DELMAR GARDENS WEST
For profit - Corporation
321 Beds
DELMAR GARDENS
Data: November 2025
1 Immediate Jeopardy citation
Trust Grade
41/100
#147 of 479 in MO
Photo by Delmar Gardens West
Photo by Brian Yost
Photo by Donald Meissner
1 / 5 photos
Last Inspection: April 2025
Within standard 12-15 month inspection cycle. Federal law requires annual inspections.
Overview
Delmar Gardens West has a Trust Grade of D, indicating below average performance with some concerns about care. It ranks #147 out of 479 nursing homes in Missouri, placing it in the top half, and #18 out of 69 in St. Louis County, meaning there are only a few local options that are rated better. The facility's performance is stable, with eight issues reported in both 2024 and 2025, which shows no improvement or worsening. Staffing is relatively strong with a 4/5 rating and a turnover rate of 40%, which is better than the Missouri average of 57%. However, the facility has faced serious issues, including a critical incident where a resident did not receive timely CPR when needed, leading to their death, and another serious incident involving physical abuse causing injury to a resident. Additionally, there were concerns about food safety and hygiene practices in the kitchen. Overall, while there are strengths in staffing, the facility has significant weaknesses that families should consider carefully.
- Trust Score
- D
- In Missouri
- #147/479
- Safety Record
- High Risk
- Inspections
- Holding Steady
- Staff Stability ○ Average
- 40% turnover. Near Missouri's 48% average. Typical for the industry.
- Penalties ✓ Good
- $22,623 in fines. Lower than most Missouri facilities. Relatively clean record.
- Skilled Nurses ⚠ Watch
- Each resident gets only 22 minutes of Registered Nurse (RN) attention daily — below average for Missouri. Fewer RN minutes means fewer trained eyes watching for problems.
- Violations ⚠ Watch
- 30 deficiencies on record. Higher than average. Multiple issues found across inspections.
41/100
Top 30%
Review needed
8 → 8 violations
★★★☆☆
3.0
Overall Rating
★★★★☆
4.0
Staff Levels
★★★☆☆
3.0
Care Quality
★★★☆☆
3.0
Inspection Score
↔
Stable
2024: 8 issues
2025: 8 issues
The Good
-
4-Star Staffing Rating · Above-average nurse staffing levels
-
Full Sprinkler Coverage · Fire safety systems throughout facility
-
No fines on record
-
Staff turnover below average (40%)
8 points below Missouri average of 48%
Facility shows strength in staffing levels, fire safety.
The Bad
3-Star Overall Rating
Above Missouri average (2.5)
Meets federal standards, typical of most facilities
Staff Turnover: 40%
Near Missouri avg (46%)
Typical for the industry
Federal Fines: $22,623
Below median ($33,413)
Minor penalties assessed
Chain: DELMAR GARDENS
Part of a multi-facility chain
Ask about local staffing decisions and management
The Ugly 30 deficiencies on record
1 life-threatening 1 actual harm
Apr 2025
8 deficiencies
CONCERN
(D)
Potential for Harm - no one hurt, but risky conditions existed
Safe Environment
(Tag F0584)
Could have caused harm · This affected 1 resident
Based on observation, interview and record review, the facility failed to provide a clean, comfortable, home-like environment when staff did not ensure one resident's (Resident #53's) shower drainage ...
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Based on observation, interview and record review, the facility failed to provide a clean, comfortable, home-like environment when staff did not ensure one resident's (Resident #53's) shower drainage was properly maintained to allow water to flow unobstructed. The sample size was 35. The census was 181.
Review of Resident #53's annual Minimum Data Set (MDS), a federally mandated assessment instrument completed by facility staff, dated 1/9/25, showed the following:
-Diagnoses included dementia and chronic obstructive pulmonary disease (COPD, lung disease);
-Shower/bathe self with Partial to moderate assistance.
Review of the resident's care plan, dated 3/11/25, showed a deficit in mobility and activities of daily living (ADL) functions with COPD, dementia with cognitive impairment, and the need for occasional supervision and cueing with ADLs.
Observation of the resident's shower on 4/7/25 at 2:39 P.M., showed the shower floor had a slight slope towards the drain which created a pool of water within 20 seconds during the water flow.
Observation of the resident's shower on 4/8/25 at 1:55 P.M., showed the shower floor had a slight slope towards the drain which created a pool of water that measured 4 inches in dominator during the 1 minute and 2 second water flow duration.
Observation of the resident's shower on 4/9/25 at 7:41 A.M., showed the shower floor had a slight slope towards the drain which created a pool of water that measured 10 inches in diameter during the 2 minute water flow duration.
During an interview on 4/7/25 at 2:39 P.M., the resident said he/she had reported the issue to staff last week, but it was still not fixed. When he/she attempted to take a shower this morning, he/she could not wash his/her hair and only rinse off due to the amount of water that was backing up.
During an interview on 4/9/25 at 10:15 A.M., Certified Nursing Assistant (CNA) K said the resident made him/her aware of the water backup in the shower a few days ago but he/she could not remember the exact day. He/She immediately told Maintenance L when he/she walked past him/her in the hallway. He/She had no knowledge if the problem was fixed. The process in which staff inform the maintenance department of any issues is when maintenance passes them in the hallway, they let them know.
During an interview on 4/9/25 at 10:20 A.M., Maintenance L said he/she could not remember if he/she was made aware of the drain in the resident's shower, but he/she probably was and just forgot. He/She is generally made aware of any maintenance issues by the staff when he/she passes the staff in the hallway. Maintenance L is unaware of any maintenance log or any other type of maintenance request system to document maintenance needs.
During an interview on 4/9/25 at 9:40 A.M., Receptionist M said when he/she gets maintenance or housekeeping requests, it is recorded in the carbon copy call-log book. He/She then gives the top copy to the appropriate department. Receptionist M was unsure if all the other receptionists do the same.
During an interview on 4/10/25 at 8:45 A.M., the Maintenance Director said he was unaware there was an issue in the resident's shower. The facility does not have a process to document maintenance concerns. Staff will tell maintenance in passing if they have concerns. It was not uncommon for things to be forgotten when they are reported maintenance as they are walking by to complete another task. However, requests are also sometimes given to the receptionist. He expected for the shower drain to have been unclogged the same day they were made aware of the issue.
CONCERN
(D)
Potential for Harm - no one hurt, but risky conditions existed
Accident Prevention
(Tag F0689)
Could have caused harm · This affected 1 resident
Based on observation, interview and record review, the facility failed to maintain an environment free of accident hazards by not maintaining proper body mechanics while transferring a dependent resid...
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Based on observation, interview and record review, the facility failed to maintain an environment free of accident hazards by not maintaining proper body mechanics while transferring a dependent resident (Resident #67). Two Certified Nursing Assistants (CNAs) placed a gait belt around Resident #67's abdomen loosely, and both CNAs placed their arms directly up and under resident's arm pits to lift the resident. One CNA grabbed his/her waistband to pull him/her to a standing position. The sample was 35. The census was 181.
Review of the facility's Gait belt policy, dated effective 7/2015, Reviewed 6/21, showed:
-Wrap gait belt around resident's waist and pull the strap through the buckle to tighten;
-4. Gait belt should be snug but not uncomfortable. Make sure you can slide your open flat hand between the belt and resident;
-6. Face resident when assisting resident with mobility by pulling on belt;
-9. Follow proper body mechanics when using gait belt and refer to transfer policy for proper transfer techniques.
Review of Resident #67's diagnoses, showed dementia, mood disturbance, anxiety, high blood pressure, type 2 diabetes mellitus with diabetic neuropathy-Polyneuropathy (with a decrease in nerve sensation), cervical disc degeneration (degeneration of the spine in the neck area), urinary incontinence, age-related physical debility, and repeated falls.
Review of the resident's admission Minimum Data Set (MDS) a federally mandated assessment instrument completed by facility staff, dated 12/30/24, showed:
-Cognitively intact;
-Used a wheelchair;
-Range of motion coded no impairment
Review of the resident's physician orders, showed an order, dated 1/7/25, transfer order: x1 assist.
Review of the resident's care plan, in use at the time of the survey, showed:
-Problem: At a risk for falls, due to dementia, high blood pressure and incontinence;
-Goal: Decrease the risk of falls and/or injury should a fall occur;
-Intervention: Assess for additional safety devices and ability to use call-light. Staff will also adjust environment low stimulation and free from clutter for increased confusion and poor vision;
-The care plan updated as of April 1, 2025, to show the residents recent decline in mental and physical status.
Observation on 4/8/25 at 8:04 A.M., showed CNA N entered the resident's room. CNA O also entered the resident's room. A CNA placed a gait belt above the resident's belly button but below the breast line loosely. His/Her wheelchair was positioned perpendicular to the bed. Both CNAs placed their forearms directly underneath his/her arm pits and lifted the resident to an upright stance. Resident # 67 was not given any warning, or verbal communication prior to the CNAs lifting him/her out of the wheelchair. Resident #67 had a tennis shoe on the right foot and a heel protective boot (heel float boot) on the left foot. During the transfer the resident's legs were in a locked position and the resident did not pivot his/her feet. When staff placed him/her in bed, his/her legs faced to the left, and his/her upper body leaned right in a twisted and unnatural body alignment.
During an interview on 4/9/25 at 11:38 A.M., Physical Therapy Assistant (PTA) F said he/she was involved with the resident's therapeutic needs regarding range of motion (ROM). He/she has worked with the resident approximately 7 times since the beginning of 2025. He/She acknowledges the resident's ability to use a sliding board for self-transfer with a CNA present. He/She is unaware what medical change occurred, but noticed a mentation change that included decline in physical stamina along with personality and assumed a urinary tract infection (UTI). PTA F recalls the resident falling and it physically took 3 staff members and the PTA assist to help Resident #67 into a chair. After that encounter, PTA F believes Resident #67 was sent to local hospital for an evaluation. Since his/her return from a week long hospitalization, no new orders or physical assessment was completed. Resident #67 remains a x1 assist.
During an interview on 4/8/25 at 10:30 A.M., the Director of Physical Therapy said she was unable to give specifics regarding Resident #67 and is unfamiliar with personalized care of residents at this time. On 4/9/25 at 11:30 A.M., the Director of Physical therapy said a resident who required a 2 person assist with a gait belt would present like this: a staff member would position the chair 45 degrees to one side of the bed. The gait belt would be positioned around the upper portion of the belly button but below the breast line. The safety device should appear snuggly, but not tightly. Both staff members need to be in ready motion, with a staff personnel standing in the front of the resident. Staff should have bent knees, providing verbal cues to the resident before the resident is in an upright stance. Personnel continues verbal commands to the resident until the transfer is completed. The resident's body would remain free from abnormal ligament, twisting motions or restricting devices limiting range of motions, which includes a heel float boot.
During an interview on 4/10/25 at 1:50 P.M., the Director of Nursing (DON) said nursing staff should transfer residents according to facility policy. He/She confirmed the proper technique was to use a gait belt around the mid sections of the individual and have the belt snuggly, leaving enough space for the CNA's hand to slide comfortably between the resident and the belt. The belt is the only garment that should be held by the staff when transfers occur. Using an article of clothing, for example utilizing a fabric waist band, would be considered noncompliant with facility policy. Failure to follow policy could lead to harm to staff and ultimately the resident. It is essential for there to be verbal communication from staff to Resident #67 during the transfer. Failure to provide cues or step by step directions during the transfer can lead to confusion. A resident who is dependent on 2 staff assist is required to be able to pivot their own weight during the transfer. He/She could not see a safety concern with a resident being transferred with a heel protective boot on. The resident should be a mechanical lift if they cannot transfer themselves or a physical decline is noted. Resident #67 was noted to have a decline and is not fully back to baseline after readmission from the hospital.
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 F0694
(Tag F0694)
Could have caused harm · This affected 1 resident
**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on interview and record review, the facility failed to ensure intravenous (IV) services provided were consistent with prof...
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**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on interview and record review, the facility failed to ensure intravenous (IV) services provided were consistent with professional standards of practice when a Licensed Practical Nurse (LPN) removed a peripherally inserted central catheter (PICC line, a thin, soft, long catheter (tube) that is inserted into a vein in the arm, leg or neck that is used for IV medications and fluids) for one resident (Residents #142). The sample was 35. The census was 181.
Review of the Rules of Department of Commerce and Insurance, Division 2200-State Board of Nursing, Chapter 6-Intravenous Infusion Treatment Administration, dated 5/31/24, showed:
-Definitions: Administer: to carry out comprehensive activities involved in IV infusion treatment modalities that include, but are not limited to, the following: observing; performing; monitoring; discontinuing; maintaining; regulating; adjusting; documenting; assessing; diagnosing; planning; intervening and evaluating;
-Central venous catheter: a catheter that is advanced through the internal jugular vein (vein in the neck), cephalic (a superficial vein in the arm) or basilic vein(vein in the upper arm) in the antecubital fossa (front of the elbow, between the arm and forearm) or subclavian vein (vein under the collarbone), with the catheter tip terminating in the superior vena cava (a large vein that carries deoxygenated blood from the head, neck, arms, and upper chest back to the heart). Central venous catheters may be used to administer prescribed IV infusion treatments modalities or to perform prescribed IV infusion diagnostic procedures and include but not limited to PICC (line);
-Graduate practical nurses, IV-certified LPN, and LPN nurse who hold an active multistate license to practice under the nurse licensure compact shall not, under any condition, perform the following functions or duties:
-Remove a mid-line catheter (a catheter that is inserted into a vein in the antecubital fossa and then advanced three to 12 inches into the proximal (near the center) upper arm) or any type of central venous catheter.
Review of the facility's LPN Job Description, undated, showed:
-IV certified LPNs may manage IVs within the restrictions of his/her certification. They may not administer IV push medications, may not add medication to IV fluids and may not access an implanted port;
-See that all physician orders are carried out or appropriate arrangements made.
Review of the facility's investigation, dated 1/29/25 through 1/30/25, showed:
-On 1/29/25, nurse discontinued IV PICC line on 1/28/25;
-On 1/28/25, Register Nurse (RN) placed call to Infectious Disease (ID) to obtain order to remove at 9:47 A.M.;
-On 1/28/25, resident requested PICC line to be discontinued;
-On 1/28/25, an order was obtained (LPN) at 9:51 P.M.,
-On 1/29/25, no adverse outcome, educated LPN on practice;
-On 1/30/25, no adverse outcome.
Review of the nursing schedule dated 1/28/25, showed, 2:30 P.M. through 11:00 P.M. there was two RNs scheduled and 10:30 P.M. through 7 A.M., there was one RN was scheduled.
Review of LPN Z's employee file, showed:
-LPN had an active license and was IV certified;
-The Counseling Form dated 1/29/25, showed:
-When performance or behavior issues arise, a counseling session is used to help employees focus on the area of concern. The issue that leads up to this counseling is: removed PICC line;
-In order to achieve acceptable level of performance, the following change(s) must take place: you must practice within your scope. LPN may insert, remove IV lines that are three inches or less in length. You may administer medications and flush a PICC line;
-As an employer, we will provide the following support, training and/or coaching to help you achieve this goal: if procedures come up or orders are obtained that are not within your scope of practice you must defer the procedure to an RN or report to the Director of Nursing (DON) so he/she can delegate;
-Services we suffer when we do not follow proper procedures or behave in an acceptable manner. The consequence of this is: termination on any other practice completed by you that is outside your scope of practice;
-The form was signed by the LPN Z, the DON and the Administrator on 1/30/25.
Review of Resident #142's admission quarterly Minimum Data Set (MDS), a federally mandated assessment instrument completed by facility staff, dated 1/7/25, showed:
-Cognitively intact;
-Diagnoses included: wound infection;
-Had IV access while a resident.
Review of the resident's quarterly MDS, dated [DATE], showed:
-Cognitively intact;
-Diagnoses included: heart failure, high blood pressure, wound infection, anxiety and depression.
Review of the care plan in use at the time of survey, showed:
-Problem: Resident required IV medication;
-Goal: Resident will not exhibit signs of complications from IV (localized infection,(infection in one part of the body), systemic infection (an infection that has spread throughout the body), electrolyte imbalance, air embolus (one or more air bubbles or gas bubbles enter a vein or artery and block it) dislodgement, infiltration (the leakage of IV fluids or medications into the surrounding tissue instead of the vein), extravasation (leakage of a solution that can cause tissue damage), phlebitis (inflammation of a vein), fluid overload (occurs when the body receives more fluid than the body can process), dehydration);
-Interventions included: Discontinue IV at the first sign of infiltration or local inflammation. Created: 1/07/2025. Discipline: Nursing.
Review of the progress notes dated 1/27/25 through 1/28/25, showed:
-On 1/27/25 at 11:46 A.M., PICC line no signs and symptoms of adverse reaction noted, stop date for vancomycin (antibiotic) per pharmacy was 1/26/25;
-On 1/28/25 at 9:47 A.M., call placed to ID office to find out about PICC line removal order or if need any lab draw or follow up appointment. Will be faxing new orders to the facility;
-On 1/28/25 at 9:52 P.M., resident request the PICC line to be removed due to possible infiltration/line unable to be flushed and because line was dislodged and hanging from site barely intact. Call place to Medical Doctor (MD). New order, ok to remove PICC line until further orders received from infection control.
Review of the Medication Administration Record (MAR) dated 1/1/25 through 1/31/25, showed:
-A physician order to remove the PICC line;
-Documentation showed on 1/28/25 at 10:00 P.M., the PICC line was removed by LPN Z.
During an interview on 4/9/25 at 6:55 A.M., the resident said he/she did not recall any issues with his/her PICC line. The staff administered his/her medications and flushed it without any problems. The dressings were changed weekly.
During an interview on 4/8/25 at 3:15 P.M., LPN Z said LPNs could administer medications and flush PICC lines. They could also change the dressings and remove them in an emergency. The resident had a PICC line in his/her left arm and he/she wanted it out. LPN Z went into the room to assess the resident. The PICC line was not intact, the line was exposed three to four inches and the dressing had come loose. Basically, the line came out, they were no longer stitching the PICC lines in place. LPN Z said in the moment he/she was concerned the resident could go septic (a severe and potentially life-threatening response to an infection, often triggered by bacteria) because the resident had Methicillin-Resistant Staphylococcus Aureus (MRSA, infection is caused by a type of staph bacteria that's become resistant to many of the antibiotics) on his/her skin. The nurse called the physician and obtained an order to discontinue the PICC line. He/She did not have to pull too much to remove the PICC line. The PICC line was discontinued on the night shift and there was no RN in the building. There was an on-call supervisor, but he/she did not call them. The DON was notified the next day, and she provided education on what LPNs could do and she clarified the difference between the IV lines.
During an interview on 4/9/25 at 8:55 A.M. LPN AA said LPNs could flush and administer medications through the PICC line. LPNs could not discontinue them.
During an interview on 4/10/25 at 10:10 A.M., LPN S said LPNs could not discontinue PICC lines. If he/she got an order to discontinue it, he/she would tell the Assistant Director of Nursing (ADON) or the DON.
During an interview on 4/8/25 at 2:03 P.M. and at approximately at 4:00 P.M., and on 4/9/25 at 9:23 A.M., the DON said LPNs could administer medications and flush PICC lines. LPNs could not remove them. The resident wanted his/her PICC line out. The day nurse called the ID doctor and left a message. The evening nurse, LPN Z, called the primary care physician and obtained an order to remove the PICC line. Then, he/she went into the resident's room and removed it. As far as the DON knew, the PICC line was intact at the time it was removed. There was an RN in the building on both the evening and the night shift that day. LPN Z did not know he/she could not remove the PICC line and that it was out of his/her scope of practice. LPN Z was provided education on his/her scope of practice and the difference between the lines. If an LPN obtained an order to discontinue a PICC line and/or there was no RN in the facility, the DON would expect for the nurse to leave the line in place and notify a RN/nurse manager or the DON. The DON also expected staff to practice within their scope of practice.
MO00250188
CONCERN
(D)
Potential for Harm - no one hurt, but risky conditions existed
Drug Regimen Review
(Tag F0756)
Could have caused harm · This affected 1 resident
**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on interview and record review, the facility failed to timely address the pharmacist recommendations from the Drug Regimen...
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**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on interview and record review, the facility failed to timely address the pharmacist recommendations from the Drug Regimen Review (DRR) for two residents (Residents #157 and #16). The sample was 35. The census was 181.
Review of the facility's DRR policy, dated reviewed 5/21, showed:
-Policy: the consultant pharmacist reviews the medications for each resident for any irregularities and to: verify appropriateness of the medications involved; evaluate disease state management; ensure appropriate medication monitoring to maximize safety and efficacy; and prioritize patient goals, safety, and quality of life;
-Procedures: the consultant pharmacist reviews each resident chart to identify and address any irregularities: medication duration and medication monitoring;
-The consultant pharmacist will review the chart of every resident each month and document the DRR as follows: the consultant pharmacist will utilize a current census or resident lists in the electronic medical record (EHR) to ensure that all active residents have been reviewed each month;
-All recommendations (including no recommendations) will be printed each month (within 72 hours of completing all the DRR's in the facility) and sent to the corresponding Director of Nursing (DON) via a delivery company to distribute and get completed;
- Pharmacy consults should be signed, completed, and acted on within 30 days of being sent to the facility;
-The facility should write a description of their attempts to get the consult completed on the actual consult (or in response to the observation in EHR). For example, faxed to physician on these dates; put in physician mailbox on this date, etc.;
-Each month the consultant pharmacist will follow up on previous consults, nursing consults will be repeated the following month if not completed; physician consults will be repeated 2 months later if not completed.
1. Review of Resident #157's quarterly Minimum Data Set (MDS), a federally mandated assessment instrument completed by the facility staff, dated 1/3/25, showed:
-readmission date of 3/13/25;
-Cognitively intact;
-Highly impaired vision;
-No behaviors or rejection of care;
-Diagnoses included: stroke, high blood pressure, diabetes, anxiety and depression.
Review of the physician order sheet, in use at the time of survey, showed a physician order for tobramycin 0.3%, instill one drop into left eye three times a day until healed and reassessed by the medical doctor (MD). Start date was 3/13/25.
Review of the Pharmacist Recommendation to Prescriber, dated 10/18/24, showed:
-Findings/recommendation: the resident has an order for tobramycin eye drops since 3/31/24 with special instructions of until healed and reassessed by the MD. The pharmacist could not find any notes if this had been assessed and if the tobramycin could be discontinued. The optometrist notes from 5/6/24 dose does not mention this medication. Please clarify with MD;
-Prescribers comments: please contact ophthalmologist, dated 11/10/24.
Review of the eye clinic notes, showed:
-On 11/6/24, the note did not address the tobramycin;
-On 3/7/25, the visit was cancelled. Patient said the light was too bright and wasn't able to keep his/her eyes open for exam.
During an interview on 4/11/25 at 9:20 A.M., 9:40 A.M. and 12:24 P.M., the Assistant Director of Nursing (ADON) said the facility did not receive the recommendations the day the pharmacist reviewed the resident's chart. Sometimes it took a couple of weeks for the facility to receive the pharmacy recommendations. Once the recommendations were delivered, the DON divided the recommendations out by physician and put them in their folders to be reviewed during their next visit. Once the recommendations were reviewed, the MD or the nurse should put a note in the medical record. The eye clinic visited the facility twice a month, but the residents were only seen every six months. The ADON looked at the resident's medical record and did not see where the recommendation was addressed. The ADON said the nurse placed a call to the physician to ask about the recommendation. The physician said the resident could continue the eye drops. The ADON would have expected the pharmacy review to have been addressed before today.
2. Review of Resident #16's quarterly MDS, dated [DATE], showed:
-admission date of 9/7/2016;
-Cognitively intact;
-Diagnoses included heart disease, high blood pressure, diabetes, and high cholesterol.
Review of the resident's electronic pharmacist DRRs, dated 9/27/24, 12/13/24, and 2/3/25, showed:
-Please take the following actions: Resident receives the following lipid-lowering medication(s): Atorvastatin 40 milligram (mg) tablet;
-Package insert and clinical guidelines recommend periodic checks of fasting lipid panels to monitor therapy;
-None in chart since 4/2023;
-Check fasting lipid panel now and yearly going forward.
Review of the resident's laboratory results, showed the most recent lipid panel was on 4/4/23. The facility did not provide laboratory results after 4/23. No hard copies of the pharmacist DRR sheets were provided on the review dates referenced in the pharmacy DRR recommendations.
During an interview on 4/10/25 at 12:42 P.M., the DON said they would not address the pharmacist's DRR and/or recommendations until they received the actual hard copies which were provided by pharmacy staff a few days after the electronic versions were posted electronically. They then sort out the DRR sheets and distribute to corresponding providers. They scanned the DRR sheets into the electronic health records once the providers addressed the DRR.
During an interview on 4/11/25 at 11:09 A.M., the Primary Care Physician (PCP) said he/she did not know how those three pharmacy DRR recommendations were missed. The PCP said if not scanned into the EHR, they would not be seen or addressed. He/She said the resident's previous lipid panels were good. He/She ordered to have the resident's lipid panel drawn and will be done for the 5/2/25 schedule.
3. During an interview on 4/11/25 at 11:59 A.M., the Pharmacy Consultant said all their DRR sheets were delivered to the facility a few days after being posted electronically. The providers may not be able to address the recommendations, depending on the timing of the visits, for up to three weeks. The pharmacy sends a monthly summary of all the residents reviewed, through email, in addition to the individual sheets provided.
4. During an interview on 4/11/25 at 11:43 A.M., the DON said she expected the staff to make sure the monthly Pharmacist DRRs were addressed timely and to follow the provider's orders.
CONCERN
(E)
Potential for Harm - no one hurt, but risky conditions existed
Unnecessary Medications
(Tag F0759)
Could have caused harm · This affected multiple residents
Based on observation, interview and record review, the facility failed to ensure a medication error rate of less than 5%. Out of 37 opportunities observed, five errors occurred resulting in a 13.51% e...
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Based on observation, interview and record review, the facility failed to ensure a medication error rate of less than 5%. Out of 37 opportunities observed, five errors occurred resulting in a 13.51% error rate (Residents #67, #112, #157 and #141). The census was 181.
Review of the facility's Insulin Administration via Pen Devices policy, last reviewed 5/2021, showed:
-Purpose: To safely administer insulin via pen devices according to physician orders and facility recommendations;
-Insulin pens containing multiple doses of insulin are meant for use on a single person only and should never be used for more than one person, even when the needle is changed. Insulin pens should be clearly labeled with the person's name or other identifying information to ensure that the correct pen is used only on the correct individual;
-Remove the pen cap and cleanse the rubber stopper wit an alcohol wipe Attach pen needle to device;
-Prime the pen immediately before injection. Priming is dialing up 2 units of insulin and pressing the button on the top of the pen to shoot some insulin into the air. You should see a drop of insulin at the end of the needle. More than one prime may be required for a new pen;
-Dial up the dose on the pen as indicated on the order;
-Verify that insulin is being given at the correct time in relation to meals;
-For Humalog (short acting insulin) administer 15 minutes before a meal or immediately following.
1. Review of Resident # 67's medical record, showed:
-Diagnoses included diabetes and dementia;
-An order dated 4/07/25, for insulin Humalog (short acting insulin) administer 8 units subcutaneous (under the skin) three times a day with meals at 8:00 A.M., 12:00 P.M. and 5:00 P.M.
Observation on 4/08/25, at 7:26 A.M., showed Licensed Practical Nurse (LPN) D obtained a blood sugar result of 115. LPN D drew up 8 units of Humalog after priming 2 units. LPN D administered the insulin into the resident's left arm without pinching the skin to ensure the insulin was administered subcutaneous. He/she existed the room. Resident #67 was not brought to breakfast until 8:13 A.M., were he/she was observed holding his/her head. When asked what's wrong, he/she said, I feel sick to my stomach, and they bring me to lunch. At this time, no residents in the unit dining room were served breakfast. Staff served the resident breakfast at 8:34 A.M. (1 hour and 8 minutes after he/she received short acting insulin).
2. Review of Resident #112's medical record, showed:
-Diagnoses included diabetes;
-An order dated 4/2/25, for insulin aspart (short acting insulin) administer 18 units three times a day with meals;
-An order dated 4/2/25, for Lantus Solostar (long-acting insulin), administer 30 units daily, scheduled administration time between 7:15 A.M. and 11:15 A.M. daily.
Observation on 4/8/25 at 7:24 A.M., showed LPN E entered the resident's room and obtained a blood sugar result of 158. He/She obtained the resident's insulin aspart pen, placed the needle on the pen, and set the pen to administer 18 units. He/She administered the insulin into the resident's abdomen. The insulin pen was not primed prior to administration. LPN E said he/she would administer the resident's Lantus after he/she obtained a Lantus pen from stock. At 8:35 A.M., LPN E obtained the resident's Lantus pen, placed the needle on the pen, and set the pen to administer 30 units. He/She administered the insulin into the resident's abdomen. The insulin pen was not primed prior to administration.
3. Review of Resident #157's medical record, showed:
-Diagnoses included diabetes;
-An order dated 3/13/25, for Basaglar (long-acting insulin) pen, administer 10 units every 12 hours, scheduled at 8:00 A.M. and 8:00 P.M.
Observation on 4/8/25 at 7:41 A.M., showed LPN E obtained a blood sugar level of 104. LPN E obtained the resident's Basaglar insulin pen, placed the needle on the pen, and set the pen to administer 10 units. He/She administered the insulin into the resident's left upper arm. The insulin pen was not primed prior to administration.
4. Review of Resident #141's medical record, showed:
-Diagnoses included diabetes;
-An order dated 8/7/24, for Humalog insulin pen, administer 7 units with meals;
-An order dated 8/7/24, for Humalog sliding scale insulin, administer no additional insulin for a blood sugar below 200.
Observation on 4/8/25 at 8:17 A.M., showed LPN E obtained a blood sugar level of 189. The resident said he/she already ate breakfast of cereal and an egg and sausage sandwich. LPN E obtained the resident's Humalog insulin pen, placed the needle on the pen, and set the pen to administer 7 units. He/She administered the insulin into the resident's upper arm. The insulin pen was not primed prior to administration.
5. During an interview on 4/10/15 at 1:50 P.M., with the Director of Nursing (DON) and Infection Preventionist, they said when administering insulin, staff should follow the facility policy on how close to mealtime the insulin should be administered. The risk of too much time going by between administration of a short acting insulin is hypoglycemia (low blood sugar level). Staff should follow facility policy on priming insulin pens. The standard is to prime with 2 units. Not priming the insulin pen could result in the wrong dose of insulin being administered. Blood sugar levels should be checked prior to the resident eating their meal. If a blood sugar level is obtained after the resident eats, the results would not be accurate, and they would get the wrong dose of sliding scale insulin.
CONCERN
(E)
Potential for Harm - no one hurt, but risky conditions existed
Deficiency F0761
(Tag F0761)
Could have caused harm · This affected multiple residents
Based on observation, interview and record review, the facility failed to ensure drugs and biologicals were stored in accordance with acceptable standards of practice. The facility identified five med...
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Based on observation, interview and record review, the facility failed to ensure drugs and biologicals were stored in accordance with acceptable standards of practice. The facility identified five medication rooms. Issues were found in two of the three medication rooms checked. Staff failed to double-lock the refrigerated controlled medications. The sample was 35. The census was 181.
Review of the facility's Medications, Controlled Drugs policy, last revised 2/2023, showed:
-All controlled medications must be stored in separately locked area that requires a different key;
-Refrigerated Ativan (Lorezepam) liquid and injectable medications require a small lock box for the refrigerator.
Review of the facility's Storage of Drugs policy, updated 12/21, showed compartments and areas containing drugs are locked when not in use or when left unattended. Such areas include drawers, cabinets, rooms, refrigerators, carts and boxes.
Observation and interview 4/8/25 at 10:20 A.M., showed a refrigerator with no lock system in the medication room of Hall 300. There was an unlocked black box inside the refrigerator which contained two unopened bottles of Lorazepam Oral Concentrate (used to treat anxiety), 2 milligrams per milliliters (mg/ml). Licensed Practical Nurse (LPN) W said they did not have a lock to the refrigerator or to the black box. He/She said they never had to lock the box since the medication room door was always locked. The nurses and Certified Medication Technicians (CMTs) had access to the medication room and refrigerator.
Observation and interview 4/8/25 at 11:15 A.M., showed a refrigerator with no lock system in the medication room of Hall 500. The unlocked black box inside the refrigerator contained five Lorazepam Oral Concentrate bottles. Registered Nurse (RN) X said they never locked the black box. RN Y said those medications were to be discarded. The black box was always unlocked. They did not have a lock and key to the box.
During an interview on 4/10/25 at 12:42 P.M., the Director of Nursing (DON) said the refrigerated controlled medications were to be stored in locked tackle boxes in each medication room. She expected the staff to double-lock the controlled medications. The nurses and CMTs should have the keys to the medication rooms and the tackle boxes.
CONCERN
(E)
Potential for Harm - no one hurt, but risky conditions existed
Infection Control
(Tag F0880)
Could have caused harm · This affected multiple residents
Based on observation, interview and record review, the facility failed to follow acceptable infection control practice during care of residents. Staff failed to follow Centers for Disease Control and ...
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Based on observation, interview and record review, the facility failed to follow acceptable infection control practice during care of residents. Staff failed to follow Centers for Disease Control and Prevention (CDC) guidance for Personal Protective Equipment (PPE) use for one resident with a contagious form of diarrhea and failed to ensure the facility policy for isolation was held to the same standard as the CDC guidance (Resident #424). Staff failed to ensure insulin pens were only for single resident use for one resident (Resident #67) when staff prepared to administer a different resident's insulin pen to the resident, prior to being stopped by the surveyor. Staff failed to follow proper enhanced barrier precaution (EBP, precautions used on residents with high risk of getting infections, who are not infectious themselves) for one resident who received personal care (Resident #22). Staff failed to cleanse the shared blood sugar machine with approved cleansing products between each resident use for four residents (Resident #112, #157, #32, and #141). Staff failed to follow proper infection control practices during medication administration for one resident (Resident #57) when staff administered a pill that had dropped on the medication cart, with their ungloved hands. In addition, staff failed to ensure resident laundry was covered when transported through the halls. The sample was 35. The census was 181.
1. Review of the facility's Clostridioides Difficile (C-diff., a very contagious bacterial infection that causes symptoms such as frequent watery diarrhea) Infection policy, dated 2/21, showed:
-Policy: it is the policy of this facility to institute contact precautions for residents with known C-diff who are exhibiting diarrhea stools due to the infection in the following situations: when the resident is incontinent and soiling of the environment with stool is likely, when the resident is noncompliant with basic personal hygiene and hand washing, when contaminated stool cannot be contained, or when the resident is confused and cannot comply with appropriate hygiene measures;
-Procedure: gowns should be worn if direct care (bathing or lifting) is provided.
Review of the CDC.gov/c-diff/hcp/clinical overview, dated 3/5/24, showed, treatment and recovery, if C-Diff infection is confirmed, continue isolation and contact precautions.
Review of Resident #424's medical record, showed:
-Resident can make his/her needs known;
-Diagnoses included hemiplegia (paralysis on one side of the body) and hemiparesis (weakness on one side of the body) following stroke affecting left non-dominant side.
Review of the resident's care plan, in use at the time of survey, showed:
-Problem: Resident had a deficit in functional ability with activities of daily living (ADLs, grooming, dressing, bathing and hygiene) for self-care and mobility related to recent stroke, weakness and required mechanical lift assistance;
-Goal: will participate in ADL activities promoting maximum independence;
-Interventions included: provide assistance with ADLs as needed or requested: bed mobility assist times one, toilet/incontinent care assist times one.
Review of the resident's physician order sheet, showed an order, dated 4/3/25, for Vancomycin (antibiotic) 125 milligrams (mg) every six hours for nine days.
Review of the resident's progress notes, dated 4/6/25 at 9:20 A.M., showed the resident continues antibiotic/vancomycin 125 mg for C-diff until 5/1/25. Resident had one episode of diarrhea prior to breakfast meal.
Observation and interview on 4/8/25 at 8:20 A.M., showed the resident up in his/her wheelchair, in the dining room. Staff propelled the resident back to his/her room. There was an EBP magnet on the door frame. PPE hung on the bathroom door. Certified Medication Technician (CMT) Q and Certified Nurse Aide (CNA) R washed their hands in the resident's bathroom and put gloves on, then they attached the mechanical lift cloth to the mechanical lift and transferred the resident from his/her chair into bed. Staff assisted the resident to roll towards the window and staff tucked the mechanical lift pad under the resident. Staff then rolled the resident towards the door and the lift cloth was removed. CMT Q and CNA R removed their gloves, performed hand hygiene and put new gloves on. Staff unfastened the resident's brief and tucked it down between his/her legs. Staff then provided perineal care (peri-care, care to the surface area between the thighs, extending from the pubic bone to tail bone). CNA R said the resident was incontinent of bowel. Staff did not wear a gown during the transfer nor while providing direct resident care.
Observation on 4/9/25 at 6:50 A.M., 4/10/25 at 7:50 A.M., and 4/11/25 at 7:20 A.M., showed the EBP magnet remained on the door frame. No isolation sign was posted.
During an interview on 4/10/25 at 10:10 A.M., Licensed Practical Nurse (LPN) S said the resident was on EBP because he/she had C-diff.
During an interview on 4/10/25 at 9:20 A.M., CNA T said residents who had wounds or Covid had an EBP magnet outside their door. Staff should wear gloves, N95 mask, face shield and gown every time they enter the resident's room.
During an interview on 4/10/25 at 9:47 A.M., CNA U said residents who had wounds had an EBP magnet outside their door. He/She performed hand hygiene and wore gloves for all personal care. He/She did not know if any other PPE would be required or not.
During an interview on 4/10/25 at 10:10 A.M., LPN S said residents who have catheters or infections had an EBP magnet on their door frame. Staff should wear gloves and gowns while providing care. During report, the CMT/CNAs are made aware of which residents require PPE.
During an interview on 4/10/25 at 12:00 P.M., CNA R said he/she was made aware which residents required PPE during report. If the resident had an EBP magnet outside their door, that meant the resident had an infection and staff should wear gown and gloves and if there are face shields by the door, they should also wear it. The PPE should be worn every time staff enter the room.
During an interview on 4/11/25 at 9:40 A.M., with the Director of Nursing (DON) and the Infection Preventionist (IP), the IP said she was responsible for putting the EBP magnets out. Residents who have wounds, intravenous lines (IV), catheters and gastric tubes would have a magnet placed outside their door. Staff should wear gown and gloves while providing direct patient care. If staff was transferring a resident with the mechanical lift and the resident was already dressed, the staff are not required to wear a gown. If staff was performing peri care on a resident, staff should wear a gown. If a resident had C-Diff and their BM was not contained, that resident would be placed on contact precautions, but if the BM was contained the resident was placed on EBP. If the resident is on contact precautions there would be a sign on the door, if the resident was on EBP they would have a magnet on the door frame. C-diff is highly contagious, staff should wear gown and gloves while providing direct patient care. If staff do not wear a gown there is potential for bacteria to get on their clothes or on their hands and they could spread it to other residents or staff. The IP said she would expect for staff to wear the proper PPE.
2. Review of the facility's Insulin Administration via Pen Devices policy, last reviewed 5/2021, showed:
-Purpose: To safely administer insulin via pen devices according to physician orders and facility recommendations;
-Insulin pens containing multiple doses of insulin are meant for use on a single person only and should never be used for more than one person, even when the needle is changed. Insulin pens should be clearly labeled with the person's name or other identifying information to ensure that the correct pen is used only on the correct individual.
Review of Resident #67's medical record, showed:
-Diagnoses included diabetes;
-An order, dated 4/7/25 for Humalog insulin (short acting insulin) 8 units subcutaneous (under the skin) scheduled administration at 8:00 A.M., 12:00 P.M., 5:00 P.M.
Observation on 4/8/25 at 11:22 A.M., showed LPN D obtained the lunch blood sugar for the resident with a blood sugar result of 160. He/She obtained a Humalog insulin pen and set the pen to administer 8 units. Observation of the insulin pen, showed a different resident's name listed on the pen. Before he/she could administer the insulin, the observation was stopped by the surveyor to prevent cross contamination to Resident #67. LPN D acted surprised and confirmed he/she had the wrong resident's insulin pen. At this time, he/she had to pull a new insulin pen from the E-kit (medication stock) for the resident. LPN D then primed and then resumed to administer the resident's ordered insulin.
During an interview on 4/10/25 at 1:50 P.M., the DON confirmed that facility policy is for insulin pens to be assigned to the resident and insulin pens should never be shared among other residents for any reason.
During an interview on 4/10/25 at P.M., the IP said it is important to keep insulin pens designated to one resident as opposed to sharing. Sharing insulin pens could have potential harm for blood borne pathogens to spread from resident to resident. Staff were in-serviced last month, March 26 & 27 at their annual training, regarding safety hazards if an insulin pen was to be utilized as a community pen instead of a single resident use as designed. After the in-service each nursing staff were assigned a competency test to show compliance with the education provided.
3. Review of the facility's Enhanced Barrier Precautions policy, dated July 2022, showed:
-Purpose: To reduce the spread of multi-drug resistant organisms (MDRO);
-Residents with colonization of MDRO or with indwelling devices will be placed on EBP;
-Signage will be placed outside of their rooms to alert staff that PPE is needed;
-PPE should be worn during high-contact resident care activities: Dressing, bathing/showering/providing hygiene/changing briefs or assisting with toileting;
-Resident status: Has a wound or indwelling medical device without secretions or excretions that are unable to be contained and are not know to be infected or colonized with any MDRO: Use EBP.
Review of Resident #22's medical record, showed:
-Diagnoses included quadriplegia (paralysis or lack of function in all four limbs);
-A care plan, in use at the time of the survey, showed:
-Problem start date 4/8/25: Category: Infection: Resident is at risk for contracting MDRO due to wound that requires the use of PPE during high contact activities;
-Approach: Resident is on EBP. Staff must perform hand hygiene before and after providing care. Staff to wear gloves and gowns when providing high contact activities.
Observation on 4/9/25 at 7:34 A.M., showed the resident in bed. CNA V stood at the resident's bedside and wore gloves with no gown on. CNA V assisted to lower the resident's pants and provided perineal care. The resident was incontinent of bowel. CNA V assisted the resident to roll to his/her left side and then the right. As he/she assisted the resident to roll, his/her clothing pressed up against the resident. A dressing intact to the resident's buttocks was visible. After providing care, CNA V assisted the resident to use a urinal and get dressed. No gown was worn during care. Observation in the resident's room, showed a PPE caddy with gowns available. Observation of a sign outside the resident's room, showed EBP, perform hand hygiene and wear a gown and gloves.
During an interview with the DON and IP on 4/10/25 at 2:15 P.M., they said if a resident is on EBP, a gown should be worn during perineal care because staff are attempting to curb the spread of the infection.
4. Review of the facility's Blood Glucose Monitors (Equipment Cleaning) policy, last revised February 2021, showed:
-Purpose: To prevent the spread of blood borne pathogens;
-Equipment used to obtain blood glucose (sugar) results that are used for more than one resident will be cleaned before and after each use;
-A container of Oxivir TB (disinfectant) will be stored in each treatment cart;
-Before and after the testing procedure, the nurse will cleanse the monitor with the Oxivir TB.
Review of Resident #112's medical record, showed:
-Diagnoses included diabetes;
-An order dated 4/2/25 for insulin aspart (short acting insulin) administer 18 units three times a day with meals. The medication administration record required a documented blood sugar before administration.
Review of Resident #157's medical record, showed:
-Diagnoses included diabetes;
-An order dated 3/13/25, for blood sugar check every 12 hours, scheduled at 8:00 A.M. and 8:00 P.M.
Review of Resident #32's medical record, showed:
-Diagnoses included diabetes;
-An order dated 1/22/25, for blood sugar check twice a day, scheduled between 7:15 A.M. through 11:15 A.M. and 7:15 P.M. through 11:00 P.M.
Review of Resident #141's medical record, showed:
-Diagnoses included diabetes;
-An order dated 8/7/24, for Humalog (short acting insulin), administer 7 units with meals. The medication administration record required a documented blood sugar before administration.
Observation on 4/8/25 at 7:23 A.M., showed LPN E obtained a blood sugar machine from the medication cart and obtained a blood sugar result from the resident. He/She then wiped off the blood sugar machine with an alcohol wipe and placed the machine back into the top drawer of the medication cart. At 7:41 A.M., LPN E propelled the medication cart to the room of Resident #157. He/She obtained the resident's blood sugar result and cleaned the machine with the approved disinfectant wipes located in the bottom drawer of the medication cart. At 7:53 A.M., LPN E went to the room of Resident #32 and obtained a blood sugar result from the resident. The blood sugar machine was placed directly on the medication cart after use while LPN E administered insulin to the resident. LPN E returned to the medication cart and cleaned the machine with an alcohol wipe. At 8:06 A.M., LPN E went to the room of Resident #141. He/She obtained the resident's blood sugar result and cleaned the machine with the approved disinfectant wipes located in the bottom drawer of the medication cart. LPN E said he/she is agency and really does not get any orientation when coming to the facility for the first time. He/She can ask the staff about care needs of the residents.
During an interview with the DON and IP on 4/10/25 at 2:15 P.M., they said staff should use Oxivir wipes to cleanse the blood sugar machines between resident use. Machines are not to be cleaned with alcohol.
5. Review of Resident #57's electronic Medication Administration Record (eMAR), for April 2025, showed orders for:
-Acetaminophen (Tylenol) tablet 500 mg, administer 1000 mg by mouth three times a day;
-Bethanechol chloride (for urinary retention) tablet, administer 25 mg by mouth three times a day;
-Bisacodyl (for constipation) tablet 5 mg, administer 2 tablets once a day, every other day;
-Diltiazem HCl (for high blood pressure) tablet 120 mg, administer 1 tablet by mouth once a day;
-Docusate sodium (for constipation) tablet 100 mg, administer by mouth once a day;
-Eliquis (blood thinner) tablet 2.5 mg, administer by mouth twice a day;
-Ergocalciferol (vitamin D2, for vitamin d deficiency) capsule by mouth, 1,250 micrograms (mcg) or 50,000 units, administer one capsule by mouth, once a day on Mondays;
-Furosemide (for fluid retention) table 20 mg, administer 1 tablet by mouth once a day;
-Magnesium oxide (for constipation) tablet 400 mg, administer 1 tablet by mouth once a day;
-Montelukast (for asthma) tablet 10 mg, administer 1 tablet by mouth once a day.
During a medication administration observation on 4/8/25 at 8:10 A.M., showed CMT P prepared the residents ordered medication. He/She dropped one of the resident's pills directly on the medication cart. CMT P picked up the pill with his/her bare hand and placed it back in the medication cup with the other pills, then administered them to the resident. The medication cart had some white laxative powder spills on top of the cart when the CMT dropped and picked up the pill.
During an interview on 4/11/25 at 9:40 A.M., the DON said if a staff member dropped a pill, she expected him/her to discard the pill and obtain a new one.
6. Observation on 4/8/25 at 6:27 A.M., showed Laundry Attendant A propelled an uncovered laundry rack full of resident personal clothing, down the 400 halls. At 6:29 A.M., Laundry Attendant A said the facility does all their own laundry. They do not outsource any laundry. They do linen, towels, resident clothing, etc. they have staff on all shifts. Day, evening, and night.
Observation of the laundry room on 4/9/25 at 10:36 A.M., showed two different types of personal laundry racks. One that had a cover and one that did not. Laundry Attendant B said resident personal clothes are transported to the halls using the hanging cart with a cover. The uncovered cart is for laundry room use only.
During an interview with the DON and IP on 4/10/25 at 2:15 P.M., they said clean resident clothing should be covered when transported down the hall. If not covered, contamination could occur.
CONCERN
(F)
Potential for Harm - no one hurt, but risky conditions existed
Food Safety
(Tag F0812)
Could have caused harm · This affected most or all residents
Based on observation, interview and record review, the facility failed to store food in accordance with professional standards for food service safety by failing to cover food and failed to ensure tha...
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Based on observation, interview and record review, the facility failed to store food in accordance with professional standards for food service safety by failing to cover food and failed to ensure that expired thickened dairy products were discarded. The facility also failed to ensure kitchen equipment was kept clean during three of five days of observation. In addition, the facility failed to maintain records of dish washing temperature logs as well as chloride testing logs. Furthermore, the facility failed to follow the puree recipes for six of the seven purees observed and failed to ensure dishes were properly washed in between use. These deficient practices had the potential to affect all residents who consumed food from the facility kitchen. The census was 181.
1. Observation of the kitchen walk in (left side) cooler on 4/7/25 at 11:12 A.M., 4/8/25 at 3:13 P.M. and 4/9/25 at 11:15 A.M., showed:
-An opened box of turkey sausage links exposed to air;
-An opened box of sausage patties exposed to air;
-An opened box of bacon exposed to air.
2. Observation of the kitchen's large storage room on 4/7/25 at 11:12 A.M., 4/8/25 at 3:13 P.M. and 4/9/25 at 11:15 A.M., showed:
-Six-gallon size containers of mustard, with best by dates of 3/6/25;
-Two boxes that contained several containers of Thick and Easy Thickened Dairy Drink, with best by date of 3/6/25;
-One box that contained several containers of Thick and Easy Thickened Dairy Drink, with best by date of 4/2/25;
-One box of Ready Care Apple Juice, with best by date of 1/1/25.
3. Observation of the kitchen on 4/7/25 at 11:12 A.M. and 4/8/25 at 3:13 P.M. and 4/9/25 at 11:15 A.M., showed the following:
-The stove:
-Heavy caked-on stains on the stove burners;
-Heavy caked-on stains along the front of the stove;
-The double deep fryer:
-Old grease in the fryers;
-Baked on grease on strainers and along the inside of the fryers;
-Heavy caked-on stains along the front and on the side in between the grill;
-Stand-alone double oven:
-Heavy caked-on stains along the front inside doors;
-Heavy caked-on stains along the bottom, and sides of oven.
4. Review of the undated puréed food preparation policy, showed:
-Guideline: Puréed foods will be prepared, using standardized recipes to ensure quality, flavor, palatability, and maximum nutritive value;
-Procedure:
-Each menu cycle will be reviewed to ensure there is a puréed recipe for each item to be served;
-Standardized recipes will be used to prepare all puréed foods. The recipes will be adjusted according to the number of puréed diets needed, indicating seasoning and technique to ensure the highest quality;
-Recipes will not use water to thin puréed foods. Only broth, milk, juice, gravy, margarine, or another appropriate condiment that preserves flavor shall be used.
-Food thickener will be used only in accordance with a specific recipe or product instructions. Measure and add commercial thickener, stabilizer, or shaping/enhancing product as directed in the recipe and process until blended.
-Serve with appropriate scoop number or divide equally to provide an equal number portions. All of the pureed foods must be used in order to deliver the correct nutrient density to each resident. The number of servants obtained from the purée recipe must be equal to the number of servings from which you started. For example, if ten servings of the regular recipe are to be puréed, follow the purée recipe for ten servings. The yield of the puréed recipe must give you ten equal puréed servings. If the recipe was altered, the scoop size may also need to be altered. Due to the nature of variance in foods, it is possible that slight alterations or not using all the liquid in a recipe will be required. Therefore, the division of an equal portion of final product to the starting number of servings insures equal nutritive value in each portion. Record this alteration information on the recipe with the date and your initials. Review altered puréed recipes with the facility Registered Dietitian.
-Puréed foods will be the consistency of pudding or smooth, mashed potatoes. A food processor is preferred; however, a blender may be used to make puréed foods.
-The flavor of puréed food will be assessed. The puréed food should have the same desirable flavor as the menu item.
-Staff will be in-serviced on proper preparation of puréed foods.
Observation on 4/9/25 at 7:18 A.M., showed Dietary [NAME] (DC) BB pureed eggs. During an interview at that time, DC BB said he/she was pureeing dishes for five residents. He/She used a jumbo-sized scoop that appeared to look like an ice scoop. He/She placed two full scoops, and two half sized scoops of unmeasured scrambled eggs into the food processor. DC BB poured an unmeasured amount of apple juice into the food processor and pureed the items for approximately ten seconds. He/She stopped and said the mixture needed more thickener and added three scoops of thickener at that time and added an additional unmeasured amount of apple juice and pureed the items for approximately ten more seconds. DC BB stopped the food processor and added an additional unmeasured amount of apple juice and pureed for another ten seconds. DC BB then stopped the food processor and stirred the mixture. DC BB placed the mixture into four small metal aluminum pans and covered the pans with the lids. The consistency was somewhat thick but with a fluffy texture. The mixture was not smooth. Further observation showed DC BB did not consult the recipe book during the preparation.
Review of the pureed eggs recipe, showed the following for nine servings:
-Ingredients:
-Twelve #16 scoops of scrambled eggs (see recipe);
-3/4 cup of milk;
-Method:
-Count out the number of prepared scrambled eggs according to yield desired. Place in food processor;
-Add milk. Purée until smooth. Eggs will be thin cake batter consistency (will tighten up on steam table);
-Portion into steam table pans according to each dining room count. Cover and place in oven or warmer until serving time. Temperature 165 degrees.
Observation on 4/9/25 at 7:28 A.M., showed DC BB pureed bread. DC BB said sometimes he/she would use three or four loaves of bread so he/she would have enough. DC BB tore open the packaging and placed all the bread from four loaves of bread into the food processor. He/She then poured an unmeasured amount of apple juice into the food processor and pureed the items. As the items pureed, DC BB poured an additional unmeasured amount of apple juice through the opening in the lid and pureed the items for a total of approximately 20 seconds and then stopped the food processor. He/She poured an additional unmeasured amount of apple juice into the food processor and then blended the mixture for approximately 15 seconds and stopped the blender. DC BB got another box of apple juice and poured an unmeasured amount of apple juice into the food processor and pureed the items for approximately 15 seconds. DC BB stopped the food processor and then added an unmeasured amount of apple juice and pureed the items for an additional 20 seconds. The consistency was thick but smooth in consistency. Further observation showed DC BB did not consult the recipe book during the preparation.
Review of the pureed bread recipe, showed the following for five servings:
-Ingredients:
-Five slices of bread;
-1/2 cup plus two tablespoons of milk.
Method:
-Place bread in blender or food processor;
-Gradually add milk; blend until smooth; chill until serving time. Serve chilled or reheat to 165° degrees;
-Portion with number 16 scoop.
Observation on 4/9/25 at 7:35 A.M., showed DC BB pureed ham. He/She rinsed out the bowl and rinsed off the lid of the food processor from the previous bread puree with water. There was still residue on the lid and batter on the inside on the sides of the bowl. DC BB placed 17 pieces chunks of ham inside the food processor and blended about ten seconds and stopped the food processor. He/She poured an unmeasured amount of apple juice inside the food processor. DC BB got another box of apple juice and poured an additional unmeasured amount of apple juice inside the food processor and blended for another 15 seconds. He/She stopped the blender and added an additional unmeasured amount of apple juice and pureed the mixture for an additional 20 seconds. He/She placed the mixture into four small aluminum metal pans and placed lids on top of them. The mixture was gritty in consistency. The mixture was not smooth. Further observation showed DC BB did not consult the recipe book during the preparation.
Review of the pureed meat recipe, showed the following:
-Ingredients:
-Chicken, beef, liver, ham, pork, or fish;
-Method:
-Count out number of portions needed. Place in robot coupe;
-Add complementary broth to reach desired consistency;
-Should be between applesauce and mashed potato consistency;
-Thickener may be added as needed to reach the appropriate consistency;
- Reheat to 165.
Observation on 4/9/25 at 11:17 A.M., showed DC CC pureed pineapple coleslaw. DC CC placed three scoops of thickener, eight scoops of coleslaw and an unmeasured amount of apple juice inside the food processor and pureed the items for approximately ten seconds. He/she stopped the food processor and placed three more scoops of slaw and an additional unmeasured amount of apple juice inside the blender and pureed the items for an additional 30 seconds. DC CC stopped the food processor and said he/she would eyeball the mixture to make sure it was correct and then he/she pureed the mixture for an additional 30 seconds. DC CC placed the mixture into four small aluminum metal pans and placed lids on top of them. The mixture was gritty but soupy in consistency. Further observation showed DC CC did not consult the recipe book during the preparation.
Review of the pureed fruit recipe, showed the following:
-Ingredients:
-Canned fruit or fresh fruit;
-Method:
-Count out number of portions needed;
-Drain canned fruit and place in blender. Fresh fruit in robot coupe;
-Pureed until consistency of applesauce or thicker;
-Juice or thickener may be added to reach consistency.
Observation on 4/9/25 at 11:27 A.M., showed (DC) CC prepared pureed salami, turkey, and pepperoni. DC CC placed four scoops of thickener, nine scoops of salami, turkey, and pepperoni along with an unmeasured amount of beef broth inside the food processor inside the food processor and pureed the items for approximately 45 seconds. He/She stopped the food processor, looked at the mixture, and then poured an additional unmeasured amount of beef broth inside the food processor and stopped it. DC CC pureed the mixture for an additional 35 seconds. He/She stopped the food processor and poured the mixture inside of four small aluminum metal pans. Further observation showed DC CC did not consult the recipe book during the preparation.
Review of the pureed meat recipe, showed the following:
-Ingredients:
-Chicken, beef, liver, ham, pork, or fish;
-Method:
-Count out number of portions needed. Place in robot coupe;
-Add complementary broth to reach desired consistency;
-Should be between applesauce and mashed potato consistency;
-Thickener may be added as needed to reach the appropriate consistency;
- Reheat to 165.
Observation on 4/9/25 at 11:32 A.M., showed DC CC prepared pureed rolls. DC CC placed three scoops of thickener, a package of rolls, and an unmeasured amount of two percent milk inside the food processor and pureed the items for approximately 15 seconds. He/She stopped the food processor and added an unmeasured amount of two percent milk inside the food processor and pureed the items for another 20 seconds. DC CC stopped and said he/she probably needed to add a little more bread. He/She placed three hamburger buns inside the food processor and pureed the mixture for an additional 20 seconds. The mixture was smooth in consistency. Further observation showed DC CC did not consult the recipe book during the preparation.
Review of the pureed bread recipe, showed the following for five servings:
-Ingredients:
-Five slices of bread;
-1/2 cup plus two tablespoons of milk.
-Method:
-Place bread in blender or food processor;
-Gradually add milk; blend until smooth; chill until serving time. Serve chilled or reheat to 165° degrees;
-Portion with number 16 scoop.
5. Observation on 4/9/25 at 11:27 A.M., showed DC CC prepared pureed salami, turkey, and pepperoni. He/She rinsed out the bowl and the lid from the previous pureed onion ring puree. After (DC )CC rinsed the bowl and lid off, residue from the onion ring puree was on the lid and batter was along the inside of the bowl. (DC) CC proceeded to puree the salami, turkey, and pepperoni at that time.
6. Observation of the kitchen on 4/7/25 at 11:12 A.M., 4/8/25 at 3:13 P.M., 4/9/25 at 11:15 A.M. and 4/11/25 at 11:28 A.M., showed:
-Incomplete temperature logs for April 1-11, 2025;
-No temperature logs for February and March 2025;
-No logs for testing the chloride for February, March, and April 2025.
7. During an interview on 4/11/25 at 11:28 A.M., the Dietary Manager (DM) said she expected all food and drinks to be properly labeled, dated and stored, and for all expired items to be discarded. She expected all kitchen equipment to be clean and in proper working order. General cleaning is done every day and deep cleaning of certain items is done daily and some are done weekly. During the dish cleaning cycle, the temperatures are taken and recorded. Staff should be running the machines twice to make sure everything is working properly. The temperatures should be taken at breakfast, lunch and dinner everyday and logged. The test strips to test the chloride in the water should be used as well and logged after every dish washing cleaning service. This is done to make sure that the dishes are being sanitized. This should be done regularly. This was her expectation. She expected proper infection control practices followed while preparing food as well as ensuring dishes are thoroughly cleaned in between use. The DM expected staff follow puree recipes. The recipes should be followed so the food had the right consistency and texture and the flavor should match the food. The texture is part of the consistency. She was not aware the staff used apple juice for a lot of the purees. She expected the puree recipe book to have been opened and used during the preparation of pureed meals. The staff who did the purees worked there for years so he/she knew how to do the purees. They should read the book to make sure nothing changed. She expected the dishes to have been properly cleaned. You don't want bread to taste like meat. She would want the food items to taste like what it is supposed to be.
Oct 2024
2 deficiencies
CONCERN
(D)
📢 Someone Reported This
A family member, employee, or ombudsman was alarmed enough to file a formal complaint
Potential for Harm - no one hurt, but risky conditions existed
Deficiency F0658
(Tag F0658)
Could have caused harm · This affected 1 resident
See Event ID 0G6G12
Based on interview and record review, the facility failed to provide services per acceptable standards of practice and per the resident's plan of care for one of three sampled resi...
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See Event ID 0G6G12
Based on interview and record review, the facility failed to provide services per acceptable standards of practice and per the resident's plan of care for one of three sampled residents (Residents #1) when staff failed to obtain daily weights and send them to the resident's cardiologist per the physician's order. The census was 180.
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
Accident Prevention
(Tag F0689)
Could have caused harm · This affected 1 resident
See Event ID 0G6G12
Based on observation, interview and record review, the facility failed to ensure the residents' environment remained as free of accident hazards as possible and each resident recei...
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See Event ID 0G6G12
Based on observation, interview and record review, the facility failed to ensure the residents' environment remained as free of accident hazards as possible and each resident received adequate supervision and assistive devices to prevent accidents by failing to follow their transfer policy when Certified Nurse Aide (CNA) B, without assistance, attempted to transfer a resident using a Hoyer lift (mechanical lift) (Resident #1). The attempted transfer resulted in the resident sliding off of the lift and hitting the floor. The resident was sent to the hospital for evaluation. The census was 180.
Aug 2024
3 deficiencies
CONCERN
(D)
📢 Someone Reported This
A family member, employee, or ombudsman was alarmed enough to file a formal complaint
Potential for Harm - no one hurt, but risky conditions existed
Deficiency F0658
(Tag F0658)
Could have caused harm · This affected 1 resident
Based on interview and record review, the facility failed to provide services per acceptable standards of practice and per the resident's plan of care for one of three sampled residents (Residents #1)...
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Based on interview and record review, the facility failed to provide services per acceptable standards of practice and per the resident's plan of care for one of three sampled residents (Residents #1) when staff failed to obtain daily weights and send them to the resident's cardiologist per the physician's order. The census was 180.
Review of the facility's Physician Orders, Following policy, dated 6/29/21, showed:
-Purpose: It is the policy of the community to ensure that all Licensed Professional Nurses (Registered Nurse (RN)/Licensed Practical Nurse (LPN)) and other Healthcare Professionals, follow Physician Orders in accordance to State, Federal regulations and their respective practice acts;
-Procedure included:
-All physician orders will be followed as prescribed and if not followed, the reason shall be recorded on the resident's medical record;
-All physician or other healthcare professional's verbal, telephone or written orders will be immediately entered into the electronic health record (EHR) by the nurse obtaining the order.
Review of Resident #1's quarterly Minimum Data Set (MDS), a federally mandated assessment instrument completed by facility staff, dated 8/18/24, showed:
-No cognitive impairment;
-Diagnoses included: stroke, congestive heart failure (CHF, a chronic condition in which the heart doesn't pump blood as well as it should. When this happens, blood often backs up and fluid can build up in the lungs), high blood pressure and hemiplegia (weakness or an inability to move on one side of the body).
Review of the resident's care plan, last reviewed on 8/24/24, and in use during the survey, showed:
-Problem: Resident receives daily diuretic therapy (any substance that promotes diuresis, the increased production of urine) related to diagnosis of CHF;
-Goal: Resident will not exhibit signs/symptoms of hypokalemia (low potassium)/dehydration and will be monitored on an ongoing basis;
-Interventions included obtain/record weight as ordered.
Review of the physician order sheet (POS) , showed an order, dated 8/24/24,for daily weights. Call physician group if weight is up more than three pounds in one day or five pounds in a week.
Review of the resident's medical record, showed a letter from the resident's cardiologist to the facility, dated 9/11/24. The letter included: Resident's cardiologist is requesting resident's daily weights to be sent to our office on a weekly basis starting on 9/11/24. Fax number provided.
Review of the resident's medical record, showed:
-A progress note, dated 9/12/24: New order entered to fax daily weights to resident's cardiologist on a weekly basis. This nurse entered order into EHR for every Monday;
-A progress note, dated 9/12/24: This nurse faxed daily weights from 9/1/24 through 9/11/24 to resident's cardiologist;
-No documentation staff faxed the resident's weight on the following two Mondays, 9/16 and 9/23/24;
-A progress note, dated 9/26/24: Around 12:45 P.M. spoke with representative from resident's cardiologist's office. Informed weights for 9/1 through 9/11/24 were received and weights for 9/12 until now needed to be re-faxed, along with CHF form. Form completed and faxed as requested.
Review of the POS, showed an order dated 9/27/24, daily weights to physician's office on a weekly basis starting on 9/11/24. Once a day on Mondays.
Review of the resident's medical record, showed:
-No documentation staff faxed the resident's weight on the following Monday, 9/30/24;
-A progress note, dated 10/7/24: Weekly weights faxed to resident's cardiologist.
During an interview on 10/9/24 at 12:21 P.M., LPN A said physician orders should be followed. Any nurse could have faxed the resident's weights to his/her cardiologist. He/She said the resident's family member was there last night asking about the weights. Yesterday, LPN A reviewed the resident's weights through 10/7/24 and faxed them to the cardiologist. LPN A said the nurse assigned to the resident on Mondays was responsible to fax the weekly weights to the cardiologist. LPN A said new orders pop up on the EHR screen to sign off on and when there was something to complete for the order.
During an interview on 10/9/24 at 12:39 P.M., LPN D said physician orders should be followed and care plans should be followed as best as possible.
During an interview on 10/9/24 at 2:30 P.M., the Director of Nursing (DON) said nurses knew when there were new orders through shift report and the new orders would pop up on their screen for them to sign off on. She said existing orders would pop up too on the nurse's screen if the order required the nurse to do something. They communicated the resident's weights over the phone with the cardiologist's office. She expected nurses to fax the weights every Monday between 7 A.M. and 3 P.M., as the physician order specified. The nurse responsible for faxing the resident's weights was the nurse assigned to the resident on that shift. The DON said nursing staff spoke to the cardiologist and the cardiologist's office said they received all the weights. She couldn't say what the impact of not receiving the weights would be because all residents were different.
MO00242708
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
Accident Prevention
(Tag F0689)
Could have caused harm · This affected 1 resident
Based on observation, interview and record review, the facility failed to ensure the residents' environment remained as free of accident hazards as possible and each resident received adequate supervi...
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Based on observation, interview and record review, the facility failed to ensure the residents' environment remained as free of accident hazards as possible and each resident received adequate supervision and assistive devices to prevent accidents by failing to follow their transfer policy when Certified Nurse Aide (CNA) B, without assistance, attempted to transfer a resident using a Hoyer lift (mechanical lift) (Resident #1). The attempted transfer resulted in the resident sliding off of the lift and hitting the floor. The resident was sent to the hospital for evaluation. The census was 180.
Review of the facility's Transfer and Lift policy, reviewed 5/2021, showed:
-Purpose: To provide communication to staff about resident transfer abilities and to assure we take all precautions necessary to maintain the safety of our residents including acknowledgement that this facility has adopted a NO LIFT policy (approach that aims to reduce or eliminate staff from the manual lifting of residents) by for residents requiring a mechanical means of transfer;
-Upon admission each resident will be assessed by the inter-disciplinary team on the capability of how the resident transfers; this will be re-assessed with changes in condition and at the quarterly care plan;
-The resident's transfer ability will be indicated in the resident's orders and included on the resident profile and care plan;
-When using a mechanical lift to transfer residents, two employees are required to assist in the transfer, without exception.
Review of Resident #1's medical record, showed a physician order, dated 6/22/24, for: Transfer status x 2 Hoyer lift.
Review of the resident's quarterly Minimum Data Set (MDS), a federally mandated assessment instrument completed by facility staff, dated 8/18/24, showed:
-No cognitive impairment;
-Chair/bed-to-chair transfer, Ability to transfer to and from a bed to a chair (wheelchair): Dependent, staff does all of the effort. Resident does none of the effort;
-Diagnoses included: stroke, congestive heart failure (CHF), high blood pressure and hemiplegia (weakness or an inability to move on one side of the body).
Review of the resident's care plan, reviewed on 8/24/24 and in use during the survey, showed:
-Problem: Resident experiences a deficit in mobility/Activities of Daily Living (ADLs, self-care) function related to hemiplegia, incontinence and the need for assistance with ADL care;
-Goal: Resident will maintain current level of mobility;
-Approaches included: Provide assistance for transferring. Uses the Hoyer lift with two person assist.
Review of the resident's progress notes, showed on 10/9/24 at 9:38 A.M. Licensed Practical Nurse (LPN) A wrote: CNA called for nurse to come to resident's room due to him/her falling from the Hoyer lift during transfer to chair. Resident was on the floor in between the lift and bed, moaning and calling for help. Upon assessment, resident was complaining of neck and back pain with hip and knee pain. Primary doctor and family member notified. Family member requested resident be sent to the hospital for further evaluation. Ambulance transferred resident to the hospital at 9:40 A.M.
During an interview on 10/9/24 at 12:21 P.M., LPN A said the resident had been taken to the hospital. This morning, CNA B went to weigh the resident alone. When he/she moved the resident away from the bed in the Hoyer lift, the resident slipped and fell underneath the lift. LPN A said it always took two people to operate the lift. He/She said all CNA B had to do was ask someone to help him/her because there was more than enough staff on the floor. LPN A would have helped if CNA B would have asked. He/She said CNA B was suspended after the incident. LPN A said the expectation for CNA B was for him/her to ask for help from a peer or the nurse when transferring the resident or any other resident who needed a mechanical lift.
During an interview on 10/9/24 at 2:07 P.M., Certified Medication Technician (CMT) H said he/she knew the resident and had helped with transferring the resident in the past. CMT H said the resident was a Hoyer lift transfer and it took two people to work the lift always, no exception. He/She said there would never be a time when only one staff transferred a resident with a mechanical lift. Everyone knew that. He/She knew what type of transfer the resident was by a sign on his/her door, shift report, and by looking in the resident's chart. CMT H said he/she never transferred the resident or any other resident using a mechanical lift alone. He/She said CNA B did not ask him/her for help to transfer the resident.
During an interview on 10/9/24 at 2:13 P.M., CNA I said he/she knew the resident and his/her transfer information was posted on the wall in the resident's room. He/She said the resident was a Hoyer lift transfer and he/she would know because a lift pad would be in the resident's chair. He/She said it took two people to work the Hoyer lift and there was never a time when only one person should use it to transfer a resident. He/She never transferred the resident or any other resident with a mechanical lift alone. CNA I had been educated on mechanical lifts.
During an interview on 10/9/24 at 12:48 P.M., CNA E said it always took two people to operate a mechanical lift. He/She said one person should not use the lift to transfer a resident.
During an interview on 10/9/24 at 2:30 P.M., the Director of Nursing (DON) said what happened to the resident today was bad. She helped the charge nurse with the assessment and there didn't appear to be any apparent injuries. She spoke with the hospital, and they told her the resident had no trauma or acute injury. The hospital was looking to discharge the resident back to the facility today. She expected nursing staff to follow the physician's orders. She expected CNA B to ask for help with transferring the resident using a Hoyer lift. She said they provided comprehensive education and reminded staff what the transfer policy was. She expected CNA B and all other staff to follow the transfer policy.
MO00242708
CONCERN
(F)
📢 Someone Reported This
A family member, employee, or ombudsman was alarmed enough to file a formal complaint
Potential for Harm - no one hurt, but risky conditions existed
Deficiency F0925
(Tag F0925)
Could have caused harm · This affected most or all residents
Based on observation, interview, and record review, the facility failed to maintain an effective pest control program to prevent roaches and gnats in the kitchen, where residents' food was prepared an...
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Based on observation, interview, and record review, the facility failed to maintain an effective pest control program to prevent roaches and gnats in the kitchen, where residents' food was prepared and served. The census was 181.
Review of the facility's Pest Control Policy, revised 08/2024, showed:
-Purpose: To ensure that the facility is free to exposure to pests to include, but not limited to insects, cockroaches, rats, mice, bed bugs, etc;
-Procedure:
-The Director of Environmental Services is the designated coordinator for this facility. This person acts as a liaison between the building occupants and the pest management provider;
-Regular inspections will be performed by both the Director of Environment Service/designee and the contracted pest management professional. They will note situations that are conducive to pest populations and recommend repairs, sealing of pest entry points, clutter reduction, improved sanitation, and monitoring procedures;
-Repairs will be performed as needed to prevent pest access to buildings or to hiding spaces in walls and equipment. Water leaks will be repaired, and standing water will be eliminated whenever possible;
-Proper sanitation will be maintained, and clutter reduced to prevent food and harborage for pests;
-Proactive/preventative measures for roaches and other pest: The Environmental and Dining Services staff will regularly inspect and perform and/or request preventative maintenance to ensure areas are clean, dry and pest free;
-Wet places: Water is the main draw for any pest, so inspect sinks (including under the lip), dishwashers, pipes, cooler and refrigerator doors, ice machine lids and other areas of water pooling and condensation. Include drains and wet floor mats;
-Areas where food debris accumulates: Organic matter collects just about anywhere in a commercial kitchen. Look in the obvious areas - where food is stored, prepared, and served, and where trash is discarded - but also in less conspicuous places, i.e. under equipment;
-Storage rooms: Remove all cardboard boxes and other clutter provide harborage for roaches, rodents, and ants;
-Heat sources: Inspect all equipment that generates heat, pests will gravitate toward it;
-Cracks and holes: Look for any structural weaknesses that might offer pests access to the kitchen. Also check for cracks in the floor tile or worn-away grout;
-Drains and garbage disposal: Roaches are nocturnal, so it is important to block drains at night after pouring Consume Chemical (enzyme that removes food source) down each kitchen drain and garbage disposal (after ensuring disposal is clean and free of food/garbage). Run hot water down sink for a couple minutes prior to pouring Consume down disposal;
-If a roach/pest infestation is found in kitchen or service area, proceed with the Night Kitchen Cleaning - Roach/Pest Control check list and immediately call provider.
Review of the facility's Kitchen/Service Area/Dry Storage and Dish Room Night Cleaning/Checks - Roach/Pest Control form, showed:
-Leave floor fans blowing at top speed in infested area(s);
-Ensure no leaks or water sitting in areas;
-Ensure all food is completely covered--NO FOOD SHOULD BE LEFT OUT AT NIGHT;
-Ensure no open cracks/crevices in walls/floors;
-Ensure that no produce boxes, paper bags or cardboard are left in area;
-Ensure no dirty dishes are left on dish machine;
-Cover all floor and sink drains with stopper and/or rubber mats every night.
Review of the facility's Pest Control vendor binder, showed:
Areas of concern:
-9/29/23: Gnats entire dietary kitchen, office, dish room and janitor area;
-10/28/23: Kitchen and doors to kitchen, roaches;
-5/20/24: Human Resource/Public Relations office - roaches;
-5/21/24: 500 Serving and hot cart - roaches;
-8/19/24: Roaches in Recreation office;
-The pest control binder concerns were written randomly, were not in chronological order, and did not include the concern for all entries.
During an interview on 8/21/24 at 10:14 A.M., the Maintenance Director said he had gone around the facility to caulk cracks and holes, anywhere there were hiding spots. He measured all the drains and was in the process of getting covers for the drains. He thought keeping food put away and boxes off the floor would help because the boxes were just an extra place for the roaches to hide. He said the night staff in the kitchen was supposed to put baking soda and vinegar down the drains after dinner. He was Floor Technician D's supervisor, but he didn't know if he/she had sprayed or treated the kitchen in the evening with the chemical.
Observation of the facility's main kitchen on 8/20/24 between 10:49 A.M. and 11:55 A.M., showed:
-Bait traps filled with brown cockroaches;
-Cockroaches crawled on multiple walls and on the floor in the kitchen;
-There were dead cockroaches in the corners of the kitchen floor;
-There was a dead cockroach on a prep table near two boxes of gloves;
-Multiple cockroaches crawled on the silver platform where dishes were placed for washing after meal service;
-Some cockroaches were dead on the platform in puddles of water;
-There were three large white trash bags tied up on the floor near a large trash can in the kitchen;
-There was one black fan in the kitchen near a door and was not running.
During an interview on 8/20/24 at 10:49 A.M., the Dietitian said the Kitchen Manager was not in today. She said the pest control company came out two times a week. The pest control company left Maintenance some of the chemical used to treat the roaches in the kitchen. The Dietitian said staff sprayed the kitchen last night and thought that was why the roaches were so active today.
During an interview on 8/20/24 at 11:15 A.M., a Dietary Aide A said the facility had a lot of roaches and gnats. He/She was told the facility was sprayed last week. He/She had seen the pest control person spray and take away old traps. He/She didn't know when the last time the roach bait traps had been replaced. He/She had seen roaches crawl on resident's plates, but he/she did not serve those plates to residents.
Observation on 8/20/24 at 11:15 A.M., showed brown boxes in the walk-in cooler and one large brown box on the floor near a trash can in the kitchen.
During an interview on 8/20/24 at 11:55 A.M., Dietary Aide C said bugs and roaches came out from time to time. He/She said a company sprayed every other week and Maintenance had sprayed before too. He/She was off yesterday but thought the last time the facility had been sprayed was four days ago.
Observation on 8/20/24 at 11:55 A.M., showed boxes and other items on the floor and up against the wall in the office located in the kitchen area.
During an interview on 8/21/24 at 10:28 A.M., Resident #3 said he/she had seen roaches in his/her room before but not many. He/She saw roaches on the dining room floor yesterday, but not in his/her food.
During an interview on 8/21/24 at 2:17 P.M., Resident #2 said he/she had seen roaches in his/her room and the dining room. He/She said the facility tried to spray when they were told about the roaches. He/She saw roaches crawling on his/her friend's chair in the dining room at lunch today. Resident #2 said he/she had friends living in the facility, whose rooms were infested with roaches. He/She said the residents were moved to a different room and all their clothing was thrown away because of the roaches. He/She said the facility tried to blame the roaches on the residents, but they were clean people. He/She didn't think they were the reason for the roaches in their room.
During an interview on 8/20/24 at 12:08 P.M., the Administrator said the pest control company came out last night, so he stayed late. Two guys came out last night and set traps and sprayed an aerosol and liquid spray. The Administrator said he didn't know if the pest control company changed the bait traps every time they came, but they sprayed the kitchen every two weeks. The pest control company left the facility some of the spray concentrate and a Maintenance Technician sprayed the kitchen with it a couple times a week. He said staff mopped the kitchen everyday but the owner of the pest company, who was there last night, said the pest control company told him not to mop the floors for at least twelve hours. The Administrator said before the owner told him that, staff mopped the floor after each meal. He said he had help to power spray the kitchen floor and found he was standing in water. The water wasn't going down the drain. He thinks the facility had the roaches on the run and were in pretty good shape. The Administrator said the pest control company didn't give him any written recommendations but said they were supposed to keep the standing water off the floor.
During an interview on 8/20/24 at 1:51 P.M., a Pest Control Company Representative said on 8/19/24, the owner of the pest control company told him/her the roaches were from produce boxes and deliveries being brought into the facility. He/She said that's usually where the problem started. The Pest Control Company Representative said the owner also said the facility's cleaning needed to be stepped up and getting the boxes out of the facility would really help. He/She said getting the water off the floor would really help. When water was on the floor and the chemical was sprayed, it laid on top of the water and was washed away when the water was cleaned up or went down the drain. He/She said water rendered the chemical ineffective. He/She said keeping the floor dry and clean was all that was needed to be done. He/She didn't know if the problem was improving or not but was told it seemed to be improving.
Observation and interview on 8/20/24 at 2:01 P.M., showed one black fan running in the kitchen. Dietary Aide A said the fan was on because the kitchen was hot. He/She said the Dishwasher/Pot Cleaner cleaned the floors.
During an interview on 8/20/24 at 2:06 P.M., the [NAME] E said he/she cleaned the front line at the end of shift. The fan was on to help keep the kitchen cool. The building was old and had cracks for roaches to hide. He/She saw the pest control company before but didn't know how often they came. He/She said maybe every two weeks.
During an interview on 8/21/24 at 9:42 A.M., the Administrator said staff knew what the cleaning procedure was, and they had been in-serviced. He said the exterminator said the more fans the facility had in the kitchen the better it would be. The Administrator was was told dietary staff said they used the fan to cool off the kitchen and not used as an intervention for the roaches to keep the floor dry. He said not all staff had been in-serviced on the purpose of the fan to deep the floor dry as an intervention for roaches. The checklist was just created last week. They would in-service everyone. The Administrator said they started taking the boxes out of the kitchen at night and put them in the storeroom they used to share with maintenance. Bugs like boxes and water, so taking the boxes out at night would give the kitchen a clean slate every morning. The Administrator said he spoke with the owner of the pest control company and was told to keep everything off the floor in the kitchen and to keep it dry. He said the owner of the pest control company suggested using bleach and water for the drains, but he thought that might be bad for the pipes, so he suggested baking soda and vinegar. The Administrator said the night shift dishwasher or floor technician was responsible to use the baking soda and vinegar. Dayshift had a cleaning schedule, but it was different from night shift's deep cleaning schedule.
MO00240710
MO00240668
Apr 2024
2 deficiencies
CONCERN
(D)
📢 Someone Reported This
A family member, employee, or ombudsman was alarmed enough to file a formal complaint
Potential for Harm - no one hurt, but risky conditions existed
Safe Environment
(Tag F0584)
Could have caused harm · This affected 1 resident
**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, interview and record review, the facility failed to provide a homelike environment by failing to ensure th...
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**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, interview and record review, the facility failed to provide a homelike environment by failing to ensure three sampled residents on the 100 unit had sufficient hot water for at least three months (Residents #1, #4 and #6). This had the potential to affect all 17 residents who resided on the 100 unit. The census was 185.
1. Review of Resident #1's admission Face Sheet showed the resident was admitted to the facility on [DATE] with diagnoses that included major depressive disorder, generalized anxiety disorder and pain in right hip due to osteonecrosis (occurs when part of the bone does not get blood flow and dies).
Review of the resident's admission Minimum Data Set (MDS), a federally mandated assessment instrument completed by facility staff, dated 8/18/23, showed:
-Cognitively intact;
-Able to make self understood;
-Able to understand others.
During an interview on 4/24/24 at 11:50 A.M., the resident, with his/her family member on the phone, said:
-There had been an issue with the water heater since he/she had been admitted ;
-There had been no hot water in the seven months he/she had been in the facility;
-The lack of hot water had limited the resident's ability to shower;
-The resident would clean himself/herself up in the bathroom sink most days;
-He/She was able to shower independently but did not get showers due to water being too cold for a shower.
Observation on 4/25/24 at 11:28 A.M., showed the water temperature at the handwashing sink in the resident's room, was 86 degrees Fahrenheit (F), after the water was allowed to run for two minutes in that room.
Observation on 4/29/24 at 10:13 A.M., showed the water temperature at the handwashing sink in the resident's room, was 97 degrees F, after the water was allowed to run for four minutes in that room.
2. Review of Resident #4's admission Face Sheet, showed the resident was admitted to the facility on [DATE] with diagnoses that included epilepsy (a disorder in which nerve cell activity in the brain is disturbed, causing seizures), left sided hemiplegia (paralysis of one side of the body) and hemiparesis (weakness or the inability to move on one side of the body), and cognitive communication deficit (difficulty with thinking and how someone uses language).
Observation on 4/29/24 at 2:40 P.M., showed the water temperature at the handwashing sink in the resident's room, was 98 degrees F, after the water was allowed to run for two and a half minutes in that room.
3. Review of Resident #6's admission Face Sheet, showed the resident was admitted to the facility on [DATE] with diagnoses that included generalized anxiety disorder and cognitive communication deficit.
Observation on 4/29/24 at 2:45 P.M., showed the water temperature at the handwashing sink in the resident's room, was 90 degrees F, after the water was allowed to run for four minutes in that room.
4. Review of the facility's 100 Unit Weekly Water Temperature Log, dated February 2024, showed:
-Week one, 2/7/24:
--room [ROOM NUMBER], temperature 111 degrees F;
--room [ROOM NUMBER], temperature 102 degrees F, indicating the water temperature was below the standard 105 degrees F to 120 degrees F;
--room [ROOM NUMBER], temperature 101 degrees F, indicating the water temperature was below the standard 105 degrees F to 120 degrees F;
-Week two, 2/14/24:
--room [ROOM NUMBER], temperature 99 degrees F, indicating the water temperature was below the standard 105 degrees F to 120 degrees F;
--room [ROOM NUMBER], temperature 98 degrees F, indicating the water temperature was below the standard 105 degrees F to 120 degrees F;
--room [ROOM NUMBER], temperature 106 degrees F;
-Week three, 2/21/24:
--room [ROOM NUMBER], temperature 106 degrees F;
--room [ROOM NUMBER], temperature 96 degrees F, indicating the water temperature was below the standard 105 degrees F to 120 degrees F;
--room [ROOM NUMBER], temperature 104 degrees F, indicating the water temperature was below the standard 105 degrees F to 120 degrees F;
-Week four, 2/28/24:
--room [ROOM NUMBER], temperature 101 degrees F, indicating the water temperature was below the standard 105 degrees F to 120 degrees F;
--room [ROOM NUMBER], temperature 104 degrees F, indicating the water temperature was below the standard 105 degrees F to 120 degrees F;
--room [ROOM NUMBER], temperature 106 degrees F.
Review of the facility's 100 Unit Weekly Water Temperature Log, dated March 2024, showed:
-Week one, 3/6/24:
--room [ROOM NUMBER], temperature 90 degrees F, indicating the water temperature was below the standard 105 degrees F to 120 degrees F;
--room [ROOM NUMBER], temperature 105 degrees F;
--room [ROOM NUMBER], temperature 108 degrees F;
-Week two, 3/13/24:
--room [ROOM NUMBER], temperature 103 degrees F, indicating the water temperature was below the standard 105 degrees F to 120 degrees F;
--room [ROOM NUMBER], temperature 89 degrees F, indicating the water temperature was below the standard 105 degrees F to 120 degrees F;
--room [ROOM NUMBER], temperature 100 degrees F, indicating the water temperature was below the standard 105 degrees F to 120 degrees F;
-Week three, 3/20/24:
--room [ROOM NUMBER], temperature 96 degrees F, indicating the water temperature was below the standard 105 degrees F to 120 degrees F;
--room [ROOM NUMBER], temperature 105 degrees F;
--room [ROOM NUMBER], temperature 110 degrees F;
-Week four, 3/27/24:
--room [ROOM NUMBER], temperature 111 degrees F;
--room [ROOM NUMBER], temperature 100 degrees F, indicating the water temperature was below the standard 105 degrees F to 120 degrees F;
--room [ROOM NUMBER], temperature 101 degrees F, indicating the water temperature was below the standard 105 degrees F to 120 degrees F.
Review of the facility's 100 Unit Weekly Water Temperature Log, dated April 2024, showed:
-Week one, 4/3/24:
--room [ROOM NUMBER], temperature 105 degrees F;
--room [ROOM NUMBER], temperature 102 degrees F, indicating the water temperature was below the standard 105 degrees F to 120 degrees F;
--room [ROOM NUMBER], temperature 99 degrees F, indicating the water temperature was below the standard 105 degrees F to 120 degrees F;
-Week two, 4/10/24:
--room [ROOM NUMBER], temperature 112 degrees F;
--room [ROOM NUMBER], temperature 100 degrees F, indicating the water temperature was below the standard 105 degrees F to 120 degrees F;
--room [ROOM NUMBER], temperature 106 degrees F;
-Week three, 4/17/24:
--room [ROOM NUMBER], temperature 103 degrees F, indicating the water temperature was below the standard 105 degrees F to 120 degrees F;
--room [ROOM NUMBER], temperature 101 degrees F, indicating the water temperature was below the standard 105 degrees F to 120 degrees F;
--room [ROOM NUMBER], temperature 98 degrees F, indicating the water temperature was below the standard 105 degrees F to 120 degrees F;
-Week four, 4/25/24:
--room [ROOM NUMBER], temperature 100 degrees F, indicating the water temperature was below the standard 105 degrees F to 120 degrees F;
--room [ROOM NUMBER], temperature 86 degrees F, indicating the water temperature was below the standard 105 degrees F to 120 degrees F;
--room [ROOM NUMBER], temperature 78 degrees F, indicating the water temperature was below the standard 105 degrees F to 120 degrees F.
5. During an interview on 4/29/24 at 1:54 P.M., the Maintenance Director said:
-He/She was the one who did the temperature testing of the water;
-Water temperatures should be between 105 degrees F and 120 degrees F after running the water for two minutes;
-There had been issues with water temperatures on the 100 division being low for a while now, but only on the 100 division;
-It is not acceptable for the residents to go without hot water for so long;
-No residents had complained of low water temperatures to him/her personally, but staff had complained to him/her about it;
-The facility had plumbers come out in February for a couple of weeks to try and figure out the problem and spent thousands of dollars on it and still no definitive answers on what the problem it;
-He/she had changed all the shower heads on the 100 unit and that did not fix the problem;
-He/she is in the process of changing out all the balancing spools also. They only had 10 in stock and had to order the rest.
MO00234143
CONCERN
(D)
📢 Someone Reported This
A family member, employee, or ombudsman was alarmed enough to file a formal complaint
Potential for Harm - no one hurt, but risky conditions existed
Deficiency F0740
(Tag F0740)
Could have caused harm · This affected 1 resident
Based on observation, interview and record review, the facility failed to ensure a resident who was issued a 30-day discharge and known to be homeless, with a diagnosis of major depression, did not re...
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Based on observation, interview and record review, the facility failed to ensure a resident who was issued a 30-day discharge and known to be homeless, with a diagnosis of major depression, did not receive access to behavioral health services as an option to process emotional stressors (Resident #1). The census was 185.
Review of the trauma informed care and behavioral health management policy, revised 9/2022, showed:
-Purpose: the facility will treat all residents with love, care and understanding. The facility believes all behaviors have meaning and is often a way of communication of a need. Assist in the early identification of residents past traumatic events/behaviors and to develop and implement interventions to manage or deescalate those behaviors. The community provides behavioral health services to residents requiring such services;
-Definition: Behavioral health: a state of mental/emotional being and /or choices and actions that affect wellness;
-Procedure:
-Notification and necessary referrals will be sent to the resident's physician and/or psychiatrist;
-Resident identified with or a history of trauma related disorders will have non-pharmacological interventions implemented;
-The resident and/or resident representative are active participants in identifying triggers for behaviors and developing coping interventions;
-Consult with psychiatry for additional interventions once medical and environmental reasons have been ruled out.
Review of the PHQ-2 assessment (used to determine the frequency of depressed mood), dated 11/13/23, showed:
-Should the resident mood interview be conducted: yes;
-Little interest or pleasure in doing things over the last two weeks: no;
-Over the last two weeks, felt down, depressed or hopeless: no;
-Over the last two weeks, have trouble falling or staying asleep or sleeping to much: no;
-Over the last two weeks, been bothered by feeling tired or having little energy: no;
-Over the last two weeks, been bothered by overeating: no;
-Over the last two weeks, feeling bad about self or that your a failure, let yourself or family down: no;
-Over the last two weeks, have trouble concentrating on things, such as reading the paper or watching TV: no;
-Over the last two weeks, been bothered by moving or speaking slowly that others have noticed or being fidgety or restless and moving more than usual: no;
-Over the last two weeks, been bothered by thoughts of being better off dead, or harming self: no;
-Severity score: 0.
Review of Resident #1's quarterly Minimum Data Set (MDS), a federally mandated assessment instrument completed by facility staff, dated 2/10/24, showed:
-admitted : 8/11/23;
-Able to make needs and wants known;
-Does not refuse care, no mood problems;
-Propels self in wheelchair;
-Staff provide set up for care;
-Diagnoses included heart disease, heart failure, anxiety, depression and lung disease;
-Takes as needed pain medication;
-Pain affects sleep occasionally;
-Receives routine antidepressants and narcotic pain medication.
Review of the resident's care plan, dated 2/22/24, showed:
-Problem: Receives antidepressant medications related to depression;
-Goal: Will not exhibit signs of drug related sedation;
-Approach: assess/record effectiveness of the drug treatment, staff monitor and report changes. Monitor the resident's mood and response to medication.
Review of the physician order sheet, showed an order, dated 4/16/24: Prozac (used to treat anxiety and depression) 20 milligram (mg). Take 40 mg once daily.
During an interview on 4/24/24 at 11:50 A.M., the resident said he/she had lived at the facility since August 2023. He/She lived out in the community previously and admitted to the hospital for neck surgery. He/She had been notified in the hospital, he/she had become homeless and lost his/her apartment. He/She admitted to the facility for therapy services. He/She had a bill at the facility and was stressed on how to pay the bill. His/Her family did not agree with the billing, and he/she had been issued a 30-day discharge. He/She appealed the discharge and is awaiting the hearing. He/She was stressed and upset at the loss of his/her home, being discharged from the facility and additional stressors. He/She had anxiety and depression and took routine medication. The facility had not offered a therapist or counselor since his/her admission. He/She said he/she may like to speak to a counselor or therapist.
During an interview on 4/24/24 at 1:50 P.M., the Compliance Officer (CO) said the resident admitted to the facility in August 2023. The resident had a diagnosis of depression and was notified in the hospital, he/she had been evicted from his/her apartment. The resident received routine medication for depression. The resident had been issued a 30-day discharge for failure to pay. The facility had offered different payment arrangements, the resident and family refused the alternative payment options. The resident had no orders for a psychiatric evaluation.
During an observation and interview on 4/29/24 at 11:12 A.M., the resident was in his/her room. He/She appeared frustrated and stressed. The resident called his/her family and said he/she was anxious regarding scheduling orthopedic surgery. He/She was nervous about the upcoming discharge appeal hearing. The facility notified him/her of one other facility willing to accept him/her, but he/she did not want to move to that facility.
During an interview on 4/29/24 at 12:30 P.M., the Social Worker (SW) said the resident admitted to the facility following neck surgery. The resident received therapy services. The resident is his/her own responsible party and the family is very involved in the resident's care. The resident has diagnoses of anxiety and depression and received routine medication. The resident had no history of trauma and staff had not reported any behaviors. The resident was issued a Notice of Medicare Non-Coverage (NOMNC) and the resident refused to apply for Medicaid. The resident had been evicted from his/her apartment during his/her hospital stay. The resident wanted to be discharged to the community and the SW offered contact information to long term stay hospitals. The resident became upset and told him/her that he/she would find a place to stay in the community himself/herself. The resident had been issued a 30-day discharge and appealed the discharge. The appeal hearing was upcoming. The resident had many stressors occurring. The SW conducted a cognitive assessment and depression assessment every 90 days. The resident has visitors frequently and attends physician appointments outside of the facility. Facility management had instructed the management staff to only speak with the resident with two management staff due to developing issues. The SW had not referred the resident to a counselor or therapist. She had backed off the resident. The resident had been accepted into other facilities, and she notified the facility management team of those facilities. She left the notification of acceptance to the facility management to tell the resident.
During an interview on 4/29/24 at 2:21 P.M., the Admissions staff said he/she was present the day the resident came into the facility. He/She attempted to present and read the admission paperwork to the resident. The resident yelled at him/her and tore up the paperwork. He/She did not have any additional interaction with the resident. He/She had been told the resident had been evicted from his/her apartment while in the hospital. He/She did not know if the resident was seen by mental health services.
Review of the PHQ-2 assessment, dated 4/30/23, showed:
-Should the resident mood interview be conducted: yes;
-Little interest or pleasure in doing things over the last two weeks: no;
-Over the last two weeks, felt down, depressed or hopeless: yes;
-How often bothered by this: 7-11 days;
-Over the last two weeks, have trouble falling or staying asleep or sleeping to much: yes;
-How often been bothered by this: 12-14 days;
-Over the last two weeks, been bothered by feeling tired or having little energy: no;
-Over the last two weeks, been bothered by poor appetite or overeating: yes;
-How often have you been bothered by this: 2-6 days;
-Over the last two weeks, feeling bad about self or that your a failure, let yourself or family down: no;
-Over the last two weeks, have trouble concentrating on things, such as reading the paper or watching TV: no;
-Over the last two weeks, been bothered by moving or speaking slowly that others have noticed or being fidgety or restless and moving more than usual: no;
-Over the last two weeks, been bothered by thoughts of being better off dead, or harming self: no;
-Severity score: 3;
-Minor depressive syndrome is suggested if of the 9 items, (1) feeling down, depressed or hopeless, (2) trouble falling or staying asleep, or sleeping too much or (3) feeling tired or having little energy are identified at the frequency of half or more of the days (7-11 days) during he assessment period;
-The assessment is used to track changes in severity over time. The total score can be interpreted 1-4 minimal depression.
MO00234143
Apr 2024
1 deficiency
1 IJ
CRITICAL
(J)
📢 Someone Reported This
A family member, employee, or ombudsman was alarmed enough to file a formal complaint
Immediate Jeopardy (IJ) - the most serious Medicare violation
Deficiency F0678
(Tag F0678)
Someone could have died · This affected 1 resident
**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on interview and record review, the facility failed to provide timely basic life support, including cardiopulmonary resusc...
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**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on interview and record review, the facility failed to provide timely basic life support, including cardiopulmonary resuscitation (CPR, a lifesaving technique that is used in emergencies in which someone's breathing or heartbeat has stopped) for one of four sampled residents, who had physician orders for CPR and was found by staff without a pulse (Resident #1). The resident expired. The census was 191.
The Administrator was notified on [DATE], of the Immediate Jeopardy (IJ) past non-compliance, which occurred on [DATE]. The facility provided training and in-servicing for all staff regarding the facility's CPR policy and using proper definitions/verbiage when reporting on CPR/Death Reporting Form. The IJ was corrected on [DATE].
Review of the facility's CPR Initiation, When Indicated Policy, revised [DATE], showed:
-Purpose: To assure we meet professional standards of quality and provide the necessary care and services to attain or maintain the highest practicable well-being of the residents according to their requests and/or as stated in their Advanced Directives;
-Policy: All licensed nurses are to be CPR certified by a qualified instructor. CPR code status of each resident is to be established and documented by the physician. Code status should then be identified on the physician order sheet. If CPR is indicated, CPR should be performed properly and promptly until advanced medical treatment can be obtained.
-The American Heart Association (AHA) guidelines reflect global resuscitation science and treatment recommendations and are recognized by the Centers for Medicare and Medicaid Services (CMS). AHA has established evidence-based decision-making guidelines for initiating CPR when cardiac arrest occurs in or out of the hospital. AHA urges all rescuers to initiate CPR unless: A valid Do Not Resuscitate (DNR) order is in place, obvious signs of clinical death (e.g. rigor mortis, dependent lividity, decapitation, transection (body is split in two), or decomposition) are present, or initiating CPR could cause injury or peril to rescuer.
-Dependent Lividity: Dependent lividity is a settling of the blood in the lower (dependent) portion of the body postmortem (after death), causing a purplish red discoloration of the skin. When the heart stops functioning and is no longer agitating the blood, heavy red blood cells sink through the serum by action of gravity.
-Rigor Mortis: rigor mortis is the stiffening of muscles due to the absence of adenosine triphosphate (ATP) after death. Without ATP, the myosin and actin (myosin and actin are muscle proteins that work together for muscle contraction) bind together, and the muscle fibers to become rigid. This process begins one to three hours after death.
Review of the resident's Physician's Orders Summary (POS), showed an order, start date [DATE], for Full Code: Administer CPR.
Review of Resident #1's admission Minimum Data Set (MDS), a federally mandated assessment instrument completed by facility staff, dated [DATE], showed:
-Severe cognitive impairment;
-Diagnoses of lung cancer, anxiety, and acute respiratory failure.
Review of the resident's progress notes, showed on [DATE] at 11:27 P.M., Licensed Practical Nurse (LPN) A wrote: This nurse was doing rounds, upon arrival to room, no obvious signs of life, pupils fixed, mucus membranes dry, no rise and fall of chest, no bowel sounds upon auscultation (listening to the sounds of organs, usually with a stethoscope), no pulse obtainable, fingers and toes cyanotic (blue discoloration due to lack of oxygen). Death was pronounced by two nurses at 11:18 P.M. Hospice called to come in and complete end of life notifications, per hospice.
Review of the facility's investigative summary, dated [DATE], showed:
-There were obvious signs of death when LPN A identified the resident had passed away/expired. The obvious signs of death were cyanotic/purplish hands and feet as described by charge nurses LPN A and LPN B. LPN A followed policy and procedure for not administering CPR when there are obvious signs of death present when encountering a resident without vital signs. LPN A followed facility protocol by notifying hospice, family, physician, and medical examiner after death;
-The written statement from LPN B showed:
-On [DATE] at approximately 11:10 P.M., LPN B received call from LPN A who requested assistance with a death assessment. LPN B asked status, and LPN A said the resident was on hospice.
-Upon arrival LPN B walked into the room behind LPN A. The resident showed no signs of life. The resident's pupils were fixed with no response to light, oral cavity was dry, mouth open, no rise/fall of chest, hands and feet dark blue, neither nurse able to find a pulse at any locations. Time of death pronounced at 11:18 P.M
-The written statement from LPN B did not note the resident had rigor mortis or dependent lividity and the clinical definition of rigor mortis and/or dependent lividity was not described in the interview.
During an interview on [DATE] at 11:05 A.M., Certified Nurse's Assistant (CNA) C said on [DATE] at 10:00 P.M. he/she completed a round on the resident, and he/she was breathing evenly. CNA C then left at the end of his/her shift.
During an interview on [DATE] at 10:54 A.M., LPN A said on [DATE] at approximately 11:18 P.M., he/she was completing rounds and found the resident with no signs of life. He/She called LPN B from another hallway to assist. The resident's pupils were fixed, mucus membranes were dry, no rise and fall of resident's chest observed, no bowel sounds, no obtainable pulse, fingers and toes were cyanotic. Mottling (common symptom that occurs near end of life where red and purple spots appear on toes, feet, fingers and spread slowly up the arms and legs) present in hands and feet. Feet and hands were dark blue. LPN A said his/her hands are always cold, so when he/she checked the resident's body temperature by hand, the resident felt not hot and not cold, more lukewarm. When asked during the interview if dependent lividity or rigor mortis were present when examining the resident, LPNA said No. LPN A said he/she did not administer CPR because he/she felt the resident had obvious signs of death.
During an interview on [DATE] at 3:00 P.M., LPN B said he/she received a call from LPN A to come assist with the resident, who had expired. The resident showed no signs of life, with fixed pupils unresponsive to light, dry oral cavity, no rise and fall of chest, hands and feet dark blue, legs mottled. Neither he/she nor LPN A could palpate a pulse at any location. When asked during the interview if dependent lividity or rigor mortis were present LPN B said No when examining the resident. LPN B said he/she did not administer CPR because there were obvious signs of death.
The statements from LPN A and LPN B did not provide a description showing the clinical definition of rigor mortis and/or dependent lividity in their interviews.
During an interview on [DATE] at 1:00 P.M., Physician D said even if a resident is full code and on hospice, he/she would expect the facility to administer CPR and send the resident out to the hospital.
During an interview on [DATE] at 12:15 P.M., the Administrator said when reviewing LPN A's progress notes and LPN B's written statement, he thought both nurses described dependent lividity, not just mottling. He believed the word dependent lividity was not a word that the staff were use to using when charting.
MO00229571
Nov 2023
7 deficiencies
CONCERN
(D)
📢 Someone Reported This
A family member, employee, or ombudsman was alarmed enough to file a formal complaint
Potential for Harm - no one hurt, but risky conditions existed
ADL Care
(Tag F0677)
Could have caused harm · This affected 1 resident
**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, interview and record review, the facility failed to ensure residents received the necessary services to ma...
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**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, interview and record review, the facility failed to ensure residents received the necessary services to maintain good personal hygiene for one resident observed during perineal care (cleansing of the area between the legs to include the buttock and genitals), who was left soiled for an extended period of time (Resident #11). In addition, the facility failed to adequately groom one resident (Resident #90), who was observed with food in his/her beard. The sample size was 35. The census was 183.
Review of the facility's Call Lights-Answering policy and procedure, revised January 2017, showed:
-Purpose: To get to the resident when he/she calls for assistance. To assist the nurse in meeting the resident's request;
-Procedure:
-Go to the resident as soon as he/she calls. Answer within five to 15 minutes. Emergency lights should be responded to immediately to prevent injury;
-Ask the resident, in a friendly manner, what he/she needs;
-Before leaving the resident, tell him/her you will do what was asked.
1. Review of Resident #11's care plan, revised on 6/26/23, showed:
-Problem: The resident is incontinent of bowel and bladder related to functional mobility deficit, wheelchair dependency and the need for staff assistance with care;
-Goal: Staff will attempt to keep the resident dry and free of odors and infection through the next review;
-Approach: Assist to toilet per scheduled plan.
Review of the resident's annual Minimum Data Set (MDS), a federally mandated assessment instrument completed by facility staff, dated 9/3/23, showed:
-Cognitive status not assessed;
-Rejection of care occurred one to three days out of seven;
-Required substantial/maximal assistance for toilet hygiene;
-Always incontinent of bowel and bladder;
-Diagnoses included heart failure, diabetes, asthma, arthritis, depression and anxiety.
During an observation and interview on 11/14/23 at 7:57 A.M., the resident lay in bed on his/her back. The resident smelled of urine and said he/she was soiled. He/She was soiled around 2:00 A.M. and was changed by the evening Certified Nursing Assistant (CNA). The resident pushed his/her call light around 6:00 A.M. but someone came in and turned the light off without checking on him/her. The resident pressed his/her call light. At approximately 7:59 A.M., CNA K entered the resident's room and asked what he/she needed. The resident said he/she was wet and needed to be changed. CNA K turned off the resident's call light and said, I am not your aide today and will not be able to change you. Your regular aide is assisting other residents and when (he/she) is done, (he/she) will change you. CNA K asked the resident what he/she wanted for breakfast. The resident said he/she was soiled and could not think of food while wet. CNA K said, When your aide comes to your room, you can tell (him/her) what you want for breakfast and walked out of the resident's room. The resident said staff will answer call lights, turn them off and won't return.
Observation on 11/14/23 at 8:09 A.M., showed the resident lay in bed on his/her back, still visibly soiled. CNA K walked past the resident's room. At 8:20 A.M., CNA K stood at the nurse's station talking with other staff. At 8:27 A.M. and 8:33 A.M., CNA K walked past the resident's room and did not check to see if he/she had been changed.
Observation on 11/14/23 at 8:54 A.M., showed the resident in bed, still soiled. He/she pushed the call light. At 8:57 A.M., CNA L entered the resident's room, turned the call light off and said, What do you want. The resident said he/she needed to be changed. CNA L told the resident he/she would change him/her after he/she delivered his/her breakfast tray and left the room
Observation on 11/14/23 at 9:07 A.M., showed the resident lay in bed. The surveyor requested to observe perineal care on the resident. CNA L and Nurse M performed perineal care on the resident. The resident's brief was heavily soiled. Nurse M confirmed the resident was soiled. CNA L cleaned between the folds and pink areas on both sides. Pink areas were observed on both sides under his/her buttocks area that appeared to be previously healed areas.
During an interview on 11/14/23 at 9:31 A.M., CNA L said he/she knew the resident needed to be changed but was busy getting other residents out of bed.
During an interview on 11/14/23 at 9:28 A.M., Nurse M said the resident was soiled when they performed perineal care. When the resident pushed his/her call light at 7:57 A.M., the aide should have changed him/her. It was not acceptable to allow the resident to lay in urine for an extended amount of time.
During an interview on 11/17/23 at 10:38 A.M., the Administrator and Director of Nursing (DON) said waiting over an hour to be changed was not acceptable. The CNA should have changed the resident when he/she first entered the resident's room. The CNA should not have left the resident soiled.
2. Review of Resident #90's quarterly MDS, dated [DATE], showed:
-Cognitively intact;
-Exhibited no behaviors such as rejection of care;
-Need for assistance with personal hygiene not assessed;
-Diagnoses included stroke, heart disease and depression.
Review of the resident's care plan, revised 11/14/23, showed:
-Problem: The resident has a deficit in activities of daily living functioning related to dementia, weakness and decreased mobility;
-Goal: The resident will participate in activities promoting maximum independence and staff will assist as needed through next review;
-Approach: Encourage activities of daily living participation to maximize independence. Provide set-up/cueing/assistance as needed. The resident needs extensive assist to dependent with activities of daily living.
During an interview on 11/13/23 at approximately 9:47 A.M., the resident said he/she needed a haircut and beard trim. He/She does not refuse services but felt staff had an attitude when he/she asked for assistance. The resident said his/her beard needed cleaned and trimmed.
Observations on 11/13/23 at approximately 9:47 A.M., and 5:52 P.M., 11/14/23 at 8:11 A.M. and 9:24 A.M., 11/15/23 at 4:43 A.M. and 11/16/23 at 8:35 A.M., showed the resident lay in bed. The resident had a long white beard. Food crumbs were visible in the beard.
During an interview on 11/15/23 at 10:46 A.M., CNA N said the aides were responsible for beard care when showering residents.
During an interview on 11/16/23 at 8:43 A.M., CNA L said the resident was not confused and would allow staff to wash and trim his/her beard.
During an observation and interview on 11/17/23 at 7:50 A.M., CNA O said the resident's beard was filled with crumbs of food and needed to be cleaned and trimmed.
During an observation and interview on 11/17/23 at 7:53 A.M., Nurse A said the resident's beard was dirty and filled with crumbs of food. The resident did not reject care and would allow the aides to clean his/her beard. The condition of the resident's beard was not acceptable.
During an interview on 11/17/23 at 10:38 A.M., the Administrator and DON said the resident's beard should have been cleaned.
MO00209998
MO00226786
MO00209198
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, interview and record review, the facility failed to ensure respiratory services were provided were consistent with professional standards of practice on one resident (Resident #1...
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Based on observation, interview and record review, the facility failed to ensure respiratory services were provided were consistent with professional standards of practice on one resident (Resident #128) when staff failed follow the facility policy and obtain physician orders related to cleaning the resident's Continuous Positive Airway Pressure machine, (C-PAP, a device that uses mild air pressure to keep breathing airways open while sleeping). The sample was 35. The census was 183.
Review of the facility's C-PAP Respiratory Care policy, revised July 2021, showed:
-Purpose: Obstructive sleep apnea (periods when breathing stops) is a sleep disorder that occurs when the airway is obstructed or blocked and as a result, no air moves into or out of the lungs;
-Cleaning:
-Daily: Wash mask with warm washcloth or C-PAP mask or wipes;
-Weekly: Wash mask, tubing and humidifier chamber in mild soapy water, rinse and allow to air dry;
-Monthly: Wash head gear and chin straps monthly and as needed by handwashing with mild soapy water, rinse well and allows to air dry; Filters should be cleaned according to the manufacturer recommendations and replaced monthly.
Review of the resident's face sheet, dated 11/13/23, showed his/her diagnoses included obstructive sleep apnea, heart failure, chronic (long term) kidney disease, diabetes, generalized anxiety disorder, and history of cardiac arrest (heart stops beating).
Review of the resident's care plan, in use at the time of survey, showed it did not address the resident's use of the C-PAP machine.
Review of the resident's Physician Order Sheets (POS), dated 11/13/23, showed;
-An order, dated 4/28/22, C-PAP machine at bedtime;
-An order, dated 4/28/22, wash C-PAP mask with warm wash cloth or C-PAP mask wipes, once daily;
-No further orders for C-PAP cleaning was noted.
During observation and interview on 11/13/23 at 9:15 A.M., the resident said he/she uses his/her CPAP machine every night. The facility staff has never thoroughly cleaned his/her machine in years. A C-PAP machine was observed on a table next to the resident's bed. The water chamber of the C-PAP machine had a small amount of cloudy liquid. The resident said he/she worries about getting a respiratory infection due to the CPAP machine not being properly cleaned.
Observation on 11/15/23 at 4:35 A.M., showed the resident lying in bed with his/her eyes closed and his/her C-PAP machine was on and attached to the resident.
During an interview with on 11/17/23 at 7:50 A.M., Licensed Practical Nurse (LPN) A said he/she was aware the C-PAP machine was to be cleaned daily with wipes but was not aware of a weekly or monthly cleaning schedule.
During an interview on 11/17/23 at 8:02 A.M., Registered Nurse (RN) B said he/she was not aware of a weekly or monthly cleaning schedule for the resident's C-PAP machine. The daily cleaning was the only cleaning that was completed. Proper cleaning of the C-PAP machine is important to maintain so the resident does not develop any type of respiratory infection.
During an interview on 11/17/23 at 10:39 A.M., the Director of Nurses (DON) said she expected nursing staff to follow the facility policies and obtain physician orders related to the cleaning schedule of the resident's C-PAP machine and add it to the care plan.
CONCERN
(D)
Potential for Harm - no one hurt, but risky conditions existed
Deficiency F0760
(Tag F0760)
Could have caused harm · This affected 1 resident
Based on observation, interview and record review, the facility failed to ensure one resident (Resident #127) was free from significant medication error by not notifying the physician and the pharmacy...
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Based on observation, interview and record review, the facility failed to ensure one resident (Resident #127) was free from significant medication error by not notifying the physician and the pharmacy that the resident was refusing his/her Incruse Ellipta inhaler (a medication to treat chronic (long term) lung disease) that was dispensed in place of Spiriva Respimat (a medication to treat chronic lung disease). The sample size was 35. The census was 183.
Review of the facility's Following Physician Orders policy, dated 6/29/21, showed:
-Purpose: It is the policy of the community to ensure that all licensed professional nurses and other healthcare professional, follow the physician order in accordance to State, Federal regulations and their respective practice acts;
-Procedure: All physician orders will be followed as a prescribed and if not followed, the reason shall be recorded on the resident's medical record.
Review of the resident's quarterly Minimum Data Set (MDS, a federally mandated assessment instrument completed by facility staff), dated 11/4/23, showed the resident was cognitively intact.
Review of the resident's face sheet, dated 11/13/23, showed his/her diagnoses included diabetes, pneumonia, and panlobular emphysema (damage to the lung tissue that causes difficulty in breathing).
Review of the resident's care plan, in use at the time of survey, showed it did not address the resident's respiratory issues.
Review of the resident's Physician Order Sheets (POS), dated 11/14/23, showed:
-An order, dated 6/22/23, for Incruse Ellipta Inhaler with device, 62.5 micrograms (mcg), one puff daily;
-An order, dated 11/3/23, for Spiriva Respimat 2.5 mcg, two puffs daily.
Review of the resident's Medication Administration Record (MAR), dated October, 2023, showed:
-On 10/2, 10/3, 10/5, 10/6, 10/8, 10/9, 10/13, 10/14, 10/16, 10/17, 10/18, 10/28, 10/29, 10/30 and 10/31/23, Incruse Ellipta documented as not administered;
-On 10/19 through 10/27/23, staff documented the resident was not in the facility.
Review of the resident's MAR, dated 11/1 through 11/14/23, showed:
-On 11/1, 11/2, 11/3, 11/4, 11/5, 11/7, 11/8, 11/9, and 11/14/23, Incruse Ellipta documented as not administered;
-On 11/3, 11/4, 11/5, 11/7, 11/8, 11/9, and 11/14/23, Spiriva Respimat documented as not administered.
Review of the resident's progress notes, showed no documentation the physician or the pharmacy was notified of the resident's inhaler issues.
During an interview on 11/13/23 at 9:35 A.M., the resident said he/she has been refusing the Incruse Ellipta inhaler because it makes him/her feel like his/her throat is scratchy and clamps up. When he/she was at the hospital a few weeks ago, the resident said the pulmonologist (lung physician) said he/she would write a prescription for the Spiriva Respimat inhaler which worked better for the resident. When the resident returned from the hospital, the facility only offered him/her the Incruse Ellipta inhaler and said the Spiriva Respimat inhaler was not available. The resident said he/she can breathe better and be more active with the Spiriva Respimat. He/She has told multiple facility staff that he/she needs the Spiriva Respimat inhaler.
During observation and interview on 11/14/23 at 9:50 A.M., Certified Medication Technician (CMT) I said the resident has been refusing the Incruse Ellipta for several weeks and the Spiriva Respimat inhaler was not available. The Incruse Ellipta doses were observed unopened in CMT I's medication cart. The resident's Spiriva Respimat inhaler was not located in CMT I's medication cart. CMT I said he/she had let the nurse know of the refusals and they are responsible to call the physician and pharmacy to get medications clarified. CMT I said the resident has not been receiving the Incruse Ellipta inhaler or Spiriva Respimat inhaler.
During an interview on 11/14/23 at approximately 10:00 A.M., Registered Nurse (RN) A said he/she was aware of the resident's refusals and said the resident does what he/she wants and picks and chooses what medication he/she is going to take for the day. He/She wasn't sure if the physician or the pharmacy was made aware of the resident's inhaler issues.
During an interview on 11/14/23 at 11:25 A.M., Pharmacist J said that there was no record of communication between the facility and the pharmacy that the resident was refusing the Incruse Ellipta inhaler. The Incruse Ellipta was sent because the resident's insurance would not cover the Spiriva Respimat inhaler. He/She expected the facility to contact the resident's pulmonologist and let the physician know of the resident's refusals and see if there was any other options available. He/She expected the pharmacy to be notified within a couple of days of the resident refusing medications.
During an interview on 11/16/23 at 9:40 A.M., the Director of Nurses (DON) said the nursing staff is expected to follow physician orders and staff are expected to address resident's inhaler issues by notifying the physician and the pharmacy of the resident refusals and the resident's requests. This would provide better direction with the resident's medications.
CONCERN
(D)
Potential for Harm - no one hurt, but risky conditions existed
Deficiency F0761
(Tag F0761)
Could have caused harm · This affected 1 resident
Based on observation, interview and record review, the facility failed to store all drugs and biologicals at the proper temperature controls when the medication refrigerator thermometer in unit 100 me...
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Based on observation, interview and record review, the facility failed to store all drugs and biologicals at the proper temperature controls when the medication refrigerator thermometer in unit 100 medication room showed out-of-range temperatures. The facility identified having five medication rooms. The census was 183.
Review of the facility's Pharmacy Policy/Procedures Storage of Drugs policy, dated revision 12/21, showed;
-Drugs and medications are to be stored in the original container in which they were received. Refrigerator, freezer and control room will be available in the pharmacy for medications requiring specific storage;
-Medication which require refrigeration are kept in a refrigerator in the locked medication room. Drugs stored under refrigeration are stored separately from food. All refrigerated areas and devices have a temperature between 36 - 46 degrees Fahrenheit (F).
During an interview and observation on 11/15/23 at 8:45 A.M., the temperature of the medication refrigerator on unit 100 showed 56 degrees F. During an interview at this time, Licensed Practical Nurse (LPN) C verified the reading and said he/she did not know what the ranges should be. LPN C attempted to locate refrigerator range in the policy and procedure manual. LPN C verified the temperature parameter on the monthly log sheet which was placed/hung above the refrigerator, cabinet door. He/She was unaware of the temperature range on the log sheet.
Review of the unit 100 medication refrigerator temperature log, reviewed on 11/15/23, for November 2023, showed sections for:
-Day of the week;
-Midnight refrigerator temperature (34-41 degrees F);
-Employee initials;
-Out of range column;
-Notification maintenance temperature range;
-Month/year;
-Unit/area;
-High temperatures or not within parameters, and initialed by staff, on the following dates;
-11/2 - 43 degrees F;
-11/3 - 44 degrees F;
-11/9 - 50 degrees F;
-11/11 - 45 degrees F;
-11/13 - 50 degrees F;
-11/14 - 48 degrees F;
-11/15 - 56 degrees F.
-Out of range and notified maintenance sections blank on the above dates.
Observation and interview on 11/15/23 10:32 A.M., of the unit 100 medication refrigerator, showed temperature at 52 degrees F, LPN C verified the reading. LPN C said the night shift staff is responsible for logging in or checking the refrigerator temperatures. LPN C verified temperature parameter on log sheet which was placed/hung above the fridge, cabinet door. Per log sheet, temperature should be from 34-41 degrees F.
During an interview and observation on 11/16/23 at 8:26 A.M., LPN C said the thermometer was supposed to be placed inside the refrigerator instead of the door. LPN C showed thermometer located in the door, showed a temperature at 52 degrees F. LPN C said he/she checked at around 6:45 A.M. and it was 49 degrees F.
During an interview on 11/16/23 at 2:00 P.M., the Director of Nursing (DON) said review of temperature log sheets are done on a monthly basis. New sheets are posted each month. Certified Medication Technicians (CMTs) monitor temperatures on the day shift. The temperature range on the logs should match the temperature range on the policy. The Administrator and DON were not aware of their policy not matching the log sheet. Both were not aware of exact medication storage refrigerator temperature parameters. The DON expected employees to investigate when temperatures are out of range. She said out of range temperatures should be reported to staff maintenance and nursing management. The DON said they will check with pharmacy, investigate and find the source of the problem, whether the refrigerator or the thermometer were non-functional. She said LPN C had mentioned the day before that there was something wrong with the thermometer. The DON did not investigate.
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
Resident Rights
(Tag F0550)
Could have caused harm · This affected multiple residents
Based on observation, interview and record review, the facility failed to uphold residents' rights by turning off residents' call lights without helping the residents, resulting in residents having to...
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Based on observation, interview and record review, the facility failed to uphold residents' rights by turning off residents' call lights without helping the residents, resulting in residents having to wait long periods of time for help, including one sampled resident (Resident #11) and failed to provide a homelike environment when the residents were served meals on Styrofoam plates for an extended amount of time, including one sampled resident (Resident #182). The sample was 35. The census was 183.
1. Review of Resident #11's care plan, revised on 6/26/23, showed:
-Problem: The resident is incontinent of bowel and bladder related to functional mobility deficit, wheelchair dependency and the need for staff assistance with care;
-Goal: Staff will attempt to keep the resident dry and free of odors and infection through the next review;
-Approach: Assist to toilet per scheduled plan.
During an observation and interview on 11/14/23 at 7:57 A.M., the resident lay in bed on his/her back. The resident smelled of urine and said he/she was soiled. The resident pressed his/her call light. At approximately 7:59 A.M., Certified Nurse Aide (CNA) K entered the resident's room and asked what he/she needed. The resident said he/she was wet and needed to be changed. CNA K turned off the resident's call light and said, I am not your aide today and will not be able to change you. Your regular aide is assisting other residents and when (he/she) is done, (he/she) will change you. CNA K asked the resident what he/she wanted for breakfast. The resident said he/she was soiled and could not think of food while wet. CNA K said, When your aide comes to your room, you can tell (him/her) what you want for breakfast and walked out of the resident's room. The resident said staff will answer call lights, turn them off and won't return. The resident was upset and said he/she would not want to eat breakfast if he/she was wet.
Observation on 11/14/23 at 8:57 A.M., showed CNA L walked into the resident's room after he/she pushed his/her call light. CNA asked the resident, What do you want? and turned the call light off. The resident asked to be changed. The CNA told the resident he/she would change him/her after he/she brought the resident's breakfast. The resident asked the CNA what his/her name was. The CNA replied with the first letter in his/her first name and walked out of the room.
Observation on 11/14/23 at 9:07 A.M., showed the resident lay in bed. The surveyor requested to observe perineal care on the resident. CNA L and Nurse M performed perineal care on the resident. The resident's brief was heavily soiled. Nurse M confirmed the resident was soiled.
During an interview on 11/14/23 at 9:28 A.M., Nurse M said if the resident needed to be changed, the CNA should have prioritized and cleaned the resident.
During an interview on 11/17/23 at 10:38 A.M., the Administrator and Director of Nursing (DON) said residents should be treated with dignity and respect. The CNAs should have changed the resident when he/she told them he/she was soiled.
2 During a group interview on 11/16/23 at 11:00 A.M., six residents, whom the facility identified as alert and oriented, attended the group meeting. Six out of six residents said sometimes they had to wait up until an hour and a half before call lights were answered. Staff would see their call lights going off and would enter the room, turn the call light off and didn't return. At times, staff won't ask the residents what it was they needed when they pressed the call light.
3. Review of Resident #182's admission Minimum Data Set (MDS), a federally mandated assessment instrument completed by facility staff, dated 9/1/23, showed:
-Cognitively Intact;
-Diagnoses of muscle weakness, epilepsy and chronic kidney disease;
-Independent with eating.
During an interview on 11/13/23 at 10:06 A.M., the resident said the facility has been giving residents food on Styrofoam plates and plastic silverware for the past two weeks. He/She said the plastic silverware was hard to use and he/she had difficulty cutting his/her food.
4. During a group interview on 11/16/23 at 11:00 A.M., six residents, whom the facility identified as alert and oriented, attended the group meeting. Six out of six residents said staff served food on a Styrofoam plate and plastic utensils and did not feel this was homelike. Two residents said the food burned through the Styrofoam. The facility had been using Styrofoam for over two weeks.
5. During an interview on 11/17/23 at 7:50 A.M., the Dietary Manager said it is not homelike for residents to be eating on Styrofoam plates because the plates can start melting with warm food. She does not know why the facility decided to use Styrofoam plates instead of other options.
6. During an interview on 11/17/23 at 10:38 A.M., the Administrator said the dishwasher in the kitchen was broken and they were waiting on a part to arrive. Styrofoam plates were not considered homelike but was acceptable.
MO00209198
CONCERN
(E)
Potential for Harm - no one hurt, but risky conditions existed
Deficiency F0658
(Tag F0658)
Could have caused harm · This affected multiple residents
**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, interview and record review, the facility failed to ensure services provided met professional standards of...
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**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, interview and record review, the facility failed to ensure services provided met professional standards of practice by not completing post-fall documentation for two residents (Resident #10 and Resident #128). The facility also failed to follow their policy by not completing a self-administration assessment and obtain physician orders for one resident (Resident #127) that had medications located at his/her bedside. The sample was 35. The census was 183.
Review of the facility's Post-Fall Assessment policy, revised October, 2021, showed:
-The nurse on duty will complete a post-fall assessment event for each fall;
-The charge nurse will implement any immediate interventions necessary to minimize risk of future falls. Be sure to note the date of the fall, any injuries and any new/revised interventions;
-Nurse must assess the resident's condition following the fall and document every shift for 72 hours after a fall.
Review of the facility's Self Administration of Medications policy, reviewed June 2021, showed:
-Before a resident is considered for self-administration of medications an assessment will be performed by the charge nurse and reviewed by the interdisciplinary care plan team for approval;
-A re-assessment will be repeated quarterly unless there is a significant change in condition affecting cognitive abilities and safety regarding self-administration;
-Following the approval of the assessment the charge nurse will obtain a physician order for the resident to self-administer medications noting which medications may be self-administered;
-The resident will be monitored as to usage and effectiveness of as needed (PRN) medications daily to insure that there are no problems that need to be addressed;
-The resident's medication administration record (MAR) will indicate that the resident may self-administer their medication;
-Medications will be stored in the resident's room in a secured area;
-Self-administration of medication is to be addressed in the care plan.
1. Review of Resident #10's, quarterly minimum data set (MDS), a federally mandated assessment instrument completed by facility staff, dated 10/4/23, showed:
-Moderate cognitive impairment;
-No behaviors;
-Impairment to one side of upper extremities and one side to lower extremities;
-Used a wheelchair;
-Diagnoses included traumatic brain dysfunction, heart failure, aphasia (difficulty speaking), anxiety, and depression.
Review of the resident's care plan, in use at time of survey, showed:
-Problem: The resident had a history of falling and was at risk for continued falls;
-Approach: Analyze pattern and trend of falls; Keep call light in reach; Keep bed in lowest position; Provide an environment free of clutter.
Review of the resident's progress notes, showed:
-On 10/28/23 at 9:08 P.M., The resident had a fall this evening and has an abrasion to the right knee. Vital signs (blood pressure (BP), pulse, respiratory rate, and temperature) are within normal limits. No signs or symptoms of distress. Treatment order obtained for knee abrasion. The resident is now at the nurses' station at this time. The bed is in lowest position and mats on the floor. Will continue to monitor;
-On 11/11/23 at 12:36 P.M., The resident remains on post-fall follow up. No post fall injuries noted. Vital signs obtained. The resident's appetite good and no further behaviors at this time;
-No further documentation of the falls.
Review of the resident's event reports in the medical record, showed no event report for the fall on 11/11/23.
During observation and interview on 11/16/23 at 11:15 A.M. the resident sat in a Broda chair (a specialized assistive chair) in his/her room and could not recall any fall he/she had.
2. Review of Resident #128's quarterly MDS, dated [DATE], showed:
-Cognitively intact;
-No behaviors;
-Independent with transfers;
-Diagnoses included heart failure, heart disease, kidney failure, diabetes, anxiety, and depression.
Review of the resident's care plan, in use at the time of survey, showed:
Problem: The resident was at risk for falls related to weakness, anxiety and daily use of diuretics (a medication that removes excess fluid from the body and causes an increase in urination);
Approach: Encourage resident to ask for assistance for periods of unsteadiness. Evaluate the cause of the fall and make changes if needed. Observe resident and redirect for any unsafe behaviors. Keep environment free of clutter.
Review of the resident's progress notes, showed:
-On 11/13/23 at 8:27 A.M., Certified Nursing Assistant (CNA) notified the nurse that the resident was on the floor. Resident was found on floor on his/her back next to bed. The resident denied hitting his/her head. Skin tear to the top of the resident's foot. Active range of motion (ROM) to all extremities. Vital signs obtained. The resident said he/she was attempting to get into his/her wheelchair and his/her knee gave out and the resident slid to the floor. The resident was educated of the benefits of asking for assistance with transfers;
-On 11/15/23 at 3:21 P.M., The resident was found on the floor outside the restroom in front of his/her locked wheelchair. The resident was fully assessed and denied hitting his/her head and denies pain. No new skin injuries. No loss in ROM. The resident said he/she lost balance when attempting to return to his/her wheelchair. Will continue to monitor;
-No further documentation related to falls.
Review of the resident's event reports in the medical record, showed no event report for the resident's 11/13/23 fall.
During an interview on 11/16/23 at 8:30 A.M., the resident said he/she fell on the 11/13/23 and 11/15/23. The resident said his/her knee gave out when he/she tried to transfer himself/herself.
During an interview on 11/16/23 at 8:46 A.M., Registered Nurse (RN) Q said an event report was started after a fall. It had multiple types of nursing assessments to be completed. After the fall, a progress note was made with a general assessment related to the fall every shift for 72 hours.
During an interview on 11/17/23 at 10:39 A.M., the Director of Nurses (DON) said post fall documentation was expected to include an initial fall event report. A progress note related to the fall and vital signs were expected to be documented every shift for 72 hours.
3. Review of Resident #127's quarterly MDS, dated [DATE], showed the resident was cognitively intact.
Review of the residents face sheet, dated 11/13/23, showed diagnoses included diabetes, pneumonia, and panlobular emphysema (damage to the lung tissue that causes difficulty in breathing).
Review of the residents physician order sheets (POS), dated 11/14/23, showed:
-An order, dated 4/29/23, albuterol sulfate inhaler (medication to treat lung disease) 90 micrograms (mcg); two puffs every six hour PRN for shortness of breath;
-An order, dated 5/4/23, albuterol solution for nebulizer (a device that converts the solution into a fine mist for inhalation) 2.5 milligrams (mgs) per 3 milters (mls); administer one vial;
-An order, dated 5/3/23, Budesonide Formoterol aerosol inhaler (a medication that treats lung disease) 160-4.5 mcg; two puffs twice a day;
-No physician order for resident to self-administer medications was noted.
Review of the resident's medical record, showed no assessment for the resident to self-administer medication was documented.
Review of the resident's care plan, in use at the time of survey, showed it did not address the self-administration of medications.
During observation and interview on 11/13/23 at 9:35 A.M., 11/14/23 at 8:30 A.M., and 11/16/23 at 9:00 A.M., the resident said he/she completed his/her own albuterol nebulizer and Budesonide inhaler. Staff did not watch him/her when he/she took the medication. He/She used the albuterol inhaler when he/she felt shortness of breath. He/She usually let staff know when he/she took the medications. The resident's bedside table had two inhalers labeled albuterol and Budesonide Formoterol observed. Multiple vials labeled albuterol solution were located in a white Styrofoam cup located on the resident's night stand.
During an interview on 11/16/23 at 8:48 A.M., Certified Medication Technician (CMT) R said the resident was very alert and was not confused. CMT R said he/she left a cup of medications at the resident's bedside and he/she would take them on his/her own. The resident would let staff know when running low on his/her inhalers and nebulizer solution. The resident did his/her own thing when it came to his/her breathing medication. CMT R was not sure if a physician order was needed for self-administration.
During an interview on 11/14/23 at approximately 9:00 A.M., RN A said the resident's medications were given by the CMT, therefore he/she was not aware if the resident was taking his/her own medications. RN A was not aware if a physician order or an assessment was needed.
During an interview on 11/16/23 at 9:40 A.M., the DON said it was expected that physician orders be obtained, an assessment completed, and the care plan updated for resident medication self- administration. The medication was expected to be in a locked and secure box in the resident's room.
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 keep storage areas clear of trash, keep the kitchen floor, walk in fridge, ice cream storage, and fryer clean, and failed to ensure staff fol...
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Based on observation and interview, the facility failed to keep storage areas clear of trash, keep the kitchen floor, walk in fridge, ice cream storage, and fryer clean, and failed to ensure staff followed the facility's hairnet/beard net policy. This had the potential to affect all residents who consumed food prepared by the facility. The sample was 35. The census was 183.
Review of the facility's cleaning rotation policy, dated 2014, showed:
-Guideline: Equipment and utensils will be cleaned according to the following guidelines, or manufacturer's instructions.
-Procedure: items cleaned daily: kitchen floors, stove top, exterior of large equipment; Items cleaned weekly: store rooms and shelves.
1. Observation on 11/13/23 at 8:44 A.M., on 11/14/23 at 6:48 A.M., on 11/15/23 at 4:26 A.M., and on 11/17/23 at 7:46 A.M., showed the dry storage room to have sticky floors with clear liquid substance covering the main floor. An opened box of potatoes was observed to have a used cup with red liquid and a package of trash in the box on top of potatoes. A shelf with snack food was observed to have two pairs of used gloves, an opened can of soda, and an opened package of snack crackers.
During an interview on 11/17/23 at 7:40 A.M., the Dietary Manager said she expected the dry storage room and box of potatoes to be free of trash. She expected all staff to clean up trash in the kitchen.
Observation on 11/13/23 at 8:42 A.M., 11/14/23 at 6:46 A.M., and on 11/15/23 at 4:25 A.M., showed the doors to the ice cream storage box to be covered with a sticky, red, liquid substance.
Observation on 11/13/23 at 8:48 A.M., showed the floors in the main kitchen to have dirty grout with various crumbs, food debris and scum.
Observation on 11/13/23 at 8:49 A.M., showed the walk in refrigerator number 3 to have a murky white spill on boxes storing food. A dirty towel had been placed on part of the spill. The area under the boxes was caked with brown substance.
Observation on 11/13/23 at 8:51 A.M., 11/14/23 at 6:51 A.M., and on 11/15/23 at 4:27 A.M., showed the fryer covered with sticky grease build up on both sides.
Observation on 11/14/23 at 6:53 A.M., showed the kitchen floors sticky in various locations with clear liquid substance. The grout of the kitchen was observed to have grime and substance.
Observation on 11/14/23 at 6:54 A.M., showed the walk in refrigerator with caked brown substance under boxes being stored on the ground of the refrigerator. A liquid spill was observed under the boxes.
Observation on 11/15/23 at 4:23 A.M., showed the floors of the kitchen had various trash items including white powder substance, broken glass and food wrappers.
During an interview on 11/17/23 at 7:43 A.M., [NAME] E said all dietary staff are in charge of cleaning the floors in the kitchen. He/She said cooks are responsible for cleaning the appliances after each use.
During an interview on 11/17/23 at 7:50 A.M., the Dietary Manager said all staff should clean the kitchen floors and refrigerator doors when they see a mess but that the task is assigned to the dishwasher. She expected cooks to clean appliances after each use.
During an interview on 11/17/23 at 8:02 A.M., the Administrator said he expected the kitchen to be clean and free of trash per the facility's policy.
2. Review of the facility's hair restraint policy, dated 2014, showed:
-Guideline: Hair restraints shall be worn by all Dining Services staff when in food production, dishwashing areas or when serving food from the steam table;
-Procedure: Staff shall wear hair restraints in all food production, dishwashing and serving areas. Hair restraints, hats, and/or beard guards shall be used to prevent hair from contacting exposed food. Facial hair is discouraged.
Observation on 11/14/23 at 6:52 A.M., showed [NAME] E making pancakes. He/She did not wear a beard net. His/Her beard was approximately 3 inches long.
Observation on 11/14/23 at 9:07 A.M., showed Dietary Staff F walked in the kitchen next to where eggs were being cooked, He/She did not wear a beard net. His/Her beard was approximately 3 inches long.
Observation on 11/14/23 at 9:09 A.M., showed a maintenance employee walk through the kitchen prep area where lunch was being prepped. He/She did not wear a hair net. His/Her hair was approximately an inch and a half long.
Observation on 11/17/23 at 7:42 A.M., showed [NAME] E making eggs. He/She did not wear a beard net. His/Her beard was approximately 3 inches long. When interviewed at that time, [NAME] E said hair and beard nets should be worn any time staff are in the kitchen in order to keep hair from getting in the residents' food.
During an interview on 11/17/23 at 7:47 A.M., Dietary Staff G said hair and beard nets should be worn at all times while in the kitchen to ensure no hair gets in the food.
During an interview on 11/17/23 at 7:50 A.M., the Dietary Manager said she expected all staff who enter the kitchen to wear a hair or beard net for sanitary reasons.
During an interview on 11/17/23 at 8:02 A.M., the Administrator said he expected all staff to follow the facility's policy on hair and beard nets.
Jul 2023
1 deficiency
1 Harm
SERIOUS
(G)
📢 Someone Reported This
A family member, employee, or ombudsman was alarmed enough to file a formal complaint
Actual Harm - a resident was hurt due to facility failures
Free from Abuse/Neglect
(Tag F0600)
A resident was harmed · This affected 1 resident
**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, interview, and record review, the facility failed to ensure one resident was free from physical abuse (Res...
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**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, interview, and record review, the facility failed to ensure one resident was free from physical abuse (Resident #2), when staff inflicted injury to a resident, bruising underneath the eye, and also caused the resident to be fearful. The sample was three residents. The census was 194.
The Administrator was notified on 7/21/23 of the past-noncompliance which began on 7/10/23. The facility conducted an investigation and immediately in-serviced staff on 7/10/23 regarding combative residents, abuse/neglect/exploitation and body mechanics. The facility instituted corrective measures on 7/10/23, including suspension of Certified Nurse Aide (CNA) G. The violation was corrected on 7/10/23.
Review of facility's Abuse, Neglect and Exploitation policy, revised 01/2022, showed:
-Policy: It is the policy of [NAME] Gardens to maintain a work and living environment that is professional and residents are free from threat or occurrence of harassment, abuse (verbal, physical, mental or sexual), neglect, corporal punishment, involuntary seclusion, and misappropriation of property;
-Residents must not be subjected to abuse by anyone, including, but not limited to, facility staff, other residents, consultants or volunteers, staff of other agencies serving the resident, family members or legal guardians, friends, or other individuals;
-It is the responsibility and the law that every staff member, volunteer, contractor or consultant immediately report any suspected abuse or neglect of any type;
-Definitions:
--Abuse means the willful infliction of injury, unreasonable confinement, intimidation or punishment with resulting physical harm, pin or mental anguish; Instances of abuse of all residents, irrespective of any mental or physical condition, cause physical harm, pain or mental anguish. It includes verbal abuse, physical abuse, and mental abuse including abuse facilitated or enabled through the use of technology;
--Mistreatment - means inappropriate treatment or exploitation of a resident.
1. Review of Resident #2's Minimum Data Set (MDS), a federally mandated assessment instrument completed by facility staff, dated 7/9/23, showed:
-Cognitively intact;
-Diagnoses included Alzheimer's disease and polyneuropathy (nerve damage).
Review of the resident's progress notes showed:
-Received a call this morning 7/10/23, around 8:27 A.M. from facility educator notifying this writer that the patient reported being assaulted by CNA. Patient with facial ecchymoses and a blood shot eye per educator. Please refer to detailed notes by nursing staff. Writer gave orders for facial and skull x-ray, but to notify the power of attorney as a CT of the head may be warranted to rule out intracranial bleed and further follow-up;
-7/10/23 at 8:30 A.M., patient seen and examined this evening with physician's progress note to follow. Patient reported that CNA G was talking mean to him/her and then at some point last night punched the patient in the face once. Patient noted to have surrounding ecchymoses (bruising) and swelling around OS (left eye) and noted a headache and pointed to his/her left forehead. Patient also noted that he/she did not want to go to the hospital;
-7/11/23 at 07:14 P.M., facial bones x-ray from today did not reveal a grossly displace or depressed facial fracture. Of note, the palliative care nurse practitioner did speak to patient's power of attorney who was a lawyer and legal representative who wanted a complete workup just to rule out any underlying issues such as intracranial bleed. Patient did have slightly more confusion last night, however, this may be attributable to patient's facial ecchymoses;
-7/12/23 at 11:13 A.M., check on resident bruising: bilateral facial bruising had improved slightly, swelling on the right was decreased as well. Bruise on right elbow no longer visible. Bruise on left elbow still visible more green in color. Same discoloration/bruising visible on left forearm.
Review of the residnet's hospital Progress note, dated 07/11/23 at 9:28 P.M., showed per report, only superficial, visible echymosis was the only injury. No orbital fracture, cranial fracture, or brain bleed noted. No new orders provided.
Review of the resident's Social Worker B's note, dated 7/12/23, showed staff documented when meeting with victim he/she appeared with swollen, black and purple and blood shot left eye. He/She also had a purple blackish swell on his/her right cheek below his/her right eye. He/She stated that he/she was sore and was OK. Victim reported that he/she was assaulted by a CNA by the name of CNA G when victim was laying in his/her bed in the process of being changed and dressed for the day. The perpetrator had been terminated since the incident. Victim with facial ecchymosis and blood shot eye per doctor's report. Resident reported going to the hospital.
Review of the facility's documentation, submitted to the Department of Health and Senior Services (DHSS) on 7/10/23, showed:
-Reporting category: Abuse;
-Date and time of alleged incident: 7/10/23 at approximately 6:15 A.M. or before;
-Resident involved: Resident #2;
-Staff involved: CNA G;
-Summary: CNA F was doing morning rounds, when he/she went into the resident's room and he/she noted a red area on the resident's left side of face near his/her eye. When asked what happened, the resident said CNA G caused it. CNA F asked the resident how did CNA G cause it. He/She said CNA G hit harder than a man. CNA F reported it to Nurse I. Nurse I asked CNA F if the red area was old and CNA F said no. Nurse I reported to Nurse D, who noted a red/purple bruise to the resident's left eye. Nurse D notified Nurse H and Nurse S. The physician, family, and Administrator were notified. MO DHSS notified. After interviewing all the staff, it was reported that the resident would often get upset, swinging his/her arms up and down and would sometimes hit himself/herself or throw himself/herself on the floor.
Review of CNA F's statement, dated 7/10/23, showed:
-Last night on 7/9/23, the resident cried for a while. When he/she got up and was still crying, CNA F asked him/her why. But when fear came over the resident, CNA F insisted in him/her telling what happened. The resident said CNA G did it and he/she also said as CNA G was punching him/her, he/she hit harder than a man. He/She immediately told Nurse I and told CNA G that he/she was reporting him/her. Nurse I asked CNA F if that was old, and CNA F told Nurse I, no. CNA F said this was about 6:20 A.M. to 6:30 A.M. He/She said he/she went into the room, because the resident was crying.
Review of CNA E's statement, dated 7/9/23 and signed by CNA E on 7/10/23, showed:
-He/She had rooms 211 through 200. He/She only went in the rooms that were given to him/her. He/She saw the nurse go in the room between 1 A.M. to 3 A.M., once. Then he/she saw the aide (CNA G) CNA E said CNA G come out the room. CNA E said the aide said he/she ain't getting him/her up. He/She fighting him/her. That was before 6:15 A.M.
Review of CNA G's statement, dated 7/10/23, showed:
-He/She was the resident's aide. He/She was combative, but that is normal for him/her. As of me doing my rounds, CNA G said he/she did not notice anything on him/her. Upon doing his/her last round, CNA F came and told him/her that he/she should leave, because the resident said he/she hit him/her. Come to find out he/she was making rounds, as he/she rolled the resident facing the wall, he/she had his/her hands on the wall and CNA G changed him/her. CNA G said he/she did not notice a black eye. There was no injury that he/she caused. He/She was unaware of how this could have possibly happened. A remote was underneath the resident.
Review of Nurse D's statement, dated 7/10/23, showed:
-Agency nurse came to him/her this morning asking him/her to look at a resident's face, saying the resident stated that CNA G hit/punched him/her. The resident had red/purple bruising to left eye and says it hurt. CNA G said that he/she didn't touch the resident. Nurse D called Nurse H to investigate until he/she was free to take care of what he/she needed to do. Nurse D gave the resident an ice pack for pain.
Review of Nurse H's statement, dated 7/10/23, showed:
-Night nurse called him/her stating the resident said the aide punched him/her in the face. He/She went and interviewed the resident. Nurse H said the resident stated CNA G punched him/her several times, once blacking his/her left eye. Left eye noted purple bruise and bruise noted to right side of face cheek bone area. Nurse H and other nurse manager did full skin assessment. Bruises noted to bilateral elbows, no other bruising besides face bruising noted above. Administrator made aware and resident resting in wheelchair with call light in reach.
Review of Nurse S's statement, dated 7/10/23, showed:
-He/She was asked on the morning of 7/10/23, towards the end of night shift to come to division 200, because the resident was claiming a CNA had hit him/her. When he/she arrived, the resident was tearful. When asked what happened, the resident stated CNA G punched him/her. Resident had visible bruising to the left eye and right cheek and under eye the right cheek was also swollen. When asked if there were other places, he/she had been hit, the resident stated, all over. A head to toe skin assessment was completed at this time. Bruising on left elbow was dark purple. Bruising on the right elbow was light gray. No other bruising was noted at this time. Resident stated he/she didn't feel safe with CNA G in the room. CNA G was removed from the assignment.
Review of CNA M's statement, dated 7/8/23, showed:
-He/She took care of the resident on Saturday and Sunday, day shift. The resident had no marks on his/her face.
During observation and interview on 7/19/23 at 10:27 A.M., the resident said he/she did not want to talk about what happened at first. He/She looked away, looked down and his/her eyes became wide. The resident said he/she had been punched in the eye by CNA G. He/She had purplish bruising underneath his/her left eye, yellow-green discoloration at the top of left eyebrow, temple, and cheek. The left eyelid crease had a thin line of purple colored bruising across the length of the eye and the resident's right cheek had yellow-green discoloration. The resident said it was the weekend when it happened and there was a lot of different staff. He/She said CNA G brought his/her dinner with no problem. He/She was hoping to keep CNA G from doing anything. Before dinner, CNA G said to get up, sit up for dinner. The resident said that was unusual because dinner would not come for an hour. CNA G ordered him/her to get up but he/she did not. The resident sat up when it was dinner time and when CNA G came into the room and saw him/her sitting up, the resident said CNA G said something like good. He/she knew what pissed CNA G off. CNA G was loud and brash for no reason. The resident said he/she had a bowel movement and it stank, so CNA G opened the window, left, and the door slammed. The resident said he/she did not like the door closed so he/she yelled for CNA G to open the door and close the window. CNA G closed the window. The resident showed how the CNA bawled up his/her fist and then took his/her fist to the left side of the cheek to show how CNA G hit him/her. The resident said when he/she told CNA G you hit me, he/she said CNA G said he/she did not. The resident said he/she said the weekend is almost over, can't you just get through it. CNA G came back into the room on Monday and he/she said, oh my God, wasn't (CNA G) supposed to be off. The resident thought CNA G hit him/her two times, because he/she felt pain later on. The resident said he/she was afraid of CNA G. Observation showed the resident's eyes got really big and wide when he/she said he/she was afraid of CNA G. CNA G was the kind of person you could not reason with. The resident said he/she went to the hospital but not the same day it happened. It happened on Sunday and he/she did not go to the hospital until Tuesday. The resident said he/she was convinced CNA G hit him/her on both sides of his/her face after CNA G protested that he/she did not hit him/her. He/She was convinced CNA G hit him/her on both sides of his/her face, but he/she dropped it because he/she did not want to make matters worse. He/She was afraid of CNA G because he/she wondered about the people CNA G knew who worked at the facility. He/She said this was the first time he/she had been punched.
During an interview on 7/19/23 at 7:34 P.M., CNA G said the resident was being combative during his/her double shift on 7/9/23 and 7/10/23. He/She turned the resident to the wall. The resident had a sheet on his/her head and then when the sheet was removed was when he/she saw the bruises on the left and right side. CNA G said he/she reported it to the nurse Nurse I and the nurse said he/she knew about the bruises. That was not his/her regular assignment. The resident likes to fight and the resident was swinging. He/She rolled the resident over and turned towards the wall. He/She said he/she didn't think anything was wrong. He/She said when the resident rolled towards him/her, the resident started swinging. CNA G said when he/she left, there were no concerns. CNA G said he/she would not do that to anyone. He/She did not hit the resident. CNA G said the resident will hit himself/herself. CNA G never hit the resident and has no ill will for the resident. CNA G said he/she did report to the nurse around 5:30 A.M. or 5:50 A.M. He/She said the nurse said he/she knew, so CNA G said he/she wasn't going to make a big deal about it. He/She thinks the resident did it to himself/herself.
During an interview on 7/19/23 at 6:48 P.M., CNA E said he/she heard CNA G say he/she wasn't getting the resident up, because he/she was fighting him/her in the early morning of 7/10/23. He/She said a few minutes later, the resident screamed. Other staff went in the room. He/She said the resident was petrified. CNA G kept talking to the nurse, saying the resident was violent, but the resident was not violent. He/She said CNA G did hit the resident. He/She did not see it, but could tell by the way CNA G was acting. CNA G never went back into the resident's room to check on him/her. If CNA G did go back into the resident's room, he/she went with another staff. The resident had been calm the whole shift. People think residents' don't know what's going on. He/She said CNA G said if the bruising happened the night before, it would have been reported already. CNA F was crying and distraught, because he/she knew CNA G hit the resident.
During an interview on 7/19/23 at 2:30 P.M., CNA M said he/she got to work around 5 A.M. or 6 A.M. on 7/10/23. The bruising appeared sometime after that. The resident was yelling and screaming. He/She said it was like a bruise at first but as the day went on, the bruising got darker. The bruising was underneath the resident's eye. CNA M said CNA F came into the room and asked the resident what's wrong and what happened to him/her. CNA M said he/she left the room. CNA M did not report it because CNA F didn't give him/her a chance too. CNA F told the nurse that CNA G was supposed to get written up. CNA F told the nurse that if he/she did not write up CNA G, he/she was going to tell the Administrator. CNA M said he/she only went into the resident's room, because he/she was screaming. He/She told CNA G he/she could go and that he/she would get the resident up. CNA M said the resident was fully dressed. The resident did not look like himself/herself and the resident looked scared. The resident became calm after CNA G left. The resident said oh (CNA M), you're here, you're here. CNA M said he/she left the room when CNA F came.
During an interview on 7/19/23 at 7:02 P.M., CNA F said when he/she came in to work at 10:42 P.M on 7/9/23, he/she let CNA G keep that assignment because he/she worked a double, but that was CNA F's normal assignment. CNA F said when he/she went to get flat sheets that morning, he/she could see in the resident's room and he/she was crying. If something had happened the night before, the resident would be over it. CNA F said he/she asked the resident what was wrong. The resident was scared, but he/she just kept asking what was wrong. The resident said CNA G punched him/her in the face. The resident said CNA G said, I hit harder than a man. CNA F asked CNA G what happened. CNA G said the resident was lying. CNA F told CNA G that he/she was lying and he/she told Nurse I. He/She said Nurse I asked if the bruising was old. CNA F told Nurse I the bruising was not old and resident had swelling. CNA F told Nurse I if he/she did not check the resident out, he/she was going to report him/her too. Whenever there are scratches or anything, it was supposed to be reported. The resident was not a malicious person and he/she did not lie. CNA F was pretty sad that happened to the resident and he/she believed the resident when he/she said CNA G punched him/her in the face. The resident was visibly upset and scared. CNA F said the resident's face was swollen and red. He/She said the bruising was not old, it was new.
During an interview on 7/20/23 at 10:20 A.M., Nurse I said he/she started his/her shift at 10:30 P.M. on 7/9/23, and he/she received report from off going shift, but during the report, he/she was not told any resident had bruising. He/She said that was his/her first time working on division 200, but the resident had not been combative and did not seem to be combative. He/She said the resident was pretty with it. He/She heard from CNA F about the abuse. He/She said CNA F said he/she had to go into the resident's room to look at him/her. Nurse I asked the resident what happened and the resident said CNA G hit him/her, but he/she could not remember exactly. He/She said the resident looked shook and scared when he/she went into the resident's room. He/She said CNA G was not allowed back into the resident's room. Nurse I said it was a quiet night and CNA G did not tell him/her anything about the bruising before it was discovered that morning. When the morning staff came in, they said the resident was alert, knows peoples' names, and would not say stuff that was not true. Nurse I said CNA G's demeanor changed once he/she knew the event had been reported. CNA G was mad with CNA F for reporting the incident to the nurse. Another nurse came to separate CNA F and CNA G, because they were arguing back and forth about what happened to the resident.
During an interview on 7/20/23 at 3:31 P.M., Nurse D said it was about 5 A.M. on 7/10/23 when Nurse I reported to him/her the resident was complaining that CNA G had hit him/her. Nurse D said he/she asked CNA G what happened. CNA G said he/she did not hit the resident. He/She said he/she looked to see if it could have been environmental, but he/she said there was nothing there. Nurse D said the resident could tell you what happened and said CNA G had punched him/her in the face. He/She got the resident an ice pack. The resident was shaken up and did not want to talk about it and was scared. Nurse D asked the resident if he/she fell and the resident said he/she did not fall and that CNA G hit him/her. Nurse G said the resident's face was red, not quite purple. The resident knew what he/she was talking about. CNA G was looking like he/she did not do it, shrugged his/her shoulders up and threw up his/her hands into the air. CNA G said the resident was lying on him/her.
During interview on 07/20/23 at 9:58 A.M., Nurse H said he/she came into work between 6 A.M. and 6:30 A.M. on 7/10/23, and he/she and Nurse S went straight to the resident's room. The resident said CNA G punched him/her in the face. CNA M got the resident into his/her wheelchair. The resident seemed distracted and scared. The resident admitted he/she was afraid of CNA G. The resident's left eye was reddish-purple and the right cheek was a little swollen. Nurse H said the resident's elbows had dull bruising.
During an interview on 7/20/23 at 2:01 P.M., Social Worker P said the resident answers question appropriately, knew a lot of things, and the resident may have a little dementia, but not much. He/She said the resident had never made false allegations against anyone and if someone had did something inappropriate to the resident, he/she would be able to say the person did it. Social Worker P said the resident had never been involved in anything like this before. No one had ever reported to him/her that the resident was aggressive or had combative behavior. At 3:09 P.M., Social Worker P said he/she did not think CNA G would have hauled off and hit the resident, but CNA G probably became really frustrated with the resident. He/She thought there was a big argument, with the resident pulling one way and CNA G pulling another way, causing the resident to hit himself/herself in the face. It was possible CNA G could have become frustrated and hit the resident.
During an interview on 7/20/23 at 2:27 P.M. , Social Worker B said the resident was not combative at all and he/she had been seeing him/her for the past four months, weekly or about three times a month. Social Worker B said the resident explained to him/her an aide punched him/her in the face. He/She said the resident said he/she was supposed to be getting changed and dressed at the time. Social Worker B said the resident might struggle a little with orientation but the resident was cognizant and lucid.
During an interview on 7/20/23 at 3:09 P.M., Hosptial Nurse C said the resident told him/her that CNA G got mad at him/her and hit him/her in the face. He/She asked the resident how many times did CNA G hit him/her but he/she could not remember. The resident had bruising to inner/outer left eye.
During an interview on 7/19/23 at 11:34 A.M., Nurse K said he/she never saw the resident swinging his/her arms, hitting out at staff or hitting self. Nurse K said he/she had not seen any aggressive behavior from the resident and was not aware of the resident being aggressive towards others.
During an interview on 7/19/23 at 11:40 A.M., CNA L said he/she never saw the resident hit himself/herself in the face or be abusive.
During an interview on 7/19/23 at 2:05 P.M., CNA N said the resident seemed real [NAME] and he/she never saw the resident act out except at bath time. CNA N had not seen the resident be combative or aggressive and the resident wanted to be dry and clean for real.
During an interview on 7/20/23 at 11:27 A.M., the Director of Nursing (DON) said the resident was pretty stable and had been the same for the past six years he/she had been working at the facility. At 2:30 P.M., the DON said he/she could not find anything that showed the resident had bruising in the past. He/She said the resident did not have a history of bruising.
MO00221193
MO00221315
MO00221766
Jan 2020
6 deficiencies
CONCERN
(E)
Potential for Harm - no one hurt, but risky conditions existed
Deficiency F0577
(Tag F0577)
Could have caused harm · This affected multiple residents
Based on observation and interview, the facility failed to post the most recent survey results in a place readily accessible to residents, family members and the public. Furthermore, the facility fail...
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Based on observation and interview, the facility failed to post the most recent survey results in a place readily accessible to residents, family members and the public. Furthermore, the facility failed to post the plan of correction related to the most recent survey and post notice in prominent locations of the availability of the reports for any individual to review. The census was 235.
Observation of the facility's front lobby on 1/7/20, 1/8/20, 1/9/20, 1/10/20, 1/13/20 and 1/14/20, showed the following:
-A frame sat on a ledge behind the receptionist desk, contained an 8 1/2 inch by 11 inch sign which read For your review, a copy of the current facility inspection is located at the reception desk in a binder marked State Survey. Our administrative staff will be happy to answer any content questions you may have.
-The binder was not accessible to residents, family members and the public, without asking the receptionist;
-The plan of correction to the most recent state inspection was not included for review.
During an interview on 1/14/20 at approximately 11:30 A.M., the administrator said the survey binder was located at the reception desk. He was not aware the inspection results should be accessible without asking or that the plan of correction for the most recent inspection was not in the binder for review.
CONCERN
(E)
Potential for Harm - no one hurt, but risky conditions existed
Deficiency F0658
(Tag F0658)
Could have caused harm · This affected multiple residents
**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, interview and record review, the facility failed to document if a registered dietician (RD) recommendation...
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**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, interview and record review, the facility failed to document if a registered dietician (RD) recommendation was given to a resident's physician, obtain a physician order to discontinue weekly weights, complete a resident assessment and/or vital signs upon readmission to the facility, obtain an order to care for a colostomy (a surgical procedure that brings one end of the large intestine out through the abdominal wall), date oxygen tubing, and conduct monthly blood pressures. In addition, the facility failed to obtain orders for tubi grips (tubular bandage that can be used to treat edema (swelling)) and to record urinary output from the catheter (a sterile tube inserted into the bladder to drain urine) each shift as physician ordered, for ten of 35 sampled residents (Resident #381, #15, #91, #141, #140, #160, #153, #20,#100 and #129). The census was 235.
1. Review of Resident #381's annual Minimum Data Set (MDS), a federally mandated assessment instrument completed by facility staff, dated 11/8/19, showed the following:
-Severe cognitive impairment;
-Required total care from staff for activities of daily living (ADLs, personal care tasks);
-Indwelling catheter; Supra pubic (a sterile tube inserted into the bladder through the abdominal wall to drain urine);
-Nutrition approach while a resident: Feeding tube (a tube surgically inserted into the stomach to provide hydration, nutrition and medications);
-Diagnoses included: high blood pressure, neurogenic bladder (lack of bladder control due to a brain, spinal cord or nerve problem), aphasia (loss of ability to understand or express speech, caused by brain damage), quadriplegia (paralysis from the neck down), seizure disorder and feeding tube.
Review of the resident's progress notes, showed the following:
-A dietary note from the RD, dated 6/3/19, continues to tolerate Jevity 1.5 (tube feeding formula that provides daily nutrition) at 50 milliliters (ml) an hour (hr) (rate the formula is infused into the body) and water flushes (provides hydration and prevents tube from clogging) at 400 ml every four hours. Continues to meet estimated kcal (unit of energy provided from food), protein and while exceeding fluid needs. Continue to monitor;
-An RD note, dated 7/8/19, readmission nutrition assessment completed. Continues to tolerate
Jevity 1.5 at 50 ml/hr with flushes 100 ml every four hours. Continues to meet estimated kcal, protein needs. Previous flushes were 400 ml every four hours due to history of urinary tract infections (UTIs) although this exceeded needs. Recommend increase flushes to 250 ml every four hours to provide 2412 ml (82 ounces) of water a day. Continue to monitor tube feedings/weights;
-Staff failed to document if this recommendation was given to the resident's physician;
-An RD note, dated 8/7/19, Tube Feeding Review: Weight stable. Continues to tolerate Jevity 1.5 at 50 ml/hr with flush at 100 ml every four hr, 1512 ml (51 ounces) water flush a day. Continues to meet estimated kcal, protein needs. Recommended flush increase upon readmission but no changes to order made by resident's physician. Continue to monitor tube feedings/weights/labs;
-Staff failed to document if this recommendation was given to the resident's physician;
-An RD note, dated 9/3/19, Weight/Tube Feeding Review: Weight remains stable and continues to tolerate Jevity 1.5 at 50 ml/hr with flush at 100 ml every four hours. 1800 kcal, 76 grams protein and 1512 ml water flush a day. Continues to meet estimated kcal, protein needs. Note resident may need increased flushes if he/she shows signs of dehydration. Continue to monitor tube feedings/weights/labs;
-An RD note, dated 10/10/19, Tube Feeding Review: Weight remains stable. On tube feeding only of Jevity 1.5 at 50 ml/hr with water flushes of 100 ml every four hours. Continues to meet estimated kcal, protein needs. Res on antibiotic for UTI. Will increase water flushes to 150 ml every four hours to provide 1812 ml (61.2 ounces) water flush a day to better meet fluid needs. No recent labs available. Continue to monitor tube feeding tolerance/weights;
-An RD note, dated 11/4/19, Tube Feeding Review: current weight 148 pounds on 11/4/19, 148.9 pounds on 10/7/19, 147.6 pounds on 8/5/19, and 144.6 pounds on 5/6/19. Weight remains stable. Tolerated Jevity 1.5 @50 ml/hr with water flushes of 150 ml every four hours. Continues to meet estimated kcal, protein needs. Monitor tube feeds/weights.
During an interview on 1/14/20 8:41 A.M., the Corporate RD said she would expect there to be documentation as to why a recommendation was not followed up on. Normally they use a paper slip to make a recommendation. If the recommendation wasn't addressed, then she expected there to be a conversation and documentation with nursing to determine why. She increased the resident's water flushes from 100 ml to 150 ml.
During an interview on 1/14/20 at 9:30 A.M., the Director of Nursing (DON) said the RD recommendations should be communicated with the charge nurse who would contact the resident's physician and obtain an order or not. There should be a progress note regarding the recommendation by nursing staff. Sometimes recommendations were communicated on the division when working with the resident, and the RD leaves notes, and sometimes the RDs can write their own orders. The DON would look into it.
As late as 1/17/20 at 1:30 P.M., the DON provided no further information regarding the resident's delay in receiving increased water flushes.
2. Review of Resident #15's medical record, showed the following:
-admission date of 9/15/19 and readmission date of 12/17/19;
-Diagnoses included high blood pressure and congestive heart failure (CHF, impaired heart function).
Review of the resident's current electronic physician's orders sheet (ePOS), dated January 2020, showed the following:
-An order, dated 12/17/19, to obtain weekly weights for four weeks;
-No order to discontinue weekly weights.
Review of the resident's weights documented in the computer, showed the following:
-On 12/18/19, weight of 198 pounds;
-On 1/6/20, weight of 197.2 pounds;
-No other weights documented.
Review of the resident's treatment administration record (TAR) and medication administration record (MAR), dated December 2019 and January 2020, showed no weekly weights documented.
Review of the resident's progress notes, dated 12/17/19 through 1/14/20, showed no documentation of the resident's refusal for his/her weekly weights.
3. Review of Resident #91's electronic medical record, showed the following:
-Electronic admission face sheet, showed an admission date of 9/24/19 and readmission date of 12/20/19;
-Diagnoses included high blood pressure and CHF.
Review of the resident's current ePOS, dated January 2020, showed the following:
-An order, dated 12/20/19, to obtain weekly weights for four weeks;
-No order to discontinue weekly weights.
Review of the resident's weights in the computer, showed the following:
-12/24/19, weight of 146 pounds;
-1/6/20, weight of 147.6 pounds;
-No other weights documented.
Review of the resident's TAR and MAR, dated December 2019 and January 2020, showed no documented weekly weights.
Review of the resident's progress notes, dated 12/20/19 through 1/11/20, showed no documentation of the resident's refusal for weekly weights.
During an interview on 1/14/20 at 9:15 A.M., the DON said Certified Nurses Assistants (CNA) were responsible for obtaining daily, weekly and monthly weights, and charge nurses were responsible to ensure the residents' weights were obtained as ordered. She said the weights should be documented in the computer under the vital sign section.
4. Review of Resident 141's electronic medical record, showed the following:
-Electronic face sheet, showed an original admission date of 1/26/15 and readmission date of 12/29/19 (time 7:15 P.M.);
-Diagnoses included CHF, chronic obstructive pulmonary disease (COPD, lung disease) and pneumonia (inflammation and/or infection in the lungs).
Review of the resident's admission nursing assessment form dated 12/30/19 (time 5:58 A.M.), showed form left blank without any documented admission assessment and/or vital signs (blood pressure, respirations, pulse rate and temperature) regarding the resident's condition upon readmission to the facility.
Review of the resident's progress notes/nurses notes, dated 12/29/19 through 1/14/20, showed the following:
-12/29/19 at 12:23 P.M., resident to be readmitted from local hospital around 7:00 P.M., this evening. Social worker made nursing staff aware of resident's readmission plan and hospital paperwork taken to Division 100 (social service department);
-12/30/19 at 11:35 A.M., readmission nutritional assessment completed by RD;
-12/31/19 at 10:40 A.M., nursing staff documented resident's cardiac pacemaker check completed and resident tolerated;
-No admission assessment and/or complete vital signs regarding the resident's condition upon readmission to the facility on [DATE].
Review of the resident's electronic vital sign sheet, showed no complete vital signs obtained by nursing staff until 1/1/20 at 1:53 P.M.
Review of the resident's MAR, dated 12/29/19 through 1/14/20, showed no admission vital signs documented on 12/29/19.
During interviews on 1/14/20 at 11:45 A.M. and 12:35 P.M., the DON said she expected the charge nurse who admitted the resident on 12/29/19, to have completed a thorough assessment of the resident including complete vital signs at the time the resident was readmitted on [DATE] and to monitor the resident for any changes in his/her condition and/or care needs. She verified the resident's nursing admission form, dated 12/30/19, was left blank and no complete set of vital signs obtained until 1/1/20. The DON said it was unacceptable nursing practice to not complete a thorough assessment of the resident with a full set of vital signs at the time residents were admitted or readmitted to the facility.
5. Review of Resident #140's quarterly MDS, dated [DATE], showed the following:
-Cognitively intact;
-Required total care for ADLs;
-Indwelling catheter;
-Ostomy (prosthetic medical device that provides a means for the collection of waste);
-Diagnoses included: high blood pressure, neurogenic bladder, paraplegia, muscular sclerosis (a disease in which the immune system eats away at the protective covering of nerves), anxiety, depression and neurogenic bowel (the inability to control defecation due to a nervous system problem, resulting in fecal incontinence or constipation).
Review of the resident's January 2020 POS, showed the following:
-An order, dated 12/17/19, for urinary output every shift at 7:00 A.M., 3:00 P.M. and 11:00 P.M.;
-No order for care of the colostomy.
Review of the resident's urine output documentation, showed the following:
-For December 2019:
-Staff documented output one time a day from 12/1/19 through 12/3/19;
-Staff did not document any output from 12/4/19 through 12/8/19;
-The resident was hospitalized from [DATE] through 12/16/19;
-Staff did not document any output from 12/17/19 through 12/23/19;
-Staff documented output one time a day on 12/24/19 and two times a day on 12/31/19;
-Staff did not document any output on 12/25/19 through 12/29/19;
-For January 2020:
-Staff documented output one time a day from 1/1/20 through 1/6/20 and 1/10/20 through 1/11/20;
-Staff documented output two times a day on 1/7/20 thorough 1/9/20 and 1/12/20.
During an interview on 1/7/19 at 3:59 P.M., the resident confirmed he/she had an indwelling catheter and a colostomy.
During an interview on 1/17/20 at 9:30 A.M., the DON said there should be an order for colostomy care to ensure it is provided. She expected staff to follow physician orders, and catheter output should be documented every shift.
6. Review of Resident #160's quarterly MDS, dated [DATE], showed the following:
-Moderate impairment;
-Oxygen therapy;
-Diagnoses included heart failure, respiratory failure and COPD.
Review of the resident's POS, in use at the time of the survey, showed an order, dated 1/21/18, for oxygen per nasal cannula at 2 liters per minute, continuous every shift; 7:00 A.M.-3:00 P.M., 3:00 P.M.-11:00 P.M., and 11:00 P.M.-7:00 A.M.
Observations of the resident on 1/8/20 at 10:49 A.M. and 1:17 P.M., on 1/9/20 at 10:39 A.M., on 1/10/20 at 10:24 A.M. and on 1/13/20 at 11:07 A.M., showed the resident sat in the wheelchair in his/her room. Oxygen administered and set at 2 liters per nasal cannula with no date on the oxygen tubing.
7. Review of Resident #153's quarterly MDS, dated [DATE], showed the following:
-Severe cognitive impairment;
-Oxygen therapy;
-Diagnoses included high blood pressure and dementia (non- Alzheimer's).
Review of the resident's ePOS, in use at the time of the survey, showed the following :
-An order, dated 5/26/17, for oxygen at 2 liters per nasal cannula, three times a day;
7:00 A.M.-3:00 P.M., 3:00 P.M.-11:00 P.M., and 11:00 P.M.-7:00 A.M.
-An order, dated 6/15/18, for Metoprolol tartrate (high blood pressure tablet), once a day 7:15 A.M.-11:15 A.M.
Review of the resident's medical record, showed no documentation that the resident's blood pressure had been checked and/or recorded since July 2019.
Observations of the resident on 1/7/20 at 1:32 P.M., on 1/8/20 at 9:58 A.M., on 1/10/20 at 9:45 A.M. and at 2:21 P.M. and on 1/13/20 at 10:38 A.M., showed the resident sat in the wheelchair in his/her room. Oxygen administered per nasal cannula with no date on the oxygen tubing.
During an interview on 1/17/20 at 9:30 A.M., the DON said she expected residents' oxygen tubing to be dated. Furthermore, she expected blood pressures to be taken and recorded at least monthly for residents who were prescribed high blood pressure medications.
8. Review of Resident #20's quarterly MDS, dated [DATE], showed the following:
-Cognitively intact;
-Required limited assistance from staff for transfers, dressing and personal hygiene;
-Diagnoses included heart failure, high blood pressure and Parkinson's disease (a disorder of the central nervous system that affects movement, often including tremors).
Review of the resident's January 2020 POS, showed an order, dated 12/14/19 for the following:
-Tubi grips from toes up to under knee, on in daytime from 7:00 A.M. to 3:00 P.M.;
-Tubi grips from toes up to under knee, off at bedtime from 7:15 P.M. to 11:00 P.M.
Review of the MAR and TAR showed no orders regarding tubi grips.
During an interview on 1/10/20 at 11:04 A.M., the resident was observed not wearing tubi grips. He/she said he/she had worn them before, but lost them. He/she had not worn them in a long time.
9. Review of Resident #100's quarterly MDS, dated [DATE], showed the following:
-Severe cognitive impairment;
-Dependent on staff for all hygiene and mobility;
-Indwelling catheter;
-Diagnosis of Parkinson's disease.
Review of the ePOS, showed an order, dated 4/13/18, for urinary output every shift at 7:00 A.M., 3:00 P.M. and 11:00 P.M
Review of the output record, dated 12/12/19 through 1/13/20, showed the following:
-99 opportunities for urinary output to be recorded;
-Urine output recorded a total of 28 times, nine of those outputs recorded as medium amount.
10. Review of Resident #129's quarterly MDS, dated [DATE], showed the following:
-Severe cognitive impairment;
-Dependent on staff for all hygiene and mobility;
-Indwelling catheter;
-Diagnoses included multiple sclerosis and quadriplegia.
Review of the ePOS, showed an order, dated 12/2/19, for urinary output every shift 7:00 A.M., 3:00 P.M. and 11:00 P.M
Review of the output record, dated 12/12/19 through 1/13/20, showed the following:
-99 opportunities for urinary output to be recorded;
-Urine output recorded a total of 30 times, nine of those recorded as medium amount.
During an interview on 1/14/19 at 9:15 A.M., the DON and corporate nurse said the physician's order should be followed and the output should be recorded. Noting a moderate amount was not sufficient output documentation; the amount should be recorded.
11. During an interview on 1/17/20 at 9:30 A.M., the DON said she expected staff to follow physician's orders.
MO00165458
CONCERN
(E)
Potential for Harm - no one hurt, but risky conditions existed
Accident Prevention
(Tag F0689)
Could have caused harm · This affected multiple residents
**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, interview and record review, the facility failed to protect three residents (Resident #65, #129 and #203) ...
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**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, interview and record review, the facility failed to protect three residents (Resident #65, #129 and #203) from potential harm by not following the facility policy for transferring with a Hoyer lift (mechanical lift used to transfer a resident from one surface to another) for three of five Hoyer lift transfers observed. The sample size was 35. The facility census was 235.
1. Review of Resident #65's significant change Minimum Data Set (MDS), a federally mandated assessment instrument completed by facility staff, dated 10/27/19, showed the following:
-Severely impaired cognition;
-Dependent on staff for mobility and personal hygiene;
-Diagnoses included heart failure, dementia and chronic lung disease.
Review of the electronic physician's order sheet (ePOS), showed an order, dated 11/23/15, for two person transfer assist with full body lift.
Review of the care plan, dated 4/10/18 and last updated 11/4/19, showed the following:
-Problem: Dependent on staff for all activities of daily living (ADL)s, incontinent of bowel and bladder, has advanced dementia and limited mobility;
-Goal: Staff will assist resident to maintain optimal level of function;
-Interventions: Restorative therapy as ordered, wheelchair and dependent on staff for mobility, perform incontinence care after each incontinent episode, assist with oral hygiene daily and as needed, full body lift for transfers with assistance of two, has to be fed, positioning devices as ordered and assist with range of motion of extremities.
Observation on 1/8/20 at 9:50 A.M., showed the resident in his/her room seated in the wheelchair on a Hoyer sling (large piece of material that cradles the resident during transfer). Certified Nurse Aide (CNA) D opened the legs of the Hoyer lift around the wheelchair, and CNA C and D connected the Hoyer lift to the sling. CNA D lifted the resident from the chair, pulled the Hoyer away from the chair and closed the legs of the lift. CNA C guided the resident's legs as CNA D rolled the Hoyer lift approximately 4 feet across the floor to the bed. With the legs of the lift closed, CNA D lowered the resident to the bed.
During an interview on 1/8/20 at approximately 10:00 A.M., CNA C said he/she always had the legs of the lift open when lifting the resident from the bed/chair but then closed them because some rooms just don't have enough room. Both CNAs C and D said a resident's weight also played a role in if the legs of the lift were open or closed because it was too hard to push a heavier resident when the legs of the lift were closed.
2. Review of Resident #129's quarterly MDS, dated [DATE], showed the following:
-Severe cognitive impairment;
-Dependent on staff for all hygiene and mobility;
-Unable to ambulate;
-Indwelling urinary catheter (small rubber tube inserted into the bladder to drain urine);
-Diagnoses included multiple sclerosis (MS-disease of the brain and spinal cord) and quadriplegia (paralysis from the neck down).
Review of the ePOS, showed an order, dated 12/2/19, for a two person Hoyer transfer.
Review of the care plan, dated 1/15/18 and last updated 11/28/19, showed the following:
-Problem: Resident requires extensive to total assistance with ADLs due to MS and quadriplegia, non-ambulatory and uses a Hoyer for transfers, and requires extensive assistance with meals and to propel wheelchair;
-Goal: Resident will maintain or improve present level of function through the next review;
-Interventions: Two person assist while giving care in bed, do not rush resident, allow extra time to complete ADLs, follow therapy recommendations, provide assistance for ADLs, therapy for strengthening and endurance, transfers with Hoyer and assistance of two.
Observation on 1/8/20 at 11:51 A.M showed the resident lay in bed and CNAs B and C rolled the resident back and forth to place a Hoyer sling under him/her. CNA B rolled the Hoyer under the bed and CNAs B and C connected the Hoyer sling to the Hoyer. With the legs of the Hoyer lift closed, CNA B lifted the resident from the bed, pulled the lift away from the bed, rolled the lift approximately 6 feet to the wheelchair, and lowered him/her to the wheelchair while CNA C guided the resident's legs. The legs of the lift remained closed throughout the entire transfer.
During an interview on 1/8/20 at approximately 12:05 P.M., CNA B said the legs of the lift should be closed at all times except to fit around the chair, if needed.
3. Review of Resident #203's significant change MDS, dated [DATE], showed the following:
-Cognitively intact;
-Extensive assistance required for mobility and personal hygiene;
-Unable to ambulate;
-Diagnoses included fibromyalgia (a disorder characterized by widespread musculoskeletal pain accompanied by fatigue, sleep, memory and mood issues), stroke and above the knee amputation (AKA) of the left leg.
Review of the ePOS, showed an order, dated 12/20/19, for two person mechanical lift transfer.
Review of the care plan, dated 11/11/18 and last updated 12/30/19, showed the following:
-Problem: Resident needs extensive to total assistance with ADLs, numerous previous strokes with one in the last month, feeds self with set up and left AKA;
-Goal: Staff will assist resident to maintain optimal level of function;
--Interventions: Restorative therapy, assist of two persons with full body lift for transfers, examine skin during bathing for skin tears, bruises, open areas or other problems, wheelchair for mobility propelled by staff, position devices as ordered, provide the standard of care/nursing practice per facility policy/procedure/protocol in all ADL care, therapies as ordered and reinforce teachings.
Observation on 1/9/20 at 7:45 A.M., showed the resident lay in bed on a Hoyer sling. CNAs E and F entered the room, and CNA F rolled the Hoyer lift under the bed with the legs of the lift closed. Both CNAs attached the sling to the lift, CNA F pulled the Hoyer lift away from the bed approximately 3 feet, turned a half circle, opened the legs of the lift around the wheelchair and lowered the resident to the chair.
During an interview on 1/9/20 at approximately 7:50 A.M., CNA E said he/she has not attended a Hoyer lift inservice, but he/she thought the legs of the Hoyer lift should only be opened around the chair. CNA F said he/she thought the legs of the lift should always be closed except when getting to the chair and added It's too hard to push it with the legs open.
4. Review of the facility's Lift, Mechanical Full Body Policy, dated 9/2014 and last updated 1/2017, showed the following:
-Purpose: To ensure that all nursing staff are using proper transfer techniques to minimize the risk of injury to resident and staff, while using full body lift;
-Procedure:
1. Gather necessary equipment and make sure you are using the correct pad for the lift;
2. Secure the assistance of another CNA or other qualified employee;
7. Adjust bed to the same height as the surface transferring to. Lock brakes of bed/chair;
8. Position of transferring surfaces should be in close proximity to minimize transport area allowing enough room to move base from bed to chair or chair to bed;
10. Wheel the lift into place over the resident with the widened base beneath the bed or around the chair;
12. Widen the base/legs of the lift prior to moving the lift. The lift is more stable when the legs are widened;
13. Unlock the wheels of the lift when actually lifting the resident on an electric lift. This allows the lift to adjust for the change in weight;
17. Lift the resident only high enough to clear both the surface they are on, and the surface they are moving to. The higher a resident is lifted in the air, the less stable the transfer;
18. The second staff member monitors the resident's body position, making sure the resident's extremities or head does not bump or swing into any object.
5. During an interview on 1/14/20 at approximately 9:30 A.M., the Director of Nursing (DON) and administrator said that some of the beds prevented spreading the legs of the Hoyer lift under the bed, but they did expect the staff person to spread the legs before movement of the lift. They added that given the size of some of the rooms, it was not always possible to spread the legs of the lift to a complete open position, however, they should spread the legs as far as possible and the legs should be open before moving and while moving the lift. The facility policy should be followed. All staff were inserviced on the lift and the size of the resident did not determine if the legs of the lift should be open or closed. The DON added that sometimes the transfer order was written, assist of two persons with full body lift for transfers, and that may mean transfer with a gait belt. These three residents, however, transfer with a Hoyer lift.
CONCERN
(E)
Potential for Harm - no one hurt, but risky conditions existed
Drug Regimen Review
(Tag F0756)
Could have caused harm · This affected multiple residents
**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on interview and record review, the facility failed to ensure physicians addressed residents' pharmacist recommendations w...
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**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on interview and record review, the facility failed to ensure physicians addressed residents' pharmacist recommendations within an acceptable time frame for seven (Residents #94, #213, #28, #100, #187, #20 and #51) of 35 sampled residents. The census was 235.
1. Review of Resident #94's quarterly Minimum Data Set (MDS), a federally mandated assessment instrument completed by facility staff, dated 10/10/19, showed the following:
-Limited assistance required for dressing;
-Received dialysis (process for removal of waste and excess water from the blood due to kidney failure);
-Diagnoses included orthostatic hypotension (decrease in blood pressure when standing), end stage renal disease (ESRD-chronic irreversible kidney failure), diabetes, hyperkalemia (higher than normal potassium level in the blood), depression and bipolar (mood swings between depression and mania) disorder.
Review of the resident's pharmacy medication regimen review (MRR), dated 12/13/19, showed the resident's chart was reviewed, please take the following action described below; resident receives the following antipsychotic: Invega (antipsychotic medication). Assessments are due at initiation of therapy/admission and every six months thereafter. Please complete current Abnormal Involuntary Movement Scale (AIMS- measures involuntary movements that sometimes develop as a side effect of long-term treatment with antipsychotic medications), and add a standing order to complete AIMS every six months.
Review of the resident's assessments, showed an AIMS completed on 12/26/19.
Review of the resident's January 2020 physician's order sheet (POS), did not show an order for an AIMS to be completed every six months as the pharmacist recommended.
2. Review of Resident #213's quarterly MDS, dated [DATE], showed the following:
-Extensive assistance of staff required for toilet use;
-Indwelling catheter (a sterile tube inserted into the bladder to drain urine);
-Diagnoses of anemia, neurogenic bladder (the bladder does not empty properly due to a neurological condition), depression and bipolar disorder.
Review of the resident's MRR, dated 8/13/19, showed the resident's chart reviewed, please take the following action described below; Resident has received vitamin D 50,000 international units (IU) one monthly, since at least 2017. Vitamin D level (most accurate way to measure how much vitamin D is in the body) in March 2019 was still insufficient at 20 nanograms per milliliter (ng/ml). Increase vitamin D to 50,000 IU weekly and recheck vitamin D level in three months?
Review of laboratory results, dated 8/15/19, showed the resident's Vitamin D level at 20 ng/ml (insufficiency is less than 30 ng/ml.)
Review of the resident's MRR, dated 10/11/19, showed the following:
-Resident chart reviewed, please take the following action described below; Resident has received vitamin D 50,000 IU, one monthly, since at least 2017. Vitamin D level in March 2019 was still insufficient at 20 ng/ml. Increase vitamin D to 50,000 IU weekly and recheck vitamin D level in three months?
Review of the resident's MRR, dated 12/13/19, showed the following:
-Resident chart reviewed, please take the following action described below; Resident has received vitamin D 50,000 IU, one monthly since at least 2017. Vitamin D level in August 2019 was still insufficient at 20 ng/ml. Increase vitamin D to 50,000 IU weekly and recheck vitamin D level in three months?
Review of the resident's January 2020 POS, showed an order, dated 12/23/19, for Vitamin D2, 50,000 IU, once every 14 days.
3. Review of Resident #28's significant change MDS, dated [DATE], showed the following:
-Total assistance of staff required for transfers, toileting and bathing;
-Incontinent of bowel and bladder;
-Had a condition or chronic disease that may result in a life expectancy of less than six months;
-Received hospice care;
-Diagnoses included diabetes.
Review of the resident's care plan, updated on 10/15/19, showed the resident admitted to hospice care on 9/12/19 with a diagnosis of heart failure. Additional diagnoses included respiratory failure, kidney disease and history of urinary tract infection.
Review of the resident's MRR, dated 8/13/19, showed resident's chart reviewed, please take the following action described below:
-Resident receives oxybutynin (medication used to treat overactive bladder) Extended release (ER) 10 milligrams (mg) daily and is [AGE] years old. Oxybutynin is not recommended for use in patients greater than [AGE] years old due to increased sedation and anticholinergic (substance that blocks the action of neurotransmitters in the central and the peripheral nervous system) effects in the elderly. It has a higher risk for anticholinergic effects than some of the newer agents for overactive bladder/bladder spasms, and can increase the risk of falls and confusion. Please consider the following:
-Discontinue oxybutynin due to risks outweighing benefits or lack of continued need;
-Change oxybutynin to Myrbetriq (medication used to treat overactive bladder) 25 mg daily (Myrbetriq does not have the same anticholinergic effects);
-Continue oxybutynin as ordered - medication is still necessary and risks vs. benefits have been evaluated.
Further review of the resident's signed pharmacy recommendation, showed the physician agreed to change oxybutynin to Myrbetriq 25 mg on 9/12/19, with a handwritten note on the page that showed 'Done 9/22/19'.
Review of the resident's January 2020 POS, showed an order, dated 11/21/19, for Myrbetriq 25 mg daily.
4. Review of Resident #100's quarterly MDS, dated [DATE], showed the following:
-Severe cognitive impairment;
-Dependent on staff for all hygiene and mobility;
-Diagnoses of Parkinson's disease (progressive nervous system disorder that affects movement) and heart failure.
Review of the MRR, dated 6/18/19, showed a recommendation to the physician to reduce Trazodone (antidepressant) from 50 mg twice a day to 25 mg twice a day.
Further review of the pharmacy MRR, dated 6/18/19, showed the physician signed and dated the form on 9/22/19, to decrease the dose of Trazodone to 25 mg twice a day.
Review of the January 2020 POS, showed an order, dated 12/4/19, for Trazodone 25 mg twice a day.
5. Review of Resident #187's annual MDS, dated [DATE], showed the following:
-Severe cognitive impairment;
-Extensive assistance required for all care;
-Diagnoses included heart failure and Alzheimer's disease.
Review of the pharmacy MRR, dated 7/9/19, showed a recommendation to decrease Tramadol (analgesic) from 50 mg at bedtime (HS) to 25 mg every HS.
Further review of the pharmacy MRR, dated 7/9/19, showed the physician signed and dated the form on 7/17/19 to decrease Tramadol to 25 mg every HS.
Review of the pharmacy MRR, dated 8/16/19, showed the pharmacy requested nursing change the order for Tramadol on the POS.
Review of the January 2020 POS, showed an order, dated 9/3/19, for Tramadol 25 mg every HS.
6. Review of Resident #20's quarterly MDS, dated [DATE], showed the following:
-Cognitively intact;
-Required limited assistance from staff for transfers, dressing and personal hygiene;
-Diagnoses included heart failure, high blood pressure and Parkinson's disease.
Review of the resident's MRR's, showed the following:
-On 10/14/19, The resident's vitamin D level was checked in January. It came back very low at 16 ng/ml. Resident has been on 50,000 units monthly since August, 2018. It does not appear that any dose change was made, or lab redrawn. Draw vitamin D level to see if a dose increase is warranted?;
-On 11/19/19, Resident receives Levothyroxine (Synthroid, Levoxyl, medication for low thyroid function). Manufacturer recommends periodic checks of thyroid function. None in chart since 9/2018. Check TSH level (thyroid stimulating hormone)?;
-On 12/17/19, the November pharmacy consult requested a TSH level. The resident's physician signed the consult ordering a TSH level 12/9/19. This lab is not in the resident's profile. Please make sure TSH is ordered. The resident's vitamin D was recently increased. The physician ordered a vitamin D level now and in 3 months on 2/3/20. There is a vitamin D level scheduled for tomorrow, but the level in 3 months is not scheduled in electronic health record. Please make sure this lab is scheduled.
Review of the resident's medical record, showed the following;
-No vitamin D level lab results;
-No order for vitamin D level on 2/3/20;
-No TSH level lab results;
-No documentation the resident refused to have laboratory work completed.
7. Review of Resident #51's annual MDS, dated [DATE], showed the following:
-Mild cognitive impairment;
-Independent with activities of daily living;
-Diagnoses included high blood pressure, anxiety and bipolar disorder.
Review of the resident's January 2020 POS, showed an order, dated 10/9/18, for monthly vital
signs to be completed every shift on the first Monday of the month in the evening.
Review of the resident's MRR, dated 12/12/19, showed the resident has orders for vital signs monthly on the first Monday of the month. The last blood pressure documented in the chart is from 8/9/19. Please make sure vitals are recorded as ordered.
Review of the resident's monthly vital sign documentation, showed the last recorded blood pressure dated 8/9/19.
8. During an interview on 1/14/20 at 9:15 A.M., the Director of Nursing said pharmacy reviews were done monthly and could be found in the electronic medical record under observations. If the pharmacist made a recommendation, it could be found in resident documents, pharmacy tab, along with follow up to the recommendation. She expected a pharmacy recommendation to be followed up on within a couple of weeks. Some physicians took a month. The recommendations were sent to the physicians and also put in their facility mailbox. Staff should implement the response from the physician as soon as they receive it.
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 store food in accordance with professional standards for food service safety by failing to discard expired milk and failed to ensure that thi...
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Based on observation and interview, the facility failed to store food in accordance with professional standards for food service safety by failing to discard expired milk and failed to ensure that thickening products were used or discarded by the recommended date. The census was 235.
1. Observation of the middle cooler on 1/10/20 at 6:45 A.M. showed a whole gallon of whole milk with an expiration date of 1/7/2020.
2. Observations of the large storage room on 1/7/20 at 10:58 A.M. and 1/10/20 at 6:45 A.M., showed several individual boxes of Thick and Easy, nectar consistency containers, with best by dates of 11/12/19.
3. During an interview on 1/14/20 at approximately 10:30 A.M., with the corporate nurse, registered dietician, food services manager and the administrator, the food services manager said he would expect all food items to be properly labeled, dated and stored. He has servers that go around constantly to make sure old food is thrown out. The manager then goes behind the servers to make sure old food is properly discarded.
CONCERN
(E)
Potential for Harm - no one hurt, but risky conditions existed
Infection Control
(Tag F0880)
Could have caused harm · This affected multiple residents
**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, interview and record review, the facility staff failed to follow acceptable infection control practices to...
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**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, interview and record review, the facility staff failed to follow acceptable infection control practices to prevent the spread of infections by not washing their hands and/or changing gloves during perineal care (peri-care, cleaning the front of the body from hips, between legs and the buttocks) and improper placement of urinary catheter tubing and drainage bag for five sampled residents (Residents #159, #280, #129, #213 and #200). The sample size was 35. The census was 235.
1. Review of Resident #159's quarterly Minimum Data Set (MDS), a federally mandated assessment instrument completed by facility staff, dated 11/16/19, showed the following:
-Cognitively intact;
-Extensive assistance required for toileting and personal hygiene;
-Occasionally incontinent of bowel and bladder;
-Diagnoses included diabetes, dementia and lung disease.
Observation on 1/8/20 at 5:35 A.M., showed Certified Nurse Aide (CNA) A entered the resident's room and donned gloves without washing his/her hands. He/she released the wet with urine brief, provided perineal care and applied barrier cream to the resident's buttocks. The CNA then placed a clean brief under the resident's right hip, turned him/her back and forth and secured the brief. Without washing hands or changing gloves, the CNA put socks on the resident's feet, slacks over his/her feet and assisted him/her to a seated position at the side of the bed. Without washing hands or changing gloves, CNA A wet a cloth and cleansed the resident's upper chest, upper back and axilla (underarm area). He/she re-wet the cloth and handed it to the resident to wipe his/her face. The resident said he/she had to urinate, and CNA A assisted him/her to stand, pulled up his/her slacks and assisted him/her to the bathroom. After he/she urinated, CNA A dried the genital area, secured the brief, pulled up his/her slacks and assisted him/her to the wheelchair. Without changing gloves or washing his/her hands, CNA A dressed the resident in a shirt and placed the oxygen prongs (small curved tips on the end of oxygen tubing to provide oxygen) in his/her nares (nostrils). The CNA then made the bed, gathered soiled supplies, removed gloves, walked to the dirty utility room and deposited the soiled supplies in a bag and left the room without washing his/her hands.
During an interview on 1/8/20 at approximately 5:45 A.M., CNA A said he/she should have washed hands before beginning care and realized he/she did not do that. He/she added that he/she should have washed his/her hands at different times during care, but since he/she was using different towels and washcloths and only working with him/her, he/she didn't think it mattered. He/she said he/she did not wash his/her hands at the end of care because he/she washed them down the hall.
2. Review of Resident #280's medical record, showed the following:
-Electronic admission face sheet, showed admission date of 12/20/19;
-Diagnoses included diabetes and hemiplegia (paralysis affecting one side of the body);
-admission assessment form, dated 12/20/19, showed resident incontinent of bladder.
Observation on 1/9/20 at 8:00 A.M., showed CNA G and CNA H entered the resident's room and provided incontinence care. Both CNAs washed their hands and applied gloves. CNA G cleansed the resident's perineal area, right/left groin and inner/outer labia front to back and dried the resident's skin. CNA G removed his/her gloves, did not wash and/or sanitized his/her hands, applied gloves and cleansed the resident's buttocks, rectal area and hips front to back and dried the resident's skin. CNA G removed his/her gloves, did not wash and/or sanitize his/her hands, donned gloves, and applied barrier cream to the residents buttocks. CNA G removed his/her gloves, did not wash or sanitize his/her hands, donned gloves, and applied a clean incontinence brief on the resident. Both CNAs then removed their gloves and washed their hands.
Review of the facility's Hand Washing and Use of Gloves for Providing Care to Residents Policy and Procedure, dated January 2017, showed the following:
-Purpose: To provide guidelines to employee for proper and appropriate hand washing techniques that will aide in the prevention of the transmission of infections;
-When to wash hands:
-Before and after each resident contact;
-When hands are obviously soiled;
-After touching a resident or handling his/her belongings;
-After handling any contaminated items (linens and/or soiled briefs);
-Procedure:
1. Gloves are to be used:
A. When touching excretions, secretions, blood, body fluids, mucous membranes or non-intact skin;
2. When gloves are indicated, disposable single-use gloves are to be worn;
3. After use, remove gloves and wash hands;
4. Gloves do not replace hand washing.
During an interview on 1/14/20 at approximately 9:30 A.M., the Director of Nursing (DON) said staff should wash their hands prior to providing care, when going from dirty to clean, when they change gloves and at the completion of care. The DON expected nursing staff to follow the facility's policy regarding hand washing and removal of gloves.
3. Review of Resident #129's quarterly MDS, dated [DATE], showed the following:
-Severe cognitive impairment;
-Dependent on staff for all hygiene and mobility;
-Indwelling urinary catheter (small rubber tube inserted in to the bladder to drain urine);
-Diagnoses included multiple sclerosis (disease of the brain and spinal cord) and quadriplegia (paralysis from the neck down).
Observation on 1/8/20 at 11:51 A.M., showed the resident lay in bed and incontinent of a large amount of feces. CNAs B and C washed their hands, donned gloves and turned the resident to his/her right side. CNA B lay the catheter drainage bag on the bed at the resident's feet and provided incontinence care. Both CNAs rolled the resident back and forth to lay a Hoyer sling (large piece of material that cradles the resident during transfer) under the resident, placed slacks over his/her feet and draped the catheter tubing and drainage bag through the leg of the slacks. CNA B lay the catheter drainage bag on the resident's lap and both CNAs transferred the resident to the wheelchair with a Hoyer lift (mechanical lift used to transfer a resident from one place to another). After positioning him/her for comfort, CNA B placed the catheter bag in a privacy bag under the wheelchair.
During an interview on 1/14/19 at approximately 9:30 A.M., the DON said the catheter drainage bag should always be below the level of the bladder, even during a transfer. If the bag isn't below the level of the bladder, it does not drain properly and could cause adverse effects such as infection.
4. Review of Resident #213's quarterly MDS, dated [DATE], showed the following:
-Extensive assistance of staff required for toilet use;
-Indwelling catheter (a sterile tube inserted into the bladder to drain urine);
-Diagnoses of anemia, neurogenic bladder (the bladder does not empty properly due to a neurological condition), depression and bipolar (mood swings between depression and mania) disorder.
Review of the resident's care plan, updated on 12/26/19, showed the following:
-Problem, required an indwelling catheter related to urinary retention (inability of urine to drain completely from the bladder);
-Goal, catheter care managed appropriately as evidenced by not exhibiting signs of urinary tract infection or urethral trauma (problems with the tube that allows urine to pass out of the body);
-Approach, has been educated and is independent at times with indwelling urinary catheter drainage bag and positioning, do not allow tubing or any part of the drainage system to touch the floor, store collection bag inside a protective dignity pouch.
Review of the resident's physician's order sheet (POS), in use at the time of the survey, showed an order, dated 7/19/19, for a #18 French Foley (size and type of catheter) catheter, with a 10 cubic centimeters (cc) balloon (holds the catheter tubing in place) to be changed as needed.
Observations of the resident showed the following:
-On 1/7/20 at 10:28 A.M., the resident lay in bed with a urine collection bag contained in a privacy bag, and approximately 8 inches of catheter tubing lay on the floor;
-On 1/8/20 at 9:39 A.M., the resident lay in bed with a urine collection bag contained in a privacy bag, and approximately 8 inches of catheter tubing lay on the floor;
-On 1/9/20 at 7:41 A.M., the resident lay in bed with a urine collection bag, not contained in a privacy bag, approximately half full of amber colored urine. The catheter tubing lay on the floor;
-On 1/13/20 at 8:30 A.M., the resident stood next to the bed at a tray table with the urine collection bag not contained in a privacy bag. Approximately 1 foot of catheter tubing lay on the floor and then extended upward into the drainage bag.
During an interview on 1/14/20 at 9:15 A.M., the DON said the resident was very independent and took care of the catheter him/herself. He/she had been educated on proper placement of the catheter and staff should re-educate or fix it if they see improper placement. She talked to the resident several times about it this week. The resident did not have a history of urinary tract infections. The bag and tubing should not be on the floor due to infection control issues. She did not know how she would get the resident to comply.
5. Review of Resident #200's quarterly MDS, dated [DATE], showed the following:
-Severe cognitive impairment;
-Extensive assistance of staff required for toilet use;
-Indwelling urinary catheter;
-Diagnoses included neurogenic bladder.
Review of the resident's care plan, updated on 12/20/19, showed the following:
-Problem, required an indwelling catheter related to urinary retention;
-Goal, catheter care managed appropriately as evidenced by not exhibiting signs of urinary tract infection or urethral trauma;
-Approach, Assess the drainage every shift and as needed. Record the amount, type, color, and odor. Observe for leakage.
Review of the resident's POS, in use at the time of the survey, showed an order, dated 12/6/19, for a #18 French urinary catheter, with a 10 cc balloon, to be changed each month, on the 8th of the month, 11:00 P.M. to 7:00 A.M.
Observations of the resident showed the following:
-On 1/8/20 at 11:00 A.M., the resident lay in bed with a urine collection bag contained in a privacy bag, and approximately 8 inches of catheter tubing lay directly on the floor;
-On 1/08/20 at 1:26 P.M., the resident lay in bed with a urine collection bag contained in a privacy bag, and approximately 8 inches of catheter tubing lay directly on the floor;
-On 1/13/20 at 11:23 A.M., the resident lay in bed with a urine collection bag contained in a privacy bag, and approximately 8 inches of catheter tubing lay on the bottom of the bedside table beside the resident's bed;
-On 1/13/20 at 3:42 P.M., the resident lay in bed with a urine collection bag contained in a privacy bag, and approximately 8 inches of catheter tubing lay directly on the floor beside the bedside table, with sediment (debris) in the tubing.
6. During an interview on 1/14/20 at 9:15 A.M., the DON said urinary catheter tubing and drainage bags should not lay directly on the floor due to infection control concerns. The nursing staff were responsible to ensure proper placement of the catheter tubing and drainage bag.
Understanding Severity Codes (click to expand)
Life-Threatening (Immediate Jeopardy)
J - Isolated
K - Pattern
L - Widespread
Actual Harm
G - Isolated
H - Pattern
I - Widespread
Potential for Harm
D - Isolated
E - Pattern
F - Widespread
No Harm (Minor)
A - Isolated
B - Pattern
C - Widespread
Questions to Ask on Your Visit
- "What changes have you made since the serious inspection findings?"
- "Can I speak with families of current residents?"
- "What's your RN coverage like on weekends and overnight?"
Our Honest Assessment
Strengths
- • 40% turnover. Below Missouri's 48% average. Good staff retention means consistent care.
Concerns
- • Multiple safety concerns identified: 1 life-threatening violation(s), 1 harm violation(s). Review inspection reports carefully.
- • 30 deficiencies on record, including 1 critical (life-threatening) violation. These warrant careful review before choosing this facility.
- • $22,623 in fines. Higher than 94% of Missouri facilities, suggesting repeated compliance issues.
- • Grade D (41/100). Below average facility with significant concerns.
Bottom line: Trust Score of 41/100 indicates significant concerns. Thoroughly evaluate alternatives.
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About This Facility
What is Delmar Gardens West's CMS Rating?
CMS assigns DELMAR GARDENS WEST an overall rating of 3 out of 5 stars, which is considered average nationally. Within Missouri, this rating places the facility higher than 99% of the state's 100 nursing homes. This mid-range rating indicates the facility meets federal standards but may have areas for improvement.
How is Delmar Gardens West Staffed?
CMS rates DELMAR GARDENS WEST's staffing level at 4 out of 5 stars, which is above average compared to other nursing homes. Staff turnover is 40%, compared to the Missouri average of 46%. This relatively stable workforce can support continuity of care.
What Have Inspectors Found at Delmar Gardens West?
State health inspectors documented 30 deficiencies at DELMAR GARDENS WEST during 2020 to 2025. These included: 1 Immediate Jeopardy (the most serious level, indicating potential for serious harm or death), 1 that caused actual resident harm, and 28 with potential for harm. Immediate Jeopardy findings are rare and represent the most serious regulatory concerns. They require immediate corrective action.
Who Owns and Operates Delmar Gardens West?
DELMAR GARDENS WEST 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 DELMAR GARDENS, a chain that manages multiple nursing homes. With 321 certified beds and approximately 185 residents (about 58% occupancy), it is a large facility located in TOWN AND COUNTRY, Missouri.
How Does Delmar Gardens West Compare to Other Missouri Nursing Homes?
Compared to the 100 nursing homes in Missouri, DELMAR GARDENS WEST's overall rating (3 stars) is above the state average of 2.5, staff turnover (40%) is near the state average of 46%, and health inspection rating (3 stars) is at the national benchmark.
What Should Families Ask When Visiting Delmar Gardens West?
Based on this facility's data, families visiting should ask: "What changes have been made since the serious inspection findings, and how are you preventing similar issues?" "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?" These questions are particularly relevant given the facility's Immediate Jeopardy citations.
Is Delmar Gardens West Safe?
Based on CMS inspection data, DELMAR GARDENS WEST has documented safety concerns. Inspectors have issued 1 Immediate Jeopardy citation (the most serious violation level indicating risk of serious injury or death). The facility has a 3-star overall rating and ranks #1 of 100 nursing homes in Missouri. Families considering this facility should ask detailed questions about what corrective actions have been taken since these incidents.
Do Nurses at Delmar Gardens West Stick Around?
DELMAR GARDENS WEST has a staff turnover rate of 40%, which is about average for Missouri nursing homes (state average: 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 Delmar Gardens West Ever Fined?
DELMAR GARDENS WEST has been fined $22,623 across 2 penalty actions. This is below the Missouri average of $33,305. While any fine indicates a compliance issue, fines under $50,000 are relatively common and typically reflect isolated problems that were subsequently corrected. Families should ask what specific issues led to these fines and confirm they've been resolved.
Is Delmar Gardens West on Any Federal Watch List?
DELMAR GARDENS WEST 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.