weekly skin observation, dated 12/30/19: Left gluteal fold with current treatment in place;
-The order for skin prep wipes to left gluteal two times a day not documented as completed as ordered or refused, seven of 43 opportunities in January 2020;
-The order for skin prep to left buttocks daily not documented as completed as ordered or refused, seven of 22 opportunities in January 2020;
-A weekly skin observation, dated 1/6/20: Left buttocks treatment in place;
-A weekly wound observation tool, dated 1/8/20: Left medial thigh MASD 5 x 4 x 0.2;
-A weekly skin observation, dated 1/13/20: Left gluteal fold open area with treatment in place;
-A weekly skin observation, dated 1/20/20: Left gluteal fold open area with treatment in place;
-An order dated 1/22/20, to discontinue both orders for skin prep;
-No treatment for the left buttocks/thigh wound ordered or documented as applied from 1/23/20 through 2/11/20;
-No skin assessments or wound assessment completed from 1/23/20 through 2/10/20;
-A weekly skin observation, dated 2/11/20: Left buttocks open area;
-An order dated 2/12/20 and discontinued 2/17/20, for Venelex ointment (combination medicine used to treat skin wounds) apply to left buttocks topically two times a day for left buttocks abrasion;
-Not documented as applied as ordered or refused, three of 12 opportunities in February 2020;
-A weekly skin observation, dated 2/17/20: Left buttocks treatment in place;
-An order dated 2/18/20, for Venelex ointment, apply to right buttocks topically every day and evening shift for right buttocks abrasion;
-Not documented as applied as ordered or refused, 13 of 24 opportunities in February 2020;
-A weekly skin observation, dated 2/24/20: Left buttocks dressing intact;
-A weekly skin observation, dated 3/2/20: Right gluteal fold buttocks, treatment nurse aware;
-A weekly skin observation, dated 3/9/20: Right gluteal fold wound to area beefy red;
-An order dated 3/9/20, for the wound care clinic to evaluate and treat;
-No further wound measurements since 1/8/20. No further descriptions of wound appearance or drainage. No clarification if the wound was on the left or right buttock.
Further review of the resident's medical record, showed an order, dated 3/11/20 at 7:00 A.M., to clean wound with wound cleaner, pat dry, apply calcium alginate (used to absorb moisture) to wound bed, cover with ABD and secure with tape daily;
Observation on 3/11/20 at 7:43 A.M., showed Wound Nurse O provided wound care for the resident with the nurse from the wound clinic. The wound was located on the resident's left posterior thigh/buttocks area. A dressing dated 3/10/20 was in place. The wound was large and beefy red. An area with loose grey tissue visible. The wound care nurse measured the wound.
Review of the wound care clinic note, dated 3/11/20, showed the following for the resident:
-Wound assessment: Left thigh acute full thickness (extend past the two layers of skin (dermis and epidermis) and extend into the subcutaneous (fat) tissue). Measurements 7.5 centimeter (cm) length (L) by 8.3 cm width (W) by 0.2 cm depth (D), there is a moderate amount of serosanguineous (thin, watery, pale red to pink drainage) drainage noted. Wound bed has 51-75% slough (moist dead tissue), 26-50% granulation (new tissue growth). The wound is deteroriating.
Review of the facility's wound report, dated 2/28/20 and the most recent wound report provided by the facility, showed the resident listed with a new wound onset date of 3/2/20.
During an interview on 3/12/20 at 6:35 P.M., with the DON, Administrator and Wound Nurse O, they said the documentation in the wound report and documentation in the medical record should be accurate. The wound on the resident is MASD and not pressure. Nurses are not trained to stage wounds and should not be staging wounds. The nurse practitioner or wound company are the only ones who can stage a wound. If staff observe a wound, they should describe the wound and measure the wound. Staff should be knowledgeable with anatomical locations of wounds. The resident has had the wound healed out and then comes back, as well as having other wounds that have healed. Documentation should clearly identify wounds and show the progression of the wounds. Wound assessment and measurements should be obtained immediately upon admission and the wound nurse will assess any reported wounds to determine if the wound company needs to be consulted. The wound policy should be followed and measurements obtained weekly. The resident's wound was just added to the February 28th wound report, which is why the onset date shows March 2nd. The facility is currently transitioning from one wound nurse to another. Treatments should be administered as ordered and current wounds should have orders for treatments.
3. Review of Resident #135's quarterly MDS, dated [DATE], showed:
-Cognitively intact;
-No behaviors;
-Total dependence for bed mobility, transfer, dressing and personal hygiene;
-Diagnoses included quadriplegia (paralysis of all four limbs), seizure disorder, anxiety and depression;
-Total number of venous and arterial ulcers, one;
-Surgical wound care not indicated.
Review of the resident's care plan, in use at the time of the survey, showed:
-Focus: Chronic pressure ulcers present on admission due to limited mobility. Open areas to Coccyx/sacral, medial back, both gluteal fold, right lateral leg distal and open areas to left and right hip, left lateral foot:
-Goal: Pressure ulcers/other wounds will show signs of healing and remain free from infection;
-Interventions: Administer treatments as ordered and monitor for effectiveness. Follow facility policies/protocols for the prevention/treatment of skin breakdown. Weekly treatment documentation to include measurement of each area of skin breakdown's width, length, depth, type of tissue and exudate.
Review of the resident's medical record, showed:
-A skin/wound note, dated 10/25/29: Resident seen by wound care:
-Area to right distal lateral lower leg presents as a chronic full thickness arterial ulcer measuring at 37.8x2.5x0.4, with moderate serosanguineous drainage. Tendon and bone are exposed. Wound bed has 51-75% bright red granulation;
-Area to medial abdomen presents as an acute full thickness surgical wound measuring at 01.3x0.8x0.2, with moderate serosanguineous drainage. Wound bed has 76-100% granulation;
-Area to left anterior ankle presents as an acute full thickness arterial ulcer measuring at 1.4x2.4x0.2, with moderate serosanguineous drainage. Wound bed has 76-100% bright red granulation;
-A weekly skin observation, dated 10/26/19: Skin issues present. Right lower leg treatment in place, left lower leg treatment in place (no mention of abdomen wound);
-A weekly skin observation, dated 11/2/19: Skin issues present. Right lower leg treatment in place, left lower leg treatment in place (no mention of abdominal wound);
-A weekly skin observation, dated 11/9/19: Skin issues present. Right lower leg treatment in place, left lower leg treatment in place (no mention of abdominal wound);
-A weekly skin observation, dated 11/16/19: No skin issues present;
-A weekly skin observation, dated 12/17/19: No skin issues present;
-A weekly skin observation, dated 12/24/19: No skin issues present;
-A weekly skin observation, dated 12/31/19: No skin issues present;
-A weekly skin observation, dated 1/7/20: No skin issues present;
-A weekly skin obser
SERIOUS
(G)
Actual Harm - a resident was hurt due to facility failures
Pressure Ulcer Prevention
(Tag F0686)
A resident was harmed · This affected 1 resident
**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, interview and record review, the facility failed to ensure residents received care to prevent pressure ulc...
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**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, interview and record review, the facility failed to ensure residents received care to prevent pressure ulcers and ensure residents with pressure ulcers receive the necessary treatment and services to promote healing, for five of seven residents investigated for pressure ulcers (Residents #56, #135, #60, and #143). The facility failed to assess wounds per facility policy and standards of practice and provide treatments as ordered. Resident #56 had a delay in identification of a pressure ulcer. When first identified by the facility, the pressure ulcers was a stage III. This resulted in a delay of treatment. After identified, the facility failed to assess and monitor the wound and failed to provide treatments as ordered consistently, which resulted in the wound developing into a stage IV pressure ulcer. The wound became infected and the resident required hospitalization for sepsis and surgical wound debridement. The sample was 29. The census was 143.
Review of the facility's Centers for Medicare and Medicaid (CMS) form 802, showed:
-The facility identified five resident's as having pressure ulcers (any lesion caused by unrelieved pressure that results in damage to the underlying tissue);
-Residents #56 and #143 were not identified as having pressure ulcers.
Review of the facility's Facility Assessment Tool, updated 2/25/20, showed:
-Purpose: To determine what recourses are necessary to care for residents competently during both day-to-day operations and emergencies. Use this assessment to make decisions about your direct care staff needs, as well as your capabilities to provide services to the residents in your facility. Using a competency-based approach focuses on ensuring that each resident is provided care that allows the resident to maintain or attain their highest practicable physical, mental and psychosocial well-being;
-Services and care offered based on resident needs: Pressure injury prevention and care, skin care, wound care.
Review of the facility's Skin Ulcer-Wound Policy, dated 8/15/18, showed:
-All caregivers are responsible for preventing, caring for and providing treatment for skin ulcerations;
-Purpose: To identify at risk residents for potential breakdown or ulcerations, to prevent breakdown of tissue or ulcerations and to provide treatment that promotes prevention of ulcerations and healing of existing ulcerations;
-Definition: For the purpose of this policy, a skin ulcer (wound) is defined as any open area of the skin regardless of origin. It may also include an area of discoloration that is not open if the nurse identifies an area of concern that may potentially ulcerate and then confirms suspicion with a provider (physician/nurse practitioner/physician assistant/midlevel) for diagnosis;
-Assessment:
-Licensed staff will, upon admission, perform a head to toe body audit within 2 hours of admission. The findings will be documented in the resident's clinical record. Any items not documented in the admission assessment form will be charted in the nurse's notes;
-Licensed staff will complete a head to toe skin assessment weekly and as needed. The skin assessment will be documented on a skin assessment form and become part of the resident's clinical record. Any unusual findings will be documented on the form with a follow-up note in the nurse's notes further describing the area of concern;
-Treatment protocols:
-Consult wound care providers when appropriate;
-Until wound care providers can assess and order treatment, the following techniques may be employed:
-Follow standard precautions and good hand hygiene techniques;
-For non-open areas of concern or areas covered with stable eschar (dry dead tissue), apply skin prep (protective barrier wipe) daily and use preventative measures. On areas where skin prep is not appropriate (i.e. buttocks, etc.) moisture barrier cream is adequate. Skin prep may also be used for un-ruptured serous fluid (clear drainage) or blood-filled blisters;
-For all other open areas, the treatment is determined based on tissue type and drainage;
-All orders must be approved by a physician within 24 hours of discovering the open area or change in treatment;
-Assessment protocols:
-Nurses may not diagnose, just describe;
-Measurements must be completed weekly;
-At the time a skin issue is discovered, it must be measured. Wounds are three dimensional; therefore length, width and depth must be documented if using measuring instrument. It is acceptable to measure using common household objects (i.e. dime size, quarter size, half dollar) until actual measurements can be obtained per facility protocol;
-Length of wound should always be measured in head to toe alignment. Width should always be measured in hip to hip or side to side alignment. Depth should always be the deepest part of the wound in perpendicular alignment;
-If a reddened area is identified, the nurse should assess if the area is blanching (when skin color fades when pressure is applied and returns when pressure is released). If it is no blanching, then it should be captured on the licensed body audit report.
1. Review of Resident #56's quarterly Minimum Data Set (MDS), a federally mandated assessment instrument completed by facility staff, dated 10/3/19, showed:
-Moderate cognitive impairment;
-Extensive assistance required for bed mobility, toilet use and personal hygiene;
-Diagnoses included stroke;
-At risk for pressure ulcers;
-Does the resident have one or more unhealed pressure ulcers: Yes;
-Number of stage I pressure ulcers (intact skin with non-blanchable redness): 0;
-Number of stage II pressure ulcers (partial thickness loss of dermis presenting as a shallow open ulcer, may also present as an intact or open blister): 0;
-Number of stage III pressure ulcers (full thickness tissue loss, subcutaneous fat may be visible but the bone, tendon or muscle is not exposed): 0;
-Number of stage IV pressure ulcers (full thickness tissue loss with exposed bone, tendon or muscle): 0;
-Number of unstageable pressure ulcers (depth unable to be determined due to coverage of wound bed by slough (moist dead tissue) or eschar).
Review of the resident's care plan, updated 2/29/20, showed:
-Focus: Incontinent of bowel and bladder which increases risk for pressure related injuries:
-Goal: Will remain free from skin breakdown;
-Interventions: Check resident every two hours and assist with toileting as needed;
-Focus: Impaired skin integrity, pressure injuries to left lower leg, coccyx (tailbone area) and left heel;
-Goal: Be free of complications related to skin breakdown;
-Interventions: Treatments per physician orders, low air loss mattress, weekly treatment documentation, wound clinic to treat.
Review of the resident's medical record, showed:
-No ordered treatment to the buttocks area from 11/1/19 through 11/26/19;
-A weekly skin observation, dated 11/11/19: Skin issues present. Right buttocks open areas moisture associated skin damage. Moisture barrier cream applied to areas on buttocks, referred to wound nurse;
-A weekly skin observation, dated 11/18/19: Skin issues present (the buttocks area not documented as an area of concern);
-A weekly skin observation, dated 11/25/19: Skin issues present (the buttocks area not documented as an area of concern);
-A weekly wound observation tool, dated 11/26/19: Left buttocks pressure ulcer, acquired stage III. First observation, no reference. Granulation tissue (new tissue growth) present, slough tissue present. Percent of necrosis and/or slough in wound bed, 26-50%. Moderate amount of serosanguineous (thin, watery, pale red to pink) drainage. Measurement: Length (L) 3.8 centimeter (cm) by width (W) 5.5 cm by depth (D) 0.2 cm;
-An order dated 11/27/19, to cleanse area to left buttocks with wound cleanser, pat dry, apply hydrogel (gel used to keep the wound bed moist and aid in healing) and calcium alginate (absorbent product) daily. Order discontinued on 11/27/19, after the first application of the treatment;
-An order dated 11/28/19, to cleanse area to left buttocks with wound cleanser, pat dry and apply Santyl (ointment used to remove dead tissue) and calcium alginate daily;
-A weekly skin observation, dated 12/2/19: Skin issues present. Left buttocks dressing intact to area. Treatment done per wound nurse;
-A weekly skin observation, dated 12/9/19: Skin issues present. Left buttocks open area with granulation and slough tissue present;
-A weekly wound observation, dated 12/12/19: Left buttocks pressure ulcer, acquired stage III, improving. Granulation tissue present, slough tissue present. Percent of necrosis and/or slough in wound bed, 26-50%. Moderate amount of serosanguineous drainage. Measurement (LxWxD): 2.8 by 0.5 by 0.2;
-A weekly wound observation, dated 12/12/19: Right buttocks partial thickness wound acquired 12/12/19. First observation, no reference. Granulation tissue present. Scan serosanguineous drainage. Measurements (LxWxD): 3.0 cm by 1 cm by 0.1 cm;
-The prior treatment order to the left buttocks discontinued on 12/13/19;
-An order dated 12/14/19, skin prep to right buttocks daily:
-The treatment not documented as completed five of 18 opportunities in December 2019;
-No treatment for the stage III left buttocks pressure ulcer ordered or documented as applied from 12/14/19 through 12/22/19;
-A weekly skin observation, dated 12/16/19: Skin issues present. Area to buttocks with current treatment in place;
-A weekly wound observation, dated 12/18/19: Left buttocks pressure ulcer, acquired stage III, unchanged. Epithelial (new tissue growth) and granulation tissue present. Measurement (LxWxD): 6.0 cm by 4.0 cm by 0.2 cm:
-Further review of prior wound measurements for the left buttocks, showed the wound grew in size and was not unchanged as indicated on the assessment;
-A weekly wound observation, dated 12/18/19: Right buttocks acute full thickness wound, unchanged. Epithelial and granulation tissue present. Moderate amount of serosanguineous drainage. Measurement (LxWxD): 6 cm by 4 cm by 0.2 cm;
-Further review of prior wound measurements for the right buttocks, showed the wound grew in size and was not unchanged as indicated on the assessment;
-An order dated 12/23/19, to cleanse area to coccyx with wound cleanser, pat dry, apply Santyl and cover with dry dressing daily:
-The treatment not documented as completed as ordered three of nine opportunities in December 2019 and four of 16 opportunities in January 2020;
-A weekly skin observation, dated 12/23/19: Skin issues present. Area to coccyx with current treatment order in place;
-A weekly skin observation, dated 12/31/19: No skin issues;
-A weekly skin observation, dated 1/6/20: Right buttocks with current treatment in place;
-A weekly skin observation, dated 1/13/20: Area to coccyx with current treatment in place;
-The prior treatment order to the coccyx discontinued on 1/16/20;
-An order dated 1/17/20, to cleanse area to coccyx with wound cleanser, pat dry, mix gentamycin (antibiotic) ointment with Santyl and cover with dry dressing daily:
-The treatment not documented as completed as ordered two of 15 opportunities in January 2020 and three of nine opportunities in February 2020;
-A weekly skin observation, dated 1/20/20: No skin issues present;
-A weekly skin observation, dated 2/3/20: Sacrum (buttocks area) stage IV pressure ulcer, treatment in place;
-No measurements documented from 12/18/19 through the resident being sent to the hospital on 2/9/20;
-A transfer to hospital summary, dated 2/9/20: Resident stated to writer he/she did not feel good and wanted to go to hospital. Vital signs taken at that time were blood pressure 132/77 (normal 90/60 through 120/80), heart rate 88 (normal 60 through 100), respirations 20 (normal 12 through 22), temp 101.0 temporal (taken on the skin over the temple, normal 97.8 through 99.1). Call placed to resident's doctor to inform doctor of resident's condition. New order given to send resident out to hospital for evaluation and treatment. Resident left building via ambulance transport at 5:55 P.M.
Review of the resident's hospital records, showed resident admitted to the hospital on [DATE] with severe sepsis (systemic infection) related to infected sacral decubitus ulcer (pressure ulcer). General surgery consulted for wound debridement (surgical removal of dead tissue) at bedside on 2/10/20 and operating room on 2/11/20 for further debridement.
Further review of the resident's medical record, showed:
-The resident readmitted to the facility on [DATE];
-A readmission assessment, dated 2/20/20: admitted from hospital on 2/20/20 at approximately 5:45 P.M. Skin issues present (skin assessment blank);
-An order dated, 2/21/20 for collagenase ointment (an enzyme that helps promote healthy tissue growth), apply to affected area topically daily;
-The treatment not documented as completed as ordered six of nine opportunities;
-A weekly skin observation, dated 2/24/20: Area to coccyx with treatment in place;
-A skilled charting note, dated 2/29/20: Total care, no resident participation for bed mobility. Skin integrity: No new changes to skin integrity noted. Resident has treatable wounds, pressure to coccyx. Dressing change not required;
-The ordered treatment for collagenase ointment to affected area discontinued on 2/29/20;
-No new treatment ordered for the buttocks pressure ulcer until 3/2/20;
-An order dated 3/2/20: Change wound vac (medical vacuum device used to apply light suction to pull excess fluid from wounds with drainage) to buttocks on Mondays, Wednesdays and Fridays:
-Not documented as applied until 3/4/20.
Observation of the resident on 3/11/20 at 6:32 A.M., showed the resident lay in his/her bed, asleep. Wound vac attached.
During an interview on 3/12/20 at 6:35 P.M., with the Director of Nursing (DON), Administrator and Wound Nurse O, they said the resident came back to the facility today after leaving to have a second scheduled surgical debridement of the wound. He/she had originally gone to the hospital to have surgical debridement of the wound to the coccyx in February. Wound Nurse O said when the resident returned from the hospital in February, he/she had an order for a wound vac. Due to the location of the wound and anatomy of the resident, several attempts were unsuccessful in applying the wound vac. The physician was notified and supplies were obtained to build up the site, so the wound vac could be applied. Once the site was ready, the order for the wound vac was entered in the system and the wound vac was applied. He/she did not document any of this. The administrator said any treatment changes, treatments applied and communication with the physician should be documented. Wounds should be identified, assessed and documented with treatment orders obtained. People do not just wake up one day with a stage III wound. The wound should have been identified and treated prior to becoming a stage III. They would expect the documentation regarding the location of the wound be accurate. The wound was on the buttocks. Staff will use different locations interchangeable and this is not the correct way to do it. Staff would benefit from training on locations of wounds. Documentation should be accurate. Treatments should be applied as ordered. Staff should follow the wound policy and obtain measurements weekly.
2. Review of Resident #135's quarterly MDS, dated [DATE], showed:
-Cognitively intact;
-No behaviors;
-Total dependence for bed mobility, transfer, dressing and personal hygiene;
-Diagnoses included quadriplegia (paralysis of all four limbs), seizure disorder, anxiety and depression;
-At risk for pressure ulcers;
-Two stage II pressure ulcers;
-Two stage III pressure ulcers;
-One [NAME] IV pressure ulcer;
-One unstageable pressure ulcer.
Review of the resident's care plan, in use at the time of the survey, showed:
-Focus: Chronic pressure ulcers present on admission due to limited mobility. Open areas to coccyx/sacral, medial back, both gluteal fold, right lateral leg distal and open areas to left and right hip, left lateral foot:
-Goal: Pressure ulcers/other wounds will show signs of healing and remain free from infection;
-Interventions: Administer treatments as ordered and monitor for effectiveness. Follow facility policies/protocols for the prevention/treatment of skin breakdown. Weekly treatment documentation to include measurement of each area of skin breakdown's width, length, depth, type of tissue and exudate.
Review of the resident's medical record, showed:
-A skin/wound note, dated 10/25/29: Resident seen by wound care:
-Area to left ischium presents as a chronic stage III pressure injury measuring at 2.0x2.5x0.6 with moderate serosanguineous drainage. Wound bed is 1-25% slough 76-100% granulation;
-Area to medial coccyx presents as a chronic stage IV pressure injury measuring at 6.0x11.0x1.0 with moderate serosanguineous drainage. Wound bed has 76-100% bright red granulation;
-A weekly skin observation, dated 10/26/19: Skin issues present. Vertebrae (upper middle) treatment in place (no mention of the left ischium or medial coccyx wound);
-A weekly skin observation, dated 11/2/19: Skin issues present. Left gluteal fold treatment in place, coccyx treatment in place, vertebrae (upper middle) treatment in place;
-A weekly skin observation, dated 11/9/19: Skin issues present. Left gluteal fold treatment in place, coccyx treatment in place, vertebrae (upper middle) treatment in place;
-A weekly skin observation, dated 11/16/19: No skin issues present;
-A weekly skin observation, dated 12/17/19: No skin issues present;
-A weekly skin observation, dated 12/24/19: No skin issues present;
-A weekly skin observation, dated 12/31/19: No skin issues present;
-A weekly skin observation, dated 1/7/20: No skin issues present;
-A weekly skin observation, dated 1/14/20: Skin issues present. Treatment in progress buttocks (no mention of the ischium or back wound);
-A weekly skin observation, dated 1/21/20: Skin issues present. Treatment in progress buttocks (no mention of the ischium or back wound);
-A weekly skin observation, dated 1/28/20: Skin issues present. Treatment in progress buttocks (no mention of the ischium or back wound);
-A weekly skin observation, dated 2/5/20: Skin issues present. Treatment in progress abdomen, buttocks, right lower extremity dressings dry and intact;
-A weekly skin observation, dated 2/11/20: Skin issues present. Treatment in progress buttocks (no mention of the ischium or back wound);
-A weekly skin observation, dated 2/18/20: Skin issues present. Treatment in progress buttocks (no mention of the ischium or back wound);
-A weekly skin observation, dated 2/25/20: Skin issues present. Treatment in progress coccyx, left ischium (no mention of the back wound);
-A weekly skin observation, dated 2/25/20: Treatment in progress coccyx, left ischium (no mention of the back wound);
-A weekly skin observation, dated 3/3/20: Treatment in progress coccyx, back (no mention of the ischium wound);
-No further weekly wound observations from September 2019 through March 2020;
-No further pressure ulcer measurements or descriptions from September 2019 through March 2020.
Review of the resident's wound clinic notes, dated 3/11/20, showed:
-Medial back acute stage III pressure ulcer. Measurement (LxWxD): 2 cm by 4.1 cm by 0.2 cm. Scant amount of drainage. Wound is improving;
-Left ischial chronic stage III pressure ulcer. Measurement (LxWxD): 2 cm by 2.5 cm by 0.7 cm, moderate amount of serosanguineous drainage. The wound is deteriorating;
-Coccyx chronic stage IV pressure ulcer. Measurement (LxWxD): 6 cm by 11 cm by 1.4 cm, moderate amount of serosanguineous drainage. Wound is deteriorating.
Further review of the resident's medical record, showed:
-An order dated 1/9/20: Cleanse area to right mid back with wound cleanser, pat dry, apply calcium alginate and dry dressing daily;
-An order dated 2/7/20: Cleanse area to left ischium with wound cleanser, pat dry, apply Hydrofera (antibacterial foam dressing), ABD and secure with tape, every day shift Mondays, Wednesdays, and Fridays;
-An order dated 2/7/20: Cleanse area to coccyx with wound cleanser, pat dry, apply Hydrofera, ABD and secure with tape, every day shift Mondays, Wednesdays, and Fridays;
-No order for a right medial back wound treatment.
Observation of the resident's pressure ulcer treatments, on 3/13/20 at 9:18 A.M., showed Nurse A entered the resident's room with the treatment cart. Nurse A washed his/her hands and applied gloves. A Certified Nurse Aide (CNA) M assisted the nurse in turning the resident on his/her left side by using the turning sheet. The resident did not have anything covering his/her back, ischium, or coccyx wounds. Bloody wound discharge was visible on the bed. Nurse A returned to his/her cart removed a spray bottle of wound cleanser, returned to the resident's bed side, sprayed all open wound areas on the resident's back, coccyx and ischium. He/she did not pat the wounds dry. Two wounds located on the resident's back. One to the right medial side of the back and one to the medial back:
-Nurse A applied a piece of calcium alginate to the right medial back wound. The wound bed beefy red. He/she placed a piece of gauze 4 by 4 on top (there was no treatment order for this wound);
-Nurse A took two precut pieces of Hydrofera from clean area on cart and placed it on the medial back wound. The wound bed appeared beefy red (calcium alginate not applied as ordered and Hydrofera applied and was not ordered for this wound);
-Nurse A applied an ABD pad over both back wounds and secured with tape;
-Nurse A placed a large piece of Hydrofera, shaped like a half moon, on the resident's coccyx wound, covered with an ABD pad and secured with tape;
-Nurse A used an applicator and applied collagen powder to the left ischium wound, placed gauze over the area and secured with tape (Hydrofera not applied as ordered and collagen powder applied and was not ordered for this wound).
During an interview on 3/13/20 at 10:13 A.M., CNA M said the pad was visibly soiled with wound drainage and dirt from the resident.
During an interview on 3/13/20 at 10:13 A.M., Nurse A said all dressings were removed earlier when the resident was cleaned up from a large bowel movement. He/she has no way to measure the wounds and does not know the size. The wound nurse normally does the treatments and measurements. The resident's wounds are very time consuming.
3. Review of Resident #60's quarterly MDS, dated [DATE], showed:
-Cognitively intact;
-Rejection of care: Behavior not exhibited;
-Total dependence for bed mobility, dressing and personal hygiene;
-Diagnoses included cerebral palsy (disorder that affect movement and muscle tone), anxiety and depression;
-At risk for pressure ulcers;
-One stage III pressure ulcer;
-Two stage IV pressure ulcers;
-One unstageable pressure ulcer.
Review of the resident's care plan, dated 7/9/18, showed:
-Focus: Will often refuse care:
-Goal: Fewer episodes of refusal of care behaviors;
-Interventions: Monitor behavior episodes;
-Focus: Has open areas throughout his/her body. Remains at risk for further decline and/or new open areas as he/she remains dependent on staff for bed mobility, transfers and incontinent care:
-Goal: Will show signs and symptoms of healing without infection;
-Interventions: Pressure relieving mattress, pressure relieving cushion to protect the skin while up in chair. Monitor/document location, size and treatment of skin injury. Treatment per Physician orders.
Review of the resident's medical record, showed he/she frequently refused wound care and skin assessments.
Review of the resident's medical record, reviewed on 3/11/20, showed:
-An order dated 2/29/20, cleanse area to coccyx with wound cleanser, pat dry, apply Santyl nickel thick, apply calcium alginate over Santyl, cover with ADB pads (absorbent dressing), secure with tape daily:
-Not documented as completed as ordered or refused three of 10 opportunities;
-An order dated 2/29/20, cleanse area to left ischium (lower buttocks) with wound cleanser, pat dry, and apply Santyl nickel thick. Apply calcium alginate over Santyl, cover with ABD pads and secure with tape daily:
-Not documented as completed as ordered or refused three of 10 opportunities;
-An order dated 2/29/20, cleanse area to right ischium with wound cleanser, pat dry, apply Santyl nickel thick, apply calcium alginate over Santyl, cover with ABD pads and secure with tape daily:
-Not documented as completed or refused three of 10 opportunities;
-An order dated 2/29/20, cleanser area to right medial foot with wound cleanser, pat dry, protect peri-wound (skin surrounding wound bed) with skin protectant, apply Santyl nickel thick, apply dry dressing and secure with tape:
-Not documented as completed or refused three of 10 opportunities;
-An order dated 2/29/20, use skin prep to left back, and do not wash skin around wound. Apply dry dressing and secure with tape every day shift:
-Not documented as completed or refused three of 10 opportunities;
-An order dated 3/2/20, cleanse area to left lower lateral leg with cleanser, pat dry, apply Santyl nickel thick, cover with ABD pads and secure with tape daily:
-Not documented as completed or refused two of nine opportunities;
-No order for treatment to a left outer thigh wound.
Review of Drugs.com, showed Santyl: Apply this medication only to the affected skin wound. Try not to get any ointment on the healthy skin around the wound.
Observation on 3/10/20 at 10:09 A.M., showed Wound Nurse Q said he/she used to be the wound nurse and is currently filling in until the facility can find a different full time wound nurse. He/she prepped the treatment cart, obtained supplies. He/she had two whole ABD pads and several pieces of ABD pad cut into various sizes. He/she obtained Santyl ointment from cart, and the tube of Santyl not labeled with a resident's name. The tube appeared new and unused. He/she squirt a large amount of Santyl in a swirling motion on three of the small and one of the whole ABD pads. He/she entered the resident's room with the treatment cart and supplies. As the wound nurse repositioned the resident, a fowl wound odor permeated the room. The resident complained about the smell. The wound nurse cut more ABD pads and applied the remainder of the tube of Santyl onto the dressings. Each dressing had a large amount of Santyl piled up on the dressing:
-The buttocks/coccyx dressing saturated and the date unable to be read. The wound nurse removed the dressing and exposed an approximate basketball sized wound. When removing this dressing, the dressing to the left and right ischium also came off. The wound nurse cleansed the buttocks/coccyx area with wound cleanser, patted dry, applied ABD dressings with the Santyl ointment already applied, over the wound. The Santyl on the ABD pads more than a nickel thick and pushed into the wound when the dressing was applied (no calcium alginate applied as ordered);
-An elongated wound to the left ischium, extended vertical in relation to the resident's body. The wound nurse cleansed the area with wound cleanser, patted dry, applied ABD dressings with the Santyl ointment already applied, over the wound. The Santyl on the ABD pads more than a nickel thick and pushed into the wound when the dressing was applied (no calcium alginate applied as ordered);
-An elongated wound to the right ischium, extended vertical in relation to the resident's body. The wound nurse cleansed the area with wound cleanser, patted dry, applied ABD dressings with the Santyl ointment already applied, over the wound. The Santyl on the ABD pads more than a nickel thick and pushed into the wound when the dressing was applied (no calcium alginate applied as ordered);
-The left back/shoulder area dressing had peeled off, the date could not be read and the area surrounding the wound red and inflamed. The wound nurse cleansed the wound with wound cleanser spray (the order indicated not to cleanser the skin around the wound), patted dry, and applied an ABD dressing with the Santyl ointment already applied, over the wound. The Santyl on the ABD pads more than a nickel thick and expanded outside the wound edges and onto healthy tissue when the dressing was applied;
-The left lateral lower leg/knee dressing, dated 3/9. The dressing removed and exposed an approximate quarter sized wound. The wound nurse removed a second tube of Santyl from the treatment cart. He/she applied the Santyl to an ABD pad and placed the Santyl on the treatment cart. He/she cleansed the wound to the leg/knee, patted dry, applied the ABD pad with Santyl. The Santyl on the ABD pad more than a nickel thick and expanded outside the wound edges and onto healthy tissue. The dressing secured with tape. Observation of the tube of Santyl used on the leg/knee wound, showed a different resident's name labeled on the tube;
-The left outer thigh dressing removed and exposed an approximate dime size wound. No dressing or treatment applied to thigh wound. The wound remained open to air;
-The right inner foot dressing removed and exposed a wound approximately larger than quarter size. The wound nurse cleansed the area with wound cleanser, patted dry, applied ABD dressings with the Santyl ointment already applied and applied over the wound. The Santyl on the ABD pads more than a nickel thick and expanded outside the wound and onto healthy tissue when the dressing was applied (no skin protectant applied to the wound edges as ordered).
During an interview on 3/16/20 at 12:09 P.M., with the DON, Administrator and nurse practitioner, they said physician orders should be followed. Treatments and creams cannot be shared between residents.
4. Review of Resident #143's admission MDS, dated [DATE], showed:
-admitted [DATE] from an acute care hospital;
-Total dependence for bed mobility, dressing, eating, toilet use and personal hygiene;
-Diagnoses included high blood pressure and seizure disorder;
-At risk for pressure ulcers;
-One stage II pressure ulcer on admission.
Review of the resident's medical record, reviewed on 3/11/20, showed no comprehensive care plan completed.
Review of the resident's baseline care plan, dated 2/13/20, showed for his/her skin assessment: Normal color, skin temperature dry and warm, no skin issues.
Review of the resident's medical record, showed:
-An admission Assessment Nursing, dated 2/13/20, showed no skin conditions;
-A weekly skin observations progress note, dated 2/13/20, showed:
-Resident admitted on [DATE];
-Refer to assessment for more information;
-An admission Weekly Skin Observation assessment, dated 2/13/20, showed:
-Skin issues: yes;
-Sacrum (buttocks) wound to bottom, treatment nurse did assessment;
-No measurement or description of the sacrum wound documented;
-A progress note, showed a skin/wound note, dated 2/13/20 at 4:30 P.M., showed an area to right and left buttocks observed as unstageable and measured 5.0 by 7.5 by 0.1, moderate drainage with epithelial tissue to periwound (skin around wound edges);
-The ePOS, showed an order dated 2/14/20, to cleanse area to buttocks with wound clenser, pat dry, apply calcium alginate and dry dressing daily:
-Treatment not documented as applied or refused five of 16 opportunities in February 2020;
-Treatment not documented as applied or refused three of 10 opportunities in March 2020;
-A weekly skin observation assessment, dated 2/18/20, showed no skin issues;
-Further review of progress notes, showed a skin/wound note, dated 2/25/20 and 3/3/20, showed skin color normal, skin temperature dry and warm. Skin issues present. Refer
CONCERN
(D)
Potential for Harm - no one hurt, but risky conditions existed
Deficiency F0558
(Tag F0558)
Could have caused harm · This affected 1 resident
Based on observation, interview and record review, the facility failed to provide reasonable accommodations of individual needs and preferences by failing to assess if a resident's bed/side rails pose...
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Based on observation, interview and record review, the facility failed to provide reasonable accommodations of individual needs and preferences by failing to assess if a resident's bed/side rails posed a safety risk or if they could be used by the resident safely, providing independence with bed mobility and/or transfers in and out of the bed. The facility removed Resident #38's bed with bed/side rails and replaced it with a regular bed without bed/side rails, without assessing and providing the resident an alternate accommodation to allow the resident to maintain independence with bed mobility, for one of 29 residents sampled (Resident #38). The census was 143.
Review of Resident #38's quarterly Minimum Data Set (MDS), a federally mandated assessment instrument completed by facility staff, dated 12/14/19, showed:
-Moderate cognitive impairment;
-No behaviors;
-Extensive assistance for bed mobility, dressing, personal hygiene, toilet use and with locomotion on and off unit;
-Total dependence for transfers;
-No bed/side rails used.
Review of the resident's care plan, dated 12/22/19, showed the following:
-Limited physical mobility related to weakness;
-The resident continued to be at risk for pressure injuries and received treatment for a wound to his/her coccyx;
-Low air loss (LAL) mattress and turn/reposition every two hours or as needed;
-No documentation regarding bed/side rails.
Observation on 3/10/20 between 2:40 P.M. and 3:00 P.M., showed the resident lay on his/her back in bed. The resident's bed featured quarter length bed/side rails on both sides of the head of the bed and a LAL mattress. The resident grabbed the bed/side rail on his/her right side and used it to shift his/her weight from his/her bottom, to his/her side. The resident used the bed/side rails several times to shift and reposition his/her weight.
Review of the resident's medical record on 3/10/20, showed no documented bed/side rail assessment completed.
Observation on 3/11/20 at 2:00 P.M., showed the resident's bed no longer featured bed/side rails.
During an interview on 3/11/20 at 2:00 P.M., the resident said staff changed out his/her bed because he/she couldn't have a bed with bed/side rails with a LAL mattress. He/she missed having bed/side rails because they helped him/her turn and reposition him/herself while in his/her bed. Now if he/she wanted to turn, he/she would need nursing staff to help him/her.
Observations on 3/12/20 between 9:00 A.M. and 5:00 P.M. and on 3/13/20 between 9:00 A.M. and 4:00 P.M., showed the resident's bed no longer featured bed/side rails.
During an interview on 3/16/20 at 11:00 A.M., the resident said he/she would like something to help him/her move and do some stuff on his/her own since his/her bed with bed/side rails was taken away. The bed/side rails gave him/her a little bit of independence and he/she liked this. Staff just came in his/her room and told him/her they were taking his/her bed. Staff did not ask the resident if this was okay with the resident and did not offer him/her anything else to help make things easier for him/her.
During an interview on 3/16/20 at 12:32 P.M., the administrator said she was not aware the resident had a bed with bed/side rails and she was not aware the bed was removed and no alternate assistive device provided to the resident. The facility did not use beds with bed/side rails with LAL mattresses and this is probably why the resident's bed was swapped out for one without bed/side rails. Nursing should have been involved with the decision to swap out the resident's bed and the resident could have been assessed for use of an alternate positioning device such as a trapeze (a triangular bar hung over the bed to allow more independence by allowing the resident to assist with repositioning). Staff discuss equipment at their weekly clinical meetings to ensure residents have the right equipment and to make sure the equipment makes it on the care plans.
CONCERN
(D)
Potential for Harm - no one hurt, but risky conditions existed
Abuse Prevention Policies
(Tag F0607)
Could have caused harm · This affected 1 resident
Based on interview and record review, the facility failed to develop and implement written policies and procedures that include screening potential employees for a history of abuse, neglect, exploitat...
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Based on interview and record review, the facility failed to develop and implement written policies and procedures that include screening potential employees for a history of abuse, neglect, exploitation, or misappropriation of resident property by failing to complete required background checks timely for three of 10 employees sampled. In addition, the facility policy failed to require the nurse aide registry check on employees. The census was 143.
Review of the facility's Employment Screening policy, revised 12/2016, showed:
-In accordance with state and federal regulations, this facility will not knowingly hire, contract or retain any individual that is ineligible to work in healthcare facility, that has been excluded from participation in the Medicare or Medicaid programs, or that has not met required licensure or certification requirements for the position being considered;
-Unless otherwise stipulated by this policy a new employee may not start working until all the following is completed or initiated:
-At least two days prior to scheduled resident contact check the employment disqualification list (EDL) on any and all individual(s);
-Criminal background check: At least two working days prior to scheduled resident contact, check the Missouri Family Care Safety Registry (FCSR) for registration and any disqualifying conditions;
-The policy failed to require the nurse aide (NA) register check be completed on all employees to verify the employee does not have a federal indicator for abuse, neglect or misappropriation of resident property, disqualifying them from working in a federally certified facility.
1. Review of Registered Nurse C's employee file, showed:
-Date of hire: 8/7/19;
-FCSR letter dated 8/13/19;
-EDL check completed 8/13/19;
-NA registry check completed 8/13/19.
2. Review of Dietary Aid I's employee file, showed:
-Date of hire: 3/15/19;
-No NA registry check completed as of 3/10/20.
3. Review of Licensed Practical Nurse L's employee file, showed:
-Date of hire: 2/6/19;
-FCSR letter dated 2/7/19.
4. During an interview on 3/16/20 at 7:57 A.M., the Human Resource Director said he is responsible to ensure all required background checks are completed. Employee background check results should be obtained prior to employment. He was informed Registered Nurse C was starting at a later date than he/she actually did, that is why the background checks were completed late. Dietary Aid I was hired for dietary and not as a certified nursing assistant, so his/her NA registry check was not completed.
CONCERN
(D)
Potential for Harm - no one hurt, but risky conditions existed
Deficiency F0655
(Tag F0655)
Could have caused harm · This affected 1 resident
**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, interview and record review, the facility failed to develop and implement a baseline care plan for each re...
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**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, interview and record review, the facility failed to develop and implement a baseline care plan for each resident that includes the instructions needed to provide effective and person-centered care of the resident for two of three sampled residents admitted within the past 30 days (Residents #143 and #498). The census was 143.
1. Review of Resident #143's admission Minimum Data Set (MDS), a federally mandated assessment instrument completed by facility staff, dated 2/20/20, showed:
-admitted [DATE] from an acute care hospital;
-Total dependence for bed mobility, dressing, eating, toilet use and personal hygiene;
-Diagnoses included high blood pressure and seizure disorder;
-At risk for pressure ulcers (injury to the skin and/or underlying tissue, as a result of pressure or friction);
-One stage II pressure ulcer (a partial thickness loss of dermis presenting as a shallow open ulcer with a red-pink wound bed, may also present as an intact or open/ruptured blister) on admission.
Review of the resident's medical record, reviewed on 3/11/20, showed:
-No comprehensive care plan completed;
-An order dated 2/13/20, cleanse gastrostomy (g-tube, tube inserted into the stomach to provide food, fluid and medication) site with soap and water, apply triple antibiotic ointment and drain sponge every night shift;
-An order dated 2/13/20, #6 tracheostomy (tube inserted into the airway for breathing) check placement and patency every shift for maintenance;
-An order dated 2/13/20, for an indwelling urinary catheter (tube inserted into the bladder to drain urine) 16 French (FR, size);
-An order dated 2/13/20, enteral feed order Jevity (liquid nutrition) 1.5 continuous via g-tube;
-A skin/wound note, dated 2/13/20 at 4:30 P.M., showed:
-Area to right and left buttocks observed as unstageable (depth unable to be determined due to wound covered by dead tissue) and measured 5.0 by 7.5 by 0.1;
-Area to left gluteal (buttocks) fold observed as shearing measuring 0.5 x 1.0 x 0.1, with no drainage;
-Area to left back observed as open area measuring 0.5 x 0.5 x 0.1, with no drainage present;
-Area to right lateral (side) and plantar (bottom) foot observed as fluid filled blister with periwound (skin surrounding the wound) purplish in color;
-Area to right back observed as open area measuring 2 x 3 x 0.1;
-An order dated 2/14/20, oxygen 28% per tracheostomy collar with 4 liters oxygen.
Review of the resident's admission Assessment: Nursing, provided as the baseline care plan, dated 2/13/20, showed:
-Respiratory/chest:
-Regular rate and rhythm;
-Tracheostomy not indicated;
-Oxygen use not indicated;
-Bowel: Incontinent:
-Not indicated as a focus area;
-No goal related to incontinence;
-No interventions;
-Bladder: Catheter 16 FR:
-Not indicated as a focus area;
-No goals related to catheter use;
-No interventions;
-Skin assessment: No skin issues:
-Pressure ulcers and wounds not indicated;
-The use of a g-tube or nutritional needs not indicated.
Observation on 3/10/20 at 9:57 A.M., showed the resident in bed. Oxygen on at 4 liters per high humidity tracheostomy collar at 28%. Tracheostomy suction machine at the bedside. Urinary catheter drained to gravity. Air mattress on the bed. Tube feeding, Jevity 1.5 infused at 55 milliliters per hour.
During an interview on 3/16/20 at 12:09 P.M., the Director of Nursing (DON) if a resident had a tracheostomy, g-tube, wound or oxygen use, she would expect this be listed on the baseline care plan.
2. Review of Resident #498's hospital records, showed the following:
-admit date : [DATE];
-discharge date : [DATE];
-Chief Complaint: Abdominal pain;
-History of Present Illness: alcohol abuse, smoker, lung nodule (single mass on the lung) and rectal adenocarcinoma (cancer in the epithelium or lining of the large intestine) not currently on chemotherapy.
Review of the resident's admission assessment, dated 3/9/20, showed the following:
-The facility admitted the resident from the hospital on 3/9/20;
-Bowel: Ostomy (procedure that allows bodily waste to pass through a surgically created opening called a stoma on the abdomen into a prosthetic known as a 'pouch'). Bladder: continent.
Observation on 3/10/20 at 9:52 A.M., showed the resident lay on his/her back, in his/her bed, with his/her stomach area exposed. The resident's colostomy bag (a plastic bag that collects fecal matter from the digestive tract) was visible when the resident lifted his/her shirt and exposed his/her stomach area. A bedside urinal bottle sat on the resident's bedside table.
During an interview on 3/10/20 at 9:52 A.M., the resident said he/she suffered from pain in his/her stomach due to colon cancer. The staff give him/her pain medication and it does help. He/she had a colostomy and staff emptied the bag for him/her. The resident was not sure if staff were aware of how often to empty or change his/her colostomy bag.
Review of the resident's baseline care plan, dated 3/10/20, showed the following:
-The care plan did not address the resident's bladder and bowel concerns and did not direct staff on how to care for the resident's colostomy;
-The care plan addressed resident's pain but did not specify any characteristics of the resident's pain such as location or conditions related to pain.
During an interview on 3/16/20 at 12:40 P.M., the administrator and DON said the resident's colostomy care and any other bladder/bowel concerns should have been documented on the resident's care plan. Pain should be addressed on care plans and care plans should be resident specific.
3. During an interview on 3/16/20 at 12:09 P.M., the DON said the admitting nurse completes the baseline care plan on admission. Documentation should be complete and accurate.
CONCERN
(D)
Potential for Harm - no one hurt, but risky conditions existed
Deficiency F0657
(Tag F0657)
Could have caused harm · This affected 1 resident
**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, interview and record review, the facility failed to develop the comprehensive care plan within 7 days afte...
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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 develop the comprehensive care plan within 7 days after completion of the comprehensive assessment, for one of three sampled residents admitted within the past 30 days (Resident #143). The census was 143.
Review of Resident #143's admission MDS, dated [DATE], showed:
-admitted [DATE] from an acute care hospital;
-Total dependence for bed mobility, dressing, eating, toilet use and personal hygiene;
-Diagnoses included high blood pressure and seizure disorder;
-Care area assessment summary (CAAS), showed the following care areas triggered and the facility indicated the areas were care planned:
-Urinary incontinence and indwelling catheter (tube inserted into the bladder to drain urine);
-Nutritional status;
-Feeding tube;
-Dehydration/fluid maintenance;
-Pressure ulcer (any lesion caused by unrelieved pressure that results in damage to the underlying tissue).
Review of the resident's medical record, reviewed on 3/11/20, showed:
-No comprehensive care plan completed;
-An order dated 2/13/20, to cleanse gastrostomy (g-tube, tube inserted into the stomach to provide food, fluid and medication) site with soap and water, apply triple antibiotic ointment and drain sponge every night shift;
-An order dated 2/13/20, for #6 tracheostomy (tube inserted into the airway for breathing) check placement and patency every shift for maintenance;
-An order dated 2/13/20, for an indwelling urinary catheter 16 French (FR, size);
-An order dated 2/13/20, for enteral feed order Jevity (liquid nutrition) 1.5 continuous via g-tube;
-A skin/wound note, dated 2/13/20 at 4:30 P.M., showed:
-Area to right and left buttocks observed as unstageable (depth unable to be determined due to wound covered by dead tissue) and measured 5.0 by 7.5 by 0.1;
-Area to left gluteal (buttocks) fold observed as shearing measuring 0.5 x 1.0 x 0.1, with no drainage;
-Area to left back observed as open area measuring 0.5 x 0.5 x 0.1, with no drainage present;
-Area to right lateral (side) and plantar (bottom) foot observed as fluid filled blister with periwound (skin surrounding the wound) purplish in color;
-Area to right back observed as open area measuring 2 x 3 x 0.1;
-An order dated 2/14/20, oxygen 28% per tracheostomy collar with 4 liters oxygen.
Observation on 3/10/20 at 9:57 A.M., showed the resident in bed. Oxygen on at 4 liters oxygen per high humidity tracheostomy collar at 28%. Tracheostomy suction machine at the bedside. Urinary catheter drained to gravity. Air mattress on the bed. Tube feeding, Jevity 1.5 infused at 55 milliliters per hour.
During an interview on 3/16/20 at 12:09 P.M., the Director of Nursing (DON) said the comprehensive care plan should be completed within 21 days of admission. It is the MDS coordinator's responsibility to ensure the care plan is completed timely.
CONCERN
(D)
Potential for Harm - no one hurt, but risky conditions existed
ADL Care
(Tag F0677)
Could have caused harm · This affected 1 resident
**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, interview and record review, the facility failed to provide the necessary services to maintain good groomi...
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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 services to maintain good grooming and personal hygiene per resident wishes and standards of practice for two residents (Residents #60 and #135). The sample was 29. The census was 143.
1. Review of Resident #60's quarterly Minimum Data Set (MDS), a federally mandated assessment instrument completed by facility staff, dated 1/5/20, showed:
-Cognitively intact;
-Rejection of care: Behavior not exhibited;
-Total dependence for bed mobility, dressing and personal hygiene;
-Bathing: Total dependence;
-Diagnoses included cerebral palsy (disorder that affect movement and muscle tone), anxiety and depression.
Review of the resident's care plan, dated 7/9/18, showed:
-Focus: Activities of daily living (ADL) self-care performance deficit related to limited mobility and quadriplegia. Required total assistance with ADLs. Prefers to have showers done at 10:00 A.M. on Mondays and Wednesdays:
-Goal: Would like for staff to anticipate needs through next review period;
-Bathing/Showering: Provide sponge bath when a full bath or shower cannot be tolerated;
-Focus: Will often refuse care:
-Goal: Fewer episodes of refusal of care behaviors;
-Interventions: Monitor behavior episodes.
Review of the resident's medical record, showed task list: Bathing preference: Specify frequency, as necessary.
During an interview on 3/10/20 at 9:43 A.M., the resident said he/she wanted a shower and he/she had not had his/her hair washed since August 2019. Observation, showed the resident's hair oily. The resident said his/her hair stinks, so he/she keeps it up in a ponytail so it stays out of his/her face.
Observation on 3/10/20 at approximately 10:00 A.M., of the shower room located next to the resident's room, showed a roll in shower buddy (a shower chair used to meet the needs of those with disabilities by use of a tilting chair that offers core and extremity support for individuals unable to maintain their own positioning) available.
Observation on 3/10/20 at 10:09 A.M., showed Wound Nurse Q provided wound care to the resident. During care, the resident asked to get a shower and said he/she has been fighting staff to get a shower. The wound nurse did not respond to the resident's request.
During an interview on 3/12/20 at 1:57 P.M., the resident said he/she still was not given a shower. Observation, showed his/her hair pulled in a ponytail and appeared oily.
During an interview on 3/13/20 at 9:57 A.M., the resident said he/she has still not been provided a shower. He/she has scabs on his/her head from not having a shower.
Observation and interview on 3/13/20 at 9:58 A.M., showed Nurse R assessed the resident's scalp. Nurse R said the resident has flaky, itchy hair and he/she was just in the resident's room scratching the resident's head for him/her, per the resident's request. He/she did not know if the resident was receiving showers because he/she was switched from days to evenings for showers. The resident said he/she attended a care plan meeting in January and said he/she wanted to take showers. The staff in the care plan meeting said they would put it in the care plan. Observation during a skin assessment of the resident's hair and scalp, showed the resident's hair oily with chunks of dry skin in the scalp and flakes on the resident's pillow, bed and shirt. The resident's hair had a pungent odor and the hair appeared thick and oily. As the nurse brushed through the resident's hair, dandruff flaked off, all over the resident's shoulders. The resident said everyone says I refuse showers but they don't ask.
Review of the resident's documented bath/showers from 1/1/20 through 3/10/20, showed on 2/14/20, a skin monitoring shower review form completed. The form did not indicate if the resident received a bath or shower and/or if the resident had his/her hair washed. No skin concerns documented on the form, despite the resident having multiple skin issues.
During an interview on 3/16/20 at 12:09 P.M., the Director of Nursing (DON) and administrator said when the resident refuses a bath or shower, staff educate him/her. Refusing care is a normal behavior for the resident. He/she goes through cycles where he/she refuses care. They did not know when the resident's hair was last washed. Interventions for staff to attempt when the resident refused showers should be documented in the care plan. The facility does have a beauty shop. If it is determined it is safe for the resident to use the hair bowl in the beauty shop, staff could us this to wash the resident's hair. The DON said she believed this may have been attempted before and the resident could not be positioned properly to use the beauty shop. She thinks staff had issues with the tilt shower chair not being safe as well. The resident's hair can be washed during a bed bath.
Further review of the resident's care plan, showed the care plan failed to provide interventions to attempt if the resident refuses a bath/shower, the resident's preference to receive a shower over a bath, the availability of a shower buddy shower chair, and failed to direct staff to wash the resident's hair as requested with alternative ways to wash his/her hair if a shower was not possible. The care plan did not identify the resident as a resident that could not have a shower due to inability to position self or that he/she was unable to go to the beauty shop to have his/her hair washed.
2. Review of Resident #135's quarterly MDS, dated [DATE], showed the following:
-Cognitive intact;
-Ability to understand others and to make him/herself understood;
-Always incontinent of bowel and bladder, with use of ostomy (allows bodily waste to pass through a surgically created stoma on the abdomen) and catheter (a sterile tube inserted into the bladder to drain urine);
-Dependent on staff for all ADLs;
-No behaviors of rejection of care;
-Diagnoses including quadriplegia (paralysis of all four limbs), seizure disorder, anxiety and depression.
Review of the resident's care plan, in use at time of survey, showed the following:
-Focus: The resident is dependent for ADL self-care performance related to diagnosis of quadriplegia;
-Goal: The resident will maintain current level of function in ADL tasks through the review date;
-Interventions: The resident is totally dependent on staff to provide bath/shower. Observe skin during care and report any changes to nurse. Avoid scrubbing over bony prominences. Check nail length, trim and clean on bath day and as needed. The resident is totally dependent on staff for repositioning and turning in bed, dressing and personal hygiene. The resident is totally dependent on staff for ostomy and incontinence care.
Observation and interview on 3/13/20 at 9:18 A.M., showed the resident's nails approximately 1 inch long on all fingers and short facial hair. The resident said he/she wishes the staff would cut his/her nails and help him/her shave.
During an interview on 3/16/20 at 12:09 P.M., the DON said she expects all residents to receive assistance with nail care and shaving during bathing, showers or as needed.
MO00167111
MO00167377
CONCERN
(D)
Potential for Harm - no one hurt, but risky conditions existed
Deficiency F0698
(Tag F0698)
Could have caused harm · This affected 1 resident
**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, interview and record review, the facility failed to routinely assess, monitor and document on two resident...
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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 routinely assess, monitor and document on two residents receiving dialysis (process for removing toxins from the blood for individuals with kidney failure). The facility identified 6 residents as receiving routine dialysis treatments, three were sampled and problems were found with all three. (Residents #123, #62 and #127). The census was 143.
Review of the facility's End Stage Renal Disease Dialysis Policy, dated 1/4/20, showed the following:
-Purpose: To ensure a resident with End Stage Renal Disease (ESRD), including dialysis care and treatment outside the facility, receive services by facility staff trained in the care and special needs of these residents;
-Policy: Staff caring for residents with ESRD, including residents receiving dialysis care outside the facility shall be trained in the care and special needs of these residents;
-Education and training of staff in the care of ESRD/dialysis resident may be managed by the contracted dialysis facility or by the facility staff development coordinator or Director of Nursing (DON)/qualified designee;
-Agreements between this facility and the contracted ESRD facility include all aspects of how the resident's care will be managed, including how the care plan will be developed and implemented or how information will be exchanged between the facilities;
-To prevent infection and/or clotting:
-Check for signs of infection (warmth, redness, tenderness or edema) at the access site when performing routine care and at regular intervals;
-Check the color and temperature of the fingers, and the radial pulse of the access arm when performing routine care and at regular intervals;
-Check patency of the site at regular intervals, palpate the site to fee the thrill (the vibration felt when blood flows through the dialysis access site) or use a stethoscope to hear the bruit (sound heard when blood flows through the dialysis access site) of blood flow through the access;
-Additionally, all care instructions should be documented in the resident's plan of care;
-Care of the central dialysis catheters: Check for signs of infection (warmth, redness, tenderness, edema, or drainage) every shift and document findings.
1. Review of Resident #123's admission Minimum Data Set (MDS), a federally mandated assessment instrument completed by facility staff, dated 2/5/20, showed the following:
-Cognitively intact;
-Diagnoses included end stage renal disease (ESRD);
-Received dialysis.
Review of the resident's care plan, revised 2/27/20, showed the following:
-Focus: Resident is dependent upon dialysis three times weekly. He/she attends the dialysis center on Tuesday, Thursday and Saturday. He/she has a left upper extremity arterial/venous fistula (AV fistula, connection between an artery and vein);
-Goal: The resident will have no signs or symptoms of complication from dialysis;
-Interventions: Encourage resident to attend all scheduled dialysis appointments. Monitor vital signs. Notify physician of significant abnormalities. Monitor, document and report as needed any sign or symptoms of infection to access site, redness, swelling, warmth or drainage, renal (kidney) insufficiency, changes in level of consciousness, changes in skin turgor, oral mucous, changes in heart and lung sounds, bleeding, hemorrhage, bacterium or septic shock.
Review of the resident's electronic POS, showed the following:
-An order dated 3/8/20, dialysis on Tuesday, Thursday and Saturday at 10:30 A.M.;
-An order dated 3/9/20, access bruit and thrill every shift related to ESRD;
-An order dated 3/9/20, dialysis access left upper extremely AV Fistula.
Review of the resident's medical record, showed no documentation of consistent monitoring during routine care and at regular intervals of the resident's dialysis access site and physical condition before and after visits to the dialysis center.
Observation on 3/12/20 at 12:11 P.M., showed the resident up in his/her wheelchair in the dining room with the fistula in his/her left upper arm.
2. Review of Resident #62's admission MDS, dated [DATE], showed:
-Cognitively intact;
-Diagnoses included ESRD;
-Received dialysis.
Review of the resident's care plan, in use at the time of the survey, showed:
-Focus: Attends dialysis three times weekly on Tuesdays, Thursdays and Saturdays;
-Goal: Have no signs or symptoms of complications;
-Interventions: Check and change dressing daily at access site, right chest dialysis catheter. Encourage to go to dialysis appointments. Monitor/document/report as needed any signs and symptoms of infection to access site. Monitor/document/report as needed any signs and symptoms of renal insufficiency. Monitor/document/report as needed for signs and symptoms of the following: Bleeding, hemorrhage, bacteremia, septic shock.
Review of the resident's ePOS, showed:
-An order dated 2/23/20, for dialysis on Tuesday, Thursday and Saturday at 11:30 A.M.;
-An order dated 3/9/20, for a right chest dialysis catheter.
Review of the resident's medical, showed no documentation of consistent monitoring during routine care and at regular intervals of the resident's dialysis access site and physical condition before and after visits to the dialysis center.
3. Review of Resident #127's annual MDS, dated [DATE], showed:
-Cognitively intact;
-Diagnoses included ESRD;
-Dialysis while a resident.
Review of the resident's care plan, in use at the time of the survey, showed:
-Focus: The resident needs dialysis, has a left upper extremity AV fistula;
-Goal: Have no signs and symptoms of complications from dialysis;
-Interventions: Assess bruit and thrill every shift and notify physician of any abnormalities. Do not draw blood or take blood pressure in arm with fistula. Encourage to attend all appointments on Mondays, Wednesdays and Fridays, pick up around 8:45 A.M. Vital signs per facility protocol. Monitor/document/report as needed any signs and symptoms of infection to the access site, renal insufficiency, bleeding, hemorrhage, bacteremia, septic shock, new/worsening of edema.
Review of the resident's ePOS, showed:
-An order dated 3/3/20, no blood pressure in the left arm;
-An order dated 3/3/20, dialysis on Monday, Wednesday, Friday.
Review of the resident's medical, showed no documentation of consistent monitoring during routine care and at regular intervals of the resident's dialysis access site and physical condition before and after visits to the dialysis center.
4. During an interview on 3/16/20 at 12:21 P.M., the Director of Nursing (DON) said she would expect the dialysis policy to be followed as written. The charge nurse should assess the resident before and after dialysis. This would include obtaining and documenting vital signs, general appearance and assessing the dialysis fistula.
CONCERN
(D)
Potential for Harm - no one hurt, but risky conditions existed
Deficiency F0804
(Tag F0804)
Could have caused harm · This affected 1 resident
Based on observation and interview, the facility failed to ensure hot foods were at least 120 degrees Fahrenheit (F) when served to residents for one of one test trays sampled on the 100 hall. The cen...
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Based on observation and interview, the facility failed to ensure hot foods were at least 120 degrees Fahrenheit (F) when served to residents for one of one test trays sampled on the 100 hall. The census was 143.
Observation of the 100 hall meal service on 3/11/20, showed the following:
-At 8:30 A.M., during an interview, Nurse A said breakfast trays had not arrived to the hall;
-At 8:35 A.M., observation of the main dining room showed five trays covered. During an interview, the Assistant Dietary Supervisor (ADS) said the meal trays were for 101 to 116 hall trays;
-At 8:50 A.M., observation showed hall trays delivered to the hall;
-At 9:00 A.M., hall trays passed out by staff. A test tray of a hall tray, completed with ADS, showed eggs at 100 degrees F and sausage at 80 degrees F. The sausage was cold to taste. During an interview at that time the ADS said the food should be served at 160 degrees F.
During an interview on 3/12/20 at 10:06 A.M., seven of seven residents said there is too much of the same types of food and food can often be cold for most meals.
During an interview on 3/16/20 at 9:59 A.M., the Dietary Manager said the food should be served at 165 degrees F. The hall was short staffed and the trays were not delivered in a timely manner.
CONCERN
(D)
Potential for Harm - no one hurt, but risky conditions existed
Medical Records
(Tag F0842)
Could have caused harm · This affected 1 resident
Based on observation, interview and record review, the facility failed to maintain medical records on each resident that are complete and accurately documented, for two resident (Residents #56 and #38...
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Based on observation, interview and record review, the facility failed to maintain medical records on each resident that are complete and accurately documented, for two resident (Residents #56 and #38). The sample was 29. The census was 143.
1. Review of Resident #56's hospital discharge transfer orders for the receiving facility, showed:
-discharged to facility on 2/20/20;
-Procedure site: Sacral/coccyx (buttocks/tailbone area): Wound vac (medical vacuum device used to apply light suction to pull excess fluid from wounds with drainage) to sacrum.
Review of the resident's medical record, showed:
-A readmission assessment, dated 2/20/20: admitted from hospital on 2/20/20 at approximately 5:45 P.M. Skin issues present;
-An order dated, 2/21/20 for collagenase ointment (an enzyme that helps promote healthy tissue growth), apply to affected area topically daily;
-An order dated 3/2/20: Change wound vac (medical vacuum device used to apply light suction to pull excess fluid from wounds with drainage) to buttocks on Mondays, Wednesdays and Fridays:
-Not documented as applied until 3/4/20;
-No order for or documentation of the wound vac prior to 3/2/20.
Observation of the resident on 3/11/20 at 6:32 A.M., showed the resident in his/her bed, asleep. The wound vac was attached.
During an interview on 3/12/20 at 6:35 P.M., with the Director of Nursing (DON), Administrator and Wound Nurse O, they said the resident had gone to the hospital to have surgical debridement of the wound to the coccyx in February. Wound Nurse O said when the resident returned from the hospital in February, he/she had an order for a wound vac. Due to the location of the wound and anatomy of the resident, several attempts were unsuccessful in applying the wound vac. the physician was notified and supplies was obtained to build up the site, so the wound vac could be applied. Once the site was ready, the order for the wound vac was entered in the system and the wound vac was applied. He/she did not document any of this. The administrator said any treatment changes, treatments applied and communication with the physician should be documented.
2. Review of Resident #38's electronic physician order sheet, showed and order dated 2/7/20, for Tramadol HCl (narcotic pain medication) 50 milligram (mg) Give 1 tablet by mouth every 4 hours as needed for moderate and severe pain.
Review of the resident's March 2020 medication administration record (MAR), reviewed on 3/13/20, showed no documentation Tramadol had been administered to the resident.
Review of the resident's narcotic sign out sheet, showed Tramadol HCL 50 mg administered nine times from 3/3/20 through 3/13/20.
During an interview on 3/16/20 at 12:09 P.M., the DON staff should document in the MAR when medication is administered.
CONCERN
(E)
Potential for Harm - no one hurt, but risky conditions existed
Assessment Accuracy
(Tag F0641)
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 the resident Minimum Data Set (MDS, a federally mandated ass...
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**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on interview and record review, the facility failed to ensure the resident Minimum Data Set (MDS, a federally mandated assessment instrument completed by facility staff) assessment accurately reflected the resident's status, for five of 29 sampled residents (Resident #141, #143, #56, #38 and #60). The census was 143.
1. Review of Resident #141's medical record, showed:
-An incident note, dated 11/9/19, resident stated he/she had an area on his/her bottom that he/she wanted evaluated. Upon assessment, Non blanchable, red excoriation noted to left buttocks. Area approximately 3.3 x 1.0 centimeter (cm). Physician notified and new orders obtained;
-An order dated 11/10/19, for skin prep wipes to left gluteal (buttocks) two times day;
-An annual MDS, dated [DATE], showed:
-Other ulcer, wounds and skin problems: No;
-Moisture associated skin damage (MASD): Not marked;
-A weekly wound observation tool, dated 12/10/19: Left buttocks MASD measured 1.8 x 2 x 0.1;
-A weekly skin observation, dated 2/11/20: Left buttocks open area;
-A quarterly MDS, dated [DATE], showed:
-Other ulcer, wounds and skin problems: No;
-MASD: Not marked.
During an interview on 3/12/20 at 6:35 P.M., the Director of Nursing (DON) said the wound on the resident is MASD and not pressure.
During an interview on 3/16/20 at 8:44 A.M., the MDS coordinator said MDS should be accurate.
2. Review of Resident #143's medical record, showed:
-A skin/wound note, dated 2/13/20 at 4:30 P.M., showed:
-Area to left gluteal fold observed as shearing measuring 0.5 x 1.0 x 0.1, with no drainage;
-Area to left back observed as open area measuring 0.5 x 0.5 x 0.1, with no drainage present;
-Area to right lateral (side) and plantar (bottom) foot observed as fluid filled blister with periwound (skin surrounding the wound) purplish in color;
-An area to right and left buttocks observed as unstageable (depth of wound not known due to coverage of the wound bed) and measured 5.0 by 7.5 by 0.1, moderate drainage;
-Area to right back observed as open area measuring 2 x 3 x 0.1;
-An admission MDS, dated [DATE], showed:
-admitted [DATE] from an acute care hospital;
-One stage II pressure ulcer (partial thickness loss of dermis presenting as a shallow open ulcer, may also present as an intact or open blister);
-Other ulcers, wounds and skin problems: None present;
-Unstageable ulcer not indicated as present.
3. Review of Resident #56's medical record, showed:
-On 8/23/19 159.2 pounds (Lbs)
-On 9/9/19 161.2 Lbs;
-A quarterly MDS, dated [DATE], showed:
-Assessment reference date (ARD) 10/3/19;
-Weight 159 Lbs;
-No weight of 159 documented in the medical record in the seven day ARD look back period;
-On 10/9/19 161.7 Lbs;
-On 11/28/19 163.0 Lbs;
-On 12/15/19 163.6 Lbs;
-A quarterly MDS, dated [DATE], showed:
-ARD 1/3/20;
-weight 159 Lbs;
-No weight of 159 documented in the medical record in the seven day ARD look back period.
During an interview on 3/16/20 at 8:44 A.M., the MDS coordinator said the weights entered in the MDS are obtained from the vitals section of the resident's medical record. Weights should be accurate as they are used to determine if there had been a significant weight loss.
4. Review of the facility's wound report dated 11/20/19, showed the following for Resident #38:
-Onset date: 11/14/19;
-Stage: Full thickness;
-Prior measurements: New. Current Measurements: 7.0 cm by 2.9 cm by 0.2 cm;
-Site: Left posterior thigh;
-Acquired: in house.
Review of Resident #38's quarterly MDS, dated [DATE], showed:
-Does the resident have one or more unhealed pressure ulcers: No.
5. Review of Resident #60's medical record, showed:
-A care plan, dated 7/9/18, showed will often refuse care;
-An order dated 9/10/19, for wound care to the coccyx (tailbone area), refused on 1/2 and 1/5/20;
-An order dated 9/10/19, for wound care to the right ischium (buttocks), refused on 1/2 and 1/5/20;
-An order dated 9/25/19, for wound care to the left ischium, refused on 1/2 and 1/5/20;
-An order dated 11/6/19, for wound care to the right medial foot, refused on 1/2 and 1/5/20;
-An order dated 12/14/19, for skin prep (protective barrier) to right second toe, refused on 1/2 and 1/5/20;
-A quarterly MDS, dated [DATE], showed rejection of care: Behavior not exhibited;
6. During an interview on 3/12/20 at 6:35 P.M., the DON and administrator said they would expect MDS be accurate, to include the presence of wounds and pressure ulcers.
7. During an interview on 3/16/20 at 8:44 A.M., the MDS coordinator said MDS should be accurate. She is currently the only MDS coordinator.
CONCERN
(E)
Potential for Harm - no one hurt, but risky conditions existed
Comprehensive Care Plan
(Tag F0656)
Could have caused harm · This affected multiple residents
**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, interview and record review, the facility failed to develop and implement a comprehensive person-centered ...
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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 develop and implement a comprehensive person-centered care plan regarding infections, nutrition/weight loss, and pain management for eight of 29 sampled residents (Residents #138, #56, #38, #60, #85, #123, #62 and #127). The census was 143.
1. Review of Resident #138's admission Minimum Data Set (MDS), a federally mandated assessment instrument completed by facility staff, showed:
-admitted [DATE] from an acute hospital;
-Diagnoses included septicemia (sepsis, systemic infection of the blood);
-Infection of the foot;
-Application of nonsurgical dressings other than to feet;
-Applications of dressings to feet.
Review of the resident's care plan, in use while a resident at the facility, showed:
-Focus: The resident has infection of the (specify):
-Goal: Be free from complications related to infection;
-Interventions: (blank).
Review of the resident's diagnoses list, showed:
-Cellulitis (infection of the skin), acute infection, diagnosis on admission;
-Cellulitis of the right lower limb, acute infection, diagnosis on admission;
-Osteomyelitis (inflammation of the bone caused by infection), diagnosis on admission;
-Sepsis, history diagnosis;
-Local infection of the skin and subcutaneous tissue (lower layer of the skin), history diagnosis.
2. Review of Resident #56's significant change MDS, dated [DATE], showed:
-Moderate cognitive impairment;
-Supervision required with eating;
-Signs and symptoms of possible swallowing disorders: Loss of liquids/solids from mouth when eating or drinking;
-Care area assessment summary: Nutritional status triggered and indicated as care planned by the facility.
Review of the resident's care plan, updated 2/29/20, showed:
-Focus: At risk for nutrition due to diagnosis of severe protein malnutrition. Has a swallowing problem, dementia, dysphagia (difficulty swallowing). Regular puree diet with nectar thick liquids for all meals. On 3/4/19 was reported the resident was pocketing food;
-Goal: Free of complications related to nutrition;
-Approach: New admit 3/30/18 initiate weekly weights.
Review of the resident's weight record, showed:
-On 8/23/19 159.2 pounds (Lbs)
-On 9/9/19 161.2 Lbs;
-On 10/9/19 161.7 Lbs;
-On 11/28/19 163.0 Lbs;
-On 12/15/19 163.6 Lbs;
-On 1/10/20 142.6 Lbs;
-On 1/16/20 142.6 Lbs;
-On 2/3/20 143.1 Lbs;
-No further weights documented;
-A significant weight loss in 6 months, from August 2019 until February 2020 of 10.11%;
-A significant weight loss in 3 months, from November 2019 until February 2020 of 12.21%;
-A significant weight loss in 1 month, from December 2019 to January 2020 of 12.82%.
During an interview on 3/16/20 at 12:09 P.M., with the Director of Nursing (DON), administrator and the nurse practitioner, they said residents are weighed monthly, and some residents are weighed more. The resident is not a resident weighed weekly. If the care plan directed staff to weigh the resident weekly, they would expect this be done.
3. Review of Resident #38's annual MDS, dated [DATE], showed:
-Mild cognitive impairment;
-Received as needed pain medication.
Review of the resident's electronic physician order sheet, showed an order dated 2/7/20, for Tramadol HCl (narcotic pain medication) 50 milligram (mg) Give 1 tablet by mouth every 4 hours as needed for moderate and severe pain.
Review of the resident's narcotic sign out sheet, showed Tramadol HCL 50 mg administered nine times from 3/3/20 through 3/13/20.
Review of the resident's care plan, in use at the time of the survey, showed:
-Focus: Depends on staff for meeting emotional, intellectual, physical and social needs related to cognitive deficit and physical limitations;
-Focus: Activity of daily living (ADL) self-care performance deficit related to cognitive impairment and left side hemiplegia (weakness or paralysis on one side of the body);
-Focus: Limited physical mobility related to weakness;
-Focus: Continued risk for impaired cognitive function and decision making related to stroke. Soft spoken but able to make needs known. Sometimes needs extra time to process information;
-Focus: High blood pressure and congestive heart failure;
-Focus: At risk for falls related to daily psychotropic drug use, limited mobility, impaired balance and cognitive impairment;
-Pain not listed on the care plan as a care area with goals and/or interventions to minimize the effects of pain.
During an interview on 3/11/20 at 2:00 P.M., the resident said his/her wound on his/her bottom hurt. Staff just changed his/her dressing on his/her bottom but he/she was in pain before they changed the dressing. Staff cleaned the wound and the pain stayed after they were finished. He/she was waiting on the nurse to come back and give him/her some pain medication. His/her pain was at a 25 on a scale of 0-10 (0 indicated no pain and 10 indicated the worse pain imaginable, a 25 would indicate pain off the chart). Staff administer him/her tramadol because acetaminophen was not doing anything to relieve the pain. He/she was up earlier in the day to go to therapy but he/she was not able to participate or do much because he/she was in pain and hurting.
Observation on 3/13/20 at 8:46 A.M., showed the staffing coordinator provided wound care for the resident. The resident moaned and yelled out loud during the treatment.
During an interview on 3/16/20 at 12:09 P.M., the DON said if a resident has pain, it should be listed on the care plan with interventions.
4. Review of Resident #60's quarterly MDS, dated [DATE], showed:
-Cognitively intact;
-Rejection of care: Behavior not exhibited;
-Total dependence for bed mobility, dressing and personal hygiene;
-Bathing: Total dependence;
-Diagnoses included cerebral palsy (disorder that affects movement and muscle tone), anxiety and depression.
Review of the resident's care plan, dated 7/9/18, showed:
-Focus: ADL self-care performance deficit related to limited mobility and quadriplegia. Required total assistance with ADLs. Prefers to have showers done at 10:00 A.M. on Mondays and Wednesdays:
-Goal: Would like for staff to anticipate needs through next review period;
-Bathing/Showering: Provide sponge bath when a full bath or shower cannot be tolerated;
-Focus: Will often refuse care:
-Goal: Fewer episodes of refusal of care behaviors;
-Interventions: Monitor behavior episodes.
During an interview on 3/10/20 at 9:43 A.M., the resident said he/she wanted a shower and he/she had not had his/her hair washed since August 2019. Observation, showed the resident's hair oily. The resident said his/her hair stinks, so he/she keeps it up in a ponytail so it stays out of his/her face.
Observation on 3/10/20 at approximately 10:00 A.M., of the shower room located next to the resident's room, showed a roll in shower buddy (a shower chair used to meet the needs of those with disabilities by use of a tilting chair that offers core and extremity support for individuals unable to maintain their own positioning) available.
During an interview on 3/13/20 at 9:57 A.M., the resident said he/she has still not been provided a shower. He/she has scabs on his/her head from not having a shower.
Observation and interview on 3/13/20 at 9:58 A.M., showed Nurse R assessed the resident's scalp. Nurse R said the resident has flaky, itchy hair and he/she was just in the resident's room scratching the resident's head for him/her, per the resident's request. He/she did not know if the resident was receiving showers because he/she was switched from days to evenings for showers. The resident said he/she attended a care plan meeting in January and said he/she wanted to take showers. The staff in the care plan meeting said they would put it in the care plan. Observation during a skin assessment of the resident's hair and scalp, showed the resident's hair oily with chunks of dry skin in the scalp and flakes on the resident's pillow, bed and shirt. The resident's hair had a pungent odor and the hair appeared thick and oily. As the nurse brushed through the resident's hair, dandruff flaked off, all over the resident's shoulders. The resident said everyone says I refuse showers but they don't ask.
During an interview on 3/16/20 at 12:09 P.M., the Director of Nursing (DON) and administrator said when the resident refuses a bath or shower, staff educate him/her. Refusing care is a normal behavior for the resident. He/she goes through cycles where he/she refuses care. They did not know when the resident's hair was last washed. Interventions for staff to attempt when the resident refused showers should be documented in the care plan. The facility does have a beauty shop. If it is determined it is safe for the resident to use the hair bowl in the beauty shop, staff could use this to wash the resident's hair. The DON said she believed this may have been attempted before and the resident could not be positioned properly to use the beauty shop. She thinks staff had issues with the tilt shower chair not being safe as well. The resident's hair can be washed during a bed bath.
Further review of the resident's care plan, showed the care plan failed to provide interventions to attempt if the resident refuses a bath/shower, the resident's preference to receive a shower over a bath, the availability of a shower buddy shower chair, and failed to direct staff to wash the resident's hair as requested with alternative ways to wash his/her hair if a shower was not possible. The care plan did not identify the resident as a resident that could not have a shower due to inability to position self or that he/she was unable to go to the beauty shop to have his/her hair washed.
5. Review of Resident #85's annual MDS, dated [DATE], showed the following:
-Severe cognitive impairment;
-Supervision with eating;
-Diagnoses of high blood pressure, high cholesterol, dementia, anxiety, depression and psychotic disorder;
-Weight: 182 Lbs;
-No weight loss or gain;
-CAAS: Nutritional status triggered and indicated as care planned by the facility.
Review of the resident's medical record, showed:
-An order dated 1/9/19, for a regular diet, regular texture, regular consistency;
-The last Registered Dietician assessment completed on 1/10/19;
-No quarterly nutritional assessments.
Review of the resident's care plan, dated 2/19/19, showed no documentation regarding the resident's nutritional needs.
6. Review of Resident #123's admission MDS, dated [DATE], showed the following:
-Limited assistance with eating;
-Diagnoses of anemia, high blood pressure, end stage renal disease (ESRD), diabetes and depression;
-Weight: 126 lbs;
-No weight loss or gain.
Review of the resident's care plan, dated 2/27/20, showed the following:
-Focus: Resident has potential nutritional problem with regards to ESRD, diabetes and high blood pressure;
-Goal: The resident will comply with recommended diet for weight stability through review date;
-Interventions: Provide and serve diet as ordered. Registered Dietician to make diet change recommendations as needed.
Review of the resident's medical record, showed:
-An order dated 3/8/20, for regular texture, regular consistency, renal (kidney) diet (no oranges/juice, bananas, limited potato).
-No documentation regarding an assessment from the Registered Dietician;
-No quarterly nutritional assessments.
Further review of the resident's care plan, showed it did not address the resident's need for a renal diet and/or dietary restrictions to include no oranges/juice, bananas, limited potato.
7. Review of Resident #62's admission MDS, dated [DATE], showed:
-Cognitively intact;
-Supervision required with eating;
-CAAS: Nutritional status triggered and indicated as care planned by the facility.
Review of the resident's care plan, in use at the time of the survey, showed:
-Focus: Potential nutritional problem related to therapeutic diet for ESRD and diabetes;
-Goal: Maintain adequate nutritional status as evidenced by maintaining stable weight no signs and symptoms of malnutrition, and consuming at least 50% meals daily;
-Interventions: Explain and reinforce to the resident the importance of maintaining the diet ordered. Encourage the resident to comply. Explain consequences of refusal, obesity/malnutrition risk factors. RD to evaluate and make diet change recommendations as needed.
Review of the resident's medical record, showed an order dated 2/21/20, for renal diet (no oranges/juice, bananas, limit potato), regular texture, regular consistency.
Further review of the resident's care plan, showed it did not address the resident's need for a renal diet and/or dietary restrictions to include no oranges/juice, bananas, limited potato.
8. Review of Resident #127's annual MDS, dated [DATE], showed:
-Cognitively intact;
-Supervision required with eating;
-CAAS: Nutritional status triggered and indicated as care planned by the facility.
Review of the resident's care plan, in use at the time of the survey, showed:
-Focus: At risk for potential nutritional problems related to chronic kidney disease (CKD);
-Goal: Maintain adequate nutrition by consuming at least 75% of meals daily;
-Interventions: Provide and serve diet as ordered. Registered Dietician to evaluate and make diet change recommendations as needed.
Review of the resident's medical record, showed an order dated 3/3/20, renal diet (no oranges/juice, bananas, limit potato), regular texture, regular consistency.
Further review of the resident's care plan, showed it did not address the resident's need for a renal diet and/or dietary restrictions to include no oranges/juice, bananas, limited potato.
9. During an interview on 3/16/20 at 12:09 P.M., with the DON, administrator and nurse practitioner, they said care plans should be complete and accurate. The MDS coordinator is responsible for the care plans.
CONCERN
(E)
Potential for Harm - no one hurt, but risky conditions existed
Deficiency F0660
(Tag F0660)
Could have caused harm · This affected multiple residents
**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, interview and record review, the facility failed to ensure a discharge planning process was in place which...
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**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, interview and record review, the facility failed to ensure a discharge planning process was in place which addressed discharge goals and needs, including an updated care plan, caregiver support and referrals to local contact agencies as appropriate, that involved the resident and interdisciplinary team in developing a discharge plan for four of 29 sampled residents (Residents #139, #398, #2, and #1). The census was 143.
1. Review of Resident #139's Minimum Data Set (MDS), a federally mandated assessment instrument completed by facility staff, dated 2/16/20, showed the following:
-admitted to the facility on [DATE];
-Ability to understand others and to make him/herself understood;
-Always continent of bowel and bladder;
-Adequate speech, hearing and vision;
-A Brief Interview for Mental Status (BIMS, a screening tool used to determine cognitive impairment) score of 15 out of 15 (cognitively intact);
-No behaviors;
-Independent with all activities of daily living (ADLs);
-Diagnosis that include cancer, diabetes, high blood pressure and depression.
Review of the resident's care plan, in use at time of survey, showed the following:
-Focus: The resident is very independent of his/her daily activities. He/she attends most activity of her/his choosing, there are times you find him/her sitting and chatting with his/her peers or playing bingo or attending music socials and socials of food. His/her sister visits a couple times per week. Sometimes the resident likes to spend time in his/her room coloring or watching television;
-Goal: Staff to provide the resident with a monthly calendar. Ask resident about his/her preferences as it relates to daily group activities;
-Intervention: Keep the resident encouraged daily although he/she is very independent of his/her daily activities;
-Focus: The resident is at risk for a decline in his/her ADLs related to disease process Parkinson's disease (a disorder of the central nervous system that affects movement, often including tremors) and major depressive disorder, impaired mobility related to osteoarthritis, neuropathy (numbness, pain or tingling in the extremities) and headaches;
-Goal: The resident will maintain current level of function ADLs through the review date;
-Intervention: Monitor the resident for impaired mobility related to unsteady gait and balance. Bathing/showering: Check nail length and trim and clean on bath day and as necessary. Report any changes to the nurse. He/she is able to shower and eat with setup assist. The resident is independent with all other ADLs;
During an interview on 3/11/20 at 5:36 P.M., the Director of Social Services (DSS), said the 500 hall is a long-term care floor recently opened due to increased census. The resident may not need skilled nursing. He/she does not do well with roommates, was evicted from his/her house, is emotional since his/her spouse passed away and has pain in his/her shoulders. There is no discharge planning for the resident. At admission, he/she needed skilled nursing. The resident does not feel safe returning to community and does not want to participate with Money Follows the Person (a government program used to enable people with chronic conditions and disabilities transitioned from institutions back into the community).
2. Review of Resident #398's admission MDS, dated [DATE], showed the following:
-admitted to the facility on [DATE];
-Ability to understand others and to make him/herself understood;
-Always continent of bowel and bladder;
-Adequate speech, hearing and vision;
-A BIMS of 15;
-No behaviors;
-One-person physical assist with all ADLs;
-Uses wheelchair for movement;
-Diagnoses that include high blood pressure and chronic obstructive pulmonary disease (COPD, lung disease).
Review of the resident's care plan, in use at time of survey, showed the following:
-Focus: The resident is alert and oriented. He/she enjoys reading books on the western world and other great authors. He/she is always engaged in his/her favorite TV programs. He/she has been invited to activities but has not attended as of yet;
-Goal: To have the resident attend at least one activity per week;
-Interventions: The resident has been informed of activity programs. Encourage the resident to attend daily activities of choice. Although the resident is independent, monitor him/her for socialization;
-Focus: The resident has an ADL self-care performance deficit due to having a diagnosis of gout (a form of arthritis), pancreatitis (infection/inflammation of the pancreas), osteoarthritis, and asthma. He/she requires limited assist with all activities of daily living, bed mobility and personal hygiene tasks and is continent of bowel and bladder;
-Goal: The resident will improve current level of function in ADLs through the review date;
-Intervention: He/she uses a manual wheelchair to assist with mobility. The resident is able to propel self while in wheelchair. Assist as needed. The resident is continent of bowel and bladder and requires limited assist with toileting tasks and personal care. He/she transfers with one assist with a gait belt for all transfers.
During an interview on 10/10/20 at 10:36 A.M., the resident said there is never any staff on his/her floor. He/she does his/her own showers and laundry.
During an interview on 3/11/20 at 5:36 P.M., the DSS said the resident's goal is to enroll in Money Follows the Person. He/she was sick when he/she arrived at the facility.
During an interview on 3/12/20 at 12:07 P.M., the resident said he/she just talked with DSS today and asked about Money Follows the Person this morning. He/she did not know of the program before. He/she would like to get his/her own place. He/she cannot walk right now but is working with therapy.
Further review of the resident's care, showed no discharge planning or goals and documentation regarding the Money Follows the Person program.
3. Review of Resident #2's admission MDS, dated [DATE], showed the following:
-admitted to the facility on [DATE];
-A BIMS of 9 out of 15 (moderate cognitive impairment);
-Ability to understand others and to make him/herself understood;
-Always continent of bowel and bladder;
-Adequate speech, hearing and vision;
-Independent with all ADLs;
-Steady gait and balance with no limitations regarding all extremities range of motion;
-Diagnoses including heart disease and COPD.
Review of the resident's care plan, in use at time of the survey, showed the following:
-Focus: The resident is alert and oriented. He/she would like to watch TV in his/her room, take smoke breaks and attend socials with peers;
-Goal: the resident will attend at least two activities of choice per week;
-Intervention: Provide meaningful activities, provide access to channel 2 from his/her TV to see the daily activities. Monitor the resident for socialization and ask preference as it relates to activities;
-Focus: The resident is a smoker and attends smoke breaks of choice;
-Goal: The resident will not smoke without supervision;
-Intervention: The resident is able to smoke independently with supervision;
-Focus: The resident is at risk for falls due to being independently ambulatory;
-Goal: The resident will be free of injury related to falls;
-Intervention: Anticipate and meet the resident's needs as needed.
Review of the resident's 3/10/20 nursing home referral form, signed and dated by the resident, showed the resident was referred to Money Follows the Person.
During an interview on 3/12/20 at 11:15 A.M., the resident said he/she smokes and goes out on smoke breaks with staff. He/she has signed up for Money Follows the Person.
During an interview on 3/11/20 at 5:36 P.M., the DSS said the resident signed up for Money Follows the Person and is waiting to be accepted.
Further review of the resident's care plan, showed no discharge planning and no documentation related to Money Follows the Person.
4. Review of Resident #1's quarterly MDS, dated [DATE], showed the following:
-admitted to the facility on [DATE];
-A BIMS score of 11 out of 15 (moderate cognitive impairment);
-Ability to understand others and to make him/herself understood;
-Always continent of bowel and bladder;
-Adequate speech, hearing and vision;
-Steady gait and balance with no limitations regarding all extremities range of motion;
-Requires supervision and oversight with all self-preformed activities of daily living;
-Diagnoses including traumatic brain injury and depression.
Observation of the resident during survey, showed he/she walked free and independent throughout the building.
Review of the resident's nursing home referral form, signed and dated by the resident, showed the resident was referred to Money Follows the Person on 12/27/19.
During an interview on 3/11/20 at 5:36 P.M., the DSS said the resident is actively participating in Money Follows the Person program and must remain at the facility during this time.
Review of the resident's care plan, in use at time of the survey, showed no documentation of the resident's participation in the Money Follows the Person program, nor any discharge planning.
5. During an interview on 3/11/20 at 5:36 P.M., the DSS said discharge goals should be part of the care plan. A care plan should be updated every three months. He is in the process of reviewing all of these residents, case by case.
6. During an interview on 3/12/20 at 12:52 P.M., the administrator said discharge planning starts at the moment the resident is admitted to the facility. The MDS coordinator is in charge of care plans, and they have two currently on staff. There is no discharge planning on these residents' care plans. She expected the discharge goals be discussed at admission, quarterly and asked with all MDS updates. Any and all discharge goals to include Money Follows the Person, should be addressed on the resident's care plan.
CONCERN
(E)
Potential for Harm - no one hurt, but risky conditions existed
Deficiency F0692
(Tag F0692)
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 properly monitor residents nutritional status to ensure early ident...
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**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on interview and record review, the facility failed to properly monitor residents nutritional status to ensure early identification of residents with, or at risk for, impaired nutrition or hydration status. This would allow the interdisciplinary team to develop and implement interventions to stabilize or improve nutritional status before complications arise. The facility failed to obtain weights as directed by the resident's care plan for one resident (Resident #56) and failed to ensure the dietician monitored residents nutritional status quarterly for four of eight residents reviewed for nutritional needs (Resident #56, #85, #123, and #144). The sample was 29. The census was 143.
Review of the facility's Nutrition and Unplanned Weight Loss/Gain policy, dated 6/28/19, showed:
-The facility will assess and monitor the nutritional status of residents to assist the resident in maintaining adequate nutritional status, to the extent possible, giving careful consideration to the following: The residents choice to make informed decisions, the residents nutritional and hydration needs and by considering any pomological or functional impairment which may need to be addressed;
-Definitions:
-One month: 5% weight loss = significant loss. Greater than 5% = severe loss;
-Three months: 7.5% weight loss = significant loss. Greater than 7.5% = severe loss;
-Six months: 10% weight loss = significant loss. Greater than 10% = severe loss;
-All residents shall be weighed upon admission, monthly and as required by their clinical condition and/or as ordered by nursing and/or physician orders;
-Routine weight measurements will occur at least monthly unless otherwise noted in the resident's plan of care;
-The physician and the resident's responsible party will be notified of any significant weight changes and the need for modifications of the resident's nutritional regimen within 72 hours of identification of a significant loss or gain;
-The registered dietician (RD) is responsible to complete an assessment; estimating calorie, nutrient and fluid needs of all residents upon admission, annually and as needed;
-Residents with significant weight loss will be referred to their physician/practitioner for orders or additional diagnostic testing;
-The policy failed to identify who would be responsible to complete resident's quarterly nutritional assessments.
1. Review of Resident #56's significant change Minimum Data Set (MDS), a federally mandated assessment instrument completed by facility staff, dated 4/2/19, showed:
-Moderate cognitive impairment;
-Supervision required with eating;
-Signs and symptoms of possible swallowing disorders: Loss of liquids/solids from mouth when eating or drinking;
-Care area assessment summary (CAAS): Nutritional status triggered and indicated as care planned by the facility.
Review of the resident's electronic physician order sheet (ePOS), showed:
-An order dated 2/21/19, for Ready Care (nutritional supplement) four times a day;
-An order dated 2/25/19, for regular diet, pureed texture, nectar consistency.
Review of the resident's care plan, updated 2/29/20, showed:
-Focus: At risk for nutrition due to diagnosis of severe protein malnutrition. Has a swallowing problem, dementia, dysphagia (difficulty swallowing). Regular puree diet with nectar thick liquids for all meals. On 3/4/19 was reported the resident was pocketing food;
-Goal: Free of complications related to nutrition;
-Approach: New admit 3/30/18 initiate weekly weights.
Review of the resident's medical record, showed:
-A Registered Dietician Assessment, dated 4/16/19, showed:
-Nutritional risk factors: Below desired weight range, potential for poor intake, current history of pressure ulcers, difficulty chewing/swallowing/dysphagia, altered texture diet, thickened liquids, risk for dehydration;
-No further Registered Dietician Assessments completed as of 3/16/20;
-No quarterly nutritional assessments;
-No dietary progress notes.
Review of the resident's weight record, showed:
-On 8/23/19 159.2 pounds (Lbs)
-On 9/9/19 161.2 Lbs;
-On 10/9/19 161.7 Lbs;
-On 11/28/19 163.0 Lbs;
-On 12/15/19 163.6 Lbs;
-On 1/10/20 142.6 Lbs;
-On 1/16/20 142.6 Lbs;
-On 2/3/20 143.1 Lbs;
-No further weights documented;
-A significant weight loss in 6 months, from August 2019 until February 2020 of 10.11%;
-A significant weight loss in 3 months, from November 2019 until February 2020 of 12.21%;
-A significant weight loss in 1 month, from December 2019 to January 2020 of 12.82%.
Further review of the resident's medical record, showed no documentation the physician and the resident's responsible party were notified of any significant weight changes and the need for modifications of the resident's nutritional regimen within 72 hours of identification of a significant loss or gain, per the facility's policy.
During an interview on 3/16/20 at 10:23 A.M., the RD said he/she became aware of the resident's significant weight loss in February and ordered double portions.
Further review of the resident's medical record, showed no order for double portions.
During an interview on 3/16/20 at 12:09 P.M., with the Director of Nursing (DON), administrator, and the nurse practitioner, they said residents are weighted monthly, and some residents are weighed more. The resident is not a resident weighed weekly. If the care plan directed staff to weight the resident weekly, they would expect this be done.
2. Review of Resident #85's annual MDS, dated [DATE], showed the following:
-Severe cognitive impairment;
-Trouble concentrating on things;
-No behaviors;
-Supervision with eating;
-Diagnoses of high blood pressure, high cholesterol, dementia, anxiety, depression, and psychotic disorder;
-Weight: 182 Lbs;
-No weight loss or gain;
-CAAS: Nutritional status triggered and indicated as care planned by the facility.
Review of the resident's medical record, showed:
-An order dated 1/9/19, for a regular diet, regular texture, regular consistency;
-The last Registered Dietician Assessment completed on 1/10/19;
-No quarterly nutritional assessments.
Review of the resident's care plan, dated 2/19/19, showed no documentation regarding the resident's nutritional needs.
3. Review of Resident #123's admission MDS, dated [DATE], showed the following:
-No cognitive impairment;
-Feeling depressed and down at times;
-Limited assistance with eating;
-Diagnoses of anemia, high blood pressure, end stage renal disease (ESRD), diabetes, and depression;
-Weight: 126 lbs;
-No weight loss or gain.
Review of the resident's care plan, dated 2/27/20, showed the following:
-Focus: Resident has potential nutritional problem with regards to ESRD, diabetes and high blood pressure;
-Goal: The resident will comply with recommended diet for weight stability through review date;
-Interventions: Provide and serve diet as ordered. Registered Dietician to make diet change recommendation as needed.
Review of the resident's medical record, showed:
-An order dated 3/8/20, for regular texture, regular consistency, renal (kidney) diet (no oranges/juice, bananas, limited potato).
-No documentation regarding an assessment from the Registered Dietician;
-No quarterly nutritional assessments.
4. Review of Resident #144's quarterly MDS, dated [DATE], showed the following:
-No cognitive impairment;
-No moods;
-No behaviors;
-Supervision with eating;
-Diagnoses of high blood pressure, diabetes, stroke and depression;
-Weight: 231 lbs;
-No weight loss or gain.
Review of the resident's care plan, last revised 5/15/19, showed the following:
-Focus: Resident is frequently non complaint with recommend diet. Resident will order fast food on occasion and will frequently purchase snacks out of the vending machine;
-Goal: Resident will have no complication relate to diabetes through the review date;
-Interventions: Dietary consult for nutritional regimen and ongoing monitoring. Discuss meal times, portion sizes, dietary restrictions, snacks allowed in daily nutritional plan, compliance with nutritional regimen.
Review of the resident's medical record, showed:
-An order dated 1/24/17, for a regular diet, regular texture and regular consistency;
-A Dietary Note/Nutritional Note, completed by the Dietary Manager, dated 2/25/20, showed the resident is currently on a regular diet. He/she does not complain about meals and as of 2/1/20, he/she weighed 230 lbs;
-The last Register Dietician Assessment, completed on 2/19/19;
-No quarterly nutritional assessments.
5. During an interview on 3/16/20 at 10:23 A.M., the RD said she visits the facility two times a month. She documents nutritional assessments on residents annually and on admission. She does not complete the quarterly assessments. That is the responsibility of the dietary manager.
6. During an interview on 3/16/20 at 10:30 A.M., the dietary manager said he has been in his position for 8 to 10 months. He recently found out he was supposed to be doing the quarterly nutritional assessments on residents and has started to do them.
7. During an interview on 3/16/20 at 12:27 P.M., the administrator said the RD comes in twice a month. The RD should be assessing and documenting quarterly, annually and for a significant change of the resident. She did not know why the RD was not assessing the resident quarterly. The assessments are important to address any nutritional concerns of the resident. The dietary manager is not qualified to complete the assessments.
CONCERN
(E)
Potential for Harm - no one hurt, but risky conditions existed
Deficiency F0726
(Tag F0726)
Could have caused harm · This affected multiple residents
Based on observation, interview and record review, the facility failed to assure that all nursing staff possess the competencies and skill sets necessary to provide nursing and related services. The f...
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Based on observation, interview and record review, the facility failed to assure that all nursing staff possess the competencies and skill sets necessary to provide nursing and related services. The facility relied on staffing agencies to provide nursing services for the residents. The facility did not train the agency staff on facility policies and procedures. In addition, the facility staff failed to demonstrate competency in care provided to treat wounds. The census was 143.
Review of the facility assessment, revised 12/9/19, showed:
-Staff:
-Registered Nurses (RN);
-Licensed Practical Nurses (LPN);
-Direct care staff;
-Nurse educator;
-(Agency staff not indicated as staff utilized)
-Staff training/education and competencies:
-All employees participate in a series of competencies upon hire and again quarterly and as needed. Education needs are also identified through performance observation, resident/family concerns and regulation changes;
-Certified Nursing Assistants (CNAs) are given core in-service to ensure completion of mandatory 12 hours of training in conjunction with facility identified training needs.
During an interview upon entrance to the facility, on 3/10/20 at 8:30 A.M., the administrator said the facility utilizes staff from nursing agencies to fulfill staffing needs.
Observations during the survey, showed:
-The facility failed to ensure residents receive care to prevent pressure ulcers (injury to the skin and/or underlying tissue, as a result of pressure or friction) and ensure residents with pressure ulcers receives necessary treatment and services to promote healing, for five of seven residents investigated for pressure ulcers (Resident #56, #135, #60, and #143). The facility failed to assess wounds per facility policy and standards of practice and provide treatments as ordered. Resident #56 had a delay in identification of a pressure ulcer. When first identified by the facility, the pressure ulcers was a stage III (full thickness tissue loss, subcutaneous fat may be visible but the bone, tendon or muscle is not exposed). This resulted in a delay of treatment. After identified, the facility failed to assess and monitor the wound and failed to provide treatments as ordered consistently, which resulted in the wound developing into a stage IV pressure ulcer (full thickness tissue loss with exposed bone, tendon or muscle). The wound became infected and the resident required hospitalization for sepsis (systemic infection) and surgical wound debridement (removal of dead tissue);
-The facility failed to ensure that residents receive treatment and care in accordance with professional standards of practice for four residents (#138, #141, #135, and #143), of six residents investigated for non-pressure wounds and wound care when the facility failed to assess and treat wounds per facility policy and standards of practice. Resident #138 had a delay in treatment orders after admission. The facility failed to routinely apply the ordered treatments and assess the wounds. The resident had a change in level of swelling and wound drainage and the facility failed to timely notify the physician after identifying the change. The resident had a change in mental status after several days of increased swelling, drainage and pain; and was sent to the hospital. The resident required surgical debridement of a right heel wound and a below the knee amputation (BKA) of the left lower extremity due to the condition of the wounds;
-The facility failed to implement procedures for the provision of infection prevention and control utilizing current standards of practice for three of four residents observed during wound care (Resident #135, #60 and #38).
During an interview on 3/12/20 at 6:35 P.M., with the Director of Nursing (DON), administrator and Wound Nurse O, they said the facility just got a new nurse educator a couple weeks ago. Prior to that, the facility would have blitz days and competency exams. Staff should be competent in their ability to know how to determine the onset of a wound and have the ability to know if a wound is getting better, worse or unchanged. Staff are trained on the facility's wound policy. No other specialized training is provided at this time. The DON was asked to provide the most recent training provided to facility staff on wound care, to include what staff were educated on during the training.
During an interview on 3/16/20 at 8:29 A.M., the Quality Assurance (QA) nurse said she was also hired as the infection preventionist and the nurse educator, but she has only been at the facility for a couple of weeks and has only been trained in the QA part of her job, as of this point. The DON said the facility is going to reach out to the wound clinic to see if they will provide training on wounds. The former QA nurse left in January. When asked about the documentation of the most recent training provided to facility staff on wound care, the DON said the only documentation of training the facility has is the logs. The former QA nurse was also responsible for staff training. No information is provided to agency staff when they come to work for the facility and the do not receive orientation. They get report during rounds from the off-going staff. The facility depends on the agency training their own staff. Usually, before agency staff come, the facility will tell them where manuals are. The facility utilizes both licensed nurses and CNAs from the nursing agency weekly.
CONCERN
(E)
Potential for Harm - no one hurt, but risky conditions existed
Deficiency F0730
(Tag F0730)
Could have caused harm · This affected multiple residents
Based on interview and record review, the facility failed to ensure each nurse aide had no less than 12 hours of in-service education per year based on their individual performance review, calculated ...
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Based on interview and record review, the facility failed to ensure each nurse aide had no less than 12 hours of in-service education per year based on their individual performance review, calculated by hire date. The facility identified 68 certified nursing assistants (CNAs) employed at the facility for more than a year. Seven CNAs were sampled and five of the seven did not have the required 12 hours of in-service training. The census was 143.
Review of the facility assessment, revised 12/9/19, showed:
-Staff training/education and competencies:
-All employees participate in a series of competencies upon hire and again quarterly and as needed. Education needs are also identified through performance observation, resident/family concerns and regulation changes;
-CNAs are given core in-service to ensure completion of mandatory 12 hours of training in conjunction with facility identified training needs.
1. Review of CNA S's employee file and training log, showed:
-Date of hire (DOH) 8/27/17;
-Training hours reviewed from 8/2018 through 7/2019 = 0.
2. Review of CNA V's employee file and training log, showed:
-DOH 3/30/16;
-Training hours reviewed from 3/2019 through 2/2020 = 7.
3. Review of CNA W's employee file and training log, showed:
-DOH 11/22/16;
-Training hours reviewed from 11/2018 through 10/2019 = 6.5.
4. Review of CNA X's employee file and training log, showed:
-DOH 10/18/17;
-Training hours reviewed from 10/2018 through 9/2019 = 0 hours.
5. Review of CNA Y's employee file and training log, showed:
-DOH 6/25/18;
-Training hours reviewed from 6/2018 through 5/2019 = 0 hours.
6. During an interview on 3/16/20 8:29 A.M., the Quality Assurance (QA) nurse said she was also hired as the infection preventionist and the nurse educator, but she has only been at the facility for a couple of weeks and has only been trained in the QA part of her job, as of this point. The former QA nurse left in January. The DON said the only documentation of training the facility has are the logs. The former QA nurse was also responsible for staff training. The QA nurse said she was not sure how training was tracked.
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 observation, interview and record review, the facility failed to ensure drugs and biologicals used in the facility are ...
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**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, interview and record review, the facility failed to ensure drugs and biologicals used in the facility are stored and labeled in accordance to current acceptable professional standards for two of three observed medication carts and two of three observed nurse treatment carts. The census was 143.
1. Observation on [DATE] at 6:36 A.M., of the second floor treatment cart, showed the following:
-A tube of protective ointment cream labeled with a resident's name, the lid opened, and the tube lay directly in the drawer of the cart;
-A tube of hydrogel wound cream (ointment used to keep wounds moist and promote healing) with vitamin E, the lid opened and the tube lay directly in the drawer of the cart. No resident name labeled on the tube;
-A tube of itch relief cream, opened and lay directly in the drawer of the cart. No resident name labeled on the tube;
-A 30 gram tube of Santyl cream (used to treat wounds), opened and lay directly in the drawer of the cart. No resident name labeled on the tube;
-A tube of clobetasol propionate (used to treat skin conditions such as eczema) cream, opened and lay directly in the drawer of the cart. No lid for the tube in the cart. The tube soiled on the outside, no resident name labeled on the tube;
-A bottle of eye drops opened, no name or pharmacy label. No resident name labeled on the bottle and no box to identify the medication.
2. Observation on [DATE] at 1:34 P.M., of the third floor medication cart, showed the following:
-Outside pharmacy bottle of doxycycline hyclate (antibiotic) 100 milligram (mg) with 6 tablets inside, filled on [DATE];
-Outside pharmacy bottle of imatinib 100 mg (chemotherapy drug), filled on [DATE].
During an interview on [DATE] at 1:53 P.M., Nurse P said these drugs are no longer being used and should be disposed of.
3. Observation on [DATE] at 1:53 P.M., of the third floor nurse treatment cart, showed the following:
-A tube of triple antibiotic cream with an expiration date of [DATE];
-A tube of gentamicin (antibiotic cream) with an expiration date of [DATE].
4. Observation on [DATE] at 3:00 P.M., of the 100 hall medication cart, showed the following:
-Two weeks of individually packaged medications for a resident who was discharged to the hospital;
-Three unknown loose pills at the bottom of the last drawer;
-A sharps container in use, connected to the side of the cart, filled with sharps past the safety full line.
5. During an interview on [DATE] at 3:30 P.M., the Director of Nursing (DON) said she expected all carts to be neat and organized. All medications that have expired and old prescriptions should be discarded and not stored in the cart. If a resident is no longer at the facility, their medication should be returned to pharmacy and not stored in the cart. On [DATE] at 12:09 P.M., the DON said medications should be labeled with the resident's name and have a pharmacy label.
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 and interview, the facility failed to keep items labeled and dated in the kitchen storage rooms, to ensure ...
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**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation and interview, the facility failed to keep items labeled and dated in the kitchen storage rooms, to ensure the deep fryer was free of debris, microwaves and cabinets were free of dirt and debris and the vents above the preparation areas were free of dust buildup. This had the potential to affect residents who received food from the facility kitchen. The census was 143.
Observation of the kitchen on 3/11/20, showed the following:
-At 6:45 A.M., three large containers of dry cereal in the storage room did not have a label or date;
-At 6:46 A.M., grease and debris on the top and sides of the deep fryer. The vents above the food preparation area covered with dust;
-At 6:50 A.M., the microwave in the kitchenette of the main dining room had dried food and debris on the inside. Three dead bugs in the cabinets next to the microwave in the kitchenette of the main dining room;
-At 7:15 A.M., the microwave in the [NAME] kitchenette had dried food and debris on the inside.
Observation of the kitchen on 3/16/20 at 7:20 A.M., showed in the food storage and preparation areas in the kitchen, two large containers of chips and six large containers of bulk cereal did not have a label or a date. There was grease and debris on the top and sides of the deep fryer and the vents were covered with dust above the food preparation area.
During an interview on 3/16/20 at 8:30 A.M., the Dietary Manager (DM) said the Dietary Aides (DA) should be cleaning the microwaves and the cooks should be cleaning the deep fryer. He did not realize they were not being done. The stock person should be labeling and dating the bulk items. He did not realize the items were not being labeled and dated. The DA should be cleaning the vents in the kitchen and the maintenance team cleans the vents in the dining room. There is no actual schedule for the cleaning of the vents.
CONCERN
(E)
Potential for Harm - no one hurt, but risky conditions existed
QAPI Program
(Tag F0867)
Could have caused harm · This affected multiple residents
**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, interview and record review, the facility failed to ensure the quality assessment and assurance committee ...
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**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, interview and record review, the facility failed to ensure the quality assessment and assurance committee develop and implement appropriate plans of action to correct identified quality deficiencies. The facility received repeated deficiencies for the prior year's annual survey to the current year's annual survey. In addition, the facility failed to implement a performance improvement plan for an identified concern with pressure ulcer (injury to the skin and/or underlying tissue, as a result of pressure or friction) care that resulted in a citation at the isolated actual harm level, which is a higher grid level than the citation received the prior year for the same concern. The census was 143.
Review of the facility's Quality Assurance Process Improvement and Compliance policy, last revised 4/30/18, showed:
-This organization will implement and maintain an active quality assurance process improvement and compliance (QAPIC) program;
-QAPIC efforts will be ongoing, comprehensive and will encompass the full range of services performed by the facility and its departments including but not limited to clinical care, quality of life, resident rights, safety, operations, billing human resources and management practices;
-The QAPIC committee has been empowered to: Charter and oversee process improvement teams to accomplish its goals, perform system and process assessments; complete process improvement projects (PIPs) and to establish a structure of responsibility;
-Feedback, data systems and monitoring: Monitoring performance through data collection is the foundation of all performance improvement and compliance activities. Data may be obtained from a variety of sources, including but not limited to:
-Centers for Medicare and Medicaid services (CMS) Quality Measures;
-Hospitalization data;
-Infection control data;
-Survey and regulatory findings;
-Nutrition reports;
-PIPs: PIPs are conducted to examine and improve care or services in areas that have been identified by the QAIPC committee as areas that need attention or that demonstrate a clear opportunity for improvement. In order to provide a consistent approach to performance improvement, the organization has adopted the FOCUS-PDSA model:
-Find a process/system to improve;
-Organize a team that knows the process/system;
-Clarify current knowledge of the process/system;
-Understand the causes of process variation;
-Select the process improvement;
-Plan the improvement and continue data collection;
-Do the improvement, data collection and analysis;
-Study the results and lessons learned from the effort;
-Act to standardize the improvement and continue to improve the process by reviewing what to do next;
-Implementation of PIPs are generally expected to be conducted using teams. Some situation may dictate the use of other methodologies as deemed appropriate for the opportunity for improvement being addressed.
1. Review of form CMS-2567, dated 1/15/19, showed the facility cited the following deficiencies:
-F656: Develop/implement Comprehensive Care Plan, cited at the isolated no actual harm with potential for more than minimal harm level;
-F657: Care Plan Timing and Revision, cited at the isolated no actual harm with potential for more than minimal harm level;
-F677: ADL Care Provided for Dependent Residents, cited at the pattern no actual harm with potential for more than minimal harm level;
-F686: Treatment/services to Prevent/Heal Pressure Ulcers, cited at the isolated no actual harm with potential for more than minimal harm level;
-F692: Nutrition/Hydration Status Maintenance, cited at the isolated no actual harm with potential for more than minimal harm level;
-F761: Label/Store Drugs and Biologicals, cited at the pattern no actual harm with potential for more than minimal harm level;
-F812: Food Procurement, store/prepare/serve-Sanitary, cited at the pattern no actual harm with potential for more than minimal harm level.
Review of form CMS-2567, dated 8/9/19, showed F684: Quality of Care, cited at the isolated actual harm level
Review of the current CMS-2567, dated 3/16/20, showed:
-F656: Develop/implement Comprehensive Care Plan, cited at the pattern no actual harm with potential for more than minimal harm level;
-F657: Care Plan Timing and Revision, cited at the isolated no actual harm with potential for more than minimal harm level;
-F677: ADL Care Provided for Dependent Residents, cited at the isolated no actual harm with potential for more than minimal harm level;
-F684: Quality of Care, cited at the isolated actual harm level;
-F686: Treatment/services to Prevent/Heal Pressure Ulcers, cited at the isolated actual harm level;
-F692: Nutrition/Hydration Status Maintenance, cited at the pattern no actual harm with potential for more than minimal harm level;
-F761: Label/Store Drugs and Biologicals, cited at the pattern no actual harm with potential for more than minimal harm level;
-F812: Food Procurement, store/prepare/serve-Sanitary, cited at the widespread no actual harm with potential for more than minimal harm level.
2. Observation, interview and record review during the survey, showed:
-The facility failed to ensure residents receive care to prevent pressure ulcers and ensure residents with pressure ulcers received necessary treatment and services to promote healing, for five of seven residents investigated for pressure ulcers (Resident #56, #135, #60, and #143). The facility failed to assess wounds per facility policy and standards of practice and provide treatments as ordered;
-Review of Resident #56's medical record, showed the resident had skin issues identified on 11/11/19. No treatment order for the identified area obtained until 11/27/19, at which time the area was identified as acquired stage III pressure ulcer (full thickness tissue loss, subcutaneous fat may be visible but the bone, tendon or muscle is not exposed). The facility failed to assess and monitor the wound per facility policy and failed to consistently provide treatments as ordered. On 2/3/20 the wound worsened to a stage IV (full thickness tissue loss with exposed bone, tendon or muscle). The resident had a change in condition and was sent to the hospital on 2/9/20 with a diagnosis of severe sepsis (systemic infection) related to infected sacral (buttocks) decubitus ulcer (pressure ulcer). The resident required surgical wound debridement (surgical removal of dead tissue);
-Review of Resident #135's medical record, showed on 10/25/29 the resident had a left ischium (lower buttocks area) stage III pressure ulcer and a medial coccyx (tailbone area) stage IV pressure ulcer. On 10/26/19, the resident had an area to the upper middle back, later staged as a stage III pressure ulcer by the wound clinic. The facility failed to assess and monitor the wound per facility policy. Observation during the survey, showed staff failed to apply the treatment per acceptable standards of practice and/or as ordered;
-Review of Resident #60's medical record, showed a right ischial stage IV pressure ulcer, a coccyx stage IV pressure ulcer, a medial foot stage III pressure ulcer, a left ischial stage III pressure ulcer, a left lower leg stage II pressure ulcer and a left thigh stage III pressure ulcer. Observation during the survey, showed staff failed to apply the treatment per acceptable standards of practice and/or as ordered and failed to treat all area;
-Review of Resident #143's medical record, showed the resident admitted on [DATE] with an unstageable pressure ulcer to the buttocks. The facility failed to assess and monitor the wound per facility policy.
3. During an interview on 3/12/20 at 6:35 P.M., the Administrator and Director of Nursing (DON) said the medical director, DON, Assistant DON, administrator, Minimum Data Set (MDS) coordinators, medical records department, social service, dietary and any other department needed regularly attend the quality assurance and performance improvement (QAPI) meetings. The Quality Assurance (QA) nurse is also the infection preventionist and she attends routinely as well. The last meeting was in March, the week prior to the start of the annual survey. Issues with pressure ulcers and wounds had been identified as an area of concern.
4. During an interview on 3/16/20 at 8:29 A.M., the DON said it was probably a month and a half ago that pressure ulcers were identified as a concern. The QAPI team discussed the issue on 3/13/20, and are going to assign the Assistant DONs to do the wounds. The PIP will start this week. The DON will be auditing the wounds. The PIP is all in the works, and not started yet.
CONCERN
(E)
Potential for Harm - no one hurt, but risky conditions existed
Infection Control
(Tag F0880)
Could have caused harm · This affected multiple residents
**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, interview and record review, the facility failed to implement procedures for the provision of infection pr...
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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 implement procedures for the provision of infection prevention and control utilizing current standards of practice for three of four residents observed during wound care (Resident #135, #60 and #38). In addition, the facility failed to ensure employee purified protein derivative (PPD) test (a test that helps diagnose (TB) tuberculosis) results were documented completely for seven of 10 sampled employees. The sample was 29. The census was 143.
Review of the facility's Skin Ulcer-Wound policy, dated 8/15/18, showed:
-All caregivers are responsible for preventing, caring for and providing treatment for skin ulcerations;
-Purpose: To provide treatment that promotes prevention of ulcerations and healing of existing ulcerations;
-Skin ulceration prevention: Promotion of clean, dry and well moisturized skin;
-Treatment protocols: Follow standard precautions and good hand hygiene techniques.
Review of the facility's Infection Control Program, dated 8/2017, showed:
-The infection control preventionist (ICP) is a registered or licensed practical nurse who has received formal training in the prevention and control of infections;
-The facility will maintain an infection control program that is designed to provide a safe, sanitary and comfortable environment and to help prevent the development and transmission of disease and infection.
1. Review of Resident #135's quarterly Minimum Data Set (MDS), a federally mandated assessment instrument completed by facility staff, dated 2/12/20, showed:
-Cognitively intact;
-Total dependence for bed mobility, dressing and personal hygiene;
-Diagnoses included quadriplegia (paralysis of all four limbs);
-At risk for pressure ulcers (injury to the skin and/or underlying tissue, as a result of pressure or friction);
-Two, stage II pressure ulcers (a partial thickness loss of dermis presenting as a shallow open ulcer with a red-pink wound bed without slough (moist dead tissue), may also present as an intact or open/ruptured blister);
-Two, stage III pressure ulcers (full thickness tissue loss, subcutaneous fat may be visible but the bone, tendon or muscle is not exposed);
-One stage IV pressure ulcer (full thickness tissue loss with exposed bone, tendon or muscle);
-One unstageable pressure ulcer (depth unable to be determined due to coverage of the wound bed);
-Total number of venous and arterial ulcers, one;
-Surgical wound care not indicated.
Review of the resident's care plan, in use at the time of the survey, showed:
-Focus: Chronic pressure ulcers present on admission due to limited mobility. Open areas to Coccyx/sacral (tailbone/buttocks area), medial back, both gluteal (buttocks) fold, right lateral (side) leg distal and open areas to left and right hip, left lateral foot:
-Goal: Pressure ulcers/other wounds will show signs of healing and remain free from infection;
-Interventions: Administer treatments as ordered and monitor for effectiveness. Follow facility policies/protocols for the prevention/treatment of skin breakdown.
Review of the resident's electronic physician order sheet (ePOS), showed:
-An order dated 1/9/20: Cleanse area to right mid back with wound cleanser, pat dry, apply calcium alginate (absorbent dressing) and dry dressing daily;
-An order dated 2/7/20: Cleanse area to left ischium (lower buttocks) with wound cleanser, pat dry, apply Hydrofera (antibacterial foam dressing), ABD (absorbent dressing) and secure with tape, every day shift Mondays, Wednesdays, and Fridays;
-An order dated 2/7/20: Cleanse area to coccyx with wound cleanser, pat dry, apply Hydrofera, ABD and secure with tape, every day shift Mondays, Wednesdays, and Fridays;
-An order dated 3/2/20: Cleanse area to right distal lower leg with wound cleanser, pat dry, apply calcium alginate, ABD pad, wrap with Kling (gauze wrap) and secure with tape, every day shift Mondays, Wednesdays, and Fridays;
-An order dated 3/2/20: Cleanse area to left anterior (front) ankle with wound cleanser, pat dry, apply collagen powder and dry dress daily;
-An order dated 3/2/20: Cleanse area to mid abdomen with wound cleanser, pat dry, apply collagen powder and dry dressing daily.
-No order for a right medial back wound treatment.
Observation on 3/13/20 at 9:18 A.M., showed Nurse A provided wound care for the resident. He/she entered the room with the treatment cart and placed it against the wall near the foot of the resident's bed. He/she created a clean area on the cart with a paper barrier between the cart and treatment supplies. The barrier covered approximately half of the top of the treatment cart. Nurse A washed his/her hands and applied gloves. The resident lay in bed, dressed in a hospital gown, opened to the back. A chuck pad (disposable pad) lay on top of a turn sheet (a sheet that is folded to provide support to the weight bearing parts of the body, used to assist in repositioning). The turn sheet placed under the resident and on top of a low air loss mattress that appeared dirty with dry skin flakes and a brown substance. The chuck pad and turn sheet under the resident from approximately 4 inches from shoulders to just below buttocks. Certified Nursing Assistant (CNA) M assisted the nurse to turn the resident on his/her left side by using the turning sheet. The resident did not have treatments or bandages over his/her back, ischium, or coccyx wounds. As the resident was turned, a foul wound odor permeated the room. The turn sheet and chuck pad appeared soiled with large black/brown stains, brown substance, bloody wound discharge and a substance that appeared to be fresh and old bowel feces. Nurse A returned to the treatment cart and removed a spray bottle of wound cleanser from the top of the cart. He/she returned to the resident's bed side, sprayed all of the resident's wound areas on the resident's back, coccyx and ischium and placed the wound cleaner back on cart. With same gloved hands, he/she obtained a clean piece of calcium alginate and placed it in the right medial back wound and then placed a piece of gauze 4 by 4 on top. He/she failed to sanitize his/her hands and change gloves after cleansing the wounds and before applying a clean treatment. Nurse A returned to the treatment cart with the same gloved hands, grabbed two precut pieces of Hydrofera from the top of the cart and placed it on the middle back wound. He/she opened the drawer of the treatment cart, that had not been sanitized prior to the dressing changes, with same gloved hands, removed a single packet of skin prep (protective barrier wipe), and closed the cart drawer. Nurse A failed to sanitize his/her hands and apply new gloves. He/she returned to the resident and opened the skin prep. He/she placed the trash created from opening the skin prep on the resident's bed and then applied the skin prep on the wound edges. He/she then picked up the trash from off the bed and placed it in the trash can. He/she removed his/her gloves and without sanitizing his/her hands, opened the treatment cart drawer and pulled out an ABD pad. He/she applied new gloves without sanitizing his/her hands, returned to the resident and opened the ABD pad. He/she placed the ABD pad over both back wounds. He/she returned to the treatment cart with the same gloved hands and opened cart drawer. He/she retrieved a yellow handled scissors from the drawer and without sanitizing the scissors, cut a piece of adhesive gauze tape. With the same gloved hands, Nurse A returned to the resident and secured the ABD pad with tape. He/she removed one of his/her gloves, reached into his/her shirt pocket and removed a marker. He/she initialed and dated tape on resident's back treatment. He/she then removed his/her other glove and washed his/her hands for the first time since starting the treatments. He/she returned to the treatment cart and looked at the resident's wound orders in computer. He/she used the mouse and keyboard on cart that had not been sanitized. At this time the resident verbalizes pain in his/her back, CNA M asked the nurse if the resident could be turned to his/her back to help relieve his/her pain. Nurse A said yes. The CNA assisted the resident to roll onto his/her back any lay, with no barrier or bandage on his/her coccyx and ischium wounds, on the soiled chuck pad, turn sheet and mattress. The nurse finished the computer review, applied new gloves without sanitizing his/her hands after touching the computer, and stood at the foot of the bed. He/she removed a bandage from the resident's left foot, removed his/her gloves and placed them into the trashcan. He/she washed his/her hands and puts on new gloves. He/she opened cart drawer with his/her gloved hands, looked inside, and closed drawer. The nurse walked behind the privacy curtain and returned with the wound cleanser bottle. With the same gloved hands, he/she sprayed the wound cleanser onto the resident's left foot and then placed wound cleanser bottle back on to the top of the treatment cart. With same gloved hands, picked up the yellow handed scissors and cut a piece of calcium alginate and tape. He/she placed the calcium alginate and a piece of gauze over left foot wound, and secured it with tape. He/she removed one glove, reached into his/her shirt pocket, pulled out a marker, initialed and dated the tape over the wound, and placed the marker back into his/her pocket. He/she removed the other glove and without sanitizing his/her hands, placed on new gloves. He/she pulled the resident's hospital gown down, past his/her stomach and removed the old dressing from the resident's abdomen area. With the same gloved hands, he/she grabs the same wound cleanser bottle and sprayed the wound on the resident's stomach, that appeared red with slight drainage and beefy red wound base. He/she applied new gloves without sanitizing his/her hands, cut tape with the yellow handed scissors, and pick up a piece of calcium alginate with the same gloved hands. He/she applied the calcium alginate directly to the wound bed, covered it with gauze and secured it with tape. He/she removed a glove, reached into his/her pocket, pulled out a marker, initialed and dated the tape over wound. The nurse then picked up bandage wrapper trash from the mattress and sheet and placed it in the trash can. With the same gloved hands, opened the cart drawer, looked inside, reached in his/her shirt pocket and removed a pair of bandage scissors. He/she pulled out a single use alcohol wipe from the top of the cart, opened package and cleansed the scissors. He/she placed the scissors on the clean barrier on the cart. He/she placed new gloves on without sanitizing his/her hands. He/she used the bandage scissors and cut the old dressing off the resident's right leg, from ankle to knee. With the same gloved hands, removed another alcohol pad from the cart drawer and wipes down the bandage scissors. He/she placed the scissors next to the computer keyboard. Nurse A and CNA M grabbed the soiled turn sheet and turned the resident back onto his/her left side. The nurse returned to the treatment cart, opened the drawer and threw a hand towel from the cart onto the bed. He/she closed the cart drawer, returned to the resident, and placed the hand towel on top of the resident's urine collection bag, which lay on the mattress. The nurse collected the old bandages from off the resident's right leg and revealing a large open wound from knee to ankle, with bloody drainage and a beefy red wound base. He/she placed the old dressing in the trash can. Without sanitizing his/her hands; the nurse applied new gloves, grabbed the same wound cleanser from the cart, and sprayed it down the leg wound, from knee to ankle. He/she then applied square 4x4 gauze pads to the right leg wound, one by one, starting at the knee and working towards the ankle until the wound was covered by 10 gauze pieces. With the same gloved hands, the nurse removed the gauze pads he/she had just applied. He/she placed the gauze and gloves in the trash, applied new gloves without sanitizing his/her hands, picked up several pieces of Hydrofera from the clean area on the cart and the yellow handed scissors and moves towards the resident's back side. He/she placed the yellow handled scissors on the resident's soiled chuck pad. Nurse A failed to re-clean the coccyx wound, potentially contaminated with feces. While holding all pieces of the Hydrofera, the nurse placed a few pieces of the Hydrofera into the open left leg wound. With the same gloved hands, he/she returned to the coccyx area and placed a large piece of Hydrofera shaped like a half moon, into the resident's coccyx wound and packed it under the wound edges. He/she returned to the right leg wound, and with the same gloved hands, placed a few more pieces of precut Hydrofera into the open leg wound. He/she returned again to the coccyx wound with the same gloved hands, removed the piece of Hydrofera that had been placed on the coccyx wound, and repositioned it. Without sanitizing his/her hands or changing gloves, Nurse A held up a separate piece of Hydrofera to the coccyx wound, picked up the yellow handled scissors off of the soiled bed and cut the Hydrofera. He/she returned the scissors to the bed and took the cut piece of Hydrofera and packed it under the wound edges of the coccyx wound. Nurse A then removed both the cut piece and half-moon shaped piece of Hydrofera from the coccyx wound, repositioned the pieces again and placed them back into the wound. Then, with same gloved hands, returned to the resident's left leg and placed the remaining cut pieces of Hydrofera into the open leg wound, one by one, till it reached the resident's ankle. He/she collected the trash and placed it into the trash can. Nurse A changed his/her gloves without sanitizing his/her hands and took an ABD pad from the treatment cart. He/she placed the ABD pad on the resident's coccyx wound, returned to the cart, opened the cart drawer, pulled out a large precut piece of adhesive gauze tape and secured the dressing onto the coccyx. He/she removed one glove, reached into his/her shirt pocket, pulled out a marker, and initialed and dated the tape over wound. Nurse A applied new gloves, without sanitizing his/her hands, removed a package of collagen powder (used to promote healing) and an applicator, opened the package and applied the collagen powder to ischium wound with the applicator. Nurse did not re-clean the ischium wound, potentially contaminated with feces. Nurse A then placed gauze on the area and secured with precut tape. He/she removed a glove, reached into his/her shirt pocket, pulled out a marker, and initialed and dated the tape over wound. Collected the trash and placed it in the trash can and removed his/her gloves. He/she removed an ABD pad from the top of the treatment cart, tossed it onto the resident's bed, and pulled a large piece of precut adhesive bandage tape out of the cart. He/she applied new gloves without sanitizing his/her hands, took the adhesive tape to the resident, opened the ABD pad, places the ABD pad on top of the completed dressings on residents back, and secured with another large piece of adhesive tape. He/she removed a glove, reached into his/her shirt pocket, pulled out a marker, and initialed and dated the tape over the wound. The nurse collected the bandage trash, threw it in the trashcan and removed his/he gloves. Without sanitizing his/her hands, he/she tossed four ABD pads in and several packages of rolled gauze onto the resident's soiled bed, near left leg wound. He/she applied new gloves without sanitizing his/her hands. At the bed side, the nurse picked up and opened the ABD pads and placed them on the resident's right leg wound, on top of the Hydrofera. He/she opened the rolled gauze, held up the resident's right leg at the ankle with his/her left hand, and rolled the gauze around the leg (starting at ankle and working up towards the knee). The nurse would wrap the gauze around the leg, allow it to drop on the bed and rolled the gauze under the leg, over the soiled hand towel (now soiled with bloody wound drainage) before picking it up from the other side and repeating the process until the leg was wrapped. Nurse A reached into his/her shirt pocket, pulled out bandage scissors, took an alcohol pad from the cart and cleansed the scissors. He/she then removed his/her gloves and washed his/her hands, returned to the cart, applied new gloves, took the scissors and cut the tape. He/she used the tape to secure the rolled gauze on resident's left leg. Nurse A announced he/she was then completed with the resident's treatments.
During an interview 3/13/20 at 10:13 A.M., CNA M said the chuck pad was visibly soiled with wound drainage and dirt from resident.
During an interview 3/13/20 at 10:13 A.M., Nurse A said all dressings were removed earlier when the resident was cleaned up from a large bowel movement. He/she had no way to measure the wounds and does not know the sizes. The wound nurse normally does the treatments and measurements. The resident's wounds are very time consuming.
During an interview on 3/16/20 at 12:09 P.M., the Director of Nursing (DON), administrator and nurse practitioner said if the wound bed becomes contaminated after the dressing was removed and site cleaned, it should be re-cleaned.
2. Review of Resident #60's quarterly MDS, dated [DATE], showed:
-Cognitively intact;
-Total dependence for bed mobility, dressing and personal hygiene;
-Diagnoses included cerebral palsy (disorder that affect movement and muscle tone);
-At risk for pressure ulcers;
-One stage III pressure ulcer;
-Two stage IV pressure ulcers;
-One unstageable pressure ulcer.
Review of the resident's care plan, dated 7/9/18, showed:
-Focus: Has open areas throughout his/her body. Remains at risk for further decline and/or new open areas as he/she remains dependent on staff for bed mobility, transfers and incontinent care:
-Goal: Will show signs and symptoms of healing without infection;
-Interventions: Pressure relieving mattress, pressure relieving cushion to protect the skin while up in chair. Monitor/document location, size and treatment of skin injury. Treatment per Physician orders.
Review of the resident's medical record, reviewed on 3/11/20, showed:
-An order dated 2/29/20, cleanse area to coccyx with wound cleanser, pat dry, apply Santyl (used to remove dead tissue from the wound bed) nickel thick, apply calcium alginate over the Santyl, cover with ADB pads, secure with tape daily;
-An order dated 2/29/20, cleanse area to left ischium with wound cleanser, pat dry, and apply Santyl nickel thick. Apply calcium alginate over Santyl, cover with ABD pads and secure with tape daily;
-An order dated 2/29/20, cleanse area to right ischium with wound cleanser, pat dry, apply Santyl nickel thick, apply calcium alginate over Santyl, cover with ABD pads and secure with tape daily;
-An order dated 2/29/20, cleanse area to right medial foot with wound cleanser, pat dry, protect peri-wound (skin surrounding wound bed) with skin protectant, apply Santyl nickel thick, apply dry dressing and secure with tape;
-An order dated 2/29/20, use skin prep to left back, and do not wash skin around wound. Apply dry dressing and secure with tape every day shift;
-An order dated 3/2/20, cleanse area to left lower lateral leg with cleanser, pat dry, apply Santyl nickel thick, cover with ABD pads and secure with tape daily:
-No order for treatment to a left outer thigh wound.
Review of Drugs.com, showed Santyl: Apply this medication only to the affected skin wound. Try not to get any ointment on the healthy skin around the wound.
Observation on 3/10/20 at 10:09 A.M., showed Wound Nurse Q cleansed the top of the treatment cart with bleach and placed down a plastic wrap barrier, sanitized his/her hands with alcohol gel and placed gloves on. He/she obtained an ABD pad x 3, removed scissors directly from the treatment cart and without cleansing the scissors, cut an ABD pad into multiple pieces. He/she placed the scissors on the clean barrier of the cart. He/she precut tape with the same scissors and placed them directly on the treatment cart, off to the side of the clean barrier. He/she entered the resident's room, washed his/her hands and placed gloves on. The Nurse repositioned the resident and applied wound treatments using the dressings cut with the potentially soiled scissors. When applying the treatment to the right medial foot, the nurse obtained a partially used tube of Santyl from the treatment cart, labeled with a different resident's name, and used it on the resident.
During an interview on 3/16/20 at 12:09 P.M., with the DON, Administrator and nurse practitioner, they said physician order should be followed. Treatments and creams cannot be shared between residents.
3. Review of Resident #38's annual MDS, dated [DATE], showed:
-Extensive assistance required for bed mobility, toilet use, and personal hygiene;
-Other problems: moisture associated skin damage (MASD);
-Diagnoses included stroke.
Review of the resident's ePOS, showed an order dated 3/13/20, to cleanse area to coccyx with wound cleanser, pat dry, apply nickel thick Santyl and calcium alginate, dry dressing and secure with tape every day.
Observation on 3/13/20 at 8:46 A.M., showed the staffing coordinator provided wound care for the resident. He/she cleaned the treatment cart with bleach and set up a clean area, washed his/her hands with soap and water and applied gloves.The scissors were cleaned with bleach wipes. The staffing coordinator removed the dressing from the coccyx, changed his/her gloves but did not sanitize his/her hands. He/she cleansed the wound with wound cleanser, changed his/her gloves but did not sanitize his/her hands. He/she applied Santyl with an applicator, changed his/her gloves but did not sanitize his/her hands. He/she cut a piece of calcium alginate, packed it into the wound with his/her gloved hand and changed his/her gloves but did not sanitize his/her hands. He/she placed gauze over the site, covered it with an ABD pad and secured it with tape. He/she remove his/her gloves, labeled the dressing and sanitized his/her hands.
4. During an interview on 3/12/20 at 6:35 P.M., with the DON, administrator and Wound Nurse O, they said hands should be sanitized when going from clean to dirty. Supplies should be placed on a clean barrier and clean supplies should be used.
5. Review of the facility's Physical Examinations and Health Requirements policy, dated 6/2017, showed:
-This policy will provide the health requirements which apply to employee and volunteers at the time of hire and annually thereafter;
-A licensed nurse will conduct the first step of a two-step TB skin test. The test must be read within 48 to 72 hours after the administration. Failure of the employee to return for the reading will delay his/her date of hire until the testing is completed. A second test must be administered seven to 21 days after the first test was given.
Review of employee files, showed:
-Registered Nurse C date of hire 8/7/19: First step PPD administered 8/7/19 (after start of employment), read as negative. The date read not indicated. Second step PPD administered 8/21/19, read as negative. The date read not indicated;
-Activity Aid D date of hire 4/11/19: First step PPD administered 4/9/19, read as negative. The date read not indicated. Second step PPD administered 4/20/19, read as negative. The date read not indicated;
-Assistant Director of Nursing E date of hire 2/6/20: First step PPD administered 2/6/20, read as negative. The date read not indicated. Second step PPD administered 2/20/20, read as negative. The date read not indicated;
-Certified Medication Technician F date of hire 6/25/19: First step PPD administered 6/20/19, read as negative. The date read not indicated. Employment terminated before the second step PPD was due;
-Certified Nursing Assistant G date of hire 1/8/20: First step PPD administered 1/6/20, read as negative. The date read not indicated. Employment terminated before the second step PPD was due;
-Cook H date of hire 9/26/19: First step PPD administered 9/24/19, read as negative. The date read not indicated. Second step PPD administered 10/28/19, read as negative. The date read not indicated;
-Laundry Aide K date of hire 2/21/20: First step PPD administered 2/28/20, read as negative. The date read not indicated. Employment terminated before the second step PPD was due.
During an interview on 3/16/20 at 7:57 A.M., the Human Resource Director said the date the PPD is read should be documented to ensure it was read within the required timeframe. The first PPD should be completed prior to employment.
CONCERN
(E)
Potential for Harm - no one hurt, but risky conditions existed
Deficiency F0943
(Tag F0943)
Could have caused harm · This affected multiple residents
Based on interview and record review, the facility failed to implement a training program to provide training to agency staff tasked with the responsibility to care for residents to include abuse, neg...
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Based on interview and record review, the facility failed to implement a training program to provide training to agency staff tasked with the responsibility to care for residents to include abuse, neglect, exploitation, misappropriation of resident property, dementia management and resident abuse prevention. The census was 143.
Review of the State Operations Manual, showed staff includes for the purposes of the training guidance, all facility staff, (direct and indirect care and auxiliary functions) contractors, and volunteers.
Review of the facility assessment, revised 12/9/19, showed:
-Staff:
-Registered Nurses (RN);
-Licensed Practical Nurses (LPN);
-Direct care staff;
-Nurse educator;
-(Agency staff not indicated as staff utilized);
-Staff training/education and competencies:
-All employees participate in a series of competencies upon hire and again quarterly and as needed. Education needs are also identified through performance observation, resident/family concerns and regulation changes;
-Abuse, neglect and exploitation: Training that at a minimum educates staff on 1) activities that constitute abuse, neglect, exploitation and misappropriation of resident property; 2) Procedures for reporting incidents of abuse, neglect, exploitation or the misappropriation of resident property; 3) Care/management for persons with dementia and resident abuse prevention.
During an interview on 3/16/20 at 8:29 A.M., the Quality Assurance (QA) nurse said she was also hired as the infection preventionist and the nurse educator, but she has only been at the facility for a couple of weeks and has only been trained in the QA part of her job, as of this point. The DON said there is no information provided to agency staff when they come to work for the facility and they do not receive orientation. They get report during rounds from the off-going staff. The facility depends on the agency training their own staff. Agency staff are not trained on the facility abuse and neglect policy. The facility utilizes both licensed nurses and CNAs from the nursing agency weekly.
Understanding Severity Codes (click to expand)
Life-Threatening (Immediate Jeopardy)
J - Isolated
K - Pattern
L - Widespread
Actual Harm
G - Isolated
H - Pattern
I - Widespread
Potential for Harm
D - Isolated
E - Pattern
F - Widespread
No Harm (Minor)
A - Isolated
B - Pattern
C - Widespread
Questions to Ask on Your Visit
- "What changes have you made since the serious inspection findings?"
- "Why is there high staff turnover? How do you retain staff?"
- "Can I speak with families of current residents?"
- "What's your RN coverage like on weekends and overnight?"
Our Honest Assessment
Strengths
- • Licensed and certified facility. Meets minimum state requirements.
Concerns
- • Multiple safety concerns identified: 1 life-threatening violation(s), 5 harm violation(s), $91,045 in fines, Payment denial on record. Review inspection reports carefully.
- • 76 deficiencies on record, including 1 critical (life-threatening) violation. These warrant careful review before choosing this facility.
- • $91,045 in fines. Extremely high, among the most fined facilities in Missouri. Major compliance failures.
- • Grade F (0/100). Below average facility with significant concerns.
Bottom line: Trust Score of 0/100 indicates significant concerns. Thoroughly evaluate alternatives.
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About This Facility
What is Beauvais Rehab And Healthcare Center's CMS Rating?
CMS assigns BEAUVAIS REHAB AND HEALTHCARE CENTER an overall rating of 2 out of 5 stars, which is considered below average nationally. Within Missouri, this rating places the facility higher than 0% of the state's 100 nursing homes. A rating at this level reflects concerns identified through health inspections, staffing assessments, or quality measures that families should carefully consider.
How is Beauvais Rehab And Healthcare Center Staffed?
CMS rates BEAUVAIS REHAB AND HEALTHCARE CENTER's staffing level at 2 out of 5 stars, which is below average compared to other nursing homes. Staff turnover is 56%, which is 10 percentage points above the Missouri average of 46%. High turnover can affect care consistency as new staff learn residents' individual needs.
What Have Inspectors Found at Beauvais Rehab And Healthcare Center?
State health inspectors documented 76 deficiencies at BEAUVAIS REHAB AND HEALTHCARE CENTER during 2020 to 2025. These included: 1 Immediate Jeopardy (the most serious level, indicating potential for serious harm or death), 5 that caused actual resident harm, 69 with potential for harm, and 1 minor or isolated issues. Immediate Jeopardy findings are rare and represent the most serious regulatory concerns. They require immediate corrective action.
Who Owns and Operates Beauvais Rehab And Healthcare Center?
BEAUVAIS REHAB AND HEALTHCARE CENTER is owned by a for-profit company. For-profit facilities operate as businesses with obligations to shareholders or private owners. The facility is operated by AMA HOLDINGS, a chain that manages multiple nursing homes. With 184 certified beds and approximately 137 residents (about 74% occupancy), it is a mid-sized facility located in SAINT LOUIS, Missouri.
How Does Beauvais Rehab And Healthcare Center Compare to Other Missouri Nursing Homes?
Compared to the 100 nursing homes in Missouri, BEAUVAIS REHAB AND HEALTHCARE CENTER's overall rating (2 stars) is below the state average of 2.5, staff turnover (56%) is near the state average of 46%, and health inspection rating (2 stars) is below the national benchmark.
What Should Families Ask When Visiting Beauvais Rehab And Healthcare Center?
Based on this facility's data, families visiting should ask: "What changes have been made since the serious inspection findings, and how are you preventing similar issues?" "How do you ensure continuity of care given staff turnover, and what is your staff retention strategy?" "Can you walk me through typical staffing levels on day, evening, and night shifts?" "Can I visit during a mealtime to observe dining assistance and food quality?" These questions are particularly relevant given the facility's Immediate Jeopardy citations, the facility's high staff turnover rate, and the below-average staffing rating.
Is Beauvais Rehab And Healthcare Center Safe?
Based on CMS inspection data, BEAUVAIS REHAB AND HEALTHCARE CENTER has documented safety concerns. Inspectors have issued 1 Immediate Jeopardy citation (the most serious violation level indicating risk of serious injury or death). The facility has a 2-star overall rating and ranks #100 of 100 nursing homes in Missouri. Families considering this facility should ask detailed questions about what corrective actions have been taken since these incidents.
Do Nurses at Beauvais Rehab And Healthcare Center Stick Around?
Staff turnover at BEAUVAIS REHAB AND HEALTHCARE CENTER is high. At 56%, the facility is 10 percentage points above the Missouri average of 46%. High turnover means new staff may not know residents' individual needs, medications, or preferences. It can also be disorienting for residents, especially those with dementia who rely on familiar faces. Families should ask: What is causing the turnover? What retention programs are in place? How do you ensure care continuity during staff transitions?
Was Beauvais Rehab And Healthcare Center Ever Fined?
BEAUVAIS REHAB AND HEALTHCARE CENTER has been fined $91,045 across 2 penalty actions. This is above the Missouri average of $33,989. Fines in this range indicate compliance issues significant enough for CMS to impose meaningful financial consequences. Common causes include delayed correction of deficiencies, repeat violations, or care failures affecting resident safety. Families should ask facility leadership what changes have been made since these penalties.
Is Beauvais Rehab And Healthcare Center on Any Federal Watch List?
BEAUVAIS REHAB AND HEALTHCARE CENTER is not on any federal watch list. The most significant is the Special Focus Facility (SFF) program, which identifies the bottom 1% of nursing homes nationally based on persistent, serious quality problems. Not being on this list means the facility has avoided the pattern of deficiencies that triggers enhanced federal oversight. This is a positive indicator, though families should still review the facility's inspection history directly.
BEAUVAIS REHAB AND HEALTHCARE CENTER
3625 MAGNOLIA AVENUE, SAINT LOUIS, MO 63110 | (314) 771-2990
F
Trust Grade (0/100)
2.0
CMS Rating
76
Deficiencies
Strengths
- Licensed facility
Concerns
- 1 Immediate Jeopardy citation
- 2-star rating
- 76 deficiencies
Ask about: Inspection Response, Staff Retention, Rn Coverage
nursinghomedata.org | Data: CMS November 2025