MAPLES HEALTH AND REHABILITATION, THE
For profit - Individual
120 Beds
ANTHONY & BRYAN ADAMS
Data: November 2025
Trust Grade
65/100
#96 of 479 in MO
Photo by The Maples Health & Rehabilitation
Photo by The Maples Health & Rehabilitation
Photo by The Maples Health & Rehabilitation
1 / 10 photos
Last Inspection: March 2025
Within standard 12-15 month inspection cycle. Federal law requires annual inspections.
Overview
Maples Health and Rehabilitation in Springfield, Missouri has a Trust Grade of C+, which means it is slightly above average but not particularly outstanding. Ranked #96 out of 479 facilities in Missouri, it falls in the top half, while its county ranking of #5 out of 21 suggests there are only a few better options nearby. The facility's trend is worsening, with reported issues increasing from 3 in 2024 to 8 in 2025. Staffing is rated average with a turnover rate of 53%, which is below the state average of 57%, indicating staff generally stay longer. While the facility has not incurred any fines, there have been some concerning incidents. For example, staff failed to manage a resident's pain effectively, neglecting to document medication changes and ignoring the resident’s severe pain response. Additionally, food storage practices did not meet safety standards, and the facility lacks a full-time qualified dietary manager, which raises questions about food safety and nutrition. Overall, while there are strengths, particularly in staff retention, there are significant areas for improvement that families should consider.
- Trust Score
- C+
- In Missouri
- #96/479
- Safety Record
- Moderate
- Inspections
- Getting Worse
- Staff Stability ⚠ Watch
- 53% turnover. Above average. Higher turnover means staff may not know residents' routines.
- Penalties ✓ Good
- No fines on record. Clean compliance history, better than most Missouri facilities.
- Skilled Nurses ⚠ Watch
- Each resident gets only 29 minutes of Registered Nurse (RN) attention daily — below average for Missouri. Fewer RN minutes means fewer trained eyes watching for problems.
- Violations ⚠ Watch
- 23 deficiencies on record. Higher than average. Multiple issues found across inspections.
65/100
Top 20%
Needs review
3 → 8 violations
★★★★☆
4.0
Overall Rating
★★★☆☆
3.0
Staff Levels
★★★★★
5.0
Care Quality
★★★☆☆
3.0
Inspection Score
↔
Stable
2024: 3 issues
2025: 8 issues
The Good
-
5-Star Quality Measures · Strong clinical quality outcomes
-
Full Sprinkler Coverage · Fire safety systems throughout facility
-
No fines on record
Facility shows strength in quality measures, fire safety.
The Bad
Staff Turnover: 53%
Near Missouri avg (46%)
Higher turnover may affect care consistency
Chain: ANTHONY & BRYAN ADAMS
Part of a multi-facility chain
Ask about local staffing decisions and management
The Ugly 23 deficiencies on record
1 actual harm
Mar 2025
8 deficiencies
CONCERN
(D)
Potential for Harm - no one hurt, but risky conditions existed
Deficiency F0582
(Tag F0582)
Could have caused harm · This affected 1 resident
Based on interview and record review, the facility failed to provide a Skilled Nursing Facility Advance Beneficiary Notice (SNFABN - form CMS-10055) or a denial letter at the initiation, reduction, or...
Read full inspector narrative →
Based on interview and record review, the facility failed to provide a Skilled Nursing Facility Advance Beneficiary Notice (SNFABN - form CMS-10055) or a denial letter at the initiation, reduction, or termination of Medicare Part A benefits for one resident (Resident #18) who remained in the facility upon discharge from Medicare Part A services. The facility census was 89 at the time of survey.
Review of the Centers for Medicare and Medicaid Services Survey and Certification memo (S&C -09-20), dated 01/09/09, showed the following information:
-The Notice of Medicare Provider Non-Coverage (NOMNC - form CMS-10123) is issued when all covered Medicare services end for coverage reasons;
-If the skilled nursing facility (SNF) believes on admission or during a resident's stay that Medicare will not pay for skilled nursing or specialized rehabilitative services and the provider believes that an otherwise covered item or service may be denied as not reasonable or necessary, the facility must inform the resident or his/her legal representative in writing why these specific services may not be covered and the beneficiary's potential liability for payment for the non-covered services. The SNF's responsibility to provide notice to the resident can be fulfilled by use of either the SNFABN (form CMS-10055) or one of the five uniform denial letters;
-The SNFABN provides an estimated cost of items or services in case the beneficiary has to pay for them his/herself or through other insurance they may have;
-If the SNF provides the beneficiary with either the SNFABN or a denial letter at the initiation,
reduction, or termination of Medicare Part A benefits, the provider has met its obligation to inform the beneficiary of his/her potential liability for payment and related standard claim appeal rights. Issuing the NOMNC to a beneficiary only conveys notice to the beneficiary of his/her right to an expedited review of a service termination.
1. Review of Resident #18's SNF Beneficiary Protection Notification Review showed the following information:
-On 11/19/24, Medicare Part A skilled services started;
-On 12/12/24, the last covered day of Medicare Part A service;
-Facility staff did not provide the resident or his/her legal representative the required SNFABN form CMS-10055 or an alternative denial letter.
During an interview on 03/05/25, at 3:26 P.M., the Business Office Manager (BOM) said she did not complete SNF ABN form for the resident. The BOM said she checked the electronic records and the resident's paper file, and the form was not there. It was her responsibility to complete the form, and she doesn't know why it wasn't completed.
During an interview on 03/07/25, at 2:24 P.M., the Social Service Director (SSD) said she goes over insurance and billing information with residents - including the SNFABN - form. As SSD for rehabilitation, she fills out the form and then sends the information to the BOM. She was unable to find that the form had ever been completed for the resident.
During an interview on 03/07/25, at 3:45 PM, the Administrator said the SNFABN - form should be completed for all residents who qualify. It is the responsibility of the SSD to complete the form, and for the BOM to ensure the form was completed, and to keep it as resident records.
CONCERN
(D)
Potential for Harm - no one hurt, but risky conditions existed
Deficiency F0625
(Tag F0625)
Could have caused harm · This affected 1 resident
Based on record review and interview, the facility failed to give written information to the resident and/or resident's representative of the facility's bed-hold policy for one resident (Resident #65)...
Read full inspector narrative →
Based on record review and interview, the facility failed to give written information to the resident and/or resident's representative of the facility's bed-hold policy for one resident (Resident #65) who was transferred out to the hospital. The facility census was 89.
Review of the facility's policy titled Bed-Holds and Returns, undated, showed the following information:
-All residents/representatives were provided written information regarding the facility and state bed-hold policies, which addressed holding or reserving a resident's bed during periods of absence (hospitalizations or therapeutic leave);
-Residents, regardless of payor source, are provided written notice about these policies at least twice: in the admission packet and at the time of transfer (or, if the transfer was an emergency, within 24 hours);
-The written bed-hold notices provided to the resident/representative shall explain in detail the duration of the bed hold, the reserve bed payment (for Medicaid residents), the facility per-diem rate required to hold a bed (for non-Medicaid residents), and the facility return policy.
1. Review of Resident #65's face sheet (brief resident profile sheet) showed the following information:
-admission date of 02/06/25;
-Resident was his/her own responsible party.
Review of the resident's admission Minimum Data Set (MDS - a federally mandated assessment instrument completed by facility staff), dated 02/10/25, showed the resident was cognitively intact.
Review of the resident's nurse's note dated 02/14/25, at 8:22 P.M., showed a nurse documented that the resident was reporting increased pain and increased swelling to the left upper extremity since initially reporting the previous day. The resident was requesting to go to the emergency room (ER). Staff notified the physician and received orders to send the resident to the ER for evaluation and treatment. (Staff did not document providing the resident or his/her representative a copy of the bed hold policy.)
Review of the resident's medical record showed the following information:
-A facility-initiated transfer form was completed;
-Date of transfer was 02/14/25;
-Date of notice was 02/17/25;
-Resident was transferred to the ER on ly;
-Notice was hand delivered to the resident;
-No other information noted.
During an interview on 03/06/25, at 12:05 P.M., Business Office Manager (BOM) said that he/she sends out all the hospital transfer/discharge bed holds. He/she does not put a bed payment amount on the form. The BOM said that he/she also does not list a reason for the transfer, only that the facility cannot meet their needs. There was not a place on the form that asks for payment amount per day or the reason why they are leaving the facility. The BOM said that he/she doesn't know that information. The nurse knows that information, but the nurse does not fill out the form.
During an interview on 03/07/25, at 09:40 A.M., Licensed Practical Nurse (LPN) H said the administrative staff complete the bed holds for all residents that are transferred or discharged from the facility. The nursing staff will complete a change in condition form and LPN H said that administration must run a report to know which residents have transferred from the facility.
During an interview on 03/07/25, at 11:15 A.M., Director of Social Services - Long Term Care (LTC) said that he/she did all the bed holds for all LTC residents, but he/she did not do the resident's bed hold. He/she said that the Admissions Director did his/her bed hold.
During an interview on 03/07/25, at 11:20 A.M., Admissions Director said that he/she doesn't have anything to do with bed holds. The Admissions Director said that he/she had never done a bed hold.
During an interview on 03/07/25, at 10:30 A.M., the Director of Nursing (DON) said that the BOM completed all bed holds. The BOM was notified of the transfers during the daily stand-up meetings.
During an interview on 03/07/25, at 1:50 P.M., the Administrator said that either the BOM or the Director of Social Services completes the bed hold transfers. They discuss the transfers in their daily stand-up meetings. The Administrator will email the ombudsman monthly of all the transfers and discharges.
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 interview and record review, the facility failed to develop and implement a comprehensive person-centered care plan consistent with each resident's medical needs when staff failed to care pla...
Read full inspector narrative →
Based on interview and record review, the facility failed to develop and implement a comprehensive person-centered care plan consistent with each resident's medical needs when staff failed to care plan urinary care concerns, including urine retention and urology referral, for one resident (Resident #65). The facility census was 89.
1. Review of Resident #65's face sheet (brief resident profile sheet) showed the following information:
-admission date of 02/06/25;
-Diagnoses included stage 5 chronic kidney disease, end stage renal disease (a condition in which the kidneys lose the ability to remove waste and balance fluids), and dependence on renal dialysis (procedure to remove waste products and excess fluid from the blood when the kidneys stop working properly).
Review of the resident's February 2025 Physician Order Sheet (POS) showed the following information:
-An order, dated 02/06/25, give finasteride (medication used to treat benign prostatic hyperplasia (bph - a condition where the prostate gland is enlarged, causing frequent urination, difficulty starting or stopping urination, and a weak stream) 5 milligram (mg) tablet, daily;
-An order, dated 02/08/25, for staff may straight catheter every six hours as needed for complaints of urinary retention.
Review of the resident's February 2025 Treatment Administration Record (TAR) showed staff straight catheterized the resident on 02/08/25.
Review of the resident's progress note, dated 02/08/25, showed the following information:
-Straight catheter completed and 150 milliliters (ml) of dark brown, creamy white urine was removed;
-Resident tolerated the sterile procedure well.
Review of the resident's February 2025 POS showed an order, dated 02/09/25, for staff to monitor resident every shift for urinary retention.
Review of the resident's admission Minimum Data Set (MDS - a federally mandated assessment instrument completed by facility staff), dated 02/10/25, showed the following information:
-Cognition intact;
-Independent with mobility;
-Required setup assistance with shower and dressing;
-Required substantial assistance with toileting hygiene.
Review of the resident's February 2025 POS showed an order, dated 02/16/25, for staff to set-up urology follow up appointment for resident concerns.
Review of the resident's February 2025 TAR showed staff straight catheterized the resident on 02/24/25.
Review of the resident's progress note, dated 02/24/25 showed the following information:
-Straight catheter completed and 250 ml of amber colored urine was removed;
-The resident immediately stated he/she felt so much better.
Review of the resident's February 2025 TAR showed staff straight catheterized the resident on 02/28/25.
Review of the resident's progress note, dated 02/28/25, showed the following information:
-The resident insisted on having a urinalysis (UA - a laboratory test that analyzes a urine sample to detect various substances and conditions) obtained due to pain and burning with urination:
-Straight catheter completed and 40 ml of urine collected;
-Specimen placed in laboratory refrigerator for morning pick-up;
-Laboratory order placed for urinalysis.
Review of the resident's care plan, revised 03/03/25, showed staff to monitor/document/report signs and symptoms of renal insufficiency. (Staff did not care plan related to urinary care concerns (including straight catheterization, urinary retention, or referral to urology.)
During an interview on 03/07/25, at 9:20 A.M., the Director of Nursing (DON) said urinary retention should have been placed on the resident's care plan and got missed.
CONCERN
(D)
Potential for Harm - no one hurt, but risky conditions existed
Deficiency F0678
(Tag F0678)
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 have a system in place to ensure each resident's code...
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 have a system in place to ensure each resident's code status preference was clear and accurate when staff failed to update a do not resuscitate (DNR - an order that instructs providers not to start cardiopulmonary resuscitation (CPR - an emergency procedure that is done when a person stops breathing or heart stops) if a person stops breathing or heart stops) to a full code (every possible measure, including CPR, to save a person's life) in the resident record for one resident (Resident #10). The facility census was 89.
Review of a facility policy titled 'Advance Directives, dated [DATE], showed the following:
-Advance directives will be respected in accordance with state and federal law policies;
-Upon admission, the resident will be provided with written information concerning the right to refuse or accept medical or surgical treatment and to formulate an advance directive if he or she chooses to do so;
-Prior to or upon admission, the Social Services Director (SSD) will inquire about the existence of any written advance directives;
-The plan of care for each resident will be consistent with his or her documented treatment preferences;
-The Interdisciplinary team (IDT) will review annually with the resident his or her advance directives to ensure such directives are still the wishes of the resident;
-The resident has the right to revoke an advance directive at any time by physical destruction, written revocation, or oral revocation.
1. Review of the Resident #10's face sheet (a document that gives a resident's information at a quick glance) showed the following:
-admission date of [DATE];
-Diagnoses included atrial fibrillation (a type of irregular heartbeat), weakness, and chronic kidney disease (progressive damage of the kidneys which decrease the ability to filter blood).
-Resident was a full code.
Review of the resident's admission Minimum Data Set (MDS - a federally mandated assessment instrument completed by facility staff), dated [DATE], showed the resident had moderate cognitive impairment.
Review of resident's Outside Hospital Do Not Resuscitate Order (OHDNR), dated [DATE], shows the order signed and dated by physician and resident representative.
Review of the resident's February 2025 Physician Order Sheet (POS) showed an order, dated [DATE], for CPR.
Review of a facility form titled Code Status, dated [DATE], showed the resident signed the form indicating he/she wanted to be a full code.
Review of the resident's February 2025 POS showed an order, dated [DATE], for DNR.
Review of the resident's care plan, revised on [DATE], showed the following:
-Resident code status was DNR;
-If resident's heart stopped beating or the resident stopped breathing, CPR will not be initiated per the resident's/responsible party's wishes and the physician's order;
-Staff will acknowledge the resident's right to revoke DNR status at any time in any manner.
Review of the resident's [DATE] POS showed an order, dated [DATE], for CPR.
During an interview on [DATE], at 10:50 A.M., the resident said he/she would like to be a full code.
During an observation on [DATE], at 11:02 A.M., showed the resident's code status indicated as DNR on paper inside a armoire in the resident's room.
During an interview on [DATE], at 10:52 P.M., Certified Nursing Aide (CNA) A said the following:
-He/she would ask the nurse any questions about a resident's code status
-He/she did not know where to locate a resident's code status, but would ask the nurse;
-He/she would get the nurse if a resident appeared to need CPR.
During an interview on [DATE], at 11:03 A.M., CNA D said the following:
-A resident's code status was in the computer and the care plan;
-He/she did not know the resident's code status.
During an interview and observation on [DATE], at 10:56 A.M., Licensed Practical Nurse (LPN) B said the following:
-The code status was located on the care plan on the closet door in resident's room;
-There was a list with resident code status at the nurses' station;
-The resident's name was not on the list on the list. The LPN viewed the resident's code status in the resident's chart and reported it was a DNR;
-Social services reviewed code status at care plan meetings and upon admission.
During an interview on [DATE], at 10:59 A.M., LPN C said the following:
-A resident's code status was in the computerized medical record, on the care plan, and on the armoire door in the resident's room;
-The resident was a DNR;
-Nurses discuss code status with residents and contact the physician for any changes;
-The Social Service Director (SSD) would advise the nurse if a resident had questions over code status.
During an interview on [DATE], at 11:06 A.M., the SSD said the following:
-He/she usually followed up with resident code status after admission;
-He/she confirmed the resident wanted to be a DNR if they come to facility with a DNR form;
-He/she would have the resident complete a code status form if they would like to change their code status and then it would be changed and uploaded in the computer;
-SSD would make sure upon admission code status paperwork was signed and initialed by resident;
-The Assistant Director of Nursing (ADON) made the necessary changes in resident chart.
During an interview on [DATE], at 11:10 A.M., the ADON said the following:
-The SSD was responsible for resident's code status;
-The admission Coordinator would obtain code status upon admission and the SSD will confirm with the resident;
-The ADON or the Director of Nursing (DON) were responsible for changing code status in the resident's care plan and chart;
-Medical records scans all the code status paperwork into the chart;
-The SSD would have a resident sign a revocation on the DNR form if a resident requested a change in status;
-The code status would be changed in computer after paperwork is signed.
During an interview on [DATE], at 11:40 A.M., the DON said the following:
-Code status was reviewed during the admission process;
-The SSD followed up with the resident and obtained a signature on the DNR form;
-Code status was reviewed in every care plan meeting;
-The SSD would discuss and review code status with the resident if a change was requested;
-The DON or ADON would change code status once the form to change status were signed;
-Medical records was responsible for uploading the signed forms;
-The resident had a DNR form sent from the hospital upon admission and the full code form was signed with the admission Coordinator.
During an interview on [DATE], at 1:55 P.M., the Administrator said the following:
-The admission Coordinator reviewed code status during the admission process;
-Code status was discussed at stand-up meetings every morning;
-The ADON and SSD were responsible for resident code status changes;
-A change in code status should be updated immediately.
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 interview, and record review, the facility failed to provide care per standards of practice for all residents when staf...
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 care per standards of practice for all residents when staff failed to failed to obtain ordered labs for possible infection in a timely manner for two residents (Resident #65 and #59). The facility census was 89.
Review of a facility policy titled, Lab and Diagnostic Test Results - Clinical Protocol, dated [DATE], showed the following:
-The physician will identify and order diagnostic and lab testing based on the resident's diagnostic and monitoring needs;
-The staff will process test requisitions and arrange for tests;
-The laboratory will report test results to the facility;
-When test results are reported to the facility, a nurse will first review the results;
-If the staff who first received or reviewed lab results cannot follow the remainder of the procedure for reporting and documenting results and their implications, another nurse in the facility should follow or coordinate the procedure;
- Before contacting the physician, the person who is to communicate the results should be prepared to discuss the following individual's current condition and any acute changes; diagnosis, allergies, current medications, and lab work; reason lab and diagnostic tests were obtained; and how results may relate to individuals' treatment or condition;
-A nurse will identify the urgency of communicating with the physician based on the request, seriousness of the abnormality, and individual's current condition;
-A nurse will try to determine whether the test was done for a routine screen or follow up, a condition change, or to monitor a drug level.
-Nursing staff will consider the following to identify situations requiring prompt physician notifications concerning lab results physician request to be notified as soon as result is received; whether the result should be conveyed to the physician regardless of other circumstances; and if the resident has signs and symptoms of an acute illness or condition change.
-A physician can be notified by phone, fax, voicemail, e-mail, pager, or telephone message.
1. Review of Resident #65's face sheet (brief resident profile sheet) showed the following information:
-admission date of [DATE];
-Diagnoses included stage 5 chronic kidney disease, end stage renal disease (a condition in which the kidneys lose the ability to remove waste and balance fluids), and dependence on renal dialysis (procedure to remove waste products and excess fluid from the blood when the kidneys stop working properly).
Review of the resident's February 2025 Physician Order Sheet (POS) showed the following information:
-An order, dated [DATE], give finasteride (medication used to treat benign prostatic hyperplasia (bph - a condition where the prostate gland is enlarged, causing frequent urination, difficulty starting or stopping urination, and a weak stream) 5 milligram (mg) tablet, daily;
-An order, dated [DATE], for staff may straight catheter every six hours as needed for complaints of urinary retention.
Review of the resident's February 2025 Treatment Administration Record (TAR) showed staff straight catheterized the resident on [DATE].
Review of the resident's progress note, dated [DATE], showed the following information:
-Straight catheter completed and 150 milliliters (ml) of dark brown, creamy white urine was removed;
-Resident tolerated the sterile procedure well.
Review of the resident's February 2025 POS showed an order, dated [DATE], for staff to monitor resident every shift for urinary retention.
Review of the resident's admission Minimum Data Set (MDS - a federally mandated assessment instrument completed by facility staff), dated [DATE], showed the following information:
-Cognition intact;
-Independent with mobility;
-Required setup assistance with shower and dressing;
-Required substantial assistance with toileting hygiene.
Review of the resident's February 2025 POS showed an order, dated [DATE], for staff to set-up urology follow up appointment for resident concerns.
Review of the resident's February 2025 TAR showed staff straight catheterized the resident on [DATE].
Review of the resident's progress note, dated [DATE] showed the following information:
-Straight catheter completed and 250 ml of amber colored urine was removed;
-The resident immediately stated he/she felt so much better.
Review of the resident's February 2025 TAR showed staff straight catheterized the resident on [DATE].
Review of the resident's progress note, dated [DATE], showed the following information:
-The resident insisted on having a urinalysis (UA - a laboratory test that analyzes a urine sample to detect various substances and conditions) obtained due to pain and burning with urination:
-Straight catheter completed and 40 ml of urine collected;
-Specimen placed in laboratory refrigerator for morning pick-up;
-Laboratory order placed for urinalysis.
Review of the resident's progress note, dated [DATE], showed the resident's urine sample was not collected in time by the lab and would have to be collected again. (Staff did not document an attempt to obtain the sample between [DATE] and [DATE]).
Review of the resident's care plan, revised [DATE], showed staff to monitor/document/report signs and symptoms of renal insufficiency.
During an interview on [DATE], at 10:30 A.M., the resident said that the nurse collected a urine specimen a few days ago via straight catheter. The resident said he was still waiting on the results of the UA. The resident said that he had a history of having urinary tract infections (UTI's) and will need to take antibiotics if it comes back positive.
During an interview on [DATE], at 9:30 A.M., the resident's spouse said the resident did not catheterize himself. The the nurses catheterize him/her and that the nurse catheterized the resident on [DATE] around 6:30 A.M. and told them that he/she put a urine specimen in the refrigerator and that we should have the results back in a few days. They are still waiting on the results. They are worried since he/she may have a UTI.
During an interview on [DATE], at 9:40 A.M., Licensed Practical Nurse (LPN) H said that he/she had never had to straight catheter (cath) the resident, but he/she did have orders to do so if needed. The resident had needed to be straight cathed a few times after dialysis. Sometimes they don't pull off enough fluid and the resident will feel full and uncomfortable. The nurse straight caths the resident. The resident doesn't cath himself/herself. A specimen was collected and placed in the refrigerator [DATE]. The lab doesn't pick up specimens on weekends so that specimen expired. It doesn't look like there was any follow up with that.
During an interview on [DATE], at 9:20 A.M., the Director of Nursing (DON) said that the resident straight catheterized himself/herself and had been doing it at home. The nurses don't straight catheter him/her. The resident had not had any issues while here. The facility had not had to send out any UAs on the resident since admission. The urinary retention should have been placed on the resident's care plan and got missed.
During an interview on [DATE], at 10:00 A.M., the Nurse Consultant said that after reviewing the resident's record it appeared that the nurse did collect a urine specimen and placed it in the refrigerator on [DATE]. That specimen expired and it was recollected on [DATE]. That order was not put in the system after the specimen was collected, therefore, the second specimen also expired. The nurse consultant said that it may need to be recollected for a third time.
During an interview on [DATE], at 1:40 P.M., the Assistant Director of Nursing (ADON) said nurses enter an order for a urinalysis into the electronic medical record and the laboratory website. The lab results are faxed and sent directly to the results tab in the electronic medical record by the lab. The DON was responsible for lab result audits.
During an interview on [DATE], at 1:55 P.M., the Administrator said that nurses should collect urine specimens when needed, place them in the lab refrigerator, put an order in the electronic medical record and report any abnormal results to the physician. The lab collected specimens 7 days per week. The DON followed up with all lab results.
2. Review of Resident #59's face sheet showed the following:
-admission date of [DATE];
-Diagnoses included dementia (loss of memory, problem solving, language and other thinking abilities that interfere with daily life).
Review of the resident's quarterly minimum data set (MDS), dated [DATE], showed the following:
-Resident had severe cognitive impairment;
-Dependent on staff assistance with dressing, transfers, and bed mobility;
-Resident did not have any behavioral symptoms.
Review the resident's progress note, dated [DATE], showed the resident continued to scream with changes and even light touching. Resident resists care and said, I hate you to staff.
Review of the resident's progress note, dated [DATE], showed the resident continued to be verbally and physically aggressive with staff when attempting to provide cares. Resident noted to have soiled clothes during dinner and when aide approached resident to provide peri care, resident became agitated. The nurse and aide were able to assist resident to toilet and resident became agitated when staff attempted to provide peri care.
Review of resident's care plan, revised on [DATE], showed the following:
-Required one staff assistance with showers, toileting, mobility, and dressing;
-Resident was incontinent of bladder and bowel;
-Staff to monitor and document signs and symptoms of UTI including pain, blood-tinged urine, cloudiness, no output, urine color, increased pulse or temperature, urine frequency, foul smelling urine, altered mental status, and change in behavior or eating patterns.
Review of the resident's progress note, dated [DATE], showed it required two aides to convince resident to allow them to assist to bathroom to check brief. Resident yelled at staff.
Review of the resident's progress note, dated [DATE], showed staff informed nurse that resident gets combative when toileted and refused to sit on the toilet.
Review of the resident's progress note, dated [DATE], showed it took three staff to assist resident to toilet. The resident would scream out every time they attempted to transfer. After toileting, the resident sat in the hallway stating he/she hated everyone.
Review of the resident's progress note, dated [DATE], showed staff informed the nurse practitioner of the resident's refusal of medications and he/she ordered a urinalysis (UA).
Review of the resident's February 2025 POS showed staff did not transcribe the order for a UA.
Review of the resident's physician progress note, dated [DATE], showed the resident reported mild dysuria (painful urination) with a UA pending. The resident had increased behaviors lately, and was uncooperative and refusing medications.
Review of the resident's progress note, dated [DATE], showed staff collected urine and put in refrigerator for pick up (twelve days after initial order).
Review of the resident's progress note, dated [DATE], showed the lab at the facility to pick up urine for UA.
Review of the resident's lab results report, dated [DATE], showed a UA collected on [DATE] and received by the laboratory on [DATE]. The results reported to facility on [DATE] and showed white blood cells (WBC), red blood cells (RBC), nitrites (chemical compound that could indicate a UTI when found in urine), and leukocyte esterase (enzyme produced by WBC's that can indicate a UTI when found in urine) were present
Review of the resident's progress note, dated [DATE], showed staff reported the UA results to the physician on [DATE] at 2:30 P.M. and a new order was received for Keflex (an antibiotic) 500 milligrams (mg) four times daily for seven days (reported four days after results received by facility).
During an interview on [DATE], at 2:00 P.M., LPN E said the resident had no orders entered for a urinalysis. The urinalysis was ordered on [DATE] and readdressed on [DATE]. The urinalysis was collected on [DATE] and the results returned on [DATE]. There was no physician notification in chart regarding lab results on [DATE].
During an interview on [DATE], at 3:24 P.M., LPN K said increased behaviors and mood swings could indicate a UTI,
He/she was unaware the resident had a urinalysis order.
During an interview on [DATE] at 1:20 P.M., the DON said there were no orders in the medical record for a urinalysis dated [DATE] or [DATE] for the resident.
3. During an interview on [DATE], at 1:44 P.M., CNA F said signs and symptoms of a UTI would be confusion, increased need to use the restroom, urine odor, and urine color. He/she would report UTI symptoms to the nurse.
During an interview on [DATE], at 2:00 P.M., LPN E said signs and symptoms of UTI would be dysuria (painful or uncomfortable urination), urine retention, frequency, or urine odor. He/she would notify the physician to obtain urinalysis if resident had symptoms. An order for a lab should be entered in the computer and on the lab website. The family should be notified, the lab obtained, and this information should be documented. Lab results were entered into the electronic medical record by the lab and faxed to the facility. The charge nurse should check the fax for lab results throughout the day. The DON completed daily audits on lab results. The physician should be notified of abnormal results.
During an interview on [DATE], at 3:24 P.M., LPN K said signs and symptoms of UTI could be confusion, increased temperature, behaviors, nausea, urine odors, cloudy urine, and burning with urination. He/she would advise the physician of resident symptoms, vital signs and obtain an order for a urinalysis. He/she would make a progress note regarding order, resident symptoms, vital signs, and physician and family notification. The lab comes every morning except weekends. The lab faxes result to facility and the DON will pick them up. Nurses can view lab results on the computer. He/she would enter a urinalysis order into chart and obtain sample right away. Nurses should not wait until [DATE] to obtain a urinalysis ordered on [DATE]. Abnormal results should be reported to physician and family immediately.
During an interview on [DATE] at 1:20 P.M., the DON said an order should be entered when the physician gives the order. Lab results go to the medical record and are faxed. Nurses should monitor lab results. The DON does daily audits to confirm lab results are picked up from the fax and notify nurses. The physician should be notified within 24 hours of abnormal lab results. Signs and symptoms of a UTI are different for everyone. Nurses should not have waited two weeks to obtain an ordered urinalysis. -Nurses should notify physician immediately for abnormal results.
During an interview on [DATE], at 1:40 P.M., the ADON said nurses should enter an order for a urinalysis into the electronic medical record and the laboratory website. Lab results are faxed and sent directly to the results tab in the electronic medical record by the lab. Nurses were responsible for checking the fax for any results multiple times per shift. The DON was responsible for lab result audits. Nurses should notify the physician of any abnormal results when they are received.
During an interview on [DATE], at 1:55 P.M., the Administrator said the nurse should carry out an order for a urinalysis when received. Nurses should report abnormal lab results to the physician prior to the end of shift.
CONCERN
(D)
Potential for Harm - no one hurt, but risky conditions existed
Respiratory Care
(Tag F0695)
Could have caused harm · This affected 1 resident
**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, interview, and record review, the facility failed to provide respiratory care per standards of practice wh...
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 provide respiratory care per standards of practice when staff obtain a physician's order for the use of and complete a care plan for the use of a CPAP (continuous positive airway pressure - a machine that uses air pressure to keep airways open while a resident sleeps) for two residents (Resident #398 and #65).The facilities census was 89.
Review of the facility's policy titled, CPAP/BiPAP Support, dated March 2015, showed the following:
-Purpose to provide the spontaneously breathing resident with continuous positive airway pressure with or without supplemental oxygen; to improve arterial oxygenation in residents with respiratory insufficiency, obstructive sleep apnea, or restrictive/obstructive lung disease; and to promote resident comfort and safety;
-Only a qualified and properly trained nurse or respiratory therapist should administer oxygen through a CPAP mask;
-Review the resident's medical record to determine his/her baseline oxygen saturation;
-Review the physician order to determine the oxygen concentration flow, and the pressure (CPAP, IPAP and EPAP) for the machine;
-Review and follow manufacturer's instructions for CPAP machine setup and oxygen delivery.
1. Review of Resident #398's admission Minimum Data Set (MDS - a federally mandated assessment tool completed by facility staff), dated 02/26/25, showed the following:
-No cognitive impairment;
-Current diagnosis for sleep apnea;
-Did not use oxygen or CPAP.
Observation and interview on 03/03/25, at 11:59 A.M., showed the following:
-Resident sat in his/her room in a wheelchair;
-The CPAP machine was on his/her nightstand next to his/her bed;
-The CPAP was plugged in with hosing and face mask attached;
-The resident said he/she used his/her CPAP at night;
-The resident said he/she used a CPAP at the hospital and his/her family brought his/hers to the facility when he/she was admitted .
Review of the resident's current care plan, dated 02/23/25, showed staff did not care plan related to CPAP use.
Review of the resident's current physician orders, dated 03/06/25, showed no physician's orders for CPAP use.
Review of the resident's March 2024 Medication Administration Record (MAR) and Treatment Administration Record (TAR) showed no record of CPAP use or administration.
During an interview on 03/06/25, at 11:05 A.M., Licensed Practical Nurse (LPN) I said he/she did not know if the resident had a CPAP and did not know if the resident had an order for a CPAP.
During an interview on 03/06/25, at 11:24 A.M., Registered Nurse (RN) J said the resident did use a CPAP. He/she was unsure if the resident's CPAP came from the hospital or if family brought it in. He/she was unsure if the resident had an order for a CPAP.
During an interview on 03/06/25, at 12:38 P.M., the Director of Nursing (DON) said the resident used a CPAP.
During an interview on 03/06/25, at 1:49 P.M., the MDS Coordinator said he/she did not know the resident had a CPAP.
During an interview on 03/07/25, at 2:19 P.M., the Administrator said the resident's family brought in a CPAP for him/her to use.
2. Review of Resident #65's face sheet (brief resident profile sheet) showed the following information:
-admission date of 02/06/25;
-Diagnoses included cerebral infarction (stroke) and heart failure with congestive heart disease (heart does not pump blood adequately)
Review of the resident's admission MDS, dated [DATE], showed the following information:
-Cognition intact;
-Independent with mobility;
-Did not use oxygen or CPAP.
Observation on 03/03/25, at 1:35 P.M., showed the following information:
-The resident sat in his/her room in a recliner;
-A CPAP machine sat on the nightstand next to the bed, plugged into wall with face mask attached;
-A gallon of distilled water (to use with CPAP), half empty, sat on floor next to nightstand;
-The resident said he/she used the CPAP at night and was not able to sleep without it;
-The resident said staff fill the reservoir with distilled water every evening and he/she put on the mask when going to bed;
-The resident said he/she brought the CPAP with him/her on the first day of admission and has used it nightly since.
Review of the resident's care plan, revised 03/03/25, showed staff did not care plan related the use of CPAP.
Review of the resident's current POS, dated 03/06/25, showed staff did not transcribe order for use of a CPAP.
Review of the resident's TAR, dated 02/01/25 through 03/06/25, showed staff did not document use of the CPAP.
During an interview on 03/06/25, at 11:53 A.M., Certified Nurse Aide (CNA) P said the resident had a CPAP on his/her bedside table and the CNA's make sure that the water reservoir was filled every day. The resident kept a gallon of distilled water on the floor next to his/her bedside table to use in his/her CPAP. The resident put his/her mask on him/herself whenever he/she was ready to go to sleep at night.
During an interview on 03/06/25, at 12:00 P.M., CNA Q said that the resident has a CPAP machine on his/her bedside table and staff ensure that it had water in the reservoir. The resident put on his/her mask and turns on the machine when he/she went to bed.
During an interview on 03/06/25, at 12:15 P.M., the DON the resident did not have an order for a CPAP machine and didn't know that the resident had a CPAP machine in his/her room. It was not on his/her orders, or discharge orders, nor is it care planned.
3. During an interview on 03/06/25, at 10:31 A.M., CNA G said CNA's do not do anything with oxygen or CPAP machines. The nurses administer oxygen and CPAP. He/she was unaware of any residents using a CPAP currently.
During an interview on 03/06/25, at 10:39 A.M., LPN H said the following:
-Nurses obtain orders through the nurse practitioner (NP) or the physician;
-He/she notified the DON if a resident had a CPAP;
-He/she notified the DON if a resident's family brought in a CPAP;
-CNA's may turn on CPAP's, but are not allowed to adjust the settings;
-He/she will check medical records and contact the physician for orders if a resident needs a CPAP;
-The medical records clerk inputs admission orders into the computer;
-Residents are supposed to have orders for oxygen and CPAP;
-CPAP instructions should be in the orders and in the care plan.
During an interview on 03/06/25, at 11:05 A.M., LPN I said the following:
-He/she asked the resident about their CPAP settings;
-He/she would review hospital records for CPAP use;
-He/she would notify the physician if there was no order;
-If a family member brought in a CPAP for a resident, he/she would ask the family about CPAP settings and use;
-Residents must have an order for a CPAP.
During an interview on 03/06/25, at 11:24 A.M., RN J said the following:
-Orders for medical equipment like oxygen and CPAP come from the hospital;
-He/she could obtain orders from the primary physician;
-He/she would expect orders and instructions for a CPAP to be in the care plan.
During an interview on 03/06/25, at 12:38 P.M., the DON said the following:
-Staff was to report to him/her if a resident came to the facility with a CPAP;
-Staff was to report to him/her if a family member brought in a CPAP for a resident;
-He/she expected a resident with a CPAP to have an order for a CPAP;
-He/she expected a resident with a CPAP to have that in their care plan.
During an interview on 03/06/25, at 1:49 P.M., the MDS Coordinator said the following:
-Staff should notify the charge nurse if a resident had a CPAP;
-Staff should notify the charge nurse if a residents family brings in a CPAP;
-He/she would obtain an order for use of and update a resident's care plan if he/she was informed they have a CPAP;
-She does all baseline care plans stating that during the care meeting staff review and make sure they are all in the care plan;
-Normally if he/she knew about a CPAP, she would put in the care plan including the setting if they had specific settings;
-Normally during morning meetings, staff go over any equipment the resident had or that needed to be ordered;
-If staff noticed a CPAP in a resident's room, they should notify the charge nurse, and it should be added to the care plan and the nurse should make sure they have orders.
During an interview on 03/07/25, at 8:30 A.M., the facility's Physician said the following:
-He/she had written protocols for the facility to continue current medications on admission and to contact him if staff have any concerns;
-Residents with medical equipment need a physician order;
-He/she expected the facility to obtain an order for residents using medical equipment such as oxygen and CPAP.
During an interview on 03/07/25, at 2:19 P.M., the Administrator said he/she expected staff to obtain an order and update the resident's care plan for any resident using a CPAP. On admission he/she informed family members to notify staff before bringing in medical equipment or medications.
CONCERN
(E)
Potential for Harm - no one hurt, but risky conditions existed
Deficiency F0692
(Tag F0692)
Could have caused harm · This affected multiple residents
Based on observation, interview, and record review, the facility failed to ensure resident weight loss was unavoidable when staff failed to notify the physician and dietician of weight loss, failed to...
Read full inspector narrative →
Based on observation, interview, and record review, the facility failed to ensure resident weight loss was unavoidable when staff failed to notify the physician and dietician of weight loss, failed to care plan actual weight loss and new interventions, and failed to implement current care planned inventions to prevent future weight loss for one resident (Resident # 43). The facility census was 89.
Review of the facility policy titled Weight Assessment and Intervention, dated September 2008, showed the following:
-The nursing staff will measure resident weights on admission, the next day, and weekly for four weeks thereafter. If no weight concerns are noted at this point, weights will be measured monthly;
-Any weight change of 5% or more since the last weight will be retaken the next day for conformation. If the weight is verified, nursing will immediately notify the dietician;
-The dietary manager will review all weight records by the 5th of the month to follow weight trends over time. The treatment team will evaluate negative trends;
-The threshold for significant unplanned and undesired weight loss will be based on the following criteria 1 month of 5% weight loss is significant, greater than 5% is severe; 3 months of 7.5% is significant, greater than 7.5% is severe; 6 months of 10% is significant, greater than 10% is severe;
-Assessment information shall be analyzed by the multidisciplinary team and conclusions made regarding the resident's target weight range; calorie, protein, and other needs compared with resident current intake; relationship between current medical or clinical situation and recent fluctuations in weight; and whether and to what extent weight stabilization or improvement can be anticipated;
-Physician and multidisciplinary team will identify conditions and medications that may be cause or risk of weight loss including cognitive or functional decline; chewing or swallowing abnormalities; pain; medication related consequences; environmental factors; increased calorie needs; poor digestion or absorption; and fluid and nutrient loss;
-Care planning for weight loss will be a multidisciplinary effort;
-Individualized care plans shall address identified cause of weight loss, goals and benchmarks for improvement, and time frames;
-Interventions for undesirable weight loss shall be based on careful consideration of resident choice and preferences, nutrition and hydration needs, functional or environmental factors, chewing and swallowing abnormalities, medications, supplementations, end of life decisions.
1. Review of Resident #43's face sheet (brief resident profile sheet) showed the following information:
-admission date of 01/25/19;
-Diagnoses included epilepsy (seizure disorder), hemiplegia (a condition characterized by paralysis or weakness on one side of the body) of left non dominate side, depression, and anxiety disorder.
Review of the resident weight, dated 12/03/24 showed, the the resident weighed 148.2 pounds.
Review of the resident's care plan, revised 01/03/25, showed the following information:
-Allow resident ample time to ingest meal;
-Encourage meals in dining room;
-Resident feeds self in restorative dining room for assistance as needed. Resident uses plate guard to aide in meal independence;
-Weights per physician orders and notify physician of significant weight changes;
-Monitor, document, and report any signs of dysphagia (difficulty swallowing foods or liquids);
-Monitor, record, and report to physician significant weight loss equal to or above 5% in a month, equal to or above 7.5% in 3 months, or equal to or above 10% in 6 months;
-Registered dietician (RD) to evaluate and make diet change recommendations as needed;
-Provide and serve diet as ordered, monitor intake, and record every meal.
Review of the resident's dietary profile, dated 01/06/25, showed the resident was on a mechanical soft diet and receiving health shakes three times daily. The resident noted to have a fair appetite. The resident required total assistance with feeding and used a plate guard.
Review of the resident's nutrition assessment, dated 01/07/25, showed the resident was on a regular mechanical soft diet and had no chewing or swallowing difficulty. The resident dined in the restorative dining room, utilized a plate guard, and had a good appetite averaging 50% per meal. The resident had a 7% weight loss in one month. Current nutrition regimen appropriate.
Review of the resident weight, dated 01/07/24 showed, the the resident weighed 136.8 pounds (a loss of 11.4 pounds, 7.7% loss in one month).
Review of the resident's weekly weight progress note, dated 01/09/25, showed the resident triggered for a 5% weight loss. Diet changed to regular enhanced, mechanical soft diet with the use of a plate guard. Resident continued to eat in the restorative dining room.
Review of the resident's progress notes showed staff did not document physician notification of the weight loss.
Review of the resident's current care plan showed staff did not update the care plan with the new weight loss or new interventions to prevent future weight loss.
Review of the resident's significant change Minimum Data Set (MDS - a federally mandated assessment instrument completed by facility staff), dated 01/09/25, showed the following information:
-Severe cognitive impairment;
-Required staff assistance with eating;
-Loss of 5% or more in last month or 10% or more in last six months.
Review of the resident's current physician order sheet (POS), dated 03/07/25, showed an order, dated 01/09/25, for a regular enhanced diet mechanical soft (soft easy to chew foods that are easy to swallow) texture.
Review of the resident's weekly weight note, dated 01/24/25, showed the resident weight on 01/14/25 was 136.8 pounds, which was a 7.7% weight loss. Diet indicated as regular enhanced mechanical soft in restorative dining with use of a plate guard. Current intake was 30% of meals. Snack at 10:00 A.M. added as intervention.
Review of the resident's progress notes showed staff did not document physician notification of the weight loss.
Review of the resident's current care plan showed staff did not update the care plan with the new weight loss or new intervention.
Review of the resident's nurse practitioner (NP) progress note, dated 02/01/25, showed staff felt resident was eating and sleeping well. (The NP did not address recent weight loss.)
Review of the resident's weight, dated 02/03/25, showed the resident weighed 137.5 pounds.
Review of the resident's current POS, dated 03/07/25, showed an order, dated 02/05/25, for a regular puree diet.
Review of the resident's progress note, dated 02/05/25, showed the resident noted to be pocketing food this morning. Puree diet trial started for three days. Resident consumed 100% of evening meal with maximum assistance.
Review of the resident's care plan, updated 02/10/25, showed staff regular diet, pureed texture, regular consistency to the care plan. (Staff did not update to show actual weight loss the intervention of a 10:00 A.M. snack.)
Observation on 03/03/25, at 12:05 P.M., showed the resident in the restorative dining room with a meal ticket indicating plate guard. An aide was assisted the resident with eating and provided encouragement. The resident's plate did not have a plate guard and had diced chicken and vegetables with potatoes and gravy and ice cream. The resident consumed 50% of meal.
Observation on 03/04/25, at 11:52 A.M., showed the resident ate pureed spaghetti, vegetables, and ice cream in the restorative dining room with no plate guard.
Review of the resident's weight, dated 03/04/25, showed the resident weighed 131 pounds (a loss of 6.5 pounds in one month, 17.4 pounds total and 11.6 % in four months).
Review of the resident's weekly weight note, dated 03/06/25, showed the resident's weight was 131 pounds on 03/04/25, which is a 5.1% loss in 30 days and 10.4% loss over six months. Diet indicated resident on a regular enhanced, pureed diet (current diet order does not indicate enhanced for puree diet) and Med pass 2.0 (supplement) 60 milliliters (ml) added.
Review of the resident's current POS, dated 03/07/25, showed an order, dated 03/06/25, for Med Pass 2.0 60 ml at 2:00 P.M.
Observation and interview on 03/06/25, at 12:20 P.M., showed the resident ate in the restorative dining room with an aide assisting with the meal. The resident's meal ticket showed an enhanced puree diet, plate guard, and red napkin program written on it. The resident consumed about 25% of meal. The resident reported the food was good and he/she was not hungry. No plate guard noted.
Observation on 03/07/25, at 12:15 P.M., showed the resident had finished eating lunch in the restorative dining room and ate less than 25% of the meal. No plate guard noted.
During interviews on 03/06/25, at 12:30 P.M. and 1:44 P.M., Certified Nurse Aide (CNA) F said the resident did not eat a lot and had declined in health lately. The resident was on a puree diet and did not use any adaptive equipment with meals. He/she would ask family for assistance, offer an alternate item, or have another staff try to help if a resident was not eating. He/she would notify the nurse if a resident refused two meals during the shift. The red napkin program was for a resident that had enhanced foods due to weight loss or decreased appetite. Enhanced food would be extra food or a shake.
During an interview on 03/06/25, at 3:15 P.M., CNA N said the resident ate in the restorative dining room, but was unsure of his/her diet. The resident did not appear to have any weight loss. He/she would report to the nurse if a resident did not eat at mealtime and document the amount consumed.
During an interview on 03/06/25, at 2:00 P.M., Licensed Practical Nurse (LPN) E said the following:
-The aides report to the nurse if a resident was observed not eating at meals;
-He/she would try to find out why the resident was not eating, check on dietary preferences, contact dietary, and if there was a medical concern, call the physician;
-The Assistant Director of Nursing (ADON) and dietary director were involved in weight meetings;
-The ADON manages any weight changes and will initiate supplements or find out what's going on with the resident;
-There was a list of weights that any aide could do;
-The resident had an overall decline and had increased chewing and pocketing difficulty so the diet was changed to puree;
-He/she did not monitor weights and did not know if resident had a weight gain or loss;
-The resident was on a puree diet with thin liquids, but had two different diet orders listed;
-There should not be two diet orders listed and an order probably did not get discontinued;
-The red napkin program was set up assistance at mealtimes.
During an interview on 03/06/25, at 3:24 P.M., LPN K said the following:
-He/she would let the physician know, encourage fluids, obtain a speech evaluation, check for a dental problem, and obtain weights if a resident had a decreased appetite;
-There was not a specific staff assigned to do weights;
-The ADON monitored resident weights;
-The resident ate in the restorative dining room and did not eat well;
-The resident was on a mechanical soft diet, but had orders for puree and mechanical soft diet;
-Mechanical soft is resident's main diet because it is listed first in the orders and puree must be for certain foods;
-The kitchen knew if there was something he/she could not eat and would send an alternate;
-The resident did not use any specialized equipment during meals.
During an interview on 03/07/25, at 11:26 A.M., the Registered Dietician (RD) O said the following:
-He/she visited the facility three times monthly and the ADON or Dietary Manager (DM) would contact her sooner if needed;
-He/she completed an onsite recommendation and intervention form which was reviewed by the ADON and the DM;
-He/she met with the ADON and DM when at the facility;
-He/she reviewed residents with weight loss, wounds, dialysis, and fluid restriction while in the facility;
-The resident's last assessment was in January 2025;
-The resident triggered for weight loss on last visit;
-The resident dined in the restorative dining room and utilized a plate guard, had house shakes three times a day, snacks, and med pass was added in the afternoon;
-He/she had not been notified of any weight loss for the resident;
-Interventions for weight loss would include an enhanced diet, assessing resident preferences, or adding a supplement shake.
During an interview on 03/07/25, at 1:20 P.M., the Director of Nursing (DON) said the following:
-The ADON was over the weight committee and monitored weights;
-The ADON and DM attend weight meetings and enter a progress note in the resident chart;
-The facility had a weight aide assigned to do weights, but does not have one currently;
-If a resident had a 5% weight loss, they would go on weekly weights until stable;
-The physician should be notified of a 5% weight loss and resident placed on an enhanced diet;
-Notification to the physician about weight loss should be documented;
-The resident diet order showed both mechanical soft and puree diets;
-The nurse must have not deleted the mechanical soft diet order as resident was currently on puree;
-The resident ate in the restorative dining room. The DON did not know if the resident used an assistive device with meals.
During an interview on 03/07/25, at 1:40 P.M., the ADON said the following:
-He/she printed out a sheet with weights that were due and assigned them to specific aides;
-Residents that trigger for weight loss were discussed during weekly weight meetings;
-Resident diet, restorative dining, supplements, intake, and medications are reviewed during the meeting;
-The physician might be contacted if a resident is eating less than 25% of meals;
-The resident was being monitored during weight meetings;
-The physician had not been notified about the resident's weight loss due to losing only 10 pounds in three months;
-He/she would notify the physician if resident had continued weight loss;
-A plate guard should be used at each meal, but resident will push it away at times;
-The DM would update orders during the weight meetings.
During an interview on 03/07/25, at 1:55 P.M., the Administrator said a lot of factors go into weight decisions. Staff would review residents with weight loss and interventions would depend on specific perimeters and diagnosis. He/she attended the weekly weight meetings and a resident with a 5% weight loss would trigger and would be monitored.
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 record review, the facility failed to store food in accordance with professional standards of practice and protect food from possible contamination when staff di...
Read full inspector narrative →
Based on observations, interviews, and record review, the facility failed to store food in accordance with professional standards of practice and protect food from possible contamination when staff did not store food properly after opening and staff did not consistently label food after opening. The facility census was 89.
Review of the facility policy titled, Food Receiving and Storage, revised October 2017, showed the following:
-Foods shall be received and stored in a manner that complies with safe food handling practices;
-Wrappers of frozen foods must stay intact until thawing;
-Other opened containers must be dated and sealed or covered during storage.
Record review of the 2013 Missouri Food Code showed food shall be protected from contamination by storing the food in a clean, dry location, and where it is not exposed to splash, dust, or other contamination.
1. Observations on 03/03/25 at 10:40 A.M., showed the following:
-A box of flake cereal labeled with a resident's name and room number stored on the shelf of dry storage room, unsealed and opened to air, and not labeled with date opened;
-A box of oat cereal labeled with a resident's name and room number stored on the shelf of dry storage room, unsealed and open to air, and not labeled with date opened;
-A box of cinnamon cereal labeled with a resident's name and room number stored on the shelf of dry storage room, unsealed and opened to air, and not labeled with date opened;
-An opened to air and unsealed carton of liquid eggs with yellow substance showing on the opening of the carton and not labeled with date open.
Observations on 03/05/25, at 9:56 A.M., showed the following:
-A box of flake cereal labeled with a resident's name and room number stored on the shelf of dry storage room, unsealed and opened to air, and not labeled with date opened;
-A box of oat cereal labeled with a resident's name and room number stored on the shelf of dry storage room, unsealed and open to air, and not labeled with date opened;
-An opened to air and unsealed carton of liquid eggs with yellow substance showing on the opening of the carton, and not labeled with the date open.
Observations on 03/06/25 at 11:30 A.M., showed the following:
-A box of flake cereal labeled with a resident's name and room number stored on the shelf of dry storage room, unsealed and opened to air, and not labeled with date opened;
-A box of oat cereal labeled with a resident's name and room number stored on the shelf of dry storage room, unsealed and open to air, and not labeled with date opened;
-A large box containing a blue bag of frozen peas and carrots stored in the walk-in freezer. Both the box and the blue bag were unsealed and open to air;
- A large box containing a blue bag of frozen broccoli stored in the walk-in freezer. Both the box and the blue bag were unsealed and open to air;
- A large box containing a blue bag of frozen mixed vegetables stored in the walk-in freezer. Both the box and the blue bag were unsealed and open to air.
Observations on 03/07/25, at 9:55 A.M., showed the following:
-A box of flake cereal labeled with a resident's name and room number stored on the shelf of dry storage room, unsealed and opened to air, and not labeled with date opened;
-A large box containing a blue bag of frozen broccoli stored in the walk-in freezer. Both the box and the blue bag were unsealed and open to air;
-A large box containing a blue bag of frozen mixed vegetables stored in the walk-in freezer. The box was closed, but blue bag was open to air and unsealed.
During an interview on 03/07/25, at 9:38 A.M., Dietary Aide (DA) L said the following:
-Staff should store opened food with a label containing the item name, date opened, date used by, and initials of staff who opened it;
-Staff should leave residents' personal cereal in the original box labeled with name and room number and should be closed and not open to air;
-Staff should ensure opened bags of frozen vegetables are wrapped closed and the box is closed.
During an interview on 03/07/25, at 9:46 A.M., Dietary [NAME] M said the following:
-Staff should store opened food items in sealed zip lock bags, and label with date opened and use by date within three days;
-Staff should store residents' personal cereal in original box with bag rolled up and top closed;
-Staff should store an opened carton of eggs with the top pushed down to ensure it is completely closed and write the date opened in sharpie and use by manufacture's date;
-Staff should twist the bag closed containing frozen vegetables and ensure the box is completely closed after opening. Staff should label with open date and use by date.
During an interview on 03/07/25, at 9:59 A.M., the Kitchen Supervisor said the following:
-Staff should store open food in sealed gallon bags and label with the open date;
-Staff should store an opened carton of liquid eggs inside of something else like a zipper bag if not sealing properly, with use by manufacture's expiration date, and it should not have yellow substance on the opening;
-Staff should store residents' personal cereal boxes in the original box labeled with the resident's name and room number, date opened, and roll up the bag and make sure it is sealed and close the box;
-Staff should store opened boxes of vegetables in a gallon bag with open date or at least have the bag twisted and closed inside the closed box.
During an interview on 03/07/25, the Dietary Manager (DM) said the following:
-Staff should ensure opened food products were sealed and labeled with the date open for storage;
Staff should store residents' personal cereal boxes in the original box labeled with the resident's name and room number, bag folded, and box closed;
-Staff should reclose an opened carton of liquid eggs, and if the carton does not seal, place in a plastic bag and seal, and label with open date for storage. Liquid egg cartons should not have yellow substances on the opening;
-Staff should seal the bags of opened vegetables in the freezer and close the box for storage. If a small amount of frozen vegetables, transfer to a zipper bag and seal. All opened frozen vegetable containers should be labeled with the open date.
During the interview on 03/07/25, at 10:55 A.M., the Registered Dietician (RD) said the following:
-Staff should store opened food items in a sealed container such as a zipper bag, container with lid or if able to seal in original container, with date received and date opened, and name of item if not easily identifiable;
-Staff should label and store residents' personal cereal boxes with the bag and box closed;
-Staff should transfer opened liquid egg cartons to a container with lid and labeled and should not have a yellow substance on top;
-Staff should tie off the bag of opened frozen vegetables and close the box for storage.
During an interview on 03/07/25, at 1:02 P.M., the Director of Nursing (DON) said opened food should be sealed and labeled with the throw away date within three days.
Dec 2024
1 deficiency
CONCERN
(D)
📢 Someone Reported This
A family member, employee, or ombudsman was alarmed enough to file a formal complaint
Potential for Harm - no one hurt, but risky conditions existed
Deficiency F0602
(Tag F0602)
Could have caused harm · This affected 1 resident
Based on interview and record review, the facility failed to protect all resident from misappropriation of property, when a facility staff member (Certified Nurse Aide (CNA) A) took one resident's (Re...
Read full inspector narrative →
Based on interview and record review, the facility failed to protect all resident from misappropriation of property, when a facility staff member (Certified Nurse Aide (CNA) A) took one resident's (Resident #1's) bank debit card without permission and made fraudulent purchases totaling over $90.00 on the resident's card. The facility census was 96.
Review of the facility policy titled, Abuse, Neglect, Exploitation or Misappropriation Prevention Program, revised April 2021, showed, in part, the following:
-Residents have the rights to be free from abuse, neglect, misappropriation of resident property and exploitation.
-The resident abuse, neglect, and exploitation prevention program consists of a facility-wide commitment and resource allocation to support the following objectives including protect residents from abuse, neglect, exploitation, or misappropriation from anyone; develop and implement policies and protocols to prevent and identify theft, exploitation, and misappropriation of resident property; identify and investigate all possible incidents of abuse, neglect, mistreatment, or misappropriation of resident property; investigate and report any allegations within timeframes required by federal requirements; protect residents from any further harm during investigations; and establish and implement a quality assurance and performance improvement (QAPI) review and analysis of reports, allegations or finding of abuse, neglect, mistreatment, or misappropriations or property.
1. Review of Resident #1's face sheet showed:
-admission date of 12/06/23;
-Diagnoses included sepsis, acute respiratory failure, type 2 diabetes mellitus, and history of a stroke.
Review of the resident's 5-day Minimum Data Set (MDS - a federally mandated comprehensive assessment completed by facility staff), dated 12/02/24, showed the following:
-Cognitively intact;
-No behavioral symptoms exhibited;
-Functional limitation to range of motion with impairment to upper and lower extremity on one side of the resident's body.
Review of the facility's investigation summary submitted to the Department of Health and Senior Services (DHSS), dated 12/06/24, showed the following:
-On Tuesday, 12/03/24, the resident reported to the Director of Nursing (DON) that he/she noticed some charges on his/her credit card statement that he/she did not recognize. His/her last charge was to a restaurant delivery service so he/she thought it was possible that the card was compromised through that company, The DON notified the Administrator and the facility began an investigation. After continued research into the situation, the facility uncovered some information that led the facility to believe the misappropriation involved a facility employee;
-Coincidentally, the accused employee came to the DON and confessed to taking the resident credit card, By mistake, and when the employee realized he/she had possession of the resident's card, that staff member brought the card back to the resident and reimbursed the resident for all charges;
-The facility suspended the employee and re-opened the investigation with the new information that was uncovered. The employee was suspended, and interviews were conducted with all residents on the hall. No other issues were reported at this time.
-Based on the information the facility received, and interviews conducted, the facility felt the accused employee made some very wrong decisions, that led to him/her taking a resident's item off premises without the resident's knowledge.
Review of the facility investigation into misappropriation of the resident's debit card showed the DON spoke with the resident and they reviewed the charges to his/her online bank account which showed the following charges which the resident said he/she did not make:
-On 11/28/24, at a convenience store for $7.08;
-On 11/28/24, at a convenience store for $7.24;
-On 11/28/24, at a convenience store for $9.17;
-On 11/29/24, at a grocery store for $33.17;
-On 11/29/24, at a grocery store for $30.00;
-On 11/29/24, at a convenience store for $11.02.
Review of facility investigation's attached statement from CNA D, dated 12/03/24, showed the following:
-On Tuesday, 12/03/24, at around 1:30 P.M., CNA C and CNA D assisted the resident with cares;
-During the cares, CNA A came in and assisted with resident cares;
-The resident told the CNAs that his/her credit card was hacked and someone spent money on the card and the resident mentioned the stores where the card was used;
-After the resident's cares, CNA A told CNA D, he/she (CNA A) must have been the one to use the resident's card;
-CNA A said while cleaning up the resident's room CNA A saw the resident's debit card and, Poked it;
-CNA D asked for CNA A to explain and CNA A said he/she became sidetracked and forgot about the card until later in the day when he/she found the resident's card in his/her own pocket;
-CNA A thought he/she was using a friend's card because the card was tap to pay and did not require a pin number for use;
-CNA D told CNA A to report the situation to the DON.
During an interview on 12/18/24, at 10:15 A.M., the DON said the following:
-On 12/03/24, the resident noted several debits to his/her online bank account for purchases at a convenience store and grocery store that he/she did not make;
-The resident showed the DON the online bank statement and explained which purchases he/she did not make or authorize;
-This constituted a total of six purchases over a two day period (11/28/24 to 11/29/24) equaling $97.68;
-The DON then reported the theft to the police department and the Department of Health and Senior Services (DHSS) hotline and began an investigation;
-On 12/05/24, CNA A reported while the resident was in the hospital during the last part of November, 2024, he/she went into the resident's room to clean up the room;
-The CNA observed the resident's debit card had fallen off of the resident's over bed table;
-The CNA said he/she inadvertently placed the debit card in his/her pocket;
-The CNA said he/she was carrying linens at the time and intended to take the debit card to the nurse on duty, but forgot to do so;
-The CNA said he/she thought he/she was using a debit card borrowed from a friend, but overheard the resident telling CNA B and CNA C that his/her debit card was used for purchases at the convenience store and grocery store;
-CNA A then realized he/she must have mistakenly used the resident's card for purchases.
Observation and interview of the resident on 12/18/24, at 11:27 A.M., showed the following:
-The resident sat in his/her wheelchair with his/her left arm supported on a supportive tray;
-The resident said the facility sent him/her to the hospital during the last part of November 2024;
-After his/her return to the facility, on 12/03/24, he/she checked his/her online bank statement and noticed six charges that he/she could not have made to a convenience store and grocery store for a total amount of approximately $98.00 dollars;
-He/she reported to the DON about the false charges;
-He/she did not know who made the charges to his/her account, but initially he/she suspected a food delivery service might have stolen his/her information;
-A few days later, the DON told the resident CNA A admitted to using the resident's debit card, but said it was an accident and the CNA brought the money in to the resident;
-The resident said he/she did not leave his/her debit card out, because he/she always kept the card in his/her wallet in a drawer.
During an interview on 12/18/24, at 11:50 A.M., Registered Nurse (RN) B said the following:
-He/she worked as the charge nurse three days per week on the hall where the resident resided;
-On 12/03/24, the resident reported he/she was going through his/her online banking statement and discovered someone had used his/her debit card without permission;
-The nurse immediately notified the DON of the situation and the DON came directly to the resident's room and started talking with the resident about the issue;
-The nurse said he/she was not aware of any other stolen resident items or resident money.
During an interview on 12/18/24, at 12:20 P.M., CNA C said the following:
-On 12/03/24, he/she and CNA D were standing by the nurses' station and CNA A said he/she took the resident's debit card;
-CNA C asked CNA A if he/she reported what had happened and he/she said no. CNA D told CNA A to go to the DON and report what had happened;
-CNA C said he/she did not report the conversation immediately to the DON, but he/she should have. He/she talked with the DON about the matter on 12/04 or 12/05 and wrote a statement.
During an interview on 12/18/24, at 2:18 P.M., CNA A said the following:
-He/she accidentally placed the resident's debit card in his/her pocket while cleaning the resident's room;
-He/she intended to give the debit card to the nurse on duty, but forgot about the card;
-He/she found the debit card and returned the card to the resident's wallet on 11/30/24 without telling the resident or the facility;
-On 12/03/24, when he/she heard staff say someone had made unauthorized purchases on the resident's debit card at a convenience store and grocery store and realized, he/she must have mistakenly used the resident's card for purchases;
-On 12/03/24, he/she went to the DON and informed the DON of what he/she had done;
-On 12/05/24, he/she brought in money to cover the charges he/she made on the resident's account and the DON suspended the CNA pending the investigation.
During an interview on 12/18/24, at 2:40 P.M., the Assistant Director of Nursing said the following:
-If he/she became aware of an allegation of misappropriation or resident property, he/she would remove the alleged perpetrator from resident care areas and notify the DON and Administrator immediately;
-The facility would notify DHSS within 24 hours of any allegation of misappropriation and conduct and submit an investigation into the allegation.
During an interview on 12/18/24, at 3:14 P.M., the DON said if an allegation of misappropriation of resident property occurred, he/she expected the staff to notify the charge nurse or direct supervisor. The nurse or supervisor should then immediately notify the DON, so he/she could notify DHSS Hotline within 2 hours.
During an interview on 12/18/24, at 3:30 P.M., the Administrator said the facility staff should follow the facility's misappropriation policy.
MO00246163
Oct 2024
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 F0806
(Tag F0806)
Could have caused harm · This affected multiple residents
**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on interviews and record review , the facility failed to have a process in placed to ensure all residents food preferences...
Read full inspector narrative →
**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on interviews and record review , the facility failed to have a process in placed to ensure all residents food preferences were honored and meal alternatives were available to all residents when facility failed to ensure five residents (Resident #1, #2, #3, #4, and #5), who routinely ate in their rooms, were unable to have their preferred drink and the ability to obtain an alternative meal. The facility census was 91.
Review of the facility policy titled, Food and Nutrition Services, revised October 2017, showed the following:
-Each resident is provided with a nourishing, palatable, well-balanced diet that meets his or her daily nutritional and special dietary needs, taking into consideration the preferences of each resident;
-Each resident's nutritional needs, food dislikes, and eating habits, as well as physical, functional, and psychosocial factors that affect eating and nutritional intake and utilization will be assessed;
-A resident-centered diet and nutrition plan will be based on this assessment;
-Meals and/or nutritional supplements will be provided within one hour of either resident request or scheduled mealtime, and in accordance with the resident's medication requirements;
-Reasonable efforts will be made to accommodate resident choices and preferences.
1. Observation on 10/02/24, at 10:10 A.M., showed the menu for the day was displayed in the dining room along with an always available menu. The menu read Please place order from Always Available Menu 2 hours prior to the meal you are replacing.
2. Review of Resident #1's face sheet (brief resident profile) showed the following:
-admission date of 11/08/21;
-Diagnoses included type II diabetes mellitus, generalized anxiety disorder, morbid obesity, acute kidney failure, high cholesterol, and high blood pressure.
Review of the resident's quarterly Minimum Data Set (MDS - a federally mandated assessment tool completed by staff), dated 08/15/24, showed the resident was cognitively intact.
Review of the resident's care plan, last revised on 08/21/24, showed the following:
-Resident had nutritional problem or potential nutritional problem related to type II diabetes mellitus, obesity and high cholesterol;
-Resident will maintain adequate nutritional status as evidenced by no signs or symptoms of significant weight change through review date;
-Provide and serve diet as order. Staff to monitor intake and record every meal;
-Registered dietician (RD) to evaluate and make diet change recommendations as needed;
-Weight loss plan with goal of 20 pounds with goal weight of 270 pounds.
Review of the resident's current physician order sheet showed an order, dated 04/04/23, for regular diet with regular texture and consistency.
During interviews on 10/02/24, at 9:36 A.M. and 4:15 P.M., the resident said the following:
-The facility had alternative meals available if ordered two hours prior to the meal service;
-If residents fail to place the alternative meal order two hours prior to the meal service, the facility will not provide an alternative meal. Residents will receive the meal being served;
-The facility does not provide residents who eat in their rooms different options for drinks. They only get the drinks on the drink cart serving the hall residents;
-The residents were told there are not enough staff to go get items not served on the drink cart, such as hot water.
3. Review of Resident #2's face sheet showed the following:
-admission date of 04/29/22;
-Diagnoses included muscle wasting and atrophy, morbid obesity with alveolar hypoventilation (a rare disorder in which a person does not take enough breaths per minute), and type II diabetes mellitus.
Review of the resident's care plan, last revised on 08/28/24, showed the following:
-Resident had nutritional problem related to body mass index (BMI) and obesity, type II diabetes mellitus, and chronic kidney disease;
-Resident receives fresh seasonal fruit and when seasonal fruit is not available, than an alternative fruit will be offered;
-Provide and serve diet as ordered. Staff to monitor intake and record every meal;
-RD to evaluate and make diet change recommendations as needed.
Review of the resident's quarterly MDS, dated [DATE], showed the resident was cognitively intact.
Review of the resident's current physician order sheet showed an order, dated 04/29/22, for a regular diet with regular texture and consistency.
During an interview on 10/02/24, at 1:53 P.M., the resident said the following:
-The facility has a two-hour window for ordering alternative meals prior to meal service;
-The facility is not providing residents who eat on the halls the same options for drinks such as alternative juices, lemonade, and punch as offered in the dining room;
-The Administrator has said staff should not be running back and forth to get resident drinks;
-The residents are not provided a daily menu.
4. Review of Resident #3's face sheet showed the following:
-admission date of 05/27/22;
-Diagnoses included Parkinson's disease (a chronic, progressive neurological disease that affects the central nervous system and causes movement problems) and morbid obesity.
Review of the resident's quarterly MDS, dated [DATE], showed the resident was cognitively intact.
Review of the resident's care plan, last revised on 08/26/24, showed the following:
-Resident had nutritional problem or potential nutritional problem related to Parkinson's disease;
-Resident will maintain adequate nutritional status as evidenced by no signs or symptoms of significant weight loss;
-Diet will be enhanced to help with weight loss prevention;
-Provide and serve regular diet as ordered. Staff to monitor intake and record every meal;
-RD to evaluate and make diet change recommendations as needed.
Review of the resident's current physician order sheet showed an order, dated 04/11/24, for a regular diet with regular texture and consistency.
During an interview on 10/02/24, at 10:55 A.M., the resident said the following:
-Staff have said residents will not receive the alternative meal if not ordered two hours prior to the meal service;
-He/she has gone without eating because the alternative meal was not ordered two hours prior to the meal service, and he/she was served the regular meal he/she did not like;
-He/she did not receive lemonade during a meal as it was not offered on the drink cart for the halls;
-He/she heard the Administrator say the facility does not provide a delivery service;
-Aides just began telling him/her the menu items this week, prior he/she did not know what the menu items were unless he/she went to the dining room to look at the menu displayed on the wall for the day,
5. Review of Resident #4's face sheet showed the following:
-admission date of 09/16/20;
-Diagnoses included congestive heart failure (CHF - a chronic condition that occurs when the heart can't pump enough blood to meet the body's needs), major depressive disorder, and myocardial infarction type II (a heart condition that occurs when the supply of oxygen to the heart muscle doesn't match the demand).
Review of the resident's quarterly MDS, dated [DATE], showed the resident was cognitively intact.
Review of the resident's care plan, last revised on 08/28/24, showed the following:
-Resident at risk for nutritional complications/decline related to having no teeth and preferred not to have a mechanically altered diet;
-Interventions will be in place for resident to prevent nutritional decline and/or maintain current status to the extent possible related to the disease;
-Diet per physician order;
-Assist with condiments. If resident changes preferences, update menu card system;
-Resident continued to have food delivered daily family brings in food;
-Staff to ensure food safety by monitoring what is in room and placing items in the refrigerator.
Review of the resident's current physician order showed an order, dated 04/04/23, for a regular diet with regular texture and consistency.
During an interview on 10/02/24, at 2:28 P.M., the resident said the following:
-The facility required residents to order alternative meals two hours prior to the meal service;
-If a resident does not order the alternative meal two hours prior, he/she will not receive the alternative and will be served the regular meal;
-Residents eating in the dining room can order an alternative meal after the two-hour window and will receive the alternative meal;
-Drinks for the residents eating in their rooms is whatever is on the drink cart for the halls;
-Staff are not supposed to be running back and forth to get different drinks for residents eating in their rooms;
-The meals for the day are displayed in the dining room, not at the nurses' stations and none are passed out to the residents.
6. Review of Resident #5's face sheet showed the following:
-admission date of 03/02/22;
-Diagnoses included type II diabetes mellitus, morbid obesity, CHF, and major depressive disorder.
Review of the resident's care plan, last revised 08/28/24, showed the following:
-Resident nutritional problem or potential nutritional problem related to type II diabetes mellitus, acute kidney failure, metabolic encephalopathy (a brain dysfunction caused by a chemical imbalance in the blood that affects the brain), and obesity;
-Resident will maintain adequate nutritional status as evidenced by no signs or symptoms of malnutrition and no significant weight changes through the review period;
-Provide and serve regular diet as ordered. Staff to monitor intake and record every meal;
-RD to evaluate and make diet change recommendations as needed.
Review of the resident's quarterly MDS, dated [DATE], showed the resident was cognitively intact.
Review of the resident's current physician order sheet showed an order, dated 04/04/23, for a regular diet with regular texture and consistency.
During an interview on 10/02/24, at 2:57 P.M., the resident said the following:
-The facility had alternative meals, but residents must order two hours before the meal service;
-The new Administrator came in and made the rule that residents have to eat the meal being served if they do not place an alternative order two hours before the meal service;
-The daily menu is posted in the dining room, but not at the nurses' station. Occasionally staff comes around and asks residents if residents want an alternative, but mostly the residents have to ask staff;
-Residents eating in their rooms can only get the drinks available on the drink cart because staff are not to be running back and forth to the kitchen to get other drinks.
7. During an interview on 10/02/24, at 3:32 P.M., License Practical Nurse (LPN) A said the following:
-Residents who go to the dining room to eat and do not like the meal are provided an alternative without ordering two hours prior to the meal;
-Residents choosing to eat in their rooms are required to put in an order for an alternative meal two hours prior to the meal and if they do not, they are to eat the meal being served;
-Resident who eat in the dining room have more choices for drinks;
-Resident who eat in the rooms have the drink choices on the beverage cart;
-He/she tries to get residents eating in their rooms other drinks from the kitchen when requested, but there is not always enough staff;
-The menu is posted in the dining room and today was the first time it was posted at the nurses' station;
-There is no process to ensure all residents know what is on the menu for the day.
8. During an interview on 10/03/24, at 9:41 A.M., LPN B said the following:
-Residents should order alternative meals two hours prior to the meal service;
-Staff writes the alternative meal order on a white board in the kitchen;
-Residents who eat in the dining room are not required to order the alternative meal two hours prior to the service;
-The menu is posted in the dining room. Sometimes aides tell residents what is on the menu and some residents ask, but the facility has no process in place to ensure all residents know what is on the menu for the day;
-Residents can choose to eat in their rooms, but if they do not order the alternative meal two hours in advance, they will have to eat the meal being served;
-It is a resident's right to have the same food available in the rooms as is available in the dining room.
9. During an interview on 10/03/24, at 2:39 P.M., the Director of Nursing (DON) said the following:
-Menus are posted in the dining room, 300 hall dining room, and each nursing station;
-Staff do not pass menus to residents and there is no process to ensure all residents know what is on the menu for the day;
-The two-hour requirement is for special meals they do not normally have and not the alternative menu;
-She believes staff always get residents the alternative meals;
-Staff should get the resident what he/she wants. This is a right;
-The facility needed to do some education;
-The drink carts for the halls do not have all of the different choices, but after staff pass the trays, they should get residents drinks requested that are not available on the cart but are in the kitchen.
10. During an interview on 10/04/24, at 8:30 A.M., the Administrator said the following:
-Meals for the day are posted in both dining rooms;
-The two-hour notice for special requests practice has been in process for years;
-The two-hour notice is for special requests, not the always available alternatives;
-The always available menu is always available and does not require a two-hour notice;
-Staff cannot put all selections of drinks on the drink carts for hall trays, but should get residents any drinks they request, and drinks can be added to a resident's preference list;
-Residents eating in their rooms are afforded all items available to residents eating in the dining room.
MO00242527
Feb 2024
1 deficiency
CONCERN
(D)
📢 Someone Reported This
A family member, employee, or ombudsman was alarmed enough to file a formal complaint
Potential for Harm - no one hurt, but risky conditions existed
Deficiency F0658
(Tag F0658)
Could have caused harm · This affected 1 resident
Based on observation, interview, and record review, the facility failed to provide medication administration per professional standards when staff failed have a system in place for timely administrati...
Read full inspector narrative →
Based on observation, interview, and record review, the facility failed to provide medication administration per professional standards when staff failed have a system in place for timely administration of medications to residents when one resident (Resident #1), out of six sampled residents, received their medications late. The facility census was 95.
Review of the facility's policy titled, Adverse Consequences and Medication Errors, dated 04/2014, showed the following:
-Medication error is defined as the preparation or administration of drugs or biological which is not in accordance with physician's orders, manufacturer specifications, or accepted professional standards and principles, errors include wrong time.
Review of the facility's policy titled, Documentation of Medication Administration, dated 11/2022, showed the following;
-Documentation of administration includes the date and time of administration, initials, signature, and title of person administering.
1. Review of Resident #1's face sheet showed the following information:
-admission date of 08/06/21;
-Diagnoses included metabolic encephalopathy (problem in the brain), chronic obstructive pulmonary disease (inflammation of the lungs causing airflow problems), type 2 diabetes (problem in the way the body regulates and uses sugar for fuel), transient cerebral ischemic attack (interruption of blood supply to the brain), hypertension (high blood pressure), and heart failure.
Review of the resident's care plan, revised 11/10/23, showed the following:
-Resident has congestive heart failure. Staff to administer cardiac medications as ordered;
-Resident has hypertension. Staff to administer antihypertensives medications as ordered;
-Resident has dehydration or potential for fluid deficiency. Staff to administer medications as ordered;
-Resident is on anticoagulant therapy Eliquis. Staff to administer anticoagulant medications as ordered by physician;
-Resident is on antidepressant. Staff to administer antidepressant medications as ordered by physician.
Review of the resident's February 2024 Physician Order Sheet (POS) showed the following orders:
-An order, dated 08/06/21, for Eliquis (used to treat and prevent blood clots) 5 milligrams (mg), one tablet by mouth two times per day for afib (irregular heart beat);
-An order, dated 10/07/21, for meclizine HCI (used to control nausea, vomiting, and dizziness) 12.5 mg tablet, one tablet by mouth three times a day for vertigo (feeling of moving, spinning, or off balance);
-An order, dated 06/26/22, for Miralax powder (used to treat constipation) 10 grams/scoop, one scoop by mouth one time a day related to constipation;
-An order, dated 10/04/22, for cinnamon capsule 1000 mg by mouth one time per day for supplement;
-An order, dated 12/08/22, for myrbetriq (used treat overactive bladder) tablet extended release 24 hour 50 mg tablet, one tablet by mouth one time a day for bladder spasm;
-An order, dated 02/13/23, for acidophilus oral capsule (used to promote good bacteria), give one tablet by mouth two times per day;
-An order, dated 03/27/23, for famotidine (used to treat heartburn) 10 mg, one tablet by mouth one time a day for acid indigestion;
-An order, dated 07/20/23, for hydralazine HCI (used to treat high blood pressure) 10 mg, one tablet mouth three times a day for blood pressure control;
-An order, dated 07/24/2023, for torsemide (used to treat fluid retention) 20 mg, give two tablets by mouth one time per day for edema (swelling caused by too much fluid);
-An order, dated 08/25/23, for oxybutynin chloride (used to treat overactive bladder) ER (extended release 24 hour) tablet, 15 mg, give one table by mouth one time per day for bladders spasms;
-An order, dated 09/15/2023, for potassium chloride (used to treat low blood levels of potatssium) ER tablet 20 meq (milliequivalent), one tablet by mouth two times a day for supplement;
Review of the resident's February 2024 Medication Administration Record (MAR) showed the following medications were scheduled for administration at 9:00 A.M.
-Eliquis 5 mg;
-Meclizine HCI 12.5 mg;
-Miralax powder 10 gm/scoop;
-Cinnamon capsule 1000 mg;
-Myrbetriq tablet extended release 24 hour 50 mg tablet;
-Acidophilus oral capsule;
-Famotidine 10 mg;
-Hydralazine HCI 10 mg;
-Torsemide 20 mg, give two tablets by mouth.
-Oxybutynin chloride ER tablet extended release 24 hour 15 mg;
-Potassium chloride ER tablet extended release 20 meq.
Observation on 02/05/24, at 10:35 A.M., showed Certified Medication Technician (CMT) A prepared medications for administration to the resident including the following medications:
-Eliquis 5 mg;
-Meclizine HCI 12.5 mg;
-Miralax powder 10 gm/scoop;
-Cinnamon capsule 1000 mg;
-Myrbetriq tablet extended release 24 hour 50 mg tablet;
-Acidophilus oral capsule;
-Famotidine 10 mg;
-Hydralazine HCI 10 mg;
-Torsemide 20 mg, give two tablets by mouth.
-Oxybutynin chloride ER tablet extended release 24 hour 15 mg;
-Potassium chloride ER tablet extended release 20 meq.
-The electronic MAR (eMAR) showed all of the medications showed in red (indicating the administration was late);
-CMT A administered all medications as at 10:35 A.M., one hour and 35 minutes after the scheduled administration time.
During an interview on 02/05/23, at 10:45 A.M., the resident said he/she has always gotten his/her morning medications around 10:30 A.M. and he/she isn't sure what time they're prescribed.
During interviews on 02/05/23, at 10:40 A.M. and 2:25 P.M., CMT A said the following:
-The MARs tell staff which medications and times the medications are to be administered;
-Staff clicks each medication in the electronic record and that indicated staff administered the medication;
-Medications can be administered one hour before or after the time they're due, if it's given after that time frame it's technically late;
-If the electronic record shows the medications in red/pink color that means they are overdue;
-The system documents the time the medication is administered;
-If the medications is not given on time and the resident takes the same medication two or three times per day, he/she adjusts the time in between to make sure it is not given to soon;
-There is usually one CMT per hall and he/she begins the shift at 7:00 A.M. Sometimes the two CMT's split a third hall if they have a call in.
During an interview on 02/05/23, at 2:40 P.M., CMT B said the following:
-The MARS shows him/her all medications a resident is prescribed;
-Medications are to be administered no sooner than one hour before or later than an hour after the time to be administered;
-When the medication is late, the electronic record shows the medication on the screen in red;
-Sometimes medications are not given on time. Staff have a lot of medications to administer in the morning;
-If the medications are not administered within the time frame they are considered late;
-He/she usually has one hall, but a lot of people require blood pressure checks and need help so this does slow him/her down.
During an interview on 02/05/23, at 2:45 P.M., Licensed Practical Nurse (LPN) C said the following:
-The electronic records have color codes. Yellow are medications that are due and red means the medications are overdue;
-Staff know which meds are given by looking at the MARS and the colors that show on the screen;
-The techs click off each medication they administer on the MARS;
-Medications can be administered one hour before or after the time listed on the MARs;
-If the medication is administered over an hour after the ordered time, it would be considered late;
-If residents take the same medication multiple times, staff would look at the previous time it was administered and back off some.
During an interview on 02/05/23, at 4:17 P.M., the Administrator and Director of Nursing (DON) said the following:
-Staff know the times medications are to be administered and which medications to administer by looking at the MARS in the electronic record;
-The electronic records have colors. Yellow color means the medications are to be administered and red color means the medications are late;
-Staff check yes on the electronic record when administering the medications;
-Medications can be given one hour before and one hour after time listed;
-Medications due at 9, if administered at 10:35 A.M., would be late;
-When running late staff should prioritize meds based on ones that may not be as necessary. They could wait, but need to give the meds that are significant and know specific meds and how they interact;
-They were not aware medications were being administered late.
MO00225840
Jun 2023
8 deficiencies
1 Harm
SERIOUS
(G)
Actual Harm - a resident was hurt due to facility failures
Deficiency F0697
(Tag F0697)
A resident was harmed · This affected 1 resident
Based on record review, observation, and interview, the facility failed to document reason for reduction in pain medication, failed to notify the physician when pain medication did not relieve pain, a...
Read full inspector narrative →
Based on record review, observation, and interview, the facility failed to document reason for reduction in pain medication, failed to notify the physician when pain medication did not relieve pain, and failed to stop a dressing removal after the resident verbalized severe pain and exhibited nonverbal signs of severe pain for one resident (Resident #330) out of a sample of two. The facility census was 85.
Review of the facility's policy Pain - Clinical Protocol, revised March 2018, showed the following:
-The physician and staff will identify the individuals who have pain or who are at risk for having pain;
-The staff and physician will identify the characteristics of pain such as location, intensity, frequency, pattern and severity;
-The staff will use a consistent approach and a standardized pain assessment instrument appropriate to the resident's cognitive level;
-The nursing staff will identify any situation or interventions where an increase in the resident' pain may be anticipated, for example, wound care, ambulation or repositioning;
-The staff and physician will evaluate how pain is affecting mood, activities of daily living, sleep, and the resident's quality of life, as well as how pain may be contributing to complications such as gait disturbances, social isolation, and falls;
-The staff will evaluate and report the resident/patient's use of standing and as needed (PRN) analgesics (pain medication);
-Depending on the characteristics of pain, the physician may start with PRN doses or supplement standing doses with PRN doses for breakthrough pain;
-If there are more than occasional analgesic requests, the physician will consider changing to regular administration of at least one analgesic with another medication for PRN use, increasing the standing dose of an existing analgesic, switching to another analgesic, and/or adding non-pharmacological measures.
1. Review of the Resident #330's face sheet (resident's information at a quick glance) showed the following:
-admission date of 06/19/23;
-Diagnoses included bipolar disorder (a mental illness that causes unusual shifts in a person's mood, energy, activity levels, and concentration), general anxiety disorder (worrying constantly and cannot control the worrying), infection following a procedure, osteomyelitis of vertebra (a spine infection), and postlaminectomy syndrome (condition characterized by chronic back or neck pain following surgery).
Review of the resident's nursing admission assessment, dated 06/19/23, showed the following:
-The resident had a large wound on his/her upper mid-back that measured 9 centimeter (cm) (depth) by approximately 10 cm (length) by 5 cm (wide) with a wound vacuum assisted closure (wound vac - a treatment that helps a wound heal by applying a vacuum through a special sealed dressing. The purpose of the vacuum is to draw the fluid out of the wound and increase blood flow to the area) running at 125 millimeters (mm)/mercury (hg) continuously and changed every Monday and Friday;
-The resident rated his/her current pain as a four out ten and with a verbal description as moderate;
-The resident had negative vocalizations such an occasional moan or groan. His/her body language was tense/distressed with pacing/fidgeting and was distracted or reassured by voice or touch;
-Received scheduled oxycodone (a medication used to treat severe pain);
-The resident had acute (sharpness or severity of sudden onset) or chronic (long-term) pain;
-The resident had pain related to sciatica (pain, weakness, numbness, or tingling in the leg).
Review of the resident's care plan, dated 06/19/23, showed the following:
-The resident would not have an interruption in normal activities due to pain;
-Anticipate the resident's need for pain relief and respond immediately to any complaint of pain;
-Monitor/document for side effects of pain medication
-Observe for constipation; new onset or increased agitation, restlessness, confusion, hallucinations, or dysphoria; nausea or vomiting; dizziness and falls. Report occurrences to the physician;
-Monitor/record/report to the nurse resident complaints of pain or requests for pain treatment;
-Notify physician if interventions are unsuccessful or if current complaint is a significant change from residents past experience of pain.
Review of the resident's June 2023 Medication Administered Record (MAR) showed the following information:
-An order, dated and discontinued on 06/19/23, for oxycodone 5 milligrams (mg), one tablet by mouth, four times a day for pain, every six hours, at 2:00 A.M., 8:00 A.M., 2:00 P.M., and 8:00 P.M.;
-On 6/19/23, staff administered oxycodone to the resident at 2:00 P.M. for a pain level of 0 and at 8:00 P.M. for a pain level of 8;
-An order, dated 6/19/23, for oxycodone 5 mg, one tablet by mouth, every six hours as needed for pain.
-On 6/20/23, at 9:04 A.M., staff administered oxycodone to the resident for a pain level of 6.
Observation and interview conducted on 06/20/23, at approximately 10:00 A.M., showed the following:
-The resident sat in his/her recliner in his/her room. The resident had a wound vac attached to his/her lower back wound;
-The resident said he/she admitted to the facility yesterday for wound care and therapy;
-The resident said he/she was in a lot pain and said he/she hurt so much it made him/her nauseous;
-The resident was tearful when describing pain;
-The resident said that when he/she was at the hospital he/she received oxycodone 10 mg every four hours, but when he/she discharged from hospital, the physician decreased the dosage to 5 mg every 6 hours;
-The resident said he/she always had pain, but the pain medication usually helped ease the pain. Staff brought him/her a pain pill a short time ago and he/she thought it would help.
Record review of the resident's medical record showed staff did not document a reason for the reduction in pain medication.
Review of the resident's June 2023 MAR showed the following:
-An order dated 06/19/23, for ondansetron (used to treat reflux) 4 mg, one tablet by mouth, every 6 hours as needed for nausea/vomiting. Staff administered the medication to the resident on 6/20/23, at 12:27 P.M. and 5:10 P.M.
-On 06/20/213, staff administered oxycodone to the resident at 4:18 P.M. for a pain level of 8, and at 10:28 P.M. for a pain level of 8;
-On 6/21/23, staff administered oxycodone to the resident at 4:28 A.M. for a pain level of 7.
Review of the nurses 24 hour report for the night shift, dated 06/21/23 to 06/22/23, (10:00 P.M.- 6:00 A.M.) a nurse documented the following related to the resident:
-The resident was alert and oriented. He/she received oxycodone 5 mg every six hours as needed for pain;
-The resident could become very hateful and combative when in pain. Make sure the resident received his/her pain medications and assess his/her pain every 6 hours;
-The resident needed scheduled or as needed anxiety medication, please contact the physician today (06/21/23) for an order;
-The resident could become irate very quickly when he was in pain or had increased anxiety. The nurse had to calm the resident at the beginning of his/her shift because the resident tried to start a fight due to pain and increased anxiety.
During an interview on 06/22/23, at 7:10 P.M., Licensed Practical Nurse (LPN) R said the following:
-The nurse assessed residents' pain levels based on what the resident reported and nonverbal signs of pain. The nurse documented the numeric pain scale in the electronic medical record, and followed up with the effectiveness about one hour after administration;
-On 06/20/23, at 10:00 P.M., he/she arrived at the facility to start his/her shift. While he/she was at the main nurses' station, Nurse's Assistant (NA) F told him/her that the resident was yelling and in pain. The nurse asked one of the three CMTs in the medication room when the resident could have his/her pain medication. About halfway down the hall, the nurse heard the resident yelling and entered his/her room. The nurse told the resident who he/she was and that he/she was there to help him/her (the resident). The resident jumped up from his/her bed, standing approximately one foot in front of the nurse, and said he/she did not care who the nurse was, he/she was mad because staff told him/her he/she could not have his/her pain medication. Then the resident told the nurse to get out of his/her face and shoved the nurse in the chest with his/he left hand and cocked his/her right hand back as if he/she was getting ready to hit the nurse. The resident told the nurse he/she was in so much pain and he/she could not take it anymore. Someone had to do something. Maybe he/she (the resident) needed to call the police or go to the hospital. The nurse assured the resident he/she was there to assist him/her (the resident), and would get the resident his/her pain medication. The resident lowered his/her arm and sat on the bed;
-The nurse looked in the electronic medical record to find out when the resident could have his/her pain medication then returned to the resident's room to let him/her know it was time to take his/her medication. The resident was on the phone with a family member yelling about how much pain he/she had and how it (being at the facility) was not going to work, he/she could not stay at the facility, staff did not want to give him/her his/her pain medication on time. The nurse closed the resident's door when he/she left the room;
-The nurse returned a short time later and administered the pain medication to the resident. The resident continued yelling and cursing while on the phone with his/her family member. He/she told his/her family member, he/she should just walk out, he/she had enough, they did not want to mess with him/her;
-As the night went on, the resident calmed then became remorseful. He/she was tearful and apologized to the nurse a couple of times. The nurse thought the cause of resident's aggressive behavior was 50% pain and 50% situation. The 50% situational was because the resident had surgery, and the incision became infected resulting in prolonged recovery time, plus the resident asked for pain medication and staff told him/her he/she could not have it. All of these issues combined caused the resident's aggressive behavior;
-The resident admitted with scheduled pain medication. The nurse did not know why the order changed to as needed (PRN);
-If a resident had scheduled medication, staff could administer the medication one hour before or after the scheduled time, but if the medication was a PRN, staff had to administer at the time it was due.
Observations and interviews on 6/21/23 showed the following:
-At 10:42 A.M., Certified Medication Technician (CMT) P and another staff member entered the resident's room and administered his/her pain medication;
-At 10:50 A.M., the resident sat on his/her bed with the wound vac attached to his/her lower back. The resident's family member sat in the recliner next to the resident;
-The resident said yesterday, around 3:00 P.M., the resident asked for his/her pain medication, it was due at that time. Staff did not bring the medication for over an hour. Later that evening, he/she became angry because he/she asked for his/her pain medication and staff said they could not give him/her any more pain medication for the rest of the night, and then, when the nurse did administer his/her pain medication, it was an hour and a half late.
During an interview on 06/21/23, at 10:55 A.M., the resident's family member said the following:
-He/she knew that the resident's behavior was escalating that night before (6/20/23) because staff did not administer the resident's pain medication on time and the resident was in pain.
Record review showed staff did not document notifying physician of pain control concerns.
Observation and interview conducted on 6/21/23 showed the following:
-At 11:03 A.M., Registered Nurse (RN) N entered the resident's room to remove the wound vac. The wound nurse washed his/her hands and applied gloves. The resident laid on his/her stomach on the bed, and raised his/her shirt to expose the dressing. The wound nurse removed the transparent film dressing adhered to the resident's lower back. The nurse used wound cleanser and a cotton-tipped applicator to remove the black foam. The wound tissue adhered to the black foam and while the nurse sprayed and loosened the foam, the resident winced, flinched, and moaned. The wound nurse soaked up the wound spray that accumulated in the wound bed with 4 x 4 gauze. The large diamond shaped open surgical wound had a pink wound bed with a deeper linear center. The deep center contained a piece of black foam. The nurse sprayed the small piece of black foam and using a cotton tipped applicator, attempted to loosen the tissue from the black foam. The tissue firmly adhered to the foam. The resident moaned and grimaced each time the nurse attempted to loosen the adhered tissue. After multiple tries and sprays of wound cleanser, the nurse tried to remove the foam by placing a cotton tipped applicator at each end of the foam lifting upwards. After several unsuccessful tries, the nurse asked the CMT to get her a pair of tweezers. The nurse then used tweezers and a cotton tipped applicator to remove the black foam. When she finished with the removal, she noticed a piece of black foam broke off and remained in the wound. The wound nurse used tweezers to remove the small broken piece of black foam. The nurse then packed the wound loosely with moistened gauze. After he/she removed the last piece of foam from the wound, the nurse loosely placed moistened gauze into the wound. During the procedure the resident moaned, grimaced and began sweating. He/she attempted to distract himself/herself from the procedure by wiggling his/her toes and moving his/her legs, chanting and singing in a strained voice. (The staff did not stop the treatment or attempt to get get approval for additional pain medication when the resident showed signs of pain.)
During an interview on 6/21/23, at 2:15 P.M., RN N said staff administered pain medications to residents 45 minutes to an hour before he/she changed the resident's dressing. Wound vac dressing were very painful. When he/she assisted with the resident's dressing change on 6/19/23, the resident had pain medication before the procedure and his/her pain was controlled. Today, the dressing change was pretty painful for the resident.
During an interview on 06/21/23, at 1:04 P.M., Certified Medication Tech (CMT) P said the following:
-When staff administered pain medications, staff asked the resident to rate the severity of his/her pain using a 1 to 10 scale, with one meaning little pain and ten as the worst pain imaginable.
-If a resident had different types and strengths of pain medications such as Tylenol and a narcotic pain medication, staff used the resident's pain score to determine what medication was appropriate for that level of pain;
-Staff got to know residents and knew their preferences for when they needed or wanted to take their pain medication. Staff also tried to administer pain medication prior to therapy and wound care, but they had to know the residents schedules to do that. If a resident asked for pain medication and it was not yet time, the CMT would let the resident know when he/she could have the medication;
-The CMT did not always ask residents to rate their pain, even if the resident could verbalize their pain. In those instances, he/she determined pain severity by non-verbal cues;
-Staff followed up on the effectiveness of the pain medication about thirty minutes after he/she administered the medication. The CMT did not usually ask the resident to rate their pain again (for the follow-up). He/she determined medication effectiveness based on the resident's body language;
-The CMT did not think the resident's pain was controlled, and the pain made him/her nauseous. The resident's pain medication was scheduled, but then changed to as needed and he/she had to ask for it. It seemed the pain medication helped his/her pain a little, but it did not last long;
-Yesterday (6/20/23), the CMT administered ondansetron to the resident for the nausea caused from the pain. The CMT told RN K that the resident's pain was not controlled, but the CMT did not know if the nurse contacted the physician.
During an interview on 06/21/23, at 1:28 P.M., RN K said the following:
-The CMTs usually administered pain medication to residents and charted their pain scores in the electronic medication administration record. Nonverbal signs of pain included guarding, irregular or increased breaths and grimacing. Sometimes residents also act agitated and mad if they are experiencing pain;
-If a resident's pain was not controlled with his/her current pain medication or orders, the nurse would contact the physician;
-Staff had a range of time they could administer medication, one hour before and one hour after it was due. This included pain medication, but staff used their judgement and did not administer pain medication early if the resident was sedated or had low blood pressure;
-He/she did not remember CMT P telling him/her yesterday the resident had uncontrolled pain;
-The nurse thought, for the most part, the resident's pain was controlled with his/her current 5 mg of oxycodone;
-Last night (6/20/23), around shift change (10:00 P.M.), the resident asked for pain medication and because it was too early, the resident became angry at the nurse's aide. He/she thought the aide lied about it being too early. That was the first time the resident asked for his/her pain medication before it was due. Later that night, the resident grabbed the night shift nurse's shirt and reared his/her arm back, the resident did not hit the nurse and calmed after the nurse addressed the resident's pain;
-The resident's pain could have contributed to his/her behavior the prior night;
-The RN did not know why the resident's medication order changed from scheduled to as needed.
During an interview conducted on 06/21/23, at 5:38 P.M., CMT Q said the following:
-When a resident asked for pain medication, staff asked the resident to rate his/her pain on a scale of one to ten. If a resident could not verbalize or rate his/her pain, staff relied on non-verbal signs of pain such as grimacing, frowning and moaning;
-The CMT evaluated the effectiveness of the pain medication one hour administration;
-If the pain medication was not effective, the CMT told the nurse.
During an interview conducted on 06/21/23, at 6:07 P.M., Nursing Assistant (NA) F said the following:
-On 6/20/23, near during the evening shift, the resident had pain and asked for pain medication. The NA asked the CMT about the resident's pain medication and the CMT said he/she could not have it until midnight. When the NA relayed that information to the resident he/she became angry and yelled and cursed. The resident was in pain and could not control his/her emotions;
-The resident calmed down after he/she received his/her pain medication then was pleasant.
During an interview on 6/22/23, at 2:00 P.M., Physical Therapist (PT) L said the following:
-The PT only worked with the resident a day or two;
-The resident had constant pain. His/her back hurt and burned with movement, but he/she pushed through his/her pain when in therapy. A few times the resident appeared in a lot of pain, but the resident did not want to stop therapy so the therapist worked strengthening exercises, nothing too strenuous;
-The PT did not tell nursing about the resident's constant pain because they already knew the resident had pain;
-Initially the resident's pain medication was scheduled but then the order changed to PRN.
During an interview on 06/22/23, at 5:21 P.M., NA E said on 06/20/23, at 11:00 P.M., the resident became agitated and yelled at the staff. The resident's outburst was due to his/her pain at that time.
During an interview on 06/23/23, at 1:05 P.M., Licensed Practical Nurse (LPN) O said the following:
-Non-verbal signs of pain included grimacing, fidgeting, facial expressions, and clinching;
-LPN O asked residents to rate their pain using the zero to ten pain scale, zero being no pain and 10 being the worst pain;
-On 6/19/23, the resident told the nurse, during the wound vac dressing change, that the pain medication was not adequate during the dressing change. He/she said he/she received 10 mg at the hospital. The nurse told the resident that often, the physician will decrease the pain medication when a person discharged from the hospital;
-The resident admitted to the facility with scheduled oxycodone 5 mg, four times a day. Due to the verbiage of the order, the system scheduled the pain medication during the day with no pain medication scheduled from 9:00 P.M. to 9:00 A.M. The nurse obtained that information from the hospital nurse before the resident admitted to the facility. The nurse relayed this information to the Nurse Practitioner (NP) who changed the resident's pain medication order from scheduled to every six hours as needed;
-Staff could usually administer scheduled pain medication an hour before or an hour after the scheduled time. With PRN medications, giving them early depended on the severity of the resident's pain and if the physician knew of the resident's increased pain.
During an interview on 06/23/23, at 2:03 P.M., the NP said the following:
-Staff should assess residents' pain at least every shift. Nonverbal indicators of abuse included grimacing, fidgeting, yelling, and combative behaviors;
-The NP thought she changed the resident's scheduled pain medication to PRN because the resident could verbalize when he/she had pain;
-When the resident is alert and oriented it is rare to order scheduled pain medications.
During an interview conducted on 06/23/23, at 12:13 P.M., the Medical Director said nurses assessed residents' pain based on cognition. If a resident was alert and oriented, staff asked the resident to rate his/her pain on a one to ten scale. If the resident was confused, the nurses used nonverbal signs of pain to determine severity. Staff should reassess the resident's pain an hour after administration. If the pain medication was not effective at relieving the resident's pain, the nurses should notify the physician.
During an interview on 06/23/23, at 2:34 P.M., the Director of Nursing (DON) said the following:
-The staff should use the pain scale and smiley/frown faces to assess the resident's pain;
-Nonverbal signs of pain included grimacing, frowning, agitation, and crying;
-After staff administered pain medication, they should assess the effectiveness of the pain medication 30 minutes after administration which included asking the resident to rate his/her pain;
-If administered pain medication did not relieve the resident's pain, the nurses should notify the physician and document the notification in the progress notes.
-Staff should assess a resident's pain prior to a procedure such as a dressing change. If the resident wanted or could have pain medication at that time, staff should administer it and reassess the resident 30 minutes later. If the pain medication helped, the nurse proceeded with the dressing change;
-The DON thought the resident's pain was controlled. On 6/20/23, the resident became upset and angry, and threatened one of the nurses because he/she had to wait 20 minutes for his/her pain medication.
During an interview on 06/23/23, at 3:02 P.M., the Administrator said the nurses should administer pain medication to residents as ordered.
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
Based on observation, interview, and record review, the facility failed to follow physician orders for wound treatment and failed to contact physician to obtain new orders using wound supplies that we...
Read full inspector narrative →
Based on observation, interview, and record review, the facility failed to follow physician orders for wound treatment and failed to contact physician to obtain new orders using wound supplies that were available for one resident (Resident #330) out of a sample of two residents. The facility census was 85.
Review of the facility's Wound Care Procedure Policy, revised October 2010, showed instructions to verify there was a physician's order for the procedure.
1. Review of the Resident #330's face sheet (resident's information at a quick glance) showed the following:
-admission date of 06/19/23;
-Diagnoses included general anxiety disorder (worrying constantly and cannot control the worrying), infection following a procedure, osteomyelitis of vertebra (a spine infection), and postlaminectomy syndrome (condition characterized by chronic back or neck pain following surgery).
Review of the resident's nursing admission assessment and care plan, completed on 06/19/23, showed the resident had a large wound on his/her upper mid-back that measured 9 centimeter (cm) (depth) by approximately 10 cm (length) by 5 cm (wide) with a wound vacuum assisted closure (wound vac - a treatment helps a wound heal by applying a vacuum through a special sealed dressing. The purpose of the vacuum is to draw the fluid out of the wound and increase blood flow to the area) running at 125 millimeters (mm)/mercury (hg) continuous and changed every Monday and Friday.
Review of the resident's June 2023 Treatment Administered Record (TAR) showed the following:
-An order, dated 06/19/23, to cleanse the wound to the mid lower back with wound cleanser/normal saline (NS). Skin prep (a fast-drying sterile liquid that forms a skin-protectant film, to provide a protective layer on intact skin) to the peri-wound (tissue surrounding the wound), white foam (hydrophilic foam or moisture-retaining foam that is far less porous and commonly used in the wound bed where there is exposed bone, tendon or surgical hardware. The moist white foam protects these sensitive areas and eases patient discomfort during dressing changes) to bone, gray (black) foam (a hydrophobic or water repelling foam with open pores that facilitated drainage removal and stimulated tissue formation granulation (newly forming tissue)) to the rest of the wound bed. Place drape and wound vac set to 125 mm/hg continuous, change canister when full, every Monday and Friday.
Observation and interview on 06/20/23, at 11:25 A.M., showed the resident sat in his/her recliner in his/her room. The wound vac machine laid on the floor in a protective bag. The resident said he/she developed an infection in his/her incision after back surgery. He/she came to the facility for wound treatment and therapy.
Observation and interview on 6/21/23 showed the following:
-At 10:50 A.M., the resident sat on the side of his/her bed in his/her room. He/she had a wound vac attached to his/her lower back wound;
-At 11:03 A.M., the wound nurse/Registered Nurse (RN) N entered the resident's room to remove the resident's dressing and wound vac. The nurse said on 6/19/23, she assisted another nurse with the application of the wound vac. The wound nurse washed his/her hands and applied gloves. The resident laid on his/her stomach on the bed, and raised his/her shirt to expose the dressing. The wound nurse removed the transparent film dressing then used wound cleanser and a cotton-tipped applicator to remove the black foam. The wound nurse soaked up the wound spray that accumulated in the wound bed with 4 x 4 gauze. The wound was large diamond shaped surgical wound had a pink wound bed with a deeper linear center. The deep center contained a piece of black foam (not the ordered white foam). The nurse sprayed the small piece of black foam with wound cleanser and using a cotton tipped applicator and attempted to loosen the tissue from the black foam. The tissue firmly adhered to the foam. After multiple tries and sprays of wound cleanser, she tried to remove the foam by placing a cotton tipped applicator at each end of the foam gently lifting upwards in attempts to loosen the adhered tissue. After several unsuccessful tries, Certified Medication Technician (CMT) P left the room and returned with a pair of tweezers. The nurse then used the tweezers and a cotton tipped applicator to slowly remove the black foam. After the initial removal, the nurse noticed a piece of black foam broke off and remained in the wound. The wound nurse used tweezers to remove the small broken piece of black foam then packed the wound loosely with moistened gauze.
During an interview on 06/21/23, at 2:13 P.M. and 5:33 P.M., RN N said the following:
-RN N assisted Licensed Practical Nurse (LPN) O with the resident wound vac dressing change;
-The order for wound vac treatment included black and white foam, but the white foam was not available at the time of the dressing change;
-The nurses placed only black foam in the resident's surgical wound;
-The nurses should call the physician when an ordered wound supply was not available. The RN did not contact the physician to obtain an order to use only black foam. LPN O admitted the resident should have contacted the physician;
-The RN told the Director of Nursing (DON) they did not have any white foam. The DON said she would order the foam and it would be available for the next dressing change;
-The black foam adhered to the granulation tissue (type of new connective tissue) in the resident's wound which made it difficult to remove;
-The vast majority of wound vacs dressing she changed, used only black foam. [NAME] foam differed from black foam in size. It was smaller to fit in deeper wounds easier.
During an interview on 6/23/23 at 1:05 P.M., LPN O said the following;
-Before a resident admitted to the facility with a wound vac, the supplies were ordered and delivered to the facility prior to the resident's arrival. The LPN did not know who ordered the supplies, only that they were delivered;
-On 6/19/23, he/she admitted the resident to the facility. He/she asked RN N to assist him/her with the wound vac dressing;
-The white foam used with wound vacs was softer and not as dense as the black foam;
-He/she should have notified the physician when the white foam was not available;
During an interview on 06/23/23, at 2:03 P.M., the Nurse Practitioner (NP) said if ordered supplies were not available for a treatment, staff should notify her to obtain orders for a substitute until the supply company could deliver the ordered supplies.
During an interview on 06/23/23, at 2:34 P.M., the Director of Nursing (DON) said the following:
-She ordered residents' wound care supplies;
-The nurses should notify the physician if the ordered supplies were not available.
-When she ordered the wound vac supplies prior to the the resident's admission, the supply company delivered the standard supplies which included only black foam;
-The DON had to special order the white foam and did order the white foam after the resident admitted to the facility;
-The resident discharged from the facility before the supply company delivered the white foam;
-The admitting nurse should contact the physician if ordered treatment supplies were not available;
-The DON said she was not really familiar with the white foam since they typically used only black foam with wound vacs.
During an interview on 06/23/23, at 3:02 P.M., the Administrator said the following:
-If ordered wound care supplies were not available, she expected the nurses to notify the physician to obtain an order for a substitution until the ordered supplies could be delivered;
-The DON ordered the wound care supplies;
-She knew the white foam ordered for the resident's wound vac dressing was not available and needed to be special ordered. The order instructed the staff to apply the white foam over the bony prominence;
-The facility had not used white foam previously
CONCERN
(D)
Potential for Harm - no one hurt, but risky conditions existed
Pressure Ulcer Prevention
(Tag F0686)
Could have caused harm · This affected 1 resident
Based on record review, observation, and interview, failed to follow appropriate infection control measures when completing a wound treatment and failed to follow physician's order in the timeliness o...
Read full inspector narrative →
Based on record review, observation, and interview, failed to follow appropriate infection control measures when completing a wound treatment and failed to follow physician's order in the timeliness of a treatment for one resident (Resident #331), who had a pressure injury on his/her neck, in a selected sample of six residents. The facility census was 85.
Review of the facility's Wound Care Procedure Policy, revised October 2010, showed the following:
-Wash and dry your hands thoroughly;
-Put on exam gloves. Loosen tape and remove dressing;
-Pull glove over dressing and discard into appropriate receptacle. Wash and dry hands thoroughly;
-Put on gloves. Use no-touch technique. Use sterile tongue blades and applicators to remove ointments and creams from their containers;
-Dress wound. [NAME] tape with initials, time, and date and apply to dressing;
-Remove gloves and discard into designated container. Wash and dry hands thoroughly;
-Make the resident comfortable, place call light within easy reach of the resident and place the over bed table to its proper position;
-Wash and dry hands thoroughly.
1. Review of Resident #331's face sheet (resident's information at a quick glance) showed the following:
-admission date of 06/06/23;
-Diagnoses included non-displaced dens fracture (a fracture, that occurs through the second bone in the neck) and unspecified fracture of the ring finger and pinky finger of the right hand.
Review of the resident's nursing admission assessment and care plan, dated 06/06/23, showed the following:
-The resident had a pressure injury on his/her right shoulder that measured 3 centimeters (cm) (length) by 2.4 cm (width) by 0.1 cm (depth);
-The resident's Braden Scale for predicting pressure ulcer risk showed the resident was at risk for developing a pressure injury;
-The resident had potential/actual impairment to skin integrity.
Review of the resident's admission Minimum Data Set (MDS -a federally mandated assessment tool completed by facility staff), dated 06/09/23, showed the following information:
-Severe cognitive impairment;
-Required limited assistance with transfers, dressing, walking, toileting, and personal hygiene;
-Used a wheelchair for mobility;
-Fracture related to a fall within six months prior to admission;
-At risk of developing pressure ulcers;
-No pressure ulcers.
Review of resident's June 2023 Physician Order Summary report showed the following:
-An order, dated 6/12/23, to monitor shearing (two forces rubbing together with the force of gravity) on the resident's right neck for signs of infection or pain and dressing placement every shift;
-An order, dated 6/12/23, for the shearing on the resident's right neck under his/her c-collar (cervical collar - a device designed to limit movement of the neck), cleanse with dermal (relating to the skin) wash, pat dry, paint open area with Medihoney (a wound gel that helps clear bacteria and unhealthy tissue from a wound), and cover with foam dressing every three days and as needed if dressing is soiled or missing.
Review of the resident's care plan, updated 06/13/23, showed the following information:
-The resident had limited physical mobility related to a recent neck fracture and fracture of the fourth and fifth fingers of his/her right hand;
-The resident had a potential for pressure ulcer development related to impaired mobility;
-The resident had actual impairment to his/her skin integrity on the right side of his/her neck related to his/her cervical collar;
-Monitor/document location, size and treatment of skin injury;
-Report abnormalities, failure to heal, signs and symptoms of infection, maceration (skin exposed to moisture for too long), etc., to the physician.
Review of the resident's June 2023 Treatment Administration Records (TAR) showed on 6/19/23 staff did not document completing treatment on the resident's neck.
During an interview on 06/23/23, at 1:05 P.M., Licensed Practical Nurse (LPN) O said the following:
-The resident had a wound on her right collar bone caused by the c-collar;
-The LPN worked on 06/19/23, but did not complete the treatment on the resident's neck because he/she thought the wound nurse would complete the treatment
Review of the resident's Nursing Every Shift Skilled Charting, dated 06/22/23, showed a nurse documented the following:
-The resident had a Stage 2 pressure injury (partial-thickness skin loss with exposed tissue);
-Dressing or treatment per treatment orders;
-Turning and repositioning;
-Pressure relieving devices to bed or chair;
-The resident did not have a wound infection, diabetic ulcer, or an open lesion or infection on foot.
Observations and interviews on 06/22/23, at 2:36 P.M. and 4:13 P.M., showed the following:
-The resident laid in bed positioned on his/her back. Registered Nurse (RN) H and Certified Nurse Aide (CNA) M stood near the resident's bed. The nurse assembled the wound care supplies and placed them on the resident's nightstand. The nurse gloved prior to the observation;
-The nurse removed the resident's c-collar and asked the CNA to support the resident's neck while he/she changed the dressing;
-The nurse removed the dressing located on the resident's right collar bone and shoulder area. The resident had a nickel-quarter sized open wound with a white/pink wound bed. Redness surrounded the open wound extending approximately one inch around the wound. The nurse said the serosanguinous (contains or relates to both blood and the liquid part of blood (serum)) drainage on the soiled bandage had a slight odor;
-Without changing his/her gloves or performing hand hygiene, the nurse cleansed the wound with a wound spray and 4 x 4 gauze;
-Without changing his/her gloves or performing hand hygiene, the nurse squeezed a small amount of Medihoney onto his/her gloved index finger, applied it to the wound, and then covered the area with a bordered gauze dressing;
-The nurse placed the c-collar around the resident's neck then removed his/her gloves and washed his/her hands;
-RN H said the wound on the resident's collar bone was caused by the c collar rubbing on the resident's skin, and was a Stage 2 pressure injury;
-The RN said when he/she completed a wound treatment, he/she gathered the wound care supplies, washed his/her hands and gloved, assessed the wound, applied the treatment then washed his/her hands before he/she left the room . The nurse documented in progress note if there was a change in the wound.
-The RN said the nurses perform the wound treatment every three days.
During an interview on 06/23/23, at 12:13 P.M., the resident's physician said he thought the wound on the resident's right shoulder was a pressure injury.
During an interview on 06/23/23, at 2:34 P.M., the Director of Nursing (DON) said the following:
-When the nurses performed a wound treatment, they should wash their hands, apply gloves, remove the old bandage, clean the wound, change gloves, perform hand hygiene, apply the ointment with a clean gloved finger or gauze, change gloves, and perform hand hygiene and apply the new dressing;
-Staff should follow physician's orders for dressing changes;
-If the previous shift's nurse did not complete a treatment, the nurse should pass that on to the oncoming nurse to complete.
During an interview on 06/23/23, at 3:02 P.M., the Administrator said the following:
-She expected the nurses to follow infection control protocol during wound care treatments;
-She considered friction/shearing on a bony prominence a pressure injury.
CONCERN
(D)
Potential for Harm - no one hurt, but risky conditions existed
Respiratory Care
(Tag F0695)
Could have caused harm · This affected 1 resident
Based on observation, record review, and interview, the facility failed to ensure staff followed physician orders regarding administration of the oxygen at the correct liters per minute (LPM - measure...
Read full inspector narrative →
Based on observation, record review, and interview, the facility failed to ensure staff followed physician orders regarding administration of the oxygen at the correct liters per minute (LPM - measurement of oxygen) used with supplemental oxygen for one resident (Resident #73) out of two sampled residents. The facility census was 85.
Review of the facility's policy titled Oxygen Administration, revised 10/2010, showed the following:
-The purpose of this procedure is to provide guidelines for safe oxygen administration;
-Unless otherwise ordered, start the flow of oxygen at the rate of 2 to 3 liters per minute;
-Observe the resident upon setup and periodically thereafter to be sure oxygen is being tolerated.
1. Review of Resident #73's face sheet (a document that gives a patient's information at a quick glance) showed the following:
-admission date of 03/03/23;
-Diagnoses included heart failure (a condition in which the heart muscle can't pump enough blood to meet the body's needs for blood and oxygen), hypoxemia (a low level of oxygen in the blood), and dependence on supplemental oxygen.
Review of the resident's quarterly Minimum Data Set (MDS - a federally mandated comprehensive assessment instrument completed by facility staff), dated 06/06/23, showed the following:
-Moderate cognitive impairment;
-The resident became short of breath or had trouble breathing when lying flat;
-The resident had oxygen therapy.
Review of the resident's care plan, revised 06/08/23, showed the following:
-The resident had altered cardiovascular status related to congestive heart failure (heart failure), atrial fibrillation (a fib - an irregular and often very rapid heart rhythm) and non-rheumatic mitral valve insufficiency (the mitral valve (one of four valves in the heart that keep blood flowing in the right direction) does not close properly allowing blood to flow backwards);
-Monitor vital signs as ordered and as needed;
-Notify physician of significant abnormalities;
-Monitor, document, and report as needed any changes in lung sounds on auscultation (the action of listening to sounds from the heart, lungs, or other organs, typically with a stethoscope, as a part of medical diagnosis), edema (swelling) and changes in weight;
-Oxygen (O2) via nasal cannula (a tube that is placed approximately one-half inch into the resident's nose) at three LPM to keep SPO2 (oxygen saturation) greater than 90%.
Review of the resident's Physician's Order Sheet, dated 06/2023, showed the following:
-An order, dated 03/23/23, for O2 at 2 Liters (L) via nasal cannula to keep oxygen saturation at 90 % or above every shift for shortness of breath;
-An order, dated 04/14/23, for vital signs and notify the physician SPO2 less than 90% every evening shift every Friday.
Review of the resident's nurses' progress notes, dated 06/01/23 to 06/23/23, showed staff did not document related to the resident's SPO2 dropping below 90% or the need for increased O2 LPM due to increased shortness of breath or any decline in the resident's condition resulting in a need for increased O2 LPM.
Review of the resident's SPO2 vitals documentation, dated 04/01/23 to 06/23/23, showed no readings below 91%.
Observations on 06/21/23, at 10:05 A.M. and 3:55 P.M., and on 06/22/23, at 12:51 P.M. and 4:54 P.M., showed the residents O2 concentrator in his/her room set at 6 LPM. The concentrator sat against a wall to the right side of the resident's bed, not within the resident's reach.
During an interview on 06/22/23, at 12:51 P.M., the resident said he/she could not reach his/her O2 concentrator to adjust it and would not even know how to adjust.
During an interview on 06/22/23, at 2:05 P.M., Certified Nursing Assistant (CNA) B said the following:
-The resident was on 2 LPM of O2 and should not be on 6 LPM;
-The charge nurse adjusted the LPM on the O2 concentrators;
-A resident required a physician's order for O2;
-He/she knew the O2 setting for a resident by asking a charge nurse;
-If a resident was supposed to be on 2 LPM and he/she noticed they were on 6 LPM, he/she notified the charge nurse;
-Residents could get sick if they received too much O2.
During an interview on 06/22/23, at 1:41 P.M., CNA A said the following:
-The charge nurse set the LPM on the O2 concentrators;
-He/she was not allowed to change the setting on the O2 concentrator;
-If an O2 concentrator was supposed to be set at 2 LPM, it should not be set at 6 LPM;
-He/she looked at the concentrators from time to time, but the settings were not the same for every resident;
-He/she knew the O2 setting for a resident by looking in the computer or asking the charge nurse;
-If he/she saw an O2 concentrator not set on the correct LPM, he/she told the charge nurse.
During an observation and interview on 06/22/23, at 4:59 P.M., Licensed Practical Nurse (LPN) C said the following:
-The resident had a physician's order for O2 at 2 LPM to keep SPO2 above 90%;
-The resident did not have a reason to be on 6 LPM;
-The resident was on 3 LPM prior to being on 2 LPM;
-The resident does not get out of bed and cannot reach his/her O2 concentrator;
-The LPN went to the resident's room to adjust the resident's O2 concentrator to 2 LPM;
-After adjusting the resident's O2 back to 2 LPM, his/her SPO2 dropped to 75% because the resident was compensating on 6 LPM;
-The resident should not be on 6 LPM of O2;
-When doing vitals, he/she assessed a resident's O2 and if it was low, he/she notified the physician and obtained orders for O2;
-If a resident currently on O2 desaturated (SPO2 decreased), he/she notified the physician to see if the resident needed increased O2;
-The charge nurse checked O2 concentrators every shift during rounds;
-If a resident had a physician's order for 2 LPM, but received 6 LPM instead, they could get sick as the O2 would not be as effective and the resident could desaturate;
-The CNA's took the resident's SPO2 during vitals and noted if the resident was on room air or O2;
-The charge nurse was responsible for checking the LPM on O2 concentrators every shift.
During an interview on 06/23/23, at 9:19 A.M., the MDS Coordinator said the following:
-The resident had a physician's order for 2 LPM to maintain SPO2 above 90%;
-The charge nurse did not document turning down the resident's O2 from 6 LPM to 2 LPM, the resident's SPO2 dropping to 75%, or notification of the physician, but the charge nurse should have;
-If a resident required O2, they required a physician's order that told LPM, if the O2 was to be continuous, as needed or to keep the resident's SPO2 above 90%;
-The charge nurse was responsible for checking O2 concentrators every shift when they completed their assessment on the resident;
-If a resident had an order for 2 LPM they should not be on 6 LPM without a documented reason and a new physician's order;
-If a resident received too much O2, they could blow their lungs out and may not be able to get rid of all of their carbon dioxide (CO2) which could cause them to desaturate;
-If the charge nurse noticed a resident who was supposed to be on 2 LPM was on 6 LPM and the charge nurse turned it down, the resident could pass out, desaturate or go into respiratory distress because their body did not have enough time to process the decrease since the resident would have been compensating at 6 LPM and would have to adjust to the decrease to 2 LPM;
-If the wrong setting was brought to a charge nurse's attention and they turned the O2 down and the resident's SPO2 dropped to 75%, the charge nurse should document this in a nurse's progress note and notify the resident's physician.
During an interview on 06/23/23, at 10:58 A.M., the Director of Nursing (DON) said the following:
-The resident had an order for 2 LPM and should not be on 6 LPM;
-The resident cannot reach his/her concentrator;
-If the resident was on 6 LPM, he/she could overcompensate, get sick and have difficulty breathing when his/her O2 was adjusted from 6 LPM back to 2 LPM;
-The charge nurse should document the resident's change in SPO2 when he/she adjusted the resident's O2 back to 2 LPM;
-If a resident required O2, the charge nurse obtained a physician's order for the LPM and the SPO2 percentage they physician wants the resident to maintain;
-The charge nurse should check O2 concentrators every shift and was responsible to ensure the resident's concentrators were set to the correct LPM;
-If a resident had an order for 2 LPM, the resident should not receive 6 LPM unless the resident had a change in condition and the charge nurse notified the physician and the physician gave a new order;
-If a charge nurse became aware a resident received the wrong LPM, adjusted the resident to the correct LPM and the resident's SPO2 dropped to 75%, the charge nurse should document this with increased monitoring and notification of the physician.
During an interview on 06/23/23, at 1:19 P.M., the Administrator said the resident should be on 2 LPM of oxygen. He/she expected the resident's concentrators be set to the correct LPM. The charge nurse, Assistant Director of Nursing (ADON) and DON were responsible for checking O2 concentrators on rounds.
CONCERN
(D)
Potential for Harm - no one hurt, but risky conditions existed
Deficiency F0700
(Tag F0700)
Could have caused harm · This affected 1 resident
Based on observation, interview, and record review, the facility failed to obtain signed informed consent and physician orders for side rails, failed to add side rails to the resident's care plan, and...
Read full inspector narrative →
Based on observation, interview, and record review, the facility failed to obtain signed informed consent and physician orders for side rails, failed to add side rails to the resident's care plan, and failed to complete side rail assessments on a regular basis for one resident (Resident #32) out of six sampled residents. The facility census was 85.
Review of the facility's policy titled Proper Use of Side Rails, revised 12/2016, showed the following:
-The purposes of these guidelines are to ensure the safe use of side rails as resident mobility aids and to prohibit the use of side rails as restraints unless necessary to treat a resident's medical symptoms;
-Side rails are only permissible if they are used to treat a resident's medical symptoms or to assist with mobility and transfer of residents;
-An assessment will be made to determine the resident's symptoms, risk of entrapment, and reason for using side rails. When used for mobility or transfer, an assessment will include a review of the resident's bed mobility, ability to change positions, transfer to and from bed or chair, and to stand and toilet, risk of entrapment from the use of side rails and that the bed's dimensions are appropriate for the resident's size and weight;
-The use of side rails as an assistive device will be addressed in the resident care plan;
-Consent for using restrictive devices will be obtained from the resident or legal representative per facility protocol;
-Consent for side rail use will be obtained from the resident or legal representative, after presenting potential benefits and risks;
-The resident will be checked periodically for safety relative to side rail use;
-Facility staff, in conjunction with the Attending Physician, will assess and document the resident's risk for injury due to neurological disorders or other medical conditions.
1. Review of Resident #32's face sheet (a document that gives a patient's information at a quick glance) showed the following:
-admission date of 08/06/21;
-Diagnoses included diabetes, transient ischemic attack (TIA - a stroke that lasts only a few minutes), obesity, and heart disease.
Review of the resident's admission Minimum Data Set (MDS - a federally mandated comprehensive assessment instrument completed by facility staff), dated 3/27/23, showed the following:
-The resident was cognitively intact;
-The resident required extensive assistance of two or more staff for bed mobility, transfers, toilet use and personal hygiene; extensive assistance of one staff for dressing; and limited assistance from one staff for eating.
During an observation and interview on 06/21/23, at 1:54 P.M., the resident said the following:
-He/she used the side rails daily;
-He/she knew the risks and benefits, but had not signed a consent form;
-He/she had not seen staff measure the side rails and if they became loose, he/she told staff and they tightened the side rails;
-The resident had quarter side rails on both sides of his/her bed towards the head of the bed.
Observation on 06/22/23, at 1:13 P.M., showed the resident had quarter side rails on both sides of his/her bed towards the head of the bed.
Review of the resident's care plan, revised 5/12/23, showed the staff did not care plan the resident's use of side rails.
Review of the resident's physician's order sheet (POS), dated 06/2023, showed no physician's order for side rails or positioning devices.
Review of the resident's risk assessments showed no side rail risk assessment completed.
Review of the resident's consents showed no signed side rail informed consent.
During an interview on 06/22/23, at 1:41 P.M., Certified Nursing Assistant (CNA) A said the following:
-If a resident required bed rails, the charge nurse told maintenance and maintenance installed them;
-Maintenance measured and checked bed rails monthly. This was important due to the risk of entrapment;
-If he/she noticed a bed rail was loose, he/she told maintenance and if the maintenance director was not in the building, he/she told the charge nurse;
-Residents' bed rails should be on their care plan;
-Bed rails required a physician's order;
-He/she did not know if bed rails required signed informed consent.
During an interview on 06/22/23, at 2:05 P.M., CNA B said the following:
-If a resident required bed rails, therapy obtained a physician's order and if the facility Administrator approved the bed rails, the Maintenance Director installed them and measured them on a regular basis. He/she did not know how often the Maintenance Director measured them;
-Bed rails had a risk for entrapment. If a gap between the bed rail and bed was too big, a resident could fall and get their arms or hands caught;
-If he/she noticed a bed rail was loose, he/she notified the Maintenance Director and if the Maintenance Director was not available, he/she notified the charge nurse.
During an interview on 06/22/23, at 4:59 P.M., Licensed Practical Nurse (LPN) C said the following:
-The resident should have a physician's order, signed informed consent, a bed rail risk assessment and bed rails included on their care plan;
-If a resident required bed rails, therapy evaluated and completed the bed rail risk assessment, the charge nurse obtained a physician's order and the Maintenance Director installed them;
-The MDS Coordinator added bed rails to the resident's care plan;
-He/she was not sure if the resident or resident representative completed a signed informed consent for bed rails
During an interview on 06/23/23, at 8:48 A.M., the Rehab Director said the following:
-The resident had bed rails for a long time;
-He/she did not see a signed informed consent for the resident;
-He/she did not see a physician's order for bed rails or bed rails on the resident's care plan;
-He/she did not find where therapy evaluated the resident for bed rails;
-The resident should have signed informed consent, a physician's order, side rails on his/her care plan and he/she believed the MDS Coordinator should have completed a bed rail assessment;
-If therapy saw a resident that showed a need for bed rails, the therapist documents this in their daily documentation that the resident needed bed rails to assist with bed mobility, positioning, and increased independence;
-He/she told the MDS Coordinator and the MDS Coordinator gave him/her an informed consent. The informed consent included recommendations for the side of the bed the resident needed the bed rails and the risks and benefits of bed rails. It also included the therapist's recommendations for when the bed rails should be used;
-He/she discussed this with the resident or resident representative and had them sign the informed consent;
-He/she gave the signed informed consent back to the MDS Coordinator;
-The MDS Coordinator completed their assessment and obtained a physician's order prior to telling the Maintenance Director to install the bed rails;
-Once the Maintenance Director installed the bed rails, the Rehab Director completed monthly gap measurements;
-The MDS Coordinator added the bed rails to the resident's care plan and gave the signed informed consent to medical records to upload to their medical record.
During an interview on 06/23/23, at 9:19 A.M., the MDS Coordinator said the following:
-The resident did not have a physician's order for bed rails, a signed informed consent, bed rails on his/her care plan or a side rail risk assessment;
-The resident should have all of those in place prior to installation of the bed rails;
-He/she was responsible for ensuring all items are in place before the maintenance director installed the side rails;
-Therapy evaluated residents for bed rails and completed the signed informed consent after either the resident or responsibility signed it;
-The informed consent included the risks and benefits of bed rails, the size of the bed rails, the side of the bed they recommend the bed rail be installed and therapist signature as well;
-When the Rehab Director gave him/her the signed informed consent, he/she obtained a physician's order, completed a side rail risk assessment and then gave the information to the Maintenance Director to install the side rails. He/she then gave the signed informed consent to medical records to upload to the resident's medical record;
-He/she was not sure how often he/she should complete the side rail risk assessment, but thought he/she should complete it at least quarterly;
-The MDS Coordinator was responsible for ensuring all the required documentation was completed prior to the installation of bed rails.
During an interview on 06/23/23, at 10:20 A.M., the Maintenance Director said the following:
-He/she would not have installed the resident's bed rails until the MDS Coordinator gave him/her the information;
-The MDS Coordinator gave him/her the information of which resident and how many bed rails prior to him/her installing bed rails
During an interview on 06/23/23, at 10:58 A.M., the Director of Nursing (DON) said the following:
-The resident had bed rails on both sides of his/her bed;
-The resident should have a physician's order, signed informed consent, a bed rail risk assessment and the bed rails should be included on his/her care plan;
-He/she did not see any of this information in the resident's medical record;
-If a resident required bed rails, the MDS Coordinator told the Rehab Director and the Rehab Director screened the resident to see if there was a need;
-The Rehab Director gets the resident or resident representative to sign the informed consent that included the risks and benefits of bed rails and gave this form to the MDS Coordinator;
-The MDS Coordinator uploaded the signed informed consent into the resident's medical record, completed a bed rail risk assessment and obtained a physician's order prior to instructing the Maintenance Director to install the bed rails;
-The MDS Coordinator added the bed rails to the resident's care plan.
During an interview on 06/23/23, at 1:19 P.M., the Administrator said the following:
-Bed rails required gap measurements, bed rail risk assessment, signed informed consent and a physician's order prior to the Maintenance Director installing them;
-The MDS Coordinator should complete the risk assessment at least quarterly and if there was a change in the resident's mattress and add the bed rails to the resident's care plan.
CONCERN
(E)
Potential for Harm - no one hurt, but risky conditions existed
Abuse Prevention Policies
(Tag F0607)
Could have caused harm · This affected multiple residents
Based on interview and record review, the facility failed ensure staff checked the employee disqualification list (EDL - a list of individual unable to work in long-term care), Nurse Aide (NA) Registr...
Read full inspector narrative →
Based on interview and record review, the facility failed ensure staff checked the employee disqualification list (EDL - a list of individual unable to work in long-term care), Nurse Aide (NA) Registry was checked to ensure they did not have a Federal Indicator (a marker given to a potential employee who has committed abuse, neglect, or misappropriation of property against residents) prohibiting them to work in a certified facility, and request a Criminal Background Check (CBC) prior to contact with residents for two employees (Dietary Manager (DM) and Nursing Assistant (NA) F) out of ten sampled employee files. The facility census was 85.
Review of the facility's policy titled Abuse Prevention Program, revised 12/2016, showed the following:
-As part of the resident abuse prevention, the administration will conduct employee background checks and will not knowingly employ or otherwise engage any individual who has: have been found guilty of abuse, neglect. exploitation, misappropriation of property, or mistreatment by a court of law; have had a finding entered into the State Nurse Aide Registry concerning abuse, neglect, exploitation, mistreatment of residents or misappropriation of their property; or have a disciplinary action in effect against his or her professional license by a state licensure body as a result of a finding of abuse, neglect, exploitation, mistreatment of residents or misappropriation of resident property.
1. Review of the DM's personnel file showed the following:
-Hire/start date of 10/20/22;
-Staff checked the EDL check on 10/21/22;
-Staff checked the CBC and NA Registry on 10/24/22.
During an interview on 06/22/23, at 3:35 P.M., the Human Resources (HR) Director said he/she should have checked the DM's EDL, CBC, and NA Registry prior to the DM's start date.
During an interview on 06/23/23, at 10:58 A.M., the Director of Nursing (DON) said the HR Director should have checked the DM's EDL, CBC and NA Registry prior to the DM's start date.
2. Review of NA F's personnel file showed the following:
-Hire/start date of 10/27/22;
-Staff checked the CBC 10/31/22;
-Staff checked the EDL and NA Registry 11/02/22.
During an interview on 06/22/23, at 3:35 P.M., the HR Director said he/she should have checked the NA F's EDL, CBC, and NA Registry prior to the NA F's start date.
During an interview on 06/23/23, at 10:58 A.M., the DON said the HR Director should have checked NA F's EDL, CBC and NA Registry prior to the NA F's start date.
3. During an interview on 06/22/23, at 3:35 P.M., the HR Director said he/she completed checks of the EDL, NA Registry, and CBC prior to a new employees start date.
4. During an interview on 06/23/23, at 10:58 A.M., the DON said the HR Director was responsible for checking the CBC, EDL, and NA Registry for new employees prior to their start date.
5. During an interview on 06/23/23, at 1:19 P.M., the Administrator said the HR Director was responsible for checking the EDL, CBC, and NA Registry prior to a new employee's start date.
CONCERN
(E)
Potential for Harm - no one hurt, but risky conditions existed
Infection Control
(Tag F0880)
Could have caused harm · This affected multiple residents
Based on interview and record review, facility staff failed follow the facility's infection control policies and maintain infection control system to help prevent possible transmission of communicable...
Read full inspector narrative →
Based on interview and record review, facility staff failed follow the facility's infection control policies and maintain infection control system to help prevent possible transmission of communicable diseases/infection when staff failed to ensure the required two step tuberculosis (TB-a communicable disease that affects the lungs characterized by fever, cough, and difficulty breathing) screening test was administered timely, per facility policy, for seven out of ten sampled staff members. The facility census was 85.
Review of the facility's policy titled Employee Screening for Tuberculosis, revised 07/2010, showed the following:
-All employees shall be screened for tuberculosis (TB) infection and disease, using a two-step tuberculin skin test (TST) or blood assay for Mycobacterium tuberculosis (BAMT) and symptom screening, prior to beginning employment. The need for annual testing shall be determined by the annual TB risk classification or as per State regulations;
-Each newly hired employee will be screened for TB infection and disease after an employment offer has been made, but prior to the employee's duty assignment;
-The Employee Health Coordinator (or designee) will accept documented verification of two-step TST or BAMT results within the preceding 12 months. If the TST or BAMT result was negative, the employee will not be given another skin test prior to beginning employment. If the previous skin test result was positive or unavailable, the employee must have additional verification of absence of active TB;
-The facility's Employee Health Coordinator will administer a TST to all newly hired employees except those who have documented positive TST or BAMT results, and those who provide documented verification of having had a negative TST or BAMT within the preceding 12 months;
-The initial TB testing will be a two-step TST performed by injecting 0.1 ml (5 tuberculin units) of purified protein derivative (PPD) intradermally (under the skin). If the reaction to the first skin test is negative, the facility will administer a second skin test one to two weeks after the first test. The employee may begin duty assignments after the first skin test (if negative) unless prohibited by state regulations. If the reaction to the TST is positive, the employee will be referred for a chest X-ray and symptom screening, which must be completed prior to employment.
1. Review of Licensed Practical Nurse (LPN) D's personnel file showed the following:
-Hire date of 12/15/21;
-Staff documented administration of the first step of the TB test on 12/13/21 and read the results on 12/15/21. Staff did not document completion of the second step.
During an interview on 06/22/23, at 3:35 P.M., the Human Resources Director said staff should have administered the second step of a TB test within fourteen days of 12/13/21, but they did not.
During an interview on 06/22/23, at 4:59 P.M., the Infection Preventionist (IP) said the LPN should have completed the second step of a TB test within fourteen days of 12/13/21.
During an interview on 06/23/23, at 10:58 A.M., the Director of Nursing (DON) said the LPN did not complete his/her two-step TB test until 09/2022. The LPN should have completed his/her second step within seven to ten days of 12/13/21.
2. Review of the Dietary Manager's (DM) personnel file showed the following:
-Hire date of 10/20/22;
-Staff documented administration of the first step of a TB test on 10/17/22 and read the results on 10/19/22. Staff did not document completion of the second step of the TB test;
-Staff documented administration of the first step of a TB test on 01/10/23 and read the results on 01/13/23. Staff did not document completion of the second step of the TB test.
During an interview on 06/22/23, at 3:35 P.M., the Human Resources Director said the amount of time between the DM's first and second step of a TB test was too long. Staff should have administered his/her second step of a TB test at the end of 10/2022.
During an interview on 06/22/23, at 4:59 P.M., the IP said the amount of time between the DM's TB tests was not appropriate. He/she should have completed the second step at the end of 10/2022.
During an interview on 06/23/23, at 10:58 A.M., the DON said the DM should have completed his/her second step within seven to ten days of 10/17/22.
3. Review of Nurse Aide (NA) F's personnel file showed the following:
-Hire date of 10/27/22;
-Staff documented administration of the first step of a TB test on 10/25/22 and read the results on 10/27/22;
-Staff did not document completion of the second step of a TB test.
During an interview on 06/22/23, at 3:35 P.M., the Human Resources Director said staff should have administered a second step of a TB test within fourteen days of the first step but did not.
During an interview on 06/22/23, at 4:59 P.M., the IP said the NA should have completed a two-step TB test, but did not.
During an interview on 06/23/23, at 10:58 A.M., the DON said the NA did not complete a two-step TB test.
4. Review of Dietary Aide (DA) G's personnel file showed the following:
-Hire date of 12/14/22;
-Staff documented administration of the first step of a TB test on 12/13/22, but did not read the results;
-Staff documented administration of the first step of a TB test on 1/10/23 and read the results on 1/12/23;
-Staff did not document completion of the second step of a TB test.
During an interview on 06/22/23, at 3:35 P.M., the Human Resources Director said staff should have read the first step of a TB test and the DA's second step should be within fourteen days of administration of a read first step.
During an interview on 06/22/23, at 4:59 P.M., the IP said staff should have read the DA's first step and the DA's second step was late.
During an interview on 06/23/23, at 10:58 A.M., the DON said staff administered the first step of a TB test, but did not read it;
-The DA sis not complete a two-step TB test.
5. Review of Registered Nurse (RN) H's personnel file showed the following:
-Hire date of 01/26/23;
-Staff documented administration of the first step of a TB test on 01/24/23 and read the results on 01/26/23;
-Staff documented administration of the first step of a TB test on 03/09/23 and read the results on 03/12/23.
During an interview on 06/22/23, at 3:35 P.M., the Human Resources Director said staff should have administered the second step of a TB test within fourteen days of 01/24/23.
During an interview on 06/22/23, at 4:59 P.M., the IP said the RN should have completed the second step of a TB test within fourteen days of 01/24/23.
During an interview on 06/23/23, at 10:58 A.M., the DON said the RN did not complete a two-step TB test.
6. Review of Certified Nursing Assistant (CNA) I's personnel file showed the following:
-Hire date of 03/22/23;
-Staff documented administration of the first step of a TB test on 03/20/23 and read the results on 03/22/23, but did not document if the results were positive or negative;
-Staff documented administration of the first step of a TB test on 06/14/23 and read the results on 061/6/23. Staff did not document results of the test.
During an interview on 06/22/23, at 3:35 P.M., the Human Resources Director said the following:
-Staff should have documented the result of the first step of a TB test and should have administered the second step of a TB test within fourteen days of 03/20/23;
-The staff member required the two step TB test to start over.
During an interview on 06/22/23, at 4:59 P.M., the IP said the following:
-Staff should have documented a result of positive or negative in the first step of his/her TB test;
-The CNA should have completed the second step of a TB test within fourteen days of 03/20/23 and should start the two step TB test over.
During an interview on 06/23/23, at 10:58 A.M., the DON said the following:
-Staff did not document the results of the CNA's first step of a TB test;
-The CNA did not complete a two-step TB test.
7. Review of Housekeeper (HK) J's personnel file showed the following:
-Hire date of 05/22/23;
-Staff documented administration of the first step of a TB test on 05/15/23 and read the results on 05/17/23;
-Staff documented administration of the first step of a TB test on 06/16/23 and read the results on 06/18/23.
During an interview on 06/22/23, at 3:35 P.M., the Human Resources Director said staff should have administered the second step of a TB test within fourteen days of 05/15/23.
During an interview on 06/22/23, at 4:59 P.M., the IP said the HK should have completed the second step of a TB test within fourteen days of 05/15/23.
During an interview on 06/23/23, at 10:58 A.M., the DON said staff should have administered the second step within seven to ten days of 05/15/23.
8. During an interview on 06/22/23, at 3:35 P.M., the Human Resources Director said the following:
-After he/she offered a job to a staff member, they were required to complete a two-step TB test;
-The staff administered the first step of a TB test two days prior to starting orientation and staff read the results during orientation;
-Staff administered the second step fourteen days after administration of the first-step;
-After staff read the second step they returned the forms to him/her and he/she placed them in the employees personnel file;
-He/she and the Infection Preventionist (IP) tracked employee TB testing;
-He/she generated a report of employees due for their second step weekly and gave the report to IP. If the IP was not available, he/she gave the report to the DON or Assistant Director of Nursing (ADON). He/she also gave the report to the Administrator;
-The Administrator and DON were responsible for ensuring new employees completed their two-step TB test.
9. During an interview on 06/22/23, at 4:59 P.M., the IP said the following:
-New employees required a two-step TB test;
-Staff administered the first step of a TB test two days before orientation and read the results on orientation day;
-He/she read the results during orientation and educated the new staff to complete their second step within two weeks. He/she told new staff that any nurse in the building can administer and read a TB test;
-The HR Director gave him/her a weekly list of TB tests due and he/she hung reminders of TB tests due near the time clock;
-If he/she had issues getting a new staff member to complete their second TB test, he/she notified that staff member's supervisor;
-He/she was responsible for ensuring new staff completed their two-step TB test timely.
10. During an interview on 06/23/23, at 10:58 A.M., the DON said the following:
-New employees required a two-step TB test;
-Staff administered the first step two days before orientation and read the results during orientation;
-Staff should administer the second step within seven to ten days;
-When each step was completed, staff gave the form to Human Resources to place in their personnel file;
-Human Resources tracks the completed TB test and gave the IP a list of which staff were due for their second step;
-If a new employee did not receive their second step timely, they needed to start the two-step TB test over;
-Any nurse in the facility could administer and read a TB test;
-Human Resources sent out a memo of TB tests due and nurses administer and read the TB tests;
-If the IP could not get a staff member to complete the second step timely, he/she notified HR and the employee's supervisor. The supervisor should remove the employee from the schedule until they completed their second step and if the employee did not complete the second step timely, they required the two-step process to start over.
11. During an interview on 06/23/23, at 1:19 P.M., the Administrator said the following:
-He/she expected new employees to have a two-step TB test;
-Staff administered the first step two days before orientation and read the results the day of orientation and staff administered the second step within fourteen days of the first step.
CONCERN
(F)
Potential for Harm - no one hurt, but risky conditions existed
Deficiency F0801
(Tag F0801)
Could have caused harm · This affected most or all residents
Based on interview and record review, the facility staff failed to employ a qualified dietary manager for food and nutrition services when the dietitian was not employed full-time by the facility. The...
Read full inspector narrative →
Based on interview and record review, the facility staff failed to employ a qualified dietary manager for food and nutrition services when the dietitian was not employed full-time by the facility. The facility census was 85 .
Review of the facility's job description titled Director of Food Services/Dietary Manager/Supervisor, undated, showed the following:
-The primary purpose of the job position is to work with the corporate dietitian in planning, organizing, developing, and directing the overall operation of the dietary department in accordance with current federal, state, and local standards, guidelines, and regulations governing the facility, and, as may be directed by the Administrator, to assure that quality nutritional services are provided on a daily basis and that the dietary department is maintained in a clean, safe, and sanitary manner;
-Must possess, as a minimum, a high school diploma.
-Must be a graduate of an accredited course in dietetic training approved by the American Dietetic Association;
-Must have experience in a supervisory capacity in a hospital, skilled nursing care facility, or other related medical facility;
-Must have training in cost control, food management, diet therapy, etc.;
-Must be registered as a Food Service Director in this state.
1. During an interview on 06/20/23, at 9:07 A.M., the Dietary Manager (DM) said the following:
-He/she was not a Certified Dietary Manager (CDM) and not enrolled in a training/certification course. He/she planned on getting enrolled when he/she returned from vacation in August;
-He/she was not a Certified Food Services Manager and did not have an associate's degree or higher in food service management or hospitality;
-He/she started the DM position eight months ago;
-He/she had six years in food service management, but none of those years were in a skilled nursing facility;
-A Registered Dietitian came to the facility weekly and was available at all times by telephone.
Review of the DM's personnel file showed no completed Certified Dietary Manager course, Certified Food Services Manager certification, or higher education related to food service management or hospitality.
During an interview on 06/22/23, at 8:26 A.M., the Dietician said the following:
-The DM was not a certified dietary manager (CDM);
-The DM started approximately seven months ago and the facility planned to enroll him/her in the CDM course;
-The facility should have enrolled the DM in a CDM course already, but thought they had one year to get the DM enrolled;
-He/she did not know if the DM had an associate's degree or higher in food service management or hospitality;
-The DM had no other experience in a skilled nursing facility as a DM;
-He/she visited the facility weekly and as needed and was available by telephone at all times.
During an interview on 06/23/23, at 1:19 P.M., the Administrator said the following:
-The DM was not a Certified Dietary Manager and was not enrolled a course at this time;
-The DM was not a Certified Food Services Manager and did not have an associate's degree or higher in food service management or hospitality;
-The DM had no prior experience as a DM in a skilled nursing facility;
-He/she had not enrolled the DM in a CDM course yet due to the high amount of turnover of staff;
-He/she was responsible for enrolling the DM in a CDM course.
Dec 2022
1 deficiency
CONCERN
(D)
📢 Someone Reported This
A family member, employee, or ombudsman was alarmed enough to file a formal complaint
Potential for Harm - no one hurt, but risky conditions existed
Deficiency F0602
(Tag F0602)
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 all residents from misappropriation of property when two re...
Read full inspector narrative →
**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on interview and record review, the facility failed to protect all residents from misappropriation of property when two residents (Resident #2 and Resident #3) had checks that were in the possession of the residents while in the facility taken and written without resident approval for non-resident expenses. The facility census was 93.
Record review of the facility's policy titled, Recognizing Signs and Symptoms of Abuse/Neglect, dated April 2021, showed the following:
-All types of resident abuse, neglect, exploitation, or misappropriation of resident property is strictly prohibited.
Record review of the facility's policy titled, Abuse Investigation and Reporting , dated 2017, showed the following:
-All reports of resident abuse, neglect, exploitation, misappropriation of resident property, mistreatment and/or injuries of unknown source (abuse) shall be promptly reported to local, state, and federal agencies (as defined by current regulations) and thoroughly investigated by facility management. Findings of investigations will also be reported;
-All alleged violations involving abuse, neglect, exploitation, or mistreatment, including injuries of unknown source and misappropriation of property will be reported by the facility Administrator, or his/her designee, to the following persons or agencies: the State licensing/certification agency responsible for surveying/licensing the facility, the resident's representative of record, adult protective services (where state law provides jurisdiction in long-term care), law enforcement officials, attending physician, and the facility medical director.
1. Record review of Resident #2's face sheet showed the following:
-admission date of 5/27/22;
-Diagnoses included Parkinson's disease (a disorder of the central nervous system that affects movement, often including tremors), embolism (a blood clot) and thrombosis (a piece of blood clot) of femoral vein (inside the leg, from the groin), and hypertension (high blood pressure).
Record review of the resident's quarterly MDS, dated [DATE], showed the resident to be cognitively intact.
Record review of the resident's progress notes, dated 11/9/22, showed the following:
-Resident received a call from the bank asking him/her if he/she had written a check for $6000.00 to an individual;
-The resident denied writing the check, and the bank advised they were not letting the check go through;
-Resident asked staff if there was an employee by the name of the individual attempting to cash the check and was informed no employee by that name;
-The resident's checkbook was located in his/her armoire;
-Resident refuses to hand over the checkbook to be securely locked up in business office;
-Resident will be contacting bank for further information about the check.
Record review of the facility's investigation, dated 11/11/22, showed the following:
-On 11/9/22, the resident received a call from his/her bank at approximately 10:30 A.M., stating check #1003 was written for $6000.00;
-An individual attempted to cash the check, however the bank declined to cash the check;
-A nurse went to the resident's room to check his/her checkbook;
-On 11/9/22, at 12:00 P.M., the Administrator notified the Director of Nursing (DON) that the resident had two checks missing from his/her checkbook, check #1003 and #1004;
-At 1:00 P.M., the resident's family was contacted by the Administrator. The family member said the individual who attempted to cash the check received the check from his/her tenant for late rent. The family member provided the name of the landlord and the tenant;
-At 2:00 P.M., a representative from the bank came to the facility to assist the resident with paperwork to cancel his/her account. The bank representative confirmed the information regarding the landlord and tenant.
During an interview on 12/15/22, at 9:09 A.M., the resident said the following:
-The resident had a new checkbook and did not notice any checks missing;
-The resident had written two checks out of the new book;
-The bank called when an individual presented a check to the bank for $6000.00;
-The bank asked the resident if they wrote the check, and he/she said they did not;
-The resident never gave anyone checks, or gave anyone permission to take any checks.
During an interview on 12/15/22, at 3:30 P.M., the Administrator said the following:
-The Administrator was notified by a nurse that the resident received a call from his/her bank regarding an individual trying to cash a check;
-The bank provided the names of the two individuals associated with the resident's check, a landlord who was attempting to cash the check, and the individual who wrote the check;
-The Administrator said the bank caught the check because it was not signed like the resident normally signs his/her checks.
2. Record review of Resident #3's face sheet showed the following:
-admission date of 4/29/22;
-Diagnoses included kidney disease, type II diabetes (a chronic condition that affects the way the body processes blood sugar (glucose)), atrial fibrillation (an irregular heart rate), and lymphedema (swelling in the arms and legs).
Record review of the resident's quarterly MDS, dated [DATE], showed the resident to be cognitively intact.
Record reviewed of the resident's progress notes, dated 11/9/22, showed the following:
-The DON called the Administrator to notify that the resident's bank called stating an individual was trying to cash a check from his/her account for $3100.00;
-The bank declined to cash the check.
Record review of the facility's investigation, dated 11/11/22, showed the following:
-On 11/09/22, at 7:00 P.M., the Administrator received a call from the DON, stating the resident received a call from his/her bank stating someone had tried to cash a check from her account for $3100.00;
-Per the bank, the individual who attempted to cash the check was the same individual who tried to cash the check written from Resident #2's account;
-The bank said the landlord said he/she received the check from his/her tenant, who was the same tenant who gave him/her a check from Resident #2.
Record review of the resident's progress notes, dated 11/10/22, showed the following:
-The resident's checking account has been closed to ensure no further transaction can be made on the account.
Record review of the resident's progress notes, dated 12/1/22, showed the following:
-The Administrator overheard the resident speaking to staff about the check that was taken from him/her;
-The resident said the bank cashed the check which was written for $3080.00;
-The Administrator asked the resident when he/she was advised of this, which the resident said he/she was notified by the bank on 11/12/22;
-The resident is working with the bank fraud department.
During an interview on 12/15/22, at 9:20 A.M., the resident said the following:
-The resident was notified by Resident #2 at lunch that Resident #2 had received a phone call from his/her bank asking if he/she had written a check for $6000.00;
-The cashier was suspicious and compared signatures;
-The resident returned to his/her room and had a message of his/her phone from the bank;
-The resident returned the call and was asked by the bank if he/she wrote a check for $3000.00;
-The resident denied writing a check, and advised that he/she only writes checks to the facility;
-The resident mentioned the call to an aide, and the aide reported it to the nurse;
-The DON told the Administrator and then the Police came to speak with him/her;
-The resident said he/she kept his/her checkbook in a grey envelope on his/her tray table. At the time, there were several items stacked on top of it;
-The resident is only missing one check, and it went missing sometime between 10/25/22 and 11/1/22;
-The resident did not give anyone a check, or permission to take a check.
During an interview on 12/15/22, at 3:30 P.M., the Administrator said the following:
-On 11/9/22, around 7:00 P.M., the Administrator received a call from the DON stating the resident received a call from their bank about a check that was attempted to be cashed.
3. Record review of the facility's investigation, dated 11/11/22, showed the following:
-On 11/10/22, at 7:00 A.M., the Administrator pulled the personal file of Housekeeper B, who only works on the 100 hall (the hall the Resident #2 and Resident #3 resides on). In reviewing background information, it was noted the individual who wrote the checks (the tenant) on Resident #2 and Resident #3's accounts was listed in HK B's file under a background check and exclusion report (a roster of individuals and organizations that are not eligible to participate in federal or state contracts due to criminal behavior or misconduct). The two were shown at the same address;
-The Administrator ran a new background report and found that the individual who wrote the checks and HK B names were co-mingled throughout the report;
-The individual who wrote the checks on Resident #2 and Resident #3's accounts was the tenant, per both banks;
-At 8:30 A.M., the Administrator and Housekeeping Supervisor suspended HK B pending investigation.
4. During an interview on 12/15/22, at 10:35 A.M., Certified Nursing Assistant (CNA) C said staff cannot ask a resident for money or accept gifts, as it is considered stealing.
5. During an interview on 12/15/22, at 10:39 A.M., Licensed Practical Nurse (LPN) D said the following:
-Staff cannot take items out of a resident's room, or accept gifts, or ask for money;
-If staff take items or accept gifts, it is considered stealing, which is a form of financial abuse.
6. During an interview on 12/15/22, at 10:54 A.M., Certified Medication Technician (CMT) E said staff cannot accept money/gifts, or access a resident's account as it is considered abuse.
7. During an interview on 12/15/22, at 11:20 A.M., HKS said staff cannot take items, accept gifts, or access resident bank accounts, as it would be considered misappropriation which is abuse.
8. During an interview on 12/15/22, at 1:53 P.M., the Social Worker said staff cannot accept gifts, ask for money, or access resident accounts as it is considered financial abuse.
9. During an interview on 12/15/22, at 3:30 P.M., the Administrator said the following:
-During the Administrator's investigation involving Resident #2 and Resident #3, he/she discovered the checks were missing from the same hall;
-When looking at staffing, the Administrator found that HK B only worked on the 100 hall;
-The Administrator reviewed HK B's personal file and found the individual's name who gave the check's to the individual who tried to cash the checks in HK B's record review. HK B and the individual who provided the checks have listed residences together;
-When interviewed, HK B said he/she does not have contact with that individual;
-Staff cannot accept personal gifts, money, or have access to resident bank accounts as it is considered abuse.
MO00208923, MO00209688, MO00209721
Feb 2020
3 deficiencies
CONCERN
(D)
Potential for Harm - no one hurt, but risky conditions existed
Unnecessary Medications
(Tag F0759)
Could have caused harm · This affected 1 resident
Based on observation, interview, and record review, the facility failed to ensure staff administered medications with an error rate of less than five percent when staff made two errors out of 25 oppor...
Read full inspector narrative →
Based on observation, interview, and record review, the facility failed to ensure staff administered medications with an error rate of less than five percent when staff made two errors out of 25 opportunities, resulting in an error rate of eight percent affecting two residents (Resident #83 and #247). The facility census was 78.
According to Medscape website (medical reference website for healthcare professionals) showed the following:
-Rapid-acting insulin can cause hypoglycemia (low blood glucose). This may occur when enough calories are not consumed after taking the insulin within the time frame;
-Older adults may be more sensitive to the side effects of low blood glucose from rapid-acting insulin's.
Record review of the Novolog (a rapid-acting insulin) undated manufacturer's insert showed the following:
-Novolog starts acting fast;
-A meal should be eaten within five to ten minutes of taking a dose of Novolog;
-Dosage adjustments may be needed in regards to timing of food intake.
Record review of the Symbicort (an inhaler medication used to relax the muscles in the airway and improve breathing) aerosol inhaler manufacture's recommendations dated December 2019 showed the following:
-Localized infections of the mouth and pharynx has occurred in patients treated with Symbicort;
-Patients should rinse their mouth after inhalation of Symbicort.
Record review of the facility's policy titled Insulin Administration, dated January 2014, showed the following:
-Staff will have access to specific instructions including manufacturer's direction on all forms of insulin;
-Rapid-acting insulin has on onset of action in 10 minutes to 15 minutes.
1. Record review of Resident #247's face sheet (a document that gives a resident's information at a quick glance) showed the following:
-admission dated 2/10/20;
-Diagnosis of diabetes mellitus (DM - a disease that results in too much sugar in the blood).
Record review of the residents' physician's order, dated 2/10/20, showed direction to staff to administer Novolog insulin according to a sliding scale (progressive increase in the pre-meal insulin dose, based on pre-defined blood glucose ranges):
-If blood glucose level is 0-139 milligrams/deciliter (mg/dL) administer no insulin;
-If blood glucose level is 140-199 mg/dL, administer two units of insulin;
-If blood glucose level is 200-249 mg/dL, administer four units of insulin;
-If blood glucose level is 250-299 mg/dL, administer six units of insulin;
-If blood glucose level is 300-350 mg/dL, administer eight units of insulin;
-If blood glucose level is greater than 350 mg/dL administer ten unit of insulin.
Observations on 2/12/20 showed the following:
-At 11:06 A.M., Licensed Practical Nurse (LPN) B administered four units of Novolog insulin according to the sliding scale (based on a blood glucose level of 218 mg/dL);
-At 11:58 A.M., staff served the resident lunch in the dining room (52 minutes after the LPN administered the resident's rapid-acting insulin).
2. Record review of Resident #83's face sheet showed the following:
-admission dated 10/11/19;
-Diagnosis of chronic obstructive pulmonary disease (COPD - a lung disease that blocks airflow and makes it difficult to breathe).
Record review of the residents' physician's order, dated 1/13/20, showed direction to staff to administer the Symbicort inhaler, two puffs two times a day for COPD.
Observations on 2/12/20, at 8:50 A.M., showed Certified Medication Technician (CMT) A administered the resident's Symbicort inhaler. The CMT did not instruct the resident to rinse his/her mouth after inhaling the Symbicort.
3. During an interview on 2/18/20, at 10:50 A.M., Registered Nurse (RN) C said the following:
-Staff should instruct residents' to rinse their mouth after administering a Symbicort inhaler;
-Resident's receiving rapid-acting insulin should eat within 30 minutes after the insulin is administered.
4. During an interview on 2/18/20, at 11:05 A.M., the Director of Nursing (DON) said the following:
-She expects staff to following the manufactures' guidelines when administering inhalers and rapid-acting insulin;
-Staff should always encourage the resident to rinse their mouth after administering a Symbicort inhaler;
-Resident's using Symbicort inhalers are at risk for oral fungal infections;
-The nurse should monitor to ensure residents receive food within the recommended timeframe when receiving a rapid-acting insulin and the nurse should monitor and assess for signs and symptoms of low blood sugar after administering a resident's rapid-acting insulin.
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 observation, interview and record review the facility failed to use appropriate infection control procedures to prevent...
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 use appropriate infection control procedures to prevent the spread of bacteria or other infectious causing contaminants when staff failed to use appropriate hand hygiene during pericare and urinary catheter (a hollow, partially flexible tube maintained within the bladder for the purpose of continuous drainage of urine) care for two residents (Resident #6 and #8), and failed to prevent contamination of a nasal cannula (tubing split into two prongs placed in the nostrils used to deliver oxygen) for one resident (Resident #6) in a selected sample of 18 residents. The facility's census was 78.
According to the Center for Disease Control's (CDC) Guideline for Hand Hygiene in Healthcare Settings, 2002, volume 51 showed the following:
-The hands are the most common mode of transmitting pathogens (microorganisms);
-Clean hands are the single most important factor in preventing the spread of pathogens and antibiotic resistance (infections caused by microorganisms that are resistant to antibiotics) in healthcare settings;
-There is substantial evidence that hand hygiene reduces the incidence of infections.
Record review of the manual titled, Nurse Assistant in a Long-term Care Facility, 2001 revision edition, showed the following:
-Wash hands before and after contact with the resident which is the single most important means of preventing the spread of infection;
-Always wash hands after using gloves;
-Wash hands before and after glove use;
-Gloves do not eliminate the need to wash hands;
-Never touch unnecessary articles in the room or one's face, hair, contact lens, or glasses when wearing gloves.
Record review of the facility's policy titled Urinary Catheter Care, dated January 2014, showed the following:
-Purpose to prevent catheter-associated urinary tract infections;
-Use standard precautions when handling or manipulating the drainage system.
Record review of the facility's policy titled Perineal Care, dated January 2014, showed the following:
-Purpose to provide cleanliness and comfort to the resident to prevent infections,and skin irritations;
-Gather necessary supplies, wash and dry hands thoroughly, put on gloves, wash perineal area wiping front to back;
-Remove gloves, wash and dry hands thoroughly and reglove. Wash the rectal area thoroughly. Do not reuse the same washcloth /wipe or water to clean. Dry area. Remove gloves, discard into the designated container, wash and dry hands thoroughly. Clean the bedside stand. Wash and dry hands thoroughly.
1. Record review of Resident #6's face sheet (a document that gives a resident's information at a quick glance) showed the following:
-re-admission dated 10/25/19;
-Diagnoses of high blood pressure, anxiety and urinary tract infection (UTI).
Record review of the resident's quarterly Minimum Data Set (MDS), a federally mandated assessment instrument completed by facility staff, dated 1/27/20, showed the following:
-Moderately impaired cognition;
-Extensive staff assistance of one required for transfers, personal hygiene and toileting.
Observations on 02/14/20, at 10:04 A.M., showed the following:
-Certified Nurse Assistant (CNA) E and CNA F in the resident's room with gloves on;
-CNA E assisted the resident to the bathroom in a wheelchair and removed the resident's adult brief. CNA E did not change gloves after removing the adult brief and handed the resident a clean wet wash cloth to wipe his/her face. The resident had a bowel movement;
-CNA E and CNA F assisted the resident up from the toilet. CNA F wiped the resident several times. CNA F said he/she was stimulating the resident to have a bowel movement when he/she would wipe over the anus area. CNA F said they should wait to finish cleaning the resident until later to make sure the resident finished the bowel movement;
-CNA E removed his/her gloves. The CNA did not wash his/her hands. The CNA brushed the resident's hair, assisted the resident with putting on a clean pajama gown, and took the resident back to bed. CNA E assisted the resident back to bed and put an adult brief on the resident.
-CNA E placed the nasal cannula on the resident, but the tubing was tangled. While CNA E untangled the nasal cannula tubing CNA dragged the nasal cannula on the floor.
-CNA E untangled the nasal cannula and placed it on the resident's face. The CNA did not clean the nasal cannula.
2. Record review of the Resident #8's face sheet showed the following:
-admission dated 4/15/16;
-Diagnoses of retention of urine.
Record review of the residents' physician's order summary report showed the following:
-Dated 4/18/16, the physician direction for a foley catheter;
-Dated 3/14/18, the physician directed staff to provide foley catheter care with soap and water every shift.
Record review of the resident's quarterly MDS, dated [DATE], showed the following:
-Usually understands and usually understood;
-Severely impaired cognition;
-Extensive staff assistance of two required for transfers, bed mobility, personal hygiene and toileting;
-Diagnoses included dementia and stroke.
Observations on 02/14/20, at 1:27 P.M., showed the following:
-CNA E and CNA F entered the resident's room, washed their hands and put gloves on;
-CNA E assisted the resident to bed. The CNA's rolled resident and pulled the residents pants down. CNA E removed the resident's unsoiled adult brief. The CNA did not remove his/her gloves and wash his/her hands;
-CNA E used a personal hygiene wipe to clean the resident's perineal area. The CNA wrapped another wipe around the used wipe and wiped around the insertion site of the catheter. The CNA continued wiping down and around the shaft of the resident's penis. The CNA did not pull the foreskin down to clean the resident;
-CNA E discarded the used wipes in the trash and obtained a clean wipe. CNA E wiped the catheter tubing in a back and forth motion three times (toward the insertion site);
-CNA F put Lanaseptic (a skin protectant) cream on CNA E's contaminated glove. CNA E spread the cream over the resident's scrotum. With the same gloves, CNA E and F put a clean adult brief on the resident and pulled up the resident's pants;
-CNA F removed his/her gloves and assisted the resident into a lift chair.
-CNA E did not change gloves or wash his/her hands throughout the cares.
During an interview on 02/14/20, at 1:40 PM, CNA E said they do not change gloves with the resident until they are all finished because the resident can get very grouchy.
3. During an interview on 02/17/20, at approximately 3:00 PM, CNA G said he/she did not think gloves would be changed until after pericare.
4. During an interview on 02/18/20, at approximately 3:15 PM, Licensed Practical Nurse (LPN) B said during pericare gloves are to be changed whenever a caregiver goes from a dirty area to a clean area.
5. During an interview on 02/18/20, at approximately 3:25 PM, the Director of Nursing (DON) said she expects staff to change gloves when going from a dirty site to a clean site.
CONCERN
(E)
Potential for Harm - no one hurt, but risky conditions existed
Food Safety
(Tag F0812)
Could have caused harm · This affected multiple residents
Based on observation and interview, the facility failed to provide the required air gap between two ice machine drains and floor drains that would prevent the backflow of wastewater. This facility pra...
Read full inspector narrative →
Based on observation and interview, the facility failed to provide the required air gap between two ice machine drains and floor drains that would prevent the backflow of wastewater. This facility practice could lead to contamination of ice and possible food-borne illness, potentially affecting all residents at the facility. The facility had a census of 78.
According to the Missouri Food Code, adopted by the Missouri Department of Health and Senior Services (DHSS) June 3, 2013, in order to prevent backflow, a direct connection may not exist between the sewage system and a drain originating from equipment in which food is placed. A backflow prevention device or an air gap must be in place to prevent wastewater back-siphonage.
1. Observations on 2/11/20, at 10:25 A.M., showed one of the facility's kitchen ice machine with a drainpipe leading out of the machine. The end of the pipe was in contact with the floor drain. There was a buildup of a light brown substance on the end of the drainpipe.
Observations on 2/11/20, at 11:10 A.M., of the nutrition room showed one of the facility's ice machines with the drainpipe leading out of the machine. The end of the pipe was in contact with the floor drain. There was a small buildup of a light brown substance on the end of the drainpipe.
Observations on 2/13/20, at 10:39 A.M., showed one of the kitchen's ice machine with the drainpipe leading out of the machine. The end of the pipe was in contact with the floor drain. There was a buildup of a light brown substance on the end of the drainpipe.
Observations on 2/13/20, at 11:03 A.M., of the nutrition room showed one of the facility's ice machines with the drainpipe leading out of the machine. The end of the pipe was in contact with the floor drain. There was a buildup of a light brown substance on the end of the drainpipe.
During an interview on 2/13/20, at 2:34 P.M., the Dietary Manager said kitchen staff surface clean the ice machines on a regular basis. Housekeeping defrosts the ice machines and clean the ice machines out on a semi-monthly schedule. The Director of Maintenance is in charge of maintaining the ice machines. He/She was not aware of the need to keep the ice machine drains off the floor and off the floor drains.
During an interview on 2/19/20, at 3:21 P.M., the Maintenance Director said the maintenance department cleans the interior of the ice machine monthly. Routine ice machine maintenance is performed quarterly. The regular cleaning and the monthly maintenance do not cover cleaning the ice machine drain or adjusting the height above the floor drain. The drain and air gap are not checked. He was not aware it needed to be checked.
Understanding Severity Codes (click to expand)
Life-Threatening (Immediate Jeopardy)
J - Isolated
K - Pattern
L - Widespread
Actual Harm
G - Isolated
H - Pattern
I - Widespread
Potential for Harm
D - Isolated
E - Pattern
F - Widespread
No Harm (Minor)
A - Isolated
B - Pattern
C - Widespread
Questions to Ask on Your Visit
- "Can I speak with families of current residents?"
- "What's your RN coverage like on weekends and overnight?"
Our Honest Assessment
Strengths
- • No fines on record. Clean compliance history, better than most Missouri facilities.
Concerns
- • 23 deficiencies on record, including 1 serious (caused harm) violation. Ask about corrective actions taken.
Bottom line: Mixed indicators with Trust Score of 65/100. Visit in person and ask pointed questions.
✓ Report will be sent to your email
About This Facility
What is Maples, The's CMS Rating?
CMS assigns MAPLES HEALTH AND REHABILITATION, THE an overall rating of 4 out of 5 stars, which is considered above average nationally. Within Missouri, this rating places the facility higher than 99% of the state's 100 nursing homes. This rating reflects solid performance across the metrics CMS uses to evaluate nursing home quality.
How is Maples, The Staffed?
CMS rates MAPLES HEALTH AND REHABILITATION, THE's staffing level at 3 out of 5 stars, which is average compared to other nursing homes. Staff turnover is 53%, compared to the Missouri average of 46%.
What Have Inspectors Found at Maples, The?
State health inspectors documented 23 deficiencies at MAPLES HEALTH AND REHABILITATION, THE during 2020 to 2025. These included: 1 that caused actual resident harm and 22 with potential for harm. Deficiencies causing actual harm indicate documented cases where residents experienced negative health consequences.
Who Owns and Operates Maples, The?
MAPLES HEALTH AND REHABILITATION, THE 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 ANTHONY & BRYAN ADAMS, a chain that manages multiple nursing homes. With 120 certified beds and approximately 94 residents (about 78% occupancy), it is a mid-sized facility located in SPRINGFIELD, Missouri.
How Does Maples, The Compare to Other Missouri Nursing Homes?
Compared to the 100 nursing homes in Missouri, MAPLES HEALTH AND REHABILITATION, THE's overall rating (4 stars) is above the state average of 2.5, staff turnover (53%) is near the state average of 46%, and health inspection rating (3 stars) is at the national benchmark.
What Should Families Ask When Visiting Maples, The?
Based on this facility's data, families visiting should ask: "Can I visit during a mealtime to observe dining assistance and food quality?" "How do you handle medical emergencies, and what is your hospital transfer rate?" "Can I speak with family members of current residents about their experience?"
Is Maples, The Safe?
Based on CMS inspection data, MAPLES HEALTH AND REHABILITATION, THE has a clean safety record: no substantiated abuse findings (meaning no confirmed cases of resident harm), no Immediate Jeopardy citations (the most serious violation level indicating risk of serious injury or death), and is not on the Special Focus Facility watch list (a federal program monitoring the lowest-performing 1% of nursing homes). The facility has a 4-star overall rating and ranks #1 of 100 nursing homes in Missouri. While no facility is perfect, families should still ask about staff-to-resident ratios and recent inspection results during their visit.
Do Nurses at Maples, The Stick Around?
MAPLES HEALTH AND REHABILITATION, THE has a staff turnover rate of 53%, which is 7 percentage points above the Missouri average of 46%. Moderate turnover is common in nursing homes, but families should still ask about staff tenure and how the facility maintains care continuity when employees leave.
Was Maples, The Ever Fined?
MAPLES HEALTH AND REHABILITATION, THE has no federal fines on record. CMS issues fines when nursing homes fail to meet care standards or don't correct problems found during inspections. The absence of fines suggests the facility has either maintained compliance or corrected any issues before penalties were assessed. This is a positive indicator, though families should still review recent inspection reports for the full picture.
Is Maples, The on Any Federal Watch List?
MAPLES HEALTH AND REHABILITATION, THE is not on any federal watch list. The most significant is the Special Focus Facility (SFF) program, which identifies the bottom 1% of nursing homes nationally based on persistent, serious quality problems. Not being on this list means the facility has avoided the pattern of deficiencies that triggers enhanced federal oversight. This is a positive indicator, though families should still review the facility's inspection history directly.