LINCOLN COUNTY NURSING & REHAB
For profit - Individual
90 Beds
JAMES & JUDY LINCOLN
Data: November 2025
1 Immediate Jeopardy citation
Trust Grade
0/100
#413 of 479 in MO
Last Inspection: May 2024
Within standard 12-15 month inspection cycle. Federal law requires annual inspections.
Overview
Lincoln County Nursing & Rehab has received a Trust Grade of F, indicating significant concerns about the quality of care provided. With a state ranking of #413 out of 479, this facility falls in the bottom half in Missouri, and it's #2 out of 3 in Lincoln County, meaning there is only one local option that is better. The facility is reportedly improving, with issues dropping from 64 in 2024 to just 2 in 2025, but it still has serious staffing challenges, reflected in an 82% turnover rate, which is much higher than the state average. They also face a concerning $235,414 in fines, higher than 97% of facilities in the state, potentially indicating ongoing compliance problems. There were troubling incidents noted in the inspector findings. For example, one resident with pressure ulcers did not receive the necessary treatment, leading to infection and hospitalization. Additionally, a resident suffered a severe burn from a hot beverage that was not served correctly, and another resident was not offered pain medication when needed, causing significant discomfort. While there is more RN coverage than 93% of state facilities, the overall low ratings in health inspection and staffing highlight the need for families to carefully consider this facility.
- Trust Score
- F
- In Missouri
- #413/479
- Safety Record
- High Risk
- Inspections
- Getting Better
- Staff Stability ⚠ Watch
- 82% turnover. Very high, 34 points above average. Constant new faces learning your loved one's needs.
- Penalties ✓ Good
- $235,414 in fines. Lower than most Missouri facilities. Relatively clean record.
- Skilled Nurses ⚠ Watch
- Each resident gets only 9 minutes of Registered Nurse (RN) attention daily — below average for Missouri. Fewer RN minutes means fewer trained eyes watching for problems.
- Violations ⚠ Watch
- 112 deficiencies on record. Higher than average. Multiple issues found across inspections.
0/100
Bottom 14%
Review needed
64 → 2 violations
★☆☆☆☆
1.0
Overall Rating
★☆☆☆☆
1.0
Staff Levels
★☆☆☆☆
1.0
Care Quality
★☆☆☆☆
1.0
Inspection Score
↔
Stable
2024: 64 issues
2025: 2 issues
The Good
-
Full Sprinkler Coverage · Fire safety systems throughout facility
-
No fines on record
Facility shows strength in fire safety.
The Bad
1-Star Overall Rating
Below Missouri average (2.5)
Significant quality concerns identified by CMS
Staff Turnover: 82%
36pts above Missouri avg (46%)
Frequent staff changes - ask about care continuity
Federal Fines: $235,414
Well above median ($33,413)
Significant penalties indicating serious issues
Chain: JAMES & JUDY LINCOLN
Part of a multi-facility chain
Ask about local staffing decisions and management
Staff turnover is very high (82%)
34 points above Missouri average of 48%
The Ugly 112 deficiencies on record
1 life-threatening 7 actual harm
Jan 2025
2 deficiencies
CONCERN
(E)
📢 Someone Reported This
A family member, employee, or ombudsman was alarmed enough to file a formal complaint
Potential for Harm - no one hurt, but risky conditions existed
ADL Care
(Tag F0677)
Could have caused harm · This affected multiple residents
**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, interview, and record review, the facility failed to ensure staff provided the necessary care and services...
Read full inspector narrative →
**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, interview, and record review, the facility failed to ensure staff provided the necessary care and services to maintain comfortable positioning in bed for one resident (Resident #4), nail care for one resident (Resident #10) and bathing for three residents (Resident#1, #5, and #14) who required assistance to perform their activities of daily living, in a review of 14 sampled residents. The facility census was 71.
Review of the facility's Bath (Bed) policy, undated showed care of fingernails is part of the bath, be certain nails are clean, and licensed nurses cut fingernails of diabetic residents.
1. Review of Resident #4's undated face sheet, showed the following:
-The resident admitted on [DATE];
-Diagnoses included flaccid hemiplegia affecting left dominant side (the left side of the body is completely limp and unable to move effectively) caused by a stroke.
Review of the resident's baseline care plan, dated 1/8/25, showed the following:
-The resident was cognitively intact;
-He/She had disease management concerns of diabetes (chronic condition that occurs when the pancreas can no longer make insulin, or the body cannot effectively use insulin), hypertension (high blood pressure), weakness, post cerebrovascular accident (CVA; stroke) and psychiatric illness;
-He/She required assistance of two staff members for bed mobility and transfer;
-Assist with activities of daily living care (ADL) as needed to promote health, hygiene, and safety;
-Always incontinent of bladder and bowel;
-The resident was unable to manage own toileting functions and required all cares to be provided by staff;
-The resident will receive cares necessary to maintain hygiene, promote dignity, and avoid skin breakdown;
-He/She used incontinence briefs and pads.
Review of the resident's nurse's note, dated 12/31/24 at 1:01 A.M., showed the following:
-The resident admitted post cerebrovascular accident (CVA, stroke);
-Able to make some needs known, the resident speaks rapidly and at times had difficulty expressing needs;
-Flaccid from the CVA on the left side;
-Dependent on staff for activities of daily living (ADL) required a mechanical lift with transfers, and needed supervision and reminders with eating and completing tasks;
-Incontinent of bladder.
Observation on 1/16/25 at 11:00 A.M., showed the following:
-The resident lay in bed, wearing a facility gown with the head of bed elevated. The resident slid down in bed, his/her legs hung off the foot of the bed, the resident's neck was located in the bed at the angle in the middle of the bed (head of bed raised and foot of bed flat);
-A urinal with urine in it sat on the overbed table;
-A towel in the bed that the resident rubbed on his/her abdomen.
Observation on 1/16/25 at 12:15 P.M., showed the following:
-The resident lay in bed on his/her right side on the flat section in the middle of the bed, the head of the bed remained elevated;
-His/her legs continued to hang off the foot of the bed;
-A Certified Medication Technician (CMT) entered the room and administered medications to the resident's roommate. When finished the CMT emptied the resident's urinal. The towel remained on the resident's bed;
-The CMT left the room without repositioning the resident.
During an interview on 1/16/25 at 12:15 P.M., the resident said the following:
-He/She was not comfortable and felt cramped up;
-The staff gave him/her the towel to clean up urine if the urinal spilled;
-The resident did not know how long he/she was in this position but wanted to be moved back up in bed and to be dry.
Observation on 1/16/25 between 11:00 A.M. and 12:40 P.M., showed the following:
-No staff repositioned the resident;
-The resident used the towel to wipe over his/her abdomen while he/she complained of feeling wet.
During an interview on 1/16/25 at 1:12 P.M., Licensed Practical Nurse (LPN) B said the following:
-Staff were supposed to check incontinent residents every two hours;
-The resident was incontinent at times.
During an interview on 1/16/25 at 3:30 P.M., Certified Nurse Aide (CNA) D said the following:
-He/She checked on the residents before lunch for incontinence;
-He/She pulled the resident up in bed;
-The resident must have slid back down after he/she left.
2. Review of Resident #10's Care Plan, updated 10/7/24, showed staff were to encourage the resident to take time with ADLs and to break tasks into segments to ease respiratory stress.
Review of the resident's quarterly Minimum Data Set (MDS), a federally mandated assessment instrument required to be completed by facility staff, dated 12/1/24, showed the following:
-The resident was cognitively intact;
-Needed setup assistance from staff for personal hygiene.
During an interview on 1/16/25 at 12:45 P.M., Licensed Practical Nurse (LPN) A said the resident required more assistance with ADLs over the past few days.
Observation on 1/16/24 at 2:30 P.M., showed the resident had brown debris under the fingernails on his/her left hand.
During an interview on 1/16/25 at 2:30 P.M., the resident said the following:
-He/She did not know there was brown debris under the fingernails on his/her left hand;
-The resident was upset because no one told him/her earlier and the resident did not like his/her fingernails being dirty.
3. Review of Resident #1's quarterly MDS, dated [DATE], showed the following:
-The resident was cognitively intact;
-He/She required supervision from staff with bathing.
Review of the resident's care plan, dated 12/19/24, showed the following:
-The resident had minimal deficits in ADLs related to minimal weakness, but usually independent in all ADLs;
-Determine his/her preferences for shower days to assure the staff were meeting the resident's needs
Review of the resident's shower sheets, dated 11/3/24 through 1/15/25, showed the following:
-The resident's shower days were Wednesdays and Saturdays;
-The staff assisted the resident with a shower on 11/11/24, seven days from the previous shower;
-The staff assisted the resident with a shower on 11/20/24, nine days from the previous shower;
-The staff assisted the resident with a shower on 12/21/24;
-The staff assisted the resident with a shower on 12/28/24, seven days from the previous shower;
-The staff assisted the resident with a shower on 1/1/25;
-The staff assisted the resident with a shower on 1/8/25, seven days from the previous shower.
During an interview on 1/16/25 at 11:30 A.M., the resident said the following;
-He/She did not always get a bath twice a week, he/she was lucky to get a bath once a week;
-He/She wanted to have two showers a week.
4. Review of Resident #5's care plan, updated 12/10/24, showed the following:
-The resident had limited mobility due to hemiplegia and hemiparesis (hemiplegia refers to a severe or complete loss of strength, whereas hemiparesis refers to a relatively mild loss of strength) following a stroke affecting right side;
-The resident preferred showers to bed baths and will receive showers twice weekly.
Review of the resident's quarterly MDS, dated [DATE], showed the following:
-The resident had modified independent cognitive skills for daily decision making;
-He/She required moderate assistance with bathing.
Review of the resident's shower sheets, dated 11/3/24 through 1/15/25, showed the following:
-The resident's shower days were Tuesdays and Fridays;
-Staff showered the resident on 11/25/24;
-The staff offered but the resident refused a shower on 12/9/24, 14 days since last shower;
-The staff showered the resident on 12/23/24, 14 days since last shower;
-The staff offered the resident a shower on 12/26/24, but he/she refused;
-The staff offered the resident a shower on 12/30/24, but he/she refused;
-The staff offered but the resident refused a shower on 1/13/25, which was 14 days since staff offered the resident a shower.
Observation on 1/16/25 at 10:45 A.M., showed the resident lay in bed with eyes closed, his/her hair was disheveled and oily.
During an interview with Resident #6 (Resident #5's roommate) on 1/16/25 at 10:45 A.M., the resident said the following:
-Resident #5 usually received one shower a week when the facility was short staffed;
-When Resident #5 started to smell from across the room, Resident #6 and staff Resident #5 liked convinced him/her to take a bath.
5. Review of Resident #14's Care Plan, updated 8/13/24, showed the following:
-The resident displayed signs of moderate dementia sequencing and steps of tasks if asked to deliberately perform, i.e., dressing and showers;
-The staff provided cues and supervision for tasks which require numerous steps if the resident appears confused or stressed.
Review of the resident's quarterly MDS, dated [DATE], showed the following:
-The resident was cognitively intact;
-He/She required moderate assistance with showering.
Review of the resident's shower sheets, dated 11/3/24 through 1/15/25, showed the following:
-The resident's shower days were Wednesdays and Saturdays;
-Staff showered the resident on 11/13/24, ten days after previously scheduled shower;
-Staff showered the resident on 11/20/24, seven days since the previous shower;
-Staff showered the resident on 11/27/24, seven days since previous shower;
-Staff showered the resident on 12/4/24, seven days since previous shower;
-Staff showered the resident on 12/18/24, 14 days since the previous shower;
-Staff showered the resident on 12/29/24, eleven days since previous shower;
-Staff showered the resident on 1/1/25;
-Staff showered the resident on 1/11/25, ten days since the previous shower.
Observation on 1/16/25 at 3:10 P.M., showed the following:
-The resident self-propelled the wheelchair down the hallway;
-His/Her hair was disheveled and oily.
During an interview on 1/16/25 at 3:10 P.M., the resident said he/she did not get a shower twice a week, but did not complain because the staff were busy.
During an interview on 1/16/25 at 2:20 P.M., Nurse Aide (NA) C said the following:
-Resident showers were often missed;
-He/She had difficulty keeping up with brushing hair, brushing teeth and providing incontinence care while making sure all the residents got up in the morning and before meals.
During an interview on 1/16/25 at 3:30 P.M., Certified Nurse Aide (CNA) D said the following:
-When a resident refused to take a shower/bath, staff were supposed to ask again later on in the shift;
-A different staff member should offer the resident a shower/bath because sometimes a resident would refuse for some staff but liked other staff members better;
-Staff could offer to give the shower/bath on the next shift or another day.
During an interview on 1/16/25 at 12:45 P.M., Licensed Practical Nurse (LPN) A said the following:
-Staff are supposed to give residents a shower twice a week;
-The aide scheduled on the hall was responsible for making sure the showers were done.
During an interview on 1/16/25 at 1:12 P.M., LPN B said when a resident refused a bath or shower, staff were supposed to ask again during the shift and have a different staff member approach the resident about a shower/bath.
During an interview on 1/16/25 at 4:00 P.M., the Assistant Director of Nursing (ADON) said the following:
-He/She collected shower sheets;
-If he/she was aware showers/baths were not completed or offered, it should have been addressed with the staff to ensure the showers/baths were completed.
During an interview on 1/23/25 at 9:55 A.M., the Director of Nursing said the following:
-Staff were supposed to shower/bath residents twice a week;
-For the most part, there was enough staff to complete showers/baths;
-The Assistant Director of Nursing tracked the shower sheets;
-The staff were supposed to check incontinent residents every two hours;
-If a staff member saw a resident needed to be repositioned, staff should reposition or ask for help to reposition a resident;
-Staff should check resident fingernails on their shower day and as needed.
MO247389
MO248026
CONCERN
(E)
📢 Someone Reported This
A family member, employee, or ombudsman was alarmed enough to file a formal complaint
Potential for Harm - no one hurt, but risky conditions existed
Deficiency F0725
(Tag F0725)
Could have caused harm · This affected multiple residents
**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, interview, and record review, the facility failed to provide sufficient staffing to meet residents' needs,...
Read full inspector narrative →
**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, interview, and record review, the facility failed to provide sufficient staffing to meet residents' needs, including bathing for three residents (Resident #14, #5, and #1), in a review of 14 sampled residents. The facility census was 71.
Review of an email from the Administrator on 1/23/25 showed the facility did not have a policy on staffing.
1. Review of the facility assessment, dated 7/1/24, showed the following:
-The facility had an average daily census of 60;
-Forty residents required assistance of one to two staff with bathing;
-Eighteen residents were dependent on staff for bathing:
-Twenty-four residents required assistance of one to two staff for transfers;
-Fourteen residents were dependent on staff for transfers;
-Based on the average census of sixty, the staffing criteria was 112 certified nurse aide (CNA) hours per day.
2. Review of the facility's daily staffing sheets, dated 12/26/24 through 1/15/2025, showed the following:
-On 12/29/24 the census was 68, the CNA hours totaled 84 hours, 28 hours less than the criteria listed in the facility assessment;
-On 12/30/24 the census was 68, the CNA hours totaled 101 hours, 11 hours less than the criteria listed in the facility assessment;
-On 12/31/24 the census was 68, the CNA hours totaled 104 hours, eight hours less than the criteria listed in the facility assessment;
-On 1/1/25 the census was 69, the CNA hours totaled 98 hours, 14 hours less than the criteria listed in the facility assessment;
-On 1/2/25 the census was 69, the CNA hours totaled 80 hours, 32 hours less than the criteria listed in the facility assessment;
-On 1/3/25 the census was 69, the CNA hours totaled 104 hours, eight hours less than the criteria listed in the facility assessment;;
-On 1/4/25 the census was 69, the CNA hours totaled 80 hours, 32 hours less than the criteria listed in the facility assessment;
-On 1/5/25 the census was 69, the CNA hours totaled 96 hours, 16 hours less than the criteria listed in the facility assessment;
-On 1/6/25 the census was 69, the CNA hours totaled 68 hours, 44 hours less than the criteria listed in the facility assessment;
-On 1/7/25 the census was 69, the CNA hours totaled 105 hours, seven hours less than the criteria listed in the facility assessment;
-On 1/8/25 the census was 69, the CNA hours totaled 93.5 hours, 18.5 hours less than the criteria listed in the facility assessment;
-On 1/11/25 the census was 69, the CNA hours totaled 88 hours, 24 hours less than the criteria listed in the facility assessment;
-On 1/12/25 the census was 69, the CNA hours totaled 96 hours, 16 hours less than the criteria listed in the facility assessment;
-On 1/13/25 the census was 69, the CNA hours totaled 82 hours, 30 hours less than the criteria listed in the facility assessment;
-On 1/14/25 the census was 69, the CNA hours totaled 98 hours, 14 hours less than the criteria listed in the facility assessment;
-On 1/15/25 the census was 70, the CNA hours totaled 84 hours, 28 hours less than the criteria listed in the facility assessment.
3. Review of Resident #14's Care Plan, updated 8/13/24, showed the following:
- The resident displayed signs of moderate dementia sequencing and steps of tasks if asked to deliberately perform, i.e., dressing and showers;
-The staff provided cues and supervision for tasks which required numerous steps if he/she appears confused or stressed.
Review of the resident's quarterly Minimum Data Set (MDS), a federally mandated assessment instrument required to be completed by facility staff, dated 11/26/24, showed the following:
-The resident was cognitively intact;
-He/She required moderate assistance with showering.
Review of the resident's shower sheets, dated 11/3/24 through 1/15/25, showed the following dates when staff provided showers for the resident:
-The resident's shower days were Wednesdays and Saturdays;
-No documentation the resident received a shower from 11/3/24 through 11/12/24, nine days;
-11/13/24;
-11/20/24, seven days since the previous shower;
-11/27/24, seven days since previous shower;
-12/4/24, seven days since previous shower;
-12/18/24;
-12/29/24, eleven days since previous shower;
-1/1/25;
-1/11/25, ten days since previous shower.
Observation on 1/16/25 at 3:10 P.M., showed the following:
-The resident self-propelled the wheelchair down the hallway;
-His/Her hair was disheveled and oily.
During an interview with the resident on 1/16/25 at 3:10 P.M., the resident said he/she did not get a shower twice a week, but he/she did not complain because the staff were busy.
4. Review of Resident #5's Care Plan, updated 12/10/24, showed the following:
-The resident had limited mobility due to hemiplegia and hemiparesis (Hemiplegia refers to a severe or complete loss of strength, whereas hemiparesis refers to a relatively mild loss of strength) following cerebral vascular accident (CVA, stroke) affecting the right side;
-The resident preferred showers to bed baths and will receive showers twice weekly.
Review of the resident's quarterly MDS, dated [DATE], showed the following:
-The resident had modified cognitive skills for daily decision making;
-He/She required moderate assistance with bathing.
Review of the resident's shower sheets, dated 11/3/24 through 1/15/25, showed the following dates staff provided the resident a shower:
-The resident's shower days were Tuesdays and Fridays;
-11/25/24;
-Staff offered but the resident refused a shower on 12/9/24, 14 days since last shower;
-12/23/24, 14 days since the resident's last shower;
-Staff offered the resident a shower on 12/26/24, but he/she refused;
-Staff offered the resident a shower on 12/30/24, but he/she refused;
-Staff offered but the resident refused a shower on 1/13/25, 14 days since staff offered the resident a shower.
Observation on 1/16/25 at 10:45 A.M., showed the resident lay in bed with eyes closed, his/her hair was disheveled and oily.
During an interview with Resident #6 (Resident #5's roommate) on 1/16/25 at 10:45 A.M., he/she said the following:
-Resident #5 usually received one shower a week because the facility was short staffed;
-When Resident #5 started to smell from across the room, Resident #6 and the staff Resident #5 liked, convinced him/her into taking a bath.
5. Review of Resident #1's quarterly MDS, dated [DATE], showed the following:
-The resident was cognitively intact;
-He/She required supervision from staff with bathing.
Review of the resident's Care Plan, dated 12/19/24, showed the following:
-The resident had minimal deficits in ADLs related to minimal weakness, but was usually independent in all ADLs;
-Determine his/her preferences for shower days to assure the staff were meeting the resident's needs
Review of the resident's shower sheets, dated 11/3/24 through 1/15/25, showed staff showered the resident on the following dates:
-The resident's shower days were Wednesdays and Saturdays;
-No documentation staff offered or provided a shower to the resident from 11/3/24 through 11/10/24 (nine days);
-11/11/24;
-11/20/24, nine days from the previous shower;
-12/21/24;
-12/28/24, seven days from the previous shower;
- 1/1/25;
-1/8/25, seven days from the previous shower.
During an interview on 1/16/25 at 11:30 A.M., the resident said the following:
-He/She did not always get a bath twice a week, he/she was lucky to get a bath once a week;
-He/She wanted two showers a week.
6. During an interview on 1/16/25 at 2:20 P.M., Nurse Aide (NA) C said the following:
-There was not enough staff to get everything done;
-Showers were missed;
-He/She had difficulty keeping up with brushing hair, brushing teeth, providing incontinence care while making sure all the residents got up in the morning and before meals.
During an interview on 1/16/25 at 1:12 P.M., LPN B said the following:
-There was not enough staff to get showers done, especially since the facility cut agency staffing;
-The residents were lucky if they received two showers a week;
-The facility had four certified nurse aides (CNA) for four halls with some residents requiring two staff members assistance;
-Evening shift was the worst with staffing.
During an interview on 1/23/25 at 8:56 A.M., the Assistant Director of Nursing said the following:
-He/She had difficulty filling open slots on the nursing schedule at times;
-The staff member on-call covered when a staff member called off or did not show up for the shift, however, if the on-call staff was already in the building for several hours, then another staff member covered;
-He/She did not know the hours per day per discipline required on the facility assessment.
During an interview on 1/23/25 at 9:55 A.M., the Director of Nursing said the following:
-She assisted the Staffing/Wound Nurse and Assistant Director of Nursing with the schedule;
-The issue was multiple staff calling off;
-There were four nursing administrative staff to cover openings in the schedule, the Assistant Director of Nursing, Staffing/Wound Nurse, MDS Coordinator, and herself;
-She did not know the hours per discipline needed to care for 60 residents as listed on the facility assessment until recently.
During an interview on 1/17/25 at 9:53 A.M., the Administrator said the following:
-The Director of Nursing, Assistant Director of Nursing, and Staffing/Wound Nurse worked together to make the nursing schedule;
-Her expectation was enough nursing staff be scheduled to provide quality care to the residents;
-She was not sure if the Staffing/Wound Nurse, Assistant Director of Nursing or Director of Nursing, who were responsible for staffing, knew the number of hours needed per discipline according to the facility assessment.
MO247389
MO248026
Oct 2024
2 deficiencies
CONCERN
(E)
📢 Someone Reported This
A family member, employee, or ombudsman was alarmed enough to file a formal complaint
Potential for Harm - no one hurt, but risky conditions existed
Deficiency F0761
(Tag F0761)
Could have caused harm · This affected multiple residents
**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, interview, and record review, the facility failed to maintain a safe and effective medication system when ...
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**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, interview, and record review, the facility failed to maintain a safe and effective medication system when morphine (narcotic with a high potential for abuse) prescribed for Resident #1 and Resident #2, had been tampered with, a card of oxycodone (a potent semisynthetic opioid agonist prescription medication used to treat severe pain) was missing from the facility emergency medication kit, when staff failed to document the narcotic count was completed before and after their shift, and when an Ozempic (prescription injectable medication used to treat type 2 diabetes: and for weight loss) insulin pen was found to be tampered with and the contents replaced by another type of insulin for Resident #4. The facility census was 71.
Review of the undated facility policy for Storage of Medication showed the following:
-All medications for residents must be stored at or near the nurse's station in a locked cabinet, a locked medicine room, or one or more locked mobile medication carts;
-Biologicals or medications requiring refrigeration must be kept in a separate, securely fastened refrigerator at or near the nurses' station; or in a refrigerator within a locked medication room.
-All controlled substances must be stored under double lock and key.
Review of the undated facility policy for Scheduled II-V Medications (Schedule II medications are typically prescribed to treat severe pain, anxiety and insomnia. Schedule II drugs, substances, or chemicals are defined as drugs with a high potential for abuse, with use potentially leading to severe psychological or physical dependence. These drugs are also considered dangerous. Schedule V medications are drugs with lower potential for abuse than Schedule IV and consist of preparations containing limited quantities of certain narcotics. Schedule V drugs are generally used for antidiarrheal, antitussive, and analgesic purposes) showed:
-Schedule II-V medications may be kept in medication cart lock box, refrigerator, boxes, or double lock box maintained in medication rooms;
-Scheduled medications will have disposition records that are in a binder on medication cart or area instructed by the Director of Nursing (DON);
-All Schedule II, III, IV and V medications must be counted (comparing number of pills to disposition record) at every change of shift by two Certified Medication Technicians (CMT), or one CMA and one licensed nursing staff. Both personnel must sign verification of correct count for Schedule II, III, IV and V medications.
The facility did not provide a requested policy for utilization of the Stat Safe (emergency medication kit).
1. Review of Resident #1's face sheet showed the resident admitted to the facility on [DATE] with diagnoses of chronic obstructive pulmonary disease (COPD - a lung disease that results from damage to the lungs or airways, which can lead to inflammation and other issues that make breathing difficult), shortness of breath, chronic cough, and kidney disease.
Review of the resident's quarterly Minimum Data Set (MDS) a federally mandated assessment instrument completed by staff, dated 8/31/24 showed:
-The resident was able to make self understood and able to understand others;
-Alert and oriented and able to make appropriate decisions;
-Independent with Activities of Daily Living (ADLs);
-Has pain at a level 6 (zero being no pain and 10 being unbearable pain) and was taking opioid medication.
Review of the resident's Physician Order Sheet (POS) for September 2024 showed an order for morphine concentrate (opioid medication for relief of moderate to severe acute and chronic pain), Schedule II medication solution; 100 milligrams (mg) per 5 milliliter (ml) (20 mg/ml); amt: 0.25 ml; orally for pain every 4 hours as needed with an order date of 2/28/24.
Review of the resident's Medication Administration Record (MAR) for September 2024 showed morphine concentrate 0.25 mg administered on 9/10/24 at 5:37 P.M.
2. Review of Resident #2's face sheet showed the following:
-admitted to the facility on [DATE];
-Diagnoses of acute respiratory failure and pain.
Review of the resident's quarterly MDS dated [DATE] showed the following:
-Sometimes understands others and sometimes able to make self understood;
-Unable to make decisions;
-Dependent upon staff for ADLs';
-Has occasional pain at a level 4 and receives pain medication as needed.
Review of the resident's POS for September 2024 showed and order for morphine concentrate - Schedule II solution; 100 mg/5 ml (20 mg/ml); amt: 0.25 ml; orally with special instructions to give 0.25 ml sublingual (under the tongue) every 4 hours as needed.
Review of the resident's MAR for September 2024 showed morphine concentrate 0.25 mg administered on 9/10/24 at 10:20 A.M. and 7:15 P.M.
During an interview on 10/15/24 at 12:40 P.M. LPN A said the following:
-Resident #1 requested morphine for pain on 9/13/24, when he/she opened the morphine bottle to administer the medication, the morphine had a funny smell, like mint. The morphine he/she had given in the past, had no particular smell. He/She notified the Assistant Director of Nursing (ADON) and upon checking the morphine for Resident #2, noted the resident's morphine had a bubblegum smell. Both were removed and destroyed and the pharmacy replaced the medication;
-He/she had counted medication with the off going nurse at 6:00 A.M. on 9/13/24, but had not smelled the medication (morphine).
During an interview on 10/4/24 the Director of Nursing (DON) said the following:
-It was reported on 9/13/24 by Licensed Practical Nurse (LPN) A that the morphine concentrate for Resident #1 did not smell right. The morphine smelled like mint which was unusual. Upon checking the morphine in the medication cart, the morphine for Resident #2 had a bubblegum smell. Both of the morphine bottles were removed from the medication cart and destroyed. The facility contacted the pharmacy and had the medication replaced.
3. Observation on 10/4/24 at 4:30 P.M. of the Certified Medication Technician (CMT) medication cart showed the following:
-A controlled substance shift change log book with individual sheets for the staff to sign by the on coming staff and off going staff that the controlled substance count and number of medication cards was correct;
-A notation at the bottom of the sheet signing signified all doses are recorded on the MAR, count sheets match inventory on hand and package log matches actual package count;
-No off going signature for 10/1/24 at 7:00 A.M.;
-No on coming signature or off going signature for 10/1/24 at 11:00 P.M.;
-No off going signature for 10/2/24 at 7:00 A.M. and no on coming signature for 3:00 P.M ;
-No off going signature for 10/3/24 or on coming signature for 3:00 P.M. and no count or on coming or off going signature for 11:00 P.M.
-No off going signature for 10/4/24 at 7:00 A.M.
-Several medication cards for lorazepam (used to relieve anxiety and is a controlled substance) and alpramazole (Alprazolam is frequently prescribed to manage panic and anxiety disorders and is a controlled substance)
During an interview on 10/4/24 at 4:30 P.M. the DON and Assistant Director of Nurses (ADON) said the CMTs pass lorazepam (a schedule IV controlled medication to relieve anxiety) and was not a narcotic that needed to be monitored. The facility does not audit the CMT medication carts for any tampering or missing medications.
During an interview on 10/4/24 at 4:35 P.M. CMT B said the following:
-Two CMT's or a CMT and a nurse will count the number of cards of narcotics in the medication cart and then count the number of pills in each card. They will sign the shift change log indicating that the count was right;
-He/She did not count when he/she came on the shift as the day shift CMT had already left and there wasn't a nurse available to count with him/her.
During an interview on 10/8/24 at 12:20 P.M. CMT C said the following:
-The on coming CMT should count the cards of narcotics with the off going shift CMT or nurse and then the actual pills in each card of the medication;
-This should be done at every shift change.
4. Observation on 10/8/24 at 2:00 P.M. of a nurse medication cart for the 100 and 400 halls and the refrigerator in the nurses' medication room showed the following:
-A controlled substance shift change log book with individual sheets for the staff to sign by the on coming staff and off going staff that the controlled substance count and number of medication cards were correct;
-A notation at the bottom of the sheet signing signified all doses are recorded on the MAR, count sheets match inventory on hand and package log matches actual package count;
-No off going signature for 10/1/24 at 7:00 A.M., no count of medication noted for 10/1/24 or an on coming signature for 7:00 A.M.;
-No count of medication noted on 10/2/24 or on coming or off going signatures;
-No off going signature for 10/3/24 at 7:00 A.M.
-No off going signature for 10/6/24 at 11:00 P.M.;
-Several bottles of morphine, cards of oxycodone and liquid Ativan (controlled medication) that were kept in the refrigerator in the nurses' medication room
Observation on 10/8/24 at 2:15 P.M. of the Med Nurse cart for the 200, 500 and 600 halls and the refrigerator in the nurses' medication room showed the following:
-A controlled substance shift change log book with individual sheets for the staff to sign by the on coming staff and off going staff that the controlled substance count and number of medication cards were correct;
-A notation at the bottom of the sheet signing signified all doses are recorded on the MAR, count sheets match inventory on hand and package log matches actual package count;
-No off going signature on 10/1/24 at 7:00 A.M. or no on coming signature on 10/1/24 at 11:00 P.M.
-No off going signature on 10/2/24 at 7:00 A.M. or on coming signature for 11:00 P.M.;
-No off going signature for 10/2/24 at 7:00 A.M. or 3:00 P.M. or on coming signature for 3:00 P.M.;
-No on coming signature for 10/4/24 at 7:00 A.m. or 3:00 P.M. or no count of medication noted at 3:00 P.M.
-Several bottles of morphine, cards of oxycodone and liquid Ativan that were kept in the refrigerator in the nurses' medication room
During an interview on 10/8/24 at 3:05 P.M. the DON said she would expect the CMT's and the nurses to count the number of cards that are in the locked narcotic box and the number of pills in each card and the number of liquid bottles and the amount in each bottle when they come on the shift and when they go off shift together and document on the controlled substance shift change log.
During an interview on 10/8/24 at 3:10 P.M. the Administrator said the following:
-She would expect staff to follow the policy for medication administration and narcotics;
-She would expect staff to count the narcotics at the beginning of their shift with the on coming staff and the off going staff;
-She would expect all medications to be documented and accounted for.
5. Review of Resident #4's face sheet showed:
-admitted to the facility on [DATE];
-Diagnoses of diabetes.
Review of the POS for September 2024 showed the following:
-Ozempic (semaglutide) pen injector; 2 mg/dose (8 mg/3 ml); amt: 2 mg; subcutaneous with special instructions to inject 2 mg once a day on Wednesday;
-Order date of 7/25/24.
During an interview on 10/4/24 at 1:30 P.M. the Administrator said the following:
-Several weeks ago, a resident's morphine (another resident in addition to Resident #1 and #2), had been tampered with. The DON and ADON had been doing audits of the narcotics three times a week;
-On 9/13/24, the facility had two bottles of morphine concentrate that appeared to have been tampered with. The smell of the medication in both of the bottles was not correct. The pharmacy indicated that the morphine concentrate should smell like raspberry.
-On 9/25/24, the consultant pharmacist discovered that a card of oxycodone (a Schedule II narcotic used to treat severe pain, for example after an operation or a serious injury, or pain from cancer) was missing from the facility Stat Safe (emergency drug kit). Only the pharmacist had been checking the Stat Safe monthly on their routine visits to the facility;
-A couple of weeks ago, a pen of Ozempic (a prescription injectable medication used to treat Type II diabetes in adults), was found to tampered with and replaced with a different type of insulin (replaced with a pen that was not an Ozempic pen). No one had been checking the Ozempic insulin pens to see if the medication had been tampered with.
During an interview on 10/8/24 at 3:05 P.M. the DON said she would expect the CMT's and the nurses to count the
-When the pharmacist found the missing oxycodone, they discovered that a nurse did not have to have a witness of when they took a medication from the Stat Safe.
-She would expect the staff to have to nurses when getting medication out of the Staff Safe, and have two staff members count the narcotic medication at the beginning of each shift and sign that the count is correct.
MO242133
MO242628
CONCERN
(E)
📢 Someone Reported This
A family member, employee, or ombudsman was alarmed enough to file a formal complaint
Potential for Harm - no one hurt, but risky conditions existed
Deficiency F0804
(Tag F0804)
Could have caused harm · This affected multiple residents
Based on observation, interview, and record review, the facility failed to provide food items at a safe and appetizing temperature. The facility census was 71.
Review of the facility policy for Food T...
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Based on observation, interview, and record review, the facility failed to provide food items at a safe and appetizing temperature. The facility census was 71.
Review of the facility policy for Food Temperatures dated 5/2015 showed:
-The Dietary Manager or designee is responsible for seeing that all food is the proper serving temperature(s) before trays are assembled;
-Keep the temperature of hot foods no less than 140 degrees Fahrenheit (F) during meal service;
-Hot foods should be at least 120 degrees F when served to the resident;
-Keep the temperature of potentially hazardous cold foods no greater than 40 degrees F. Prepare cold items a day in advance when possible. Please items in freezer 45 minutes before service and use ice baths when needed;
-A test meal should be sent with the hall trays when there are food temperature complaints until the temperatures are at the appropriate levels. Record on Temperature Record of Test Trays form;
-Do not cook or heat food in the steam able because it fosters bacteriological growth and is detrimental to product quality. Heat food to the proper temperature by direct heat (using a stove, over, steamer, etc.) and then transfer food to the preheated steam table no more than 30 minutes before meal service;
-Place cold items such as ham salad and egg salad in the steam table over an ice bath with the well of the steam table turned off.
-Potentially hazardous foods are not held at room temperature during meal service.
1. During an interview on 10/4/24 at 2:05 P.M. Resident #8 and Resident #9 said the following:
-They get meals in their rooms and the food was cold and often late;
-Staff usually brought their breakfast around 8:30 A.M. or 9:00 A.M., lunch around 1:00 P.M. to 1:30 P.M., and supper at 6:00 P.M. to 6:30 P.M.
During an interview on 10/4/24 at 2:30 P.M. Resident #10 said he/she eats meals in his/her room. When staff serve the meals the food was almost always cold.
During an interview on 10/8/24 at 11:30 A.M. Resident #11 said he/she eats meals in his/her room. When staff serve the meals the food was never hot.
Observation on 10/8/24 at 12:05 P.M. showed the following:
-Staff served the noon meal to 22 residents in the main dining room with four staff members present;
-The meal consisted of vegetable soup, a cold ham sandwich, chips, sliced melon, milk, tea, fruit punch or coffee;
-Glasses of milk, tea and fruit punch sat on a cart. None of the items were on ice;
-Staff completed meal service to the main dining room at 1:00 P.M.;
-At 1:10 P.M. the hall cart for the 400 hall left the kitchen for food service;
-At 1:15 P.M. the hall cart for the 500 hall left the kitchen for food service;
-At 1:15 P.M. dietary staff prepared four trays for the 100 hall cart. The trays sat on the counter for five minutes as there was no staff in the dining room to place the drinks on the trays and load the trays onto the cart. At 1:22 P.M. a staff member came into the dining room and placed the trays on the 100 hall cart and placed glasses of milk, tea and fruit punch on the trays;
-The cart for the 100 hall left the dining room for service with the last tray being served to a resident on the 100 hall at 1:34 P.M.
Observation at 1:35 P.M. of food temperatures of the test tray showed the following:
-Soup was 118 degrees F;
-Milk was 62 degrees F;
-Tea was 60 degrees F;
-Ham on the sandwich was 52 degrees F.
During an interview on 10/8/24 at 1:40 P.M. the Dietary Manager said the following:
-She had taken the temperature of the soup before meal service and it was 165 degrees F;
-Hot food should be served at 120 degrees F and cold food at 42 degrees or below;
-The drinks should have been placed on ice;
-She was not sure how to keep the soup hot for serving.
During an interview on 10/8/24 at 2:05 P.M. the Administrator said the following:
-Beverages should be kept on ice until served;
-She would expect the meal to be served in a timely manner and the foods to be at the proper temperatures.
MO242628
May 2024
54 deficiencies
3 Harm
SERIOUS
(G)
Actual Harm - a resident was hurt due to facility failures
Deficiency F0697
(Tag F0697)
A resident was harmed · This affected 1 resident
Based on observation, interview and record review, the facility failed to routinely assess pain as ordered for one resident, (Resident #38), in a review of 24 sampled residents. The facility failed to...
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Based on observation, interview and record review, the facility failed to routinely assess pain as ordered for one resident, (Resident #38), in a review of 24 sampled residents. The facility failed to make the resident aware he/she had as needed (PRN) medication available for pain and failed to offer PRN pain medications when the resident complained of pain. The resident was agitated and unable to sleep due to pain. The census was 67.
During an interview on 05/22/24 at 11:00 A.M., the Director of Nursing (DON) said the facility did not have a specific policy related to pain management.
1. Review of Resident #38's face sheet showed the resident had diagnoses that included joint pain, surgical amputation and acquired absence of left leg above the knee.
Review of the resident's significant change Minimum Data Set (MDS) (a federally mandated assessment instrument), completed by facility staff and dated 4/10/24 showed the following:
-Clear speech; makes self understood;
-Cognitively intact;
-No behaviors;
-On a pain management program;
-Received scheduled and PRN opioids (narcotic pain medication);
-Did not receive non-medication interventions;
-Pain presence; frequently;
-Pain interferes with day to day activities.
Review of the resident's pain assessment, dated 4/11/24 and completed by facility staff, showed the following:
-Had pain or hurt in the last five days; noted as phantom leg pain of the lower left extremity;
-Pain occasionally makes it hard to sleep;
-Manner of expressing pain included agitation;
-Measures taken to alleviate pain included analgesics;
-On scheduled pain regimen that was always effective;
-Receives PRN medication for pain.
Review of the resident's care plan, last updated 4/13/24, showed the following:
-Problem Start Date: 10/12/2023; Category: Pain; Presence of chronic pain in areas of his/her amputation site, back and in general has pain;
-Goal: Will verbalize satisfaction with current pain management plan;
-Approach: Administer as needed (PRN) or routine medications as ordered; monitor for adverse effects and for effectiveness; report for ineffectiveness.
Review of the resident's May 2024 physician order sheet (POS) showed orders for the following:
-Hydrocodone (narcotic pain medication) 5/325 milligram (mg), one tablet at 8:00 P.M. (scheduled for block time of 7:00 P.M. to 10:00 P.M.) and one tablet every 12 hours PRN; order date of 10/3/23;
-Pain assessment every shift using pain scale of 0 - 10 every shift; scheduled for day, evening and night; order date of 11/3/23.
Review of the resident's May monthly summary, dated 5/12/24 and completed by facility staff, showed the following:
-Oriented times three; person, place and time;
-Makes self understood;
-Has not expressed pain verbally or exhibited non-verbal signs/symptoms of pain;
-Pain management program was not necessary.
During an interview on 5/19/24 at 4:29 P.M., the resident said the following:
-His/Her pain was never controlled;
-He/She only gets one pill a day.
During an interview on 5/20/24 at 9:15 A.M., the resident yelled and said the following:
-He/She had a terrible night; just hurt;
-I told you my pain is never controlled!;
-He/She did not know he/she could ask for additional, as needed, pain medication.
Observation and interview on 5/21/24 at 6:02 A.M., showed the following:
-The resident sat in his/her wheelchair in his/her doorway rocking back and forth;
-When asked if he/she slept better last night, the resident angrily responded, No I didn't, then yelled, because I hurt!
-He/She said it would do no good to ask for pain medication because they wouldn't give it to him/her;
-Certified Medication Technician (CMT) M stood in the hallway at the medication cart, two doors down from the resident, preparing and administering medications to the residents on the hall.
Review of the resident's May 2024 medication administration record (MAR) on 5/21/24 showed the following:
-Hydrocodone 5/325 mg, one tablet at 8:00 P.M. (scheduled for block time of 7:00 P.M. to 10:00 P.M.) and one tablet every 12 hours PRN; no documentation staff had ever administered the resident a PRN dose of his/her pain medication;
-Pain assessment every shift using pain scale of 0 - 10 every shift; scheduled for day, evening and night; in the administration boxes, staff documented their initials but there were no pain scores documented.
Review of the resident's May 2024 progress notes showed no documentation of pain scores.
Review of the resident's electronic health record showed no documentation of pain scores under the vital signs tab.
During an interview on 5/19/24 at 4:50 P.M., CMT Q said the following:
-The resident was usually very angry and does not allow you to watch him/her take his/her medications, let alone ask about his/her pain;
-There was a box on the MAR to assess pain; he/she has never put a pain score in the box;
-The resident just seemed to be agitated, grumpy and mad all of the time;
-He/She has been responsible for the resident's medications and assessments;
-He/She has never offered the resident PRN pain medications for pain because the resident never asked for it.
During an interview on 5/21/24 at 7:22 A.M., CMT M said the following:
-He/She heard the resident yelling earlier that morning but did not pay attention to what he/she was yelling. The resident was always grumpy and yelled;
-He/She was not aware there was a box on the MAR to assess pain with a pain score; he/she had never put a pain score in the box;
-He/She, as the CMT, was always responsible for the resident's medications and assessments;
-He/She has never offered the resident PRN pain medications for pain because the resident never asked for it.
During an interview on 5/21/23 at 11:18 A.M., the DON said the following:
-She expected staff to follow physician orders;
-If the order was to enter a pain score, she expected a pain score to be entered and it should populate on the MAR;
-If the pain score was not documented on the MAR, it could be documented in the progress notes or in the resident's electronic health record under vital signs;
-Staff should assess pain per physician order and ask the resident to rate the pain;
-She expected staff to offer as needed pain medication to anyone they might assess as being in pain;
-She was not aware the resident was complaining of more frequent pain and was not able to sleep due to pain.
SERIOUS
(G)
Actual Harm - a resident was hurt due to facility failures
Deficiency F0742
(Tag F0742)
A resident was harmed · This affected 1 resident
**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on interview and record review, the facility failed to ensure one resident (Resident #40), who was admitted to the facilit...
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**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on interview and record review, the facility failed to ensure one resident (Resident #40), who was admitted to the facility with mental illness, received appropriate person-centered and individualized treatment and services to meet his/her assessed needs. Resident #40 presented with behaviors including entering another resident's room (Resident #21) wearing no pants and only a brief, taking a cigarette from another resident and lighting it in the tea room and throwing the lit cigarette in a trash can causing trash to ignite, smoking in his/her room, and yelling and cussing at another resident (Resident #15). The resident frequently made threatening gestures (threats or attempts to choke) other residents. The facility failed to adequately implement meaningful interventions, including non-pharmacological interventions, alternate strategies, or ensure the resident received services to address the resident's behaviors. The facility census was 67.
During interview on 6/11/24 at 9:50 A.M. the administrator said he did not have a policy regarding behavior management.
1. Review of Resident #40's face sheet, undated, showed the following:
-He/She had a durable power of attorney;
-Diagnoses included schizoaffective disorder (mental disorder characterized by abnormal thought processes and an unstable mood), major depressive disorder (common and serious medical illness that negatively affects how someone feels, the way someone thinks and how someone acts), anxiety disorder (persistent and excessive worry that interferes with daily activities), and history of mood disorder (mental health condition that primarily affects your emotional state).
Review of the resident's Pre-admission Screening and Resident Review Level II (PASRR II) (comprehensive evaluation required as a result of a positive Level I Screening), dated 7/6/20, showed the following:
-The resident was physically and emotionally abused by a parent all his/her life and by a second spouse that the resident divorced;
-He/She became aggressive when staff woke the resident for breakfast and shower at previous facility;
-Assessment and implementation of behavioral support plan included monitoring of behavioral symptoms, provision of behavioral supports, allow the resident to have as much control of his/her care as possible, and give him/her choices in care;
-Provision of a structured environment: provide for individual personal space, establish consistent routines, and provide schedule of daily tasks/activities.
Review of the resident's care plan, updated on 12/16/21, showed the following:
-Problem: Inappropriate sexual behavioral symptoms directed towards residents and staff of the opposite sex. On 12/15/21, the resident touched another resident's private area;
-Obtain a psych consult/psychosocial therapy;
-Avoid offering staff of the opposite sex for care;
-Redirect the resident when appropriate sexual behaviors are present.
Review of the resident's quarterly Minimum Data Set (MDS), a federally mandated assessment instrument required to be completed by facility staff, dated 12/24/23, showed the following:
-The resident had moderately impaired cognition;
-He/She was independent with rolling left and right in bed, sitting to lying in bed, lying to sitting on side of bed, sit to stand, chair/bed-to-chair transfer, walk tenfeet, and wheelchair locomotion;
-He/She received antipsychotic, antianxiety, and antidepressant medications.
Review of the resident's psychiatric progress note, dated 12/27/23, showed the following:
-The physician saw the resident for a follow up visit of sleep, mood, anxiety, delusions, and medication reconciliation;
-The resident had impaired insight and judgement as evidenced by decisions of recent past.
Review of the resident's nurse note, dated 1/6/24 at 1:41 P.M., showed the following:
-The resident inappropriately touched another resident of the opposite sex in the dining room during lunch;
-The residents were separated;
-The durable power of attorney (DPOA) was notified of the incident. The DPOA requested the resident be checked for urinary tract infection and to see if any medications had recently been changed as this was out of the resident's normal behavior.
Review of the resident's care plan, updated on 1/6/24, showed the following:
-Problem: the resident chose to smoke;
-He/She was a safe smoker, however, history of elopement so the resident will smoke with supervision;
-Designated smoking area, designated smoking times, staff assigned to assist with residents that smoke;
-Cigarettes and lighters are kept at nursing station;
-Problem: Inappropriate sexual behavioral symptoms directed towards residents and staff of opposite sex. On 12/15/21, the resident touched another resident's private area;
-The resident and power of attorney agreed of the benefit from a device for self-gratification, new intervention identified on 1/6/24;
-1/6/2, the resident will remain on hallway with predominately same sex residents;
- There were no interventions to address the resident's sexually inappropriate behavior when in other common/areas of the facility.
Review of the resident's nurse note, dated 1/26/24 a 8:57 P.M., showed the following:
-The resident was found walking away from his/her roommate's bed (Resident #8);
-Resident #8's face was red and purple in color. He/She said Resident #40 was choking him/her and Resident #8 couldn't breathe;
-The nurse assisted Resident #40 out of the room and away from Resident #8;
-Resident #40 said Resident #8 was hitting the remote on the bed, and he/she didn't want to hear it, so he/she choked Resident #8;
-The staff called for psych evaluation. Resident #40 was discharged with the emergency medical team (EMT) via ambulance.
Review of the resident's nurse notes, dated 2/2/24 at 12:45 P.M., showed the following:
-The Director of Nursing and Social Services went to the hospital to evaluate the resident;
-Per hospital staff, the resident displayed inappropriate sexual behaviors on 1/29/24 and 1/30/24;
-Per hospital nurse notes, on 1/31/24, the resident was easily annoyed and angered;
-Per hospital care plan, 2/1/24 at 1:30 A.M, the resident was not on sexually acting out precautions, it was then noted at 10:15 A.M., the resident was on sexually acting out precautions;
-Per hospital care plan, 2/1/24 at 8:51 P.M., documentation showed the resident was easily annoyed or angered and unable to tolerate the presence of others;
-The resident said he/she did not remember anything, however, the resident almost immediately said he/she had an altercation with another resident;
-The resident said he/she shocked the roommate by choking him/her because the roommate would not stop banging the remote;
-When the staff asked the resident what he/she would do if another situation arrived, to which the resident said he/she would stay away or tell the nurse;
-It was explained to the facility staff the resident's behaviors would need to improve before the resident could safely come back to the nursing home.
Review of the resident's social services note, dated 2/2/24 at 3:34 P.M., showed the following:
-The Social Services Director and DON went to evaluate the resident at the hospital before the resident returned back to the facility;
-Based on the assessment, the staff believed it was not possible for the resident to return safely.
Review of the resident's nurse note, dated 2/6/24 at 12:30 P.M., showed the following:
-The DON spoke with a staff member from the hospital where the resident was located. He/She expressed concern that the resident was exhibiting behaviors on 2/2/24;
-Per hospital staff, their physician signed off and the resident was supposed to be discharged ;
-Per the hospital they were sending an ambulance at 12:00 because insurance was no longer paying, and they could not keep the resident there. DON expressed concern over sending resident without an assessment, to which hospital staff said it was their policy to have residents out before a certain time. The DON again expressed concern over resident having recent behaviors just four days prior;
-Per hospital staff they were sending the resident whether or not the assessment found the resident was still having unsafe behaviors.
Review of the resident's nurse notes, dated 2/7/24 at 5:30 P.M., showed the following:
-The resident arrived to the facility;
-The staff placed the resident on frequent monitoring for 72 hours.
Review of the resident's nurse note, dated 2/8/24 at 7:04 P.M., showed the following:
-The resident waited for the smoking session to begin and sat in the main dining room;
-The resident stood behind another resident with his/her hands up in the choking position; no contact was made with the other resident;
-The staff separated both residents. The nurse asked the resident what happened, and the resident said, I did not touch him/her. The resident put his/her hands like this demonstrating for the nurse;
-The nurse explained to the resident that what he/she did could be considered a threat;
-One-on-one care provided with the resident and will continue until ordered otherwise.
Review of the resident's nurse note, dated 2/8/24 at 8:30 P.M., showed the following:
-At 7:05 P.M., staff member overheard residents yelling profanity near the smoking exit. Staff observed the resident immediately behind another resident;
-The staff moved the resident to a more appropriate distance from the other resident to de-escalate the situation;
-The staff placed the resident on one-on-one supervision;
-Per witness, the resident wanted to be first in line to smoke. He/She did not ask the other resident (Resident #8), to move. Resident #40 came up behind the other resident and started to kick the other resident's wheelchair, then Resident #40 placed his/her hands bilaterally on the resident's neck with forceful gripping hands;
-Per alleged victim, he/she was talking with another resident and Resident #40 came from behind, almost wrapping his/her hands around the alleged victim, the alleged victim asked Resident #40 what his/her hands were doing around his/her throat, and Resident #40 denied it;
-Resident #40 said he/she was behind the alleged victim and his/her hands started cramping so he/she stretched them out, about four inches from the alleged victim's neck, and he/she was not upset at the time;
-Resident #40 will remain on one-on-one supervision for the safety of all residents.
Review of the resident's care plan showed no update to address the incident on 2/8/24 or any additional inverventions implemented after the one on one monitoring was discontinued.
Review of the resident's Social Services Director (SSD)'s note, dated 2/22/24 at 1:48 P.M., showed the following:
-The SSD spoke with the resident about room change to see if the resident enjoyed the private room and the resident said, doing ok;
-The SSD reminded the resident if she had any issues with another resident in the facility, the resident needed to talk to the charge nurse or SSD to help the resident with any concerns or issues at the time.
Review of the resident's quarterly MDS, dated [DATE], showed the following:
-The resident was cognitively intact;
-He/She was independent with rolling left and right in bed, sitting to lying in bed, lying to sitting on side of bed, sit to stand, chair/bed-to-chair transfer, walk ten feet, and wheelchair locomotion;
-He/She received an antipsychotic, antianxiety, and antidepressant;
- The resident had no behaviors towards others.
Review of the resident's care plan, updated on 3/27/24, and additions dated 1/6/24 showed the following:
Problem: The resident displayed aggressive behavior toward peers;
-The resident was sent to the emergency department for psychiatric evaluation;
-He/She was referred to psychiatric provider for care of behaviors;
-Standing order for urinalysis due to altered mental status;
-The staff moved the resident to a private room (2/27/24);
Problem: The resident continued to inappropriately touch residents of the opposite sex in a sexual manner;
-The staff will check the resident for a urinary tract infection;
-The staff will observe the resident closely when interacting with peers.
Review of the resident's nurse notes, dated 3/30/24 at 1:50 P.M., showed the following:
-The staff found Resident #40 in another resident's room of the opposite sex and on the same hall as Resident #40, but he/she was about six feet away from the other resident;
-No inappropriate behaviors seen at the time;
-The resident made sexual comments to the staff;
-The staff notified the nurse practitioner, and new order received for urinalysis;
-The staff notified the DON. Staff to closely monitor.
Review of the resident's nurse note, dated 3/31/24 at 1:47 A.M., showed the following:
-The staff found the resident going into Resident #21's room, a resident of the opposite sex and accross the hall from Resident #40, wearing no pants, only his/her brief;
-The staff informed Resident #40 it was inappropriate for him/her to be in there and he/she needed to go back to his/her room;
-The resident argued with staff but went back to his/her room.
Review of the resident's physician's orders showed a new order, dated 4/1/24, for Provera (progesterone hormone) 5 mg give one tablet orally daily.
Review of the resident's nurse note, dated 4/3/24 at 5:11 A.M., showed the following:
-Resident #40 approached an independent smoker in the tea room and grabbed the other resident's cigarettes out of his/her hand, stole one, and lit it;
-Resident #40 threw the lit cigarette in the trash can causing the trash to smoke;
-The staff and the other resident extinguished the lit cigarette. Resident #40 was taken back to his/her room. )
Review of the resident's care plan showed no documentation of the incident of the resident taking another resident's cigarettes and lighter, throwing a lit cigarette in the trash, or interventions to address this behavior.
Review of the resident's primary care physician's notes , dated 4/25/24, showed the following:
-When the resident had urinary tract infection symptoms, he/she became very hypersexual and had a lot of irritability;
-Urine culture on 4/4/24 showed infection with Escherichia coli (E. coli-type of bacteria that normally lives in your intestines) extended-spectrum beta-lactamases (ESBL-enzymes or chemicals produced by germs like certain bacteria that make bacterial infections harder to treat with antibiotics).
Review of the resident's nurse practitioner note, dated 5/13/24, showed the following:
-Schizoaffective disorder, depressive type - continue aripiprazole (antipsychotic medication) 10 milligrams (mg) daily, Buspar (antianxiety medication) 5 mg twice a day, hydroxyzine (an antihistamine used to treat anxiety) as needed, Seroquel (antipsychotic medication) 25 mg at bedtime, Zoloft (antidepressant medication) 200 mg daily, and monitor mood and behavior;
-Major depressive disorder- continue aripiprazole 10 mg daily, Buspar 5 mg twice a day, hydroxyzine as needed, Seroquel 25 mg at bedtime, Zoloft 200 mg daily, and monitor mood and behavior;
-Inappropriate sexual behavior - continue Provera (progesterone hormone) 5 mg orally daily and monitor behaviors.
Review of the resident's nurse notes, dated 5/18/24 at 10:24 P.M., showed the following:
-The staff caught Resident #40 and Resident #15 smoking in the dining room;
-The staff took the cigarettes and lighter away from the resident, then educated the resident as to the dangers of what smoking inside can do to him/her and others in the facility;
-Neither of the residents were independent smokers.
Review of the resident's nurse note, dated 5/23/24 at 6:50 A.M., showed the following:
-The nurse heard the resident arguing with Resident #15. Both residents were in wheelchairs at arm's length away from each other by the nurses' station;
-Both residents were exchanging words and yelling at one another before a staff member separated them;
-Resident #40 said Resident #15 slapped him/her on the arm;
-The staff member witnessed Resident #15 slap Resident #40 on the arm and said to stop calling him/her a fat bitch;
-The staff started 15 minute observation checks on both residents.
Review of the resident's physician orders, dated May 2024, showed the following:
-Aripiprazole 10 mg, give one tablet orally daily after lunch for treatment of major depressive disorder;
-Buspirone (antianxiety) 5 mg, give one tablet orally twice a day (started on 2/7/24);
-Hydroxyzine 25 mg give one tablet orally every six hours as needed for anxiety (started 2/7/24);
-Provera 5 mg give one tablet orally daily (started 4/1/24);
-Seroquel 25 mg give one tablet orally at bedtime;
-Sertraline (antidepressant) 100 mg give two tablets orally daily (started 4/29/24);
-Behavior monitoring and behavior interventions every shift (started 9/24/20).
Observation on 5/19/24 at 5:00 P.M., showed the following:
-Eight residents of the opposite sex lived on the same hall as the resident; (The resident's care plan showed the resident was to be living on a hall with all same sex residents.)
-Resident #21 had the resident enter his/her room without pants;
-Resident #21 lived across the hall from the resident.
During an interview on 5/23/24 at 8:30 A.M., Certified Nurse Assistant (CNA) C said the following:
-The staff put the resident on every 15-minute checks when he/she had behaviors;
-The resident had a behavior with Resident #15 yesterday (5/22/24);
-The resident called Resident #15 a fat bitch, then Resident #15 hit the resident on the arm and told him/her to stop calling him/her a bitch;
-The staff separated the residents and put the resident on 15-minute checks;
-The staff were supposed to bhe present and monitor the resident, but not required every 15-minutes, when the resident waited at the door for a smoke break;
-The staff reminded the independent smokers not to give the resident any cigarettes or a lighter;
-The resident stole other residents' cigarettes at times;
-CNA C was present when the resident sexually touched Resident #57's crotch;
-He/She said, if the resident sits or interacts with any residents of the opposite sex, then he/she will try to move Resident #40 because he/she didn't know when it will happen again.
Observation on 5/23/24 at 12:50 P.M., showed the following:
-The resident propelled self from dining room towards his/her room;
-He/She stopped twice and stared at residents sitting in the common area;
- No staff were observed monistoring the resident.
During an interview on 5/23/24 at 12:50 P.M., Licensed Practical Nurse (LPN) A said the following:
-The resident usually did not come out of his/her room, except to smoke;
-The staff were supposed to redirect the resident when he/she had a negative behavior, then call the physician to request a urinalysis order;
-The resident kept to himself/herself;
-The resident's behaviors were random without triggers.
During an interview on 5/23/24 at 1:08 P.M., the Director of Nursing (DON) said the following:
-The confrontation between Resident #15 and Resident #40 would not have happened if Resident #15 would have just rolled away;
-Resident #40's behaviors were triggered by urinary tract infections, that could not be predicted;
-Resident #40 spent most of his/her time sleeping in his/her room and only came out to smoke and sometimes ate in dining room;
-The staff were supposed to watch the resident's behaviors when he/she came out of his/her room;
-She was aware the resident became angry when he/she slept past the smoking times, however, the resident was usually redirected;
-She did not want staff waking up the resident while sleeping because he/she needed it, with the resident's mental health history, his/her brain benefited from sleep;
-The staff reminded the independent smokers not to give cigarettes to other residents, however, they still gave other residents cigarettes;
-The staff saw the resident throw a lit cigarette in a trash can on 4/3/24 and intervened immediately, nothing happened because of it;
-She was going to talk to Resident #15's anger management counselor to request that coping skills were discussed.
During an interview on 6/6/24 at 1:32 P.M., the Director of Nursing said the following:
-Frequent monitoring depended on the reasoning for the initiation of the frequent monitoring;
-The more serious the issue then the more frequently staff were to monitor a resident;
-Resident #40 did not have any symptoms related to a urinary tract infection except having a change in behavior;
-The intervention to prevent urinary tract infection for the resident was to encourage fluids.
SERIOUS
(H)
Actual Harm - a resident was hurt due to facility failures
Accident Prevention
(Tag F0689)
A resident was harmed · This affected multiple residents
**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Surveyor: Day, [NAME]
Based on observation, interview, and record review, the facility failed to have a system in place to ensur...
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**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Surveyor: Day, [NAME]
Based on observation, interview, and record review, the facility failed to have a system in place to ensure staff served hot beverages at an appropriate temperature, in an appropriate cup and placed within one resident's (Resident #63), of 24 sampled residents, reach. The resident sustained a third degree burn and required treatment for the burn. The facility failed to consistently evaluate, implement, and modify interventions, in accordance with current standards of practice, and as necessary, to reduce the risk of falls for two residents (Resident #42, and #52). Resident #42 was sent to the emergency room after he/she experienced a dislocated right shoulder and a laceration above his/her right eye requiring sutures, injuries requiring treatment at the hospital. Resident #52 was sent to the emergency room for a laceration above the left eye requiring glue repair by the emergency room. The facility failed to safely transport two sampled residents (Resident #22, and #68) and two additional residents (Resident #1 and #14) when staff pushed them in wheelchairs without foot pedals and the resident's feet drug the floor. The facility census was 67.
Request for a hot liquid or food service policy was made with no policies provided.
Review of the facility policy, Fall Prevention, taken from the facility's Fall Prevention Manual, dated 06/2006, showed the following:
-Falls are a serious health risk for older persons. Much can be done to prevent falls. Because of the high incidence of falls in the elderly, skilled nursing facilities (SNF) have an important role to play in preventing falls. SNF are in a unique position to identify patient risks and to coordinate a fall prevention and fall reduction program. Moreover, falls can be prevented, and their severity reduced without an increased use of restraints;
-Most falls are the result of a complex interaction of environmental, medical, and physical factors. Therefore, one intervention alone is less likely to be as successful as a combination of interventions. This quality improvement project incorporates a patient fall risk assessment, care planning and an exercise component;
-Assessment is the cornerstone of a fall prevention program. Literature supports that a fall risk assessment that incorporates a focused history, environmental and physical risks to persons has a positive impact on reduction in fall rates, deaths from falls, and hospitalization rates among residents of long-term residential facilities;
-Research shows that care planning by an interdisciplinary team soon after admission, with revisions as conditions change, is the most effective way to provide individualized care. Risk factors identified in the risk assessment should be the basis for an individualized care plan;
-A performance-improvement approach to falls and injuries requires interdisciplinary involvement. Therefore, a resident safety management committee should be composed of members from each of the facility's departments and each member should have specific duties and obligations in the fall-management process;
-The three steps the committee should take are to collect data, implement both facility-wide and individualized plans, and evaluate those plans;
-The fall policy did not address transporting residents in wheelchairs without foot pedals.
Review of the undated facility policy, Use of Wheelchairs, showed the following:
-Do not remove footrests unless the resident uses feet on floor to enable mobility;
-Lower footrests and place the resident's feet on footrests if used; position feet and legs in good body alignment, and elevate leg(s) as ordered.
1. Review of Resident #63's quarterly Minimum Data Set (MDS), a federally mandated assessment instrument required to be completed by facility staff, dated 4/18/24, showed the following:
-The resident was cognitively intact;
-He/She had limited range of motion to bilateral upper and lower extremities;
-The resident required setup assistance with eating;
-He/She was independent with rolling left and right in bed.
Review of the resident's nurse notes, dated 4/28/24 at 1:12 PM, showed the following:
-The resident said that very morning he/she received hot water for tea;
-The Certified Nurse Assistant (CNA) sat the breakfast tray down and walked out of the room;
-The resident moved the bedside tray closer so he/she could eat;
-The hot water tipped over and spilled onto the resident's left leg;
-The resident's left leg had redness and some raised areas to the back of the left leg;
-Staff applied a cool towel, and the resident received Norco (opioid pain medication) and alprazolam (antianxiety) at 10:00 AM;
-At 10:00 A.M., the nurse reassessed the resident and found five blisters to the back of the left leg behind the knee;
-The nurse received orders to apply Silvadene (topical antibiotic) twice a day, wrap loosely with gauze and apply cool compress;
-At 2:10 P.M., the resident rated his/her pain an eight out of 10 (one a scale of one to 10 with 10 being the most pain) to bilateral knees and burn.
During an interview on 5/23/24 at 8:30 A.M., CNA C said the following:
-He/She worked the shift when the resident was burned on the back of his/her leg with hot liquid (4/28/24);
-He/She was in the kitchen getting the room trays ready on the cart;
-The dishwashing machine was broken, so the kitchen used disposable (Styrofoam) cups;
-The kitchen staff instructed him/her to fill the cup and put aluminum foil cover over the cup.
During an interview on 5/20/24 at 12:50 P.M., the resident said the following:
-On 4/28/24, the CNA brought in the breakfast tray and sat it on the overbed table out of his/her reach;
-Staff brought the hot water for tea in a large Styrofoam cup;
-He/She started to pull the overbed table closer to him/her in order to eat;
-The cup of hot water fell off the tray and onto the bed;
-He/She was covered with a blanket, but the hot water still contacted his/her skin;
-He/She tried to get the wet items away from him/her and it burned every time he/she moved anything;
-The burn caused constant pain with it being severe most of the time;
-The staff told the resident it was his/her fault because he/she won't get out of bed for meals;
-He/She experienced pain, however, it was worse with the burn on his/her leg;
-He/She preferred pain be less than five out of 10.
Review of the resident's medication administration record (MAR), dated April 2024, showed staff administered pain medication as follows::
-Hydrocodone/acetaminophen (opioid pain medication) 5/325 milligrams (mg) on 4/28/24 at 6:45 P.M. for pain at 8/10;
-Hydrocodone/Acetaminophen 5/325 mg on 4/29 at 3:00 P.M. for left leg pain at 7/10;
-Hydrocodone/Acetaminophen 5/325 mg on 4/29 at 9:58 P.M. for pain at 6/10;
-Hydrocodone/Acetaminophen 5/325 mg on 4/30 at 10:30 P.M. for pain at 7/10.
Review of the resident's nurse note, dated 4/30/24 at 1:12 P.M., showed the following:
-Wound type: third degree burn to posterior left lower extremity, inferior to knee;
-Measurements: 2.2 centimeters (cm) by 11 cm by 0.2 cm;
-Moderate amount of serous drainage (clear fluid that leaks out of wounds) present;
-Updated treatment: cleanse with wound cleanser gently, apply skin prep to peri wound, apply Silvadene to wound bed, cover with non-adherent dressing, secure in place, and change daily.
Review of the resident's physician orders, dated 4/30/24, showed an order for Silvadene cream 1%, apply to posterior left lower extremity below knee. Cleanse with wound cleanser gently, apply skin prep to peri wound, apply Silvadene to wound bed, cover with non-adherent dressing, secure in place, and change daily related to burn.
Review of the resident's care plan, last updated 4/30/24, showed the following:
-The resident had a burn on his/her posterior left lower extremity inferior to knee caused by hot water during mealtime;
-Delayed healing factors: poor mobility, high body mass index (BMI) (measure of body fat based on height and weight that applies to adult men and women), spending majority of time laying in bed, incontinence, diagnoses of type II diabetes mellitus (problem in the way the body regulates and uses sugar);
-Staff educated the resident on the importance of not consuming meals in bed including spilling hot drinks.
Review of the resident's MAR, dated May 2024, showed staff administered the following pain medication:
-Hydrocodone/Acetaminophen 5/325 mg on 5/2 at 7:09 A.M. for pain at 8/10;
-Hydrocodone/Acetaminophen 5/325 mg on 5/2 at 8:56 P.M. for pain at 6/10;
-Hydrocodone/Acetaminophen 5/325 mg on 5/3 at 10:57 A.M. for pain at 5/10;
-Hydrocodone/Acetaminophen 5/325 mg on 5/5 at 8:05 A.M. for pain at 7/10;
-Hydrocodone/Acetaminophen 5/325 mg on 5/5 at 5:34 P.M. for pain at 6/10.
Review of the resident's nurse note, dated 5/9/24 at 11:03 A.M., showed the following:
-Burn to the left lateral posterior thigh currently measuring 2.4 cm by 1.5 cm, no drainage;
-Left inferior knee measures 6.8 cm by 11.9 cm, scant exudate, yellow in color;
-The resident reported pain with the dressing change to the knee.
Observation on 5/19/24 at 5:44 P.M., showed the following:
-The resident lay in bed with headphones on watching television;
-The resident's meal tray sat covered on the over bed table;
-The over bed table sat perpendicular to the bed with the tray on the side of the over bed table away from the resident and not within reach.
Observation on 5/20/24 at 1:16 P.M., showed the following:
-The kitchen staff provided hot water in a red coffee cup with a disposable lid;
-Staff obtained the hot water from a spigot on the coffee machine for resident use:
-The hot water temperature was 160 degrees Fahrenheit.
Review of the National Library of Medicine, dated August 2008, showed hot beverage served at temperatures between 160 degrees Fahrenheit and 185 degrees Fahrenheit can cause significant scald burns (caused by something wet, such as hot water or steam) with brief exposure.
Observation on 5/21/24 at 8:50 A.M., showed the following:
-The resident lay in bed with headphones on and eyes closed;
-The resident's meal tray sat covered on the over bed table;
-The over bed table sat perpendicular to the bed with the tray on the side of the over bed table away from the resident, not within reach;
-A coffee cup with a lid sat on the far end of the tray.
During an interview on 5/22/24 at 9:40 A.M., CNA FF said the following:
-The facility provided an in-service to staff about not using Styrofoam cups, and to only use the coffee cups in the kitchen;
-The in-service did not include placement of trays or drinking cups within reach;
-The in-service did not include allowing the cup to sit and cool prior to giving to a resident.
During an interview on 5/22/24 at 9:48 A.M., CNA G said the following:
-The facility provided staff training after the resident was burned;
-The training included not using Styrofoam cups, only cups provided in the kitchen;
-The training did not include where to place the trays or drinks, because staff should already know to keep things safely in the resident's reach;
-The training did not include allowing drinks to sit and cool before use.
During an interview on 5/23/24 at 6:49 P.M., the Director of Nursing (DON) said the following:
-The staff were supposed to use red coffee cups;
-The staff needed to take time to hand wash the coffee cups instead of using Styrofoam;
-No assessments were done to assess the water temperature in the kitchen for resident use;
-CNAs are trained to put items within reach during training to become a CNA.
2. Review of Resident #42's Care Plan, dated 6/28/23, showed the following:
-The resident is at risk for injury related to a history of falls related to acute medical condition and fall within 36 hours of admission;
-The resident will remain free from injury;
-Analyze the resident's falls to determine a pattern/trend, which appear to be related to medical trauma and possibly delirium/confusion.
-Give the resident verbal reminders not to transfer without assistance;
-Keep the resident's bed in the lowest position with brakes locked;
-Keep call light in reach at all times;
-Keep personal items and frequently used items within reach;
-Place fall mats by bed (both sides);
-Staff to provide substantial assistance for pivot transfer,with a gait belt during transfers for balance/safety.
Review of the resident's care plan showed staff reviewed the care plan on 5/1/24 and made no changes to the resident's care plan for fall risk.
Review of the resident's quarterly MDS, dated [DATE], showed the following:
-Moderate cognitive impairment;
-Scheduled pain medication;
-Independent with transfers and walking;
-Continent of bowel and bladder.
Review of the resident's nurses notes, dated 5/9/24, showed the following:
-Heard yelling from the resident's room;
-When entering the room, the resident lay on his/her right side holding his/her arm;
-The resident had blood dripping from his/her right eyebrow;
-Laceration to right eyebrow, along with right shoulder that was displaced;
-The resident was unable to move his/her right arm;
-The resident was sent to the emergency room via emergency medical services (EMS).
Review of the resident census showed the resident went to the hospital on 5/9/24 and returned on 5/10/24.
Review of the resident's nurses notes, dated 5/10/24, at 7:36 A.M. the interim Director of Nursing documented the following:
-Returned to facility at 7:32 A.M. by ambulance transport from the hospital;
-Laceration to right forehead; stitches noted;
-The resident had a dislocation of his/her right shoulder, these injuries were from his/her fall in her room last
night.
Review of the resident's nurses notes, dated 5/10/24, at 1:50 P.M., showed the following:
-Skin assessment performed post fall;
-Area above right eyebrow measured 4.9 cm in length and 0.5 cm in width;
-Sutures in place, left open to air;
-Area on right cheek measures 1.6 cm in length and 0.3 cm in width left open to air;
-No bruising noted to right shoulder.
Review of the resident's medication administration record, dated May 2024, showed the following:
-On 5/11/24, staff documented the resident's pain score as five out of 10 (with 10 being the highest) on the evening shift;
-On 5/12/24, staff documented the resident received PRN (as needed) Tylenol (pain reliever) 650 milligrams (mg) at 12:21 P.M. and night shift documented a pain score of four out of 10.
Review of the resident's nurses notes, dated 5/12/24, showed the following:
-Aide reported the resident had an unwitnessed fall;
-Upon entering the resident's room, the resident was sitting on his/her buttocks beside his/her bed and was leaning on his/her right arm;
-When asked what happened, the resident said, I was about to wet myself;
-The resident was educated on using call light for safety due to previous fall.
Review of the resident's physician's orders, dated 5/13/24, showed hydrocodone-acetaminophen 5-325 milligrams two times daily for pain.
Review of the resident's nurses notes, dated 5/19/24, showed the following:
-The resident was found on the floor next to his/her bed;
-The resident said he/she slid off the bed and onto his/her bottom;
-The resident had chronic pain complaints in his/her right shoulder due to a previous fall and dislocation.
Review of the resident's electronic medical record showed no evidence of analysis of the resident's falls, review or revision of the resident's care plan after each fall, or any additional changes to prevent further injuries from falls.
Observation on 5/19/24, at 3:45 P.M., showed the resident in his/her wheelchair sitting in the hall by the nurses desk. The resident had sutures to a laceration above his/her right eye brow approximately 4-5 centimeters in length and he/she had a black eye.
3. Review of Resident #52's admission MDS, dated [DATE], showed the following:
-Severe cognitive impairment;
-Diagnoses included dementia chronic pain, fusion of spine (surgical connection of two bones in the spine to prevent movement), and spinal stenosis (space inside the backbone is too small that can put pressure on the spinal cord and nerves that travel through the spine, can cause pain, tingling, numbness and muscle weakness);
-Independent with transfers and ambulation;
-No mobility devices used;
-Occasionally incontinent of bladder and bowel;
-No toileting program;
-Scheduled pain medications.
Review of the resident's care plan, dated 6/27/23, documented the resident has cognitive loss. The care plan did not identify the resident was at risk for falling.
Review of the resident's nurses notes, dated 7/11/23 at 6:39 A.M., showed the following:
-The resident continues observation for recent fall. Steri-strips to left hand intact with no drainage noted;
-The resident's family member said the resident fell because the resident was trying to get assistance from the staff, for his/her family member (also a resident), and no one answered the call light;
-Upon entering the room, the resident was found on top of his/her covers that were in his/her recliner, most likely due to the resident sliding to the floor while lying on top of the items;
-The resident denied pain or discomfort and had no visible injuries;
-Education was provided to the resident about allowing staff to assist his/her spouse to avoid future injury;
-The resident voiced understanding but additional teaching and reinforcement is required related to his/her cognitive decline. No change in status at this time.
Review of the resident's nurses notes, dated 7/11/23 at 5:43 P.M., showed the following:
-The resident had unsteady gait and lost balance causing a fall when he/she tried to assist staff who were assisting the resident's family member (also a resident);
-The resident sustained a laceration to his/her left eye;
-The resident was transferred to the emergency room via EMS.
Review of the resident's nurses notes, dated 7/11/23 at 10:14 P.M., showed the resident's laceration above the resident's left eye required glue repair by the emergency room. No other injuries noted.
Review of the resident's care plan showed no evidence staff updated the resident's care plan, after he/she fell on 7/11/23, to include/address interventions related to helping his/her (resident) family member.
Review of the resident's nurses notes, dated 7/15/23 at 7:47 A.M., showed the following:
-The resident sat on the floor to the front and left side of the chair, up against the wall;
-The resident said he/she was getting up to help his/her family member (also a resident) and he/she slid out of the chair;
-The resident had a small abrasion to his/her lower back from sliding down the wall;
-The resident was significantly more confused than baseline, likely related to current diagnosis of urinary tract infection and was currently on antibiotics.
Review of the resident's care plan showed no evidence staff updated the resident's care plan, after he/she fell on 7/15/23, to include/address interventions related to helping his/her (resident) family member.
Review of the resident's care plan, updated 7/26/23, showed the following:
-The resident was at risk for falls due to declining cognitive level and unsteady gait;
-Ensure the resident's room was free of clutter that he/she could potentially trip over;
-Increased staff supervision with intensity based on resident need.
Review of the resident's nurses notes, dated 8/16/23 at 3:24 P.M., showed the following:
-Interdisciplinary note showed the resident had three falls in the month of July;
-All of the resident's falls were related to him/her assisting his/her family member (also a resident);
-The resident's fall risk score was a 21, which put him/her at a high risk for falls.
Review of the resident's Nurses Notes, dated 9/12/23 at 11:45 P.M., showed the following:
-The resident sustained a non-injury, witnessed fall in the dining room;
-The resident sat at the dining room table and slid out of his/her chair onto his/her bottom.
The resident's medical record showed no evidence the facility attempted to identify the root cause of the fall.
Review of the resident's care plan showed no evidence staff updated the resident's care plan after he/she fell on 9/12/23.
Review of the resident's quarterly MDS, dated [DATE], showed the following:
-Severe cognitive impairment;
-Requires supervision, touch or verbal cues for transfers and ambulating;
-Requires partial/moderate assistance from staff for upper body dressing;
-Requires substantial maximal assistance from staff for lower body dressing and put on/take off footwear;
-Frequently incontinent of bladder and continent of bowel;
-Two or more injury falls since last assessment.
Review of the resident's nurses notes, dated 9/25/23 at 10:23 P.M., showed the following:
-The resident sustained a fall at 1:00 P.M. The resident stood up out of his/her wheelchair and was walking toward the nursing station;
-The resident turned around and fell backward, striking his/her left posterior head against the nursing station counter;
-The resident was immediately assessed for injury and a silver dollar sized raised area was noted to his/her left posterior head;
-Neurological checks initiated per facility protocol.
Review of the resident's care plan showed no evidence staff updated the resident's care plan after he/she fell on 9/25/23.
Review of the resident's nurses notes, dated 10/12/23 at 1:48 P.M., showed the following:
-The care plan team met with the resident's family member;
-The resident receives assistance getting into bed, but was able to get out of bed on his/her own;
-The resident will propel his/her wheelchair around the building from time to time;
-The resident had not had any recent falls.
Review of the resident's nurses notes, dated 10/14/23 at 10:14 P.M., showed the following:
-Kitchen staff witnessed the resident fall in the dining room. The resident struck his/her head against the piano and fell to the floor;
-The resident had a superficial laceration (cut or tear to the skin) and a silver dollar sized hematoma (localized bleeding), from the fall, to top of his/her posterior (back) head;
-The resident was assessed, a dressing was placed on the resident's head wound and neurological checks (series of tests and questions to evaluate the nervous system) initiated.
Review of the resident's medical record showed no evidence the facility attempted to identify the root cause of the fall.
Review of the resident's care plan, updated 10/14/23, showed the resident fell in the dining room and hit his/her head against the piano. Laceration and hematoma noted. No interventions were added or revised on the resident's care plan.
Review of the resident's nurses notes, dated 11/22/23 at 9:56 P.M., showed the resident was found sitting on the floor with his/her legs crossed, going through his/her closet.
Review of the resident's medical record showed no evidence the facility attempted to identify the root cause of the fall.
Review of the resident's care plan showed no evidence staff updated the resident's care plan after he/she fell on [DATE].
Review of the resident's nurses notes, dated 11/24/23 at 6:36 P.M., showed the following:
-The resident was sent to the emergency room for further evaluation related to a fall;
-The resident has a hematoma to the left ear.
Review of the resident's medical record showed no evidence the facility attempted to identify the root cause of the fall.
Review of the resident's care plan, updated 11/24/23, showed the following:
-On 11/24/23, the resident was found on the floor in the television area;
-He/She had been sitting in his/her wheelchair and fell;
-He/She hit his/her head on the floor;
-The resident's left ear became red and swollen; received an order to send to the hospital for evaluation;
-When the resident was not in his/her room, place the resident by the nurses station for close supervision.
Review of the resident's quarterly MDS, dated [DATE], showed the following:
-Diagnoses of depression and Alzheimer's disease;
-Severe cognitive impairment;
-Used a walker;
-Frequently incontinent of bladder and bowel;
-Requires supervision, touch or verbal cues for transfers and ambulating;
-Two or more no injury falls since last assessment
-Received an antidepressant medication daily.
Review of the resident's nurses notes, dated 12/31/23 at 10:02 P.M., showed the following:
-The resident had an unwitnessed fall in his/her room; when staff arrived, the resident was sitting on the floor next to his/her wheelchair;
-The resident did not have socks on and had spilled his/her water on the floor;
-The resident was holding his/her left hand and had a small cut to his/her left pinky finger and a blood blister, cleansed and bandaged;
-Abrasion noted to the resident's left lower back measuring 10 centimeters (cm) in length by 1.3 cm in width; redness to area noted;
-Staff placed the resident on neurological checks.
Review of the resident's care plan showed no evidence staff updated the resident's care plan after he/she fell on [DATE].
Review of the resident's nurses notes, dated 1/6/24 at 2:29 P.M., showed the following:
-The resident had a witnessed fall in the living area;
-Staff witnessed the resident lower himself/herself to the floor;
-Mechanical lift pad caught under the resident's chair.
Review of the resident's care plan showed no evidence staff updated the resident's care plan after he/she fell on 1/6/24.
Review of the resident's quarterly MDS, dated [DATE], showed the following:
-Severe cognitive impairment;
-Moderate to severe depression;
-Does not use a wheelchair;
-Always incontinent of bladder and bowel;
-Pain medication scheduled,
-Non-verbal sounds, facial expressions that could indicate pain in the five days;
-Requires supervision, touch or verbal cues for transfers and ambulating;
-Two or more no injury falls since last assessment.
Review of the resident's nurses notes, dated 5/10/24 at 5:44 P.M., showed the following:
-The resident had an unwitnessed fall in his/her room;
-Staff observed the resident sitting on his/her buttocks on his/her fall mat;
-The resident's bed was in the lowest position at the time;
-The resident has a laceration to his/her right forearm;
-Neurological checks initiated.
Review of the resident's care plan showed no evidence staff updated the resident's care plan after he/she fell on 5/10/24.
Observation on 5/19/24, at 4:33 P.M., showed the following:
-The resident lay in his/her bed with the door to his/her room closed;
-The resident's bed was low to the ground;
-There was a fall mat propped against the dresser across the room;
-There was no fall mat next to the resident's bed.
During an interview on 5/23/24 at 10:45 A.M., the DON said the following:
-The facility has had change over in nursing administration so all systems were not in place;
-All of the licensed staff are agency and not full time;
-The charge nurse would immediately assess a resident after each fall and treat or get orders to treat any injury accordingly;
-Ideally there would be a review of each fall the next day;
-During the review, staff would try to determine the cause of the fall, evaluate the care plan to see what can be done to prevent further falls and/or reduce injury if there is a future fall;
-If a fall was unwitnessed, or the resident hit their head, then the staff are expected to do neurological checks;
-Staff would notify the physician, family, and nursing administration of each fall.
4. Review of Resident #14's care plan, last updated 1/31/24, showed the following;
-The resident was at risk for falls due to cerebrovascular disease with hemiparesis and hemiplegia (loss of strength in the arm, leg, and sometimes face on one side of the body) of right dominant side;
-Restorative therapy for lower extremity exercise three times per week;
-Two person staff to assist with pivot transfers.
Review of the resident's quarterly MDS, dated [DATE], showed the following:
-The resident had severely impaired cognitive skills for daily decision making;
-He/She had disorganized thinking the fluctuated;
-He/She was independent with wheelchair locomotion.
Observation on 5/19/24 at 5:09 P.M. showed the following:
-CNA O pushed the resident in a wheelchair into the dining room;
-The wheelchair did not have foot pedals;
-The residents feet were touching the floor and dragged along the floor while being pushed.
Observation on 5/21/24 at 11:10 A.M., showed the following:
-CNA O pushed the resident in a wheelchair from the common television area to his/her room;
-The wheelchair did not have foot pedals;
-The resident's feet touched the floor three times during locomotion; the resident wore non-skid socks.
During an interview on 5/21/24 at 11:40 A.M., CNA O said the following:
-He/She did not know where the resident's foot pedals were and did not see them in the resident's room;
-The resident usually did well with keeping his/her feet up off the floor.
5. Review of Resident #1's quarterly MDS, dated [DATE], showed the following:
-Severe cognitive impairment;
-Uses wheelchair for mobility;
-Diagnoses included traumatic brain injury.
Observation on 5/19/24 at 5:00 P.M. showed the following:
-CNA C pushed the resident in his/her wheelchair on the 400 hallway;
-The wheelchair had no foot pedals; the resident's sock feet drug on the tile floor. His/Her right foot was bent back under the wheelchair seat.
Observation on 5/20/24 at 2:55 P.M., CNA C pushed the resident in a wheelchair with no foot pedals. The resident's feet drug under the wheelchair.
During an interview on 5/23/24 at 9:30 A.M., CNA C said all the foot pedals had been taken off the wheelchairs for unknown reasons. The pedals had been placed in a room on the B hallway. CNA C said the resident did not self propel himself/herself. CNA C said he/she pushed the resident in a wheelchair without pedals. CNA C said that it would be unsafe to transport residents without foot pedals. He/She tried to stop if a resident's feet drug on the floor and reminded the resident to lift their feet.
6. Review of Resident #22's continuity of care document showed the resident's diagnoses included dementia and cognitive communication deficit (difficulty with memory, organization and problem solving that can make it difficult to properly speak, listen, read, write or interact in social situations).
Review of the resident's quarterly MDS, dated [DATE], showed the following:
-Severely impaired cognitive skills for daily decision making;
-Supervision for mobility in his/her wheelchair for short distance;
-Partial/moderate assistance from staff for wheelchair mobility for long distances.
Review of the resident's care plan, revised on 03/28/24, showed the following:
-The resident is at high risk for falls related to history of falls, limited mobility and hip/knee contractures;
-Used a wheelchair for mobility.
Observation on 05/19/24 at 4:45 P.M., showed CNA FF pushed the resident to the dining room in a wheelchair. There were no foot pedals attached to the resident's wheelchair. Both of the resident's feet drug on the floor as CNA FF pushed the resident from the dayroom to the dining room.
7. Review of Resident #68's continuity of care document showed the resident's diagnoses included cerebrovascular disease (a group of conditions that affect blood flow and the blood ve[TRUNCATED]
CONCERN
(D)
📢 Someone Reported This
A family member, employee, or ombudsman was alarmed enough to file a formal complaint
Potential for Harm - no one hurt, but risky conditions existed
Resident Rights
(Tag F0550)
Could have caused harm · This affected 1 resident
**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on interview and record review, the facility failed to provide care in a manner that enhanced resident dignity for one res...
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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 care in a manner that enhanced resident dignity for one resident (Resident #63), in a review of 24 sampled residents, and for one additional anonymous resident (Resident #100). The facility census was 67.
Review of the undated facility policy, Resident Rights, showed the resident has a right to a dignified existence, self-determination and communication with and access to persons and services inside and outside the facility.
1. Review of Resident #63's quarterly Minimum Data Set (MDS), a federally mandated assessment instrument required to be completed by facility staff, dated 4/18/24, showed the following:
-The resident was cognitively intact;
-He/She had limited functional range of motion to bilateral upper and lower extremities;
-He/She required maximal assistance with upper body dressing;
-He/She required moderate assistance with personal hygiene;
-He/She was dependent for toileting hygiene and lower body dressing;
-He/She was always incontinent of bladder and bowel.
Review of the resident's care plan, last updated 4/24/24, showed the following:
-The resident needed assistance with personal hygiene and bathing, and he/she participated in bed mobility but did need assist;
-He/She received antipsychotic medication for the treatment of bipolar disorder (mood disorder that can cause intense mood swings).
During an interview on 5/22/24 at 9:10 A.M., the resident said the following:
-When the facility was short of nursing staff, everyone was busy and in a rush;
-The nursing staff told him/her they were busy and would get to him/her eventually;
-A few times, the nursing staff answered his/her call light and said, What do you want now?
-The nursing staff also said, Let's get this done. I have several things to do;
-The nursing staff's comments makes him/her feel like a burden;
-He/She didn't want to be a burden but needed help.
2. Review of Resident #100's quarterly MDS, dated [DATE], showed the resident was cognitively intact.
Review of the resident's care plan, revised 3/18/24, showed the resident made his/her own decisions.
During an interview on 5/22/24, at 5:15 P.M., the resident said the following:
-The social service director (SSD) does not treat residents with dignity and respect;
-He/She does not know if the SSD was aware, but she would scold residents and speak to them like they were children;
-The resident said he/she has been scolded by the SSD in front of others and it was humiliating. He/She felt embarrassed and angry;
-He/She has seen the SSD scold and talk down to several residents and it really bothered him/her; the SSD's behavior was intimidating;
-He/She had reported this to a previous Director of Nursing.
During an interview on 5/22/24 at 10:15 A.M., the SSD said staff are expected to treat residents with respect. Staff should not scold residents or talk down to residents in any way.
During an interview on 5/23/24 at 10:34 A.M., the Director of Nursing said the following:
-Staff are expected to treat resident's with dignity and respect;
-Staff are expected to speak to resident's like adults and not scold residents;
-She was not aware of any concerns with the SSD.
CONCERN
(D)
Potential for Harm - no one hurt, but risky conditions existed
Deficiency F0569
(Tag F0569)
Could have caused harm · This affected 1 resident
Based on record review and interview, the facility failed to notify the resident and/or resident representative when the resident's trust account reached $200 less the Supplemental Security Income (SS...
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Based on record review and interview, the facility failed to notify the resident and/or resident representative when the resident's trust account reached $200 less the Supplemental Security Income (SSI) resource for one resident that received Medicaid benefits for one resident (Resident #4), in a sample of 24 residents. The facility census was 67.
Review of an undated blank sampled letter for notification of fund balance, provided by the facility, showed the facility would notify the resident and/or resident representative of the resident's current balance when the balance was within $200.00 of the Medicaid resource limit. If the amount in the fund exceeded the Medicaid resource limit of $5,726.00, the resident may lose eligibility for Medicaid or SSI.
Review of Resident #4's face sheet showed the resident has family member as the responsible party and Durable Power of Attorney for financial and health care decisions.
Review of the resident trust fund account balance report, dated 4/30/24 showed the resident to have an account balance of $5887.24.
Review of the facility provided resident trust fund account binder for the month of April showed no evidence that a notice was given to the resident/legal representative that the resident's trust fund balance was over the maximum amount a Medicaid recipient can have in cash assets for Medicaid Eligibility Limit.
Review of the facility provided resident trust fund account balance report, dated 5/20/24, showed the resident to have an account balance of $5748.24.
Review of the facility provided resident trust fund account binder for the month of May showed no evidence that a notice was given to the resident/legal representative that the resident's trust fund balance was within, or approaching, $200 of the maximum amount a Medicaid recipient can have in cash assets for Medicaid Eligibility Limit.
During an interview on 05/22/24 at 5:10 P.M. and 05/23/24 at 11:50 A.M., the BOM said the following:
-She did not realize that Resident #4 was over his/her limit of maximum a Medicaid resident can have in cash assets;
-She had not sent a notice to the resident's durable power of attorney (DPOA) informing them the resident was approaching his/her maximum amount in the resident trust fund;
-She was not sure how the balance was missed by herself or the resident fund manager.
During an interview on 05/23/24, at 11:45 A.M., the regional resident fund manager said the following:
-She relies on the bookkeeper at the facility to monitor the resident trust fund for balances that are approaching the spend down limit;
-She runs a balance report at the end of the month and if we see there is a balance within $200 we try to spend that excess to provide things like clothes, equipment, or anything the resident might need;
-It was not only the facility's responsibility to monitor the balance, but was also the family's responsibility to monitor that trust fund balance.
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
Investigate Abuse
(Tag F0610)
Could have caused harm · This affected 1 resident
Based on interview and record review, the facility failed to complete a thorough investigation of an allegation of abuse per facility's policy after one resident (Resident #55), of 24 sampled resident...
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Based on interview and record review, the facility failed to complete a thorough investigation of an allegation of abuse per facility's policy after one resident (Resident #55), of 24 sampled residents, reported an allegation of abuse. The resident alleged Certified Nurse Assistant (CNA) DD slapped him/her in the face while providing cares. The facility census 67.
Review of an undated facility policy, titled, Abuse Prohibition Protocol Manual, Investigation Section 7, showed the following:
-It is the policy of this facility that reports of abuse (mistreatment, neglect, or abuse, including injuries of unknown source, exploitation, and misappropriation of property) are promptly and thoroughly investigated;
-Procedure: The investigation is the process used to try and determine what happened. The designated facility personnel will begin the investigation immediately. A root cause and analysis will be completed. The information gathered will be given to administration;
-When an incident or a suspected incident of abuse is reported, the Administrator or Designee will investigate the incident with the assistance of the appropriate personnel. The investigation will include:
-i. Who was involved;
-ii. Residents' statements;
-iv. Interviews obtained from three to four residents who received care from the alleged staff;
-v. Interviews obtained from 3-4 department staff (if applicable);
-vi. Involved staff and witness statements of events;
-vii. A description of the resident's behavior and environment at the time of incident;
-viii. Injuries present including a resident assessment.
1. Review of the staffing schedule for night shift (6:00 P.M. to 6:00 A.M.) on 5/10/24, showed the following staff who worked:
-Charge: Licensed Practical Nurse (LPN) AA;
-CNA (no specific assignment): CNA Z;
-CNA (no specific assignment): CNA Y;
-CNA (no specific assignment): CNA W;
-CNA (no specific assignment): CNA DD;
-CNA (no specific assignment): CNA V.
2. Review of the staffing schedule (staff who worked) for day shift (6:00 A.M. to 6:00 P.M.) on 5/11/24 showed the following staff who worked:
-Charge: LPN EE;
-Meds: LPN D;
-CNA (no specific assignment): CNA C;
-CNA (no specific assignment): CNA BB;
-CNA (no specific assignment): CNA CC;
-CNA (no specific assignment): CNA F; (worked 6:00 A.M. to 2:30 P.M.);
-CNA (no specific assignment): CNA O; (worked 6:00 A.M. to 2:30 P.M.).
3. Review of a Department of Health and Senior Services report, dated 5/11/24 at 7:59 P.M., showed the facility self-reported an allegation of abuse when a resident (Resident #55) alleged CNA (CNA DD) was abusive with him/her.
4. Review of Resident # 55's admission Minimum Data Set (MDS), a federally mandated assessment instrument, dated 3/26/24, showed the following:
-Cognition was not addressed;
-The resident has need for assistance with sit to stand, impairment of one side upper body and both sides lower body.
Review of the resident's facility face sheet showed he/she had diagnoses that included pain, osteoarthritis (joint disease, in which the tissues in the joint break down over time) and muscle weakness.
During an interview on 5/19/24 at 3:20 P.M., the resident said the following:
-He/She was was in his/her bed and waiting to get up for the day (day unknown), it was around 6:00 A.M.;
-Staff (name unknown) came in his/her room to help him/her up;
-He/She was leaning over his/her bed, trying to reach into his/her bedside drawer;
-The same staff thought he/she (the resident) smacked him/her (staff);
-The same staff member then smacked him/her on the face;
-He/She fell out of bed and the staff member left him/her on the floor and left the room;
-He/She got a skin tear to his/her arm from the fall;
-The same staff member returned to his/her room with another staff (name unknown) and they got him/her up;
-He/She had reported the incident to the police (through the administrator).
Review of the resident's facility progress notes showed staff documented the following:
-On 5/10/24 at 3:02 P.M., resident was alert and oriented times three (person, place and time), was assist times one and was able to make his/her needs know;
-On 5/11/24 at 5:22 P.M., administration, director of nursing (DON), family member, and physician updated on resident's fall and skin tear to his/her right forearm;
-Resident had a fall after CNA (not specific as to who) was coming into the room to get the resident up for breakfast. CNA said the resident became combative and the CNA walked out of the room. Nurse receiving day shift report (the writer of this note, Licensed Practical Nurse (LPN ) D) and nurse from previous shift (not specified) went into room noting resident sitting on bed with skin tear to right arm. Nurse from previous shift (not specified) administered first aide to the resident's skin tear. Resident said, I have cuts all over my body, nurse (not specified) assessed thoroughly, no new areas noted. Vitals obtained all entered into Matrix and are stable. Resident denied pain and placed into wheelchair. Safety measures in place, will continue to monitor;
-There was no documentation in the notes regarding the resident's allegation of being slapped by staff.
Review of the documents provided by the facility for their facility investigation showed the following:
-A statement had been collected from CNA DD;
-No documentation to show an interview or written statement from the resident's night shift nurse (LPN AA) or day shift nurse (LPN EE), who were responsible for the resident; (the incident/allegation occurred at shift change);
-No documentation to show an interview or written statement from other staff (night shift) possibly involved, including CNA Z, CNA Y, CNA W or CNA V;
-No documentation to show an interview or written statement from other staff (day shift) possibly involved, including CNA C, CNA BB, CNA CC, CNA F or CNA O;
-No documentation to show interviews were obtained from residents.
During an interview on 5/22/24 at 8:55 A.M., CNA F said the following:
-The resident was on the floor when he/she went to the resident's room with CNA DD;
-He/She saw the skin tear;
-He/She did not know anything about either the resident or CNA DD allegedly slapping each other.
During an interview on 5/21/24 at 6:21 P.M., LPN D said the following:
-At morning shift change on 5/11/24, he/she was aware that the resident was on the floor and night staff, including LPN EE (this would not have been accurate per the schedule), tended to the resident;
-He/She made the nursing note entry because he/she saw that LPN EE had not documented the fall;
-He/She was not aware of any slapping that took place between the resident and CNA DD;
-He/She was not the nurse for the resident on 5/11/24 and could not recall who was;
-No one had ever asked her about any concerns he/she might have regarding CNA DD.
During an interview on 5/21/24 at 1:17 P.M., the DON said the following:
-She was called on 5/11/24 at about 6:00 P.M. by the agency nurse (name unknown) regarding the incident of CNA DD slapping the resident;
-She asked the nurse to do an assessment while she was on the phone;
-The only injury was a skin tear on the resident's right lower arm;
-No interviews with other residents on CNA DD's assignment were completed.
During an interview on 5/23/24 at 1:21 P.M., the Administrator said the following:
-On 5/11/24, the DON called him at 6:00 P.M. and reported CNA DD slapped a resident;
-No residents on CNA DD's assignment had been interviewed, other staff interviews and statements had only been collected from a few staff and no education to staff on abuse had been started;
-These things would need to be included with/for a thorough investigation.
CONCERN
(D)
Potential for Harm - no one hurt, but risky conditions existed
Assessment Accuracy
(Tag F0641)
Could have caused harm · This affected 1 resident
**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on interview and record review, the facility failed to accurately code the Minimum Data Set (MDS), a federally mandated as...
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**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on interview and record review, the facility failed to accurately code the Minimum Data Set (MDS), a federally mandated assessment completed by staff, according to the Resident Assessment Instrument (RAI) manual for one sampled residents (Resident #52), in a review of 24 sampled residents. The facility census was 67.
Review of the Resident Assessment Instrument (RAI) Manual, dated October 2023, showed the following:
-Medicare and Medicaid participating long-term care facilities are required to conduct comprehensive, accurate, standardized and reproducible assessment of each resident's functional capacity and health status;
-The RAI process has multiple regulatory requirements. Federal regulations require that (1) the assessment accurately reflects the resident's status (2) a registered nurse conducts or coordinates each assessment with the appropriate participation of health professionals (3) the assessment process includes direct observation, as well as communication with the resident and direct care staff on all shifts;
-It is important to note here that information obtained should cover the same observation period as specified by the Minimum Data Set (MDS) items on the assessment and should be validated for accuracy (what the resident's actual status was during that observation period) by the interdisciplinary team (IDT) completing the assessment. As such, nursing homes are responsible for ensuring that all participants in the assessment process have the requisite knowledge to complete an accurate assessment.
Review of the facility assessment, updated 5/20/24, showed the facility resources needed to provide competent support and care for the resident population, every day and during emergencies, included MDS Coordinator coverage eight hours per day.
1. Review of Resident #52's, admission MDS, a federally mandated assessment completed by staff, dated 6/16/23, showed the following:
-Severe cognitive impairment;
-Diagnosis include: dementia, chronic pain, fusion of spine (surgical connection of two bones in the spine to prevent movement) and spinal stenosis (space inside the backbone is too small that can put pressure on the spinal cord and nerves that travel through the spine, can cause pain, tingling, numbness and muscle weakness);
-Independent with transfers and ambulation;
-No mobility devices used;
-Occasionally incontinent of bladder and bowel;
-No toileting program;
-Scheduled pain medications received.
Review of the resident's nurses notes, dated 7/11/23 at 6:39 A.M., showed the resident continues observation for recent fall.
Review of the resident's nurses notes, dated 7/11/23 at 5:43 P.M., showed the resident had unsteady gait and lost balance causing a fall.
Review of the resident's nurses notes, dated 7/15/23 at 7:47 A.M., showed the resident was observed sitting on the floor to the front and left side of his/her chair against the wall.
Review of the resident's nurses notes, dated 8/16/23 at 3:24 P.M., showed the IDT note showed the resident had three falls in the month of July.
Review of the resident's nurses notes, dated 9/12/23 at 11:45 P.M., showed the resident sustained a non-injury fall, witnessed in the dining room.
Review of the resident's quarterly MDS, dated [DATE], showed the following:
-Requires supervision, touch or verbal cues for transfers and ambulating 50 feet and to make turns;
-Requires partial/moderate assistance from staff for upper body dressing;
-Requires substantial maximal assistance from staff for lower body dressing and putting on/taking off footwear;
-Frequently incontinent of bladder; continent of bowel;
-Two or more injury falls since last assessment;
-The MDS did not include the non injury falls.
Review of the resident's nurses notes, dated 9/25/23 at 10:23 P.M., showed the resident sustained a fall at 1:00 P.M. The resident turned and fell backward, striking his/her left posterior (back) head against the nursing station counter. The resident was immediately assessed for injury and a silver dollar sized raised area noted to his/her left posterior head.
Review of the resident's nurses notes, dated 10/14/23 at 10:14 P.M., showed the resident sustained a fall in the dining room, witnessed by kitchen staff, striking his/her head against the piano and fell to the floor. The resident had a superficial laceration (tear or cut in the skin and underlying tissue) and a noted silver dollar sized hematoma (similar to a bruise) from the fall to the top of his/her posterior head.
Review of the resident's nurses notes, dated 11/22/23 at 9:56 P.M., showed the resident was found to be sitting on the floor, with his/her legs crossed, going through his/her closet.
Review of the resident's nurses notes, dated 11/24/23 at 6:36 P.M., showed the resident was being sent to the emergency room for further evaluation, related to a fall. Resident had a hematoma to the left ear.
Review of the resident's quarterly MDS, dated [DATE], showed the following:
-Diagnosis of depression and Alzheimer's
-Uses a walker;
-Frequently incontinent of bladder and bowel;
-Two or more no injury falls since last assessment;
-Takes antidepressant medication daily;
The MDS did not include the injury falls.
Review of the resident's nurses notes, dated 12/31/23 at 10:02 P.M., showed the following:
-The resident had an unwitnessed fall in his/her room; when staff arrived, he/she was sitting on the floor next to his/her wheelchair;
-The resident was holding his/her left hand; he/she had a small cut to his/her left pinky finger and had a blood blister; areas cleansed and bandaged;
-Abrasion noted to the resident's left lower back .
Review of the resident's nurses notes, dated 1/6/24 at 2:29 P.M., showed the following:
-The resident had witnessed fall in the living area;
-The resident lowered him/herself to the floor; witnessed by staff;
-Hoyer (mechanical lift) pad caught under the resident's chair.
Review of the resident's quarterly MDS, dated [DATE], showed the following:
-Moderate to severe depression;
-Does not use a wheelchair;
-Ambulates with walker;
-Always incontinent of bladder and bowel;
-Pain medication scheduled,
-Has non-verbal sounds and facial expressions that could indicate pain five day of the seven day look back period;
-Two or more no injury falls since the last assessment;
-The MDS did not include the injury falls.
Observation of the resident during the survey process, from 5/19/24 to 5/23/24, showed the resident to always be in a wheelchair when out of bed. The resident did not walk independently or with staff.
During an interview on 5/20/24 at 1:51 P.M. and 2:00 P.M. the acting MDS coordinator said:
-She worked at a sister facility and came over one or two days a week and helped complete the MDS's;
-She did not know the residents, so he/she would ask the staff questions about the residents and complete the MDS's as best as he/she could;
-She only completed what needed to be done;
-She was not usually at the facility when the interdisciplinary team was there so does what she can.
During an interview on 5/21/24 at 10:04 A.M., the Director of Nursing said the MDS assessments are expected to be completed according to the RAI manual. She was not sure if they were accurate or up to date as the MDS coordinator was part time and only in the facility on the weekends.
CONCERN
(D)
Potential for Harm - no one hurt, but risky conditions existed
PASARR Coordination
(Tag F0644)
Could have caused harm · This affected 1 resident
**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on interview and record review, the facility failed to have documentation of a Level I (level of care) PASARR (Pre-admissi...
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**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on interview and record review, the facility failed to have documentation of a Level I (level of care) PASARR (Pre-admission Screening and Resident Review), failed to file for a Level II PASARR (an in-depth assessment of the resident's mental health and intellectual needs) when conditions/diagnoses changed or were added, and failed to notify the appropriate state-designated authority for a significant change PASARR evaluation and determination for one resident (Resident #6), in a review of 24 sampled residents, when the resident reported suicidal thoughts and ideations and required hospitalization. The facility census was 67.
Record review of the Missouri Department of Health and Senior Services (DHSS) guide titled, PASARR Desk Reference, dated [DATE], showed the following:
-The PASARR is a federally mandated screening process for any person for whom placement in a Medicaid Title (XIX) certified bed is being sought. This is a Level I screening (completion of the DA124C form);
-A Level II assessment is completed on those persons identified at Level I who are known or suspected to have a serious mental illness (such as schizophrenia, dementia, major depression, etc., mental retardation (MR) or related MR condition to determine the need for specialized service (completion of the DA124A/B form). The facility is responsible for completing the DA124A/B and/or DA124C forms and is also responsible for submitting completed form(s) to DHSS, Division of Regulation and Licensure, Section for Long Term Care Regulation, Central Office Medical Review Unit (COMRU);
-PASARR screening is required to assure appropriate placement of persons known or suspected of having a mental impairment;
-To assure that the individual needs of mentally impaired persons can be and are being met in the appropriate placement environment;
-To be compliant with the Omnibus Budget Reconciliation Act (OBRA)/PASARR federal requirements, see 42 CFR 483.Subpart C; and
-To assure Title XIX funds are expended appropriately and in accordance with Legislative intent.
Request for a facility policy regarding PASARRs was made and no policy received.
1. Review on [DATE] of Resident #6's medical record showed the following:
-An admission date of [DATE] (latest return) and [DATE] (current);
-Diagnoses at admission ([DATE]) included major depressive disorder, recurrent severe without psychotic features.
Review of the resident's entry tracking record Minimum Data Set (MDS), a federally mandated assessment instrument, completed by facility staff, dated [DATE], showed the following:
-admitted to the facility on [DATE];
-No documentation of a PASARR being completed.
Review of the resident's facility progress notes, dated [DATE] at 4:38 P.M., showed staff documented an admission assessment that included the following:
-Alcohol: Educated no alcohol to be in the building unless it is locked up. States he/she has been sober since September of 2022. Asked resident if he/she needed any support measures such as a psychologist and resident denied at this time;
-Mood: Recently lost a child. He/She was struggling with this loss. Offered support and psychologist to talk to. Resident again refused at this time but said maybe at a later time.
Review of the resident's continuity of care document showed a new diagnoses of schizophrenia (mental illness) added on [DATE].
Review of the resident's discharge MDS, dated [DATE], showed the following:
-Unplanned discharge; return anticipated;
-Had been evaluated by Level II PASARR and determined to have a serious mental illness;
-Diagnoses included depression and schizophrenia;
-No behaviors or rejection of cares.
Review of the resident's medical record showed the resident hospitalized on [DATE] and returned [DATE].
Review of the resident's care plan showed a problem start date [DATE]: Category: psychotropic drug use; Approach: psychiatric and psychological services as needed.
Review of the resident, facility provided, Level I PASARR, completed by the Business Office Manager, dated [DATE] (243 days since admission), showed the following:
-Diagnoses included major depressive disorder, personality disorder, bipolar disorder (mental illness) and other mental disorder in the Diagnostic and Statistical Manual of Mental Disorders (DSM); the box for schizophrenia was not marked;
-To the question, Does the individual have a substance related disorder, the box was marked no; to the question, When did the most recent substance abuse occur, the unknown box was marked; (the resident's admission note showed he/she had been sober from alcohol since September of 2022);
-admission date to the facility was [DATE].
Review of the resident's medical record showed a new diagnoses of anxiety added [DATE].
Review of the resident's quarterly MDS, dated [DATE], showed the resident had behaviors and rejection of cares one to three days a week.
Review of the resident's care plan showed a problem start date: [DATE]: Category: behavioral symptoms; potential for inappropriate social behavior related to episodes of sudden anger related to diagnoses of schizophrenia and mood disorder; Goal: resident will not harm self.
Review of the resident's facility progress notes showed staff documented the following:
-On [DATE] at 8:09 A.M., resident reported having suicidal idealizations with a plan. Updated physician's clinic. Resident will be evaluated at hospital. Resident 1:1 until transport to the hospital by facility transportation. Two staff escorted resident. While in transit resident pulled out a half pint of vodka with approximately six ounces of liquor remaining in the bottle. Bottle was then given to staff;
-On [DATE] at 11:25 A.M., resident remains in hospital;
-On [DATE] at 1:59 P.M., resident returned to the facility.
Review of the resident's hospital discharge notes, dated [DATE], showed the following:
-The resident arrived on [DATE] via long term care facility (LTCF) after making suicidal statements;
-Presents for worsening depression and suicidal ideations;
-According to resident, depression has gotten worse thinking about the holidays and two of his/her deceased spouses;
-If he/she had a rope, he/she would hang him/herself;
-Has a history of alcohol and drug abuse and prior suicide attempts;
-Diagnoses of alcohol use disorder and had become more depressed recently following alcohol use recurrence;
-Resident reminded alcohol use can bring on bad thoughts such as he/she has had recently;
-Resident reported he/she was drinking three pints of alcohol per day; LTCF reported resident's family member brought him/her alcohol;
-Discharge recommendation included to continue treatment on an outpatient basis (has outpatient psych providers through LTCF); seek substance use treatment; possible naltrexone to help with alcohol cravings.
Review of the resident's medical record showed no updates to his/her care plan or MDS regarding the resident's suicidal thoughts, ideation and/or plan and no documentation to show the resident was set up with outpatient psych services.
Review of the resident's facility progress notes showed staff documented on [DATE] at 9:10 A.M., Behavior: resident yelling at this nurse, who was at the nursing station, regarding the way his/her eggs were prepared; was yelling very loud,stated that he/she wanted to speak with the Administrator, resident told Administrator and later this nurse that his/her child had died from an overdose. This nurse offered understanding (no documentation that support services were offered); care plan updated.
Review of the resident's care plan showed a problem start date of [DATE]; Category: psychosocial well being; resident has experienced the recent loss of his/her child related to overdose; child expired on [DATE]. Goal: resident will express feelings about recent loss appropriately.
Review of the resident's facility progress notes showed staff documented the following:
-On [DATE] at 10:09 P.M., resident walked by nurses desk and nurse at desk alerted the resident's nurse the resident had returned and could receive his/her medication. Resident wanted nurse to give him/her his/her medication in hand and said, I will take them later, it is too early for me right now. Nurse relayed he/she would keep the medications in the cart and when the resident was ready, the resident could have them. Resident started yelling at nurse, cussing screaming. This nurse walked to resident's room to talk to him/her and calm him/her down. Resident said he/she was going through a lot and he/she didn't like the nurse. While talking to resident, this nurse smelled alcohol on resident's breath. This nurse asked resident have you been drinking? Resident said, Yes, I got the ok I am my own person. Resident then said he/she was at the bar down the street;
-On [DATE] at 2:03 P.M., resident in kitchen yelling at the cook telling cook he/she didn't want what the cook was making. Director of Nursing asked resident to step out of the kitchen area, resident then went into the ice machine and cursed staff out. Contacted physician about behaviors, resident is on multiple medications for behaviors, was advised to get alcohol (ETOH) level in the morning.
Review of the resident's medical record showed no documentation staff obtained an alcohol level on [DATE] and no documentation staff offered support services for alcohol use.
During an interview on [DATE] at 11:26 A.M., the resident said the following:
-He/She was his/her own person;
-Before coming to the facility, he/she was a heavy drinker but got help and had been sober since before coming to the facility;
-He/She had begun drinking again; life was just stressful;
-He/She had lost a couple of children; children were not supposed to die before their parent;
-He/She felt guilty for having addictions because he/she must have passed it down to the child that died of an overdose; that made him/her sad; drinking made that feeling go away;
-Talking to people and attending groups for addictions and problems had helped in the past;
-He/She would consider getting help again if someone helped him/her;
-He/She just felt like staff was not consistent at the facility to help or even care;
-He/She felt better as a person when he/she was sober;
-When he/she drinks, he/she sometimes makes bad decisions or treats people badly and he/she does not like to do that.
Review of email communication from COMRU to the state agency, dated [DATE] at 4:09 P.M. showed the following:
-COMRU does not have a valid application;
-The last application was pending corrections and was for a Special admission Category only (would have triggered a Level 2);
-The SNF will need to submit an online application for processing.
Review of email communication from COMRU to the state agency, dated [DATE] at 2:53 P.M., showed the following:
-An application was submitted on 4-19-2023 and correction sent on 4-23-2023;
-A 2nd correction was sent on 4-28-2023 and 3rd correction on 06-07-2023; this application was a special admission category as well;
-This correction indicated that the SNF would need to submit another application for the 04-07-2023 admission.;
-The application should have been submitted within 14-20 days of admission due the COVID 19 waiver; (The COVID 19 wavier was available until 05-11-2023);
-If the suicidal ideation and plan was a new behavior, then a change in condition would have needed to be submitted;
-The SNF does not have a current Level 1/Level of Care application.
During an interview on [DATE] at 10:40 A.M., the Business Office Manager said the following:
-He/She had been responsible for the PASARRs and had completed the resident's PASARR;
-A Level I should be completed before admission;
-There should be documentation of the PASARR in the resident's medical record;
-There was no PASARR in the resident's medical record other than the one completed [DATE];
-He/She thought the resident's PASARR was complete;
-He/She did not recall getting any communication that corrections were needed,
During an interview on [DATE] at 2:40 P.M., the Social Services Designee said she did not know she was responsible for ensuring the PASARRs were completed when they should be. She was new to her position (started in [DATE]) and had not completed the resident's PASARR, the business office manager had completed it.
During an interview on [DATE] at 6:49 P.M., the Director of Nursing said the following:
-Social services was responsible for ensuring the PASARRs were completed when they should be;
-She could not find where the resident had had the alcohol level drawn; the resident was his own person and was more frequently leaving and going to a bar and returning. The resident had had a lot of life stressors which have probably caused him/her to fall back into old habits and patterns;
-She knew on admission the resident had refused any additional services. She was not sure if any had been offered since the resident lost his/her child or since the facility became aware the resident was drinking again.
CONCERN
(D)
Potential for Harm - no one hurt, but risky conditions existed
Incontinence Care
(Tag F0690)
Could have caused harm · This affected 1 resident
**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, interview, and record review, the facility failed to ensure one resident (Resident #20), in a review of on...
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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 (Resident #20), in a review of one resident who had an indwelling urinary catheter (a flexible tube inserted into the bladder to allow urine to drain from the bladder), and who had a history of urinary tract infections (UTI), was provided with the proper care of the urinary catheter device when staff allowed the collection bag and tubing to touch the floor. The facility also failed to provide urinary incontinence care in a manner to prevent the spread of bacteria that cause infections for one resident, (Resident #28), who also had a history of UTI's, in a review of 24 sampled residents. The facility census was 67.
Review of the undated facility policy titled, Catheter, Emptying a Urinary Drainage Bag, showed staff was to keep the drainage bag and tubing off the floor at all times to prevent contamination and damage.
1. Review of Resident #20's care plan, dated 11/24/23, showed the following:
-The resident required an indwelling urinary catheter related to urine retention;
-Do not allow tubing or any part of the drainage system to touch the floor. The resident at times will refuse to raise bed to ensure bag is off the floor.
Review of the resident's progress note, dated 12/22/23 at 10:43 P.M., showed the resident received a new order for an antibiotic for a urinary tract infection (UTI).
Review of the resident's progress note, dated 1/11/24 at 2:24 P.M., showed the following:
-Staff encouraged the to raise the bed off of the floor because the catheter bag was touching the floor;
-The resident refused to raise the bed.
Review of the resident's progress note, dated 2/4/24 at 12:38 A.M., showed the resident received a new order for Omnicef (an antibiotic) for a UTI.
Review of the resident's May 2024 physician order sheet (POS) showed an order for an indwelling urinary catheter.
Review of the resident's care plan, dated 5/20/24, showed the following:
-The resident lowers his/her bed independently causing his/her catheter collection bag to come into contact with floor;
-The resident was educated on appropriate bed height to prevent the bag from coming into contact with the floor and the infection control risk associated with this;
-Staff will check bed height when doing rounds to ensure the bag is not touching floor and provide the resident education as needed.
Observation on 05/21/24 at 10:29 A.M. showed the following:
-The resident lay in his/her bed;
-The resident's urinary catheter drainage bag was attached to the side of his/her bed;
-The urinary drainage bag was in a dignity bag and the catheter tubing was outside of the dignity bag;
-The catheter tubing and the dignity bag both touched the floor;
-The urine in the urinary catheter bag was brown and cloudy;
-The urine in the urinary catheter tubing was red and filled with sediment (a substance that settles at the bottom of urine) (normal urine does not have sediment).
During interview on 5/22/24 at 2:00 P.M., Certified Nurse Aide (CNA) E said the following:
-The resident's catheter tubing should not be on the floor;
-The resident lowered his/her bed to the floor and CNA E was unsure what to do to keep the tubing off of the floor;
-Overnight staff removed the resident's dignity bag and he/she observed the uncovered urinary bag and tubing on the floor.
2. Review of Resident #28's, admission Minimum Data Set (MDS), a federally mandated assessment instrument, dated 6/16/23, showed the following:
-Moderately impaired cognition;
-Requires substantial or maximum assistance from staff for toileting hygiene, lower body dressing, going from sitting to standing and transfers;
-Occasionally incontinent of bladder and frequently incontinent of bowel.
Review of the resident's care plan, dated 6/28/23, showed the following:
-Deficit in activities of daily living (ADLs) completion related to limited mobility, pain and frozen shoulders/neck from medical diagnoses;
-Diagnosis of nerve injury of cervical (neck region) spine, arthralgia (joint stiffness) of bilateral (both) temporomandibular joint (joint connecting lower jaw to skull) and degeneration of the spinal cord;
-Resident will have ADL needs met daily by being clean and with adequate hygiene;
-Assist daily and as needed with hygiene needs;
-Because of neck/shoulder range of motion (ROM) limits, give physical assist or perform the ADL tasks he/she cannot perform during cares;
-Assist with perineal/personal hygiene needs.
Review of the resident's nurses notes, dated 12/1/23, showed the resident was transferred to the hospital on [DATE] and returned on 12/1/23 with a diagnosis of urinary tract infection. The hospital sent a prescription for Cipro (an antibiotic).
Review of the resident's quarterly MDS, dated [DATE], showed the following:
-Cognitively intact;
-UTI in the last 30 days.
Observation on 5/21/24 at 5:30 A.M., showed the following:
-The resident lay in his/her bed;
-CNA W donned gloves and assisted Resident #49 (the resident's roommate), who had been incontinent of feces, to clean his/her perineal area and change his/her clothing;
-CNA W removed his/her gloves after assisting Resident #49 and did not wash his/her hands with soap and water or cleanse them with alcohol gel;
-CNA W donned new gloves (without washing hands) and assisted Resident #28 with perineal care;
-CNA W cleaned down the resident's front perineal area three times, with the same area of one cloth and then down the center of the resident's perineal area with the same wipe;
-CNA W rolled the resident to his/her side;
-The pad under the resident was wet with urine;
-The CNA's did not provide incontinence care in a manner to prevent the spread of contaminates that cause infection.
During an interview on 5/21/24 at 6:15 A.M., CNA W said the following:
-Staff are expected to clean their hands with soap and water before and after contact with each resident and before and after gloving;
-When providing perineal care, staff should use a clean part of the wipe with each swipe and clean the resident from the front to the back or clean to dirty.
During an interview on 5/21/24 at 8:45 A.M., CNA FF said staff are expected to clean incontinent residents perineal area from front to back with one wipe per swipe.
During interviews on 5/23/24 at 6:49 P.M. and 6/11/24 at 3:22 P.M., the DON said the following:
-Catheter bags should be kept in a privacy bag;
-Catheter bags and tubing should not be kept on the floor;
-When staff found the resident's urinary catheter bag or tubing on the floor, the staff were to educate the resident on raising his/her bed;
-There were no other interventions provided after the resident had been educated on keeping his/her bed in a position where the urinary catheter drainage system was off the floor;
-She had to educated the resident several times on his/her bed position and keeping the urinary drainage system off the floor.
-Staff are to wash their hands with soap and water before applying gloves, after removing gloves and when dirty;
-Staff should be changing gloves when dirty or after completing a procedure and between dirty and clean processes;
-She would not expect staff to use the same cloth for wiping a resident more than once.
CONCERN
(D)
Potential for Harm - no one hurt, but risky conditions existed
Respiratory Care
(Tag F0695)
Could have caused harm · This affected 1 resident
**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, interview, and record review, the facility failed to ensure one resident (Resident #68), in a review of 24...
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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 (Resident #68), in a review of 24 residents, and one additional resident (Resident #16), received oxygen therapy consistent with professional standards of practice and the residents' plan of care. The facility census was 67.
Review of the facility's undated policy, Oxygen Administration, showed the following:
-Purpose: To administer oxygen to the resident when insufficient oxygen is being carried by the blood to the tissues;
-Nasal Cannula: Connect tubing to humidifier outlet and adjust liter flow as ordered. Place prongs of cannula into the resident's nares. Adjust the plastic slide to hold cannula in place;
-At regular intervals, check and clean oxygen equipment, masks, tubing and cannulas;
-At regular intervals, check liter flow contents of oxygen cylinder, fluid level in humidifier and assess resident's respiration to determine further need for oxygen therapy.
1. Review of Resident #68's face sheet showed a diagnosis of chronic atrial fibrillation (an irregular, often rapid heart rate that commonly causes poor blood flow) and cerebrovascular disease (a group of disorders that affect the blood vessels and blood supply to the brain).
Review of the resident's quarterly Minimum Data Set (MDS), a federally mandated instrument completed by facility staff, dated 03/01/24, showed the following:
-Severely impaired cognition;
-Able to make needs known;
-Shortness of breath or trouble breathing with exertion and while lying flat;
-Oxygen therapy while a resident.
Review of the resident's May 2024 physician order sheet showed an order for oxygen at two LPM (liters per minute) per nasal cannula, continuous during the day time and four LPM per nasal cannula continuous during the bedtime hours, with an order start date of 12/13/23.
Review of the resident's care plan, revised 05/01/24, showed the following:
-Requires continuous oxygen supplementation;
-Oxygen as ordered and monitor for oxygen saturation rate as needed.
Observation on 05/19/24 from 4:40 P.M. to 5:48 P.M., showed the following:
-The resident sat up in his/her wheelchair at the dining room table;
-During the entire observation the resident's oxygen tubing connector laid on the dining room floor;
-Both the oxygen concentrator and supplemental oxygen tank were on with no tubing connected to either oxygen source;
-The oxygen tubing and nasal cannula were attached to the resident's ears and in his/her nostrils.
Observation on 05/22/24 at 6:18 A.M., showed the following:
-Morning care provide for the resident by Certified Nursing Assistant (CNA) E and CNA C;
-The resident's oxygen concentrator was running and set at four LPM;
-The oxygen tubing was not attached to concentrator and the tubing lay in the bed with the resident;
-CNA E adjusted the resident's bed so the resident lay flat to provide care;
-The resident said, Oh come on, lets get this done. The resident's face was turning pink and the resident coughed;
-CNA E dressed the resident while waiting for assistance from staff to bring incontinence care product supplies, all the while the resident lay flat with no oxygen;
-The resident said, I'm choking a little bit - come on;
-CNA C recognized the oxygen was not hooked up and did not attach to the concentrator;
-The resident remained flat and tried to clear his/her throat. The resident said again, Come on.;
-After CNA C and CNA E provided care, approximately 15 minutes in total, staff assisted the resident to stand and transferred the resident to his/her wheelchair;
-CNA C attached the nasal cannula to the oxygen tank at 6:32 A.M. and took the resident to the dining room.
During an interview on 05/22/24 at 6:35 A.M., CNA C said the following:
-The resident requires oxygen all of the time and oxygen should be reapplied if staff notice it is not in his/her nose or not connected to the concentrator;
-The resident has a habit of messing with his/her tubing and taking off his/her oxygen;
-The resident does get short of breath without the oxygen on;
-He/She should have hooked up the oxygen when he/she first noticed it was not connected.
2. Review of Resident #16's annual MDS, dated [DATE], showed the following:
-Cognitively intact;
-Diagnosis of chronic obstructive pulmonary disease (COPD) (chronic respiratory illness);
-No behaviors or rejection of care;
-Oxygen therapy while a resident.
Review of the resident's care plan, last reviewed/revised 3/6/24, showed the following:
-Alteration in respiratory function related to COPD;
-Encourage resident to take his/her time with activity of daily living (ADL) tasks;
-Encourage resident to break tasks into segments to ease respiratory stress;
-Medications as ordered whether by mouth, nebulizer or inhaler;
-Monitor for effectiveness by assessment of respiratory ease and by asking the resident if they seem effective;
-Oxygen as ordered and monitor for effectiveness:
-Step in to physically assist if the resident seems short of breath or fatigued.
Review of the resident's physician orders, dated May 2024, showed the following:
-Oxygen 2 Liters per minute per nasal cannula continuous;
-Change O2 tubing weekly on Sundays;
Review of the resident's Medication Administration Record (MAR), dated May 2024, showed the following:
-Change oxygen tubing weekly on Sundays;
-On 5/2/24, staff documented changing the oxygen tubing as ordered;
-On 5/5/24, staff documented changing the oxygen tubing as ordered;
-On 5/12/24, staff documented changing the oxygen tubing as ordered.
Observation on 5/19/24 at 3:59 P.M., showed the following:
-The resident in his/her bed with his/her nasal cannula tubing in his/her nares;
-The tubing was dated 5/2/24 with a piece of tape on the tubing (the oxygen tubing had not been changed as staff documented it had been on 5/5/24 or 5/12/24);
-The resident's oxygen concentrator was set to 2 liters of oxygen.
During an interview on 5/19/24 at 3:59 P.M., the resident said the following:
-He/She has COPD and wears oxygen at 2 liters at all times;
-Staff had not changed his/her tubing in a while;
-Staff were supposed to change his/her oxygen tubing every week on Sunday, but it rarely happened;
-When the staff do not change the tubing, the tubing got hard and rigid;
-It was not clean and was uncomfortable;
-The tubing he/she had now was old, rigid, and uncomfortable.
During an interview on 5/21/24 at 11:22 A.M., Licensed Practical Nurse (LPN) R said oxygen tubing was changed weekly by night shift licensed nurses. All of the nurses are agency so he/she would not know who to ask why Resident #16's oxygen tubing had not been changed.
During an interview on 05/23/24 at 6:49 P.M., the Director of Nurses (DON) said the following:
-If a resident has an order for continuous oxygen, she would expect the resident to be monitored to ensure they are receiving the oxygen as ordered;
-She would expect staff to monitor to make sure the nasal cannula is attached to the concentrator or supplemental oxygen tank to ensure the resident is getting the prescribed oxygen;
-Oxygen tubing should be labeled and dated;
-Staff are expected to change the tubing weekly.
CONCERN
(D)
Potential for Harm - no one hurt, but risky conditions existed
Deficiency F0757
(Tag F0757)
Could have caused harm · This affected 1 resident
Based on interview and record review, the facility failed to ensure one resident (Resident #13), in a review of 24 sampled residents, remained free from unnecessary drugs when the facility failed to h...
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Based on interview and record review, the facility failed to ensure one resident (Resident #13), in a review of 24 sampled residents, remained free from unnecessary drugs when the facility failed to have adequate indications for multiple blood thinning medications. The facility census was 67.
The facility provided no policy for unnecessary drug use following request.
1. Review of Resident #13's undated physician order sheets (POS) showed the following:
-Plavix (a blood thinning medication) 75 milligrams (mg) once a day, started 7/28/23;
-Xarelto (a blood thinning medication) 20 mg, started 10/1/23.
(Review showed no diagnosis for the use of the blood thinning medications.)
Review of the resident's progress note, dated 10/29/23 at 1:45 P.M., showed the pharmacy consultant wrote see report. (Review of the resident's medical record showed no documentation of the pharmacy consultant's report with recommendations and no documentation to show the facility addressed any recommendations with the resident's physician.)
Review of the resident's progress note, dated 12/13/23 at 12:58 P.M., showed the pharmacy consultant wrote see report. (Review of the resident's medical record showed no documentation of the pharmacy consultant's report with recommendations and no documentation to show the facility addressed any recommendations with the resident's physician.)
Review of the resident's progress note, dated 1/17/24 at 1:26 P.M., showed the pharmacy consultant wrote see report. (Review of the resident's medical record showed no documentation of the pharmacy consultant's report with recommendations and no documentation to show the facility addressed any recommendations with the resident's physician.)
Review of the resident's progress note, dated 2/5/24 at 8:04 A.M., showed staff wrote the resident had orders for both Xarelto and Plavix. The Director of Nursing (DON) called to verify orders. Waiting response at this time.
Review of the resident's records show no response regarding Xarelto and Plavix.
During interview on 6/11/24 at 3:22 P.M., the DON said the following:
-She had been interim DON twice at the facility;
-She did not know why the resident was on an anticoagulant and an antiplatelet medication;
-She did not remember if she was DON in February when a progress note was made regarding clarification on Xarelto and Plavix;
-She did not remember if a nurse reported needing clarification on Xarelto and Plavix;
-The physician often came into the facility;
-She did not know when the physician had last seen the resident.
CONCERN
(D)
Potential for Harm - no one hurt, but risky conditions existed
Deficiency F0760
(Tag F0760)
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 administer insulin according to manufacturers' recomme...
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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 administer insulin according to manufacturers' recommendations to ensure staff administered the prescribed insulin dose for one resident (Resident #27) in a review of 24 sampled residents and two additional residents (Resident #44 and #45). The facility census was 67.
During an interview on 05/22/24, at 11:00 A.M., the Director of Nursing (DON) said the facility did not have a specific policy for Insulin Pen administration.
Review of the, How to use your Lantus SoloStar Pen information sheet, revised 08/2022, showed the following:
-Wipe the [NAME] tip (rubber seal) with an alcohol swab;
-Dial a test dose of 2 units;
-Hold pen with the needle pointing up and lightly tap the insulin reservoir so the air bubbles rise to the top of the needle. This will help you get the most accurate dose;
-Press the injector button all the way in and check to see that insulin comes out of the needle. The dial will automatically go back to zero after you perform the test;
-Make sure the window shows 0 and then select the dose.
Review of the Novolog FlexPen instructions for use, revised 02/2023, showed the following:
-Pull off the pen cap. Wipe the rubber stopper with an alcohol swab;
-Attach the needle;
-Before each injection small amounts of air may collect in the cartridge during normal use. To avoid injecting air and to ensure proper dosing: turn the dose selector to select 2 units;
-Hold the FlexPen with the needle pointing up. Tap the cartridge gently with your finger a few times to make any air bubbles collect at the top of the cartridge;
-Keep the needle pointing upwards, press the push-button all the way in. The dose selector returns to 0. A drop of insulin should appear at the needle tip;
-Check and make sure the dose selector is set at 0;
-Turn the dose selector to the number of units you need to inject.
1. Review of Resident #27's face sheet showed a diagnosis of type II diabetes mellitus (too much sugar in the blood stream).
Review of the resident's May 2024 physician order sheet showed the following:
-Novolog FlexPen 100 units/milliliter (u/ml), administer 1 unit per sliding scale for a blood sugar result of 201 to 250, with an order start date of 11/29/23;
-Lantus Solostar 100u/ml, administer 21 units subcutanously once a day between 5:00 A.M. and 10:00 A.M., with a start date of 04/25/24.
Observation on 05/21/24, at 6:55 A.M., showed the following:
-Licensed Practical Nurse (LPN) R reviewed the blood sugar results for the resident with a recorded result of 201;
-The blood sugar result required 1 unit of sliding scale Novolog as well as 4 units of scheduled Novolog;
-LPN R attached a new needle to the Novolog pen;
-LPN R did not dial the Novolog pen to 2 units to prime the pen;
-LPN R attached a new needle to the Lantus pen;
-LPN R did not dial the Lantus pen to 2 units to prime the pen;
-LPN R dialed the Lantus pen to 21 units and administered both insulins to the resident.
2. Review of resident #44's face sheet showed a diagnosis of type II diabetes mellitus.
Review of the resident's May 2024 physician order sheet showed an order for Lantus Solostar insulin pen, 50 units once a day between 6:00 A.M. to 8:00 A.M., with an order start date of 09/04/23.
Observation on 05/21/24, at 6:45 A.M., showed the following:
-LPN R reviewed the blood sugar results for the resident with a recorded result of of 86;
-The blood sugar result did not require any sliding scale insulin;
-LPN R attached a new needle to the insulin pen;
-LPN R did not dial the pen to 2 units to prime the pen;
-LPN R dialed the Lantus pen to 50 units and administered the insulin to the resident.
e. Review of Resident #45's face sheet showed a diagnosis of type II diabetes mellitus.
Review of the resident's May 2024 physician order sheet showed an order for Lantus 30 units once a day with an order start date of 09/18/23.
Observation on 05/21/24, at 6:50 A.M., showed the following:
-LPN R reviewed the blood sugar results for the resident with a recorded result of 115;
-LPN R attached a new needle to the Lantus insulin pen;
-LPN R did not dial the pen to 2 units to prime the pen;
-LPN R dialed the Lantus pen to 30 units and administered the insulin for the resident.
During an interview on 06/07/24, at 12:15 P.M., LPN R said the following:
-He/She was unaware that an insulin pen needed to be primed with 2 units of insulin prior to administration;
-He/She did not prime the pens for resident #27, #44 or #45 during observation on annual survey.
During an interview on 05/23/24, at 6:49 P.M., the DON said the following:
-Insulin pens should be primed with 2 units of insulin;
-The pen needs to be dialed to a 2, wasted and then dialed to dose to administer;
-If the pen was not primed the resident might not get the full dose of insulin.
CONCERN
(D)
Potential for Harm - no one hurt, but risky conditions existed
Deficiency F0761
(Tag F0761)
Could have caused harm · This affected 1 resident
**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, interview, and record review, the facility failed to ensure medications were secured when staff left medic...
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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 medications were secured when staff left medications unattended and out of sight, on top of the medication cart, with residents in the vicinity of the medications. The facility census was 67.
Review of the facility policy, Medication Administration Guidelines, revised [DATE], showed the policy did not address the storage of medications.
Review of the undated facility policy, Medication Administration, showed the policy did not address the storage of medications.
Request for a medication storage policy was requested but none received.
1. Review of Resident #40's face sheet showed he/she had dementia.
2. Observation on [DATE] at 10:53 A.M., showed the following:
-Licensed Practical Nurse (LPN) N sat inside the nursing station doing paperwork;
-Medication Cart #2 sat outside the nursing station, in front of LPN N;
-On top of the medication cart was an open computer with the lid in the upright position;
-On top of the medication cart was also a box of half-full box of DuoNeb nebulizer treatment solution (breathing treatment medication), an open tube of triamcinolone cream (topical product used to treat redness, itching, swelling or other discomfort caused by skin conditions), an open tube of permethrin cream (topical product used to treat scabies (mites that attach themselves to the skin) and two open tubes of Nystatin cream (topical product used to treat fungal or yeast infections of the skin);
-LPN N did not respond when the surveyor picked up each medications and observed the labels;
-Resident #40 self propelled up to Medication Cart #2 and asked the surveyor who stood by the medication cart for Tums (antacid); the resident extended his/her arm to the medication cart drawer, attempting to pull it open, stating, they should be right in there;
-LPN N did not respond to the resident's statement/request.
During an interview on [DATE], at 10:57 A.M., LPN N said the following:
-He/She was responsible for Medication Cart #2;
-Medications should not be left on top of the medication cart unsupervised or not within sight;
-He/She had completed a medication cart inspection and pulled the observed medications from the cart because they were either expired and needed to be destroyed, had been discontinued, or he/she was getting ready to use the medication to complete an ordered treatment;
-He/She was unable to see the top of the medication cart or the medications as he/she sat at the desk because the view was obstructed by the computer;
-He/She had not seen the surveyor pick up each of the medications nor was he/she aware there were residents sitting near the medication cart.
During an interview on [DATE] at 6:49 P.M., the Director of Nursing said medications should not be left out, unattended. They should always be stored/kept locked up when not in use and should always be in sight if being used.
CONCERN
(E)
Potential for Harm - no one hurt, but risky conditions existed
Deficiency F0565
(Tag F0565)
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 consistently address and respond to concerns brought forth by the r...
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**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on interview and record review, the facility failed to consistently address and respond to concerns brought forth by the resident council. The facility census was 67.
Review of the undated facility policy, Grievance Protocol, showed the following:
-Purpose: to provide a written record of each resident and family concern and to insure proper follow-up through the appropriate discipline;
-The Social Services Director (SSD) is responsible for the program, although the administrator is ultimately responsible for the proper implementation of the program. The SSD informs the administrator of each incident;
-Any member of the social services staff can complete the grievance complaint report. The appropriate situations for use of the grievance complaint report are:
a. Resident articles that are lost or cannot be located - continual concern of lost resident items
b. Resident care or personal hygiene issues that cannot be immediately resolved;
c. Resident or family concerns with dietary issues - diet or temperature of meals;
d. Any resident or family concern with a staff member;
e. Any resident or family issue that would require a resolution;
-The SSD will:
a. Obtain the original grievance complaint report;
b. Record the grievance on the monthly grievance log;
c. Inform the administrator of the grievance;
d. Forward a copy of the grievance to the appropriate discipline;
-That administrator and SSD evaluate the monthly grievance log for trends or patterns and devise an action plan to correct the issues;
-A new grievance log should be completed each month. It should be presented at the Quality Assurance meeting quarterly.
1. Review of the facility's Resident Council Meeting Minutes, dated 2/13/24, showed the following:
-Evening meal: Need to follow recipes, appropriate portions, silverware left off hall trays, and no condiments given out;
-Train staff on how to order food; tired of running out of food;
-Bariatric sheets (bed sheets) still not being returned to right people;
-Activity calendar review: keep horse racing and more crafts;
-Maintenance: New cap on floor on A Hall; no safety bar on A Hall door.
Review of the facility's Resident Council Meeting Minutes, dated 3/12/24, showed the following:
-No documentation on the follow up or resolution to the concern/requests made during last meeting;
-Food is not good; very bland, no flavor, mashed potatoes not cooked, grated cheese not properly cooked, and dinner rolls unevenly cooked;
-Cooks don't care and not paying attention;
-Nursing-not being taken care of properly, tired of medications running out, look into new pharmacy, no ice water passed during evenings/nights;
-Laundry-same problems as always (bleach spots, holes, missing);
-Housekeeping-not enough help;
-Activities-find new vice president for resident council, new store trip times, and look into other stores for shopping.
Review of the facility's Resident Council Meeting Minutes, dated 4/9/24, showed the following:
-Previous meeting minutes missing due to Activity Director out of building;
-No documentation on the follow up or resolution to the concern/requests made during last meeting;
-Food concerns-tasteless, orders not matching menu, not enough condiments, bread is stale, potatoes burnt, and bacon not served on weekend;
-Nursing concerns: room [ROOM NUMBER]'s bed not changed for months, and blood sugars taken too early;
-Laundry-missing clothes;
-Activity calendar review: residents need to agree on activities, stick with scheduled activities, things being canceled, and more things to do;
-Maintenance-room [ROOM NUMBER]-D bed was broken, a resident's wheelchair brakes broke, a resident's bed not locking, and air conditioner filters need to be replaced.
During an interview on 5/21/24 at 2:26 P.M., Resident #34, a member of the Resident Council, said the following:
-The department supervisors did not always provide a response with an answer to the Resident Council's questions or recommendations;
-This problem occurred for the past five to six months.
During an interview on 5/21/24 at 2:26 P.M., Resident #48, a member of the Resident Council, said the following:
-The staff did not provide a copy of the meeting minutes to the Resident Council;
-If the department supervisors responded to a resident's requests or grievances, the staff did not provide the Resident Council with the department supervisors' response.
During an interview on 5/22/24 at 9:24 A.M., the Activities Director said the following:
-He/She kept the Resident Council meeting minutes;
-He/She reviewed the previous months meeting minutes, but did not know to provide a copy to the residents;
-He/She notified the department supervisors about the grievances or recommendations made at the Resident Council meetings, but did not follow up for a response.
During an interview on 5/23/24 at 4:45 P.M., the Administrator said the following:
-He expected the department supervisors to provide the Resident Council with an answer as soon as possible;
-He expected the department supervisors to keep the Resident Council up to date on what was going on with the grievances/recommendations.
CONCERN
(E)
Potential for Harm - no one hurt, but risky conditions existed
Grievances
(Tag F0585)
Could have caused harm · This affected multiple residents
Based on interviews and record review, the facility failed to ensure one resident (Residents #39), in a review of 24 sampled residents, and one additional resident (Resident #48), were able to voice g...
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Based on interviews and record review, the facility failed to ensure one resident (Residents #39), in a review of 24 sampled residents, and one additional resident (Resident #48), were able to voice grievances to the facility without discrimination, fear of discrimination, or reprisal. The facility failed to assist two sampled residents (Residents #36 and #46) and one additional resident (Resident #34) on how to file a grievance or complaint. The facility census was 67.
Review of the facility's admission packet showed the following:
-Any person(s) who believes that he/she or any class of individuals has been subjected to discrimination as prohibited by section 504 of the Rehabilitation Act of 1973 may file a complaint pursuant to the procedures set forth below, on his/her own behalf, on behalf of another person or on behalf of handicapped person as a class;
-All persons are encouraged to file grievance in order to resolve any disputes arising under section 504;
-Filing a compliant will not subject you to any form of adverse action, reprimand, retaliation or negative treatment by the facility;
-Accordingly, the facility has adopted an internal grievance procedure providing for the prompt and equitable resolution of complaints alleging any action prohibited by the United States Department of Health and Human Service regulations;
-Complaint processing procedure is as follows:
1. All complaints involving matters prohibited by section 504 shall first be filed with the facility administrator, who shall render an initial determination and resolution within seven days of receipt of the complaint;
-The director of operations or designee shall take steps to insure an appropriate investigation of each complaint to determine its validity;
-The following agencies may be contacted for assistance if a concern is not handled to resident satisfaction and/or the resident wished to file a complaint concerning abuse, neglect or misappropriation of resident property in the facility: compliance hotline, Ombudsman for nursing home residents, state survey and certification agency, Missouri Department of Health and Senior Services and the hotline.
Review of the undated facility policy, Grievance Protocol, showed the following:
-Purpose: to provide a written record of each resident and family concern and to insure proper follow-up through the appropriate discipline;
-The Social Services Director (SSD) is responsible for the program, although the administrator is ultimately responsible for the proper implementation of the program. The SSD informs the administrator of each incident;
-Any member of the social services staff can complete the grievance complaint report. The appropriate situations for use of the grievance complaint report are:
a. Resident articles that are lost or cannot be located - continual concern of lost resident items;
b. Resident care or personal hygiene issues that cannot be immediately resolved;
c. Resident or family concerns with dietary issues - diet or temperature of meals;
d. Any resident or family concern with a staff member;
e. Any resident or family issue that would require a resolution;
-The SSD will:
a. Obtain the original grievance complaint report;
b. Record the grievance on the monthly grievance log;
c. Inform the administrator of the grievance;
d. Forward a copy of the grievance to the appropriate discipline;
-That administrator and SSD evaluate the monthly grievance log for trends or patterns and devise an action plan to correct the issues;
-A new grievance log should be completed each month. It should be presented at the Quality Assurance meeting quarterly.
1. During an interview on 5/21/24 at 2:26 P.M., Resident #48 said the following:
-Staff was not changing his/her roommate or providing his/her roommate with attention in a timely fashion;
-He/She reported this grievance with administration;
-After he/she reported the grievance to administration, the staff said out loud, Look out, the resident will tell on you;
-Some staff stopped talking to the resident afterwards;
-The grievance resulted in a negative response from staff toward his/her roommate related to him/her not receiving needed care.
2. During an interview on 5/21/24 at 2:26 P.M., Resident #39 said he/she was afraid to file a grievance or complaint because of retaliation. The staff already retaliated when he/she asked for something.
3. During an interview on 5/21/24 at 2:26 P.M., Resident #34 said he/she did not know how to file a grievance at the facility or where the information was posted to file a grievance.
4. During an interview on 5/21/24 at 2:26 P.M., Resident #36 said he/she did not know how to file a grievance at the facility, did not know he/she could file a grievance directly with State, or where the information was posted to file a grievance with the state agency.
5. During an interview on 5/21/24 at 2:26 P.M., Resident #46 said he/she did not know how to file a grievance at the facility, that a grievance could be filed directly with the state agency, or where the information was posted to file a grievance with the state agency.
6. During interview on 05/22/24 at 1:30 P.M., the social services director said the following:
-She was the grievance officer for the facility and was the first step of investigation related to grievances;
-She kept a grievance book for review;
-She was unable to locate the grievance book.
Observation on 05/22/24, at 1:30 P.M., showed the following:
-The SSD located the grievance book in a resident room in the resident's toilet bowl;
-The grievance book was saturated and wet. The information within the book was not readable as multiple pages were stuck together and the ink had run on some pages.
During an interview on 5/23/24 at 11:10 A.M., the social services director said she was not aware of Resident #48's concerns or that the staff responded negatively to the resident after he/she made a grievance.
During an interview on 5/23/24 at 4:45 P.M., the Administrator said the following:
-He expected staff to provide information to all residents how to file a grievance and to encourage and show residents how to do so;
-When a resident filed a complaint, he expected the staff to be accepting of the resident, because all residents have the right to voice a grievance without fear of reprisal.
CONCERN
(E)
Potential for Harm - no one hurt, but risky conditions existed
Deficiency F0637
(Tag F0637)
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 complete a significant change in status assessment (S...
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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 complete a significant change in status assessment (SCSA) Minimum Data Set (MDS), a federally mandated assessment, required to be completed by facility staff, for three residents (Resident #54, #42, and #52), in a review of 24 sampled residents, within 14 days after the facility determined, or should have determined, there had been a significant change (major decline or improvement in the resident's status) in the resident's physical or mental condition which had an impact on more than one area of the resident's health status and required interdisciplinary review and/or revision of the care plan. The facility census was 67.
Review of the Long Term Care Facility Resident Assessment Instrument (RAI) User's Manual, version 3.0 showed a significant change is a decline or improvement in a resident's status that:
-Will not normally resolve itself without intervention by staff or by implementing standard disease-related clinical interventions, is not self-limiting;
-Impact more than one area of the resident's health status;
-Requires interdisciplinary review and/or revision of the care plan;
-SCSA was appropriate if there was a consistent pattern of changes, with either two or more areas of decline, or two or more areas of improvement. This may include two changes within a particular domain (e.g., two area of activity of daily living (ADL) decline or improvement);
-An SCSA is required to be performed when a terminally ill resident enrolls in a hospice program (Medicare-certified or State-licensed hospice provider) or changes hospice providers and remains a resident at the nursing home. The ARD must be within 14 days from the effective date of the hospice election (which can be the same or later then the date of the hospice election statement, but not earlier than). An SCSA must be performed regardless of whether an assessment was recently conducted on the resident. This is to ensure a coordinated plan of care between the hospice and nursing home is in place. A Medicare-certified hospice must conduct an assessment at the initiation of its services. This is an appropriate time for the nursing home to evaluate the MDS information to determine if it reflects the current condition of the resident since the nursing home remains responsible for providing necessary care and services to assist the resident in achieving their highest practicable well-being at whatever stage of the disease process the resident is experiencing;
-When a resident's status changes and it is not clear whether the resident meets the SCSA guidelines, the nursing home may take up to 14 days to determine whether the criteria are met;
-If a significant change in status is identified in the process of completing any OBRA (Omnibus Budget Reconciliation Act of 1987) assessment except admission and SCSA's code and complete the assessment as a comprehensive SCSA instead.
Review of the facility assessment, updated 5/20/24, showed the facility resources needed to provide competent support and care for the resident population, every day and during emergencies, included MDS Coordinator coverage eight hours per day.
1. Review of Resident #54's quarterly Minimum Data Set (MDS), a federally mandated assessment instrument required to be completed by facility staff, dated 4/19/24, showed the following:
-The resident had severe cognitive impairment;
-He/She wandered daily;
-He/She required setup assistance with eating;
-He/She was independent with rolling right and left in bed and wheelchair locomotion;
-He/She required moderate assistance with sitting to lying in bed and lying to sitting in bed;
-No oxygen therapy.
Review of the resident's care plan, updated on 4/22/24, showed the following:
-The resident required assistance of one staff member with meals, bed mobility, dressing, toileting, and personal hygiene:
-Either mechanical lift with two assist or two with gait belt depending on how the resident was doing;
-Used wheelchair for mobility due to limited range of motion in both legs due to being contracted;
-May use a mechanical lift for transfers if he/she was experiencing or displaying weakness, otherwise, use less distressing measure of one to two with gait belt;
-Eats with assistance of staff in dining room;
-Extensive assistance required for transfers;
-No oxygen therapy.
Review of the resident's nurse note, dated 5/8/24 at 10:07 A.M., showed the following:
-Certified nurse assistant (CNA) assisted the resident with eating;
-The resident remained on oxygen at 2 liters/minute per nasal cannula.
Review of the resident's nurse notes, dated 5/13/24 at 6:05 P.M., showed the facility placed the resident on comfort care only with no hospitalizations.
Observation in the resident's room on 5/19/24 at 3:10 P.M., showed the resident received oxygen per nasal cannula and had a Broda chair (wheelchair that provides supportive positioning) in his/her room.
During an interview on 5/21/24 at 5:40 A.M., CNA P said the following:
-The resident did not move on his/her own;
-The resident spoke to staff to let them know if he/she hurt or needed something;
-Previously, the resident laughed, smiled, and was talkative;
-The resident drank a few sips when staff held a glass with a straw for the resident.
Observation in the resident's room on 5/21/24 at 6:10 A.M., showed CNA O and CNA FF rolled the resident from side to side in the bed without any assistance from the resident.
During an interview on 5/21/24 at 6:40 A.M., CNA FF said the following:
-The resident used to propel himself/herself via wheelchair around the facility;
-The resident was a happy person and the staff had difficulty preventing the resident from trying to leave the building;
-Since the resident first developed pneumonia, mid-April, he/she had a big change;
-Now the resident stayed in bed all day and slept more and was dependent on all cares, but still talked to people.
During an interview on 5/21/24 at 9:44 A.M., the resident's family member said the following:
-The staff had to assist the resident with drinking;
-The staff had to reposition the resident in bed.
A significant change MDS was not completed to show a decline in the resident's ability to eat, locomotion via wheelchair, chair/bed-to-chair transfers, bed mobility, cessation of wandering behavior, or that the resident received oxygen therapy.
2. Review of Resident #42's, annual MDS, dated [DATE], showed the following:
-Severe cognitive impairment;
-Diagnosis: Alzheimer's, arthritis, fracture and chronic pain;
-Requires partial/moderate assistance from staff for putting on/taking off footwear, and transfers;
-Scheduled and (as needed) PRN pain medication and frequent pain;
-Opioid use daily;
-Wheelchair use;
-Resident did not ambulate.
Review of the resident's nurses notes, dated 12/29/24, showed the resident up in wheelchair.
Review of the resident's quarterly MDS, dated [DATE], showed the following:
-Moderate cognitive impairment;
-Scheduled pain medication;
-Bed rails used as restraints daily;
-No use of PRN (as needed) pain medications and pain assessment questions not completed;
-Independent with transfers and walking 150 feet.
The facility did not complete a SCSA after they documented a significant increase in cognitive ability, decrease in pain, new bed rail use and the resident independent with ambulation and transfers.
Review of the resident's nurses notes, dated 5/15/24, showed the resident used a manual wheelchair to assist with mobility.
Observation of the resident during the survey process, from 5/19/24 to 5/23/24, showed the resident was always in a wheelchair when out of bed. The resident did not walk independently. The resident had bed rails on his/her bed.
3. Review of Resident #52's, admission MDS, dated [DATE], showed the following:
-Severe cognitive impairment;
-Diagnosis included dementia, chronic pain, fusion of spine (surgical connection of two bones in the spine to prevent movement) and spinal stenosis (space inside the backbone is too small that can put pressure on the spinal cord and nerves that travel through the spine, can cause pain, tingling, numbness and muscle weakness);
-Independent with transfers, dressing and ambulation;
-No mobility devices used;
-Occasionally incontinent of bladder and bowel;
-No toileting program;
-Scheduled pain medications.
Review of the resident's quarterly MDS, dated [DATE], showed the following:
-Requires supervision, touch or verbal cues for transfers and ambulating 50 feet and to make turns;
-Requires partial/moderate assistance from staff for upper body dressing;
-Requires substantial maximal assistance from staff for lower body dressing and put on/take off footwear;
-Frequently incontinent of bladder, continent of bowel;
-Two or more injury falls since last assessment
The facility did not complete a SCSA after the resident required more assistance with ambulation, dressing, transfers, increase in incontinence and falls since the last comprehensive assessment.
Review of the resident's quarterly MDS, dated [DATE], showed the following:
-Diagnosis of depression, and Alzheimer's
-Uses a walker;
-Frequently incontinent of bladder and bowel;
-Two or more no injury falls since last assessment;
-Takes antidepressant medication daily.
The facility did not complete a SCSA after the resident required more assistance with ambulation, dressing, transfers, increase in incontinence, falls, new diagnosis, use of a walker, and antidepressant medication since the last comprehensive assessment
Review of the resident's quarterly MDS, dated [DATE], showed the following:
-Moderate to severe depression;
-Does not use a wheelchair;
-Always incontinent of bladder and bowel;
-Pain medication scheduled;
-Non-verbal sounds, facial expressions that could indicate pain in five days of the seven day look back period;
-Two or more no injury falls since last assessment.
Observation of the resident during the survey process, from 5/19/24 to 5/23/24, showed the resident to always be in a wheelchair when out of bed. The resident did not walk independently or with staff.
The facility did not complete a SCSA after the resident required more assistance with ambulation, dressing, transfers, increase in incontinence, falls, new diagnosis, use of a walker, antidepressant medication, increase in depressive symptoms, and physical signs of pain since the last comprehensive assessment.
During an interview on 5/20/24 at 1:51 P.M. and 2:00 P.M., the acting MDS coordinator said the following:
-She worked at a sister facility and came over one or two days a week and helped complete the MDS's;
-She did not know the residents, so he/she would ask the staff questions about the residents and complete the MDS's as best as he/she could;
-She only completed what needed to be done;
-She was not sure if residents needed a significant change assessment; she was not usually there when the interdisciplinary team was at the facility, so she did what she could.
During an interview on 5/21/23 at 10:04 A.M., the Director of Nursing said the MDS assessments are expected to be completed according to the RAI manual. She was not sure if they are up to date as the MDS coordinator was part time and only in the facility on the weekends.
CONCERN
(E)
Potential for Harm - no one hurt, but risky conditions existed
Comprehensive Care Plan
(Tag F0656)
Could have caused harm · This affected multiple residents
**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, interview, and record review, the facility failed to develop a person-centered comprehensive care plan, sp...
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**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, interview, and record review, the facility failed to develop a person-centered comprehensive care plan, specific to the resident, for three residents (Resident #4, #20, and #68) in a review of 24 residents. The facility census was 67.
Review of the undated facility policy, Care Plan Comprehensive, showed the following:
-Purpose: An individualized comprehensive care plan that includes measurable goals and time frames will be developed to meet the resident's highest practicable physical, mental, and psychosocial well-being;
-Guidelines: The interdisciplinary care plan team with input from the resident, family, and/or legal representative will develop and maintain a comprehensive care plan for each resident that identifies the highest level of functioning the resident may be expected to attain;
-The comprehensive care plan will be based on a thorough assessment that includes, but is not limited lo, the MDS;
-A well-developed care plan will be oriented to:
a. Preventing avoidable declines in functioning or functional levels or otherwise clarifying why another goal takes precedence (e.g., palliative approaches in end of life situation);
b. Managing risk factors to the extent possible or indicating the limits of such interventions;
c. Addressing ways to try to preserve and build upon resident strengths;
d. Applying current standards of practice in the care planning process;
e. Evaluating treatment of measurable goals, timetables and outcomes of care;
f. Respecting the resident's right to decline treatment;
g. Offering alternative treatments, as applicable;
h. Using an appropriate interdisciplinary approach to care plan development to improve the resident's functional abilities;
i. Involving resident, resident's family and other resident representatives as appropriate;
j. Assessing and planning for care to meet the resident's medical, nursing, mental and psychosocial needs;
k. Involving the direct care stall with the care planning process relating to the resident's expected outcomes;
I. Addressing additional care planning areas that are relevant to meeting the resident's needs in the long-term care setting.
1. Review of Resident #20's undated face sheet showed the following:
-admission date 10/5/23;
-Code status: Do Not Resuscitate (DNR);
-Diagnoses of major depressive disorder (a mood disorder that causes a persistent feeling of sadness and loss of interest) and generalized anxiety disorder (excessive worry and feeling of fear, dread, and uneasiness).
Review of the resident's out-of-hospital DNR form, dated 10/9/23, located in the resident's paper chart, showed the physician and the resident signed the form, indicating the resident's code status was DNR.
Review of the resident's care plan, dated 11/24/23, showed the following:
-The resident required an indwelling urinary catheter;
-The staff were to provide catheter care every shift and as needed;
-The resident's care plan did not identify the resident's preferred code status.
Review of the resident's progress note, dated 4/6/24 at 1:59 P.M., showed the resident refused to allow the nurse to complete peri-care and apply a treatment to his/her groin.
Review of the resident's progress note, dated 4/7/24 at 2:33 P.M., showed the resident refused all attempts for staff to perform peri-care.
Review of the resident's progress note, dated 4/11/24 at 12:37 P.M., showed the resident refused all attempts for staff to perform peri-care.
Review of the resident's MDS, dated [DATE], showed the following:
-The resident had intact cognition;
-The resident did not refuse care;
-The resident was dependent with toileting and personal hygiene;
-The resident has an indwelling urinary catheter;
-The resident was always incontinent of bowel.
Review of the resident's progress note, dated 4/12/24 at 1:33 P.M., showed the resident refused his/her shower.
Review of the resident's progress note, dated 4/17/24 at 2:40 P.M., showed the resident's physician was notified of the resident's refusal to have his/her catheter flushed.
Review of the resident's May 2024 Physician Order Sheet (POS) showed the resident needed catheter care completed every shift.
Review of the resident's progress note on 5/1/24 at 1:46 P.M. showed the resident refused to have his/her catheter changed as it was ordered.
Review of the resident's care plan, dated 5/20/24, showed no documentation the resident refused care and approaches to address his/her refusal, and no documentation of the resident's preferred code status.
During interview on 5/21/24 at 5:55 A.M., Certified Nurse Assistant (CNA) V said the following:
-The resident would let him/her perform care on him/her but would often refuse care from other staff;
-The resident often refused catheter care.
During interview on 5/21/24 at 10:23 A.M., the resident said he/she wanted to be a DNR.
Observation on 5/21/24 at 10:29 A.M. showed CNA E and CNA C changed the resident's incontinence brief. The resident told the staff he/she did not want catheter care performed. The staff did not provide care per the resident's request.
2. Review of Resident #68's face sheet showed the resident's diagnoses included vascular dementia and diabetes (too much sugar in the blood stream).
Review of the resident's admission MDS, dated [DATE], showed the following:
-Severely impaired cognition;
-Usually able to make his/her needs known;
-Diagnoses of diabetes mellitus and dementia;
-Care Assessment Area (CAA) of cognitive loss/dementia triggered and was to be addressed on the resident's care plan.
Review of the resident's quarterly MDS, dated [DATE], showed the following:
-Severely impaired cognition;
-Usually able to make needs known;
-Diagnoses of diabetes mellitus and dementia.
Review of the resident's May 2024 physician order sheet showed the following:
-Donepezil (a medication used to treat dementia) 10 milligrams daily at bedtime (original order dated 12/02/23);
-Januvia (a medication used to treat diabetes) 100 milligrams once a day (original order dated 04/03/24).
Review of the resident's care plan, revised 05/01/24, showed no problem, goal or interventions related to cognitive loss/dementia or diabetes.
3. Review of Resident #4's quarterly Minimum Data Set (MDS), a federally mandated assessment instrument completed by the facility, dated 2/25/24, showed the following:
-Substantial/Maximum assistance from staff for sit to stand transfer, chair/bed-to-chair transfer, toilet transfer and tub/shower transfer;
-No use of oxygen therapy indicated.
Review of the resident's care plan, revised on 02/28/24, showed the following:
-The resident has an activity of daily living deficit related to progression of dementia;
-Restorative therapy three times a week for active range of motion both lower extremities;
-The resident's care plan did not include how the resident was to transfer.
Review of the resident's May 2024 physician order sheet showed the following:
-Administer two liters of oxygen as needed for pulse oxygen saturation (the amount of oxygen in the blood stream measured by percentage of 100 or less) rate less than 92 percent (original order dated 12/14/23);
-Change oxygen tubing weekly on Sunday on the night shift (original order dated 12/06/23);
-Restorative program established for two times a week to address bilateral upper body range of motion, discontinued on 05/08/24.
Review of the resident's care plan showed no documentation the resident was to receive oxygen as needed, no documentation as to how the resident was to transfer, and no documentation the resident was no longer to receive restorative nursing services.
During an interview on 5/20/24 at 1:51 P.M. and 2:00 P.M. the acting MDS coordinator said:
-She worked at a sister facility and came over one or two days a week and helped complete the MDS's;
-She did not know the residents, so he/she would ask the staff questions about the residents and complete the MDS's as best as he/she could;
-She only completed what needed to be done;
-She did not complete the care plans that were done by the previous assistant director of nursing (ADON).
During interview on 5/21/24 at 1:57 P.M., the Training/MDS Coordinator said the following:
-She was temporarily helping complete MDS assessments and care plans;
-She stopped completing care plans because the previous Assistant Director of Nursing (ADON) completed observations and the care plan;
-She did not know who was completing the care plan after the ADON left.
During interview on 5/23/24 at 6:49 P.M., the Director of Nursing (DON) said the following:
-The MDS Coordinator was responsible for completing and updating care plans;
-She had been updating care plans because the facility did not have an MDS Coordinator;
-She read the nursing notes to determine if an addition was needed to the care plan;
-She did not think the care plans were getting updated due to agency staffing not reporting if something needed to be added to the care plan;
-She would expect the care plans to be complete with a comprehensive picture of how to care for the residents.
CONCERN
(E)
Potential for Harm - no one hurt, but risky conditions existed
Deficiency F0657
(Tag F0657)
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 update interventions in the comprehensive care plan f...
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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 update interventions in the comprehensive care plan for three resident's (Resident #17, #52 and #42), in a review of 24 sampled residents. The facility census was 67.
Review of the undated facility policy, Comprehensive Care Plan, showed the following:
-The interdisciplinary care plan team is responsible for the periodic review and updating of care plans:
a. When a significant change in the resident's condition has occurred;
b. At least quarterly;
c. When changes occur that impact the resident's care (i.e., change in diet, discontinuation of therapy,
changes in care areas that do not require a significant change assessment).
Review of Resident #17's quarterly Minimum Data Set (MDS), a federally mandated assessment instrument required to be completed by facility staff, dated 10/28/23, showed the following:
-The resident had moderately impaired cognition;
-He/She did not have any signs or symptoms of depression;
-He/She did not have limited range of motion;
-He/She was independent with rolling left and right in bed, sit to lying in bed, and lying to sitting;
-He/She required supervision with oral hygiene, upper body dressing, and personal hygiene;
-He/She required moderate assistance with bathing, toilet hygiene, lower body dressing, sit to stand, chair/bed-to-chair transfer, and toilet transfer;
-He/She was frequently incontinent of bladder and bowel.
Review of the resident's care plan, updated 10/31/23, showed the following:
-The resident had minimal deficit in activities of daily living (ADLs) related to weakness, disease process affecting cognitive status;
-Provide assistance with any ADLs as needed/indicated, daily: bladder and bowel, hygiene, hair/oral/nail/skin care, tray preparation, dressing, etc.;
-Provide items as needed for completion of ADLs;
-Provide non-distracting environment for grooming/personal hygiene.
Review of the resident's significant change MDS, dated [DATE], showed the following:
-The resident had severe cognitive impairment;
-He/She had mild depression symptoms;
-He/She had limited functional range of motion in bilateral lower extremities;
-He/She required maximal assistance with oral hygiene;
-He/She was dependent on toileting hygiene and personal hygiene;
-He/She required moderate assistance with rolling left and right in bed,
-He/She was frequently incontinent of bladder;
-He/She was always incontinent bowel;
-The care area assessment (CAA) was triggered for activities of daily living (ADL) functional/rehabilitation potential, but was not updated on the care plan.
Review of the resident's care plan, updated on 11/15/23, showed the care plan was not updated to show a decrease in the resident's cognition from moderate to severe impairment.
Review of the resident's nurse note, dated 11/30/23 at 1:54 P.M., showed the following:
-The resident had some medication additions since being admitted to hospice (admitted [DATE]);
-The resident started Zoloft for depression;
-He/She could take morphine three times a day as needed for pain.
Review of the resident's physician orders, dated November 2023, showed Zoloft (antidepressant) 50 milligrams (mg) give one tablet orally daily for major depressive disorder (started 11/27/23).
Review of the resident's quarterly MDS, dated [DATE], showed the following:
-The resident had severe cognitive impairment;
-He/She had mild depression symptoms;
-He/She had limited functional range of motion in bilateral lower extremities;
-He/She required maximal assistance with oral hygiene;
-He/She was dependent on toileting hygiene and personal hygiene;
-He/She required moderate assistance with rolling left and right in bed,
-He/She had an indwelling urinary catheter;
-He/She was always incontinent of bowel.
Review of the resident's care plan, updated 2/15/24, showed the following:
-The resident had increased potential for urinary tract infection (UTI) related to presence of indwelling catheter for urinary retention;
-Avoid lying on top of tubing;
-Keep catheter system a closed system as much as possible;
-Position bag below level of bladder;
-Provide catheter care per facility policy and procedure;
-Report signs of urinary tract infection;
-Store collection bag inside a protective dignity pouch;
-The care plan was not updated to address the resident's change in cognition from moderate impairment to severe impairment, addition of an antidepressant along with monitoring for specific behaviors along with potential side effects and potential for pain to include monitoring for specific symptoms and administration of PRN pain medication.
Review of the resident's nurse note, dated 2/22/24 at 1:16 P.M., showed the resident no longer ambulated with the aid of a wheelchair.
Review of the resident's physician order, dated March 2024, showed the following:
-Zoloft (antidepressant) 50 milligrams (mg), give one tablet orally daily for major depressive disorder (started 11/27/23);
-Lorazepam (antianxiety) 2 mg/milliliter (ml), give 0.25 ml orally every four hours as needed for anxiety (started on 3/26/24).
Review of the resident's physician orders, dated April 2024, showed the following:
-Zoloft 50 mg, give one tablet orally daily for major depressive disorder (started 11/27/23);
-Lorazepam 2 mg/ml, give 0.25 ml orally every four hours as needed for anxiety (started on 3/26/24);
-Tramadol (opioid pain medication) 50 mg, give one tablet orally twice a day for pain (started 4/24/23).
Review of the resident's nurse note, dated 4/12/24 at 3:20 P.M., showed the hospice nurse removed the indwelling urinary catheter during a visit earlier in the day.
Review of the resident's care plan, last updated 4/27/24, showed the following:
-The care plan was not updated to show the addition of an antianxiety medication with monitoring specific behaviors, and monitoring for adverse effects from medication;
-The care plan was not updated to show the resident's indwelling urinary catheter was removed on 4/15/24;
-The care plan was not updated to show the resident received a scheduled medication for pain;
-The care plan did not include the resident no longer ambulated.
Observation on 5/19/24 at 3:55 P.M. showed the following:
-The resident sat in recliner chair in his/her room;
-The resident was unable to have a conversation.
Observation on 5/19/24 at 5:05 P.M. showed the resident propelled himself/herself in his/her wheelchair from his/her room to the dining room.
2. Review of Resident #52's admission MDS, dated [DATE], showed the following:
-Severe cognitive impairment;
-Diagnoses included dementia, chronic pain, fusion of spine (surgical connection of two bones in the spine to prevent movement) and spinal stenosis (space inside the backbone is too small that can put pressure on the spinal cord and nerves that travel through the spine, can cause pain, tingling, numbness and muscle weakness);
-Independent with transfers and ambulation;
-No mobility devices used;
-Occasionally incontinent of bladder and bowel;
-No toileting program;
-Scheduled pain medications.
Review of the resident's care plan, dated 6/27/23, documented the resident had cognitive loss. The care plan did not identify the resident was at risk for falling.
Review of the resident's nurses notes, dated 7/11/23 at 6:39 A.M., showed the following:
-The resident continues observation for recent fall. Steri-strips to left hand intact with no drainage noted;
-The resident's family member said the resident fell because the resident was trying to get assistance from the staff, for his/her family member (also a resident), and no one answered the call light;
-Upon entering the room, the resident was found on top of his/her covers that were in his/her recliner, most likely due to the resident sliding to the floor while lying on top of the items;
-The resident denied pain or discomfort and had no visible injuries;
-Education was provided to the resident about allowing staff to assist his/her spouse to avoid future injury;
-The resident voiced understanding but additional teaching and reinforcement is required related to his/her cognitive decline. No change in status at this time.
The resident's care plan was not updated after the resident's fall.
Review of the resident's nurses notes, dated 7/11/23 at 5:43 P.M., showed the following:
-The resident had unsteady gait and lost balance, causing a fall when he/she tried to assist staff who were assisting the resident's family member (also a resident);
-The resident sustained a laceration to his/her left eye;
-The resident was transferred to the emergency room via emergency medical services (EMS).
Review of the resident's nurses notes, dated 7/11/23 at 10:14 P.M., showed the resident's laceration above the resident's left eye required glue repair by the emergency room. No other injuries noted.
Review of the resident's care plan showed no evidence staff updated the resident's care plan, after he/she fell on 7/11/23, to include/address interventions related to helping his/her (resident) family member.
Review of the resident's nurses notes, dated 7/15/23 at 7:47 A.M., showed the following:
-The resident sat on the floor to the front and left side of the chair, up against the wall;
-The resident said he/she was getting up to help his/her family member (also a resident) and he/she slid out of the chair;
-The resident had a small abrasion to his/her lower back from sliding down the wall;
-The resident was significantly more confused than baseline, likely related to current diagnosis of urinary tract infection and was currently on antibiotics.
Review of the resident's care plan showed no evidence staff updated the resident's care plan, after he/she fell on 7/15/23, to include/address interventions related to helping his/her (resident) family member.
Review of the resident's care plan, updated 7/26/23, showed the following:
-The resident was at risk for falls due to declining cognitive level and unsteady gait;
-Ensure the resident's room was free of clutter that he/she could potentially trip over;
-Increased staff supervision with intensity based on resident need.
Review of the resident's nurses notes, dated 8/16/23 at 3:24 P.M., showed the following:
-Interdisciplinary note showed the resident had three falls in the month of July;
-All of the resident's falls were related to him/her assisting his/her family member (also a resident);
-The resident's fall risk score was a 21, which put him/her at a high risk for falls.
Review of the resident's Nurses Notes, dated 9/12/23 at 11:45 P.M., showed the following:
-The resident sustained a non-injury, witnessed fall in the dining room;
-The resident sat at the dining room table and slid out of his/her chair onto his/her bottom.
Review of the resident's care plan showed no evidence staff updated the resident's care plan after he/she fell on 9/12/23.
Review of the resident's quarterly MDS, dated [DATE], showed the following:
-Severe cognitive impairment;
-Requires supervision, touch or verbal cues for transfers and ambulating;
-Requires partial/moderate assistance from staff for upper body dressing;
-Requires substantial maximal assistance from staff for lower body dressing and put on/take off footwear;
-Frequently incontinent of bladder and continent of bowel;
-Two or more injury falls since last assessment.
The resident's care plan was not updated after the resident required more assistance with ambulation, dressing, transfers, increase in incontinence and falls since the last comprehensive assessment.
Review of the resident's nurses notes, dated 9/25/23 at 10:23 P.M., showed the following:
-The resident sustained a fall at 1:00 P.M. The resident stood up out of his/her wheelchair and was walking toward the nursing station;
-The resident turned around and fell backward, striking his/her left posterior head against the nursing station counter;
-The resident was immediately assessed for injury and a silver dollar sized raised area was noted to his/her left posterior head;
-Neurological checks initiated per facility protocol.
Review of the resident's care plan showed no evidence staff updated the resident's care plan after he/she fell on 9/25/23.
Review of the resident's nurses notes, dated 10/12/23 at 1:48 P.M., showed the following:
-The care plan team met with the resident's family member;
-The resident receives assistance getting into bed, but was able to get out of bed on his/her own;
-The resident will propel his/her wheelchair around the building from time to time;
-The resident had not had any recent falls.
Review of the resident's nurses notes, dated 10/14/23 at 10:14 P.M., showed the following:
-Kitchen staff witnessed the resident fall in the dining room. The resident struck his/her head against the piano and fell to the floor;
-The resident had a superficial laceration (cut or tear to the skin) and a silver dollar sized hematoma (localized bleeding), from the fall, to top of his/her posterior (back) head;
-The resident was assessed, a dressing was placed on the resident's head wound and neurological checks (series of tests and questions to evaluate the nervous system) initiated.
Review of the resident's care plan, updated 10/14/23, showed the resident fell in the dining room and hit his/her head against the piano. Laceration and hematoma noted. No interventions were added or revised on the resident's care plan.
Review of the resident's nurses notes, dated 11/22/23 at 9:56 P.M., showed the resident was found sitting on the floor with his/her legs crossed, going through his/her closet.
Review of the resident's care plan showed no evidence staff updated the resident's care plan after he/she fell on [DATE].
Review of the resident's nurses notes, dated 11/24/23 at 6:36 P.M., showed the following:
-The resident was sent to the emergency room for further evaluation related to a fall;
-The resident has a hematoma to the left ear.
Review of the resident's care plan, updated 11/24/23, showed the following:
-On 11/24/23, the resident was found on the floor in the television area;
-He/She had been sitting in his/her wheelchair and fell;
-He/She hit his/her head on the floor;
-The resident's left ear became red and swollen; received an order to send to the hospital for evaluation;
-When the resident was not in his/her room, place the resident by the nurses station for close supervision.
Review of the resident's quarterly MDS, dated [DATE], showed the following:
-Diagnoses of depression and Alzheimer's disease;
-Severe cognitive impairment;
-Used a walker;
-Frequently incontinent of bladder and bowel;
-Requires supervision, touch or verbal cues for transfers and ambulating;
-Two or more no injury falls since last assessment
-Received an antidepressant medication daily.
The resident's care plan was not updated after the resident required more assistance with ambulation, dressing, transfers, increase in incontinence, falls, new diagnosis, use of a walker, and antidepressant medication since the last comprehensive assessment
Review of the resident's nurses notes, dated 12/31/23 at 10:02 P.M., showed the following:
-The resident had an unwitnessed fall in his/her room; when staff arrived, the resident was sitting on the floor next to his/her wheelchair;
-The resident did not have socks on and had spilled his/her water on the floor;
-The resident was holding his/her left hand and had a small cut to his/her left pinky finger and a blood blister, cleansed and bandaged;
-Abrasion noted to the resident's left lower back measuring 10 centimeters (cm) in length by 1.3 cm in width; redness to area noted;
-Staff placed the resident on neurological checks.
Review of the resident's care plan showed no evidence staff updated the resident's care plan after he/she fell on [DATE].
Review of the resident's nurses notes, dated 1/6/24 at 2:29 P.M., showed the following:
-The resident had a witnessed fall in the living area;
-Staff witnessed the resident lower himself/herself to the floor;
-Mechanical lift pad caught under the resident's chair.
Review of the resident's care plan showed no evidence staff updated the resident's care plan after he/she fell on 1/6/24.
Review of the resident's quarterly MDS, dated [DATE], showed the following:
-Severe cognitive impairment;
-Moderate to severe depression;
-Does not use a wheelchair;
-Always incontinent of bladder and bowel;
-Pain medication scheduled,
-Non-verbal sounds, facial expressions that could indicate pain in the five days;
-Requires supervision, touch or verbal cues for transfers and ambulating;
-Two or more no injury falls since last assessment.
Review of the resident's nurses notes, dated 5/10/24 at 5:44 P.M., showed the following:
-The resident had an unwitnessed fall in his/her room;
-Staff observed the resident sitting on his/her buttocks on his/her fall mat;
-The resident's bed was in the lowest position at the time;
-The resident has a laceration to his/her right forearm;
-Neurological checks initiated.
Review of the resident's care plan showed no evidence staff updated the resident's care plan after he/she fell on 5/10/24.
Observation on 5/19/24, at 4:33 P.M., showed the following:
-The resident lay in his/her bed with the door to his/her room closed;
-The resident's bed was low to the ground;
-There was a fall mat propped against the dresser across the room;
-There was no fall mat next to the resident's bed.
Observation of the resident during the survey process, from 5/19/24 to 5/23/24, showed the resident to always be in a wheelchair when out of bed. The resident did not walk independently or with staff.
The facility did not update the resident's care plan after the resident required more assistance with ambulation, dressing, transfers, increase in incontinence, falls, new diagnosis, use of a wheelchair, antidepressant medication, increase in depressive symptoms, and physical signs of pain since the last comprehensive assessment.
3. Review of Resident #42's Care Plan, dated 6/28/23, showed the following:
-The resident is at risk for injury related to a history of falls related to acute medical condition and fall within 36 hours of admission;
-The resident will remain free from injury;
-Analyze the resident's falls to determine a pattern/trend, which appear to be related to medical trauma and possibly delirium/confusion;
-Give the resident verbal reminders not to transfer without assistance;
-Keep the resident's bed in the lowest position with brakes locked;
-Keep call light in reach at all times;
-Keep personal items and frequently used items within reach;
-Place fall mats by bed (both sides);
-Staff to provide substantial assistance for pivot transfer with a gait belt during transfers for balance/safety.
Review of the resident's, annual MDS, dated [DATE], showed the following:
-Moderate hearing difficulties, hearing aide present;
-Vision issues and device;
-Severe cognitive impairment;
-Diagnosis: Alzheimer's, Renal (kidney) disease, thyroid disorder, arthritis, fracture and chronic pain;
-Requires set up/clean up from staff for eating and oral hygiene;
-Requires supervision or touch assistance from staff for toilet hygiene and dressing;
-Requires partial/moderate assistance from staff for shower/bathe and putting on/taking off footwear;
-Scheduled and as needed (PRN) pain medication, frequent pain;
-No natural teeth or tooth fragments.
-Opioid use daily;
-Wheelchair for mobility;
-The resident did not walk.
Review of the resident's Care plan, last updated 2/12/24, showed the following;
-Resident is at risk for falls due to history of falling.
-No falls in at least the last year;
-U-bar (small assist bed rail) on right side of bed: U bar for increased mobility/leverage in bed and for transfers;
-Encourage and provide toileting assistance when he/she requests-usually independent;
-Encourage resident to assume a standing position slowly;
-Keep bed in lowest position with brakes locked;
-Keep call light in reach at all times;
-Keep personal items and frequently used items within reach;
-Provide an environment free of clutter;
-Provide proper, well-maintained footwear;
-Remind resident to lock brakes on wheelchair before transferring to/from.
Review of the resident's quarterly MDS, dated [DATE], showed the following:
-Moderate cognitive impairment;
-Moderate hearing difficulties, hearing aide present;
-Independent with transfers and walking;
-Continent of bowel and bladder.
The resident's care plan was not updated after the resident had improvements in transfer, ambulation, continence and cognition.
Review of the resident's nurses notes, dated 5/9/24, showed the following:
-Heard yelling from the resident's room;
-When entering the room, the resident lay on his/her right side holding his/her arm;
-The resident had blood dripping from his/her right eyebrow;
-Laceration to right eyebrow, along with right shoulder that was displaced;
-The resident was unable to move his/her right arm;
-The resident was sent to the emergency room via EMS.
Review of the resident's census showed the resident went to the hospital on 5/9/24 and returned on 5/10/24.
Review of the resident's nurses notes, dated 5/10/24 at 7:36 A.M., the interim Director of Nursing documented the following:
-Returned to facility at 7:32 A.M. by ambulance transport from the hospital;.
-Laceration to right forehead, stitches noted;
-The resident had a dislocation of his/her right shoulder; these injuries were from his/her fall in his/her room last
night.
Review of the resident's nurses notes, dated 5/10/24 at 1:50 P.M., showed the following:
-Skin assessment performed post fall;
-Area above right eyebrow is measuring 4.9 cm in length and 0.5 cm in width;
-Sutures in place, left open to air;
-Area on right cheek measures 1.6 cm in length and 0.3 cm in width, left open to air;
-No bruising noted to right shoulder.
Review of the resident's medication administration record, dated May 2024, showed the following:
-On 5/11/24, staff documented the resident's pain score as five out of 10 (with 10 being the highest) on the evening shift;
-On 5/12/24, staff documented the resident received PRN (as needed) Tylenol (pain reliever) 650 milligrams (mg) at 12:21 P.M. and night shift documented a pain score of four out of 10.
The resident's care plan was not updated after a fall with injury to face requiring sutures, a dislocated shoulder and increased evidence of pain.
Review of the resident's nurses notes, dated 5/12/24, showed the following:
-Aide reported the resident had an unwitnessed fall;
-Upon entering the resident's room, the resident was sitting on his/her buttocks beside his/her bed and was leaning on his/her right arm;
-When asked what happened, the resident said, I was about to wet myself;
-The resident was educated on using the call light for safety due to previous fall.
The resident's care plan was not updated after a fall on 5/12/24.
Review of the resident's physician's orders, dated 5/13/24, showed hydrocodone-acetaminophen 5-325 milligrams two times daily for pain.
Review of the resident's nurses notes, dated 5/19/24, showed the following:
-The resident was found on the floor next to his/her bed;
-The resident said he/she slid off the bed and onto his/her bottom;
-The resident had chronic pain complaints in his/her right shoulder due to a previous fall and dislocation.
Review of the resident's electronic medical record showed no evidence of revision of the resident's care plan after each fall or any additional changes to prevent further injuries from falls.
Observation and interview on 5/19/24 at 3:45 P.M., showed the resident in his/her wheelchair in the hall by the nurses desk. The resident had sutures to a laceration above his/her right eye brow approximately 4-5 centimeters in length and a black eye. During the observation, the resident said he/she is hard of hearing and said that staff lost his/her hearing aides and it would be nice to be able to hear.
During an interview on 5/20/24 at 2:30 P.M., the resident said his/her hearing aide has been missing for a few weeks and it made it hard to communicate with staff and other residents.
Review of the resident's care plan did not show any updates regarding the resident's missing hearing aides or how to effectively communicate with the resident.
During an interview on 5/23/24, at 2:42 P.M., the Social Service Director said she does not update the care plans for things like hearing aides; she was not sure who did.
During an interview on 5/20/24 at 1:51 P.M. and 2:00 P.M., the acting MDS coordinator said:
-She worked at a sister facility and came over one or two days a week and helped complete the MDS's;
-She did not know the residents, so he/she would ask the staff questions about the residents and complete the MDS's as best as he/she could;
-She only completed what needed to be done;
-She did not complete the care plans that were done by the previous assistant director of nursing (ADON).
During interview on 5/21/24 at 1:57 P.M., the Training/MDS Coordinator said the following:
-She was temporarily helping complete MDS assessments and care plans;
-She stopped completing care plans because the previous ADON completed observations and the care plan;
-She did not know who was completing the care plan after the ADON left.
During an interview on 5/23/24 at 10:45 A.M. and 6:49 P.M., the DON said the following:
-The facility has had change over in nursing administration so all systems were not in place;
-Ideally there would be a review of each fall the next day;
-During the review, staff would try to determine the cause of the fall, evaluate the care plan to see what can be done to prevent further falls and/or reduce injury if there is a future fall;
-The care plans were probably not getting updated because most staff were from agency;
-She read the day notes to determine if an addition was needed to the care plan.
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 residents received care and services in accord...
Read full inspector narrative →
**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, interview, and record review, the facility failed to ensure residents received care and services in accordance with professional standards of practice for one sampled resident (Resident #59), in a review of 24 sampled residents and seven additional residents (Resident #45, #14, #1, #38 and #25). Staff failed to ensure medications were available for administration, did not follow physician orders when laboratory orders were not obtained as ordered, when staff left medications at bedside with residents who did not have may keep at bedside orders, and when staff administered oxygen without a physician's order. The facility census was 67.
Review of the facility policy, Medication Administration Guidelines, revised 2/7/13, showed the following:
- It is the purpose of this facility that residents receive their medications on a timely basis and in accordance with established policies. Drug administration shall be defined as an act in which an authorized person, in accordance with all laws and regulations governing such acts, gives a single dose of a prescribed drug or biological to a resident. The complete act of administration entails removing an individual dose from a previously dispensed, properly labeled container (including a unit dose container), verifying it with the physician's orders, giving the individual dose to the proper resident, and promptly recording the information;
-The same person preparing the doses for administration must administer the medications;
-Medications may not be prepared in advance and must be administered within one hour of preparation;
-Self-administration of drugs is permitted with the written order of the attending physician;
-Medication administration: Medications are given to benefit a resident's health as ordered by the physician;
-Important: If the resident refuses medication, indicate failure to administer medication on the medication record by circling initials and making a notation on the back of the medication record (include date, time, what occurred, initials, and title);
-Remain in the room while the resident takes the medication.
Review of the undated facility policy, Medication Administration, showed the following:
-Medications are given to benefit a resident's health as ordered by the physician;
-Remain in the room while the resident takes the medication.
Review of the undated facility policy, Physician Orders, showed the following:
-Current lists of orders must be maintained in the clinical record of each resident to avoid confusion and errors;
-Physician orders must be reviewed and renewed;
-Oxygen Orders: Specify the rate of flow, route, and rationale (i.e., 2-3 liters/min per nasal cannula PRN for shortness of breath).
Review of the undated facility policy, Physician Services, showed the following:
-The medical care of each resident is under the supervision of a licensed physician:
- Physician orders and progress notes shall be maintained in accordance with current Omnibus Budget Reconciliation Act (OBRA) regulations and facility policy.
A policy regarding blood draws or lab work was requested but no policy received.
1. Review of Resident #38's face sheet showed the resident's diagnoses included chronic obstructive pulmonary disease (COPD) (lung/breathing disorder), pneumonia, acute respiratory distress, seasonal allergic rhinitis, acute and chronic respiratory failure (serious condition that makes it difficult to breathe), gastroesophageal reflux disease (GERD) (stomach disorder), joint pain, shortness of breath and malignant neoplasm of bronchus or lung (tumors in the lung).
Review of the resident's May 2024 physician order sheets (POS) showed the following:
-Albuterol Sulfate HFA inhaler (inhaled lung medication), two puffs as needed (PRN). (The resident did not have an order allowing him/her to keep the medication at bedside.)
-Gabapentin (nerve pain medication) 600 milligrams (mg) three times daily, scheduled for block times 5:00 A.M. to 10:00 A.M., 11:00 A.M. to 2:00 P.M. and 7:00 P.M. to 10:00 P.M. (The resident did not have an order allowing him/her to keep the medication at bedside.)
-Tums (heartburn reliever), one to two tablets three times daily PRN. (The resident did not have an order allowing him/her to keep the Tums at bedside.)
Observation on 5/19/24 at 4:21 P.M. of the resident's bedside table showed the following:
-One plastic medication cup contained a white oblong tablet;
-One plastic medication cup contained four round tablets that were red, yellow or green in color;
-One albuterol sulfate HFA inhaler.
During an interview on 5/19/24 at 4:29 P.M., the resident said the following:
-The medication technician brought him/her those pills around 4:00 P.M.;
-The white pill was his/her pain pill;
-The cup of multi-colored pills were Tums he/she could take whenever he/she needed;
-He/She used the inhaler when he/she needed them;
-He/She could take care of himself/herself.
Observation on 5/19/24 at 4:45 P.M. of the medication cart showed a medication card, labeled for the resident, that contained gabapentin 600 mg. The gabapentin tablets were oblong and white.
During an interview on 5/19/24 at 4:50 P.M., Certified Medication Technician (CMT) Q said the following:
-He/She just came on duty at 3:00 P.M. and had not administered the resident any medications;
-The resident was usually very angry and did not allow staff to watch him/her take his/her medications. The resident demanded for staff to leave his/her medications at his/her bedside and told staff he/she will take them when he/she was ready;
-Staff were not to leave medications at a resident's bedside unless the resident had an order to do so;
-He/She did not know when the medications were left at the resident's bedside.
2. Review of Resident #59's face sheet showed his/her diagnoses included pain in his/her left ankle and joints of left foot and polyneuropathy (condition that causes burning pain).
Review of the resident's May 2024 POS showed an order for gabapentin 300 mg three times daily; scheduled for block times of 5:00 A.M. to 10:00 A.M., 11:00 A.M. to 2:00 P.M. and 7:00 P.M. and 10:00 P.M. The resident did not have an order to keep medications at bedside.
Observation on 5/19/24 at 4:04 P.M. showed the following:
-The resident lay in bed;
-A plastic medication cup containing a beige capsule sat on the bedside table near the resident's bed.
During an interview on 5/19/24 at 4:07 P.M., the resident said he/she did not know if he/she was supposed to take the capsule. He/She was not sure who or when it was brought to him/her. He/She would take it later.
Observation on 5/19/24 at 4:10 P.M. showed the medication cart contained a pharmacy medication card, labeled for the resident, that contained Neurontin (gabapentin) 300 mg. The Neurontin was a beige capsule.
On 5/19/24 at 4:17 P.M., the surveyor asked Licensed Practical Nurse (LPN) A to observe the resident's bedside table.
During an interview on 5/19/24 at 4:18 P.M., LPN A said the following:
-The resident had a cup of medication at his/her bedside table;
-The CMT was responsible for the resident's medications;
-He/She was the charge nurse for the resident and over the CMT;
-The surveyor would have to ask the CMT about the cup of medication;
-LPN A did not remove the cup of medications from the resident's bedside table.
During an interview on 5/19/24 at 4:57 P.M., CMT Q said the following:
-The resident did not like to be watched while taking his/her medications and asked that the medications be left at his/her bedside;
-He/She had not administered the resident any medications since starting his/her shift today;
-The resident should not have medications left at bedside.
On 5/19/24 at 5:00 P.M., the surveyor asked CMT Q to observe the resident's bedside table.
Observation and interview on 5/19/24 at 5:02 P.M. showed the following:
-The cup of medication previously on the resident's bedside table was gone;
-The resident said he/she just took the capsule.
During an interview on 5/21/24 at 1:15 P.M., the Director of Nurses (DON) said she expected medications to only be left at a resident's bedside if they had a may keep at bedside order.
3. Review of Resident #1's face sheet showed the following:
-Date of admission 9/28/23;
-Diagnoses included convulsions (seizures).
Review of the resident's May 2024 POS showed the following:
-Phenytoin sodium extended capsule (Dilantin) (medication to treat seizures) 300 mg twice daily;
-Dilantin laboratory level (a blood test that checks the level of the seizure medication in the blood) the first of the month in March and September.
Review of the resident's medical record showed no documentation the facility obtained the resident's ordered Dilantin laboratory level in March 2024.
During an interview on 5/23/24 at 6:49 A.M., the DON said the following:
-The admitting nurse was responsible for ensuring physician ordered laboratory orders were entered into the lab tech electronic system;
-She could not see that the resident had ever had the ordered Dilantin level drawn;
-She was not sure how the physician ordered lab got missed.
4. Review of Resident #25 face sheet showed the resident's diagnoses included chronic obstructive pulmonary disease (COPD) (lung disorder) and chronic respiratory failure with hypoxia (low blood oxygen levels).
Review of the resident's admission MDS, dated [DATE], showed the resident received oxygen therapy at home and while at the facility.
Review of the resident's care plan, dated 3/12/24, showed the following:
-The resident had an alteration in respiratory function due to chronic obstructive pulmonary disease/chronic respiratory failure and its effects on his/her ability to perform activities of daily living (ADLs), tolerate activities without fatigue and shortness of breath (SOB);
-Approach: oxygen as ordered and monitor for oxygen saturation (level of oxygen in the blood) as needed.
Observation on 5/19/24 at 3:05 P.M., showed the following:
-The resident sat in his/her recliner in his/her room;
-He/She had oxygen administered through a nasal cannula (prongs in the nose) and long tubing connected to an oxygen concentrator (machine that delivers oxygen);
-The dial was set to 4 liters per minute (the amount of oxygen being delivered).
Review of the resident's May 2024 POS on 5/22/24 at 10:38 A.M. showed no order for oxygen.
Observation and interview on 5/22/24 at 3:05 P.M. showed LPN R went to the resident's room (at the surveyor's request) and verified the resident was on oxygen at four liters per minute. He/She checked the resident's physician orders and was unable to find an order for the oxygen.
During an interview on 5/22/24 at 3:30 P.M., LPN R said he/she called the physician and received order for oxygen at 3.5 liters continuous.
Review of the resident's May 2024 POS on 5/22/24 at 3:50 P.M. showed an order for oxygen at 3.5 liters.
During an interview on 5/23/24 at 6:49 P.M., the DON said the following:
-She expected there to be orders for all treatments performed, including oxygen;
-Staff should not perform treatments or procedures without a physician's order.
5. Review of Resident #14's primary care physician progress note, dated 4/25/24, showed the following:
-The resident was having some elevated blood glucose levels with levels ranging from 168-442 (a normal non-fasting blood sugar level is less than 140 mg/dL) the last few days;
-Diagnosis of type II diabetes mellitus (problem in the way the body regulates and uses sugar as a fuel) with diabetic chronic kidney disease (chronic loss of kidney function occurring in those with diabetes mellitus);
-The resident was supposed to have a hemoglobin A1C (blood test that can provide information about average blood sugar levels); it was not drawn;
-The physician wanted the lab test reordered for the next week.
Review of the resident's physician order, dated May 2024, showed an order dated 5/2/24 for hemoglobin A1C.
During interviews on 5/23/24 at 1:59 P.M. and 6:49 P.M., the DON said the following:
-She was unable to find test results for a hemoglobin A1C for May 2024;
-Staff filled out requisitions for an outside company to come to the facility and obtain the lab specimens;
-She helped staff fill out the requisitions, because not everyone had access;
-She did not remember if she filled out or helped staff fill out the requisition for the resident's lab order.
6. Review of Resident #45's face sheet showed a diagnosis of type II diabetes mellitus.
Review of the resident's May 2024 physician order sheet showed an order for Victoza pen injector (an injectable medication to treat type II diabetes mellitus) 1.2 milligrams (mg) injection once a day (original order dated 09/13/23).
Review of the resident's May 2024 medication administration record (MAR) showed the following:
-On 5/10/24, Victoza 1.2 mg was not administered due to drug/item unavailable;
-On 5/11/24, the P.M. blood sugar was 253 (a normal blood sugar range is 70 - 140);
-On 5/12/24, the P.M. blood sugar was 186;
-On 5/13/24, the P.M. blood sugar was 201;
-On 5/16/24, the P.M. blood sugar was 164;
-On 5/17/24, Victoza 1.2 mg was not administered due to awaiting prior authorization;
Review of the resident's nursing progress notes, dated 5/7/24 at 1:21 P.M., showed Victoza was awaiting prior authorization. Paperwork was faxed to the physician.
Review of the resident's May 2024 MAR showed the following:
-On 5/18/24, Victoza 1.2 mg was not administered due to drug/item unavailable;.
-On 5/19/24, Victoza 1.2 mg was not administered due to drug/item unavailable, the P.M. blood sugar was 171;
-On 5/20/24, Victoza 1.2 mg was not administered due to drug/item unavailable, the A.M. blood sugar was 151 and the P.M. blood sugar was 187.
During an interview on 05/21/24, at 6:50 A.M., the resident said was out of Victoza for four or five days.
During an interview on 05/21/24, at 6:55 A.M., LPN R said the following:
-Victoza was not a medication stored in the emergency kit;
-Staff fax the pharmacy when a medication is out; he/she will make a follow-up call to the pharmacy and will call the physician to make them aware.
Review of the resident's May 2024 MAR showed on 5/21/24, Victoza 1.2 mg was not administered due to drug/item unavailable. Comment: will call pharmacy. The P.M. blood sugar was 195.
Review of the resident's nursing progress notes, dated 5/21/24 at 9:39 A.M., showed Victoza insulin not in stock at this time. Pharmacy to request and ask why it is not being filled. Informed that an authorization signature was needed by the physician. Nurse called the physician to inform of the request signature needed and to send back to pharmacy. Physician was aware of the missed dose on 5/21/24 and the statement from the resident saying he/she had missed it for the past few days. Pharmacy also sent another request for signature.
Review of the resident's May 2024 MAR showed on 5/22/24, Victoza 1.2 mg was not administered due to drug/item unavailable. The P.M. blood sugar was 208.
During an interview on 05/23/24, at 6:49 P.M., the DON said the following:
-She expected staff to follow physician orders as written;
-If a medication was not available, she expected the staff to call the pharmacy as soon as they noticed the medication was needed;
-She expected staff to call the pharmacy if a resident missed one day of medication;
-She expected staff to call the physician if a resident missed more than one day of a medication.
CONCERN
(E)
Potential for Harm - no one hurt, but risky conditions existed
ADL Care
(Tag F0677)
Could have caused harm · This affected multiple residents
**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, interview and record review, the facility failed to ensure staff provided two residents (Resident #4 and #...
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**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, interview and record review, the facility failed to ensure staff provided two residents (Resident #4 and #28) in a review of 24 sampled residents and two additionally sampled resident (Resident #26 and #61), that were unable to perform their own activities of daily living (ADL), the necessary care and services to maintain good personal hygiene. The facility census was 67.
Review of the facility's undated policy, Activities of Daily Living (ADL), showed the following:
-Purpose: To assist residents in achieving maximum function;
-The policy did not address the frequency of showers or bathing.
Review of the facility's undated policy, A.M. Care (Early Morning Care), showed the following:
-Purpose: To provide cleanliness, comfort and neatness;
-Take the resident to the bathroom or provide peri-care;
-Allow resident to brush teeth, or brush teeth or dentures for the resident if he/she is not able;
-Wash resident's face and hands and dry well;
-Straighten and/or change all bed linen, blankets and spread, as needed.
Review of the facility's undated policy, Shaving the Resident, showed the following:
-Purpose: To remove facial hair and improve the resident's appearance and morale;
-The policy did not address how often or when to shave residents.
Review of the undated facility policy, Baths (showers), showed the following:
-Purpose: To maintain skin integrity, comfort and cleanliness;
-The policy did not address the frequency of showers or bathing.
Request for a facility policy regarding proper pericare was requested and none provided.
Request for a facility policy for linen changes was requested and none provided.
1. Review of Resident #4's quarterly Minimum Data Set (MDS), a federally mandated assessment instrument completed by the facility, dated 2/25/24 showed the following:
-Severely impaired cognition;
-Substantial/Maximum assistance from staff for shower/bathe;
-Dependent on staff for personal hygiene.
Review of the resident's care plan, revised on 02/28/24, showed the following:
-Activities of daily living (ADLs) completion deficit related to progression of dementia;
-The resident will have ADL needs met as evidenced by being clean, neat, appropriately groomed and with proper personal hygiene;
-Provide assistance as needed for each ADL task.
Observation on 05/19/24, at 4:50 P.M., showed the resident sat in the dining room and had approximately 1/4 inch long whiskers on his/her chin.
During an interview on 05/19/24, at 4:50 P.M., the resident said he/she would rather not have whiskers.
Observation on 05/20/24, at 10:39 A.M., showed the resident sat in his/her room in his/her wheelchair. The resident had chin whiskers approximately 1/2 inch long.
Observation on 05/22/24, at 5:30 P.M., showed the resident sat in his/her wheelchair in the dining room and had whiskers on his/her chin, approximately 1/2 inch long.
During an interview on 05/23/24, at 5:30 P.M., the resident said he/she would like the whiskers cut off. He/She did not like to have whiskers on his/her chin.
2. Review of Resident #26's care plan, updated 4/17/19, showed the following:
-Resident was incontinent of bowel and bladder;.
-Resident frequently experiences loose stools;
-Resident chooses not to use a bed pan and can be resistant to care at times;
-At very high risk of recurrent urinary tract infections;
-Assist of one to two staff with toileting and hygiene;
-Encourage use of bedpan;
-Provide incontinence care after each incontinent episode.
Review of the resident's annual MDS, dated [DATE], showed the following:
-Requires substantial/maximal assistance for upper body dressing and to roll left and right;
-Dependent on staff for toileting hygiene;
-Always incontinent of bowel and bladder.
Observation on 5/21/24 at 6:03 A.M., showed the following:
-The resident was in his/her bed;
-Certified Nurse Assistant (CNA) W and CNA FF donned gloves;
-CNA FF cleaned the resident's front perineal care with one wipe down each side; he/she did not clean the resident's skin folds between the perineum (patch of skin between the genitals and anus) and the legs;
-The CNA's rolled the resident onto his/her side which showed the resident's bed pad was saturated and soiled with feces;
-The CNA's rolled the saturated and feces soiled pad under the resident; under that pad was another pad that was wet with urine; the CNA's rolled the wet pad under the resident along with the first pad; there was a third pad under the resident that was wet with a yellow to brown color;
-CNA FF cleaned the feces from the resident's buttock;
-CNA FF did not clean the resident's lower buttock or top of the resident's legs (where they meet the buttock) where skin had come in contact with urine.
3. Review of Resident #28's, admission MDS, dated [DATE], showed the following:
-Moderately impaired cognition;
-Requires supervision or cues from staff for oral hygiene;
-Requires partial or moderate assistance from staff for upper body dressing;
-Requires substantial or maximum assistance from staff for toileting hygiene, lower body dressing, going from sitting to standing and transfers;
-Dependent on staff to put on/take off footwear;
-Occasionally incontinent of bladder and frequently incontinent of bowel.
Review of the resident's care plan, dated 6/28/23, showed the following:
-Deficit in ADLs completion related to limited mobility, pain, and frozen shoulders/neck from medical diagnoses;
-Diagnosis of nerve injury of cervical (neck region) spine, arthralgia (joint stiffness) of bilateral (both) temporomandibular joint (joint connecting lower jaw to skull) and degeneration of the spinal cord;
-Resident will have ADL needs met daily by being clean, appropriately dressed, groomed and with adequate hygiene;
-Assist daily and as needed with hygiene needs;
-Place items such as toothbrush/toothpaste/towels within reach for him/her to use;
-Assist or perform dressing steps he/she cannot;
-Because of neck/shoulder range of motion (ROM) limits, give physical assist or perform the ADL tasks he/she cannot perform during cares, including hair care;
-Assist with perineal/personal hygiene needs.
Observation on 5/21/24 at 5:30 A.M., showed the following:
-The resident lay in his/her bed wearing socks and a shirt;
-CNA W donned gloves and assisted Resident #28 with perineal care;
-CNA W cleaned down the resident's front perineal area three times with the same area of one cloth and did not clean the folds between the resident's legs and the perineal area;
-CNA W rolled the resident to his/her side;
-The pad under the resident was wet with urine;
-CNA W cleaned down the center of the resident's buttock; the CNA did not clean the resident's entire buttock that was in contact with urine;
-CNA W put a clean brief and pants on the resident;
-CNA W assisted the resident to sit on the side of the bed and changed the resident's shirt;
-CNA W transferred the resident to his/her wheelchair;
-The resident's hair was unkempt and the resident had dried matter around his/her eyes;
-CNA W did not offer or perform hair care, wash the resident's face, offer deodorant or provide oral care for the resident;
-CNA W propelled the resident in his/her wheelchair out of his/her room and to the dining room table.
4. Review of Resident #61's admission MDS, dated [DATE], showed the following:
-Cognitively intact;
-No rejection of care;
-Requires supervision or touching assistance from staff for shower/bathe and personal hygiene;
-Requires partial or moderate assistance from staff for tub/shower transfers.
Review of the resident's care plan, dated 3/15/24, showed the following:
-Self care deficit in ADLs related to debilitation/weakness, physical discomfort from significant ascites (build up of fluid in the abdomen), episodes of shortness of breath, supervision to partial assist depending on his/her physical feeling at the time;
-Resident will have assistance with his/her ADLs as needed during periods of weakness/fatigue;
-Encourage the resident to allow staff to perform tasks that may require bending at the waist to reduce pressure/pain to abdomen;
-Allow resident to make decisions about his/her care;
-The care plan did not provide direction on how often to bathe or shower the resident.
Review of the resident's shower sheets, dated April 2024, showed staff documented the resident had a shower on the following days:
-On 4/10/24 (first one documented for April);
-On 4/16/24 (six days since last shower);
-On 4/26/24 (10 days since last shower);
-On 4/29/24;
-No documentation the resident refused the offering of a shower;
-No documentation to show how often the resident was to be offered a shower or what day/s his/her shower was scheduled.
Review of the resident's shower sheets, dated May 2024, reviewed on 5/20/24, showed staff documented the resident had a shower on the following days:
-On 5/2/24;
-On 5/9/24 (seven days since last shower);
-No documentation the resident refused the offering of a shower;
-No documentation to show how often the resident was to be offered a shower or what day/s his/her shower was scheduled;
-At the time of review, it had been 11 days since the resident's last documented shower.
Observation on 5/19/24 at 4:16 P.M., showed the following:
-The resident sat in his/her wheelchair in his/her room;
-The resident had long facial hair on his/her chin and had body odor.
During an interview on 5/19/24 at 4:16 P.M., the resident said the following:
-He/She often goes a week without a shower;
-He/She would like at least two showers a week;
-He/She does not want whiskers on his/her chin; they are long because staff only trim his/her facial hair during baths and he/she has not had one this week (it had been 10 days since the last documented shower);
-He/She has asked for his/her sheets to be changed, but it has been weeks because there were not enough staff to do those kinds of things.
During an interview on 5/21/24, at 6:15 A.M., CNA W said the following:
-Staff are expected to keep residents clean, dry, and well groomed;
-When providing perineal care, staff should use a clean part of the wipe with each wipe and clean the resident from the front to the back or clean to dirty;
-Staff are expected to wipe all areas where urine or feces touch the resident's skin;
-Resident's should have all of their clothing changed everyday;
-When getting resident's up in the morning, staff offer perineal care, oral care, brush their hair, apply deodorant and basic grooming;
-Residents are expected to get showers on shower days, but sometimes there was not enough staff.
During an interview on 5/21/24, at 8:45 A.M., CNA FF said the following:
-Staff are expected to change the resident's bed linens with showers, but sometimes there was not enough linen or staff to complete linen changes;
-Every morning staff are expected to wash resident's faces, hands, comb their hair, brush teeth, wash perineal area, arm pits and apply deodorant;
-Staff are expected to clean incontinent residents everywhere urine or feces touch;
-Clean perineal area's front to back with one wipe per swipe;
-Residents should not have three pads on the bed, not sure why Resident #26 had three.
During an interview on 05/23/24 at 6:49 P.M., the Director of Nursing (DON) said the following:
-Staff should provide showers per the resident's preference;
-She expected staff to provide routine oral care and shaving; this would be for all residents;
-Staff should provide peri-care which includes all areas that are soiled, including the buttocks.
CONCERN
(E)
Potential for Harm - no one hurt, but risky conditions existed
Deficiency F0679
(Tag F0679)
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 design an activity program to meet the needs, interes...
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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 design an activity program to meet the needs, interests, physical, mental and psychosocial well being for two residents (Resident #22 and #52), in a review of 24 sampled residents and one additional resident (Resident #44). Staff failed to ensure evening and weekends, as well as activities focusing on dementia residents were occurring. The facility census was 67.
During an interview on 5/22/24 at 11:00 A.M., the Director of Nursing (DON) said the facility did not have a specific policy related to the activities program.
1. Observation of the posted activity calendar for the month of May 2024, on 5/19/24 at 5:45 P.M., showed the following:
-Every Saturday: weekend packet and Bingo at 2:00 P.M.;
-Every Sunday: devotionals with a resident at 10:30 A.M. and Bingo at 2:00 P.M.;
-No evidence of any evening activities scheduled;
-No evidence of activities for dementia residents or one on one activities scheduled.
2. Review of Resident #22's face sheet showed the following:
-He/She had a guardian;
-Diagnosis of dementia (a group of thinking and social symptoms that interferes with daily functioning).
Review of the resident's annual Minimum Data Set (MDS), a federally mandated assessment instrument completed by the facility, dated 6/23/23, showed the following:
-Severely impaired cognitive skills for daily decision making;
-Makes self understood;
-Sometimes understands others;
-Short term and long term memory problems;
-No behaviors or rejection of cares;
-Likes participating in favorite activities.
Review of the resident's quarterly MDS, dated [DATE], showed the following:
-Severely impaired cognitive skills for daily decision making;
-Makes self understood;
-Sometimes understands others;
-Short-term and long-term memory problems;
-No behaviors or rejection of cares.
Review of the resident's care plan, revised on 03/28/24, showed the following:
-The resident likes to socialize with staff and other residents;
-He/She enjoys participating in ice cream socials and wandering the halls;
-Adjust the intensity, frequency, and/or duration of activities to accommodate the resident's energy level and tolerance;
-Encourage the resident to become involved with activities, adapt to his/her current abilities;
-Inform the resident of upcoming activities by providing activities calendar, verbal reminders, escort, encouragement, etc.;
-Involve the resident with those who have shared interests.
Daily observation during the facility's annual survey, from 5/19/24 to 5/23/24, showed the resident had no involvement in activities. The resident frequently sat in the day room with minimal interaction from staff or residents.
3. Review of Resident #44's annual MDS, dated [DATE], showed the following:
-Severe cognitive impairment;
-Diagnosis of dementia;
-Wandering present one to three days;
-No hallucinations or delusions;
-No rejection of care;
-Interview for activities, the resident said favorite activities and religious services were very important to him/her and music, pets and going outside when the weather is good was somewhat important to him/her.
Review of the resident's care plan, last reviewed 2/14/24, showed the following:
-Resident has impaired memory due to diagnosis of dementia;
-Resident will sometimes become agitated, cursing at others and wandering halls, or revert back to his/her childhood and believe he/she is living in that time;
-Provide reality orientation when necessary, but don't argue or try to force resident to believe;
-Sometimes it may be best to allow resident to live in his/her own world with his/her beliefs for a period of time;
-Provide reassurance when frustration and fear is present.
The care plan did not provide guidance to staff on the resident's activity needs.
The resident's medical record did not include evidence of any activity assessments, activity notes, attendance in activities or one on one activities.
Daily observation during the facility's annual survey, from 5/19/24 to 5/23/24, showed the resident had no involvement in activities. The resident frequently sat in his/her wheelchair at the end of the hallway looking out a window.
4. Review of Resident #52's, admission MDS, dated [DATE], showed the following:
-Severe cognitive impairment;
-Diagnosis of dementia;
-Unable to answer depression questions;
-Activity preferences include it was very important for the resident to have: things to read, music he/she likes, animals/pets. It is somewhat important to keep up with news, do things with groups of people, go outside and religious activities.
Review of the resident's care plan, last reviewed/revised 4/24/24, showed the following:
-Potential for unmet needs (physical/cognitive nutritional/hydration) related to cognitive deficit,
-Encourage resident to socialize, participate in activities of interest and getting exposure to sunlight, either through the window or outside when the weather allows.
The care plan did not provide guidance to staff on the resident's activity needs.
The resident's medical record did not include evidence of any activity assessments, activity notes, attendance in activities or one on one activities.
Daily observation during the facility's annual survey, from 5/19/24 to 5/23/24, the resident had no involvement in activities. The resident frequently sat in his/her wheelchair in the living room/television area with his/her head on the table or in his/her bed. He/She went to the dining room for meals.
During an interview on 5/20/24 at 10:52 A.M., the resident's responsible party said the following:
-He/She was at the facility four to five days a week, sometimes three times a day;
-There were not enough activities for dementia residents;
-No one at the facility completed activities with the dementia residents;
-There were no activities for any residents on the weekend except what the residents do themselves.
5. During an interview on 5/20/24 at 11:03 A.M., Resident #41 said the following:
-The facility has Bingo on Monday, Wednesday and Friday; another resident organized this activity and calls the Bingo and will call Bingo on the weekend as well;
-The facility hardly ever had weekend activities;
-He/She would like more variety in activities;
-Many activities got canceled if the activity director had transportation responsibilities, which was weekly;
-The activity director was not enthusiastic about activities and always complained about his/her job because they pull him/her to transportation a lot.
During an interview on 5/23/24 at 11:20 A.M., the Activity Director said the following:
-She was a new Activity Director;
-She did not receive any training and she does not know how or what to chart;
-There was a state Activity Director class, but she was not scheduled for it;
-She was not able to do the activities every day because she also does transportation;
-She splits her time as best she can with 1/2 activities and 1/2 transportation, but if there are too many appointments, she may not get as much time in activities;
-She was the only employee in the activities department;
-If she has to go on transport, and there was supposed to be an activity, the activity doesn't get done, unless a resident does it for her;
-The facility did not arrange for her to have a resource person to call with questions about activities that she knew of;
-She does not know much about dementia or what kind of activities to do for the residents with dementia;
-The Social Service designee has tried to teach her about one on one activities and dementia, but she has not had time to do any;
-There were no activities scheduled the 2nd and 4th Thursday's, so staff play music during dinner;
-She has a few activities where she documents attendance, but didn't know she was supposed to;
-She does not know what an activity assessment is and has not done any;
-The residents with dementia do not come to many activities;
-Bingo was held several times a week because a resident will call the Bingo numbers.
During an interview on 5/23/24 at 6:49 P.M., the Director of Nurses said the following:
-She would expect activities to be offered to all residents, including the dementia residents;
-Weekend activities are usually things like bingo and games the residents initiate;
-She is not sure what specific activities occur in the evening.
CONCERN
(E)
Potential for Harm - no one hurt, but risky conditions existed
Deficiency F0687
(Tag F0687)
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 proper treatment and care to maintain foot heal...
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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 proper treatment and care to maintain foot health for two residents (Resident #9 and #36) in a sample of 24 residents and one additional sampled resident (Resident #34). The facility census was 67.
Review of the facility's undated policy, Nail Care of (FINGERS AND TOES), showed the following:
-Purpose: To provide cleanliness, comfort, prevent spread of infection;
-The Nursing assistants may perform nail care on the residents who are not at risk for complications of infection. The licensed nurse or podiatrist must perform nail care on residents suffering from diabetes or vascular disease.
Review of the facility assessment, updated 5/20/24, showed the facility out-sourced providers included one average visit per month by a podiatrist.
1. Review of Resident #36's undated face sheet showed his/her diagnoses included congestive heart failure (build up of fluid in the heart), end stage kidney disease (on dialysis), and diabetes mellitus (inability to control blood sugar levels).
Review of the resident's care plan, last revised 4/25/24, showed the resident may need assistance with his/her ADL's.
Review of the resident's skilled nursing facility (SNF)/dialysis communication form, dated 4/26/24, showed orders from the dialysis clinic that a foot check was done at the clinic, big toe toe nails need trimmed as soon as possible. Licensed Practical Nurse (LPN) N documented his/her initials to the side of the order on this form, indicating the order had been noted.
Review of the resident's quarterly Minimum Data Set (MDS), a federally mandated assessment instrument completed by facility staff, dated 5/13/24, showed the following:
-Cognitively intact;
-No rejection of cares or behaviors;
-Diagnosis of end stage renal (kidney) disease and diabetes mellitus;
-Receives insulin injections and anticoagulants (blood thinners) daily;
-Receives dialysis (filtration of the blood to perform the function of the kidneys).
Review of the resident's SNF/Dialysis communication form, dated 5/15/24, showed the toe nails must be cut as soon as possible.
Review of the resident's SNF/Dialysis communication form, dated 5/17/24, showed to please trim toe nails.
Review of the resident's SNF/Dialysis communication form, dated 5/20/24, showed to trim the resident's toenails.
Observation on 5/23/24, at 2:15 P.M., showed the following:
-The resident's toenails were long and uneven, the resident's big toe nails were thick and long;
-His/Her toe nails showed signs of pressure on the sides of his/her nails.
During an interview on 5/23/24 at 2:15 P.M., the resident said he/she felt pressure on his/her toes when his/her shoes were on and it was uncomfortable. He/She has not seen a podiatrist in a long time. He/She would like to get his/her toe nails trimmed.
2. Review of Resident #9's face sheet showed diagnoses included heart failure.
Review of the resident's quarterly MDS, dated [DATE], showed the following:
-Moderately impaired cognition;
-No behaviors or rejection of cares;
-Partial/Moderate assistance from staff for personal hygiene;
-Substantial/Maximum assistance from staff for shower/bathe self and putting on/taking off footwear.
Review of the resident's care plan, revised on 03/11/24, showed the following:
-The resident is at risk for deterioration in completing activities of daily living (ADL) related to tardive dyskinesia (a condition affecting the nervous system, often caused by long-term use of some psychiatric drugs);
-His/Her needs will be met through next review;
-Provide assistance in performing ADLs as needed.
Review of the resident's May 2024 physician order sheet showed an order for a podiatry consult and evaluate to treat with an order start date of 05/09/24.
During an interview on 05/19/24, at 4:30 P.M., the resident said he/she would like to see the podiatrist, he/she was not sure when he/she saw one last, but it had been a long time.
3. Review of Resident #34's face sheet showed the diagnosis of diabetes mellitus.
Review of the resident's quarterly MDS, dated [DATE], showed the following:
-Makes self understood and understands others;
-Cognitively intact;
-No behaviors or rejection of cares;
-Set up or clean up assistance only for personal hygiene and shower/bathe self.
Review of the resident's care plan, revised 04/14/24, showed no problem, goal or interventions related to foot care.
Review of the resident's May 2024 physician order sheet showed the following:
-The resident requires diabetic shoe insoles with an order start date of 02/27/20;
-Podiatry evaluation to consult and treat with an order start date of 05/04/24.
During an interview on 05/19/24, at 3:55 P.M., the resident said he/she had not seen a podiatrist for over a year. He/She was diabetic and would like to see one as soon as possible.
During an interview on 5/21/24 at 6:10 A.M., Certified Nurse Assistant (CNA) W said the CNA's are not allowed to clip resident's toe nails if they are diabetic and some of the residents' toe nails were too thick to cut. The night shift CNA's started a list for the podiatrist six weeks ago, but a podiatrist still had not come to the facility.
During an interview on 5/22/24, at 1:42 P.M., LPN R said the following;
-The aides started a list for residents who need to see the podiatrist several weeks ago;
-Some of the residents' nails are too thick for the nurses to cut and they need to see a podiatrist;
-There was also an issue with agency nurse staffing as some were only in the facility for short assignments and facility staff were always assisting them. This resulted in little time to trim nails;
-He/She tries to cut resident's toe nails that he/she can, but cannot get to all of them, or they are too thick for him/her to cut.
During an interview on 05/22/24, at 11:12 A.M., the social services director said the following:
-She has been responsible for making outside appointments and obtaining podiatry services for the facility for about a month;
-Prior to a month ago, a medical records staff member was responsible for outside appointments and obtaining podiatry services, but he/she no longer worked with the facility;
-The prior podiatrist resigned and the facility obtained a new podiatrist a couple weeks ago;
-The facility sent out consent forms and got permission from the residents who could sign for themselves to see the new podiatrist;
-As soon as all the forms were returned to the facility, the podiatrist would see everyone in the facility.
During an interview on 05/23/24, at 6:49 P.M., the Director of Nursing said the following:
-Having a foot care provider had been a problem recently;
-The last provider they had did not work out well;
-She thought a new podiatrist has been contracted;
-Nursing should keep nails trimmed if possible.
CONCERN
(E)
Potential for Harm - no one hurt, but risky conditions existed
Deficiency F0688
(Tag F0688)
Could have caused harm · This affected multiple residents
**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, interview, and record review, the facility failed to provide restorative services to assist three resident...
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**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, interview, and record review, the facility failed to provide restorative services to assist three residents (Resident #28, #41 and #68), in a review of 24 sampled residents, with mobility and/or limited range of motion, to attain or maintain their highest level of functioning. The facility census was 67.
Review of the facility's undated policy, The Restorative Nursing (RNA) Program, showed the following:
-The restorative nursing program is an integral part of maximizing the daily restorative care process for the residents;
-A pro-active approach is necessary to prevent future negative outcomes;
-It is the purpose of this facility to see that each resident receives and the facility provides the necessary care and services to attain or maintain the highest practicable physical, mental, and psychosocial well-being in accordance with the comprehensive assessment and plan of care. (OBRA 1987);
-It is the entire staff's responsibility to prevent deterioration and further functional loss of each resident in the facility. The objective of the RNA program is to provide restorative care necessary to meet the needs of all residents to enable them to achieve the standard of care as described by OBRA 1987;
-Goals:
-1. Clear lines of authority, expectations and responsibilities are necessary for implementation of the RNA program;
-2. Restorative services are to be made available per residents' assessed needs;
-3. Criteria for resident entry to, movement within and discharge from the RNA program must be clearly established;
-4. A mechanism for monitoring and on-going evaluation of the RNA programs must be established;
-5. Restorative Nursing Aides (RNAs) must be adequately trained and provided with on-going training and consultation.
Review of the facility's undated policy, Role of the Restorative Nurse Aide (RNA), showed the following:
-The Restorative Nurse Aide will be given specialized training by the nursing and therapy departments;
-The training and documentation of training will be done internally;
-This training will enable the RNA to carry out instructions for specialized care as identified below for those residents assessed by nursing, physical therapy (PT), occupational therapy (OT) and speech therapy (ST) as requiring such services;
-The RNA will perform services to assigned residents based on an individual plan, using restorative approaches and motivational techniques that promote independence, self-help and active participation;
-The RNA will perform the duties as assigned by the nurse management and therapist. The duties may include:
- Body alignment and positioning;
-Eating independence/retraining;
-ADL's - bathing, dressing, grooming and toileting;
-Range of motion;
-Transfers;
-Ambulation;
-Prosthetic management;
-Whirlpools;
-Restorative adaptive devices;
-The RNA will communicate significant changes in the resident's condition to the appropriate staff;
-The RNA will document the progress of residents on the restorative case load as stated in the Resident Treatment Plan;
-The RNA will report to nursing, PT, OT and ST any problems, referrals or needed reassessments as needed;
-The RNA will attend the weekly interdisciplinary team (IDT) meetings and any in-services offered.
A request was made for a restorative nursing program log book and none was provided.
During an interview on 6/25/24, at 8:59 A.M., the administrator said the facility's restorative aide was terminated on 3/19/24.
1. Review of Resident #28's care plan, dated 6/28/23, showed the following:
-The resident had range of motion (ROM) limits of his/her neck/shoulder;
-Give physical assist or perform the activity of daily living (ADL) tasks he/she cannot perform;
(The approaches on the resident's care plan did not include a restorative nursing program.)
Review of the resident's physician's order sheet, dated 12/6/23, showed the resident discharged from skilled physical and occupational therapy services.
Review of the resident's quarterly MDS, dated [DATE], showed the following:
-Moderately impaired cognition;
-Requires partial or moderate assistance from staff for oral hygiene;
-Requires substantial or maximum assistance from staff for shower/bathe, toileting hygiene, upper and lower body dressing, put on/take off footwear, going from sitting to standing and transfers;
-Limited range of motion in both upper extremities;
-No restorative nursing.
Review of the resident's Nursing-Restorative Program Referral, dated 2/21/24, showed the following:
-Goal: Maintain upper body strength and stand tolerance;
-Restorative nursing two times weekly;
-Upper body strength with minimum to moderate resistance;
-Standing tolerance with upper body support.
Review of the resident's quarterly Minimum Data Set (MDS), a federally mandated assessment completed by staff, dated 3/17/24, showed the resident had limited range of motion to both upper extremities and did not receive restorative nursing.
Review of the resident's medical record showed no evidence the resident received restorative nursing services.
Observation on 5/21/24 at 5:30 A.M., showed the following:
-The resident was in his/her bed;
-The resident was unable to assist the staff with his/her upper body;
-The resident did not move his/her neck or arms;
-The resident required maximum assist from a staff member for a pivot transfer, the resident was unable to stand upright.
During an interview on 5/21/23 at 5:59 A.M., Certified Nurse Assistant (CNA) W said the following:
-The resident used to walk with assist until a few months ago.;
-The facility used to have a restorative aide, but he/she left and the facility had not replaced him/her;
-He/She had not been instructed to complete restorative services and would not have time to do them unless the facility increased staffing.
2. Review of Resident #41's face sheet, showed he/she had diagnoses that included chronic kidney disease, non-pressure chronic ulcer of skin of other sites limited to breakdown of skin, cellulitis (infection) of right lower limb, cellulitis of left lower limb, complete traumatic amputation (removal) of the leg at level between the right knee and ankle and diabetes mellitus (inability to regulate blood sugar) with diabetic neuropathy (nerve disease cause numbness and or weakness).
Review of the resident's physician orders, dated 3/6/23, showed restorative plan of care for bilateral upper extremity and lower extremity strengthening as tolerated and sit to stand at grab bar or parallel bar to maintain modified independence for transfers.
Review of the resident's annual MDS, dated [DATE], showed the following:
-Cognitively intact;
-Independent with eating and oral hygiene;
-Requires partial/moderate assistance from staff for upper body dressing;
-Requires substantial/maximal assistance from staff to shower/bathe, to go from sitting to lying flat and lying to sitting on the side of the bed;
-Dependent on staff for toilet hygiene, lower body dressing and footwear, to roll left and right and to transfer;
-Wheelchair use;
-No impairments to range of motion;
-No restorative nursing minutes.
Review of the resident's Nursing-Restorative Program Referral, dated 11/14/23, showed the following:
-Goal: Maintain upper body and lower body strength;
-Restorative Nursing two times weekly;
-Upper body strength with approximately 6 lbs. resistance;
-Lower body strength with moderate resistance;
-Precaution: watch skin integrity on legs.
Review of the resident's quarterly MDS, dated [DATE], showed functional limitation in range of motion to one lower extremity. No restorative nursing minutes.
Review of the resident's medical record showed no evidence the resident received restorative nursing services.
During an interview on 5/22/24 at 2:04 P.M., the resident said he/she would like restorative nursing but the facility has not had the staff to do restorative nursing.
3. Review of Resident #68's continuity of care document showed the resident's diagnoses included cerbrovascular disease (a group of conditions that affect blood flow and the blood vessels in the brain that could include blood clots and strokes) and vascular dementia (brain damage caused by multiple strokes that causes memory loss).
Review of the resident's physical therapy treatment encounter note, dated 01/23/24, showed the following:
-Discharge summary completed and established a restorative program;
-Issued written handout to restorative.
Review of the resident's nursing-restorative program referral, dated 01/23/24, showed the following:
-Goals for restorative included for the resident to maintain/improve bilateral lower extremities range of motion and strength and transfers with stand-by to minimal assist with grab bar;
-Approach/techniques included therapeutic exercises bilateral lower extremities all planes for range of motion and strengthening and transfers at grab bars or parallel bars with stand-by to minimal assist.
Review of the resident's quarterly MDS, dated [DATE], showed the following:
-Severe cognitive impairment;
-No behaviors or rejection of cares;
-Substantial/maximum assist from staff for sitting to lying and lying to sitting on the side of the bed position changes;
-Dependent on staff for sit to stand, chair/bed-to-chair and tub transfers, lower body dressing and putting on/taking off footwear;
-Partial/moderate assist from staff for rolling left to right in bed and upper body dressing;
-Uses a wheelchair for mobility;
-No restorative nursing program documented.
Review of the resident's May 2024 physician order sheets showed the resident was discontinued from skilled occupational therapy on 01/22/24. (The resident did not have an order for a restorative nursing program.)
Review of the resident's care plan, revised 05/01/24, showed the resident required assistance with activities of daily living (ADLs) and mobility due to functional limitations following a stroke. (The approaches on the resident's care plan did not include a restorative nursing program.)
Observation on 05/22/24, at 6:18 A.M., showed the following:
-CNA E and CNA C assisted the resident to sit on the side of the bed from a lying position. CNA E moved the resident's legs to have his/her feet touch the floor;
-The resident did not participate in lifting his/her legs from the bed to the side of the bed;
-CNA E placed the resident's walker at the side of the resident's bed;
-CNA C placed a gait belt around the resident's waist;
-CNA E and CNA C instructed the resident to stand and assisted the resident to a standing position by lifting on the gait belt with the resident pushing up to a standing position using the walker;
-CNA C instructed the resident to pivot to his/her wheelchair and assisted to a sitting position;
-CNA C transported the resident to the dining room.
During an interview on 05/23/24, at 1:35 P.M., the therapy director said the following:
-She was the director at the facility since late February;
-When she first started, there was a RA for the restorative program;
-The RA quit not to long after she started at the facility (late February) and there was currently no restorative program;
-The Director of Nursing (DON) discharged everyone from the RA program due to no current RA.
During an interview on 05/23/24 at 6:49 P.M., the DON said the following:
-The facility currently did not have a restorative nursing program due to there being no trained restorative aide available for the program;
-The RA quit, and when he/she quit, all of the residents who were on the restorative nursing program were discontinued from the program;
-CNAs could do the walk to dine program for any resident;
-CNAs could perform range of motion;
-She expected any resident who needed to have restorative nursing, to receive it;
-The facility had not been able to hire an RA since the last RA quit several months ago.
CONCERN
(E)
Potential for Harm - no one hurt, but risky conditions existed
Deficiency F0700
(Tag F0700)
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 assess residents for the use of bed rails/assist bars ...
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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 assess residents for the use of bed rails/assist bars prior to installation, to have a system in place to obtain informed consent and educate residents and their responsible parties about the risks of bed rail use prior to use, assess residents for entrapment risk and failed to assess for continued safe use of bed rails for one resident, (Residents #39), in a review of 24 sampled residents and two additional residents (Resident #15 and #44). The facility census was 67.
Review of the facility's undated policy, Bed Rails, showed the following:
-The objective of the bed rail use policy is to determine if resident use is safe and appropriate;
-Overview of FDA potential zones of entrapment with FDA dimension recommendations;
-Prior to use of bed rails the facility should complete the Matrix Bed Rail Observation including the following:
-a. Observation detail;
-b. Clinical assessment;
-c. Alternatives attempted prior to bed rail implementation;
-d. Bed rail details;
-e. Assessment of potential entrapment zones;
-f. Review the risk and benefits with resident and resident representative;
-g. Obtain informed consent with resident and/or resident representative signature;
-h. Obtain physician order for medical symptom assessed requiring bed rail use;
-Once the Bed Rail observation is completed, the facility will print the observation and review associated risks and benefits with the resident and/or resident representative. After the review is complete, the resident and/or resident representative will sign the consent line and the nurse will sign as well;
-Educate the resident/legal representative on the benefits and risks of bed rail use;
-a. A resident may try to climb through/under or over rails or footboard which could increase risk for injury;
-b. Issues that often result in bed rail use include memory disorders, impaired mobility, risk for injury, nocturia/incontinence and sleep disturbances;
-c. Risk of entrapment;
-d. Individuals with agitation, delirium, confusion, pain, uncontrolled body movement, hypoxia and elimination issues are at risk for entrapment and/or suffering serious injury from a fall;
-e. Importance of mattress and bed equipment per manufacturers guidelines to reduce risk for injury;
-Develop a care plan that outlines the medical factors necessitating bed rails and an explanation of how the use of a bed rail is intended to treat the specific resident's condition. Care plan considerations include the following:
-a. Identify the specific medical symptom/indication for use of the bed rail;
-b. Explanation of how the use of a bed rail is intended to treat the specific resident's condition;
-c. Identify and address any underlying issues causing the medical symptom/indication for usage;
-d. Identify potential loss of autonomy, dignity and self-respect;
-e. Identify the specific time periods of bed rail usage;
-f. Interventions identified to mitigate resident specific risks associated with the use of a bed rail;
-g. Individualized interventions determined to meet the resident's needs.
Review of the Food and Drug Administration (FDA) Guide of Bed Safety, Bed Rails in Hospitals, Nursing Homes and Home Health Care: The Facts, revised April 2010, showed the following:
-Patients who have problems with memory, sleeping, incontinence, pain, uncontrolled body movement, or who get out of bed and walk unsafely without assistance, must be carefully assessed for the best ways to keep them from harm, such as falling;
-Assessment by the patient's health care team will help to determine how best to keep the patient safe;
-Potential risks of bed rails may include strangling, suffocating, bodily injury or death when patients or part of their body are caught between rails or between the bed rails and mattress, more serious injuries from falls when patients climb over rails, skin bruising, cuts, and scrapes, feeling isolated or unnecessarily restricted, and preventing patients, who are able to get out of bed, from performing routine activities such as going to the bathroom or retrieving something from a closet;
-When bed rails are used, perform an on-going assessment of the patient's physical and mental status and closely monitor high-risk patients;
-A process that requires ongoing patient evaluation and monitoring will result in optimizing bed safety;
-Reassess the need for using bed rails on a frequent, regular basis.
1. Review of Resident #15's undated face sheet showed the following:
-Responsible for himself/herself;
-Diagnoses included repeated falls, generalized muscle weakness, anxiety, restless leg syndrome, morbid obesity, insomnia, and obstructive sleep apnea.
Review of the resident's care plan, dated 12/23/23, showed the following:
-At risk for falls related to poor balance/gait, impulsive, poor safety awareness, and has a history of falls;
-Fall on 12/17/22 after rolling out of bed trying to pick up Continuous Positive Airway Pressure (CPAP) mask off the floor.
-The resident's care plan did not address bed rails.
Review of the resident's Minimum Data Set (MDS), a federally mandated assessment completed by facility staff, dated 3/3/24, showed the following:
-Intact cognition;
-Had no upper extremity or lower extremity impairments;
-Used a walker and a wheelchair;
-Independent with transfers;
-Independent with bed mobility.
Observation on 5/19/24 at 4:32 P.M. showed the resident lay on his/her left side in his/her bed. The half bed rail on the right side of the resident's bed was in the raised position. The half bed rail on the left side of the resident's bed was lowered.
Observation on 5/21/24 at 10:29 A.M. showed the half bed rail on the right side of the resident's bed was in the raised position. The left rail was lowered.
During interview on 5/21/24 at 12:49 P.M., the resident said the following:
-Someone put the right bed rail up and put the left bed rail down on his/her bed;
-The right bed rail will not come down;
-He/She did not want the right bed rail up, but would like the left bed rail raised;
-He/She had this bed for over a year. The last bed had assist bars;
-He/She used the bed rails for safety and comfort.
Review of the resident's medical record showed no documentation the facility completed a bed rail entrapment assessment or received consent prior to installing bed rails on the resident's bed.
During interview on 5/21/24 at 12:57 PM., Licensed Practical Nurse (LPN) N said the following:`
-The resident used the bed rails for safety;
-He/She thought the therapy department completed the bedrail assessments.
2. Review of Resident #39's face sheet showed the resident was his/her own responsible party.
Review of the resident's care plan, revised 11/29/23, showed the following:
-The resident is at risk for falls related to physical weakness/debility, impaired posture and decision to sometimes attempt transfers without assist;
-U-bar (a 1/8 bed rail used for bed mobility) on left side.
Review of the resident's significant change MDS, dated [DATE], showed the following:
-Cognitively intact;
-Limited range of motion on the upper and lower extremities on one side of his/her body;
-Substantial/Maximum assistance required for rolling left and right, lying to sit on side of bed transfers, sit to stand transfers and chair/bed-to-chair transfers.
Observation on 5/19/24 at 3:35 P.M., showed the resident sat in his/her wheelchair in his/her room. The resident had 1/8 bed rail in the raised position on the left side of the bed.
During an interview on 5/19/24 at 3:35 P.M., the resident said he/she used the 1/8 bed rail to turn in bed and help him/her get out of bed.
Observation on 5/21/24 at 5:33 A.M., showed the resident lay in bed sleeping. The 1/8 bed rail on the left side of the bed was in the raised position.
Review of the resident's medical record showed no bed rail assessment, no bed rail entrapment assessment or informed consent from the resident for the use of the bed rail.
3. Review of Resident #44's annual MDS, dated [DATE], showed the following:
-Severe cognitive impairment;
-Wandering present one to three days;
-Requires partial/moderate assistance to roll left and right;
-Requires substantial/maximum assistance from staff to move from sitting to lying, lying to sitting on the side of the bed, from sitting to standing, and chair to bed or bed to chair transfers.
Review of the resident's care plan, last reviewed/revised 5/7/24, showed the following:
-The resident had cognitive impairment related to dementia;
-The resident was a fall risk;
-Fall mats to both sides of the bed;
-Resident needs assistance with activities of daily living (ADLs) and mobility due to weakness, and cognition;
-Resident will be as independent as safely possible and any additional needs will be met with the assistance of staff;
-Restorative therapy three times weekly for lower extremities strength and range of motion (ROM);
-Assist of one to two staff members with bed mobility: rolling side to side, sitting up and lying down;
-Assist of one to two staff members toileting- toilet transfers, peri-care and clothing management;
-Often incontinent of bowel and bladder, especially at night;
-Wheelchair with wedge cushion for mobility;
-Able to self-propel short distances, but needs assistance with longer-distances;
-Unable to walk at this time;
-The care plan did not address the use of bed rails or entrapment risk.
Observation on 5/19/24 at 3:54 P.M., showed the resident was not in his/her room. The 1/8 bed rail on the resident's right side of the bed was in the raised position.
Review of the resident's medical record, on 5/20/24, showed no side rail assessments, no physician order for side rails, no documentation of interventions attempted prior to installation of bed rails, no bed rail entrapment assessment or informed consent from the resident or resident's representative for bed rail use.
Observation on 5/21/24 at 5:30 A.M., showed the resident in bed with the 1/8 bed rail on the resident's right side of the bed in the raised position.
During interview on 5/21/24 at 1:30 P.M., the Certified Occupational Therapy Assistant (COTA) and Physical Therapist (PT) said the following:
-The therapy department only suggested when bed rails should be used;
-The nursing department completed the consent form and assessments.
During an interview on 5/21/24 at 1:51 P.M. Training Coordinator said the following:
-She did MDS assessments to help the facility;
-She pulled a report and did the MDS assessments that were due;
-The facility lost the MDS Coordinator and Director of Nursing (DON) over a year ago;
-The current MDS Coordinator had started three weeks ago but had not had training yet.
During interview on 5/23/24 at 6:49 P.M., the DON said the following:
-The MDS Coordinator was responsible for completing the bedrail assessments;
-Bedrail assessments should be completed quarterly;
-The resident should sign a consent form for bedrails.
CONCERN
(E)
Potential for Harm - no one hurt, but risky conditions existed
Deficiency F0728
(Tag F0728)
Could have caused harm · This affected multiple residents
Based on interview and record review, the facility failed to ensure two nurse aides (NA NN and NA OO), completed a nurse aide training program within four months of their employment as an NA in the fa...
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Based on interview and record review, the facility failed to ensure two nurse aides (NA NN and NA OO), completed a nurse aide training program within four months of their employment as an NA in the facility. The facility census was 67.
During an interview on 5/22/24 at 11:00 A.M., the Director of Nursing (DON) said the facility did not have a specific policy regarding certification of nurse aides. The facility followed the regulatory guidance.
1. Review of NA NN's employee file showed his/her employment as an NA started on 11/13/23 (approximately six months and one week from the time of hire to the time of review).
Review of the state NA registry showed no evidence the employee was certified as a nurse aide.
2. Review of NA OO's employee file showed his/her employment as an NA started on 10/3/23 (approximately seven months and three weeks from the time of hire to the time of review).
Review of the state NA registry showed no evidence the employee was certified as a nurse aide.
During an interview on 5/21/24 at 8:10 A.M., the Director of Nursing said the following:
-Nurse aides are sent to another facility to do their initial 16 hours of training;
-The facility does not have any NA's at this time;
-If the facility has NA's, they have to complete the NA certification within four months of their hire date;
-The Social Service Director (SSD) tracks the NA and certified nurse aide (CNA) training hours.
During an interview on 5/21/24 at 8:25 A.M., the SSD said the following:
-She no longer kept track of CNA or NA training;
-When she did, if a NA started, they had to complete 16 hours of training before they could work on the floor;
-The NA's had to be registered for class and certified within four months;
-If they did not complete their certification within four months, they have to move to another position;
-The Registered Nurse (RN) Training Coordinator/MDS Coordinator did all of the CNA training.
During an interview on 5/21/24 at 1:51 P.M., the (RN) Training Coordinator/MDS Coordinator said the following:
-She does not do any CNA education;
-She does not do annual training or competencies for CNA's
-She only assist with NA training on Fridays at another facility (this facility sends NA's to that facility);
-She takes the NA's to another facility to do their training;
-There are two NA's, she was not sure of their hire dates, that have completed their classroom training but have not passed the test;
-The NA's are required to be certified within four months.
During an interview on 5/22/24 at 3:16 P.M., the Business Office Manger (BOM) confirmed the NA's hire dates and provided a copy of their training record.
CONCERN
(E)
Potential for Harm - no one hurt, but risky conditions existed
Deficiency F0730
(Tag F0730)
Could have caused harm · This affected multiple residents
Based on interview and record review, the facility failed to ensure each Certified Nurse Assistant (CNA) had no less than 12 hours of in-service education per year based on their individual performanc...
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Based on interview and record review, the facility failed to ensure each Certified Nurse Assistant (CNA) had no less than 12 hours of in-service education per year based on their individual performance review, calculated by hire date. The facility identified two CNAs employed by the facility for more than a year. Two of two CNAs (CNA C, and CNA PP) sampled did not have the required 12 hours of in-service education. The facility census was 67.
Review of the Facility Assessment, updated 5/20/24, showed the following staff education and competencies will be shown with each area below:
-Activities of daily living: Bathing, showers, oral/denture care, dressing, eating, support with needs related to hearing/vision/sensory impairment; supporting resident independence in doing as much of these activities by himself/herself. All CNA, CMT, LPN, RN will do a return demonstration to observe their ability;
-Mobility and fall/fall with injury prevention: Transfers, ambulation, restorative nursing, contracture prevention/care; supporting resident independence in doing as much of these activities by himself/herself. All CNA, CMT, LPN, RN will do a return demonstration to observe their ability;
-Bowel/bladder toileting programs, incontinence prevention and care, intermittent or indwelling or other urinary catheter, ostomy, responding to requests for assistance to the bathroom/toilet promptly in order to maintain continence and promote resident dignity. All CNA, CMT, LPN, RN will do a return demonstration to observe their ability;
-Skin integrity: Pressure injury prevention and care, skin care, wound care (surgical, other skin wounds). All CNA, CMT, LPN, RN will do a return demonstration to observe their ability;
-Mental health and behavior: Manage the medical conditions and medication-related issues causing psychiatric symptoms and behavior, identify and implement interventions to help support individuals with issues such as dealing with anxiety, care of someone with cognitive impairment, care of individuals with depression, trauma/PTSD, other psychiatric diagnoses, intellectual or developmental disabilities. All CNA, CMT, LPN, RN will do in-servicing and performance reviews;
-Infection prevention and control: Identification and containment of infections, and prevention. All CNA, CMT, LPN, RN will do education and a return demonstration to observe their ability;
-Therapy Physical therapy, Occupational therapy, Speech/Language, Respiratory therapy, management of braces, splints. All CNA, CMT, LPN, RN will do a return demonstration to observe their ability;
-Other special care needs: Dialysis, hospice, ostomy care, and tracheostomy care. All CNA, CMT, LPN, RN will do a return demonstration to observe their ability;
-Nutrition: Individualized dietary requirements, liberal diets, specialized diets, IV nutrition, tube feeding, cultural or ethnic dietary needs, assistive devices, fluid monitoring or restrictions. All Dietary services, CNA, CMT, LPN, RN will do a return demonstration to observe their ability;
-Provide person centered/directed care: Psycho/social/spiritual support: Build relationship with resident/get to know him/her; engage resident in conversation Find out what resident's preferences and routines are; what makes a good day for the resident; what upsets him/her. ALL staff performance review and observed ability.
The facility conducts monthly in-service meetings with staff. Competency assessments, performance reviews, and observed abilities are also completed. Training is conducted based from the assessments and observation results.
1. Review of CNA C's employee education file showed the employee was hired 12/5/17. The employee education file did not contain any evidence of education hours or competencies in the last year. (The only training documented was new hire training 12/5/17 and did not contain any competencies).
2. Review of CNA PP's employee education file showed the employee was hired 4/17/23. The employee education file did not contain any evidence of education hours or competencies in the last year. (The only training documented was new hire training 4/17/23 and did not contain any competencies).
During an interview on 5/21/24, at 8:10 A.M., the Director of Nursing said the the Social Service Director (SSD) tracks the NA and CNA training hours and competencies.
During an interview on 5/21/24, at 8:25 A.M., the SSD said the following:
-She no longer kept track of CNA or NA training;
-Registered Nurse (RN) Training Coordinator/MDS Coordinator does all of the CNA training and competencies.
During an interview on 5/21/24, at 1:51 P.M., the (RN) Training Coordinator/MDS Coordinator said the following:
-She does not do any CNA education or CNA competencies;
-She does not do annual training or competencies for CNA's.
During an interview on 5/22/24, at 3:16 P.M., the Business Office Manger (BOM) confirmed the NA's hire dates, and provided a copy of their training record.
During an interview on 5/23/24 at 6:49 P.M., the Interim Director of Nursing said the following:
-The facility was trying to implement a computer software training system;
-It was not accomplished.
-There has been no training schedule;
-When she was at the facility earlier in the year she did do observations of staff using gait belts for transfers;
-The facility was documenting when it was completed but there have been changes to nursing administration since then and she was not sure where the documentation would be or if any of the current staff attended.
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
Based on interview and record review, the facility failed to ensure residents' monthly pharmacy drug regimen recommendations were reviewed or followed up on for three residents (Resident #20, #13, #8)...
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Based on interview and record review, the facility failed to ensure residents' monthly pharmacy drug regimen recommendations were reviewed or followed up on for three residents (Resident #20, #13, #8), of 24 sampled residents. The census was 67.
Review of the facility policy, Consultant Pharmacist Reports, dated July 2021, showed the following:
-Medication Regimen Review: The consultant pharmacist performs a comprehensive review of each resident's medication regimen and clinical record at least monthly. The medication regimen review (MRR) includes evaluating the resident's response to medication therapy to determine that the resident maintains the highest practicable level of functioning and preventing or minimizing adverse consequences related to medication therapy. The MRR also involves thorough review of the resident records, and may include collaboration with other members of the interdisciplinary team, collaboration with the resident, family members or other resident representatives. MRR also involves reporting of findings with recommendations for improvement. All findings and recommendations are reported to the director of nursing and the attending physician, the medical director and the administrator;
-The consultant pharmacist reviews the medication regimen of each resident at least monthly;
-The findings are phoned, faxed, or e-mailed within (24 hours) to the director of nursing or designee and are documented and stored with the other consultant pharmacist recommendations in the resident's active record.
1. Review of Resident #8's Annual Minimum Data Set (MDS), a federally mandated assessment instrument, completed by facility staff and dated 1/31/24, showed the following:
-Severe cognitive impairment;
-Physical behaviors 1-3 days during the look back period.
Review of the resident's continuity of care document (CCD) (a facility used form that details resident information) showed the following:
-Diagnoses included bipolar (a mental health condition that causes extreme mood swings), depression and anxiety;
-Divalproex tablet, delayed release (used to treat certain types of seizures) 500 milligrams (mg), two tablets at bedtime;
-Quetiapine tablet (antipsychotic medication that treats several kinds of mental health conditions) 300 mg twice daily;
-Haloperidol (to treat nervous, emotional, and mental conditions) 0.5 mg twice daily;
-Venlafaxine (used to treat depression) 75 mg daily.
Review of the resident's progress notes showed the the pharmacy consultant documented the following:
-On 06/16/2023 at 4:45 P.M., see report;
-On 07/18/2023 at 03:47 P.M., see report;
-On 08/17/2023 at 12:05 P.M., see report;
-On 10/20/2023 at 04:16 P.M., see report;
-On 11/14/2023 at 01:06 P.M., see report;
-On 12/13/2023 at 04:11 P.M., see report;
-On 01/17/2024 at 05:04 P.M., see report;
-On 03/04/2024 at 08:33 P.M., see report for recommendation;
-On 04/12/2024 at 12:11 P.M., see report for recommendation;
(Review of the resident's medical record showed no documentation of the pharmacy consultant's report with recommendations and no documentation to show the facility addressed any recommendations with the resident's physician.)
The state agency (SA) requested the resident's pharmacy recommendation reports, as indicated in his/her progress notes, of the Director of Nursing (DON) on 5/23/24 at 1:51 P.M. (none were provided).
2. Review of Resident #13's undated face sheet showed the following:
-The resident's original admission date was 7/28/23;
-Diagnosis of bipolar disorder (a disorder associated with episodes of mood swings, ranging from depressive lows to manic highs), conversion disorder (a psychiatric condition that causes physical and sensory symptoms that can't be explained by a known medical condition) with seizures or convulsions, psychotic disorder with delusions due to known physiological condition, major depressive disorder (a mood disorder that causes a persistent feeling of sadness and loss of interest), and hypertension (high blood pressure)
Review of the resident's undated physician order sheets (POS) showed the following:
-Lexapro (an antidepressant medication) 20 mg once a day, started 7/28/23;
-Plavix (a blood thinning medication) 75 mg once a day, started 7/28/23;
-Wellbutrin XL (an antidepressant medication) 300 mg once a day, started 7/28/23
-Hydrocodone-acetaminophen (a pain medication) 5-325 mg every 12 hours as needed, started 8/25/23;
-Xarelto (a blood thinning medication) 20 mg, started 10/1/23.
Review of the resident's progress note, dated 10/29/23 at 1:45 P.M., showed the pharmacy consultant wrote see report. (Review of the resident's medical record showed no documentation of the pharmacy consultant's report with recommendations and no documentation to show the facility addressed any recommendations with the resident's physician.)
Review of the resident's progress note, dated 12/13/23 at 12:58 P.M., showed the pharmacy consultant wrote see report. (Review of the resident's medical record showed no documentation of the pharmacy consultant's report with recommendations and no documentation to show the facility addressed any recommendations with the resident's physician.)
Review of the resident's progress note, dated 1/17/24 at 1:26 P.M., showed the pharmacy consultant wrote see report. (Review of the resident's medical record showed no documentation of the pharmacy consultant's report with recommendations and no documentation to show the facility addressed any recommendations with the resident's physician.)
Review of the resident's physician's orders showed an order dated 2/1/24 for Seoquel (an antipsychotic medication) 300 mg at bedtime.
3. Review of Resident #20's undated face sheet showed the following:
-admission date of 10/3/23;
-Diagnosis of chronic pain syndrome, major depressive disorder (a mood disorder that causes a persistent feeling of sadness and loss of interest), generalized anxiety disorder (excessive worry and feeling of fear, dread, and uneasiness), hypertension (high blood pressure), atrial fibrillation (an irregular, often rapid heart rate that commonly causes poor blood flow), dysarthria (slurred speech) following unspecified cerebrovascular disease (conditions that affect the blood vessels and blood supply to the brain).
Review of the resident's undated physician order sheets (POS) showed the following:
-Eliquis (a blood thinning medication) 5 mg twice a day, started on 10/5/23;
-Alprazolam (an anxiety medication) 0.5 mg every six hours, started on 10/12/23.
Review of the resident's progress note, dated 11/14/23 at 10:13 A.M., showed the pharmacy consultant wrote see report. (Review of the resident's medical record showed no documentation of the pharmacy consultant's report with recommendations and no documentation to show the facility addressed any recommendations with the resident's physician.)
Review of the resident's May 2024 POS showed an order, dated 12/8/23, showed an order for hydrocodone-acetaminophen (a pain medication) 10-325 mg, one tablet as needed (PRN).
Review of the resident's care plan, dated 12/12/23, showed the following:
-The resident was at risk for adverse effects related to taking antianxiety medication;
-Attempt a gradual dose reduction as recommended;
-Pharmacy consultant review routinely.
Review of the resident's progress note, dated 2/12/24 at 1:06 P.M., showed the pharmacy consultant wrote see report. (Review of the resident's medical record showed no documentation of the pharmacy consultant's report with recommendations and no documentation to show the facility addressed any recommendations with the resident's physician.)
Review of the resident's progress note, dated 3/4/24 at 8:46 A.M., showed the pharmacy consultant wrote see report for gradual dose reduction (GDR) recommendations.
Review of the resident's consultant pharmacist report, dated 3/4/24, showed GDR recommendation for Alprazolam, however, there was no response from the resident's physician.
Review of the resident's consultant pharmacist report, dated 5/21/24, showed there was no response from the first GDR recommendation from 3/24.
During interview on 5/23/24 at 6:49 P.M., the DON said the following:
-The pharmacist came to the facility monthly to review the residents' medications;
-He/She thought the pharmacist sent recommendations by email.
-She was unaware the pharmacy recommendations had to be printed from the pharmacy website. She did not have access to the pharmacy reports until 5/23/24. She did not have access to the pharmacist previous reports. There was a binder where the facility kept old reports and recommendations, but a lot of the reports were missing.
CONCERN
(E)
Potential for Harm - no one hurt, but risky conditions existed
Medication Errors
(Tag F0758)
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 two residents (Resident #55 and #8) and one add...
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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 two residents (Resident #55 and #8) and one additionally sampled resident (Resident #6), with orders for as needed (PRN) psychotropic medications, in a review of 24 sampled residents, were limited to 14 days as required, except if an attending or prescribing physician believed that it was appropriate for the PRN order to be extended beyond 14 days. The facility failed to attempt a gradual dose reduction (GDR) on psychotropic medications or document a clinical justification to continue current dosage for three residents (Resident #54, #66 and #13). The facility census was 78.
Review of the undated facility policy, antipsychotic medication use, showed the following:
-Purpose: Antipsychotic medication therapy shall be used only when it is necessary to treat a specific condition;
-Guidelines:
-The attending physician will identify, evaluate and document, with input from other disciplines and consultants as needed, symptoms that may warrant the use of antipsychotic medications;
-Based on assessing the resident's symptoms and overall situation, the physician will determine whether to continue, adjust, or stop existing antipsychotic medication;
Antipsychotic medication use:
-For acute psychiatric situations, antipsychotic medication use shall meet the following criteria:
-The acute treatment period is limited to seven days or less;
-A clinician, in conjunction with the interdisciplinary team, must evaluate and document the situation within seven days, to identify and address any contributing and underlying causes of the acute psychiatric condition and verify the continuing need for antipsychotic medication;
-Pertinent non-pharmacological interventions must be attempted, unless
contraindicated, and documented following the resolution of the acute
psychiatric situation;
-If antipsychotic medications are administered as PRN dosages repeatedly over several days, the physician should discuss the situation with staff and evaluate the resident as needed to determine whether the use is appropriate and the symptoms are responding to the medication;
-The physician shall respond appropriately by changing or stopping problematic doses or medications, or clearly documenting (based on assessing the situation) why the benefits of the medication outweigh the risks or suspected or confirmed
adverse consequences;
-The policy did not specifically address GDRs or 14 day stop dates.
1. Resident #66's face sheet showed he/she had diagnoses that included major depressive disorder.
Review of the resident's quarterly Minimum Data Set (MDS) (a federally mandated assessment instrument completed by facility staff), dated 4/16/24, showed the following:
-Takes antipsychotics routinely;
-Takes antidepressants;
-No GDR attempted;
-Has not been documented by a physician that a GDR is clinically contraindicated.
Review of the resident's May 2024 physician order sheets (POS) showed orders for the following:
-Trintellix (antidepressant) 30 milligrams (mg) daily; order date of 7/11/23;
-Rexulti (antipsychotic to treat major depressive disorder) 2 mg every day; order date of 2/1/24.
Review of the resident's medical record showed no documentation of a GDR being completed or that one had been documented as contraindicated by the physician for Trintellix or Rexulti.
2. Review of Resident #6's face sheet showed he/she had diagnoses that included anxiety.
Review of the resident's February 2024 POS showed an order for Ativan (antianxiety medication) 0.5 milligrams (mg) three times daily as needed (PRN) every eight hours; order date of 2/7/24; no stop date.
Review of the resident's February 2024 MAR showed the following:
-Ativan 0.5 mg three times daily PRN every eight hours;
-No documentation staff administered the medication to the resident during the month.
Review of the resident's March 2024 POS showed an order for Ativan 0.5 mg three times daily PRN every eight hours, order date of 2/7/24 with no stop date.
Review of the resident's March 2024 MAR showed the following:
-Ativan 0.5 mg three times daily PRN every eight hours;
-No documentation staff administered the medication to the resident during the month.
Review of the resident's April 2024 POS showed an order for Ativan 0.5 mg three times daily PRN every eight hours, order date of 2/7/24 with no stop date.
Review of the resident's April 2024 medication administration record (MAR) showed the following:
-Ativan 0.5 mg three times daily PRN every eight hours;
-On 4/16/24 at 1:13 P.M., staff documented administering the resident the Ativan medication;
-On 4/18/24 at 7:48 P.M., staff documented administering the resident the Ativan medication;
-On 4/19/24 at 8:23 P.M., staff documented administering the resident the Ativan medication;
-On 4/20/24 at 7:53 P.M., staff documented administering the resident the Ativan medication;
-On 4/22/24 at 9:47 P.M., staff documented administering the resident the Ativan medication;
-On 4/23/24 at 7:23 P.M., staff documented administering the resident the Ativan medication;
-On 4/28/24 at 7:19 P.M., staff documented administering the resident the Ativan medication;
-On 4/29/24 at 9:19 P.M., staff documented administering the resident the Ativan medication.
Review of the resident's May 2024 POS showed an order for Ativan 0.5 mg three times daily PRN every eight hours, order date of 2/7/24 with no stop date.
Review of the resident's May 2024 MAR showed the following:
-Ativan 0.5 mg three times daily PRN every eight hours;
-On 5/1/24 at 8:54 P.M., staff documented administering the resident the Ativan medication.
3. Review of Resident #55's March 2024 POS showed an order for Ativan 0.25 mg for anxiety twice daily PRN, order date of 3/23/24 with no stop date and diagnoses anxiety.
Review of the resident's March 2024 MAR showed the following:
-Ativan 0.25 mg for anxiety twice daily PRN, order date of 3/23/24 with no stop date;
-No documentation staff administered the medication for any day, time or shift during the month.
Review of the resident's April 2024 POS showed an order for Ativan 0.25 mg for anxiety twice daily PRN, order date of 3/23/24 with no stop date.
Review of the resident's April 2024 MAR showed the following:
-Ativan 0.25 mg for anxiety twice daily PRN, order date of 3/23/24 with no stop date;
-On 4/7/24 at 4:21 A.M., staff documented administering the resident his/her Ativan medication.
Review of the resident's May 2024 POS showed an order for Ativan 0.25 mg for anxiety twice daily PRN, order date of 3/23/24 with no stop date.
Review of the resident's May 2024 MAR showed the following:
-Ativan 0.25 mg for anxiety twice daily PRN, order date of 3/23/24 with no stop date;
-No documentation staff administered the medication 5/1/24 through 5/23/24.
4. Review of Resident #54's face sheet, undated, showed the resident's diagnoses included depression (common and serious medical illness that negatively affects how you feel, the way you think and how you act) and generalized anxiety disorder (persistent feeling of anxiety or dread that interferes with how you live your life).
Review of the resident's physician orders, dated May 2024, showed Zoloft (antidepressant) 50 mg, one tablet orally at bedtime for depression (started on 06/27/23).
Review of the resident's medical record showed no documentation a gradual dose reduction of Zoloft was attempted or contraindicated.
5. Review of Resident #8's Annual MDS, dated [DATE], showed the following:
-Severe cognitive impairment;
-Physical behaviors one to three days during the look back period.
Review of the resident's March 2024 POS showed an order for Ativan 0.5 mg for anxiety three times daily PRN, order date of 10/1/23 with no stop date and diagnoses of anxiety.
Review of the resident's March 2024 MAR showed the following:
-Ativan 0.5 mg for anxiety three times daily PRN, order date of 10/1/23 with no stop date;
-No documentation staff administered the medication for any day, time, or shift during the month.
Review of the resident's April 2024 POS showed an order for Ativan 0.5 mg for anxiety three times daily PRN, order date of 10/1/23 with no stop date.
Review of the resident's April 2024 MAR showed the following:
-Ativan 0.5 mg for anxiety three daily PRN, order date of 10/1/23 with no stop date;
-No documentation staff administered the medication for any day, time, or shift during the month.
Review of the resident's May 2024 POS showed an order for Ativan 0.5 mg for anxiety three times daily PRN, order date of 10/1/23 with no stop date.
Review of the resident's May 2024 MAR showed the following:
-Ativan 0.5 mg for anxiety three times daily PRN order date of 10/1/23 with no stop date;
-No documentation staff administered the medication for any day, time, or shift during the month.
6. Review of Resident #13's undated face sheet showed the following:
-The resident's original admission date was 7/28/23;
-Diagnosis of bipolar disorder (a disorder associated with episodes of mood swings, ranging from depressive lows to manic highs), conversion disorder (a psychiatric condition that causes physical and sensory symptoms that can't be explained by a known medical condition) with seizures or convulsions, psychotic disorder with delusions due to known physiological condition, major depressive disorder (a mood disorder that causes a persistent feeling of sadness and loss of interest), and hypertension (high blood pressure)
Review of the resident's undated physician order sheets (POS) showed the following:
-Lexapro (an antidepressant medication) 20 mg once a day, started 7/28/23;
-Wellbutrin XL (an antidepressant medication) 300 mg once a day, started 7/28/23.
Review of the resident's progress note, dated 10/29/23 at 1:45 P.M., showed the pharmacy consultant wrote see report. (Review of the resident's medical record showed no documentation of the pharmacy consultant's report with recommendations and no documentation to show the facility addressed any recommendations with the resident's physician.).
Review of the resident's progress note, dated 12/13/23 at 12:58 P.M., showed the pharmacy consultant wrote see report. (Review of the resident's medical record showed no documentation of the pharmacy consultant's report with recommendations and no documentation to show the facility addressed any recommendations with the resident's physician.).
Review of the resident's progress note, dated 1/17/24 at 1:26 P.M., showed the pharmacy consultant wrote see report. (Review of the resident's medical record showed no documentation of the pharmacy consultant's report with recommendations and no documentation to show the facility addressed any recommendations with the resident's physician.)
Review of the resident's medical record showed no documentation a gradual dose reduction on Lexapro and Wellbutrin XL was attempted or contraindicated.
7. Review of Resident #20's undated face sheet showed the following:
-admission date of 10/3/23;
-Diagnosis of chronic pain syndrome, major depressive disorder (a mood disorder that causes a persistent feeling of sadness and loss of interest), generalized anxiety disorder (excessive worry and feeling of fear, dread, and uneasiness), hypertension (high blood pressure), atrial fibrillation (an irregular, often rapid heart rate that commonly causes poor blood flow), dysarthria (slurred speech) following unspecified cerebrovascular disease (conditions that affect the blood vessels and blood supply to the brain).
Review of the resident's undated physician order sheets (POS) showed an order for alprazolam (an anti-anxiety medication) 0.5 mg every six hours, started on 10/12/23.
Review of the resident's progress note, dated 11/14/23 at 10:13 A.M., showed the pharmacy consultant wrote see report. (Review of the resident's medical record showed no documentation of the pharmacy consultant's report with recommendations and no documentation to show the facility addressed any recommendations with the resident's physician.)
Review of the resident's care plan, dated 12/12/23, showed the following:
-The resident was at risk for adverse effects related to taking antianxiety medication;
-Attempt a gradual dose reduction as recommended;
-Pharmacy consultant review routinely.
Review of the resident's progress note, dated 2/12/24 at 1:06 P.M., showed the pharmacy consultant wrote see report. (Review of the resident's medical record showed no documentation of the pharmacy consultant's report with recommendations and no documentation to show the facility addressed any recommendations with the resident's physician.)
Review of the resident's progress note, dated 3/4/24 at 8:46 A.M., showed the pharmacy consultant wrote see report for gradual dose reduction (GDR) recommendations.
Review of the resident's consultant pharmacist report, dated 3/4/24, showed GDR recommendation for alprazolam, however, there was no response from the resident's physician.
Review of the resident's consultant pharmacist report, dated 5/21/24, showed there was no response from the first GDR recommendation from 3/24.
Review of the resident's medical record showed no documentation the physician addressed the recommended gradual dose reduction for alprazolam or documented the reason a GDR was contraindicated.
During interview on 5/21/24 at 2:22 P.M. and 5/23/24 at 6:49 P.M., the DON said the following:
-The pharmacist came to the facility monthly to review the residents' medications; this review would include the need for GDRs;
-He/She thought the pharmacist sent recommendations by email;
-She was unaware the pharmacy recommendations had to be printed from the pharmacy website. She did not have access to the pharmacy reports until 5/23/24. She did not have access to the pharmacist previous reports. There was a binder where the facility kept old reports and recommendations, but a lot of the reports were missing;
-Nurses obtaining orders for PRN psychotropic medications should be asking physicians for the 14 day stop date when obtaining an order;
-She would also hope that the pharmacist doing the reviews would catch these situations and document them on their monthly reports.
CONCERN
(E)
Potential for Harm - no one hurt, but risky conditions existed
Deficiency F0804
(Tag F0804)
Could have caused harm · This affected multiple residents
Based on observation, interview, and record review, the facility failed to ensure food served to residents was palatable and served at a safe and appetizing temperature. The facility census was 67.
Re...
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Based on observation, interview, and record review, the facility failed to ensure food served to residents was palatable and served at a safe and appetizing temperature. The facility census was 67.
Review of the facility policy, Dietary Services, dated April 2006, showed the facility will serve each resident nutritious food properly prepared and appropriately seasoned, in accordance with the physician's order and as recommended by the National Research Council.
1. During an interview on 5/19/24 at 4:30 P.M., Resident #9 said the food was not always served warm and was cold a lot of the time.
During interview on 5/19/24 at 4:19 P.M., Resident #26 said the food was always served cold.
During an interview on 5/19/24 at 4:48 P.M., Resident #41 said the food was terrible and was cold. Sometimes the food was overcooked and hard.
During an interview on 5/19/24 at 3:55 P.M., Resident #34 said he/she ate in his/her room all the time. The food was not good and was never warm.
During interview on 5/19/24 at 3:35 P.M., Resident #39 said the food was not always served warm.
During interview on 5/19/24 at 3:55 P.M., Resident #46 said the food could be better and was not always served warm.
2. Observation on 5/19/24 at 5:15 P.M. showed staff served the supper meal, which consisted of sloppy joes, green beans and a hashbrown, from the steam table in the kitchen. At 5:38 P.M., staff began preparing the hall trays for residents who chose to eat in their rooms. Staff prepared the last hall tray at 5:47 P.M.
Observation of the test tray on 5/19/24 at 5:55 P.M., received after the last resident was served from the hall cart, showed the following:
-The temperature of the green beans was 114 degrees Fahrenheit. The green beans were bland in flavor;
-The temperature of the hashbrown was 96 degrees Fahrenheit. The hashbrown was greasy and soggy;
-The sloppy joe mixture was salty.
During an interview on 5/19/24 at 5:35 P.M., Resident #26 said the green beans and the hashbrown were cold and did not taste good. The hashbrown was soggy.
During an interview on 5/19/24 at 5:37 P.M., Resident #48 said the sloppy joe was salty and did not taste right.
3. Observation on 5/20/24 at 12:23 P.M., showed Dietary [NAME] H took holding temperatures of the lunch items located on the steam table, which included ham and beans, fried potatoes and cooked cabbage.
Review of the holding temperature log for the lunch meal on 5/20/24, showed the following:
-Ham and beans: 165 degrees Fahrenheit;
-Fried potatoes: 145 degrees Fahrenheit;
-Cooked cabbage: 143 degrees Fahrenheit;
Observation on 5/20/24 at 12:30 P.M., showed the following:
-Dietary [NAME] H began serving residents in the dining room from the steam table in the kitchen;
-Staff served ham and beans, fried potatoes, and cooked cabbage from the steam table;
-The dining room lunch service ended at 12:58 P.M.
Observation on 5/20/24 at 1:01 P.M., showed the following:
-Dietary [NAME] H began preparing hall trays from the steam table in the kitchen;
-Staff served ham and beans, fried potatoes, and cooked cabbage on hot plates from the warming cart and covered each plate with an insulated base and cover;
-Staff finished preparing the hall trays at 1:31 P.M. and placed the test tray on the hall cart with the residents' hall trays.
Observation of the food temperatures for the test tray (last tray served from hall cart) on 5/20/24 at 1:49 P.M., showed the following:
-The temperature of the fried potatoes was 90.3 degrees Fahrenheit;
-The temperature of the cooked cabbage was 93.3 degrees Fahrenheit.
During an interview on 5/22/24 at 6:50 A.M., Dietary [NAME] H said the following:
-He/She expected hot foods to be served hot;
-Staff check the final holding temperatures just before serving and recorded the temperatures in the temperature log;
-It usually took 30 to 35 minutes for him/her and the aide to serve out the dining room trays from kitchen, and 30 to 35 minutes to serve out the hall trays from kitchen;
-He/She was not aware of any issues with the meal temperatures. If there would be an issue, the plate of food would be warmed, or a new plate served out to the resident.
During an interview on 5/22/24 at 8:30 A.M., the Dietary Manager said the following:
-She expected hot foods to be served hot;
-Staff should prepare meals by methods that conserve nutritive value, flavor, and appearance;
-She expected food to be palatable, attractive, and at a safe and appetizing temperature.
During an interview on 5/22/24 at 8:40 A.M., the Administrator said the following:
-He expected staff to prepare meals by methods that conserve the nutritive value, flavor, and appearance;
-He expected food to be palatable, attractive, and at a safe and appetizing temperature.
During an interview on 5/24/24 at 10:35 A.M., the Registered Dietician said the following:
-She expected hot foods to be served hot;
-She expected meals to be prepared by methods that conserve nutritive value, flavor, and appearance;
-She expected food to be palatable, attractive, and at safe and appetizing temperature.
CONCERN
(E)
Potential for Harm - no one hurt, but risky conditions existed
Antibiotic Stewardship
(Tag F0881)
Could have caused harm · This affected multiple residents
Based on interview and record review, the facility failed to follow an antibiotic stewardship program as part of their infection prevention and control program that included antibiotic use protocols a...
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Based on interview and record review, the facility failed to follow an antibiotic stewardship program as part of their infection prevention and control program that included antibiotic use protocols and a system to monitor antibiotic use. The facility census was 67.
Review of the facility's undated policy, Antibiotic Stewardship Program, showed the following:
-The infection preventionist(IP)/designee will be responsible to audit the clinical assessment documentation at the time of antibiotic prescription;
-The IP/designee will be responsible for auditing of completeness of antibiotic prescribing documentation to include dose, route, start date, end date, days of therapy and indication;
-The IP/designee will monitor antibiotic imitation. This is done by taking the number of new antibiotic starts for a single infection,dividing by total number of resident days, and multiplying by 1000;
-The IP/designee will track C. difficle (inflammation of the colon caused by the bacteria Clostridium difficle) and antibiotic resistant infections;
-The monthly infection/antibiotic control log contains: resident room number, resident name, type of infection, symptoms, date of symptoms, date physician notified, date antibiotic started, culture yes/no, pathogen identified, date antibiotic completed, reculture yes/no, resolved yes/no;
-The monthly infection control line listing contains: resident name, age, sex, room number, infection site, date lab pathogen, date symptoms, date treatment, appropriate yes/no, resolved yes/no.
Review of the facility's undated policy, Antibiotic Stewardship Champion Program, showed the following:
-Purpose: to reduce unnecessary antibiotic usage and led to fewer antibiotic failures and/or adverse events;
-Goal: to monitor infection and antibiotic usage by having champions list the infections and antibiotics on a monthly infection control log, trending the infections and determine if the correct antibiotic was used for the correct length of time;
-Champion program: The community will select an antibiotic stewardship champion (ASC) who will be responsible for implementing and maintaining the antibiotic stewardship champion program. The ASC will obtain certification through the Center for Disease Control and Prevention (CDC) for nursing home infection preventionist;
-The ASC will also keep track of the location of infections throughout the facility on a monthly basis by highlighting the location of infections on a map of the facility.
During annual survey medical record review showed the following:
-Resident #27 was being treated with Bactrim DS 800-160mg (antibiotic therapy), one tablet twice a day, for a diagnosis of ESBL (extended spectrum beta-lactamase, an enzyme found in some strains of bacteria that cannot be killed by many types of antibiotics) in the urine from 05/18/24 to 05/25/24;
-Resident #54 was recently treated with azithromycin 250 milligrams (antibiotic therapy) once a day from 05/07/24 through 05/10/24 for a diagnosis of pneumonia;
-Additional sampled Resident #10 was recently treated with azithromycin 250 milligrams once a day from 05/06/24 through 05/12/24 for a diagnosis of pneumonia.
During an interview on 05/22/24, at 6:07 P.M., the interim Director of Nursing (DON) said the following:
-She had been at the facility since off and on since November 2023 serving as the interim DON;
-When she started the facility had an IP that was in charge of the antibiotic stewardship program;
-She has been serving as the IPCP for the last two months with staffing turnover;
-She has not done anything specific with the antibiotic stewardship program since she took over as the IP:
-She had not done any antibiotic surveillance logs or tracking of antibiotic use since she took over as the IP;
-She has not had the time to complete the surveillance.
CONCERN
(E)
Potential for Harm - no one hurt, but risky conditions existed
Deficiency F0909
(Tag F0909)
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 complete inspections of bed frames, mattresses and bed...
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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 complete inspections of bed frames, mattresses and bed rails, as part of a regular maintenance program, to identify areas of possible entrapment for one resident (Resident #39 ), in a review of 24 sampled resident and two additional residents (Resident #15 and #44), who used bed rails/assist bars. The facility census was 67.
Review of the undated facility policy, Bed Rails, showed the following:
-The objective of the bed rail use policy is to determine if resident use is safe and appropriate;
-Overview of Food and Drug Administration (FDA) potential zones of entrapment with FDA dimension recommendations:
-Zone 1: within the rail: any open space between the perimeters of the rail can present a risk of head entrapment. FDA recommended space: less than 4 3/4;
-Zone 2: under the rail, between the rail supports or next to a single rail support: the gap under the rail between the mattress, may allow for dangerous head entrapment. FDA recommended space: less than 4 3/4;
-Zone 3: between the rail and the mattress: this area is the space between the inside surface of the bed rail and the mattress, and if too big it can cause a risk of head entrapment. FDA recommended space: less than 4 3/4;
-Zone 4: under the rail at the ends of the rail, a gap between the mattress and the lowermost portion of the rail poses a risk of neck entrapment. FDA recommended space is less than 2 Ml;
-The FDA has not provided dimension recommendations for Zones 5-7. These zones should be assessed for entrapment risk. The facility should refer to manufacturer guidelines for the bed rails, mattresses, and beds;
-Zone 5: between split bed rails: when partial length head and split rails are used on the same side of the bed, the space between the rails may present a risk of either neck or chest entrapment;
-Zone 6: between the end of the rail and the side edge of the head or foot board: a gap between the end of the bed rail and the side edge of the headboard or footboard can present the risk of resident entrapment;
-Zone 7: between the head or foot board and the end of the mattress: when there is too large of a space between the inside surface of the headboard or footboard and the end of the mattress, the risk of head entrapment increases;
-When installing or maintaining bedrails, staff should follow manufacturer's recommendations and specifications for applicable bed rails, mattresses and bedframes;
-Staff will conduct regular inspections of all bedframes, mattresses, and bed rails, to identify areas of possible entrapment. When bed rails and mattresses are used and purchased separately from the bed frame, the facility will select equipment such as bed rails, mattresses and bedframes that are compatible.
1. Review of Resident #15's care plan, dated 12/23/23, showed the following:
-At risk for falls related to poor balance/gait, impulsive, poor safety awareness, and has a history of falls;
-Fall on 12/17/22 after rolling out of bed trying to pick up Continuous Positive Airway Pressure (CPAP) mask off the floor.
Review of the resident's Minimum Data Set (MDS), a federally mandated assessment completed by facility staff, dated 3/3/24, showed the following:
-Intact cognition;
-Independent with transfers and bed mobility.
Observation on 5/19/24 at 4:32 P.M. showed the resident lay on his/her left side in his/her bed. The half bed rail on the right side of the resident's bed was in the raised position. The half bed rail on the left side of the resident's bed was lowered.
Observation on 5/21/24 at 10:29 A.M. showed the half bed rail on the right side of the resident's bed was in the raised position. The left rail was lowered.
During interview on 5/21/24 at 12:49 P.M., the resident said the following:
-Someone put the right bed rail up and put the left bed rail down on his/her bed;
-The right bed rail will not come down;
-He/She did not want the right bed rail up, but would like the left bed rail raised.
Review of the resident's medical record showed no documentation the facility conducted a regular inspection of the resident's bed frame, mattress and bed rails to identify any possible areas for entrapment.
2. Review of Resident #39's care plan, revised 11/29/23, showed the following:
-The resident is at risk for falls related to physical weakness/debility, impaired posture and decision to sometimes attempt transfers without assist;
-U-bar (a 1/8 bed rail used for bed mobility) on left side.
Review of the resident's significant change MDS, dated [DATE] showed the following:
-Cognitively intact;
-Limited range of motion upper and lower one side only;
-Substantial/Maximum assist from staff for rolling left and right, lying to sit on side of bed transfers, sit to stand transfers and chair/bed-to-chair transfers.
Observation on 05/19/24, at 3:35 P.M., showed the resident sat in his/her wheelchair in his/her room. The resident had a 1/8 bed rail in the raised position on the upper left side of the bed.
Observation on 05/21/24, at 5:33 A.M., showed the resident lay in bed sleeping. The 1/8 bed rail on the left side of the resident's bed was in the raised position.
Review of the resident's medical record showed no documentation the facility conducted a regular inspection of the resident's bed frame, mattress and bed rails to identify any possible areas for entrapment.
3. Review of Resident #44's annual MDS, dated [DATE], showed the following:
-Severe cognitive impairment;
-Requires partial/moderate assistance to roll left and right;
-Requires substantial/maximum assistance from staff to move from sitting to lying, lying to sitting on the side of the bed, from sitting to standing and chair to bed or bed to chair transfers.
Review of the resident's care plan, last reviewed/revised 5/7/24, showed the following:
-The resident has cognitive impairment related to dementia;
-The resident is a fall risk;
-Assist of 1-2 staff members with bed mobility: rolling side to side, sitting up and lying down;
-Assist of 1-2 staff members toileting- toilet transfers, peri-care, and clothing management;
-Often incontinent of bowel and bladder, especially at night.
-Wheelchair with wedge cushion for mobility;
-Unable to walk at this time.
-Apply positioning bar;
-The care plan does not address the use of bed rails or entrapment risk.
Observation on 5/19/24 at 3:54 P.M., showed the resident was not in his/her room. The 1/8 bed rail on the resident's right side of the bed was in the raised position.
Observation on 5/21/24 at 5:30 A.M., showed the resident in bed with the 1/8 bed rail on the resident's right side of the bed was in the raised position.
Review of the resident's medical record showed no evidence staff conducted an inspection of the resident's bed frame, mattress or assist bars to identify areas of possible entrapment.
During interview on 5/21/24 at 1:03 P.M., the Certified Occupational Therapy Assistant (COTA) and Physical Therapist (PT) said the following:
-The therapy department only suggested when bedrails should be used;
-The nursing department completed the consent form and assessments;
-The maintenance department would do any measurements of the entrapment zones.
During interview on 5/22/24 at 3:31 P.M., the Maintenance Supervisor said the following:
-He only installed the bedrails;
-He did not measure for entrapment zones;
-The nurses do the measurements.
During interview on 5/23/24 at 6:49 P.M., the Director of Nursing (DON) said the following:
-Maintenance should measure the entrapment zones monthly;
-The Maintenance Supervisor did not know he was responsible for measuring entrapment zones;
-Staff have not measured the entrapment zones monthly.
CONCERN
(F)
Potential for Harm - no one hurt, but risky conditions existed
Safe Environment
(Tag F0584)
Could have caused harm · This affected most or all residents
**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, interview and record review, the facility failed to keep the floors and walls in good repair and failed to...
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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 keep the floors and walls in good repair and failed to maintain a homelike environment in the facility. The facility census was 67.
Review of the undated facility policy, Housekeeping Department, Seven Steps of Cleaning a Resident Room, showed tasks to be completed included the following:
-Emptying trash;
-Clean and disinfect the bathroom;
-Sanitize floor;
-Report any needed maintenance work;
-The policy did not identify how often the tasks were to be completed.
Request for a homelike environment policy was requested of the facility but none provided.
1. Observation on 5/19/24 at 4:04 P.M., in occupied resident room [ROOM NUMBER] (area near window), showed the following:
-Resident #59 resided in this room; he/she was lying in his/her bed;
-A musty odor was present in the room;
-A trash can sat on the floor between the resident's bed and the wall;
-Two urinals hung on the lip and inside the trash can;
-One urinal held approximately 900 milliliters (ml) of urine (full is 1000 ml) and the other was empty but had a thick, yellow brown sediment at the bottom of the urinal;
-Both urinals had caps to close the urinals that were in place and dated 5/10/24.
During an interview on 5/19/24 at 4:06 P.M., the resident said if the urine odor got too bad, he/she had to empty the urinals. Sometimes the staff who cleaned his/her room emptied them.
Review of the resident's May 2024 physician order sheets (POS) showed an order to change urinal weekly; label with date and initials (it had been nine days since staff changed the urinals).
2. Observation on 5/19/24 at 4:21 P.M., in occupied resident room [ROOM NUMBER] (area near the door) showed the following:
-Resident #38 resided in this room; he/she sat in a recliner in the room, the resident was noted to have an above the knee amputation;
-A musty odor was present in the room;
-A trash can sat on the floor behind the resident's recliner;
-One urinal hung on the lip and inside the trash can and one urinal hung on the lip and outside the trash can;
-One urinal held approximately 400 ml of urine and the other approximately 700 ml of urine;
-Both urinals had caps to close the urinals that were in place and dated 5/10/24.
During an interview on 5/19/24 at 5:25 P.M., the resident said staff were to empty the urinals and replace them and it stinks in here when they don't.
Review of the resident's May 2024 POS showed an order to change urinal weekly; label with date and initials (it had been nine days since staff changed the urinals.)
During an interview on 5/22/23 at 1:18 P.M., the Director of Nursing (DON) said the following:
-Urinals should be checked often and emptied when there was any urine present in them. Any staff are capable of doing this task and should be doing it when entering the resident room multiple times daily;
-Urinals should be replaced weekly;
-When staff do these things, odors are better controlled.
3. Observation on 5/19/24 at 5:00 P.M., in occupied resident room [ROOM NUMBER], showed the wall area under the air conditioner with a black substance the length of the air conditioner; the wall area also had a brown circular ring, approximately two feet by one foot and had a warped appearance as if it had been wet and then dried.
4. Observation on 5/19/24 at 3:54 P.M., showed occupied resident room [ROOM NUMBER], with paint missing on the walls by the resident's bed, a missing closet handle and the toilet grout was thick with dark brown sediment.
5. Observation on 5/19/24 at 3:59 P.M., showed occupied resident room [ROOM NUMBER]'s closet door with many scuffs in the wood and chips in the paint.
6. Observation on 5/20/24 at 10:26 A.M., showed occupied resident room [ROOM NUMBER] with deep gouges into the bathroom door.
7. Observation on 5/19/24 at 5:07 P.M., in occupied resident room [ROOM NUMBER], showed the middle of the tile floor had chips and cracks in the tile with missing pieces of tile in the flooring.
8. Observations on 5/19/23 at 4:00 P.M. showed the following:
-In occupied resident room [ROOM NUMBER], the first bed in the room was unmade, the mattress was dirty with white spots and flakes of a whitish substance. The metal bed frame was rusty. The privacy curtain between the first and second bed was dirty;
-In occupied resident room [ROOM NUMBER], the wall by the first bed was gouged with dry wall exposed and a hole in the corner above the baseboard, the foot board of the second bed had a piece of the particle board off the end of the foot board and there were dirty clothes on the floor in the bathroom.
During an interview on 5/19/21 at 4:15 P.M., Resident #13, who resided in room [ROOM NUMBER], said the following:
-He/She waited weeks to get his/her bed changed due to no linen to change the bed;
-He/She checked the closets daily for the linen;
-If he/she found the linen, he/she changed his/her own bed.
9. Observation on 5/20/24 at 10:20 A.M., in occupied resident room [ROOM NUMBER], showed the following:
-Two residents occupied the room;
-Two uncovered bed pans were stored on the bathroom sink;
-A graduated cylinder (used to measure the volume of a liquid, such as urine) was stored on the bathroom shelf and was uncovered with the resident's personal hygiene supplies;
-The ceiling vent in the bathroom was soiled with debris.
10. Observation on 5/20/24 at 10:27 A.M., in occupied resident room [ROOM NUMBER], showed the following:
-Two residents occupied the room;
-The bathroom floor around the toilet was stained an orange, brown color;
-A pile of clothes lay on the shower floor;
-An uncovered pillow was on the shower floor next to the clothes.
11. Observation on 05/22/24 at 10:39 A.M., in occupied resident room [ROOM NUMBER], showed the following:
-The bathroom door had multiple gouges exposing the wood underneath;
-The door frame to the bathroom had multiple black marks toward the bottom of the door frame;
-The bathroom floor had multiple brown stains;
-The tile under the bathroom sink was stained a pink/orange color;
-The bathroom sink had a large amount of white to light green sediment covering the base of the faucet and the knobs to turn the water on and off.
12. Observation on 5/21/24 at 5:30 A.M., showed CNA W assisted Resident #49 from his/her bed to the bathroom. Observations showed feces on the floor under the resident's bed and on every other floor tile (12 inch floor tiles) from the bed to the bathroom. Feces were present on the bathroom floor and toilet seat.
Observation on 5/22/23, at 8:30 A.M., showed the feces remained on Resident #49's floor under his/her bed, on the floor tiles to the bathroom, on the bathroom floor and the toilet seat.
Observation on 5/22/23, at 2:30 P.M., showed the feces remained on Resident #49's floor under his/her bed, on the floor tiles to the bathroom, on the bathroom floor and the toilet seat.
During an interview on 5/23/24, at 1:54 P.M., the Housekeeping Supervisor said the following:
-Staff are assigned to clean every room every day;
-Staff are expected to clean all toilets in the facility every day;
-The housekeeping department was short staffed;
-Staff, housekeeping and nursing, are expected to keep the rooms clean; feces should not be left on the floor or on the toilet.
13. Observation on 5/21/25 at 9:00 A.M., of the facility linen rooms, showed the following:
-No linens in the linen room on E hall;
-No linens in the linen closet on B hall; the linen cart on the hall did not contain any linen;
-The linen cart on F hall contained only pads and gowns.
During an interview on 5/21/24 at 9:00 A.M., Certified Nurse Assistant (CNA) C said the following:
-He/She had no linen to use to give resident care;
-He/She could not make any of the beds.
14. Observation on 5/22/24 at 10:55 A.M. showed the following:
-The linen cart on the E hall contained several wash clothes, three sheets and two gowns;
-The linen cart on A hall contained three pads, several sheets, a couple of blankets and a gown. The cart did not contain any wash cloths or towels;
-The linen closet on B hall contained eight bed spreads and one blanket. The closet did not contain any towels, wash cloths, sheets, or gowns;
-The small linen cart on B hall contained two pads, five wash cloths and three towels;
-The linen room on B hall contained four gowns, two pads, three pillow cases, five wash cloths and three towels;
-The linen cart on D hall contained three gowns and three pillow cases;
-The main linen closet on the F hall contained seven towels, 12 hand towels and wash cloths, 12 sheets, several pads and six gowns;
-The small linen cart on F hall contained disposable incontinence briefs, three wash cloths and a open package of wipes.
During an interview on 5/22/24 at 11:15 A.M., the Laundry Supervisor said the following:
-She noticed in the last several months that washcloths and towels had disappeared. There had not been a lot of linen to put out on the floor;
-She thought the agency staff was throwing the linen away and not rinsing them out;
-She told the old administrator they were short on linen;
-The linen supplier will only fill according to their census.
During an interview on 5/23/24, at 1:54 P.M., the Housekeeping Supervisor said the following:
-She does not know how much linen the facility is supposed to have on hand;
-She has never done an inventory on linens she has never been told to;
-Many of the linen carts were empty when she was checking the linen.
15. Observation and interview on 5/23/24 at 9:00 A.M. showed the Laundry Supervisor said the following:
-She got the dirty linen barrels several times a day to keep the linen washed so the aides had linen on the floor;
-There was not a lot of linen to wash and there was not a lot of linen to put out;
-In the clean side of the laundry there was three and half packages of wash cloths, three of which were not open, and one package of hand towels not open;
-There were no sheets, no bath towels, no pillow cases, or any blankets noted on the shelves.
During an interview on 5/22/24 at 12:15 P.M. the Administrator said the following:
-There should be enough linen to provide resident care and to ensure bed linen was changed as needed;
-The facility did not have a policy for linens;
-The linen was contracted through an outside contractor;
-The linen provider filled a linen order based on current census, but would provide linen if requested. He did not know if anyone has requested any linens.
16. Observations on 5/20/24 between 9:44 A.M. and 4:45 P.M., showed the following:
-In occupied resident room [ROOM NUMBER], the right-hand wardrobe handle was loose and missing a screw. The bathroom floor was discolored gray and there were several scraped areas on the wall;
-In occupied resident room [ROOM NUMBER], the left handle of the wardrobe was missing one screw and was loose;
-At the end of the A hall, an approximate 3-foot by 3-foot section of flooring was approximately 0.25 inches lower than the rest of the flooring;
-In the B hall medication room, a 2-inch by 4-inch rectangular hole in the drywall (on the right side when entering through the door) and there was no cover on the ceiling light fixture;
-In the B hall shower room, the shower handle was missing and the surrounding tile was broken in an approximate 8-inch by 18-inch area;
-In the B hall dirty utility room (the sign on the room door read 'spray room'), there was a 3-inch hole in the ceiling that was surrounded by an approximate 2-foot by 3-foot area of flaking paint and exposed drywall and the drywall tape hung down from the ceiling;
-In occupied resident room [ROOM NUMBER], there were several large brown stains on the white textured ceiling in a 3-foot by 3-foot area;
-In the E hall medication room, there was a 2-inch by 4-inch open hole in the wall on the right side of the room (when entering the room);
-In the E hall spa room, there was a moderate accumulation of dust and debris on a 12-inch by 12-inch ceiling vent. There was a 3-foot by 8-foot patched area of wall that was unpainted and a 2-inch circular area of paint on the ceiling that was loose and flaking from the painted surface;
-In the E hall, there was an approximate 6-foot by 6-foot area of unpainted and untextured ceiling;
-In occupied resident room [ROOM NUMBER], the cove base trim located under the HVAC unit was pulled away from the wall in an approximate 4-foot section and pulled away from the wall approximately 2-inches. The bathroom sink sprayed water out onto the floor when the faucet was turned on. The resident in the room said the water got on the floor after he/she used the sink because the faucet sprayed out water so bad;
-In occupied resident room [ROOM NUMBER], one of two bulbs in the bathroom ceiling light fixture was not working;
-In the hallway outside resident rooms [ROOM NUMBERS], two light fixtures were missing the light covers;
-In occupied resident room [ROOM NUMBER], an approximate 5-foot piece of cove base trim was missing under the HVAC unit. The wardrobe handle was missing one screw and the handle was loose;
-In occupied resident room [ROOM NUMBER], two small white tiles were missing along the trim in the bathroom. One of two bulbs in the bathroom ceiling light fixture was not working;
-In occupied resident room [ROOM NUMBER], a 3-foot piece of cove base trim under the HVAC unit was missing. There was a 3-inch by 6-inch brown stained area on the ceiling outside of the bathroom;
-In occupied resident room [ROOM NUMBER], one of two bulbs in the bathroom ceiling light fixture was not working;
-In occupied resident room [ROOM NUMBER], there was a 2-inch hole in the wall behind the door handle. One of two bulbs in the bathroom ceiling light fixture was missing;
-In occupied resident room [ROOM NUMBER], there was an approximate 1-foot by 1-foot area of wall that had gouges located on the right side wall (when entering the room) and a 2-inch by 12-inch scrape on the inside right wall of the bathroom The cold water at the bathroom faucet was not working. The resident in the room said it had not worked since he/she moved into the room a couple weeks ago;
-In occupied resident room [ROOM NUMBER], the left side wardrobe door was missing the screw and the handle was loose
-In occupied resident room [ROOM NUMBER], three pieces of duct tape held the HVAC unit vent cover on;
-In unoccupied resident room [ROOM NUMBER], there was a 3-inch by 1- inch bubbled area on the bathroom wall and two of two bulbs in the ceiling light fixture were missing;
-In unoccupied resident room [ROOM NUMBER], there was a 3-foot by 5-foot bubbled area with cracks in the ceiling texture and the ceiling in the left-side closet was unfinished and unpainted;
-Above the northwest exit dining door, the cover for a light fixture was missing;
-In the main dining room, two covers for light fixtures were missing and one bulb in one of these fixtures was not working;
-In the beverage and serving area, located between the kitchen and dining room, the wall behind the ice machine had pieces of broken drywall and missing cove base trim in an approximately 2-foot by 4-foot area;
-In the activity director's office, the cover for a light fixture was missing;
-In the water heater room, located near the private dining room, there was a moderate accumulation of dust and cobwebs on the 6-inch by 6-inch ceiling vent;
-In the copy room, located across from the dining room, there was a moderate accumulation of dust on the 12-inch by 12-inch ceiling vent;
-In the central supply room, there was a heavy accumulation of dark gray debris on the 12-inch circular metal ceiling vent and on the nearby curtain and ceiling;
-In the library, there was a 3-foot by 6-foot area of ceiling that was discolored a light brown and the textured ceiling was drooping slightly. There was an approximate 2-foot long crack in one of the windows;
-In the private dining room, the plastic soap dispenser was cracked;
-In the sitting area by the nurses station, two 12-inch round metal ceiling vents had a moderate accumulation of dark gray buildup and debris;
-In the bathroom to the right (as entering the building) of the main entrance, the floor was discolored yellow and had an approximate 8-inch cut in a triangular shape at one corner of the flooring;
-In the bathroom to the left (as entering the building) of the main entrance, the plastic soap dispenser was cracked;
-In the front entryway, an approximately 6-inch by 3-foot area of white floor tile at the door threshold was cracked and broken across approximately 50% of the tile surface.
17. Observations on 5/21/24 between 7:51 A.M. and 9:03 A.M., during an exterior tour of the facility, showed the following:
-At the front entrance, to the left of the front door, an approximate 1-inch by 2-foot trim board was loose and hung down approximately 3 inches;
-At the right of the front entrance, an approximate 3-inch by 2-foot board hung loose with exposed nails visible and the board hung down from the soffit approximately 6 inches;
-At the front entrance overhang, two areas of an approximate area of 3-foot by 3-foot had dried brown splatters across the surface of the exterior ceiling;
-At the end of the A hall, the trim boards were severely rotted and missing paint in approximately 50 percent (%) of the surface. Three window screens were badly worn and one window screen was missing from a window;
-At the corner of the A and B halls, there was an approximate 3-inch by 6-inch hole in the soffit;
-Above unoccupied resident room [ROOM NUMBER], the soffit vent was loose and hung down approximately 0.5 inches;
-At the end of the B hall, the wood siding and trim boards were coming loose from the building and in some areas were missing as much as 50% of the paint on the boards;
-There was a white cloth towel hanging outside of the HVAC unit for occupied resident room [ROOM NUMBER] that was pinched in between the HVAC cover and the inner portion of the HVAC unit;
-No exterior cover was on the HVAC units for unoccupied resident rooms [ROOM NUMBERS], occupied resident rooms [ROOM NUMBER];
-Above occupied resident room [ROOM NUMBER], the gutter was slightly twisted and there was a 0.5 inch gap at the gutter seam;
-At the E hall portion of the building, there was an approximate 4-inch by 6-inch hole in the wood near the gutter downspout. At the end of the E hall, there was an approximate 2-inch by 4-inch hole in the fascia board near the gutter downspout;
-Above occupied resident room [ROOM NUMBER], the wooden fascia and soffit had multiple holes including an approximate 3-inch by 3-inch hole in the fascia, an approximate 4-inch by 8-inch hole in the soffit, and an approximate four-inch by 20-inch hole in the soffit with a two-foot long board that was nailed at one end and hanging loosely and resting on the nearby gutter downspout;
-Between occupied resident rooms [ROOM NUMBERS], a vent in the soffit was missing approximately 50% of its fins and there was a two-inch by two-inch hole near the vent;
-Along the F hall, there was a three-inch by six-inch piece of trim that was missing and the wooden siding in this area was coming loose from the building and hung away from the building approximately one-inch;
-Above the director of nursing office, an approximate 12-inch by 12-inch area of wooden siding was decayed across approximately 25% of its surface and was coming away from the surface of the building;
-In the area outside the dining room, the wooden trim board located near a gutter downspout was severely rotted and had an approximate 3-inch by 12-inch hole in the soffit;
-Near the kitchen, a wooden trim and soffit board was severely rotted in an approximate 3-inch by 2-foot section.
During interviews on 5/21/24 at 7:51 A.M., 8:00 A.M., and 8:33 A.M., the maintenance director said the following:
-He had asked previous facility administrators about replacing the rotted trim and fascia boards on the exterior of the facility but was told it was not in the budget at that time;
-He was aware of the missing HVAC covers on the exterior of the building and had asked a previous administrator about replacing the covers but was told the units did not need covers;
-He was unaware why the cloth towel was in the HVAC unit of occupied resident room [ROOM NUMBER];
During an interview on 5/20/24 at 11:34 A.M., 11:41 A.M., and 3:21 P.M. and on 5/21/24 at 2:45 P.M., the maintenance director said the following:
-He put down a new section of flooring at the end of the A hall and failed to level it properly;
-He was waiting on new drywall to come from the facility's vendor so he could repair the damaged wall in the E hall spa room;
-The 6-foot by 6-foot damaged area of ceiling on the E hall was a result of a contractor stepping through the ceiling prior to him becoming maintenance director;
-If staff noticed items that needed repaired, he expected staff to fill out a work order and place it in the maintenance binder for him to address.
During an interview on 5/22/24 at 7:22 A.M., the housekeeping supervisor said staff cleaned the vents in the residents' rooms once a month but she was considering cleaning them more frequently such as once per week.
During an interview on 5/22/24 at 7:31 A.M., Housekeeping Aide U said the following:
-He/She cleaned the floors during the week (Monday through Friday);
-When he/she started employment at the facility, about a month ago, the buffer was broken;
-He/She had to delay stripping and buffing certain floors, such as bathrooms that had tight spaces, because he/she needed the buffing machine to complete the work.
During an interview on 5/22/24 at 9:33 A.M., the administrator said he expected equipment and items to be in safe condition and good working order.
CONCERN
(F)
Potential for Harm - no one hurt, but risky conditions existed
Deficiency F0678
(Tag F0678)
Could have caused harm · This affected most or all residents
**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on interview and record review, the facility failed to ensure systems were in place to clearly document residents' choice ...
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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 systems were in place to clearly document residents' choice for code status. The facility also failed to clearly communicate the choice of code status to direct care staff so staff knew immediately what actions to take in the event of an emergency for six residents (Residents #8, #9, #20, #59, #66 and #68), in a review of 24 sampled residents, for nine additional residents (Residents #1, #16, #18, #25, #32, #34, #45, #58 and #64), and for one closed record (Resident #71). This had the potential to result in a resident who wished to be full code status not receiving cardiopulmonary resuscitation (CPR) (an emergency lifesaving procedure performed when the heart stops beating) in the event of an emergency, or residents receiving CPR who wished to be a do-not-resuscitate (DNR) (when a person elects to not have CPR attempted on them if their heart or breathing stops). The facility failed to ensure a staff member with required CPR certification was scheduled for each shift. The facility failed to ensure staff had adequate training in CPR when the certification for seven staff did not meet the requirements for CPR certification for basic life support (BLS)/Healthcare providers with a hands on skills test. The facility census was 67.
The surveyors requested a facility policy regarding staff CPR certification, scheduling for CPR coverage and code status documentation and no received no policies.
During an interview on [DATE] at 11:10 A.M., the Director of Operations said the following:
-If the state agency requested any policy and one was not received, the facility did not have one;
-The facility did not have policies on CPR certification for staff or how staff are to identify a resident's code status.
1. Review of Resident #1's face sheet (located in the electronic health record in the computer), showed the following:
-He/She had a listed responsible party;
-No documentation of the resident's code status.
Review of the resident's care plan showed the following:
-Problem Start Date: [DATE];
-Category: Psychosocial Well-Being;
-In absence of written directives, the resident is a full code and the resident will have wishes followed;
-In case of no pulse and no respirations, start CPR and call 911;
-Review quarterly with resident, responsible party and with significant changes to ensure wishes remain the same.
Review of the resident's [DATE] Physician Order Sheet (POS) (located in the electronic health record in the computer) showed the resident had elected a full code status.
Review of the resident's paper chart showed the front page of the chart showed the resident was a full code.
Review of the facility 24-hour daily nursing report (a communication sheet for staff (typically the charge nurse) that gives a quick overview of the resident's care), dated [DATE], showed the resident was a DNR.
During an interview on [DATE] at 2:09 P.M., the resident's responsible party said he/she wanted the resident to be a full code.
(The resident's code status on the 24-hour daily nursing report was inconsistent with the resident's code status identified on his/her care plan, POS, and paper chart. The resident's face sheet did not identify his/her preferred code status.)
2. Review of Resident #8's face sheet showed the following:
-He/She had a listed responsible party;
-The resident elected a full code status.
Review of the resident's care plan showed the following:
-Problem Start Date: [DATE];
-The resident's code status is a full code;
-Staff will be aware of the resident's code status and honor his/her wishes;
-Code status will be reviewed quarterly and with a change of condition.
Review of the resident's paper chart showed the following:
-The front page of the chart showed the resident was a DNR;
-The chart contained an Emergency Medical Treatment & Labor Act (EMTALA), out-of-hospital DNR form. The resident signed the form on [DATE] and the resident's physician signed the form on [DATE].
Review of the resident's [DATE] POS showed the resident was a full code.
Review of the facility 24-hour daily nursing report, dated [DATE], showed the resident was a full code.
(The resident's code status on his/her face sheet, care plan, POS, and 24-hour daily nursing report was inconsistent with the resident's code status identified on his/her out-of-hospital DNR form.)
3. Review of Resident #18's face sheet showed the resident's code status was DNR. The resident had a Durable Power of Attorney (DPOA) for health care/responsible party.
Review of the resident's care plan, revised on [DATE], showed the resident's code status was DNR.
Review of the resident's [DATE] physician order sheet showed no order for code status.
Review of the resident's paper chart showed an EMTALA out-of-hospital physician signed DNR, purple sheet, in the medical record behind the red DNR sheet.
Review of the facility 24-hour daily nursing report sheet, dated [DATE], showed the resident was a full code.
During an interview on [DATE], at 9:51 A.M., the resident's responsible party said he/she would expect for all areas of the medical record to match and for a physician order to be present for the code status. The resident's code status was to be DNR.
(The resident's code status on the 24-hour daily nursing report was inconsistent with the resident's code status on his/her face sheet, care plan, and out-of-hospital DNR form. The resident did not have a code status identified on his/her physician orders.)
4. Review of Resident #20's face sheet showed the following:
-An admission date of [DATE];
-The resident elected a Do Not Resuscitate (DNR) code status.
Review of the resident's out-of-hospital DNR form, dated [DATE], printed on white paper in the resident's paper chart, showed the physician and the resident signed the form, indicating the resident's code status was DNR.
Review of the resident's [DATE] POS showed the resident was a full code.
Review of the resident's paper chart showed the the front page was red and said DNR in large letters.
Review of the 24-hour daily nursing report dated [DATE] showed the resident was a full code.
During interview on [DATE] at 10:23 A.M., the resident said he/she wished to be a DNR.
(The resident's code status on the 24-hour daily nursing report and physician's orders was inconsistent with the resident's preferred code status on his/her face sheet and out-of-hospital DNR form.)
5. Review of Resident #32's face sheet showed the following:
-The resident elected a DNR code status;
-He/She had a DPOA.
Review of the resident's care plan showed the following:
-Problem Start Date: [DATE];
-The resident had a DNR code status;
-No cardiopulmonary resuscitation/no 911 for cardiac arrest;
-Review quarterly and as needed to ensure the resident's wishes were as he/she chose.
Review of the resident's physician orders, dated [DATE], showed the resident had elected a full code status.
Review of the resident's paper chart showed the following:
-The front page of the chart showed the resident was a DNR;
-The chart had a signed out-of-hospital DNR form.
Review of the facility 24-hour daily nursing report, dated [DATE], showed the resident was a DNR.
(The resident's code status on the resident's physician orders was inconsistent with his/her code status on his/her face sheet, care plan, paper chart and the 24-hour daily nursing report.)
6. Review of Resident #34's face sheet showed the following:
-The resident was his/her own responsible party;
-The resident's code status was DNR.
Review of the resident's care plan, revised [DATE], showed a code status of full code.
Review of the resident's [DATE] physician order sheet showed an order for full code (dated [DATE]).
Review of the resident's paper chart showed an EMTALA out-of-hospital physician signed DNR, purple sheet, in the medical record behind the red DNR sheet.
Review of the facility 24-hour daily nursing report sheet, dated [DATE], showed the resident was a full code.
During an interview on [DATE] at 12:50 P.M., the resident said he/she wanted to be a DNR and understood what DNR status meant. He/She would expect his/her code status to be the same throughout his/her medical record.
(The resident's code status on the care plan, physician's orders and 24-hour daily nursing report was inconsistent with the resident's preferred code status on his/her face sheet and out-of-hospital DNR form.)
7. Review of Resident #45's face sheet showed the following:
-No documented code status;
-The resident was his/her own person.
Review of the resident's care plan, revised on [DATE], showed it did not include a code status for the resident.
Review of the resident's quarterly MDS, dated [DATE], showed the resident was cognitively intact.
Review of the resident's [DATE] POS showed no physician's order to address the resident's code status.
Review of the resident's paper chart showed no EMTALA out-of-hospital physician signed DNR purple sheet in the medical record behind the red DNR sheet.
Review of the facility 24-hour daily nursing report sheet, dated [DATE], showed the resident's code status was full code.
(The resident's medical record did not indicate the resident's code status.)
8. Review of Resident #58's face sheet showed the following:
-He/She had a legal guardian;
-He/She had elected a DNR code status.
Review of the resident's paper chart showed the following:
-The front page of the chart showed the resident was a DNR;
-The chart contained an out-of-hospital DNR form signed and dated [DATE].
Review of the resident's care plan showed the following:
-Problem Start Date: [DATE];
-Category: Psychosocial Well-Being:
-The resident chose to be a DNR and his/her wishes would be followed;
-No CPR/No 911 for cardiac arrest;
-Review quarterly and as needed to ensure the resident's wishes are as he/she chooses.
Review of the resident's May POS showed the resident was a DNR.
Review of the facility 24-hour daily nursing report, dated [DATE], showed the resident was a full code.
During an interview on [DATE] at 11:20 A.M., the resident's legal guardian said he/she and the resident would want the resident to be a DNR.
(The resident's code status on the 24-hour daily nursing report was inconsistent with the resident's preferred code status on his/her face sheet, out-of-hospital DNR form, care plan and POS.)
9. Review of Resident #59's face sheet showed the following:
-He/She had an emergency contact/POA;
-He/She elected a full code status.
Review of the resident's care plan showed the following:
-Problem Start Date: [DATE];
-Category: Psychosocial Well-Being:
-Resident chooses to be a full code;
-In case of no pulse and no respirations, start CPR and call 911;
-Review quarterly with resident and responsible party and with significant changes to ensure wishes remain the same.
Review of the resident's [DATE] POS showed the resident had an order for a full code.
Review of the resident's paper chart showed the front page of the chart showed the resident was a full code.
Review of the facility 24-hour daily nursing report, dated [DATE], showed the resident was a DNR.
During an interview on [DATE] at 3:00 P.M., the resident's POA said he/she wished for the resident to be a full code. That is what the resident had always told him/her.
(The resident's code status on the 24-hour daily nursing report was inconsistent with the resident's preferred code status on his/her face sheet, care plan, paper chart, and POS.)
10. Review of Resident #64's face sheet showed the following:
-He/She had a DPOA for health care;
-He/She had elected a DNR code status.
Review of the resident's paper chart showed the following:
-The front page of the chart showed the resident was a DNR;
-The chart contained an out-of-hospital DNR form on white paper; the form was signed and dated [DATE].
Review of the resident's care plan showed the following:
-Problem Start Date: [DATE];
-Category: Psychosocial Well-Being:
-The resident chose to be a DNR and his/her wishes would be followed;
-No CPR/No 911 for cardiac arrest;
-Review quarterly and as needed to ensure the resident's wishes are as he/she has chosen.
Review of the resident's [DATE] POS showed the resident was a DNR.
Review of the facility 24-hour daily nursing report, dated [DATE], showed the resident was a full code.
During an interview on [DATE] at 2:18 P.M., the resident's DPOA said the resident would want to be a DNR, but to ask the resident to confirm.
During an interview on [DATE] at 3:22 P.M., the resident said he/she would want to be a DNR.
(The resident's code status on the 24-hour daily nursing report was inconsistent with the resident's preferred code status on his/her face sheet, care plan, paper chart, and POS.)
11. Review of Resident #9's face sheet showed an advanced directive of DNR. The resident had a durable power of attorney for health care (DPOA/HC)/responsible party.
Review of the resident's care plan, revised on [DATE], showed an advanced directive of DNR.
Review of the resident's [DATE] POS showed a code status of DNR (original order dated [DATE]).
Review of the facility 24-hour daily nursing report sheet, dated [DATE], showed a code status of DNR.
Review of the resident's paper chart showed the first page of the chart was a red piece of paper that read DNR. The body of the chart showed no EMTALA, out-of-hospital physician signed DNR on purple paper.
During an interview on [DATE], at 3:23 P.M., the resident's DPOA/HC said he/she would expect the resident's chart to contain the purple EMTALA sheet for staff to review. The resident's code status was to be a DNR.
(The resident did not have a signed EMTALA form in his/her medical record.)
12. Review of Resident #16's face sheet on [DATE] at 10:07 A.M., showed no documentation of the resident's preferred code status, the resident has family as responsible party for accounts receivable. The face sheet did not indicate if the resident is his/her own party for health care decisions.
Review of the resident's quarterly MDS, dated [DATE], showed the resident was cognitively intact.
Review of the resident's care plan, revised on [DATE], showed the resident's code status was DNR.
Review of the resident's [DATE] POS showed no physician's order to address the resident's code status.
Review of the resident's paper chart showed the first page of the chart was a red page with the word DNR. The body of the chart contained no physician signed EMTALA out-of-hospital form on purple purple paper.
Review of the facility 24-hour daily nursing report sheet, dated [DATE], showed code status of DNR.
During an interview on [DATE], at 10:00 A.M., the resident said he/she did not want CPR in the event his/her heart stops or he/she stops breathing.
(The resident did not have a physician ordered code status or a signed EMTALA form in his/her medical record.)
13. Review of Resident #25's face sheet showed the following:
-He/She had a responsible party;
-He/She had elected a DNR code status.
Review of the resident's care plan showed the following:
-Problem Start Date: [DATE];
-Category: Psychosocial Well-Being;
-The resident has a DNR code status;
-Staff will be aware of and follow the resident's wishes;
-Do not call 911;
-Review quarterly and as needed to ensure patients wishes are as he/she chooses.
Review of the resident's [DATE] POS showed no code status listed for the resident.
Review of the resident's paper chart showed the following:
-The front page of the chart showed the resident was a DNR;
-The chart contained a purple, out of hospital DNR form. The form had not been signed by the resident or physician.
Review of the 24-hour daily nursing report, dated [DATE], showed the resident was a DNR.
(The resident did not have a physician ordered code status or a signed EMTALA form in his/her medical record.)
14. Review of Resident #66's face sheet showed the following:
-He/She was his/her own responsible party;
-He/She had elected a DNR code status.
Review of the resident's care plan showed the following:
-Problem Start Date: [DATE];
-Category: Psychosocial Well-Being;
-The resident chose to be a DNR and his/her wishes would be followed;
-No CPR/No 911 for cardiac arrest;
-Review quarterly and as needed to ensure patients wishes are as he/she chooses.
Review of the resident's [DATE] POS showed no code status listed for the resident.
Review of the resident's paper chart showed the following:
-The front page of the chart showed the resident was a DNR;
-The chart contained a purple, out-of-hospital DNR form, dated and signed [DATE] by the resident and physician.
Review of the facility 24-hour daily nursing report, dated [DATE], showed the resident was a DNR.
During an interview on [DATE] at 3:30 P.M., the resident said he would want to be a DNR in the event of an emergency.
(The resident did not have a physician ordered code status.)
15. Review of Resident #68's face sheet showed the following:
-An advanced directive of DNR;
-The resident has a DPOA for health care/responsible party.
Review of the resident's [DATE] POS showed no code status listed for the resident.
Review of the resident's care plan, revised on [DATE], showed an advanced directive of DNR.
Review of the resident's paper chart showed an EMTALA out-of-hospital physician signed DNR purple sheet in the medical record behind the red DNR sheet.
Review of the facility 24-hour daily nursing report sheet, dated [DATE], showed a code status of DNR.
During an interview on [DATE], at 3:36 P.M., the resident's DPOA for health care said he/she would expect the resident's medical chart to have a physician order code status. The resident's code status was to be a DNR.
(The resident did not have a physician ordered code status.)
16. Review of Resident #71's medical record showed the the resident was admitted to the facility on [DATE] with a diagnosis of lung cancer, hospice care and comfort measures only with an order from the discharging hospital for DNR, No CPR, no shock, dated [DATE], DNR with comfort measures only.
Review of the resident's admission agreement showed an outside-the-hospital DNR order, dated [DATE] and signed by the resident. The form was not signed by the physician.
Review of the resident's face sheet showed the resident was a full code.
Review of the resident's [DATE] POS showed a physician ordered code status of DNR.
Review of the resident's baseline care plan, dated [DATE], showed the resident was a full code.
(The resident's code status on the face sheet and baseline care plan was inconsistent with the resident's code status on his/her hospital discharge orders, POS, and out-of-hospital DNR form.)
17. Review of the facility staffing sheets showed day shift, 8 hour shifts, were from 6:00 A.M.-2:30 P.M., 8 hour evening shifts from 2:30 P.M. to 10:30 P.M., and 8 hour night shift from 10:30 P.M. to 6:00 A.M.; 12 hour day shifts were from 6:00 A.M., to 6:00 P.M., and night shift 12 hour shifts are from 6:00 P.M. to 6:00 A.M. The staffing sheets did not indicate which staff members were CPR certified or who should respond to an emergency cardiac or respiratory event.
The facility provided a list of agency staff names and CPR certification cards that had worked since February 2024. The facility used agency nurses and had no full time nurse. Of the 56 CPR cards reviewed, 27 could be confirmed valid CPR for BLS/Healthcare providers, with hands on skills test. There were seven cards that did not meet the requirements for CPR certification for BLS/Healthcare providers with a hands on skills test. The staffing sheets were compared with the employees that had valid CPR certifications.
The seven CPR cards that were invalid included the following staff members, agency staff GG, agency staff HH, agency staff II, agency staff JJ, agency staff KK, agency staff LL and agency LPN R.
During an interview on [DATE] at 10:22 A.M., the Director of Nursing said the facility had residents that elected a full code status; she just was not sure how many were full code and how many were DNR.
Review of the facility staffing sheets, dated [DATE]-[DATE], showed the following shifts without a staff member with required CPR certification:
-[DATE] , evening and night shift;
-[DATE], day shift;
-[DATE], evening shift;
-[DATE], night shift;
-[DATE], evening and night shift.
Review of the facility staffing sheets, dated [DATE]-[DATE], showed the following shifts without a staff member with required CPR certification:
-[DATE], evening and night shift;
-[DATE], evening and night shift;
-[DATE], no certified staff from 6:00 P.M. on the evening shift and on the night shift;
-[DATE], no certified staff from 6:00 P.M. on the evening shift and on the night shift;
-[DATE], no certified staff from 6:00 P.M. on the evening shift and on the night shift;
-[DATE], no certified staff from 6:00 P.M. on the evening shift and on the night shift;
-[DATE], no certified staff from 2:30 P.M. to 6:00 P.M. on the evening shift;
-[DATE], evening shift;
-[DATE], evening shift;
-[DATE], no certified staff from 2:30 P.M. to 6:00 P.M. on the evening shift;
-[DATE], no certified staff from 6:00 P.M. on the evening shift and on the night shift;
-[DATE], no certified staff from 6:00 P.M. on the evening shift and on the night shift.
Review of the facility staffing sheets, dated [DATE]-[DATE], showed the following shifts without a staff member with required CPR certification:
-[DATE], night shift;
-[DATE], evening shift;
-[DATE], evening shift;
-[DATE], evening and night shift;
-[DATE], evening shift;
-[DATE],night shift.
During an interview on [DATE] at 8:44 A.M., Certified Nurse Assistant (CNA) G said the following:
-He/She was CPR certified;
-In the event he/she found someone unresponsive and not breathing, he/she would have to check the computer or hard (paper) chart or ask the nurse for the resident's code status;
-If he/she saw (in documentation) or was told the resident's code status was a full code, he/she would start CPR;
-If he/she saw (in documentation) or was told the resident's code status was a DNR, he/she would not start CPR.
During interview on [DATE] at 11:09 A.M., CNA C said the following:
-A resident had a red paper in the front of his/her paper chart if he/she was a DNR.
-A resident had a green paper in the front of his/her paper chart if he/she was a Full Code.
During an interview on [DATE] at 8:51 A.M., Certified Medication Technician (CMT) M said the following:
-He/She was not CPR certified;
-In the event he/she found someone unresponsive and not breathing, he/she would yell for the nurse to help;
-If he/she was ever asked to confirm a resident's code status, he/she would check the resident's face sheet for the information.
During an interview on [DATE] at 8:46 A.M., Licensed Practical Nurse (LPN) N said the following:
-He/She was CPR certified;
-In the event he/she found someone unresponsive and not breathing, he/she would check the 24-hour daily nursing report, because he/she always carried it with him/her and it would be faster than checking the computer to confirm a resident's code status;
-If he/she saw the resident's code status was a full code, he/she would start CPR;
-If he/she saw (in documentation) the resident's code status was a DNR, he/she would not start CPR;
-At the beginning of his/her shift, he/she always checked the 24-hour daily nursing report against the resident's face sheet to make sure they matched;
-He/She had not found any discrepancies in the residents he/she was responsible for today; he/she was responsible for residents on D and E halls. (Residents #1, #8, #35, #58, #59, #64, and #66 resided on the D hall and had inconsistent documentation of their code status in their medical records.)
During an interview on [DATE] at 3:30 P.M., the Social Service Director (SSD) said he/she took over staffing and scheduling for the nursing department recently. She made sure the agency software said the staff were CPR certified before she scheduled those staff, but does not look at their certification to ensure it meets requirements on hands on skills test or BLS/for healthcare providers.
During interviews on [DATE] at 1:31 P.M. and [DATE] at 10:00 A.M. and 6:49 P.M., the Director of Nursing (DON) said the following:
-The staff should look in the paper chart for a red or green paper and a purple sheet for a DNR to determine a resident's code status;
-She expected staff to look on the purple Out of Hospital DNR EMTALA form for the resident's code status first, then the resident's face sheet;
-All residents were to have a code status on their POS;
-If there was no physician ordered code status, that could mean the resident was a full code;
-The admitting nurse was responsible for obtaining the resident's code status on admission;
-The resident's code status should be consistent throughout the electronic medical record and paper chart;
-She did not expect staff to follow the report sheet (24-hour daily nursing report) because it was not accurate;
-The report sheets was something the staff do; they are not reconciled or checked by anyone for accuracy. Since the facility has all agency nurses, the 24-hour daily nursing report was not always correct; she wouldn't trust the report sheet;
-If there was no purple sheet in the hard chart, she considered the resident's code status to be full code;
-She refers to the purple Out of Hospital DNR EMTALA form in the hard chart; the resident would be a Full Code status and would receive CPR if there was no purple out of hospital EMTALA form;
-The facility does not identify which staff are CPR certified on the staffing sheets;
-All agency nurses are required to be properly CPR certified, which would include the hands on portion of the training;
-She did not know if agency CPR certifications met regulatory requirements;
-The facility did not verify credentials with the agency, it (agency report) just says they have CPR certification; the facility would have to go in (the agency computer system) to review their credentials to see their CPR certification;
-She did not know some of the CPR certifications may not meet regulatory requirements.
CONCERN
(F)
Potential for Harm - no one hurt, but risky conditions existed
Deficiency F0680
(Tag F0680)
Could have caused harm · This affected most or all residents
Based on interview and record review, the facility failed to employee a qualified activity professional to oversee the activity program for the facility. The facility employed an activity director but...
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Based on interview and record review, the facility failed to employee a qualified activity professional to oversee the activity program for the facility. The facility employed an activity director but she has not completed an approved activity professional training program. This practice affected all residents in the facility. The facility census was 67.
Request was made for the activity director job title responsibilities and qualifications and none were provided. The facility provided a job description for an assistant activity director.
Review of the employee list with job titles, showed the activity director department head was the activity director.
1. Review of the Activities Director's employee file on 5/22/24, showed no current certification in therapeutic recreation or activities professional. The employee also did not have a state certification.
During an interview on 5/23/24 at 11:20 A.M., the Activity Director said the following:
-She has not had any activities training;
-She does activities half of the time and transportation for the residents the other half of her time;
-There was no one else in the activity department and no one else assisted her with activities;
-She did not have an activity director for a resource person available to her;
-She did not know what kind of activities were appropriate for residents with dementia.
During an interview on 5/23/24 at 6:49 P.M., the Director of Nursing said the administrator was responsible to ensure the staff have their certifications.
During an interview on 5/23/24, at 2:45 P.M., the Administrator said he would expect the Activity Director to be certified by the state certification. If the Activity Director was not supervised, he would expect a certified Activity Director to train, oversee and be a resource until she was certified. He had not been at the facility long enough to know everyone's certifications, he did not know if the facility Activity Director was certified or not.
CONCERN
(F)
Potential for Harm - no one hurt, but risky conditions existed
Deficiency F0725
(Tag F0725)
Could have caused harm · This affected most or all residents
**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, interview and record review, the facility failed to provide sufficient nursing staff to meet residents' ne...
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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 sufficient nursing staff to meet residents' needs for one resident (Resident #41) in a review of 24 sampled residents and for one additional resident (Resident #61). Staff failed to provide routine showers to ensure good personal hygiene and prevent body odors for Resident #61, failed to respond timely to call lights, and failed to provide restorative therapy when the restorative aide (RA) no longer worked at the facility for Resident #28 and #41. The facility did not have a Registered Nurse (RN) eight consecutive hours a day seven days a week. The facility did not consistently have nursing staff as identified in the facility assessment, or provide the education, training, and competencies as identified in the facility assessment. The facility census was 67.
Review of the Facility Assessment, revised 5/20/24, showed the following:
-Nursing Services, hours per day based on average census:
-Director of Nursing (DON) eight hours a day for 40 hours per week;
-Minimum Data Set (MDS) Coordinator eight hours a day for 40 hours per week;
-Nurse Educator eight hours a day for 40 hours per week;
-Medical Records eight hours per day;
-RN eight hours per day;
-Licensed Practical Nurse (LPN) 24 hours per day;
-Certified Medication Technician (CMT) 16 hours per day;
-Certified Nurse Assistant (CNA) 75 hours per day (10 CNA's between all shifts working 7.5 hr shifts).
1. Review of minutes of a resident council meeting, on 5/21/24 at 2:26 P.M., showed the following:
-Resident #48 said he/she had a roommate that was not getting changed (provided incontinent care) or attention in a timely fashion. The facility still had times when there was an agency staff they were not familiar with;
-Resident #41 and #39 said agency staff do not pass medications on time. Resident #39 said he/she didn't get his/her pain pill until late yesterday, then couldn't get his/her afternoon pain pill as a result;
-Resident #41 said sometimes they have to wait an hour for help.
2. Review of Resident #61's admission MDS, dated [DATE], showed the following:
-Cognitively intact;
-Uses walker and wheelchair;
-Requires supervision or touching assistance from staff to shower/bathe, for lower body dressing and personal hygiene;
-Requires partial or moderate assistance from staff for tub/shower transfers.
Review of the resident's care plan, dated 3/15/24, showed the following:
-Activities of Daily Living (ADLs) Functional Status/Rehabilitation Potential:
-Self care deficit in ADLs related to debilitation/weakness, physical discomfort from significant ascites (build up of fluid in the abdomen), episodes of shortness of breath and supervision to partial assist depending on his/her physical feeling at the time;
-Resident will have assistance with his/her ADLs as needed during periods of weakness/fatigue;
-Encourage the resident to allow staff to perform tasks that may require bending at the waist to reduce pressure/pain to abdomen;
-Allow resident to make decisions about his/her care.
Review of the resident's facility shower sheets, for the month of April 2024, showed staff documented assisting the resident with showering on the following days:
-On 4/10/24 (first one documented for April);
-On 4/16/24 (six days since last shower);
-On 4/26/24 (10 days since last shower);
-On 4/29/24.
Review of the resident's facility shower sheets, for the month of May 2024, showed staff documented assisting the resident with showering on the following days:
-On 5/2/24;
-On 5/9/24 (seven days since last shower/bath).
Observation on 5/19/24 at 4:16 P.M., showed the following:
-The resident in his/her room in his/her wheelchair;
-The resident had long facial hair on his/her chin and body odor.
During an interview on 5/19/24 at 4:16 P.M., the resident said the following:
-The resident often goes a week without a shower/bath;
-He/She would like at least two showers a week.
-He/She does not want whiskers on his/her chin, but they are long because the facility only trims his/her facial hair during baths and he/she has not had on this week;
-The facility was often short staffed;
-He/She has asked for his/her sheets to be changed, but it has been weeks because there weren't enough staff to do those kinds of things.
The resident did not have a documented shower or bath for 10 days prior, from the record review to the observation and interview.
3. During an interview on 5/19/24 at 4:19 P.M., Resident # 26 said when there was not enough staff, it took 30 minutes to one hour to answer his/her light and that happened frequently.
4. During an interview on 5/20/24 at 10:52 A.M., Resident #52's responsible party said the following:
-He/She was at the facility four to five days a week, sometimes three times a day;
-There are not enough activities for dementia residents;
-No one does activities with the dementia residents;
-There were no activities for any residents on the weekend except what the residents do themselves;
-When he/she visits, he/she sees lights on and no one answers them sometimes.
5. During an interview on 5/21/24 at 6:15 A.M., CNA W said the residents are expected to be assisted with showers on shower days, but sometimes there was not enough staff because staff called in or did not show up for work.
6. Review of Resident #41's face sheet showed his/her diagnoses included chronic kidney disease, non-pressure chronic ulcer of skin of other sites limited to breakdown of skin, cellulitis (infection) of right lower limb, cellulitis of left lower limb, complete traumatic amputation (removal) of the leg at level between knee and ankle of the right lower leg and diabetes mellitus (inability to regulate blood sugar) with diabetic neuropathy (nerve disease cause numbness and or weakness).
Review of the resident's physician orders, dated 3/6/23, showed restorative plan of care for bilateral upper extremity and lower extremity strengthening as tolerated and sit to stand at grab bar or parallel bar to maintain modified independence for transfers.
Review of the resident's annual MDS, dated [DATE], showed the following:
-Cognitively intact;
-Independent with eating and oral hygiene;
-Requires partial/moderate assistance from staff for upper body dressing;
-Requires substantial/maximal assistance from staff to shower/bathe, to go from sitting to lying flat and lying to sitting on the side of the bed;
-Dependent on staff for toilet hygiene, lower body dressing and footwear, to roll left and right and to transfer;
-Wheelchair use;
-No impairments to range of motion;
-No restorative nursing minutes.
Review of the resident's Nursing-Restorative Program Referral, dated 11/14/23, showed the following:
-Goal: Maintain upper body and lower body strength;
-Restorative Nursing two times weekly;
-Upper body strength with approximately six pound (lbs.) resistance;
-Lower body strength with moderate resistance;
-Precaution: watch skin integrity on legs.
Review of the resident's quarterly MDS, dated [DATE], showed functional limitation in range of motion to one lower extremity. No restorative nursing minutes.
Review of the resident's medical record showed not evidence staff completed restorative nursing.
During an interview on 5/19/24 at 4:48 P.M., the resident said there was not enough staff to give him/her a bath. He/She would like two baths a week. He/She rarely got one bath and never gets two baths.
During an interview on 5/22/24, at 2:04 P.M., the resident said he/she would like restorative nursing but the facility did not had the staff to do restorative nursing.
During an interview on 05/23/24 at 1:35 P.M., the therapy director said the following:
-She was the director at the facility since late February;
-When she first started, there was a RA for the restorative program;
-The RA quit not to long after she started at the facility (late February) and there was currently no restorative program;
-The Director of Nursing (DON) discharged everyone from the RA program due to no current RA.
7. Review of the facility's RN payroll and RN agency staffing sheets, dated March 2024, showed the facility did not have evidence of any RN hours on 3/4/24, 3/9/24, 3/10/24, and 3/31/24.
Review of the facility's RN payroll and RN agency staffing sheets, dated April 2024, showed the facility did not have evidence of any RN hours on 4/19/24, and only had 6.75 hours (did not fulfill the eight hour requirement) on 4/5/24.
Review of the facility's RN payroll and RN agency staffing sheets, dated May 2024, showed the facility did not have evidence of any RN hours on 5/18/24.
8. During the survey entrance conference on 5/19/24, the state agency (SA) requested staffing sheets for the prior month. The facility had to research agency staff and payroll data to accurately complete the staffing sheets for review to show which staff accurately worked. The SA did not receive the staffing sheets until 5/22/23.
During an interview on 5/21/24 at 8:25 A.M., the SSD said she took over staffing several weeks ago to help out. She did not know who or how they did staffing prior to that. She over schedules agency staff and they send home who they don't need because often agency staff do not show up to work.
During an interview on 05/23/24 at 6:49 P.M., the DON said the following:
-The facility does not have any full time licensed nurses besides her. The facility used agency staff for the licensed nurses;
-The facility currently did not have a restorative nursing program due to no trained restorative aide being available for the program;
-The RA quit, and when he/she quit, all of the residents who were on the restorative nursing program, were discontinued from the program;
-She was the only full time RN at the facility. The facility utilized agency RNs for the weekends, except for a couple of weekends that she worked. For the recent shifts that the facility had not had RN coverage, it was because the Agency RNs had not shown up
During an interview on 6/25/24 at 8:59 A.M., the Administrator said the restorative aide was terminated on 3/19/24. He expected the facility to staff according to the facility assessment and to meet resident needs.
CONCERN
(F)
Potential for Harm - no one hurt, but risky conditions existed
Deficiency F0726
(Tag F0726)
Could have caused harm · This affected most or all residents
Based on interview and record review, the facility failed to provide education, test, and return demonstrations, as identified by the facility on the facility assessment, to ensure competent staff. Th...
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Based on interview and record review, the facility failed to provide education, test, and return demonstrations, as identified by the facility on the facility assessment, to ensure competent staff. The facility census was 67.
Review of the Facility Assessment, updated 5/20/24, showed the following staff education and competencies will be shown with each area below:
-Activities of daily living: Bathing, showers, oral/denture care, dressing, eating, support with needs related to hearing/vision/sensory impairment; supporting resident independence in doing as much of these activities by himself/herself. All Certified Nurse Assistant (CNA), Certified Medication Technician (CMT), Licensed Practical Nurse (LPN) and Registered Nurses (RN) will do a return demonstration to observe their ability;
-Mobility and fall/fall with injury prevention: Transfers, ambulation, restorative nursing, contracture prevention/care; supporting resident independence in doing as much of these activities by himself/herself. All CNA, CMT, LPN and RN's will do a return demonstration to observe their ability;
-Bowel/bladder toileting programs, incontinence prevention and care, intermittent or indwelling or other urinary catheter, ostomy, responding to requests for assistance to the bathroom/toilet promptly in order to maintain continence and promote resident dignity. All CNA, CMT, LPN and RN's will do a return demonstration to observe their ability;
-Skin integrity: Pressure injury prevention and care, skin care, wound care (surgical, other skin wounds). All CNA, CMT, LPN and RN's will do a return demonstration to observe their ability;
-Mental health and behavior: Manage the medical conditions and medication-related issues causing psychiatric symptoms and behavior, identify and implement interventions to help support individuals with issues such as dealing with anxiety, care of someone with cognitive impairment, care of individuals with depression, trauma/post traumatic stress disorder (PTSD) (mental and behavioral disorder that develops from experiencing a traumatic event), other psychiatric diagnoses, intellectual or developmental disabilities. All CNA, CMT, LPN and RNs will do in-servicing and performance reviews;
-Medications and Pain management: Awareness of any limitations of administering medications, administration of medications that residents need by route: oral, nasal, buccal, sublingual, topical, subcutaneous, rectal, intravenous (peripheral or central lines), intramuscular, inhaled (nebulizer), vaginal, ophthalmic (eye), etc. Assessment/management of polypharmacy. Assessment of pain, pharmacological and nonpharmacological pain management. All CMT, LPN and RNs will have ability observed and LPN/RN will have performance review;
-Infection prevention and control: Identification and containment of infections and prevention. All CNA, CMT, LPN and RNs will do education and a return demonstration to observe their ability;
-Management of medical conditions: Assessment, early identification of problems/deterioration, management of medical and psychiatric symptoms and conditions such as heart failure, diabetes, chronic obstructive pulmonary disease (COPD) (lung disorder), gastroenteritis (intestinal infection) , infections such as urinary tract infection (UTI), pneumonia and hypothyroidism. LPN and RNs will do a performance review;
-Therapy: physical therapy, occupational therapy, speech/language, respiratory therapy, management of braces, splints. All CNA, CMT, LPN and RNs will do a return demonstration to observe their ability;
-Other special care needs: Dialysis, hospice, ostomy care and tracheostomy care. All CNA, CMT, LPN and RNs will do a return demonstration to observe their ability;
-Nutrition: Individualized dietary requirements, liberal diets, specialized diets, IV nutrition, tube feeding, cultural or ethnic dietary needs, assistive devices, fluid monitoring or restrictions. All dietary service staff, CNA, CMT, LPN and RNs will do a return demonstration to observe their ability;
-Provide person centered/directed care: Psycho/social/spiritual support: Build relationship with resident/get to know him/her; engage resident in conversation, find out what resident's preferences and routines are; what makes a good day for the resident; what upsets him/her. ALL staff performance review and observed ability;
-Facility conducts monthly in-service meetings with staff. Competency assessments, performance reviews and observed abilities are also completed. Training is conducted based from the assessments and observation results.
1. Review of CNA C's employee education file showed the employee was hired 12/5/17. The employee education file did not contain any evidence of education hours or competencies in the last year. (The only training documented was new hire training, dated 12/5/17, and did not contain any competencies).
2. Review of CNA PP's employee education file showed the employee was hired 4/17/23. The employee education file did not contain any evidence of education hours or competencies in the last year. (The only training documented was new hire training, dated 4/17/23, and did not contain any competencies).
During an interview on 5/21/24 at 8:10 A.M., the Interim Director of Nursing said the the Social Service Director (SSD) tracks the NA and CNA training hours and competencies. She did not know if the facility had any other official training schedule at this time.
During an interview on 5/21/24 at 8:25 A.M., the SSD said the following:
-She no longer kept track of CNA or NA training;
-Registered Nurse (RN) Training Coordinator/Minimum Data Set (MDS) Coordinator does all of the CNA training and competencies.
During an interview on 5/21/24 at 1:51 P.M., the RN Training Coordinator/MDS Coordinator said the following:
-She does not do any CNA education or CNA competencies;
-She does not do annual training or competencies for staff except the uncertified nurse assistants.
During an interview on 5/22/24 at 3:16 P.M., the Business Office Manger (BOM) confirmed the CNA's hire dates and provided a copy of their training record. She does not have any other training information.
During an interview on 5/23/24 at 6:49 P.M., the Interim Director of Nursing said the following:
-The facility was trying to implement a computer software training system but it had not been accomplished yet;
-There was no training schedule;
-When she was at the facility earlier in the year, she did do observations of staff using gait belts for transfers;
-The facility was documenting when training was completed, but there have been changes to nursing administration since then and she is not sure where the documentation would be or if any of the current staff attended.
-She does not know if there were any documented competencies, if there were she could not locate them.
CONCERN
(F)
Potential for Harm - no one hurt, but risky conditions existed
Deficiency F0727
(Tag F0727)
Could have caused harm · This affected most or all residents
Based on interview and record review, the facility failed to provide the services of a Registered Nurse (RN) for at least eight consecutive hours a day, seven days a week. This had the potential to af...
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Based on interview and record review, the facility failed to provide the services of a Registered Nurse (RN) for at least eight consecutive hours a day, seven days a week. This had the potential to affect all residents. The facility census was 67.
Review of the facility assessment, updated 5/20/24, showed the facility resources needed to provide competent support and care for the resident population, every day and during emergencies, included RN coverage eight hours per day.
Review of the facility's RN payroll and RN agency staffing sheets, dated March 2024, showed the facility did not have evidence of any RN hours on 3/4/24, 3/9/24, 3/10/24, and 3/31/24.
Review of the facility's RN payroll and RN agency staffing sheets, dated April 2024, showed the facility did not have evidence of any RN hours on 4/19/24, and only had 6.75 hours (did not fulfill the eight hour requirement) on 4/5/24.
Review of the facility's RN payroll and RN agency staffing sheets, dated May 2024, showed the facility did not have evidence of any RN hours on 5/18/24.
During an interview on 5/21/24 at 8:10 A.M., the interim Director of Nursing said she was the only full time RN at the facility. The facility utilized agency RNs for the weekends, except for a couple of weekends that she worked. For the recent shift that the facility had not had RN coverage, it was because the Agency RNs had not shown up.
CONCERN
(F)
Potential for Harm - no one hurt, but risky conditions existed
Deficiency F0801
(Tag F0801)
Could have caused harm · This affected most or all residents
Based on interview and record review, the facility failed to ensure the Dietary Manager (DM) had the appropriate competencies and skills set to carry out the function of the food and nutrition service...
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Based on interview and record review, the facility failed to ensure the Dietary Manager (DM) had the appropriate competencies and skills set to carry out the function of the food and nutrition services. This practice effected all residents in a facility. The facility census was 67.
Review of the facility job description, titled Dietary Manager, dated May 2006, showed the minimum qualifications and education for the position included the completion of an approved Certified Dietary Managers Course.
Review of the employee list with job titles, showed the dining services department head was the dietary manager.
1. Review of the dietary manager's employee file on 5/23/24, showed the following:
-Date of hire was 1/23/23;
-No certification showing the DM was a certified dietary manager (a federal requirement for long-term care facilities);
-No certification showing the DM was a certified food service manager;
-No certification showing the DM had a national certification for food service management;
-No documentation of an associate's or higher degree in food service management or in hospitality;
-No documentation to show the DM had two or more years of experience in the position of director of food and nutrition services in a nursing facility setting;
-State Food Safety Food Protection Manager Certification certification, which allows food service managers to get certified to provide safe food in their establishments (this certification does not meet the dietary manager certification requirements).
During an interview on 6/27/24 at 8:50 A.M., the Dietary Manager said the following:
-She had been employeed as the Dietary Manager since September 2023;
-The facility had not provided any training related to the Dietary Manager position; she had just attended a food safe course;
-She had not received an associate's or higher degree in food service management or in hospitality.
During an interview on 5/23/24 at 11:59 A.M., the Registered Dietitian said the following:
-She comes to the facility monthly;
-The dietary manager said as far as she knew, the dietary manager was not certified.
During an interview on 5/23/24 at 6:49 P.M., the Director of Nursing said the following:
-The dietary manager does not have a Certified Dietary Manager (CDM) certification;
-The administrator was responsible to ensure the staff have their certifications.
During an interview on 5/23/24, at 2:45 P.M., the Administrator said he would expect the Dietary Manager to be certified as required. If the Dietary Manager was not supervised, he would expect a certified Dietary Manager or Dietitian to train, oversee and be a resource until she was certified. He has not been at the facility long enough to know everyone's certifications, he does not know if she is certified or not.
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, prepare, and serve food under sanitary conditions in accordance with professional standards for food service safety. S...
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Based on observation, interview, and record review, the facility failed to store, prepare, and serve food under sanitary conditions in accordance with professional standards for food service safety. Staff failed to label and date, opened food items. Staff failed to store food items off the floor. Staff failed to properly clean the ice machine and ensure an air gap was present at each ice machine drain. Staff failed to ensure food service equipment and surfaces were appropriately cleaned. Staff failed to follow proper hygienic practices when preparing and serving food to residents, including using hair restraints appropriately, and hand hygiene technique. The facility census was 67.
1. Review of the dietary service manual dated April 2006, Food Storage Guidelines showed the following:
-Dietary employees will follow safe food handling guidelines to prevent the spread of foodborne illness;
-All food, including bulk items, should be tightly sealed with an identifying label and date.
Observation on 5/20/24 at 4:28 P.M., in the kitchen refrigerator unit one, showed the following:
-Three ham and cheese sandwiches in plastic bags were not labeled and dated;
-Two bowls of pudding covered with plastic were not labeled and dated;
-One chicken salad sandwich in a plastic bag was not labeled and dated.
During an interview on 5/21/24 at 1:39 P.M., Dietary [NAME] H said the following:
-Items placed in the refrigerators and freezers should be labeled and dated;
-He/She was behind on checking items in the refrigerators and freezers for labeling and dating;
-All kitchen staff were to check for labeling and dating of items in the refrigerators and freezers.
2. Review of the facility policy, Ice Maker, dated April 2006, showed the following:
-Run ice scoop through dish machine daily and replace in plastic container;
-The outside of the machine will be cleaned weekly;
-Monthly, wash inside of machine thoroughly with warm detergent solution, rinse with baking soda water and dry, wash outside with soft brush or cloth and dry, machine is to be free of extraneous material, except for properly stored ice scoop.
Observation on 5/20/24 at 9:59 A.M., in the ice machine room, showed the following:
-The wall mounted ice scoop holder had a white scaly material in the bottom, and an ice scoop in the holder was in contact with the material;
-A white scaly material was on the outside of the ice machine door and on the right hinge;
-A yellowish slime substance was across the interior surface of the ice tray dump system;
-The upper exterior drain tube inserted into a 1.5-inch wall mounted drain pipe had no air gap.
During an interview on 5/21/24 at 4:20 P.M., the Maintenance Director said the following:
-He expected the ice machine to have an appropriate air gap at the drain;
-He was responsible for ensuring a proper drain air gap, and was unaware the ice machine did not contain an air gap;
-Dietary staff was responsible for cleaning and sanitizing the ice machine, and he was responsible for checking the interior section of the ice machine for biofilm and ensuring dietary staff cleaned the machine;
-He expected the ice machine to be cleaned monthly and have a deep cleaning performed annually.
3. Review of the facility policy, Cleaning Schedules, dated April 2006, showed the following:
-It is the responsibility of the Dietary Service Manager to enforce the cleaning schedules and to monitor the completion of assigned cleaning tasks;
-Daily, weekly, and monthly cleaning schedules prepared by the Dietary Service Manager with all cleaning tasks listed will be posted in the Dietary Department;
-Specify the day(s) the cleaning schedule will be done, specify who is responsible to do the cleaning by shift and position, post the schedule prior to the beginning of each week, the employee will initial in the column under the day the task is completed.
Observation on 5/20/24 at 10:05 A.M., in the kitchen, showed the following:
-Each compartment in the five-compartment steam table contained slime and debris in 1-inch of water;
-The exterior and interior surfaces of the sneeze guard were coated with oil, debris, and dried food runs;
-Food debris and liquid run marks were on the outside metal surface.
Observation on 5/20/24 at 10:11 A.M., in the kitchen, showed the following:
-Dust, debris, and an oily material were on the exterior of the kitchen hood and the fire suppression system control panel;
-Dust, debris and an oily material were on the interior of the hood, fire suppression piping manifold, and four suppression nozzles;
-Three filters/baffles had a moderate buildup of oily material.
Observation on 5/20/24 at 10:13 A.M., in the kitchen, showed the following:
-The burners on the six-burner stove top were covered with black carbon buildup, oily material and food/debris;
-Oily material, food splatters and run marks were on the metal back splash behind the stove top and griddle;
-Oily material, food and debris were on the metal splash guard on the right side of the griddle;
-The deep fryer had a buildup of oily material, food, debris and brown stains;
-A yellowish brown debris was on the wall behind the stovetop, griddle, and deep fryer.
Observation on 5/20/24 at 10:20 A.M., in the kitchen, showed the following:
-The top of the toaster oven was covered with brown/black material and there were food crumbs underneath the unit;
-The metal electrical box and conduit mounted on the wall above the toaster oven had a buildup of oil, dust and debris;
-Dust and debris were on the wall-mounted emergency light located above the toaster oven/microwave;
-Oily material, dust and debris were on the wall-mounted magnetic knife holder;
-Dried food splatters were on the interior surface of the microwave and food crumbs were underneath the unit;
-Food splatters were on the wall behind the toaster oven and microwave from the right side of kitchen hood to the corner of the unit one refrigerator;
-The stainless-steel countertop and the lower shelf had a buildup of food debris;
-The stainless-steel countertop with the food processor had oily material, dust, and debris on the lower shelf.
Observation on 5/20/24 at 10:25 A.M., in the kitchen, showed the following:
-A moderate covering of dust and debris was on the square ceiling vent located in the corner between the two-compartment sink and the unit one refrigerator;
-A black material, dust and debris were on three round ceiling vents located above the food preparation table, steam table, and serving table;
-A black material, dust, and debris were on four round ceiling vents in the Dietary Manager's office area and the dishwasher area.
Observation on 5/20/24 at 10:35 A.M., in the kitchen, showed the following:
-An oil/grease material and spill stains were on the exterior surfaces of the flour and sugar bins;
-An oil/grease material and spill stains were on the exterior surface of the oatmeal bin.
Observation on 5/20/24 at 10:45 A.M., in the kitchen and dishwasher areas, showed the following:
-The ceilings had a yellow discoloration, dust/debris, and peeling paint;
-The walls had a yellow discoloration, dust/debris, and food splattering;
-The floor was dirty and sticky. Dirt and debris were located under the equipment, tables, and shelving.
Observation on 5/20/24 at 10:52 A.M., in the kitchen dry storage room, showed a cardboard box of potatoes sat directly on the floor next to a water softener salt solution storage tank.
Observation on 5/20/24 at 10:57 A.M., in the kitchen, showed the following:
-Food splatters, oily material, dust and debris on the windows and frames to the Dietary Manager's office (located within the kitchen preparation area);
-The walls, located on the kitchen side of the Dietary Manager's office, had food splatters and debris.
Observation on 5/20/24 at 11:03 A.M., in the kitchen, showed food splatters, crumbs, and debris on the exterior surface and bottom rubber corner guards of the plate warmer.
Observation on 5/20/24 at 2:42 P.M., in the kitchen, showed the industrial mixer was not in use. A buildup of dried food splatter was on the food surface of the mixing bowl, and the mixing bowl was not covered.
Observation on 5/20/24 at 2:44 P.M., in the kitchen, showed the following:
-The unit one refrigerator had stains and dirt/debris on the exterior surface and food and debris on the bottom/floor inside the unit;
-The unit three refrigerator had stains and dirt/debris on the exterior surface and dirt and debris on the bottom/floor inside the unit;
-The unit four freezer had stains and dirt/debris on the exterior surface and dirt and debris on the bottom/floor inside the unit;
-The unit five freezer had stains and dirt/debris on the exterior surface and dirt and debris on the bottom/floor inside the unit;
Observation on 5/20/24 at 2:51 P.M., in the kitchen dishwashing room, showed the following:
-The top of the dishwasher was covered with dirt and debris;
-Four 1-foot by 1-foot floor tiles were missing under the garbage disposal;
-The floor tile next to the floor drain was cracked/broken.
Observation on 5/20/24 at 3:59 P.M., in the ice machine room, showed dirt and debris on the exterior surface of the lid to the red and white ice chest.
During an interview on 5/20/24 at 4:05 P.M., Dietary Aide J said the following:
-He/She was responsible for cleaning the dishwasher area, three-compartment sink, the exterior surfaces of the refrigerator and freezer units daily;
-He/She did not always clean these items daily due to not having enough time to finish before clocking out;
-He/She did not use the daily, weekly, and monthly cleaning log sheets on the refrigerator units, because he/she forgot about them.
During an interview on 5/20/24 at 4:45 P.M., Dietary [NAME] K said the following:
-The cooks were responsible for daily cleaning of all the cooking equipment after use, and the evening cook was responsible for cleaning the kitchen floor;
-Cleaning was not always completed due to running out of time.
During an interview on 5/21/24 at 5:55 A.M., Dietary [NAME] H said the following:
-He/She would like to see the kitchen in a cleaner condition when he/she arrived to work at 5:30 A.M.;
-Staff should clean the dietary equipment used to prepare meals after each use. The evening staff should clean the steamtable water compartments at end of that shift.
4. Review of the Handwashing/Glove Use Guidelines, dated April 2006, showed the following:
-Hands should be washed: Before beginning each shift; After breaks; After using the restroom; After smoking or eating; After blowing nose; After disposing of trash or food; After handling dirty dishes; After handling raw meat, poultry or eggs; After picking up anything from the floor; When changing tasks; Any other time deemed necessary;
-To ensure safe and proper food handling during food preparation and service, the food code states that food items should not be handled with bare hands;
-Utensils or tongs should be used to serve or handle foods, both raw and cooked, whenever possible;
-Do not use gloves unless only one task is being performed;
-When preparing or handling food items such as meatloaf or raw chicken, gloves should be worn;
-Handwashing per guidelines should occur between each task;
-Gloves should be worn if handling food I necessary;
-Gloves should be removed when changing or walking away from specific tasks and hands should then be washed per guidelines.
Observations on 5/20/24 at 12:10 P.M., 12:14 P.M., and 12:31 P.M., showed Certified Nurse Aide (CNA E entered the kitchen area without a hairnet. He/She did not wash his/her hands and filled water pitchers, then left the kitchen and returned to the dining room area during the meal service.
Observation on 5/20/24 at 1:05 P.M., showed the following:
-Dietary [NAME] K entered the kitchen and put on gloves without washing his/her hands;
-He/She picked up a clean baking sheet and placed it on the food preparation counter;
-He/She went to the kitchen back hall area and returned with a plastic bag of frozen dinner rolls, opened the plastic bag, reached in with the same gloved hands, picked up frozen dinner rolls from inside the bag, and placed them on the baking sheet.
During an interview on 5/20/24 at 4:45 P.M., Dietary [NAME] K said the following:
-He/She did not remember entering the kitchen and not washing hands before putting on gloves;
-Staff should wash their hands at the hand wash sink before putting on gloves and washing hands.
Observation on 5/20/24 at 1:21 P.M., showed Dietary [NAME] H dropped a meal tray ticket on the floor, picked up the ticket with his/her gloved hand and placed it back on the resident's meal tray before handing the tray to dining room staff through the kitchen serving window. The cook did not discard his/her gloves, wash his/her hands, and continued to serve meal trays at the steam table.
During an interview on 5/21/24 at 5:55 A.M., Dietary [NAME] H said when picking the lunch meal tray ticket up off the floor on 5/20/24, he/she should not have placed it back on the meal tray. He/She should have removed his/her gloves, washed his/her hands and put on new gloves on before returning to serving meal trays from the steamtable.
Observation on 5/21/24 at 12:09 P.M., in the kitchen, showed the following:
-The housekeeping manager wore gloves and picked up a container of peanut butter and placed it on the preparation table;
-She went to the refrigerator, opened the door, picked up a container of jelly from inside the refrigerator, closed the door and placed the container on the preparation table with the peanut butter;
-Without changing his/her gloves, she reached into a loaf of white bread, pulled out pieces of bread with his/her gloved hands, placed the bread on a cutting board, and prepared peanut butter sandwiches;
-After she made each peanut butter sandwich, she picked up each sandwich with his/her gloved hands and placed them into a sandwich bag.
-While wearing the same gloves, she opened the refrigerator and placed the bagged sandwiches inside the unit.
Observation on 5/21/24 at 1:21 P.M., showed the following:
-Dietary [NAME] H wore gloves as he/she served the lunch meal trays from the steamtable;
-He/She went to the preparation area, opened a bag of potato chips, reached inside with his/her gloved hands, and obtained a hand full of chips. He/She placed the chips in his/her hand into a bowl and placed the bowl on a resident's meal tray.
During an interview on 5/21/24 at 1:39 P.M., Dietary [NAME] H said the following:
-He/She did not realize he/she reached into the bag of chips with the same gloves he/she used to serve at the steam table. The noon meal was running behind and he/she was rushed;
-He/She should have washed his/her hands and put on new gloves before reaching into the chip bag or used clean tongs to reach into the chip bag.
During an interview on 5/22/24 at 6:50 A.M., Dietary [NAME] H said the following:
-Facility staff/nursing staff should wear hair nets when entering the kitchen;
-Staff have been educated on hair net use in the kitchen;
-Staff should wash their hands when entering the kitchen, and should wash their hands and change gloves between tasks in the kitchen.
During an interview on 5/22/24 at 7:20 A.M., the housekeeping supervisor said the following:
-She did not normally work in the kitchen, and was helping out on 5/22/24 because only the cook and a dishwasher were on duty;
-She did not realize she used the same gloved hands for all the tasks in preparing the peanut butter sandwiches;
-She probably should have washed his/her hands and changed his/her gloves between tasks when preparing the sandwiches.
During an interview on 5/22/24 at 8:30 A.M., the Dietary Manager said the following:
-In general, she was aware of the identified items not being clean and in a sanitized condition. She had been absent from work for approximately one week, and this is her first day back;
-She was not aware of cleaning issues with the ice machine, and was not aware of the required air gap at the ice machine drains;
-She was not aware of food items in the refrigerators/freezers that were not properly labeled and dated. She expected all items to be labeled and dated;
-She expected facility staff to wear hairnets in the kitchen area;
-She expected staff to use proper handwashing and gloving practices in the kitchen;
-She expected staff to store, prepare and serve food in a safe and sanitary manner.
During an interview on 5/22/24 at 8:40 A.M., the Administrator said the following:
-He was not aware the ice machine did not have the required air gap, and was not in a clean and sanitized condition;
-He expected facility staff to wear hairnets in the kitchen;
-He expected staff to use proper hand washing and gloving practices in the kitchen;
-He expected dietary staff to store, prepare and serve food in a safe and sanitary manner.
During an interview on 5/24/24 at 10:35 A.M., the Registered Dietician said she expected dietary staff to store, prepare and serve food in a safe and sanitary manner.
CONCERN
(F)
Potential for Harm - no one hurt, but risky conditions existed
Administration
(Tag F0835)
Could have caused harm · This affected most or all residents
Based on observation, interview, and record review, the administration of the facility failed to use resources effectively to attain or maintain the highest practicable physical, mental, and psychosoc...
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Based on observation, interview, and record review, the administration of the facility failed to use resources effectively to attain or maintain the highest practicable physical, mental, and psychosocial well-being of each resident. The facility census was 67.
1. Observations during survey from 05/19/24 through 05/23/24 showed the following:
-No record of infection control logs;
-No yearly staff education regarding care of residents with dementia;
-No yearly staff education on abuse and neglect;
-Yearly required training hours for certified nursing assistants not provided;
-No organized Quality Assurance and Performance Program (QAPI);
-No facility hired licensed nursing staff; utilizing all agency staff as licensed nursing staff;
-Cardiopulmonary resuscitation status not consistent throughout a resident's medical record for numerous residents;
-Dietary services not provided in a sanitary environment and not provided to meet residents individual needs/requests on an ongoing basis;
-Medication administration not provided consistently according to professional standards and without errors;
-Quality of care issues regarding management of foot care and services to prevent decline in mobility and range of motion not consistently provided;
-Protective oversight and safety measures with prevention of injuries not provided consistently;
-Supplies, like linens for bathing and bed changes, not available to provide resident cares;
-Assistance with activities of daily living not provided to meet the needs of individual residents consistently;
-Staff not following infection control measures consistently;
-Activities program not provided that met the needs and interests of all residents, including dementia residents and weekend/evening activities;
-Proper certification for activities director, infection preventionist and dietary manager;
-Resident rights of dignity and reasonable accommodation of needs, preferences and choices were not ensured;
-Grievances were not being followed up on;
-No oversight to ensure proper Advance Beneficiary Notices (ABN) were completed had not been provided;
-No oversight to ensure proper resident and/or resident representative notification when a resident's trust account reached $200 less the Supplemental Security Income (SSI) resource for a resident who received Medicaid benefits;
-No oversight to ensure residents fully understood what a binding arbitration agreement was;
-The facility failed to keep the floors and walls in good repair and failed to maintain a homelike environment in the facility;
-Professional standards of care not consistently followed while providing care and increased the risks of infections and contaminations;
-Sufficient staffing to ensure residents needs were met was not provided;
-The facility failed to complete a thorough investigation of an allegation of abuse per the facility policy;
-No oversight to ensure a notice of transfer to the hospital or bed hold policy was being provided to a resident and/or the resident representative;
-The facility did not have dedicated staff to complete required assessments timely and accurately;
-The facility failed to ensure pharmacy reviews were being received and followed up on.
During an interview on 5/22/24 at 6:07 P.M., the Interim Director of Nursing (DON) said the following:
-She had been at the facility off and on since November 2023 serving as the Interim DON;
-She had not had a DON or assistant DON for the last couple of months;
-All licensed nursing staff currently utilized at the facility were agency staff;
-The facility had not had full time permanent administration, so some systems were not in place.
During an interview on 5/23/24 at 3:54 P.M., the Interim Administrator said the following:
-He started at the facility 5/7/24;
-He was told the facility had a lot of turn over and was relying heavily on agency staffing;
-He was working with the DON to get systems in place but has not been at the facility very long.
CONCERN
(F)
Potential for Harm - no one hurt, but risky conditions existed
Deficiency F0865
(Tag F0865)
Could have caused harm · This affected most or all residents
Based on interview and record review, the facility failed to identify, develop and implement a Quality Assurance and Performance Improvement Plan (QAPI) to monitor and evaluate system problems. The fa...
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Based on interview and record review, the facility failed to identify, develop and implement a Quality Assurance and Performance Improvement Plan (QAPI) to monitor and evaluate system problems. The facility census was 67.
Request for a Quality Assurance (QA)/QAPI policy was made of the facility and none provided.
Review of a binder, provided by the administrator, on 5/23/24 at 3:54 P.M., labeled QAPI, showed the last meeting minute notes were dated January 2023. No current, facility specific, QAPI plan was included in the binder for review.
During an interview on 5/23/24, at 3:54 P.M., the Interim Administrator said the following:
-He started at the facility 5/7/24;
-The QAPI policy/program/plan as requested on entrance was not provided to the state agency (SA) because the facility does not have a policy or recent minutes or completed QAPI information that he could find;
-The last QAPI minutes he found were dated 1/23/23;
-He interviewed current staff and no staff remember having a QAPI committee or meeting recently;
-He found an outline of what to do but was not sure if it was a current outline;
-He would expect the facility to have a QAPI program with process improvement activities that meets quarterly with the appropriate team members.
CONCERN
(F)
Potential for Harm - no one hurt, but risky conditions existed
QAPI Program
(Tag F0867)
Could have caused harm · This affected most or all residents
Based on interview and record review, the facility staff failed to implement an effective quality assessment and assurance (QAA) committee to develop and track any identified concerns for resolution. ...
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Based on interview and record review, the facility staff failed to implement an effective quality assessment and assurance (QAA) committee to develop and track any identified concerns for resolution. The facility census was 67.
Request for a Quality Assurance (QA)/QAPI policy was made of the facility and none provided.
Review of a binder, provided by the administrator, on 5/23/24 at 3:54 P.M., labeled QAPI, showed the last meeting minute notes were dated January 2023.
During an interview on 5/23/24, at 3:54 P.M., the Interim Administrator said the following:
-He started at the facility 5/7/24;
-The QAPI policy and QAPI members were not given to the state agency (SA) team as requested on entrance because the facility did not have a policy or recent minutes that he/she can find;
-The last QAPI minutes he found were dated 1/23/23;
-He interviewed current staff and no staff remember having a meeting recently;
-The current staff could not give him any Process Improvement Plans that are currently being worked on;
-He would expect the facility to have a QA/QAPI program with process improvement activities that meets quarterly with the appropriate team members.
CONCERN
(F)
Potential for Harm - no one hurt, but risky conditions existed
Deficiency F0868
(Tag F0868)
Could have caused harm · This affected most or all residents
Based on interview and record review, the facility failed to provide documentation of a Quality Assurance and Process Improvement (QAPI) committee that included the appropriate attendees. The facility...
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Based on interview and record review, the facility failed to provide documentation of a Quality Assurance and Process Improvement (QAPI) committee that included the appropriate attendees. The facility census was 67.
Request for a Quality Assurance (QA)/QAPI policy was made of the facility and none provided.
Review of a binder, provided by the administrator, on 5/23/24 at 3:54 P.M., labeled QAPI, showed the last meeting minute notes were dated 1/23/23.
During an interview on 5/23/24 at 3:54 P.M., the Interim Administrator said the following:
-He started at the facility 5/7/24;
-The QAPI policy and QAPI members were not given to the state agency (SA) team as requested on entrance because the facility does not have a policy or recent minutes that he can find;
-The last QAPI minutes he found were dated 1/23/23;
-He interviewed current staff and no staff report being on a QA/QAPI committe;
-He would expect the facility to have a QAPI program with process improvement activities that meets quarterly with the appropriate team members;
-He expects the Administrator, Director of Nursing, a few floor staff, most of the department heads, medical director, pharmacist, and the dietitian to participate in the QAPI program and attend at least the qarterly meetings;
-He had not attended or been part of a QA/QAPI meeting since he began working at the facility.
CONCERN
(F)
Potential for Harm - no one hurt, but risky conditions existed
Infection Control
(Tag F0880)
Could have caused harm · This affected most or all residents
**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, interview, and record review, the facility failed to follow current infection control for six residents (R...
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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 follow current infection control for six residents (Resident #20, #46, #13, #4, #39 and #68), in a review of 24 sampled resident and six additional residents (Resident #34, #14, #49, #38, #6 and #28). Staff failed to follow Enhanced Barrier Precautions (EBH) for one resident (Resident #20) who had an indwelling catheter. The facility failed to follow infection control practices while performing blood glucose monitoring (a procedure where a drop of blood is obtained to test the amount of sugar in the blood) for five residents (Resident #46, #34, #14, #49 and #13) when staff failed to appropriately sanitize the glucometer (a machine that tests a drop of blood for the amount of sugar it contains) after use, and failed to place the glucometer on a clean surface after use and cleaning. The facility failed to store oxygen tubing and nebulizer equipment (equipment used to give aerosol breathing treatments) when not in use in a way to prevent potential contamination from unclean surfaces, failed to change oxygen tubing as ordered and failed to clean the nebulizer treatment cup reservoirs per facility policy for four residents (Resident #4, #38, #39 and #68). The facility failed to maintain the prevention of communicable disease in regards to Tuberculosis (TB) (a communicable disease that affects the lungs characterized by fever, cough, and difficulty breathing) when the facility failed to ensure Tuberculin Skin Tests (TST) for three residents (Resident #6, #13 and #38) and for two new employees (Certified Nursing Assistant CNA DD and the Administrator), in a review of 12 new employees, were completed in accordance with the general requirements for TB testing for long-term care residents and staff. The facility staff failed to clean feces from Resident #49's toilet and from under the resident's bed after he/she had been incontinent. Staff failed to wash their hands with soap and water when necessary and failed to change gloves, when staff used soiled gloves to provide care to Resident #28 and touched clean linen and other items with soiled gloves. The facility failed to have a water management plan, water flow map/diagram, acceptable water parameters to monitor for Legionella (a bacteria that can cause a severe type of pneumonia and mild flu-like illness) did not follow up on water temperatures that were out of range and did not have a water management team or screen suspected residents for Legionella. The facility census was 67.
Review of the facility undated facility policy, Catheter, Emptying A Urinary Drainage Bag, showed the drainage bag and tubing should be kept off the floor at all times to prevent contamination and damage.
Review of the facility policy for Enhanced Barrier Precautions (EBP) to Infection Control Guidance dated 3/2024 showed the following:
-Purpose: To prevent broader transmission of MDRO (multidrug-resistance organism) and to help protect residents with chronic wounds and indwelling devices. EBP (Enhanced barrier precautions) should be implemented for the period of their stay or until wounds have resolved or indwelling medical devices have been removed.;
-Residents to be included: Residents known to be infected or colonized with a MDRO; residents with an indwelling medical device including the following: Central venous catheter, urinary catheter, feeding tube (PEG tube, G-tube), tracheostomy/ventilator regardless of their MDRO status; residents with a wound, regardless of their MRDO status;
-When to use EBP: Use EBP when providing high-contact resident care activities such as: bathing/showering, transferring residents from one position to another, providing hygiene, changing bed linens, changing briefs or assisting with toileting, caring for or using an indwelling medical device, performing wound care;
-Guidelines: Conduct proper hand hygiene before starting care; gloves and donning and doffing of gown are required when conducting high-contract resident care activities that are listed. Gloves and gown should be removed and discarded after each resident care encounter. Attempts to arrange cares to be grouped together to assist in reducing consumption of supplies where practical; EBP's do not require placement of resident in a private room and they can continue to participate in group activities;
-Residents with a wound or indwelling medical device and excretions or secretions that are unable to be covered or contained and are not known to be infected or colonized with any MDRO should be placed on contact precautions unless or until a specific organism is identified;
-EBP should be followed when performing transfers or assisting during bathing in a shared/common shower and when working with residents in the therapy gym. (Specifically, when anticipating close physical contact while assisting with transfers and mobility);
-Residents that are placed on EBP should have PPE in close proximity outside the door and trash can in resident's room for disposal prior to leaving the room;
-Multi-resident medical equipment must be sanitized between resident uses.
Review of the facility's undated policy, Blood Glucometer Disinfecting, showed the following:
-Purpose: to prevent the spread of infection;
-Equipment: Approved wipes with 10% bleach or comparable product;
-Guidelines:
1. Wash hands;
2. Put on gloves;
3. Provide a clean field in which to place the glucose meter (a paper towel works well for this);
4. Clean the blood glucose meter prior to using with approved wipes with 10% bleach or comparable product, place on clean field and let air dry according to manufacturer's directions. Do not touch the clean field with gloves, including the test port. Glucometer may be wrapped in another wipe and stored;
5. Remove gloves;
6. Wash hands.
-The policy did not instruct how long to keep the glucometer wet while/after cleaning;
-The policy did not include the manufacturer's instructions.
Review of the undated facility policy, Oxygen Administration, showed the following:
-Purpose: To administer oxygen to the resident when insufficient oxygen is being carried by the blood to the tissues;
-At regular intervals, check and clean oxygen equipment, masks, tubing and cannulas;
-Place cannula tubing in plastic bag attached to concentrator when tubing is not in use;
-Care and Use of Prefilled Disposable Humidifiers:
9. Label humidifier with date and time opened.
Review of the undated facility policy, Cleaning Guidelines - Oxygen Equipment, showed the following:
-Purpose: Oxygen equipment will be cleaned to ensure safety in handling and administering oxygen;
3. Prefilled humidifier bottles will be discarded when empty;
6. Tubing, masks, and cannulas used with oxygen therapy should be replaced monthly and PRN, and marked with date and initials.
Review of the undated facility policy, Cleaning Guidelines - Medication Nebulizers/Continuous Aerosol, showed the following:
-After completion of therapy:
a. Remove nebulizer container;
b. Rinse container with fresh tap water;
c. Dry with clean paper towel or gauze sponge (Use caution not to contaminate internal nebulizer tubes);
-Store circuit in plastic bag marked with date and resident name between uses.
Review of the undated facility policy, Gloves, showed the following:
-Wear gloves when it can be reasonably anticipated that hands will be in contact with mucous membranes, non intact skin, any moist body substances (blood, urine, feces, wound drainage, oral secretions, sputum, vomitus, or items/surfaces soiled with these substances) and/or persons with a rash;
-Gloves must be changed between residents and between contacts with different body sites of the same resident;
-If the glove is torn or a needle stick or other injury occurs, the glove should be removed, discarded in the trash and a new glove used promptly as resident safely permits;
-Dirty gloves are worse than dirty hands because microorganisms adhere to the surface of a glove easier than lo the skin on your hands;
-Change gloves between contacts (as defined above) with different residents or with different body sites of the same resident.
Review of the undated facility policy, Handwashing showed the following:
-Turn on water and adjust temperature;
-Soap hands well;
-Rub hands briskly, paying special attention to area between fingers;
-Use brush to clean under nails as necessary;
-Rinse with hands lowered to allow soiled water to drain directly into sink;
-Do not splash water onto clothing;
-Do not allow hands to touch sink;
-Use disposable hand towel to turn off faucet and dry hands well, especially between fingers.
Review of the undated facility policy titled, Tuberculosis Policy, showed the following:
-It is important for each facility to have a tuberculosis control program in place. This must include the documentation of the tuberculosis status of each resident, staff member, and volunteer of each long term care facility. This can best be accomplished by screening residents on admission, and pre-employment and annual testing of employees and volunteers as outlined below;
-RECOMMENDATIONS FOR RESIDENTS:
-All residents new to long-term care who do not have documentation of a previous skin test reaction > 10 mm or a history of adequate treatment of tuberculosis infection or disease, shall have the initial test of a Mantoux PPD two- step skin test to rule out tuberculosis within one month prior to or one week after admission as required by Department of Health Rule 19 CSR 20-20.100. If the initial result is 0-9 mm, the second test, which can be given after admission, should be given at least one week and no more than three weeks after the first test. The result of the second test is used as the baseline. Documentation of a chest x-ray ruling out pulmonary tuberculosis within one month prior to admission, along with an evaluation to rule out signs and symptoms of tuberculosis, may be acceptable by the facility on an interim basis until the Mantoux PPD two-step test is completed;
-Skin test results of> 10 mm, whether documented in the resident's medical history, obtained by the first test, or obtained by the second of the two-step test applied by the facility require a chest x-ray to rule out current tuberculosis disease. It is important to also perform an evaluation to determine if signs or symptoms of tuberculosis (unexplained weight loss, fever, and persistent cough) are present. Once tuberculosis disease is ruled out, it is important to record the results of the skin test in millimeters (mm), in a prominent place on the resident's medical record. Including the skin test result at the same place and in the same manner as the resident's allergies is appropriate;
-The policy did not address what to do if a resident refused testing;
-RECOMMENDATIONS FOR EMPLOYEES:
-The results of annual tuberculin testing of employees in a long-term care facility are a good indicator of the extent of transmission of tuberculosis within that facility. The following occupationally-exposed persons should be tested at least annually: all employees, attending physicians and dentists, volunteers who spend > 10 hours weekly in the facility, nursing and allied health personnel, students, instructors and other individuals in regular attendance within long-term facilities. Every facility should have a tuberculosis surveillance program that includes the following procedures:
-Initial Examination: Provide a tuberculin skin test (Mantoux, five tuberculin units (TU) of purified protein derivative (PPD) to all employees during pre-employment procedures, unless a previous reaction > 10 mm is documented. If the initial skin test result is 0-9 mm, a second test should be given at least one week and no more than three weeks after the first test. The results of the second test should be used as the baseline in determining treatment and follow-up of these employees. A history of BCG (bacilli Calmette-Guerin) does not preclude an initial screening test, and a reaction of 10 mm or more should be managed as a tuberculosis infection. A chest x-ray examination should be provided for employees who have a skin test reaction> 10 mm or who have symptoms compatible with pulmonary tuberculosis in order to determine the presence of current disease;
Review of the Centers for 17-30, dated 06/02/17 and revised on 06/09/17, showed the following:
-The bacterium Legionella can cause a serious type of pneumonia called LD in persons at risk. Those at risk include persons who are at least [AGE] years old, smokers, or those with underlying medical conditions such as chronic lung disease or immunosuppression. Outbreaks have been linked to poorly maintained water systems in buildings with large or complex water systems including hospitals and long-term care facilities. Transmission can occur via aerosols from devices such as shower heads, cooking towers, hot tubs, and decorative fountains;
-Facilities must develop and adhere to policies and procedures that inhibit microbial growth in building water systems that reduce the risk of growth and spread of Legionella and other opportunistic pathogens in water;
-CMS expects Medicare certified healthcare facilities to have water management policies and procedures to reduce the risk of growth and spread of Legionella and other opportunistic pathogens in building water systems. An industry standard calling for the development and implementation of water management programs in large or complex building water systems to reduce the risk of legionellosis was published in 2015 by American Society of Heating, Refrigerating, and Air Conditioning Engineers (ASHRAE). In 2016, the CDC and its partners developed a toolkit to facilitate implementation of this ASHRAE Standard (https://www.cdc.gov/Legionella/maintenance/wmp-toolkit.html). Environmental, clinical, and epidemiological considerations for healthcare facilities are described in this toolkit;
-Surveyors will review policies, procedures, and reports documenting water management implementation results to verify that facilities:
-Conduct a facility risk assessment to identify where Legionella and other opportunistic waterborne pathogens (e.g. Pseudomonas, Acinetobacter, Burkholderia, Stenotrophomonas, nontuberculous mycobacteria, and fungi) could grow and spread in the facility water system;
-Implement a water management program that considers the ASHRAE industry standard and the CDC toolkit, and includes control measures such as physical controls, temperature management, disinfectant level control, visual inspections, and environmental testing for pathogens;
-Specify testing protocols and acceptable ranges for control measures, and document the results of testing and corrective actions taken when control limits are not maintained.
Review of the Centers for Disease Control and Prevention Legionella Environmental Assessment Form, undated, showed Legionella generally grow well between 77 degrees Fahrenheit (F) and 113 degrees F. The optimal growth range for Legionella is between 85 degrees F and 108 degrees F. Growth slows between 113 degrees F and 120 degrees F, and Legionella begin to die above 120 degrees F. Growth also slows between 68 degrees F and 77 degrees F, and Legionella become dormant below 68 degrees F.
Review of the facility Weekly Water Temperature Log form SWO26, undated, showed the following directions to staff completing the form:
-Check two random rooms per wing for proper water temperature;
-Resident rooms should reach temperatures of 105-120 degrees F, maximum;
-If a resident's water temperature is below 105 degrees: look for a cold water mix at a fixture such as a whirlpool, shower faucet, or chemical additive machine, turn cold side off. If too low of temperature still occurs, call for service;
-If a resident's room's water temperature is above 120 degrees: adjust the water heater, look for a hot water leak, or check mixing valves. If too high of temperature still occurs, call for service;
-Kitchen and laundry room temperatures should reach 140 degrees unless low temperature chemicals are being used;
-When it is necessary to replace a faucet, ensure it is replaced with a double lever faucet.
1. Review Resident #20's care plan, dated 11/24/23, showed the resident required an indwelling urinary catheter (a tube inserted into the bladder to empty urine from the bladder) related to urine retention.
Review of resident's progress note dated 12/22/23 at 10:43 P.M. showed the following:
-The resident returned from the hospital;
-The resident received a new order for antibiotic for a urinary tract infection (UTI).
Review of resident's progress note, dated 2/4/24 at 12:38 A.M., showed the following:
-The resident returned from hospital by ambulance;
-The resident received a new order for Omnicef (an antibiotic) for a UTI.
Review of resident's progress note, dated 2/27/24 at 6:54 P.M., showed the following:
-The resident received intravenous (IV) fluids and IV antibiotics;
-The resident returned back to the facility;
-The resident returned with a prescription for oral antibiotics.
Review of the resident's May 2024 physician order sheet (POS) showed the resident had an indwelling urinary catheter for urinary retention.
During interview on 05/21/24 at 9:35 A.M., Certified Nurse Aide (CNA) C and CNA E said the following:
-They did not know what Enhanced Barrier Precautions (EBP) were;
-No residents were on precautions.
-There were no gowns available, only gloves.
Observation on 05/21/24 at 10:29 A.M. showed the following:
-The resident lay in bed and had a urinary catheter;
-The urine in the catheter drainage bag was brown and cloudy;
-The urine in the catheter tubing was red and filled with sediment (a substance that settles at the bottom of urine) (normal urine does not have sediment);
-CNA E and CNA C put on gloves and changed the resident's incontinence brief;
-CNA E wiped discharge from the catheter insertion site and the resident's inner thighs.
-Neither CNA E or CNA C wore a gown when providing care for the resident.
During interview on 5/22/24 at 11:30 A.M., Licensed Practical Nurse (LPN) R said he/she did not know what enhanced barrier precautions were.
2. Review of Resident #49's face sheet showed his/her diagnoses included diabetes.
Review of the resident's POS, dated 5/1/24, showed an order for glucose monitoring twice a day (BID) before breakfast and dinner.
Observation on 5/21/24 at 5:31 A.M. showed the following:
-LPN D placed a multi use glucometer on top of the medication cart;
-LPN D sanitized his/her hands with hand sanitizer, applied gloves and took a glucose test strip out of the bottle and placed it in the glucometer; he/she then took the machine in the resident's room, wiped one of the resident's fingers with an alcohol wipe, used a lancet to prick the resident's finger, and with the first drop of blood, placed the test strip to the drop;
-LPN D then brought the machine back to the cart and placed the machine on top of the cart, (not on a barrier), removed a wipe from a container of Micro kill bleach wipes and wiped the glucometer with the wipe a couple of times, sat the machine back on top of the medication cart (without a barrier) and moved to the next room.
3. Review of Resident #14's face sheet showed his/her diagnoses included diabetes.
Review of the resident's POS, dated 5/1/24, showed an order for glucose monitoring daily.
Observation on 5/21/24 at 5:45 A.M. showed:
-LPN D placed a multi use glucometer on top of the medication cart;
-LPN D sanitized his/her hands with hand sanitizer, applied gloves and took an glucose test strip out of the bottle and placed it in the glucometer; he/she then took the machine in the resident's room, wiped one of the resident's fingers with an alcohol wipe, used a lancet to prick the resident's finger, and with the first drop of blood, placed the test strip to the drop;
-LPN D then brought the machine back to the cart and placed the machine on top of the cart, (not on a barrier), removed a wipe from a container of Micro kill bleach wipes and wiped the glucometer with the wipe a couple of times, sat the machine back on top of the medication cart (without a barrier) and moved to the next room.
4. Review of Resident #13's face sheet showed his/her diagnosis included diabetes.
Review of the resident's POS, dated 5/1/24, showed an order for blood glucose monitoring three times daily.
Observation on 5/21/24 at 5:50 A.M. showed the following:
-LPN D placed a multi use glucometer on top of the medication cart;
-LPN D sanitized his/her hands with hand sanitizer, applied gloves and took a glucose monitoring strip out of the bottle and placed it in the glucometer; he/she then took the machine in the resident's room, wiped one of the resident's finger with an alcohol wipe, used a lancet to prick the finger, and with the first drop of blood, placed the test strip to the drop;
-LPN D then brought the machine back to the cart and placed the machine on top of the cart, (not on a barrier), removed a wipe from a container of Micro kill bleach wipes and wiped the glucometer with the wipe a couple of times, sat the machine back on top of the medication cart (without a barrier) and moved to the next room.
5. Review of Resident #34's face sheets showed his/her diagnoses included diabetes.
Review of the resident's POS, dated 5/1/24, showed an order for blood glucose monitoring twice daily.
Observation on 5/21/24 at 5:55 A.M. showed the following:
-LPN D placed a multi use glucometer on top of the medication cart;
-LPN D sanitized his/her hands with hand sanitizer, applied gloves, took a glucose strip out of the bottle and placed it in the glucometer; he/she then took the machine in the resident's room, wiped one of the resident's finger with an alcohol wipe, used a lancet to prick the finger, and with the first drop of blood, placed the test strip to the drop;
-LPN D then brought the machine back to the cart and placed the machine on top of the cart, (not on a barrier), removed a wipe from a container of Micro kill bleach wipes and wiped the glucometer with the wipe a couple of times, sat the machine back on top of the medication cart (without a barrier) and moved to the next room.
6. Review of Resident #46's face sheet showed his/her diagnoses included diabetes.
Review of the resident's POS, dated 5/1/24, showed an order for Aspart Insulin (a short acting insulin) per sliding scale (an amount to be determined based off an glucose test result), before meals.
Observation on 5/21/24 at 5:00 A.M. showed the following:
-LPN D placed a multi use glucometer on top of the medication cart;
-LPN D sanitized his/her hands with hand sanitizer, applied gloves, took a glucose test strip out of the bottle and placed it in the glucometer; he/she then took the machine in the resident's room, wiped one of the resident's fingers with an alcohol wipe, used a lancet to prick the finger, and with the first drop of blood, placed the test strip to the drop;
-LPN D then brought the machine back to the cart and placed the machine on top of the cart, (not on a barrier), removed a wipe from a container of Micro kill bleach wipes and wiped the glucometer with the wipe a couple of times, sat the machine back on top of the medication cart (without a barrier) and moved to the next room.
During an interview on 5/21/24 at 6:45 A.M., LPN D said the following:
-The glucometer is sanitized after each use by using a wipe from the Micro Kill bleach container, wiping front and back, then placing the glucometer on the cart to let dry before use on another resident;
-He/She should have cleaned the top of the medication cart each time he/she used the glucometer to ensure a clean field. He/She had not done this.
During an interview on 5/23/24 at 5:00 P.M. the Director of Nursing (DON) said the following:
-The glucometer should be cleaned between each resident use.
-The facility uses a bleach wipe, the machine should be wiped off after each use and left wet to dry a few minutes then air dry;
-A clean field should be used when sitting the machine on the medication cart, staff can use a paper towel as a barrier, not the top of the medication cart.
7. Review of CNA DD's employee file showed the following:
-Hire date 10/1/23;
-No documentation of a prior TB test;
-First step TB test administered on 3/4/24 (176 days from the date of hire and since first contact with residents) and read 3/7/24;
-No documentation of a two step test.
8. Review of the administrator's employee file showed the following:
-Hire date 5/1/24;
-No documentation of a prior TB test;
-First step TB test administered on 5/14/24 (13 days from the date of hire and since first contact with residents) and read 5/16/24;
-No documentation of a two step test.
9. Review of Resident #6's face sheet showed the following:
-admit date of 12/09/23 and re-admit 3/30/23;
-Diagnoses that included chronic cough.
Review of the resident's immunization record showed the following:
-No documentation the resident received a first or second step TB test at admission on [DATE];
-On 3/12/24 at 11:32 A.M., the resident received a TB test; test to be read on 3/14/24; the test was read on 3/15/24 (more than 48 hours after the test was administered) at 8:00 A.M. with negative (zero mm) result documented; next scheduled administration was for 3/22/24;
-No documentation the resident received a second step TB test on 3/22/24.
-The resident had not received a proper TB testing and the medical record showed no documentation of a chest x-ray to rule out TB.
10. Review of Resident #38's face sheet showed his/her admission date was 10/03/23.
Review of the resident's immunization record showed the following:
-On 11/24/23 at 9:45 A.M., the resident received a TB test. The test was read on 11/27/23 at 8:31 A.M. with negative result documented (not documented in mm of induration); next scheduled administration was for 12/4/23;
-No documentation a second step TB test was administered on 12/4/23.
Review of the resident's progress notes showed on 12/04/2023 at 10:26 A.M., resident refused TB test.
Review of the resident's immunization record showed the following:
-On 3/12/24 at 11:46 A.M., the resident received a TB (1st step) test; the test was read on 3/15/24 at 8:00 A.M. with negative result documented (not in mm); next scheduled administration was for 3/22/24;
-On 3/22/24 at 2:15 P.M., the resident received a TB (2nd step) test;
-No documentation the 2nd step TB test was read or results documented.
11. Review of Resident #13's undated face sheet showed the resident's original admission date was 7/28/23.
Review of the resident's undated immunization record showed the following:
-No record of first or second TB test was administered on admission;
-First-step TB test administered on 3/12/24 to right forearm;
-First-step TB test read on 3/15/23 and was negative, 0 mm;
-Second-step TB test administered 3/22/24 to left forearm;
-No documentation to show staff read the results of the second-step TB test.
During interview on 5/22/24 at 11:30 A.M., LPN R said the nurses administer the TB tests on admission.
During an interview on 5/23/24 at 6:49 P.M., the DON said nurses were responsible for resident and staff TB tests. If a resident refused a TB test, then they educate the resident and get a consent. Staff get the first step TB test upon hire and then the second step fourteen days later.
12. Review of Resident #38's face sheet showed his/her diagnoses included chronic obstructive pulmonary disease (COPD) (lung/breathing disorder), pneumonia, acute respiratory distress, seasonal allergic rhinitis, acute and chronic respiratory failure (serious condition that makes it difficult to breathe), shortness of breath and lung cancer.
Review of the resident's progress notes showed on 11/21/23 at 2:17 P.M., discontinue as needed oxygen orders per provider due to standing orders.
Review of the resident's May 2024 POS showed orders for the following:
-No order for oxygen use;
-An order to change oxygen tubing weekly on Tuesdays.
Review of the resident's May 2024 medication administration record (MAR) showed the following:
-Change oxygen tubing weekly on Tuesdays at 8:00 P.M.;
-The 5/7/24 administration box for 8:00 P.M., showed LPN X documented changing the oxygen tubing as ordered;
-The 5/14/24 administration box for 8:00 P.M., showed LPN A documented changing the oxygen tubing as ordered.
Observation on 5/19/24 at 4:21 P.M. of the resident and the resident's room showed the following:
-The resident sat in his/her recliner with oxygen on via nasal cannula (prongs in his/her nose delivering oxygen);
-The oxygen tubing was connected to an oxygen concentrator and the tubing labeled with a date of 5/2/24 (the tubing had not been changed on 5/7/24 or 5/14/24 as documented);
- The concentrator was set at 3 liters per minute.
Observation on 5/20/24 at 9:15 A.M. of the resident and the resident's room showed the resident sat in his/her wheelchair in his/her doorway with oxygen on via nasal cannula. The oxygen tubing was connected to an oxygen tank and the tubing was labeled with a date of 5/2/24. The oxygen tank was set at 4 liters per minute.
Observation on 5/21/24 at 5:58 A.M. of the resident and the resident's room showed the resident sat in his/her recliner with oxygen on via nasal cannula. The oxygen tubing was connected to a concentrator and the tubing was labeled with a date of 5/2/24. The concentrator was set at 3 liters per minute.
Review of the resident's May 2024 MAR showed the following:
-Change oxygen tubing weekly on Tuesdays at 8:00 P.M.;
-The 5/21/24 administration box for 8:00 P.M., showed LPN N documented changing the oxygen tubing as ordered.
Observation on 5/22/24 at 3:22 P.M. of the resident and the resident's room showed the resident sat in his/her recliner with oxygen on via nasal cannula. The oxygen tubing was connected to a concentrator and the tubing was labeled with a date of 5/2/24. (the oxygen tubing was not changed on 5/21/24 as the documentation showed). The concentrator was set at 3 liters per minute of concentration.
Observation on 5/23/24 at 8:50 A.M. of the resident and the resident's room showed the resident sat in his/her recliner with oxygen on via nasal cannula. The oxygen tubing was connected to a concentrator and the tubing was labeled with a date of 5/2/24. The concentrator was set at 3 liters per minute of concentration.
Observation and interview on 5/23/24 at 8:55 A.M., showed LPN N said the following:
-He/She was responsible for changing the resident's oxygen tubing on 5/21/24;
-When tubing is changed, staff should initial, date and time, the tubing was changed on the tubing label;
-LPN N confirmed the date on the tubing to be 5/2/24;
-He/She thought he/she had changed the tubing;
-If he/she had not changed the tubing, he/she should not have documented changing the tubing.
13. Review of Resident #4's face sheet showed his/her diagnoses include congestive heart failure (a chronic condition in which the heart doesn't pump blood as well as it should).
Review of the resident's quarterly Minimum Data Set (MDS) (a federally mandated assessment instrument completed by facility staff), dated 2/25/24, showed no use of oxygen therapy indicated.
Review of the resident's care plan, revised on 02/28/24, showed no indication of oxygen usage.
Review of the resident's May 2024 POS showed the following:
-Administer two liters of oxygen as needed for pulse oxygen saturation (the amount of oxygen in the blood stream measured by percentage of 100 or less) rate less than 92 percent;
-Change oxygen tubing weekly on Sunday on the night shift.
Review of the resident's May 2024 treatment administration record (TAR) showed the follow[TRUNCATED]
CONCERN
(F)
Potential for Harm - no one hurt, but risky conditions existed
Deficiency F0882
(Tag F0882)
Could have caused harm · This affected most or all residents
Based on interview and record review, the facility failed to ensure the infection preventionist (IP) completed specialized training in infection prevention and control that worked at least part time a...
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Based on interview and record review, the facility failed to ensure the infection preventionist (IP) completed specialized training in infection prevention and control that worked at least part time at the facility. This practice effected all residents in a facility. The facility census was 67.
Review of the facility's undated policy, Antibiotic Stewardship Champion Program, showed the following:
-The community will select an antibiotic stewardship champion (ASC) who will be responsible for implementing and maintaining the antibiotic stewardship champion program;
-The ASC will obtain certification through the Center for Disease Control and Prevention (CDC) for nursing home infection preventionist.
Review of the Center for Disease Control website, Nursing Home Infection Preventionist Training, showed a required program of completion of 23 modules and sub-modules to obtain certification.
During an interview on 5/22/24 at 6:07 P.M., the interim Director of Nursing (DON) said the following:
-She had been serving as the IP since the DON and assistant director of nursing (ADON) left the facility a couple of months ago;
-She completed the IPCP, program but her certificate was at home on her computer a few hours from the facility.
Review of an email communication from the administrator, on 6/03/24 at 12:44 P.M., the facility provided completed module certifications for module 1 through module 15, but did not provide a course completion certificate for the interim DON, who was serving as the facility's IP. Review of the provided documentation did not show a completed IPCP program certification for the interim DON.
Review of an email communication from the administrator on 6/07/24 at 2:55 P.M., showed a certificate of completion for the Infection Prevention Control Program (IPCP) for the Minimum Data Set (MDS) coordinator.
During an interview on 6/10/24 at 12:43 P.M., the MDS coordinator said the following:
-She was employed part-time at the facility to do MDS assessments;
-She had not done anything at the facility directly related to the IPCP program;
-She only reviewed the residents' records for antibiotic use for completion of the MDS assessment;
-She provided a copy of her certificate to the facility in case she needed to assist in that capacity in the future.
CONCERN
(F)
Potential for Harm - no one hurt, but risky conditions existed
Deficiency F0944
(Tag F0944)
Could have caused harm · This affected most or all residents
Based on interview and record review, the facility failed to provide mandatory training for all staff on the facility's quality assurance and performance improvement (QAPI) program that included goals...
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Based on interview and record review, the facility failed to provide mandatory training for all staff on the facility's quality assurance and performance improvement (QAPI) program that included goals and various elements of the program. This included how the facility intents to implement the program, the staff's role in the facility's QAPI program and how to communicate concerns, problems or opportunities for improvement to the facility's Quality Assessment and Assurance (QAA) Committee. The facility census was 67.
Review of the Facility Assessment, updated 5/20/24, showed the following staff education and competencies will be shown with each area below:
-Activities of daily living: Bathing, showers, oral/denture care, dressing, eating, support with needs related to hearing/vision/sensory impairment; supporting resident independence in doing as much of these activities by himself/herself. All Certified Nurse Assistant (CNA), Certified Medication Technician (CMT), Licensed Practical Nurse (LPN) and Registered Nurses (RN) will do a return demonstration to observe their ability;
-Mobility and fall/fall with injury prevention: Transfers, ambulation, restorative nursing, contracture prevention/care; supporting resident independence in doing as much of these activities by himself/herself. All CNA, CMT, LPN and RN's will do a return demonstration to observe their ability;
-Bowel/bladder toileting programs, incontinence prevention and care, intermittent or indwelling or other urinary catheter, ostomy, responding to requests for assistance to the bathroom/toilet promptly in order to maintain continence and promote resident dignity. All CNA, CMT, LPN and RN's will do a return demonstration to observe their ability;
-Skin integrity: Pressure injury prevention and care, skin care, wound care (surgical, other skin wounds). All CNA, CMT, LPN and RN's will do a return demonstration to observe their ability;
-Mental health and behavior: Manage the medical conditions and medication-related issues causing psychiatric symptoms and behavior, identify and implement interventions to help support individuals with issues such as dealing with anxiety, care of someone with cognitive impairment, care of individuals with depression, trauma/post traumatic stress disorder (PTSD) (mental and behavioral disorder that develops from experiencing a traumatic event), other psychiatric diagnoses, intellectual or developmental disabilities. All CNA, CMT, LPN and RNs will do in-servicing and performance reviews;
-Medications and Pain management: Awareness of any limitations of administering medications, administration of medications that residents need by route: oral, nasal, buccal, sublingual, topical, subcutaneous, rectal, intravenous (peripheral or central lines), intramuscular, inhaled (nebulizer), vaginal, ophthalmic (eye), etc. Assessment/management of polypharmacy. Assessment of pain, pharmacological and nonpharmacological pain management. All CMT, LPN and RNs will have ability observed and LPN/RN will have performance review;
-Infection prevention and control: Identification and containment of infections and prevention. All CNA, CMT, LPN and RNs will do education and a return demonstration to observe their ability;
-Management of medical conditions: Assessment, early identification of problems/deterioration, management of medical and psychiatric symptoms and conditions such as heart failure, diabetes, chronic obstructive pulmonary disease (COPD) (lung disorder), gastroenteritis (intestinal infection) , infections such as urinary tract infection (UTI), pneumonia and hypothyroidism. LPN and RNs will do a performance review;
-Therapy: physical therapy, occupational therapy, speech/language, respiratory therapy, management of braces, splints. All CNA, CMT, LPN and RNs will do a return demonstration to observe their ability;
-Other special care needs: Dialysis, hospice, ostomy care and tracheostomy care. All CNA, CMT, LPN and RNs will do a return demonstration to observe their ability;
-Nutrition: Individualized dietary requirements, liberal diets, specialized diets, IV nutrition, tube feeding, cultural or ethnic dietary needs, assistive devices, fluid monitoring or restrictions. All dietary service staff, CNA, CMT, LPN and RNs will do a return demonstration to observe their ability;
-Provide person centered/directed care: Psycho/social/spiritual support: Build relationship with resident/get to know him/her; engage resident in conversation, find out what resident's preferences and routines are; what makes a good day for the resident; what upsets him/her. ALL staff performance review and observed ability;
-Facility conducts monthly in-service meetings with staff. Competency assessments, performance reviews and observed abilities are also completed. Training is conducted based from the assessments and observation results.
-The facility assessment did not identify QAPI training for all staff.
Review of the undated facility, new employee training, showed the following:
-Resident Rights information and signature of acknowledgement;
-Abuse and Neglect prevention and reporting review, short test and signature of acknowledgement;
-Social Media Policy and signature of acknowledgement;
-Company Ethics policy review and signature of acknowledgement;
-Protected Health information agreement;
The new employee training did not include training identified QAPI training for all staff.
1. Review of CNA C's employee education file showed the employee was hired 12/5/17. The employee education file did not contain any evidence of QAPI training.
2. Review of CNA PP's employee education file showed the employee was hired 4/17/23. The employee education file did not contain any evidence of QAPI training.
During an interview on 5/21/24 at 8:10 A.M., the Director of Nursing said the the Social Service Director (SSD) tracked the NA and CNA training. She did not know if anyone kept track of facility wide training other than new hire training.
During an interview on 5/21/24 at 8:25 A.M., the SSD said the following:
-She no longer kept track of CNA or NA training;
-Registered Nurse (RN) Training Coordinator/Minimum Data Set (MDS) Coordinator does all of the CNA training.
-She does not train staff or track facility wide training.
During an interview on 5/21/24 at 1:51 P.M., the RN Training Coordinator/MDS Coordinator said the following:
-She does not do any CNA education or CNA competencies;
-She does not do annual training or competencies for CNAs or for all employees.
During an interview on 5/22/24, at 3:16 P.M., the Business Office Manger (BOM) confirmed the CNA's hire dates, and provided a copy of their training record. She did not have any other training information.
During an interview on 5/23/24 at 6:49 P.M., the Interim Director of Nursing said the facility was trying to implement a computer software training system but that had not been accomplished yet. The facility had no training schedule.
CONCERN
(F)
Potential for Harm - no one hurt, but risky conditions existed
Deficiency F0945
(Tag F0945)
Could have caused harm · This affected most or all residents
Based on interview and record review, the facility failed to maintain an effective training program for all staff, which included training on the standards, policies and procedures for the infection p...
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Based on interview and record review, the facility failed to maintain an effective training program for all staff, which included training on the standards, policies and procedures for the infection prevention and control program, that was appropriate and effective, and as determined by staff need. The facility census was 67.
Review of the Facility Assessment, updated 5/20/24, showed the following staff education and competencies will be shown with each area below:
-Infection prevention and control: Identification and containment of infections, and prevention. All Certified Nurse Assistant (CNA), Certified Medication Technician (CMT), Licensed Practical Nurse (LPN) and Registered Nurses (RN) will do education and a return demonstration to observe their ability;
-Facility conducts monthly in-service meetings with staff. Competency assessments, performance reviews and observed abilities are also completed. Training is conducted based from the assessments and observation results.
Review of the facility new employee training, undated, showed the following:
-Resident Rights information and signature of acknowledgement;
-Abuse and Neglect prevention and reporting review, short test and signature of acknowledgement;
-Social Media Policy and signature of acknowledgement;
-Company Ethics policy review and signature of acknowledgement;
-Protected Health information agreement;
-The new employee training did not include infection control training identified in the facility assessment.
1. Review of CNA C's employee education file showed the employee was hired 12/5/17. The employee education file did not contain any evidence of infection control training or competencies.
2. Review of CNA PP's employee education file showed the employee was hired 4/17/23. The employee education file did not contain any evidence of infection control training or competencies.
During an interview on 5/21/24 at 8:10 A.M., the Director of Nursing said the the Social Service Director (SSD) tracks the NA and CNA training. She does not know if anyone keeps track of facility wide training other than new hire training.
During an interview on 5/21/24 at 8:25 A.M., the SSD said the following:
-She no longer kept track of CNA or NA training;
-Registered Nurse (RN) Training Coordinator/Minimum Data Set (MDS) Coordinator does all of the CNA training.
-She does not complete or track facility wide training.
During an interview on 5/21/24 at 1:51 P.M., the RN Training Coordinator/MDS Coordinator said the following:
-She does not do any CNA education or CNA competencies;
-She does not do annual training or competencies for CNAs or for all employees.
During an interview on 5/22/24 at 3:16 P.M., the Business Office Manger (BOM) confirmed the CNA's hire dates and provided a copy of their training record. She does not have any other training information.
During an interview on 5/23/24 at 6:49 P.M., the Interim Director of Nursing said the following:
-The facility was trying to implement a computer software training system but that had not been accomplished yet;
-There was no training schedule.
CONCERN
(F)
Potential for Harm - no one hurt, but risky conditions existed
Deficiency F0947
(Tag F0947)
Could have caused harm · This affected most or all residents
Based on interview and record review, the facility failed to ensure nurse aides received the required 12 hours of in-service education annually. The facility also did not provide or identify dementia ...
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Based on interview and record review, the facility failed to ensure nurse aides received the required 12 hours of in-service education annually. The facility also did not provide or identify dementia training on the facility assessment. The facility did not provide annual abuse and neglect training. Two of two Certified Nurse Assistants (CNA)s (CNA C, and CNA PP) sampled did not have the required 12 hours of in-service education. The facility census was 67.
Review of the Facility Assessment, updated 5/20/24, showed the following staff education and competencies will be shown with each area below:
-Activities of daily living: Bathing, showers, oral/denture care, dressing, eating, support with needs related to hearing/vision/sensory impairment; supporting resident independence in doing as much of these activities by himself/herself. All Certified Nurse Assistant (CNA), Certified Medication Technician (CMT), Licensed Practical Nurse (LPN) and Registered Nurses (RN) will do a return demonstration to observe their ability;
-Mobility and fall/fall with injury prevention: Transfers, ambulation, restorative nursing, contracture prevention/care; supporting resident independence in doing as much of these activities by himself/herself. All CNA, CMT, LPN and RN's will do a return demonstration to observe their ability;
-Bowel/bladder toileting programs, incontinence prevention and care, intermittent or indwelling or other urinary catheter, ostomy, responding to requests for assistance to the bathroom/toilet promptly in order to maintain continence and promote resident dignity. All CNA, CMT, LPN and RN's will do a return demonstration to observe their ability;
-Skin integrity: Pressure injury prevention and care, skin care, wound care (surgical, other skin wounds). All CNA, CMT, LPN and RN's will do a return demonstration to observe their ability;
-Mental health and behavior: Manage the medical conditions and medication-related issues causing psychiatric symptoms and behavior, identify and implement interventions to help support individuals with issues such as dealing with anxiety, care of someone with cognitive impairment, care of individuals with depression, trauma/post traumatic stress disorder (PTSD) (mental and behavioral disorder that develops from experiencing a traumatic event), other psychiatric diagnoses, intellectual or developmental disabilities. All CNA, CMT, LPN and RNs will do in-servicing and performance reviews;
-Medications and Pain management: Awareness of any limitations of administering medications, administration of medications that residents need by route: oral, nasal, buccal, sublingual, topical, subcutaneous, rectal, intravenous (peripheral or central lines), intramuscular, inhaled (nebulizer), vaginal, ophthalmic (eye), etc. Assessment/management of polypharmacy. Assessment of pain, pharmacological and nonpharmacological pain management. All CMT, LPN and RNs will have ability observed and LPN/RN will have performance review;
-Infection prevention and control: Identification and containment of infections and prevention. All CNA, CMT, LPN and RNs will do education and a return demonstration to observe their ability;
-Management of medical conditions: Assessment, early identification of problems/deterioration, management of medical and psychiatric symptoms and conditions such as heart failure, diabetes, chronic obstructive pulmonary disease (COPD) (lung disorder), gastroenteritis (intestinal infection) , infections such as urinary tract infection (UTI), pneumonia and hypothyroidism. LPN and RNs will do a performance review;
-Therapy: physical therapy, occupational therapy, speech/language, respiratory therapy, management of braces, splints. All CNA, CMT, LPN and RNs will do a return demonstration to observe their ability;
-Other special care needs: Dialysis, hospice, ostomy care and tracheostomy care. All CNA, CMT, LPN and RNs will do a return demonstration to observe their ability;
-Nutrition: Individualized dietary requirements, liberal diets, specialized diets, IV nutrition, tube feeding, cultural or ethnic dietary needs, assistive devices, fluid monitoring or restrictions. All dietary service staff, CNA, CMT, LPN and RNs will do a return demonstration to observe their ability;
-Provide person centered/directed care: Psycho/social/spiritual support: Build relationship with resident/get to know him/her; engage resident in conversation, find out what resident's preferences and routines are; what makes a good day for the resident; what upsets him/her. ALL staff performance review and observed ability;
-Facility conducts monthly in-service meetings with staff. Competency assessments, performance reviews and observed abilities are also completed. Training is conducted based from the assessments and observation results.Training is conducted based from the assessments and observation results;
-The facility assessment did not address dementia or annual resident abuse and neglect prevention training.
1. Review of CNA C's employee education file showed the employee was hired 12/5/17. The employee education file did not contain any evidence of education hours or competencies in the last year. (The only training documented was new hire training 12/5/17 and did not contain any competencies.)
2. Review of CNA PP's employee education file showed the employee was hired 4/17/23. The employee education file did not contain any evidence of education hours or competencies in the last year. (The only training documented was new hire training 4/17/23 and did not contain any competencies.)
3. During an interview on 5/21/24 at 8:10 A.M., the Director of Nursing said the the Social Service Director (SSD) tracked the NA and CNA training hours and competencies.
During an interview on 5/21/24 at 8:25 A.M., the SSD said the following:
-She no longer kept track of CNA or NA training;
-Registered Nurse (RN) Training Coordinator/Minimum Data Set (MDS) Coordinator did all of the CNA training and competencies.
During an interview on 5/21/24 at 1:51 P.M., the RN Training Coordinator/MDS Coordinator said the following:
-She did not do any CNA education or CNA competencies;
-She did not do annual training or competencies for CNAs.
During an interview on 5/22/24 at 3:16 P.M., the Business Office Manger (BOM) confirmed the CNA's hire dates and provided a copy of their training records.
During an interview on 5/23/24 at 6:49 P.M., the Interim Director of Nursing said the following:
-The facility was trying to implement a computer software training system but they had not accomplished that yet;
-There was no training schedule;
-When she was at the facility earlier in the year, she did do observations of staff using gait belts for transfers;
-The facility was documenting when training was completed, but there had been changes to nursing administration since then and she was not sure where the documentation would be or if any of the current staff attended.
CONCERN
(F)
Potential for Harm - no one hurt, but risky conditions existed
Deficiency F0949
(Tag F0949)
Could have caused harm · This affected most or all residents
Based on interview and record review, the facility failed to maintain a training program for all staff, which includes at a minimum, training on behavioral health care and services that was appropriat...
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Based on interview and record review, the facility failed to maintain a training program for all staff, which includes at a minimum, training on behavioral health care and services that was appropriate and effective, as determined by staff need and the facility assessment. The facility census was 67.
Review of the Facility Assessment, updated 5/20/24, showed the following staff education and competencies will be shown with each area below:
-Mental health and behavior: Manage the medical conditions and medication-related issues causing psychiatric symptoms and behavior, identify and implement interventions to help support individuals with issues such as dealing with anxiety, care of someone with cognitive impairment, care of individuals with depression, trauma/post traumatic stress disorder (PTSD) (mental and behavioral disorder that develops from experiencing a traumatic event), other psychiatric diagnoses, intellectual or developmental disabilities. All Certified Nurse Assistant (CNA), Certified Medication Technician (CMT), Licensed Practical Nurse (LPN) and Registered Nurse (RN) will do in-servicing and performance reviews;
-Provide person centered/directed care: Psycho/social/spiritual support: Build relationship with resident/get to know him/her; engage resident in conversation, find out what resident's preferences and routines are; what makes a good day for the resident; what upsets him/her. ALL staff performance review and observed ability;
-Facility conducts monthly in-service meetings with staff. Competency assessments, performance reviews and observed abilities are also completed. Training is conducted based from the assessments and observation results.
All facility staff were not included on the Mental health and behavior training identified on the facility assessment, the facility assessment only identified nursing staff.
Review of the undated facility, new employee training, showed the following:
-Resident Rights information and signature of acknowledgement;
-Abuse and Neglect prevention and reporting review, short test and signature of acknowledgement;
-Social Media Policy and signature of acknowledgement;
-Company Ethics policy review and signature of acknowledgement;
-Protected Health information agreement;
-The new employee training did not include behavioral health training for all staff or for staff identified in the facility assessment.
1. Review of CNA C's employee education file showed the employee was hired 12/5/17. The employee education file did not contain any evidence of education on behavioral health care and services.
2. Review of CNA PP's employee education file showed the employee was hired 4/17/23. The employee education file did not contain any evidence of education on behavioral health care and services.
During an interview on 5/21/24 at 8:10 A.M., the Director of Nursing said the the Social Service Director (SSD) tracked the NA and CNA training. She did not know if anyone kept track of facility wide training other than new hire training.
During an interview on 5/21/24 at 8:25 A.M., the SSD said the following:
-She no longer kept track of CNA or NA training;
-Registered Nurse (RN) Training Coordinator/Minimum Data Set (MDS) Coordinator did all of the CNA training.
-She does not do or track facility wide training.
During an interview on 5/21/24 at 1:51 P.M., the RN Training Coordinator/MDS Coordinator said the following:
-She does not do any CNA education or CNA competencies;
-She does not do annual training or competencies for CNAs or for all employees.
During an interview on 5/22/24 at 3:16 P.M., the Business Office Manger (BOM) confirmed the CNA's hire dates and provided a copy of their training record. She does not have any other training information.
During an interview on 5/23/24 at 6:49 P.M., the Interim Director of Nursing said the following:
-The facility was trying to implement a computer software training system but they had not accomplished that yet;
-There was no training schedule.
MINOR
(C)
Minor Issue - procedural, no safety impact
Deficiency F0582
(Tag F0582)
Minor procedural issue · This affected most or all residents
**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on record review and interview, the facility failed to give appropriate Centers of Medicare and Medicaid Services (CMS) Sk...
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**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on record review and interview, the facility failed to give appropriate Centers of Medicare and Medicaid Services (CMS) Skilled Nursing Facility (SNF) Advance Beneficiary Notice (ABN) (CMA-10055) in writing to one Resident (Resident #63) reviewed when the facility initiated discharge from Medicare Part A services and the resident remained in the facility. The facility census was 67.
Review of the facility undated admission agreement related to ABN showed when a resident is not covered Medicare Part A because daily skilled service is not needed:
1. Approval of Quality Assurance Nurse is required;
2. SNF-ABN (form CMS-10055) is issued;
3. Generic notice of Medicare Non-Coverage (form CMS-10123) is issued.
Review of the SNF Notices of Non-Coverage Cheat Sheet, date 3/19/14, provided by the facility as their policy for ABN, showed if a beneficiary drops to a non-skilled level of care, benefits have not exhausted, and the beneficiary remains in the facility, the facility is to provide the SNF-ABN and Notice of Medicare Provider Non-Coverage (CMS-10123) no later than two days before covered services end.
1. Review of Resident #63's face sheet showed the resident admitted to the facility on [DATE] from an acute care hospital.
Review of the resident's medical record showed the resident admitted on [DATE] and received skilled services. The resident discharged from skilled services on 11/23/23 and remained in the facility with a different pay source. (Review showed no documentation the facility provided the resident with the SNF-ABN when his/her skilled services were ending and he/she remained in the facility.)
During an interview on 5/22/24 at 12:15 P.M. the Social Services Designee said the following:
-Nursing does the Medicare discharge notices;
-She was not aware that she had to complete the notices and she did not complete one.
During an interview on 5/22/24 at 12:20 P.M., the Administrator said he expected staff to issue an SNF-ABN notice in a timely manner and per the facility policy.
MINOR
(C)
Minor Issue - procedural, no safety impact
Transfer Notice
(Tag F0623)
Minor procedural issue · This affected most or all residents
Based on interview and record review, the facility failed to provide a notice of transfer to the resident and/or resident representative when one additional resident (Resident #6) and one closed recor...
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Based on interview and record review, the facility failed to provide a notice of transfer to the resident and/or resident representative when one additional resident (Resident #6) and one closed record (Resident #56), were transferred to the hospital. The facility census was 67.
1. Review of Resident #6's face sheet showed he/she was his/her own person.
Review of the resident's progress notes, dated 4/5/23 at 9:13 P.M., showed staff documented the resident came to the nursing station holding his/her chest and complaining of chest pain, left jaw pain, and left arm pain at 7:40 P.M. Vitals were taken, physician and assistant director of nursing (ADON) called, and 911 called for ambulance. The resident left the facility at 8:05 P.M. via ambulance. When asking the resident who he/she wanted staff to contact, he/she said, no one at this time. The resident was taken to the hospital.
Review of the resident's progress notes, dated 4/7/23 at 2:40 P.M., showed the resident returned to facility via public transport from the hospital.
Review of the resident's progress notes, dated 12/08/23 at 8:09 A.M., showed the resident reported having suicidal idealizations with a plan. The resident will be evaluated at the hospital. The resident was transported to the hospital.
Review of the resident's progress notes, dated 12/09/23 at 12:23 P.M., showed the resident was being sent back to the facility.
Review of the resident's medical record showed no documentation facility staff provided the resident with a written notice of transfer when the resident was transferred to the hospital on 4/7/23 and 12/8/23.
During an interview on 5/23/24 at 1:15 P.M., the resident said the facility never gave him/her any type of paperwork when he/she transferred to a hospital.
2. Review of Resident #56's face sheet showed the resident was his/her own person.
Review of the resident's progress notes dated 5/11/24 at 5:23 A.M. showed the resident was found on the floor and complained of extreme pain with bleeding from the head/face area. 911 called and the resident sent to a local hospital.
Review of the resident's medical record showed no documentation facility staff provided the resident with a written notice of transfer when the resident was transferred to the hospital on 5/11/24.
During an interview on 5/23/24 at 2:11 P.M., Licensed Practical Nurse (LPN) A said he/she did not have any knowledge of what to do with a discharge letter. He/She only sent a transfer sheet, face sheet, medication list, and code status with the residents when they were sent to the hospital.
During an interview on 5/23/24 at 2:15 P.M., LPN B said he/she did not have any information regarding the discharge policy.
During an interview on 5/23/24 at 2:24 P.M. the Social Services Designee (SSD) said the following:
-The nurses were supposed to do the discharge letters;
-Nursing staff sent Resident #56 to the hospital. The nurses were supposed to do the letters, as they were the ones who sent the residents out.
During interview on 5/21/24 at 1:26 P.M. and on 5/23/24 at 2:05 P.M. and 3:04 P.M., the Director of Nursing
(DON) said the following:
-The discharge letters should be in the resident's hard charts or uploaded into the Electronic Medical Record (EMR).
-The charge nurses do not know about the discharge/transfer notices;
-She expected the social services director to complete the transfer/discharge notices;
-The discharge notice was not completed for Resident #56. His/Her condition was so bad, she informed the nurses not to worry about it. Social Services should have followed up the next day and completed the discharge letter. This was not done.
MINOR
(C)
Minor Issue - procedural, no safety impact
Deficiency F0625
(Tag F0625)
Minor procedural issue · This affected most or all residents
Based on interview and record review, the facility failed to inform residents and/or legal representatives of their bed hold protocol at the time of transfer for one additional resident (Resident #6) ...
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Based on interview and record review, the facility failed to inform residents and/or legal representatives of their bed hold protocol at the time of transfer for one additional resident (Resident #6) and one closed record (Resident #56), who were transferred to the hospital. The facility census was 67.
Review of the undated facility policy for Bed Hold Policy Guidelines showed this facility will notify all residents and/or their representative of the bed hold policy guidelines. This notification shall be given upon admission to the facility, at the time of transfer to the hospital or leave, and at the time of non-covered therapeutic leave.
1. Review of Resident #6's face sheet showed he/she was his/her own person.
Review of the resident's progress notes, dated 4/5/23 at 9:13 P.M., showed the resident came to nursing station holding his/her chest and complaining of chest pain, left jaw pain, and left arm pain at 7:40 P.M. Vitals were taken, physician and assistant director of nursing (ADON) called, and 911 called for ambulance. The resident left the facility at 8:05 P.M. via ambulance. When asking the resident who he/she wanted staff to contact, he/she said, no one at this time. The resident was taken to the hospital.
Review of the resident's progress notes, dated 4/7/23 at 2:40 P.M., showed the resident returned to facility from the hospital.
Review of the resident's progress notes, dated 12/08/23 at 8:09 A.M., showed the resident reported having suicidal idealizations with a plan. The resident will be evaluated at the hospital. The resident was transported to the hospital.
Review of the resident's progress notes, dated 12/09/23 at 12:23 P.M., showed the resident was being sent back to the facility.
Review of the resident's medical record showed no documentation facility staff provided the resident with a written notice of the bed hold policy when the resident was transferred to the hospital on 4/7/23 and 12/8/23.
During an interview on 5/23/24 at 1:15 P.M., the resident said the facility never gave him/her any type of paperwork when he/she transferred to a hospital.
2. Review of Resident #56's face sheet showed the resident was his/her own person.
Review of the resident's progress notes, dated 5/11/24 at 5:23 A.M., showed the resident was found on the floor and complained of extreme pain with bleeding from the head/face area. Staff called 911 and the resident was sent to a local hospital.
Review of the resident's medical record showed no documentation facility staff provided the resident with a written notice of the bed hold policy when the resident was transferred to the hospital on 5/11/24.
During an interview on 5/23/24 at 2:11 P.M., Licensed Practical Nurse (LPN) A said the following:
-He/She did not have any knowledge of what to do with a bed hold policy.
-He/She only sent a transfer sheet, face sheet, medication list, and code status with the resident when they were sent to the hospital.
During an interview on 5/23/24 at 2:15 P.M., LPN B said he/she did not have any information about a bed hold letter.
During an interview on 5/23/24 at 2:24 P.M., the Social Services Designee (SSD) said the following:
-The nurses were supposed to do the bed hold letters;
-Nursing staff sent Resident #56 to the hospital. The nurses were suppose to do the letters, as they are the ones who were sending out the residents.
During interview on 5/21/24 at 1:26 P.M. and on 5/23/24 at 2:05 P.M., the Director of Nursing ( DON) said the following:
-The bed hold letters should be in the resident's hard charts or uploaded into the Electronic Medical Record (EMR).
-If the resident is capable, the nurses will give them the bed hold notice and have the resident sign it before they are sent to the hospital. If the resident is not able to sign, the nurses should make a note in the medical record that the resident was unable to sign. This is then given to the Social Services to follow up. She was not sure if they were doing this.
-The bed hold letter was not completed for Resident #56. His/Her condition was so bad, she informed the nurses not to worry about it. Social Services should have followed up the next day and completed the bed hold letter. This was not done.
-The bed hold policy was not signed at times due to the resident's condition at the time of transfer.
MINOR
(C)
Minor Issue - procedural, no safety impact
Staffing Information
(Tag F0732)
Minor procedural issue · This affected most or all residents
Based on observation and interview, the facility failed to post required nurse staffing information, which included the facility name, total actual hours worked by both licensed and unlicensed nursing...
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Based on observation and interview, the facility failed to post required nurse staffing information, which included the facility name, total actual hours worked by both licensed and unlicensed nursing staff to include Registered Nurses (RN), Licensed Practical Nurses (LPN), Certified Nurse Assistants (CNA)s directly responsible for resident care and the resident census on a daily basis. The facility census was 67.
Request was made for a facility policy regarding posted staffing and none was provided.
1. Observation on 5/19/24 at 3:34 P.M., showed the following:
-Dry erase board at the nursing station, dated 5/18/24, with two names under nurses and one name beside Certified Medication Technician (CMT), a name at the bottom of the board and five more names without labels;
-The dry erase board did not include the facility name, staff titles, actual hours worked or the facility census;
-There was also a binder at the desk that was not where residents and visitors could see it;
-The binder had staff and hours scheduled, but it did not show the facility name, the census or the titles of the staff, just first names of staff.
Observation on 5/20/24 at 3:04 P.M., showed the following:
-Dry erase board at the nursing station with two names under nurses, and one name beside CMT and six more names without labels;
-The dry erase board did not include the facility name, staff titles, actual hours worked,or the facility census;
-There was also a binder at the desk that was not where residents and visitors could see it;
-The binder had staff and hours scheduled, but it did not show the facility name, the census or the titles of the staff, just first names of staff.
Observation on 5/21/24 at 10:14 A.M., showed the following:
-Dry erase board at the nursing station with one name with RN written beside it, two names under nurses and one name beside CMT and six more names without labels;
-The dry erase board did not include the facility name, staff titles, actual hours worked or the facility census;
-There was also a binder at the desk that was not where residents and visitors could see it;
-The binder had staff and hours scheduled, but it did not show the facility name, the census or the titles of the staff, just first names of staff.
During the survey entrance conference on 5/19/24, the state agency (SA) requested staffing sheets for the prior month. The facility had to research agency staff and payroll data to accurately complete the staffing sheets for review to show which staff accurately worked. The SA did not receive the staffing sheets until 5/22/23.
During an interview on 5/23/24 at 6:49 P.M., the Director of Nursing said the staff posting should be posted by the front door where everyone can see it and have all the required information (facility name, census, total numbers and hours of staff working directly with residents for RN, LPN, CMT and CNA's for each shift).
MINOR
(C)
Minor Issue - procedural, no safety impact
Deficiency F0847
(Tag F0847)
Minor procedural issue · This affected most or all residents
Based on interview and record review, the facility failed to ensure two additional sampled resident s (Resident #34 and #48), fully understood the binding arbitration agreement (a private process wher...
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Based on interview and record review, the facility failed to ensure two additional sampled resident s (Resident #34 and #48), fully understood the binding arbitration agreement (a private process where disputing parties agree that one or several individuals can make decisions about the dispute after receiving evidence and hearing arguments) prior to signing the agreement. Additionally the facility failed to ensure required elements for the binding arbitration agreement were part of the facility policy. The facility census was 67.
Review of the undated facility admission packet showed the following:
-Alternative Dispute Resolution Addendum: All claims, disputes, and controversies arising out of or in any manner relating, directly or indirectly, to the resident's care of stay that the facility (in each case, a dispute) shall be subject to certain alternative dispute resolution procedures that must be exhausted prior to pursuing any other remedy that may be available. Those required alternative dispute resolution procedures are: (a) mandatory non-binding mediation; and (B) mandatory non-binding appeal arbitration;
-Each party agrees that compliance with the requirements of the addendum shall be a condition precedent to its right to assert any claims with respect to a dispute in any other form;
-Mandatory Non-Binding Mediation: If there is a dispute, the party claiming the existence of a dispute must make written demand for mediation prior to instituting a lawsuit, action or arbitration proceeding. Mediation of any dispute must be attempted in good faith;
-The mediation shall be conducted in the county where the facility is located, unless another location is mutually agreed upon by the parties. The cost and expenses of mediation, with the exception of the costs and expenses relating to investigation, representation and case presentation on behalf of the resident, shall be borne by the facility;
-The mediator shall be chosen by joint agreement of the resident and the facility. In the even an agreement cannot be reached with respect to a mediator, either party may request that Judicial Arbitration and Mediation Services, Inc. or it successor appoint a mediator. Selection of the mediator by its successor shall be binding on the resident and the facility;
-Mandatory Non-Binding Appealable Arbitration: Should mandatory non-binding mediation of the dispute be unsuccessful, it is agreed that the dispute shall be submitted to non-binding appealable arbitration in accordance with the Health Care Clams Settlement Procedures, as promulgated, amended and administered by the American Arbitration Association;
-All arbitration hearings conducted hereunder shall take place in the county where the facility is located. The hearing before the arbitrator(s) of the matter to be arbitrated shall be at the time and place within said county as selected by the arbitrator(s);
-The decision of the arbitrator(s) with respect to a dispute shall be non-binding and appealable to a court having jurisdiction;
-This contract contains an arbitration provision. This may be enforced by the parties.
Review of the facility provided admission agreement showed the arbitration agreement did not include:
-The resident or his/her representative is not required to enter into the agreement as a condition of admission to the facility or as a requirement to continue to receive care;
-Did not include language which prohibited or discouraged the resident or representative from communicating with federal, state, or local officials;
-The resident or his/her representative has the right to rescind the agreement within 30 calendar days of signing the agreement.
During an interview on 05/23/24, at 3:31 P.M., Resident #34 said the following:
-He/She was his/her own responsible party;
-He/She knew what arbitration meant but was unsure if he/she signed any agreement and the facility had not specifically explained anything to him/her about arbitration.
During an interview on 05/23/24, at 3:20 P.M., Resident #48 said the following:
-He/She has been at the facility for eight or nine months;
-He/She was his/her own responsible party;
-He/She understood what arbitration was, but was unsure if she specifically signed an agreement;
-He/She signed a lot of papers and did not recall a staff member specifically discussing the arbitration agreement with him/her.
During an interview on 05/23/24, at 3:48 P.M., the Social Service Designee said the following:
-She has been doing social services and admission packets since September 2023;
-She was responsible for completing the admission packet that included the arbitration agreement;
-Arbitration meant if there was an outstanding bill or something like that, that it will go to court;
-She tells the residents if they don't understand something that she will explain it in more detail;
-She explains the process during the admission process;
-She uses the form the company provides for the arbitration agreement signatures;
-She was unaware of any specific components that are required to be listed on the arbitration agreement.
The SSD did not provide requested documentation from Resident #34 and #48's admission packet to show what the residents may or may not have signed.
During an interview on 05/23/24, at 4:20 P.M., the Administrator said the following:
-He is not aware of what the arbitration agreement is, he just learned that term during the facility's annual survey;
-Social services would be responsible for getting the arbitration agreement signed;
-He is unaware of what components exactly needs to be listed on the agreement.
Mar 2024
6 deficiencies
3 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
Based on interview and record review, the facility failed to ensure one resident (Resident #1), in a review of 10 residents was free from abuse when Certified Medication Technician (CMT) B yelled and ...
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Based on interview and record review, the facility failed to ensure one resident (Resident #1), in a review of 10 residents was free from abuse when Certified Medication Technician (CMT) B yelled and cussed directly at the resident and told the resident he/she was just going to have to fucking wait, wagged his/her finger in Resident #1's face and lunged at the resident. Resident #1 said he/she felt threatened, frightened and abused. The facility census was 70.
Review of the facility undated Abuse Policy showed the following:
-It was the policy of the facility that each resident would be free from abuse. Abuse could include verbal, mental, sexual or physical abuse, misappropriation of resident property and exploitation, corporal punishment or involuntary seclusion. Additionally, residents would be protected from abuse, neglect, and harm while they were residing at the facility. No abuse or harm of any type would be tolerated and residents and staff would be monitored for protection;
-Abuse was the willful infliction of injury, unreasonable confinement, intimidation, or punishment with resulting physical harm, pain or mental anguish. Abuse also included deprivation by an individual including a caretaker, of goods or services that were necessary to attain or maintain physical, mental and psychosocial well-being. Instances of abuse of all residents, irrespective of any mental or physical condition, caused physical harm, pain or mental anguish. It included verbal abuse, sexual abuse, physical abuse and mental abuse. Willful meant the individual must have acted deliberately, not that the individual must have intended to inflict injury or harm;
-Verbal abuse was defined as the use of oral, written or gestured language that willfully included disparaging and derogatory terms to residents or their families or within their hearing distance, regardless of their age, ability to comprehend, or disability;
-Mental abuse included but not limited to, humiliation, harassment, threats of punishment or deprivation.
1. Review of the resident's Physician Order Sheet dated 9/21/23, showed an order for hydrocodone/acetaminophen (narcotic pain medication) 7.5 milligrams (mg)/325 mg one tablet four times daily at 6:00 A.M., 12:00 P.M., 6:00 P.M. and 12:00 P.M. for pain.
Review of the resident's care plan dated 10/18/23 showed the following:
-Diagnoses of pain, edema (swelling of tissues in the legs), right and left leg cellulitis (infected tissue), below knee amputation (removal of leg below the knee), sciatica (pinched nerve causing nerve pain), and arthritis;
-The resident had potential for acute or chronic pain or discomfort. Staff should administer medications as ordered, monitor and record effectiveness, allow uninterrupted rest periods, assess effects of pain (disturbances in sleep, activity, self-care, appetite, psychosocial), monitor and record any complaints of pain, alleviating and aggravating factors.
Review of the resident's quarterly Minimum Data Set (MDS) a federally mandated assessment instrument, completed by facility staff, dated 2/29/24 showed the following:
-Cognitively intact;
-No physical or verbal behaviors;
-Received scheduled and as needed pain medications for frequent pain and occasionally disrupted the resident's sleep and day to day activities.
Review of the facility Self-Report investigation dated 3/20/24 showed the following:
-On 3/20/24 at 6:10 P.M. a verbal dispute with name calling happened between Certified Medication Technician (CMT) B and Resident #1. The language and action of CMT B was abusive and the resident felt threatened. CMT B was asked to give a statement and walked out of the facility;
-There was no question the verbal abuse happened. The resident reported being physically in fear.
During an interview on 3/26/24 at 10:35 A.M. the resident said the following:
-On 3/20/24 at 6:20 P.M. he/she asked CMT B for his/her pain medication that was scheduled for 6:00 P.M. CMT B got upset, was crabbing about it and said there were 75 people here and he/she could not get everyone's medications at the same time. CMT B said Resident #1 was just going to have to fucking wait and wagged his/her finger in Resident #1's face. CMT B cussed, said fuck several times and put his/her finger in Resident #1's face and lunged at the resident;
-Resident #1 moved away from CMT B's medication cart, CMT B threw his/her keys and an ink pen almost hitting another resident (unknown resident) with the ink pen. CMT B went down the hall saying he/she was not going to fucking deal with any of these people;
-Resident #1 got upset when CMT B argued with him/her and felt threatened when CMT lunged at him her, and wagged his/her finger in the resident's face. It felt abusive at that moment.
Review of the resident's written statement dated 3/20/24 showed the following:
-Resident #1 asked CMT B for a pain pill. CMT B said it would be a minute and Resident #1 told CMT B he/she would be at the nurses' desk. Resident #1 heard CMT B say there were 75 other residents and he/she was not going to give Resident #1 his/her pain pill yet, CMT B would give the pain pill with the resident's other medications at 8:00 PM;
- Resident #1 had a scheduled pain pill every six hours and if not received until 8:00 PM it would be two hours late. Resident #1 asked nicely and then CMT B and Resident #1 raised their voices and cussed saying the F word. At one point it was a little threatening when CMT B lunged forward at Resident #1. Resident #1 thought CMT B was going to hit him/her. If CMT B would have given Resident #1 his/her pain pill none of this would have happened.
During an interview on 3/27/24 at 9:15 A.M. Certified Nurse Assistant (CNA) D said the following:
-CNA D was at the nurses' desk and saw Resident #1 at CMT B's medication cart. CMT B snapped and yelled at Resident #1 he/she could fucking wait. Resident #1 told CMT B he/she did not understand why he/she needed to wait until 8:00 PM to get his/her pain medication;
-CMT B screamed at the resident, said fuck directly at Resident #1, and was in Resident #1's face. CMT B verbally abused Resident #1;
-CMT B threw his/her ink pen and almost hit another resident while yelling at Resident #1;
-CMT B went outside the facility, came back after 10 minutes and took the medication cart down the hall.
Review of CNA D's written statement dated 3/21/24 showed the following:
-On 3/20/24 at 6:15 P.M. CNA D was at the nurses' desk and heard Resident #1 ask CMT B for pain medication. CMT B told Resident #1 he/she needed to fucking wait until CMT B came down Resident #1's hall and CMT B was not going to give Resident #1 his/her medication right now;
-Resident #1 kept asking for his/her medication and said he/she did not understand why he/she could not get the medication right then. Resident #1 said he/she did not want to wait until after 8:00 P.M. to get the medication;
-CMT B started yelling and said Resident #1 could wait and learn to respect CMT B and not be disrespectful;
-CMT B and Resident #1 argued and cussed at each other for three to five minutes straight;
-Resident #1 left the situation and CMT B threw down his/her ink pen on the medication cart and the pen bounced and almost hit another resident. CMT B walked out of the facility.
During an interview on 3/26/24 at 12:30 P.M. Licensed Practical Nurse (LPN) E said the following:
-On 3/20/24 around 6:00 P.M., Resident #1 and two other residents waited near the medication cart and CMT B put his/her hands in the air and said they are sitting here waiting on medication. CMT B said he/she liked to give the residents all the evening medications at once;
-Resident #1 asked for his/her pain medication and CMT B went off, said he/she would give the pain medication later and raised his/her voice towards Resident #1. CMT B yelled at Resident #1, argued with the resident and threw his /her ink pen, slammed the medication cart and said I am done. CMT B walked outside the facility;
-Yelling at the resident was abuse. CMT B verbally abused Resident #1.
Review of LPN E's written statement dated 3/20/24 showed the following:
-On 3/20/24 at 6:15 P.M. LPN E witnessed CMT B yell at Resident #1. Resident #1 sat by the medication cart and asked CMT B for his/her pain medication;
-CMT B yelled and explained in a hateful manner that CMT B was not going to give the resident his/her medications right now and the resident had to wait;
-Resident #1 got very upset with CMT B. CMT B yelled and screamed at Resident #1, threw his/her ink pen and walked out of the facility.
Review of LPN C's written statement dated 3/20/24 showed the following:
-On 3/20/24 at 6:15 P.M., CMT B came up from E-hall and said he/she was getting pissed. LPN C asked why and CMT B said because of this and pointed to Resident #1 sitting next to the medication cart waiting for his/her pain medication;
-When CMT B got to the medication cart, Resident #1 asked for his/her medications. CMT B said not yet, when I get to you. Resident #1 replied, I am not waiting until 8:00 or 9:00, I need my medication now, you (CMT B) gave everyone else their medication when they came to the medication cart. CMT B yelled I do not!. CMT B continued to yell back and forth with Resident #1, cussing at the resident and in general. CMT B was approximately one to two feet away from the resident the entire time;
-CMT B began throwing ink pens, keys and yelling I am done! CMT B walked outside to take a break and came back in the facility approximately 10 minutes later. CMT B went to his/her medication cart and took the medication cart down the hallway to continue with the medication pass.
During an interview on 3/26/24 at 12:00 P.M. the Social Services Designee (SSD) said the following:
-He/She heard yelling and screaming near the nurses' desk that got intense. CMT B was at the medication cart with Resident #1. CMT B threw his/her pen and said to Resident #1, fuck this shit, I quit. CMT B went out the facility door;
-Resident #1 said he/she asked CMT B for his/her pain medication, CMT B got in Resident #1's face, cussed at the resident and Resident #1 said he/she was afraid;
-CMT B was verbally abusive to Resident #1.
Review of the Social Services Designee (SSD) written statement dated 3/21/24 showed the following:
-At 6:15 P.M. he/she was in the dining room area and heard two people yelling and shouting at each other. The SSD went to the nurses' desk area, where CMT B was yelling and threw his/her ink pen that flew past the SSD's face and hit the wall. At that time CMT B said he/she quit and walked out of the facility.
During an interview on 3/29/24 at 3:10 P.M. the Director of Nurses (DON) said CMT B was verbally abusive to Resident #1. CMT B should not have yelled and cussed at the resident. The resident felt threatened by CMT B.
During an interview on 3/29/24 at 3:20 P.M. the Administrator said CMT B verbally abused Resident #1 and threatened the resident. CMT B should not have cussed or yelled at the resident for any reason. CMT B was suspended that same day and was terminated due to verbal abuse of a resident.
MO #00233510
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
Quality of Care
(Tag F0684)
A resident was harmed · This affected 1 resident
**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, interview and record review, the facility failed to ensure one resident (Resident #3), in a review of 10 s...
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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 (Resident #3), in a review of 10 sampled residents, received care and treatment in accordance with professional standards of practice to meet the resident's physical, mental and psychosocial needs. Staff failed to assess the resident, notify the physician and obtain treatment following a change in condition when the resident had ongoing diarrhea, vomiting and increased weakness. The resident required hospitalizaiton for a hypokalemia (a critically low potassium level which can be life threatening), and moisture related skin breakdown. Upon return to the facility, staff failed to ensure supplemental potassium medication and a nutritional supplement were obtained and administered as ordered. Staff also failed to provide incontinence care and provide appropriate care and services to ensure known moisture related skin breakdown treatment was implemented, and failed to ensure safe transfers of the resident from the wheelchair to bed. The facility census was 70.
Review of the facility's Resident Condition Change Policy dated March 2015 showed the purpose was to observe, record and report any condition change to the attending physician so proper treatment can be implemented.
Review of the undated facility policy Medication Administration showed the following:
-Medications are given to benefit a resident's health as ordered by the physician;
-Administer medications as ordered by the physician.
Review of the undated facility policy Wound Care and Treatment showed the following:
-It was the purpose of the facility to prevent and treat all wounds;
-Prevention strategies included on-going skin assessment with weekly documentation of status, minimize dry skin, apply house moisturizer to areas of dry skin , after bath and as needed. Minimize friction and sheer through proper positioning, transferring and turning. Develop and implement method of communicating position changing;
-Incontinence management included minimize skin exposure to incontinence. Cleanse skin following each episode of incontinence.
Review of the facility's undated policy Gait Belt Use showed the following:
-Purpose: To provide better control and balance while assisting resident with ambulation and transfer;
-Guidelines: Assist the resident to a sitting position, apply belt to resident's waist - tighten to fit snugly with the buckle at the back side, face the resident, bend your knees and place your hands around the gait belt on each side of the resident's waist Bring the resident to a standing position while straightening your knees, after the resident is standing, the belt provides assistance stabilizing the turning the resident.
1. Review of Resident #3's care plan dated 12/14/23 showed the following:
-Diagnoses of Alzheimer's, osteoarthritis, pain in legs, atrial fibrillation (irregular heart rhythm that caused poor blood flow and risk of blood clots) and cardiac arrythmia (irregular heart rythym) ;
-Potential for pain. Staff should administer medications as ordered, monitor and record effectiveness, encourage sufficient uninterrupted rest periods, assist with comfort and physical support as necessary, avoid undue stress and irritation to joints;
-Risk of skin breakdown related to incontinence and limited mobility. Staff should apply barrier cream, encourage to lay down in the afternoon, assist with toileting and hygiene, keep the resident clean and dry.
Review of the resident's Physician Order Sheet (POS) dated 2/1/24 showed the following:
-Lasix (medication used to treat fluid retention, remove excess fluid by stimulating the kidneys to produce more urine. Lasix also removes potassium from the body) 20 milligrams (mg) daily;
-Eliquis (a blood thinning medication used to prevent the development of blood clots) 5 mg twice daily;
-Imodium (medication used to treat diarrhea) 2 mg, give 2 tablets as needed after first episode of diarrhea, then 1 tablet after each loose stool, not to exceed 6 tablets in 24 hours;
-Zofran (medication used to treat nausea) 4 mg every 6 hours as needed for nausea.
Review of the resident's skin assessment dated [DATE] showed staff documented the resident's skin was intact.
Review of the resident's nurses note dated 2/21/24 showed staff documented the following:
-At 3:53 P.M. the resident's family called to say the resident was struggling with nausea and acid reflux daily. The resident was more confused than usual and requested a urinalysis (a diagnostic lab procedure used to determine urinary changes and infection). Staff notified the physician and awaited new orders;
-At 4:40 P.M., physician order received for urinalysis, physician's staff would call back with new orders pertaining to nausea and acid reflux.
Review of the resident's record showed no documentation staff obtained a urine sample as ordered. There was no documentation of urinalysis laboratory results (ordered on 2/21/24).
Review of the resident's POS dated 2/23/24 showed an order for Prevacid (medication used to treat gastric reflux) 30 mg twice daily.
Review of the resident's Medication Administration Record (MAR) dated 2/23/24 through 2/29/24, showed staff did not administer Prevacid 30 mg twice daily as ordered and noted the medication was not available.
Review of the resident's record showed no documentation staff notified the physician the Prevacid 30 mg twice daily was not administered from 2/23/24 through 2/29/24.
Review of the resident's MAR for 3/10/24 staff did not document administration of Eliquis 5 mg evening dose.
Review of the resident's record showed no documentation staff notified the physician the Eliquis 5 mg was not administered as ordered for the evening dose on 3/10/24.
Review of the resident's quarterly Minimum Data Set (MDS) a federally mandated assessment instrument, completed by facility staff, dated 3/13/24, showed the following:
-Severely impaired cognition;
-Required substantial staff assistance (staff does more than half the effort) with toileting hygiene, showers, dressing, and personal hygiene;
-Independent in bed mobility and transfers;
-Independently mobile in a wheelchair;
-Frequently incontinent of bladder;
-Always continent of bowel;
-At risk for pressure ulcers, no current pressure ulcers or other open wounds or moisture associated skin damage.
Review of the resident's MAR dated 3/16/24 showed staff did not document administration of Eliquis 5 mg evening dose.
Review of the resident's record showed no documentation staff notified the resident's physician Eliquis 5 mg was not administered on 3/16/24 for the evening dose.
Review of the resident's MAR dated 3/20/24 at 6:45 A.M. showed staff documented Zofran 4 mg administered for nausea with some relief of nausea as the result.
Review of the resident's nurses' notes showed no documentation or assessment indicating the resident had nausea.
Review of the resident's MAR showed staff did not document administration of Eliquis 5 mg evening dose on 3/20/24 and 3/21/24.
Review of the resident's record showed no documentation staff notified the resident's physician Eliquis 5 mg was not administered on 3/20/24 and 3/21/24 for the evening doses.
Review of the resident's MAR dated 3/21/24 at 12:10 P.M. showed staff documented Imodium 2 mg administered for loose stools. Staff did not document the result following administration.
Review of the resident's nurses' notes showed no documentation or assessment regarding the resident's diarrhea.
Review of the resident's nurses noted dated 3/24/24 showed staff documented the following:
-At 3:51 P.M. family visiting and reported the resident had loose stools for the past week. The Imodium was not helping. The resident had loss of appetite and seemed more confused. Staff called the physician for new physician orders;
-At 4:17 P.M. a urine specimen was collected pending any new physician orders;
-At 5:38 P.M. the resident was listless, vomited and family said the resident's speech was slower than normal. The physician was notified with orders to send the resident to the emergency room. The resident was transported by the family to the emergency room.
Review of the resident's urinalysis report obtained by the facility and dated 3/24/24 showed the following:
-Nitrite (indicated evidence of bacteria in the urine), result positive (normal negative);
-WBC (White Blood Cell, indicated infection), result 6-20 (normal less than 6);
-Epithelial Cell (cells that cover the inside of the organ, when present in a urine sample indicated infection), result few (normal negative);
-Bacteria (organisms), result TNTC (too numerous to count, indicating a large amount of bacteria, normal negative);
-Culture (diagnostic lab procedure used to identify the type of bacteria causing an infection) indicated and completed 3/28/24 with Escherichia coli (bacteria normally present in the intestines, frequent cause of urinary tract infections) confirmed organism.
Review of the resident's hospital emergency room report dated 3/24/24 showed the following:
-Presented to the emergency room with nausea, vomiting, diarrhea and slurred speech;
-Symptoms began earlier in the week. Family noted slurring of the resident's speech while talking on the phone two days previously;
-Resident complained of nausea, vomiting and multiple episodes of diarrhea. Vomiting was described as dry heaving with vomitus of mostly sputum. Diarrhea was watery and brown;
-Critically low (life threatening) potassium (a type of electrolyte or mineral required to help nerves to function and muscles to contract including the heart muscle. Low potassium can be caused by medications such as Lasix, diarrhea and vomiting, a large drop in blood potassium level can cause abnormal heart rhythms and a very low blood potassium level can cause the heart to stop), level of 1.6 (3.6 to 5.2 normal range);
-Intravenous (IV) and oral (by mouth) potassium as well as magnesium (a mineral that helps maintain a normal heart rhythm) bolus administered (a large dose);
-Clinical impression of nausea, vomiting and diarrhea, hypokalemia (low blood potassium level), dysarthria (weakness in the muscles used for speech, slowed or slurred speech);
-Transfer to another hospital for further management and admit to Intensive Care Unit (ICU).
Review of the resident's hospital admission record dated 3/25/24 showed moisture associated skin damage of the buttocks, coccyx (tailbone area), groin and perineal skin folds. All areas beefy red.
Review of the resident's hospital discharge records dated 3/28/24 showed the following:
-Apply barrier paste to coccyx twice daily and as needed after soiling or incontinence. Cleanse the area and reapply the barrier where needed to provide protection;
-While up in the chair, alternate lifting hips or prop on pillow alternating every 15 minutes, while in bed turn every two hours;
-Start taking potassium bicarbonate-citric acid (Effer-K, potassium supplement)10 milliequivalents (mEq), effervescent (dissolving powder causes bubbles), take 30 mEq twice daily;
-Start taking Ensure MAX protein (nutritional supplement) twice daily.
Review of the resident's POS dated 3/28/24 showed the following:
-Effer-K 10mEq, administer 30mEq twice daily;
-Ensure MAX protein twice daily.
Review of the resident's POS showed no physician's order for barrier cream to the coccyx twice daily and as needed after soiling or incontinence.
Review of the resident's skin assessment dated [DATE] at 3:39 P.M. showed staff documented excoriation to the buttocks and inner thighs.
Review of the resident's MAR showed the following:
-On 3/28/24 staff documented the Effer-K 30mEq evening dose was not administered, medication not available;
-On 3/28/24 staff documented Ensure MAX protein evening dose was not administered, the supplement was not available;
-On 3/28/24 staff documented Eliquis 5 mg evening dose was not administered;
-On 3/29/24 staff documented Effer-K 30mEq morning dose was not administered, medication not available;
-On 3/29/24 staff documented Ensure MAX protein evening dose was not administered, the supplement was not available.
During an interview on 3/29/24 at 9:45 A.M. the resident's family member said the following:
-At the end of February, the resident was more confused and family asked for a urinalysis, staff said they could not get the specimen and no urinalysis was completed;
-The resident remained confused and had diarrhea for several days. Staff said they gave the resident Imodium. On 3/22/24 staff told the family the resident did not eat breakfast or lunch, vomited and was given Zofran and Imodium;
-On 3/24/24 the resident was weak and could not sit up in the bed, his/her lips were cracked and peeling, tongue was dry and cracked. Family asked staff for help and offered Zofran and Imodium. Family requested the resident be sent to the emergency room;
-On 3/24/24 family transported the resident to the emergency room and was present when hospital staff removed the resident's soiled incontinence brief. The incontinence brief contained urine and feces. The resident's buttocks and perineal skin were red and raw with open sores and the resident's skin was tender to the touch;
-The emergency room transferred the resident to a larger hospital ICU for treatment of the low potassium, irregular heart rate, nausea, vomiting and diarrhea;
-On 3/28/24 the resident returned to the facility. About 8:00 P.M. the resident was incontinent of bowel and bladder, staff changed the resident and the brief was marked with an x by the family. On 3/29/24 at 8:00 A.M. the resident wore the same x marked brief the resident had on 12 hours earlier.
Observation on 3/29/24 at 2:30 P.M. showed the following:
-The resident sat in the wheelchair with his/her head down and eyes closed. Certified Nurse Assistant (CNA) F woke the resident and lifted the resident under the arms, without the use of a gait belt (a device put on a resident who has mobility issues, by a caregiver prior to that caregiver moving the resident. A gait belt may be used to aid in the safe movement of a resident), and transferred the resident to bed. The resident's incontinence brief sagged in the back as CNA F lifted the resident out of the wheelchair. The resident's legs were slightly bent, and the resident leaned forward toward CNA F as CNA F pivoted the resident towards the bed. The resident moaned during the transfer and did not attempt to stand and bear weight;
-CNA F turned the resident to his/her side and pulled the resident's pants and incontinence brief down. The resident's entire buttock skin folds, coccyx and perineal skin folds, extending to the groin areas, were dark red with open areas to the buttocks with dark purple areas noted. A brownish stain was noted on the incontinence brief. No barrier cream was noted on the resident's buttocks or perineal skin folds. CNA F did not change the resident's soiled incontinence brief or provide incontinence care. CNA F pulled the resident's soiled incontinence brief and pants up, positioned the resident on his/her back and left the resident's room.
During an interview on 3/29/24 at 2:40 P.M. CNA F said the following:
-He/She was working a double shift from 10:30 P.M. on 3/28/24 to 3:00 P.M. on 3/29/24. He/She was responsible for the resident since 10:30 P.M. on 3/28/24. He/She was the only CNA on the resident's hall during the night shift and had assistance if needed from staff on other halls during the day shift;
-The resident slept all night and wore an incontinence brief all night. CNA F was sure at some point during the night, he/she had changed the resident's incontinence brief and had changed the resident around 8:00 A.M. on 3/29/24 when the family was visiting. CNA F had not changed the resident since 8:00 A.M. on 3/29/24 and the resident remained in the wheelchair all day. The resident was weak and had difficulty turning. CNA F had taken the resident to the dining room for meals in his/her wheelchair on 3/29/24;
-CNA F used either a lift or gait belt for transfers or lifted under the resident's arms like he/she had just lifted Resident #3. The resident had to be lifted today because he/she could not hold any weight on his/her legs. CNA F did not always use a gait belt but he/she should when the resident could not bear weight. There was no gait belt in Resident #3's room for use at the time of the transfer from the wheelchair to the bed;
-The resident was dry when he/she pulled the resident's incontinence brief and pants down. He/She did not know what the brown stain was in the resident's incontinence brief. CNA F did not know if the resident had skin issues previously and did not know if the resident needed changed more frequently. The resident was not wet but did have a brownish stain in the brief. CNA F did not know what the redness on the resident's skin was, he/she did see the resident had an open area on his/her buttocks.
Review of the resident's record showed no assessment of the resident's reddened and open perineal skin and showed no orders for barrier cream or treatment of reddened and open perineal skin.
During an interview on 3/29/24 at 12:00 P.M. Certified Medication Technician (CMT) G said the resident had a new order for Effer-K. The medication was not available in the Stat Safe (emergency medication supply safe provided and stocked by the pharmacy). The order was sent to the pharmacy and should arrive after 5:00 P.M. on 3/29/24. The resident had not received any potassium supplement since his/her return to the facility on 3/28/24. CMT G was not aware the resident had a critically low potassium while hospitalized .
During an interview on 3/29/24 at 12:40 P.M., the pharmacy nurse consultant said delivery of medications was available 24 hours per day. Staff were aware of the procedure to obtain medications other than the routine delivery. The procedure was posted in the medication room and staff were informed by pharmacy staff. If the pharmacy was not notified of an emergent need, the medication was delivered the following day after 5:00 P.M. at the normal delivery time. The Stat Safe did not contain Effer-K.
During interviews on 3/29/24 at 12:20 P.M. and 3:10 P.M., the Director of Nursing (DON) said the following:
-She was unaware staff had not administered the resident's Effer-K since the resident's return from the hospital. No stat (emergent) order was sent to the pharmacy and the physician was not notified the medication was not administered. She was not aware the resident had a critically low potassium when admitted to the hospital. It was important the resident received the supplemental potassium;
-Staff should always provide incontinence care and prevent skin breakdown. The resident had skin breakdown when he/she went to the hospital caused by the diarrhea and incontinence;
-Staff should have assessed the resident and obtained treatment for the resident sooner. Staff did not obtain the urinalysis as ordered on 2/21/24. Staff did not call the physician and report the resident's change in condition. Staff gave the resident Imodium with no relief of the symptoms. Staff were not assessing and monitoring the resident. The family took the resident to the hospital for care;
-The DON expected staff to follow the physician's orders, obtain laboratory tests and provide treatments and medications as ordered and keep the physician informed of the resident's ongoing condition. Staff should not miss doses of any resident's medication;
-Staff should always do what was needed, and always follow up with any change in a resident's condition, call the physician for treatment orders and implement those orders immediately.
During interview on 3/29/24 at 3:20 P.M. the Administrator said staff should always follow the physician's orders, administer medications as ordered and follow up when a resident had a change in condition. Staff should notify the physician of any change in a resident's condition, provide thorough assessments, and implement new physician orders, treatments and laboratory testing immediately.
During an interview on 4/11/24 at 10:00 A.M. the physician's nurse said the following:
-Facility staff notified the physician of the resident's gastric reflux on 2/21/24 and indicated the resident had some nausea related to gastric reflux. Prevacid was ordered twice daily. Staff had not informed the physician Prevacid twice daily was not admininstered as ordered for six days. Staff had not informed the physician of any missed doses of Eliquis;
-Staff sent the resident's hospital discharge orders for review regarding the 3/28/24 hospital discharge. Staff should have administered the resident's supplemental potassium starting the eveing of 3/28/24 and if unavailable called the physician for direction. Staff had not informed the physician the Effer-K was not available and no supplemental potassium was administered as ordered on the evening of 3/28/24 and morning of 3/29/24;
-Staff should inform the physician of missed doses of medications, medications unavailable for adminstration and should call the physician regarding any change in condition that required an immediate response;
-Staff did not communicate with the physician about the resident's on going nausea, vomiting and diarrhea. If the change in condition was communicated, treatment could have been started sooner and possibly prevented the resident's critically low potassium level and hospitalization.
MO#00233663
SERIOUS
(G)
📢 Someone Reported This
A family member, employee, or ombudsman was alarmed enough to file a formal complaint
Actual Harm - a resident was hurt due to facility failures
Pressure Ulcer Prevention
(Tag F0686)
A resident was harmed · This affected 1 resident
**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on interview and record review, the facility failed to ensure one resident (Resident #10), in a review of 10 sampled resid...
Read full inspector narrative →
**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on interview and record review, the facility failed to ensure one resident (Resident #10), in a review of 10 sampled residents, received care and treatment to prevent pressure ulcers (a localized injury to the skin and/or underlying tissue usually over a bony prominence, as a result of pressure, or pressure in combination with shear and /or friction) and received necessary treatment and services consistent with professional standards of practice, to promote healing and prevent new ulcers from developing. The resident, who staff determined was at risk for developing pressure ulcers, developed pressure ulcers to both the right and left heels, the coccyx (tailbone area), left posterior calf (lower back leg area) and right lower leg. The facility census was 70.
Review of the facility's undated policy, Pressure Ulcer Care and Prevention, showed the following:
-Purpose: To prevent and treat further breakdown of pressure ulcers;
-Treatment of pressure ulcers will vary depending on the orders of the attending physician. The nurse is responsible for carrying out the treatment as ordered by the attending physician and for implementing measures to prevent pressure ulcers;
-Observe skin. Any persistent reddened area that remains after pressure is relieved is a high risk for pressure ulcer to begin;
-Apply lotion gently to dry skin;
-Change bed linen promptly whenever wet or soiled;
-Keep sheets dry, free of wrinkles and free of debris;
-Use pressure reducing devices to relieve pressure;
-Turn the resident every two hours and position with pads or pillows to protect bony prominences;
-Use elbow and heel protectors if needed;
-Assist resident at mealtime to assure adequate nutrition.
Review of the facility undated policy, Wound Care and Treatment, showed the following:
-It was the purpose of the facility to prevent and treat all wounds;
-The care plan should reflect the current status of the wound and appropriate goals and approaches;
-Prevention strategies included on-going skin assessment with weekly documentation of the status, minimize dry skin, apply moisturizer to areas of dry skin, minimize friction and sheer through proper positioning, transferring and turning;
-Incontinence managment included minimize skin exposure to incontinence, and /or wound drainage. Provide incontinence care following each incontinent episode;
-Positioning and pressure reduction included for the resident at moderate risk of developing pressure ulcers and did not have a current pressure ulcer, apply pressure-reduction mattress or overlay onto the bed, provide pressure reduction wheelchair cushion.
Review of the National Pressure Injury Advisory Panel (NPIAP), prevention and treatment of pressure ulcers: quick reference guide, Washington DC: National Pressure Injury Advisory Panel 2019, showed the following:
-Assess the pressure ulcer initially and re-assess it at least weekly;
-With each dressing change, observed the pressure ulcer for signs that indicate a change in treatments as required (e.g., wound improvement, wound deterioration, more or less exudate, signs of infection, or other complications);
-Address the signs of deterioration immediately.
Review of the Long Term Care Facility Resident Assessment Instrument User's Manual, Version 3.0, Chapter 3, Section M, defines the different stages of pressure ulcers (localized injury to the skin and/or underlying tissue usually over a bony prominence, as a result of pressure, or pressure in combination with shear and/or friction) as follows:
-Stage I: an observable, pressure related alteration of intact skin, whose indicators as compared to an adjacent or opposite area on the body may include changes in skin temperature, tissue consistency, sensation, and/or a defined area of persistent redness;
-Stage II: Partial thickness loss of dermis (the inner layer that makes up skin) presenting as a shallow open ulcer with a red-pink wound bed, without slough (non-viable yellow, tan, gray, green or brown tissue). May also present as an intact or open/ruptured blister;
-Stage III: full thickness tissue loss. Subcutaneous fat may be visible but bone, tendon or muscle is not exposed. Slough may be present but does not obscure the depth of tissue loss. May include undermining (destruction of tissue or ulceration extending under the skin edges) or tunneling (a passage way of tissue destruction under the skin surface that has an opening at the skin level from the edge of the wound);
-Stage IV: Full thickness tissue loss with exposed bone, tendon or muscle. Slough or eschar (dead or devitalized tissue that is hard or soft in texture; usually black, brown, or tan in color) may be present on some parts of the wound bed. Often includes undermining and tunneling;
-Unstageable pressure ulcers (known but unstageable due to coverage the wound bed by slough (necrotic/avascular tissue in the process of separating from the viable portion of the body, usually light colored, soft, moist and stringy) and or eschar (thick leathery, frequently black or brown in color, necrotic tissue). Until enough slough and/or eschar is removed to expose the base of the wound, the true depth, and therefore stage, cannot be determined;
-Deep tissue injury: Purple or maroon area of discolored intact skin due to damage of underlying soft tissue damage. The area may be preceded by tissue that is painful, firm, mushy, boggy, warmer or cooler as compared to adjacent tissue;
-Slough: necrotic/avascular tissue in the process of separating from the viable portions of the body and is usually light colored, soft, moist, and stringy;
-Eschar: thick, leathery, frequently black or brown in color, necrotic (dead) or devitalized tissue that has lost its usual physical properties and biological activity. Eschar may be loose or firmly adhered to the wound.
1. Review of Resident #10's Base Line (initial care plan completed on admission) care plan showed the following:
-admission date 12/28/23;
-Diagnoses of dementia, arthritis, heart failure, diabetes, pain and abnormal gait and mobility.
-Alert and cognitively intact;
-Required assistance of one staff member with bed mobility, hygiene, and bathing;
-Required assistance of two staff members with transfers and toileting;
-Always incontinent of bowel and bladder. Unable to manage own toileting functions and required all cares to be provide by staff. The resident wore incontinence briefs. Staff should provide cares necessary to maintain hygiene, promote dignity and avoid skin breakdown;
-History of falls, was a fall risk, unsteady with transfers and balance, muscle weakness, fatigue and endurance concerns;
-Staff should monitor medications, provide a safe environment, monitor condition and report changes to Director of Nursing (DON) and physician as applicable, provide comfort and care, monitor lab values and report to physician;
-Staff should provided cushions for the resident's wheelchair,
-Goals were to maintain health and safety while performing Activities of Daily Living (ADLs) as independently as possible.
Review of the resident's weekly skin assessment dated [DATE] showed staff documented the following:
-Right and left heels were firm (normal condition) and intact;
-Missing second and third toe on right foot;
-Bruising to hands and forearms and scabs to bridge of nose;
-No documented pressure ulcers.
Review of the resident's Braden Scale (a tool used for predicting pressure ulcer risk, made up of six scored subscales for a total score range from 6-23. A lower score indicated a lower level of functioning and a hgher level of risk for pressure ulcer development) dated 12/28/24 showed the following:
-No impairment in ability to respond meaningfully to pressure-related discomfort;
-Very moist, skin was often but not always moist, linen must be changed at least once a shift;
-Chairfast, ability to walk was severely limited;
-Very limited, unable to make frequent or significant changes independently in body or extremity position;
-Adequate ability to eat over half of most meals;
-Problem with shear and friction, rquired moderate to maximum assist in moving;
-Score of 14 indicating moderate risk for developing pressure ulcers.
Review of the resident's nurses note dated 12/29/23 showed staff documented the following:
-At 3:00 A.M. the resident was alert and oriented with occasional periods of confusion. Incontinent of bowel and bladder;
-At 9:47 A.M. the resident was admitted to the facility on [DATE] for physical therapy due to falling, had two falls prior to facility admission. The resident was cooperative with care, able to communicate needs, wore incontinence briefs and used a wheelchair for locomotion.
Review of the resident's admission Minimum Data Set (MDS) a federally mandated assessment instrument, completed by facility staff, dated 1/3/24, showed the following:
-Cognitively intact;
-Independent with eating;
-Required partial/moderate assistance (staff provided less than half the effort) with dressing upper body, and bed mobility (turning from side to side in the bed, moving from lying flat in the bed to sitting on the side of the bed and sitting on the side of the bed to lying flat on the bed);
-Required substantial/maximum staff assistance (staff provided more than half the effort) with personal hygiene, putting on/taking off footwear, and transfers from a chair, bed or toilet;
-Dependent on staff (staff provided all the effort) with toileting, showers, dressing lower body and standing up from a sitting position;
-Unable to walk;
-Wheelchair for mobility with substantial/maximal staff assistance;
-Frequently incontinent of bowel and bladder;
-At risk for developing pressure ulcers;
-No current pressure ulcers or moisture associated skin damage;
-Pressure reducing device (equipment that aims to relieve pressure away from areas of high risk for skin breakdown) for chair.
Review of the resident's nurses note dated 1/6/24 at 12:30 P.M. showed staff documented the resident was incontinent of bowel and bladder. A spot was noted on the resident's mid back. The area looked like an old scab. A dressing was placed over the scab and information passed along at change of shift report.
Review of the resident's Physician Order Sheet (POS) dated 1/9/24 showed an order to cleanse both heels with normal saline (NS) (a sterile wound cleansing fluid) and pat dry, apply Skin Prep (protective wipe used to form a barrier to help preserve skin integrity and prevent injury to the skin) to bilateral heels daily and heel protector (pressure relieving padded boots) to bilateral feet.
Review of the resident's nurses notes showed staff documented the following:
-On 1/9/24 a t 10:20 A.M. the resident had a blister (fluid filled skin injury) on each heel. Skin prep applied to heels. The resident required two staff member assistance with transfers;
-On 1/10/24 at 5:33 P.M. the resident required assistance of two staff members with all cares and a mechanical lift for transfers.
Review of the resident's POS dated 1/16/24, showed wash bilateral heels with wound wash (cleansing wound agent) and pat dry, apply petroleum gauze to open area and cover with non-adherent pads and wrap with gauze.
Review of the resident's weekly skin assessment dated [DATE] showed staff documented the resident had open blisters to both heels and redness to the coccyx (tailbone area). Review showed no documentation regarding the size and condition of the open blisters.
Review of the resident's nurses notes showed staff documented the following:
-On 1/19/24 at 1:56 P.M,. the resident was alert and oriented. Blisters to both heels had opened, dressing change provided as ordered and educated family and resident on pressure relief. Physician notified and request for Wound Care Plus consult (consulting wound care management company) ordered;
-On 1/20/24 at 3:04 P.M. the buttock wound treatment was done, the resident was incontinent of bowel and bladder.
Review of the resident's wound management report dated 1/22/24 showed staff documented the following:
-Stage III presure ulcer of the coccyx, measured 1.2 cm by 2 cm by 0.2 cm deep. Scant amount of bloody drainage, no odor. The wound bed presented with granulation and slough.The peri-wound area was intact, the resident complained of pain with debridement (cleaning of the wound bed).
Review of the wound management report dated 1/22/24 showed no documentation regarding the size and condition of the resident's right and left heel open blisters.
Review of the resident's POS dated 1/23/24 showed the following:
-Cephalexin (an antibiotic) 500 milligrams twice daily for 10 days;
-Float (elevate the heels off the bed) the resident's heels at all times as tolerated.
Review of the resident's nurses notes showed the following:
-On1/23/24 at 10:10 P.M., a urinary catheter (a sterile tube inserted into the bladder to drain urine) was inserted;
-On 1/24/24 at 3:28 P.M., the resident continued with urinary catheter due to buttock wound. Resident in bed.
Review of the resident's weekly skin assessment dated [DATE] showed staff documented the resident had open wounds on both heels and a Stage II pressure ulcer (a partial thickness loss of dermis presenting as a shallow open ulcer with a red-pink wound bed, without slough. May also present as an intact or open/ruptured blister) on the coccyx.
Review of the resident's POS dated 1/24/24 showed Wound Care Plus to evaluate and treat related to pressure ulcers on the heels.
Review of the resident's care plan dated 1/24/24 showed the resident required an indwelling urinary catheter for wound healing. Staff should assess the urine drainage every shift. The resident received antibiotic therapy for prevention of wound infection. Staff should provide extra nutritional calories to help with infection and wound healing, obtain wound cultures as indicated and check resident's temperature every shift.
Review of the resident's care plan showed no staff direction or interventions regarding the resident's pressure ulcers prevention and treatment.
Review of the resident's wound managment report dated 1/24/24 showed staff documented right heel wound was 8.2 cm by 7 cm by 0.1 cm with bloody drainage and mild odor. The wound edges were macerated and soft with edema (swelling) and redness to the surrounding skin.
Review of the Wound Care Plus progress note dated 1/24/24 showed the following:
-Evaluation and management of multiple wounds;
-Wound #1, left heel chronic Stage III pressure injury pressure ulcer (a full thickness tissue loss. Subcutaneous fat may be visible but bone, tendon or muscle is not exposed) with status of not healed. Initial wound encounter measurements 10 centimeters (cm) by 9.4 cm by 0.1 cm deep with bloody drainage, no odor. The peri (surrounding) wound skin exhibited maceration (softening and braking down of skin resulting from prolonged exposure to moisture) and erythema, peri wound skin friable (fragile skin, tears, bruises or breaks easily) and moist. Unable to determine depth of the wound;
-Wound #2, right heel chronic unstageable pressure injury (unable to determine the stage) obscured full-thickness skin and tissue loss pressure ulcer and had status of not healed. Initial wound encounter measurements 8.2 cm by 7 cm by 0.1 cm deep with small amount of blood drainage with mild odor. The peri wound skin exhibited edema (swelling) and erythema (redness), peri wound skin friable and moist, presented with signs and symptoms of infection. Topical antibiotics (placed directly on the skin) prescribed. Unable to determine depth of the wound due to area of eschar (necrotic dead tissue usually black in color, dry, firm and adhered to the wound bed);
-Wound #3, coccyx Stage III pressure injury pressure ulcer with status of not healed. Initial wound encounter measurements 1.2 cm by 2 cm by 0.2 cm deep with scant bloody drainage with no odor. The peri wound skin was friable and moist, peri wound skin did not exhibit signs or symptoms of infection;
-The resident's affected body parts were recently (last 2 weeks) immobile prior to the wound developing. Nursing staff noted the pressure ulcers were directly from positioning. The ulcers were mixed etiology including pressure;
-Education provided regarding proper offloading of affected area to maintain wound healing.
Review of the resident's POS dated 1/25/24 showed the following:
-Treatment for bilateral heel pressure ulcers. Cleanse with wound wash and pat dry, apply Santyl (medication ointment used to remove damaged tissue from skin ulcers), Mupirocin ointment (antibiotic ointment applied to the skin or wounds to treat infected wounds) and calcium alginate (wound dressing used to promote healing) to wound bed, cover with non-adherent pad, apply ABD pad (thick absorbent dressing used to cover a wound and absorb drainage, provide protection of the wound) to bilateral heels and wrap with loose gauze, change daily and as needed;
-Treatment for Stage II pressure ulcer of the coccyx. Cleanse coccyx with wound wash and pat dry, apply skin prep to peri-wound area, apply Santyl and Calcium Alginate to wound bed, cover with self-adhesive dressing, change daily and as needed.
Review of the resident's wound management report dated 1/25/24 showed staff documented the following:
-Stage III pressure ulcer of the left heel. Measured 10 cm by 9.4 cm by 0.1 cm deep. Small amount of bloody drainage with no odor. The wound bed presented with granulating tissue, slough and eschar. The surrounding skin was macerated and reddened. No signs or symptoms of infection noted. The resident presented with pain during debridement of the wound.
Review of the resident's nurses notes showed staff documented the following:
-On 1/25/24 at 7:32 A.M. completed initial consult with Wound Care Plus. New wound care orders for the
Stage II pressure ulcer of the coccyx and bilateral heels;
-On 1/30/24 at 7:05 P.M. the resident's family member reported the resident was not waking up. Staff woke the resident and the resident responded to the family and told staff his/her incontinence brief needed to be changed.
Review of the Wound Care Plus progress note dated 1/31/24 showed the following:
-Evaluation and management of multiple wounds;
-Wound #1, left heel chronic Stage III pressure injury pressure ulcer with status of not healed. Measurements 6.7 cm by 8.1 cm by 0.1 cm deep, small amount of bloody drainage with no odor. Unable to determine depth of the wound;
-Wound #2, right heel chronic unstageable pressure injury obscured full-thickness skin and tissue loss pressure ulcer and had status of not healed. Measurements 8.4 cm by 6.6 cm by 0.1 cm deep with small amount of blood drainage with mild odor. 51% to 75% eschar (one-half to three-fourths of the wound base covered by eschar) Unable to determine depth of the wound due to area of eschar;
-Wound #3, coccyx Stage III pressure injury pressure ulcer with status of not healed. Measurements 2.4cm by 3.1 cm by 0.2 cm deep with scant bloody drainage with no odor.
Review of the resident's wound managment report dated 1/31/24 showed staff documented the following:
-Stage III pressure of the left heel measured 6.7 cm by 8.2 cm by 0.1 cm deep with bloody drainage and no odor. The wound bed tissue contained slough, granulation tissue and eschar. The surrounding skin was macerated wtih redness;
-Unstageable pressure injury of the right heel. Obscured full-thickness skin and tissue loss, measured 8.4 cm by 6.6 cm by 0.1 cm with bloody drainage and mild odor. The wound bed presented with granulation tissue, slough and eschar. The wound edges were macerated and soft with edema and redness to the surrounding skin;
-Stage III pressure ulcer of the coccyx measured 2.4 cm by 3.1 cm by 0.2 cm. Small amount of bloody drainage with no odor. The wound bed presented with granulation and slough tissue. The surrounding wound skin was intact. The resident complained of pain with debridement.
Review of the resident's nurses' notes showed staff documented the following:
-On 2/2/24 at 6:35 P.M. the resident had several episodes of loose stools;
-On 2/3/24 at 12:46 P.M. the resident was incontinent and reported mild buttock pain;
-On 2/3/24 at 10:15 P.M. the resident yelled out and said he/she felt the metal in his/her heels. Staff tried to reposition the resident. The resident remained uncomfortable, as needed pain medication given with no relief.
Review of the resident's weekly skin assessment dated [DATE] showed staff documented the right heel and left heels were not assessed. The left foot and ankle had existing issues. The right foot and ankle had existing issues. Bilateral heel wounds, blisters to the right inner and outer lower extremities and a coccyx wound. No staff documentation regarding the size and condition of the wounds.
Review of the resident's wound management report dated 2/7/24 showed staff documented the following:
-Unstageable pressure injury of the posterior left calf. Obscured full-thickness skin and tissue loss. No drainage noted and no odor. The wound bed contained eschar;
-Stage III pressure of the left heel measured 2 cm by 5 cm by 0.1 cm deep with no drainage and no odor. The wound bed tissue was necrotic with eschar. The surrounding skin was macerated wtih redness;
-Unstageable pressure injury of the right heel. Obscured full-thickness skin and tissue loss, measured 6 cm by 6.7 cm by 0.1 cm with bloody drainage and no odor. The wound bed presented eschar. The wound edges were macerated and soft with edema and redness to the surrounding skin;
-Stage III pressure ulcer of the coccyx measured 2.8 cm by 4.5 cm by 0.1 cm. Small amount of bloody drainage with no odor. The wound bed presented with granulation and slough tissue. The surrounding wound skin was intact.
Review of the Wound Care Plus progress note dated 2/7/24 showed the following:
-Evaluation and management of multiple wounds;
-Wound #1, left heel chronic Stage III pressure injury pressure ulcer with status of not healed. Measurements 2cm by 5cm by 0.1 cm deep, no drainage. Unable to determine depth of the wound;
-Wound #2, right heel chronic unstageable pressure injury obscured full-thickness skin and tissue loss pressure ulcer and had status of not healed. Measurements 6cm by 6.7cm by 0.1 cm deep with small amount of blood drainage with mild odor. 76% to 100% (three-fourths to complete covering of the wound base covered) eschar. Unable to determine depth of the wound due to area of eschar;
-Wound #3, coccyx Stage III pressure injury pressure ulcer with status of not healed. Measurements 2.8cm by 4.5cm by 0.1cm deep with scant bloody drainage with no odor;
-Wound #4 left posterior calf is chronic unstageable pressure injury obscured full-thickness skin and tissue loss pressure ulcer with status of not healed. Initial wound encounter measurements 15.7cm by 1.8cm by 0.1 cm depth, no drainage, wound bed 51% to 75% eschar. Unable to determine depth of the wound due to area of eschar.
Review of the resident's POS dated 2/8/24 showed the following:
-Treatment for Stage III pressure ulcer of the left heel. Cleanse left heel with wound wash pat dry, apply skin prep over stable area of eschar and peri-wound area, change dressing daily and as needed;
-Treatment for unstageable pressure ulcer of the right heel. Cleanse right heel with wound wash and pat dry. Apply skin prep to peri-wound area, apply xeroform (a fine mesh gauze dressing that maintained a moist wound environment to promote healing) to wound bed, (cut to fit wound edges), cover with non-adherent pad, apply ABD, cover with loose gauze and change daily and as needed.
Review of the resident's POS dated 2/9/24 showed the following:
-Treatment for Stage III pressure ulcer of the coccyx. Cleanse coccyx with wound wash and pat dry, apply Santyl to wound bed, cover with super absorbent dressing, change daily every other day;
-Treatment for unspecified pressure ulcer of the left posterior calf. Cleanse left posterior calf with NS and pat dry, apply skin prep to peri-wound area, apply xeroform to wound bed, cover with self-adherent dressing and change every other day.
Review of the resident's Treatment Administration Record (TAR) for February 2024 showed no documentation staff provided the physician ordered treatment to the resident's Stage III pressure ulcer of the coccyx every other day as scheduled on 2/9/24 or 2/11/24.
Review of the Wound Care Plus progress note dated 2/14/24 showed the following:
-Evaluation and management of multiple wounds;
-Wound #1, left heel chronic Stage III pressure injury pressure ulcer with status of not healed. Measurements 2cm by 4cm by 0.1 cm deep, no drainage. Unable to determine depth of the wound;
-Wound #2, right heel chronic unstageable pressure injury obscured full-thickness skin and tissue loss pressure ulcer and had status of not healed. Measurements 6cm by 10cm with no measurable depth and small amount of bloody drainage with no odor. 76% to 100% eschar;
-Wound #3, coccyx Stage III pressure injury pressure ulcer with status of not healed. Measurement 3cm by 4cm with no measurable depth, large amount of bloody drainage with no odor. 76% to 100% eschar;
-Wound #4, left posterior calf is chronic unstageable pressure injury obscured full-thickness skin and tissue loss pressure ulcer with status of not healed. Initial wound encounter measurements 15cm by 2cm with no measurable depth, small amount of bloody drainage, wound bed 51% to 75% eschar.
Review of the resident's POS dated 2/15/24 showed the following:
-Cleanse right heel with wound wash and pat dry. Apply skin prep to stable eschar and peri-wound area, cover with ABD, wrap loosely with rolled gauze and change daily and as needed for unspecified stage pressure ulcer of the right heel;
-Cleanse left posterior calf with NS and pat dry, apply skin prep to peri-wound area, apply Santyl to wound bed, cove with self-adhesive dressing and change daily for unspecified stage pressure ulcer of the left posterior calf.
Review of the resident's wound management report dated 2/15/24 showed staff documented the following:
-Left posterior calf unstageable pressure ulcer, measured 15 cm by 2 cm with no measurable depth. Bloody drainage with no odor;
-Stage III pressure of the left heel measured 2 cm by 4 cm by 0.1 cm deep with no drainage and no odor.The surrounding skin was macerated with redness;
-Unstageable pressure injury of the right heel. Obscured full-thickness skin and tissue loss, measured 6 cm by 10 cm with no depth. Bloody drainage was noted with no odor. The wound bed presented with granulation tissue and eschar. The wound edges were macerated and soft with edema and redness to the surrounding skin;
-Unstageable pressure injury of the coccyx. Obscured full thickness skin and tissue loss. Measured 3 cm by 4 cm with no measurable depth. Heavy amount of bloody drainage with no odor. The wound bed presented with granulation tissue and eschar. The surrounding wound skin was intact.
Review of the resident's TAR for February 2024 showed no documentation staff provided the physician ordered treatment to the resident's Stage III pressure ulcer of the coccyx every other day as scheduled on 2 /15/24, 2/17/24 or 2/19/24.
Review of the resident's weekly skin assessment dated [DATE] showed staff documented the following:
-Edema (swelling) with right and left heels soft (not normal, indicating tissue injury);
-Left and right foot and ankle with existing issues (no specific documentation describing the issues);
-No documentation regarding the resident's unstageable pressure ulcer of the coccyx and no documentation regarding an unstageable pressure ulcer of the left posterior calf.
Review of the Wound Care Plus progress note dated 2/21/24 showed the following:
-Evaluation and management of multiple wounds;
-Wound #1, left heel chronic Stage III pressure injury pressure ulcer with status of not healed. Measurements 2.4cm by 2.4cm by 0.1 cm deep, no drainage. Unable to determine depth of the wound;
-Wound #2, right heel chronic unstageable pressure injury obscured full-thickness skin and tissue loss pressure ulcer and had status of not healed. Measurements 7cm by 7.9cm by 0.1cm deep with small amount of bloody drainage with no odor. 76% to 100% eschar;
-Wound #3, coccyx Stage III pressure injury pressure ulcer with status of not healed. Measurements 8.7cm by 6.4cm by 0.2cm deep large amount of bloody drainage with mild odor. 76% to 100% eschar;
-Wound #4, left posterior calf is chronic unstageable pressure injury obscured full-thickness skin and tissue loss pressure ulcer with status of not healed. Measurements 16.9cm by 4cm by 0.2cm deep with small amount of bloody drainage, wound bed 51% to 75% eschar.
-Wound #5, right lateral lower leg acute unstageable pressure injury obscured full-thickness skin and tissue loss pressure ulcer with status of not healed. Initial wound encounter measurements 11.4 cm by 4.4 cm by 0.2 cm deep, small amount of bloody drainage with mild odor, wound bed 51% to 75% eschar.
Review of the resident's POS dated 2/21/24 showed the following:
-Cleanse right ankle and lateral calf with wound cleanser and pat dry. Apply skin prep to peri-wound area and eschar. Apply Santyl and calcium alginate to wound beds. Cover with non-adherent dressing. Apply ABD pad and wrap with loose gauze, change every other day for unspecified stage pressure ulcer of the right ankle and lateral (outer) calf;
-Cleanse the right heel with wound cleanser and pat dry, apply skin prep to peri wound area, apply xeroform to wound bed, cover with non-adherent pad, apply ABD pad around affected area, wrap with loose gauze and change every other day and as needed for unstageable pressure ulcer of the right heel.
Review of the resident's wound managment report dated 2/21/24 showed staff documented the following:
-Unstageable pressure injury of the right lower lateral leg. Obscured full-thickness and tissue loss. Measured 11.4 cm by 4.4 cm by 0.2 cm. Small amount of bloody drainage with no odor. The wound bed contained granulation tissue, slough and eschar. The surrounding skin area showed edema and maceration;
-Left posterior calf unstageable pressure ulcer measured 16.9 cm by 4 cm by 0.2 cm. Bloody drainage with no odor. Necrotic tissue was present;
-Stage III pressure of the left heel measured 2.4 cm by 2.4 cm by 0.1 cm deep with no drainage and mild odor. The wound bed presented with healing tissue. The surrounding skin was macerated with redness;
-Unstageable pressure injury of the right heel. Obscured full-thickness skin and tissue loss, measured 7 cm by 7.9 cm by 0.1 depth. Bloody drainage was noted with no odor. The wound bed presented with eschar. The wound edges were macerated and soft with edema and redness to the surrounding skin;
-Unstageable pressure injury of the coccyx. Obscured full thickness skin and tissue loss. Measured 8.7 cm by 6.4 cm by 0.2 cm depth. Heavy amount of bloody drainage with foul odor. The wound bed presented with granulation tissue slough and eschar. The surrounding wound skin showed edema and redness.
Review of the resident's TAR for February 2024 showed no documentation staff provided the physician ordered treatment to the Stage III pressure ulcer of the coccyx every other day as scheduled on 2/21/24.
Review of the resident's POS dated 2/22/24 showed the following:
-Cleanse coccyx wound with wound cleanser and pat dry, apply Mupirocin, Santyl and Calcium Alginate to the wound bed, cover with self-adhesive dressing, change daily for Stage 3 pressure ulcer of the coccyx region.
Review of the resident's POS dated 2/26/24 showed the following:
-Cleanse right and left heel wounds, apply betadine and cover with foam pad, change daily and as needed for Stage 3 pressure ulcer of the left heel.
-Cleanse unstageable wounds
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
Investigate Abuse
(Tag F0610)
Could have caused harm · This affected 1 resident
Based on interview and record review the facility failed to thoroughly investigate an allegation of misappropriation of narcotic medications when the consultant pharmacist completed a monthly audit of...
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Based on interview and record review the facility failed to thoroughly investigate an allegation of misappropriation of narcotic medications when the consultant pharmacist completed a monthly audit of the facility Stat-Safe (automated emergency medication supply system) on 3/4/24 and notified facility administrative staff of a discrepancy involving 21 doses of Schedule II (controlled substance) narcotics. The facility census was 70.
Review of the facility undated Abuse Policy showed the following:
-It was the policy of the facility that each resident would be free from abuse. Abuse could included verbal, mental, sexual or physical abuse, misappropriation of resident property and exploitation, corporal punishment or involuntary seclusion;
-Misappropriation of resident property meant the deliberate misplacement, exploitation, or wrongful, temporary or permanent use of a resident's belongings or money without the resident's consent;
-Employees must report any abuse or suspicion of abuse immediately to the Administrator, Director of Nursing (DON) or immediate supervisor;
-The Administrator would involve key leadership personnel as necessary to assist with reporting, investigation and follow up;
-The Administrator would make an initial immediate report to the Sate Agency and a follow up investigation would be submitted to the State Agency within five working days;
-The facility must have evidence all alleged violations were thoroughly investigated and prevent further potential abuse or misappropriation while the investigation was in progress.
Review of the facility undated Narcotic Count policy showed the following:
-The purpose was to complete a physical inventory of narcotics at each shift change to identify discrepancies;
-Narcotic records were reconciled by a physical count of the remaining narcotic supply at each shift change by the incoming and outgoing nurse. Emergency kits containing narcotics would be checked at the same time;
-Discrepancies found at any time were to be immediately reported to the DON. The DON would initiate an investigation to determine the cause of the discrepancy and contact the pharmacist for assistance as needed.
1. Review of the pharmacy audit report dated 3/4/24 and sent to the facility by email showed the following:
-State-Safe drawer K (narcotic controlled substances drawer) discrepancy report;
-Please look into/resolve all discrepancies;-Pleae perform weeky audits on the control drawer K;
-consider ading two step code verifiction for control pulls from the emergency kit (facility would have to call pharmacy for a code each time a control from the emergency kit was needed);
-Hydrocodone/APAP 10/325 mg audit discrepancy of 4 tablets;
-Oxycodone/APAP 5/325 mg chart audit discrepancy of 3 tablets;
-Hydrocodone/APAP 7.5/325 mg audit discrepancy of 2 tablets;
-Oxycodone/APAP 10/325 mg chart audit discrepancy of 2 tablets;
-Oxycodone 5 mg chart audit discrepancy of 1 tablets;
-Oxycodone/APAP 10/325 mg chart audit discrepancy of 7 tablets.
Observation on 3/29/24 at 10:40 A.M. showed the following:
-Certified Medication Technician (CMT) G logged into the facility Stat-Safe, entered a password and requested one Norco (hydrocodone, controlled narcotic medication) from the list provided on the screen. The list included the names of the narcotic medications available and the number of doses that remained in the Stat-Safe. The system indicated Norco 5/325 milligrams (mg) two doses remained in the Stat-Safe;
-The locked narcotic drawer opened;
-No Norco 5/325 mg tablets remained in the Stat-Safe narcotic drawer;
-CMT G closed the narcotic drawer, locked the Stat-Safe and informed the Director of Nursing (DON) of the discrepancy.
During interview on 3/29/24 at 10:50 A.M. the DON said CMT G informed her of the Norco discrepancy in the Stat-Safe. The pharmacy managed and stocked the Stat-Safe medications. The pharmacy consultant was onsite and conducting an audit of the Stat-Safe currently.
Review of the pharmacy consultant Stat-Safe audit conducted on 3/29/24 showed the following:
-Hydrocodone (narcotic pain medication, controlled substance)/APAP (Tylenol, pain medication) 10/325 mg chart audit discrepancy of 16 tablets;
-Oxycodone/APAP 5/325 mg chart audit discrepancy of 5 tablets;
-Hydrocodone/APAP 5/325 mg chart audit discrepancy of 2 tablets;
-Oxycodone 5 mg chart audit discrepancy of 4 tablets;
-Hydrocodone/APAP 7.5/325 mg audit discrepancy of 6 tablets;
-Hydrocodone/APAP 10/325 mg audit discrepancy of 1 tablets;
-Oxycodone/APAP 10/325 mg chart audit discrepancy of 8 tablets;
-Oxycodone IR 10 mg chart audit discrepancy of 4 tablets;
-Oxycodone ER 20 mg chart audit discrepancy of 4 tablets;
-Hydrocodone/APAP 5/325 mg chart audit discrepancy of 15 tablets.
During an interview on 3/29/24 at 12:40 P.M. the pharmacy consultant said the following:
-The Stat-Safe reconciliation of the narcotics should be conducted weekly or more frequently by the DON or Assistant DON;
-A pharmacy audit was conducted monthly and on the last audit, conducted 3/4/24, discrepancies were identified of 21 doses of narcotics. The facility was notified of the discrepancies by email and should have conducted an investigation into the narcotic discrepancy immediately;
-The 3/29/24 audit showed all the narcotic medications were gone from the Stat-Safe except one dose. Staff should have identified the discrepancies during weekly audits and prevented further narcotic diversion from occurring.
During an interview on 3/29/24 at 1:10 P.M. the Assistant Director of Nursing (ADON) said the following:
-She did not have a facility email address and had not received any information regarding a discrepancy in the Stat-Safe narcotic reconciliation. She was not aware the Stat-Safe narcotic count was off on 3/4/24;
-She had never reconciled the Stat-Safe narcotics and did not have access to the Stat-Safe auditing system.
During an interview on 3/27/24 at 12:15 P.M. the DON said the following:
-The Stat-Safe was not audited by the DON or any other staff. The DON currently did not have access to audit the Stat-Safe;
-Pharmacy staff audited the Stat-Safe narcotics monthly. The DON was not aware there was a discrepancy of the narcotic reconciliation found on 3/4/24 during the pharmacy audit.
During an interview on 3/28/24 at 2:00 P.M. and on 3/29/24 at 9:30 A.M. the administrator said the following:
-The Stat-Safe was not reconciled following the 3/4/24 pharmacy audit and currently no staff audited and reconciled the Stat-Safe narcotics;
-Every administrative staff who received the pharmacy email regarding the 3/4/24 audit results should have reviewed the information, discussed the information and started an investigation into the missing narcotics. No investigation was done;
-He had not reviewed the administrators emails prior to starting at the facility 3/15/24 and was not aware of the pharmacy Stat-Safe audit results showing the discrepancy in the narcotic count;
-The Stat-Safe needed reconciled at least weekly to ensure the narcotic counts were correct. An audit of the narcotics removed from the Stat-Safe compared with the residents MARs should be conducted to ensure accuracy and reconciliation on a routine basis.;
-Staff should follow the facility misappropriation policy and start an investigation immediately.
CONCERN
(E)
📢 Someone Reported This
A family member, employee, or ombudsman was alarmed enough to file a formal complaint
Potential for Harm - no one hurt, but risky conditions existed
Deficiency F0725
(Tag F0725)
Could have caused harm · This affected multiple residents
**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observaton, interview and record review, the facility failed to provide sufficient nursing staff to meet the needs of t...
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**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observaton, interview and record review, the facility failed to provide sufficient nursing staff to meet the needs of two resident (Resident #3 and #10) in a review of 10 sampled residents. The facility failed to provide Resident #3 incontinence care and provide appropriate care and services to ensure known moisture related skin breakdown treatment was implemented and failed to ensure safe transfers from the wheelchair to bed. The facility also failed to ensure Resident #10 received care and treatment to prevent pressure ulcers (a localized injury to the skin and/or underlying tissue usually over a bony prominence, as a result of pressure, or pressure in combination with shear and /or friction) and received necessary treatment and services, consistent with professional standards of practice, to promote healing and prevent new ulcers from developing. The resident, who staff determined was at risk for developing pressure ulcers, developed pressure ulcers to bilateral (both right and left) heels, the coccyx (tailbone area), left posterior calf (lower back leg area) and right lower leg. The facility census was 70.
During interview on 3/29/24 at 3:00 P.M the Administrator said the facility did not have a policy regarding sufficient staffing.
1. Review of the facility assessment dated [DATE] showed the following:
-Average daily census was 70 residents;
-41 residents required assistance with dressing, transfers and toileting;
-57 residents required assistance with bathing;
-Facility staffing was based from census and acuity. If the census or acuity fluctuated, the facility made every effort to ensure there was adequate staff to meet the needs of the residents.
Review of the facility Nursing Daily Staffing Sheets showed the following:
-On 2/7/24 two CNA and one NA staff documented as worked day shift. Daily census was blank;
-On 2/8/24 two CNA staff documented as worked night shift. Daily census was blank;
-On 2/9/24 two CNA staff documented as worked night shift. Daily census was blank;
-On 2/26/24 two CNA staff documented as worked day shift. Daily census was blank;
-On 2/28/24 two CNA and one NA staff documented as worked night shift. Daily census was blank;
-On 3/9/24 two CNA and one NA staff documented as worked night shift. Daily census was 71 residents;
-On 3/11/24 one CNA and one NA staff documented as worked night shift. Daily census was 71 residents;
-On 3/15/24 one CNA and one NA staff documented as worked night shift. Daily census ws 75 residents;
-On 3/19/24 one CNA staff documented as worked day shift. Daily census was 74 residents;
-On 3/20/24 two CNA staff documented as worked evening shift. Daily census was 75 residents;
-On 3/24/24 one CNA staff documented as worked evening shift. Daily census was 70 residents;
-On 3/25/24 two CNA staff documented as worked day shift. Daly census was 70 residents.
2. Review of Resident #10's Base Line (initial care plan completed on admission) care plan showed the following:
-admission date 12/28/23;
-Diagnoses of dementia, arthritis, heart failure, pain and abnormal gait and mobility;
-Alert and cognitively intact;
-Required assistance of one staff member with bed mobility, hygiene, and bathing;
-Required assistance of two staff members with transfers and toileting;
-Always incontinent of bowel and bladder. Unable to manage own toileting functions and required all cares to be provide by staff. The resident wore incontinence briefs. Staff should provide cares necessary to maintain hygiene, promote dignity and avoid skin breakdown;
-History of falls, was a fall risk, unsteady with transfers and balance, muscle weakness, fatigue and endurance concerns;
-Staff should monitor medications, provide a safe environment, monitor condition and report changes to Director of Nursing (DON) and physician as applicable, provide comfort and care, monitor lab values and report to physician;
-Staff should provided cushions for the resident's wheelchair,
-Goals were to maintain health and safety while performing Activities of Daily Living (ADLs) as independently as possible.
Review of the resident's weekly skin assessment dated [DATE] showed staff documented the following:
-Right and left heel were firm (normal condition) and intact;
-Missing second and third toe on right foot;
-Bruising to hands and forearms and scabs to bridge of nose;
-No documented pressure ulcers.
Review of the resident's Braden Scale (a tool used for predicting pressure ulcer risk, made up of six scored subscales for a total score range from 6-23. A lower score indicated a lower level of functioning and a hgher level of risk for pressure ulcer development) dated 12/28/24 showed the following:
-No impairment in ability to respond meaningfully to pressure-related discomfort;
-Very moist, skin was often but not always moist, linen must be changed at least once a shift;
-Chairfast, ability to walk was severely limited;
-Very limited, unable to make frequent or significant changes independently in body or extremity position;
-Adequate ability to eat over half of most meals;
-Problem with shear and friction, rquired moderate to maximum assist in moving;
-Score of 14 indicating moderate risk for developing pressure ulcers.
Review of the resident's admission Minimum Data Set (MDS) a federally mandated assessment instrument, completed by facility staff, dated 1/3/24 showed the following:
-Cognitively intact;
-Required partial/moderate assistance (staff provided less than half the effort) with dressing upper body, and bed mobility (turning from side to side in the bed, moving from lying flat in the bed to sitting on the side of the bed and sitting on the side of the bed to lying flat on the bed);
-Required substantial/maximum staff assistance (staff provided more than half the effort) with personal hygiene, putting on/taking off footwear, and transfers from a chair, bed or toilet;
-Dependent on staff (staff provided all the effort) with toileting, showers, dressing lower body and standing up from a sitting position;
-Unable to walk;
-Wheelchair for mobility with substantial/maximal staff assistance;
-Frequently incontinent of bowel and bladder;
-At risk for developing pressure ulcers;
-No current pressure ulcers or moisture associated skin damage;
-Pressure reducing device (equipment that aims to relieve pressure away from areas of high risk for skin breakdown) for chair.
Review of the resident's weekly skin assessment dated [DATE] showed staff documented the resident had open blisters to both heels and redness to the coccyx (tailbone area).
Review of the resident's nurses notes showed staff documented the following:
-On 1/19/24 at 1:56 P.M. the resident was alert and oriented. Blisters to both heels had burst, dressing change provided as ordered and educated family and resident on pressure relief. Physician was notified and request for Wound Care Plus consult (consulting wound care management company);
-On 1/20/24 at 3:04 P.M. the buttock wound treatment was done, the resident was incontinent of bowel and bladder.
Review of the resident's POS dated 1/23/24 showed float (elevate the heels off the bed) the resident's heels at all times as tolerated.
Review of the resident's weekly skin assessment dated [DATE] showed staff documented the resident had open wounds on both heels and Stage 2 pressure ulcer (a partial thickness loss of dermis presenting as a shallow open ulcer with a red-pink wound bed, without slough. May also present as an intact or open/ruptured blister) on the coccyx.
Review of the Wound Care Plus progress note dated 1/24/24 showed the following:
-Evaluation and management of multiple wounds;
-Wound #1, left heel chronic Stage 3 pressure injury pressure ulcer (a full thickness tissue loss. Subcutaneous fat may be visible but bone, tendon or muscle is not exposed) with status of not healed. Initial wound encounter measurements 10 centimeters (cm) by 9.4 cm by 0.1 cm deep with bloody drainage, no odor. The peri (surrounding) wound skin exhibited maceration (softening and braking down of skin resulting from prolonged exposure to moisture) and erythema, peri wound skin friable (fragile skin, tears, bruises or breaks easily) and moist. Unable to determine depth of the wound;
-Wound #2 right heel chronic unstageable pressure injury (unable to determine the stage) obscured full-thickness skin and tissue loss pressure ulcer and had status of not healed. Initial wound encounter measurements 8.2 cm by 7 cm by 0.1 cm deep with small amount of blood drainage with mild odor. The peri wound skin exhibited edema (swelling) and erythema (redness), peri wound skin friable and moist, presented with signs and symptoms of infection. Topical antibiotics (placed directly on the skin) prescribed. Unable to determine depth of the wound due to area of eschar (necrotic dead tissue usually black in color, dry, firm and adhered to the wound bed);
-Wound #3 coccyx Stage 3 pressure injury pressure ulcer with status of not healed. Initial wound encounter measurements 1.2 cm by 2 cm by 0.2 cm deep with scant bloody drainage with no odor. The peri wound skin was friable and moist, peri wound skin did not exhibit signs or symptoms of infection;
-The resident's affected body parts were recently (last 2 weeks) immobile prior to the wound developing. Nursing staff noted the pressure ulcers were directly from positioning. The ulcers were mixed etiology including pressure;
-Education provided regarding proper offloading of affected area to maintain wound healing.
Review of the Wound Care Plus progress note dated 1/31/24 showed the following:
-Evaluation and management of multiple wounds;
-Wound #1 left heel chronic Stage 3 pressure injury pressure ulcer with status of not healed. Measurements 6.7 cm by 8.1 cm by 0.1 cm deep, small amount of bloody drainage with no odor. Unable to determine depth of the wound;
-Wound #2 right heel chronic unstageable pressure injury obscured full-thickness skin and tissue loss pressure ulcer and had status of not healed. Measurements 8.4 cm by 6.6 cm by 0.1 cm deep with small amount of blood drainage with mild odor. 51% to 75% eschar (one-half to three-fourths of the wound base covered by eschar) Unable to determine depth of the wound due to area of eschar;
-Wound #3 coccyx Stage 3 pressure injury pressure ulcer with status of not healed. Measurements 2.4cm by 3.1 cm by 0.2 cm deep with scant bloody drainage with no odor.
Review of the resident's nurses' notes showed staff documented the following:
-On2/2/24 at 6:35 P.M. the resident had several episodes of loose stool;
-On 2/3/24 at 12:46 P.M. the resident was incontinent and reported mild buttock pain;
-On 2/3/24 at 10:15 P.M. the resident yelled out and said he/she felt the metal in his/her heels. Staff tried to reposition the resident. The resident remained uncomfortable, as needed pain medication given with no relief.
Review of the Wound Care Plus progress note dated 2/7/24 showed the following:
-Evaluation and management of multiple wounds;
-Wound #1 left heel chronic Stage 3 pressure injury pressure ulcer with status of not healed. Measurements 2cm by 5cm by 0.1 cm deep, no drainage. Unable to determine depth of the wound;
-Wound #2 right heel chronic unstageable pressure injury obscured full-thickness skin and tissue loss pressure ulcer and had status of not healed. Measurements 6cm by 6.7cm by 0.1 cm deep with small amount of blood drainage with mild odor. 76% to 100% (three-fourths to complete covering of the wound base covered) eschar. Unable to determine depth of the wound due to area of eschar;
-Wound #3 coccyx Stage 3 pressure injury pressure ulcer with status of not healed. Measurements 2.8cm by 4.5cm by 0.1cm deep with scant bloody drainage with no odor;
-Wound #4 left posterior calf is chronic unstageable pressure injury obscured full-thickness skin and tissue loss pressure ulcer with status of not healed. Initial wound encounter measurements 15.7cm by 1.8cm by 0.1 cm depth, no drainage, wound bed 51% to 75% eschar. Unable to determine depth of the wound due to area of eschar.
Review of the Wound Care Plus progress note dated 2/14/24 showed the following:
-Evaluation and management of multiple wounds;
-Wound #1 left heel chronic Stage 3 pressure injury pressure ulcer with status of not healed. Measurements 2cm by 4cm by 0.1 cm deep, no drainage. Unable to determine depth of the wound;
-Wound #2 right heel chronic unstageable pressure injury obscured full-thickness skin and tissue loss pressure ulcer and had status of not healed. Measurements 6cm by 10cm with no measurable depth and small amount of bloody drainage with no odor. 76% to 100% eschar;
-Wound #3 coccyx Stage 3 pressure injury pressure ulcer with status of not healed. Measurement 3cm by 4cm with no measurable depth, large amount of bloody drainage with no odor. 76% to 100% eschar;
-Wound #4 left posterior calf is chronic unstageable pressure injury obscured full-thickness skin and tissue loss pressure ulcer with status of not healed. Initial wound encounter measurements 15cm by 2cm with no measurable depth, small amount of bloody drainage, wound bed 51% to 75% eschar.
Review of the Wound Care Plus progress note dated 2/21/24 showed the following:
-Evaluation and management of multiple wounds;
-Wound #1 left heel chronic Stage 3 pressure injury pressure ulcer with status of not healed. Measurements 2.4cm by 2.4cm by 0.1 cm deep, no drainage. Unable to determine depth of the wound;
-Wound #2 right heel chronic unstageable pressure injury obscured full-thickness skin and tissue loss pressure ulcer and had status of not healed. Measurements 7cm by 7.9cm by 0.1cm deep with small amount of bloody drainage with no odor. 76% to 100% eschar;
-Wound #3 coccyx Stage 3 pressure injury pressure ulcer with status of not healed. Measurements 8.7cm by 6.4cm by 0.2cm deep large amount of bloody drainage with mild odor. 76% to 100% eschar;
-Wound #4 left posterior calf is chronic unstageable pressure injury obscured full-thickness skin and tissue loss pressure ulcer with status of not healed. Measurements 16.9cm by 4cm by 0.2cm deep with small amount of bloody drainage, wound bed 51% to 75% eschar.
-Wound #5 right lateral lower leg acute unstageable pressure injury obscured full-thickness skin and tissue loss pressure ulcer with status of not healed. Initial wound encounter measurements 11.4 cm by 4.4 cm by 0.2 cm deep, small amount of bloody drainage with mild odor, wound bed 51% to 75% eschar.
During an interview on 3/26/24 at 12:30 P.M. Licensed Practical Nurse (LPN) E said the following:
-The resident had no pressure ulcers or wounds on admission to the facility. The resident was incontinent;
-The resident was wet and soiled frequently and staff did not change the resident frequently, it was difficult to change the resident, he/she had pain with turning and was stiff. The resident wore the same clothes for extended periods of time. The facility had staffing issues and not a lot of staff to help care for the resident. The resident required at least two staff for turning and incontinence care;
-It seemed like overnight the resident's heel and coccyx wounds got bad, there was no pressure relieving devices in place and the resident stayed on his/her back most of the time;
-Staff leaving the resident wet and soiled and the added pressure of remaining in the same position caused the resident's skin breakdown and pressure ulcers.
During an interview on 3/26/24 at 1:35 P.M. RN A said the following:
-The resident had generalized pain when moving and developed pressure ulcers on the buttocks and heels. Staff left the resident wet with urine for extended periods of time and did not turn the resident side to side due to pain and stiffness. RN A had concerns about staff not turning the resident and providing incontinence care. RN A started (unknown date) initialing the resident's incontinence brief at the end of his/her shift (day shift) and the same brief was in place the following morning saturated with urine;
-Staff should provide incontinence care every two hours and every time the resident was soiled. The resident did not have pressure ulcers on admission and should not have developed pressure ulcers;
-Staffing was not the best, had one day when day shift only had one CNA providing care for 70 residents, not much personal care was done, the residents were fed and checked on, everyone was breathing and the nurses passed medications. It was a rough day.
During an interview on 3/28/24 at 9:15 A.M. CNA D said the following:
-The resident was soiled with urine often and some staff left the resident soiled, staff did not want to hear the resident cry with discomfort when repositioning the resident or providing incontinence care. Staff just let the resident be and did not change or reposition the resident for extended periods of time. It was difficult to provide the resident's incontinence care;
-The resident's heels and buttocks started to develop pressure ulcers. Staff used barrier cream at first and the wounds got larger. The resident's legs were wrapped with a wound dressing, his/her heels were painful;
-Some days, there was only two CNA staff on the day shift, those were bad days and staff struggled to keep up with the residents' needs. Staff did the best they could but residents were not provided incontinence care or turned and positioned;
-At the 6:00 A.M. change of shift multiple resident's had brown rings (indicating a soiled bed). This usually occurred when limited staff worked the night shift.
During an interview on 3/29/24 at 1:10 P.M. the Assistant Director of Nursing (ADON) said the following:
-The resident was difficult to change and required at least two staff to provide incontinence care;
-The facility had staffing issues with lack of CNA staff to provide cares as frequently as the residents needed;
-Regular adequate staff would have helped the resident's wounds.
3. Review of Resident #3's care plan dated 12/14/23 showed the following:
-Diagnoses of Alzheimer's, osteoarthritis, pain in legs, atrial fibrillation (irregular heart rhythm that caused poor blood flow and risk of blood clots) and cardiac arrythmia (improper beating of the heart) ;
-Risk of skin breakdown related to incontinence and limited mobility. Staff should apply barrier cream, encourage to lay down in the afternoon, assist with toileting and hygiene, keep the resident clean and dry.
Review of the resident's quarterly Minimum Data Set (MDS) a federally mandated assessment instrument, completed by facility staff, dated 3/13/24 showed the following:
-Severely impaired cognition;
-Required substantial staff assistance (staff does more than half the effort) with toileting hygiene, showers, dressing, and personal hygiene;
-Frequently incontinent of bladder, always continent of bowel;
-At risk for pressure ulcers, no current pressure ulcers or other open wounds or moisture associated skin damage.
During an interview on 3/29/24 at 9:45 A.M. the resident's family member said the following:
-On 3/24/24 the resident was weak and could not sit up in the bed, his/her lips were cracked and peeling, tongue was dry and cracked. Family asked staff for help and was offered Zofran (nausea medication) and Imodium (diarrhea medication). Family requested the resident be sent to the emergency room;
-On 3/24/24 family transported the resident to the emergency room and was present when hospital staff removed the resident's soiled incontinence brief. The incontinence brief contained urine and feces. The resident's buttocks and perineal skin was red and raw with open sores, tender to the touch;
-On 3/28/24 the resident returned to the facility. About 8:00 P.M. the resident was incontinent of bowel and bladder, staff changed the resident and the brief was marked with an x by the family member. On 3/29/24 at 8:00 A.M. the resident wore the same x marked brief that was placed at 8:00 P.M. the day prior.
Observation on 3/29/24 at 2:30 P.M. showed the following:
-The resident sat in the wheelchair with head down and eyes closed. Certified Nurse Assistant (CNA) F woke the resident and lifted the resident under the arms without the use of a gait belt and transferred the resident to bed. The resident's incontinence brief sagged in the back as CNA F lifted the resident out of the wheelchair. The resident's legs were slightly bent, and he/she leaned forward toward CNA F as CNA F pivoted the resident to the bed. The resident moaned during the transfer and did not attempt to stand and bear weight;
-CNA F turned the resident to his/her side and pulled the resident's pants and incontinence brief down. The resident's entire buttock skin folds, coccyx and perineal skin folds extending to the groin areas were dark red with open areas to the buttocks and dark purple areas noted. A brownish stain was noted on the incontinence brief. No barrier cream was noted on the resident's buttocks or perineal skin folds. CNA F did not change the resident's soiled incontinence brief or provide incontinence care. CNA F pulled the resident's soiled incontinence brief and pants up, positioned the resident on his/her back and left the resident's room.
During an interview on 3/29/24 at 2:40 P.M. CNA F said the following:
-He/She was working a double shift from 10:30 P.M. on 3/28/24 to 3:00 P.M. on 3/29/24. He/She was responsible for the resident since 10:30 P.M. on 3/28/24. He/She was the only CNA on the resident's hall during the night shift;
-The resident slept all night and wore an incontinence brief all night. CNA F was sure at some point during the night, he/she had changed the resident's incontinence brief and had changed the resident around 8:00 A.M. on 3/29/24 when the family was visiting. CNA F had not changed the resident since 8:00 A.M. and the resident remained in the wheelchair all day. He/She was weak and had difficulty turning. CNA F had taken the resident to the dining room for meals on 3/29/24;
-CNA F used either a lift or gait belt for transfers or lifted under the resident's arms like he/she had just lifted Resident #3. The resident had to be lifted today because he/she could not hold any weight on his/her legs. CNA F did not always use a gait belt but he/she should when the resident could not bear weight. There was no gait belt in Resident #3's room for use at the time of the transfer from the wheelchair to the bed;
-The resident was dry when he/she pulled the resident's incontinence brief and pants down. He/She did not know what the brown stain was in the resident's incontinence brief. CNA F did not know if the resident had skin issues previously and did not know if the resident needed changed more frequently. The resident was not wet but did have a brownish stain in the brief. CNA F did not know what the redness on the resident's skin was, he/she did see the resident had an open area on the buttocks.
4. During an interview on 3/26/24 at 10:35 A.M. Resident #1 siad staff turn the call light off, do not provide assistance and leave the room. Sometimes it was a one to two hour wait time for assistance to the bathroom.
During an interview on 3/26/24 at 11:05 A.M. Resident #2 said staff turn call lights off and never come back to help with cares. The facility was short staffed.
During an interview on 3/26/24 at 3:30 P.M. CNA I said the day shift was usually staffed with three CNA staff for 70 residents. Three CNA staff were not enough on day shift, personal care and Activities of Daily Living (ADLs) were not always completed for the residents.
5. During an interview on 3/26/24 at 3:40 P.M. Resident #8 said staff were slow to answer the call lights.
During an interview on 3/26/24 at 4:00 P.M. Resident #4 said staffing was unstable and not dependable.
During an interview on 3/29/24 at 12:20 P.M. and 3:10 P.M. the DON said the following:
-Staff should implement interventions and prevent skin breakdown. Residents admitted without pressure ulcers should not develop pressure ulcers unless it was unavoidable. Staff should always follow up on any change in a wound or pressure ulcer, ensure treatments were implemented and preventative measures. Staff should have prevented Resident #10 from developing multiple pressure ulcers and implemented measures to prevent the pressure ulcers from worsening;
-Staff should always provide incontinence care every time a resident was a soiled. Staff should leave a resident soiled for extended periods of time causing skin damage and breakdown. Resident #3 had skin breakdown when he/she went to the hospital caused by the diarrhea and incontinence;
-Staff should always do what was needed, and always follow up with any change in a resident's condition;
-The issue was staffing and the overall lack of staff. The facility needed adequate staff with knowledge of the resident's needs.
During an interview on 3/29/24 at 3:20 P.M. the Administrator said the following:
-Staff should assess each resident for pressure ulcer risk and implement appropriate measures to prevent pressure ulcers from developing. Staff should provide treatment and follow the physician's orders, document treatments were provided and document the resident's condition in the medical record;
-Staff should ensure residents were kept clean and dry and not leave residents soiled in urine or feces causing skin breakdown;
-The overall issue was lack of adequate and educated staff to provide resident care. The facility needed good consistent staff and currently did not have adequate staff.
During an interview on 4/12/24 at 9:00 A.M. the DON said the following:
-Social Services and the DON were responsible for facility staffing;
-Scheduled staff who did not show up for work and did not call in caused the biggest issues with staffing. Currently the schedule was routinely over staffed with two extra CNA staff to cover the staff who do not show up for work. Seven CNAs were scheduled in the hope five show up for work;
-The facility utilized agency staff who at times did not show up for work when scheduled;
-He/She currently wanted at least five CNA staff on day shift and evening shift and at least three CNA staff on night shift as well as charge nurses and CMT staff to meet the needs of residents;
-If staff called in or did not show up for work, the Social Services Director called agency staff to fill the open spots.
MO#00233392
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
Pharmacy Services
(Tag F0755)
Could have caused harm · This affected multiple residents
Based on observation, interview and record review the facility failed to ensure an accurate reconciliation of narcotic (controlled) medications was maintained in the facility 's Stat-Safe (automated e...
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Based on observation, interview and record review the facility failed to ensure an accurate reconciliation of narcotic (controlled) medications was maintained in the facility 's Stat-Safe (automated emergency medication supply system) and failed to ensure drug records were in order and that an account of all controlled drugs was maintained and periodically reconciled. The facility census was 70.
Review of the facility undated policy, Medications, Scheduled II - V (controlled substances based on their abuse potential and potential for addiction);
-The purpose was to provide medication for residents as prescribed and to comply with State and Federal guidelines regarding these medications;
-Schedule II-V medications must be kept in medication cart lock box or double lock box maintained in medication room;
-All Scheduled II-V medications must be counted at every change of shift by two Certified Medication Technicians (CMTs), or one CMT and one licensed nurse. Both personnel must sign verification of correct counts;
-If at any time, the count was incorrect, CMT must notify licensed nursing staff, who will call the Director of Nursing (DON) or designees for instructions.
Review of the facility undated Narcotic Count policy showed the following:
-The purpose was to complete a physical inventory of narcotics at each shift change to identify discrepancies;
-Narcotic supplies were to be kept under two locks at all times;
-The on-coming nurse must count and justify accuracy of narcotics supply for each individual resident at the change of each shift;
-Narcotic records were reconciled by a physical count of the remaining narcotic supply at each shift change by the incoming and outgoing nurse. Emergency kits containing narcotics would be checked at the same time;
-Discrepancies found at any time were to be immediately reported to the DON. The DON would initiate an investigation to determine the cause of the discrepancy and contact the pharmacist for assistance as needed.
Review of the facility undated Medication Administration policy showed the following:
-Medications were given to benefit a resident's health as ordered by the physician;
-Read the label three times before administering the medication;
-Administer the medication. If the resident refused the medication, indicate failure to administer medication on the Medication Administration Record (MAR) by circling initials and making a notation on the back of the MAR;
-Record the medication given on the MAR;
-Chart any and all controlled medications immediately on the narcotic record when given.
During an interview on 3/29/24 3:15 P.M. the Director of Nursing said if a narcotic dose was dropped or wasted, two staff were required to verify and document the destruction of the medication on the corresponding disposition form reconciling the narcotic count. The narcotic count was not reconciled if two staff did not verify destruction.
1. Review Resident #3's Physician Order Sheet (POS) dated 6/7/23 showed Hydrocodone (schedule II narcotic controlled substance)/APAP (Tylenol pain medication) 5/325 milligrams (mg) administer one tablet three times daily for pain between 5:00 A.M. and 10:00 A.M., between 11:00 A.M. and 2:00 P.M. and between 7:00 P.M. and 10:00 P.M.
Review of the resident's Controlled Drug Receipt/Record/Disposition form (form used to reconcile the narcotic medication and document the date, time of administration, amount of narcotic administered and the remaining count and signature of the Certified Medication Technician (CMT) or nurse removing and administering the narcotic) dated 3/18/24 showed the following:
-At 8:00 P.M. CMT B signed out one Hydrocodone/APAP 5/325 mg tablet, 6 tablets remained and documented the tablet was wasted (destroyed). There was no additional licensed nurse or CMT signature verifying the tablet was wasted;
-At 8:00 P.M. CMT B signed out one Hydrocodone/APAP 5/325 mg tablet, 5 tablets remained.
Review of the resident's Medication Administration Record (MAR) dated 3/18/24 showed CMT B documented between 7:00 P.M. and 10:00 P.M. one Hydrocodone/APAP 5/325 mg tablet was administered.
2. Review of Resident #8's POS dated 10/3/23 showed Hydrocodone/APAP 5/325 mg administer one tablet at bedtime for pain between 7:00 P.M. and 10:00 P.M.
Review of the resident's Controlled Drug Receipt/Record/Disposition form dated 3/6/24 showed the following:
-At 8:00 P.M. CMT B signed out one Hydrocodone/APAP 5/325 mg tablet, 9 tablets remained and documented the tablet was dropped and wasted. There was no additional licensed nurse or CMT signature verifying the tablet was dropped and wasted;
-At 8:00 P.M. CMT B signed out one Hydrocodone/APAP 5/325 mg tablet, 8 tablets remained.
Review of the resident's MAR dated 3/6/24 showed CMT B documented between 7:00 P.M. and 10:00 P.M. one Hydrocodone/APAP 5/325 mg tablet was administered.
Review of the resident's Controlled Drug Receipt/Record/Disposition form dated 3/12/24 showed the following:
-At 8:00 P.M. CMT B signed out one Hydrocodone/APAP 5/325 mg tablet, 2 tablets remained and documented the tablet was dropped and wasted. There was no additional licensed nurse or CMT signature verifying the tablet was dropped and wasted;
-At 8:00 P.M. CMT B signed out one Hydrocodone/APAP 5/325 mg tablet, 1 tablet remained.
Review of the resident's MAR dated 3/6/24 showed CMT B documented between 7:00 P.M. and 10:00 P.M. one Hydrocodone/APAP 5/325 mg tablet was administered.
3. Review of Resident #7's POS dated 10/3/23 showed Hydrocodone/APAP 7.5/325 mg administer one tablet every six hours for pain at 12:00 A.M., 6:00 A.M., 12:00 P.M. and 6:00 P.M.
Review of the resident's Controlled Drug Receipt/Record/Disposition form dated 3/2/24 showed at 12:00 A.M. one Hydrocodone/APAP 7.5/325 mg was removed, 27 tablets remained. The staff signature line was blank with no staff signature indicating who removed the one tablet.
Review of the resident's MAR dated 3/2/24 at 12:00 A.M. showed no staff documentation Hydrocodone/APAP 7.5/325 mg was administered.
Review of the resident's Controlled Drug Receipt/Record/Disposition form dated 3/3/24 showed the following:
-At 6:00 P.M. CMT B signed out one Hydrocodone/APAP 7.5/325 mg tablet, 20 tablets remained and documented the tablet was dropped. There was no additional licensed nurse or CMT signature verifying the tablet was dropped;
-At 6:00 P.M. CMT B signed out one Hydrocodone/APAP 7.5/325 mg tablet, 19 tablets remained.
Review of the resident's MAR dated 3/3/24 showed CMT B documented at 6:00 P.M. one Hydrocodone/APAP 7.5/325 mg tablet was administered.
Review of the resident's Controlled Drug Receipt/Record/Disposition form dated 3/4/24 showed the following:
-At 6:00 P.M. CMT B signed out one Hydrocodone/APAP 7.5/325 mg tablet, 15 tablets remained and documented the tablet was wasted. There was no additional licensed nurse or CMT signature verifying the tablet was wasted;
-At 6:00 P.M. CMT B signed out one Hydrocodone/APAP 7.5/325 mg tablet, 14 tablets remained.
Review of the resident's MAR dated 3/4/24 showed CMT B documented at 6:00 P.M. one Hydrocodone/APAP 7.5/325 mg tablet was administered.
Review of the resident's Controlled Drug Receipt/Record/Disposition form dated 3/18/24 showed the following:
-At 6:00 P.M. CMT B signed out one Hydrocodone/APAP 7.5/325 mg tablet, 17 tablets remained and documented the tablet was wasted. There was no additional licensed nurse or CMT signature verifying the tablet was wasted;
-At 6:00 P.M. CMT B signed out one Hydrocodone/APAP 7.5/325 mg tablet, 16 tablets remained.
Review of the resident's MAR dated 3/18/24 showed CMT B documented at 6:00 P.M. one Hydrocodone/APAP 7.5/325 mg tablet was administered.
4. Review of Resident #4's POS dated 9/26/23 showed Oxycodone (schedule II narcotic controlled substance)/APAP 5/325 mg, one tablet three time daily for pain between 5:00 A.M. and 10:00 A.M., between 11:00 A.M. and 2:00 P.M. and between 7:00 P.M. and 10:00 P.M.
Review of the resident's Controlled Drug Receipt/Record/Disposition form dated 3/2/24 showed the following:
-At 8:00 P.M. CMT B signed out one Oxycodone/APAP 5/325 mg tablet, 26 tablets remained and documented the tablet was wasted. There was no additional licensed nurse or CMT signature verifying the tablet was wasted;
-At 8:00 P.M. CMT B signed out one Oxycodone/APAP 5/325 mg tablet, 25 tablets remained.
Review of the resident's MAR dated 3/2/24 showed CMT B documented between 7:00 P.M. and 10:00 P.M.one Oxycodone/APAP 5/325 mg tablet was administered.
Review of the resident's Controlled Drug Receipt/Record/Disposition form dated 3/5/24 showed the following:
-At 8:00 P.M. CMT B signed out one Oxycodone/APAP 5/325 mg tablet, 16 tablets remained and documented the tablet was wasted. There was no additional licensed nurse or CMT signature verifying the tablet was wasted;
-At 8:00 P.M. CMT B signed out one Oxycodone/APAP 5/325 mg tablet, 15 tablets remained.
Review of the resident's MAR dated 3/5/24 showed CMT B documented between 7:00 P.M. and 10:00 P.M one Oxycodone/APAP 5/325 mg tablet was administered.
Review of the resident's Controlled Drug Receipt/Record/Disposition form dated 3/13/24 showed the following:
-At 5:00 P.M. CMT B signed out one Oxycodone/APAP 5/325 mg tablet, 21 tablets remained and documented the tablet was wasted. There was no additional licensed nurse or CMT signature verifying the tablet was wasted.
Review of the resident's MAR dated 3/13/24 showed no documentation CMT B administered the resident's Oxycodone/APAP 5/325 mg tablet at 5:00 P.M.
Review of the resident's Controlled Drug Receipt/Record/Disposition form dated 3/17/24 showed the following:
-At 8:00 A.M. CMT B signed out one Oxycodone/APAP 5/325 mg tablet, 10 tablets remained and documented the tablet was wasted. There was no additional licensed nurse or CMT signature verifying the tablet was wasted;
-At 8:00 A.M. CMT B signed out one Oxycodone/APAP 5/325 mg tablet, 9 tablets remained.
Review of the resident's MAR dated 3/17/24 showed CMT B documented between 5:00 A.M. and 10:00 A.M. one Oxycodone/APAP 5/325 mg tablet was administered.
5. Review of Resident #5's POS dated 9/26/23 showed Hydrocodone/APAP 5/325 mg, one tablet twice daily for pain between 5:00 A.M. and 10:00 A.M. and between 7:00 P.M. and 10:00 P.M.
Review of the resident's Controlled Drug Receipt/Record/Disposition form dated 3/2/24 showed the following:
-At 8:00 A.M. CMT B signed out one Hydrocodone /APAP 5/325 mg tablet, 27 tablets remained and documented the tablet was dropped. There was no additional licensed nurse or CMT signature verifying the tablet was dropped;
-At 8:00 A.M. CMT B signed out one Hydrocodone /APAP 5/325 mg tablet, 26 tablets remained.
Review of the resident's MAR dated 3/2/24 showed CMT B documented between 5:00 A.M. and 10:00 A.M. one Hydrocodone/APAP 5/325 mg tablet was administered.
6. Review of Resident #1's POS dated 9/21/23 showed Hydrocodone/APAP 7.5/325 mg, one tablet four times daily for pain at 12:00 A.M., 6:00 A.M., 12:00 P.M. and 6:00 P.M.
Review of the resident's Controlled Drug Receipt/Record/Disposition form dated 3/2/24 showed the following:
-At 12:00 A.M.one Hydrocodone/APAP 7.5/325 mg was removed, 19 tablets remained. The staff signature line was blank with no staff signature indicating who removed the one tablet;
-At 6:00 A.M. CMT B signed out one Hydrocodone/APAP 7.5/325 mg, 18 tablets remained;
-At 12:00 P.M. CMT B signed out one Hydrocodone/APAP 7.5/325 mg, 17 tablets remained;
-At 6:00 P.M. CMT B signed out one Hydrocodone/APAP 7.5/325 mg, 16 tablets remained;
-At undocumented time CMT B signed out one Hydrocodone/APAP 7.5/325 mg and documented the tablet was dropped, 15 tablets remained. The time of removal line was blank with no indication what time the tablet was removed. There was no additional licensed nurse or CMT signature verifying the tablet was dropped.
Review of the resident's Controlled Drug Receipt/Record/Disposition form dated 3/5/24 showed the following:
-At 6:00 P.M. staff signed out one Hydrocodone/APAP 7.5/325 mg, 6 tablets remained, and documented the tablet was dropped. The staff signature line was blank with no staff signature indicating who removed the one tablet. There was no additional licensed nurse or CMT signature verifying the tablet was dropped.
Review of the resident's MAR dated 3/5/24 showed CMT B documented at 6:00 P.M. one Hydrocodone/APAP 7.5/325 mg tablet was administered.
Review of the resident's Controlled Drug Receipt/Record/Disposition form dated 3/11/24 showed the following:
-At 6:00 P.M. CMT B signed out one Hydrocodone /APAP 7.5/325 mg tablet, 17 tablets remained and documented the tablet was dropped. There was no additional licensed nurse or CMT signature verifying the tablet was dropped.
Review of the resident's MAR dated 3/11/24 showed no documentation CMT B administered the resident's Hydrocodone /APAP 7.5/325 mg tablet one tablet at 6:00 P.M.
Review of the resident's Controlled Drug Receipt/Record/Disposition form dated 3/13/24 showed the following:
-At 6:00 P.M. CMT B signed out one Hydrocodone /APAP 7.5/325 mg tablet, 9 tablets remained and documented the tablet was wasted. There was no additional licensed nurse or CMT signature verifying the tablet was wasted.
Review of the resident's MAR dated 3/13/24 showed CMT B documented at 6:00 P.M. one Hydrocodone/APAP 7.5/325 mg tablet was administered.
Review of the resident's Controlled Drug Receipt/Record/Disposition form dated 3/13/24 showed the following:
-At 8:00 P.M. CMT B signed out one Hydrocodone /APAP 7.5/325 mg tablet, 8 tablets remained.
Review of the resident's MAR dated 3/13/24 showed no documentation CMT B administered one Hydrocodone/APAP 7.5/325 mg tablet at 8:00 P.M.
7. Observation on 3/29/24 at 10:40 A.M. showed the following:
-CMT G logged into the facility Stat-Safe, entered a password and requested one Norco (hydrocodone controlled narcotic medication) from the list provided on the screen. The list included the names of the narcotic medications available and the number of doses that remained in the Stat-Safe. The system indicated Norco 5/325 mg, two doses remained in the Stat-Safe;
-The locked narcotic drawer opened;
-No Norco 5/325 mg tablets remained in the Stat-Safe narcotic drawer;
-CMT G closed the narcotic drawer, locked the Stat-Safe and informed the DON of the discrepancy.
During interview on 3/29 24 at 10:50 A.M. the DON said CMT G informed her of the Norco discrepancy in the Stat-Safe. The pharmacy managed and stocked the Stat-Safe medications. The pharmacy consultant was at the facility conducting an audit of the Stat-Safe currently.
Review of the pharmacy consultant Stat-Safe audit conducted on 3/29/24 showed the following:
-Hydrocodone/APAP 10/325 mg chart audit discrepancy of 16 tablets;
-Oxycodone/APAP 5/325 mg chart audit discrepancy of 5 tablets;
-Hydrocodone/APAP 5/325 mg chart audit discrepancy of 2 tablets;
-Oxycodone 5 mg chart audit discrepancy of 4 tablets;
-Hydrocodone/APAP 7.5/325 mg audit discrepancy of 6 tablets;
-Hydrocodone/APAP 10/325 mg audit discrepancy of 1 tablets;
-Oxycodone/APAP 10/325 mg chart audit discrepancy of 8 tablets;
-Oxycodone IR 10 mg chart audit discrepancy of 4 tablets;
-Oxycodone ER 20 mg chart audit discrepancy of 4 tablets;
-Hydrocodone/APAP 5/325 mg chart audit discrepancy of 15 tablets.
During an interview on 3/29/24 at 12:40 P.M. the pharmacy consultantant said the following:
-The Stat-Safe reconciliation of the narcotics should be conducted weekly or more frequently by the DON or Assistant DON;
-A pharmacy audit was conducted monthly and on the last audit conducted 3/4/24 discrepancies were identified of 21 doses of narcotics. The facility was notified of the discrepancies by email and should have conducted an investigation into the narcotic discrepancy immediately;
-The 3/29/24 audit showed all the narcotic medications were gone from the Stat-Safe except one dose. Staff should have identified the discrepancies during weekly audits and prevented further narcotic diversion from occurring.
During an interview on 3/29/24 at 1:10 P.M. the Assistant DON said the following:
-She did not have a facility email address and had not received any information regarding a discrepancy in the Stat-Safe narcotic reconciliation. She was not aware the Stat-Safe narcotic count was off on 3/4/24;
-She had never reconciled the Stat-Safe narcotics and did not have access to the Stat-Safe auditing system;
-She did not think the narcotic medications pulled from the Stat-Safe were reconciled with the residents' MARs.
During an interview on 3/27/24 at 12:15 P.M. the DON said the following:
-Staff should sign out each dose of narcotic medication on the corresponding narcotic disposition form at the time the narcotic was removed from the locked medication cart. Staff should administer the narcotic and document the administration on the resident's MAR immediately following the medication administration;
-If a narcotic dose was dropped or wasted, two staff were required to verify and document the destruction of the medication on the corresponding disposition form reconciling the narcotic count. The narcotic count was not reconciled if two staff did not verify destruction;
-Staff should count all narcotics at the change of every shift. The narcotic counts must be correct before the off-going nurse left the facility;
-The Stat-Safe was not audited by the DON or any other administrative staff. The DON currently did not have access to audit the Stat-Safe;
-The pharmacy audits the Stat-Safe narcotics monthly. The DON was not aware there was a discrepancy of the narcotic reconciliation found on 3/4/24 during the pharmacy audit. There was monitoring of the narcotic sign out logs for errors or discrepancies.
During an interview on 3/28/24 at 2:00 P.M. and on 3/29/24 at 9:30 A.M. the administrator said the following:
-The Stat-Safe was not reconciled following the 3/4/24 pharmacy audit and currently no staff audited and reconciled the Stat-Safe narcotics;
-All narcotics should be reconciled. Staff should count all the narcotics at the change of every shift and ensure all the counts were correct. Staff should sign out every narcotic removed from the locked narcotic box at the time of removal and document on the resident's MAR immediately following the narcotic administration;
-The Stat-Safe needed reconciled at least weekly to ensure the counts were correct. An audit of the narcotics removed from the Stat-Safe compared with the residents MARs should be conducted to ensure accuracy and reconciliation on a routine basis.
Jan 2024
2 deficiencies
CONCERN
(E)
📢 Someone Reported This
A family member, employee, or ombudsman was alarmed enough to file a formal complaint
Potential for Harm - no one hurt, but risky conditions existed
Deficiency F0725
(Tag F0725)
Could have caused harm · This affected multiple residents
**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, interview and record review, the facility failed to provide sufficient nursing staff to meet the needs of ...
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**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, interview and record review, the facility failed to provide sufficient nursing staff to meet the needs of three residents (Resident #8, #9 and #10), in a review of 11 sampled residents, when the facility failed to provide regular baths or showers and did not respond to resident call lights in a timely manner. Additionally, staff failed to provide incontinence care for one resident (Resident #8). The facility also failed to maintain staffing hours per day, based on average census and per the facility assessment, to meet resident care needs. The facility census was 69.
Review of electronic mail on 01/04/24 at 3:30 P.M., and interview on 01/08/24, at 3:37 P.M., the administrator said the facility did not have a specific staffing policy and the facility goes by federal guidelines. The administrator provided the facility assessment but was unaware of what the staffing hours numbers on the facility assessment indicated. The facility also did not have a policy related to providing/passing fresh water.
Review of the facility's undated policy, Bath (shower), showed the purpose is to maintain skin integrity, comfort and cleanliness (the policy did not address frequency of bathing).
Review of the facility's undated policy, Activities of Daily Living (ADL), showed the purpose is to assist resident in achieving maximum function.
1. Review of the Facility Assessment, updated 06/22/23, showed the following:
-The facility's average daily census was 60;
-Dressing: two residents independently dressed themselves, 40 residents required assistance from 1-2 staff to complete the task and 18 residents were dependent on staff to complete the task;
-Bathing: two residents independently bathed themselves, 40 residents required assistance from 1-2 staff to complete the task and 18 residents were dependent on staff to complete the task;
-Transfers: 22 residents transferred independently, 24 residents required assistance from 1-2 staff to complete the task and 14 residents were dependent on staff to complete the task;
-Toileting: 18 residents had independent toileting status, 29 residents required assistance from 1-2 staff to complete the task and 13 residents were dependent on staff to complete the task;
-Facility resources needed to provide competent support and care for resident population every day and during emergencies: staffing to meet care needs:
a. Registered Nurse (RN) - 8 hours per day based on average census;
b. Certified Nursing Assistant (CNA) - 112/136 hours per day based on average census;
-Facility staffing is based on census and acuity;
-If the census or acuity fluctuates, the facility makes every effort to ensure there is adequate staff to meet the needs of the residents.
2. Review of staffing sheets provided by the facility dated 12/19/23 through 01/03/24 showed the following:
-12/20/23 total working hours for CNA staff was 96 hours with a facility census of 72;
-12/21/23 total working hours for CNA staff was 96 hours with a facility census of 72;
-12/22/23 total working hours for CNA staff was 104 hours with a facility census of 72;
-12/23/23 total working hours for RN staff was 0 hours with a facility census of 72;
-12/24/23 total working hours for CNA staff was 104 hours with a facility census of 72;
-12/25/23 total working hours for RN staff was 0 hours and total working hours for CNA staff was 100.5 hours with a facility census of 72;
-12/29/23 total working hours for CNA staff was 96 hours with a facility census of 69;
-12/30/23 total working hours for RN staff was 0 hours and total working hours for CNA staff was 100.5 hours with a facility census of 70;
-12/31/23 total working hours for RN staff was 0 hours and total working hours for CNA staff was 85.5 hours with a facility census of 70;
-01/01/24 total working hours for RN staff was 0 hours and total working hours for CNA staff was 64 hours with a facility census of 70;
-01/03/24 total working hours for CNA staff was 104 hours with a facility census of 69;
-The facility had not staffed per the facility assessment, for RN coverage, for five of the sixteen days reviewed;
-The facility had not staffed per the facility assessment, for CNA coverage, for ten of the sixteen days reviewed.
3. Review of the Resident #8's Continuity of Care Document (CCD) showed the resident had diagnoses that included dysuria (discomfort, pain or burning when urinating), history of urinary tract infection and overactive bladder.
Review of the resident's quarterly Minimum Data Set (MDS), a federally mandated assessment instrument, completed by facility staff, dated 09/23/23, showed the following:
-Able make needs known and understand others;
-Cognitively intact;
-No behaviors or rejection of cares;
-Partial/Moderate assistance from staff to complete shower/bath;
-Occasionally incontinent of urine.
Review of the resident's care plan, revised on 09/26/23, showed the following:
-Resident experiences occasional bladder incontinence;
-Provide incontinence care after each incontinent episode;
-No indication of an ADL deficit or bathing routine on the care plan.
Review of the weekly shower list provided by the facility showed the resident was to receive a shower/bath each Monday and Thursday.
Review of the shower sheets provided by the facility, for 12/20/23 through 01/03/24, showed the resident had a shower on Thursday 12/21/23 and Monday 01/01/23 (10 days from the previous shower). The resident did not have a documented shower on Monday, 12/25/23 or Thursday 12/28/23.
Review of the resident's progress notes showed no refusal of a bath/shower for the time period between 12/21/23 and 01/01/24.
During an interview on 01/03/24, at 11:42 A.M., the resident said the following:
-It takes a long time to answer his/her call light;
-He/She does not get fresh water but maybe once or twice a week;
-He/She gets to take a bath one time a week if he/she was lucky;
-He/She would like a bath every day;
-He/She only gets changed when he/she has an accident (incontinent) and needs staff assistance to change himself/herself when he/she has an accident (is incontinent);
-He/She was currently wet and needed to be changed;
-He/She has not been checked on since last night.
Observation of the resident on 01/03/24, at 11:42 A.M. showed the following:
-The resident lay in bed on his/her side;
-Noted to have a large brown stain on the blanket covering his/her bottom;
-Noted to have a slight urine smell during interview;
-His/Her hair was unkempt with a slight greasy appearance;
-He/She activated his/her call light for assistance to use the bathroom.
Observation of the resident on 01/03/24, at 12:15 P.M. showed the following:
-CNA H answered the resident's call light approximately 33 minutes after it was activated;
-CNA H assisted the resident to sit on the side of the bed for transfer;
-CNA H assisted the resident to a standing position to transfer to the wheelchair;
-A large, wet brown stain was noted on the resident's bottom sheet approximately 1.5-2 feet in diameter that had a strong urine smell;
-The resident was not wearing pants but was wearing a pull-up brief;
-The resident's brief was saturated with tan/brown urine and drooped at the bottom;
-CNA H assisted the resident in removal of the incontinent brief and when placed in the trash can, it made a thumping sound when dropped in the trash can due to saturation;
-CNA H provided incontinence care for the resident and applied a new incontinence brief and clean pants.
Observation from 11:00 A.M. through 4:30 P.M. during the on-site process showed no staff passed fresh water to the residents on any hall.
During an interview on 01/03/24, at 12:15 P.M. and 2:42 P.M. CNA H said the following:
-He/She was assigned to Resident #8's hall and was responsible for his/her care and works the day shift 7:00 A.M. to 3:00 P.M.;
-No one else was assigned to the resident; there was only one aide assigned per hall;
-Resident #8 has periods of incontinence;
-When he/she provided incontinence care for the resident at 12:15 P.M., that was the first time he/she had checked the resident on 01/03/24;
-Residents should be checked every two hours, but sometimes they are so short staffed they do the best they can;
-On 01/03/23, he/she felt like they did not have enough staff to complete all of the resident care needed to be done;
-He/She had not checked the resident before 12:15 P.M. because he/she had three shower to give directly after breakfast;
-Residents are scheduled to be given a bath two times a week or when they ask for them;
-They do not always have enough staff to get showers done or to provide the care the residents need;
-Call lights should be answered timely, and it should not take 30 minutes to answer a call light.
4. Review of Resident #10's CCD showed the resident had diagnoses that included morbid obesity and cellulitis (a potentially serious bacterial skin infection).
Review of the resident's care plan, revised 11/25/23, showed the following:
-The resident has some ADL deficit, but with good compensation in completing with no to minimal assist;
-Allow sufficient time to complete grooming/personal hygiene;
-Follow his/her lead in caring for personal hygiene needs such as perineal and shower care;
-Provide assistance for hygiene tasks as he/she needs such as hair, nails, skin and oral care.
Review of the resident's quarterly MDS, dated [DATE], showed the following:
-Able to make needs known and understands others;
-Cognitively intact;
-No behaviors or rejection of cares;
-Supervision or touch assistance for toileting, showering, upper body dressing and all transfers;
-Partial/moderate assistance for lower body dressing and putting on/taking off footwear;
-Continent of bowel and bladder.
Review of the weekly shower list provided by the facility showed the resident was to receive a shower/bath on Wednesday and Saturday each week.
Review shower sheets for the past two weeks, for 12/20/23 through 01/03/24, showed the resident had a shower on Saturday 12/23/23. The resident did not have a documented shower on Wednesday 12/20/23, Wednesday 12/27/23 or Saturday 12/30/23.
Review of the resident's progress notes showed no refusal of bath/shower for the time period between 12/21/23 and 01/01/24.
During an interview on 01/03/24, at 12:22 P.M., the resident said the following:
-Water was not passed routinely;
-He/She had not had a bath/shower for about three weeks and only got one today because he/she caused a stink;
-He/She was supposed to get a bath/shower two times a week and that never happened;
-He/She gets a red rash from sweating when he/she does not get showers.
5. Review of Resident #11's CCD showed the resident had diagnoses that included pressure ulcer of the sacral region (the coccyx or area above the tailbone), unspecified bacterial infection, pain and overactive bladder.
Review of the resident's quarterly MDS, dated [DATE], showed the following:
-Able to make needs known and understands others;
-Cognitively intact;
-No behaviors or rejection of cares;
-Substantial/maximal assistance for toileting and all transfers;
-Partial/moderate assistance for shower/bathing;
-Always incontinent of bowel and bladder.
Review of the resident's care plan, revised 12/26/23, showed the following:
-Resident has open lesions (sores) bilateral (both) buttocks due to moisture associated skin damage, redness under breasts and armpits;
-The resident was frequently non-compliant with treatment done to open areas and to be changed when he/she was wet;
-Assist resident in repositioning approximately every two hours or as tolerated/desired by resident;
-Keep clean and dry as possible;
-Minimize skin exposure to moisture;
-No indication of ADL deficit or bathing routine was noted on the care plan.
Review of the weekly shower list provided by the facility showed the resident was to receive a shower/bath on each Monday and Thursday.
Review of the shower sheets for the past two weeks, for 12/20/23 through 01/03/24, showed staff provided no showers for the resident. The resident did not have a documented shower on Thursday 12/21/23, Monday 12/25/23, Thursday 12/28/23 or Monday 1/1/24.
Review of the resident's progress notes showed no refusals of a bath/shower for the time period between 12/21/23 and 01/01/24.
During an interview on 01/03/24, at 12:22 P.M., the resident said the following:
-It had been a while since he/she took a shower or was given a bed bath. He/She did not remember when he/she had the last one;
-He/She had recently been in isolation due to COVID (Coronavirus disease, an infectious disease) and did not receive any type of bath the entire time he/she was in isolation;
-He/She has a patch of hair on the back of his/her head that was a knotted mess;
-He/She is incontinent and only gets changed about three times a day;
-He/She does not feel like being changed three times a day is enough as he/she has sores on his/her bottom;
-He/She has had to wait an hour and sometimes two hours for staff to answer his/her call light;
-He/She only gets fresh water maybe once a day, which was not enough.
Observation on 01/03/24 at 12:22 P.M., showed the resident sitting up in his/her wheelchair with unkempt slightly oily hair and a large area of matted hair approximately the size of a golf ball in the back right side of his/her hair.
During an interview on 01/03/24 at 1:50 P.M., CNA C said the following:
-Residents are supposed to be checked and changed every two hours or more if needed, that happens most of the time;
-Water is supposed to be passed frequently; CNAs pass the water;
-Residents are supposed to get two showers a week;
-Sometimes there are not enough staff to have a shower aide so CNAs have to do their own showers;
-Sometimes the showers do not get done if the facility is short staffed.
During an interview on 01/03/24 at 2:03 P.M., Nursing Assistant (NA) E said the following:
-The facility does not have enough staff most of the time to meet resident needs;
-Residents are to be checked every two hours but there are not always enough staff to make that happen;
-Residents are supposed to get a bath two times a week, but there was not always enough staff to provide those two showers a week.
During an interview on 01/03/24 at 3:56 P.M., NA I said the following:
-Residents are checked as often as staff can;
-If staff call in, showers might not be completed;
-A resident in isolation should be given a bed bath at least two times a week.
During an interview on 01/03/24 at 2:17 P.M., Licensed Practical Nurse (LPN) F said the following:
-Some days staffing was not very good, and they do not have enough staff to meet resident needs;
-Residents are supposed to be checked and changed every two hours;
-He/She did not know how often water was supposed to be passed, but he/she does not see it passed very often;
-Residents are supposed to get a bath every three days, sometimes they have enough staff to give baths but not always.
During an interview on 01/03/24 at 4:03 P.M., the interim Director of Nursing (DON) said the following:
-To her knowledge, they are meeting staffing numbers;
-She expected incontinent or dependent residents to be checked and changed every two hours and she felt like there was enough staff to accomplish that task;
-The expectation is that staff pass water each shift, she was not sure if that happened;
-Showers are to be offered two times a week, some days staffing makes it difficult to get those done;
-She would expect call lights to be answered timely.
During an interview on 01/03/24 at 10:00 A.M., the administrator said the following:
-The facility staffs to meet fire code;
-Agency staff is utilized to ensure enough staff are available to provide care to meet resident acuity;
-She expected residents that are dependent or incontinent to be checked every two hours or more if needed and she feels like there is enough staff to accomplish that;
-She expected water to be passed every shift;
-She expected residents to be given a bath at least two times a week or by resident preference;
-They do not have enough staff currently to always provide two showers a week.
MO00229544
MO00229628
MO00229629
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 F0727
(Tag F0727)
Could have caused harm · This affected most or all residents
Based on interview and record review, the facility failed to provide/designate a registered nurse (RN) eight consecutive hours a day, seven days a week. The facility census was 69.
1. During review o...
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Based on interview and record review, the facility failed to provide/designate a registered nurse (RN) eight consecutive hours a day, seven days a week. The facility census was 69.
1. During review of electronic mail, on 01/04/24 at 3:30 P.M., and interview on 01/08/24 at 3:37 P.M., the administrator said the facility did not have a specific staffing policy, the facility goes by federal guidelines. The administrator provided the facility assessment but was unaware of what the staffing hours numbers on the facility assessment indicated.
2. Review of the Facility Assessment, updated 06/22/23, showed the following:
-Facility resources needed to provide competent support and care for resident population every day and during emergencies: staffing to meet care needs included:
-a Registered Nurse (RN) - eight hours per day based on average census;
-If the census or acuity fluctuates, the facility makes every effort to ensure there is adequate staff to meet the needs of the residents.
3. Review of staffing sheets provided by the facility from 12/19/23 through 01/03/24 showed the following:
-On 12/23/23 total working hours for RN staff was 0 hours (no RN coverage); the facility census was 72;
-On 12/25/23 total working hours for RN staff was 0 hours (no RN coverage); the facility census was 72;
-On 12/30/23 total working hours for RN staff was 0 hours (no RN coverage); the facility census was 70;
-On 12/31/23 total working hours for RN staff was 0 hours (no RN coverage); the facility census was 70;
-On 01/01/24 total working hours for RN staff was 0 hours (no RN coverage); the facility census was 70;
-The facility did not meet the regulation for RN staffing requirement or follow their facility assessment for RN staffing for five of the sixteen days reviewed.
During an interview on 01/08/24 at 3:37 P.M., the administrator said the following:
-The Director of Nursing (DON) has been the only RN for the building for a while;
-She was trying to get RN's hired but there have been no applicants;
-She was aware of the regulation requiring an RN has to be in the building for 8 hours every day;
-She was aware they did not meet the requirement for the five days listed.
MO00229544
MO00229628
MO00229629
Oct 2023
3 deficiencies
1 IJ
CRITICAL
(J)
📢 Someone Reported This
A family member, employee, or ombudsman was alarmed enough to file a formal complaint
Immediate Jeopardy (IJ) - the most serious Medicare violation
Pressure Ulcer Prevention
(Tag F0686)
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 ensure one resident (Resident #1), with pressure ulcers received ne...
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**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on interview and record review, the facility failed to ensure one resident (Resident #1), with pressure ulcers received necessary treatment and services, consistent with professional standards of practice, to promote healing and prevent infection in a review of ten sampled residents. Staff failed to obtain physician orders for a newly identified pressure ulcer, failed to conduct and document assessment of the resident's pressure ulcers to determine if the wounds were deteriorating and required a change in treatment, and failed to complete dressing changes as ordered by the physician. The pressure ulcers deteriorated and became infected. Staff failed to begin treatment of the infection with antibiotics as ordered by the wound consultant nurse practitioner. The resident required hospitalization to treat the infection and returned to the facility on hospice care on [DATE] and passed away at the facility on [DATE]. The facility census was 70.
The administrator was notified on [DATE] at 5:15 P.M. of an Immediate Jeopardy (IJ) which began on [DATE]. The IJ was removed on [DATE] as confirmed by surveyor on-site verification.
Review of the facility policy, Wound Care and Treatment, undated, showed the following:
-It is the purpose of this facility to prevent and treat all wounds;
-There must be a specific order for the treatment;
-Apply a clean dressing as ordered. Label with the nurse's initials, date and time;
-Documentation of the treatment should be done immediately after the treatment;
-Prevention strategies include on-going skin assessment with weekly documentation of status.
Review of the National Pressure Ulcer Advisory Panel (NPUAP) guidelines, dated [DATE], showed the following definitions:
-Stage I pressure ulcer is intact skin with localized area of non-blanchable (when you press on the area of redness the redness does not go away) erythema (redness). Presence of blanchable erythema changes in sensation, temperature, or firmness may precede visual changes;
-Stage II pressure ulcer is a partial-thickness loss of skin with exposed dermis (the thick layer of living tissue below the top layer of skin that forms the true skin). The wound bed is viable, visible and deeper tissue are not visible. Granulation tissue (new connective tissue), slough (dead tissue in the process of separating from the body which is usually light colored, soft, moist, or stringy), and eschar (dead tissue that sheds or falls off from health skin) are not present;
-Stage III pressure ulcer is a full thickness loss of skin, where adipose (fat) is visible in the ulcer and granulation tissue and rolled wound edges are often present. Slough and eschar may be visible, but do not obscure the extent of tissue loss. The depth of tissue damage varies by the location on the body. Undermining and tunneling may occur. Fascia (a thin sheath of fibrous tissue), muscle, tendon, ligament, cartilage or bone are not exposed;
-Stage IV pressure ulcer is a full-thickness skin and tissue loss with exposed or directly palpable fascia, muscle, tendon, ligament, cartilage or bone in the ulcer. Slough and or eschar may be visible, but do not obscure the extent of tissue loss. Rolled edges, undermining and or tunneling often occur. Depth varies by location;
-Unstageable pressure ulcer is a full thickness skin and tissue loss in which the extent of tissue damage within the ulcer cannot be confirmed because it is obscured by slough or eschar;
-Deep Tissue Pressure Injury (DTI) is an intact or non-intact skin with localized area of persistent non-intact skin with localized area of persistent non-blanchable deep red, maroon, purple discoloration or epidermal separation revealing a dark wound bed or blood filled blister. This injury results from intense and/or prolonged pressure and shear forces at the bone-muscle interface. The wound may evolve rapidly to reveal the actual extent of tissue injury, or may resolve without tissue loss. If necrotic tissue, subcutaneous tissue, granulation tissue, fascia, muscle, or other underlying structures are visible, this indicates a full thickness pressure ulcer (unstageable, Stage III or Stage IV pressure ulcer).
1. Review of Resident #1's undated face sheet, showed diagnoses including pressure ulcer sacral region (a large triangular bone at the base of the spine) unspecified stage, pressure induced deep tissue damage unspecified site, pressure ulcer of unspecified buttock, unspecified stage, weakness and altered mental status.
Review of the resident's Braden Scale (an tool for predicting pressure ulcer risk; a low score indicates higher levels of risk for pressure ulcer development) assessment form, dated [DATE], completed by facility staff, showed a score of 16, indicating the resident was at risk for pressure ulcer development.
Review of the resident's quarterly Minimum Data Set (MDS), a federally mandated assessment instrument completed by facility staff, dated [DATE] showed the following:
-Severe cognitive impairment;
-Extensive assistance of one staff member for bed mobility;
-Dependent on one staff member for transfers, dressing, toilet use, and personal hygiene;
-Always incontinent of bowel and bladder;
-At risk for pressure ulcers;
-The resident did not have any pressure ulcers;
-The resident did not have a pressure reducing device for chair or bed and was not on a turning and repositioning program.
Review of the resident's weekly skin assessment, dated [DATE] at 10:56 A.M., showed his/her skin was intact. No skin issues present.
Review of the resident's nursing note, dated [DATE] at 9:44 P.M., showed the nurse was called into the resident's room due to staff finding two open areas on the resident's skin. One open area on the coccyx (also known as the tailbone is the triangular arrangement of bone that makes up the very bottom portion of the spine below the sacrum) measured 2.0 centimeters (cm) by 2.0 cm by 0.1 cm. The other open area was on the left heel and measured 4.0 cm by 3.0 cm by 0.0 and was dark purple to black in color. Staff applied a foam dressing to both areas.
Review of the resident's physician order sheet (POS) for [DATE] showed no evidence facility staff obtained a physician's order for treatment of the new skin issues identified on [DATE] until [DATE].
Review of the resident's interdisciplinary team note, dated [DATE] at 9:46 A.M. showed the following:
Assessment: Wounds to sacral bone: Stage II 0.5 cm x 0.5 cm x 0.1 cm, round with linear extension to the left side measured 1.5 cm x 0.1 cm., wound bed pink, clean, edges well defined and without maceration (when skin has been exposed to moisture for too long) and peri-wound clean;
-Left foot: plantar aspect (bottom of foot) over lateral calcaneus (side of the heel bone) measured 5.0 cm x 5.0 cm x 0 cm. Area not open: DTI (deep tissue injury) with light brown firm/hard cover, mildly boggy (soft) center. Edges well defined;
-Left foot: lateral (side) metatarsal (middle bones in our feet between your toes and your ankle bones) near 5th digit: 2.0 cm x 0.5 cm x 0 cm; not open. DTI with firm light brown cover. Edges clearly defined and without maceration;
Multiple confounding factors: debility, immobility, contractures of the hips/knees, dementia precluding ability to understand measures to heal, historically poor appetite, dependence for all activities of daily living (ADL), and incontinence.
Visual/physical assessment: when in bed the resident lays to the left, with direct pressure to areas noted to have damage. Immobile, contractures.
Review of the resident's weekly skin assessment, dated [DATE], at 10:33 A.M. showed left heel, left lateral metatarsal immediate above fifth digit. New order obtained.
Review of the resident's care plan, revised on [DATE], showed the following:
-Pressure ulcer/injury, skin integrity impairment: pressure induced DTI to the left foot, plantar heel and lateral metatarsal fifth toe,
-Assess progress of wound treatments per facility policy, and report need for changes as needed;
-Avoid friction, and shearing during transfer and position changes;
-Keep bony prominences of legs, knees, heels from direct contact with one another with pillows and pads when in bed;
-Pillow behind legs to keep heels from hitting surface of lower chair;
-Pillow behind legs when in broad to keep heels from hitting surface of lower chair;
-Turning and repositioning every two hours when in bed, using side to side schedule; pillows and pads for alignment, padding and position;
-Use heel protectors to relieve pressure on the heels, as well as floating the heels when in bed;
-Stage II pressure ulcer to sacrum, incontinent care every two hours and as needed to keep skin clean and dry as possible; barrier cream to surrounding skin;
-Keep linens clean and dry, and wrinkle free;
-Monitor for wound condition, weekly skin assessment. Report issues to the physician;
-The resident will be on a side to side turn schedule when in bed, pillows and pads for positioning, comfort and padding;
-Treatment as ordered and monitor for effectiveness.
Review of the resident's POS, dated [DATE], showed the following:
-Treatment to left heel and left lateral foot pressure induced (DTI) areas; skin prep (a liquid film-forming dressing) to each area, wrap foot with light kling and change every day (start date [DATE]);
-Treatment to sacral Stage II: gently cleanse with wound cleanser. Skin prep to periwound. No product to the wound. Cover with a 2 x 2 gauze or folded 4 x 4 gauze, secure with tape, twice a day (start date [DATE]).
Review of the resident's medical record showed no evidence facility staff completed a weekly skin assessment on [DATE].
Review of the resident's treatment administration record (TAR), dated [DATE], showed the following:
-Treatment to left heel and left lateral foot pressure induced (DTI) areas; skin prep to each area wrap foot with light kling and change every day (start date [DATE]);
-The dressing to the left heel was not documented as completed per order on 8/17, 8/19, 8/20, 8/24, 8/25, 8/28, 8/29, and [DATE];
-Treatment to the sacral wound stage II: gently cleanse with wound cleanser. Skin prep to periwound. No product to the wound. Cover with a 2 x 2 gauze or folded 4 x 4 gauze secure with tape, twice a day (start date [DATE]);
-The dressing to the sacral wound was not documented as completed on 8/19, 8/20, 8/23, 8/24, 8/25, 8/29, and [DATE].
Review of the resident's medical record showed no evidence the facility staff completed a weekly skin assessment on [DATE].
Review of the resident's TAR, dated [DATE], showed the following:
-There was no documentation staff completed a dressing change to the left heel and left lateral foot on [DATE];
-There was no documentation staff completed a dressing change to the sacral wound on [DATE].
Review of the resident's physician order dated [DATE] showed wound care plus (wound care consultant company) to evaluate and treat.
Review of the resident' medical record showed no evidence the facility staff completed a weekly skin assessment on [DATE].
Review of the wound care plus consultant note, dated [DATE] at 9:29 A.M., showed the following:
-The resident was seen for evaluation and management of multiple wounds;
-Sacral and heel wounds with signs and symptoms of infection. Culture and sensitivity (C&S) (a test that detects germs present and determines which antibiotic will be most affective in treating an infection) of the wound was obtained. All wounds were debrided (excision of damaged tissue) and the foot wound was unroofed (opening or taking off the top) due to fluctuance (a pocket of fluid trapped in the tissues), X-ray of sacrum ordered. Treatment plan updated as indicated;
Wound assessments:
-Wound #1, sacral wound was a chronic unstageable pressure injury, obscured full-thickness skin and tissue loss and has a status of not healed. Measurements were 8.6 cm x 4.0 cm x 0.3 cm. There was a moderate amount of purulent drainage noted which had a strong odor. The wound bed had 1- 25 % pink granulation tissue and 51 - 75 % slough. The periwound skin exhibited edema, scarring and erythema. The periwound was friable (skin that is easily irritated, which makes it prone to bleeding or tearing) and moist. The periwound skin presents with signs and symptoms of infection, C&S pending, X-ray/Scan, topical antibiotic prescribed;
-Wound #2, left heel was a Stage III, chronic deep tissue pressure injury, persistent nonblancheable deep red, maroon or purple discoloration, pressure ulcer has received a status of not healed. Measurements were 4.8 cm x 4. 8 cm x 0.1 cm. There was moderate purulent (consisting or containing pus) drainage which had a strong odor. The periwound skin exhibited erythema and edema. The periwound was friable and moist. Periwound skin presents with signs and symptoms of infection, topical antibiotics prescribed;
-Wound #3 left, lateral foot was a chronic unstageable pressure ulcer and has received a status of not healed. Measurements were 0.7 cm x 1.0 cm x 0.1 cm depth. Wound bed with 76% to 100% eschar. The periwound skin exhibited callus, fluctuance and ecchymosis (bruising).
Review of the resident's culture and sensitivity, report summary dated [DATE], untimed, showed the following:
-Sample type was wound;
-Organisms detected: Bacteroides fragilis (a bacteria that is a common component of the colon, spread of the bacteria to the blood stream or surrounding tissues results in clinically significant infection);
-Enterobacteriaceae bacterium (large family of bacteria);
-Enterococcus faecalis (a bacteria found in the intestines,while it tends to be harmless in the colon it can cause serious infection if spread to other areas of the body);
-Escherichia coli (a type of bacteria that normally lives in your intestines and can cause skin infections);
-Finegoldia [NAME] (a bacteria associated with severe infections);
-Proteus mirabilis (a bacteria that can cause wound infections);
-Streptococcus viridians group (a bacteria that can cause infections in the tissue under the skin and bloodstream);
-Treatment option delafloxacin (oral antibiotic) 450 milligrams (mg) by mouth every twelve hours for five days for possible skin and soft tissue infections;
-Alternate treatment options: Ertapenum (intravenous antibiotic, that goes directly in to the bloodstream, used to treat certain serious infections) one gram every 24 hours for five days or Levafloxcin (antibiotic used to treat bacterial infections) 750 mg by mouth and Metronidazole (used to treat various infections caused by bacteria) 500 mg IV (intravenous, administered directly into the bloodstream) every eight hours for five days.
Review of the resident's nurses note, dated [DATE] at 10:15 P.M., showed a new order for the resident to start delafloxacin (oral antibiotic) 450 mg by mouth for five days for wound infection. The pharmacy called and the medication was on order and would be delivered on [DATE].
Review of the resident's POS for [DATE] showed the antibiotic order from the culture and sensitivity report dated [DATE] was not transcribed to the POS.
Review of the resident's MAR for [DATE] showed the antibiotic order from the culture and sensitivity report dated [DATE] was not transcribed to the MAR.
Review of the resident's nurses note, dated [DATE] at 11:47 A.M., showed the following:
-The resident presented in the morning with altered mental status and febrile (fever) at 101.3 degrees Fahrenheit (normal temperature 97.0 degrees Fahrenheit to 99 degree Fahrenheit). The resident was awake but non-responsive. Given the resident's decline and staff being unable to reach the power of attorney (POA), the physician gave an order to send the resident to the hospital emergency room for evaluation. The resident left facility at 10:00 A.M.
Review of the resident's hospital history and physical, dated [DATE], showed the following:
-Reason for admission was sepsis (a serious condition that happens when the body's immune system has an extreme response to an infection) likely secondary to gluteal decubitus ulcer verses other cause;
-Right gluteal ulcer with underlying soft tissue gas (underlying infectious process) and associated cellulitis (common, potentially serious bacterial skin infection).
Review of the resident's readmission nurses note, dated [DATE] at 1:42 A.M., (recorded as a late entry) showed the resident returned from the hospital at 10:18 P.M., via ambulance. The resident's discharge diagnosis was decubitus ulcer and sepsis. The resident was admitted on hospice care.
Review of the resident's nurses note, dated [DATE] at 11:04 A.M., showed the resident died.
During an interview on [DATE] at 8:00 A.M. Licensed Practical Nurse (LPN) B said the following:
-He/She noted the wounds to the resident on [DATE] and documented the areas found in the resident's nursing notes;
-He/She covered the wound with a foam dressing and notified the wound nurse at that time of the wounds. LPN B thought the wound nurse would stage the wounds, notify the physician and obtain treatment orders.
During an interview on [DATE] at 4:00 P.M. the facility's assistant director of nursing (ADON)/wound Nurse/LPN D (who no longer worked at the facility) said the following:
-A Certified Nurse Aide (CNA) brought to his/her attention the resident had an open area on his/her buttock sometime in [DATE];
-He/She did not recall if orders were obtained for a treatment of the area or not;
-If a charge nurse found an open area they should have obtained orders;
-He/She may have missed completing some skin assessments on the resident;
-The wound care plus nurse practitioner notified him/her of the resident's wound culture results and orders for antibiotics on the evening of [DATE] while he/she was not at work;
-He/She notified Registered Nurse (RN) A of the culture and sensitivity results and the antibiotic orders, along with the alternate option, which was available in the E-kit at the facility;
-He/She expected RN A to start the antibiotic as ordered.
During an interview on [DATE] at 10:36 A.M., RN A said the following:
-He/She worked on [DATE], when the ADON/wound nurse called him/her at the facility and said the resident's wound culture was back. The wound care plus nurse practitioner had notified the ADON of the culture results;
-Wound care plus ordered an antibiotic and the pharmacy would not have it available until [DATE] (three days later);
-The ADON said he/she would call wound care plus and let them know the antibiotic was not available until [DATE];
-RN A worked on [DATE] and [DATE] and noticed the resident's wounds had an odor when he/she was in the resident's room;
-RN A checked the resident's temperature and vital signs over the weekend, but did not document her assessment;
-On [DATE] the resident was not responsive and was running a fever. RN A contacted the resident's physician and the physician gave the order to send the resident to the hospital. The resident was very ill;
-RN A did not notify the resident's physician about the wound culture or antibiotic orders from wound care plus on [DATE]. RN A thought the ADON would take care of notifying the physician.
During an interview on [DATE] at 10:30 A.M., the wound consultant nurse practitioner said the following:
-He/She would expect the nursing staff to start the antibiotics as ordered;
-The resident may have already been septic, but there was no way to know at that time;
-The wound status could worsen if the antibiotics weren't started;
-He/She gave antibiotic alternatives, if the initial antibiotic was not available.
During an interview on [DATE] at 9:38 A.M., the resident's physician said the following:
-Staff should have notified him if there was an order for an antibiotic and it was not available;
-The antibiotic would have probably improved the resident's health;
-There was a system failure. Things could have been done differently including issues with delays in starting antibiotics, not contacting him regarding the culture report and antibiotic orders, the nursing staff not following standard nursing practice, not notifying him of the wound status, not completing dressing changes possibly hastened the resident's health decline, antibiotics may have improved things temporarily.
During an interview on [DATE] at 11:30 A.M., and 2:45 P.M., and [DATE] at 3:00 P.M., the director of nursing (DON) said the following:
-She would expect skin assessments be completed weekly on each resident;
-She would expect staff to obtain treatment orders for any new wounds;
-The previous ADON was responsible for wound care and dressing changes when he/she was working;
-She did not feel the previous ADON/wound nurse was completing routine weekly wound assessments, completing wound care as ordered, or notifying the residents' physicians as he/she should have;
-The resident's pharmacy could not get the antibiotics until [DATE], the resident's condition deteriorated, the wounds had a very strong odor and the resident started running a fever. The DON thought RN A was in contact with wound care plus regarding the antibiotics not being available.
During an interview on [DATE] at 2:20 P.M., the administrator said the following:
-He would expect skin assessments be completed weekly;
-He would expect wound care to be completed as ordered;
-Staff should notify the physician of any new open areas immediately;
-He would expect antibiotics to be administered as ordered;
-Nursing staff should notify the physician of any concerns or changes with a wound.
NOTE: At the time of the abbreviated survey, the violation was determined to be at the immediate jeopardy level J. Based on observation, interview and record review completed during the onsite visit, it was determined the facility had implemented corrective action to remove the IJ violation at the time. A final revisit will be conducted to determine if the facility is in substantial compliance with participation requirements.
At the time of exit, the severity of the deficiency was lowered to the G level. This statement does not denote that the facility has complied with State law (Section 198.026.1 RSMo.) requiring that prompt remedial action to be taken to address Class I violation(s).
MO00224696
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 F0825
(Tag F0825)
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 follow physician's orders in a timely manner for rehabilitation ser...
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**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on interview and record review, the facility failed to follow physician's orders in a timely manner for rehabilitation services for two residents (Resident #2 and #3) in a review of ten sampled residents. The facility census was 70.
Review of the facility policy physician orders, undated, showed the following:
-The following information is provided to assist in recording physician's orders;
-Current lists of orders must be maintained in the clinical record of each resident to avoid confusion or errors;
-Physician orders are needed for physical therapy (PT), speech therapy(ST) and occupational therapy (OT).
1. Record review of Resident #2's undated face sheet showed the following:
-The resident admitted to the facility on [DATE];
-Diagnoses included repeated falls, abnormalities of gait and mobility, dementia and cerebral infarction (stroke).
Review of the resident's physician order, dated 6/13/23, showed an order for physical therapy (PT) and occupational therapy (OT) to evaluate and treat as needed.
Record review of the resident's admission Minimum Data Set (MDS), a federally mandated assessment instrument required to be completed by facility staff, dated 6/16/23; showed the following:
-Severe cognitive impairment;
-The resident required setup or cleanup assistance from a staff member with eating, oral hygiene, toilet hygiene, and dressing;
-The resident was independent with chair/bed transfer and independent with toilet transfer;
-The resident was independent with walking 50 feet and making two turns;
-The resident was independent with walking 150 feet once standing, without assistance;
-No falls since admission to the facility;
-The resident did not receive PT or OT services.
Review of the resident's fall event report, dated 7/8/23 at 9:30 A.M., showed the resident was observed on the floor with a large abrasion to the left arm.
Review of the resident's nursing note, dated 7/11/23 at 5:34 P.M., showed the resident fell due to unsteady gait and lost balance in his/her room.
Review of the resident's nursing note, dated 7/15/23 at 7:47 P.M., showed a fall occurred. Staff observed the resident sitting on the floor to the front and left side of his/her wheelchair.
Review of the resident's care plan, dated 7/26/23, showed the following:
-The resident was at risk for falls due to declining cognitive level and unsteady gait;
-Physical therapy to evaluate for strengthening (approach start date 7/26/23).
Review of the resident's nursing note, dated 8/3/23 at 2:56 P.M., showed a care plan meeting was held with the resident's family member. The family member said he/she felt the resident was declining.
There was no evidence in the medical record the resident received PT or OT services as ordered 6/13/23.
Review of the resident's PT evaluation and plan of treatment, dated 8/15/23 (completed two months following the order for the services), showed the following:
-Treatment approaches may include neuromuscular reeducation, gait training reeducation, and therapeutic exercises;
-Frequency, three times a week for four weeks.
Review of the resident's OT evaluation and plan of treatment, dated 8/15/23, showed the following:
-Treatment approaches may include therapeutic exercises, neuromuscular reeducation, therapeutic activities and self-care management training;
-Frequency, three times a week for 30 days.
2. Review of Resident #3's undated face sheet showed the following:
-The resident admitted to the facility on [DATE];
-Diagnoses included abnormalities of gait and mobility, dementia, heart failure (a condition where the heart does not pump blood as well as it should) and chronic pain.
Review of the resident's nursing note dated 6/13/23 at 2:00 A.M., showed the resident ambulated slowly and steadily with a walker and required standby assistance to toilet.
Review of the resident's physician order, dated 6/13/23, showed an order for PT and OT to evaluate and treat as needed.
Review of the resident's admission MDS, dated [DATE], showed the following:
-Cognition was intact;
-The resident required setup or cleanup assistance from a staff member with eating, oral hygiene, and dressing upper body;
-The resident required partial to moderate assistance from a staff member with toileting, bathing/showering, and putting on and taking off footwear,
-The resident required staff supervision or touching assistance with dressing lower body, chair/bed transfers and with toilet transfers.
-The resident was able to walk ten feet with staff supervision or touching assistance;
-The resident did not use a wheelchair;
-The resident was not receiving PT or OT services.
Review of the resident's care plan, dated 6/29/23, showed the following:
-The resident was at risk for falls due limited mobility and generalized weakness due to lack of mobility/ exercise and new environment;
-Self-care deficit in some activities of daily living (ADLs) related to weakness, ensure walker in reach to ensure increased mobility and independence.
There was no evidence in the medical record that the resident received PT or OT services as ordered 6/13/23.
Review of the resident's occupational therapy evaluation and treatment plan, dated 8/15/23, showed the following:
-Treatment approaches may include gait training therapy, therapeutic activities, neuromuscular reeducation, and therapeutic exercises;
-Frequency was three times a week for four weeks.
Review of the resident's physical therapy evaluation and plan of treatment, dated 8/15/23, showed the following:
-Treatment approaches include therapeutic exercises, neuromuscular reeducation, occupational therapy evaluation, moderate complexity, therapeutic exercises, self care management training and wheelchair management training;
-Frequency three times a week;
-Duration: 30 days.
3. During interview on 10/25/23 at 10:00 A.M. Resident #2 and #3's family member said the following:
-Both residents had an order for rehab services at admission. The residents did not receive the services until the middle of August;
-He/She questioned facility staff about therapy services and was told that both residents were on the list for physical therapy and receiving therapy services;
-Both residents had a decline in strength and mobility. He/She was concerned and questioned the therapy director. The therapy director told the family member that the payer source had not been verified and therapy had not started;
-Resident #3 could no longer walk at all and had to be transferred by a mechanical lift (a lift used to safely transfer resident who have limited mobility or are unable to bear weight);
-Resident #2 was walking upon admission, but was now was using a wheelchair.
During an interview on 10/5/23 at 10:00 A.M. the therapy director said the following:
-Resident #2 and #3 had an order for rehab services upon admission;
-He/She submitted a payer verification form to the business officer manager for PT and OT services for both residents on 6/12/23, 7/14/23 and again on 8/8/23;
-Therapy could not start services until the payer source was approved;
-Therapy was finally approved on 8/14/23;
-Waiting to start rehab services for over two months was detrimental to the two residents, causing them to lose strength;
-Resident #3 remained in bed for over two months because he/she was not fitted for a wheelchair. The resident became weaker and had a decline in strength.
During an interview on 10/5/23 at 10:15 A.M. the business office manager (BOM) said the following:
-He/She thought the initial payer verification for rehab services was sent to the wrong email at the corporate office;
-In July 2023, the rehab services payer verification was approved and the BOM placed it in the therapy box. The BOM was not sure what happened to the form approving rehab services, as it was picked up by someone or misplaced;
-On 8/14/23, he/she emailed for payer verification again for both residents and it was approved.
During an interview on 10/5/23 at 11:05 A.M. the director of nursing (DON) said the following:
-The facility had problems with the payer source verification coming back in a timely manner;
- She would expect it be verified timely;
- The resident could deteriorate or decline waiting for rehab services.
During an interview on 10/5/23 at 2:20 P.M. the administrator said the following:
-He would expect a resident to get rehab services as ordered in a timely manner;
-The verification process for rehab services should not take over two months;
-The resident's family came to him because the residents had waited so long for therapy services. The administrator took care of the payer source verification process in August.
During an interview on 10/11/23 at 9:38 A.M. the residents' physician/ medical director said the following:
-He would expect rehab services be started as soon as possible after the order was given;
-The residents could decline in strength and mobility as a result of the delay in therapy services.
MO223134
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 F0882
(Tag F0882)
Could have caused harm · This affected most or all residents
Based on interview and record review, the facility failed to designate a qualified individual in the role of infection preventionist (IP) who has completed specialized training in infection prevention...
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Based on interview and record review, the facility failed to designate a qualified individual in the role of infection preventionist (IP) who has completed specialized training in infection prevention and control. The facility census was 70.
Review of the facility's policy, Infection Prevention and Control program, undated, showed the following:
-The facility maintains an organized, effective facility wide program designated to systematically identify and reduce risk of acquiring and transmitting infections among residents, visitors and healthcare workers. This program involves collaboration of many programs and services within the facility and designated to meet the intent of regulatory and accrediting agencies;
-The IP responsibilities for infection prevention and control include, but may not be limited to the following:
-Conducts surveillance for facility associated infections and/or communicable diseases;
-In collaboration with administration and the medical director, establish short and long-term goals;
-Assures compliance with state/federal regulatory and accreditation standards as they pertain to infection and/or communicable diseases;
-Maintains facility infection prevention/control policy and procedure manuals;
-Collaborates with facility leadership and administration in the identification of employee occupational exposures incidents and assist with exposure evaluations;
-Notifies the local health department of all reportable disease, identified as a result of microbiological sampling in the facility's clinical laboratory;
-Communicates infection prevention and control data to the facility leadership, appropriate facility committees, facility staff, pubic health department (local and state) and referring/receiving health care facility as appropriate;
-Develops and presents educational programs for employee orientation, in-services and annual updates;
-The IP is qualified to conduct infection prevention and control activities as a result of education training and experience (he/she will complete the CDC Long-term Care Infection preventionist module).
During an interview on 10/17/23 at 10:00 A.M. the Minimum Data Set (MDS) coordinator said the following:
-She kept a list of antibiotics that were ordered each month, what infection the antibiotics were prescribed for, and how long the residents were to take the antibiotics;
-She tried to watch for trends with antibiotic use;
-She was very busy in his/her position as the MDS coordinator and that was his /her primary role at the facility.
During an interview on 10/18/23 at 9:30 A.M. the director of nursing (DON) said the following:
-She recently started reviewing the facility activity report to see if any antibiotics were ordered and if those antibiotics were started;
-She has not completed any training for the IP role;
-She was not sure of what the IP duties were;
-The MDS Coordinator has not had training for the IP role either;
-She knew there was a binder regarding infection control, but she had not reviewed it to see what was required in the infection control program;
-The facility did not have an IP.
During an interview on 10/17/23 at 9:25 A.M. and 3:10 P.M. the administrator said the following:
-He tracked any facility positive cases of Covid;
-The DON and MDS coordinator would be responsible for the facility's infection control program;
-He was not aware of any required training for the infection preventionist role;
-The facility did not discuss facility infections or review and evaluate the infection control plan in the monthly QA meeting;
-He would expect for the facility to follow their infection control policy and procedure.
Oct 2022
26 deficiencies
1 Harm
SERIOUS
(G)
Actual Harm - a resident was hurt due to facility failures
Accident Prevention
(Tag F0689)
A resident was harmed · This affected 1 resident
**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Surveyor: [NAME], [NAME]
Based on observation, interview, and record review, the facility failed to consistently assess the pote...
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**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Surveyor: [NAME], [NAME]
Based on observation, interview, and record review, the facility failed to consistently assess the potential root cause of residents' falls and evaluate current interventions and/or develop and implement meaningful interventions to reduce the potential for falls for three residents (Residents #20, #27, and #46), in a review of 26 sampled residents. Residents #27 and #46 required sutures (also known as stitches used to hold body tissues together and approximate wound edges after an injury) to repair lacerations (a deep cut or tear in the skin) acquired as a result of falls. The facility also failed to ensure staff safely transferred one sampled resident (Residents #36) and on additional resident (Resident #48) during a mechanical lift transfer, and failed to safely transport one sampled resident (Resident #27) and an additional resident (Resident #48) while in a wheelchair. The facility census was 68.
Review of the facility's policy, Implementation of a Fall Prevention Program, dated June 2006, showed the following:
-Identify all current residents at risk for falls at the beginning of the program using the facility risk assessment form or a chosen form.
-Assess all new residents for fall risk on admission using an additional fall assessment screen. The form should be completed within the first 12 hours following admission by the admitting nurse, or the oncoming nurse;
-Reassess all residents as a part of quarterly assessment and care planning;
-The effectiveness of a facility's fall prevention program should be part of continuous quality improvement. Keep a fall log to analyze causes of falls and facility trends or needs. The data in the log may point to variables that are present when falls commonly occur. Review the surveillance fall log to make sure the process is working and falls are being prevented. Include tracking of falls on new admissions as an indicator of the effectiveness of fall risk assessment and orientation;
-Once trends are identified, the following steps may be taken:
1. Review the trend for a potential cause for this group of falls. Do not assume the cause;
2. Implement an action plan based on root cause;
3. Set a re-evaluation dated to determine how the solution is working;
4. Perform follow-up and document results;
5. Continue the action, if it is working, or perform additional analysis as to why it is not working and decide on a new action plan for implementation.
Review of the undated facility policy, Use of Wheelchair, showed the following:
-Purpose was to provide mobility for the non-ambulatory resident with safety and comfort and to provide mobility for residents learning to become independent in activities of daily living;
-Lower footrests and place resident's feet on footrests if used;
-Assist resident to the area of the facility desired. Encourage and instruct resident in proper guidelines for safely propelling the wheelchair.
1. Review of Resident #27's face sheet showed the resident's diagnoses included dementia with behavior disturbance (a group of thinking and social symptoms that interferes with daily functioning) and Parkinson's disease (a disorder of the central nervous system that affects movement, often including tremors).
Review of the resident's care plan, updated on 8/2/21, showed the following:
-The resident was placed on a fall prevention program;
-Provide the resident with safety device - dycem (a non-slip material) to wheelchair;
-Provide the resident with anti-rollback on wheelchair in case resident forgets to lock wheelchair brakes.
Review of the resident's annual Minimum Data Set (MDS), a federally mandated assessment instrument required to be completed by facility staff, dated 2/26/22, showed the following:
-Severely impaired cognition;
-Limited assist of one staff member for bed mobility, transfers, and locomotion on and off the unit;
-Walking in room occurred one to two times with assist of one staff member;
-Functional limitation in range of motion on one side lower extremity;
-Two non-injury falls since last reporting period;
-One minor-injury fall since last reporting period.
Review of the resident's nursing progress notes dated 4/16/22 at 11:39 A.M., showed the resident was found on the floor in his/her room. The resident's shoes were by his/her closet and the resident only had socks on his/her feet. The resident was sitting on his/her buttocks with his/her feet extended in front of him/her. The resident had clothes in his/her hand from the resident's closet.
Review of the resident's care plan showed an update dated 4/16/22 the resident had an unwitnessed non-injury fall. (Review showed no documentation staff evaluated current interventions or identified new interventions after the resident fell on 4/16/22.)
Review of the resident's nursing progress notes dated 5/25/22 at 10:40 P.M., showed the resident was found on the floor by his/her bed. The resident rolled to the right side of the bed onto the floor on the right side. The resident hit his/her head on the plastic tote sitting beside the head of the bed. The resident had a three centimeter (cm) laceration on his/her forehead with a moderate amount of bleeding and two skin tears on his/her left forearm. The resident was sent to the emergency room for evaluation.
Review of the resident's nursing progress notes dated 5/26/22 at 3:53 A.M., showed the resident returned from hospital evaluation after receiving sutures for the laceration to his/her forehead following a fall. The resident is resting quietly in bed with the bed in low position and call light in place.
Review of the resident's electronic medical record showed staff completed a fall risk assessment on 5/26/22 at 10:17 A.M. due to a change in condition/fall. The fall risk assessment showed the resident was a high fall risk.
Review of the resident's nursing progress notes dated 6/2/22 at 7:20 P.M. showed the Interdisciplinary Team (IDT) met and noted the resident's fall on 5/25/22. The resident was unsafe with transfers and standing. Added floor mats beside the bed as an intervention.
Review of the resident's care plan showed an update dated 5/25/22, the resident had an unwitnessed fall with injury, found lying beside bed with a three centimeter laceration to the forehead and received two stitches. (Review showed no documentation staff updated the care plan with the new interventions identified in the 6/2/22 IDT meeting after the resident fell on 5/25/22.)
Review of the resident's nursing progress notes dated 8/1/22 at 4:23 P.M. showed the resident was found sitting on the floor at 4:00 P.M. and was unable to explain how he/she got there related to dementia diagnosis. The resident continues on antibiotics one more day for a urinary tract infection.
Review of the resident's medical record showed no evidence staff attempted to identify the root cause of the resident's fall on 8/1/22.
Review of the resident's care plan showed no documentation the resident fell on 8/1/22 and no documentation to show staff evaluated current interventions or identified new interventions after the resident fell on 8/1/22.
Review of the resident's nursing progress notes dated 8/4/22 at 3:30 P.M., showed the resident was found sitting on the floor on the right side of his/her bed and voiced he/she did not fall but slid to the floor out of bed.
Review of the resident's care plan showed no documentation the resident fell on 8/4/22 and no documentation to show staff evaluated current interventions or identified new interventions after the resident fell on 8/4/22.
Review of the resident's nursing progress notes on 8/14/22 at 10:30 P.M. showed the resident was found sitting on the floor by his/her bed, unable to explain how he/she got there due to confusion. Safety mat placed at bedside.
Review of the resident's care plan updated on 8/16/22 showed the resident had a fall on 8/14/22 and fall mats were placed beside the resident's bed. (Staff identified fall mats as an intervention to prevent falls after the resident fell on 5/25/22 and sustained an injury that required sutures, however, this intervention was not included on the resident's care plan until 8/16/22 after the resident fell on 8/14/22.)
Review of the resident's nursing progress notes on 8/24/22 at 5:30 A.M. showed the resident was found on the floor in his/her room. The resident's call light was within reach and the bed was lowered to the floor for safety.
Review of the resident's care plan showed no documentation the resident fell on 8/24/22 and no documentation of interventions after the resident fell on 8/24/22.
Review of the resident's nursing progress notes dated 8/25/22 at 11:00 P.M. showed the resident was found lying on the floor in his/her room. The resident had a laceration on his/her forehead and two skin tears on his/her left forearm.
Review of the resident's medical record showed no evidence staff attempted to identify the root cause of the resident's fall on 8/25/22.
Review of the resident's care plan showed no documentation the resident fell on 8/25/22 and no documentation to show staff evaluated current interventions or identified new interventions after the resident fell on 8/25/22.
Review of the resident's quarterly MDS, dated [DATE], showed the following:
-Severely impaired cognition;
-Limited assist of one staff member for bed mobility, transfers, and locomotion on and off the unit;
-Walking in room occurred one to two times with assist of one staff member;
-Functional limitation in range of motion on one side lower extremity;
-Two non-injury falls since last reporting period;
-One minor-injury fall since last reporting period.
Observation on 10/24/22 at 6:43 A.M., showed the following:
-Certified Nurse Assistant (CNA) C transported the resident from his/her room to the dining room in his/her wheelchair;
-The wheelchair did not have foot pedals;
-During the transport, both of the resident's feet drug along the floor.
Observation on 10/24/22, at 3:13 P.M., showed the following:
-The resident lay in bed with his/her eyes open;
-A fall mat lay on the floor on the right side of the resident's bed;
-An additional fall mat was folded in half and against the wall;
-The resident did not have a fall mat on the floor on the left side of his/her bed;
-The height of the bed was at the normal height and not in the low position.
Observation on 10/26/22, at 5:02 A.M., showed the following:
-The resident lay in bed sleeping;
-The resident's bed was not in the low position;
-A fall mat lay on the floor on the right side of the resident's bed;
-The second fall mat was moved away from the left side of the resident's bed and slightly under his/her roommate's bed.
During an interview on 10/27/22, at 2:00 P.M., CNA C said the following:
-Sometimes the resident will hold his/her feet up when staff push him/her in the wheelchair;
-There are no wheelchair foot pedals in the resident's room;
-If foot pedals are needed, the nurse or therapy will get them;
-A resident's feet should not touch the floor during transport in a wheelchair because the resident could get hurt or fall out of the wheelchair;
-The fall mats are for the resident's safety due to the resident falling a lot;
-Staff should put the fall mats on the floor and not lean them against the wall;
-If a resident was a fall risk, the bed should be in the low position when the resident is in the bed.
2. Review of Resident #46's care plan, dated 4/27/22, showed the following:
-The resident has history of falling related to altered mental status and encephalopathy (diffuse disease of the brain;
-Provide proper, well-maintained footwear.
Review of resident's monthly comprehensive assessment, dated 9/07/22 at 5:02 P.M., showed the following:
-Problem - Falls:
-Interventions - physical therapy and occupational therapy PRN (as needed), staff to assist during transfers, resident to use call light, and monitor for falls;
-Progress - The resident had two falls in April. He/She uses a walker to ambulate.
Review of the resident's quarterly MDS, dated [DATE], showed the following:
-Cognition moderately impaired;
-Required total assist of one person for transfers and toileting;
-Used a walker and wheelchair for mobility;
-Always incontinent of bowel and bladder;
-One fall since last assessment.
Review of resident's progress note, dated 10/16/22 at 5:54 P.M., showed the following:
-A CNA called the nurse to the resident's room at 4:55 P.M.;
-The resident was found on the floor face down with his/her head towards the head board and his/her feet towards the foot board;
-The resident was yelling for staff to get him/her off his/her stomach;
-The resident had a split on his/her forehead on the top right at the beginning of his/her hair line in the center of his/her forehead. It was two cm in length and not open;
-The resident complained of left knee pain;
-The resident could not remember what happened;
-The resident was sent to the hospital.
Review of resident's progress notes, dated 10/16/22 at 9:27 P.M., showed the following:
-The resident came back to facility at 9:10 P.M.;
-The resident had three stitches to the laceration on his/her forehead.
Review of resident's care plan, updated on 10/16/22, showed the resident rolled out of bed with laceration to forehead and pain to left knee. (Review of the resident's care plan showed no documentation staff evaluated current interventions or developed new interventions after the resident fell on [DATE].)
Review of resident's progress notes, dated 10/17/22, showed the following:
-History: The resident had a fall with a laceration to his/her forehead and was sent to the emergency room on [DATE]. He/She said he/she did not lose consciousness apparently hitting his/her head on the floor. He/She has dementia and can be a poor historian at times. He/She had three sutures placed to the laceration. No acute fracture/head injury confirmed via x-ray and CT scan (computed tomography scan; a medical imaging technique used to obtain detailed internal images of the body.);
-Plan: Continue to monitor sutures.
Review of resident's paper medical record showed a statement with no date, at 12:50 A.M., showed the following:
-The aide on duty found the resident on the floor next to the bed;
-The resident said, I laid on the floor;
-The resident was on his/her back, feet towards the bed, and his/her head towards the door. The resident's wheelchair was tipped over;
-Bruising seen on forehead and injury covered by bandage on forehead.
Review of the resident's medical record showed staff began a post fall 72-hour monitoring report on 10/18/22 at 12:50 A.M.
Review of the resident's care plan showed no documentation staff evaluated current interventions or developed new interventions after the resident fell on [DATE].
Review of a written statement, dated 10/21/22 at 4:15 P.M., in the resident's paper medical record showed the following:
-Staff heard a loud noise come from the resident's room;
-The resident was on the floor next to the bed on his/her stomach;
-The nurse noted bruising and a lump on the resident's forehead;
-New order to apply ice pack, place floor mats next to bed;
-Floor mat is on floor.
Review of the resident's care plan showed no documentation the resident fell on [DATE] and no documentation staff updated the care plan to include floor mats on the floor.
Review of the resident's physician's orders, dated 10/21/22, showed orders to monitor the resident closely and mats on floor due to diagnosis of fall.
Review of resident's progress note, dated 10/22/22 at 11:30 A.M., showed the following:
-The nurse was called to the resident's room;
-The resident lay on his/her left side on the floor mat with his/her head towards the head of bed and feet towards the foot of the bed;
-His/Her arm was bent at the elbow holding his/her upper body up;
-The resident said he/she was trying to get up to go home.
Review of resident's care plan, updated on 10/22/22, showed the resident fell getting out of bed to go home. (Review of the resident's care plan showed no documentation staff evaluated current interventions or developed new interventions after the resident fell on [DATE].)
Review of resident's progress note, dated 10/23/22 at 5:51 P.M., showed the resident was up in his/her wheelchair. He/She took himself/herself to the bathroom. Staff attempted to educate the resident. The resident was not receptive.
Observation on 10/24/22, at 9:56 A.M., showed the resident asleep in bed. There was no mat on the floor next to the bed.
Observation on 10/25/22 at 4:00 P.M., showed the resident was in his/her room in his/her wheelchair. No staff was present in the resident's room. The resident stood from his/her wheelchair and transferred himself/herself to his/her bed.
During an interview on 10/27/22, at 11:17 A.M., Nurse Aide (NA) G said the resident had a fall mat by his/her bed, but he/she did not know where it went.
During an interview on 10/27/22, at 5:20 P.M., Registered Nurse (RN) O said the following:
-The resident required minimal assistance from one person to transfer;
-The facility had not identified new interventions for this resident since recent falls;
-He/She was not aware there was an order for fall mats.
During an interview on 10/27/22, at 5:29 P.M., CNA U said the following:
-The resident needs assistance from one staff;
-The resident goes to the bathroom by himself/herself;
-The resident does not have fall mats in his/her room.
3. Review of Resident #20's admission MDS, dated [DATE], showed the following:
-admission date of 7/28/22;
-Diagnoses included stroke and hemiplegia (paralysis on one side of the body) with right side affect.
Review of the resident's fall risk assessment, dated 9/3/22, showed a score of 55, indicating a very high risk for falls.
Review of the resident's care plan, dated 7/28/22, showed the following:
-The resident is at risk for falls due to cerebrovascular disease with hemiparesis (muscle weakness or partial paralysis on one side of the body) and hemiplegia of right dominant side;
-Fall mats to side of bed;
-On 8/28/22, the resident rolled out of bed. No injury. Bed placed in lowest possible position;
-On 9/3/22, the resident rolled out of bed on to mat then to floor, no injury. Replaced fall mats with larger mats due to size.
Review of the resident's progress note, dated 9/17/22, showed the resident fell on 9/16/22 at 7:45 P.M. No complaints of pain and sustained a small laceration to his/her left knee that has been cleaned and bandaged.
Review of the resident's medical record showed no documentation regarding further details of the resident's fall on 9/17/22, and no documentation staff attempted to identify the root cause of the fall, evaluated the current interventions or updated the care plan with new interventions after the resident fell on 9/17/22.
Review of the resident's progress note, dated 9/20/22, showed the resident was sitting on the floor in front of his/her wheelchair. The resident was not able to relay what happened.
Review of the resident's medical record showed no documentation staff attempted to identify the root cause of the fall, or evaluated the current interventions or updated the care plan with new interventions after the resident fell on 9/20/22.
Review of the resident's care plan, updated on 9/29/22, showed staff to assist the resident with transfers, toileting, etc. as needed to reduce risk for falls.
Review of the resident's progress note, dated 10/3/22, showed the resident was on his/her buttocks by the door of his/her room. The resident tried to stand up while holding onto the door. The resident was unharmed, alert with confusion as is his/her baseline. Staff assessed the resident and assisted him/her back to his/her wheelchair. One-on-one care not feasible due to short staff of one nurse on the floor with two aides.
Review of the resident's medical record showed no documentation staff attempted to identify the root cause of the fall, or evaluated the current interventions or updated the care plan with new interventions after the resident fell on [DATE].
Review of the resident's fall risk assessment, dated 10/3/22, showed a score of 40 indicating low risk for falls.
Review of the resident's progress note, dated 10/7/22, showed the resident was observed lying on his/her back on the safety mat on the right side of his/her bed. The resident said he/she rolled out of bed. The resident is alert to self with confusion and forgetfulness. Staff assisted the resident back to bed.
Review of the resident's medical record showed no documentation staff attempted to identify the root cause of the fall, or evaluated the current interventions or updated the care plan with new interventions after the resident fell on [DATE].
Review of the resident's progress note, dated 10/16/22, showed staff were summoned to the dining room and found the resident on his/her back on the floor near the 400 hall dining room door with his/her feet facing the door and his/her head toward the tables. The resident's wheelchair was directly behind him/her.
Review of the resident's medical record showed no documentation staff attempted to identify the root cause of the fall, or evaluated the current interventions or updated the care plan with new interventions after the resident fell on [DATE].
During interview on 10/26/22 at 12:46 P.M., Licensed Practical Nurse (LPN) B said he/she was unsure if the resident had a history of falls. He/She would find out in report if there were any new falls from the previous shift.
During interview on 10/27/22 at 8:23 A.M., LPN D said when a resident falls staff assess the resident for injury and add a progress note in the electronic medical record. The department heads discuss the falls/interventions the next morning in their morning meeting.
4. Review of Resident #48's quarterly MDS, dated [DATE], showed the following:
-Diagnoses include dementia and anxiety disorder;
-Cognition was severely impaired;
-Totally dependent on two staff for transfers.
Review of the resident's care plan, revised 11/16/21, showed the following:
-May use a hoyer lift or two person assist;
-He/She uses a wheelchair for mobility and requires assistance at times and for longer distances.
Observation on 10/26/22, at 5:03 A.M., showed the following:
-The resident lay in bed;
-CNA N and CNA M hooked the resident's hoyer lift pad that lay under the resident to the mechanical lift;
-CNA N operated the lift while CNA M moved behind the resident's wheelchair;
-CNA N raised the resident up off the bed with the lift, and then maneuvered the mechanical lift toward the resident's wheelchair;
-CNA N was behind the lift and CNA M was behind the resident's wheelchair during the transfer;
-The resident was free swinging in the air during the transfer;
-CNA M used the handles on the lift pad to position the resident in the wheelchair while CNA N lowered the lift.
Observation on 10/26/22, at 5:11 A.M., showed CNA N transported the resident in his/her wheelchair from his/her bedroom to the dining room. The resident's wheelchair did not have any foot pedals attached. The resident's right foot drug the floor the entire way to the dining room.
During an interview on 10/26/22, at 5:59 A.M., CNA N said the following:
-During a hoyer lift transfer, staff who are not running the lift should always have their hands touching the resident for the resident's safety;
-CNA M was behind the resident's wheelchair to guide the resident into the wheelchair;
-Staff did not have their hands on the resident while the resident was raised into the air and during the transfer;
-CNA M should have had his/her hands on the resident during the transfer;
-He/She did not get any training on the mechanical lift from the facility;
-If a resident cannot hold his/her feet up during transport in a wheelchair, wheelchair pedals should be used to prevent injury;
-The resident did not foot pedals in his/her room.
During an interview on 10/26/22, at 6:42 A.M., CNA M said the following:
-During a hoyer lift transfer, one staff ran the lift and one staff guided the resident to his/her chair, with hands on the resident at all times;
-Staff should have their hands on the resident during a transfer for the resident's safety;
-He/She helped CNA N transfer the resident to his/her wheelchair;
-He/She guided the resident into his/her wheelchair by standing behind the resident's wheelchair;
-He/She did not have hands on the resident during the transfer.
5. Review of Resident #36's quarterly MDS, dated [DATE], showed the following:
-Cognition severely impaired;
-Totally dependent on two staff for transfers;
Review of the resident's care plan, revised 12/23/21, showed the following:
-The resident was at risk for falls related to weakness, impaired cognition, rigid muscle tone, limited mobility/range of motion, and need for maximum assist for transfers;
-Hoyer lift (a sling type mechanical lift) with two assist for all transfers.
Observation on 10/24/22, at 7:20 A.M., showed the following:
-The resident lay in bed;
-CNA C and Nurse Assistant (NA) G placed a hoyer lift pad under the resident;
-Staff placed the hooks of the hoyer lift pad onto the lift, and CNA C raised the resident off the bed with the lift;
-NA G stood behind the resident's broda chair (tilt-in-space reclining wheelchair);
-CNA C moved the lift with the resident in the sling toward the resident's broda chair (tilt in space specialized chair) while NA G continued to stand behind the resident's broda chair;
-The resident was free swinging in the air during the transfer as CNA C operated the lift and NA G stood behind the resident's chair.
-NA G stood behind the resident's broda chair and grabbed the sides of the lift pad to bring the resident back into the chair as CNA C lowered the resident into the chair.
During an interview on 10/27/22, at 2:00 P.M., CNA C said the following:
-A hoyer lift transfer requires two staff, one to run the lift and one to position the resident in the wheelchair;
-Most of the time staff do not put their hands on the resident when the resident is raised off the bed and transferred to the wheelchair;
-He/She did not receive any annual training from the facility on mechanical lift usage.
During an interview on 10/27/22, at 2:27 P.M., NA G said the following:
-He/She helped CNA C do a hoyer transfer with the resident on 10/24/22;
-Staff raised the resident into the air and the resident was free swinging from the bed to the broda chair during the transfer;
-He/She stood behind the resident's broda chair to help guide the resident into the chair;
-He/She did not feel like he/she had received adequate training on transfers and would like more training.
During interview on 10/27/22 at 5:47 P.M., the Director of Nursing (DON) said the following:
-Resident #20 had falls and she expected the nurses to put new interventions in place as appropriate after a fall;
-Staff discuss falls in the morning stand-up meeting to determine what happened and put new interventions into place;
-Nurses can update the care plan or communicate the fall and new interventions to the MDS Coordinator so the care plan can be updated;
-During a hoyer transfer, she expected staff to have their hands on the resident at all times for the resident's safety and to make the resident feel more secure;
-At no time during a hoyer transfer should a resident be free swinging;
-If a resident cannot independently hold their feet up during a wheelchair transport, foot pedals should be used to prevent injury;
-Resident #27 and #48 should have foot pedals on their wheelchairs if their feet drag during a transport;
-Fall mats would be used for safety for a resident with a history of falls;
-If a resident had an order for fall mats, there should be fall mats in the resident's room;
-She expected the fall mats to be used and the beds to be lower when a resident who was at risk for falls was in bed;
-Interventions should be put in place for residents who are falling.
CONCERN
(D)
Potential for Harm - no one hurt, but risky conditions existed
Deficiency F0637
(Tag F0637)
Could have caused harm · This affected 1 resident
**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on interview and record review, the facility failed to complete a significant change status assessment (SCSA) Minimum Data...
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**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on interview and record review, the facility failed to complete a significant change status assessment (SCSA) Minimum Data Set (MDS), a federally mandated assessment, required to be completed by the facility staff, for one resident (Resident 255 ), in review of 26 sampled residents. This assessment should have been completed within 14 days after the facility determined, or should have determined, there had been a significant change (major decline or improvement in the resident's status) in the resident's physical or mental condition which had an impact on more than one area of the resident's health status and required interdisciplinary review and/or revision of the care plan. The facility census was 68.
Review of the Centers for Medicare and Medicaid Services (CMS) Long-Term Care Facility Resident Assessment Instrument (RAI) 3.0 User's Manual, version 1.17.1, revised October 2019, showed a significant change is a decline or improvement in a resident's status that:
-Will not normally resolve itself without intervention by staff or by implementing standard disease-related clinical interventions, is not self-limiting;
-Impacts more than one area of the resident's health status;
-Requires interdisciplinary review and/or revision the care plan.
-A Significant Change in Resident Status (SCCA) is apporopriate if there is a consistent pattern of changes, with either two or more areas of decline, or two or more areas of improvement. This may include two changes within a particular domain (e.g., two areas of ADL decline or improvement).
Guidelines for determining significant change in resident status included the following:
-Any decline in an ADL physical functioning area where a resident is newly coded as 3,4,or 8;
-Resident's incontinence pattern changes from 0 or 1 to 2,3, or 4;
-Emergence of a pressure ulcer at Stage II or higher, when no pressure uclcers were previously present at Stage II or higher;
-Emergence of an unplanned weight loss problem (5% change in 30 days or 10% change in 180 days).
1. Review of Resident #255's undated facesheet showed the following:
-admission on [DATE];
-Diagnoses include: post Covid-19 (an infectious disease caused by the SARS-CoV-2 virus), anxiety disorder (a mental health disorder characterized by feelings of worry, anxiety, or fear that are strong enough to interfere with one's daily activities), diabetes mellitus (a group of diseases that result in too much sugar in the blood), atrial fibrillation (an irregular, often rapid heartbeat that commonly causes poor blood flow) and chronic kidney disease (a longstanding disease for the kidneys leading to renal failure).
Review of the resident's quarterly MDS, dated [DATE] showed the following:
-No acute mental status changes;
-No hallucinations/delusions;
-No behaviors noted;
-No falls since last reporting period;
-Supervision only for bed mobility, transfers, walking with wheeled walker, locomotion on and off the unit, eating and toileting;
-Limited assistance from one staff for dressing;
-Continent of urine;
-No complaints of pain;
-No falls since last assessment.
Review of the resident's medical record showed a missing MDS assessment for July 2022.
Review of the resident's nursing notes showed the following:
-On 9/25/22 the resident was diagnosed with Covid-19 and placed on isolation;
-On 9/25/22 the resident was found on the floor with no injuries with some confusion and weakness noted;
-On 9/28/22 the resident was found on the floor with no injuries with some confusion;
-On 10/2/22 the resident was found on the floor with minor injuries with weakness and fatigue noted;
-On 10/12/22 the resident complained of fatigue that is preventing him from completing his activities of daily living;
-On 10/16/22 the resident was found on the floor with no injuries with confusion noted;
-On 10/17/22 the resident was started on antibiotics for a urinary tract infection;
-On 10/24/22 the resident was noted to have increased confusion stating someone was under his/her bed and complained of neck, back and shoulder pain.
Observation on 10/24/22, at 7:35 A.M., showed the resident's mobility was now in a wheelchair and the resident required assistance of one staff for transfer and for bed mobility.
Observation on 10/24/22, at 9:40 A.M., showed the resident lay in bed crying out in pain complaining of his/her back hurting.
During an interview on 10/24/22, at 9:40 A.M., Licensed Practical Nurse (LPN) B said the resident was noted to be more confused today and that he/she just had not bounced back to his/her normal since he/she had Covid a few weeks ago and then a urinary tract infection. He/She used to be ambulatory with his/her wheeled walker and could do pretty much everything on his/her own, but not since his/her Covid diagnosis.
Observation of the resident on 10/24/22 and 10/25/22 showed numerous resident care area changes for the resident including ambulation, behaviors, pain, and falls compared to the resident's last quarterly MDS on 4/15/22. The resident would have meet the criteria for a significant change MDS 14 days after his/her acute episode that did not return to baseline.
During an interview on 10/27/22, at 5:46 P.M. the Director of Nurses said the following:
-Corporate personnel comes to the facility once weekly to update resident MDS's;
-MDS and care plans need to be updated when there has been a significant change.
CONCERN
(D)
Potential for Harm - no one hurt, but risky conditions existed
Deficiency F0657
(Tag F0657)
Could have caused harm · This affected 1 resident
**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on interview and record review the facility failed to revise care plans with changes in resident needs for two residents (...
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**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on interview and record review the facility failed to revise care plans with changes in resident needs for two residents (Resident #27, #255) in a review of 26 sampled residents. The facility census was 68.
Review of the facility's Care Plan Policy dated March 2015 showed the following:
-Purpose: An individualized comprehensive care plan that ·includes measurable goals and time frames will be developed to meet the resident's highest practicable physical, mental, and psychosocial well-being.
-Guidelines: The interdisciplinary care plan team with input from the resident, family, and/or legal representative will develop and maintain a comprehensive care plan for each resident that identifies the highest level of functioning the resident maybe expected to attain;
-The comprehensive care plan will be based on a thorough assessment that includes, but is not limited to, the MDS (Minimum Data Set, a federally mandated assessment completed by facility staff);
-Assessment of each resident is ongoing process and the care plan will be revised as changes occur in the resident's condition;
-A well-developed care plan will be oriented to: Preventing avoidable declines in functioning or functional levels or otherwise clarifying why another goal takes precedence (e.g., palliative approaches in end of life situation). Managing risk factors to the extent possible or indicating the limits of such interventions. Addressing ways to try to preserve and build upon resident strengths. Applying current standards of practice in the care planning process. Evaluating treatment of measurable goals, timetables and outcomes of care. Respecting the resident's right to decline treatment. Offering alternative treatments, as applicable. Using an appropriate interdisciplinary approach to care plan development to improve the resident's functional abilities;
Involving resident, resident's family and other resident representatives as appropriate. Assessing and planning for care to meet the resident's medical, nursing, mental and psychosocial needs;
Involving the direct care staff with the care planning process relating to the resident's expected outcomes. Addressing additional care planning areas that are relevant to meeting the resident's needs in the long-term care setting.
-The interdisciplinary care plan team is responsible for the periodic review and updating of care plans when a significant change in the resident's condition has occurred; at least quarterly, when changes occur that impact the resident's care (i.e. change in diet, discontinuation of therapy, changes in care areas that do not require a significant change assessment).
Review of the Centers for Medicare and Medicaid Services (CMS), Long-Term Care Facility Resident Assessment Instrument (RAI) 3.0 User's Manual, Version 1.17.1, Chapter 4, revised October 2019, showed the following:
-The care plan is driven not only by identified resident issues and/or conditions but also by a resident's unique characteristics, strengths, and needs;
-A care plan that is based on a thorough assessment, effective clinical decision making, and is compatible with current standards of clinical practice can provide a strong basis for optimal approaches to quality of care and quality of life needs of individual residents;
Reviews and revises the current care plan.
1. Review of Resident #27's face sheet showed the following:
-admitted on [DATE];
-Diagnoses include: dementia with behavior disturbance (a group of thinking and social symptoms that interferes with daily functioning), Parkinson's disease (a disorder of the central nervous system that affects movement, often including tremors), generalized anxiety (intense, excessive, and persistent worry and fear about everyday situations) and depression (a group of conditions associated with elevation or lowering of a person's mood).
Record review of the resident's nursing notes showed the following:
-On 4/16/22 at 11:39 A.M. the resident was found on the floor, no injuries noted and no interventions implemented.
-On 5/25/22 at 10:40 P.M. the resident was found on the floor by his/her bed with a laceration on forehead and skin tear times two on his/her left forearm, intervention of bed in low position and call light in place;
-6/2/22 at 7:20 P.M. Interdisciplinary team meeting and reviewed the resident fall on 5/25/22, resident is unsafe with transfers and standing. He/She has Parkinson 's disease. Added floor mats beside the bed as an intervention.
-On 8/1/22 at 4:00 P.M. the resident was found sitting on the floor with no injuries, no interventions implemented;
-On 8/4/22 at 3:30 P.M. the resident was found sitting on the floor by his/her bed and voiced he/she slid to the floor out of bed, no injuries noted and no interventions implemented;
-On 8/14/22 at 10:30 P.M. the resident was found on the floor by his/her bed with no injuries, intervention of fall mats placed at bedside;
-On 8/24/22 at 5:30 A.M. the resident was found on the floor in his/her room with no injuries, interventions of bed was lowered to the floor and call light in reach for resident safety;
-On 8/25/22 at 11:00 P.M. the resident was found on the floor in his/her room, noted a laceration on forehead and two skin tears on left forearm, no interventions implemented.
Review of the resident's quarterly MDS, dated [DATE], showed the following:
-Severely impaired cognition;
-Limited assist of one staff member for locomotion on and off the unit;
-Two non-injury falls since last reporting period;
-One minor-injury fall since last reporting period;
-Daily antipsychotic, anti-anxiety, and anti-depressant medication taken.
Review of the resident's care plan, revised on 9/2/22, showed the following:
-Resident takes antidepressant medication daily for depression and episodes of anxiety;
-The resident is at risk for falls due to decreased mobility and decreased safety awareness;
-The resident was placed on a fall prevention program;
-No indication of fall mat placement on 6/2/22;
-No indication of fall noted on 8/1/22, 8/4/22, 8/14/22, 8/24/22, 8/25/22;
-No indication of interventions noted for fall on 8/1/22, 8/4/22, 8/14/22, 8/24/22 or 8/25/22.
2. Review of Resident #255's face sheet showed the following:
-admission on [DATE];
-Diagnoses included post COVID-19 (an infectious disease caused by the SARS-CoV-2 virus), anxiety disorder (a mental health disorder characterized by feelings of worry, anxiety, or fear that are strong enough to interfere with one's daily activities), diabetes mellitus (a group of diseases that result in too much sugar in the blood), atrial fibrillation (an irregular, often rapid heartbeat that commonly causes poor blood flow) and chronic kidney disease (a longstanding disease for the kidneys leading to renal failure).
Review of the resident's quarterly MDS, dated [DATE] showed the following:
-No acute mental status changes;
-No hallucinations/delusions;
-No behaviors noted;
-No falls since last reporting period;
-Supervision only for bed mobility, transfers, walking with wheeled walker, locomotion on and off the unit, eating and toileting.
Review of the resident's nursing notes showed the following:
-On 9/25/22 the resident was diagnosed with COVID-19 and placed on isolation;
-On 9/26/22 the resident was found on the floor with no injuries, no interventions indicated;
-On 9/28/22 the resident was found on the floor with no injuries, no interventions indicated;
-On 10/2/22 the resident was found on the floor with minor injuries, no interventions indicated;
-On 10/16/22 the resident was found on the floor with no injuries, no interventions indicted.
Review of the resident's care plan, revised on 10/20/22, showed the following:
-Resident is at risk for falling due to cognitive deficit and difficulty with mobility at times;
-Resident walks with wheeled walker implemented on 6/2/22;
-No indication of falls on 9/26/22, 9/28/22, 10/2/22, or 10/16/22;
-No indication interventions implemented to prevent potential falls since 6/2/22;
-No indication of change in ambulatory status.
Observation on 10/24/22, at 7:35 A.M., showed the resident's mobility was now in a wheelchair and required assistance of one staff for transfer and bed mobility.
During an interview on 10/24/22, at 9:40 A.M., Licensed Practical Nurse (LPN) B said the resident just had not bounced back to his normal since he/she had COVID a few weeks ago and then a urinary tract infection. He/She used to be ambulatory with his/her wheeled walker and could do pretty much everything on his/her own, but not since his/her COVID diagnosis. The resident had some increased falls, probably related to being weak.
During interview on 10/27/22 at 5:47 P.M., the Director of Nurses (DON) said she would expect the care plan to be up-to-date with the most current interventions to provide the best care for the residents.
CONCERN
(D)
Potential for Harm - no one hurt, but risky conditions existed
Deficiency F0692
(Tag F0692)
Could have caused harm · This affected 1 resident
Based on interview and record review, the facility failed to follow their Weight Champion Program to ensure weights were monitored weekly per the recommendation of the dietician after a significant we...
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Based on interview and record review, the facility failed to follow their Weight Champion Program to ensure weights were monitored weekly per the recommendation of the dietician after a significant weight loss was identified for one resident (Resident #2) in a review of 26 sampled residents, reweigh the resident when a weight variance was identified or document/address the resident's meal consumption. The facility census was 68.
Review of the facility's policy, Weight Champion Program, undated, showed the following:
-The purpose of this program is to take a proactive stance against weight loss and collaborate to decrease weight loss numbers;
-The weight champion will be responsible for keeping the weight variance report from Matrix, as well as being custodian of the Daily, Weekly and Monthly facility weight lists;
-The champion is responsible for: ensuring all new admits are weighed upon admission and weekly for four weeks; ensuring all daily, weekly and monthly weights are obtained and documented; ensuring re-weights are done for anything that is a three pound gain/loss; data entry and printing of weight reports; writing weekly Interdisciplinary team (IDT) notes and updating the care plan during the IDT meeting; contacting the dietician with weight concerns between visits; follow up on dietary recommendations (must be done within three days); contacting the physician and family with any significant weight loss; ensuring that all the above being documented in the medical record; ensuring a copy of the wound report, weight reports and consumption records are ready and accessible to the dietician for their visit as well as the reporting form found in the dietary manual that lists residents with feeding tubes and new admits;
-All residents will be weighed monthly unless otherwise indicated;
-Residents are to be weighed weekly if they have displayed significant weight loss at the time of their monthly weight;
-Any residents experiencing a variance will be reweighed to ensure accuracy immediately;
-Weights will be entered into Matrix (electronic medical record) by the weight champion and/or designee;
-Weights should be reviewed weekly in the IDT meeting. IDT notes and care plans should be updated at this time;
-Consumption of meals will be documented in Matrix and will be reviewed by the Weight Champion. This should also be reviewed at IDT meeting;
-Weight should be assessed by the IDT at the time that the loss is noted. If a supplement is necessary, food items should be tried first, then exception is that of those residents that drinking is more feasible for the resident i.e.: due to shortness of breath or energy expenditure. This must be documented.
1. Review of Resident #2's Quarterly Minimum Data Set (MDS), a federally mandated assessment instrument required to be completed by facility staff, dated 4/19/22, showed the following:
-Cognitively intact;
-Required limited assistance of one staff for eating;
-Weight 233 pounds (lbs);
-No dental issues.
Review of the resident's weight record showed the following:
-On 5/7/22, staff documented the resident weighed 232 lbs;
-On 6/9/22, staff documented the resident weighed 232.8 lbs;
-On 7/13/22, staff documented the resident weighed 233.4 lbs;
-On 8/9/22, staff documented the resident weighed 220.8 lbs, (a loss of 12.6 lbs.);
-No documentation for weight in September 2022;
-On 10/4/22, staff documented the resident weighed 181.0 lbs,( loss of another 39.8 lbs);
-No documentation to show staff re-weighed the resident to check accuracy of monthly weight when a large weight loss was apparent.
Review of the registered dietician's note, dated 10/14/22, showed the following:
-Current weight: 181 lbs;
-7.5% weight loss in 90 days;
-Supplement: Arginaid (for wound healing) twice daily with medication pass;
-Average intake percentage: 76-100%;
-Resident independent with eating;
-Comment: Resident has had a 52 lb (22.5%) weight loss in the past quarter per history. Unsure of cause. Weight was trending down prior to this. Fluid shifts may contribute to weight changes; difficult to assess true dry weight loss/trend. Recommend weekly weights for four weeks to trend and close monitoring of oral intake. Will monitor and follow up as needed.
Review of the resident's physician order sheet (POS), dated October 2022, showed the following:
-Level seven regular diet (regular diet, regular texture);
-No order for weekly weights as recommended by the dietician;
-Diagnoses included chronic obstructive pulmonary disease, right ankle wound, diabetes mellitus type two and chronic kidney disease stage three.
Review of the resident's care plan, last reviewed 10/22/21, showed no documentation the resident had a significant weight loss.
Review of the resident's electronic medical record showed no documentation of meal consumptions.
Review of the resident's physician progress note, dated 10/24/22, showed the resident has lost a lot of weight. The resident says the food is not very good. The resident knows he/she needs to lose weight and is feeling a little bit better but he/she was still weak. The resident was not happy with the facility food Diagnosis documented as unintentional weight loss.
During interview on 10/24/22 at 10:26 A.M., the resident said the food portions are small and he/she never gets full. He/She said he/she puts x 2 for portions on the menu but they don't give it to him/her. He/She has had weight loss.
During interview on 10/25/22 at 8:58 A.M., the resident said lunch yesterday was not great. He/She only ate about half his/her lunch yesterday.
Review of email correspondence on 11/10/22 at 2:48 A.M., showed the Director of Nurses (DON) responded she did not have any record of the resident's meal consumption for the last 90 days.
During interview on 10/26/22 at 2:02 P.M., Certified Nurse Assistant (CNA) C said he/she is the restorative aide on day shift but gets pulled to work the floor frequently. He/She would normally be responsible for getting monthly weights. Licensed Practical Nurse (LPN) A and the DON have been getting monthly weights the last few months.
During interview on 10/26/22 at 12:46 P.M., Licensed Practical Nurse (LPN) B said he/she was unsure if the resident had any weight loss. He/She was unsure how the meal consumption was documented. He/She had not seen any dietician recommendations for the resident.
During interview on 10/27/22 at 8:23 A.M., LPN D said he/she was not aware of the resident having any weight loss. If a resident has weight loss they would start weighing the resident weekly and he/she has not seen any orders regarding that for the resident. He/She did not know of any issues with the resident's appetite and was not aware of the dietician recommendation for weekly weights.
During interview on 10/27/22 at 5:47 P.M., the DON said there was currently no Weight Champion at the facility and CNA C usually obtained resident weights. She (the DON) obtained weights for this month. She was aware Resident #2 had a weight loss. Staff record meal consumptions in Matrix (the facility medical record). The dietician comes and sees residents and then the facility gets the visit notes later. She was not aware of the recommendation for weekly weights for Resident #2. She said she gets the dietician's notes via email and it may be a week before she has a chance to look at them.
During an interview on 11/15/22, at 4:39 P.M., the medical director said the following:
-He is the physician assigned to care for Resident #2;
-He was aware of the dietician's recommendations;
-The resident wanted to lose weight and did not care for the food at the facility;
-He would expect if the resident continued to lose weight, and no longer wanted to, at that time interventions could be put in place.
CONCERN
(D)
Potential for Harm - no one hurt, but risky conditions existed
Deficiency F0698
(Tag F0698)
Could have caused harm · This affected 1 resident
Based on observation, interview and record review, the facility failed to assess one resident's (Resident #12) dialysis arteriovenous (AV) shunt/fistula (access used to artificially connect a vein wit...
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Based on observation, interview and record review, the facility failed to assess one resident's (Resident #12) dialysis arteriovenous (AV) shunt/fistula (access used to artificially connect a vein with an artery, so that a higher blood flow is created to allow blood to be pumped out of the body to an artificial kidney machine, and returned to the body by tubes that connect the patient to the machine) daily and after he/she returned from dialysis treatments in a review of 26 sampled residents. The facility failed to include care of the resident's dialysis shunt/fistula on the resident's care plan. The facility census was 68.
Review of the facility's undated policy, Dialysis, Care of a Resident Receiving, showed the following:
-To utilize the following guideline to provide care for a resident that is receiving dialysis;
-Care of the AV shunt/fistula/graft: keep the area clean and dry; feel for the thrill sensation daily; inspect the access for redness, swelling or warmth; avoid constrictive clothing or jewelry that may bind the access site; no blood pressure on the puncture site after dialysis; watch for bleeding after dialysis; monitor for signs of infection;
-Checking the Thrill Sensation: nurses will check the thrill (whooshing sound) daily and document daily. This will be documented on the resident's treatment record; at the AV site, feel for a pulse. The pulse is the blood flow through the access; if no thrill sensation is felt, notify the physician.
1. Review of Resident #12's care plan, last reviewed 11/16/21, showed no documentation the resident had a dialysis shunt/fistula, received dialysis treatment three times a week or direction for assessment of the fistula site.
Review of the resident's Quarterly Minimum Data Set (MDS), a federally mandated assessment instrument required to be completed by facility staff, dated 8/10/22, showed the following:
-The resident's cognition was intact;
-The resident received dialysis.
Review of the resident's Physician Order Sheet (POS), dated September 2022, showed the following:
-The resident had a diagnosis of hypertensive heart and chronic kidney disease with heart failure and with stage five chronic kidney disease or end stage renal disease (complete failure of the kidneys;
-Dialysis three times per week on Monday, Wednesday and Friday;
-Remove the dressing from the fistula site in the morning the day after dialysis on day shift;
-Check AV fistula daily for thrill /Bruit (sound generated by turbulent blood flow in an artery due to either an area of partial obstruction or high rate of blood flow through an unobstructed artery) every shift;
-Check AV site for signs and symptoms of infection every shift;
-Dialysis resident, document dialysis post weight under vital signs in Matrix (electronic medical record) on dialysis days, Monday-Wednesday-Friday.
Review of the resident's Nurse Treatment Sheet, dated 9/1/22-9/31/22, showed the following:
-There was no documentation to show staff removed the dressing from the resident's AV fistula on 9/17/22 and 9/29/22;
-There was no documentation to show staff checked the AV fistula daily for thrill/Bruit on the day shift for 9/9/22, 9/14/22, 9/23/22, and 9/28/22;
-There was no documentation to show staff checked the AV fistula daily for thrill/Bruit on the evening shift for 9/14/22, 9/17/22 through 9/19/22, 9/21/22, 9/24/22, and 9/27/22 through 9/30/22/22;
-There was no documentation to show staff checked the AV fistula daily for thrill/Bruit on the night shift for 9/7/22, 9/19/22, and 9/27/22;
-There was no documentation to show staff checked the AV fistula for signs and symptoms of infection on the day shift for 9/9/22, 9/14/22, 9/22/22, 9/23/22, and 9/28/22;
-There was no documentation to show staff checked the AV fistula for signs and symptoms of infection on the evening shift for 9/14/22, 9/16/22 through 9/19/22, 9/2422, 9/27/22 through 9/30/22;
-There was no documentation to show staff checked the AV fistula for signs and symptoms of infection on the night shift for 9/19/22, 9/23/22, and 9/27/22;
-There were no documented assessment of the residents post dialysis weight on Monday, Wednesday or Friday for the month of September.
Review of the resident's Physician Order Sheet (POS), dated October 2022, showed the following:
-The resident had a diagnosis of hypertensive heart and chronic kidney disease with heart failure and with stage five chronic kidney disease or end stage renal disease (complete failure of the kidneys);
-Dialysis three times per week on Monday, Wednesday and Friday;
-Remove the dressing from the fistula site in the morning the day after dialysis on day shift;
-Check AV fistula daily for thrill /bruit (sound generated by turbulent blood flow in an artery due to either an area of partial obstruction or high rate of blood flow through an unobstructed artery) every shift;
-Check AV site for signs and symptoms of infection every shift;
-Dialysis resident, document dialysis post weight under vital signs in Matrix (electronic medical record) on dialysis days, Monday-Wednesday-Friday.
During interview on 10/25/22 at 9:55 A.M., the resident said he/she goes to dialysis three times a week. Staff do not check his/her fistula site in his/her upper left arm and he/she takes the bandage off during the night.
Review of the resident's Nurse Treatment Sheet, dated 10/1/22-10/31/22, showed the following:
-There was no documentation to show staff removed the dressing from the resident's AV fistula on 10/1/22, 10/6/22, 10/15/22, 10/18/22, 10/25/22 and 10/27/22;
-There was no documentation to show staff checked the AV fistula daily for thrill/bruit on the day shift for 10/6/22, 10/7/22, 10/16/22, 10/25/22 and 10/27/22;
-There was no documentation to show staff checked the AV fistula daily for thrill/Bruit on the evening shift for 10/6/22 through 10/10/22, 10/17/22 through 10/22/22 and 10/24/22 through 10/27/22;
-There was no documentation to show staff checked the AV fistula daily for thrill/Bruit on the night shift for 10/3/22, 10/7/22, 10/13/22, 10/14/22, 10/16/22, 10/18/22 through 10/26/22;
-There was no documentation to show staff checked the AV fistula for signs and symptoms of infection on the day shift for 10/1/22, 10/2/22, 10/6/22, 10/7/22, 10/16/22, 10/25/22 and 10/27/22;
-There was no documentation to show staff checked the AV fistula for signs and symptoms of infection on the evening shift for 10/6/22 through 10/10/22, 10/17/22 through 10/22/22, and 10/24/22 through 10/26/22;
-There was no documentation to show staff checked the AV fistula for signs and symptoms of infection on the night shift for 10/3/22, 10/7/22, 10/11/22, 10/13/22, 10/14/22, 10/16/22, 10/18/22 through 10/24/22 and 10/26/22;
-There were no documented assessment of the residents post dialysis weight on Monday, Wednesday or Friday for the month of October.
During interview on 10/26/22 at 12:46 P.M., Licensed Practical Nurse (LPN) B said the resident has a binder that he/she takes with him/her on treatment days. The dialysis clinic will write any new orders in the binder. He/She is unsure if the facility staff take the resident's vitals before he/she goes to treatment or if the dialysis clinic does that. The day after dialysis, staff are to remove the dressing from the fistula site but the resident does this.
During interview on 10/27/22 at 8:23 A.M., LPN D said the resident takes the binder with him/her to the dialysis appointment and then staff look for new orders in the binder. Staff should check the fistula site and document that on the Treatment Administration Record (TAR). The resident doesn't usually have a dressing on the fistula site when he/she comes back from dialysis.
During interview on 10/27/22 at 5:47 P.M., the Director of Nurses said she would expect assessment of the AV fistula to be documented as ordered and would expect a care plan to be in place if the resident received dialysis services with interventions on how to monitor and care for the fistula. The facility currently did not have a full time MDS/ Care plan staff member. There is a corporate MDS staff that comes once a week and updates the care plans if needed.
CONCERN
(E)
Potential for Harm - no one hurt, but risky conditions existed
Resident Rights
(Tag F0550)
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 interact with one resident, (Resident #22) in a digni...
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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 interact with one resident, (Resident #22) in a dignified and respectful manner when staff used inappropriate language while assisting a resident with clothing and presented with inappropriate actions towards the resident when serving his/her meal, failed to promote dignity when staff ignored two residents (Resident #344 and #355) when assisting the residents with a meal talking socially to other staff, rather than engaging the residents, and failed to ensure all residents at a table were served meals timely so one resident (Resident #31) did not have to sit for an extended period of time as tablemates were served and ate their meal in a sample of 26 residents. The facility census was 68.
Review of the undated facility policy, Resident Rights, showed the following:
-It is the intent of the Facility to promote and ensure that highest standards of conduct and reliability by its employees and consultants to in turn produce environments in the facility that promote the highest standards of care and security for our Residents and the Families we serve;
-Each Resident shall be treated with consideration, respect a full recognition of his/her dignity and individuality;
-Each Resident shall be permitted to communicate, associate and meet privately with persons of his/her choice whether on the Resident's initiative or the other person's initiative, unless to do so would infringe upon the rights of others. The person(s) may visit, talk with and make personal. Social or legal services available.
1. Review of the Resident #22's face sheet showed the following:
-admitted to the facility on [DATE];
-Diagnosis of dementia.
Review of the resident's Annual Minimum Data Set (MDS), a federally required assessment instrument, dated 11/15/21, showed the following:
-Severe cognitive impairment;
-Limited assistance of one staff assistance in dressing and hygiene;
-Extensive assistance of one staff needed for transfers to provide weight-bearing support.
Review of the facility's investigation, dated 10/24/22, showed the following:
-The administrator was informed by Housekeeper T he/she witnessed nurse assistant (NA) J to be inappropriate with a resident;
-NA J immediately suspended and facility investigation began.
During an interview on 10/25/22 at 9:01 A.M., Housekeeping staff T said the following:
-On 10/20/22 he/she was cleaning A hall;
-He/She heard the resident call out help me;
-He/She found the resident sitting on the couch in the common area;
-The resident said he/she wanted help with pulling up his/her pants;
-He/She saw NA J holding a lunch tray and asked her for assistance in pulling up the resident's pants;
-NA J sat down the lunch tray;
-NA J spoke to the resident in a rude manner and said you're going to piss me off today;
-The resident did not respond or react to NA J;
-NA J position the resident's wheel chair in front of him/her, slammed the resident's lunch tray on the wheelchair and rudely said eat and walked away;
-NA J did not set up lunch tray for the resident;
-He/She said this is not the first time NA J has been rude to the residents;
-He/She reported the incident to the Housekeeping Supervisor;
-He/She reported the incident to the Administrator.
During an interview on 11/8/22 at 1:03 P.M. the Director of Nurses (DON) said she expected staff to assist and speak to resident with respect.
During an interview on 10/26/22, at 8:30 A.M., the administrator said the following:
-He expected staff to be polite and assist the resident's in a positive manner;
-He would not expect staff to treat or speak to a resident in a rude manner.
2. Observation in the dining room during breakfast meal service on 10/24/22 at 8:55 A.M., showed the following:
-Five staff members present in dining room to serve breakfast to the residents;
-Licensed Practical Nurse (LPN) B and Nurse Aide (NA) G stopped serving meal trays to feed two residents #354 and #355 who were served a tray;
-LPN B and NA G spoke with other staff about personal social topics and ignored residents #354 and #355;
-One table of three residents in the dining room was served such that two of the residents were served a try at the same time, and the third resident, Resident #31, waited 25 minutes before staff brought his/her tray
-Resident #31 asked kitchen staff if he/she was forgotten because the other residents had finished breakfast and he/she did not have a tray.
During interview on 11/3/22 at 11:00 A.M., the DON said the following:
-The facility had an open dining room service with a first come first serve and try to serve all of one table at a time;
-A resident should not wait 10 to 30 minutes for a tray after their tablemates were served. especially if they were present at the same time.
MO 00208711
CONCERN
(E)
Potential for Harm - no one hurt, but risky conditions existed
Deficiency F0565
(Tag F0565)
Could have caused harm · This affected multiple residents
Based on interview and record review, the facility failed consistently address and respond to concerns brought forth by the resident council, including residents in attendance, (Resident #2, #10, #42,...
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Based on interview and record review, the facility failed consistently address and respond to concerns brought forth by the resident council, including residents in attendance, (Resident #2, #10, #42, and #50). The facility census was 68.
Review of the facility's Resident Council policy, dated 3/5/12, showed the following:
-Monthly meetings will be held with minutes of the meetings documented;
-Recommendations for changes by the council will be given to the Administrator who will evaluate the recommendations.
-Concerns and needs are addressed as voiced by members of the council.
Review of the Resident Council Minutes, dated 8/11/22, showed the following:
-Request for evening staff to resupply tea room and servicing room and silverware so it's ready on time;
-Request for ice carts to have a labeled canister for ice scoop;
-Request resident names be put in slots by doors that are still missing and new admits;
-Request once a month that mismatched socks and underwear be brought out for residents to go through.
Review of the Resident Council Minutes, dated 9/8/22, showed the following:
-Request for tea room stocked at the end of day so early risers can have coffee and still need sign on chain for servicing area (staff only);
-Request once a month that mismatched socks and underwear are brought out for residents to look through. Need it announce also for time and location;
-Request for rooms cleaned every day, especially trash cans emptied;
-Request continue to update name slots for moves and new admits.
Review of the Resident Council Minutes, dated 10/13/22, showed the following:
-Request for tea room stocked every day;
-Request set schedule for residents to go through unclaimed clothing;
-Request trash cans emptied every day and toilets cleaned more often;
-Request new residents first name and room number so they can be welcomed.
During interview on 10/24/22 at 11:34 A.M., Resident #10 said the following:
-Concerns were voiced during Resident Council Meeting on a monthly basis. The Activity Director took the concerns to supervisor meetings to report the concerns, then the Activity Director will bring the responses back at the next council meeting;
-The administration responded depending on the grievance and the weight it holds with administration;
-The resident said grievances were made, but didn't always get a response.
During interview on 10/24/22 at 11:50 A.M., the Activity Director said the following:
-He/She took concerns/grievances brought up during the Resident Council meeting to the supervisor meeting and the concern/grievance was given to the supervisor who was responsible for resolution;
-He/She reported the resolution to the members of the Resident Council at the next meeting;
-The residents are not always happy with the results, but he/she does provide reasoning for the response;
-The supervisors addressed the concerns/grievances, but some take planning and the residents will bring it up again in the next meeting until it is resolved to their preference.
During interview on 10/26/22 at 11:55 A.M., the administrator and Director of Nursing (DON) said the following:
-The concern about the tea room being stocked every day was assigned to the evening staff, however when the shift was short staffed the tea room was not a priority;
-The Housekeeping Supervisor planned to schedule a day for residents to view clothes that's labels are unreadable or missing for the residents to claim once a month, including underwear and socks per the Resident Council's request, however it was explained to the Resident Council there has to be enough staff and time to ensure everything was clean and organized before this could take place;
-The name slots outside resident room doors have been updated with the correct information, the request had changed to giving the Resident Council new resident first names and room number, personally so they could welcome new residents.
CONCERN
(E)
Potential for Harm - no one hurt, but risky conditions existed
Safe Environment
(Tag F0584)
Could have caused harm · This affected multiple residents
**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, interview, and record review, the facility failed to provide a safe, comfortable environment by failing to...
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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 safe, comfortable environment by failing to ensure walls in resident rooms, fixtures in bathrooms, and ceiling vents were kept in good repair. The facility census was 68.
Observation on 10/24/22 at 10:49 A.M. in occupied resident room [ROOM NUMBER], showed the wall was marred with exposed drywall behind the beds.
Observation on 10/24/22 a 10:49 A.M. in occupied resident room [ROOM NUMBER], showed the wall next to the bed was marred with multiple scrapes and with exposed drywall and drywall compound in two separate areas.
Observation on 10/24/22 at 10:55 A.M. in occupied resident room [ROOM NUMBER], showed the wall was marred and had drywall compound on the wall behind the bed closest to the window.
Observation on 10/24/22 at 11:07 A.M. in the unlabeled room on B Hall across from the medication room showed the ceiling vent had a heavy buildup of dark-colored debris.
Observation on 10/24/22 at 11:08 A.M. in the corridor at the top of B Hall, showed the ceiling ventilation grate had a heavy buildup of debris.
Observation on 10/24/22 at 11:14 A.M. in the C Hall, showed a heavy buildup of debris on the vent near the floor behind the dining room door.
Observation on 10/24/22 at 11:18 A.M. in the dining room, showed large cobwebs ran from the dining room exit sign closest to C Hall to the ceiling approximately one foot away and blew in the breeze.
Observation on 10/24/22 at 11:47 A.M. in the kitchen employee restroom, showed the exhaust vent had a heavy buildup of debris.
Observation on 10/24/22 at 11:59 A.M. in the mechanical room on C Hall, showed a heavy buildup of debris on the ceiling vent.
Observation on 10/24/22 at 1:08 P.M. in the mechanical room on A Hall, showed two vents with a heavy buildup of debris.
Observation on 10/24/22 at 1:20 P.M., in occupied resident room [ROOM NUMBER], showed marred walls behind both beds.
Observation on 10/24/22 at 2:03 P.M. in occupied resident room [ROOM NUMBER], showed heavy debris on the restroom exhaust vent.
Observation and interview on 10/24/22 at 2:26 P.M. in occupied resident room [ROOM NUMBER], showed two very large areas of missing wallpaper over both beds. One area measured approximately 8-inches wide by 20-inches in length. The second area measured approximately two feet in height and three feet wide. A third area of missing wallpaper measured approximately ten inches wide by one foot in height. The resident in the bed by the window said the wallpaper had been missing for about a year.
Observation on 10/24/22 at 2:37 P.M. in the clean linen room on F Hall, showed heavy debris on the ceiling vent.
Observation on 10/24/22 at 2:48 P.M. in occupied resident room [ROOM NUMBER], showed the wallpaper was marred and scraped off the wall behind the bed in a one foot section.
Observation on 10/24/22 at 2:50 P.M. in occupied resident room [ROOM NUMBER], showed dry wall compound on the wall in three large areas next to the bed.
Observation on 10/24/22 at 2:51 P.M. in occupied resident room [ROOM NUMBER], showed a large round area with a hole in the wall behind the bed.
During interview on 10/24/22 at 3:20 P.M., Resident #50, who resided in room [ROOM NUMBER], said his/her toilet moved when he/she sat down on it.
Observation on 10/24/22 at 3:20 P.M., in room [ROOM NUMBER], showed the toilet moved up and down when pressure was applied.
During an interview on 10/26/22 at 10:02 A.M., the maintenance supervisor said staff typically send him a text, call him, or find him in the building to report building issues. There was a work order binder at the nurse's station. Staff were to fill out a work request when a repair was needed. He checked the book today and there was only one work order for a toilet repair in room [ROOM NUMBER], and he had already taken care of the repair. Walls should be repaired but they were lower on the priority list. For example, leaking toilets, toilets running, etc. were a higher priority. An empty room that was getting an admission would be checked or repaired prior to the new resident's arrival. He was unsure who was responsible for cleaning the ceiling vents.
CONCERN
(E)
Potential for Harm - no one hurt, but risky conditions existed
Abuse Prevention Policies
(Tag F0607)
Could have caused harm · This affected multiple residents
Based on interview and record review, the facility failed to complete appropriate background checks for four employees (LPN CC, Housekeeper Supervisor, RN O, CMT R) in a review of 10 new employees hir...
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Based on interview and record review, the facility failed to complete appropriate background checks for four employees (LPN CC, Housekeeper Supervisor, RN O, CMT R) in a review of 10 new employees hired prior to employment. Further review showed the facility failed to check the Certified Nurse Assistant (CNA) Registry for any Federal indicators of abuse, neglect or misappropriation of property for six new employees (LPN CC, Laundry Staff DD, RN O, CNA H, and CMT R) prior to employment. The facility census was 68.
Review of an undated document titled How to Hire an Employee, provided by the facility on 10/27/22, showed the following:
- FCSR (Family Care Safety Registry) - if the prospective employee is registered, run the background check, print the form;
-If the prospective employee is not registered, fax the D & B Legal form to D & L Legal Service to have background checked;
-Check the EDL (Employee Disqualification List) - this is included in the family care safety registry but is recommended the facility run and print the report on all employees before orientation;
-Check the CNA Registry (website listed) - this is to be run and printed on all employees before orientation.
Review of an undated document titled Background checks: Family Care Safety Registry (FCSR, the EDL and CBC (Criminal Background Check) and the CNA Registry, provided by the facility on 10/27/22, showed the following:
-Family care safety registry - First thing to do check if the applicant is registered with the FCSR (website listed);
-If the applicant/employee is not registered with the FCSR, the following shall occur:
A. The applicant/employee must complete the worker registration form (email address listed),
B. The facility must contact D and B Legal Service, Inc. to complete the Criminal Background Screening,
C. The facility must use the State EDL (website listed) to check the EDL;
-If you have received the EDL results and have made the CBC request, the applicant can start working at the facility;
-Once you receive the CBC results, you then have to evaluate the results;
-Always keep a hard copy of the EDL results for each employee;
-Keep a hard copy of CNC request and the results for each employee;
-If you don't have these copies in the employees' files, the state will cite you.
1. Review of employee Licensed Practical Nurse (LPN) CC's employee file showed the following:
-He/She was hired on 5/14/21;
-No evidence of FCSR was completed;
-Date of CBC request 5/3/21;
-No evidence of EDL check;
-No evidence CNA Registry check was completed.
2. Review of Laundry Staff DD's employee file showed the following:
-He/She was hired on 9/22/21;
- No evidence CNA Registry check was completed.
3. Review of Registered Nurse (RN) O's employee file showed the following:
-He/She was hired on 4/26/22;
-No evidence of FCSR was completed;
-Date of CBC request 4/25/22;
-No evidence of EDL check;
-No evidence CNA Registry check was completed.
4. Review of Housekeeping Supervisor's employee file showed the following:
-He/She was hired 9/27/21;
-FCSR was completed 9/30/21 (3 days after hire date);
-No evidence CNA Registry check was completed.
5. Review of Activities Director's employee file showed the following:
-He/She was hired on 11/01/21;
- No evidence CNA Registry check was completed.
6. Review of Dietary Aide EE's employee file showed the following:
-He/She was hired on 10/25/21;
- No evidence CNA Registry check was completed.
7. Review of CMT R's employee file showed the following:
-He/She was hired on 8/29/22;
-No evidence of FCSR was completed;
-No evidence of Date of CBC request.
During an interview on 10/27/22, at 10:34 A.M., the business office staff stated the following:
-All new employees are supposed have a CNA Registry check regardless of their position;
-All the records reviewed had been processed by the Administrator.
During an interview on 11/10/22, at 2:30 P.M., the administrator stated the following:
-He has been responsible for collecting CNA Registry information;
-He has been responsible for collecting FSCR and CBC/EDL checks prior to new employee hire date;
-He would expect that CNA registry to be completed prior to all new employees hire date;
-He would expect that either FSRC or the combination of CBC/EDL check would be completed prior to a new employee's hire date.
CONCERN
(E)
Potential for Harm - no one hurt, but risky conditions existed
Comprehensive Assessments
(Tag F0636)
Could have caused harm · This affected multiple residents
**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on interview and record review, the facility failed to complete comprehensive assessments timely for four residents (Resid...
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**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on interview and record review, the facility failed to complete comprehensive assessments timely for four residents (Resident #104, #105, #254, and #356) in a review of 26 sampled residents. The facility census was 68.
Review of the Centers for Medicare and Medicaid Services (CMS) Long-Term Care Facility Resident Assessment Instrument (RAI) 3.0 User's Manual, version 1.17.1, revised October 2019, showed the following:
-The Omnibus Budget Reconciliation Act (OBRA) required comprehensive assessments include the completion of both the Minimum Data Set (MDS) and the Care Area Assessment (CAA) process, as well as care planning;
-Comprehensive assessments are completed upon admission, annually, and when a significant change in a resident's status had occurred or a significant correction to a prior comprehensive assessment is required;
-The admission assessment is a comprehensive assessment for a new resident and, under some circumstances, a returning resident that must be completed by the end of day 14, counting the date of admission to the nursing home as day 1 if:
-this is the resident's first time in this facility, OR
-the resident has been admitted to this facility and was discharged return not anticipated, OR
-the resident has been admitted to this facility and was discharged return anticipated and did not return within 30 days of discharge;
-The MDS completion date (item Z0500B) must be no later than day 14. This date may be earlier than or the same as the CAA(s) completion date, but not later than.
1. Review of Resident #104's electronic medical record showed the following:
-The resident was re-admitted to the facility on [DATE];
-The facility had not completed an admission assessment for the resident (263 days since the resident's admission);
-The facility failed to complete the resident's MDS admission assessment by the 14th day after admission.
2. Review of Resident #105's electronic medical record showed the following:
-The resident's most recent annual assessment was completed 6/21/21;
-The facility failed to complete an annual assessment for 6/22/22.
3. Review of Resident #254's electronic medical record showed the following:
-The resident's last three assessments were quarterly assessments dated 10/16/21, 1/24/22 and 4/18/22;
-For assessment timing the resident would have a comprehensive/annual assessment due no later than 7/19/22, 92 days since the last assessment;
-The facility failed to complete the annual assessment by 7/19/22;
-The resident's last comprehensive assessment, an annual assessment, was completed on 7/16/21.
4. Review of Resident #356's electronic medical record showed the following:
-The facility admitted the resident on 6/29/22;
-The facility did not complete an admission assessment for the resident (120 days since the resident's admission;
-The facility failed to complete the resident's MDS admission assessment by the 14th day following admission.
During interview on 10/27/22 at 5:47 P.M., the Director of Nurses said the facility follows the RAI manual to complete MDS assessments. She said the facility did not currently have a full time MDS Coordinator. The corporate MDS person was coming once a week to help out. She said getting MDSs completed timely had been a struggle.
CONCERN
(E)
Potential for Harm - no one hurt, but risky conditions existed
Deficiency F0638
(Tag F0638)
Could have caused harm · This affected multiple residents
**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on interview and record review, the facility failed to ensure a Quarterly Minimum Data Set (MDS), a federally mandated res...
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**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on interview and record review, the facility failed to ensure a Quarterly Minimum Data Set (MDS), a federally mandated resident assessment completed by the facility staff, was completed no less than once every three months for seven of 26 sampled residents (Resident #1, #2, , #3, #27, #104, #105, and #355). The facility census was 68.
Review of the Centers for Medicare and Medicaid Services (CMS) Long-Term Care Facility Resident Assessment Instrument (RAI) User's Manual MDS 3.0, dated 2019, showed the following:
-The OBRA of 1987 provided the statutory authority for federal statute and regulations that required nursing homes to conduct initial and periodic assessments for all their residents. The assessment information is used to develop, review, and revise the resident's plans of care that will be used to provide services to attain or maintain the resident's highest practicable physical, mental, and psychosocial well-being;
-The Quarterly Assessment is a non-comprehensive assessment for a resident that must be completed at least every 92 days following the previous OBRA assessment of any type;
-It is used to track a resident's status between comprehensive assessments to ensure critical indicators of gradual change in a resident's status are monitored;
-The ARD (assessment reference date), must be within 92 days after the ARD of the previous OBRA assessment (Quarterly, Admission, SCSA, SCPA, or Annual assessment plus 92 days);
-The completion date (item Z0500B) is ARD plus 14 days.
1. Review of Resident #1's MDS record showed the following:
-The resident's most recent quarterly assessment was 4/23/22;
-Staff failed to complete a quarterly assessment for the resident in July 2022 and October 2022.
2. Review of Resident #2's MDS record showed the following:
-The last quarterly assessment was dated 4/19/22;
-There was no documentation to show staff completed a quarterly assessment for the resident in July or October 2022.
3. Review of Resident #3's MDS record showed the following:
-admission assessment dated [DATE];
-There was no documentation to show staff completed a quarterly assessment for the resident in July or October 2022.
4. Review of Resident #27's MDS record showed the following:
-An annual assessment dated [DATE];
-The next assessment was a quarterly assessment dated [DATE];
-There was no documentation to show staff completed a quarterly assessment for May 2022.
5. Review of Resident #104's MDS record showed the following:
-The last quarterly assessment was dated 3/27/22;
-There was no documentation to show staff completed a quarterly assessment for the resident in of June 2022.
6. Review of Resident #105's MDS record showed the following:
-Staff completed quarterly assessment on 03/24/22;
-The facility failed to complete the annual assessment for the resident in June 2022;
-The facility failed to complete the quarterly assessment for the resident in September 2022.
7. Review of Resident #355's MDS record showed the following:
-The most recent quarterly assessment was dated 4/5/22;
-Staff failed to complete a quarterly assessment for the resident in July 2022 and October 2022.
During interview on 10/27/22 at 5:47 P.M., the Director of Nurses said the facility follows the RAI manual to complete MDS assessments. She said the facility did not currently have a full time MDS Coordinator. The corporate MDS person was coming once a week to help out. She said getting MDSs completed timely had been a struggle.
CONCERN
(E)
Potential for Harm - no one hurt, but risky conditions existed
Comprehensive Care Plan
(Tag F0656)
Could have caused harm · This affected multiple residents
**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on interview, and record review, the facility failed to develop a plan of care consistent with resident's specific conditi...
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**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on interview, and record review, the facility failed to develop a plan of care consistent with resident's specific conditions, needs and risks to provide effective person centered care for seven residents (Resident #31, #3, #27, #11, #50, #1 and #104) of 26 sampled residents. The facility census was 68.
Review of the facility's Care Plan Comprehensive policy, dated March 2015, showed the following:
-An individualized comprehensive care plan that includes measurable goals and time frames will be developed to meet the resident ' s highest practicable physical, mental, and psychosocial well-being;
-The interdisciplinary care plan team with input from the resident, family, and/or legal representative will develop and maintain a comprehensive care plan for each resident that identifies the highest level of functioning the resident may be expected to attain;
-The comprehensive care plan will be based on a thorough assessment that includes, but is not limited to, the MDS;
-A well-developed care plan will be oriented to:
a. Preventing avoidable declines in functioning or functional levels or otherwise clarifying why another goal takes precedence (e.g., palliative approaches in end of life situation);
b. Managing risk factors to the extent possible or indicating the limits of such interventions;
c. Addressing ways to try to preserve and build upon resident strengths;
d. Applying current standards of practice in the care planning process;
e. Evaluating treatment of measurable goals, timetables and outcomes of care;
f. Respecting the resident's right to decline treatment;
g. Offering alternative treatments, as applicable;
h. Using an appropriate interdisciplinary approach to care plan development to improve the resident's functional abilities;
i. Involving resident, resident's family and other resident representatives as appropriate;
j. Assessing and planning for care to meet the resident's medical, nursing, mental and sychosocial needs;
k. Involving the direct care staff with the care planning process relating to the resident's expected outcomes;
l. Addressing additional care planning areas that are relevant to meeting the resident's needs in the long-term care setting;
1. Review of the resident #31 undated face sheet showed the following:
-admitted to facility on 8/25/.;
-Diagnosis of palliative care, anticoagulants (blood thinners) use, chronic kidney disease, anemia, hyponatremia (low sodium levels), hypertension, atrial fibrillation (irregular heartbeat), congestive heart failure (CHF, heart does not pump blood as well as it should).
-He/She has a hospice provider.
Record review of the resident's admission Minimum Data Set (MDS), a federally mandated assessment completed by facility staff, dated 8/31/22 showed the following:
-The resident admitted to the facility on [DATE];
-The resident has severe cognitive impairment;
-The resident's diagnoses included renal insufficiency (decreased kidney function), anemia, hyponatremia, hypertension, atrial fibrillation, congestive heart failure;
-He/She required extensive assistance of one staff member to transfer, dress and bathe;
-He/She required incontinent of urine and bowel;
-The resident on hospice care;
-Care assessment areas triggered included cognitive loss/dementia, activities of daily living (ADL) functional/rehabilitation potential, urinary incontinence;
-Care assessment areas triggered to address in care plan included cognitive loss/dementia and urinary incontinence.
Record review of the resident's progress notes dated 8/25/22 at 11:32 P.M. showed the following:
-He/She admitted the resident from local hospital;
-Hospital discharge diagnosis of atrial fibrillation, debility (physical weakness from illness), and CHF;
-The resident is alert and oriented times one (to self);
-The resident verbally responsive, but pleasantly confused;
-Skin assessment done and redness, possible yeast with blanchable areas in groin, buttocks and underarm area;
-The resident is incontinent of bowel and bladder;
-The resident's heart rate is elevated;
-The resident's diet consists of nectar thickened liquids;
-The resident's code status, hospice.
Record review of the resident's physician order sheet (POS) dated 8/25/22 showed the the resident needs continuous care due to inability to live independently and the need for 24 hour assistance, observation, and planning;
Record review of the resident's physician order sheet (POS) dated 8/26/22 showed an order for oxygen 2-3 Liters PRN (as needed) for comfort as needed;
Record review of the resident's physician order sheet (POS) dated 10/20/22 showed
Puree diet per hospice nurse
Record review of the resident's physician order sheet (POS) dated 10/24/22 showed optifoam (wound dressing) to coccyx (tail bone) daily and PRN from soilage, every 72 Hours;
Record review of the resident's electronic record chart showed no evidence the facility completed a comprehensive care plan for the resident.
Record review of the residents paper chart showed no evidence the facility completed a comprehensive care plan for the resident.
During an interview on 10/27/22 at 8:30 A.M. Licensed Practical Nurse (LPN) D said the following:
-The resident should have a care plan written by admitting nurse within 24 hours of admission;
-Management audits newly admitted residents' charts such as orders and care plans.
During an interview on 10/27/22 at 1:50 P.M., the administrator and Director of Nurses (DON) said the following:
-The resident should have a care plan;
-They were not sure why the resident did not have a care plan.
2. Review of Resident #3's face sheet showed an admission on [DATE], a re-admission on [DATE] and a diagnosis of acute kidney failure.
Review of the residents quarterly Minimum Data Set (MDS), a federally mandated assessment instrument required to be completed by facility staff, dated 4/7/22 showed the following:
-Independent decision making ability;
-Not coded for urinary catheter.
Review of the resident's October 2022 physician order sheet showed the following orders:
-Indwelling catheter (a tube inserted into a resident's bladder to drain urine) #16 French/10 milliliter bulb with a start date of 10/6/22;
-Change catheter monthly with a start date of 10/6/22;
-Catheter care every shift with a start date of 10/6/22.
Review of the resident's care plan, revised on 10/20/22, showed no problem set, approaches or interventions related to indwelling catheter use.
During interview on 10/27/22, at 12:11 P.M., the resident said he/she was not sure why he/she had a catheter or how long he/she had the catheter, maybe a few months.
3. Review of Resident #27's face sheet showed the resident was admitted on [DATE] and had a diagnosis of dementia with behavior disturbance (a group of thinking and social symptoms that interferes with daily functioning).
Review of the resident's quarterly MDS, dated [DATE], showed the following:
-Severely impaired cognition;
-No symptoms of depression;
-No behaviors or rejection of cares;
-Daily antipsychotic, anti-anxiety, and anti-depressant medication taken;
-Care areas to address on the care plan included cognitive loss.
Review of the resident's care plan, revised on 9/2/22 showed the following:
-Resident has behavioral symptoms directed toward others;
-Remove resident from group activities when behavior is unacceptable;
-Resident has verbal behavioral symptoms directed toward others;
-When resident becomes verbally abusive, move to a quiet calm environment;
-Obtain a psychological consult/psychosocial therapy;
-Resident takes antidepressant medication daily for depression and episodes of anxiety;
-Resident is at risk for psychosocial well-being concern due to medically imposed restrictions related to COVID-19 precautions;
-No specific care area identified for cognitive-loss and/or dementia;
-No goal for addressing dementia related issues;
-No specific interventions listed for cognitive loss and/or dementia.
4. Review of the Resident # 11's annual MDS, dated [DATE], showed the following:
-Resident is always incontinent of urine;
-Resident is always incontinent of bowel;
-Required total dependence of staff to assist with toilet use;
-Required one staff member to support physically assist with toilet use.
Review of the resident's care plan showed no documentation of or interventions to address the resident's incontinence of bowel and bladder.
Observation on 10/24/22 at 8:24 A.M., showed the resident had diarrhea after breakfast, but was smelling of foul odor during breakfast.
Observation on 10/26/22, at 6:09 A.M., showed the following:
-Very strong odor of stale urine noticed;
-Residents' pants were soaked and bed was saturated with urine.
Observation on 10/27/22, at 11:23 A.M., showed the residents' brief was soaked saturated with urine.
5. Review of resident #50's progress note dated 7/05/22, showed the following:
-Morbidly obese;
-Underlying eczema (a condition that causes dry, itchy and inflamed skin);
-Increased irritation in the abdominal folds from the eczema and fungal irritation;
-Plan - Nystatin ointment ordered, if unavailable can try triamcinolone ointment with clotrimazole mixed;
-Okay to use Hibiclens (antibacterial wash) over-the-counter;
-If the intertrigo (is a common inflammatory skin condition that is caused by skin-to-skin friction (rubbing) that is intensified by heat and moisture. It usually looks like a reddish rash. Trapped moisture, which is usually due to sweating, causes the surfaces of your skin to stick together in your skin folds) worsens suggest using Diflucan again.
Review of resident's physician order sheet dated 7/05/22, showed orders written for the following:
-Nystatin Ointment, apply two times a day to abdominal folds;
-Ok to use Hibiclens.
Review of resident's physician order sheet dated 7/18/22, showed an order written for Diflucan 200 mg by mouth daily for seven days with a diagnosis of skin yeast.
Review of resident's progress note dated 7/19/22, showed the following:
-Routine monthly visit;
-Intertrigo has worsened;
-Another round of Diflucan was ordered;
-He/She is also on the nystatin/triamcinolone cream.
Review of resident's progress note dated 9/06/22, showed the following:
-Chief complaint of intertrigo causing pain and nausea;
-Morbidly obese male/female has a history of severe intertrigo;
-He/She has not been cooperative he/she has been taking baths and not showers;
-He/She has been using nystatin cream and has refused powder in the past;
-We talked about using the powder and not using a bath with taking a shower;
-He/She states that is causing pain;
-Intertrigo under abdominal folds;
-Plan - discontinue nystatin cream changed to nystatin powder, Diflucan 200 mg every 72 hours for a total of doses;
-We did talk to him/her about taking showers and not doing baths because of increased moisture from the baths and sitting in the moisture is not healthy for his/her skin.
Review of resident's physician order sheet dated 9/06/22, showed an order written for Diflucan 200 mg by mouth every 72 hours for five doses.
Review of resident's Quarterly MDS dated [DATE], showed the following:
-Cognition mildly impaired;
-Rejection of care not exhibited;
-Toilet use - independent with setup help only from staff;
-Personal hygiene - independent with setup help only from staff;
-Bathing - supervision, oversight only with setup help only from staff;
-Weight 311 pounds;
-Skin - Moisture Associated Skin Damage (MASD) and application of ointments/medications other than feet.
Review of resident's progress note dated 10/24/22, showed the following:
-History of present illness - morbidly obese, diabetic male/female;
-Chronic problems with intertrigo related to a large abdominal pannus and his/her inability to keep the area underneath the pannus clean;
-He/She complains the staff is not helping him/her enough;
-Intertrigo and erythema (superficial reddening of the skin, usually in patches, as a result of irritation) underneath the pannus and in the groin region;
-Will put him/her on Diflucan 200 mg every 72 hours for 5 doses.
During observation on 10/24/22, at 3:20 P.M. resident showed surveyor his/her groin and area under his/her abdominal pannus that looked moist and red.
Review of the resident's care plan showed no documentation for care areas related to skin care, including skin breakdown on the residents' pannus or assistance with cleansing and applying prescribed treatments.
6. Review of Resident #104's undated face sheet showed a diagnosis of tracheostomy.
Review of the resident's Quarterly MDS, dated [DATE], showed the following:
-Cognitively intact;
-Short of breath with exertion;
-Not coded for tracheostomy care;
-Not coded for oxygen therapy;
-Not coded for suctioning;
-Diagnosis of tracheostomy. (there are missing MDSs hence the date gap)
Review of the resident's care plan, last reviewed 5/23/22, showed the following:
-Potential for complications related to tracheostomy;
-Assess lung sounds every shift. Report any wheezes, crackles, or decreased breath sounds.
Review of the resident's Physician Order Sheet (POS), dated September 2022, showed the following orders on 9/1/22:
-Suction trach as needed for increased mucous/resident request/cough;
-Oxygen at three liters per min (LPM) via trach collar continuously;
-Change tubing set up for humidifier weekly and trach care each shift.
Review of the resident's nursing progress notes, dated 9/4/22, showed the resident's oxygen saturation was 77% (normal between 95-100%). The physician's office was notified, oxygen was increased to four LPM and 911 dispatched. The facility sent a trach transport bag with the resident. The resident returned back to the facility later that evening with oxygen saturations at 90% on three liters of oxygen.
Review of the nurse practitioner's progress note, dated 9/6/22, showed the resident has a trach in place and was having some increased green sputum (mucous) and respiratory difficulty and drops in oxygen saturation levels. He/she was seen in the emergency room where they did suctioning and nebulizers and his/her saturations increased. Chest x-ray was negative and the resident was stable. He/she was started on Mucinex (to thin secretions) and to continue current nebulizers and suction orders.
Review of the resident's POS, dated September 2022, showed an order on 9/6/22 for a Z-pack (antibiotic for bacterial infections) and Prednisone (steroid to decrease inflammation) 60 milligrams (mg) by mouth for two days then 40 mg by mouth for two days and then 20 mg by mouth for two days.
Observation on 10/25/22 at 5:07 P.M., showed Licensed Practical Nurse (LPN) suctioned the resident's trach per the residents request using sterile technique.
Review of the resident's care plan showed no documentation of interventions regarding the resident's tracheostomy or implementation of care instructions.
7. Review of Resident #1's face sheet, undated, showed the following:
-The facility admitted the resident on 1/5/22;
-The resident had diagnoses of hemiplegia right sided (paralysis of one side of the body), urinary tract infection, acute embolism and thrombosis of deep veins in lower extremity [Deep vein thrombosis (DVT) occurs when a blood clot (thrombus) forms in one or more of the deep veins in the body, usually in the legs and an embolism is a condition resulting from a blood clot moving through the vascular system] , and cerebral infarction (damage to tissues in the brain due to loss of oxygen in the area).
Review of the resident's admission Minimum Data Set (MDS), a federally mandated assessment completed by facility staff, dated 1/21/22, showed the following:
-The resident required extensive assistance of one staff member for personal hygiene and bathing;
-The resident had an indwelling urinary catheter;
-The resident didn't take anticoagulant medication.
Review of the resident's Physician Orders, dated April 2022, showed the following:
-Warfarin 4 mg orally daily (compound with anticoagulant properties, used in the treatment of thrombosis);
-Indwelling catheter size: 16 French with 30 ml bulb/balloon (closed sterile system with a catheter and retention balloon that is inserted either through the urethra to allow for bladder drainage);
-Catheter care every shift;
-Change catheter monthly on the tenth of the month.
Review of the resident's care plan status on 10/27/22 showed no evidence facility staff developed and implemented completed a comprehensive care plan.
During interview on 10/27/22 at 5:47 P.M., the DON said the following:
-She would expect a resident with a tracheostomy to have a care plan;
-The facility did not have an MDS coordinator;
-A corporate nurse currently helped with care plans;
-Any nurse can update a care plan;
-She would expect all active issues to be on the care plans;
-She would expect dementia care interventions to be on the care plan;
-She would expect urinary catheter orders to be addressed on the care plan.
CONCERN
(E)
Potential for Harm - no one hurt, but risky conditions existed
ADL Care
(Tag F0677)
Could have caused harm · This affected multiple residents
**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, interview, and record review, the facility failed to ensure staff provided scheduled showers for four resi...
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**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, interview, and record review, the facility failed to ensure staff provided scheduled showers for four residents (Residents #1 #28, #34, and #355) who required assistance to complete their own activities of daily living (ADL), failed to check and change/toilet one resident timely (Resident #35), and failed to perform complete perineal care for one resident (Resident #20), in a review of 26 sampled residents. The facility census was 68.
Record review of the facility's shower policy from Nursing Guidelines Manual, dated March 2015, showed the purpose was to maintain skin integrity, comfort and cleanliness.
Review of the undated facility policy, Perineal Care, showed the following:
-Purpose to cleanse the perineum and to prevent infection and odor;
-Female perineal care:
a. Ask resident to separate legs and flex knees;
b. Put on disposable gloves;
c. Wet washcloth and make a mitt with it, apply soap lightly;
d. Use one gloved hand to stabilize and separate the labia, with the other hand, wash from front to back;
e. Rinse and pat dry;
-Male perineal care:
a. Ask resident to separate and flex knees;
b. Put on disposable gloves;
c. Wet washcloth and make a mitt with it, apply soap lightly;
d. Wash pubis and genitalia, if uncircumcised, pull back foreskin of genitalia and wash;
c. Carefully dry and return foreskin to normal position;
-Turn resident away from you, use a new washcloth and wash around the anus, rinse and dry;
-Remove gloves and wash hands.
Review of the facility's policy, Oral Hygiene, dated March 2015, showed the following:
-Purpose to clean the mouth, teeth and dentures;
-Offer oral hygiene before breakfast, after each meal and at bedtime.
Review of the undated shower sheet guidelines showed the following:
The binder contains the following:
-Master shower list for the assigned area;
-Blank shower sheet;
-Census will be updated weekly and PRN (as needed)by staffing coordinator;
-Tabbed dividers for Monday through Saturday;
-Each week, nurse managers will make out the shower sheets for the weekend place in the binder;
-Shower sheets will include the resident's name, room number and ate shower is to be given;
- If the resident is given a shower on a different date the date on the shower sheet needs to reflect this;
-Staff providing showers will complete the shower sheet and leave it in the binder One hour prior to the end of their shift they will bring the binder to the Charge Nurse to discuss any residents who refuse showers to be passed on to the next shift;
-The charge nurse is to report this to the oncoming charge nurse for follow through.
-Each day, nurse managers will review the completed shower sheets and will follow up on any showers that were omitted;
-At the end of the week, nurse managers will remove completed shower sheets for filing and place new shower sheets in the binder for the following week;
-Shower sheets are not a part of the resident's clinical record but rather a communication tool for facility use.
1. Review of Resident #1's quarterly Minimum Data Set (MDS), a federally mandated assessment completed by facility staff, dated 4/23/22, showed the following:
-He/She was admitted on [DATE];
-He/She had diagnoses of right sided hemiplegia (paralysis of one side of the body), chronic pain and cerebral infarction (damage to tissues in the brain due to loss of oxygen in the area);
-He/She required extensive assistance of one staff for dressing, personal hygiene, toilet use, and bathing;
-He/She had indwelling urinary catheter;
-He/She was frequently incontinent of bowel.
Review of the resident's care plan, dated 10/13/20, showed the following:
-The resident's ability to transfer from chair to bed had deteriorated related to difficulty bringing legs back into bed;
-Don't rush the resident and allow extra time to complete ADLs.
Review of the resident's Shower Sheets, dated 9/1/22-9/20/22, showed the resident received three of eight scheduled showers.
Review of the resident's Shower Sheets for October 2022, showed the resident received two showers between October 1st to October 25th.
Observation on 10/24/22 at 7:08 A.M., showed the following:
-The resident lay in bed;
-The resident's hair was greasy and disheveled;
-His/Her facial skin was greasy;
-The resident had body odor.
During interview on 10/24/22 at 3:01 P.M., the resident said the following:
-He/She was scheduled for two showers a week;
-Since the shower aide has been sick, he/she doesn't get showers as scheduled;
-He/She liked showers twice a week, because it make him/her feel better.
Observation on 10/25/22 at 8:57 A.M., showed the following:
-The resident lay in bed;
-The resident's hair was greasy and disheveled;
-His/Her facial skin was greasy;
-The resident had body odor.
2. Review of Resident #34's face sheet, undated, showed the following:
-The resident admitted to facility on 11/25/20;
-He/She had diagnoses of amputation of toes on left foot, osteomyelitis (inflammation of bone or bone marrow, usually due to infection) and cellulitis (inflammation of subcutaneous connective tissue) right lower limb.
Review of the resident's care plan, dated 12/8/21, showed the following:
-Loss of self-care abilities/deficit in most ADLs stemming from choice to not participate;
-The resident will have basic physical needs met daily as evidenced by being clean, dry, appropriately dressed for situation, comfortable, and with proper hygiene;
-Assist the resident with ADLs he/she will not participate in, but encourage her to do so;
-Assume the physical responsibilities of performing tasks she does not want to, i.e., hair, oral, nail care, perineal hygiene after incontinent episodes.
Review of the resident's MDS, dated [DATE], showed the following:
-He/She had moderately impaired cognition;
-He/She required limited assistance of one staff member for personal hygiene;
-He/She was dependent on staff members for toilet use and bathing;
-He/She was always incontinent of bladder and bowel.
Review of the resident's Shower Sheets, dated 9/1/22-9/15/22, showed the resident received three bed baths of the nine scheduled days.
Review of the resident's Shower Sheets for October 2022 showed no documentation staff provided the resident with a shower/bath from October 1st through October 25th.
Observation on 10/24/22 at 6:28 A.M., showed the following:
- The resident lay in bed;
-The resident's hair greasy with white flakes;
-He/She had white flaky skin on his/her face and lower extremities.
During interview on 10/24/22 at 9:35 A.M., the resident said the following:
-He/She was scheduled for two bed baths a week;
-The resident said she has gone a month without a bath;
-It was important to him/her to look and feel good, but going so long between showers was unacceptable to him/her. He/She felt dirty;
-He/She said the only time his/her teeth are brushed was when he/she remembered to ask staff to help set it up.
Observation on 10/25/22 at 8:57 A.M., showed the following:
-The resident lay in bed;
-The resident's hair was greasy with white flakes;
-He/She had white flaky skin on his/her face and lower extremities.
3. Review of Resident #355's face sheet, undated, showed the following:
-The resident admitted on [DATE];
-He/She had diagnoses of central pain syndrome (neurological condition caused by damage or dysfunction of the central nervous system, which includes the brain, brainstem, and spinal cord. It may affect a large portion of the body or may be more restricted to a specific area), and diastolic heart failure (left ventricle has become stiffer than normal, so it's not able to fill properly with blood).
Review of the resident's Care Plan, dated 1/5/22, showed the following:
-Self-care deficit in daily ADLs related to aging process, effects of chronic disease on mobility, endurance, range of motion, cognition;
-Provide full staff performance for oral, hair, nail, skin care daily as needed;
-Provide routine perineal care after episodes of incontinence with barrier cream as protective emollient after care, per facility policy and procedure.
Review of the resident's quarterly MDS, dated [DATE], showed the following:
-The resident had severely impaired cognition;
-He/She did not reject care;
-He/She was dependent on two staff for dressing; toilet use, personal hygiene, and bathing;
-He/She was always incontinent of bladder and bowel.
Observation on 10/24/22 at 8:55 A.M., showed the following:
-The resident's hair was greasy;
-His/Her face had dried secretions around his/her mouth;
-His/Her fingernails had brown debris underneath the nails.
Observation on 10/25/22 at 9:39 A.M., showed the following:
-The resident's hair was greasy;
-His/Her arms and lower legs had dry flaky skin;
-His/Her fingernails had brown debris underneath the nails.
Review of the resident's Shower Sheets for October 2022, showed the resident received one shower out of six scheduled days.
4. Review of the resident #28's admission MDS dated [DATE], showed the following:
-Moderately impaired cognition;
-He/She does not reject cares;
-Needs physical help in part of bathing activity;
-Needs walker and wheelchair for mobility;
-Frequent urinary incontinence;
-Always continent of bowel;
-Active diagnosis include Alzheimer's.
Review of the resident's shower sheets for August 2022 showed no evidence the resident received a shower 8/1 through 8/31 (31 days).
Review of the resident's shower sheets for September 2022 showed no evidence the resident received a shower 9/1 through 9/30 (30 days).
Review of the resident's shower sheets for October 2022 showed no shower sheets filled out for the resident for 10/1/22 through 10/26/22 (26days).
During an interview on 10/26/22 at 9:05 A.M. and 2:45 P.M. the resident said the following:
-He/She said all the staff ever say is I will check on it when asking for a shower;
-He/She does not know if there are scheduled shower days;
-Staff had not informed the resident of scheduled shower days.
-He/She had only two to three showers since admission;
-He/She asked for a shower yesterday;
-Staff said they could not promise his/her requested shower for yesterday;
-He/She would like to plan for a shower time because he/she puts on clean clothes every day;
-He/She feels cleaner when taking showers;
-He/She prefers showers instead of a sponge bath at the sink.
5. Review of Resident #35's Care Plan, last updated 12/18/21, showed the following:
-No documentation shown for incontinence of bowel and bladder;
-No peri care or guidance in reference to checking resident every two hours to monitor incontinence.
Review of the resident's quarterly MDS dated [DATE], showed the following:
-Severely impaired cognition;
-Requires supervision and the assistance of one person for toileting,
-Always incontinent of urine;
-Always incontinent of bowel;
-No toileting program.
Observation on 10/25/22 at 8:41 A.M. showed the resident required extensive assistance to transfer,was unable to toilet or change his/herself.
Continuous observation on 10/26/22 from 5:00 A.M. to 10:10 A.M., showed the following:
-Resident fully dressed;
-The resident sat in a wheelchair in the television room;
-No staff assistance with toileting or repositioning.
During an interview on 10/26/22, at 6:42 A.M., Certified Nurse Aide (CNA) M said residents should be checked and changed at least every two hours.
6. Review of Resident #20's admission MDS, dated [DATE], showed the following:
-Severely impaired cognition;
-Required extensive assistance of two staff for transfers and toileting;
-Always incontinent of bowel and bladder;
-Diagnoses included stroke and hemiplegia (paralysis on one side).
Review of the resident's care plan, dated 9/29/22, showed the following:
-The resident experiences bladder incontinence;
-Provide assistance for toileting as needed;
-Provide incontinence care after each incontinent episode.
Observation on 10/26/22 at 05:02 A.M., showed the following:
-The resident lay on his/her back in a low bed;
-CNA E washed hands, put on gloves, pulled back the covers and removed the front of the resident's incontinence brief;
-CNA E picked up a wet washcloth and cleaned the front genitalia;
-The resident was incontinent of urine;
-CNA E assisted the resident to roll to his/her left side;
-CNA E rolled up the soiled brief and urine stained quilted pad and tucked it under the resident;
-CNA E picked up a wet washcloth and cleaned the resident's right buttock and gluteal crease;
-CNA E removed his/her gloves, covered the resident, picked up the bed control and lowered the bed;
-CNA E wet more washcloths at the sink, raised the bed and put on gloves;
-CNA E tucked a clean brief under the resident, rolled him/her to his/her right side and pulled out the soiled brief and quilted pad;
-CNA E rolled the resident to his/her back, secured the incontinence brief and covered resident;
-CNA E failed to clean the resident's left buttock and lower back which had been in contact with urine.
During interview on 10/25/22 at 05:29 A.M., CNA E said staff should clean any area that had been in contact with urine or feces.
7. During interview on 10/25/22 at 9:45 A.M. and 10/26/22 at 6:30 A.M., CNA I said the following:
-He/She did showers and/or bed baths Monday through Friday on the day shift;
-He/She said Wednesdays were catch up days for residents who didn't get bathed on their scheduled day and/or completed some evening showers, when he/she has time;
-The Director of Nursing (DON) splits evening showers among staff working the evening shift, but showers weren't completed;
-The DON designated a CNA on evening shift to complete showers/bath, however the tasks are not always completed because of staff needs.
-The evening shift shower aide been on sick leave since September;
-No resident refused showers.
Interview on 10/26/22 at 6:00 P.M. and 10/27/22, at 5:29 and 5:47 P.M., showed the DON said the following:
-Residents need to be repositioned every two hours;
-Residents who are incontinent should be checked every two hours;
-Morning care included brushing teeth, brushing hair and toileting cleaning dentures and get them in, brush teeth if resident has teeth, getting dressed, peri care, take residents' to the toilet, put on shoes and socks, and clean glasses.
-The evening shower aide was off due to illness;
-She expected staff to ask the resident again if residents refused showers;
- CNA's should fill out shower sheets with each shower and bed bath and turn them into the charge nurse who then turns them into the Assistant Director of Nurses;
-Staff should cleanse any area under the incontinence brief and any area that was soiled with urine or feces;
-Staff should reposition residents and assist with toileting every two hours.
MO204396
MO204851
CONCERN
(E)
Potential for Harm - no one hurt, but risky conditions existed
Pressure Ulcer Prevention
(Tag F0686)
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 reposition one resident (Resident #25), in a review o...
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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 reposition one resident (Resident #25), in a review of 26 sampled residents, and failed to identify a Stage II pressure ulcer (Partial thickness loss of dermis (the inner layer that makes up skin) presenting as a shallow open ulcer with a red-pink wound bed, without slough (non-viable yellow, tan, gray, green or brown tissue. May also present as an intact or open/ruptured blister). The facility failed to complete weekly skin assessments as directed in the facility's policy and the plan of care for one additional resident (Resident #36) with existing pressure ulcers, and failed to follow physicians orders for pressure relieving boots and wound treatments. The facility failed to reposition one resident (Resident #355), who was identified as at risk for developing pressure ulcers, per his/her plan of care; and failed to complete weekly skin assessment as directed in the facility's policy for two residents (Residents #2 and #10), who had existing pressure ulcers. The facility census was 68.
Review of the facility's policy on Pressure Ulcer Care and Prevention, dated March 2015, showed the following:
-Purpose: To prevent and treat further breakdown of pressure ulcers;
-Treatment of pressure ulcers will vary depending on the orders of the attending physician. The nurse is responsible for carrying out the treatment as ordered by the attending physician and for implementing measures to prevent pressure ulcers;
-Observe skin. Any persistent reddened area that remains after pressure is relieved is a high risk for pressure ulcer to begin;
-Apply lotion gently to dry skin;
-Use pressure reducing devices to relieve pressure;
-Turn the resident every two hours and position with pads or pillows to protect bony prominences.
Review of the facility's policy, Skin Assessments, updated 10/21/22, showed the following:
-Licensed nurse is to assess skin weekly and document in Weekly Skin Assessment in the electronic health record;
-If compromised skin integrity is identified, you must contact the physician by the end of your shift for treatment orders and notify the resident's representative;
-Please make sure this information is documented in the electronic health record and communicated to the next shift;
-Any assessments not completed during the week will be expected to be completed on Friday, Saturday, or Sunday by evenings and nights, then turn into the Director of Nursing (DON) or Assistant Director of Nursing (ADON) on Monday morning.
Review of the National Pressure Injury Advisory Panel (NPIAP), prevention and treatment of pressure ulcers: quick reference guide, Washington DC: National Pressure Injury Advisory Panel 2019 showed the following:
-Assess the pressure ulcer initially and re-assess it at least weekly;
-With each dressing change, observed the pressure ulcer for signs that indicate a change in treatments as required (e.g., Wound improvement, wound deterioration, more or less exudate, signs of infection, or other complications);
-Address the signs of deterioration immediately.
Review of the Long Term Care Facility Resident Assessment Instrument User's Manual, Version 3.0, Chapter 3, Section M, defines the different stages of pressure ulcers (localized injury to the skin and/or underlying tissue usually over a bony prominence, as a result of pressure, or pressure in combination with shear and/or friction) as follows:
-Stage I: an observable, pressure related alteration of intact skin, whose indicators as compared to an adjacent or opposite area on the body may include changes in skin temperature, tissue consistency, sensation, and/or a defined area of persistent redness;
-Stage II: Partial thickness loss of dermis (the inner layer that makes up skin) presenting as a shallow open ulcer with a red-pink wound bed, without slough (non-viable yellow, tan, gray, green or brown tissue). May also present as an intact or open/ruptured blister;
-Stage III: full thickness tissue loss. Subcutaneous fat may be visible but bone, tendon or muscle is not exposed. Slough may be present but does not obscure the depth of tissue loss. May include undermining (destruction of tissue or ulceration extending under the skin edges) or tunneling (a passage way of tissue destruction under the skin surface that has an opening at the skin level from the edge of the wound);
-Stage IV: Full thickness tissue loss with exposed bone, tendon or muscle. Slough or eschar (dead or devitalized tissue that is hard or soft in texture; usually black, brown, or tan in color) may be present on some parts of the wound bed. Often includes undermining and tunneling;
-Unstageable pressure ulcers (known but unstageable due to coverage the wound bed by slough (necrotic/avascular tissue in the process of separating from the viable portion of the body, usually light colored, soft, moist and stringy) and or eschar (thick leathery, frequently black or brown in color, necrotic tissue). Until enough slough and/or eschar is removed to expose the base of the wound, the true depth, and therefore stage, cannot be determined;
-Deep tissue injury: Purple or maroon area of discolored intact skin due to damage of underlying soft tissue damage. The area may be preceded by tissue that is painful, firm, mushy, boggy, warmer or cooler as compared to adjacent tissue;
-Slough: necrotic/avascular tissue in the process of separating from the viable portions of the body and is usually light colored, soft, moist, and stringy;
-Eschar: thick, leathery, frequently black or brown in color, necrotic (dead) or devitalized tissue that has lost its usual physical properties and biological activity. Eschar may be loose or firmly adhered to the wound.
1. Record review of Resident #25's undated face sheet showed the resident's diagnoses included hemiplegia (muscle weakness of one side) and hemiparesis (muscle weakness or partial paralysis on one side of the body) left side, Stage II pressure ulcer of right buttock, dysphasia (speech difficulty), and need for assistance with personal care and muscle weakness.
Record review of the resident's care plan, dated 11/19/18, showed the following:
-He/She is a risk for pressure ulcers and skin breakdown;
-Conduct a systematic skin inspection as ordered. Pay particular attention to the bony prominences;
-Keep clean and dry as possible. Minimize skin exposure to moisture;
-Keep linens clean, dry, and wrinkle free;
-Provide incontinence care after each incontinent episode.
-Report any signs of skin breakdown (sore, tender, red, or broken areas);
-Turn and reposition every two hours and as needed (PRN);
-Use moisture barrier products to perineal area.
Record review of the resident's quarterly Minimum Data Set (MDS), completed by the facility, dated 8/25/22, showed the following:
-Totally dependent on one staff for bed mobility;
-Total dependence on two staff for transfer;
-Did not walk;
-Was dependent on staff for bathing and hygiene;
-Always incontinent of bladder and bowel;
-At risk for pressure ulcers.
Review of the resident's medical record showed no Braden Risk assessment (to determine risk of skin breakdown).
Review of the resident's medical record showed no documentation staff completed a skin assessment for October, 2022.
Record review of the resident's wound management note dated 10/24/22 at 1:38 P.M. showed no documentation the resident presented with wounds.
Observations on 10/25/22 showed the following:
-At 11:30 A.M. to 1:30 P.M., the resident lay in bed on his/her back on a pressure relieving mattress. The resident lay on a draw sheet with liquid stained edges. The resident's gown, blanket and linens were wet and there was a strong urine odor in the room. No staff member repositioned the resident;
-At 3:04 P.M., the resident remained in the same position on his/her back in bed. The resident's draw sheet, blanket, gown and linens were wet and his/her room had a strong urine odor. The resident's call light was turned on;
-At 3:36 P.M., the resident remained in the same position on his/her back in bed. The resident's draw sheet, blanket, gown and linens were wet and his/her room had a strong urine odor. Certified Nurse Aide (CNA) U entered the resident's room and reset the call light. He/She told the resident he/she would change him/her after he/she assisted another resident. CNA U did not reposition the resident;
-At 4:10 P.M., the resident remained in the same position on his/her back in bed. CNA U and CNA P removed the resident's wet draw sheet, blanket, and linens from the bed and took the wet gown off of the resident. CNA U and CNA P turned the resident onto his/her side and discovered a shallow open area, approximately 1.5 centimeters (cm) by 0.5 cm in size on the resident's left buttock. The wound bed was pink and the skin surrounding the open area was red;
- CNA U and CNA P reported the open are to Licensed Practical Nurse (LPN) X.
(The resident lay without repositioning in a wet gown on wet linens for approximately four and one half hours.)
During an interview on 10/25/22 at 4:10 P.M., CNA U said the following:
-Staff should check the resident for incontinence every two hours;
-He/She was not sure of time staff last checked the resident.
Observation on 10/25/22 at 4:29 P.M. showed the following:
-CNA U reported the new open area on the resident's buttock to LPN X;
-LPN X checked the treatment administration record (TAR), and used a protective barrier wipe (protective skin barrier) to the peri wound, (skin surrounding the wound) and applied barrier cream to the resident's bottom and left buttock.
Review of the resident's medical record for dates 10/25/22 to 10/27/22 showed no documentation staff completed a skin assessment, the presence of a red open area on the resident's left buttock or interventions to address the open area. The record showed no documentation the facility notified the resident's physician of the pressure ulcer on the resident's left buttock.
Review of the resident's care plan on 10/27/22 (care plan dated 11/19/18) showed no update to reflect the resident had an open area on his/her left buttock or interventions to address the open area.
During an interview on 10/27/22 at 8:30 A.M., LPN D said the following:
-He/She was aware the resident's new pressure ulcer. She read a note LPN X wrote on piece of paper for the next shift to notify the physician because he/she did not have time to notify the physician;
-The pressure ulcer should be assessed and staff should notify the physician for orders;
-He/She has not notified the physician and there were no new orders at that time. The assistant director of nurses (ADON) tracks wounds.
During an interview on 10/27/22 at 1:55 P.M., the ADON said she was not aware the resident had a pressure ulcer on his/her left buttock until today.
During an interview on 10/26/22 at 6:00 P.M., the Director of Nurses (DON) said the following:
-She expected staff to notify the physician by the end of shift with the description of new pressure ulcer and to obtain orders for treatment;
-She would not expect staff to leave a handwritten note on the report sheet for staff to call the physician and get orders for pressure ulcers the next day.
Review of the facility wound report run on 10/27/22 at 9:40 A.M. does not include the resident.
2. Review of Resident #36's care plan, dated 2/2/22, showed the following:
-At risk for pressure ulcer due to bedfast/mobility;
-Bilateral wounds to heels;
-Consider specialty bed;
-Elevate heels off bed or use heel protectors;
-Position prone if appropriate or elevate head of bed no more than 30 degrees;
-Position with pillows to elevate pressure points off the bed;
-Turn and reposition every two hours and as needed.
Review of the resident's most recent weekly skin assessment, dated 5/17/22, showed an existing skin issue of left heel open area.
Review of the resident's care plan, updated on 6/22/22, showed skin assessment and inspection every shift with close attention to heels.
Review of the resident's progress notes, dated 6/25/22 at 11:43 A.M., showed the resident's right heel is bleeding at this time with three areas measuring approximately 0.5 centimeters (cm) that are missing the top layer of skin and soft.
Review of the resident's progress notes, dated 7/3/22 at 1:29 A.M., showed the following:
-Interdisciplinary Team (IDT)/wound note: wound to left heel is closed at this time;
-Left heel continues with dry, peeling skin and heel is boggy;
-Wound to right foot has opened with an open area measures 1.5 centimeters (cm) by 1.3 cm by 0.1 cm with 100% granulation (new connective tissue) tissue;
-Peri-wound (area surrounding the wound) is wet and macerated (softened by being wet).
Review of the resident's medical record showed no documentation staff completed weekly skin assessments between 7/3/22 and 8/3/22.
Review of the resident's progress notes, dated 8/3/22 at 1:10 P.M., showed the following:
-IDT/Wound: wound to right heel measuring 5.4 by 3.4 by 0.1 with necrotic areas (dead tissue) 90% of wound;
-Current interventions include pressure relieving mattress and boot to be worn at all times;
-Specialized wound clinic will now see the resident.
Review of the resident's physician's orders, dated 8/3/22, showed an order for the specialized wound clinic to evaluate and treat.
Review of the resident's medical record showed no documentation staff completed weekly skin assessments between 8/3/22 and 9/6/22.
Review of the resident's progress notes, dated 9/6/22 at 3:34 P.M., showed the resident has a blister on the sacral area, around his/her right buttock that is the size of a quarter. Area was cleansed and a dry padded dressing placed over the entire area for added protection.
Review of the resident's medical record showed no evidence staff notified the physician to obtain would care orders to treat the area on the resident's sacral area.
Review of the resident's quarterly Minimum Data Set (MDS), a federally mandated assessment tool completed by facility staff, dated 9/11/22 showed the following:
-Cognition severely impaired;
-Required extensive assistance with bed mobility and personal hygiene;
-Totally dependent on one staff for locomotion on and off the unit, dressing and bathing;
-Totally dependent on two staff for transfers and toileting;
-Always incontinent of bowel and bladder;
-At risk for pressure ulcers;
-On a turning and repositioning program;
-No unhealed pressure ulcers, and no venous or arterial ulcers.
Review of the resident's medical record showed no documentation staff completed a weekly skin assessment in September or October 2022.
Review of the resident's October 2022 physician orders showed the following:
-Pressure relieving boot on at all times as resident allows (original order dated 2/26/22);
-Right heel cleanse with wound cleanser and pat dry, apply skin prep to peri-wound (skin surrounding an open wound) and to eschar (slough or a piece of dead tissue) apply calcium alginate to open areas of the wound, cover with a dry dressing daily until healed (original order dated 7/28/22);
-Santyl (a topical medication used to remove damage or burned skin to allow for wound healing and growth of healthy skin) apply a thin layer to slough with bactroban once daily and as needed to stage II pressure ulcer on left heel (original order dated 10/19/22).
Review of the resident's October 2022 treatment administration record (TAR) showed no documentation staff completed the ordered treatment to the resident's right heel on 10/20/22 and 10/21/22.
Observation on 10/24/22 at 7:44 A.M. showed the following:
-LPN D removed the dressing from the resident's right heel;
-The skin on the right heel was pink and intact;
-LPN D removed the old dressing from the resident's left heel. There was a moderate amount of brown and yellow drainage on the old dressing;
-The heel had an approximately nickel sized area of black eschar in the center of the wound with a dark pink peri-wound;
-LPN D applied bacitracin (not the ordered Bactroban) mixed with Santyl to the wound base and applied a dry dressing.
During an interview on 10/24/22 at 7:44 A.M., LPN D said the following:
-The resident had a pressure ulcer on his/her left heel;
-The resident's wound on his/her left heel would be unstageable due to the eschar on the wound bed.
-The resident had a previous Stage II pressure ulcer on his/her right heel but was healed at the present;
-The resident has a current treatment for the left heel of Santyl mixed with bactroban but the family had not provided the bactroban yet;
-The resident utilizes a private pharmacy and family provides all medication;
-He/She used triple antibiotic ointment from the stock supply to complete the treatment;
-He/She is not sure if the facility would provide bactroban for the treatment since the resident utilizes an outside pharmacy;
-He/She is unsure if the bactroban is available in the emergency medication kit as he/she has never looked for it;
-If a medication was unavailable to complete a treatment, staff should call the physician;
-He/She had not called the physician for a clarification or treatment change;
-He/She was unaware there was a difference between bactroban and bacitracin.
Observation on 10/24/22 at 3:10 P.M. showed the resident lay in bed asleep with no pressure relieving boots in place.
Observation on 10/26/22 at 5:00 A.M., showed the resident lay in bed sleeping. The resident was not wearing pressure relieving boots and his/her heels lay directly on the mattress.
Observation on 10/26/22 at 7:01 A.M., showed the resident continued to lay in the same position in his/her bed sleeping. The resident was not wearing pressure relieving boots and his/her heels lay directly on the mattress.
During an interview on 10/26/22, at 5:59 A.M., CNA N said he/she was responsible for the resident's care until 7:00 A.M. on 10/26/22. He/She said wasn't sure if the resident needed to wear his/her boots on his/her feet while in bed.
Review of the resident's October 2022 physician's orders showed an order dated 10/26/22 for Mupirocin 2% ointment (also called bactroban; an antibiotic ointment used to treat skin infections), apply a thin layer with Santyl ointment daily and as needed to left heel.
Observation on 10/27/22, at 11:30 A.M., showed Registered Nurse (RN) O completed the treatment to the left heel ulcer using triple antibiotic ointment (not bactroban) mixed with Santyl ointment.
Observation on 10/27/22, at 1:38 P.M., showed LPN AA noted two open areas, about the size of a dime with a pink wound base and clear drainage on the resident's right heel.
Review of the resident's October 2022 physician's orders showed the following:
-New order obtained on 10/27/22 to use a thin layer of triple antibiotic ointment to left heel until bactroban arrives from the pharmacy;
-New order obtained on 10/27/22 to cleanse open area to genitalia/buttock with wound cleanser and apply a thin layer of Santyl ointment and apply calcium alginate and cover with optifoam dressing, change every day and as needed if soiled.
During an interview on 10/27/22 at 2:00 P.M., CNA C said the following:
-Staff should turn and reposition residents at least every two hours, even if the resident requests to be up in his/her wheelchair;
-The resident should have his/her boots on his/her feet while in bed, or at a minimum pillows under his/her ankles to keep his/her heels off of the bed.
During an interview on 10/27/22 at 5:46 P.M., the Director of Nursing said the following:
-She expected staff to follow treatment orders as written;
-On 10/19/22, an order was received for staff to treat the resident's pressure ulcer with bactroban mixed with Santyl;
-LPN D thought bactroban and bacitracin were the same thing, and had been using bacitracin for the treatment to the resident's left heel;
-If a treatment medication is ordered and not provided by the family, the facility would provide the medication for the treatment;
-If a medication was unavailable to complete a treatment, she would expect nursing staff to contact the physician to receive an order change until the original order is available.
During an interview on 11/15/22 at 4:39 P.M., the medical director said the following:
-He expected staff to follow physician orders as written;
-He expected staff to call for an order clarification if a medication for treatment was unavailable;
-He expected staff to know the difference between each type of medication.
3. Review of Resident #355's Care Plan, dated 1/5/22, showed the following:
-The resident was at risk for onset pressure ulcers related to age, multiple disease processes impacting general and skin health, immobility, incontinence, and probable nutritional/hydration inadequacy;
-Conduct a systematic skin inspection per facility policy and procedure, paying particular attention to the bony prominences;
-Keep clean and dry as possible to minimize skin exposure to moisture;
-Maintain the head of bed at the lowest degree of elevation possible;
-Provide incontinence care after each incontinent episode;
-Report any signs of skin breakdown (sore, tender, red, or broken areas),
-Turn and repositioning every two hours when in bed, pillows and pads for positioning, padding, and comfort.
Review of the resident's quarterly MDS, dated [DATE], showed the following:
-The resident had severely impaired cognition;
-He/She was dependent on two staff members for bed mobility, transfers, toilet use, personal hygiene, and bathing;
-He/She was always incontinent of bladder and bowel;
-He/She was at risk for development of pressure injury and prevention with pressure reducing device for chair, turning/repositioning program, nutrition or hydration intervention, and application of ointments/medications other than to feet.
Observation on 10/24/22 at 8:05 A.M., showed the resident sat in his/her Broda chair (a tilt-in-space positioning chair which prevent skin breakdown through reducing heat and moisture for people in any type of healthcare setting) in an upright position at the dining room table.
Observation on 10/24/22 at 9:15 A.M., showed NA G took the resident via Broda chair from the dining room to the TV area and the resident remained in the upright position.
Observation on 10/24/22 at 11:11 A.M., showed the resident sat in the Broda chair in upright position in the TV area with his/her eyes closed.
Observation on 10/24/22 at 11:50 P.M., showed the staff pushed the resident in his/her broda chair from the TV area to the dining room.
Continuous observation on 10/24/22 from 11:50 A.M. to 1:15 P.M., showed the resident sat in an upright position in the broda chair at the dining room table.
Observation on 10/24/22 at 1:16 P.M., showed staff pushed the resident in the broda chair from the dining room to the TV area.
Continuous observation on 10/24/22 at 1:16 P.M. to 2:00 P.M., showed the resident sat in upright position in the broda chair in the TV area and yelled out several times.
Observation on 10/24/22 at 2:05 P.M., showed the following:
-The resident sat in the TV area in the broda chair and continued to yell;
-CNA Y took the resident to his/her room, where CNA BB assisted to transfer the resident to bed with the mechanical lift;
-The resident had been incontinent of bladder. His/Her incontinence brief was soaked with urine, and his/her slacks, the incontinence pads in his/her chair, the lift sling that was under the resident in his/her chair, and the Roho cushion (pressure relief cushion that is made of soft, flexible air cells connected by small channels) in the Broda chair were soiled with urine;
-The resident's buttocks and back were red and had indentions from his/her incontinence brief and clothing. (Staff did not reposition the resident in his/her broda chair for at least six hours.)
During interview on 10/24/22 at 2:15 P.M., CNA Y said the following:
-He/She didn't reposition the resident between breakfast and lunch;
-He/She planned on laying the resident down right after lunch;
-Other residents had higher priority issues to address before he/she could get the resident laid down after lunch.
Continuous observation on 10/25/22 at 9:39 A.M. to 4:15 P.M., showed the following:
-At 9:39 A.M., the resident sat in the broda chair in the TV common area;
-At 9:55 A.M., CNA C took the resident to his/her room via broda chair and left the resident sitting in front of the television;
-At 10:05 A.M., the resident sat in the broda chair leaning to the right. CNA C passed ice in the resident's room, and said he/she would be back to reposition the resident;
-At 11:50 A.M., CNA C returned to the resident's room, but did not reposition the resident. He/She took the resident to the dining room for lunch;
-At 12:50 P.M., staff pushed the resident in his/her broda chair from the dining room to the TV area;
-From 1:00 P.M. to 3:55 P.M., the resident sat in the TV common area in the broda chair. He/She yelled out several times;
-At 3:55 P.M., CNA U took the resident to his/her room and left the resident sitting in front of his/her television;
-At 4:00 P.M., the resident continued to sit in the broda chair in his/her room. The resident yelled out about neck pain, and CNA U entered the room and told the resident he/she would be back in a minute;
-At 4:03 P.M., the administrator entered the resident's room due to the resident yelling out. The administrator took the resident back to the TV area, and the resident continued to yell out.
Observation on 10/25/22 at 4:30 P.M., showed the following:
-CNA U and Assistant Director of Nurses/Licensed Practical Nurse (LPN) A transferred the resident to bed with the mechanical lift;
-The resident had been incontinent of bladder. His/Her incontinence brief was soaked with urine, and his/her pants, incontinence pads, and lift sling were soiled with urine;
-The resident's buttocks and back were red and he/she had indentions in his/her skin from his/her incontinence brief and clothing. (Staff did not reposition the resident in his/her broda chair for at least six hours and 20 minutes.)
During interview on 10/27/22 at 3:30 P.M., CNA U said the following:
-He/She took the resident to his/her room because the resident was yelling out in the TV area;
-He/She told the resident to wait a minute to be repositioned, because CNA U had to check on another resident across the hall whom had been in bed all day;
-He/She went back to the resident's room and the resident was gone;
-He/She found the resident back in the TV area because the resident was yelling out;
-He/She didn't intend to leave the resident waiting in his/her room, but the other resident took longer to address his/her needs than CNA U thought it would.
4. Review of Resident #10's Braden Scale, dated 4/6/22, showed a score of 20, indicating he/she was not at risk for pressure ulcers.
Review of the resident's annual MDS, dated [DATE], showed the following:
-Cognitively intact;
-At risk for pressure ulcers;
-Had pressure relieving devices for bed and chair;
-Diagnosis of diabetes mellitus.
Review of the resident's progress note from the Nurse Practitioner (NP), dated 9/2/22, showed the following:
-Stage II pressure ulcer on left heel;
-Progress: Measurement documented 9/1/22. Resident has an 8 centimeter (cm) by 5 cm on left heel. Just above the left heel where the boot is rubbing is a 1.8 cm by 2 cm area. New referral advanced care center (for wound care).
Review of the resident's Physician Order Sheet (POS), dated September 2022, showed on 9/7/22 an order for wound care evaluation and treatment for left heel ulcers.
Review of the wound care center's progress note, dated 9/9/22, showed the following:
-Left posterior ankle is an acute Stage 4 pressure ulcer with 100% granulation. Unable to tolerate debridement. No measurements documented;
-Left heel is an acute diabetic ulcer measuring 8.5 cm x 6 cm x 0.4 cm, moderate amount sero-sanguineous drainage with 76-100% granulation.
Review of the facility's wound report, dated 9/12/22, showed the following:
-Left heel wound measured 4 cm by 2 cm and stable;
-Left heel (posterior ankle) measured 3 cm by 1 cm by 2 cm (had previously measured 1.8 cm by 2.0 cm by 0.3 cm).
Review of the resident's care plan, last reviewed 10/20/22, showed the following:
-At risk for skin impairment;
-The resident has wounds present to left heel and left Achilles areas;
-Treat left heel and left Achilles with dressing as ordered;
-Pressure relieving boot to left heel at all times;
-Weekly skin assessment and wound documentation and inspection every shift with close attention to left lower extremity wound.
Observation on 10/24/22 at 7:00 A.M., showed Licensed Practical Nurse (LPN) D changed the dressings to the resident's left heel and left posterior heel. The left heel wound was approximately the size of an tennis ball with pink wound bed and the left posterior heel was quarter sized with a pink wound bed.
Review of the resident's medical record showed no evidence of weekly skin assessments completed since 9/12/22 or wound measurements since 9/21/22.
During interview on 10/27/22 at 8:23 A.M., LPN D said the nurse completed weekly skin assessments, but doesn't always have time to put the skin assessment in the electronic medical record.
5. Review of Resident #2's care plan, dated 11/19/21, showed no evidence the resident was at risk of developing a pressure ulcer.
Review of the resident's electronic medical record showed no documentation a Braden scale was completed.
Review of the resident's quarterly MDS, dated [DATE], showed the following:
-Cognitively intact;
-Not at risk for pressure ulcers;
-No open wounds in the seven day look back period.
Review of the facility's wound report, dated 9/12/22, showed the following:
-Pressure ulcer on top of right foot, labeled as #3 and measured 1.1 cm by 2.2 cm;
-Pressure ulcer on top of right foot, labeled as #1 and measured 1.2 cm by 1.2 cm.
Review of the resident's POS, dated September 2022, showed an order dated 9/12/22, to cleanse open areas on right foot with wound cleanser, apply xeroform (dressing to cover and protect low to non-exudating wounds) gauze and wrap with kling daily and as needed;
Review of the resident's electronic medical record showed no skin assessments or wound documentation between the weeks of 9/12/22 and 10/15/22.
Review of the facility's wound report, dated 10/15/22, showed the following:
-Pressure ulcer on top of right foot documented as healed;
-Pressure ulcer on top of right foot labeled as #1 measured 0.8 cm by 0.8 cm and was improving.
6. During an interview on 10/27/22, at 5:46 P.M., the Director of Nursing said the following:
-The charge nurses completed skin assessments weekly on shower days;
-Staff only documented the skin assessments on the shower sheets;
-Staff should complete a Braden skin risk assessment on admission and then quarterly;
-She expected staff to reposition residents at a minimum of every two hours;
-If there is a skin issue then staff make a nurses note and notify the physician for orders;
-She would expect new wounds and interventions to be updated on the care plan.
CONCERN
(E)
Potential for Harm - no one hurt, but risky conditions existed
Deficiency F0804
(Tag F0804)
Could have caused harm · This affected multiple residents
Based on observation, interview, and record review, the facility failed to ensure staff prepared and provided food that was served at an appetizing temperature. The facility also failed to ensure food...
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Based on observation, interview, and record review, the facility failed to ensure staff prepared and provided food that was served at an appetizing temperature. The facility also failed to ensure food items were prepared according to the recipe to conserve nutritive value, flavor and appearance. The facility census was 68.
1. During an interview on 10/24/22 at 9:43 A.M., Resident #32 said the food was terrible and cold.
During an interview on 10/24/22, at 10:20 A.M., Resident #257 said the food was always cold and did not taste good. Many times the food was overcooked.
During an interview on 10/24/22 at 10:57 A.M., Resident #7 said the food was lousy.
During an interview on 10/24/22 at 1:45 P.M., Resident #47 said a lot of the food did not taste good and the vegetables were mushy.
During an interview on 10/24/22 at 9:35 A.M., Resident #34 said the coffee was cold and sausage was cooked too much.
During an interview on 10/24/22 at 10:05 A.M., Resident #28 said there were egg shells in the eggs for the past two days and the apple juice tasted watered down.
During Resident Council on 10/24/22 at 11:34 A.M., the residents said the food was sometimes cold or burnt.
2. Review of menu for the noon meal on 10/24/22 showed staff were to serve residents on a regular diet turkey noodle casserole, Brussel sprouts, and a dinner roll.
Review of the menu for the noon meal on 10/24/22 showed staff were to serve residents on a pureed diet pureed turkey noodle casserole, pureed Brussel sprouts, and a pureed roll.
Review of the recipe for the pureed turkey noodle casserole showed process until smooth.
Review of the recipe for the pureed Brussel sprouts showed process until smooth.
Review of the recipe for the pureed bread showed to mix with water and melted butter and mix until smooth.
Observation on 10/24/22 showed the following:
-At 12:57 P.M., the administrator made the pureed turkey casserole. He thinned the pureed casserole with water;
-At 1:00 P.M., the administrator made the pureed Brussel sprouts. He thinned the pureed Brussel sprouts with water;
-At 1:10 P.M., the administrator made the pureed bread. He mixed the pureed bread with only water and did not use melted butter as directed in the recipe;
-At 1:12 P.M., staff served the lunch meal. Staff did not take temperatures of the food items. The steam table slots where the pureed items sat were not turned on;
-At 2:12 P.M., staff finished serving the lunch meal to the residents;
-At 2:14 P.M., staff provided a test tray. The temperature of the turkey casserole was 112 degrees Fahrenheit. The casserole had little flavor and was cool to taste. The temperature of the Brussel sprouts was 100 degrees Fahrenheit. The Brussel sprouts had little flavor and were cool to taste. The temperature of the pureed turkey casserole was 92 degrees Fahrenheit. The pureed turkey casserole had little flavor and was cool to taste. The temperature of the pureed Brussel sprouts was 88 degrees Fahrenheit. The pureed Brussel sprouts had little flavor and were cool to taste.
During an interview on 10/25/22 at 8:35 A.M., the administrator said he was aware the residents were complaining about the taste of the food and they were trying to work on it. He expected the serving temperatures to be 120 degrees Fahrenheit or greater. He did not look at the recipes for the pureed items to see what he was to use to thin the pureed food.
During an interview on 10/25/22 at 9:25 A.M., the dietary manager said her first day was 10/24/22. She expected all foods to be palatable and have a better quality of food served. She would expect staff to serve the food at 120 degrees Fahrenheit or greater. Staff should take the temperature of food items before meal service. They were in a rush (on 10/24/22) and forgot to take the temperature of the food. Staff should use what the recipe calls for to thin pureed items and should not use water.
CONCERN
(E)
Potential for Harm - no one hurt, but risky conditions existed
Deficiency F0805
(Tag F0805)
Could have caused harm · This affected multiple residents
Based on observation, interview, and record review, the facility failed to ensure three residents on a pureed diet received food in the proper form in accordance with his/her physician's orders. The f...
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Based on observation, interview, and record review, the facility failed to ensure three residents on a pureed diet received food in the proper form in accordance with his/her physician's orders. The facility census was 68.
Review of the menu for the noon meal on 10/24/22 showed residents on a pureed diet were to receive pureed turkey noodle casserole and pureed Brussel sprouts.
Review of the recipe for the pureed turkey noodle casserole showed process until smooth.
Review of the recipe for the pureed Brussel sprouts showed process until smooth.
Observations on 10/24/22 between 12:57 P.M. and 1:10 P.M., showed the administrator pureed the turkey casserole and Brussel sprouts separately in the blender.
Observation on 10/24/22 at 2:14 P.M. of the test tray showed the pureed turkey casserole and the pureed Brussel sprouts were chunky.
During interview on 10/25/22 at 8:35 A.M., the administrator said the texture of pureed food items should be smooth. He would expect the texture to be checked before serving the pureed foods. He did not check the texture before serving.
During interview on 10/25/22 at 9:25 A.M., the dietary manager said the pureed foods should be smooth with no chunks.
CONCERN
(E)
Potential for Harm - no one hurt, but risky conditions existed
Infection Control
(Tag F0880)
Could have caused harm · This affected multiple residents
**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, interview and record review, the facility failed to use appropriate infection control procedures for hand ...
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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 use appropriate infection control procedures for hand hygiene and changing gloves, to prevent the spread of bacteria or other infectious causing contaminants and when indicated by professional standards of professional practice during personal care for four residents (Resident #20, #34, #11, #3) in a review of 26 sampled residents and one additional resident (Resident #36). The facility also failed to ensure a foley catheter (a tube inserted into the bladder to drain urine) drainage tube was not touching the floor while the resident lay in bed for one resident (Resident #3). Additionally, the facility failed to maintain the prevention of communicable disease in regards to Tuberculosis (TB) (a communicable disease that affects the lungs characterized by fever, cough and difficulty breathing) screening of five residents (Resident #2, #10, #12, #20, #104) of 26 sampled residents. The facility census was 68.
Review of the facility's undated policy, Handwashing, showed the following:
-Purpose: to reduce transmission of organisms from resident to resident, nursing staff to resident and resident to nursing staff.
Review of the facility's undated policy, Gloves, showed the following:
-Wear gloves when it can be reasonably anticipated that hands will be in contact with mucous membranes, non-intact skin, any moist body substances (blood, urine, feces, wound drainage, oral secretions, sputum, vomitus, or items/surfaces soiled with these substances) and/or persons with a rash. Gloves must be changed between residents and between contacts with different body sites of the same resident;
-REMEMBER: Gloves are not a cure-all. They should reduce the likelihood of contaminating the hands, but gloves cannot prevent penetrating injuries due to needles or sharp objects. Dirty gloves are worse than dirty hands because microorganisms adhere to the surface of a glove easier than to the skin on your hands. Handling medical equipment and devices with contaminated gloves is not acceptable;
-Change gloves between contacts (as defined above) with different residents or with different body sites of the same resident.
Review of the facility's undated policy, Catheter Care (Indwelling), showed the following:
-Purpose is to prevent infection and reduce irritation;
-Check drainage tubing and bag to ensure that the catheter is draining properly;
-The policy did not define expectations for catheter tubing not touching the floor.
Review of email correspondence on 11/10/22 at 11:51 A.M., showed the Director of Nurses (DON) said the facility did not have a policy that directs when to test/screen residents for tuberculosis, but they follow Centers for Disease Control (CDC) guidelines.
1. Review of Resident #20's admission MDS, dated [DATE], showed the following:
-Severely impaired cognition;
-Required extensive assistance of two staff for transfers and toileting;
-Always incontinent of bowel and bladder;
-Diagnoses included stroke and hemiplegia.
Review of the resident's care plan, dated 9/29/22, showed the following:
-The resident experiences bladder incontinence;
-Provide assistance for toileting as needed;
-Provide incontinence care after each incontinent episode.
Observation on 10/26/22 at 05:02 A.M., showed the following:
-The resident lay on his/her back in bed;
-CNA E washed his/her hands and applies gloves;
-CNA E pulled back the covers and removed the front of the resident's incontinence brief;
-The resident was incontinent of urine;
-CNA E provided peri-care to the front genitalia;
-Wearing the same soiled gloves, CNA E pulled on the quilted pad that was under the resident and assisted the resident to roll to his/her left side;
-Without washing hands, CNA E changed his/her gloves, rolled up the soiled incontinence brief and urine stained quilted pad and positioned a clean quilted pad and brief behind the resident;
-CNA E cleansed the right buttock and gluteal crease with a wet washcloth;
-CNA E removed his/her gloves, and without washing his/her hands with soap and water or sanitizing his/her hands, picked up the bed control and lowered the resident's bed;
-CNA E retrieved additional wet washcloths from the sink, laid the wet washcloths on the bed, raised the resident's bed with the bed control and then donned gloves;
-CNA E tucked a clean incontinence brief under the resident, rolled him/her to his/her right side and pulled out the soiled incontinence brief and pad and placed the soiled linen in a trash bag at the foot of the bed;
-CNA E removed his/her gloves, did not wash or sanitize his/her hands and donned another pair of gloves;
-CNA E rolled the resident to his/her back, secured the incontinence brief, covered resident with a blanket, lowered the bed with the bed control and placed the fall mat on the floor by the bed.
During interview on 10/25/22 at 5:29 A.M., CNA E said staff should wash their hands when entering a room, wash or use sanitizer between glove changes, wash after providing cares and before leaving the resident's room. Staff should change gloves when they go from dirty tasks to clean tasks. He/she said he/she usually had hand sanitizer with him/her but had ran out.
2. Review of Resident #34's Care Plan, dated 12/08/21, showed the following:
-The resident had loss of self-care abilities/deficit in most ADLs stemming from choice to not participate;
-The staff assumed the physical responsibilities of performing tasks he/she does not wish to, i.e., hair, oral, nail care, perineal hygiene after incontinent episodes.
Review of the resident's quarterly Minimum Data Set (MDS), a federally mandated assessment completed by facility staff, dated 9/3/22, showed the following:
-The resident had moderately impaired cognition;
-He/she was dependent of one staff member for toilet use;
-He/she required limited assistance of one staff member for personal hygiene;
-He/she was always incontinent of bladder and bowel.
Observation on 10/25/22 at 4:30 P.M., showed the following:
-Assistant Director of Nursing (ADON)/Licensed Practical Nurse (LPN) A applied gloves, but didn't perform hand hygiene prior to gloving;
-CNA U donned gloves without washing hands with soap and water or sanitizing and then transferred the resident from his/her Broda chair to his/her bed with a mechanical lift, turned him/her onto right side, doffed the resident's urine saturated clothing and performed peri care before turning the resident over to his/her left side;
-The ADON/LPN A removed the urine saturated disposable incontinence pad and soiled reusable bed pad out from under the resident, then pulled the clean brief and pad out and over the right side of the bed;
-With soiled gloves, CNA U attempted to fasten the clean brief on the resident but the tape ripped off the brief;
-With the same soiled gloves, CNA U took a clean brief out of the resident's closet, turned the resident onto his/her right side; the resident was incontinent of bowel;
-CNA U removed the soiled gloves and left the room to get more washcloths and bed pads without washing his/her hands with soap and water or sanitizing;
-CNA U returned to the room, performed hand hygiene and applied clean gloves;
-CNA U performed peri care and turned the resident onto his/her left side;
-ADON/LPN A removed the soiled brief and bed pad out from under the resident;
-The resident sat in bed with head of bed elevated and had an emesis;
-CNA U removed gloves and left the room to get more washcloths and bed pads, without performing hand hygiene;
-CNA U returned to the room, performed hand hygiene and applied new gloves;
-CNA U and ADON/LPN A assisted resident to clean up the emesis; ADON/LPN A still had soiled gloves on;
-ADON/LPN A applied clean gloves, but didn't perform hand hygiene;
-CNA U turned the resident onto his/her right side, performed peri care, and put clean brief and three bed pads under resident then turned him/her to left side;
-ADON/LPN A removed the soiled brief and bed pad out from under the resident;
-CNA U applied the tape to the front of the brief while ADON/LPN A assisted resident to put on a facility gown, then they repositioned the resident in bed, without changing gloves or performing hand hygiene first.
During interview on 10/26/22 at 10:58 A.M., the ADON/LPN A said the following:
-She should have performed hand hygiene upon entering the room and applying gloves, after handling soiled linen, incontinence briefs;
-She didn't think about hand hygiene or changing gloves because they were not visibly dirty and he/she was focused on getting the resident to bed, so the resident would stop yelling out and disturbing other people.
During interview on 10/27/22 at 3:30 P.M., CNA U said the following:
-He/she did perform hand hygiene prior to taking the resident to his/her room to transfer to bed;
-He/She didn't remember to perform hand hygiene before leaving the room to obtain linen because she was in a hurry and nervous;
-He/She said she should have performed an alcohol based hand sanitizer since her hands were not visibly dirty;
-He/She said she should have changed gloves between dirty and clean areas, but didn't mention hand hygiene along with changing gloves.
3. Review of Resident #11's Care Plan, last updated 12/17/21, showed the following:
-No documentation shown for incontinence of bowel and bladder;
-No peri care or guidance in reference to checking resident every 2 hours to monitor incontinence;
-No documentation of skin integrity, UTI prevention, incontinence products, or hydration needs.
Review of the resident's quarterly Minimum Data Set (MDS), a federally mandated assessment completed by facility staff dated 8/10/22, showed the following:
-Cognitively moderately impaired;
-Requires extensive assistance of one person for toileting;
-Frequently incontinent of urine;
-Always incontinent of bowel;
-No toileting program.
Observation on 10/24/22, at 9:08 A.M., showed the following:
-Resident sat in the dining room with a foul odor;
-NA G brought the resident to his/her room;
-The resident's sheets had dried yellow and darkish brown stain;
-With gloved hands, NA G stripped the dirty linens from the resident's bed, put them in a clear trash bag and put the bag on the hallway floor outside of resident's room;
-With the same soiled gloves, NA G put a gait belt around the resident, who was sitting in his/her wheelchair, and wheeled the resident into the bathroom;
-The resident held onto the handrail in the bathroom while NA G pulled his/her brief and pants down; the resident was having active diarrhea that was running down his/her legs;
-NA G took off dirty gloves and applied new gloves without washing/sanitizing hands;
-NA G wet a small towel in the sink and used it to clean resident's legs while the resident sat on the toilet;
-NA G had a clear trash bag open, tossed the small wet towel with visible fecal matter towards the open trash bag, and the towel landed on the floor beside trash bag;
-With soiled gloves, NA G took the resident's socks off and put his/her slippers on his/her feet;
-NA G stood the resident up and continued to clean diarrhea from the front of resident's peri area and buttocks;
-With soiled gloves, NA G pulled up the resident's pants and transferred the resident to his/her wheelchair and pushed the resident out of the bathroom;
-NA G wiped down the front of the toilet bowl with a wet towel; a brown fecal matter could still be seen on the surface.
During interview on 10/27/22, at 11:17 A.M., NA G stated the following:
-You should wash hands and put on gloves when toileting residents;
-Gloves should be changed every time a resident is wiped.
Observation on 10/26/22, at 6:09 A.M., showed the following:
-CNA M entered resident's room to perform morning care;
-A very strong urine odor was noted;
-Without washing hands with soap and water or sanitizing, CNA M applied gloves and transferred the resident to his/her wheelchair and pushed him/her into the bathroom;
-The resident's pants were urine soaked and his/her bed was saturated with urine;
-CNA M removed the resident's urine saturated incontinent brief and placed it on the floor;
-CNA M wiped the resident's groin on each side two times; no frontal peri care or buttocks peri care was completed;
-CNA M removed his/her gloves, did not wash his/her hands with soap and water and did not sanitize, and handed wet wash cloths to the resident who washed his/her face; the resident handed the soiled washcloths back to CNA M who took them with his/her bare hands;
-CNA M pushed the resident back to the side of his/her bed;
-The resident tried to make his/her bed and touched the urine soaked chux incontinence pad with his/her bare hand and CNA M did not clean his/her hand.
During interview on 10/26/22, at 6:35 A.M., CNA M stated the following:
-Hands should be washed before putting on gloves;
-Gloves should be changed after peri care and before care to buttock area.
4. Review of the Resident #36's quarterly Minimum Data Set (MDS), a federally mandated assessment tool completed by facility staff, dated 9/11/22 showed the following:
-Diagnoses include Alzheimer's Disease and generalized muscle weakness;
-Cognition severely impaired;
-Required extensive assistance with bed mobility and personal hygiene;
-Totally dependent on one staff for locomotion on and off the unit, dressing and bathing;
-Totally dependent on two staff for transfers and toileting;
-Always incontinent of bowel and bladder;
-At risk for pressure ulcers.
Review of the resident's care plane, revised 10/27/22, showed the following:
-Resident has bilateral wounds to his/her heels;
-Resident has old pressure areas beginning to re-open to right perineum and right upper thigh;
-Topical treatments as ordered.
Observation on 10/27/22, at 11:30 A.M., showed the following:
-Registered Nurse (RN) O was wearing gloves when SA (State Agency) entered the room;
-RN O cleansed a wound on the resident's right upper thigh as well as right buttock with wound cleanser;
-A small amount of red drainage on the gauze to cleanse the wounds was noted;
-RN O removed his/her gloves and immediately applied another pair of gloves without performing hand hygiene;
-RN O assembled the dressing supplies and applied dressing to right thigh;
-RN O removed gloves and applied a new pair of gloves without performing hand hygiene;
-Dressing applied to right buttock and gloves removed;
-Hand hygiene performed at end of treatment;
-RN O left supplies on the resident's bedside table for the treatment on his/her left heel;
-RN O left the resident's room and continued to do treatments for other residents;
-Noted wound care supplies left on the resident's bedside table that included loose 4x4 gauze pads, wound cleanser, a medicine cup with an unidentified ointment, cotton tipped wooden applicator stick, a sealed package of 4x4 gauze and tape. The wound care supplies sat next to a water pitcher and resident's personal items with no barrier between the wound care supplies and the resident's tray table.
During an interview on 10/27/22, at 5:18 P.M., RN O said the following:
-Hands should be washed before touching the resident, before doing a procedure, after each glove change, and after completing a procedure/wound care;
-He/She did not wash his/her hands between glove changes when completing a treatment for resident #36;
-He/She is unsure why he/she did not wash his/her hands or use alcohol hand sanitizer between glove changes, other than he/she was nervous;
-Wound care supplies should not be left at a resident's bedside to use later;
-If wound care supplies are left at a resident's bedside they would no longer be clean and should be thrown away;
-He/She had not completed the second part of resident #36's treatment at the time of interview and would throw the wound care supplied away.
5. Review of Resident #3's quarterly MDS, dated [DATE], showed the following:
-Resident has independent decision making ability;
-Needs limited assist of one staff member for transfers, dressing, toileting and personal hygiene;
-No indication of foley catheter;
-Frequently incontinent of bowel and bladder;
-No UTI in past 30 days.
Review of the resident's October 2022 physician orders showed an order for catheter care every shift, with a start date of 10/6/22.
Review of the resident's care plan, revised on 10/20/22, does not address the foley catheter or how to care for it.
Observation on 10/26/22, at 5:49 A.M., showed the resident sat on the side of the bed with his/her catheter tubing touching the floor, not in a dignity bag, and was draining cloudy yellow urine with a small amount of white sediment.
Observation on 10/27/22, at 12:11 P.M., showed the following:
-NA G washed his/her hands prior applying gloves;
-NA G removed incontinent care wipes from a package that was sitting on the resident's bedside table and placed them on the resident's bottom sheet next to the trash bag used for soiled attend;
-NA G performed catheter care and doffed gloves;
-Without washing hands with soap and water or sanitizing, NA G applied gloves;
-The resident's catheter bag and catheter tubing was touching the floor;
-NA G picked up the catheter bag and threaded it through the resident's right pant leg and pulled the resident's pants up;
-With soiled gloves, NA G put the wipes that had been removed from the package and sat on the resident's bottom sheet, back into the package;
-The urine in the tubing and urinary drainage bag was slightly cloudy, yellow in color and a small amount of white sediment noted.
During an interview on 10/27/22, at 2:27 P.M., NA G said the following:
-Catheter bags and tubing should not touch the floor;
-Catheter bags and tubing should be in a bag;
-Resident #3 has a bag for his/her chair but not one for his/her bed;
-Hands should be washed before and after providing resident care;
-He/She is not sure if hands should be washed in-between gloving;
-Wipes should not be put back into the container, he/she must have been nervous and put them back in the pack.
6. Review of Resident #2's electronic medical record showed the following:
-An admission date of 1/10/21 and readmission dated of 5/28/22;
-No evidence of a TST test or TB screen questionnaire documented for 2021 or 2022.
7. Review of Resident #10's electronic medical record showed the following:
-An admission date of 7/23/21;
-No evidence of a TST test or TB screen questionnaire documented for 2021 or 2022.
8. Review of Resident #12's electronic medical record showed the following:
-An admission date of 11/1/21;
-No evidence of a TST test or TB screen questionnaire documented for 2021 or 2022.
9. Review of Resident #20's electronic medical record showed the following:
-An admission date of 7/28/22;
-No evidence of a TST test or TB screen questionnaire documented for 2022.
10. Review of Resident #104's electronic medical record showed the following:
-An admission date of 9/16/20 and readmission dated of 2/7/22;
-No evidence of a TST test or TB screen questionnaire documented for 2020, 2021 or 2022.
During interview on 10/27/22 at 5:47 P.M., the Director of Nurses (DON) said the following:
-Staff should wash their hands when entering a room, when changing their gloves and when they are done. She would not expect staff to change gloves and not wash or use hand sanitizer in between applying new gloves;
-They had been doing TB screens for residents on paper. She provided a computer printout with three residents listed who had received a TST in 2022 and none of the sampled residents were listed. She said she was looking for the paper documentation requested; results were never provided;
-Hand washing should be completed before and after any care given as well as between gloving;
-Catheter tubing should never touch the floor;
-Wound care supplies should never be left unattended at a resident's beside;
-The facility does not have a specific policy on when to test/screen residents, they follow CDC guidelines for testing.
CONCERN
(E)
Potential for Harm - no one hurt, but risky conditions existed
Deficiency F0883
(Tag F0883)
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 provide pneumococcal (lung inflammation caused by bacterial or vira...
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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 pneumococcal (lung inflammation caused by bacterial or viral infection) vaccines for four residents (Resident #12, #27, #257, and #356) of 26 sampled residents. The census was 68 residents.
Review of the facility's undated policy, Immunizations, showed the following:
-Pneumococcal: PCV20 (PREVNAR 20) an PPSV23 (Pneumococcal Polysaccharide vaccine);
-Pneumococcal Vaccination in persons ages 65 and older years, unless contraindicated will be administered according to the following guidelines when determining the vaccination status:
1. Adults 19-[AGE] years old with certain medical conditions or other risk factors who have NOT already received a pneumococcal conjugate vaccine should receive either:
a. A single dose of PCV15 followed by a dose of pneumococcal polysaccharide vaccine (PPSV23), or
b. A single dose of PCV20. If PCV20 is administered, a dose of PPSV23 is NOT indicated;
2. Adults 65 years or older who have NOT already received a pneumococcal conjugate vaccine should receive either:
a. A single dose of PCV15 followed by a dose of PPSV23 one year later, or
b. A single dose of PCV20. If PCV20 is administered, a dose of PPSV23 is NOT indicated;
3. Adults 65 years or older who have only received PPSV23, should receive:
a. A single dose of PCV15 or PCV20. The PCV15 or PCV20 dose should be administered at least one year after the most recent PPSV23 vaccination;
b. Regardless whether PCV15 or PCV20 is given, an additional dose of PPSV23 is not recommended since they already received it;
4. Contraindications to Pneumococcal Conjugate Vaccine (PCV15 or PCV20) include:
a. Has had an allergic reaction after a previous dose of any type of pneumococcal conjugate vaccine (PCV13, PCV15, PCV20, or an earlier pneumococcal conjugate vaccine known as PCV7), or
b. Allergic to any vaccine containing diphtheria toxoid (for example, DTaP), or has any severe, life-threatening allergies;
5. Contraindications to Pneumococcal Polysaccharide vaccine (PPSV23) include:
a. Has had an allergic reaction after a previous dose of PPSV23, or has any severe, life-threatening allergies;
6. People with minor illnesses, such as a cold, may be vaccinated. People who are moderately or severely ill should usually wait until they recover;
7. Requirements to administer the vaccination includes:
a. Physician order;
b. Consent to receive signed by resident &/or legal representative;
c. Information sheet included with the consent to administer pneumococcal vaccine, includes general information, risks and side effects;
d. The resident will be monitored for fever for up to 72 hours.
Review of the Centers for Disease Control (CDC) recommendations for pneumococcal vaccine timing, dated 4/1/22, showed the following:
-CDC recommends pneumococcal vaccination for adults [AGE] years old or older, and for adults 19 through [AGE] years old with certain underlying medical conditions including cigarette smoking;
-For adults who have never received a pneumococcal vaccine, or those with unknown vaccination history, one dose of PCV15 (15-valent pneumococcal conjugate vaccine) or PCV20 (20-valent pneumococcal conjugate vaccine) should be administered;
-If PCV 20 is used, their pneumococcal vaccinations are complete;
-If PCV 15 is used, follow with one dose of PPSV23 (23-valent pneumococcal polysaccharide vaccine) with a recommended interval of at least one year;
-For adults who have previously received PPSV23 but who have not received any pneumococcal conjugate vaccine (PCV), one does of PCV15 or PCV20 may be administered with an interval of at least one year;
-For adults 65 years or older without an immunocompromising condition, cerebrospinal fluid leak, or cochlear implant, who have previously received PCV13 at any age, it is recommended to receive one dose of PPSV23 at or after [AGE] years of age (at least one year after PCV13 was received). Their pneumococcal vaccinations are complete;
-For adults 19 years or older with an immunocompromising condition who have previously received a PCV13 at any age, CDC recommends two doses of PPSV 23 before age [AGE] years and one dose of PPSV23 at the age of 65 or older:
-Administer a single dose of PPSV23 at least 8 weeks after the PCV13 was received;
-If the patient was younger than [AGE] years old when the first dose of PPSV23 was given and has not turned [AGE] years old yet, administer a second dose of PPSV23 at least five years after the first dose of PPSV23. This is the last dose of PPSV23 that should be given prior to [AGE] years of age;
-Once the patient turns [AGE] years old and at least five years have passed since PPSV23 was last given, administer a final dose of PPSV23 to complete their pneumococcal vaccinations.
1. Review of Resident #12's undated face sheet showed the following:
-admission date of 11/2/21;
-Resident was over the age of 65;
-Diagnoses included hypertensive heart and chronic kidney disease with heart failure and with stage five chronic kidney disease or end stage renal disease (complete failure of the kidneys), diabetes mellitus type II and congestive heart failure.
Review of the resident's quarterly Minimum Data Set (MDS), a federally mandated assessment instrument required to be completed by facility staff, dated 8/10/22, showed the following:
-The resident's cognition was intact;
-The resident received dialysis;
-Influenza vaccine was received outside the facility;
-Pneumonia vaccination was up to date.
Review of the resident's electronic medical record showed no documentation which pneumonia vaccination the resident had previously received and which vaccination he/she was eligible to receive. Further review showed no evidence the resident was offered or refused the additional pneumococcal vaccine.
During interview on 10/27/22 at 2:05 P.M., the resident said if he/she was eligible for the pneumonia vaccination then he/she would want to receive it.
2. Review of Resident #27's face sheet showed the following:
-admitted on [DATE];
-The resident was over [AGE] years of age;
-Diagnoses included dementia with behavior disturbance (a group of thinking and social symptoms that interferes with daily functioning) and Parkinson's disease (a disorder of the central nervous system that affects movement, often including tremors).
Review of the resident's quarterly MDS, dated [DATE], showed the following:
-Severely impaired cognition;
-The resident was up to date on pneumococcal vaccinations.
Review of the resident's electronic medical record showed the following:
-The resident received a PCV-13 vaccination on 10/1/2013;
-Following CDC recommendations the resident would need one PPSV-23 and was not up to date on pneumococcal vaccination.
During an interview on 10/24/22, at 1:45 P.M., the resident's legal representative said he/she would want the resident to be up to date on any vaccinations the resident's physician recommended be given.
3. Review of Resident #257's face sheet showed the following:
-admitted on [DATE];
-The resident was less than [AGE] years of age;
-Diagnoses included nicotine dependence (identified as a pneumonia risk factor by the CDC), hypertension (high blood pressure) and chronic obstructive pulmonary disease (a group of lung diseases that block airflow and make it difficult to breathe).
Review of the resident's quarterly MDS, dated [DATE], showed the following:
-Moderately impaired cognition;
-The resident was up-to-date on pneumococcal vaccination.
Review of the resident's electronic medical record showed the following:
-The resident received a PPSV-23 on 11/1/2020;
-Following CDC recommendations the resident would need one dose of pneumococcal conjugate vaccine (PCV-15 or PCV-20) one year after the PPSV-23 and was not up to date on pneumococcal vaccination.
During an interview on 10/27/22, at 4:35 P.M., the resident said he/she would want to take the pneumococcal vaccination if the physician said he/she needed it and it was time to get one.
4. Review of Resident #356 face sheet, undated, showed the following:
-The resident admitted to the facility on [DATE];
-The resident was over the age of 65;
-The resident had diagnoses of dementia (chronic or persistent disorder of the mental processes caused by brain disease or injury and marked by memory disorders, personality changes, and impaired reasoning), hypertension (abnormally high blood pressure), atrial fibrillation (irregular and often very rapid heart rhythm), Celiac disease (disease in which the small intestine is hypersensitive to gluten, leading to difficulty in digesting food), and personal history of COVID-19.
Review of the resident's Physician Orders, dated 7/28/22, showed the physician prescribed a pneumonia vaccine.
During interview on 10/27/22 at 1:28 P.M., the resident's responsible party said the following:
-He/She did not know if the resident had received any pneumococcal vaccines;
-He/She didn't remember the facility staff offering a pneumococcal vaccine;
-He/She would approve the vaccine if prescribed by the physician.
Review of the resident's electronic medical record showed no documentation the resident received, was offered, or refused the pneumococcal vaccine.
During interview on 10/27/22 at 5:47 P.M., the Director of Nurses (DON) said she was going through each resident to make sure all residents were up to date on pneumonia vaccines. The admitting nurse was responsible for obtaining immunization consents and immunization history. If a resident was found to be in need of the influenza or pneumonia vaccine then staff are expected to administer the needed vaccine after the appropriate consent was obtained. Vaccine education was provided at the time the vaccine is given.
CONCERN
(E)
Potential for Harm - no one hurt, but risky conditions existed
Deficiency F0924
(Tag F0924)
Could have caused harm · This affected multiple residents
**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation and interview, the facility failed to ensure corridors were equipped with firmly secured handrails on each ...
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**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation and interview, the facility failed to ensure corridors were equipped with firmly secured handrails on each side of the hall. The facility census was 68.
Observations on 10/24/22 between 10:32 A.M. and 3:02 P.M. showed the following:
-A 3-foot section of handrail and another 5-foot section of handrail next to the staff restroom at the top of B Hall were loose from the wall and not secured;
-A 7-foot section of handrail outside the therapy department on C Hall was loose from the wall and not secured;
-A section of handrail outside the beauty shop and resident room [ROOM NUMBER] (D Hall) was loose from the wall and not secured;
-A 5-foot section of handrail outside resident rooms [ROOM NUMBERS] (D Hall) was loose from the wall and not secured;
-A 4-foot section of handrail outside the clean linen room on F Hall was loose from the wall and not secured.
During an interview on 10/26/22 at 10:02 A.M., the maintenance supervisor said he was unaware that several handrails were loose from the wall and not secured. He did not regularly check handrails in the facility.
CONCERN
(F)
Potential for Harm - no one hurt, but risky conditions existed
Deficiency F0727
(Tag F0727)
Could have caused harm · This affected most or all residents
Based on interview and record review, the facility failed to provide the services of a registered nurse (RN), other than the Director of Nursing (DON), for at least eight consecutive hours per day sev...
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Based on interview and record review, the facility failed to provide the services of a registered nurse (RN), other than the Director of Nursing (DON), for at least eight consecutive hours per day seven days a week, as well as failed to ensure the DON did not work as a charge nurse when the facility had an average daily occupancy of 60 or more residents. The facility census was 68.
The facility did not have a specific policy addressing RN coverage and DON duties for facilities with an average daily census of 60 or more.
1. Review of the facility assessment updated 10/21/22 showed an average daily census of 70.
2. The facility did not maintain a timesheet for the DON.
3. Review of the facility staffing sheets (posted staffing sheets) dated September 2022 showed the following:
-There was no RN scheduled for eight consecutive hours on 9/24/22:
-There was no RN scheduled for eight consecutive hours on 9/25/22;
-The DON served as the charge nurse on 9/27/22 for the 3:00 P.M. to 11:00 P.M. shift, the facility census was 71.
4. Review of the facility staffing sheets dated October 2022 showed the following:
-The DON served as the charge nurse on 10/8/22 for the 3:00 P.M. to 11:00 P.M. shift, the facility census was 70;
-The DON served as the charge nurse on 10/10/22 for the 3:00 P.M. to 11:00 P.M. shift, the facility census was 70;
-The DON served as the charge nurse on 10/12/22 from 5:00 A.M. to 6:30 A.M., the facility census was 70;
-The DON served as the charge nurse on 10/13/22 for the 11:00 P.M. to 7:00 A.M. shift, the facility census was 70;
-The DON served as the charge nurse on 10/14/22 from 3:00 A.M. to 6:30 A.M., the facility census was 70;
-There was no RN scheduled for eight consecutive hours on 10/22/22;
-There was no RN scheduled for eight consecutive hours on 10/23/22;
-The DON served as the charge nurse on 10/24/22 from 5:00 A.M. to 6:30 A.M., the facility census was 69.
During an interview on 10/27/22 at 5:46 P.M., and on 11/8/22 at 5:15 P.M. the DON said the following:
-She does not know how often she has to act as a charge nurse;
-There were only two RN's on staff at the facility, one being herself and the other RN O;
-RN O's last day will be 10/31/22;
-She does not schedule herself to act as the charge nurse;
-She serves as charge nurse when there are call-in's and they are unable to cover the shifts;
-The facility does not utilize agency for RN coverage due to the cost;
-She was unaware of the requirement she not serve as a charge nurse if the average daily census was above 60;
-There had not been any days in the past two months that there has not been an RN in the building, if RN O was not scheduled she was at the facility;
-She tracks her time on an application on her phone for her own knowledge, not for the company or time keeper.
During an interview on 11/8/22, at 5:12 P.M., the administrator said the following:
-He was aware of the requirement of having an RN in the building eight hours each day and the DON not serving as the charge nurse;
-He thinks he had heard that the DON served as a charge nurse, but only on an emergency basis.
CONCERN
(F)
Potential for Harm - no one hurt, but risky conditions existed
Deficiency F0802
(Tag F0802)
Could have caused harm · This affected most or all residents
Based on observation, interview, and record review, the facility failed to provide sufficient staff to prepare and serve the meals timely. The census was 68.
Review on 10/24/22, of the meal time sched...
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Based on observation, interview, and record review, the facility failed to provide sufficient staff to prepare and serve the meals timely. The census was 68.
Review on 10/24/22, of the meal time schedule, showed the following:
-Staff was to serve breakfast at 7:30 A.M.;
-Staff was to serve lunch at 12:30 P.M.;
-Staff was to serve supper at 5:30 P.M.
During interview on 10/24/22 at 9:35 A.M., Resident #34 said he/she never knew when meals were going to be served because staff served breakfast between 9:30 A.M. to 10:00 A.M., and served lunch anywhere from 12:30 P.M. to 2:00 P.M.
Review of the kitchen staffing schedule showed no dietary staff was scheduled to work day shift in the kitchen on 10/24/22.
Observation on 10/24/22 at 10:25 A.M. showed the administrator was in the kitchen preparing and serving the breakfast meal (two hours and 25 minutes after the scheduled meal time). Only a few residents had been served their breakfast meal at this time.
Observations on 10/24/22 showed the following:
-At 11:05 A.M., the dietary manager (who was the only dietary staff working) and the administrator prepared the residents' lunch meal;
-At 1:12 P.M., staff served the first lunch meal tray to the residents (42 minutes after the scheduled meal time).
-At 2:12 P.M., staff served the last lunch meal tray to the residents (one hour and 42 minutes after the scheduled meal time).
During interview on 10/25/22 at 8:35 A.M., the administrator said the kitchen had been short staffed on and off for about a year. They had an interim dietary manager and other dietary staff quit without notice. The dietary manager and the administrator made the schedule, but when everyone suddenly quit, management was filling in. He and other department heads helped in the kitchen when they were needed. That is why meals are late at times.
During interview on 10/25/22 at 9:25 A.M., the dietary manager said her first day was 10/24/22. She would expect to have three staff in the kitchen for all meals.
MO204399
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 ensure sanitary practices in the kitchen. The facility census was 68.
Observation of the kitchen area on 10/24/22 between 10:...
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Based on observation, interview, and record review, the facility failed to ensure sanitary practices in the kitchen. The facility census was 68.
Observation of the kitchen area on 10/24/22 between 10:25 A.M. and 2:12 P.M. showed the following:
-The deep fryer was dirty with dark grease and food debris;
-The bottom and the legs of the mixer had dried yellow crusty substance on it;
-Maintenance walked through the kitchen by the food preparation table as staff prepared food in the kitchen. The maintenance staff had facial hair and did not wear a beard restraint or a hair net to cover the hair on his/her head;
-An opened bottle of enchilada sauce (one-half full) sat on a shelf in the dry food pantry. The lid on the enchilada sauce said to refrigerate after opening;
-The lid on the mustard container had a black-brownish ring all the way around it;
-The serving trays, plate warmer bottoms, and plate warmer tops all have standing water in them.
Observation on 10/24/22 showed the following:
-At 12:01 P.M. during the preparation of the lunch meal, the dietary manager washed her hands and put on gloves, she touched pot holders and used a spoon to remove a Brussel sprout out of the cooking pot. She touched the Brussel sprout for firmness with his/her gloved hand and then put the Brussel sprout back in the pot. She did not remove his/her gloves after handling the pot holders and before touching the Brussel sprout;
-At 12:10 P.M., the dietary manager washed her hands, put on gloves, and chopped onions. Without removing his/her gloves, he/she put on pot holders and took a pot off of the stove.
During interview on 10/25/22 at 9:25 A.M., the dietary manager said her first day was 10/24/22. Everything in the kitchen area needed to be cleaned. She would expect the serving trays and plate warmer tops and bottoms to be dry before staff put them away. She would expect staff to change gloves and wash hands if contaminated or soiled. She was aware she touched different things and did not change her gloves or wash her hands.
During interview on 10/25/22 at 8:35 A.M. the administrator said he expected the plate warmer tops and bottoms and the serving trays to be dry before staff put them away. He expected staff to change gloves and to wash their hands after touching anything that would contaminate or soil the gloves.
CONCERN
(F)
Potential for Harm - no one hurt, but risky conditions existed
Deficiency F0865
(Tag F0865)
Could have caused harm · This affected most or all residents
Based on interview and record review, the facility failed to identify, develop and implement a Quality Assurance and Performance Improvement Plan (QAPI) to monitor and evaluate system problems. The fa...
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Based on interview and record review, the facility failed to identify, develop and implement a Quality Assurance and Performance Improvement Plan (QAPI) to monitor and evaluate system problems. The facility census was 68.
Review of the documentation provided as a policy noted a QAPI template from Health Quality Innovators with a disclaimer statement on page three that read, The QAPI plan template is offered to nursing facilities as a guideline for developing QAPI plans and for informational and educational purposes only.
Review of the facility provided binder for review noted multiple pages of a template shown as an example to develop a facility specific QAPI plan. No facility specific QAPI plan was included in the binder for review.
During an interview on 10/27/22, at 5:07 P.M., the administrator said the following:
-The facility QAPI plan was in the binder he provided for review;
-After looking at the binder, he said he guessed there was no facility specific policy developed;
-The facility needed to do better at the QAPI process.
CONCERN
(F)
Potential for Harm - no one hurt, but risky conditions existed
QAPI Program
(Tag F0867)
Could have caused harm · This affected most or all residents
Based on interview and record review, the facility staff failed to implement an effective quality assessment and assurance (QAA) committee to develop and track any identified concerns for resolution. ...
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Based on interview and record review, the facility staff failed to implement an effective quality assessment and assurance (QAA) committee to develop and track any identified concerns for resolution. The facility census was 68.
The facility did not have a written QAA program policy.
Review of the facility provided records showed the facility did not have documentation of a QAA program. The facility did not provide information that they had identified or addressed any quality assurance issues.
During an interview on 10/27/22, at 5:15 P.M., the social services director said if there are any issues in the building, they are discussed in the daily meeting. If an emergency arises, she would let the administrator know immediately. She was not aware of a formal process to address concerns.
During an interview on 10/27/22, at 5:17 P.M., the activities director said if there are any issues with the building or residents, she brought them directly to administration during morning meeting or would address the administrator individually if needed. She was not aware of any formal process to address concerns.
During an interview on 10/27/22, at 5:07 P.M., the administrator said the following:
-The QAA committee identifies any issues with any department during the daily morning meeting;
-The morning meeting consists of all members of the QAA committee;
-Morning meeting will identify any deviation from performance or negative trend;
-The mechanism for reporting quality concerns was accomplished by having an open door policy, any staff can go to any department head with issues;
-The QAA committee discusses issues that need to be worked on and safety issues are addressed first;
-There was no formal development or specific tracking process utilized.
MINOR
(C)
Minor Issue - procedural, no safety impact
Transfer Notice
(Tag F0623)
Minor procedural issue · This affected most or all residents
**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on interview and record review, the facility failed to provide a written notice of transfer to the resident and/or the res...
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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 a written notice of transfer to the resident and/or the resident representative when two residents (Resident #13, #45), of 26 sampled residents were transferred to the hospital. The facility census was 68.
Review of the facility's undated Discharge/Transfer of Resident from the Nursing Guidelines Manual showed the following:
-To leave the facility with plans or intention to return (i.e., transfer to an acute care facility for appropriate care);
-To provide safe departure from the facility and to provide sufficient information for aftercare of the resident.
-Equipment:
1. Transfer form, if necessary (for acute facility transfer)
2. Discharge summary and post discharge plan of care forms (for discharge to home, lower level of care or other long term care facility)
3. Inventory list
4. Notice of transfer or discharge, if necessary
5. Bed hold forms
-Discharge guidelines:
1. Explain discharge guidelines and reason to resident and give copy of Transfer & Discharge Notice as required. Include resident representative.
2. Complete a discharge summary and post discharge plan of care form:
a. Include list of medications with instructions in simple terms. Do not use medical terms or abbreviations.
b. Include instructions for post discharge care and explain to the resident and/or representative.
c. Have resident and/or representative or person responsible for care sign discharge summary and post discharge care form. This includes release of medications.
d. Give copy of form to the resident and/or representative or person(s) responsible for care.
e. Place signed original of form in the medical record.
-Explain transfer and reason to the resident and/or representative and give copy of signed transfer or discharge notice to the resident and/or representative or person responsible for care. NOTE: If emergency transfer, transfer or discharge notice form may be completed later, but as soon as possible.
-Explain and give copy of bed hold form to the resident and/or representative.
-Complete transfer form, copy any portion of the medical record necessary for care of resident (i.e., physician's orders, history, physical, etc.).
-Send original of transfer form and portions of medical record that was copied with the resident.
1 Review of Resident #13 face sheet, undated, showed the resident admitted to facility on 5/5/22 with diagnoses of schizophrenia (mental illness), bipolar disorder (mental illness), and colostomy. The resident had a durable power of attorney for healthcare.
Review of the resident's nurses' notes, dated 5/14/22, showed the following:
-The resident sat down nodding off to sleep, replied slowly to questions and slurred his/her words;
-The nurse obtained vital signs of heart rate at 138 beats per minute (normal heart rate 60-100 beats per minute) and blood pressure of 89/59 (normal blood pressure 120-80);
-The resident complained of being very tired and unstable when walked;
-The nurse practitioner ordered the resident be sent to emergency department for evaluation and treatment.
Review of the resident's nurses' notes, dated 6/17/22, showed the following:
-The resident did not speak and was not responding to his/her name;
-The resident just stood at station and weaved side to side;
-The nurse tried talking to the resident, offered him/her a snack, but the resident did not respond;
-The nurse called 911;
-The resident was taken to the hospital.
Review of the resident's medical record showed no evidence facility staff provided written notice to the resident and/or his/her responsible party of the resident's transfers to the hospital on 5/14/22 and 6/17/22.
2. Review of Resident #45's undated face sheet showed the following:
-The resident was admitted to the facility on [DATE];
-The resident's diagnoses included urinary tract infection (UTI) and urinary retention;
-The resident's family member was his/her emergency contact.
Review of the resident's admission Minimum Data Set (MDS), a federally required assessment instrument completed by facility staff, dated 9/14/22, showed the following:
-Moderately impaired cognition;
-Has indwelling urinary catheter (tube to drain urine from bladder);
-He/She had a urinary tract infection (UTI) in the last 30 days.
Review of the resident's progress notes, dated 10/17/22 at 10:17 P.M., showed the following:
-Change in condition;
-Vital signs: Blood pressure (BP) 106/50, pulse (heart rate) 50 (normal 60-100 beats per minute), respirations 20 (normal respiratory rate 12-18 breaths per minute). Oxygen delivered at three liters per minute per nasal cannula with saturation (oxygen level in the blood) of 92% (normal range on room air is 94% and above);
-Order received to send out for evaluation at local hospital.
Review of the resident's progress notes, dated 10/17/22 at 10:22 P.M., showed the resident's emergency contact was notified of a change in condition and new order for transfer to the local hospital for evaluation.
Review of the resident's progress notes dated 10/18/22 at 4:23 P.M. showed an update, the resident admitted to local hospital with diagnosis of ongoing UTI, injury to coccyx (tailbone), incontinence, and urinary retention.
Review of the resident's medical record showed no documentation the facility provided a written notice to the resident and the resident representative when the resident transferred to the hospital on [DATE].
During an interview on 10/27/22 at 1:15 P.M., the resident's family member said the following:
-He/She was the resident's emergency contact;
-The facility called him/her about the resident's transfer to the local hospital on [DATE];
-The facility did not give him/her written notice of transfer when the resident was transferred to the hospital.
During an interview on 10/27/2 at 9:40 A.M., the social services director said if the discharge paper work was not in the chart then it probably was not done.
During an interview on 10/27/22 at 1:50 P.M., the Director of Nurses (DON) said the following:
-She feels staff did not fill out Immediate Discharge Notice, Transfer Notice or Bed Hold Notice for the resident when transferring to the hospital as the facility had no no system in place;
-She expected staff to follow the facility Discharge/Transfer of Resident Guidelines.
MINOR
(C)
Minor Issue - procedural, no safety impact
Deficiency F0625
(Tag F0625)
Minor procedural issue · This affected most or all residents
**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on interview and record review, the facility failed to provide a written notice of bed hold with required information to t...
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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 a written notice of bed hold with required information to the resident and/or resident representative for two resident (Resident #13 and #45) in review of three sampled residents, when the facility initiated a transfer to the hospital. The facility census was 68.
Review of the facility's undated Discharge/Transfer of Resident from the Nursing Guidelines Manual showed the following:
-To leave the facility with plans or intention to return (i.e., transfer to an acute care facility for appropriate care);
To provide safe departure from the facility and to provide sufficient information for aftercare of the resident.
Discharge guidelines:
1. Explain discharge guidelines and reason to resident and give copy of Transfer & Discharge Notice as required. Include resident representative.
-Explain and give copy of bed hold form to the resident and/or representative.
1. Review of Resident #45's undated face sheet showed the following:
-The resident admitted to the facility on [DATE];
-The resident's diagnoses included urinary tract infection (UTI) and urinary retention;
-The resident's family member was the emergency contact.
Review of the resident's progress notes dated 10/17/22 at 10:17 P.M. showed the following:
-Change in condition: The resident hollering out and wants to see her mom and dad;
-Order received to send out for evaluation at local hospital.
Review of the resident's progress notes dated 10/17/22 at 10:22 P.M. showed the resident's emergency contact notified of change in condition and new order for transfer to the local hospital for evaluation.
Review of the resident's progress notes dated 10/18/22 at 4:23 P.M. showed an update, the resident admitted to local hospital.
Review of the resident's medical record showed no documentation staff provided discharge paperwork, including the bed hold policy to the resident and the resident representative when the resident transferred to the hospital on [DATE].
During an interview on 10/27/2 at 9:40 A.M. with the social services director said if the bed hold or discharge paper work is not in the chart then it probably was not done.
During an interview on 10/27/22 at 9:45 A.M. LPN D said the following:
-He/She doesn't typically send bed hold or transfer notice with the resident when sent out emergently;
-He/She believes the bed hold paperwork was kept at facility and not sent with the resident.
During an interview on 10/27/22 at 1:15 P.M., the resident's family member said the following:
-He/She was the emergency contact;
-The facility called him/her about the resident's transfer to local hospital on [DATE];
-He/She did not receive a bed hold letter from facility when the resident transferred to hospital.
2. Review of Resident #13's face sheet, undated, showed he/she was admitted to the facility on [DATE].
Review of the resident's nurses' notes, dated 6/28/22, showed the resident was discharged to hospital on 6/17/22.
Review of the resident's nurses' notes, dated 6/22/22 showed the resident was readmitted on [DATE].
Review of the resident's medical record showed no evidence staff informed the resident and/or resident representative in writing of the facility's bed hold agreement at the time of transfer on
-The duration of the state bed-hold policy, during which the resident is permitted to return and resume residence in the nursing facility;
-The reserve bed payment policy;
-The nursing facility's policies regarding bed-hold periods;
-Permitting a resident to return.
During an interview on 10/27/22 at 1:50 P.M., the administrator and Director of Nurses (DON) said the following:
-Staff did not fill out a Bed Hold Notice for the resident when the resident transferred to the hospital, as there was no system in place;
-She expected staff to follow the facility Discharge/Transfer of Resident Guidelines.
Jun 2019
17 deficiencies
CONCERN
(D)
Potential for Harm - no one hurt, but risky conditions existed
Resident Rights
(Tag F0550)
Could have caused harm · This affected 1 resident
Based on interview and record review, the facility failed to treat one resident (Resident #65), in a review of 18 sampled residents, with dignity and respect, when a staff member raised his/her voice ...
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Based on interview and record review, the facility failed to treat one resident (Resident #65), in a review of 18 sampled residents, with dignity and respect, when a staff member raised his/her voice out of frustration in response to the resident approaching the staff member about his/her medications in the hallway. The interaction as overheard by other residents and staff and caused the resident distress. The facility census was 76.
1. Review of the facility's policy, Resident Rights, revised 10/01/17, showed treating residents with dignity and respect was not only the policy of the facility but also the law. Staff should treat all residents with consideration, respect, and dignity, at all times. Staff behavior must reflect their beliefs in that right in their daily interactions with residents, families, and visitor to the facility.
2. During the resident group meeting on 6/18/19 at 10:05 A.M., Resident #14 said the previous evening, Registered Nurse (RN) B had a melt down in the hallway when Resident #65 approached him/her in the hallway about his/her medications. RN B yelled and screamed at Resident #65. Resident #14 overheard the incident and recognized Resident #65's and RN B's voices. Resident #14 said other residents and staff overheard the incident and this was not the first time RN B had become frustrated and yelled in front of residents.
3. Review of Resident #65's quarterly Minimum Data Set (MDS), a federally mandated assessment instrument required to be completed by facility staff, dated 5/21/19, showed the following:
-Cognition was moderately impaired;
-No hallucinations, delusions, or behaviors were present.
During an interview on 6/19/19 at 11:15 A.M., Resident #65 said on 6/17/19, he/she had not received his/her 4:00 P.M. or 8:00 P.M. medications so he/she walked up the hall and approached RN B at the medication cart about his/her medications. RN B started yelling, saying his/her own name several times and said what the hell do you want me to do? RN B then threw an uncapped needle at the resident. The needle did not hit the resident but hit the wall next to the resident. RN B was waving his/her hands and jumping up and down and yelled so loudly several other staff members stuck their heads out into the hallway to see what was going on. The resident said he/she did not receive any medication until 2:00 A.M. from the night shift nurse and was so upset about the incident that he/she cried for two hours.
During an interview on 6/19/19 at 2:30 P.M., Certified Medication Technician (CMT) C said he/she worked the evening of 6/17/19. Around 8:00 P.M., Resident #65 approached RN B. CMT C was standing by the medication room and RN B and Resident #65 were about halfway down the hall. CMT C did not hear exactly what was said but both RN B and Resident #65 had raised voices. CMT C did not see RN B throw anything at the resident. CMT C did not report the incident to anyone because he/she felt it was a misunderstanding. CMT C would not want someone to speak to his/her family member the way RN B spoke to the resident. CMT C said RN B could get frustrated easily.
During an interview on 6/19/19 at 2:40 P.M., Resident #28 said on 6/17/19 around bedtime, he/she lay in bed. Resident #28 heard RN B raise his/her voice in the hallway, to whom he/she later learned was Resident #65. Resident #28 could not make out exactly what was said, but described RN B as yelling. Resident #28 said if anyone had yelled at him/her that way, he/she would have been very upset. Resident #28 said hearing RN B yell that way caused him/her to be uncomfortable and to feel anxious.
During an interview on 6/20/19 at 7:30 A.M., the administrator said Resident #65 informed him/her on 6/19/19 that on the evening of 6/17/19, RN B yelled and threw a needle at him/her. This was the first time the administrator had heard of the incident. RN B was suspended pending the facility's investigation.
Review of the facility's investigation of events, dated 6/19/19, showed the following:
-On 6/19/19, Resident #65 reported to the administrator that on 6/17/19 around 10:00 P.M. RN B yelled and threw a syringe at him/her;
-Resident #65 said he/she asked RN B for his/her medications. RN B became upset and repeated his/her name several times and said everyone needs me; well, I haven't been to the bathroom in three days because no one will leave me alone long enough to go. RN B then threw a syringe that hit the resident on his/her casted arm;
-Resident #65 then told RN B he/she did not need her medication and walked away, back to his/her room;
-Resident #65 denied being afraid of RN B but said his/her feelings were hurt;
-The administrator spoke with Certified Nurse Aide (CNA) D who said he/she was in a room when she heard RN B shout his/her own name several times. CNA D came out of the room and saw RN B waving his/her hands around. CNA D told RN B, I'm glad you know your own name. RN B said Yeah, so does everyone else and if one more person comes to me I'm going to scream. CNA D walked into another resident's room and RN B continued to be loud with Resident #65 present at the medication cart. CNA D denied seeing RN B throw anything at the resident. The administrator asked CNA D why he/she did not report the incident and CNA D said he/she did not feel the incident was abusive and RN B had a moment of being overwhelmed;
-The resident's physician was notified of the incident and the administrator reported the allegation to the state agency;
-The administrator spoke with RN B who admitted to raising his/her voice out of frustration. RN B said he/she did not yell directly at Resident #65 but out of frustration in general. RN B said he/she yelled his/her own name several times and everyone wants me right this second. RN B said he/she was tired and hungry and needed a break. The administrator provided education to RN B on taking a break when needed and about speaking inappropriately around the residents or to the residents and/or other staff members;
-The administrator spoke with Resident #14 who said he/she did not directly witness the incident but overheard RN B yell at Resident #65 because he/she could recognize their voices.
During an interview on 6/20/19 at 11:00 A.M., the administrator said she received complaints about RN B's attitude from residents in the past, but not that RN B had yelled at anyone, but that he/she could be snarky. The administrator expected staff to inform her of any incident where a staff member raised their voice in front of a resident.
During a telephone interview on 6/20/19 at 11:20 A.M., RN B said sometime on the evening of 6/17/19, three different people had approached him/her at once. Resident #65 was the third resident to approach RN B and wanted his/her 8:00 P.M. pain medication. RN B said he/she said his/her own name three times very loudly. Resident #65 told RN B he/she would wait. RN B said he/she was very frustrated at the time due to several residents making requests of him/her. RN B said he/she did get very loud. RN B did not recall tossing or throwing anything at the resident. RN B said he/she knew his/her behavior was not professional and was sorry about the whole incident but never thought Resident #65 was upset by what happened.
During an interview on 6/20/19 at 11:54 A.M., Resident #7, who is Resident #65's roommate, said he/she was in his/her room on 6/17/19 when the incident between RN B and Resident #65 occurred. Resident #7 did not see or hear what happened but said Resident #65 came back to the room after the incident and was very upset over what happened. Resident #65 said RN B had yelled at him/her and was tearful and crying about the incident. Resident #7 had seen RN B get frustrated in the past. Resident #7 tried to get to the nurse's station for his/her medications so RN B didn't have to come down to his/her room. Resident #7 had seen RN B push the medication cart so fast it slammed into the nurse's station about one month ago. Resident #7 said he/she was not fearful of RN B but may be a bit hesitant to approach RN B for anything because of his/her attitude.
During an interview on 6/20/19 at 2:50 P.M., CNA D said about 10:00 P.M. on 6/17/19 he/she was in a room assisting a resident. RN B was out in the hallway. When CNA D came out of the room, he/she saw RN B wave his/her hands in the air and yelled his/her own name loudly. He/She said, If one more person comes to me, I am going to scream. Resident #65 was standing next to the medication cart, within two feet of RN B. Resident #65 appeared confused by what had happened and told CNA D, I just got yelled at for no reason. CNA D did not see RN B throw anything at the resident. CNA D had observed RN B get frustrated and raise his/her voice in front of residents in the past. CNA D said he/she did not report the incident as RN B was the charge nurse and CNA D wasn't sure who to report the incident to. CNA D said he/she should have written a statement, but at the time was not sure what to do.
During an interview on 6/20/19 at 3:52 P.M., the Director of Nursing (DON) said it was disrespectful for staff to raise their voice in front of a resident. The DON was not aware of the incident between RN B and Resident #65 until the day before (6/19/19). The DON said RN B did not handle stress well and was not good at asking for help. The DON expected staff to inform her of a staff member raising their voice in front of a resident.
CONCERN
(D)
Potential for Harm - no one hurt, but risky conditions existed
Quality of Care
(Tag F0684)
Could have caused harm · This affected 1 resident
Based on observation, interview, and record review, the facility failed to follow professional standards of practice for one resident (Resident #54), in a review of 18 sampled residents, when staff co...
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Based on observation, interview, and record review, the facility failed to follow professional standards of practice for one resident (Resident #54), in a review of 18 sampled residents, when staff continued to change a dressing to a wound without a current order for multiple days, and failed to document the condition of the wound or the need for the dressing to remain in place. The facility census was 76.
1. Review of the facility's policy on clean dressing changes, dated March 2015, showed the following:
-Purpose: To prevent infection and spread of infection and promote healing;
-Equipment: Dressing as ordered and medication as prescribed.
2. Review of Resident #54's Quarterly Minimum Data Set (MDS), a federally mandated assessment instrument required to be completed by facility staff, dated 5/17/19, showed the following:
-Cognition was moderately impaired;
-No ulcers, wounds, or skin problems present.
Review of the resident's care plan, last revised 5/22/19, showed the following:
-At risk for skin breakdown. The resident's skin was very fragile and he/she developed skin tears easily;
-Provide treatment to skin tears that may occur as ordered/as needed;
-Report any signs of skin breakdown.
Review of the resident's physician order sheet (POS) for 5/26/19 through 6/20/19 showed an order with a start date of 1/10/19 to cleanse the right forearm with normal saline. Apply Neosporin (antibiotic ointment) and a non-adhesive dressing, cover with a dry dressing daily. The order was discontinued on 5/28/19.
Review of the resident's treatment administration record (TAR) for June 2019 showed no documentation of any dressing to the resident's upper extremities.
Review of the resident's nurse's note, dated 6/8/19 at 3:51 A.M., showed the resident remained on observation for a fall with injuries noted. A dressing was in place to both upper extremities.
(There was no further documentation found in the nurse's notes about a dressing to the residents upper extremities.)
Observation and interview on 6/17/19 at 4:16 P.M. showed the resident had a dressing of gauze wrap in place to his/her right forearm. The dressing was dated 6/4/19. The resident said he/she thought there was a cut there.
Review of the resident's shower sheet, dated 6/17/19, showed multiple areas of bruising and steri strips (adhesive wound closure strips) in place to the resident's right hand and forearm.
Observation and interview on 6/18/19 at 11:21 A.M. showed the resident had a dressing of gauze wrap in place to the right forearm. The dressing was not dated. The resident said he/she had a shower last night and staff changed the dressing. The resident said there was a cut there that was bleeding.
During an interview on 6/18/19 at 4:09 P.M., Licensed Practical Nurse (LPN) A reviewed the resident's TAR and confirmed there was no order in place for a dressing to the resident's arms. LPN A was not aware of any wound or skin concern on the resident's arms.
Observation on 6/18/19 at 5:22 P.M. showed the undated dressing remained in place to the resident's right forearm.
Observation on 6/19/19 at 9:37 A.M. showed an undated dressing in place to the resident's right forearm.
Observation on 6/19/19 at 3:20 P.M. showed the Assistant Director of Nursing (ADON) pulled up the resident's right shirt sleeve. The gauze dressing had slid down towards the resident's wrist and was no longer covering the wound. There were approximately 12 steri strips in place on the resident's right arm just below the elbow. The steri strips covered a large skin tear and there was a dark, dried, crusty, substance present on the steri strips.
During an interview on 6/20/19 at 3:10 P.M., the Director of Nursing (DON) said she expected staff to document dressing changes and contact the resident's physician if the order needed to be continued or a wound was not healing. Resident #54 had very fragile skin and obtained skin tears easily. The DON said she wasn't sure when the resident obtained the skin tear to the right arm but felt staff may have placed a dressing on the area acting on their own judgment. The DON would not expect staff to leave a dressing in place on a resident for multiple days.
CONCERN
(D)
Potential for Harm - no one hurt, but risky conditions existed
Pressure Ulcer Prevention
(Tag F0686)
Could have caused harm · This affected 1 resident
Based on observation, interview, and record review, the facility failed to timely implement measures to prevent the development of three Stage II (Partial thickness loss of dermis presenting as a shal...
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Based on observation, interview, and record review, the facility failed to timely implement measures to prevent the development of three Stage II (Partial thickness loss of dermis presenting as a shallow open ulcer with a red-pink wound bed without slough. May also present as an intact or open/ruptured blister) pressure ulcers for one resident (Resident #173), in a review of 18 sampled residents, who was admitted to the facility without any pressure ulcers and after the resident had been assessed with a Stage I pressure ulcer six days prior to identifying the Stage II pressure ulcers. The facility failed to ensure staff across all shifts was aware of the resident's pressure ulcers and need for assistance with repositioning, and failed to ensure the resident had adequate pressure relief when sitting. The facility census was 76.
1. Review of the Long Term Care Facility Resident Assessment Instrument User's Manual, Version 3.0, Chapter 3, Section M, defines the different stages of pressure ulcers (localized injury to the skin and/or underlying tissue usually over a bony prominence, as a result of pressure, or pressure in combination with shear and/or friction) as follows:
-Stage I: an observable, pressure related alteration of intact skin, whose indicators as compared to an adjacent or opposite area on the body may include changes in skin temperature, tissue consistency, sensation, and/or a defined area of persistent redness;
-Stage II: Partial thickness loss of dermis (the inner layer that makes up skin) presenting as a shallow open ulcer with a red-pink wound bed, without slough (non-viable yellow, tan, gray, green or brown tissue). May also present as an intact or open/ruptured blister;
-Stage III: full thickness tissue loss. Subcutaneous fat may be visible but bone, tendon or muscle is not exposed. Slough may be present but does not obscure the depth of tissue loss. May include undermining (destruction of tissue or ulceration extending under the skin edges) or tunneling (a passage way of tissue destruction under the skin surface that has an opening at the skin level from the edge of the wound);
-Stage IV: Full thickness tissue loss with exposed bone, tendon or muscle. Slough or eschar (dead or devitalized tissue that is hard or soft in texture; usually black, brown, or tan in color) may be present on some parts of the wound bed. Often includes undermining and tunneling.
2. Review of the facility's policy on Pressure Ulcer Care and Prevention, dated March 2015, showed the following:
-Purpose: To prevent and treat further breakdown of pressure sores;
-Treatment of pressure ulcers will vary depending on the orders of the attending physician. The nurse is responsible for carrying out the treatment as ordered by the attending physician and for implementing measures to prevent pressure ulcers;
-Observe skin. Any persistent reddened area that remains after pressure is relieved is a high risk for pressure ulcer to begin;
-Apply lotion gently to dry skin;
-Use pressure reducing devices to relieve pressure;
-Turn the resident every two hours and position with pads or pillows to protect bony prominences.
3. Review of the facility's policy on Wound Dressings, dated March 2015, showed the following:
-Stage I: Redness only, no break in the skin. Treatment: Cover with house hydrocolloid dressing (breathable, transparent wound dressing that adheres to skin), change every seven days and as needed (PRN). Other treatment as directed by the physician;
-Stage II: Partial thickness skin loss involving the epidermis or dermis. Ulcer is superficial and presents as an abrasion, blister, or shallow crater. Treatment: Low exudate (wound drainage)- Apply house hydrocolloid dressing and change every three days and as needed. Other treatment as directed by the physician. Medium exudate- House hydrocolloid or transparent dressing and change every three days and PRN. Other treatment as directed by the physician.
4. Review of Resident #173's Physician Order Sheet (POS), dated 5/25/19 through 6/25/19, showed the following:
-admission date 5/30/19;
-Diagnoses included fracture of the left femur, need for assistance with personal care, and muscle weakness.
Review of the resident's admission clinical assessment, dated 5/30/19, showed the resident was at risk for skin issues related to decreased activity level and immobility.
Review of the resident's Braden Scale, a tool for determining pressure ulcer risk, dated 5/31/19, showed a score of 18, indicating the resident was at risk for pressure ulcer development.
Review of the resident's weekly skin assessment, dated 6/1/19, showed the resident's skin was intact. The resident had no skin issues.
Review of the resident's weekly skin assessment, dated 6/5/19, showed the resident had an existing skin issue of a left hip incision that was healing nicely. No redness noted anywhere.
Review of the resident's admission Minimum Data Set (MDS), a federally mandated assessment instrument required to be completed by facility staff, dated 6/6/19, showed the following:
-Cognition was intact;
-Required extensive assistance of one staff for bed mobility, transfers, dressing, and toilet use;
-Required supervision for hygiene;
-Limitation in the range of motion, impairment on one side of the lower extremity;
-At risk for pressure ulcers;
-No unhealed pressure ulcers at Stage I or higher;
-Pressure reducing device for the chair and bed;
-Turning and repositioning program;
-Application of ointments/medications other than to feet.
Review of the resident's weekly skin assessment, dated 6/6/19, showed the resident's skin was intact. The resident had no skin issues.
Review of the resident's weekly skin assessment, dated 6/10/19, showed the resident's skin as intact. A dressing was in place to the surgical site on the left hip. There were no other areas of concern.
Review of the resident's shower sheet, dated 6/12/19, showed an area identified as a rash to the resident's buttock. Butt cream put on. A certified nurse aide (CNA) and the Assistant Director of Nursing (ADON) signed the shower sheet.
Review of the nurse's daily report sheet for the resident, dated 6/12/19, showed a new area to the coccyx (tail bone)/buttocks, Stage I. Licensed Practical Nurse (LPN) A and the Director of Nursing (DON) observed.
There was no other documentation found in the resident's record regarding the Stage I pressure ulcer assessed on 6/12/19 or interventions utilized to prevent further skin breakdown.
Review of the resident's care plan, dated 6/17/19, showed the following:
-At risk for pressure ulcers related to need for assistance with bed mobility and transfers;
-Check positioning and reposition every two hours and as needed when in the wheelchair. The resident had a tendency to slide down in the wheelchair at times;
-Assist of one staff for activities of daily living;
-Conduct a systematic ski inspection weekly. Pay particular attention to bony prominences;
-Provide incontinent care after each incontinent episode;
-Report any skin breakdown (sore, tender, red, or broken areas);
-Moisture barrier product to perineal area.
Review of the resident's nurse's note, dated 6/18/19 at 10:51 A.M., showed a new order was received to cleanse the open area to the right gluteal fold with normal saline and apply optifoam (absorbent foam dressing with an adhesive border). Nursing to change the dressing every three days and as needed (PRN).
Observation on 6/18/19 at 1:33 P.M. showed the resident lay in bed. The ADON assessed the resident's buttocks. There was an open area on the resident's coccyx approximately 4 centimeters (cm) by 1 cm with a large area of dark purple skin surrounding the ulcer. The ADON cleansed the open area with gauze. The ADON placed an optifoam dressing over the open area. There was a second, smaller, open area observed under the resident's left buttock and excoriation noted under the right buttock where it appeared the resident's incontinent brief would sit. The ADON did not apply anything to these areas.
During an interview on 6/18/19 at 1:33 P.M., the ADON said the areas on the resident's buttock were not improving. The coccyx wound started as a small area and had gotten worse over the last two or three days. The Therapy Director was in the resident's room and said he/she would look into a new cushion for the resident's wheelchair.
Observation and interview on 6/18/19 at 1:55 P.M. showed the resident lay in bed. The resident's family member said the resident had complained for the last week that his/her bottom was sore and the family member had asked staff to check on the resident's skin several times. There was a plastic covered cushion in the resident's wheelchair that was flattened in the middle. The resident said his/her wheelchair was not comfortable. The family member said he/she looked at the area one day last week with the Director of Nursing (DON) and the area was red. The family member was worried about the area then. The family member said the resident had complained about his/her wheelchair being uncomfortable and did not feel the cushion currently in the wheelchair was providing much relief.
Review of the resident's nurse's note, dated 6/18/19 at 2:46 P.M., showed a call was placed to the physician's nurse about a new open area to the coccyx/bilateral buttocks, partial thickness, greater than 0.2 millimeter depth, epithelial layer appears to be sheared away. Family at bedside during the initial dressing placement. Area was noted to be greater than dime sized, unopened pink area. New orders received for the coccyx to cleanse with normal saline, allow to dry, apply a small amount of hydrogel (gel used for wounds and pressure ulcers with little to no drainage) to the wound bed and cover with foam adhesive every other day and PRN if soiled. Right gluteal cleft small abrasion with new orders to cleanse with normal saline, skin prep (liquid, film forming substance that reduces friction to skin) around the wound, Nystat (antifungal) powder, and cover with zinc every shift and PRN. Family and resident made aware.
Observation and interview on 6/18/19 at 4:05 P.M. showed the resident lay in bed. The ADON was at the bedside and said the previous dressing already had a large amount of drainage present. The ADON received new orders for hydrogel and optifaom to be changed every other day and new orders for the gluteal cleft wounds. The ADON said the coccyx wound was at least a Stage II pressure ulcer, if not a Stage III pressure ulcer. The gluteal cleft wound was a Stage II. The CNAs had mentioned the resident's bottom was red several days ago. The ADON dressed the open area to the resident's coccyx per the physician's orders and applied zinc cream topically to the left and right gluteal cleft.
During an interview on 6/19/19 at 5:38 A.M., Licensed Practical Nurse (LPN) J said he/she thought the resident had a red bottom which had been red for a few days. LPN J was not aware of the resident having any open areas.
During an interview on 6/19/19 at 5:52 A.M., Certified Nurse Aide (CNA) K said he/she had not observed the resident's bottom and was not aware of the resident's having any open areas.
During an interview on 6/19/19 at 6:15 A.M., CNA L said the resident had a surgical incision to his/her hip. CNA L said the resident did not have any skin breakdown or open areas that he/she was aware of. CNA L said he/she was not aware of any special instructions regarding turning or repositioning the resident, and said the resident was able to reposition himself/herself in bed without any assistance.
During an interview on 6/19/19 at 6:30 A.M., CNA M said he/she was not aware of the resident having any open areas or skin issues.
Observation on 6/19/19 at 7:35 A.M. showed the resident's previous wheelchair cushion had been replaced with a Roho cushion (made of soft flexible air cells connected by small channels).
During an interview on 6/19/19 at 10:50 A.M., LPN A said he/she had just changed the dressing on the resident's coccyx. LPN A said he/she did not measure the wounds and thought the nurse who changed the dressing yesterday obtained measurements.
During an interview on 6/19/19 at 2:12 P.M., the ADON said no measurements had been obtained of the resident's wounds. The ADON would attempt to get the measurement that day.
Observation on 6/19/19 at 2:52 P.M. showed the resident lay in bed. The DON and the ADON removed the dressing to the resident's coccyx wound. A large, softball size, dark red area remained around the coccyx wound. The ADON measured the open area on the resident's coccyx as 4.25 cm by 5 cm. An open area to the left buttock measured 1.1 cm by 0.6 cm. An open area to the right buttock measured 1.3 cm by 0.4 cm. All three areas were with the superficial layer of skin gone. The ADON dressed the coccyx wound per the physician's orders. The ADON dressed the right and left buttock wounds with zinc oxide cream topically. Per the ADON the Nystat powder had not yet arrived from the pharmacy.
During an interview on 4/19/19 at 4:05 P.M., the ADON said the resident had complained of pain to his/her buttock the week before. The ADON looked at the resident's buttock at that time, which was red but did not have any open areas. The ADON said looking back, the red area could have possibly been a deep tissue injury.
During an interview on 4/19/19 at 4:08 P.M., the DON said she had looked at the resident's buttock one day last week with the resident's family member. The resident's buttock was red but was not open at that time. The DON said the CNAs applied a barrier cream to the resident's buttock but that was not documented on the resident's treatment administration record. The DON reviewed the list of residents on the turn schedule list, where staff documented turning residents routinely and found the resident was not on the turn schedule list.
During an interview on 4/19/19 at 4:18 P.M., the resident's family members said when the resident was first admitted to the facility they has requested a low air loss mattress for pressure relief. Staff told the family no because a low air loss mattress was contraindicated for a broken hip. The family members did not feel the previous cushion in the resident's wheelchair was providing adequate pressure relief. The family had told staff for over a week he/she was worried about the resident's bottom and assumed the staff was taking care of it.
During an interview won 6/20/19 at 9:50 A.M., the therapy director said he/she was not aware of any restrictions regarding the use of a low loss air mattress for a resident with a broken hip.
During an interview on 6/20/19 at 10:30 A.M., the DON said the resident's family had previously requested a low air loss mattress but the DON could not justify the low air loss mattress as the resident did not have any open areas at that time. The DON was not aware of any contraindications for the use of a low air loss mattress with a broken hip.
Observation and interview on 6/20/19 showed the following:
-At 7:15 A.M., the resident sat in a wheelchair in his/her room;
-At 8:05 A.M., the resident remained seated in the wheelchair in his/her room. The resident said he/she had been up in the wheelchair since 7:00 A.M. That's what time he/she usually got out of bed. The resident had not been out of the wheelchair since then;
-At 8:56 A.M., the resident finished eating breakfast in his/her room, seated in his/her wheelchair;
-At 9:34 A.M., the resident remained seated in his/her wheelchair in his/her room;
-At 9:43 A.M., therapy staff transferred the resident from the wheelchair to bed.
(The resident remained seated in his/her wheelchair without a change in position for at least two hours and 28 minutes.)
During an interview on 6/20/19 at 3:10 P.M., the DON said she disagreed with staff members documentation on the nurse report sheet, dated 6/12/19, that the resident had a Stage I pressure ulcer. The DON said the area was reddened but was blanchable. The resident was not very vocal with staff and tells his/her family of his/her concerns but not staff. The resident's wheelchair cushion was changed to provide additional pressure relief now that the resident had open areas. The DON was not certain what cushion was in place prior to receiving the Roho cushion. The DON said the resident's family had voiced concern over the resident's bottom. The DON said staff could have been more proactive regarding the resident's skin breakdown.
CONCERN
(D)
Potential for Harm - no one hurt, but risky conditions existed
Deficiency F0697
(Tag F0697)
Could have caused harm · This affected 1 resident
Based on observation, interview, and record review, facility staff failed to consistently document assessment of pain and failed to consistently provide interventions noted to control pain, by adminis...
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Based on observation, interview, and record review, facility staff failed to consistently document assessment of pain and failed to consistently provide interventions noted to control pain, by administering pain medication late for one resident (Resident #173), in a review of 18 sampled residents. The facility census was 76.
1. Review of the facility's Pain Management Guidelines, dated January 2017, showed the following:
-Purpose: To manage pain symptoms so residents will be as free of pain and discomfort as possible;
-The assessment scale (1-10) will be conducted whenever pain is suspected resulting in the administration of pain medications, i.e. verbal complaints of pain, behavioral or depression symptoms;
-The documentation of the Medication Administration Record (MAR)/Treatment Administration Record (TAR) is completed every shift, with documentation on the back of the MAR/TAR when an as needed (PRN) is given;
-Pain medications are to be administered according to the physician orders;
-Chronic pain is to be treated with regularly scheduled pain medications;
-PRN dosing is only appropriate for chronic pain as an adjunct to routine medications and/or to determine the need for regularly scheduled medications.
2. Review of the Resident #173's admission pain assessment, dated 5/31/19, showed the following:
-Disease Management Concerns: Pain;
-Monitor medications;
-Provide comfort and care;
-Monitor condition and report changes to the Director of Nursing (DON) and the physician as applicable.
Review of the resident's physician order sheet for 5/25/19 through 6/25/19, showed the following:
-admission date 5/30/19;
-Diagnosis of fracture of the left femur;
-Tramadol (pain medication) 50 milligrams (mg) three times a day as needed in the A.M., noon, and at bedtime;
-Norco (narcotic pain medication) 5/325 milligrams every six hours as needed (PRN) for pain.
Review of the resident's MAR for June 2019, showed the following:
-On 6/2/19, staff initialed they administered Norco 5/325 mg PRN for pain rated 7/10 on the front of the MAR. Staff documented they administered Norco 5/325 mg by mouth for pain at 10:50 P.M. on the back of the MAR. There was no follow up documented regarding the effectiveness of the medication;
-On 6/3/19, staff initialed they administered Norco 5/325 mg PRN for pain rated 8/10 on the front of the MAR. There was no documentation staff administered the medication on this date, no time listed, and no follow up documented regarding the effectiveness of the medication.
-On 6/4/19, staff initialed they administered Norco 5/325 mg PRN for pain rated 6/10 three times on the front of the MAR. Staff documented administration of the medication at 3:30 P.M. and 10:00 P.M. on the back of the MAR. There was no other documentation regarding the administration of the Norco on this date or of the effectiveness of the medication.
Review of the resident's physician order sheet showed an order dated 6/5/19 for Tramadol 50 milligrams, take two tablets at 2:00 P.M. and 8:00 P.M. daily and discontinue previous order.
Review of the resident's pain scale on the Treatment Administration Record (TAR) for June 2019 showed the following:
-Assess pain every shift using pain scale of 0-10;
-From 6/1/19 through 6/5/19, the pain scale was blank on the day and evening shifts.
Review of the resident's MAR for June 2019, showed the following:
-On 6/6/19 at 5:00 P.M., staff documented they administered Norco 5/325 mg for complaints of pain. There was no follow up documented regarding the effectiveness of the medication. There was no documentation on the front of the MAR to show staff rated the resident's pain on this date;
-On 6/7/19, staff initialed they administered the Norco 5/325 mg for pain rated 5/10. Staff documented they administered Norco 5/325 mg for pain at 3:45 A.M. on the back of the MAR. There was no follow up documented regarding the effectiveness of the medication;
-On 6/11/19, staff initialed they administered the Norco 5/325 mg PRN for pain rated 6/10. There was no documentation staff administered the medication on this date, no time listed, and no follow up documented regarding the effectiveness of the medication.
Review of the resident's physician progress note, dated 6/11/17, showed the following:
-The resident reported pain in his/her left knee;
-The resident's left knee was warm and tender to touch;
-The resident's main complaint was the timing of his/her pain medication and reports the medication dose is either missed or received late;
-Will continue Tramadol to manage the resident's pain of the same time of 2:00 P.M. and 8:00 P.M. It's a matter of when he/she will get it;
-Discussed this issue with staff.
Review of the resident's pain scale on the Treatment Administration Record (TAR) for June 2019 showed the following:
-Assess pain every shift using pain scale of 0-10;
-From 6/10/19 through 6/13/19 the pain scale was blank on the evening shift;
-From 6/15/19 through 6/18/19 the pain scale was blank on the night shift;
-On 6/17/19, 6/18/19, and 6/19/19, the pain scale was blank on the evening shift.
Review of the resident's care plan, dated 6/17/19, showed the following:
-The resident had complaints of pain related to his/her left hip fracture repair and a bad left knee;
-Administer medications as ordered;
-Assess effects of pain on the resident;
-Encourage the resident to discuss feelings about pain;
-Evaluate effectiveness of pain management interventions. Adjust if ineffective or adverse side effects emerge;
-Monitor and record complaints of pain: location, frequency, intensity, affect on function, alleviating factors, aggravating factors.
During an interview on 6/17/19 at 2:02 P.M., the resident's family member said he/she was in the facility daily. The resident did not receive his/her medications on time. The resident had scheduled pain medication at 2:00 P.M. and 8:00 P.M. The resident received the pain medication late on multiple occasions and received the 8:00 P.M. dose of pain medication as late as 11:00 P.M.
During an interview on 6/18/19 at 3:14 P.M., the resident's family member reported the resident had still not received his/her 2:00 P.M. scheduled pain medication. The resident was supposed to get Tramadol routinely at 2:00 P.M. and 8:00 P.M. When the resident received the medication on time, it seemed to manage his/her pain. This has been an ongoing issue that the family member had addressed with staff several times already. The family member informed the certified nurse aide (CNA) who was going to let the certified medication technician (CMT) know the resident was hurting and wanted his/her pain medication.
During an interview on 6/18/19 at 3:20 P.M., the resident said he/she was having pain in his/her left knee. The left knee caused the resident more pain than his/her fractured hip. The resident said the Tramadol helped and getting it regularly at 2:00 P.M. and 8:00 P.M. helped to control the pain before it became too bad. The resident said his/her pain medications had been given late several times. The resident said sometimes he/she wouldn't receive 8:00 P.M. dose of Tramadol until 10:00 P.M. or 11:00 P.M. and the 2:00 P.M. dose of Tramadol until 3:00 P.M. or 4:00 P.M. This caused the medication to not work as well in relieving his/her pain.
Observation on 6/18/19 at 3:30 P.M. showed CMT O administered the resident's 2:00 P.M. scheduled dose of Tramadol.
During an interview on 6/18/19 at 4:15 P.M., CMT O said he/she worked at the facility one or two days a week and did not arrive at the facility until 3:00 P.M. because of another commitment. The day shift CMT's shift ended at 1:30 P.M. and that CMT should administer the scheduled 2:00 P.M. medications on the days CMT O worked. CMT O was not aware the resident had not already received his/her 2:00 P.M. dose of Tramadol until the CNA told CMT O the resident had asked for it.
Observation on 6/19/19 at 2:52 P.M. showed the following:
-The Director of Nursing (DON) and the Assistant Director of Nursing (ADON) preformed a dressing change to the resident's coccyx as he/she lay in bed;
-During the dressing change, the DON asked the resident to rate his/her pain level;
-The resident rated his/her pain at five out of ten;
-There was no follow up or interventions offered in response to the resident's report of pain.
During an interview on 6/20/19 at 3:10 P.M., the DON said staff should assess residents' pain every shift. Staff should respond with interventions to relieve pain and document whether or not it was effective. The resident had orders in place for scheduled Tramadol and Norco as needed for pain. The DON was aware the resident's medication had been administered late on a couple of occasions. CMT O did come to work at 3:00 P.M. on Tuesdays. The day shift staff should be administering the 2:00 P.M. medications on those days and felt maybe that had not been communicated properly. The facility had recently switched to an open medication pass time where morning and evening medications could be administered during a block of time over several hours. Scheduled pain medications should be administered at the time specified in the physician's order, but thought the open medication times may have caused some confusion with staff. The DON did recall the resident reported pain of five out of ten during the dressing change the day before but was not certain of any interventions provided.
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 administer insulin according to the manufacturer's recommendations for two residents (Residents #22 and #68), in a review of ...
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Based on observation, interview, and record review, the facility failed to administer insulin according to the manufacturer's recommendations for two residents (Residents #22 and #68), in a review of 18 sampled residents. The failure had the potential to result in the resident not receiving the ordered dose of insulin. The facility census was 76.
1. Review of the manufacturer's instructions for use for the Humalog (insulin) KwikPen (injection cartridge device) showed the following:
-Before each injection, small amounts of air may collect in the cartridge during normal use;
-It is important to prime your pen before each injection so that it will work correctly;
-If you do not prime before each injection, you may get too much or too little insulin;
-To prime your pen, turn the dose knob to select two units;
-Hold the Humalog KwikPen with the needle pointing up;
-Tap the cartridge gently with your finger a few times to make any air bubbles collect at the top of the cartridge;
-Keep the needle pointing upwards and push the dose knob in until it stops, and 0 is seen in the dose window, hold the dose knob in a count to five slowly;
-A drop of insulin should appear at the needle tip, if not, repeat the priming procedure no more than four times;
-If you do not see a drop of insulin after four times, change the needle and repeat the priming steps;
-Turn the dose knob to the number of units of insulin you need to inject;
-Insert the needle into the skin and inject the dose by pressing the push button all the in and slowly count to five before removing the needle.
2. Review of Resident #22's Physician Order Sheet for June 2019, showed an order for Humalog KwikPen sliding scale before meals. If blood sugar is 100-150, give three units; if 151-200, give 5 units, if 201-250, give 10 units; if 251-300, give 13 units; if 301-350, give 17 units; and if greater than 350, give 20 units subcutaneous.
Observation on 6/19/19 at 11:28 A.M., showed the following:
-The resident's blood sugar was 166;
-Licensed Practical Nurse (LPN) A put a needle on the Humalog Kwikpen;
-LPN A dialed the dose knob of the resident's Humalog KwikPen to 5 units;
-LPN A did not prime the pen (as directed by the manufacturer) prior to selecting the desired dose;
-The resident administered the Humalog KwikPen LPN A prepared by LPN A into his/her right abdomen without priming the insulin pen.
3. Review of Resident #68's Physician Order Sheet for June 2019, showed an order for Humalog KwikPen sliding scale insulin subcutaneous before meals and at bedtime. If blood sugar is 0-200, give 0 units; if 200-250, give 2 units; if 251-300, give 3 units; if 301-350, give 4 units; if 351-400, give 5 units; if 401-450, give 6 units; and if greater than 450, call physician.
Observation on 6/20/19 at 07:21 A.M., showed the following:
-The resident's blood sugar was 264;
-LPN E dialed the dose knob of the resident's Humalog KwikPen to 3 units;
-LPN E did not prime the pen prior to selecting the desired dose;
-LPN E administered the Humalog KwikPen he/she prepared into the resident's right arm without priming the insulin pen.
During an interview on 6/20/19 at 8:23 A.M., LPN E said he/she was not aware the insulin pens needed to be primed prior to each use.
4. During an interview on 6/20/19 at 8:25 A.M., the Director of Nursing (DON) said the following:
-If it is a new insulin pen, staff should squeeze out a little insulin, just until they see insulin;
-If it is not a new insulin pen, then staff do not have to prime the insulin pen prior to giving a resident insulin.
CONCERN
(E)
Potential for Harm - no one hurt, but risky conditions existed
Deficiency F0565
(Tag F0565)
Could have caused harm · This affected multiple residents
Based on interview and record review, the facility failed to respond to the issues and concerns brought forth by residents during resident council meetings for five residents (Residents #14, #36, #39,...
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Based on interview and record review, the facility failed to respond to the issues and concerns brought forth by residents during resident council meetings for five residents (Residents #14, #36, #39, #65 and #67), in a review of 18 sampled residents. Facility staff failed to document and communicate their response to issues raised by the council. The facility census was 76.
1. Review of the Resident Council Minutes, dated 4/11/19, showed the following:
-Residents #14 and #67 were in attendance;
-New business [Listed for follow up from last month minutes and staff identified as responsible]: issues were staff on their phones, third shift was still slamming doors, some residents were not getting one or two showers a week. Staff not answering all lights and sleeping;
-Care Concerns: some aides turning off the call light and saying they will be back and don't come back (the resident did not want to say who). Residents asked if there could be a team aide leader for every shift to help the new aides when first on the floor. The activity director responded yes, per the administrator. Residents wanted more men's activities and more stuff outside. The activity director said he/she could make that happen and will be doing more things outside as the weather permitted;
-Other Issues: residents would like staff meetings and shift huddles to be in a closed room. Staff on all shifts were on their phones a lot and not attending to the residents. Medications were still running late.
Review of the Resident Council Minutes, dated 5/9/19, showed the following:
-Residents #14 and #67 were in attendance;
-New business [Listed for follow up from last month minutes and staff identified as responsible]: staff member still playing on phone, second shift not answering lights timely, and staff attitude;
-Care concerns: Resident #14 concerned with a resident not being turned;
-Other Issues: Resident #67 was now the acting council president.
Review of the Resident Council Minutes, dated 6/14/19, showed the following:
-Residents #14, #65, and #67 were in attendance;
-New business [Listed for follow up from last month minutes and staff identified as responsible]: still slamming doors on every shift, especially night shift. Residents want to know if staff phones can be put up during the shift; second and third shifts are the worst;
-Care Concerns: call lights not being answered timely;
-Other issues: residents want the snack cart pushed down every hall to ensure everyone gets an option and would also like fruit on the snack cart.
2. During the resident group meeting on 6/18/19 at 10:00 A.M., Residents #14, #36, #39, and #67 said no one gets back to the residents about the complaints voiced at the resident council meetings. It seemed as though the same complaints were voiced from month to month but the group was not notified of what was being done, if anything to correct the issues. Staff being on their phones, call lights not getting answered, and staff turning off the call light and saying they'd be right back but not returning have been a recurring issues.
During an interview on 6/19/19 at 11:10 A.M., Resident #14 said he/she had repeated trouble with his/her medications being administered late, or being signed out and not given. The resident had expressed this concern in the resident council many times but was not sure what, if anything was being done to correct the issue. Staff did not get back with the council to follow up on their concerns.
During an interview on 6/19/19 at 11:15 A.M., Resident #65 said he/she frequently had difficulty getting his/her medications on time. The resident had expressed this concern to multiple staff as well as the resident council but nothing ever seemed to be done about it. Staff did not follow up with him/her about his/her concerns.
3. During an interview on 6/19/19 at 11:45 A.M., the activity director said the resident council met on the second Thursday of every month. The activity director stayed during the council meeting and documented the minutes. The next day after the meeting, the activity director talked to the department heads and the administrator about the concerns from the resident council meeting. The department heads would get back with the activity director or the administrator verbally about what was being done to address the council's concerns. The activity director or the administrator would communicate back to the resident council about actions taken. The activity director gave a copy of the council minutes to all department heads. The activity director went over old business at the next month's council meeting with the residents. The residents at the council had expressed some repeated concerns, such as receiving medications on time. This concern was expressed to the administrator, and the activity director thought the administrator handled it from there. The activity director felt there weren't too many repeated concerns expressed at the council from month to month. Actions taken to resolve issues were communicated with residents verbally. Staff did not document or put their response to the council's concerns in writing.
During an interview on 6/20/19 at 3:10 P.M., the Director of Nursing (DON) said the activity director or the resident council president let him/her know about concerns from the council. The DON usually responded back to the council president or the individual resident who expressed a concern. The DON was not aware of any concern regarding snacks being passed. The DON was aware of concerns raised over call lights being answered timely. The DON had done in-servicing with staff and talked about implementing a buddy system for coverage on the halls and encouraged staff to work together to help get the call lights answered. Staff had also been in-serviced regarding phone use in the facility. The DON also tried to let residents know the nurses may be on their phones looking up medications or something related to their job.
During an interview on 6/20/19 at 1:20 P.M., the administrator said the activity director expressed residents' concerns voiced at the council meeting in the stand-up meeting and the issues were delegated to the appropriate departments. The activity director followed up with the residents and went over old business at the next month's resident council meeting to ensure issues were addressed. The administrator was aware of the group's concern over staff being on their phones. The administrator had done in-servicing with staff and monitored staff to ensure they were not on their phones. All department heads received a copy of the resident council minutes. Resident concerns were addressed verbally but there was no documentation or written response regarding actions taken to resolve the council's concerns.
CONCERN
(E)
Potential for Harm - no one hurt, but risky conditions existed
Safe Environment
(Tag F0584)
Could have caused harm · This affected multiple residents
**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, interview, and record review, the facility failed to maintain the flooring and tables in the facility dini...
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**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, interview, and record review, the facility failed to maintain the flooring and tables in the facility dining room to be clean and free of stains and an accumulation of debris, failed to maintain flooring, walls, and ceilings in resident rooms and hallways in good repair, and failed to maintain vents and ductwork to be free from an accumulation of debris. The facility census was 76.
1. Observations on 6/17/19 at 4:25 P.M. and 6/19/19 at 12:10 P.M. showed the dining room contained 22 tables. No table cloths were visible on any tables. Eighteen tables had red, pink, brown, yellow or orange-colored stains that appeared to be glass ring circles or large round spots or stains on the tables. One table had pink stains that streaked across the width of the table. The dining room measured approximately 40-feet by 33-feet and had green flooring tiles throughout the dining room. The tiles around the groupings of tables and chairs were discolored and stained with the same colors of spills and stains that the tables had on the eating surfaces.
During an interview on 6/19/19 at 9:35 A.M., Dietary Staff P said the dietary aide cleared the dishes from the tables in the dining room after each meal, wiped the tables down with the green bucket of hot soapy water, let them dry, then used the red bucket with sanitizer and wiped them down again. Housekeeping was responsible for sweeping and mopping the floors after every meal.
During an interview on 6/19/19 at 9:55 A.M., the Dietary Manager said the dietary aides clean up tables after meals, wipe tables down with soapy water, then wipe them down with sanitizer solution He didn't think any other cleaning methods had been tried to clean the tables. He had not discussed this or reported the condition of the tables to anyone else since he had been the manager.
During an interview on 6/19/19 at 11:48 A.M., the Maintenance Supervisor said he had never been asked to try to clean the dining room tables or floor tiles to get rid of the colored stains.
During an interview on 6/19/19 at 11:55 A.M., the Housekeeping Supervisor said they have tried everything to clean the table tops and floors in the dining room from everything from white vinegar to apple cider vinegar to baking soda and scrubbing. The red stains are from the red cranberry juice they used to serve. Now they have clear cranberry juice. The stains do tend to fade over time.
2. Observations on 6/17/19 between 11:40 A.M. and 12:00 P.M. showed the following:
-Dark staining on the flooring around the toilets in resident rooms 101, 102, 103, 104, 105, 106, 109 and 110;
-In resident room [ROOM NUMBER], dark staining on the flooring around the toilet, two tiles missing from the shower and four tiles missing from the base of the wall;
-In resident room [ROOM NUMBER], a buildup of dark brown and black debris around the base of the toilet and the caulking surrounding the toilet. The white grout within the floor tiles surrounding the toilet was black with a buildup of debris.
Observation on 6/17/19 at 12:17 P.M. showed a 2-inch diameter section of the ceiling in the utility room on the 200 hall was black with a mold-like substance.
During interview on 6/17/19 at 12:17 P.M., the Maintenance Supervisor confirmed the spot on the ceiling in the utility room was mold.
Observations on 6/17/19 between 12:25 P.M. and 1:07 P.M. showed yellow staining on the flooring around the toilets in resident rooms 401, 402, 403, 404, 405, 406, 407, 408, 409, and 410.
Observation on 6/17/19 at 4:00 P.M. showed in the kitchen under the dish line by the dish machine, there was a section of missing tile and a buildup of black debris on the wall and equipment.
Observation on 6/18/19 between 8:18 A.M. and 8:46 A.M. showed the following:
-In the 500 hall central bath, a 1 foot by 3 feet section of patched wall was not painted. Behind the tub, a section of wall, approximately 8 inches by 2 feet, had been cut out and not repaired. Also, an approximate 3 inch by 5 inch section of flooring behind the tub had been removed and had not been repaired. Four tiles were missing from the base of the wall, one tile at the base of the wall was broken, and the base of the wall all long the shower had a buildup of black debris;
-In resident room [ROOM NUMBER], yellow staining on the flooring around the dresser in the resident's room and around the toilet in the bathroom;
-In resident room [ROOM NUMBER], dark staining on the flooring around the toilet;
-In resident room [ROOM NUMBER], heavy dark and yellow staining on the flooring around the toilet;
-In resident room [ROOM NUMBER], an approximately 3 feet by 3 feet section of wallpaper located above the resident's bed was torn; dark staining around the toilet; the toilet continuously ran, and the bathroom smelled heavily of sewage. The Maintenance Supervisor said this room always smelled like sewage and he did not know where the smell was coming from;
-In resident room [ROOM NUMBER], the toilet continuously ran; a buildup of dark debris along the top of the base tile; and the toilet seat was worn and discolored;
-In resident room [ROOM NUMBER], the toilet continuously ran and there was yellow staining on the flooring around the toilet;
-In resident room [ROOM NUMBER], dark, heavy yellow staining on the flooring around the toilet;
-In resident room [ROOM NUMBER], there were approximately eight wall patches in the bathroom that varied in size from one inch by eight inches to four inches by 12 inches. The patches were not painted to match the walls;
-In resident room [ROOM NUMBER], the shower tiles had heavy brown and dark yellow staining;
-In resident room [ROOM NUMBER], brown and yellow staining on the flooring around the toilet.
Observation on 6/18/19 at 8:47 A.M. showed at the end of the 500 hallway, near resident rooms [ROOM NUMBERS], the ceiling was brown with water staining and blackened with a buildup of debris.
Observation on 6/18/19 between 8:49 A.M. and 9:20 A.M. showed the following:
-In resident room [ROOM NUMBER], yellow staining on the flooring around the toilet;
-In resident room [ROOM NUMBER], a 2 inch by 2 inch section of wall in the bathroom that had been patched and not painted;
-In resident room [ROOM NUMBER], yellow staining on the flooring around the toilet;
-In resident room [ROOM NUMBER], a heavy black buildup along the caulking at the base of the toilet and a heavy black buildup on the flooring behind the toilet;
-In resident room [ROOM NUMBER], two of three light bulbs were burned out in the bathroom;
-In resident room [ROOM NUMBER], yellow and brown staining on the flooring around the toilet and the grout in the shower was dark with a buildup of debris;
-In resident room [ROOM NUMBER], four of four light bulbs were burned out in the bathroom, and a bright yellow staining on the flooring around the toilet;
-In resident room [ROOM NUMBER], yellow and brown staining on the flooring all around the toilet and the floor was very sticky;
-In resident room [ROOM NUMBER], yellow and brown staining on the flooring all around toilet, and the shower tiles were dark with a buildup of debris;
-In resident room [ROOM NUMBER], a dark buildup of debris in the texture of the floor tiles in the bathroom.
Observation on 6/18/19 at 1:36 P.M. showed the water fountain in the dining room had a buildup of white and brown crusty debris in the basin of the water fountain from the fountain to the drain. The crusty debris extended in two lines from the fountain following the curvature of the basin and around the drain.
During interview on 6/19/19 at 11:42 A.M., the Housekeeping Supervisor said he didn't know why the floors were discolored; it was just something that happened.
3. Observation on 6/17/19 at 11:16 A.M. showed the vents in the waiting room and business offices were darkened in the corners with debris. Further observation showed an accumulation of fuzzy debris inside the ducts.
Observation on 6/17/19 at 12:02 P.M. showed the vents in the sitting area and nurses' station area were darkened in the corners with debris. Further observation showed an accumulation of fuzzy debris inside the ducts.
Observation on 6/17/19 at 12:05 P.M. showed the vent in the medication room on resident hall 100 was darkened in the corners with debris. Further observation showed an accumulation of fuzzy debris inside the duct.
Observation on 6/17/19 at 4:00 P.M. showed the vents in the kitchen were darkened with debris.
Observation on 6/18/19 at 8:18 A.M. showed the vent in the medication room on the 500 hall was darkened in the corners with debris. Further observation showed an accumulation of fuzzy debris inside the duct.
Observation on 6/18/19 at 8:47 A.M. showed the vents in 500 hallway were darkened with debris. Further observation showed an accumulation of fuzzy debris inside the ducts.
Observation on 6/19/19 at 7:56 A.M. showed the vents in the tea room on the 400 hall were darkened in the corners with debris. Further observation showed an accumulation of fuzzy debris inside the ducts.
During interview on 6/19/19 at 11:42 A.M., the Housekeeping Supervisor said he was responsible for cleaning the vents and ductwork. In the years since he has worked at the facility, the duct work has never been cleaned.
CONCERN
(E)
Potential for Harm - no one hurt, but risky conditions existed
ADL Care
(Tag F0677)
Could have caused harm · This affected multiple residents
**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, interview, and record review, the facility failed to ensure staff provided scheduled showers for 14 reside...
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**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, interview, and record review, the facility failed to ensure staff provided scheduled showers for 14 residents (Residents #8, #11, #13 ,#18, #23, #24, #34, #36, #38, #45, #51, #54, #59 and #66), who required assistance to complete their own activities of daily living (ADL), in a review of 18 sampled residents. The facility census was 76.
1. Review of the facility's shower policy from Nursing Guidelines Manual, dated March 2015, showed the purpose was to maintain skin integrity, comfort and cleanliness.
2. Review of Resident #59's quarterly Minimum Data Set (MDS), a federally mandated assessment instrument required to be completed by facility staff, dated 5/20/19, showed the following:
-Cognition severely impaired;
-No rejection of care;
-Required extensive assistance from one staff for personal hygiene;
-Totally dependent on one staff for bathing.
Review of the resident's care plan, last updated 5/22/19, showed the following:
-Requires assistance with all activities of daily living (ADLs);
-He/she prefers showers on Tuesday and Friday evenings.
Review of the resident's shower sheets for May 2019 and June 2019 showed the following:
-The resident refused a shower on 5/2 due to not feeling well;
-No evidence the resident received a shower 5/3 through 5/17 (15 days);
-The resident received a shower on 5/18;
-No evidence the resident received a shower 5/19 through 5/27 (nine days);
-The resident received a shower on 5/28;
-No evidence the resident received a shower 5/29 through 6/18 (21 days);
Observation on 6/17/19 at 12:55 P.M., showed the resident sat in a wheelchair in the dining room. The resident's facial hair was about 1/8 inch long on the sides of his/her face, chin and upper lip. The resident said he/she lost his/her razor and he/she doesn't like having whiskers.
Observation on 6/18/19 at 3:02 P.M., showed the resident sat in TV area. The resident's facial hair was still present.
During interview on 6/20/19 at 9:29 A.M., the resident said the following:
-He/She would like a shower every other day;
-He/She had a shower on 6/19/19 and got shaved;
-He/She doesn't like whiskers.
3. Review of Resident #34's care plan, updated 1/24/19, showed the resident likes showers on Wednesday and Saturday mornings.
Review of the resident's quarterly MDS, dated [DATE], showed the following:
-Cognition moderately impaired;
-Required limited assistance with personal hygiene;
-Required physical help for bathing.
Review of the resident's shower sheets for May 2019 showed the following:
-The resident received a shower on 5/2/19;
-No evidence the resident received a shower 5/3/19 through 5/10/19 (eight days);
-The resident received a shower on 5/11/19;
-No evidence the resident received a shower 5/12/19 through 5/31/19 (20 days).
Review showed the resident shower sheets for June 2019 showed no evidence the resident received a shower 6/1/19 through 6/17/19.
Observation on 6/17/19 at 9:08 A.M. showed the resident had dark, long facial hair on his/her upper lip and chin.
During interview on 6/17/19 at 9:08 A.M., the resident said he/she shaved at home. No one at the facility has asked him/her about the facial hair.
Observation on 6/18/19 at 3:04 P.M. showed the resident had dark, long facial hair on his/her upper lip and chin. The resident's skin on his/her lower legs was dry and flaky.
During interview on 6/18/19 at 3:04 P.M., the resident said he/she doesn't like having facial hair. If someone who works at the facility would ask, he/she would tell them to shave it off. No one has ever said anything about it or talked about it to him/her. He/she would like to shave his/her facial hair off if someone at the facility would do it for him/her.
Review showed the resident shower sheets for June 2019 showed no evidence the resident received a shower 6/18/19 through 6/20/19 ( a total of 40 days since the resident's last documented shower on 5/11/19).
During interview on 6/20/19 at 12:30 P.M., the resident said he/she wants a shower on Tuesday and Friday. He/she feels better when showered. He/she feels dirty and messy when not getting showers.
4. Review of Resident #13's admission MDS, dated [DATE], showed the following:
-Cognition severely impaired;
-No rejection of care;
-Required limited assist of one staff for personal hygiene;
-Bathing did not occur.
Review of the resident's care plan, last updated 3/31/19, showed the resident requires one to two staff assistance for ADLs.
Review of the resident's shower sheets for May 2019 and June 2019 showed the following:
-No evidence the resident received a shower 5/1 through 5/10 (ten days);
-The resident received a shower on 5/11;
-No evidence the resident received a shower 5/12 through 5/29 (18 days);
-The resident received a shower on 5/30 and 6/1;
-No evidence the resident received a shower 6/2 through 6/13 (12 days);
-The resident received a shower on 6/14;
-No evidence the resident received a shower 6/15 through 6/20 (six days).
During interview on 6/17/19 at 12:30 P.M., the resident said the following:
-He/She doesn't get a shower unless he/she asked for one;
-Sometimes it was two weeks in between showers;
-He/She would really like a whirlpool or bath to soak in.
5. Review of Resident #36's quarterly MDS, dated [DATE], showed the following:
-Cognition intact;
-No rejection of care;
-Independent with personal hygiene;
-Bathing did not occur.
Review of the resident's care plan, last updated 4/27/19, showed the following:
-Provide supervision for shower;
-Showers on Tuesday and Thursday afternoon.
Review of the resident's shower sheets for May 2019 and June 2019 showed the following:
-The resident received a shower on 5/2;
-No evidence the resident received a shower 5/3 through 5/8 (six days);
-The resident received a shower on 5/9;
-No evidence the resident received a shower 5/10 through 5/15 (six days);
-The resident received a shower on 5/16;
-No evidence the resident received a shower 5/17 through 5/27 (11 days);
-The resident received a shower on 5/28;
-No evidence the resident received a shower 5/29 through 6/18 (21 days).
During interview on 6/20/19 at 8:45 A.M., the resident said he/she would like a shower two to three times a week. When he/she did not have a shower, it made him/her feel cruddy.
6. Review of Resident #51's annual MDS, dated [DATE], showed the following:
-Cognition intact;
-No rejection of care;
-Independent with personal hygiene;
-Bathing required supervision, oversight help only.
Review of the resident's care plan, last updated 5/17/19, showed the following:
-Provide supervision for shower;
-He/she prefers baths in the afternoon on Mondays and Thursdays;
-Provide assist of one for ADLs.
Review of the resident's shower sheets for May 2019 and June 2019 showed the following:
-The resident received a shower on 5/2;
-No evidence the resident received a shower 5/3 through 5/8 (six days);
-The resident received a shower on 5/9 and 5/12;
-No evidence the resident received a shower 5/13 through 5/19 (seven days);
-The resident received a shower on 5/20;
-No evidence the resident received a shower 5/21 through 5/26 (six days);
-The resident received a shower on 5/27;
-No evidence the resident received a shower 5/28 through 6/15 (19 days);
-The resident received a shower on 6/15.
During interview on 6/20/19 at 8:47 A.M., the resident said the following:
-He/She would like a bath every four days;
-It makes him/her feel dirty when he/she doesn't get a shower;
-He/She does not like to put clean clothes on a dirty body.
7. Review of Resident #11's care plan, dated 10/13/18, showed the following:
-Required assistance with activities of daily living;
-The resident preferred showers on Monday and Thursday afternoons.
Review of the resident's quarterly MDS, dated [DATE], showed the following:
-Cognition moderately impaired;
-Required assistance from staff for personal hygiene and bathing.
Review of the resident's shower sheets for May 2019 and June 2019, showed the following:
-The resident received a shower on 5/2/19;
-No evidence the resident received a shower 5/3/19 through 5/8/19 (six days);
-The resident received a shower on 5/9/19;
-No evidence the resident received a shower 5/10/19 through 5/15/19 (six days)
-The resident received a shower on 5/16/19;
-No evidence the resident received a shower 5/17/19 through 5/26/19 (ten days);
-The resident received a shower on 5/27/19.
-No evidence the resident received a shower 5/28/19 through 6/16/19 (20 days);
-The resident received a shower on 6/17/19.
During interview on 6/20/19 at 12:45 P.M., the resident said he/she wanted to take a shower, but doesn't get them.
8. Review of Resident #18's care plan, dated 3/30/15, showed the following:
-Requires extensive assistance with hygiene;
-Resident showers on Monday and Friday afternoon.
Review of the resident's quarterly MDS, dated [DATE], showed the following:
-Diagnosis of paraplegia (paralysis);
-Cognition mildly impaired;
-Required physical help with bathing.
Review of resident's shower sheets for April 2019 showed the following:
-The resident received a shower on 4/1/19;
-No evidence the resident received a shower 4/2/19 through 4/8/19 (seven days);
-The resident received a shower on 4/9/19;
-No evidence the resident received a shower 4/10/19 through 4/15/19 (six days);
-The resident received a shower on 4/16/19;
-No evidence the resident received a shower 4/17/19 through 4/28/19 (12 days);
-The resident received a shower on 4/29/19.
Review of resident's shower sheets for May 2019 showed the following:
-The resident was in the hospital 4/29/19 and returned 5/1/19;
-The resident received a shower on 5/6/19;
-No evidence the resident received a shower 5/7/19 through 5/31/19.
Review of resident's shower sheets for June 2019 showed the following:
-No evidence the resident received a shower 6/1/19 through 6/12/19 (a total of 37 days since the resident's last documented shower);
-The resident received a shower on 6/13/19.
During interview on 6/18/19 at 3:23 P.M., the resident said he/she had only had two bed baths since returning from the hospital on 5/1/19. He/She only got the bed baths prior to going to physician appointments.
During interview on 6/20/19 at 12:15 P.M., the resident said he/she feels scummy and awful. He/She would like to take a shower every other day.
9. Review of Resident #23's quarterly MDS, dated [DATE], showed the following:
-Cognition was moderately impaired;
-No rejection of care;
-Required limited assistance of one staff for hygiene and bathing.
Review of the resident's care plan, last revised on 4/12/19, showed the following:
-The resident required assistance of one staff member for ADLs and hygiene;
-The resident preferred at least two showers a week.
Review of the resident's showed sheet for May and June 2019 showed the following:
-No documentation the resident received a shower between 5/1/19 and 5/8/18 (eight days);
-The resident received a shower on 5/9/19 and 5/14/19;
-No evidence the resident received a shower 5/15/19 through 5/23/19 (nine days)
-The resident received a shower on 5/24/19, 5/28/19, and 6/1/19;
-No evidence the resident received a shower 6/2/19 through 6/6/19 (five days);
-The resident received a shower on 6/7/19 and 6/11/19;
-No evidence the resident received a shower 6/12/19 through 6/17/19 (six days);
-The resident received a shower on 6/18/19.
During an interview on 6/17/19 at 4:00 P.M., the resident said he/she would like to receive two showers a week and it had been difficult getting this done. The resident said he/she typically got one shower a week.
Review of the resident's shower schedule, kept in a binder at the nurse's station on 6/19/19 showed the resident was scheduled to receive a shower on Tuesday and Friday afternoons.
10. Review of Resident #24's care plan, last revised on 4/12/19, showed the following:
-The resident required limited to extensive assistance with ADLs;
-The resident preferred two showers a week.
Review of the resident's shower sheet for May and June 2019 showed the following:
-No evidence the resident received a shower from 5/1/19 through 5/8/19 (eight days);
-The resident received a shower on 5/9/19;
-No evidence the resident received a shower 5/10/19 through 5/14/19 (five days);
-The resident received a shower on 5/15/19;
-No evidence the resident received a shower 5/16/19 through 5/23/19 (eight days);
-The resident received a shower on 5/24/19;
-No evidence the resident received a shower 5/25/19 through 6/5/19 (12 days);
-The resident received a shower on 6/6/19, 6/11/19, 6/15/19, and 6/18/19.
During an interview on 6/17/19 at 11:36 A.M., the resident said he/she had lived in the facility for two years. He/She was supposed to get two showers a week but had gone for over a week more than once without getting help with a shower.
Review of the resident's shower schedule, kept in a binder at the nurse's station on 6/19/19 showed the resident was scheduled to receive a shower on Tuesday and Friday mornings.
11. Review of Resident #66's shower sheets for May 2019 showed no evidence the resident received a shower 5/13/19 through 5/20/19.
Review of the resident's admission MDS, dated [DATE], showed the following:
-admit date [DATE];
-Cognition severely impaired;
-No rejection of care;
-Required extensive assistance from one staff for personal hygiene;
-Bathing did not occur.
Review of the resident's shower sheets for May 2019 showed no evidence the resident received a shower 5/20/19 through 5/28/19.
Review of the resident's care plan, last updated 5/28/19, showed he/she requires assistance with all ADLs.
Review of the resident's shower sheets for May 2019 and June 2019 showed no evidence the resident received a shower 5/28/19 through 6/14/19 (a total of 33 days without a documented shower). The resident received a shower on 6/15/19.
Observation on 6/17/19 at 12:01 P.M., showed the resident up in wheelchair. The resident's hair appeared oily.
12. Review of Resident #45's quarterly MDS, dated [DATE], showed the following:
-Cognition moderately impaired;
-Requires supervision, oversight for bathing.
Review of resident's care plan, dated 5/16/19, showed the following:
-Requires assist of one for showers/baths;
-Resident likes baths on Tuesday and Friday afternoons.
Review of the resident's shower sheets for April 2019 showed the following:
-No evidence the resident received a shower 4/1/19 through 4/8/19 (eight days);
-The resident received a shower on 4/9/19;
-No evidence the resident received a shower 4/10/19 through 4/19/19 (ten days);
-The resident received a shower on 4/20/19;
-No evidence the resident received a shower 4/21/19 through 4/27/19 (seven days);
-The resident received a shower on 4/28/19;
-No evidence the resident received a shower 4/29/19 or 4/30/19.
Review of the resident's shower sheets for May 2019 showed the following:
-No evidence the resident received a shower 5/1 through 5/5 (seven days since the resident's last documented shower on 4/28/19);
-The resident received a shower on 5/6/19;
- No evidence the resident received a shower 5/7/19 through 5/31/19 (25 days).
Review of the resident's shower sheets for June 2019 showed no evidence the resident received a shower 6/1/19 through 6/20/19 (a total of 45 days since his/her last documented shower on 5/6/19).
During an interview on 6/20/19 at 3:00 P.M., Certified Nurse Assistant (CNA) D said he/she works evening shift and has showers scheduled. More often than not, he/she does not have time to do the showers.
13. Review of Resident #54's shower sheets for May 2019 showed the resident refused showers on 5/2/19 and 5/9/19. No evidence the resident received a shower 5/1/19 through 5/17/19 (17 days).
Review of the resident's quarterly MDS, dated [DATE], showed the following:
-Cognition was moderately impaired;
-No rejection of care;
-Required limited assistance of one staff for hygiene and bathing.
Review of the resident's shower sheets for May 2019 showed the following:
-The resident received a shower on 5/18/19
-No evidence the resident received a shower 5/19/19 through 5/31/19.
Review of the resident's shower sheets for June 2019 showed the following:
-No evidence the resident received a shower 6/1/19 through 6/16/19 (29 days since his/her last documented shower).
-The resident received a shower on 6/17/19.
Review of the resident's shower schedule, kept in a binder at the nurse's station on 6/19/19 showed the resident was scheduled to receive a shower on Monday and Thursday afternoons.
14. Review of Resident #38's quarterly MDS, dated [DATE], showed the following:
-Cognition was intact;
-No rejection of care;
-Independent with showers and hygiene.
Review of the resident's care plan, last revised 4/28/19, showed the following:
-Requires supervision with showers and assistance at times related to a diagnosis of dementia;
-Does lack some safety awareness;
-Assist with ADL's as needed;
-Prefers showers on Monday, Wednesday, and Friday afternoons.
Review of the resident's shower sheet for May and June 2019 showed the following:
-The resident received showers on 5/2/19 and 5/6/19;
-No evidence the resident received a shower 5/7/19 through 5/11/19 (five days)
-The resident received a shower on 5/12/19;
-No evidence the resident received a shower 5/13/19 through 5/23/19 (11 days);
-The resident received a shower on 5/24/19;
-No evidence the resident received or refused a shower 5/25/19 through 6/18/19 (25 days).
Review of the resident's shower schedule, kept in a binder at the nurse's station on 6/19/19 showed the resident was scheduled to receive a shower on Monday, Wednesday, and Friday afternoons.
15. Review of Resident #8's care plan, dated 8/31/18, showed the resident was dependent on staff for his/her needs to be met.
Review of the resident's shower sheets for May 2019 showed the following:
-The resident received a shower on 5/2/19;
-No evidence the resident received a shower from 5/3/19 through 5/15/19.
Review of the resident's quarterly MDS, dated [DATE], showed the following:
-Cognition severely impaired;
-Totally dependent on staff for personal hygiene and bathing.
Review of the resident's shower sheets for May and June 2019 showed the following:
-No evidence the resident received a shower from 5/15/19 through 5/18/19 (a total of 16 days since his/her last documented shower);
-The resident received a shower on 5/19/19, 5/24/19, 5/27/19, 5/28/19 and 5/30/19;
-No evidence the resident received a shower 5/31/19 through 6/11/19 (12 days);
-The resident received a shower on 6/12/19 and 6/15/19;
-No evidence the resident received a shower 6/16/19 through 6/20/19.
16. During interview on 6/20/19 at 3:52 P.M., Director of Nursing (DON) said the following:
-She expected the residents to get a shower or bath at least twice a week;
-If a shower was not completed on the day shift, it was passed on to the next shift to complete or staff could try to complete it the next week;
-She would not expect the residents to go three or four weeks without a shower;
-She felt the showers were not getting done due to time management;
-The Assistant Director of Nurses (ADON) had started a binder to keep track of resident showers but it was a work in progress;
-The staff who was usually the designated shower aide also covered for the transport staff who was currently on vacation and would get pulled to cover the floor as an aide if needed;
-The DON felt staff were not filling out shower sheets every time they completed a shower, especially if the resident refused.
CONCERN
(E)
Potential for Harm - no one hurt, but risky conditions existed
Deficiency F0725
(Tag F0725)
Could have caused harm · This affected multiple residents
**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on interview and record review, the facility failed to have sufficient nursing staff on all shifts to provide nursing serv...
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**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on interview and record review, the facility failed to have sufficient nursing staff on all shifts to provide nursing services to attain or maintain the highest practicable physical, mental, and psychosocial well-being for residents in the facility. The facility failed to ensure sufficient staff to provide assistance with showers as directed by the plan of care for 14 residents (Resident #8, #11, #13 ,#18, #23, #24, #34, #36, #38, #45, #51, #54, #59 and #66), in a review of 18 sampled residents, and failed to provide sufficient staff to provide nursing services as required per the facility's assessment of residents' needs. The facility census was 76.
1. Review of the facility's assessment and facility profile, updated 11/28/18, showed the following:
-Number of licensed beds was 85;
-Average daily census was 76;
-Fifty-five residents required assistance of one or two staff for dressing;
-Six residents were dependent on staff for dressing;
-Fifty-four residents required assistance of one or two staff for bathing;
-Six residents were dependent on staff for bathing;
-Forty-two residents required assistance of one or two staff for transfers;
-Twelve residents were dependent on staff for transfers;
-Twelve residents required assistance of one or two staff for eating;
-Three residents were dependent on staff for eating;
-Forty-seven residents required assistance of one or two staff for toileting;
-Eight residents were dependent on staff for toileting;
-Facility resources needed to provide competent support and care for the resident population every day and during emergencies/staffing to meet care needs/hours per day based on average census:
-Registered Nurse (RN) = 8;
-Licensed Practical Nurse (LPN) = 24;
-Certified Medication Technician (CMT) = 16
-Certified Nurse Aide (CNA) = 112.
(The facility assessment showed 160 hours were required for direct nursing care based on an average daily census of 76.)
2. Review of the facility's daily staffing sheet for 6/1/19 showed the following:
-Census 74;
-RN daily total hours = 16 hours;
-LPN daily total hours = 28 hours;
-CMT daily total hours = 8 hours;
-CNA daily total hours = 96 hours;
-A total of 148 hours for direct care nursing staff.
Review of the facility's daily staffing sheet for 6/2/19 showed the following:
-Census of 74;
-RN daily total hours = 16 hours;
-LPN daily total hours = 28 hours;
-CMT total daily hours = 16 hours;
-CNA daily total hours = 100 hours;
-A total of 152 hours for direct care nursing staff.
Review of the facility's daily staffing sheet for 6/3/19 showed the following:
-Census of 74;
-RN daily total hours = 8 hours;
-LPN daily total hours = 24 hours;
-CMT total daily hours = 16 hours;
-CNA daily total hours = 88 hours;
-A total of 136 hours for direct care nursing staff.
Review of the facility's daily staffing sheet for 6/7/19 showed the following:
-Census of 76;
-RN daily total hours = 8 hours;
-LPN daily total hours = 24 hours;
-CMT total daily hours = 16 hours;
-CNA daily total hours = 104 hours;
-A total of 152 hours for direct care nursing staff.
Review of the facility's daily staffing sheet for 6/8/19 showed the following:
-Census of 76;
-RN daily total hours = 8 hours;
-LPN daily total hours = 36 hours;
-CMT total daily hours = 8 hours;
-CNA daily total hours = 100 hours;
-A total of 152 hours for direct care nursing staff.
Review of the facility's daily staffing sheet for 6/9/19 showed the following:
-Census of 76;
-RN daily total hours = 8 hours;
-LPN daily total hours = 36 hours;
-CMT total daily hours = 8 hours;
-CNA daily total hours = 92 hours;
-A total of 144 hours for direct care nursing staff.
Review of the facility's daily staffing sheet for 6/10/19 showed the following:
-Census of 78;
-RN daily total hours = 8 hours;
-LPN daily total hours = 24 hours;
-CMT total daily hours = 16 hours;
-CNA daily total hours = 88 hours;
-A total of 136 hours for direct care nursing staff.
Review of the facility's daily staffing sheet for 6/16/19 showed the following:
-Census of 76;
-RN daily total hours = 16 hours;
-LPN daily total hours = 28 hours;
-CMT total daily hours = 8 hours;
-CNA daily total hours = 104 hours;
-A total of 156 hours for direct care nursing staff.
3. Review of the Resident Census and Condition Report provided by the facility, dated 6/18/19, showed the following:
-Census 76;
-Fifty-three residents required assistance from one or two staff for bathing;
-Fifty-three residents required assistance from one or two staff for dressing;
-Thirty-one residents required assistance from one or two staff for transferring;
-Thirty-one residents required assistance from one or two staff for toilet use;
-Five residents required assistance from one or two staff for eating;
-Sixteen residents were dependent on staff for bathing;
-Sixteen residents were dependent on staff for dressing;
-Seventeen residents were dependent on staff for transferring;
-Seventeen residents were dependent on staff for toilet use;
-Four residents were dependent on staff for eating.
4. During the group interview on 6/18/19 10:05 A.M., Resident #51 said he/she had waited 45 minutes for staff to answer his/her call light. Resident #36 said he/she had waited an hour for staff to answer his/her call light. He/She said staff would often come in his/her room, turn off the call light, and say they would be back but would never come back. Residents #3, #51, and #67 said they felt there was not enough staff in the facility to meet the needs of the residents. Resident #36 said he/she had waited three weeks for a shower. Resident #51 said he/she had waited over two weeks for a bath. Resident #67 said residents had expressed they wanted to go outside for fresh air but were told there was not enough staff to do so.
5. Review of Resident #51's annual Minimum Data Set (MDS), a federally mandated assessment instrument required to be completed by facility staff, dated 5/15/19, showed the following:
-Cognition intact;
-Bathing required supervision, oversight help only.
Review of the resident's care plan, last updated 5/17/19, showed the following:
-Provide supervision for shower;
-He/she prefers baths in the afternoon on Mondays and Thursdays.
Review of the resident's shower sheets for May 2019 and June 2019 showed the following:
-The resident received a shower on 5/2;
-No evidence the resident received a shower 5/3 through 5/8 (six days);
-The resident received a shower on 5/9 and 5/12;
-No evidence the resident received a shower 5/13 through 5/19 (seven days);
-The resident received a shower on 5/20;
-No evidence the resident received a shower 5/21 through 5/26 (six days);
-The resident received a shower on 5/27;
-No evidence the resident received a shower 5/28 through 6/15 (19 days);
-The resident received a shower on 6/15.
During interview on 6/20/19 at 8:47 A.M., the resident said the following:
-He/She would like a bath every four days;
-It makes him/her feel dirty when he/she doesn't get a shower;
-He/She does not like to put clean clothes on a dirty body.
6. Review of Resident #36's quarterly MDS, dated [DATE], showed the following:
-Cognition intact;
-Bathing did not occur.
Review of the resident's care plan, last updated 4/27/19, showed the following:
-Provide supervision for shower;
-Showers on Tuesday and Thursday afternoon.
Review of the resident's shower sheets for May 2019 and June 2019 showed the following:
-The resident received a shower on 5/2;
-No evidence the resident received a shower 5/3 through 5/8 (six days);
-The resident received a shower on 5/9;
-No evidence the resident received a shower 5/10 through 5/15 (six days);
-The resident received a shower on 5/16;
-No evidence the resident received a shower 5/17 through 5/27 (11 days);
-The resident received a shower on 5/28;
-No evidence the resident received a shower 5/29 through 6/18 (21 days).
During interview on 6/20/19 at 8:45 A.M., the resident said he/she would like a shower two to three times a week. When he/she did not have a shower, it made him/her feel cruddy.
7. Review of Resident #24's care plan, last revised on 4/12/19, showed the following:
-The resident required limited to extensive assistance with activities of daily living (ADLs);
-The resident preferred two showers a week.
Review of the resident's shower schedule, kept in a binder at the nurse's station showed the resident was scheduled to receive a shower on Tuesday and Friday mornings.
Review of the resident's shower sheet for May and June 2019 showed the following:
-No evidence the resident received a shower from 5/1/19 through 5/8/19 (eight days);
-The resident received a shower on 5/9/19;
-No evidence the resident received a shower 5/10/19 through 5/14/19 (five days);
-The resident received a shower on 5/15/19;
-No evidence the resident received a shower 5/16/19 through 5/23/19 (eight days);
-The resident received a shower on 5/24/19;
-No evidence the resident received a shower 5/25/19 through 6/5/19 (12 days);
-The resident received a shower on 6/6/19, 6/11/19, 6/15/19, and 6/18/19.
During an interview on 6/17/19 at 11:36 A.M., the resident said he/she had lived in the facility for two years. He/She was supposed to get two showers a week and would like to get them, but he/she had gone for over a week more than once without getting help with a shower. The resident said he/she had waited up to an hour and a half on more than one occasion for staff to answer his/her call light. The resident needed help with transfers. The resident had become incontinent of bowel more than once waiting for staff to respond. Staff had also come in the room and turned off his/her call light in the past, saying they would be back, but never returned.
8. Review of Resident #59's quarterly MDS, dated [DATE], showed the following:
-Cognition severely impaired;
-Required extensive assistance from one staff for personal hygiene;
-Totally dependent on one staff for bathing.
Review of the resident's care plan, last updated 5/22/19, showed the following:
-Requires assistance with all ADLs;
-He/she prefers showers on Tuesday and Friday evenings.
Review of the resident's shower sheets for May 2019 and June 2019 showed the following:
-The resident refused a shower on 5/2 due to not feeling well;
-No evidence the resident received a shower 5/3 through 5/17 (15 days);
-The resident received a shower on 5/18;
-No evidence the resident received a shower 5/19 through 5/27 (nine days);
-The resident received a shower on 5/28;
-No evidence the resident received a shower 5/29 through 6/18 (21 days);
Observation on 6/17/19 at 12:55 P.M., showed the resident sat in a wheelchair in the dining room. The resident's facial hair was about 1/8 inch long on the sides of his/her face, chin and upper lip. The resident said he/she lost his/her razor and he/she doesn't like having whiskers.
Observation on 6/18/19 at 3:02 P.M., showed the resident sat in TV area. The resident's facial hair was still present.
During interview on 6/20/19 at 9:29 A.M., the resident said the following:
-He/She would like a shower every other day;
-He/She had a shower on 6/19/19 and got shaved;
-He/She doesn't like whiskers.
9. Review of Resident #34's care plan, updated 1/24/19, showed the resident likes showers on Wednesday and Saturday mornings.
Review of the resident's quarterly MDS, dated [DATE], showed the following:
-Cognition moderately impaired;
-Required limited assistance with personal hygiene;
-Required physical help for bathing.
Review of the resident's shower sheets for May 2019 showed the following:
-The resident received a shower on 5/2/19;
-No evidence the resident received a shower 5/3/19 through 5/10/19 (eight days);
-The resident received a shower on 5/11/19;
-No evidence the resident received a shower 5/12/19 through 5/31/19 (20 days).
Review showed the resident shower sheets for June 2019 showed no evidence the resident received a shower 6/1/19 through 6/17/19.
Observation on 6/17/19 at 9:08 A.M. showed the resident had dark, long facial hair on his/her upper lip and chin.
During interview on 6/17/19 at 9:08 A.M., the resident said he/she shaved at home. No one at the facility has asked him/her about the facial hair.
Observation on 6/18/19 at 3:04 P.M. showed the resident had dark, long facial hair on his/her upper lip and chin. The resident's skin on his/her lower legs was dry and flaky.
During interview on 6/18/19 at 3:04 P.M., the resident said he/she doesn't like having facial hair. If someone who works at the facility would ask, he/she would tell them to shave it off. No one has ever said anything about it or talked about it to him/her. He/she would like to shave his/her facial hair off if someone at the facility would do it for him/her.
Review showed the resident shower sheets for June 2019 showed no evidence the resident received a shower 6/18/19 through 6/20/19 ( a total of 40 days since the resident's last documented shower on 5/11/19).
During interview on 6/20/19 at 12:30 P.M., the resident said he/she wants a shower on Tuesday and Friday. He/she feels better when showered. He/she feels dirty and messy when not getting showers.
10. Review of Resident #13's admission MDS, dated [DATE], showed the following:
-Cognition severely impaired;
-Bathing did not occur.
Review of the resident's care plan, last updated 3/31/19, showed the resident requires one to two staff assistance for ADLs.
Review of the resident's shower sheets for May 2019 and June 2019 showed the following:
-No evidence the resident received a shower 5/1 through 5/10 (ten days);
-The resident received a shower on 5/11;
-No evidence the resident received a shower 5/12 through 5/29 (18 days);
-The resident received a shower on 5/30 and 6/1;
-No evidence the resident received a shower 6/2 through 6/13 (12 days);
-The resident received a shower on 6/14;
-No evidence the resident received a shower 6/15 through 6/20 (six days).
During interview on 6/17/19 at 12:30 P.M., the resident said the following:
-He/She doesn't get a shower unless he/she asked for one;
-Sometimes it was two weeks in between showers;
-He/She would really like a whirlpool or bath to soak in.
11. Review of Resident #11's care plan, dated 10/13/18, showed the following:
-Required assistance with activities of daily living;
-The resident preferred showers on Monday and Thursday afternoons.
Review of the resident's quarterly MDS, dated [DATE], showed the following:
-Cognition moderately impaired;
-Required assistance from staff for bathing.
Review of the resident's shower sheets for May 2019 and June 2019, showed the following:
-The resident received a shower on 5/2/19;
-No evidence the resident received a shower 5/3/19 through 5/8/19 (six days);
-The resident received a shower on 5/9/19;
-No evidence the resident received a shower 5/10/19 through 5/15/19 (six days)
-The resident received a shower on 5/16/19;
-No evidence the resident received a shower 5/17/19 through 5/26/19 (ten days);
-The resident received a shower on 5/27/19.
-No evidence the resident received a shower 5/28/19 through 6/16/19 (20 days);
-The resident received a shower on 6/17/19.
During interview on 6/20/19 at 12:45 P.M., the resident said he/she wanted to take a shower, but doesn't get them.
12. Review of Resident #18's care plan, dated 3/30/15, showed the resident showers on Monday and Friday afternoon.
Review of the resident's quarterly MDS, dated [DATE], showed the following:
-Diagnosis of paraplegia (paralysis);
-Cognition mildly impaired;
-Required physical help with bathing.
Review of resident's shower sheets for April 2019 showed the following:
-The resident received a shower on 4/1/19;
-No evidence the resident received a shower 4/2/19 through 4/8/19 (seven days);
-The resident received a shower on 4/9/19;
-No evidence the resident received a shower 4/10/19 through 4/15/19 (six days);
-The resident received a shower on 4/16/19;
-No evidence the resident received a shower 4/17/19 through 4/28/19 (12 days);
-The resident received a shower on 4/29/19.
Review of resident's shower sheets for May 2019 showed the following:
-The resident was in the hospital 4/29/19 and returned 5/1/19;
-The resident received a shower on 5/6/19;
-No evidence the resident received a shower 5/7/19 through 5/31/19.
Review of resident's shower sheets for June 2019 showed the following:
-No evidence the resident received a shower 6/1/19 through 6/12/19 (a total of 37 days since the resident's last documented shower);
-The resident received a shower on 6/13/19.
During interview on 6/18/19 at 3:23 P.M., the resident said he/she had only had two bed baths since returning from the hospital on 5/1/19. He/She only got the bed baths prior to going to physician appointments.
During interview on 6/20/19 at 12:15 P.M., the resident said he/she feels scummy and awful. He/She would like to take a shower every other day.
13. Review of Resident #23's quarterly MDS, dated [DATE], showed the following:
-Cognition was moderately impaired;
-Required limited assistance of one staff for bathing.
Review of the resident's care plan, last revised on 4/12/19, showed the following:
-The resident required assistance of one staff member for ADLs and hygiene;
-The resident preferred at least two showers a week.
Review of the resident's shower schedule (undated), kept in a binder at the nurse's station, showed the resident was scheduled to receive a shower on Tuesday and Friday afternoons.
Review of the resident's showed sheet for May and June 2019 showed the following:
-No documentation the resident received a shower between 5/1/19 and 5/8/18 (eight days);
-The resident received a shower on 5/9/19 and 5/14/19;
-No evidence the resident received a shower 5/15/19 through 5/23/19 (nine days)
-The resident received a shower on 5/24/19, 5/28/19, and 6/1/19;
-No evidence the resident received a shower 6/2/19 through 6/6/19 (five days);
-The resident received a shower on 6/7/19 and 6/11/19;
-No evidence the resident received a shower 6/12/19 through 6/17/19 (six days);
-The resident received a shower on 6/18/19.
During an interview on 6/17/19 at 4:00 P.M., the resident said he/she would like to receive two showers a week and it had been difficult getting this done. The resident said he/she typically got one shower a week.
14. Review of Resident #66's shower sheets for May 2019 showed no evidence the resident received a shower 5/13/19 through 5/20/19.
Review of the resident's admission MDS, dated [DATE], showed the following:
-admit date [DATE];
-Cognition severely impaired;
-Required extensive assistance from one staff for personal hygiene;
-Bathing did not occur.
Review of the resident's shower sheets for May 2019 showed no evidence the resident received a shower 5/20/19 through 5/28/19.
Review of the resident's care plan, last updated 5/28/19, showed he/she requires assistance with all ADLs.
Review of the resident's shower sheets for May 2019 and June 2019 showed no evidence the resident received a shower 5/28/19 through 6/14/19 (a total of 33 days without a documented shower). The resident received a shower on 6/15/19.
Observation on 6/17/19 at 12:01 P.M., showed the resident up in wheelchair. The resident's hair appeared oily.
15. Review of Resident #45's quarterly MDS, dated [DATE], showed the following:
-Cognition moderately impaired;
-Requires supervision, oversight for bathing.
Review of resident's care plan, dated 5/16/19, showed the following:
-Requires assist of one for showers/baths;
-Resident likes baths on Tuesday and Friday afternoons.
Review of the resident's shower sheets for April 2019 showed the following:
-No evidence the resident received a shower 4/1/19 through 4/8/19 (eight days);
-The resident received a shower on 4/9/19;
-No evidence the resident received a shower 4/10/19 through 4/19/19 (ten days);
-The resident received a shower on 4/20/19;
-No evidence the resident received a shower 4/21/19 through 4/27/19 (seven days);
-The resident received a shower on 4/28/19;
-No evidence the resident received a shower 4/29/19 or 4/30/19.
Review of the resident's shower sheets for May 2019 showed the following:
-No evidence the resident received a shower 5/1 through 5/5 (seven days since the resident's last documented shower on 4/28/19);
-The resident received a shower on 5/6/19;
- No evidence the resident received a shower 5/7/19 through 5/31/19 (25 days).
Review of the resident's shower sheets for June 2019 showed no evidence the resident received a shower 6/1/19 through 6/20/19 (a total of 45 days since his/her last documented shower on 5/6/19).
During an interview on 6/20/19 at 3:00 P.M., Certified Nurse Assistant (CNA) D said he/she works evening shift and has showers scheduled. More often than not, he/she does not have time to do the showers.
16. Review of Resident #54's shower sheets for May 2019 showed the resident refused showers on 5/2/19 and 5/9/19. No evidence the resident received a shower 5/1/19 through 5/17/19 (17 days).
Review of the resident's quarterly MDS, dated [DATE], showed the following:
-Cognition was moderately impaired;
-Required limited assistance of one staff for bathing.
Review of the resident's shower sheets for May 2019 showed the following:
-The resident received a shower on 5/18/19
-No evidence the resident received a shower 5/19/19 through 5/31/19.
Review of the resident's shower sheets for June 2019 showed the following:
-No evidence the resident received a shower 6/1/19 through 6/16/19 (29 days since his/her last documented shower).
-The resident received a shower on 6/17/19.
Review of the resident's shower schedule, kept in a binder at the nurse's station on 6/19/19 showed the resident was scheduled to receive a shower on Monday and Thursday afternoons.
17. Review of Resident #38's quarterly MDS, dated [DATE], showed the following:
-Cognition was intact;
-Independent with showers;
Review of the resident's care plan, last revised 4/28/19, showed the following:
-Requires supervision with showers and assistance at times related to a diagnosis of dementia;
-Does lack some safety awareness;
-Assist with ADLs as needed;
-Prefers showers on Monday, Wednesday, and Friday afternoons.
Review of the resident's shower schedule (undated), kept in a binder at the nurse's station, showed the resident was scheduled to receive a shower on Monday, Wednesday, and Friday afternoons.
Review of the resident's shower sheet for May and June 2019 showed the following:
-The resident received showers on 5/2/19 and 5/6/19;
-No evidence the resident received a shower 5/7/19 through 5/11/19 (five days)
-The resident received a shower on 5/12/19;
-No evidence the resident received a shower 5/13/19 through 5/23/19 (11 days);
-The resident received a shower on 5/24/19;
-No evidence the resident received or refused a shower 5/25/19 through 6/18/19 (25 days).
18. Review of Resident #8's care plan, dated 8/31/18, showed the resident was dependent on staff for his/her needs to be met.
Review of the resident's shower sheets for May 2019 showed the following:
-The resident received a shower on 5/2/19;
-No evidence the resident received a shower from 5/3/19 through 5/15/19.
Review of the resident's quarterly MDS, dated [DATE], showed the following:
-Cognition severely impaired;
-Totally dependent on staff for personal hygiene and bathing.
Review of the resident's shower sheets for May and June 2019 showed the following:
-No evidence the resident received a shower from 5/15/19 through 5/18/19 (a total of 16 days since his/her last documented shower);
-The resident received a shower on 5/19/19, 5/24/19, 5/27/19, 5/28/19 and 5/30/19;
-No evidence the resident received a shower 5/31/19 through 6/11/19 (12 days);
-The resident received a shower on 6/12/19 and 6/15/19;
-No evidence the resident received a shower 6/16/19 through 6/20/19.
19. During an interview on 6/17/19 at 2:02 P.M., Resident #173's family member said he/she was in the facility daily. The resident did not receive his/her medications on time. The resident had scheduled pain medication at 2:00 P.M. and 8:00 P.M. The resident had received the pain medication late on multiple occasions and had received the 8:00 P.M. dose of pain medication as late as 11:00 P.M. The resident frequently had to wait 45 minutes for staff to respond to his/her call light. When the family member was in the facility, he/she would try to find staff to answer the resident's call light. The family member felt the issues with the medications being late and the call light not being answered were due to the facility being short staffed. Staff members had complained to the family member several times about having to work short because someone called in or didn't show up. The staffing issues seemed to be worse on the weekends.
During an interview on 6/18/19 at 3:20 P.M., Resident #173 said he/she was having pain in his/her left knee. The left knee caused the resident more pain than his/her fractured hip. The resident said the Tramadol helped and getting it at regularly at 2:00 P.M. and 8:00 P.M. helped to control the pain before it became too bad. The resident said his/her pain medications had been given late several times. The resident said sometimes he/she wouldn't receive 8:00 P.M. dose of Tramadol until 10:00 P.M. or 11:00 P.M. and the 2:00 P.M. dose of Tramadol until 3:00 P.M. or 4:00 P.M. This caused the medication not work as well in relieving the resident's pain.
20. During an interview on 6/19/19 at 11:15 A.M., Resident #65 said he/she frequently had difficulty getting his/her medications on time. The resident said staff sign out medications without administering them to try and catch up because they would fall behind and could not keep up.
21. During an interview on 6/19/19 at 5:52 A.M., Certified Nurse Aide (CNA) K said there was one nurse and three aides on the night shift. It was a struggle for staff to get the call lights answered timely. One aide had been on restricted duty for the last four months and was limited in what he/she could do. The aide on restricted duty could answer call lights, but if the resident needed any hands on assistance, someone else would have to come and help. CNA K said he/she and other staff had expressed their concern to facility management about this but he/she wasn't sure what was being done.
During an interview on 6/19/19 at 6:15 A.M., CNA L said there was one nurse and three aides who worked the night shift. One of the three aides was on light duty and had been so for a few months. It was very difficult to get everything done with that amount of staff. They did the best they could, but residents would sometimes have to wait for assistance if they were busy helping other residents.
During interview on 6/19/19 at 06:00 A.M., CNA T said the following:
-There are two and a half aides on the night shift. He/She was on light duty and could not lift, so he/she passes water, linen, and answers call lights. If a resident needs to be changed, he/she has to get other staff to assist the resident;
-He/She doesn't feel like there is enough staff to meet all the residents' needs;
-If two staff are assisting a resident in the resident's room, the call lights do not get answered. All staff can do is apologize to the resident. This happens all the time;
-Normally in the morning, staff would get residents up who want to get up, but staff cannot because there isn't enough staff.
During interview on 6/20/19 at 10:22 A.M., CNA O said the following:
-Sometimes staff do not get showers completed due to staffing;
-Staff are really short of help from 2:30 P.M. to 6:30 P.M.
During an interview on 6/20/19 at 3 P.M., CNA D said he/she worked on the evening shift and had showers scheduled to complete. More often than not, he/she did not have time to complete the showers as well as his/her other duties.
22. During an interview on 6/20/19 at 3:10 P.M., the Director of Nursing (DON) said she was aware residents had complaints over call lights not being answered. The DON had done teaching with staff and encouraged them to work together. The designated shower aide was responsible for completing showers. If there was no designated shower aide, the aides on the hall were responsible for completing resident showers. The shower aide also covered for the facility transport person who was currently on vacation. The shower aide got pulled to work as an aide when needed. The DON was aware of an issue with getting showers completed but felt staff weren't always filling out shower sheets, especially if the resident refused. The DON said some staff members felt there was not enough staff but the DON felt the current staffing was adequate. The DON was aware some residents had complained of receiving medications late and felt this was due to a lack of communication between staff and confusion caused by the recently expanded medication administration times.
23. During an interview on 6/20/19 at 1:22 P.M., the administrator said there were currently two night shift staff who were on restricted duty. Only one staff on restricted duty was scheduled at a time, they were never scheduled on the same shift. There were three aides and one nurse scheduled to work night shift. The administrator felt this was a sufficient amount of staff, even with one of the three aides being on restricted duty. The administrator said there was more down time on the night shift and not as much resident care required overnight and did not feel residents had to wait for care. The administrator had received complaints from staff regarding the amount of staff on night shift but felt three nurse aides and one nurse was sufficient, although four to five aides would be ideal. The administrator was aware there was an issue with showers not being completed but felt this was a lack of time management and because of a shortage of staff.
CONCERN
(E)
Potential for Harm - no one hurt, but risky conditions existed
Deficiency F0761
(Tag F0761)
Could have caused harm · This affected multiple residents
Based on observation, interview, and record review, the facility failed to accurately label insulin to facilitate consideration of precautions and safe administration for one resident (Resident #21), ...
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Based on observation, interview, and record review, the facility failed to accurately label insulin to facilitate consideration of precautions and safe administration for one resident (Resident #21), in a review of 18 sampled residents, and for three additional residents (Residents #8, #18, and #22). The facility census was 76.
1. Review of the facility's policy Labeling Drugs and Medications from Nursing Guidelines Manual, dated March 2015, showed the following:
-All drugs and biologicals must be properly labeled and legible at all times;
-Labels must be permanently affixed to each container;
-Labels for individual drug containers must contain resident's full name, name, strength and quantity of drug, date of issue and expiration date when applicable.
2. Observation of the facility's medication cart on 6/19/19 at 1:00 P.M., showed the following:
-Resident #8's unsealed Levemir (insulin) vial without a documented open date. The pharmacy issue date was 3/9/19;
-Resident #18's unsealed Lantus (insulin) vial without a documented open date. The pharmacy issue date was 2/7/19;
-Resident #21's unsealed Novolog (insulin) vial without a documented open date. The pharmacy issue date was 5/15/19;
-Resident #22's unsealed Humalog Kwikpen (insulin) pen without a documented open date. The pharmacy issue date was 12/12/18.
3. Review of Resident #22's Physician Order Sheet (POS), dated June 2019, showed an order for Humalog Kwikpen sliding scale insulin subcutaneous before meals. If blood glucose 100-150, give 3 units; if 151-300, give 5 units; if 201-250, give 10 units; if 251-300, give 13 units; if 301-350, give 17 units; and if over 350, give 20 units.
Review of the manufacturer's information for Humalog Kwikpen suggests after opening a pen of Humalog insulin, throw away the pen after 28 days of use, even if there is insulin left in the pen.
Observation on 6/19/19 at 11:28 A.M., showed the following:
-The resident's blood sugar was 166;
-Licensed Practical Nurse (LPN) A put a needle on the Humalog Kwikpen that was located in the medication cart;
-LPN A dialed the dose knob of the resident's Humalog KwikPen to 5 units;
-The resident administered the Humalog KwikPen that LPN A prepared into his/her right abdomen.
During interview on 6/19/19 at 1:04 P.M., Registered Nurse (RN) S said the following:
-Insulin is good for 28 days after opening;
-He/She verified multiple vials of insulin in the medication cart were not dated;
-The staff used the undated insulin vials in the medication cart on a daily basis.
During interview on 6/20/19 at 12:06 P.M., the Director of Nursing (DON) said the following:
-Insulin was good for 30 days after it was opened;
-Staff were supposed to date the insulin vials when they opened them;
-If not the insulin vials were not dated, staff should throw them away and open and date a new vial.
CONCERN
(E)
Potential for Harm - no one hurt, but risky conditions existed
Menu Adequacy
(Tag F0803)
Could have caused harm · This affected multiple residents
Based on observation, interview, and record review, the facility failed to ensure staff served the correct portion sizes and prepared food items according to the dietary spreadsheet menu for residents...
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Based on observation, interview, and record review, the facility failed to ensure staff served the correct portion sizes and prepared food items according to the dietary spreadsheet menu for residents on physician-ordered mechanical soft and pureed diets. The facility census was 76.
1. Review of the facility's Order Report by Category, dated 5/17/19-6/17/19, showed 20 residents were on a mechanical soft diet and one resident was on a pureed diet.
2. Review of the diet spreadsheet for lunch on 6/17/19 (Spring/Summer 2019, Week 3, Day 16) showed residents on a mechanical soft diet were to receive 3-ounces of garlic pepper pork loin served with 2-ounces of a sauce of choice.
Review of the recipe for ground garlic pepper pork loin showed staff should serve a 3-ounce (#10 scoop) portion of ground garlic pepper pork loin.
Observation and interview on 6/17/19 at 12:25 P.M. showed the Dietary Manager placed a #24 red scoop (1.33 ounces) on the lid that covered the ground garlic pepper pork loin on the steam table. He said he would use the red scoop to serve the mechanical soft pork.
Observation on 6/17/19 at 12:41 P.M. showed the Dietary Manager started plating resident lunch trays. Staff did not prepare a sauce of choice nor was a sauce present on the steam table.
Observation on 6/17/19 between 12:41 P.M. and 1:38 P.M. showed the Dietary Manager served all residents on a mechanical soft diet a #24 scoop of ground garlic pepper pork loin instead of a 3-ounce serving. In addition, all residents on a mechanical soft diet did not receive a 2-ounce serving of a sauce of choice on top of the ground garlic pepper pork loin.
2. Review of the diet spreadsheet for lunch on 6/17/19 (Spring/Summer 2019, Week 3, Day 16) showed residents on a pureed diet were to receive a #8 scoop (4 ounces) of pureed garlic pepper pork loin served with 2-ounces of a sauce of choice, #16 scoop (1/4 cup) of pureed seasoned zucchini, and #16 scoop of pureed dinner roll.
Observation and interview on 6/17/19 at 12:25 P.M. showed the Dietary Manager placed a #20 scoop (1.6 ounces) on the lid that covered the pureed zucchini on the steam table and also placed a #24 scoop (1.33 ounces) on the lid that covered the pureed garlic pepper pork loin. He said he would use the #20 scoop to serve the pureed zucchini and the #24 scoop to serve for the pureed pork.
Observation on 6/17/19 at 12:41 P.M. showed the Dietary Manager started plating resident lunch trays. Staff did not prepare a sauce of choice or the pureed dinner roll.
Observation on 6/17/19 between 12:41 P.M. and 1:38 P.M. showed the Dietary Manager served all residents on a pureed diet a #24 scoop (1.33 ounces) of pureed garlic pepper pork loin instead of a #8 scoop (4 ounces). The Dietary Manager served all residents on a pureed diet a #20 scoop of pureed seasoned zucchini instead of a #16 scoop. All residents on a pureed diet did not receive a 2-ounce serving of a sauce of choice with their entrée' nor did they receive a #16 scoop of pureed dinner roll.
3. During an interview on 6/19/19 at 9:55 A.M., the Dietary Manager said staff should use the recipe book to find out what serving utensils to use. He was not aware the spreadsheet contained this information until Monday (6/17/19). Staff should use the recipe books to know how to prepare and serve a food item. Sauce or gravy should be prepared and served according to the spreadsheet menu. Gravy was not made on 6/17/19 because he had only used the menu at a glance and that menu did not contain information regarding all the different diets and specifically what items needed to be prepared for each diet. He did not make any pureed bread nor was bread added to any food item to satisfy the bread item for that meal. Pureed bread should have been made according to the spreadsheet menu.
During an interview on 6/19/19 at 11:30 A.M., the facility's Consultant Dietician said staff should utilize the spreadsheet menu and refer to this menu for proper serving sizes for each specific diet.
CONCERN
(E)
Potential for Harm - no one hurt, but risky conditions existed
Deficiency F0804
(Tag F0804)
Could have caused harm · This affected multiple residents
Based on observation, interview, and record review, the facility failed to ensure staff prepared and provided food that was served at an appetizing temperature. The facility also failed to ensure food...
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Based on observation, interview, and record review, the facility failed to ensure staff prepared and provided food that was served at an appetizing temperature. The facility also failed to ensure food items were prepared according to the recipe to conserve nutritive value, flavor and appearance. The facility census was 76.
1. Review of the facility policy, Food Temperatures, dated April 2011, showed the following:
-Hot food should be at least 120 degrees Fahrenheit (F) when served to the resident;
-The Dietary Services Manager or designee is responsible for seeing that all food is the proper temperature before trays are assembled.
2. Review of the facility policy, Food Preparation and Distribution, dated April 2011, showed the following:
-Foods are prepared by methods that conserve nutritive value, flavor and appearance;
-Recipes should be followed on each item prepared.
3. Review of the facility diet spreadsheet for lunch on 6/17/19 (Spring/Summer 2019 Week 3, Day 16), showed all residents on a mechanical soft diet were to receive ground garlic pepper pork loin.
Observation on 6/17/19 at 1:43 P.M. of the test tray obtained after staff served the last resident showed the temperature of the ground garlic pepper pork loin was 116.3 degrees F.
4. Review of the facility diet spreadsheet for lunch on 6/17/19 (Spring/Summer 2019 Week 3, Day 16), showed all residents on a pureed diet were to receive pureed garlic pepper pork loin.
Review of the recipe for pureed garlic pepper pork loin showed the following ingredients and directions:
-Garlic pepper pork loin,
-Chicken stock;
-Food thickener;
-Prepare pork according to regular diet recipe;
-Prepare slurry;
-Process until smooth adding 1-ounce slurry per portion.
Observation on 6/17/19 at 12:38 P.M. showed the Dietary Manager began to prepare pureed garlic pepper pork loin. He added a bowl of ground pork to the blender and poured two glass soup bowls full of tap water into the blender. He shook an unmeasured amount of food thickener from the can and added it to the other items in the blender. He turned the blender on and after approximately 15 seconds, stopped the blender and added an unmeasured amount of food thickener. He blended this mixture again for about 15 seconds and then added additional unmeasured food thickener. He scraped this mixture into a small steam table pan and sat the pan on the steam table.
Observation on 6/17/19 at 1:43 P.M. of the test tray obtained after staff served the last resident showed the temperature of the pureed garlic pepper pork loin was 94 degrees and was cold to taste. The pureed pork loin lacked flavor and was thick in appearance.
5. During an interview on 6/19/19 at 9:55 A.M., the Dietary Manager said a test tray should measure 120 degrees F for hot items on a meal tray. He does not sample or test any meal trays at this point, since he just became the Dietary Manager last week. He has not had a chance to attend resident council meeting because he still has to do a lot of the cooking in the kitchen, since there is only one cook right now.
During an interview on 6/19/19 at 9:55 A.M., the Dietary Manager said staff should use the recipe book to know how to prepare a food item.
CONCERN
(E)
Potential for Harm - no one hurt, but risky conditions existed
Deficiency F0809
(Tag F0809)
Could have caused harm · This affected multiple residents
**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on interview and record review, the facility failed to offer residents a daily bedtime snack. Four of eight residents (Res...
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**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on interview and record review, the facility failed to offer residents a daily bedtime snack. Four of eight residents (Resident #14, #36, #51 and #67) participating in group interview and seven additional residents (Resident #7, #10, #17, #18, #28, #65 and #72) reported snacks were not offered on a routine basis at the facility. The census was 76.
1. Review of the facility's nutrition policy from the Nursing Guidelines Manual, dated March 2015, showed the residents will be offered bed time snacks unless contraindicated.
2. During the group interview on 6/18/19 at 10:05 A.M., the residents in attendance said the following:
-Resident #14 said staff wheel a cart of snacks out to the nursing station. The residents have to go to the nursing station to get the bedtime snack;
-Resident #36 said the residents have to go to nursing station to get a snack;
-Resident #51 said the snacks at the nursing station are first come, first serve. He/She doesn't want to have to get up and wheel his/her wheelchair down the hall to get a bedtime snack;
-Resident #67 said he/she is diabetic and there is no special snack for him/her.
During interview on 6/17/19 at 12:15 P.M. Resident #17 said staff never pass snacks. If he/she wants snacks, he/she could have to go the nurses station and get it himself/herself.
During interview on 6/19/19 at 7:45 A.M., Resident #10 said residents can have a snack if they go to the nurse's station and get it. Staff do not come to the residents' rooms and offer snacks.
During interview on 6/19/19 at 8:09 A.M., Resident #51 said residents have to go to the nurse's station if they want a snack. Staff will not come to residents' rooms and offer snacks.
3. Review of resident #18's quarterly Minimum Data Set (MDS), a federally mandated assessment instrument to be completed by the facility, dated 3/31/19, showed the following:
-Mild cognitive impairment;
-Diagnosis of diabetes;
-Required daily injections of insulin;
-Required total assistance for transfer.
Review of resident's care plan, dated 4/2/19, showed the following:
-He/she remains in his/her room for meals;
-Provide hoyer lift and assist of two for transferring;
-Instruct him/her on importance of not skipping meal or snacks.
During interview on 6/18/19 at 3:23 P.M., the resident said if he/she wanted a snack, he/she would have to be able to go to the nurses station to get a snack. Staff do not come to his/her room and offer snacks. If staff does not get him/her up, he/she does without a snack.
4. Review of resident #14's quarterly MDS, dated [DATE], showed the following:
-Mild cognitive impairment;
-Diagnosis of diabetes;
-Receives insulin.
During interview on 6/17/19 at 12:00 P.M., the resident said staff never pass snacks. If he/she wants snacks, he/she would have to go to the nurses station and get one.
5. Review of resident #72's quarterly MDS, dated [DATE], showed the following:
-Mild cognitive impairment;
-Diagnosis of diabetes.
During interview on 6/19/19 at 8:55 A.M., the resident said residents have to go to the nurse's station for snacks, or they won't get any.
6. Review of Resident #7's quarterly MDS, dated [DATE], showed the following:
-Cognition was intact;
-Diagnosis of diabetes;
-Received insulin daily.
During an interview on 6/20/19 at 11:54 A.M., the resident said staff does not pass snacks. Residents have to go to the desk to get a snack. The first residents to get there usually take everything.
7. Review of Resident #65's quarterly MDS, dated [DATE], showed the following:
-Cognition was moderately impaired;
-Diagnosis of diabetes;
-Received insulin daily.
During an interview on 6/19/19 at 11:15 A.M., the resident said staff does not pass snacks in the facility. There was a snack cart kept at the nurse's desk, but it was first come first serve and there may not be anything left on the cart when he/she got there. The resident was a diabetic and tried to buy soda to keep in the room when he/she felt his/her blood sugar was low.
8. Review of Resident #28's significant change in status MDS, dated [DATE] showed the following:
-Cognition was intact;
-Diagnosis of diabetes.
During an interview on 9/18/19 at 9:30 A.M., Resident #28 said he/she did not get offered a snack. If residents wanted a snack, they had to go to the nurse's desk and get it or had to ask staff. The resident said he/she spent most of the time in bed due to his/her medical condition and was not always able to get to the nurse's desk to get a snack.
9. During an interview on 6/20/19 at 10:22 A.M., Certified Nurse Assistant (CNA) O said most residents know when the snack cart is at the desk and come and get a snack. Staff do not go room to room and offer each resident a snack.
During an interview on 6/20/19 at 3:10 P.M., the Director of Nursing said she was not aware of any resident complaints regarding snacks. The administrator said she was aware of resident complaints about staff not getting the snack cart down the hall in a timely manner. Staff had recently been in-serviced on the issue. Staff tried to focus on the residents who had voiced complaints.
CONCERN
(E)
Potential for Harm - no one hurt, but risky conditions existed
Deficiency F0883
(Tag F0883)
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 follow policies and procedures for immunization of residents agains...
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**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on interview and record review, the facility failed to follow policies and procedures for immunization of residents against pneumococcal disease as required. The facility failed to include all required components in the facility policy; failed to follow the Centers for Disease Control's guidelines for pneumococcal vaccinations; failed to administer pneumococcal vaccinations after consent was received; and failed to provide education of benefits and potential side effects of the pneumococcal vaccinations for two residents (Residents #18 and #42), in a review of 18 sampled residents. The facility census was 76.
1. Review of the facility's policy for pneumococcal immunizations from the Infection Control Manual, dated April 2012, showed the pneumococcal vaccine was recommended for residents age [AGE] and older. A repeat dose after six years may be given to those at highest risk.
The policy did not include the following:
-Before offering the pneumococcal immunization, each resident or the resident's representative receives education regarding the benefits and potential side effects of the immunization;
-Each resident is offered a pneumococcal immunization, unless the immunization is medically contraindicated or the resident has already been immunized;
-The resident or the resident's representative has the opportunity to refuse immunization; and the resident's medical record includes documentation that indicates, at a minimum, the resident or resident's representative was provided education regarding the benefits and potential side effects of pneumococcal immunization and the resident either received the pneumococcal immunization or did not receive the pneumococcal immunization due to medical contraindication or refusal.
2. Review of the US Department of Health and Human Services CDC Pneumococcal Vaccine Timing for Adults, dated 11/30/15, showed the following:
-Two pneumococcal vaccines were recommended for adults: 13-valent pneumococcal conjugate vaccine (PCV13, PREVNAR13) and 23-valent pneumococcal polysaccharide vaccine (PPSV23, Pneumovax 23);
-One dose of PCV 13 was recommended for adults 65 years or older who had not previously received PCV13;
-One dose of PPSV23 was recommended for adults 65 years or older, regardless of previous history of vaccination with pneumococcal vaccines. Once a dose of PPSV23 was given at age [AGE] years or older, no additional doses of PPSV23 should be administered;
-For those age [AGE] years or older who had not received any pneumococcal vaccines, or those with unknown vaccination history administer one dose of PCV13. Administer one dose of PPSV23 at least one year later for most adults or at least eight weeks later for adults with immunocompromising conditions;
-For those age [AGE] years or older who previously received one dose of PPSV 23 and no doses of PCV13 administer one dose of PCV13 at least one year after the dose of PPSV23 for all adults regardless of medical conditions.
3. Review of the facility's undated immunization consentor refusal form showed the following:
-The facility has provided me with information regarding the risks and benefits of the influenza and pneumococcal vaccines;
-I have been given the Centers for Disease Control (CDC) Vaccine Information sheets on pneumococcal vaccines;
-I hereby consent or refuse for the Pneumococcal PPSV23 and the PCV13;
-A space for the last date the pneumococcal vaccines were received and the location they were received.
4. Review of Resident #18's record showed the resident was admitted on [DATE]. The resident was over age [AGE].
Review of the facility immunization consent or refusal record showed the resident signed consent to receive the PCV13 vaccination on 6/21/18.
Review of the resident's medical record showed no evidence the resident received a pneumococcal vaccination (PCV13 or PPSV23) in the past, no evidence the resident consented or refused the PPSV23 vaccination, and no evidence staff administered the resident the PCV13 vaccination after the resident provided consent for the vaccination on 6/21/18. Review showed no evidence staff provided the resident or resident's representative with education regarding the benefits and potential side effects of pneumococcal immunization
5. Review of Resident #42's immunization record showed the resident received the PPSV23 in October 2016.
Review of the resident's medical record showed he/she was admitted to the facility on [DATE]. The resident was over age [AGE].
Review of the immunization consent or refusal form showed the resident's responsible party consented for the resident to receive the PCV13 on 4/24/19.
Review of the resident's admission MDS, dated [DATE], showed the following:
-The resident's cognition was intact;
-Pneumococcal vaccine section was blank.
During interview on 6/17/19 at 4:43 P.M., the resident said the following:
-He/She had never received any information on the pneumococcal vaccines;
-Staff had never offered him/her the pneumococcal vaccine.
6. During interview on 6/20/19 at 9:10 A.M., the Social Service Director (SSD) said the immunization form is in the admission pack. The resident or the resident's responsible party consent or refuse the pneumococcal vaccines at the time of admission. If the resident has had the pneumococcal vaccine, he/she puts it on the form. He/She then makes a copy of the form and passes it on to nursing staff.
During interview on 6/20/19 at 9:33 A.M., Licensed Practical Nurse E said the following:
-The admitting nurse is responsible to give the pneumococcal vaccines;
-Staff in the front office give the admitting nurse a sheet that is checked to show if the resident wants or does not want the vaccine;
-He/She would give the PCV13 vaccination first;
-He/she didn't know when the next pneumococcal vaccine would be due;
-The staff give the education regarding the vaccines verbally to the resident or responsible party. Staff do not print out and give the CDC education to the resident.
During interview on 6/20/19 at 9:20 A.M., the Director of Nursing said the following:
-She would be responsible for the immunization program;
-She was not familiar with the CDC guidelines for pneumococcal vaccines.
During interview on 6/20/19 at 9:15 A.M., the Administrator said if the resident wants the pneumococcal vaccinations, the staff give the vaccinations. If the resident doesn't want the vaccinations, they document a refusal. The admitting nurse is responsible for giving education to the resident on the vaccinations. The staff should follow the policy and procedure in the manual for giving vaccines.
CONCERN
(E)
Potential for Harm - no one hurt, but risky conditions existed
Deficiency F0925
(Tag F0925)
Could have caused harm · This affected multiple residents
**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, interview, and record review, the facility failed to implement an effective pest control program. The faci...
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**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, interview, and record review, the facility failed to implement an effective pest control program. The facility census was 76.
1. Review of the facility's pest control report, dated 2/25/19, showed there was damage to the floor allowing pests to gain access into the facility.
Review of the facility's pest control report, dated 3/25/19, showed the following:
-The damage note from 2/25/19 was still on the report;
-In inspection area 1, there were 10 miscellaneous flying insects noted;
-In inspection area 2, there were 15 miscellaneous flying insects noted;
-In inspection area 3, there were 15 miscellaneous flying insects noted.
Review of facility's pest control report, dated 4/22/19, showed the following:
-The damage note from 2/25/19 was still on the report;
-Cracks or damage to wall allowing pest access. Please repair to prevent pest entry. Need to seal multiple points of possible entry for pests outside room [ROOM NUMBER]. Severity: High;
-In inspection area 1, there were 25 miscellaneous flying insects noted;
-In inspection area 2, there were 50 miscellaneous flying insects noted;
-In inspection area 3, there were 100 miscellaneous flying insects noted;
-In resident hall 100, flying insects were noted.
Review of facility's pest control report, dated 5/24/19, showed the following:
-The damage notes from 2/25/19 and 4/22/19 were still on the report;
-In inspection area 1, there were 40 miscellaneous flying insects noted;
-In inspection area 2, there were 150 miscellaneous flying insects noted;
-In inspection area 3, there were 200 miscellaneous flying insects noted;
-Spiders were noted at the nurses' station.
2. Review of the Daily Nursing Report showed on 6/12/19 at 4:34 P.M., spiders were found on B hall. Two spiders were found in Resident #53's bed.
3. Observation on 6/17/19 at 11:58 A.M. showed a live spider in the soiled utility room on the 200 hall.
Observation on 6/17/19 at 12:16 P.M. showed a large number of various live insects at the end of the 200 hall. Further observations showed the exterior door at the end of the 200 hall had gaps around it large enough to easily see outside.
Observation 6/18/19 at 9:21 A.M. showed a live centipede in occupied resident room [ROOM NUMBER].
Observation on 6/18/19 at 3:38 P.M. showed a live cockroach in the library.
Observation on 6/19/19 at 5:45 A.M. showed there was a cockroach in the library.
Observation on 6/19/19 at 7:47 A.M. showed a live spider in the maintenance office.
Observation on 6/19/19 at 9:15 A.M. showed a live spider in the equipment room.
Observation on 6/19/19 at 11:25 A.M. showed a large number of various insects at the end of the 300 hall. Further observations showed the exterior door at the end of the 300 hall had gaps around it large enough to easily see outside.
Observation on 6/19/19 at 11:28 A.M. showed a live spider and several flies in occupied resident room [ROOM NUMBER].
Observation on 6/20/19 at 7:25 A.M., showed Resident #123 sat in a wheelchair in the doorway to his/her room with a fly swatter in his hand.
During interview on 6/20/19 at 7:25 A.M., Resident #123 said he/she was killing flies. He/She has had several spiders in his/her room. He/She said the facility didn't have a flyswatter so he/she had a family member bring him/her one.
During interview on 6/19/19 at 11:29 A.M., Resident #81 said he/she had an issue with flies in his/her room so he/she carries a fly swatter.
During interview on 6/19/19 at 1:50 P.M., Resident #80 said he/she often sees insects, including spiders, in his/her room and has to kill them himself/herself.
4. During interview on 6/19/19 at 3:00 P.M., the pest control company said the facility did not broad treat for spiders. The facility's pest control plan included rodents, ants, and occasional invaders. The pest control company said occasional invaders were insects that didn't really colonize, instead they just came inside from time to time. Anything noted on subsequent reports that were also on previous reports were because they were not corrected between inspections.
During interview on 6/19/19 at 3:08 P.M., the Housekeeping Supervisor said the items noted on the pest control reports were not repaired because he/she could only submit requests for repairs to administration and had to wait for approval in order to make repairs.
During interview on 7/3/19 at 11:14 A.M., the Administrator said she has not received any requests for repairs in regards to pest control since January 2019.
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 ensure kitchen cooking equipment was clean and free of a buildup of debris; failed to ensure the range hood was free of greas...
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Based on observation, interview, and record review, the facility failed to ensure kitchen cooking equipment was clean and free of a buildup of debris; failed to ensure the range hood was free of grease and debris; failed to ensure ready to eat food and plated food items were prepared in a sanitary manner; failed to ensure eggs were refrigerated when not being used for food preparation; failed to ensure the dish machine area was free of grease and debris; failed to ensure staff wore beard restraints in the kitchen during food preparation; failed to ensure raw chicken was thawed properly; and failed to ensure the ice machine had an appropriate air gap to prevent back siphonage and routine maintenance was performed. The facility census was 76.
1. Observation on 6/17/19 at 10:55 A.M. showed the stand-up mixer was running and a brown thin mixture slopped over the sides of the bowl and onto the base and table below the mixer. Staff did not clean the liquid debris off the mixer base or table below.
Observations on 6/17/19 at 11:10 A.M. and 4:18 P.M. showed wet brown liquid and a moderate amount of dried light yellow-colored debris was visible on the stand up mixer base and the table below the mixer.
Observation on 6/17/19 at 11:11 A.M. showed a large puddle of liquid milk, approximately 4-inches wide by 8-inches long, on the floor under the upright metal rack and next to the stand-up mixer. Small droplets of milk were visible on the base of the mixer. No staff was utilizing the stand-up mixer or upright metal rack at this time.
Observation on 6/17/19 at 4:18 P.M. showed the milk puddle remained on the floor and was now partially dry and yellowed around the edges. The milk droplets had dried and remained on the mixer base.
Observation on 6/18/19 at 8:12 A.M. showed the stand-up mixer base and table below had an accumulation of dried brown, yellow and white debris.
During an interview on 6/19/19 at 9:55 A.M., the Dietary Manager said staff cleaned kitchen equipment according to a monthly, weekly, and daily cleaning schedule. The schedules showed who was responsible for cleaning particular items. He was unsure who was responsible for cleaning the stand-up mixer. The day cook should sweep floors at the end of their shift. The evening cook should sweep and mop nightly. He was unsure who was responsible for cleaning walls in the kitchen. The stove and griddle backsplash was difficult to clean because the stovetop was always in use.
2. Observation on 6/17/19 at 11:13 A.M. showed a heavy buildup of yellow grease with drips and runs on the wall behind the fryer. Heavy yellow and brown grease and debris were visible on the metal backsplash behind the griddle and a large blackened area with heavy grease on the metal backsplash behind the six-burner stove.
During an interview on 6/19/19 at 9:55 A.M., the Dietary Manager said he was unsure who was responsible for cleaning walls in the kitchen. The stove and griddle backsplash were difficult to clean because the stovetop was always in use.
3. Observation on 6/17/19 at 11:13 A.M. showed a very heavy buildup of yellow grease and dark brown debris on all three range hood baffle filters. The fire suppression piping and nozzles had a heavy buildup of greasy fuzzy debris.
Observation on 6/19/19 at 9:30 A.M. showed the range hood had a very heavy buildup of yellow grease and dark brown debris on all three range hood baffle filters. The fire suppression piping and nozzles had a heavy buildup of greasy fuzzy debris.
During an interview on 6/19/19 at 9:55 A.M., the Dietary Manager said staff was to clean the range hood baffles weekly on Thursdays by soaking them in degreaser on both sides.
4. Observation on 6/17/19 at 4:00 P.M. showed the griddle had a buildup of yellow greasy debris along the edges of the cooking surface and had not been cleaned since its last use.
5. Observation on 6/17/19 at 11:21 A.M. showed the Dietary Manager rinsed tomatoes under running water and began cutting the tomatoes with a knife. He did not wear gloves and did not wash his hands prior to handling the tomatoes.
Observation on 6/17/19 at 1:06 P.M. showed the Dietary Manager did not wash his hands or put on gloves. He prepared grilled cheese sandwiches on the griddle. He buttered and placed a slice of bread on the griddle, placed a slice of cheese on the bread, and added a second buttered slice of bread on top of the cheese. After cooking the sandwich, he placed the sandwich on a plate using a spatula. He then rubbed both his eyes with the palms of his hands. He did not wash his hands after touching his eyes and continued plating lunch trays for residents.
During an interview on 6/19/19 at 9:55 A.M., the Dietary Manager said staff should wash their hands prior to handling produce. He was not sure when or if staff should wear gloves when handling produce. Staff should wash their hands before and after food preparation. He was not exactly sure when staff needed to wear gloves. He said staff should definitely change gloves in between tasks and after touching one's face or clothing.
6. Observation on 6/17/19 at 11:01 A.M. and at 11:22 A.M. showed an open flat crate containing 12 pasteurized eggs sat on a metal baking sheet that covered the fryer. No staff was preparing eggs or doing any food preparation that utilized eggs. The eggs were warm to touch on the outside of the shells.
Observation on 6/17/19 at 11:57 A.M. showed the Dietary Manager moved the crate of eggs from the fryer area to the metal preparation counter across from the stove.
Observation on 6/17/19 at 11:58 A.M. showed the Dietary Manager placed the eggs inside the reach-in cooler.
Observation on 6/17/19 at 4:19 P.M. and on 6/18/19 at 8:16 A.M. showed the crate of 12 eggs remained in the reach-in cooler.
Observation on 6/19/19 at 9:30 A.M. showed the flat crate of eggs sat on top of a metal baking sheet that covered the fryer. The empty shells for five eggs sat in the crate. Seven whole eggs sat in the crate.
During an interview on 6/19/19 at 9:35 A.M., Dietary Staff P said he/she just got this flat of 12 eggs out of the cooler about an hour ago because he/she ran out of fried eggs on the steam table and had to make more.
During an 6/19/19 at 9:55 A.M., the Dietary Manager said the eggs that were sitting out on the fryer on 6/17/19 had been out of the refrigerator since approximately 7:00 A.M. that morning and he put them back in the refrigerator at 12 noon. Staff should store the eggs in the refrigerator when they are not being used for food preparation.
7. Observations on 6/17/19 at 11:37 A.M. and 4:19 P.M., on 6/18/19 at 8:03 A.M., and on 6/19/19 at 9:30 A.M. showed the dish room area was located inside the facility kitchen. The exhaust vent for the dish machine had a heavy buildup of dark yellow-colored greasy, shiny and fuzzy debris inside the vent above the dish machine and around the edges of the vent. The wall behind the dish machine had a heavy accumulation of food debris and grease. Black-colored debris was visible on the wall behind and near the dish machine. Black-colored debris was visible below the dish machine along the cove base and on the wall. A large hole in the drywall was present under the dish machine with visible piping and debris inside the hole.
During an interview on 6/19/19 at 9:55 A.M., the Dietary Manager said the dishwasher aide should spray down the walls around the dish area to remove any debris and then spray with cleaner between each meal. He knew the walls around the dish machine had a buildup of food debris and black discolorations. He was unaware the areas below the dish machine had black areas and part of the wall was missing around the pipes.
8. Observation on 6/17/19 at 12:30 P.M. showed the Dietary Manager had a longer moustache and a goatee. He removed his beard restraint, walked past an uncovered cart of desserts and cake and left the kitchen.
Observation on 6/17/19 at 12:32 P.M. showed the Dietary Manager entered the kitchen, and walked past the steam table that contained pans of food. He was not wearing a beard restraint.
Observation on 6/17/19 at 4:05 P.M. showed the Dietary Manager stood over the metal preparation counter and did not wear a beard restraint. Dietary Staff Q stood across the counter from him and dished up diced pears from a can.
Observation on 6/17/19 at 4:20 P.M. showed the Dietary Manager prepared pureed pears in the blender and did not wear a beard restraint.
Observation on 6/18/19 at 7:55 A.M. showed the Dietary Manager plated residents' breakfast trays in the kitchen while standing over the steam table. He did not wear a beard restraint.
Observation on 6/18/19 at 10:23 A.M. showed Dietary Staff R had a visible moustache and goatee and did not wear a beard restraint. He walked past the food preparation counter while staff plated dessert and left the kitchen.
During an interview on 6/19/19 at 9:55 A.M., the Dietary Manager said staff should wear a beard restraint if they have any facial hair and should wear them all day every day in the kitchen.
9. Observation on 6/18/19 at 8:04 A.M. showed five sealed plastic bags of raw chicken pieces sat thawing in the sink and were partially submerged in approximately 3-inches of water. The sink drain was plugged with a dirty-looking dish cloth. No water was running over the thawing chicken.
Observation on 6/18/19 at 8:33 A.M. showed the Dietary Manager turned on cold water that ran over the closed bags of chicken in the sink
Observation on 6/18/19 at 10:20 A.M. showed two bags of raw chicken pieces were open and sat in the sink. One bag sat in the sink and was still closed. No cold water was running over the chicken in the open or closed bags. The chicken pieces were not soft to touch and appeared to be unthawed.
Observation on 6/18/19 at 10:21 A.M. showed Dietary Staff P removed the remaining chicken pieces from the open bags, began flouring the pieces of raw chicken, placed them on a baking sheet. He/she then began frying the chicken pieces in the fryer.
During an interview on 6/19/19 at 9:55 A.M., the Dietary Manager said staff should pull frozen meat from the freezer and place it in the refrigerator to thaw two days before it is cooked. Staff pulled the chicken out of the freezer late and did not have time to thaw the chicken in the refrigerator. He was unsure of the proper meat thawing technique.
10. Observation on 6/18/19 at 10:25 A.M. and on 6/19/19 at 9:30 A.M. showed the ice machine sat outside the kitchen door and had two drains that extended below the level of the floor approximately 2 to 3 inches and ran into the floor drain. A metal rod was secured to the drains. The ice machine drains were not equipped with an air gap. The water filter on the back of the machine was dated 2017.
During an interview on 6/19/19 at 9:55 A.M., the Dietary Manager said dietary staff was not responsible for the ice machine. Maintenance and housekeeping staff maintained the ice machine and dietary only used the ice. Dietary was not responsible for changing the filter.
During an interview on 6/19/19 at 11:40 A.M., the Maintenance Supervisor said the ice machine needed to have a 2-inch air gap. The pipes were secured to a metal rod in the drain to hold them in place, but housekeeping staff might have bumped and moved the rod. Staff was to change the filter for the ice machine annually.
CONCERN
(F)
Potential for Harm - no one hurt, but risky conditions existed
Infection Control
(Tag F0880)
Could have caused harm · This affected most or all residents
**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** 1. Review of the facility's policy on Clean Dressing Change, dated March 2015, showed the following:
-Purpose: To prevent infect...
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**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** 1. Review of the facility's policy on Clean Dressing Change, dated March 2015, showed the following:
-Purpose: To prevent infection and spread of infection and promote healing:
-Create a clean field;
-Open dressing supplies;
-Put on disposable gloves;
-Remove soiled dressing and discard in a plastic bag;
-Dispose of gloves in a plastic bag;
-Use hand sanitizer;
-Put on second pair of disposable gloves;
-Cleanse the wound;
-Wash hands, sanitize, and change gloves;
-Apply prescribed medication if ordered;
-Apply dressing and secure with tape;
-Remove gloves and discard with all unused supplies in a plastic bag.
2. Review of the Infection Control Guidelines for Long Term Care Facilities, January 2005 edition, Section 3.0, Body Substance Precautions, Subsection 3.2 Implementing the Body Substance Precautions System, showed the following regarding gloves and handwashing:
-Instructions should be followed by ALL personnel at all times regardless of the resident's diagnosis;
-Gloves: Wear gloves when it can be reasonably anticipated that hands will be in contact with mucous membranes, non-intact skin, any moist body substances (blood, urine, feces, wound drainage, oral secretions, sputum, vomitus, or items/surfaces soiled with these substances) and/or persons with a rash; gloves must be changed between residents and between contacts with different body sites of the same resident;
-REMEMBER: Gloves are not a cure-all; they should reduce the likelihood of contaminating the hands, but gloves cannot prevent penetrating injuries due to needles or sharp objects; dirty gloves are worse than dirty hands because microorganisms adhere to the surface of a glove easier than to the skin on your hands; and handling medical equipment and devices with contaminated gloves is not acceptable;
-Handwashing: Handwashing remains the single most effective means of preventing disease transmission; wash hands often and well, paying particular attention to around and under fingernails and between the fingers; wash hands whenever they are soiled with body substances, before food preparation, before eating, after using the toilet, before performing invasive procedures and when each resident's care is completed.
3. Review of the Resident #67's wound culture report, dated 5/2/19, showed the diabetic foot ulcer, [NAME] grade 4 (partial gangrene, or death of body tissue), to the resident's right foot was positive for methicillin-resistant staphylococci (MRSA, a bacterium that causes infection which is difficult to treat due to resistance to commonly used antibiotics).
Review of the resident's Annual Minimum Data Set (MDS, a federally mandated assessment instrument required to be completed by facility staff), dated 5/30/19, showed the following:
-Diagnoses included diabetes and peripheral vascular disease (PVD, a blood circulation disorder);
-Cognition was intact;
-Infection of the foot;
-Diabetic foot ulcers;
-Surgical wound care;
-Application of dressings to feet.
Review of the resident's care plan, last revised 6/4/19, showed the following:
-Diagnoses of PVD and osteomyelitis (infection of the bone). The resident had toes amputated on the right foot on 3/18/19;
-On 4/30/19, a non-healing wound to the right foot at the surgical amputation site;
-Provide treatment as ordered;
-Use principles of infection control and universal precautions.
Review of the resident's physician order sheet (POS) for 5/25/19 through 6/25/19, showed the following:
-Diagnoses included diabetes with foot ulcer, local infection of the skin and subcutaneous (under the skin) tissues, and chronic osteomyelitis (a serious infection of the bone) of the right ankle and foot;
-Right foot: Apply adaptic (non-adherent dressing) soaked with Betadine (used to treat wounds and skin infections), a gauze 4X4 soaked with Betadine, cover with a dry gauze 4X4, wrap with gauze and an ace wrap. Change every other day (original order dated 6/12/19);
-Right ankle: Apply a large foam dressing to the ankle every other day (original order dated 6/12/19).
During an interview on 6/17/19 at 4:28 P.M., the resident said he/she had toes amputated on his/her right foot. It had been infected and the resident had been been hospitalized several times because of the infection in his/her foot.
Observation on 6/18/19 at 3:42 P.M. showed the following:
-The resident lay in bed;
-Licensed Practical Nurse (LPN) A entered the room with gloves already on his/her hands, placed a clean towel under the resident's right foot, and laid dressing supplies on the bed;
-LPN A removed the old dressings from the resident's right foot wounds. There was dried, brown, drainage present on the dressings;
-There were three wounds present on the resident's right foot and ankle;
-LPN A measured the first wound, at the top of the right foot, with a disposable paper ruler and a cotton tipped applicator. Both the paper ruler and cotton tipped applicator came in direct contact with the first wound, which measured 7.2 centimeters (cm) by 4.1 cm by 1.3 cm;
-Without removing his/her gloves and washing his/her hands, LPN A measured the second wound to the top of the resident's right ankle with the same disposable ruler and cotton tipped applicator used to measure the first wound. Both the paper ruler and cotton tipped applicator came in direct contact with the second wound, which measured 6.4 cm by 2.5 cm by 0.2 cm;
-Without removing his/her gloves, LPN A measured the third wound, just below the second wound, with the same disposable ruler and cotton tipped applicator used to measure the first wound. Both the paper ruler and cotton tipped applicator came in direct contact with the third wound, which measured 1.2 cm by 1.2 cm by 0.2 cm;
-LPN A cleansed all wounds with normal saline and gauze. LPN A did not change gloves or wash his/her hands between wounds;
-LPN A placed adaptic gauze soaked in Betadine to the first wound and covered it with Betadine soaked gauze and a dry dressing;
-LPN A removed the glove on his/her right hand and placed a clean glove on without washing the hand. The old glove remained in place to LPN A's left hand;
-LPN A placed a foam dressing over the second and third wounds and wrapped the wounds with gauze and secured with tape;
-LPN A removed his/her gloves and left the room without washing his/her hands to retrieve a clean ace bandage from the treatment cart which sat in the hallway outside the resident's room;
-LPN A returned to the resident's room and put on clean gloves without washing his/her hands and applied the ace wrap to the resident's right foot.
During a telephone interview on 6/20/19 at 12:00 P.M., LPN A said the resident's wounds had been infected and the resident had been hospitalized in the past due to the infected wounds. LPN A measured the wounds in the facility. LPN A said he/she typically used the same paper ruler and cotton tipped applicator when measuring multiple wounds for the same resident. LPN A said he/she should have changed gloves and washed his/her hands after removing the old dressings and cleansing the wounds before applying a clean dressing to the wounds.
During an interview on 6/20/19 at 3:10 P.M., the Director of Nursing said staff should not use the same materials to measure multiple wounds and should wash their hands and change their gloves after removing a soiled dressing before applying a clean dressing because not doing so could contaminate the wound and spread infection.
4. Review of the Disaster Preparedness Manual and the Infection Control Guidelines Manual, provided by the facility showed the following items:
-No documentation or evidence of a comprehensive infection control policy or program designed to help prevent the development and transmission of water-borne pathogens;
-No documentation or evidence the facility had conducted a risk assessment to identify where Legionella and other opportunistic waterborne pathogens could grow and spread in the facility water system;
-No documentation or evidence of the development or implementation of a water management program that considers the American Society of Heating, Refrigerating, Air-Conditioning Engineers (ASHRAE) industry standard and the Centers for Disease Control (CDC) toolkit;
-No documentation or evidence of a water testing protocols and acceptable ranges for control measures, and documentation of testing results and corrective actions taken when control limits are not maintained.
During an interview on 6/18/19 at 2:25 P.M., the Administrator said the facility did not have a Legionella or water testing policy or program available for review. No facility water system assessments had been completed. No water samples had been tested.
Based on observation, interview, and record review, facility staff failed to wash their hands during wound care as directed by professional standards of practice to prevent the spread of infection for one resident (Resident #67), in a review of 18 sampled residents. The facility also failed to develop, implement and maintain a comprehensive infection control program designed to help prevent the development and transmission of water-borne pathogens (a bacterium, virus, or other microorganism that can cause disease), and failed to provide documented assessments for such an outbreak. The facility census was 76.
Understanding Severity Codes (click to expand)
Life-Threatening (Immediate Jeopardy)
J - Isolated
K - Pattern
L - Widespread
Actual Harm
G - Isolated
H - Pattern
I - Widespread
Potential for Harm
D - Isolated
E - Pattern
F - Widespread
No Harm (Minor)
A - Isolated
B - Pattern
C - Widespread
Questions to Ask on Your Visit
- "What changes have you made since the serious inspection findings?"
- "Why is there high staff turnover? How do you retain staff?"
- "Can I speak with families of current residents?"
- "What's your RN coverage like on weekends and overnight?"
Our Honest Assessment
Strengths
- • Licensed and certified facility. Meets minimum state requirements.
Concerns
- • Multiple safety concerns identified: 1 life-threatening violation(s), Special Focus Facility, 7 harm violation(s), $235,414 in fines, Payment denial on record. Review inspection reports carefully.
- • 112 deficiencies on record, including 1 critical (life-threatening) violation. These warrant careful review before choosing this facility.
- • $235,414 in fines. Extremely high, among the most fined facilities in Missouri. Major compliance failures.
- • Grade F (0/100). Below average facility with significant concerns.
Bottom line: This facility is on CMS's Special Focus list for poor performance. Consider alternatives strongly.
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About This Facility
What is Lincoln County Nursing & Rehab's CMS Rating?
CMS assigns LINCOLN COUNTY NURSING & REHAB an overall rating of 1 out of 5 stars, which is considered much below average nationally. Within Missouri, this rating places the facility higher than 0% of the state's 100 nursing homes. A rating at this level reflects concerns identified through health inspections, staffing assessments, or quality measures that families should carefully consider.
How is Lincoln County Nursing & Rehab Staffed?
CMS rates LINCOLN COUNTY NURSING & REHAB's staffing level at 1 out of 5 stars, which is much below average compared to other nursing homes. Staff turnover is 82%, which is 36 percentage points above the Missouri average of 46%. High turnover can affect care consistency as new staff learn residents' individual needs.
What Have Inspectors Found at Lincoln County Nursing & Rehab?
State health inspectors documented 112 deficiencies at LINCOLN COUNTY NURSING & REHAB during 2019 to 2025. These included: 1 Immediate Jeopardy (the most serious level, indicating potential for serious harm or death), 7 that caused actual resident harm, 97 with potential for harm, and 7 minor or isolated issues. Immediate Jeopardy findings are rare and represent the most serious regulatory concerns. They require immediate corrective action.
Who Owns and Operates Lincoln County Nursing & Rehab?
LINCOLN COUNTY NURSING & REHAB 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 JAMES & JUDY LINCOLN, a chain that manages multiple nursing homes. With 90 certified beds and approximately 67 residents (about 74% occupancy), it is a smaller facility located in TROY, Missouri.
How Does Lincoln County Nursing & Rehab Compare to Other Missouri Nursing Homes?
Compared to the 100 nursing homes in Missouri, LINCOLN COUNTY NURSING & REHAB's overall rating (1 stars) is below the state average of 2.5, staff turnover (82%) is significantly higher than the state average of 46%, and health inspection rating (1 stars) is much below the national benchmark.
What Should Families Ask When Visiting Lincoln County Nursing & Rehab?
Based on this facility's data, families visiting should ask: "What changes have been made since the serious inspection findings, and how are you preventing similar issues?" "How do you ensure continuity of care given staff turnover, and what is your staff retention strategy?" "Can you walk me through typical staffing levels on day, evening, and night shifts?" "Can I visit during a mealtime to observe dining assistance and food quality?" These questions are particularly relevant given the facility's Immediate Jeopardy citations, the facility's high staff turnover rate, and the below-average staffing rating.
Is Lincoln County Nursing & Rehab Safe?
Based on CMS inspection data, LINCOLN COUNTY NURSING & REHAB 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 is currently on the Special Focus Facility watch list (a federal program monitoring the lowest-performing 1% of nursing homes nationwide). The facility has a 1-star overall rating and ranks #100 of 100 nursing homes in Missouri. Families considering this facility should ask detailed questions about what corrective actions have been taken since these incidents.
Do Nurses at Lincoln County Nursing & Rehab Stick Around?
Staff turnover at LINCOLN COUNTY NURSING & REHAB is high. At 82%, the facility is 36 percentage points above the Missouri average of 46%. High turnover means new staff may not know residents' individual needs, medications, or preferences. It can also be disorienting for residents, especially those with dementia who rely on familiar faces. Families should ask: What is causing the turnover? What retention programs are in place? How do you ensure care continuity during staff transitions?
Was Lincoln County Nursing & Rehab Ever Fined?
LINCOLN COUNTY NURSING & REHAB has been fined $235,414 across 3 penalty actions. This is 6.6x the Missouri average of $35,433. Fines at this level are uncommon and typically indicate a pattern of serious deficiencies, repeated violations, or failure to correct problems promptly. CMS reserves penalties of this magnitude for facilities that pose significant, documented risk to resident health or safety. Families should request specific documentation of what issues led to these fines and what systemic changes have been implemented.
Is Lincoln County Nursing & Rehab on Any Federal Watch List?
LINCOLN COUNTY NURSING & REHAB is currently an SFF Candidate, meaning CMS has identified it as potentially qualifying for the Special Focus Facility watch list. SFF Candidates have a history of serious deficiencies but haven't yet reached the threshold for full SFF designation. The facility is being monitored more closely — if problems continue, it may be added to the official watch list. Families should ask what the facility is doing to address the issues that led to this status.