LIFE CARE CENTER OF WAYNESVILLE
For profit - Corporation
120 Beds
LIFE CARE CENTERS OF AMERICA
Data: November 2025
Trust Grade
25/100
#412 of 479 in MO
Photo by Life Care Center of Waynesville
Photo by Life Care Center of Waynesville
Photo by Life Care Center of Waynesville
1 / 5 photos
Last Inspection: March 2025
Within standard 12-15 month inspection cycle. Federal law requires annual inspections.
Overview
Life Care Center of Waynesville has received a Trust Grade of F, indicating significant concerns about the quality of care provided. Ranking #412 out of 479 facilities in Missouri places this nursing home in the bottom half, and it is the second of two options in Pulaski County, meaning only one local facility is potentially better. While the facility is improving, having reduced issues from 15 to 12 over the past year, it still has a long way to go, with 31 total issues found, including one serious and 24 concerns that could potentially harm residents. Staffing is a weakness, with a low rating of 1 out of 5, and a high staff turnover of 56%, which is slightly below the state average. Specific incidents include staff failing to prevent the development of pressure injuries for residents and not maintaining sanitary kitchen practices, like improperly thawing frozen meat, which could lead to foodborne illnesses. Overall, while there are some signs of improvement, serious care deficiencies and poor staffing ratings are significant red flags for families considering this facility.
- Trust Score
- F
- In Missouri
- #412/479
- Safety Record
- Moderate
- Inspections
- Getting Better
- Staff Stability ⚠ Watch
- 56% turnover. Above average. Higher turnover means staff may not know residents' routines.
- Penalties ✓ Good
- $33,970 in fines. Lower than most Missouri facilities. Relatively clean record.
- Skilled Nurses ⚠ Watch
- Each resident gets only 18 minutes of Registered Nurse (RN) attention daily — below average for Missouri. Fewer RN minutes means fewer trained eyes watching for problems.
- Violations ⚠ Watch
- 31 deficiencies on record. Higher than average. Multiple issues found across inspections.
25/100
Bottom 14%
Needs review
15 → 12 violations
★☆☆☆☆
1.0
Overall Rating
★☆☆☆☆
1.0
Staff Levels
★★★☆☆
3.0
Care Quality
★★☆☆☆
2.0
Inspection Score
↔
Stable
2024: 15 issues
2025: 12 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: 56%
10pts above Missouri avg (46%)
Frequent staff changes - ask about care continuity
Federal Fines: $33,970
Above median ($33,413)
Moderate penalties - review what triggered them
Chain: LIFE CARE CENTERS OF AMERICA
Part of a multi-facility chain
Ask about local staffing decisions and management
Staff turnover is elevated (56%)
8 points above Missouri average of 48%
The Ugly 31 deficiencies on record
1 actual harm
Mar 2025
12 deficiencies
1 Harm
SERIOUS
(G)
Actual Harm - a resident was hurt due to facility failures
Pressure Ulcer Prevention
(Tag F0686)
A resident was harmed · This affected 1 resident
**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, interview, and record review, facility staff failed to identify and prevent the development of a new press...
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**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, interview, and record review, facility staff failed to identify and prevent the development of a new pressure injury for one resident (Resident #8) when they failed to follow the care plan, complete assessments as directed by facility policy, and notify the physician to obtain orders for treatment. Facility staff failed to implement interventions and assess and monitor a pressure injury for one resident (Resident #2) of 20 sampled residents. The facility census was 82.
1. Review of the facility's policy titled Skin Integrity & Pressure Ulcer/Injury Prevention and Management, dated 08/25/21, showed a resident should receive care, consistent with professional standards of practice, to prevent pressure ulcers and does not develop pressure ulcers unless the individual's clinical condition demonstrates that they are unavoidable. A resident with pressure ulcers receives necessary treatment and services, consistent with professional standards of practice, to promote healing, prevent infection and prevent new ulcers from developing. Per regulation a standardized risk assessment (Braden Scale) should be completed on admission, weekly for four weeks, quarterly, and as needed based upon each resident's specific needs. A skin assessment should be performed weekly by a licensed nurse. Measures to maintain and improve the resident's tissue tolerance to pressure are implemented in the plan of care. Staff should reposition the resident at least every two to four hours, utilize positioning devices to keep bony prominence's from direct contact, heel protection and suspension if indicated. Resident and significant others involved in the resident's care are educated regarding the preventative skin care plan. When skin breakdown occurs, it requires attention and a change in the plan of care may be indicated to treat the resident.
Review of the National Pressure Injury Advisory Panels (NPIAP) definitions of staging showed:
-Pressure Injury: localized damage to the skin and underlying soft tissue usually over a bony prominence or related to a medical or other device. The injury can present as intact skin or an open ulcer and may be painful. The injury occurs as a result of intense and/or prolonged pressure or pressure in combination with shear;
-Stage 2 Pressure Injury: Partial-thickness skin loss with exposed dermis. The wound bed is viable, pink or red, moist, and may also present as an intact or ruptured serum (liquid)-filled blister. Adipose (fat) is not visible and deeper tissues are not visible. Granulation tissue (pink/red tissues, bumpy in appearance), slough (liquefied or wet dead tissue, can be yellow or white in color) and eschar (dried dead tissue, can be tan, black, or brown in color) are not present;
-Stage 4 Pressure Injury: 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. Epibole (rolled edges), undermining and/or tunneling often occur. Depth varies by anatomical location. If slough or eschar obscures the extent of tissue loss this is an Unstageable Pressure Injury;
-Unstageable Pressure Injury: 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. If slough or eschar is removed, a Stage 3 or Stage 4 pressure injury will be revealed. Stable eschar (i.e. dry, adherent, and intact without erythema or fluctuance) on the heel or ischemic limb should not be softened or removed.
2. Review of Resident #8's Quarterly Minimum Data Set (MDS), a federally mandated assessment tool, dated 01/31/25, showed staff assessed the resident as:
-Moderate cognitive impairment;
-Behaviors towards other and rejection of care not exhibited;
-Required moderate assistance from staff members with bathing;
-Independent with bed mobility;
-Required touch or supervision assistance from staff member for transfers;
-Occasionally incontinent of bowel and bladder;
-At-risk for pressure ulcers;
-Did not have unhealed pressure ulcers;
-Pressure reducing devices for bed and chair not indicated;
-Diagnosis of Peripheral Vascular Disease (PVD) (circulatory condition in which narrowed blood vessels reduce blood flow to the limbs).
Review of the care plan, dated 02/04/25, showed staff are directed as follows:
-One staff assistance required to dress upper and lower body;
-At risk for further breakdown in skin integrity due to incontinence, decreased mobility, current ulcers to legs and Dementia;
-Encourage resident to turn and reposition often;
-Float heels while in bed;
-Pressure relief boots for pressure reduction.
Review of the Braden Scale (Used for predicting pressure ulcer risk and risk factors), dated 02/28/25, showed Registered Nurse (RN) EE documented:
-Ability to respond meaningfully to pressure-related discomfort is slightly limited;
-Skin is occasionally moist;
-Chairfast, ability to walk is severely limited or non-existent, cannot bear own weight and/or must be assisted into chair or wheelchair;
-Ability to change and control body position is slightly limited;
-Friction and shear is a potential problem;
-Score of 16 (Mild risk for developing pressure sore);
-Risk factors for clinically unavoidable pressure injury includes, urinary and bowel incontinence, history of pressure injury, bedfast (21 hours per day in bed), pain that affects movement or mood, poor skin turgor and cognitive impairment.
Review of the resident's Physician Order Sheet (POS), dated March 2025, showed elevate bilateral lower extremities throughout the day, off load heels, every day.
Review of the resident's Treatment Administration Record (TAR), dated March 2025, showed elevate bilateral lower extremities throughout the day, offload the heels every day. Review showed staff documented they elevated the bilateral lower extremities throughout the day on 03/10/25, 03/11/25, 03/12/25 and 03/13/25.
Review of the nurse's notes, dated March 2025, showed staff did not document the resident had a wound to his/her right heel.
Review of the shower sheets, dated 02/03/25, 02/07/25, 03/03/25 and 03/11/25, showed staff did not document the resident had a wound to his/her right heel.
Review of the skin assessment, dated 03/12/25, showed staff did not document the resident had a wound to his/her right heel.
Observation on 03/10/25 at 11:47 A.M., showed the resident in a wheelchair in his/her room. The resident did not have pressure relief boots on and his/her feet rested directly on the tile floor.
Observation on 03/10/25 at 3:17 P.M., showed the resident in bed. His/her heels dug into the mattress with the bottom of his/her feet against the footboard of the bed, the resident did not have his/her pressure relief boots on.
Review of the resident's shower Sheet, dated 03/11/25, showed Certified Nurse Aide (CNA) C did not document the resident had a wound to his/her right heel.
Observation on 03/11/25 at 8:08 A.M., showed the resident in bed with his/her heels dug into the mattress and the bottom of his/her feet pressed up against the foot board of the bed, the resident did not have his/her pressure relief boots on.
Observation on 03/11/25 at 8:08 P.M., showed the resident in bed with his/her heels dug into the mattress with the bottom of his/her feet against the footboard of the bed, the resident did not have his/her pressure relief boots on.
Observation on 03/12/25 at 4:48 A.M., showed the resident in bed with his/her heels dug into the mattress with the bottom of his/her feet against the footboard of the bed, the resident did not have his/her pressure relief boots on.
Observation on 03/13/25 at 7:16 A.M., showed resident in bed with a large, circular dark purple area to his/her right heel.
Observation on 03/13/25 at 10:47 A.M., showed the resident in bed. The resident's heels compressed the mattress. The right heel had a large, circular, dark purple area.
During an interview on 03/13/25 at 10:47 A.M., LPN A said the resident's heels were pressed down into the mattress and not floated. The LPN said he/she had not seen a wound on the resident's heel, and there is not a treatment for one. The LPN said the wound is new. The LPN staff had not reported the right heel pressure injury to him/her. The LPN said he/she believes the resident requires help with bed mobility. The LPN said interventions for the resident's heels should have been in place. The LPN said the charge nurse is responsible for ensuring the CNA's are implementing pressure relief interventions. The LPN said the wound on the resident's heel is facility acquired.
During an interview on 03/13/25 at 11:09 A.M., CNA B said he/she is normally a CNA for the resident's hall. The CNA said he/she has been in the resident's room this morning and assisted the resident with getting comfortable in bed. The CNA said he/she had not noticed a wound on the resident's heel. The CNA said the resident's heels were digging into the mattress, and he/she told someone but does not remember who he/she told. The CNA said he/she did not know the resident's feet should be floated and if he/she found a new wound he/she would report it to the nurse.
During an interview on 03/13/25 at 11:13 A.M., CNA C said he/she gave the resident a shower on Monday and did not notice a wound on the resident's heel.
During observation and interview on 03/13/25 at 11:24 A.M., RN D said, Oh yeah, it's the right heel, it is obvious and easy to see. The RN said that is definitely a pressure injury and he/she would say it is unstageable at this point. The RN described the wound as 45 millimeters (mm) by 35 mm with a little bit of eschar on the edge and is partly black in the center and around the edges. The RN said he/she would expect a CNA to notice the wound during cares and notify the charge nurse. The RN said the charge nurse should notify the physician and obtain orders. The RN said the resident does not have a treatment in place for the wound. The RN said the nurses should use their nursing judgement and implement interventions. The RN said the resident's heel wound is facility acquired. The RN said staff should have floated the resident's heels while in bed.
During an interview on 03/13/25 at 3:00 P.M., CNA C said he/she normally works on the resident's hall. The CNA said staff has always had to assist the resident with bed mobility. The CNA said since the resident requires assistance with bed mobility bed sores are a concern. The CNA said he/she did not know why pressure relief interventions were not in place for the resident. The CNA said the nurse's are responsible for telling the CNA's what interventions should be implemented such as floating the resident's feet.
During an interview on 03/17/25 at 4:27 P.M., the Director of Nursing (DON) said staff should have identified the resident's wound and he/she did not believe the pressure injury was avoidable because of the resident's severe PVD. When asked about the resident's intervention to float his/her heels, the DON said that is from two years ago.
During an interview on 03/18/25 at 11:38 A.M., the medical director said the resident's pressure injury to his/her heel is definitely avoidable. The medical director said floating the resident's heels could have potentially prevented the pressure injury. He/She said the intervention of floating the resident's heels is there for a reason and staff should of undoubtedly followed the care plan. He/She said the PVD and insufficient blood to the area of the pressure could increase the size and severity of the pressure.
3. Review of Resident #2's Significant Change in Status Assessment (SCSA) MDS, dated [DATE], showed staff assessed the resident as:
-Moderate cognitive impairment;
-Behaviors towards others and rejection of care not exhibited;
-Required maximum assistance from staff members for bathing, dressing, personal hygiene and all transfers;
-Required moderate to maximum assistance from staff members with bed mobility;
-Always incontinent of bowel and bladder;
-One stage 4 pressure ulcer;
-Received hospice care;
-Diagnoses of Atrial Fibrillation (AFIB) (irregular heart beat) and Renal Failure.
Review of the resident's Braden Scale, dated 08/26/24, showed staff documented:
-Slightly limited ability to respond meaningfully to pressure-related discomfort;
-Very moist skin;
-Chairfast, ability to walk is severely limited or non-existent;
-Very limited ability to change and control body position;
-Food intake probably inadequate;
-Potential problem with friction and shear;
-Score of 13 (mild risk).
Review of the progress notes showed staff documented:
-12/02/24: Stage 2 pressure area to resident's left ankle;
-01/04/25: Left outer ankle is red and hot at site, 0.5 centimeter (cm) circumference around wound, purulent drainage from wound both on gauze and from wound.
Review of the care plan, dated 01/09/25, showed:
-Requires maximum assistance from one staff to turn and reposition in bed, dressing and transfers;
-At risk for skin integrity due to incontinence and decreased mobility;
-Pressure relief boots initiated on 12/10/24;
-Encourage and assist with turning and repositioning.
Review of the Nurse's Note, dated 1/31/2025, showed staff documented please use dark blue foam rectangular pillow for pressure offload of ankles and heels, check calves daily for any skin breakdown.
Review of the resident's POS, dated March 2025, showed:
-Float heels in bed;
-Left outer ankle, cleanse wound, apply skin prep, apply collagen powder and xeroform/oil dressing, and cover with dry dressing, daily for left outer ankle pressure;
-Please use dark blue foam rectangular pillow for pressure offload of ankles and heels, check calves daily for skin breakdown with start date of 12/13/2024.
Review of the TAR, dated March 2025, showed staff documented:
-Resident's heel floated while in bed on day shift 03/10/25, 03/12/25, 03/12/25 and 03/13/25;
-Left outer ankle, cleanse wound, apply skin prep, apply collagen powder, apply xeroform/oil dressing, and cover with dry dressing, every day shift for left outer ankle pressure administered on 03/10/25, 03/11/25, 03/13/25. A nurse documented did not administer, see progress note for 03/12/25.
Review of the resident's Weekly Skin Integrity Data Collection, showed nursing staff documented on:
-12/04/24 left outer foot wound, crusted over, no drainage, mepilex (absorbent foam dressing used for wound care) applied;
-12/11/24 resident has stage 2 to left ankle;
-12/18/24 open area to left lateral ankle, treatment orders in place;
-12/25/24 open area to left lateral ankle, treatment orders in place;
-01/01/25 open area to left lateral ankle, treatment orders in place;
-01/08/25 open area to left lateral ankle, treatment orders in place;
-01/15/25 left lateral ankle warm to touch;
-01/21/25 left lateral ankle, greatly improved, superficial;
-01/27/25 left lateral ankle, greatly improved, superficial;
-02/03/25 left outer ankle pressure stage 4;
-02/10/25 left outer ankle pressure stage 4;
-02/17/25 left outer ankle pressure stage 4;
-02/24/25 left outer ankle pressure stage 4;
-03/03/25 same issues continue, treatment in place;
-03/10/25 skin has issues previously noted and continues with treatment in place.
Observation 03/10/25 at 12:45 P.M., showed the resident sat up in bed with a bedside table over his/her lap. The resident's heels are not floated and the resident does not have pressure relief boots on. The resident does not have a blue foam wedge under his/her legs, or in his/her room. The resident's heels dug in to his/her air mattress.
During an interview on 03/10/25 at 12:45 P.M., the resident said staff are supposed to get him/her up in his/her chair everyday, so he/she doesn't get sores from laying on a plastic bed. The resident said he/she asked staff three times yesterday if they would get him/her up and nobody did. The resident said staff did not get him/her out of bed Saturday, Sunday and now Monday.
Observation on 03/11/25 at 9:59 A.M., showed the resident laid on an air mattress with his/her feet not floated. The resident had a bandage on the outside of his/her left ankle dated 03/10/25. The resident does not have pressure relief boots on or a blue wedge cushion under his/her legs.
During an interview on 03/11/25 at 9:59 A.M., the resident said staff used to get him/her up but now they never do. The resident said he/she can't get up without help. The resident said staff have not gotten him/her up four times in the last two weeks.
Observation 03/11/25 at 10:41 A.M., showed the resident has a flat pillow under his/her calves, with his/her heels pushed down in the mattress. The resident does not have pressure relief boots on, or a blue foam wedge under his/her legs. The bandage on the resident's left ankle is dated 03/10/25.
Observation on 03/11/25 at 7:06 P.M., showed the resident in bed with his/her feet pushed down in the mattress. The resident's heels are not floated and he/she does not have pressure relief boots on.
Observation on 03/11/25 at 7:53 P.M., showed the resident in bed with his/her feet pushed down in the mattress. The resident's heels are not floated and there is not a blue foam wedge under the resident's legs, or in the room. The resident does not have pressure relief boots on.
Observation on 03/12/25 at 4:52 A.M., showed the resident in bed with his/her feet pushed down in the mattress. The resident's heels are not floated and there is not a blue foam wedge under the resident's legs, or in the room. The resident does not have pressure relief boots on. The resident has a bandage to his/her ankle dated 03/10/25.
Observation on 03/12/25 at 7:41 A.M., showed the resident in bed with the foot and head of the bed both elevated. His/her heels are pushed down in the mattress and not floated. There is not a blue wedge in the resident's room, and the resident does not have pressure relief boots on. The resident has a bandage to his/her ankle dated 03/10/25.
Observation on 03/13/25 at 8:25 A.M., showed the resident's heels pushed down in the mattress. The resident's heels are not floated and the resident does not have pressure relief boots on. The resident has a bandage on his/her ankle dated 03/10/25.
During an interview on 03/13/25 at 8:27 A.M., CNA J said the resident should have a pillow underneath his/her legs to keep his/her feet floated off the bed and sheet. The CNA said the resident does not have a pillow under his/her legs and his/her feet are not floated. The CNA said he/she did not know the resident is supposed to have a blue foam wedge under his/her legs. He/She said he/she has access to the resident's care plan in the electronic record but he/she has not reviewed the resident's care plan. The CNA said the resident's feet were not floated because he/she had not reviewed the resident's care plan.
During an interview on 03/13/25 at 8:40 A.M., LPN O said he/she worked on the resident's hall on 03/12/25. The LPN said he/she did know if there were orders for the resident's feet to be floated. The LPN said he/she had been told he/she had to complete wound care, but said on 03/12/25 two nurses from another facility came to complete wound care so he/she did not do it. The LPN said, Oh Wow, the bandage says 03/10/25, that was when I did it on Monday, maybe I should check everyone's bandage treatments then. The LPN said he/she did the bandage change to the resident's ankle on 03/10/25 and he/she does not know why the resident's bandage was not changed on 03/12/25. The LPN said the resident's bandage is to be changed daily. He/She said if staff is not completing the treatment as ordered the resident's wound could get worse. The LPN said he/she does not know why staff are not floating the resident's feet and he/she did not know there was an order for the resident to have a blue foam cushion for repositioning.
During an interview on 03/13/25 at 11:39 A.M., RN D said he/she would expect the residents feet to be floated. The RN said he/she doesn't know why they are not.
During an interview on 03/17/25 at 2:58 P.M., LPN O said he/she has not read the resident's care plan. The LPN said he/she would assume the care plan would be in the paper chart but did not know for sure, because he/she hasn't seen any care plans.
During an interview on 03/17/25 at 4:27 P.M., the Interim DON said he/she does not know why the nurse on duty did not complete the resident's wound treatments. The DON said the nurse on duty is responsible and the DON said he/she should have followed up. The DON said the resident not getting his/her wound treatments as ordered could cause infection. The DON said it did not surprise him/her the staff did not know the resident is supposed to have a wedge to float his/her feet. The DON said the resident's wound is a stage 4 and is facility acquired.
During an interview on 03/18/25 at 11:38 A.M., the Medical Director said he/she would expect staff to follow the physician's orders and provide wound treatments daily. He/She said there are multiple risks to a resident who does not receive the ordered treatment daily, such as decreased healing and infection. It can be detrimental.
CONCERN
(D)
Potential for Harm - no one hurt, but risky conditions existed
Deficiency F0688
(Tag F0688)
Could have caused harm · This affected 1 resident
Based on observation, interview, and record review, facility staff failed to provide appropriate treatment and services to prevent further decrease in range of motion (ROM), movement of a joint, for o...
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Based on observation, interview, and record review, facility staff failed to provide appropriate treatment and services to prevent further decrease in range of motion (ROM), movement of a joint, for one resident (Resident #10) with contractures (shortening and hardening of muscles, tendons, or other tissue, often leading to deformity and rigidity of joints) out of 20 sampled residents. The facility census was 82.
1. Review of the policies provided by the facility did not contain a policy for the prevention and treatment of contractures.
Review of the facility policy titled Passive Range of Motion Exercises, dated 05/20/24, showed because changes in joints can occur within three days of immobility, start passive ROM exercises as soon as possible.
2. Review of Resident #10's Quarterly Minimum Data Set (MDS), a federally mandated assessment tool, dated 02/18/25, showed staff assessed the resident as:
-Severe cognitive impairment;
-Rejection of care not exhibited;
-ROM impairment to both upper and lower extremities;
-Dependent on staff for all Activities of Daily Living (ADLs);
-Diagnoses of Alzheimer's Disease and Dementia.
Review of the resident's Physician's Order Sheet (POS), dated March 2025, showed the physician ordered:
-Resting splint to right hand as tolerated check skin integrity throughout the day and report concerns to Occupational Therapy (OT);
-Place a rolled wash cloth in the hand and remove twice daily for hand hygiene and skin inspection;
-Resting hand splint applied to right hand as tolerated during the day and may remove at night;
-Place rolled wash cloth in left hand and check skin integrity throughout the day.
Review of the resident's Treatment Administration Record (TAR), dated March 2025, showed staff documented they applied:
-Rolled wash cloth in right hand during the day shift and night shift on the 10th, 11th and 12th;
-Resting hand splint applied to right hand on the day shift on the 10th, 11th and 12th;
-Rolled wash cloth in left hand during the day and night shift on the 10th, 11th and 12th;
Review of the resident's care plan, dated 12/03/24, showed staff is directed to place the resting hand splint to the resident's right hand as tolerated and place a rolled wash cloth in the left hand. Staff should check skin integrity throughout the day to both the right and left and hand and repot any concerns to OT.
Observation on 03/10/25 at 12:39 P.M., showed the resident in bed with both hands contracted with a flat wash cloth in the right hand and did not have a wash cloth in the left hand. The resident does not have splint on his/her right hand.
Observation on 03/10/25 at 3:37 P.M., showed the resident with wadded up wash cloth in his/her left hand and did not have a wash cloth in his/her right hand. The resident does not have a brace on his/her right hand.
Observation on 03/11/25 at 8:50 A.M., showed resident in bed. The resident left hand with a flat wash cloth inside. The resident does not have a rolled wash cloth in right hand. The resident does not have a hand splint on right hand.
Observation on 03/11/25 at 11:57 A.M., showed the resident in a wheelchair, in the dining room. The resident had a flat wash cloth in his/her left hand and did not not have a wash cloth or splint to his/her right hand.
Observation on 03/11/25 at 7:04 P.M., showed the resident in his/her room in a wheelchair. The resident does have a wash cloth in his/her left hand or his/her right hand.
Observation on 03/12/25 at 5:15 A.M., showed the resident in bed with a flat wash cloth to his/her left hand and no device or wash cloth to his/her right hand.
Observation on 03/12/25 at 7:28 A.M., showed the resident in a wheelchair by the nurses's station. The resident has a flat washcloth in his/her left hand and nothing in the right hand.
Observation on 03/13/25 at 7:21 A.M., showed the resident in a wheelchair by the nurse's station. The resident has a flat wash cloth in his/her left hand and nothing in the right hand.
During an interview on 03/13/25 at 8:52 A.M., Certified Nurse Aide (CNA) CC said he/she assisted the resident out of bed this morning. The CNA said the resident always has a wash cloth in his/her left hand. The CNA said he/she is not sure if the resident is supposed to have a brace on the right hand. The CNA said he/she did not put a brace on the resident's right hand and did not put a rolled up wash cloth in the resident's right hand. The CNA said the wash cloth in the resident's left hand is not rolled up. The CNA said it is hard to know how to do things when he/she does not have things explained well to him/her. The CNA said right now the resident does not have anything in his/her right hand.
During an interview on 03/13/25 at 9:04 A.M., CNA J said he/she just laid the resident back in his/her bed. The CNA said nurses have told him/her the resident is supposed to have a rolled up wash cloth in his/her hands. The CNA said he/she did not know the resident had a hand splint and he/she has never put a hand splint on the resident. The CNA said if the resident had a hand splint the nurses should have showed him/her how to put it on the resident. The CNA said the resident does not have anything in or on his/her right hand. The CNA said the wash cloth in resident's left hand is not rolled, it is scrunched into the resident's hand.
During an interview 03/13/25 at 9:13 A.M., Licensed Practical Nurse (LPN) O said the resident might be the resident that is supposed to have rolled wash cloths in his/her hands. The LPN said he/she doesn't know if the resident should have splint on his/her right hand. The LPN said he/she doesn't typically look at the residents' treatments until after the medication pass.
During an interview on 03/13/25 at 2:15 P.M., The Rehabilitation Director said the resident has an order for a resting hand splint. The Rehabilitation Director said using rolled wash cloths in the resident's hands prevents the resident's hands from contracting further. He/She said it is the nurses' responsibility to make sure the resident has a splint and/or wash cloths in his/her hands. The resident's contractures could get worse if the interventions are not done.
During an interview on 03/13/25 at 2:40 P.M., LPN O said it is the charge nurses responsibility to tell the aides about orders and make sure the orders are followed. The LPN said he/she thought the aides knew about the resident's hand splint.
During an interview on 03/17/25 at 2:30 P.M., CNA P said he/she doesn't know if the resident is supposed to have a hand splint on his/her right hand. The CNA said staff do not roll the cloths like they should. The CNA said he/she has not read the resident's care plan because he/she does not know where the care plans are.
During an interview on 03/17/25 at 4:27 P.M., the Interim Director of Nursing (DON) said he/she does not know why the staff are not putting the brace on the resident's right hand, or the rolled up wash cloths in both of the resident's hands. The DON said some of the staff are afraid they might hurt the resident but they should have asked the therapy department for help. The DON said if staff are not putting the brace on the resident's hand or the wash cloths in the hands it could cause the contracture to worsen.
During an interview on 03/18/25 at 11:38 A.M., The medical director said if the resident's orders are not followed there is a risk of worsening contractures and the resident's condition. Staff should follow the orders as they are written.
CONCERN
(D)
Potential for Harm - no one hurt, but risky conditions existed
Deficiency F0700
(Tag F0700)
Could have caused harm · This affected 1 resident
Based on observation, interview, and record review, facility staff failed to accurately complete a bed rail assessment and entrapment assessment for one resident (Resident #10) out of of 20 sampled re...
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Based on observation, interview, and record review, facility staff failed to accurately complete a bed rail assessment and entrapment assessment for one resident (Resident #10) out of of 20 sampled residents when staff did not accurately identify the type of bed rails used by the resident. The facility census was 82.
1. Review of the facility's policy titled Safe and Effective Use of Bed Rails, dated 09/06/24, showed all alternatives should be considered, and bed rails should only be used when identified need outweighs potential risk. The interdisciplinary team will review and revise the care plan, if indicated, upon completion of each comprehensive, significant change and quarterly MDS for the need to continue use of bed rails.
2. Review of Resident #10's Quarterly Minimum Data Set (MDS), a federally mandated assessment tool, dated 02/18/25, showed staff assessed the resident as:
-Severe cognitive impairment;
-Range of Motion (ROM) impairments to both upper and lower extremities;
-Dependent on staff for all Activities of Daily Living (ADL);
-Diagnoses of Alzheimer's Disease and Dementia.
Review of the resident's entrapment assessment, dated 04/23/24, showed the assessment did not contain an updated entrapment assessment.
Review of the resident's care plan, dated 12/03/24, showed staff documented:
-Resident is at risk for falls with bilateral upper 1/4 siderails up as ordered for intervention;
-Mechanical lift with assistance from two staff members for transfers;
-Dependent on one to two staff members to turn and reposition in bed.
Review of the resident's Quarterly Evaluation For Use of Bed Rails, dated 02/28/25, showed staff assessed resident as:
-Bed rails still appropriate for resident;
-Confused cognitive status;
-Resident not able to understand others, or make self understood;
-Resident has weakness, unable to support trunk in upright position, balance deficit and history of rolling out of bed;
-Uncontrolled or involuntary body movements, contractures, resident rocks self;
-1/4 partial rail.
Review of the resident's Physician's Order Sheet (POS), dated March 2025, showed bilateral 1/4 bed rails to bed to assist with bed mobility.
Observation on 03/10/25 at 12:39 P.M. and 3:40 P.M., showed the resident in bed with 1/2 bed rails up on both sides of the bed.
Observation on 03/11/25 at 8:50 A.M., showed the resident in bed with 1/2 bed rails up on both sides of the bed.
Observation 03/12/25 at 5:15 A.M., showed the resident in bed with 1/2 bed rails up on both sides of the bed.
During an interview on 03/13/25 at 2:15 P.M., the Rehabilitation Director said the resident does not have the mental capacity to use bed rails to reposition himself/herself.
During an interview on 03/17/25 at 2:30 P.M., Certified Nurse Aide (CNA) P said the resident has bed rails on his/her bed because he/she scoots in bed. The CNA said the resident can't use his/her hand to grab the side rails and he/she can't assist staff with bed mobility.
During an interview on 03/17/25 at 2:58 P.M., Licensed Practical Nurse (LPN) O said the resident is not able to assist with his/her bed mobility. The LPN said he/she doesn't know why the resident has bed rails. The LPN said he/she tried to complete a new bed rail assessment and couldn't because the resident is unable to safely clear the entrapment assessment as he/she can not purposely push himself/herself away from the rails. The LPN said the charge nurses are responsible to complete bed rails assessments accurately. The LPN said new bed rail assessments should be completed quarterly and with a change in resident condition.
During an interview on 03/17/25 at 4:27 P.M., the Interim Director of Nursing (DON) said the resident is not capable of assisting staff with his/her bed mobility. The DON said the bed rails are not appropriate for the resident at this time. The DON said the charge nurses are responsible for completing bed rail assessments. The DON said new bed rail assessments should be completed quarterly and with a change in the residents condition.
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, facility staff failed to provide a comfortable and homelike environment for r...
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**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, interview and record review, facility staff failed to provide a comfortable and homelike environment for residents when staff failed to maintain walls, floors, doors, and door frames. The facility staff failed to maintain the armrest on a wheelchair for one resident (Resident #35) out of 20 sampled residents. The facility census was 82.
1. Review of facility's policy titled Housekeeping - General Policy, dated 06/12/2024, directed staff as follows:
-It is the responsibility of the Executive Director through the Environmental Services Director to assure Housekeeping Policies are implemented and followed;
-Equipment must be ready for use at all times of the day and night to serve the residents' needs;
-Care should be exercised in the handling and in the use of all equipment to prevent damage or breakage;
-The policy did not address how to report maintenance concerns.
Review of the facility's policy titled Preventative Maintenance - Wheelchair:, dated 01/29/2025, directed staff as follows:
-Quarterly cleaning and inspection of all chairs will be scheduled for proper operations thereafter;
-All new wheelchairs will be inspected by rehabilitation services or the maintenance department upon arrival to the facility, inspections will be documented on a Wheelchair Inspection Log or in TELS (the work order management system used for building operations);
-Quarterly inspection and cleaning will be scheduled for all chairs by the in-house maintenance department; inspections will be documented on a Wheelchair Inspection Log or in TELS;
-Chairs which are found to have broken or missing parts or are in need of repair will be taken out of use immediately and reported to the maintenance department or rehabilitation services for repair;
-Needed repairs will be made and/or parts ordered for all broken chairs;
-Wheelchair inspections: seat bottoms, seat backs and armrests are not overly worn, torn, or otherwise in need of repair.
2. Observation on 03/10/2025 at 11:47 A.M., showed resident occupied room [ROOM NUMBER] had a toilet riser in the bathroom with missing and chipped paint on the front, with a rust colored metal bar exposed. The floor under the toilet riser with rust-colored spots and chipped area.
3. Observation on 03/10/25 at 11:47 A.M., showed resident occupied room [ROOM NUMBER] bathroom with broken and missing tiles under the sink. The mirror above the sink has reflective surfaces peeled off.
4. Observation on 03/10/2025 at 12:06 P.M., showed resident occupied room [ROOM NUMBER] bathroom ceiling around the fan vent with missing and chipped paint.
5. Observation on 03/10/25 at 12:09 P.M., showed resident occupied room [ROOM NUMBER] with damaged dry wall behind the right side of the bed, running most of the length of the bed.
6. Observation 03/10/25 at 12:39 P.M., showed resident occupied room [ROOM NUMBER] bathroom and closet with multiple areas with damage to the drywall corners and exposed metal corner brackets. Observation showed multiple tiles missing by the bed and there are multiple stained tiles by the sink.
7. Observation on 03/10/2025 at 3:05 P.M., showed resident occupied room [ROOM NUMBER] wood trim on the wall behind the bed with areas gouged and splintered.
8. Observation on 03/10/2025 at 3:19 P.M., showed resident occupied room [ROOM NUMBER] wall behind the bed with multiple areas gouged.
9. Observation on 03/10/2025 at 3:54 P.M., showed Resident #35's wheelchair right arm rest cracked with exposed padding.
During an interview on 03/20/2025 at 3:12 P.M., the administrator said they were not aware of the damaged arm rest on resident #35's wheelchair. The administrator said clinical staff should have reported this through the TELS system for the maintenance director to fix.
10. Observation on 03/10/25 at 3:58 P.M., showed the 100/300 halls and 200/400 hall nurses station wood laminate chipped with missing areas.
11. Observation on 03/11/25 at 7:05 P.M., showed resident occupied room [ROOM NUMBER] dry wall behind the residents bed with peeling and missing paint.
12. Observation on 03/11/25 at 7:10 P.M., showed resident occupied room [ROOM NUMBER] bathroom door frame with missing paint, and the bathroom exterior corner wall with drywall damaged. The baseboard with areas of brown stains and the metal edge is exposed.
13. Observation on 03/11/25 at 7:31 P.M., showed the Memory Care walls in the dining room with multiple areas of black scuff marks, missing paint and gouges.
14. Observation on 03/11/25 at 8:43 A.M., showed resident occupied room [ROOM NUMBER] room bathroom floor with multiple chipped tiles with gouges. Observation showed the linoleum floor in front of the toilet with four large tears and peeled up at the bathroom door.
15. Observation on 03/11/25 at 2:47 P.M., showed resident occupied room [ROOM NUMBER] with multiple broken tiles.
16. Observation on 03/12/25 at 7:34 A.M., showed resident occupied room [ROOM NUMBER] bathroom door with multiple areas of chipped paint, areas of wood missing. Observation showed the drywall on corner of bathroom damaged with exposed metal corner bracket and the rubber base trim lose and peeled away from wall.
17. Observation on 03/12/25 at 7:55 A.M., showed the 100 hall nurses station with missing paint and exposed metal corner bracket and nails.
18. Observation on 03/17/25 at 4:26 P.M., showed six broken tiles at the fire doors by the public restrooms.
19. During an interview on 03/17/25 at 2:30 P.M., Certified Nurse Aide (CNA) P said if staff notice something that needs to be fixed they write a note for maintenance. The CNA said he/she has not reported any issues. The CNA said he/she has noticed the damaged doors and walls on the halls but the damaged stuff is normal here. The CNA said he/she has noticed the broken tiles, chunks out of walls and the missing paint. The CNA said he/she did not report the issues because everyone is already aware.
During an interview on 03/17/25 at 3:16 P.M., Registered Nurse (RN) Q said aides report damage to him/her and he/she lets maintenance know through our system or verbally. The RN said he/she has not seen broken tile, damaged walls or doors, and he/she would expect staff to report that to him/her.
During an interview on 03/17/2025 at 4:09 P.M., the maintenance director said there is a work order system in place that all staff have access to. They can use the TELS system and complete a short form to submit a maintenance request. The maintenance director said they repair stuff as they see it or as it is reported. He/she said they do not typically get work orders for cosmetic repairs. The maintenance director said they are aware of scratched and damaged walls and floors but they not allowed to repair the issues while the room is occupied and there is not room availability to free up rooms for repairs. He/she said the therapy department is responsible for toilet risers and this has not been reported to maintenance. He/she is not aware of resident #35's wheelchair damage. He/she is able to work on wheelchairs and has gotten work orders for such issues in the past. He/She noticed the chipped laminate at the bottom of the nurse stations and he/she plans to fix it.
During and interview on 03/17/25 at 4:27 P.M., the Interim Director of Nursing (DON) said staff are supposed to report damage to floors, walls, and doors in the TELS system. He/she expects staff to report broken tiles and for maintenance to complete daily rounds on the building. The DON said he/she gets a daily report of everything that maintenance completes.
During an interview on 03/17/25 at 5:13 P.M., the administrator said staff can fill out work order requests in the TELS system to create a work report in the electronic health record through scanning a QR code. He/She said there is also a clipboard to fill out if staff need it. Maintenance should be completing general rounds and specific rounds from what TELS populates.
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, facility staff failed to review and revise the care plan for Activities of D...
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**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, interview, and record review, facility staff failed to review and revise the care plan for Activities of Daily Living (ADLs) needs for four residents (Residents #41, #51, #54, and #60 ) and failed to review and revise the care plan with changes in the resident needs for three residents oxygen use (Resident #26, #44, and #58) out of 20 sampled residents. The facility census was 82.
1. Review of the facility policy titled Comprehensive Care Plans and Revisions, dated 09/11/24, showed staff were directed as follows:
-The facility will ensure the timeliness of each resident's person-centered, comprehensive care plan, and to ensure that the comprehensive care plan is reviewed and revised by an interdisciplinary team;
-A comprehensive care plan must be developed within seven days after completion of the comprehensive assessment;
-Reviewed and revised by the interdisciplinary team (IDT) after each assessment, including both the comprehensive and quarterly review assessments;
-The facility should monitor the resident over time to help identify changes in the resident condition that may warrant an update to the person-centered plan of care;
-When these changes occur, the facility should review and update the plan of care to reflect the changes to care delivery, to include additional interventions on existing problems, updating goal or problem statements, and adding a short-term problem, goal and interventions to address a time limited condition.
2. Review of Resident #41's Quarterly Minimum Data Set (MDS), a federally mandated assessment tool, dated 12/05/24, showed staff assessed the resident as:
-Unable to assess cognitive status;
-Short and long term memory problems;
-Dependent on staff for oral hygiene, toileting, and shower/bath;
-Required substantial/maximal assistance for upper/lower body dressing and personal hygiene;
-Required partial/moderate assistance for chair/bed to chair transfers;
-Diagnoses of high blood pressure, chronic kidney disease, neurogenic bladder (chronic condition when a person lacks bladder control due to brain, spinal cord or nerve problems), and unspecified disorder of the brain.
Review of the resident's care plan, dated 12/27/24, showed it did not address the resident's ADL assistance needs.
During an interview on 03/17/25 at 2:32 P.M., Certified Nurse Aide (CNA) E said he/she works on the memory care unit often. CNA E said Resident #41 usually requires one staff assist, but it depends on the day and how he/she is doing. Some days the resident requires more assistance.
During an interview on 03/17/25 at 3:16 P.M., Registered Nurse (RN) Q said Resident #41 is dependent on one to two staff members for all ADL's. The RN said the resident can help with some cares, such as putting a shirt on.
3. Review of Resident #51's admission MDS, dated [DATE], showed staff assessed the resident as:
-Moderate cognitive impairment;
-Required partial/moderate staff assistance for eating and oral hygiene;
-Required substantial/maximum staff assistance for toileting, bathing, dressing and personal hygiene.
Review of the resident's care plan, dated 01/14/25, showed staff documented the resident requires assistance with ADL's and staff assistance for ambulation.
During an interview on 03/10/25 at 3:20 P.M., the resident said staff help him/her get out of bed and take a shower.
During an interview on 03/17/25 at 2:40 P.M., CNA P said he/she has never seen a care plan. The CNA said he/she knows how to care for the residents from other staff and asking the residents.
During an interview on 03/17/25 at 3:19 P.M., RN Q said staff review care plans to learn resident needs. The RN said ADL's should be on the care plan.
During an interview on 03/17/25 at 4:27 P.M., the interim Director of Nursing (DON) said all staff nurses can update the care plans and the MDS coordinator is responsible for the overall care plan and updates. The DON said ADL needs should be on the care plan and should reflect the residents total care needs.
4. Review of Resident #54's Annual MDS assessment, dated 01/23/25, showed staffed assessed the resident as:
-Severely cognitively impaired;
-Dependent on staff for oral hygiene;
-Required substantial/maximum assistance for toileting, shower/bath, upper/lower body dressing, and personal hygiene;
-Diagnoses of non-traumatic brain dysfunction, high blood pressure, Alzheimer's Disease, dementia with behavioral disturbances, and need for assistance with personal care.
Review of the resident's care plan, dated 01/29/25, showed staff documented the resident required supervision from one staff member for dressing, personal hygiene, oral hygiene, and toilet use. The care plan did not address the assistance the resident required for showering and bathing.
During an interview on 03/17/25 at 2:32 P.M., CNA E said he/she works on the memory care unit often. CNA E said the resident required assistance from two staff for showers and toileting, but is independent with walking around and getting up and down.
During an interview on 03/17/25 at 3:16 P.M., RN Q said the resident requires total assistance for cares like toileting and showering. RN Q said the resident is independent or requires supervision for transfers and sometimes for dressing.
5. Review of Resident #60's Quarterly MDS, dated [DATE], showed staff assessed the resident as:
-Moderately cognitively impaired;
-Required partial/moderate assistance with oral hygiene and upper body dressing;
-Required substantial/maximal assistance for toileting, shower/bathe self, lower body dressing and personal hygiene;
-Dependent for chair/bed to chair transfers;
-Diagnoses of generalized muscle weakness.
Review of the resident's care plan, dated 01/21/25, showed staff documented the resident requires partial assistance from one staff for showering and bathing, supervision for dressing, personal hygiene and oral care and maximum assistance from two staff for toileting.
During an interview on 03/17/25 at 2:32 P.M., CNA E said he/she works on the memory care unit often. CNA E said the resident usually requires two staff for almost everything and is dependent on staff.
During an interview on 03/17/25 at 3:16 P.M., RN Q said the resident is dependent on staff for all cares.
6. Review of Resident #26's Quarterly MDS, dated [DATE], showed staff assessed the resident as unable to assess cognition due to being rarely understood and required oxygen.
Review of the resident's Physician's Order Sheet (POS), dated 04/22/24, showed administer oxygen at 2 Liters Per Minute (LPN) continuously via nasal cannula.
Review of the resident's care plan, dated 11/11/24, showed staff documented to administer oxygen as ordered.
Observation on 03/10/2025 at 12:09 P.M., showed the resident in bed with his/her oxygen tubing on the floor under the bed and the concentrator turned off.
Observation on 03/12/2025 at 4:55 A.M., showed the resident in bed with his/her oxygen tubing coiled on top of the concentrator and the concentrator turned off.
Observation on 03/13/2025 at 8:36 A.M., showed the resident in bed with his/her oxygen tubing coiled on top of the concentrator and the concentrator turned off.
7. Review of Resident #44 Quarterly MDS, dated [DATE], showed staff documented the resident did not require oxygen therapy.
Review of the resident's POS, dated 03/14/25, showed it did not contain orders for oxygen use.
Review of the care plan, dated 12/24/24, showed it did not contain direction for staff in regard to oxygen use for the resident.
Observation on 03/12/25 at 4:54 A.M., showed the resident in bed with oxygen on at 2 liters per minute (LPM) via nasal cannula.
Observation on 03/12/25 at 8:27 A.M., showed the resident in bed with oxygen on a 2 LPM via nasal cannula.
8. Review of Resident #58's Quarterly MDS, dated [DATE], showed staff documented the resident did not require oxygen therapy.
Review of the resident's POS, dated 03/14/25, showed it did not contain an order for oxygen use.
Review of the care plan, dated 01/21/24, showed it did not contain direction for staff in regard to oxygen use.
Observation on 03/12/25 at 4:54 A.M., showed the resident in bed with oxygen on at 2.5 LPM via nasal cannula.
Observation on 03/12/25 at 8:26 A.M., showed the resident in bed with oxygen on at 2.5 LPM via nasal cannula.
9. During an interview on 03/17/25 at 2:32 P.M., CNA E said the care plans should direct staff in regard to the residents care needs. The CNA said when he/she gets a new resident he/she looks at the care plans, but if the resident has been at the facility a while he/she gets updated information in report. He/She said he/she does not really look at the care plans consistently.
During an interview on 03/17/25 at 2:40 P.M., CNA P said the only way staff knows a resident uses oxygen is if there is a concentrator in the residents' room. The CNA does not know how often or when each resident should receive oxygen or how many LPM each resident should receive. The CNA said they do not have access to this information and oxygen use should be on the care plan.
During an interview on 03/17/25 at 3:16 P.M., RN Q said ADL assistance should be on the care plan, but he/she had not checked the care plans to see if they are accurate. He/she said staff can go to the care plan or [NAME] to see how much assistance a resident needs for their ADLs. He/She said oxygen use should be on the care plans.
During an interview on 03/17/25 at 3:43 P.M., the MDS Coordinator said the care plans should match the MDS assessments; and the care plan should be updated to reflect changes in the residents' care. The MDS Coordinator said he/she has been pulled to the floor, and did not know the care plans were not up to date. He/she said other nurses can update the care plan as well when there are changes.
During an interview on 03/17/25 at 4:26 P.M., the Interim DON said care plans should reflect the MDS and resident observations. He/She said staff are expected to review the care plans that can be accessed through Plan Of Care under tasks in the Electronic Health Record, under the care plan button in the computer. The interim DON said any nurse should be able to update the care plans, but he/she is not sure if the nurses know that. The interim DON said he/she has been covering for the facility's DON for the last one to two weeks. He/She said oxygen use should be on the care plans.
During an interview on 03/20/2025 at 3:12 P.M., the administrator said all nurses and nurse management are responsible for updating the care plans. The administrator said oxygen use should be on the care plan if there is an order for it. The administrator said the care plans should accurately reflect the ADL needs of all residents.
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, facility staff failed to obtain physician's orders for oxygen use for two re...
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**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, interview, and record review, facility staff failed to obtain physician's orders for oxygen use for two residents (Resident #44 and #58), failed to follow physician's orders for oxygen use for one resident (Resident #26), and failed to obtain a physician's order for one resident's wound treatment (Resident #58) out of 20 sampled residents. The facility census was 82.
1. Review of the facility's policy titled Oxygen Administration, dated 10/11/24, showed staff are directed to obtain oxygen orders that are written for the specific flow rate required by the resident.
Review of the facility's policy titled Physician Orders, dated 02/27/25, showed staff are directed to:
-Have a physician, physician assistant or nurse practitioner provide orders for the resident's immediate care and ongoing care needs;
-Follow and carry out the orders of the provider in accordance with all applicable state and federal guidelines;
-Physician orders include medications, treatments and special medical procedures required for the safety and well-being of the resident;
-Medications, diets, therapy and any treatment may not be administered to the resident without a written order from the attending physician.
2. Review of Resident #44's Quarterly Minimum Data Set (MDS), dated [DATE], showed staff documented the resident did not require oxygen therapy.
Review of the resident's care plan, dated 12/24/24, showed the care plan did not contain direction for staff in regard to the resident's oxygen use.
Review of the physician's order sheet (POS), dated 03/14/25, showed POS did not contain an order for oxygen.
Observation on 03/12/25 at 4:54 A.M., showed the resident in bed with his/her oxygen on at two liters per minute (LPM) via nasal cannula.
Observation on 03/12/25 at 8:27 A.M., showed the resident in bed with his/her oxygen on at two LPM via nasal cannula.
3. Review of Resident #58's Quarterly MDS, dated [DATE], showed staff documented the resident did not require oxygen therapy.
Review of the resident's care plan, dated 01/21/24, showed the care plan did not contain direction for staff in regard to the resident's oxygen use.
Review of the POS, dated 03/14/25, showed the POS did not contain an order for oxygen.
Observation on 03/12/25 at 4:54 A.M., showed the resident in bed with oxygen on at 2.5 LPM via nasal cannula.
Observation on 03/13/2025 8:26 A.M., showed the resident in bed with oxygen on at 2.5 LPM via nasal cannula.
During an interview on 03/10/25 at 3:38 P.M., the resident said he/she breathes better with his/her oxygen on.
During an interview on 03/17/24 at 4:27 P.M., the interim Director of Nursing (DON) said all residents using oxygen should have a physician's order for the oxygen.
4. Review of resident #26's Quarterly MDS, dated [DATE], showed staff documented the resident required oxygen and had impairments to both upper and lower extremities.
Review of the resident's care plan, dated 02/04/25, showed staff are directed to administer oxygen as ordered.
Review of the resident's POS, dated 03/14/25, showed an order to administer oxygen at two LPM continuously.
Observation on 03/10/25 at 12:09 P.M., showed the resident in bed and did not have his/her oxygen on. An oxygen concentrator sat in the room turned off.
Observation 03/12/2025 at 4:55 A.M., showed the resident in bed and did not have his/her oxygen on. An oxygen concentrator sat in the room tuned off.
Observation on 3/13/25 at 8:36 A.M., showed the resident in bed without his/her oxygen on. An oxygen concentrator sat in the room turned off.
During an interview on 03/17/25 at 3:19 P.M., Registered nurse (RN) Q said staff obtain orders for medications and treatments by faxing a communication form to the physician. The RN said the nurse who receives the order is responsible for entering the order in the computer system. The RN said there should be a physician's order for oxygen use. The RN said he/she did not know why the residents did not have oxygen orders and did not know why the orders were not followed for Resident #26.
5. Review of Resident #58's quarterly MDS, dated [DATE], showed staff documented there resident is cognitively intact and has a diagnosis of heart failure.
Review of the residents POS, dated 03/14/25, showed the POS did not contain a treatment order for his/her right hand or left wrist.
Observation on 03/10/25 at 3:36 P.M., showed the resident with a gauze dressing on his/her right hand and left wrist dated 03/07.
Observation on 03/11/25 at 1:26 P.M., showed the resident with a gauze dressing on his/her right hand and left wrist dated 03/07.
Observation on 03/13/25 at 8:27 A.M., showed the resident with a gauze dressing on his/her right hand and left wrist dated 03/07.
During an interview on 03/13/25 at 11:31 A.M., the interim DON said the resident had a skin biopsy of the right hand and left wrist. The DON said a dressing was put on 03/07 when the resident returned from the clinic. The DON said he/she did not know if the resident returned from the clinic with any orders, and he/she did not know the resident had a dressing on the areas dated 03/07. The DON said there should be an order for ongoing treatment of the biopsy sites.
During an interview on 03/17/25 at 9:20 A.M., the DON said he/she could not locate documents related to treatment of the resident's biopsy sites.
During an interview on 03/20/25 at 3:12 P.M., the administrator said the nurses are responsible for obtaining orders for oxygen use, everyone who uses oxygen should have orders. The administrator said staff should have obtained orders for care following the biopsies for resident #58. The said he/she does not know why staff did not obtain orders.
CONCERN
(E)
Potential for Harm - no one hurt, but risky conditions existed
Accident Prevention
(Tag F0689)
Could have caused harm · This affected multiple residents
Based on observation, interview and record review, facility staff failed to ensure the residents' environment remained free of accident hazards, to the extent possible, when the facility staff failed ...
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Based on observation, interview and record review, facility staff failed to ensure the residents' environment remained free of accident hazards, to the extent possible, when the facility staff failed to store medications and toxic chemicals in a manner not accessible to residents. The facility census was 82.
1. Review of the facility's policy titled, Storage of Chemicals, dated 09/19/23, showed the policy directed staff to store chemicals in accordance with manufacturer guidelines while maintaining supervision while in use and out of the reach of residents when not actively in use.
Observations on 03/10/25 at 1:00 P.M. and on 03/11/25 at 12:00 P.M., showed the door to the director of nursing's (DON) office open and the room unattended by staff. Observation showed a 19 ounce (oz.) aerosol can of quaternary ammonium (QUAT) based disinfectant spray and a 32 oz. spray bottle of glass and multi-surface cleaner stored unsecured in the room. Review of the product labels showed hazard warnings which included the products were hazardous to humans and could cause eye and skin irritation.
Observations on 03/11/25 at 12:10 P.M. and on 03/12/25 at 8:30 A.M., showed the door to the shower room near the 400 hall unlocked and the area unattended by staff. Observation showed a 32 oz. spray bottle of QUAT based disinfectant stored unsecured in the room. Review of the product label showed hazard warnings which included the product was hazardous to humans, causes moderate eye irritation, and to avoid contact with eyes, skin and clothing.
During an interview on 03/12/25 at 3:00 P.M., the maintenance director said chemicals should be stored behind locked doors and not accessible to residents. The maintenance director said he/she monitors chemical storage quarterly, but all staff are trained on how to properly store chemicals and to lock up any chemicals found unsecured at the time of discovery.
During an interview on 03/13/25 at 11:00 A.M., the administrator said chemicals should be stored behind locked doors and not accessible to residents. The administrator said the housekeepers and all department heads are responsible to monitor for the proper storage of chemicals daily. The administrator said all staff are trained how to properly store chemicals and if unsecured chemicals are found, staff should take them and lock them up before they leave the area.
2. Review of the facility's policy titled Storage and Expiration Dating of Medications and Biologicals, dated 08/01/24, showed the facility staff should ensure all medications and biologicals, including treatment items, are securely stored in a locked cabinet/cart or a locked medication room that is inaccessible by residents and visitors.
Observations on 03/10/25 at 1:00 P.M. and on 03/11/25 at 12:00 P.M., showed the door to the DON's office open and the room unattended by staff. Observation showed a four oz. tube of ultra strength pain relief cream and a two gram tube of 10 percent docosanol (an antiviral) cream stored unsecured in the room.
Observation on 03/10/25 at 2:39 P.M., showed an unattended and unlocked treatment cart at end of the 100 Hall. Staff could not be observed on the hall or with the treatment cart. Observation showed the treatment cart contained 38 prescription and over the counter (OTC) ointments labeled harmful if ingested, or contact poison control if ingested. Observation at 3:19 P.M., showed the treatment cart unlocked and unsupervised.
Observation on 03/11/25 at 8:23 A.M., showed an unlocked and unattended treatment cart on the 400 hall. The treatment cart contained prescription treatments and ointments labeled to contact poison control if ingested.
During an interview on 03/17/25 at 3:16 P.M., Registered Nurse (RN) Q said staff should lock the medication and treatment carts before walking away so a resident does not take a medication they are not supposed to have. The RN said there ointments and other items in a treatment cart that can be harmful to a confused resident.
During an interview on 03/17/25 at 4:27 P.M., the DON said staff should lock the treatment cart before walking away because the carts have medications in them and the facility has confused residents. The DON said staff doesn't want someone going through the treatment cart. The DON said staff who use the cart are responsible to make sure it is locked.
CONCERN
(E)
Potential for Harm - no one hurt, but risky conditions existed
Deficiency F0698
(Tag F0698)
Could have caused harm · This affected multiple residents
**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on interview and record review, facility staff failed to completed a pre-dialysis (procedure to remove waste products from...
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**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on interview and record review, facility staff failed to completed a pre-dialysis (procedure to remove waste products from the blood when the kidneys stop functioning properly), post-dialysis assessment and to have a system in place for ongoing communication with the dialysis clinic for one resident (Resident #35). Staff failed to complete a post-dialysis assessment for one resident (Resident #59) out of two sampled residents. Facility census was 82.
1. Review of the facility's policy titled Hemodialysis Offsite Policy, dated 09/06/24, directs staff to:
-Perform ongoing assessment of the resident's condition and monitoring for complications before and after dialysis treatments received at a certified dialysis facility;
-Ongoing communication and collaboration with the dialysis facility regarding dialysis care and services;
-The facility should provide immediate monitoring and documentation of the status of the resident's access site(s) upon return from the dialysis treatment;
-The facility should weight the resident and document the findings based on orders;
-On the day of dialysis staff should observe vascular access site prior to dialysis and initiate the pre/post dialysis communication form to be sent to the dialysis clinic with the resident;
-After return from the dialysis clinic staff should obtain vitals signs and completed the pre-post dialysis communication form.
2. Review of Resident #35's admission Minimum Data Set (MDS), a federally mandated assessment tool, dated 02/18/2025, showed staff assessed the resident as requiring dialysis services.
Review of the resident's care plan, dated 02/12/25, showed staff are directed to:
-Assess shunt site for bruit and thrill (an assessment to check for proper functioning or placement of a fistula (connection between blood vessels);
-Dialysis treatment as ordered;
-Do not check blood pressure on arm with shunt;
-Dry weights (the residents weight after all excess fluids have been removed during the dialysis process) obtained from dialysis center.
Review of the Physician's Order Sheet (POS), dated March 2025, showed staff are directed to assess shunt site for thrill/bruit and bleeding every shift. Send to dialysis clinic on Tuesday, Thursday and Saturday. Do not check blood pressure on the arm with fistula/shunt.
Review of the medical record showed it did not contain a pre-dialysis or post dialysis communication form for 02/11/25, 02/15/25, 02/22/25, 02/25/25, 03/01/25 and 03/11/25. Review showed staff did not complete a post dialysis assessment for 02/13/25, 02/20/25, 02/27/25, 03/04/25, 03/06/25 and 03/08/25.
During an interview on 03/13/25 at 10:06 A.M., Licensed Practical Nurse (LPN) W said the nurse assigned to the resident's hall is responsible for completing the dialysis communication forms. The resident left for dialysis prior to the day shift starting but the resident should return with a communication form that the nurse can complete and assess the resident's weight, vitals and fistula or port site to ensure the dressing is clean and intact.
3. Review of resident #59's Quarterly MDS, dated [DATE], showed staff assessed the resident as required dialysis services.
Review of the resident's care plan, dated 01/27/2025, showed staff were directed to:
-Assess shunt site for bruit and thrill;
-Dialysis treatment as ordered;
-Do not check blood pressure on arm with shunt;
-Dry weights obtained from dialysis center.
Review of the POS, dated March 2025, showed staff are directed to assess dialysis site upon return from dialysis. Do not check blood pressure on arm with fistula/shunt. Send to dialysis on Monday, Wednesday and Friday.
Review of the resident's medical record showed staff did not complete the post-dialysis assessment on 11/27/24, 11/29/24, 12/6/24, 12/9/24, 12/9/24, 12/11/24, 12/13/24, 12/16/24, 12/20/24, 12/22/24, 01/06/25 and 01/27/25.
During an interview on 03/17/25 at 3:19 P.M., Registered Nurse (RN) Q said the residents' weight and vital signs should be completed before and after dialysis. This should be documented on the dialysis communication form and should be completed every time a resident leaves for and returns from dialysis. The RN is unsure of why the forms are not being completed as they should be.
4. During an interview on 03/17/25 at 4:27 P.M., the interim director of nursing (DON) said there is a communication form for pre and post-dialysis that should be completed by the nurse along with documentation in the electronic charting system. The communication form should contain the resident's medications, weight, and vital signs. The DON said this form should be completed every time a resident leaves for and returns from dialysis.
During an interview on 03/20/25 at 3:12 P.M., the administrator said clinical staff are responsible for sending the communication forms with the residents when they go to dialysis. If the resident does not return with the form staff should contact the dialysis clinic to get the information. The administrator said staff have received education on this process and he/she does not know why the communication forms are not being completed.
CONCERN
(E)
Potential for Harm - no one hurt, but risky conditions existed
Drug Regimen Review
(Tag F0756)
Could have caused harm · This affected multiple residents
**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on interview and record review, facility staff failed to communicate pharmacy recommendations to the physician for five re...
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**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on interview and record review, facility staff failed to communicate pharmacy recommendations to the physician for five residents (Resident #44, #49, #51, #54, and #60) out of 20 sampled residents, to prevent or minimize adverse consequences related to medication therapy to the extent possible. The facility census was 82.
1. Review of the facility policy titled Medication Regimen Review (MRR), dated 06/01/24, showed staff:
-The consultant pharmacist will conduct MRRs and will make recommendations based on the information made available in the resident's health record;
-The facility and consultant pharmacist will follow guidance outlined in the Centers for Medicare & Medicaid Services (a federal agency within the United States Department of Health and Human Services that administers the Medicare program) State Operations Manual Appendix PP and current practice guidelines, for the appropriate provision of pharmaceutical care;
-The consultant pharmacist will provide the resident's MRRs to the facility identified personnel who will ensure that the attending physician, medical director, director of nursing (DON) and other necessary facility staff receive the recommendations;
-The facility should encourage physician/prescriber or other responsible parties receiving the MRR and the DON to act upon the recommendations contained in the MRR;
-For issues that require physician/prescriber intervention, the facility should encourage physician/prescriber to either accept and act upon the recommendations contained within the MRR or reject all or some of the recommendations contained in the MRR and provide an explanation as to why the recommendation was rejected, as outlined in the State Operations Manual Appendix PP;
-Facility staff should alert the medical director when MRRs are not addressed by the attending physician in a timely manner;
-The attending physician/prescriber should address the consultant pharmacist's recommendation no later than their next scheduled visit to the facility to assess the resident per facility policy, or applicable state and federal regulations;
-The facility should maintain readily available copies of the consultant pharmacists reports on file in the facility, and as part of the resident's permanent medical record.
2. Review of Resident #44's Quarterly Minimum Data Set (MDS), a federally mandated assessment tool, dated 12/16/24, showed staff assessed the resident as:
-Severely cognitively impaired;
-Diagnoses of non-traumatic brain dysfunction, high blood pressure, high cholesterol, Alzheimer's disease, aphasia (a neurological disorder that affects the person's ability to communicate) and chronic obstructive pulmonary disease (COPD), a group of lung diseases that block airflow and make it difficult to breathe;
-Received antidepressant, antipsychotic and an anticoagulant (a medication that thins the blood to prevent blood clots) medications.
Review of the pharmacist's MRR note, showed it did not contain documentation a monthly review had been completed for November 2024.
Review of the resident's medical record showed the record did not contain documentation of the pharmacist's report or physician response.
3. Review of Resident #49's Quarterly MDS, dated [DATE], showed staff assessed the resident as:
-Severely cognitively impaired;
-Diagnoses of high blood pressure, stroke, dementia, depression, psychotic disorder (a mental disorder characterized by a disconnection from reality), and schizoaffective disorder-depressive type (a mental health condition characterized by a combination of symptoms from schizophrenia and major depression);
-Received antipsychotic, antidepressants, antidepressants, opioids, antiplatelets (drugs that prevent blood platelets from clumping together and forming clots), and hypoglycemic (drugs used to treat diabetes) medications.
Review of the pharmacist's MRR note showed:
-08/22/2024 MRR - Please see Consultant Pharmacist monthly medication regimen review report for individual recommendations;
-09/09/2024 MRR - Please see Consultant Pharmacist monthly medication regimen review report for individual recommendations;
-November 2024 - showed it did not contain documentation a monthly review had been completed;
-12/20/2024 MRR - Please see Consultant Pharmacist monthly medication regimen review report for individual recommendations;
-02/25/2025 MRR - Please see Consultant Pharmacist monthly medication regimen review report for individual recommendations.
Review of the resident's medical record showed the record did not contain documentation of the pharmacist's report or physician's response for the MMRs.
4. Review of Resident #51's admission MDS, dated [DATE], showed staff assessed the resident as:
-Moderately cognitively impaired;
-Diagnoses of stroke, high blood pressure, gastroesophageal reflux disease (GERD) a digestive disease in which stomach acid or bile irritates the food pipe lining, renal insufficiency, diabetes, high cholesterol, depression, manic depression (a disorder associated with episodes of mood swings ranging from depressive lows to manic highs) and respiratory failure;
-Received insulin, antipsychotic, antianxiety, and antiplatelet medications.
Review of the pharmacist's MRR note showed:
-01/05/2025 MRR- Please see Consultant Pharmacist monthly medication regimen review report for individual recommendations;
-02/27/2025 MRR- Please see Consultant Pharmacist monthly medication regimen review report for individual recommendations.
Review of the resident's medical record showed the record did not contain documentation of the pharmacist's report or physician's response for the MMRs.
5. Review of Resident #54's Annual MDS, dated [DATE], showed staff assessed the resident as:
-Severely cognitively impaired;
-Diagnoses of non-traumatic brain dysfunction, high blood pressure, Alzheimer's Disease, dementia with behavioral disturbances, and need for assistance with personal care;
-Received antidepressants.
Review of the pharmacist's MRR note, dated 12/20/24, showed please see Consultant Pharmacist monthly medication regimen review report for individual recommendations.
Review of the resident's medical record showed the record did not contain documentation of the pharmacist's report or physician's response.
6. Review of Resident #60's Quarterly MDS, dated [DATE], showed staff assessed the resident as:
-Moderately cognitively impaired;
-Diagnoses of heart disease, high blood pressure, major depressive disorder (disorder characterized by persistently depressed mood or loss of interest in activities causing significant impairment in daily life), Post Traumatic Stress Disorder (PTSD), a disorder in which a person has difficulty recovering after experiencing or witnessing a terrifying event, generalized muscle weakness, paranoid personality disorder (a mental health condition characterized by a long-term pattern of distrust and suspicion of other, even without a reason), and Major Depressive Disorder (MDD), a serious condition characterized by persistent feelings of sadness, hopelessness, and loss of interest or pleasure in activities);
-Received antianxiety, antidepressant, diuretic (water pill) and antiplatelet medications.
Review of the pharmacist's MRR note, dated 12/22/24 showed please see Consultant Pharmacist monthly medication regimen review report for individual recommendations.
Review of the resident's medical record showed the record did not contain documentation of the pharmacist's report or physician's response.
7. During an interview on 03/17/25 at 3:16 P.M., Registered Nurse (RN) Q said he/she knows the pharmacy comes to the facility, but he/she does not really see the pharmacy recommendations. The RN said he/she thinks the DON take care of the recommendations.
During an interview on 03/17/2025 at 4:27 P.M., the interim DON said the pharmacy consultant should complete medication reviews on all residents monthly. The DON said he/she or a designated individual is responsible for following up with the provider for the pharmacist recommendations, and he/she did not know there were missing reports from the pharmacy and physician responses. The interim DON said he/she has been covering for the facility's DON for the last week or so.
During an interview on 03/20/2025 at 3:12 P.M., the administrator said monthly medication reviews should be completed monthly and the nursing staff is responsible for the follow-up communication with the physician. The administrator said this is not getting done due to lack of nursing leadership.
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 staff failed to serve food in accordance with the nutritionally calculated menus and recipes to residents who received pureed and mechan...
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Based on observation, interview and record review, the facility staff failed to serve food in accordance with the nutritionally calculated menus and recipes to residents who received pureed and mechanically altered diets. The facility census was 82.
1. Review of the facility's Menus, Substitutions, and Alternatives policy, revised 04/25/23, showed:
-Menus are planned in advance and are followed as written in order to meet the nutritional needs of the residents in accordance with established national guidelines. Residents with known dislikes of food and be beverage items, who express a refusal of the food served or request a different meal choice are offered a substitute of similar nutritive value;
-Menus are served as written, unless changed due to an unpopular item on the menu, an item that could not be procured or a special meal. The Director of Food and Nutrition Services/Registered Dietician documents the substitution on the extended menu and the menu substitution record;
-Only the Director of Food and Nutrition Services, designee or the Registered Dietician should substitute menu items.
2. Review of the lunch menus dated 03/10/25 (Week 3, Day 16), showed the menus directed staff to provide the residents on pureed diets with:
-a #8 (four ounce) scoop of pureed Italian meat sauce;
-a #8 scoop of pureed parslied spaghetti;
-a #8 scoop of pureed Italian blend vegetables;
-a #16 (two ounce) scoop of pureed bread;
-a #8 scoop of pureed Boston cream cake.
Review showed the menus did not contain documentation of any substitutions made to the planned menu items.
Observations on 03/10/25 during the lunch meal service, which began at 11:42 A.M., showed the dietary staff served the residents on pureed diets:
-a #12 (2.66 ounce) scoop of pureed meat sauce (1.34 ounces less than directed by the menus);
-a #12 scoop of pureed Italian blend vegetables (1.34 ounces less than directed by the menus);
-a #8 scoop of mashed potatoes with two ounces of gravy;
-a #8 scoop of vanilla pudding.
Observation showed the staff did not serve or offer the residents on pureed diets the pureed parslied spaghetti, pureed bread, and pureed Boston cream pie.
During an interview on 03/10/25 at 11:57 A.M., Dietary Aide (DA) G said he/she did not have pureed bread to serve and he/she had never seen any of the staff make or serve pureed bread. The DA also said management trained him/her to give the purees pudding instead of pureed cake and he/she did not have Boston cream pie.
During an interview on 03/10/25 at 11:58 A.M., the Dietary Manager (DM) said meals should be served in accordance with the menus, but he/she did not know that the pureed bread mix came in on the truck, so he/she did not make any pureed bread for service. The DM said the previous DM trained the staff to give purees pudding instead of the menu dessert, but he/she had trained the staff to prepare the dessert on the menu. The DM said the Boston cream pies were in the freezer and he/she did not staff still gave the residents on pureed diets pudding. The DM said the previous DM trained him/her to serve mashed potatoes to residents on pureed diets and they never puree pasta. The DM said he/she did not know that he/she needed to puree the pasta. The DM said the previous DM also trained the staff to serve the pureed food with #12 scoops so that is what he/she does and has trained his/her staff to do.
Review of the lunch menus dated 03/12/25 (Week 3, Day 18), showed the menus directed staff to provide the residents on pureed diets with a #8 scoop of pureed soft fruit crisp. Review showed the menus did not contain documentation of any substitutions made to the planned menu items.
Observation on 03/12/25 during the lunch service which began at 11:30 A.M., showed the staff did not serve or offer the residents on pureed diets the pureed soft fruit crisp as directed by the menus.
3. Review of the lunch menus dated 03/10/25 (Week 3, Day 16), showed the menus directed staff to provide the residents on mechanically altered diets with a #16 scoop of pureed bread and one serving of Boston cream pie. Review showed the menus did not contain documentation of any substitutions made to the planned menu items.
Observations on 03/10/25 during the lunch meal service, which began at 11:42 A.M., showed the dietary staff served the residents on mechanically altered diets with one serving of Bishop's cake. Observation showed the staff did serve or offer the residents on mechanically altered diets the pureed bread and Boston cream pie as directed by the menus.
Review of the recipe for Bishop's cake, undated, showed instruction to prepared the cake by mixing pineapple into a yellow cake mix, bake the cake and then top the cooled cake with whipped topping and cherries.
During an interview on 03/10/25 at 11:57 A.M., Dietary Aide (DA) G said he/she did not have pureed bread to serve and he/she had never seen any of the staff make or serve pureed bread. The DA also said he/she did not have Boston cream pie and served the Bishop's cake to the residents on mechanically altered diets.
During an interview on 03/10/25 at 11:58 A.M., the Dietary Manager (DM) said meals should be served in accordance with the menus, but he/she did not know that the pureed bread mix came in on the truck, so he/she did not make any pureed bread for service. The DM said he/she had trained the staff to prepare the dessert on the menu. The DM said the Boston cream pies were in the freezer and he/she did not know staff gave the residents on mechanically altered diets the regular cake, which had pineapple and cherries baked into it.
Review of the lunch menus dated 03/12/25 (Week 3, Day 18), showed the menus directed staff to provide the residents on mechanically altered diets with a #8 scoop of soft fruit crisp. Review showed the menus did not contain documentation of any substitutions made to the planned menu items.
Observation on 03/12/25 during the lunch service which began at 11:30 A.M., showed the staff did not serve or offer the residents on mechanically altered diets the soft fruit crisp as directed by the menus.
4. During an interview on 03/13/25 at 9:50 A.M., the DM said the staff should serve the menus as planned which includes the food items listed for different diet types and the portion sizes listed on the menus. The DM said they did puree all food items as listed on the menu at one time, like the desserts, but it just stopped and he/she did not know why. The DM said he/she educated the staff on 03/10/25 on following the menus and how to read the menus after the issues found during the lunch meal, so all the meals should have been served correctly after that without excuse. The DM said he/she is responsible to monitor the meal services when he/she is on duty and when he/she is not the cook, he/she normally checks on everything before service to make sure everything is right. The DM said he/she has had trouble keeping up with his/her supervisory duties due to staffing issues and having to fill in as a cook a lot.
5. During an interview on 03/13/25 at 10:30 A.M., the administrator said, unless a resident requests otherwise, the staff should serve the menus as planned which includes the food items listed for different diet types and the portion sizes listed on the menus. The administrator said staff are trained on how to read and use the menus and the DM should monitor the meals served daily. The administrator said he/she periodically monitors the dietary department, including the actions of the DM, and has had to do some education on following the menus a couple times before.
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 facility staff failed to perform proper hand hygiene during perineal care for...
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**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, interview, and record review facility staff failed to perform proper hand hygiene during perineal care for three residents (Resident#42, #90, and #6), failed to use proper enhanced barrier precautions (EBP) (a infection control practice requiring personal protective equipment to be worn for the care of certain residents) for two residents (Resident#2 and #42) and failed to maintain proper hygiene practices for oxygen tubing for four residents (Resident#26, #44, #51, and #58) out of 20 sampled residents. The facility census was 82.
1. Review of the facility policy titled Hand Hygiene, dated 06/03/24, showed staff are to perform hand hygiene before and after resident contact, after contact with bodily fluids or a visibly contaminated surface and after removing gloves. Use alcohol-based hand rub unless hands are visibly soiled.
2. Observation on 03/10/2025 at 3:42 P.M., showed Certified Nurse Aide (CNA) Y entered Resident #42's room, applied gloves, performed perineal care, rolled the resident toward CNA P and wiped feces from the resident's back. With the same soiled gloves on, CNA Y put a clean brief on the resident. CNA P and CNA Y removed their gloves, did not perform hand hygiene, and touched the resident's brief, positioning wedge and the resident's blanket. The CNA's left the room and did not perform hand hygiene.
Observation on 03/12/25 at 5:30 A.M., showed CNA/Certified Medication Technician (CMT) V performed perineal care for Resident #42, rolled the resident, cleansed the resident's back side, removed a soiled brief, and with the same gloves on, placed a clean brief under the resident, and covered the resident with blankets. The CNA/CMT removed his/her gloves and adjusted the resident's bed and bed side table. The CNA/CMT performed hand hygiene, gathered trash, and exited the room.
During an interview on 03/17/25 at 2:45 P.M., CNA P said hand hygiene should be completed before and after care and if hands are visibly soiled. Improper hand hygiene can lead to cross contamination and infections.
4. Observation on 03/12/2025 at 5:23 A.M., showed CMT V applied gloves and provided perineal care to Resident #90. The CMT rolled the resident to his/her side, cleansed the resident's back side and removed a soiled brief. With the same gloves, the CMT put a clean brief on the resident and touched the resident's blankets.
5. Observation on 03/11/25 at 7:13 A.M., showed CNA N entered Resident #6's room, washed his/her hands and applied gloves. The CNA removed the resident's brief, wiped the resident's perineal area and wiped the resident's back side. With the same soiled gloves, the CNA reached into the dresser, got a clean brief and placed the clean brief on resident and touched the resident's blankets.
6. During an interview on 03/11/25 at 7:48 P.M. CNA N said he/she should have changed his/her gloves when moving from a dirty to clean task. The CNA said he/she forgot to change his/her gloves after wiping the resident's backside, washed his/her hands after wiping the residents backside and put new gloves on before he/she touched the resident's clean brief.
During an interview on 03/17/25 at 3:19 P.M., Registered nurse (RN) Q said hand hygiene should be completed before and after care. He/She said not performing proper hand hygiene could lead to infections or transferring infections.
During an interview on 03/20/25 at 3:12 P.M., the administrator said staff should perform hand hygiene before and after care and when moving from a dirty to clean task. The administrator said if staff are not performing proper hand hygiene it could lead to cross contamination, infections.
7. Review of the facility's policy titled Enhanced Barrier precautions, dated 06/03/24, showed Use EBP with residents who have an infection or colonization with a multi-drug resistant organism (MDRO), bacteria or fungi that have become resistant to multiple classes of antibiotics, wounds, or indwelling medical devices. EBP should be used during high-contact resident care activities which includes dressing and changing briefs. EBP is an infection control intervention that employs targeted gown and glove use during high contact resident care activities.
8. Review of Resident #2's Significant Change in Status Assessment (SCSA) Minimum Data Set (MDS), dated [DATE], showed staff assessed the resident as:
-Moderate cognitive impairment;
-Required maximal assistance from staff members for bathing, dressing, personal hygiene and all transfers;
-Required moderate to Maximal assistance from staff members with bed mobility;
-Always incontinent of bowel and bladder;
-One stage 4 (pressure ulcer involving full-thickness skin and tissue loss, where the damage extends to muscle, tendon, ligament, cartilage, or bone) pressure ulcer;
-Received hospice care;
-Diagnoses of Atrial Fibrillation (irregular heart beat) and Renal Failure.
Review of the resident's Physician's Order Sheet (POS), dated March 2025, showed an order for EBP until wound is resolved.
Review of the resident's Treatment Administration Record (TAR), dated March 2025, showed staff administered wound treatment and the resident on EBP since 03/11/25.
Review of the resident's care plan, dated 01/09/25, showed staff documented the resident required assistance from one staff member for turning and repositioning, dressing and transfers. Staff assessed the resident has a Stage 4 pressure ulcer and required EBP.
Observation on 03/11/25 at 10:41 A.M., showed CNA K and CNA L entered the resident's room with a mechanical lift, provided incontinence care for the resident and transferred him/her to a wheelchair. Staff did not wear gloves or a gown to provide resident care. Observation showed an EBP sign on the resident's door and PPE in the hallway outside the resident room.
During an interview on 03/17/25 at 2:30 P.M., CNA P said he/she doesn't have to wear a gown with the resident. The CNA said staff do not have to wear gowns with residents with wounds. The CNA said no one has taught him/her to wear a gown for residents with wounds.
During an interview on 03/17/25 at 3:16 P.M., RN Q said EBP is about infection prevention. The RN said staff has to wear a gown and it says on the resident's door what Personal Protective Equipment (PPE) is needed for the resident. The RN said staff providing care for the resident should have a gown on. RN Q said the resident has a wound.
9. Review of Resident #42's Quarterly MDS dated [DATE], showed staff documented the resident has three unstageable (a full-thickness pressure injury where the base of the wound is obscured by slough and/or eschar, making it impossible to accurately determine the true depth and stage of the wound) pressure ulcers.
Review of the resident's POS, dated March 2025, showed the record did not contain an order for EBP.
Observation on 03/10/25 at 3:42 P.M., showed CNA Y and CNA P did not perform hand hygiene when they entered the resident's room to provide perineal care and did not wear a gown. Observation showed an EBP sign on the resident's door and PPE in the hallway outside the resident room.
During an interview on 03/17/25 at 3:19 P.M., RN Q said EBP is about infection prevention and staff should wear a gown before coming in contact with bodily fluids or performing wound care. There should be a sign on the resident's door that tells staff what kind of precautions the resident requires. Staff should wear a gown when providing care for the resident.
Observation on 03/12/25 at 5:30 A.M., showed CNA/CMT V provided perineal care for the resident and did not wear a gown.
During an interview on 03/17/25 at 2:45 P.M., CNA P said EBP requires that you were a gown and gloves when providing care to a resident who has a sign on their door and a cart outside their room. EBP is not required for the resident. Gowns are only worn with residents who have certain infections.
9. During an interview on 03/17/25 at 4:17 P.M., the interim DON said EBP requires staff to wear a gown, mask, gloves, and sometimes a face shield when providing care to residents with indwelling medical devices or wounds. The DON said he/she did not know staff were not following EBP.
During an interview on 03/20/25 at 3:12 P.M., the administrator said there are signs and carts with EBP supplies outside of resident rooms to alert staff . Staff should be wearing a gown and gloves when providing direct patient care. The administrator said staff have been educated several times on this practice.
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 staff failed to thaw frozen meat in a manner to prevent the growth of food-borne pathogens. Facility staff also failed to allow sanitize...
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Based on observation, interview and record review, the facility staff failed to thaw frozen meat in a manner to prevent the growth of food-borne pathogens. Facility staff also failed to allow sanitized dishes to air dry prior to stacking in storage to prevent the growth of food-borne pathogens. These failures have the potential to affect all residents. The facility census was 82.
1. Review of the facility's Safe Food Handling policy, revised 04/26/23, showed Frozen food is thawed under refrigeration or in the cooking process. Thawing some foods at room temperature may not be acceptable because it may be within the danger zone for rapid bacterial proliferation. Recommended methods to safely thaw frozen foods include:
a. Thawing in the refrigerator, in a drip-proof container, and in a manner that prevents cross-contamination.
b. Thawing the item in the microwave oven, then cooking and serving it immediately afterward; or
c. Thawing as part of a continuous cooking process.
Observations on 03/10/25 from 10:45 A.M. to 12:42 P.M., showed three five pound packages of ground beef submerged in water in the food preparation sink without running water on it.
During an interview on 03/10/25 at 10:56 A.M., the dietary manager (DM) said the packages of ground beef were in the sink to thaw for use at dinner and he/she put them in the water about 30 minutes prior.
Observation 03/10/25 at 2:10 P.M., showed the DM removed the packages of ground beef from the sink and put the ground beef in a pot on the stove to cook for service to residents at the evening meal.
During an interview on 03/13/25 at 9:42 A.M., the DM said frozen meat should be thawed in a pan in refrigerator. The DM said he/she forgot to take the ground beef out of the freezer and knew it would not be thawed in time for dinner, so he/she put it in the sink to thaw. The DM said if frozen foods are thawed in the sink, they should be submerged in the water with water running over it to agitate the water to keep it safe. The DM said he/she previously had water running over it, but turned the water off because he/she was going to cook it, but got busy with lunch and forgot about it in the sink.
During an interview on 03/13/25 10:22 A.M. , the administrator said frozen meat should be thawed in refrigerator or under cool running for no longer than four hours. The administrator said running water allows debris to be removed during the thawing process. The administrator said staff are trained on how to thaw food properly and they should not use foods that are not thawed properly for meal service.
2. Review of the facility's Safe Food Handling policy, revised 04/26/23, showed All cooking utensils, pans, dinnerware will be stored dry.
Review of the facility's Sanitation and Maintenance policy, revised 04/26/23, showed All dishes, pots and pans must be air dried after sanitizing and should not be stored wet to prevent wet nesting.
Observation on 03/10/25 at 2:06 P.M. showed staff washed dishes in the mechanical dishwasher. Observation showed Dietary Aide (DA) DD removed wet trays from the clean side of the station and stacked them together on a service cart.
Observation on 03/10/25 at 2:21 P.M., showed [NAME] F rolled the cart of wet stacked trays from the mechanical dishwashing station to the steamtable. Observation showed 15 trays stacked together wet.
During an interview on 03/10/25 at 2:23 P.M., the DM said clean dishes should be allowed to air dry after they are washed and staff are trained on this requirement.
Observation on .3/10/25 at 2:28 P.M., showed the DM directed DA DD to allow the dishes to air dry before he/she put them away.
Observation on 03/10/25 at 2:44 P.M., showed DA DD removed wet service trays from a rack on the clean side of the mechanical dishwashing station, dried them with a towel and stacked them together on a service cart.
Observation on 03/12/25 at 11:35 A.M., showed 15 plates stacked together wet in the plate heater. Observation showed the DM used the plates to serve food to the residents at the lunch meal.
During an interview on 03/13/25 at 9:47 A.M., the DM said staff should allow dishes to air dry before they are put away and they should not dry them with a towel. The DM said all staff have been trained how to wash and store dishes appropriately and he/she retrained DA DD on 03/10/25 to allow dishes to air dry so he/she did not know why the DA dried the trays with a towel or why staff put the plates away wet. The DM said staff should not use wet stacked dishes to serve food to the residents, but he/she would not have had enough plates to serve lunch to the residents on time.
During an interview on 03/13/25 at 10:27 A.M., the administrator said the DM is responsible to monitor dish washing and storage procedures daily. The administrator said staff should allow dishes to air dry after they are washed and they should not use a towel to dry them. The administrator said staff haven been trained multiple times to allow dishes to air dry before they put them away.
Dec 2024
1 deficiency
CONCERN
(D)
📢 Someone Reported This
A family member, employee, or ombudsman was alarmed enough to file a formal complaint
Potential for Harm - no one hurt, but risky conditions existed
Deficiency F0658
(Tag F0658)
Could have caused harm · This affected 1 resident
**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on interview, and record review, facility staff failed to maintain professional standards of practice when staff failed to...
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**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on interview, and record review, facility staff failed to maintain professional standards of practice when staff failed to complete and document wound care treatments for three resident's (Resident #1, #2 and #3) out of three sampled residents. The facility census was 78.
1. Review of the facility's Treatment Orders Policy, dated 07/29/24, showed staff are directed as follows:
-Quality of care is a fundamental principle that applies to all treatment and care provided to facility residents. Based on the comprehensive assessment of a resident, the facility must ensure that residents receive treatment and care in accordance with professional standards of practice, the comprehensive person-centered car plan, and the resident's choices;
-A resident with pressure ulcers receives necessary treatment and services, consistent with professional standards of practice, to promote healing, prevent infection and prevent new ulcers from developing;
-The policy did not contain direction for staff in regard to documenting treatments in the resident's medical record.
2. Review of Resident #1's admission Minimum Data Set (MDS), a federally mandated assessment tool, dated 10/21/24, showed staff assessed the resident as cognitively intact and rejected care one to three days during the seven day look back period.
Review of the resident's Physician Order Sheet (POS), undated, showed an order to clean buttocks with normal saline and apply Triad Hydrophillic Cream (cream used to help maintain a moist healing environment) every day and night shift and an order to clean the buttucks with normal saline and apply Triad Hydrophillic Cream three times a day.
Review of the resident's Treatment Administration Record (TAR), dated 11/01/24 to 11/30/24, showed it did not contain documentation staff provided the physician ordered treatment to the buttocks as ordered on 11/02/24.
Review showed the resident's TAR, dated 11/01/24 to 11/30/24, did not contain documentation staff provided the physician ordered treatment to the buttocks as ordered on 11/17/24, 11/24/24, 11/25/24 or 11/29/24.
Review of the resident's POS, undated, showed an order to cleanse the perineal area with normal wound cleanser, apply zinc oxide generously and leave open to air on day shift every other day.
Review showed the TAR, dated 11/01/24 to 11/30/24, did not contain documentation staff applied zinc oxide and leave open to air as odered on 11/02/24.
3. Review of Resident #2's Quarterly MDS, dated [DATE], showed staff assessed the resident as severe cognitive impairment and did not reject care.
Review of the resident's POS, undated, showed an order to apply barrier paste three times a day, an order to apply skin prep to right and left heel daily every day and an order to apply Clobestasol Propionate Cream 0.05% (cream used to relieve redness, itching, swelling, or other discomfort caused by certain skin conditions) to right arm topically two times a day.
Review showed the resident's TAR, dated 11/01/24 to 11/30/24, did not contain documentation staff applied barrier paste as ordered on 11/01/24, 11/12/24, 11/16/24, or 11/25/24.
Review of the resident's TAR, dated 11/01/24 to 11/30/24, did not contain documentation staff applied skin prep to the resident's right and left heel as ordered on 11/14/24 or 11/27/24.
Review of the resident's TAR, dated 11/01/24 to 11/30/24, did not contain documentation staff applied Clobestasol Propionate Cream 0.05% to right arm topically as ordered on 11/26/24.
4. Review of Resident #3's Quarterly MDS, dated [DATE], showed staff assessed the resident as cognitively intact and did not reject care.
Review of the resident's POS, undated, showed an order to apply zinc paste to coccyx every shift and an order to apply skin prep to left lateral ankle every day .
Review of the resident's TAR, dated 11/01/24 to 11/30/24,did not contain documentation staff provided applied zinc paste to the coccyx and an order to apply skin prep to left lateral ankle every day as ordered on 11/24/24 and 11/25/24.
5. During an interview on 12/05/24 at 11:54 AM, Licensed Practical Nurse (LPN) A said staff are directed to document completed wound care on the resident's TAR. He/She said if a treatment was not documented in the resident's medical record, the nurse should complete the treatment and notify the physician. He/She said there should never be a lack of documentation on the TAR because there are codes to enter if the resident did not receive the treatment. He/She did not know there were missing treatments.
During an interview on 12/05/24 at 1:38 P.M., the Director of Nursing (DON) said he/she expected staff to follow the physician orders for wound care and complete treatments as ordered. He/She said the orders are documented in the resident's TAR. He/She said if staff noticed a missing treatment, he/she should report to himself/herself. The DON said he/she would investigate the missing treatment to verify if the treatment was completed or not. He/She said if there was a missing treatment, he/she would conduct an in-service with the nursing staff. He/She said if a treatment was not completed, there was a potential the wound would not heal as quickly as he/she would like. He/She said he/she did not know there were missing treatments.
During an interview on 12/05/24 at 1:39 P.M., the administrator said if staff noticed missing documention on a resident's TAR, the nurse would contact the physician and up the chain of command. He/She said the nurse who received the order was responsible to enter the order into the resident's medical record. He/She said staff are directed to follow physician orders and provide treatments according to the orders. He/She said staff are to document if a treatment was completed or the reason the treatment was not completed. He/She said the concern with missing treatments was the potential the wound not heal as quickly as he/she would like. He/She said staff did not notify him/her there were missing treatments. He/She said the nursing leadership is to monitor for missing treatments. He/She said there were interim nursing leaders during the period of the missing treatments, but since have hired a full-time leader.
MO00246040
Mar 2024
2 deficiencies
CONCERN
(D)
📢 Someone Reported This
A family member, employee, or ombudsman was alarmed enough to file a formal complaint
Potential for Harm - no one hurt, but risky conditions existed
Report Alleged Abuse
(Tag F0609)
Could have caused harm · This affected 1 resident
**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on record review and interviews, facility staff failed to report allegations of misappropriation to the Department of Heal...
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**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on record review and interviews, facility staff failed to report allegations of misappropriation to the Department of Health and Senior Services (DHSS) within the twenty four hour required time frame for two residents (Resident #1, and Resident #2). The facility census was 81.
1. Review of the facility's policy, Incident and Reportable Event Management, reviewed 12/1/23, showed staff are directed to report all alleged violations involving abuse. Neglect, exploitation or mistreatment, including injuries of unknown source and misappropriation of resident property, are reported immediately, but not later than two hours after the allegation is made, if the events that cause the allegation involve abuse or result in serious bodily injury, or not later than 24 hours if the events that the allegation do not involve abuse and do not result in serious bodily injury, to the administrator of the facility and to other officials, (including to the State Survey Agency and adult protective services where state law provides jurisdiction in long-term care facilities) in accordance with state law through established procedures.
2. Review of Resident #1's admission Minimum Data Set (MDS), a federally mandated assessment tool, dated 2/23/24, showed staff assessed the resident as cognitively intact.
Review of the facility's misappropriation investigation, dated 3/26/24, showed staff documented the resident reported ten dollars missing on 3/23/24 to the Business Office Manager. Review showed the resident had kept his/her wallet with cash in his/her room and was not found when searched. Review showed the investigation did not contain documentation staff notified DHSS of the allegation of misappropriation of the residents money.
During an interview on 3/26/24 at 10:27 A.M., the resident said he/she had ten dollars stolen and the office is aware. The resident said he/she saw the money in his/her wallet on 3/20/24. He/She said he/she did not access his/her wallet on 3/21/24 and noticed his/her money missing on 3/22/24. The resident said he/she did tell a nurse on 3/22/24 but can not remember which one, he/she also told the social worker and the business office manager.
During an interview on 3/26/24 at 10:48 A.M., the administrator said he/she was notified on either 3/22/24 or 3/23/24, the resident had money missing. He/She said he/she instructed staff to search the resident's room because he/she has been out of the office, but nothing formal was started until 3/25/24. The administartor said he/she was not aware the Director of Nursing (DON) was not in the building and thought he/she would start the investigation. The administartor said he/she did not report the allegation to the state survey agency and did not have a designee report to state.
During an interview on 3/26/24 at 11:51 the Business office manager said the resident told him/her about the missing money on 3/23/24 and he/she let the administrator know. He/She was not instructed to contact the state survey agency.
During an interview on 3/26/24 at 12:02 P.M., the DON said he/she was not made aware of the allegation in a timely manner to follow the regulation of reporting.
3. Review of Resident #2's medical record showed he/she admitted on [DATE] and did not have an MDS on file.
Review of the facility's misappropriation investigation, dated 3/11/24, showed staff documented the resident was discharged to the hospital on 3/11/24. Review showed the resident had kept his wallet with cash in it tucked into his/her pillowcase. Review showed the residents family member called and asked where his/her wallet was, the resident's bed had already been stripped, staff searched the linens in the dirty laundry and found the resident's wallet there. Review showed Registered Nurse (RN) A turned the wallet into the SSD without checking contents. Review showed staffed documented they kept the wallet in his/her office in an unlocked tray and did not verify the contents of the wallet. Review showed the resident's member picked the wallet up after hours on 3/11/24 and called on 3/12/24 at approximately 11:30 A.M. to report $260.00 missing out of the wallet.
Review of the DHSS online confirmation report, dated 3/15/24, showed the administrator notified DHSS of the allegation of misappropriation on 3/15/24 at 4:42 P.M., 3 days after the alleged misappropriation.
4. During an interview on 3/26/24 at 12:02 P.M., the DON said his/her expectation is to follow the policy and procedure and report to state immediately or within twenty four hours, he/she is an interim DON at the facility and was not here to report the allegation in a timely manner.
During an interview on 3/26/24 at 12:15 AP.M., the administrator said he/she expects the facility policy and procedure to be followed but is behind, he/she did not realize it was such a short time frame for reporting because it's not a high severity.
MO00233252
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
**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on interview and record review, facility staff failed to start an investigation in a timely manner when one resident (Resi...
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**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on interview and record review, facility staff failed to start an investigation in a timely manner when one resident (Resident #1) reported missing money from his/her wallet. Facility staff failed to complete a thorough investigation when a family member reported one resident (Resident #2's) money missing from his/her wallet. The facility census was 81.
1. Review of the facility's Abuse Conducting an Investigation policy, reviewed 7/18/23, showed allegations of abuse (abuse, neglect, mistreatment, including injuries of unknown source, exploitation and misappropriation of property) are promptly and thoroughly investigated. Review showed when an incident of misappropriation of resident property is reported, the administrator or designees will investigate the occurrence, if the investigation is being conducted by the designee, the administrator will be consulted daily concerning the progress of the investigation. Review showed it is expected that the investigation would include, but is not limited to:
-Conducting interviews with, as appropriate, the alleged victim and representative, alleged perpetrator, witnesses, practitioners, and hospital and emergency room staff.
-The written summary of the investigation should include, but is not limited to:
-Interviews with any witnesses to the incident;
-Interviews with the resident's roommate, family, and/or visitors who may have information regarding the incident;
-Interviews with other residents.
2. Review of Resident #1's admission Minimum Data Set (MDS), a federally mandated assessment tool, dated 2/23/24, showed staff assessed the resident as cognitively intact.
Review of the facility's misappropriation investigation, dated 3/26/24, showed staff documented the resident reported ten dollars missing on 3/23/24 to the Business Office Manager. Review showed the resident had kept his wallet with cash in his/her room and was not found when searched. Review showed the ten dollars was replaced by the facility to the resident.
During an interview on 3/26/24 at 10:27 A.M., the resident said he/she had ten dollars stolen and the office is aware. He/She said he/she saw the money in his/her wallet on 3/20/24, he/she did not access his/her wallet on 3/21/24 and noticed his/her money missing on 3/22/24. He/She said he/she did tell a nurse on 3/22/24 but can not remember which one, he/she also told the social worker and the business office manager.
During an interview on 3/26/24 at 10:48 A.M., the administrator said he/she was notified on either 3/22/24 or 3/23/24 the resident had money missing. The administrator said he/she instructed staff to search the resident's room because he/she has been out of the office but nothing formal was started until 3/25/24. The administrator said he/she was not aware the Director of Nursing (DON) was not in the building and thought he/she would start the investigation. The administrator said he/she never instructed the DON to start an investigation.
During an interview on 3/26/24 at 10:55 A.M., the DON said he/she just found out the resident reported his/her money missing three minutes ago.
During an interview on 3/26/24 at 10:58 the Social Services Director (SSD) said he/she found out the resident was missing money yesterday 3/25/24 and it was discussed in morning meeting that the facility would replace his/her money.
During an interview on 3/26/24 at 11:51 the Business Office Manager said the resident told him/her about the missing money on 3/23/24 and he/she let the administrator know. He/She was not instructed to start an investigation.
During an interview on 3/26/24 at 12:02 P.M., the DON said he/she just started the investigation into the resident's missing money. The DON said his/her expectation is to follow the policy and procedure and start the investigation promptly. He/She said, I was not made aware of the allegation in a timely manner to be able to start the investigation.
During an interview on 3/26/24 at 12:15 AP.M., the administrator said he/she expects the facility policy and procedure to be followed and did not realize and investigation needed to be started so quickly in terms of severity.
3. Review of Resident #2's medical record showed he/she admitted to the facility on [DATE] and did not have an MDS on file.
Review of the facility's misappropriation investigation, dated 3/11/24, showed staff documented the resident discharged to the hospital on 3/11/24. Review showed the resident had kept his/her wallet with cash in it tucked into his/her pillowcase. Review showed the residents family member called and asked where his/her wallet was. The residents bed had been stripped, staff searched the linens in the dirty laundry, and found the resident's wallet. Review showed Registered Nurse (RN) A turned the wallet into the SSD without checking contents. Review showed staffed documented they kept the wallet in his/her office in an unlocked tray and did not verify the contents of the wallet. Review showed the resident's family member picked the wallet up after hours on 3/11/24 and called on 3/12/24 at approximately 11:30 A.M. to report $260.00 missing out of the wallet. Review showed the investigation did not contain documentation of resident interviews with the resident's roommate, visitors, and other possible witnesses.
During an interview on 3/26/24 at 10:48 A.M., the administrator said no other residents were interviewed for the investigation.
During an interview on 3/26/24 at 10:55 A.M., the DON said he/she is unsure if any other residents, visitors, or possible witnesses were interviewed, he/she expects the SSD would oversee that.
During an interview on 3/26/24 at 10:58 the SSD said he/she did not interview any other resident's for the investigation, the DON was supposed to provider him/her with questions but never did.
During an interview on 3/26/24 at 12:02 P.M., the DON said he/she expects staff to follow policy and procedure and to always interview other residents and possible witnesses.
During an interview on 3/26/24 at 12:15 P.M., the administrator said he/she is not aware of what their facility policy says on investigations but expects it to be followed and he/she will read the policy to have a better understanding.
MO00233252
Feb 2024
12 deficiencies
CONCERN
(D)
Potential for Harm - no one hurt, but risky conditions existed
Deficiency F0658
(Tag F0658)
Could have caused harm · This affected 1 resident
Based on observations and interviews, staff failed to maintain a professional standard of care, when staff left medictions at the bedside and failed to verifying the resident took the medications for ...
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Based on observations and interviews, staff failed to maintain a professional standard of care, when staff left medictions at the bedside and failed to verifying the resident took the medications for one resident (Residents #37) out of 3 sampled. The facility census was 69.
1. Review of the facility's policies showed the facility did not provide a policy for leaving medications at the bedside.
Review of the Missouri Department of Health Certified Medication Technician (CMT) Student Manual, Unit 4: Preparation & Administration, LESSON PLAN: 13, showed staff should remain with resident until medication is swallowed.
2. Review of Resident #37's admission Minimum Data Set (MDS), a federally mandated assessment tool, dated 11/29/23, showed staff assessed the resident had a severe cognitive impairment.
Observation on 01/31/24 at 8:04 A.M., showed CMT J did not ensure the resident swallowed the following medications before he/she left the resident's room:
-Vitamin C (Supplement);
-Calcium 600 + D (Supplement);
-Vitamin B-12 (Supplement);
-Eliquis (an anticoagulant);
-Folic acid (Supplement);
-Januvia (Anti-diabetic medication);
-Potassium (Supplement);
-Florastor (Probiotic supplement);
-Senna-plus (stimulant laxatives);
-Simvastatin (a medication to treat high cholesterol).
During an interview on 01/31/24 at 08:21 A.M., CMT J said he/she usually leaves the medications in the cup on the resident's side table and then goes to the next room because the resident takes a while to take his/her medications. He/She said he/she checks on the resident after passing medications in the next room. He/She said he/she knows the resident and he/she isn't someone he/she has to worry about not taking their medications.
During an interview on 02/01/24 at 9:50 A.M., Licensed Practical Nurse (LPN) S said it is his/her expectation that staff never leave medications unattended at bedside after administration to ensure the rights of medication pass are completed. He/She said staff should watch and ensure all medications are taken before leaving the room. He/She said not observing the resident taking the medications runs the risk of not knowing if medications were taken, if another resident or roommate got ahold of the medications, or that the resident choked while they were alone.
During an interview on 02/01/24 at 1:21 P.M., the Director of Nursing (DON) said it is his/her expectation that his/her staff follow the facility policy. He/She said he/she would expect his/her staff to watch the resident take the medication. He/She said not observing the resident taking the medications could run the risk that they may not take them or that another resident got a hold of them. He/She said it is his/her expectation that staff do not leave medications at bedside. He/She said they were not aware that a staff member was regularly leaving medications at bedside unattended.
During an interview on 02/01/24 at 3:08 P.M., the Administrator said it is his/her expectation that staff watch all residents take their medications and to not leave until they take them. He/She said the policy is there to ensure resident safety and is a standard protocol. He/She said they were not aware that there were staff who did not know the policy and were leaving medications in the resident rooms after passing them. He/She said it is in the education provided for CMT training and for nurses to not leave medications at bedside and it is something the facility DON reviews and looks for on rounds.
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 interview and record review, facility staff failed to ensure one (Resident #18) received care and services for the provision of hemodialysis (the clinical purification of blood by dialysis, a...
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Based on interview and record review, facility staff failed to ensure one (Resident #18) received care and services for the provision of hemodialysis (the clinical purification of blood by dialysis, as a substitute for the normal function of the kidney) consistent with professional standards of practice when staff failed to provide orders, ongoing assessments of the resident's condition, and monitoring for complications after dialysis treatments. The facility census was 69.
1. Review of the facility's Hemodialysis Offsite Policy, reviewed 08/23/23, showed staff are directed to provide:
-Ongoing assessment of the resident's condition and monitoring for complications before and after dialysis treatments received at a certified dialysis facility;
-Ongoing communication and collaboration with the dialysis facility regarding dialysis care and services.
2. Review of Resident #18's admission Minimum Data Set (MDS), a federally mandated assessment tool, dated 12/26/23, showed facility staff assessed the resident as:
-Cognitively intact;
-Received dialysis;
-Diagnoses of End Stage Renal Disease (ESRD) a longstanding disease of the kidneys leading to renal failure.
Review of the resident's care plan, dated 01/08/24, showed:
-Assess shunt (hole or a small passage that allows movement of fluid from one part of the body to another site) for bruit (a whooshing sound) and thrill;
-Dialysis treatments as ordered;
-Do not take blood pressure on arm with shunt;
-Dry weights obtained from dialysis center;
-Fluid restriction as ordered;
-Observe for bleeding at dialysis access site.
Review of the Physician's Order Sheet (POS), dated January 2024, did not contain an order for dialysis.
Review of the resident's medical record, showed the record did not contain documentation between the facility and dialysis staff, ongoing assessments or monitoring of the resident's condition after dialysis treatments.
Review of the Pre/Post Dialysis Communication book did not have the dialysis center section completed on 12/27/23, 12/29/23, 1/24/24 and 1/26/24. Review showed the Pre/Post Dialysis Communication book did not have the post dialysis section completed for 12/29/23.
During an interview on 01/30/24 at 02:10 P.M., Registered Nurse (RN) A said the facility has a blue binder at the nurse's station, where staff are supposed to keep the Pre/Post Dialysis communication. He/She said he/she was aware there was missing or incomplete dialysis communication because the dialysis clinic is bad about not filling them out and/or returning them.
During an interview on 02/01/24 at 1:21 P.M., the Director of Nursing (DON) said the facility has a pre/post dialysis communication binder that is kept at the nurse's station. He/she is aware they have missing or incomplete pre/post dialysis communication forms. He/She said it is his/her expectation staff fill out the pre dialysis portion of the form and send it with the resident to the dialysis clinic. He/She said there is a section for the dialysis clinic to fill out and return with the resident. He/She said when the resident returns to the facility it is his/her expectation after the nurse's complete the residents' assessments, vitals and weight checks that they fill out the post dialysis portion of the form. He/She said he/she has tried to get the clinic to provide the communication at least weekly without success. He/She was not aware weights and assessments where not documented anywhere else in the resident's medical record. He/She said the concern with the lack of communication is that they do not know how the resident is handling the dialysis on a day-to-day basis or aware of any complications.
During an interview on 02/01/24 at 3:08 P.M., the administrator said dialysis communication is supposed to be maintained on a communication form that goes to and from the dialysis clinic and is kept in the resident's chart. He/She said he/she was not aware that the clinic was not providing information back and communication was not being kept. He/She said it is his/her expectation that communication is maintained.
CONCERN
(E)
Potential for Harm - no one hurt, but risky conditions existed
Deficiency F0558
(Tag F0558)
Could have caused harm · This affected multiple residents
**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, interviews, and record reviews, facility staff failed to provide reasonable accommodation of needs for thr...
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**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, interviews, and record reviews, facility staff failed to provide reasonable accommodation of needs for three sampled residents, when staff failed to accommodate one visually impaired resident (Resident #18) with activities, failed to assist one dependent resident (Resident #32) with his/her meal setup, and failed to provide one resident (Resident #55) with meal options to accommodate his/her dental needs. The facility census was 69.
1. Review of the facility's policies showed the facility did not provide a policy for accommodation of needs.
2. Review of Resident #18's admission Minimum Data Set (MDS), a federally mandated assessment, dated 12/26/23, showed staff assessed the resident as follows:
-admission date of 12/26/23;
-BIMS of 15 out of 15, cognitively intact;
-No behaviors;
-Highly impaired ability to see in adequate light;
-Rated taking care of personal belongings or things, choosing between bath or shower, choosing bedtime, having family involved in care, locking up personal belongings, listening to music, being around animals, keeping up with the news, going outside to get fresh air when the weather is good, doing his/her favorite activities as very important;
-Diagnosis of Diabetic Retinopathy (A complication of diabetes that affects the eyes causing floaters, blurriness, dark areas of vision, and difficulty perceiving colors or blindness.).
Review of the resident's care plan, dated 01/08/24, showed the following:
-Problem: He/She needs assistance meeting his/her physical needs;
-Problem start date: 1/03/24;
-Goal: The resident will attend/participate in activities of choice (SPECIFY i.e. 3-5 times weekly) by next review date;
-Approach: Provide activities that are Compatible with physical and mental capabilities, Compatible with known interests and preferences, adapted as needed (such as large print, holders if resident lacks hand strength, task segmentation), Compatible with individual needs and abilities; and Age appropriate.
During an interview on 01/30/24 at 9:51 A.M., the resident said he/she feels left out of participating in the facility activities and wishes he/she was aware of the activities available. He/She said he/she is legally blind and cannot read the activities calendar that is passed out. He/She said he/she has spoken to the activities director and staff about not being able to read the calendar. He/She said he/she was told staff would bring him/her a larger blown-up calendar but has not received one. He/She said no one comes to get him/her for activities and the only activity that he/she has been made aware of was bible study.
During an interview on 02/01/24 at 10:09 A.M., the Activity Director said he/she is aware that the resident requires special accommodations for his/her visual impairments. He/She has not figured out how to accommodate the resident's visual impairment due to not being tech savvy. He/She said he/she is still trying to figure out how to blow up the calendar for him/her. He/She feels like it is hard to accommodate all residents with different needs as just one person, because he/she does not have an activities assistant. He/She said he/she is also having trouble accommodating the resident because most of the activities he/she has are activities that require vision. He/She offers puzzles, coloring, bingo, and board games. He/She said he/she believes activities are important for fulfilling a resident's quality of life and he/she said, I have not accommodated him/her and I feel bad.
During an interview on 02/01/24 at 2:42 P.M., the Director of Nursing (DON) said that the activities director and himself/herself have discussed this resident's visual impairments in regards to activities and he/she is aware the resident is in need of special accommodations. He/She said they have discussed contacting someone to get audio books and enlarging coloring pages activities. He/She said volunteers or staff would need to assist the resident during activities like bingo. He/She said he/she is not sure who helps the resident on the weekends, but it is his/her expectation that staff ask him/her to participate in activities and assist him/her with the activity.
During an interview on 02/01/24 at 3:08 P.M., the Administrator said he/she was not aware staff were not accommodating the resident's vision. He/She said it is his/her expectation activities are made specific to the resident and are things he/she can listen to instead of having to read. He/She said he/she was told the activities director had been reading the calendar and other information to the resident and was assisting in getting things enlarged for her.
3. Review of Resident #32's Annual MDS, dated [DATE], showed staff assessed the resident as follows:
-Cognitively intact;
-Did not reject care;
-Diagnosis of Dementia (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, dated 01/15/24, showed the following:
-The resident had an Activities of Daily Living (ADL) self-care performance deficient related to a diagnosis of Dementia and Parkinson Disease and to provide assistance with ADL's as needed;
-Resident is at risk for falls and resident was educated to use call light for assistance for transfers and ADL's;
-The plan did not contain documentation in regard to rejection of care, setup of meal trays and sleep schedule preferences.
Observation on 01/29/24 at 12:40 P.M., showed the resident's meal tray sat on the bedside table out of the resident's reach, and the plate was covered with a lid. The resident laid in his/her bed.
Observation on 01/31/24 at 9:08 A.M., showed the resident's meal tray sat on the bedside table, out of the resident's reach, and the plate was covered with a lid. The resident laid in his/her bed.
Observation on 01/31/24 at 9:27 A.M., showed the resident's meal tray sat on the bedside table, out of the resident's reach, and the plate was covered with a lid. The resident laid in his/her bed.
Observation on 01/31/24 at 9:48 A.M., showed the resident's meal tray sat on the bedside table out of the resident's reach and the plate was covered with a lid. The resident laid in his/her bed. Unidentified staff walked by resident's room and did not assist the resident.
Observation on 01/31/24 at 10:03 A.M., showed the resident's meal tray sat on the bedside table out of the resident's reach and the plate was covered with a lid. The resident laid in his/her bed. Unidentified staff walked by resident's room and did not check on him/her.
Observation on 01/31/24 10:12 AM showed the resident's meal tray sat on the bedside table out of the resident's reach and the plate was covered with a lid. The resident laid in his/her bed. Unidentified staff walked by resident's room and did not check on him/her.
Observation on 01/31/24 at 10:17 A.M., showed the resident's meal tray sat on the bedside table out of the resident's reach and the plate was covered with a lid. The resident laid in his/her bed. Unidentified staff entered the resident's room to get his/her wheelchair, but did not ask the resident if he/she needed assistance with his/her meal and left the room.
Observation on 01/31/24 at 10:35 A.M., showed the Infection Preventionist (IP) entered the resident's room to remove the resident's meal tray. He/She told the resident he/she needed to remove the meal tray because it was sitting out for three hours. The resident said, it's ridiculous and, it's the best meal of the day. The IP told the resident if he/she was not ready to eat breakfast, he/she needed to tell staff, so the staff can put his/her breakfast in the fridge. The IP asked the resident if he/she wanted cereal and the resident said he/she did not because he/she wanted meat. The IP told the resident it was almost lunch time.
During an interview on 02/01/24 at 9:59 A.M., Certified Nurse Aide (CNA) F said staff are directed to attempt to wake the resident up for meals and encourage the resident to eat. He/She said staff setup the resident's meal tray and check on him/her every fifteen minutes. He/She said he/she should have been checked every fifteen minutes.
During an interview on 02/01/24 at 11:19 A.M., the IP said the resident liked his/her meal tray setup for him/her. He/She said he/she noticed the resident's meal tray was not within reach and his/her meal tray was not setup on 01/31/24. He/She said he/she would expect staff to wake up the resident, place the tray within reach, and encourage the resident to eat. He/She said he/she did not feel the resident's needs were being accommodated by placing the tray out of reach and across the room.
During an interview on 02/01/24 at 1:22 P.M., the Director of Nursing (DON) said the resident required assistance from staff to setup his/her meal tray. He/She said he/she expected staff to assist with meal setup and attempt to wake up the resident. He/She said the resident's plate should have been placed in fridge if the resident did not eat or refused to wake.
During an interview on 02/01/24 at 1:59 P.M., the Administrator said staff should have placed the resident's food in fridge if he/she was not ready to eat. He/She said the resident preferred to sleep in late and eat breakfast after he/she woke up. He/She said he/she would expect staff to setup his/her meal tray and make sure the tray is in front of the resident.
4. Review of Resident #55's admission MDS, dated [DATE], showed the following:
- admission date of 12/6/23;
- Cognitively intact;
- No behaviors;
- Diagnosis of Stroke (damage to the brain form interruption of its blood supply);
- Resident not assessed for oral/dental status.
Review of the resident's care plan, last revised 12/20/23, showed the record did not contain direction on meal accommodations for the resident and did not address the residents lack of bottom teeth.
Review of the resident's Physician Order Sheet, dated 12/06/23, showed:
-Diet type: Regular
-Diet texture: Regular
Observation on 01/29/24 at 10:45, showed the resident did not have bottom teeth.
During an interview on 01/29/24 at 10:45 A.M., the resident said he/she does not have bottom teeth so it is hard to chew. The resident said, I can't eat things I want to, because I don't have my bottom teeth.
During an interview on 01/31/24 at 12:01 P.M., the resident said, I have had chicken noodle soup the last couple days, because I can't chew well, and I am getting tired of eating it.
During an interview on 02/02/24 at 1:00 P.M., the resident said staff have not talked with him/her about modifying their diet, such as soft foods that are easier to eat. He/She said, It makes me feel like I don't matter.
During an interview on 02/01/24 at 3:25 P.M., the Administrator she would expect a residents meal/diets to be individualized and to cater to the resident's needs.
During an interview on 02/02/23 at 2:00 P.M., the DON said she would expect diets, preferences and accommodations to be provided to the resident and for them to be care planned. The DON said she does not know why it has not been done for the resident, but it is nursing responsibility to have any resident evaluated if there is a accommodation needed.
During an interview on 02/08/24 at 9:35 A.M., Registered Nurse (RN) A said when a resident admits to the facility the nurse will do a screening to see their food limitations, preferences and if something is identified that will be sent to the doctor or dietitian. RN A said the resident refused to be evaluated upon admission.
CONCERN
(E)
Potential for Harm - no one hurt, but risky conditions existed
Accident Prevention
(Tag F0689)
Could have caused harm · This affected multiple residents
**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, interview and record review, facility staff failed to provide a safe mechanical lift transfer for two resi...
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**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, interview and record review, facility staff failed to provide a safe mechanical lift transfer for two residents (Residents #17 and #22) when staff did not assist with guiding the residents while being transferred. The facility census was 69.
1. Review of the facility's policy titled, Limited Lift Program (Safe Patient Handling), dated 08/22/22, showed staff were directed to the following:
-Associates will be responsible for utilizing mechanical lifting devices, transferring devices, proper body mechanics to lift, transfer, and/or pivot non-ambulatory patients as indicated;
-The facility must ensure that each resident receives adequate supervision and assistance devices to prevent accidents;
-The facility will provide education upon hire and annually to associates on the proper use of lifts in accordance with the manufacturer guidelines. The education will include the need to have two associates present during the transfer and associate over the age of 18 should operate a lift.
-The policy did not contain direction for staff in regard to the responsibility of each staff member when transferring a resident using a mechanical lift.
2. Review of Resident #17's Quarterly MDS, dated [DATE], showed staff assessed the resident as follows:
-Did not contain documentation of Brief Interview for Mental Status;
-Totally dependent on staff for chair/bed-to chair transfers.
Observation on 01/30/24 at 11:23 A.M., showed Certified Nursing Assistant (CNA) M and CNA N entered the resident's room and provided perineal care. CNA M operated the mechanical lift to lift the resident out of his/her bed while CNA N stood at the end of the bed with the wheelchair. Observation showed CNA M lifted the resident with the mechanical lift and the resident swayed side to side above the floor without staff guidance.
During an interview on 01/31/24 at 1:53 P.M., CNA M said the purpose of using two staff members when transferring a resident with a lift was to prevent the resident from falling. He/She said he/she did receive training one person to use the lift and the other person is to guide the resident. He/She said he/she did not know why he/she did not wait for CNA N to guide the resident, but he/she was nervous.
During an interview on 01/31/24 at 1:53 P.M., CNA N said he/she did receive training on safely transferring a resident. He/She said he/she should have guided the resident while being transferred using the lift, but was nervous while being observed.
3. Review of Resident #22's Quarterly MDS, dated [DATE], showed staff assessed the resident as follows:
-Severe cognitive impairment;
-Uses a wheelchair for mobility;
-Total Dependence on staff for toileting, chair/bed transfers, and bathing;
-Diagnosis of stroke (Damage to the brain from interruption of its blood supply) and Hemiplegia (Paralysis of one side of the body).
Observation on 01/30/24 at 11:40 P.M., showed CNA E and CNA G entered the resident's room to get the resident out of bed using a mechanical lift. CNA E operated the mechanical lift while CNA G stood on the other side of the bed. Observation showed CNA E lifted the resident with the mechanical lift and the resident swayed side to side above the floor without staff guidance as he/she was moved from the bed over to the wheelchair.
During an interview on 02/01/24 at 12:04 P.M., CNA G said it is important to always use two people when operating a mechanical lift. He/She said one staff member works the lift while the other holds on to resident and guides them to the chair or bed. He/She said CNA E should have waited for him/her to get to the other side of the bed before he/she moved the residents away from the bed. He/She said it is a safety risk for injury to not have someone guiding the resident into the wheelchair.
4. During an interview on 02/01/24 at 1:22 P.M., the Director of Nursing (DON) said staff were educated to use to staff members to safely transfer a resident when using a lift. He/She said one staff member operated the lift and the other staff would guide the resident. He/She said if a staff member did not guide the resident, the resident could suffer an injury.
During an interview on 02/01/24 at 1:59 P.M., the Administrator said staff were directed to use two staff members when transferring a resident using a lift. He/She said he/she did not know why the facility is required to use two staff members when using a lift, but assumed it was for safety reasons.
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, facility staff failed to use appropriate infection control procedures to prev...
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**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, interview and record review, facility staff failed to use appropriate infection control procedures to prevent the spread of bacteria or other infectious causing contaminants when staff failed to wash or sanitize their hands in between glove changes during perineal care for two residents (Resident #14 and #17). Staff failed to provide a barrier for blood sugar care supplies and failed to appropriately sanitize a multiple use glucometer (used to measure blood sugar) between use on one resident (Resident #17). Facility staff failed to ensure all staff were screened for Tuberculosis (TB) (a potentially serious infectious bacterial disease that mainly affects the lungs) when staff failed to ensure a two-step purified protein derivative (PPD) (skin test for TB) and/or annual PPD tests were completed and documented as per the facility policy for three staff (Licensed Practical Nurse (LPN) O, [NAME] S and Dietary Aide T). The facility census was 69.
1. Review of the facility's Hand Hygiene policy, dated 06/13/23, showed staff are directed to provide:
-The facility has adopted the CDC (Centers for Disease Control) Core Infection Prevention and Control Practices for Safe Healthcare Delivery in All Settings for indications for hand hygiene that are generally consistent with the WHO (World Health Organization) 5 moments for hand hygiene;
-Associates perform hand hygiene (even if gloves are used) in the following situations:
-Before and after contact with the resident;
-After contact with blood, body fluids, or visibly contaminated surfaces;
-After contact with object and surface in the resident's environment;
-After removing personal protective equipment (e.g., gloves, gown, eye protection, facemask);and
-Before performing a procedure such as an aseptic task (e.g., insertion of an invasive device such as
as a urinary catheter, manipulation of a central venous catheter, and/or dressing care.
2. Review of Resident #14's Quarterly Minimum Data Set (MDS), a federally mandated assessment tool, dated 11/09/23, showed staff assessed the resident as:
-Severe cognitive impairment;
-Dependent on staff for toileting hygiene;
Observation on 01/29/24 at 1:28 P.M., showed Certified Nurse Aide (CNA) L entered the resident's room to provide perineal care. CNA L placed the catheter bag under the resident's bed, changed gloves, but did not perform hand hygiene. CNA L removed the resident's pants and socks and raised the bed with the same soiled gloves. CNA L repositioned the resident's soiled brief, touched the perineal wash bottle, provided perineal care on the resident's genital area, then repositioned the resident with the same soiled gloves. CNA L touched the perineal care bottle, provided perineal care on the buttocks area, removed the soiled brief, then placed the clean brief under the resident with the same soiled gloves.
During an interview on 02/06/24 at 9:42 A.M., CNA L said he/she was educated to perform hand hygiene in between glove changes to prevent the spread of infection. He/She said he/she realized he/she missed a hand hygiene opportunity when he/she changed gloves, but did not perform hand hygiene and moved from one task to another with the same soiled gloves. He/She said he/she was nervous, which is why he/she missed a hand hygiene opportunity.
3. Review of Resident #17's Quarterly MDS, dated [DATE], showed staff assessed the resident as:
-Did not contain documentation of Brief Interview for Mental Status;
-Dependent on staff for toileting hygiene.
Observation on 01/30/24 at 11:23 A.M., showed CNA M and CNA N entered the resident's room to provide perineal care. CNA M and CNA N both unfastened the soiled brief. CNA N provided perineal care to the resident's genitals and with the same soiled gloves, repositioned the resident. CNA M applied the barrier cream on the resident, removed his/her gloves and did not perform hand hygiene before repositioning the resident's leg and touching the clean brief.
During an interview on 01/31/24 at 1:53 P.M., CNA M said he/she should have changed gloves and performed hand hygiene before and after applying the gloves. He/She said it a potential infection control issue. He/She said he/she received an in-service on hand hygiene and glove change about a month ago. He/She said he/she was nervous and it caused him/her to miss hand hygiene and glove change opportunity.
During an interview on 01/31/24 at 1:53 P.M., CNA N said it is a no no, and should have wash his/her hands and changed gloves before touching the resident. He/She said it could cause an infection or spread germs by not performing hand hygiene and changing gloves when going from a dirty to a clean task. He/She said he/she was nervous while being observed and miss an hand hygiene and glove change opportunity.
4. During an interview on 01/31/24 at 2:15 P.M., the Infection Preventionist (IP) said staff received an in-service on the proper technique for perineal care, including hand hygiene and glove changes within the past three months. He/She said staff should perform hand hygiene prior to apply gloves. He/She said staff are directed to perform hand hygiene and glove change any time hands are soiled, after providing care, and going from a dirty task to a clean task. He/She said gloves are not 100 percent preventative in prevention the transmission of infection. He/She said there is a concern of spreading of bacteria, germs and viruses and could cause cross contamination.
During an interview on 02/01/24 at 1:22 P.M., Director of Nursing (DON) said staff were directed to change gloves and perform hand hygiene between dirty and clean task. He/She said he/she would expect staff to perform hand hygiene after removing gloves, since gloves are not 100 percent effective in preventing the spread of bacteria. He/She said there was a concern of cross contamination if staff did not replace gloves and perform hand hygiene prior to touching the resident or items in the resident's room.
During an interview on 02/01/24 at 1:59 P.M., the Administrator said staff were directed to change gloves and perform hand hygiene anytime staff go from a dirty to a clean task to prevent the spread of infection and germs.
5. Review of the facility's Cleaning and Disinfection of the Glucometer policy, dated 09/20/23,, showed staff are directed to provide:
-To prevent the spread of infection, specifically blood borne pathogens through the use of point of care blood glucose monitoring, by cleaning and disinfecting glucometer after each resident use;
-The policy contained a link, Glucometer-Assure Prism Quality Control Checks and Cleaning Procedures, but did not contain documentation of the cleaning procedure.
Review of the manufacturer reference manual, Assurance Prism Multi Blood Glucose Monitoring System, undated, showed the following:
-To minimize the risk of transmitting blood borne pathogens, the cleaning and disinfection procedure should be performed as recommended in the instructions below;
-Prism multi Blood Glucose Monitoring System may only be used for testing multiple patients when standard precautions and the manufacturer's disinfection procedures are followed;
-Only wipes with EPA registration numbers listed below have been validated for use in cleaning and disinfecting the meter. Wipes with EPA registration numbers not listed below should not be used to clean and disinfect the Assure Prism multi Meter;
-Clorox Professional Products Company, Clorox Healthcare Bleach Germicidal Wipes or Dispatch Hospital Cleaner Disinfectant Towels and Bleach; Professional Disposables International, Inc., Super Sani-Cloth Germicidal Disposable Wipe or Metrex Research, CaviWipes1;
-Two disposable wipes will be needed for each cleaning and disinfecting procedure; one wipe for cleaning and a second wipe for disinfecting.
Review of the facility's Blood Glucose Monitoring policy, dated 09/15/23, showed staff are directed to provide:
-Associates who obtain capillary blood glucose specimens will do so in accordance with their scope of practice and in accordance with all applicable local, state, and federal guidelines. Specimens will be collected in a manner that adheres to current standards of practice and infection control standards;
-The facility should ensure associates who authorized to perform capillary blood glucose monitoring receives training and has completed a competency (e.g., skills checked-off knowledge-based self-test);
-The policy did not contain direction for staff in regard to placing the glucometer on a sterile surface or a barrier.
6. Review of Resident #17's MDS, dated [DATE], showed staff assessed the resident as:
-Did not contain documentation of Brief Interview for Mental Status;
-Received injections and insulin seven out of seven days during the lookback period;
-Diagnosis of diabetes (a group of diseases that result in too much sugar in the blood).
Observation on 01/30/24 at 11:39 A.M., showed Licensed Practical Nurse (LPN) C gathered the blood sugar testing supplies for the resident and placed them directly on the dining table and did not sanitize the surface or place a clean barrier on the table. When asked about the last use of the glucometer LPN C said he/she just used the glucometer on another resident and did not clean the glucometer after the use on the other resident. LPN C continued to pick up the lancet to use on the resident when this surveyor stopped him/her before he/she used the soiled glucometer on the resident. LPN C took the glucometer and supplies to the medical cart and laid the supplies on the medical cart without a protective barrier. LPN C used alcohol wipes to clean the glucometer, then sat it back on the medical cart, without a barrier. LPN C gathered the blood sugar testing supplies and placed on the dining table and did not sanitize or place the supplies on a protective barrier. He/She tested the resident's blood sugar and laid the used lancet directly on the table.
During an interview on 01/30/24 at 11:45 A.M., LPN C said he/she did not know the manufacturing instructions for properly cleaning the glucometer. He/She said there is a concern of cross contamination when using a glucometer on multiple residents without cleaning the glucometer between uses. He/She said he/she should have used a protective barrier to prevent the transfer of germs onto the table and to residents.
During an interview on 01/31/24 at 11:24 A.M., LPN C said he/she was trained to clean the glucometer between uses on different residents, and to place a barrier or lay supply on a clean surface, but he/she was rushing to move on to another task.
During an interview on 02/01/24 at 11:19 A.M., the IP said staff were directed to clean the glucometer the between uses on residents. He/She said staff are to use Sani-wipes, wipe the glucometer twice with two different wipes, then place the glucometer on a wipe, or clean paper towel, to air dry. He/She would expect a clean barrier to be used. He/She said there is a concern of a risk of cross contamination if the glucometer is not cleaned between uses on different residents and an infection control issue when supplies were placed on a table without a barrier. He/She said the last in-service for cleaning of glucometer and barrier protection was about six months ago.
During an interview on 02/01/24 at 1:22 P.M., the DON said staff were directed staff to disinfect multiple use glucometers between uses. He/She said it is an infection control concern if the glucometer is not cleaned and disinfected between uses or supplied laid on the table without being sanitized or on a clean barrier.
During an interview on 02/01/24 at 1:59 P.M., the Administrator said he/she did know there was a special cleaner for disinfecting glucometers between uses. He/She said there is concern if the glucometer was used on multiple residents and not disinfected in between each use and not placing supplies on a barrier.
7. Review of the facility's Tuberculosis-Testing and Screening (Associates, and Volunteers) policy, dated 06/06/23, showed staff are directed to provide:
-The facility will evaluate each associate and volunteer for tuberculosis in accordance with current CDC guidelines, unless more stringent guidance is provided by local or state regulations;
-Missouri facilities should follow state regulation 19 CSR 20-20.100 that indicates that screening of residents on admission, and pre-employments and annual testing of associates and volunteers who work 10 hours or more per week.
8. Review of LPN O's personnel records showed:
-Hire date of 01/23/23;
-Did not contain documentation a first or second step TB test was administered.
9. Review of cook S's personnel records showed:
-Hire date of 12/23/22;
-Did not contain documentation a first or second step TB test was administered.
10. Review of Dietary Aide T's personnel records showed:
-Hire date of 04/22/22;
-Did not contain documentation a first or second step TB test was administered.
11. During an interview on 02/01/24 at 11:19 A.M., the IP said he/she was responsible to conduct TB testing for staff. He/She said the first TB test should be performed before starting on the floor and the second test would be completed two to three weeks later. He/She said there is a process in place for ensuring the TB testing was completed. He/She said the TB test is documented in a book, which he/she checked daily. He/She said it was an oversight he/she did not test the three staff members for TB.
During an interview on 02/01/24 at 1:59 P.M., the Administrator said the IP was responsible to complete the TB testing. He/She did not receive a report of missing employee TB test and understood it was logged in the nursing office.
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, facility staff failed to maintain kitchen equipment and surfaces in a clean sanitary manner to prevent the potential for cross-contamination. Facilit...
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Based on observation, interview and record review, facility staff failed to maintain kitchen equipment and surfaces in a clean sanitary manner to prevent the potential for cross-contamination. Facility staff failed to perform hand hygiene as often as necessary, using approved techniques, to prevent cross-contamination. Facility staff failed to sanitize kitchen wares in a manner to prevent contamination, and to store dishwares in a manner to prevent cross-contamination when staff stacked dishwares together wet. Facility staff failed to ensure trash can remained covered when not in use to prevent the potential for food contamination. The facility census was 69.
1. Review of the facility's Food and Nutrition Services Manual, reviewed 04/25/2023, showed:
-The Director of Food and Nutrition Services monitors the cleaning schedule to ensure the tasks are completed timely and appropriately;
-When cleaning fixed equipment (e.g., mixers, slicers and other items) the removable parts must be washed and sanitized and non-removable parts cleaned with detergent and hot water, rinsed, air dried and sprayed with a sanitizing solution;
-Physical facilities are cleaned as often as necessary to keep them clean.
Review of the facility's kitchen cleaning logs showed the last documented daily cleaning log was dated 01/10/2024.
Review of the facility's Dining Services and Sanitation Report, completed by the Registered Dietician (RD) on 12/20/2023 showed:
-Cleaning schedule is not posted and followed. Holes in cleaning schedule;
-Areas behind and under equipment very dirty;
-Ice machine is dirty on outside;
-Oven needs cleaned;
-Walls and floors in dish room need cleaned;
-Please keep lid on trash cans when not in use;
-Additional comments and three focus areas included:
-Work on keeping up with daily, weekly, monthly cleaning logs;
-Clean under and behind equipment;
-Clean up and repair all areas in dish room.
Observation on 01/29/24 at 10:00 A.M., showed the kitchen floor was dirty and littered with food debris.
Observations on 01/30/2024 from 9:15 A.M. through 1:00 P.M. showed:
-the kitchen floor was dirty and littered with food debris;
- a broken egg shell, a can and an accumulation of grease and food particles, under the stove;
-an accumulation of grease on the side of the oven next to the deep fryer;
-an accumulation of dried juice on the juice machine drip pan support bracket;
-showed excessive food build up on can opener base and blade areas;
-food debris around and under the meat slicer blade and blade guard;
-dried food debris on the stand mixer in the area above the mixing bowl;
-an accumulation of grease and dust on the top of the ice machine;
-an accumulation of grease and dust on the conduit and electrical boxes along the wall behind the stove and microwave.
During an interview on 01/30/24 at 1:06 P.M., the Food Services Director said staff should clean the floor every night. He/She said the meat slicer and should be cleaned after each use. He/She said the dietician had noted areas needing cleaning in December but they haven't been able to do a kitchen deep clean yet. He/She said kitchen staff have daily, weekly and monthly cleaning lists but he/she hasn't been keeping up with checking them.
2. Observation on 01/30/24 at 11:09 A.M., showed [NAME] O placed pre-made salad in two small bowls, placed the left over salad in a plastic bag and removed his/her gloves. [NAME] O grabbed a cutting board and knife, donned new gloves and did not wash hands before he/she sliced boiled eggs in half and placed on the salad. [NAME] O opened the refrigerator door with gloved hands when he/she returned the eggs to the refrigerator. [NAME] O grabbed another knife with gloved hands, sliced tomatoes and placed the tomatoes on the salad, removed gloves, donned new gloves and did not wash hands. [NAME] O placed shredded cheese on the salads. Observation showed the two salads were served to residents during the lunch meal.
During an interview on 01/30/24 at 12:59 P.M., [NAME] O said he/she should wash hands between glove changes. [NAME] O said he/she was in a hurry and was not paying attention to what he/she was doing.
During an interview on 01/30/24 at 1:06 P.M., the Food Services Director said staff should wash hands before meal service, after touching something other than clean food and before putting on new gloves.
3. Review of the facility's Food and Nutrition Services Manual, reviewed 04/25/2023, showed:
-A three compartment sink, if available, will be utilized to wash, rinse and sanitize pots/pans and utensils effectively;
-Sinks are filled as wash with detergent for washing, rinse with clean water to remove all soap residue and sanitize with appropriate sanitizer using guidelines noted by manufacturer;
-All dishes, pots and pans must be air dried after sanitizing and should not be stored wet to prevent wet nesting.
Review of the sanitizer instructions for use directed staff to expose all surfaces to the sanitizing solution for a period of not less than one minute. Allow equipment to drain thoroughly and air dry.
Observation on 01/30/24 at 9:53 A.M., showed the sanitizer sink contained a cutting board, a plastic pitcher and two steam table pans that were not fully submerged in the sanitizer solution.
Observation on 01/30/24 at 10:03 A.M., showed [NAME] P pushed the cutting board, pitcher and steam table pans under the sanitizing solution and removed the items from the sanitizer sink and placed them on the sink drain board. Observation showed the items were not submerged for at least one minute.
During an interview on 01/30/24 at 10:04 A.M., [NAME] P said he/she did not know how long items should be fully submerged. [NAME] P said he/she pushed the items down and moved them around but they were never fully submerged. [NAME] P said he/she guessed the items were not sanitized properly and he/she should re-do them.
Observation on 01/30/24 at 11:53 A.M., showed the sanitizer sink contained a cutting board, a plastic pitcher and two steam table pans not fully submerged in the sanitizer solution.
Observation on 01/30/24 at 11:55 A.M., showed [NAME] Q removed the cutting board, the pitcher and the steam table pans from the sanitizer solution and placed the items on the sink drain board. Observation showed the items were not submerged for at least one minute.
During an interview on 01/30/24 12:02 P.M., [NAME] Q said the items were not submerged all the way and should not have been removed from the sanitizer. [NAME] Q said he/she should have added more sanitizer to cover items and let them soak. [NAME] Q said he/she was not sure how long items should soak, but he/she thought the soak time was 15 minutes.
Observation on 01/30/24 at 12:51 P.M., showed [NAME] R dipped a large sheet pan in the sanitizer sink, then flipped the pan to wet the other side, then removed the pan and placed it on the drain board. [NAME] R then cleaned four additional large sheet pans by submerging them, flipping them over and splashing sanitizer solution to cover the pans. Observation showed all five pans were removed from the sanitizer solution without being submerged for one minute and placed on the drain board.
During an interview on 01/30/24 at 12:53 P.M., [NAME] R said items should be in the sanitizer sink for five to 10 minutes. [NAME] R said the pans were under the water for about two minutes. [NAME] R said he/she should follow the sanitizer instructions and five minutes is a good soak time.
Observation on 01/30/24 at 9:59 A.M., showed a shelving unit near the kitchen door contained six stacks of plastic drinking cups that were stacked wet.
During an interview on 01/30/24 at 1:06 P.M., the Food Service Director (FSD) said items should not sit in the sanitizer sink. The FSD said he/she washes, rinses, puts items in sanitizer and swishes and removes. The FSD said he/she did not know what the sanitizer instructions said about soak time. The FSD said items should not be stacked wet.
4. Review of the facility's Food and Nutrition Services Manual, reviewed 04/25/2023, showed:
-Garbage and refuse will be disposed of properly and per federal, state and local requirements. Food waste may be disposed of in garbage disposal or covered waste cans.
Observation on 01/29/24 at 10:00 A.M., Observation showed three trash cans were not covered and were not in use.
Observation on 01/30/24 at 9:49 A.M., showed the trash cans next to the microwave and outside the Food Service Director's office did not have lids and were not covered while not in use.
During an interview on 01/30/24 at 1:06 P.M., the Food Services Director said trash cans should be covered when not in use. He/She said some of the lids were broken but he/she had not ordered replacements.
During an interview on 1/31/24 at 11:45 A.M., the administrator said the Food Services Director is responsible for making sure kitchen staff follow proper cleaning practices and maintain kitchen cleanliness.
MINOR
(B)
Minor Issue - procedural, no safety impact
Safe Environment
(Tag F0584)
Minor procedural issue · This affected multiple residents
**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, interview and record review, the facility staff failed to provide a clean, homelike and comfortable enviro...
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**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, interview and record review, the facility staff failed to provide a clean, homelike and comfortable environment when staff failed maintain resident rooms and medical device equipment. The facility census was 69.
1. Review of the facility's policies showed the facility did not provide a policy for environmental concerns.
Review of the facility's policy titled, Medical Equipment Management Plan, dated 01/11/24, showed staff were directed to the following:
-The facility will utilize the Medical Equipment Management Plan to provide a safe and supportive environment for the efficient and effective provision of resident care services;
-The facility must be designed, constructed, equipped, and maintained to protect the health and safety of residents, personnel and the public;
-The department heads/managers are responsible for managing medical equipment within their departments. They maintain a complete inventory of such equipment, remove it for service when appropriate, repair it when needed, and ensure that the preventative maintenance is performed on time. They set the example and inspire a focus in those they supervise by assuring that the medical equipment used in resident care is maintained at 100% and policies and procedures are carried out;
-Associates are responsible for cooperating with all aspects of the Medical Equipment Management Program. They are also required to report any failures of resident care equipment immediately and remain competent in the equipment's use.
2. Observation on 01/29/24 at 1:28 PM., showed the resident occupied room [ROOM NUMBER] floor contained black marks and scratches. Observation showed the walls contained black marks and chipped paint. Observation showed the bathroom door contained chipped paint and the entry door trim detached from the front of the door frame.
Observation on 02/01/24 at 10:12 AM., showed the resident occupied room [ROOM NUMBER] floor contained black marks and scratches. Observation showed the walls contained black marks and chipped paint. Observation showed the bathroom door contained chipped paint and the entry door trim detached from the front of the door frame.
3. Observation on 01/30/24 at 8:36 A.M., showed the resident occupied room [ROOM NUMBER] the floor tile under the sink cracked and the sink base trim missing. Observation showed the bathroom door frame and entry door frame with chipped paint. Observation showed the walls behind both beds with missing paint and the closet door frame not attached.
Observation on 02/01/24 09:36 AM., showed the resident occupied room [ROOM NUMBER] the floor tile under the sink cracked and the sink base trim missing. Observation showed the bathroom door frame and entry door frame with chipped paint. Observation showed the walls behind both beds with missing paint and the closet door frame not attached.
During an interview on 02/01/24 at 9:59 A.M., Certified Nurse Aide (CNA) F said he/she reported environmental concerns for room [ROOM NUMBER] to staff.
4. Observation on 01/30/24 at 12:44 P.M., showed the resident occupied room [ROOM NUMBER] wall with chipped and missing paint. Observation showed the bathroom door trim missing and raised areas of paint.
Observation on 02/01/24 at 9:31 A.M., showed the resident occupied room [ROOM NUMBER] wall with chipped and missing paint. Observation showed the bathroom door trim missing and raised areas of paint.
During an interview on 02/01/24 at 9:59 A.M., CNA F said he/she reported environmental concerns for room [ROOM NUMBER] to staff.
5. Observation on 01/30/24 at 8:45 A.M., showed the resident occupied room [ROOM NUMBER] floor contained black marks and scratches. Observation showed the bathroom door frame and trim paint missing. Observation showed the mirrors reflective material missing.
Observation on 02/01/24 at 9:44 A.M.,showed the resident occupied room [ROOM NUMBER] floor contained black marks and scratches. Observation showed the bathroom door frame and trim paint missing. Observation showed the mirrors reflective material missing.
6. Observation on 01/29/24 at 11:53 A.M., showed Resident #32's wheelchair armrest with cracks and sections of the upholstery missing.
Observation on 01/30/24 at 1:00 P.M., showed the resident sat in his/her wheelchair. Observation showed the wheelchair armrest with cracks and sections of the upholstery missing.
Observation on 01/31/24 at 12:10 P.M., showed the resident sat in his/her wheelchair. Observation showed the wheelchair armrest with cracks and sections of the upholstery missing.
Observation on 02/01/24 at 9:25 A.M., showed the resident's wheelchair armrest with cracks and sections of the upholstery missing.
During an interview on 02/01/24 at 9:59 A.M., CNA F said he/she had not noticed the resident's torn or worn armrest.
During an interview on 02/01/24 at 11:19 A.M., the Infection Preventionist (IP) said he/she had not noticed the resident's armrest in disrepair.
During an interview on 02/01/24 at 12:27 P.M., the maintenance director said staff have not reported concerns with the armrest of the resident's wheelchair.
During an interview on 02/01/24 at 1:22 P.M., the the Director of Nursing (DON) said he/she did not notice the armrest of the resident's wheelchair in disrepair.
During an interview on 02/01/24 at 1:59 P.M., the administrator said he/she did not know the resident's wheelchair was in disrepair. He/She said if the armrest is torn or worn, it could potentially cause injury to the resident.
7. During an interview on 02/01/24 at 9:59 A.M., CNA F said he/she was directed to report maintenance issues to the nurse or the maintenance department. He/She said there is a maintenance book to document environmental or medical equipment in disrepair. He/She said the maintenance department checks the book on a daily basis.
During an interview on 02/01/24 at 11:19 A.M., the IP said staff are directed to contact the maintenance department if there are environmental concerns. He/She said he/she medical equipment in disrepair should be reporter to the charge nurse, DON or maintenance department. He/She said there is a maintenance log to document medical equipment or rooms in disrepair. He/She said he/she had not noticed environmental concerns in the resident rooms.
During an interview on 02/01/24 at 12:27 P.M., the maintenance director said staff are directed to report medical or environmental concerns directly to him/her or document in the maintenance log book. He/She said he/she checked the maintenance log once a week and no staff have reported environment concerns. He/She said he/she was working on the empty resident rooms in the memory care unit.
During an interview on 02/01/24 at 1:22 P.M., the DON said staff are directed to report environmental and wheelchairs concerns to the maintenance department. He/She said staff are directed to verbally report environmental concerns or document the concerns in the maintenance log. He/She said he/she had noticed the condition of the resident rooms and the maintenance department was working on making repairs to the rooms in the memory care unit.
During an interview on 02/01/24 at 1:59 P.M., the administrator said staff are directed to let the rehab unit or the DON know if there are wheelchairs in disrepair. He/She said staff are directed to report rooms or medical equipment in disrepair verbally to the maintenance department. He/She said he/she did not know if there was a maintenance log to document environmental concerns in. He/She said he/she is working with a regional staff to assist with environmental concerns.
MINOR
(B)
Minor Issue - procedural, no safety impact
Deficiency F0679
(Tag F0679)
Minor procedural issue · This affected multiple residents
Based on observation, interview, and record review, facility staff failed to provide an ongoing program of activities designed to meet the residents' interests for 17 of 17 residents who reside on the...
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Based on observation, interview, and record review, facility staff failed to provide an ongoing program of activities designed to meet the residents' interests for 17 of 17 residents who reside on the memory care unit. The facility census was 69.
1. Review of the facility's policy titled, Therapeutic Activities Program, 09/21/23, showed the facility should implement an ongoing resident centered activities program that incorporates the resident's interests, hobbies and cultural preferences which is integral to maintaining and/or improving a resident's physical, mental, and psychosocial well-being and independence. To create opportunities for each resident to have a meaningful life by supporting his/her domains of wellness (security, autonomy, growth, connectedness, identity, joy and meaning).
Review of the facility's Activity Calendar, dated January 2024, showed the following:
-Tuesday, 01/30/24; 10:00 A.M., Snack Cart, 11:00 A.M. Bible, 1:30 P.M., Bingo;
-Wednesday, 01/31/24; 9:30 A.M. Card games, 1:30 P.M. Arts and Crafts;
-Saturdays; 10:00 A.M. Snack and Chat, 1:00 P.M. Pick A Flick and Family Visits;
-Sundays; 10:00 A.M. Puzzle Time, Resident Choice and Family Visits.
2. Observation on 01/31/24 at 10:06 A.M., showed four residents sat in the dining room watching a movie. Staff did not invite other resident's to watch the movie.
Observation on 01/30/24 at 11:16 A.M., showed resident's sat in the dining room waiting for lunch to be served. The staff did not provide an activity.
Observation on 01/31/24 at 9:56 A.M., showed five residents sat in the dining room with no staff led activity.
Observation on 01/31/24 at 1:53 P.M. showed no staff led activity in the dining room.
3. During an interview on 02/01/24 at 10:30 A.M., the Activity Director (AD) said he/she did not work on the weekends, except when there are special events, so there are no staff led activities. He/She said he/she sets up a cart with activities for the residents to lead on the weekends. He/She said there is a scheduled activity on the memory care unit (MCU) on Monday and the rest of the week he/she will bring a couple of the independent residents from the MCU to the common area with the rest of the resident to attend activities. He/She said the residents would have a more fulfilled life if there was someone on the weekends to provide staff led activities. He/She said he/she did not feel there was enough activity staff to accommodate all the residents various needs and preferences.
During an interview on 02/01/24 at 9:59 A.M., Certified Nurse Aide F said the AD visits the MCU a couple of days a week to provide staff led activities. He/She said staff turned on the TV in the dining room and encourage the resident's to color and play board games with the staff throughout the day. He/She said staff did not ask every resident if they would like to attend an activity. He/She did not know if there are any scheduled staff led activities every day of the week.
During an interview on 02/01/24 at 11:19 A.M., the Infection Preventionist said there is an activity person on-site five days a week. He/She said he/she believed a supervisor possibly led the activities on the weekends. He/She said there should be scheduled staff led activities on the weekends to maintain a good quality of life.
During an interview on 02/01/24 at 1:22 P.M., the Director of Nursing (DON) said activities should be person centered. He/She said there are scheduled activities seven days a week. He/She said the Manager on Duty was responsible to complete the scheduled activities when the AD was not in the building, but he/she did not know about the MCU.
During an interview on 02/01/24 at 1:59 P.M., the Administrator said there should be scheduled staff led activities every day of the week, but he/she did not know if there were or not. He/She said there should be staff or volunteer led activities available to residents at least twice a day. He/She said he/she did not know if there is enough activity staff to provide to accommodate all resident preferences. He/She said he/she did not think the resident were living their best life if there are not scheduled activities available every day of week.
MINOR
(B)
Minor Issue - procedural, no safety impact
Deficiency F0761
(Tag F0761)
Minor procedural issue · This affected multiple residents
**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, interview, and record review facility staff failed to ensure medications were stored in a safe and effecti...
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**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, interview, and record review facility staff failed to ensure medications were stored in a safe and effective manner for three out of four medication carts. The facility census was 69.
1. Review of the facility's Storage and Expiration Dating of Medications Policy, dated [DATE], showed the policy directs staff as follows:
-Facility should ensure that medications and biologicals that: (1) have an expired date on the label, (2) have been retained longer then recommended by manufacturer or supplier guidelines, or (3) have been contaminated or deteriorated, are stored separate from other medications until destroyed or returned to the pharmacy or supplier;
-Facility should ensure that the medications and biologicals for each resident are stored in the containers in which they were originally received;
-Facility personnel should inspect nursing station storage areas for proper storage compliance on a regularly scheduled basis.
2. Observation on [DATE] at 9:59 A.M., showed the medication cart on the 100 hall contained the following loose pills:
-One large round orange pill;
-One small pink pill;
-One large white pill.
3. Observation on [DATE] at 10:10 A.M., showed the medication cart on the 300 hall contained the following loose pills:
-One small blue pill;
-One small oval brown capsule;
-One quarter of a small white pill;
-One small cream pill;
-Half of a small pink pill;
-Half of a small white pill;
-One small oval white pill.
During an interview on [DATE] at 11:00 A.M., Licensed Practical Nurse (LPN) C said he/she is currently the nurse using the 100 and 300 hall medication carts. He/She said it is the nurse's responsibility to maintain the medication carts. He/She said he/she is not aware of a specific timing requirement for how often they should be checking medication carts, but that they need to be done as needed and have periodic checks. He/She said there is also a nurse that comes around periodically and does cart checks for medication expirations. He/She was not aware that his/her medication cart contained loose pills and he/she was not sure where they came from.
4. Observation on [DATE] at 10:20 A.M., showed the medication cart on the 400 hall contained five small yellow pills.
During an interview on [DATE] at 10:21 A.M., LPN D said he/she is the nurse using the medication cart on the 400 hall. He/She said it is the nurse's responsibility to maintain medications. He/She is unsure where the loose pills came from. He/She said medication carts are only checked as needed.
5. During an interview on [DATE] at 1:21 P.M., the Director of Nursing (DON) said it is the responsibility of the nurses who work night shift to maintain the medication carts. He/She said the goal is that they would have time to go in and clean them and remove loose pills. He/She said in general everyone who is passing medications on a cart is responsible to maintain the carts when they are on them by monitoring them daily and cleaning them as needed.
During an interview on [DATE] at 3:08 P.M., the Administrator said the nurses and Certified medication technician's are responsible for maintaining the medication carts. He/She said he/she was not sure how often their policy required them to check for loose pills. He/She said it is his/her expectation that his/her staff always follow the policy. He/She said it is also his/her expectation the medication carts are kept clean and without loose pills.
MINOR
(C)
Minor Issue - procedural, no safety impact
Deficiency F0570
(Tag F0570)
Minor procedural issue · This affected most or all residents
Based on interview and record review, facility staff failed to purchase a surety bond in an amount sufficient to assure security of all resident funds the facility holds. The facility census was 69.
...
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Based on interview and record review, facility staff failed to purchase a surety bond in an amount sufficient to assure security of all resident funds the facility holds. The facility census was 69.
1. Review of the resident trust fund account for January 2023 through December 2023, showed an average monthly balance of $48,168.23, which required a surety bond of $72,000.00.
Review of the Department of Health and Senior Services (DHSS) database, showed the facility's approved non-cancelable Escrow Agreement Account in the amount of $69,000.00.
During an interview on 02/01/24 at 1:15 P.M., the Corporate Financial Manager said it is the business office managers (BOM) responsibility to check it quarterly and corporate office will update the bond as necessary. He/She said ultimately it is both parties responsibility to keep track, it was overlooked.
During an interview on 02/01/24 at 3:25 P.M., the administrator said she believes the corporate office is responsible to make sure the bond is sufficient. The administrator said I did not know it wasn't sufficient but I do now, and I will help the BOM make sure it is moving forward.
MINOR
(C)
Minor Issue - procedural, no safety impact
Deficiency F0575
(Tag F0575)
Minor procedural issue · This affected most or all residents
Based on observation, interview and record review, facility staff failed to post the telephone number for the Department of Health and Senior Services (DHSS) Adult Abuse and Neglect Hotline (used to r...
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Based on observation, interview and record review, facility staff failed to post the telephone number for the Department of Health and Senior Services (DHSS) Adult Abuse and Neglect Hotline (used to report allegations of abuse and neglect), the name, address, and phone number for the Long-Term Care Ombudsman (a program serving residents of nursing homes and residential care facilities to provide support and assistance with their problems or complaints) and the resident rights in a form and manner accessible to residents and visitors on the secured memory care unit (MCU). The facility census was 69.
1. Review of the facility's policies showed the facility did not provide a policy for the required postings.
2. Observation on 01/29/24 at 11:23 A.M., showed the facility staff did not post the name, address, and toll free telephone number for the Adult Abuse Hotline, the name, the address and phone number for the Long-Term Care Ombudsman, or the resident rights in the secured MCU.
Observation on 01/30/24 at 8:37 A.M., showed the facility staff did not post the name, address, and toll free telephone number for the Adult Abuse Hotline, the name, the address and phone number for the Long-Term Care Ombudsman, or the resident rights in the secured MCU.
Observation on 01/31/24 at 12:28 P.M., showed the facility staff did not post the name, address, and toll free telephone number for the Adult Abuse Hotline, the name, the address and phone number for the Long-Term Care Ombudsman, or the resident rights in the secured MCU.
Observation on 02/01/24 at 9:59 A.M., showed the facility staff did not post the name, address, and toll free telephone number for the Adult Abuse Hotline, the name, the address and phone number for the Long-Term Care Ombudsman, or the resident rights in the secured MCU.
During an interview on 02/01/24 at 9:59 A.M., Certified Nurse Aide (CNA) F said he/she did not where the required postings were posted on the MCU and did not know how resident's and/or their family would know how to report a concern without asking staff.
During an interview on 02/01/24 at 11:19 A.M., the Infection Preventionist (IP) said the required postings was not posted on the MCU.
During an interview on 02/01/24 at 1:22 P.M., the Director of Nursing (DON) said he/she did not know where the required postings were posted on the MCU.
During an interview on 02/01/24 at 1:59 P.M., the Administrator said he/she did not know where the required postings were posted on the memory care unit. He/She said he/she was responsible to ensure the required postings were posted. He/She said he/she did know the postings were posted back in the MCU at one time, but did not know the postings were not posted.
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, facility staff failed to provide written information to the resident and/or the resident's...
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**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on interview and record review, facility staff failed to provide written information to the resident and/or the resident's representative of the bed hold policy at the time of transfer to the hospital for three (Resident #3, #42, and #53) out of three sampled residents. The facility's census was 69.
1. Review of the facility's Resident admission Agreement, revised 2022, showed at the time a resident is to leave the facility for a temporary stay in a hospital or for therapeutic leave, (or within 24 hours in case of an emergency transfer) the resident or legal representative will be given a written copy of the Bed Hold Policy and may elect to hold open the residents room and bed until his/her return. At this time, the resident or his/her legal representative will indicate in writing whether the resident desired or decline the bed hold.
2. Review of Resident #3's medical record showed the following:
-Cognitively impaired;
-discharged from the facility on 01/20/24 and readmitted to the facility on [DATE];
-Did not contain written documentation staff notified the resident or the resident's responsible party of the facility's bed-hold policy.
3. Review of Resident #42's medical record showed the following:
-Cognitively intact;
-discharged from the facility on 09/16/23 and readmitted to the facility on [DATE];
-Did not contain written documentation staff notified the resident or the resident's responsible party of the facility's bed-hold policy.
4. Review of Resident #53's medical record showed the following:
-Cognitively intact;
-discharged from the facility on 11/26/23 and readmitted to the facility on [DATE];
-Did not contain written documentation staff notified the resident or the resident's responsible party of the facility's bed-hold policy.
5. During an interview on 01/30/24 at 2:10 P.M., Business Office Manager (BOM) said the facility does not send bed hold policy with the resident or their representative. The BOM said there is a bed hold policy in the admission agreement, but that is all they do with the bed hold.
During an interview on 02/01/24 at 2:00 P.M., the Director of Nursing (DON) said residents are told at admission that their beds are held for 30 days. The DON said she was not aware that the bed hold needs to go with the resident at time of discharge.
During an interview on 02/01/24 at 3:35 P.M., the administrator said she was aware the bed hold policy needed to be sent out with the resident, but was not aware it was not being done or why. The administrator said it would either be the social services director (SSD) or the BOM responsible for that process.
During an interview on 02/08/24 at 9:30 A.M., the SSD said he/she goes over the bed hold policy at admission but does not send it with the resident at discharge. The SSD said if this was his/her responsibility, he/she was not aware.
Dec 2022
1 deficiency
CONCERN
(D)
📢 Someone Reported This
A family member, employee, or ombudsman was alarmed enough to file a formal complaint
Potential for Harm - no one hurt, but risky conditions existed
Deficiency F0760
(Tag F0760)
Could have caused harm · This affected 1 resident
Based on interview and record review, facility staff failed to ensure one resident (Resident #1) remained free of significant medication errors when staff documented they administered the resident's T...
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Based on interview and record review, facility staff failed to ensure one resident (Resident #1) remained free of significant medication errors when staff documented they administered the resident's Tramadol (an Opioid pain medication used to treat moderate to moderately severe pain) outside of the scheduled medication parameters. The facility census was 60.
1. Review of the facility's Administration of Medications policy, reviewed 8/25/22, showed staff are to ensure medications are administered safely and appropriately per physician order to address residents' diagnoses and signs and symptoms. Review showed significant medication error as one which causes the resident discomfort or jeopardizes his/her health and safety. Staff who are responsible for medication administration will adhere to the Rights of Medication Administration. Check the order for when it would be given and when was the last time it was given.
2. Review of Resident #1's admission Minimum Data Set (MDS), (a federally mandated assessment tool), dated 11/23/22, showed staff assessed the resident as follows:
-Cognitively intact;
-Constant pain that limits day to day activities with a pain level of seven out of ten, with ten as the worst pain;
-Opioid use seven days out of seven days during the look back period.
Review of the resident's Physician Order Sheets (POS), dated 11/1/22-11/30/22, showed a physician order for Tramadol HCL 50 milligram (mg) tablet, directed to take two tablets by mouth every six hours if needed for moderate pain.
Review of the resident's electronic medication administration record (EMAR), dated 11/23/22, showed staff documented they administered the resident his/her Tramadol 50 mg two tablets on 11/23/22 at 12:51 A.M., 5:23 A.M., 10:51 A.M., and again at 4:11 P.M.
Review of the resident's controlled drug record, showed staff documented Tramadol 50 mg two tablets as administered to the resident orally on 11/23/22 at 12:54 A.M., 5:24 A.M., 10:51 A.M., and again at 4:11 P.M.
During an interview on 12/13/22 at 9:13 A.M., the Director of Nursing (DON) said the resident's family member questioned the resident being overmedicated and went over his/her medications with Registered Nurse (RN) A and questioned how the resident got medications when he/she was not at the facility and was gone for an appointment from approximately. 8:30 A.M. to around 3:30 P.M. on 11/23/22. The DON said the resident could not have been there to receive the 10:51 A.M. dose, even with regulation saying one hour before and one hour after is within timeframes.
During an interview on 12/13/22 at 10:47 A.M., the transport coordinator said he/she left the facility around 8:30 A.M., with the resident for a doctors appointment and did not return until around 2:00 P.M. He/She said no medications were sent with him/her or the resident to be taken during his/her absence.
During an interview on 12/13/22 at 10:59 A.M., RN L said the resident's family member was concerned with the resident being overmedicated. The RN said when reviewing the EMAR and Controlled Drug Record, the family member said the resident was gone during a scheduled time and could not have received the dose. He/She said he/she then alerted the DON.
During an interview on 12/19/22 at 2:53 P.M., Licensed Practical Nurse (LPN) D said the resident had a doctors appointment and the medication technician asked for him/her to get him/her pain medication before leaving. He/She said Tramadol was given to the resident around 8:30 A.M., but he/she got busy and forgot to chart the medication was given until 10:51 A.M. He/She said it was standard protocol to give the resident's scheduled pain medications that early, even though he/she had a dose three hours prior, if he/she was going to be unavailable for the next scheduled dose at noon.
During an interview on 12/20/22 at 3:19 P.M., the Administrator said he/she believed LPN B had a significant medication error giving the resident his/her medication only three hours after the previous dose.
During an interview on 12/20/22 at 3:44 P.M., the physician said the additional Tramadol certainly might cause negative affects to the resident's health and well-being. He/She said he/she would not have agreed to give the medication three hours after the first dose.
MO00210365
Nov 2022
3 deficiencies
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, facility staff failed to provide an ongoing program of activities designed t...
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**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, interview, and record review, facility staff failed to provide an ongoing program of activities designed to meet the residents' interests for seven residents (Resident #9, #10, #13, #22, #30, #53, and #57) and failed to provide more than one structured activity Monday through Friday or an structured activities on the weekend for the residents. The facility census was 62.
1. Review of the facility's Activities Policy, dated 11/2/21 showed staff are instructed to:
-Schedule activities, both individual and groups, implementing and/or delegating the implementation of programs, monitoring the response to the programs to determine if the activities meet the assessed needs of the resident, and making revisions as necessary;
-Implement an ongoing resident centered activities program that incorporates the residents' interests, hobbies, and cultural preferences;
-provide individual programs based on the each residents'' assessed needs and the family will be notified for any special requests;
-The individual program will be provided according to a consistent schedule identifying specific days of the week and the time frame in which the program will occur;
-Provide group programming designed to ensure each resident the opportunity for active participation in a group designed to accommodate his or her social and/or cognitive abilities and to promote quality of life; Group programming may include:
-Creative programs to promote feelings of accomplishment, opportunities for self-expression and improved self-esteem and confidence which may include art classes, crafts, poetry, music appreciation, community groups (loss of memory) and sewing groups;
-Physical programs to facilitate physical movement, use of existing mobility and physical functioning. Examples include exercise, bowling, other active games, meditative practices, yoga, tai chi, Zumba, and walking programs;
-Spiritual programs to provide outlets for spiritual expression consistent with the residents' spiritual expression consistent with the resident religious preferences. Programming will reflect observance of religious holidays. Examples include Bible studies, the Rosary, church services, prayer groups and observance of other religious practices;
-Educational programs to enhance awareness of the environment, self and promote ongoing learning. Examples include history programs, language classes, guest speakers on current topics of interests, and leisure awareness, classes;
-Intellectual programs and emotional programs that are designed to enable residents to problem solve, make decisions and promote memory recall. Examples include word games, reminiscence, library or study groups; technology, social media, laughter groups and google earth;
-Community-based programs to provide opportunities for residents to interact with community members either within or out of the facility. Examples include community service work, involvement in community events, clubs, activities, resources and outings.
2. Review of Resident #9's Annual Minimum Data Set (MDS), a federally mandated assessment tool
used to plan care, dated 9/13/22, showed staff assessed the resident as:
-Severely Cognitively impaired;
-Very important to have books, newspapers, and magazines to read;
-Very important to listen to music;
-Very important to be around animals;
-Very important to keep up with the news;
-Very Important to do things with groups of people;
-Very important to participate in religious services;
-Totally dependent on staff assistance for all activities of daily living;
-Locomotion inside and outside of the unit did not occur;
-Diagnoses of Multiple Sclerosis (disabling disease of the brain and spinal cord causing muscle weakness, stiffness, paralysis and involuntary movements), lack of coordination, stiffness in right and left hand, contracture of right hand (causes one or more fingers to bend toward the palm of hand, affected fingers cant's straighten completely), muscle weakness, and need of assistance with personal care.
Review of the resident's care plan, reviewed 11/9/22, showed the resident is dependent on
staff for meeting emotional, intellectual, physical, and social needs, and staff were directed to
assist the resident in activities of his/her choice 3-5 times per week:
-Invite to scheduled activities;
-Assistance/escort to activity functions;
-Needs assistance with activities of daily living as required during the activity;
-Prefers activities Bingo, [NAME] bingo, watching hallmark movies, visiting with family and talking to
staff.
Review of the resident's activity participation records showed the resident participated in a 1:1
activity for 20-30 minutes:
-0 days of 10 days in November 2022;
-4 days of 31 days in October 2022;
-4 days of 30 days in September 2022.
Observation on 11/8/22 at 8:58 A.M., showed the resident in his/her bed with their eyes closed
during the unit activity.
Observation on 11/9/22 at 1:33 P.M. to 2:05 P.M., showed the resident in his/her bed with their eyes
closed during the bingo activity.
Observation on 11/10/22 at 8:26 A.M., showed the resident in his/her bed, during the unit activity.
Observation on 11/10/22 at 8:41 A.M., showed the in his/her bed with their eyes closed during
the unit activity.
3. Review of Resident #10's Quarterly MDS, dated [DATE], showed staff assessed the resident as:
-Severely cognitively impaired;
-Required extensive assistance of two staff for bed mobility, transfers, and bathing;
-Used a wheelchair;
-Diagnoses of stroke (occurs as a result of disrupted blood flow to the brain due to problems with the blood vessels that supply it), lack of coordination, muscle weakness, contracture of left elbow, right and left knee, right and left shoulder, right and left hip (a condition of shortening and hardening of muscles, tendons, or other tissue, often leading to deformity and rigidity of joints), glaucoma (eye diseases that can cause vision loss and blindness by damaging a nerve in the back of your eye called the optic nerve), and blind in one eye.
Review of the resident's care plan, reviewed 8/17/22, showed the resident is independent for
meeting emotional, intellectual, social, activities:
-Goal to maintain involvement in cognitive stimulation, social activities as desired;
-To have cards and letters read to him/her.
Review of the resident's activity participation records showed the resident participated in a 1:1
activity for 15-30 minutes:
-0 of 10 days in November 2022;
-4 of 31 days in October 2022;
-4 of 30 days in September 2022.
Observation on 11/8/22 at 8:53 A.M., showed the resident in his/her recliner with his/her eyes
closed during the unit fun activity.
Observation on 11/10/22 at 10:44 A.M., showed the resident sat in his/her recliner awake during
the Buzz activity.
Observation on 11/10/22 at 11:24 A.M., showed the activity director entered the resident's room
and stayed one minute before he/she left the room.
4. Review of Resident #13's Quarterly MDS, dated [DATE], showed staff assessed the resident
as:
-Severely Cognitively impaired;
-Prefers listening to music;
-Locomotion on and off the unit required assistance of one staff.
Review of the resident's care plan, reviewed 10/24/22, showed the resident was dependent on
staff for meeting emotional, intellectual, physical, and social needs, and staff were directed to
assist the resident in activities of his/her choice 1-3 times per week:
-Holiday/Special Event Programs;
-Music activities;
-Self care (getting hair brushed, applying lotion to
hands);
-Being talked to.
Observation on 11/8/22 at 10:43 A.M., showed the resident in his/her bed.
Observation on 11/8/22 at 1:00 P.M., showed the resident sat in his/her wheelchair in the dining
room.
Observation on 11/10/22 at 9:59 A.M., showed the resident in his/her bed.
Observation on 11/10/22 at 11:20 A.M., showed the resident in sat in his/her wheelchair in the dining room and was not engaged in an activity.
Review of the resident's activity participation records showed the resident participated in a 1:1
activity for 20-30 minutes:
-0 of 10 days in November 2022;
-4 of 31 days in October 2022;
-4 of 30 days in September 2022.
5. Review of Resident #22's Quarterly MDS, dated [DATE], showed staff assessed the resident as:
-Severely cognitively impaired;
-Prefers listening to music;
-Prefers being around animals such as pets;
-Prefers doing things with groups of people;
-Locomotion required assist of one staff.
Review of the resident's care plan, reviewed 9/7/22, showed the resident was dependent on staff for meeting emotional, intellectual, physical, and social needs. No goals were listed for staff to address these needs. The care plan stated the resident's preferred activities were:
-Television;
-Bingo;
-Family visits;
-Sitting at the nurses' desk.
Review of the resident's activity participation records showed the resident participated in a 1:1 activity for 20-30 minutes:
-0 of 10 days in November 2022;
-4 of 31 days in October 2022;
-4 of 30 days in September 2022.
Observation on 11/7/22 at 11:55 A.M., showed the resident in his/her bed.
Observation on 11/8/22 at 10:44 A.M., showed the resident in his/her bed.
Observation on 11/8/22 at 1:08 P.M., showed the resident in his/her wheelchair in the dining room.
Observation on 11/10/22 at 9:59 A.M., showed the resident in his her bed.
6. Review of Resident 30's Quarterly MDS, dated [DATE], showed staff assessed the resident as:
-Severely cognitively impaired;
-Very important to do his/her favorite activities;
-Very important to listen to music he/she likes;
-Very important to be around animals such as pets;
-Very important to keep up with the news;
-Very important to do things with groups of people;
-Very important to do his/her favorite activities;
-Very important to go outside;
-Very important to participate in religious services;
-Locomotion required assist of one staff.
Review of the resident's care plan, undated, showed the care plan showed the resident's preferred activities were:
-Visiting with friends, staff and other residents;
-Music Programs;
-Outings;
-Holiday/Special Events;
-Writing Letters;
-Watching television.
Review of the resident's activity participation records showed the resident participated in a 1:1
activity for 15-30 minutes:
-0 of 10 days in November 2022;
-4 of 31 days in October 2022;
-4 of 30 days in September 2022.
Observation on 11/7/22 at 11:00 P.M., showed the resident sat in his/her room and was not engaged in an activity.
Observation on 11/8/22 at 11:38 A.M., showed the resident sat in his/her room and was not engaged in an activity.
Observation on 11/8/22 at 1:05 P.M., showed the resident sat in his/her room and was not engaged
in an activity.
Observation on 11/10/22 at 10:00 A.M., showed the resident sat in his/her room and was not engaged in an activity.
Observation on 11/10/22 at 3:30 P.M., showed the resident sat in his/her room and was not engaged in an activity.
During an interview on 11/08/22 at 11:38 A.M., the resident said he/she did not know activities were
offered in the facility, and said he/she had never been invited to an activity.
During an interview on 11/10/22 10:01 A.M., the resident said he/she has nothing to do, except eat
and sleep.
7. Review of Resident #53's Quarterly MDS, dated [DATE], showed staff assessed the resident as:
-Severely cognitively impaired;
-Prefers to listen to music;
-Prefers to be around animals such as pets;
-Prefers to do his/her favorite activities;
-Locomotion required assist of one staff.
Review of the resident's care plan, reviewed 8/31/22, showed the resident was independent of staff for meeting emotional, intellectual, physical, and social needs, and staff were directed to assist the resident in cognitive stimulation, and social activities with activities compatible with physical and mental capabilities, compatible with the resident's known interests and preferences, age appropriate, and adapted as needed:
-Invitations to scheduled activities;
-Church activities;
-Bingo;
-Watching television including news and baseball
games;
-Visiting with family and friends.
Observation on 11/7/22 at 11:45 A.M., showed the resident sat in his/her wheelchair in his/her room.
Observation on 11/7/22 at 12:48 P.M., showed the resident rocked in his/her wheelchair in the dining room.
Observation on 11/8/22 at 10:04 A.M., showed the resident in his/her bed.
Observation on 11/8/22 at 1:15 P.M., showed the resident rocked in his/her wheelchair in the dining
room.
Observation on 11/10/22 at 9:39 A.M., showed the resident in his/her bed.
Observation on 11/10/22 at 11:09 A.M., showed the resident sat in his/her wheelchair in his/her room.
Review of the resident's activity participation records showed the resident participated in a 1:1 activity for 20-30 minutes:
-0 of 10 days in November 2022;
-4 of 31 days in October 2022;
-4 of 30 days in September 2022.
8. Review of Resident #57's Annual MDS, dated [DATE], showed staff assessed the resident as:
-Moderately cognitively impaired;
-Diagnoses of Dementia (a chronic or persistent disorder of the mental processes caused by brain disease or injury and marked by memory disorders, personality changes, and impaired reasoning), abnormalities of gait and mobility, muscle weakness.
Review of the resident's care plan, reviewed 09/07/22, showed the resident is independent for meeting emotional, intellectual, physical, and social needs.
-Goal to maintain involvement in cognitive stimulation, social activities as desired through review date.
-Interventions are to encourage ongoing family involvement. Invite the resident's family to attend
special events, activities, and meals. Invite the resident to scheduled activities. Provide activities that are compatible with physical and mental capabilities, with known interests and
preferences, with individual needs and abilities, and age appropriate.
-Preferred activities are: enjoys family/friend visits, watching TV, news, getting her hair done weekly, movies, and music.
Review of the resident's activity participation records showed the resident participated in a 1:1 activity for 20-30 minutes:
-0 of 10 days in November 2022;
-4 of 31 days in October 2022;
-4 of 30 days in September 2022.
Observation on 11/8/22 at 8:56 A.M., showed the resident watched television on his/her bed, during
the unit activity.
Observation on 11/10/22 at 8:36 A.M., showed the resident in his/her bed with their eyes closed during the unit activity.
Observation on 11/10/22 at 10:24 A.M. to 11:22 A.M., showed the resident in his/her bed, during
the daily Buzz activity.
Observation on 11/10/22 at 11:22 A.M., showed the activity director entered the resident's room and stayed 26 seconds before he/she left.
9. Review of the facility's Activity Calendar, dated November 2022 showed the daily activities consisted of:
-Saturday and Sunday Puzzle Fun at 10:00 A.M., Pick a Flick at 2:00 P.M. and U Pick at 3:00 P.M
-Monday and Wednesday Daily Buzz at 10:30 A.M., Bingo at 1:30 P.M. and mail at 3:00 P.M
-Tuesday and Thursday Unit Fun at 8:00 A.M., Daily Buzz at 10:30 A.M., Crafts on Tuesday and Bingo on Thursday at 1:30 P.M. and mail at 3:00 P. M
-Friday Daily Buzz at 10:30 A.M., Crafts at 1:30 P.M. and mail at 3:00 P.M
Observation on 11/10/22 from 11:00 A.M.-11:03 A.M., in the 100 hall showed the Daily Buzz Activity consisted of the Activities Director handing out papers with the activity period lasting:
-9 seconds in room [ROOM NUMBER];
-7 seconds in room [ROOM NUMBER];
-10 seconds in room [ROOM NUMBER];
-10 seconds in room [ROOM NUMBER];
-16 seconds in room [ROOM NUMBER];
-8 seconds in room [ROOM NUMBER].
Observation on 11/10/22 from 11:05-11:09 A.M., in the 300 hall showed the Daily Buzz Activity consisted of the Activities Director handing out papers with the activity period lasting:
-3 minutes in the dining room;
-5 seconds in room [ROOM NUMBER];
-6 seconds in room [ROOM NUMBER];
-7 seconds in room [ROOM NUMBER].
Observation on 11/10/22 from 11:22-11:25 A.M., in the 200 hall showed the Activities Director handed out the Daily Buzz flyer with the activity period lasting:
-40 seconds in room [ROOM NUMBER];
-6 seconds in room [ROOM NUMBER];
-26 seconds in room [ROOM NUMBER];
-20 seconds in room [ROOM NUMBER];
-11 seconds in room [ROOM NUMBER];
-4 seconds in room [ROOM NUMBER];
-1 minute in room [ROOM NUMBER];
-2 seconds in room [ROOM NUMBER].
10. During an interview on 11/10/22 at 11:48 A.M., Certified Nurses Aid (CNA) I said it is the responsibility of the activities director to inform residents of the daily activities. The activity director updates the activity board, located near the nurse's station, or verbally notifies them. He/She said CNAs only answer the residents' questions regarding what the daily activity is.
During an interview on 11/10/22 at 3:06 P.M., the Activities Director said the mail activity consisted of the activities director handing out residents' mail. In addition, the Activities Director said no formal activities occurred on the weekends, and the activities listed on Saturday and Sunday consisted of puzzles (Puzzle Fun) and movies (Pick a Flick) which were made available and residents were able to utilize these supplies. He/She said the U Pick activity consisted of the residents getting together and
usually just talking. He/She said the men in the facility did not care to do any activity.
During an interview on 11/10/22 at 3:14 P.M., the activities director said that that for bedbound
residents, he/she reads mail to the resident, brushes their hair, or puts lotion on them. He/She
spends varying times with them, but averages 30 minutes a week. He/She said on the days he/she
is not in the facility working, such as weekends, he/she leaves a box at the nurses station with activities for the residents. There are card games, movies, puzzles, and snacks in the box. He/She said the nursing staff and CNAs are usually available to help residents with the activities when he/she is unavailable. Activities for residents with dementia are play dough, coloring pages, he/she reads to them, puts on movies, talks to them, and sometimes they watch squirrels. He/She said he/she did more one-on-one work with these residents, usually concentrating on who needs more. He/She said he/she does not have a specific schedule for the residents with dementia.
During an interview on 11/10/22 at 4:10 P.M., the Administrator said on the weekends the Activity
Director should leave activities for staff to do with residents. The administrator said she did not think mail is considered an activity but if a resident does not get out of their room it could be appropriate. The administrator said she would expect activities on the dementia unit to be cognitively appropriate for those residents, to be tailored to those residents on the unit.
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, facility staff failed to complete the siderail/bedrail risk of entrapment ass...
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**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, interview and record review, facility staff failed to complete the siderail/bedrail risk of entrapment assessment, complete initial and/or annual entrapment assessments, and/or obtain consent for the use of side rails for three (Residents #22, #29 and #57). The facility census was 62.
1. Review of the Facility's Bed Rails Policy, revised 9/12/22, showed staff are directed as follows:
-To prevent entrapment and other safety hazards associated with bed rail use.
Procedure:
-Residents will be assessed upon admission, readmission, or upon initiation utilizing the Evaluation for Use of Bed Rails Assessment (Admission/Readmission/Initial).
-If bed rails are determined to be appropriate for use with a resident, a reassessment of bed rails use will be assessed at a minimum quarterly and potentially with a change of condition utilizing the Evaluation for Use of Bed Rails Form (Quarterly);
-If a bed rail will be utilized, the risks and benefits of bed rails(s) usage will be reviewed with the resident and/or resident representative and consent will be obtained prior to installation of the bed rails or as soon a practically possible.
2. Review of Resident #22's quarterly Minimum Data Set (MDS), a federally mandated assessment tool, dated 9/2/22, showed staff assessed the resident as follows:
-Severely cognitively impaired;
-Required extensive assistance of two staff for bed mobility, transfers, and toileting;
-Used a wheelchair with assistance of one staff for mobility;
-Diagnosed with arthritis, aphasia (the loss of ability to understand or express speech), and hemiplegia (severe or complete loss of strength leading to paralysis on one side of the body).
Review of the resident's nursing evaluation for use of bed rails, dated 5/27/22 showed the resident was not being considered for bed rails.
Review of the resident's medical record showed the record did not contain an entrapment assessment.
Observation on 11/07/22 at 11:55 A.M., showed the resident's bed had quarter length bed rails on both sides of the bed.
Observation on 11/07/22 at 2:45 P.M., showed the resident in bed with the left bed rail raised.
Observation on 11/10/22 at 9:59 A.M., showed the resident in bed with the left bed rail raised.
During an interview on 11/10/22 at 3:37 P.M., Certified Nursing Aide (CNA) B said the resident assists staff by pulling himself/herself over during cares.
3. Review of Resident #29's admission MDS, dated [DATE], showed the staff assessed the resident as follows:
-Cognitively impaired;
-Required extensive, two person assistance with bed mobility, transfers;
-Required the use of a wheelchair;
-Diagnosis of Stroke (damage to the brain from interruption of its blood supply) and aphasia.
Review of the resident's medical record showed the record did not contain an entrapment assessment or a signed consent for the use of the side rails.
Observation on 11/7/22 at 10:45 A.M., showed the resident in bed with half-length bilateral bed rails in the upright position on the bed.
Observation on 11/8/22 at 9:15 A.M., showed the resident in bed with half-length bilateral bed rails in the upright position on the left side of the bed.
Observation on 11/9/22 at 2:00 A.M., showed the resident in bed with his/her eyes closed with half-length bilateral bed rails in the upright position on the bed.
Observation on 11/9/22 at 4:00 P.M., showed the resident in bed with half-length bilateral bed rails in the upright position on the left side of the bed.
Observation on 11/10/22 at 9:30 A.M., showed the resident in bed with half-length bilateral bed rails in the upright position on the left side of the bed.
4. Review of Resident #57's admission MDS, dated [DATE], showed the staff assessed the resident as follows:
-Moderate cognitive impairment;
-Required extensive, one person assistance with bed mobility and transfers;
-Required the use of a walker and wheelchair;
-Did not use bed rails;
-Diagnosis of Dementia (impaired ability to remember, think, or make decisions that interferes with doing everyday activities), and muscle weakness.
Review of the resident's medical record showed the record did not contain an entrapment assessment or a signed consent for the use of the side rails.
Observation on 11/08/22 at 8:56 A.M., showed the resident in bed with half-length bilateral bed rails in the upright position on the bed.
Observation on 11/09/22 at 2:15 A.M., showed the resident in bed with half-length bilateral bed rails in the upright position on the bed.
Observation on 11/10/22 at 8:36 A.M., showed the resident in bed with half-length bilateral bed rails in the upright position on the bed.
Observation on 11/10/22 at 10:04 A.M. to 11:16 A.M., showed the resident awake in bed with half-length bilateral bed rails in the upright position on the resident's bed.
During an interview on 11/10.22 at 3:37 P.M., Licensed Practical Nurse (LPN) D said the resident's family asked for the bed rails to make him/her more comfortable.
5. During an interview on 11/10/22 at 12:31 P.M., the maintenance director said bed rail measurements are triggered in his/her assigned tasks. He/She said all beds in the facility are measured without the resident in their beds. He/She did not know if the forms filled out during this task used the recommended Evaluation for Use of Bed Rails Assessment measurements.
During an interview on 11/10/2022 at 3:11 P.M., Certified Nurse Assistant (CNA) K said they use the bed rails if there is any fall safety concerns. He/She said it keeps residents from falling out of bed. He/She said sometimes the residents use the bed rails to hold on to for stability. He/She said the facility does not have any long bed rails and only has short ones. He/She said the bed rails would only be a concern if there was a big gap in between the rail and the mattress where someone could get stuck.
During an interview on 11/10/22 at 3:30 P.M., Registered Nurse (RN) L said he/she believes maintenance is responsible for the side rail assessments. He/She thinks the Assistant Director of Nursing (ADON) helps determine if the resident needs them and she and Maintenance Director do the measurements for the side rails. The floor nurses do assessments monthly to determine if the resident still needs or uses it.
During an interview on 11/10/22 at 3:36 P.M., the Director of Nursing (DON) said on admission the use of bed rails is evaluated. If a resident or family member wants bed rails, staff provides education on entrapment and consents are signed. Bed rails are assessed quarterly. At that time staff does an entrapment assessment, and a screening and assessment for the use of bed rails. The facility's Maintenance Director tracks his portion on a monthly basis, but she was unsure of what that entailed.
During an interview on 11/10/22 at 4:10 P.M., the Administrator said maintenance is responsible for taking care of the side/bed rails throughout the building. Maintenance does what is triggered by TELS (technology designed to specifically for senior living to create safer environments and increase Life Safety compliance), however she was not aware of an entrapment assessment or anything thing else that needs to be completed.
CONCERN
(E)
Potential for Harm - no one hurt, but risky conditions existed
Infection Control
(Tag F0880)
Could have caused harm · This affected multiple residents
**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, interview, and record review the facility staff failed to perform appropriate hand hygiene in a manner to ...
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**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, interview, and record review the facility staff failed to perform appropriate hand hygiene in a manner to prevent or reduce the spread of bacteria and other infection causing organisms during blood glucose checks for three residents (Resident #3, #52 and #362), during perineal care for three residents (Resident #9, #13 and #46) and failed to provide catheter care in a manner to prevent the spread of infection for one resident (Resident #46). The facility census was 62.
1. Review of the facility's Hand Hygiene Policy, revised July 15, 2022, showed staff are instructed as follows:
Unless hands are visibly soiled, an alcohol-based hand rubs (ABHR) is preferred over soap and water in most clinical situations due to evidence of better compliance compared to soap and water.
The facility should provide education to associates on hand hygiene routinely, and this education should include but is not limited to;
-Before and after all resident contact;
-After contact with blood, body fluids, or visibly contaminated surfaces;
-After contact with objects in the resident's room;
-Before applying gloves;
-After removal of gloves;
-Before performing a procedure such as an aseptic task.
2. Observation on 11/9/22 at 11:15 A.M., showed Licensed Nurse Practitioner (LPN) D entered Resident #52's room, applied gloves, obtained a blood sugar sample, removed his/her gloves, and did not sanitize or wash his/her hands before he/she exited the room. The LPN sanitized the glucometer then walked to Resident #3's room and did not sanitize or wash his/her hands when he/she entered the room. He/She applied gloves, obtained a blood sugar sample, removed his/her gloves and did not sanitize or wash his/her hands before he/she exited the resident's room. The LPN went to the medication cart sanitized/cleaned the glucometer and prepared the supplies for next glucose check. He/She walked into Resident #362's room, applied gloves, and obtained a blood sugar sample and removed his/her gloves, administered the resident's insulin, and exited the room. LPN D did not sanitize or wash his/her hands when he/she entered or exited the resident's room.
During an interview on 11/10/22 at 2:30 P.M., LPN D said they are expected to wash or sanitize hands before going into a room, wear gloves, and after the blood sugar check they would wash or sanitize hands before leaving the room. Staff is expected to wash hands when they are visibly soiled.
During an interview on 11/10/22 at 3:30 P.M., the Director of Nursing (DON) said she would expect staff to wash their hands or use appropriate hand hygiene before and after blood sugar checks, and wear proper gloves.
During an interview on 11/10/22 at 4:10 P.M., the Administrator said she would expect staff to either wash hands or sanitize hands, and wear gloves before checking blood sugars. Afterwards they would need to sanitize or wash again.
3. Review of the Facility's Perineal Care of the Female and Male Patient, last reviewed on 8/22/22, showed the following:
-Perform hand hygiene;
-Put on gloves and, as needed, other personal protective equipment to comply with standard precautions;
-After completing the perineum, perform hand hygiene, apply new gloves;
-Reposition the patient comfortably.
-Remove and discard your gloves and, if worn, other personal protective equipment;
-Perform hand hygiene.
4. Review of Resident #9's Annual Minimum Data Set (MDS), a federally mandated assessment tool completed by facility staff, dated 9/13/22, showed staff assessed the resident as:
-Totally dependent on two or more persons for physical assistance for bathing, toileting and personal hygiene;
-Always incontinent of bowel and bladder.
Observation on 11/9/22 at 2:05 P.M., showed Certified Nurse Aide (CNA) H and CNA G entered the resident's room to provide incontinence care. CNA H and CNA G performed hand hygiene and applied gloves. CNA H cleansed the resident's perineal area and did not perform hand hygiene and did not change his/her gloves before he/she touched the resident and his/her clean incontinence pad. CNA G assisted with incontinence care and did not perform hand hygiene in between glove changes before he/she assisted the resident with the clean incontinence pad and clean bed coverings.
5. Review of Resident #13's Quarterly MDS, dated [DATE], showed staff assessed the resident as:
-Severely Cognitively impaired;
-Required extensive assistance of two staff for bathing, toileting and personal hygiene;
-Always incontinent of bowel and bladder.
Observation on 11/8/22 at 11:08 A.M., showed CNA A entered the resident room to provide incontinent care. CNA A performed hand hygiene and applied gloves. CNA A removed the resident's soiled brief, placed a clean brief on the bed and then wiped away the resident's bowel movement from the perineal area. CNA A did not change his/her gloves or perform hand hygiene before he/she placed the clean brief under the resident, applied cream to the resident's buttock area, applied a clean brief and clean slacks.
During an interview on 11/10/22 at 3:32 P.M., Registered Nurse (RN) C said when staff perform perineal care, staff should use gloves, wash hands before and after the perineal care, when moving care from a dirty area to a clean area, and if a resident's bowel movement gets on the staff's hands.
During an interview on 11/10/22 at 3:44 P.M., CNA B said hand hygiene should be performed when staff enters and leaves the resident room, and if staff gets something on their hands.
During an interview on 11/10/2022 at 3:05 P.M., CNA K said he/she would wash hands first then put on gloves before he/she touched the resident. He/She said he/she would take gloves off and wash hands after completing care.
6. Review of the Facility's Indwelling Urinary Catheter (Foley) Management, Policy, reviewed 8/22/22, showed staff is instructed to maintain unobstructed urine flow:
-Keep the collecting bag below the level of the bladder at all times. Do not rest the bag on the floor;
-Perform routine hygiene (e.g., cleaning fecal material away from, rather than towards the point where urine exits the body in both sexes) as appropriate.
7. Review of Resident #46's admission MDS, dated [DATE], showed staff assessed the resident as follows:
-Required extensive, two person assistance with toileting and performing personal hygiene;
-Diagnoses of urinary tract infection (infection in any part of the urinary system, the kidneys, bladder, or urethra.).
-Utilized a suprapubic catheter (surgically created connection between the urinary bladder and the skin used to drain urine from the bladder in individuals with obstruction of normal urinary flow) for urinary drainage.
Observation on 11/08/22 at 9:43 A.M., showed CNA E and CNA F entered resident's room to perform incontinence care. CNA E and CNA F performed hand hygiene and applied gloves. CNA F did not keep the resident's catheter bag below the level of the bladder when he/she removed the resident's pants. CNA F did not change his/her gloves after he/she assisted with perineal care or before he/she used a new wipe to clean around the suprapubic catheter insertion site. CNA E did not change his/her gloves or perform hand hygiene after he/she assisted with perineal care or before he/she touched the resident's arm and assisted the resident to his/her right side. After completing perineal care, CNA E and CNA F changed gloves, but did not perform hand hygiene in between glove changes CNA E picked up the resident's catheter bag, above the level of the bladder, and fed it through the right side of the resident's brief, and placed the urine filled catheter bag on the resident's bed. CNA F then picked up the catheter bag, above the level of the resident's bladder, and placed the catheter bag through the resident's right pant leg and placed the bag back onto the resident's bed. CNA E held the resident's catheter bag above the level of the resident's bladder, while CNA F applied the resident's leg brace. CNA E did not change his/her gloves before he/she applied the resident's arm brace, obtained the resident's toothbrush from the sink and applied toothpaste. CNA F did not change his/her gloves before he/she made the resident's bed, replaced the call light, and organized the bed side table. CNA E gathered and tied the trash bag that contained the dirty items used for perineal care and then used the same dirty gloves to rinse the resident's toothbrush. He/She did not perform hand hygiene after he/she removed his/her gloves or before he/she combed the resident's hair.
During an interview on 11/10/22 at 11:48 A.M., CNA I said it is important to perform perineal and catheter care the correct way. Staff should use disposable wipes or soap and water to clean incontinent residents. He/She said hand hygiene and gloves are important to use when performing all types of resident care, but especially during dirty care.
During an interview on 11/10/2022 at 3:09 P.M., CNA K said he/she would wash hands and put on gloves before providing care. He/she said when providing catheter care he/she would start near the body and wipe away. He/she said he/she would get the nurse if there was anything wrong with the catheter. He/she said he/she would wash hands after taking off their gloves.
During an interview on 11/10/22 at 3:32 P.M., RN C said catheter care should move from the cleaner area near the body to the dirtier area away from the body.
During an interview on 11/10/2022 at 4:04 P.M., CNA said the catheter bag should stay below the resident's waist and never placed on the floor. He/She said the bag should be hung on the bottom of the bed. He/she said during a transfer the catheter bag should be held so it doesn't fall on the floor.
During an interview on 11/10/22 at 3:36 P.M., the Director of Nursing (DON) said staff is required to attend in-services on hand hygiene. He/She keeps a copy of their competencies in an education book and a copy goes into each staff members employee file. Staff are expected to wash their hands when they arrive to work, in between care, when they have become soiled, and before they leave for the day. Staff are expected to wear gloves when providing care to residents and dealing with potentially hazardous materials. Additionally, he/she said when performing perineal care, staff should gather supplies, wash their hands, and apply gloves before starting.
During an interview on 11/10/22 at 4:10 P.M., the Administrator said staff are expected to sanitize or wash hands when they enter the room to provide care to a resident. When providing care they are to change gloves and wash/sanitize hands before moving onto a clean task. Staff should change gloves and wash/sanitize between clean and dirty tasks. The catheter bag should be placed below the bladder line, to keep the tube where it will drain down and not back flow.
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
- "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
- • 31 deficiencies on record, including 1 serious (caused harm) violation. Ask about corrective actions taken.
- • $33,970 in fines. Higher than 94% of Missouri facilities, suggesting repeated compliance issues.
- • Grade F (25/100). Below average facility with significant concerns.
- • 56% turnover. Above average. Higher turnover means staff may not know residents' routines.
Bottom line: Trust Score of 25/100 indicates significant concerns. Thoroughly evaluate alternatives.
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About This Facility
What is Life Of Waynesville's CMS Rating?
CMS assigns LIFE CARE CENTER OF WAYNESVILLE 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 Life Of Waynesville Staffed?
CMS rates LIFE CARE CENTER OF WAYNESVILLE's staffing level at 1 out of 5 stars, which is much below average compared to other nursing homes. Staff turnover is 56%, which is 10 percentage points above the Missouri average of 46%. High turnover can affect care consistency as new staff learn residents' individual needs. RN turnover specifically is 89%, which is notably high. RNs provide skilled clinical oversight, so turnover in this role can affect medical care quality.
What Have Inspectors Found at Life Of Waynesville?
State health inspectors documented 31 deficiencies at LIFE CARE CENTER OF WAYNESVILLE during 2022 to 2025. These included: 1 that caused actual resident harm, 24 with potential for harm, and 6 minor or isolated issues. Deficiencies causing actual harm indicate documented cases where residents experienced negative health consequences.
Who Owns and Operates Life Of Waynesville?
LIFE CARE CENTER OF WAYNESVILLE 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 LIFE CARE CENTERS OF AMERICA, a chain that manages multiple nursing homes. With 120 certified beds and approximately 86 residents (about 72% occupancy), it is a mid-sized facility located in WAYNESVILLE, Missouri.
How Does Life Of Waynesville Compare to Other Missouri Nursing Homes?
Compared to the 100 nursing homes in Missouri, LIFE CARE CENTER OF WAYNESVILLE's overall rating (1 stars) is below the state average of 2.5, staff turnover (56%) is significantly higher than the state average of 46%, and health inspection rating (2 stars) is below the national benchmark.
What Should Families Ask When Visiting Life Of Waynesville?
Based on this facility's data, families visiting should ask: "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?" "How do you handle medical emergencies, and what is your hospital transfer rate?" These questions are particularly relevant given the facility's high staff turnover rate and the below-average staffing rating.
Is Life Of Waynesville Safe?
Based on CMS inspection data, LIFE CARE CENTER OF WAYNESVILLE has a clean safety record: no substantiated abuse findings (meaning no confirmed cases of resident harm), no Immediate Jeopardy citations (the most serious violation level indicating risk of serious injury or death), and is not on the Special Focus Facility watch list (a federal program monitoring the lowest-performing 1% of nursing homes). The facility has a 1-star overall rating and ranks #100 of 100 nursing homes in Missouri. While no facility is perfect, families should still ask about staff-to-resident ratios and recent inspection results during their visit.
Do Nurses at Life Of Waynesville Stick Around?
Staff turnover at LIFE CARE CENTER OF WAYNESVILLE is high. At 56%, the facility is 10 percentage points above the Missouri average of 46%. Registered Nurse turnover is particularly concerning at 89%. RNs handle complex medical decisions and coordinate care — frequent RN changes can directly impact care quality. 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 Life Of Waynesville Ever Fined?
LIFE CARE CENTER OF WAYNESVILLE has been fined $33,970 across 1 penalty action. The Missouri average is $33,419. While any fine indicates a compliance issue, fines under $50,000 are relatively common and typically reflect isolated problems that were subsequently corrected. Families should ask what specific issues led to these fines and confirm they've been resolved.
Is Life Of Waynesville on Any Federal Watch List?
LIFE CARE CENTER OF WAYNESVILLE is not on any federal watch list. The most significant is the Special Focus Facility (SFF) program, which identifies the bottom 1% of nursing homes nationally based on persistent, serious quality problems. Not being on this list means the facility has avoided the pattern of deficiencies that triggers enhanced federal oversight. This is a positive indicator, though families should still review the facility's inspection history directly.