EL JEN SKILLED CARE
For profit - Limited Liability company
144 Beds
EMPRES OPERATED BY EVERGREEN
Data: November 2025
Trust Grade
25/100
#41 of 65 in NV
Photo by Eric Dixon
Photo by mindy cannizzo
Photo by mindy cannizzo
1 / 5 photos
Last Inspection: August 2025
Inspected within the last 6 months. Data reflects current conditions.
Overview
El Jen Skilled Care has received a Trust Grade of F, indicating significant concerns about the quality of care provided at this facility. They rank #41 out of 65 nursing homes in Nevada, placing them in the bottom half, and #31 out of 42 in Clark County, meaning there are only a few options that rank lower locally. Unfortunately, the facility is worsening, with issues increasing from 5 in 2024 to 7 in 2025. While staffing is a strength, receiving a 4 out of 5-star rating and a turnover rate of 44%, which is below the state average, there are serious deficiencies to note. For example, there were critical failures in emergency response when a resident was choking, as staff did not follow proper emergency procedures or activate medical services. Additionally, expired medications were found in multiple medication rooms, which raises concerns about overall safety and care standards.
- Trust Score
- F
- In Nevada
- #41/65
- Safety Record
- High Risk
- Inspections
- Getting Worse
- Staff Stability ○ Average
- 44% turnover. Near Nevada's 48% average. Typical for the industry.
- Penalties ✓ Good
- No fines on record. Clean compliance history, better than most Nevada facilities.
- Skilled Nurses ○ Average
- Each resident gets 38 minutes of Registered Nurse (RN) attention daily — about average for Nevada. RNs are the most trained staff who monitor for health changes.
- Violations ⚠ Watch
- 58 deficiencies on record. Higher than average. Multiple issues found across inspections.
25/100
Bottom 37%
Review needed
5 → 7 violations
★★☆☆☆
2.0
Overall Rating
★★★★☆
4.0
Staff Levels
★★☆☆☆
2.0
Care Quality
★★☆☆☆
2.0
Inspection Score
↔
Stable
2024: 5 issues
2025: 7 issues
The Good
-
4-Star Staffing Rating · Above-average nurse staffing levels
-
Full Sprinkler Coverage · Fire safety systems throughout facility
-
No fines on record
-
Staff turnover below average (44%)
4 points below Nevada average of 48%
Facility shows strength in staffing levels, fire safety.
The Bad
2-Star Overall Rating
Below Nevada average (3.0)
Below average - review inspection findings carefully
Staff Turnover: 44%
Near Nevada avg (46%)
Typical for the industry
Chain: EMPRES OPERATED BY EVERGREEN
Part of a multi-facility chain
Ask about local staffing decisions and management
The Ugly 58 deficiencies on record
2 actual harm
Aug 2025
6 deficiencies
CONCERN
(D)
Potential for Harm - no one hurt, but risky conditions existed
Resident Rights
(Tag F0550)
Could have caused harm · This affected 1 resident
**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on interview, record review and document review, the facility failed to ensure staff requested permission from a resident ...
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**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on interview, record review and document review, the facility failed to ensure staff requested permission from a resident prior to removing the battery of the motorized wheelchair for 1 of 37 sampled residents (Resident (R) 31). The deficient practice had the potential for inhibiting a resident from utilizing a motorized wheelchair for independent movement in the facility. Findings include:Resident 31 (R31) was admitted on [DATE], with diagnoses including multiple sclerosis, generalized anxiety disorder, and pain.The Progress Notes dated 07/15/2025, documented R31 was notified the resident would be transferring to a manual wheelchair from the resident's electric (motorized) wheelchair due to running over another resident's foot on accident.On 07/29/2025 at 10:10 AM, R31 was sitting in a motorized wheelchair by the nurse's station. R31 revealed previously using a manual wheelchair for seven to ten days. R31 indicated the facility returned the resident's motorized wheelchair after R31 talked to the Compliance Officer yesterday (07/28/2025). R31 indicated somebody went to the resident's room and took the battery of the motorized wheelchair. R31 confirmed being upset because nobody from the facility had asked the resident's permission for the battery to be removed. R31 indicated the facility removed the battery so the resident could not use the motorized wheelchair.On 07/29/2025 at 12:52 PM, R31 indicated the Maintenance Director took the battery of the motorized wheelchair about two weeks ago without the resident's permission.On 08/01/2025 at 10:00 AM, the Administrator revealed R31 was involved in an incident on 07/15/2025 where R31 accidentally ran over another resident's foot with the motorized wheelchair. The Administrator explained R31 used a manual wheelchair after the incident for the resident's safety. R31 used a manual wheelchair for one week.The Administrator confirmed the Maintenance Director removed the battery of R31's motorized wheelchair the next day after the incident, or on 07/16/2025, per the Administrator's instruction. The Administrator indicated the battery was removed for the resident's safety, so the resident could not use the motorized wheelchair. The Administrator confirmed not talking to R31 to ask permission from the resident the battery of the motorized wheelchair would be removed. The Administrator acknowledged the resident's permission should have been obtained prior to removing the battery. The reason for removing the battery of the motorized wheelchair should have been explained to R31.On 08/01/2025 at 10:35 AM, the Maintenance Director confirmed removing the battery of R31's motorized wheelchair a couple of weeks ago per the instruction of the Administrator. The Maintenance Director indicated the motorized wheelchair was located inside R31's room. The Maintenance Director revealed R31 was not inside the room when the battery was removed. The resident was at a doctor's appointment. The Maintenance Director confirmed not asking permission from R31 prior to removing the battery.The facility's Notice of Resident Rights Under Federal Law updated in July 2025, documented the resident had the right to a dignified existence and self-determination, and to be treated with respect and dignity.
CONCERN
(D)
Potential for Harm - no one hurt, but risky conditions existed
Deficiency F0552
(Tag F0552)
Could have caused harm · This affected 1 resident
**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on interview, record review and document review the facility failed to ensure informed consent was obtained prior to admin...
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**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on interview, record review and document review the facility failed to ensure informed consent was obtained prior to administration of psychotropic medications for 1 of 37 sampled residents (Resident 8). The deficient practice potentially deprived residents of the right to be informed of the medications' risks, benefits and potential side effects.Findings include: Resident 8 (R8) was admitted on [DATE] with diagnoses including type 2 diabetes mellitus, schizoaffective disorder bipolar type, major depressive disorder, and anxiety disorder. A Physician Order dated 07/17/2025 documented Seroquel Oral Tablet 50 milligrams (mg), give one tablet by mouth one time a day for paranoia, agitation, and irritability related to schizoaffective disorder, bipolar type.R8's medical record lacked documented evidence an informed consent was obtained prior to the first administration of Seroquel on 07/17/2025. On 08/01/2025 at 3:20 PM, a Registered Nurse (RN) explained psychotropic medications required an informed consent to be signed prior to administration.On 08/01/2025 at 3:51 PM, the Director of Nursing (DON) explained when a resident had orders for psychotropic medications a consent would need to be obtained from the resident or responsible party prior to administration of the first dose. The DON reviewed R8's medical record and confirmed R8 lacked an informed consent for the administration of Seroquel. The facility policy titled Psychoactive Medications, updated June 2025, documented prior to the administration of psychotropic medication, consent is obtained from the resident or resident representative.
CONCERN
(D)
Potential for Harm - no one hurt, but risky conditions existed
Deficiency F0578
(Tag F0578)
Could have caused harm · This affected 1 resident
**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on interview, record review and document review, the facility failed to ensure an advance directive and/or public guardian...
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**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on interview, record review and document review, the facility failed to ensure an advance directive and/or public guardianship was initiated and obtained for 1 of 37 sampled residents (Resident (R)12). The deficient practice had the potential for the resident, who was evaluated as not having the capacity to manage medical and financial decisions, to have a proper representation in health care decision-making.Findings include:Resident 12 (R12) was admitted on [DATE], with diagnoses including dementia, schizophrenia, major depressive disorder, and history of traumatic brain injury.The Clinical admission notes dated 11/05/2024, documented the following:- R12's Family / support person was not in attendance.- Living situation prior to admission: R12 lived alone.- Mental Status: R12 was disoriented, disorganized in thinking, and oriented to person.R12's History and Physical dated 11/05/2024, documented the physician's assessment of the resident included altered mental status and schizophrenia.The medical record contained the following consents which were signed by R12:- Consent To Treat (undated)- Psychotropic Drugs Disclosure dated 11/05/2024- Informed Consent for Immunization with Covid-19 dated 11/05/2024- Influenza Vaccine Informed Consent dated 11/05/2024- Pneumococcal Vaccine Informed Consent dated 11/05/2024The admission Minimum Data Set (MDS) dated [DATE], documented R12's Brief Interview for Mental Status (BIMS) score was 06 (severe impairment).The Cognitive Evaluation dated 12/02/2024, documented the following:- History of Present Illness: R12 was seen on facility request to assess the resident's capacity to manage medical and financial decisions. R12 was unable to list the medications and/or diagnoses with basic understanding. R12 was unable to detail income, financial matters and/or financial obligations with basic understanding. The resident was not able to discuss the role of a Power of Attorney (POA) with superficial understanding. R12 did not understand the process of instating and rescinding POA. The resident was informed of these concepts but was unable to paraphrase these concepts after some time. The resident did not understand the scope of authority granted to a POA including the ability to overrule the resident's decisions. The resident did not understand when decision making would be deferred to a POA. The resident was informed of these concepts but was unable to paraphrase these concepts after some time. The resident did not identify a potential POA.- Assessment / Plan: R12 did not have the capacity to manage medical andfinancial decisions. Overall, the resident demonstrated insufficient understanding of the financial situation and obligations as well as the medical diagnoses andmedications to make informed decisions and manage these safely. A decision maker should be implemented. R12 did not have the capacity to identify, instate, and rescind a POA. Overall, R12 demonstrated insufficient understanding of a POA and did not appear to understand the primary components and the impact on the resident's life.The Quarterly MDS dated [DATE], documented R12's BIMS score was 03 (severe impairment).R12's medical record lacked documented evidence an advance directive and / or public guardianship was initiated and obtained for R12.On 08/01/2025 at 12:03 PM, the Director of Nursing (DON) revealed R12 had a BIMS score of 03. R12 was alert and oriented to self and current location but not oriented to time or situation / event with episodes of confusion.The DON explained R12's Cognitive Evaluation dated 12/02/2024, documented the resident had no capacity to manage medical and financial decisions. The DON confirmed R12 signed all the consents. The DON indicated R12 should not have signed the consents.The DON revealed R12 had no public guardian or family. The DON explained the nurses should have contacted the providers because two doctors could have signed the consents. The DON revealed the facility should have initiated the process to obtain a guardian or POA when the cognitive evaluation was completed on 12/02/2024. Social services were responsible for obtaining a public guardian or POA for R12. The DON confirmed Resident 12's medical record did not contain an advanced directive and there was no documented evidence of the discussion regarding advanced directive.On 08/01/2025 at 1:09 PM, a Registered Nurse (RN) revealed R12 was alert and oriented times two with episodes of confusion. The RN explained that the nurses obtained consents upon a resident's admission.The RN indicated on admission R12 was alert and oriented to person only based on the Clinical admission notes dated 11/05/2024. The RN explained the resident's emergency contact should have been called to obtain consents. If the resident had no POA or family, the RN would have referred to the supervisor. The RN confirmed R12 should not have signed the consents due to the resident's mental status. The RN acknowledged R12 could not understand the risks and benefits of the medications.The facility's policy titled Advance Directive dated 01/01/2025, documented during the admission process, the facility would identify the resident's primary decision maker or appropriate legal representative and invoked this person at any time the resident was assessed as unable to make relevant health care decisions.During the admission process, quarterly, annually, and when significant changes in condition occurred, the resident was evaluated for decision making capacity and invoked the health care agent or legal representative if the resident was determined not to have decision making capacity.
CONCERN
(D)
📢 Someone Reported This
A family member, employee, or ombudsman was alarmed enough to file a formal complaint
Potential for Harm - no one hurt, but risky conditions existed
Free from Abuse/Neglect
(Tag F0600)
Could have caused harm · This affected 1 resident
**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on interview, record review, and document review, the facility failed to ensure residents were kept safe from physical abu...
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**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on interview, record review, and document review, the facility failed to ensure residents were kept safe from physical abuse for 4 of 37 sampled residents (Resident (R) 3, 53, 113, and 151). The deficient practice had the potential for the residents to experience emotional and physical harm.Findings include:1) Resident 3 (R3) was admitted on [DATE] with diagnoses including metabolic encephalopathy, dementia with behavioral disturbance, and delusional disorders. Resident 113 (R113) was admitted on [DATE] and discharged on 7/27/2025 with diagnoses including Parkinsonism, major depressive disorder, and dementia with mood disturbance.A facility reported incident (FRI) dated 06/25/2025 documented the following:-On 06/21/2025 at approximately 11:30 AM, R113 became agitated by noise made by R3 and threw a book at R3, resulting in a minor laceration to R3's forehead and redness in the right eye.-R3 and R113 were immediately separated and R113 was placed on one-to-one supervision.-Conclusion: The incident was verified and R3 was transferred to an acute care hospital for medical evaluation and returned with treatment orders for traumatic iritis.A Behavior / Psychiatric Change of Condition Progress Note dated 06/21/2025 documented R113 had a room change for safety and security and remained on one-to-one supervision.A Daily Skilled Progress Note dated 06/22/2025 documented R113 remained in room with one-to-one supervision. No complaints.A Care Plan dated 06/25/2025 documented R113 was involved in a resident-to-resident altercation with interventions to include one-to-one supervision, and to provide a calm, quiet space when R113 appears agitated. A Fall / Accident / Injury Progress Note dated 06/21/2025 documented R3 returned to the facility with no complaints, resting in bed and safe.A Care Plan dated 06/25/2025 documented R3 was involved in a resident-to-resident altercation with interventions to include providing redirection when agitation was observed.During the onsite investigation on 07/29/2025 through 08/01/2025, the facility correction of past non-compliance related to the incident occurred as evidenced by:-Observation of resident-to-resident interactions were polite and courteous.-R113 was discharged from the facility on 07/27/2025 and had not returned.-Staff indicated the facility provided continuing education regarding abuse.-Review of the facility's training records corroborated the staff interviews regarding training.-Review of facility schedules corroborated one-to-one supervision occurred for R113 until discharge on [DATE].On 08/01/2025 at 11:10 AM, the Administrator reviewed the information reported in the FRI and explained R113 purposefully threw the book at R3 resulting in the injury. The Administrator explained R113 was placed on one-to-one supervision for resident safety.2) Resident 53 (R53) was admitted on [DATE] with diagnoses including schizophrenia, atherosclerotic heart disease, and chronic obstructive pulmonary disease. Resident 151 (R151) was admitted on [DATE] and discharged on 06/07/2025 with diagnoses including atherosclerotic heart disease, type 2 diabetes mellitus, and chronic embolism and thrombosis of unspecified deep veins of bilateral lower extremity. A facility reported incident (FRI) dated 06/10/2025 documented the following:- On 06/07/2025 at approximately 9:30 AM, R151 kicked R53 after becoming agitated due to R53 moving slowly and not clearing the path to the smoking area. The altercation was witnessed and immediately reported.-Both residents were immediately separated to prevent further incidents.-Skin assessment was completed on R53 to evaluate for injury.-R151 was placed on legal hold due to the threat of harm to self or others and metro police were notified.-Conclusion: The allegation of physical abuse between R53 and R151 was verified based on the admission of R151 and corroborating witness report. Immediate action was taken to ensure the safety of all residents and staff, and ongoing monitoring was implemented for R53. R151 was removed from the facility on a legal hold. During the onsite investigation on 07/29/2025 through 08/01/2025, the facility correction of past non-compliance related to the incident occurred as evidenced by:Observation of resident-to-resident interactions was polite and courteous.On 07/29/2025 at 12:30 PM, R53 explained no issues and gets along with others, had no concerns. A Nursing Progress Note dated 06/07/2025 documented R151 kicked R53 in the leg. When asked what happened R151 stated, Yeah, I kicked R53 because would not move out of my way.A facility document titled Police Contact Card dated 06/07/2025 documented R151caused a disturbance in facility, R151 placed under legal hold.A Resident Notice of Transfer of discharge date d 06/07/2025 documented discharge to a local correctional facility.A Nursing Progress Note dated 06/08/2025 documented R53 had no acute distress noted and no bruising observed. A Skin / Wound Progress Note dated 06/10/2025 documented R53's skin was clear with no signs of injury noted. R53 alert with confusion and denied pain or discomfort.A Care Plan dated 06/10/2025 documented R53 was the victim in a resident-to-resident altercation, causing R53 to be kicked, resulting in no injuries with interventions including encourage R53 to participate in activities throughout the day.On 08/01/2025 at 11:05 AM, the Administrator explained R151 was removed from the facility by local law enforcement. The Administrator explained based on R151's behaviors, statements, and past interactions with other residents, R151's interactions were willful. Facility Reported Incident 2294603Facility Reported Incident 2294610
CONCERN
(D)
📢 Someone Reported This
A family member, employee, or ombudsman was alarmed enough to file a formal complaint
Potential for Harm - no one hurt, but risky conditions existed
Accident Prevention
(Tag F0689)
Could have caused harm · This affected 1 resident
**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on interviews, record review and document review, the facility failed to ensure a resident with moderate cognitive impairm...
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**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on interviews, record review and document review, the facility failed to ensure a resident with moderate cognitive impairment was adequately supervised and was not able to elope from the facility for 1 of 37 sampled residents (Resident 113). The deficient practice had the potential for physical and psychosocial harm to a resident. Findings include:Resident 113 (R113) was admitted on [DATE] and discharged on 7/27/2025 with diagnoses including Parkinsonism, major depressive disorder, and dementia with mood disturbance.The Quarterly Minimum Data Set (MDS) dated [DATE] documented a brief interview for mental status (BIMS) assessment score of nine indicating R113 had moderate cognitive impairment. The Annual MDS dated [DATE] documented a BIMS assessment score of three indicating R113 had severe cognitive impairment. A facility reported incident (FRI) dated 05/31/2025 documented the following:On 05/27/2025 at 9:00 AM, the Administrator was notified that R113 eloped from the facility this morning and was found at or around 8:00 AM and brought back to the facility. Upon R113's return, the nursing staff did a skin assessment and found no injuries. The following timeline was based on the investigation notes and interviews from the facility:-On 05/26/25 at 7:00-7:30 PM, a Certified Nurse Assistant (CNA) took R113's vital signs.-On 05/26/25 at 7:41 PM, a registered nurse (RN) administered medications to R113.-On 05/27/25 at 2:05 AM, security footage showed R113 exited through door #5 independently.-On 05/27/25 at 6:40 AM, a CNA noted R113 was not in the room and began a search of the facility.-On 05/27/25 at 7:00 AM, the Assistant Director of Nursing (ADON) and a Registered Nurse (RN) were notified.-On 05/27/25 at 7:33 AM, an elopement Code Pink was initiated and a search was conducted by staff.- On 05/27/25 at 8:00 AM, a staff member saw R113 walking on cross streets near the facility while on the way to work.-On 05/27/25 at 8:05 AM, staff confirmed via internal communication that R113 had been located, and a facility driver was dispatched.-On 05/27/25 at 8:15 AM, R113 was safely returned to the facility.-On 05/27/25 at 8:40 AM, a post-elopement assessment was performed. R113 was noted to be unharmed and wearing a wander guard bracelet.-On 05/27/25 at 1:05 PM, R113's guardian and physician were notified, and an order placed to move R113 to the secured unit.-On 05/27/25 at 3:34 PM, R113 continued to exhibit no signs of injury or distress.-On 05/27/25, 3:52 PM, R113 moved to secured unit.The facility findings documented:-Upon return, R113 was found to be wearing a wander guard bracelet on right wrist.-The wander guard did not trigger an alert at the time of exit, and further evaluation of the system was initiated. -The facility will conduct in-services on elopement prevention for staff.During the onsite investigation on 07/29/2025 through 08/01/2025, the facility correction of past non-compliance related to the incident occurred as evidenced by:A Physician Order dated 05/27/2025 documented admit R113 to secure unit, for high elopement risk.A Physician Order dated 05/27/2025 documented wear wander guard for elopement.A Care Plan dated 05/27/2025 documented R113 was an elopement risk due to cognitive impairment, episodes of wandering, and psychiatric diagnosis with interventions including wander guard check for placement at least daily and ensure the exit door alarms on the secured unit activates after entering or exiting the unit.Review of the R113's Treatment Administration Record (TAR) for July 2025 provided documented evidence the wander guard was checked daily as per physician orders.On 07/29/2025 at 1:06 PM, upon entry and exit of the secured unit the alarm was activated.On 08/01/2025 at 8:26 AM, a Registered Nurse (RN) explained had a machine in the medication cart that allows staff to test the functioning of the residents wander guard bracelet to ensure it is activated. The RN explained staff could also walk the resident to the door to ensure the device was activated. The RN explained that the nurses would check each shift to ensure the wander guard device was applied to the resident and the device was functional.On 08/01/2025 at 11:20 AM, the Administrator explained an oversight had occurred for not ensuring testing of the functionality for R113's wander guard bracelet / device. The Administrator explained that the maintenance department performed checks of the wander guard system routinely to ensure it was functioning properly at the doors. The maintenance department provided the monthly wander guard testing log that documented each door of the facility equipped with the wander guard system was checked Monday through Friday of each week throughout the month. The logs documented the system was functioning. The facility training records provided documented evidence training for elopement was conducted on 5/31/2025.Facility Reported Incident 2294607
CONCERN
(D)
Potential for Harm - no one hurt, but risky conditions existed
Deficiency F0883
(Tag F0883)
Could have caused harm · This affected 1 resident
**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on interviews, record review, and document review, the facility failed to ensure education regarding the risks and benefit...
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**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on interviews, record review, and document review, the facility failed to ensure education regarding the risks and benefits of the pneumococcal, influenza, and covid-19 vaccines, and failed to ensure administration or obtain documented declinations for 2 of 5 residents sampled for infection control (Residents 95 and 155). The deficient practice compromised the facility infection prevention and control program and placed residents at increased risk for vaccine-preventable disease outbreaks, including respiratory illnesses with serious health consequences in vulnerable populations.Findings include:1) Resident 95 (R95) was admitted on [DATE] with diagnoses including infection of amputation stump, left lower extremity and cellulitis of the left limb.On 08/01/2025 in the afternoon, R95 could not recall being offered any immunizations or if staff explained the risk and benefits.2) Resident 155 (R155) was admitted on [DATE] with diagnoses including depression and chronic systolic heart failure.On 08/01/2025 in the afternoon, R155 could not recall being offered any immunizations or if staff explained the risk and benefits.The facility failed to provide evidence that R95 and R155 had been provided education on the risk and benefits of pneumococcal, influenza, and covid-19 immunizations.The facility failed to provide evidence the immunization status and / or immunizations were provided for R95 and R155.On 08/01/2025 at 3:22 PM, a Registered Nurse explained for new admissions that the nurse would interview resident, review discharge summary for immunization status, ask if the resident would like to have the immunization and obtain a signed consent from the resident and / or responsible party accepting or declining the immunization. Once consent obtained input physician order and administer.On 08/01/2025 at 1:00 PM, the Infection Preventionist (IP) verbalized after admission the IP would verify if a vaccine was administered previously. The admission packet contained information regarding vaccine status and the admission nurse would review with the resident. The IP would follow up generally within 48 hours after admission. The IP indicated there was no documented evidence of the vaccination status for R95 or R155.On 08/01/2025 at 3:40 PM, the Director of Nursing acknowledged there was no documented evidence of the vaccination status for R95 or R155.The facility policy titled Vaccination of Residents (revised 06/19/2025) documented immunization status was determined upon admission or soon afterword and was documented in the resident medical record.
Feb 2025
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
Free from Abuse/Neglect
(Tag F0600)
Could have caused harm · This affected 1 resident
**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on interview, record review and document review, the facility failed to ensure a resident was kept safe from physical abus...
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**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on interview, record review and document review, the facility failed to ensure a resident was kept safe from physical abuse for 1 of 12 sampled residents (Resident 10). The deficient practice had the potential for the resident to experience emotional and physical harm.
Findings include:
Resident 10 (R10)
R10 was admitted on [DATE] with diagnoses including acute respiratory failure with hypoxia, chronic obstructive pulmonary disease, and diabetes mellitus type 2.
The facility reported incident (FRI) dated 12/23/2024 documented the following:
-On 12/19/2024 at approximately 1:15 PM, R10 was in bed being cared for by two Certified Nurse Assistants (CNA), Employee 9 and 10 (E9 and E10).
- Per E10 an exchange of inappropriate and abusive language occurred between E9 and R10. This verbal altercation escalated, leading to E9 striking R10 in the rib area with a closed fist.
-Conclusion: The allegation of physical abuse by E9 against R10 was substantiated. The police department was contacted and responded to the incident. Subsequently E9 was taken into custody.
A progress note dated 12/19/2024 documented R10 had a Head-to-toe assessment performed to check for bruising/wound progression. At that time no bruising or discoloration noted in patient chest & rib area. Patient has no complaints of pain or discomfort.
A Social Service visit note dated 12/23/2024 documented the Social Services Director and Administrator visited R10 regarding the self-report. R10 was provided emotional support and offered Behavioral Health Services psych services, R10 denied the need for services. R10 reported no psychosocial harm from the incident and reported were not experiencing any emotional distress from the incident.
A Care Plan dated 12/23/2024 documented R10 was involved in an altercation with a staff member. Interventions included the following:
-Provide a safe environment for R10.
-Ensure employees are aware of policies and procedures for Abuse prevention and reporting.
-Encourage R10 to verbalize concerns.
-Monitor R10 for behaviors associated with the incident.
-Notify MD of any changes.
On 02/13/2025 at 9:10 AM, R10 stated they share a room with their spouse. R10 stated had an incident with one CNA punching them in the left side of their ribs. The resident shared had started screaming and asked their spouse to get the Director of Nursing, another CNA was present in the room, and had stood there looking as if afraid. The staff intervened and handled the situation, and the CNA was arrested by the police. R10 verbalized were happy with how management handled the situation, and they feel safe in the facility.
On 02/13/2025 at 1:15 PM the Director of Nursing (DON) confirmed E9 was immediately removed from R10's room and was suspended pending the investigation. The allegation of abuse was substantiated and was witnessed by another CNA resulting in termination and arrest of E9. The DON confirmed E9 was reported to the State Board of Nursing regarding the incident.
During the onsite investigation on 02/13/2025, the facility's correction of the past non-compliance related to the incident occurred as evidenced by:
-Observation of staff and resident interactions were professional and courteous.
-Interviews with residents revealed the residents were happy with staff and were treated in a polite manner.
- CNA's and Licensed Nurses indicated the facility provided continuing education regarding Abuse and Neglect.
-Review of the facility's employee file for E9 revealed reference and background checks were completed.
-Review of the facility's training records corroborated the staff interviews regarding training.
Facility Reported Incident #NV00073005
Dec 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
Based on interview, record review and document review, the facility failed to ensure an alleged incident of verbal abuse was reported to the State Agency (SA) within the required timeframes for 1 of 1...
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Based on interview, record review and document review, the facility failed to ensure an alleged incident of verbal abuse was reported to the State Agency (SA) within the required timeframes for 1 of 12 sampled residents (Resident #11). The deficient practice had the potential to place residents at risk for incidents of verbal abuse to not be adequately protected.
Findings include:
Resident #11 (R11) was admitted to the facility 03/09/2023 with a diagnosis including parkinsonism, dysphagia, cognitive communication deficit, and depression.
A Behavior Note dated 10/10/2024, documented R11 was standing in the hallway with a butter knife in their sleeve threatening to harm another resident.
A Facility Reported Incident (FRI) was submitted to the SA on 10/15/2024, documenting the resident's alleged verbal abuse on 10/10/2024.
On 12/18/2024 at 3:46 PM, the Administrator/Abuse Coordinator verbalized abuse without serious bodily harm should be reported to the SA within 24 hours of the incident. The Abuse Coordinator confirmed the FRI was not reported to the SA within the required timeframes.
The facility policy titled Freedom from Abuse, Neglect, Corporal Punishment, Involuntary Seclusion, Mistreatment, Misappropriation of Resident Property, and Exploitation, revised 10/2022, documented allegations of verbal abuse, which include threats, would be reported to the appropriate State or Federal agencies within two hours if the allegation involves abuse.
CONCERN
(D)
📢 Someone Reported This
A family member, employee, or ombudsman was alarmed enough to file a formal complaint
Potential for Harm - no one hurt, but risky conditions existed
Quality of Care
(Tag F0684)
Could have caused harm · This affected 1 resident
**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, interview, and record review, the facility failed to ensure physician's orders for the application of heel...
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**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, interview, and record review, the facility failed to ensure physician's orders for the application of heel protectors were followed for 1 of 12 sampled residents (Resident 5). The deficient practice had the potential to lead to the development of skin breakdown.
Findings include:
Resident 5 (R5) was admitted on [DATE], with diagnoses including [NAME] syndrome and peripheral vascular disease.
Physician's orders dated 09/02/2023 documented:
-Bilateral heel protectors on at all times when in bed every shift for pressure relief and skin prophylaxis.
The wound care progress note dated 11/12/2024, documented R5 was treated for a chronic non-healing arterial ulceration of the left anterior fifth toe. This was a 30 day follow up for a previously healed wound. Wound remains healed. Please continue using preventive measures which can include turning and repositioning, offloading, and nutritional supplementation.
On 12/18/2024 at 11:15 AM, R5 was noted to be lying on their back, on an air mattress in bed. One pair of blue heel protectors, a device used to minimize pressure to heels, was sitting on top of a three-drawer organizer located at the foot of R5's bed.
On 12/18/2024 at 11:30 AM, R5's room door was closed, at 11:32 AM, two Certified Nurse Aides (CNA's) exited the room and R5 was noted to be lying on their back, slightly tilted to left side, with a wedge-shaped pillow under R5's right shoulder. One pair of blue heel protectors were sitting on top of a three-drawer organizer located at the foot of R5's bed.
On 12/18/2024 at 2:02 PM, R5 was lying in bed on their back. One pair of blue heel protectors were sitting on top of a three-drawer organizer located at the foot of R5's bed.
On 12/18/2024 at 11:43 AM, a CNA expressed R5's heel protector boots are applied and removed at different times during the day.
On 12/18/2024 at 11:50 AM, a Licensed Practical Nurse (LPN) expressed R5 does not currently have wounds, the heel protectors were to be applied at night if a resident had wounds.
On 12/18/2024 at 12:05 PM, the Wound Treatment Nurse expressed R5 was seen by wound care providers once a week. R5 previously had an area to the left pinky toe that was being treated but was currently healed as of 11/12/2024. The Wound Treatment Nurse verified R5 had a current order for bilateral heel protectors at all times and confirmed due to R5's history of prior wounds to their foot and R5's risk for skin breakdown, the heel protectors should be applied as ordered.
On 12/18/2024 at 2:05 PM, the Director of Nursing (DON) verbalized the CNA's role for wound care prevention was to anticipate resident needs and provide turning and repositioning, place any supportive equipment such as heel protectors, and report any new skin issues to the licensed nurse. The DON verified R5 would require heel protectors to be in place as indicated in the physician's orders.
May 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
Abuse Prevention Policies
(Tag F0607)
Could have caused harm · This affected 1 resident
**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on interviews, record review, and document review the facility failed to ensure abuse policies and procedures were impleme...
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**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on interviews, record review, and document review the facility failed to ensure abuse policies and procedures were implemented for 1 of 5 sampled residents. The deficient practice had the potential to put residents at risk of negative physical or psychosocial outcomes.
Findings include:
Resident 3 (R3)
R3 was admitted on [DATE] and readmitted on [DATE] with diagnoses including anxiety, mood disorder, and unspecified psychosis.
A facility report indicated a Certified Nursing Assistant (CNA1) was walking past room of R3 where another Certified Nursing Assistant (CNA2) was providing care to the resident. CNA1 reported hearing a noise which sounded like a hand slapping against skin or body part.
The facility investigation documented CNA1 walked past room and had concern CNA2 was being physically abusive to R3, however did not intervene to stop the alleged abuse. CNA1 walked past the resident's room and directly to the charge nurse to report suspected abuse.
The witness statements from CNA1 confirmed CNA1 did not actually see any physical abuse only heard sounds which raised concern. CNA1 did not enter room and intervene.
On 05/16/2024 in the afternoon, a CNA indicated if there was suspected abuse the first priority was to ensure resident safety and intervene and then contact the abuse coordinator.
On 05/16/2024 in the afternoon, a Licensed Practical Nurse (LPN) verbalized for any suspected physical abuse the goal was to first ensure resident safety and contact the abuse coordinator. The LPN indicated CNA1 did not follow facility protocol by not intervening to determine if abuse was occurring and then contact the abuse coordinator.
On 05/16/2024 at 11:03 AM, a Licensed Social Worker (LSW) who was familiar with the incident indicated during the investigation the facility staff did a reenactment of the situation and found when walking past the room with the way the incident was described, it would be nearly impossible to see the interaction between staff member and resident. The LSW explained someone walking past a room would need to enter the room to see the upper part of the body of staff member at bedside.
The LSW verbalized the action of CNA1 did not meet facility expectations as it would be expected to have staff member intervene and stop any abuse occurring and then contact the abuse coordinator.
On 05/16/2024 in the afternoon, CNA1 indicated no physical abuse was observed only movement from CNA2 and then hearing what sounded like someone getting slapped in the face. CNA1 verbalized being shocked and did not know what to do and went directly to the charge nurse.
On 05/16/2024 at 2:32 PM, the Director of Nursing (DON) indicated the expectation from staff would be to intervene and stop abuse to ensure resident safety and then contact the abuse coordinator. The DON acknowledged CNA1 did not intervene and walked past where suspected abuse was occurring and directly to the charge nurse to report.
Employment training records indicated CNA1 was up to date on abuse training.
A facility document for testing to ensure comprehension of abuse policy and procedure documented the first step to take was to intervene and stop suspected abuse.
The facility policy titled Resident Rights documented all residents would be free from abuse, neglect, misappropriation of property, and exploitation.
Complaint NV00070508
FRI NV00070059
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 observation, interviews, record reviews, and document reviews, the facility failed to ensure an incident in which an el...
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**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, interviews, record reviews, and document reviews, the facility failed to ensure an incident in which an elderly resident with dementia and Alzheimer's disease was forced to take medications was promptly reported to the abuse coordinator and the agency within the mandated timeframes for 1 of 5 sampled residents (Resident 5). This deficient practice had the potential to lead to unaddressed abuse and compromise the resident's health and well-being.
Findings include:
Resident 5 (R5)
R5 was admitted on [DATE], with diagnoses including Alzheimer's disease and dementia.
The Minimum Data Set, dated [DATE], documented a brief interview of mental status score of 99, which indicated the interview had not been completed due to impairment of R5's cognitive status.
A Care Plan dated 09/22/2022, documented R5 had episodes of resistance to care during the medication pass. The interventions included re-approaching R5 calmly, redirecting behavior, and re-offering medication.
The facility report dated 02/01/2024, documented the alleged incident occurred on 01/06/2024, a Certified Nursing Assistant 2 (CNA2) witnessed another Certified Nursing Assistant 1 (CNA1) standing behind and holding the head of R5 while a Licensed Practical Nurse 1 (LPN1) held R5's cheeks and forced R5 to take the medication.
The facility investigation notes dated 01/16/2024, documented R5's family was interviewed by the Director of Nursing (DON) and the family reported previously witnessing LPN1 who forced R5 to take the medications in two incidents. The family stated LPN1 was advised to stop forcing R5 to take the medications and return later. The family ended up giving R5's medications.
On 05/16/2024 at 8:29 AM, the Director of Human Resources (DHR), indicated CNA1 and CNA2 were still employed at the facility. LPN1 resigned on 02/01/2024.
On 05/16/2024 at 8:48 AM, a Licensed Practical Nurse 2 (LPN2) assigned to R5 in the secured unit indicated R5's medications were crushed and mixed with pudding. R5 took the medication without any resistance. The LPN indicated R5 was verbally alert times one, had confusion, and was exhibiting resistive care behavior.
LPN2 indicated when R5 refused the medication, it would be re-offered and if still refused, to notify the physician and document. LPN2 indicated was familiar with R5, and the medications would have been administered when R5 was eating because R5 was in a good mood. LPN2 stated forcing medications on the resident would constitute abuse. LPN2 began employment at the facility in November 2024, confirming the last abuse training had been completed.
On 05/16/2024 at 9:04 AM, R5 was seated in bed, pleasant, and verbally responsive with confusion. When asked about any incident where staff members forced R5 to take the medications, R5 replied, I don't know. When asked if there was any concern regarding the care, R5 replied, Yes. R5 did not respond with follow-through questions.
On 05/16/2024 at 9:15 AM, the Physician Assistant (PA) indicated if a resident had dementia and Alzheimer's disease and refused the medications, the staff were expected to keep trying, but the medications could not be forced. If a resident kept refusing and was unable to administer the medications, the process was to re-offer, notify the provider, family, and document.
On 05/16/2024 at 10:02 AM, the Director of Social Services (DSW) indicated R5's family had previously witnessed the LPN forcing R5 to take the medications. The DSW indicated the incident was reported to the state on 02/01/2024 and finalized the report on 02/05/2024. The incident was substantiated when LPN1 forced the medication on R5 with three eyewitnesses. The DSW confirmed there was a delay in the investigation and reporting to the state agency when the incident occurred on 01/06/2024. The DSW indicated the staff had received abuse training.
The Nursing Assignment dated 01/06/2024 (Saturday), revealed LPN1, CNA1 and CNA2 were assigned to the secured unit during the day shift.
On 05/16/2024 at 12:43 PM, during a telephone interview, CNA2 who witnessed the incident recounted approximately in the first week of January, on a Saturday morning in the secured unit. R5 was heard yelling Stop, stop. CNA2 entered the room and witnessed R5 being forced to take the medications. CNA1 was holding R5's head, and LPN1 was holding R5's chin, and tried to put the medications in R5's mouth in a standing position. CNA2 intervened and told LPN1 could not force R5 and to try later. CNA2 explained the incident was reported to R5's family the same day, and the family responded it happened in the past. CNA2 indicated did not report the incident to the supervisor or abuse coordinator, but the family brought the matter to the management and the facility investigated the incident a few weeks later. The facility provided education during the investigation.
On 05/16/2024 at 2:50 PM, CNA1 indicated sometime in the first week of January, CNA1 walked over to R5's room when R5 was heard yelling. CNA1 indicated LPN1 was in the room, forcing R5 to take the medications. CNA1 denied helping LPN1. CNA1 indicated did not report the incident to the abuse coordinator until after being interviewed after a month. CNA1 indicated was suspended, reinstated, and provided abuse training.
The Director of Staff Development (DSD) indicated the staff were provided abuse training upon hire and every other month. The abuse incident should have been reported to the abuse coordinator immediately and reported within 24 hours to the state agency. The DSD confirmed the involved staff had completed their abuse trainings. The DSD indicated the resident who had a diagnosis of Alzheimer's had the right to refuse and should have been respected and not forced.
On 05/16/2024 at 2:54 PM, the Director of Nursing (DON) confirmed there was a delay in the investigation and reporting because there was confusion in the early stages of the investigation. The DON indicated the incident was investigated and substantiated when LPN1 forced R5 to take the medications. The DON indicated LPN1 was suspended and resigned later, CNA1 was suspended but reinstated and provided education. The facility reported the incident to the nursing board.
On 05/16/2024 in the afternoon, the former administrator recounted the incident was substantiated when it was validated LPN1 forced R5 to take the medications. The former administrator asserted forcing the resident to take the medications was unacceptable and considered it a form of abuse.
The facility report to the board of nursing on 02/27/2024, documented on 01/31/2024, R5's family reported to the administrator an incident happened approximately four weeks ago, LPN1 forced R5 to take the medication with the help of CNA1. The validity of the claim CNA1 held R5's head could not be substantiated. LPN1 forced R5 to take the medications, as witnessed by CNAs. Per LPN1, there was no forcing of medications, and R5's family was always present during medication administration time. Forcing medications when a resident refused was considered abuse. The facility suspended and reinstated CNA1, while LPN1 resigned.
The Abuse Prevention Test documented elderly people with dementia who frequently yell and resist care were most at risk for abuse. The suspicion of abuse should have been reported immediately to the supervisor.
A facility policy titled Resident Rights revised 12/2016, documented employees should treat all residents with kindness, respect, and dignity.
A facility policy titled Abuse Investigation and Reporting dated 07/2017, documented an alleged violation of abuse would be reported immediately but not later than 2 (two) hours if the alleged violation involved abuse.
Complaint #NV00070507
Facility Reported Incident #NV00070372
Jan 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
Abuse Prevention Policies
(Tag F0607)
Could have caused harm · This affected 1 resident
**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on interview, record review and document review, the facility failed to follow its abuse protocol, specifically, staff mem...
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**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on interview, record review and document review, the facility failed to follow its abuse protocol, specifically, staff members who witnessed, or were aware of a resident-to-resident altercation did not report the allegation of physical abuse to the Abuse Coordinator or designee for 2 of 2 sampled residents (Residents 1 and 2). The deficient practice placed the residents of concern and other residents at risk for abuse and maltreatment.
Findings include:
Resident 1 (R1)
R1 was admitted on [DATE], with diagnoses including schizoaffective disorder bipolar type and encephalopathy.
Resident 2 (R2)
R2 was admitted on [DATE], with diagnoses including Alzheimer's disease of late onset and age-related physical debility.
A behavior note dated 11/22/2023, revealed R2 attempted to wrap a blanket around roommate's neck trying to choke R1 and then tried to put a heel-floater boot on R1's face trying to choke R1. Staff intervened and separated the residents. A new order for room changes by psychiatry provider also indicated medication regimen for R2 would be reviewed.
A facility report dated 01/15/2024, revealed there was a resident-to-resident altercation between R1 and R2 which occurred in the semi-secured unit of the facility on 11/22/2023.
On 01/18/2024 in the morning, two Certified Nursing Assistants (CNAs) recounted witnessing the first of three incidents between R1 and R2 on 11/22/2023.
Incident #1
On 01/18/2024 in the morning, two CNAs indicated R2 was observed trying to put a blanket over R1's face. The CNAs intervened by separating the residents and reported the incident to the Licensed Practical Nurse (LPN). The CNAs indicated they were expecting the LPN to report the incident to leadership, so the CNAs did not notify anyone else in the facility about the incident.
On 01/18/2024 at 10:16 AM, the LPN recalled being informed by the CNAs regarding R2 trying to place a blanket on R1's face in the morning of 11/22/2024. The LPN Indicated dismissing the incident as a typical occurrence in the dementia unit which was de-escalated and handled appropriately in a timely manner.
Incident #2
On 01/18/2024 at 10:36 AM, the LPN recounted witnessing two incidents which occurred between R1 and R2. On 11/22/2023 at approximately 12:00 PM, the LPN was doing medication pass when the LPN witnessed R2 trying to put a heel floater boot against R1's face. The LPN immediately took the boot away from R2's hand, pulled R2's wheelchair away from R1 and called for other staff. According to the LPN, R1 appeared unharmed and unaffected by the incident. The LPN notified the family members of both residents, the psychiatric provider, and the charge nurse.
Incident #3
On 01/18/2024 at 10:40 AM, the LPN recalled on 11/22/2023 doing medication pass during dinner time in main dining area of the semi-secured unit. The LPN witnessed R1 holding a knife against own throat while looking intently at R2, which was interpreted by the LPN as a non-verbal threat. The LPN approached R1, took the knife away and re-directed R1, while R2 remained unaware of R1's gestures. The LPN recalled reporting the incident to the provider and the charge nurse. The LPN indicated the Abuse Coordinator, and the Director of Nursing should have been informed by the LPN of the incident as well.
On 01/18/2024 at 11:18 AM, an attempt to contact the charge nurse by phone was unsuccessful.
On 01/18/2024 at 12:54 PM, the Director of Nursing and Abuse Coordinator confirmed the resident-to-resident altercation between R1 and R2 on 11/22/2023 was not reported to the DON and Abuse Coordinator and should have been. The DON explained a meeting was held on 01/09/2024 which was attended by representatives of the facility's contracted behavioral services provider and facility leadership wherein medical records for behavior residents were being reviewed and audited for new behaviors, medications, and effectiveness of current care plan. According to the DON, the Assistant DON (ADON) flagged a behavior note dated 11/22/2023 which documented a choking incident between R1 and R2. The Abuse Coordinator questioned why the reportable incident was not communicated to leadership and instructed the team to initiate an investigation into the incident and appointed the Social Services Director (SSD) to submit an initial report to the state agency.
The Abuse Coordinator indicated the facility's investigation revealed the charge nurse failed to inform the Abuse Coordinator or the DON regarding the allegation of physical abuse between R1 and R2 on 11/22/2023. The Abuse Coordinator emphasized all staff members were mandatory reporters of abuse and were trained to identify and report such incidences immediately for timely investigation and reporting. The Abuse Coordinator indicated all staff members who witnessed or had heard of the incident had an independent duty to report the incident to the Abuse Coordinator.
On 01/18/2024 at 1:28 PM, the DON indicated the charge nurse had failed to communicate the multiple incidents of resident-to-resident altercations between R1 and R2 to leadership on 11/22/2023. The DON indicated there was no excuse for not informing leadership because all staff members had the contact information of the DON and the Abuse Coordinator, and both the DON and Abuse Coordinator were in the facility until late afternoon on 11/22/2023 due to thanksgiving festivities for residents.
On 01/18/2024 at 1:30 PM, the DON and Abuse Coordinator acknowledged staff did not follow the facility's abuse protocol by not informing key leadership of the alleged abuse incident which resulted in the facility being unable to carry out its investigation and reporting requirements in a timely manner.
The Abuse Prevention Program revised December 2016, revealed resident had the right to be free from abuse from staff and other residents. Policies and procedures would be developed and implemented to aid the facility in preventing abuse, neglect, and maltreatment. Staff would be trained in identification and reporting abuse which would be investigated and reported within timeframes dictated by federal requirements.
FRI #NV00070240
Aug 2023
16 deficiencies
CONCERN
(D)
Potential for Harm - no one hurt, but risky conditions existed
Resident Rights
(Tag F0550)
Could have caused harm · This affected 1 resident
**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, interview and document review, the facility failed to 1) knock on resident room doors for 2 of 28 sampled ...
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**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, interview and document review, the facility failed to 1) knock on resident room doors for 2 of 28 sampled residents (Resident 55 and 109), 2) ensure staff were not standing during feeding assistance for 1 unsampled resident (Resident 69) and 3) appropriately transport a resident from the shower room for 1 of 28 sampled residents (Resident 2). The deficient practices had the potential to compromise dignity, impact the residents' sense of well-being and feelings of self-worth and self-esteem.
Findings include:
Resident 55 (R55)
R55 was admitted on [DATE] with diagnoses including hemiplegia and hemiparesis following cerebral infarction affecting left dominant side.
Resident 109 (R109)
R109 was admitted on [DATE] with diagnoses including abdominal aortic aneurysm, unspecified sequelae of cerebral infraction, and polyneuropathy.
On 08/30/2023 at 9:32 AM a Certified Nursing Assistant (CNA1) entered room N03 without knocking or announcing self.
On 08/30/2023 at 10:09 AM, a Registered Nurse (RN) entered room [ROOM NUMBER] without knocking or announcing self.
On 08/30/2023 at 12:12 PM, a second CNA (CNA2) explained the facility taught staff to knock and make residents aware of staff entering a resident's room prior to entering. The CNA verbalized residents may feel embarrassed if staff members entered a resident's room without announcing while a resident was in the restroom.
On 08/31/2023 at 8:00 AM, CNA1 entered room N04 occupied by two residents in the room. CNA1 entered the room without knocking or announcing self.
On 08/31/2023 at 8:05 AM, CNA1 explained the facility taught staff to knock on resident room doors and introducing themself prior to entering a resident room for residents to be aware someone was going to enter the room. The CNA considered staff not knocking and announcing their entrance prior to entering residents' room to be a dignity issue.
During the resident council meeting held on 08/30/2023, a resident discussed an incident where a deaf staff member entered the resident's room without notice and the resident was undressed at the time.
Resident Council Minutes dated July 27, 2023, documented a deaf maintenance staff member entered resident rooms without knocking. There was no facility response or resolution documented.
On 08/31/2023 at 10:47 AM, the Activities Director indicated scribing meeting minutes for the resident council meetings and explained the deaf staff member knocked and entered resident rooms as they could not hear the residents' response. The Activities Director further explained the facility's resolution has been pairing another staff member with the deaf staff member to assist with communication prior to entering resident rooms.
A facility policy titled Dignity revised February 2021, documented staff are expected to knock and request permission before entering residents' rooms.
Resident 69 (R69)
R69 was admitted on [DATE] with diagnoses including ataxic cerebral palsy and lumbar spina bifida without hydrocephalus (defect that occurs when the spine and spinal cord does not form properly).
On 08/29/2023 at 12:20 PM, in the South Hall/Long Term Dining Room, a CNA (CNA1) was observed standing over R69 while assisting R69 with feeding. R69 was sitting in a wheelchair at a dining table. R69 did not verbally respond when greeted.
Shortly after, a second CNA (CNA2) brought a chair to CNA1 and reminded CNA1 to sit down while feeding residents.
On 08/29/2023 at 12:27 PM, CNA2 advised standing while assisting a resident with feeding was not appropriate and therefore, provided CNA1 with a chair to sit. The CNA explained a staff member should sit next to the resident and make eye contact to prevent the resident from feeling rushed to complete their meal. The CNA considered that to be a dignity issue.
Resident 2 (R2)
R2 was admitted on [DATE] with vision impairment issues.
On 08/30/2023 at 9:27 AM, a CNA was observed pulling R2 in a shower chair backwards in the hallway from the shower room towards R2's room.
On 08/30/2023 at 10:30 AM, R2 indicated they were fine with being pulled backwards, but preferred to be transported forwards, not backwards, due to being partially blind.
On 08/30/2023 at 12:12 PM, the CNA explained residents who are transported in a shower chair should be transported in a forward direction. The CNA verbalized it was important to transport residents in a forward direction to see what was in front of the resident and ensure the resident did not hit into something along the transported route. The CNA felt a resident may feel afraid if the resident was being transported in a backwards direction.
A facility policy titled Bath, Shower/Tub revised February 2018, was reviewed and did not document specifics of direction to transport resident.
CONCERN
(D)
Potential for Harm - no one hurt, but risky conditions existed
Deficiency F0554
(Tag F0554)
Could have caused harm · This affected 1 resident
**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, interview, record review and document review, the facility failed to ensure a resident was assessed for se...
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**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, interview, record review and document review, the facility failed to ensure a resident was assessed for self-administration of medication for 1 of 28 sampled residents (Resident 114). The deficient practice had the potential to lead to medication errors impacting the well-being of the resident.
Findings include:
Resident 114 (R114)
R114 was admitted on [DATE] with diagnoses including age-related physical debility, acquired absence of other specified parts of digestive tract and perforation of intestine.
The Brief Interview of Mental Status dated 08/29/2023, documented a score of 14/15, which meant R114's cognitive status was intact.
On 08/29/2023 at 11:31 AM, a medication cup filled with an orange liquid was observed on R114's bed side tray table. R114 indicated the orange liquid was medication to assist in gaining weight, a nurse left the medication with R114 to self-administer prior to eating lunch, and R114 was waiting to receive their lunch tray. R114 specified only one nurse who normally worked on Sundays, would remain in the room until R114 consumed the orange liquid medication.
On 08/29/2023 at 11:41 AM, a License Practical Nurse (LPN) verified R114 had a medication cup in hand with a napkin inside the cup, soaking up what appeared to be orange liquid. The LPN explained the expectation of staff was to monitor residents until the administration of medication was completed and not leave medication unattended in a resident's room.
R114's medical record revealed an order dated 06/22/2023 for Pro-Stat Oral Liquid (Amino Acids Protein Hydrolysate); give 30 milliliters by mouth three times a day for weight gain supplement.
On 08/30/2023 at 11:53 AM, a Registered Nurse (RN) retrieved the Pro-Stat medication from the medication cart, opened the medication, and verified the medication was an orange liquid. The RN explained they generally administered the medication by mixing the liquid medication in water and watch the resident consume the medication, but did not wait for the resident to complete consumption of the medication. The RN would walk away and later return to the resident room to see if the medication cup used, was in the garbage.
R114's medical record lacked documentation for self administration of medication.
On 08/31/2023 at 5:08 PM, the Director of Nursing (DON) expected staff to stay and monitor a resident until the medication administration was completed. The DON explained medication should not be left with a resident, which was not in accordance with the facility's medication administration policy. The DON indicated medication left with a resident would be considered self-administration and a resident would need to be assessed for their capability and safety of self-administering medication. The DON verified R114's medical record lacked documentation of self-administration of medication.
A facility policy titled Self-Administration of Medications revised February 2021, documented an interdisciplinary team would assess each resident's cognitive and physical abilities to determine whether self-administration of medication was safe and appropriate for the resident. If deemed safe and appropriate, the self-administration of medication should be documented in the medical record and care plan.
CONCERN
(D)
Potential for Harm - no one hurt, but risky conditions existed
Grievances
(Tag F0585)
Could have caused harm · This affected 1 resident
Based on observation, interview, and document review, the facility failed to ensure residents were notified through postings in prominent locations throughout the facility, of the right to file a grie...
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Based on observation, interview, and document review, the facility failed to ensure residents were notified through postings in prominent locations throughout the facility, of the right to file a grievance with, and contact information for the pertinent state agency. The deficient practice had the potential to result in a resident having an unresolved grievance.
The facility policy and procedure titled Grievance/Complaint Reporting, dated 06/01/2023, indicated the facility would provide the name, address and telephone number of state advocacy groups and information on how to file a grievance.
On 08/30/23 at 2:31 PM, five out of five residents in a group interview stated they did not know they could file a grievance with the state agency.
On 08/31/23 at 1:29 PM a facility tour with the Administrator revealed the facility lacked any posting visible to residents bearing the name and contact information for the pertinent state agency. The Administrator verbalized such information should be posted prominently in various areas of the facility.
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 F0603
(Tag F0603)
Could have caused harm · This affected 1 resident
**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, interviews, record review, and document review, the facility failed to ensure a physician order was obtain...
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**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, interviews, record review, and document review, the facility failed to ensure a physician order was obtained or transcribed, and consent for the resident's transitioning to a secured unit was granted for 1 of 28 sampled residents (Resident 104). This deficient practice could potentially have led to resident's frustration, isolation, depression, emotional distress, a reduced quality of life, and a decline in their overall well-being.
Findings include:
Resident 104 (R104)
R104 was admitted on [DATE], with diagnoses including epilepsy, lack of coordination and unsteadiness on feet, and major depressive disorder.
The Brief Interview of Mental Status dated 07/10/2023, documented a score of 15/15, which indicated R104's cognitive status was intact.
The Nursing Evaluation dated 05/01/2021, documented R104 was not at risk for elopement or wandering.
R104's Minimum Data Set (MDS) revealed functional status with transfer, walk in room locomotion on and off unit, eating, and personal hygiene required supervision and set-up help only. Bed mobility, dressing, and toilet use required supervision with one person's physical assistance. Walk in the corridor only once or twice. The balance during transitions and walking was not steady but was able to stabilize without staff assistance. The mobility device used was a wheelchair.
The Nursing Progress Notes dated 12/21/2023, documented R104 demanded the medication at the nurses' station, accusing the nurse of not administering the evening medications correctly, sparking a heated argument. Later, the resident dialed 911 from R104's room, ventured outside, and was discovered by incoming staff.
Despite resistance, the staff managed to bring R104 back inside, emphasizing the risks of being left out in cold weather. R104 was relocated to the secured unit as a preventive measure against potential elopement, but R104 refused. The physician was informed and suggested reaching out to the psychiatrist for an evaluation. R104's family was notified.
The Nursing Progress Notes dated 12/21/2023, documented R104 agreed to a room change. R104's providers were aware of the room change due to elopement.
A Care Plan dated 12/21/2022, documented R104 was an elopement risk or wanderer-related impaired safety awareness. The interventions included were to assess and anticipate R104's needs.
On 08/30/2023 at 1:20 PM, R104 was residing in the retirement unit, alert and verbally oriented. R104 recalled the incident on 12/21/2022. R104 indicated at the time was so angry when the staff did not give the seizure medications. R104 indicated was angry because had felt the seizure aura (an aura is the feeling one may have before the onset of a seizure), but the staff just ignored R104. Following the incident, R104 propelled the wheelchair out of the building, and thought of going to the family's house, which was a mile away from the facility.
R104 indicated the maintenance staff saw R104 and brought the resident back inside the facility. R104 indicated the nursing staff relocated R104 to the [NAME] unit (a secured unit that required a code to enter and exit). R104 expressed frustration at being locked in the secured unit, which was against R104's will, and felt restricted because R104 did not know the door code. R104 indicated the next day, the previous Assistant Director of Nursing did move R104 back to the previous room in the retirement unit.
The census documented R104 was placed in the following room or unit:
12/22/2022, room [ROOM NUMBER]-B (retirement unit)
12/21/2022, room E10-A (secured unit)
11/30/2022, room [ROOM NUMBER]-B (retirement unit)
R104's medical records lacked documented evidence; a physician order was obtained and transcribed to place R104 in the secured unit, and there was no consent signed by R104.
On 08/31/2023 at 9:30 AM, the Director of Medical Records (DOMR) confirmed the room E10 was in on the [NAME] unit, was a secured unit. The DOMR indicated R104 could not freely get in and out of the unit because a code was required to gain entry and exit unless accompanied by a staff member. The DOMR indicated the resident's placement in a secured unit required an order.
On 08/31/2023 at 9:44 AM, the Director of Nursing (DON) was recently employed at the facility and unaware of the elopement incident. The DON indicated R104 was still housed at the facility, verbally alert, and oriented. The DON indicated if R104 had attempted to elope due to the seizure medication administration issues, there should have been a medication reconciliation performed. The DON indicated the action of placing R104 in the secured unit was inappropriate because R104 was alert and oriented.
On 08/31/2023 at 12:19 PM, the Unit Manager (UM) indicated was aware of R104's elopement on 12/21/2022, when the ADON and the UM went to the secured unit the next day post-incident and transitioned R104 back to the retirement unit. The UM recalled R104 was so angry at the time and refused to be in the secured unit.
The UM explained the criteria for being in the secured unit were recurrent confused wanderers, residents who had dementia, and those who displayed disruptive, abusive, or aggressive behavior required staff intervention and redirection. The UM verbalized R104 was non-ambulatory, and the least restrictive actions should have been taken, like one-to-one. The UM indicated R104's placement in a secured unit was an inappropriate intervention because the elopement incident was a first occurrence, R104's refusal to be transitioned, and R104 was alert and oriented with a BIMS score of 15/15.
On 09/01/2023 at 9:48 AM, the DON confirmed there was no documented evidence a physician order was obtained and transcribed, and no consent signed by R104 to transition from the retirement unit to the secured unit.
A facility policy tiled Elopement/Wandering/Exit Seeking, Unsafe Resident dated 07/10/2020, indicated the facility would strive to prevent unsafe wandering while maintaining the least restrictive environment for residents who were at risk for elopement. A care plan would be written for all residents at risk to include interventions that would be followed to reduce the risk.
Facility Reported Incident #NV00067646
CONCERN
(D)
Potential for Harm - no one hurt, but risky conditions existed
Deficiency F0655
(Tag F0655)
Could have caused harm · This affected 1 resident
**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, interview, record review and document review, the facility failed to ensure a baseline care plan was initi...
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**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, interview, record review and document review, the facility failed to ensure a baseline care plan was initiated for a resident who was admitted with an indwelling catheter for 1 of 28 sampled residents (Resident 132). The deficient practice placed the resident at risk for receiving inappropriate catheter care.
Findings include:
R132 was admitted on [DATE], with diagnoses including hemiplegia and hemiparesis with cerebral infarction and urinary retention.
On 08/29/2023 at 11:39 AM, R132 laid awake in a low bed. The resident was uncovered which revealed an incontinent brief, an indwelling catheter tubing stabilized on left upper thigh and a covered urinary bag hanging on left side of the bed.
A Nursing admission/readmission evaluation dated 07/17/2023, revealed R132 was admitted with an indwelling catheter 20 French (Fr -diameter size) and 30 cubic centimeters (cc) bulb for urinary retention.
A physician's order dated 07/17/2023, documented indwelling Foley catheter 20 Fr 30 cc balloon to dependent drainage. Justification: terminal illness for comfort. Cleanse catheter site with warm water and soap every shift and change drainage bag every two weeks on Sunday 11:00 AM to 7:00 PM shift.
On 08/31/2023 at 9:27 AM, R132 indicated the Foley catheter was inserted at the hospital and had not been replaced since admission to the facility on [DATE]. R132 indicated sometimes staff cleaned around the resident's catheter insertion site around the penis but sometimes staff did not.
The Urinary Catheter Care policy revised September 2014, instructed to review the resident's care plan to any special needs to the resident's catheter.
The medical record lacked documented evidence a plan of care was developed for R132's indwelling Foley catheter.
On 08/31/2023 at 10:17 AM, R132's indwelling catheter care plan was requested from the Registered Nurse (RN) Clinical Manager.
On 08/31/2023 at 11:18 AM, a follow up request was made to the Licensed Practical Nurse (LPN) assigned to R132's care. The LPN reviewed the resident's care plan and confirmed there was no care plan in place for R132's indwelling catheter. The LPN indicated R132 was admitted with an indwelling Foley catheter and the admission nurse should have initiated a baseline care plan for the resident's Foley catheter. According to the LPN, typical interventions included maintaining patency of tubing, perineal care, and assessment every shift, ensuring the bag is at drainage level, monitoring urine characteristics and reporting abnormalities to the physician.
On 08/31/2023 at 11:55 AM, the Director of Nursing (DON) indicated when a resident was admitted with an indwelling catheter and after continued use was determined by the physician, any nurse could and should have initiated a baseline care plan for the resident's indwelling catheter. The DON indicated typical interventions included maintaining patency of tubing, perineal care every shift, ensuring the bag is at drainage level, monitoring insertion site and urine characteristics and reporting abnormal findings to the physician. The DON indicated it was not acceptable to not have a care plan in place for R132's indwelling Foley catheter.
The Baseline Care Plan policy revised December 2016, documented a baseline plan of care shall be developed to meet the immediate needs of the resident within 48 hours from admission. To ensure immediate care needs were maintained and included any medications, treatments, and services to be administered.
CONCERN
(D)
Potential for Harm - no one hurt, but risky conditions existed
Quality of Care
(Tag F0684)
Could have caused harm · This affected 1 resident
**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, interview, record review, and document review, the facility failed to ensure a compression stocking was ap...
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**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, interview, record review, and document review, the facility failed to ensure a compression stocking was applied to treat edema as ordered for 1 of 28 sampled residents (Resident 104). This deficient practice placed the resident at risk of exacerbation of the resident's condition and could have compromised their overall health management.
Findings include:
Resident 104 (R104)
R104 was admitted on [DATE], with diagnoses including pain and hypertension.
The Brief Interview of Mental Status dated 07/10/2023, documented a score of 15/15, which indicated R104's cognitive status was intact.
The admission Nursing assessment dated [DATE], documented R104 had edema of bilateral lower extremities (BLE).
The Physician Progress Notes (undated), documented the assessment and plan, indicating BLE chronic edema elevation at bedtime and compression stockings were available.
A Physician order dated 03/23/2023, documented the placement of compression hose stockings on BLE in the morning and off at bedtime for edema.
A Care plan dated 05/10/2023, documented the compression stockings to be worn as ordered to prevent edema in R104's BLE.
On 08/29/2023 at 1:46 AM, was verbally alert and oriented. R104's lower extremities were moderately swollen, not elevated, and there were no compression stockings on.
The Medication Administration Record dated 08/29/2023 and 08/30/2023, documented R104's compression stockings were placed or applied to R104's BLE for edema.
On 08/30/2023 at 11:07 AM, R104 was seated in the wheelchair, verbally alert, and oriented. R104 indicated the compression stockings were not applied a long time ago, approximately for more than three months. R104 indicated when it was ordered, it was applied a few times but not anymore. R104 indicated the stockings were helping swelling of the lower extremities. A Registered Nurse (RN) confirmed the compression stockings were not applied to R104's lower extremities, but the order was signed off or documented in the MAR as applied.
On 08/30/2023 at 11:20 AM, a Registered Nurse who was assigned to R104 confirmed the stockings were not applied to R104's BLE and documented as applied.
On 08/30/2023 at 11:49 AM, a Unit Manager (UM) indicated the nurses were expected to follow the physician's order to apply the compression stockings to R104's lower extremities in the morning. The UM indicated if the compression stockings were no longer needed or the edema had been resolved, an assessment should have been done and the physician should have been notified to discontinue the order. The UM indicated the nurses were expected to document appropriately if an order was provided or not.
A facility policy titled Applying Anti-Emboli Stockings (TED Hose) revised 10/2010, documented the purpose of the procedure was to improve venous return to the heart, improve arterial circulation to the feet, minimize edema to the legs and feet, and prevent complications associated with deep vein thrombosis and pulmonary embolism.
CONCERN
(D)
Potential for Harm - no one hurt, but risky conditions existed
Incontinence Care
(Tag F0690)
Could have caused harm · This affected 1 resident
**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, interview, record review and document review, the facility failed to ensure appropriate indwelling cathete...
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**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, interview, record review and document review, the facility failed to ensure appropriate indwelling catheter care was provided and physician's orders were followed for 2 of 28 sampled residents (Resident 132 and 116). The deficient practice potentially resulted in a urinary tract infection (UTI) for Resident 132 and placed Resident 116 at risk for urethral trauma.
Findings include:
Resident 132 (R132)
R132 was admitted on [DATE], with diagnoses including hemiplegia and hemiparesis with cerebral infarction and urinary retention.
On 08/29/2023 at 11:39 AM, R132 laid awake in a low bed. The resident was wearing an incontinent brief, an indwelling catheter tubing was stabilized on left upper thigh and a covered urinary bag hung on left side of the bed.
A Nursing admission/readmission evaluation dated 07/17/2023, revealed R132 was admitted with an indwelling catheter 20 French (Fr diameter size) and 30 cubic centimeters (cc) bulb for urinary retention.
A physician's order dated 07/17/2023, documented indwelling Foley catheter 20 Fr 30 cc bulb to dependent drainage. Justification: terminal illness for comfort. Cleanse catheter site with warm water and soap every shift and change drainage bag every two weeks on Sundays 11:00 AM to 7:00 PM shift.
On 08/31/2023 at 9:27 AM, R132 indicated the Foley catheter was inserted at the hospital and had not been replaced since admission to the facility on [DATE]. R132 indicated sometimes staff cleaned around the resident's catheter insertion site around the penis but sometimes staff did not.
On 08/31/2023 at 9:30 AM, a Certified Nursing Assistant (CNA) and a Licensed Practical Nurse (LPN) were in R132's room when the resident permitted surveyor to be present for an indwelling catheter site assessment. The resident removed the incontinent brief with right hand exposing penile area and catheter tubing.
On 08/31/2023 at 9:31 AM, the LPN lifted R132's penis with gloved hand which revealed a thick, yellowish drainage which the LPN described, appears like pus. The LPN held the catheter tubing and indicated approximately two inches of the catheter tubing right by the insertion site had a heavy build-up of dried black and brown dirt mixture of unknown origin. The LPN assessed the resident's urine in the tubing and the urinary bag and stated R132's urine was cloudy and contained sediments.
On 08/31/2023 at 9:35 AM, the CNA indicated offering R132 perineal wash this morning, but the resident refused. The resident interrupted the CNA and denied refusing perineal care this morning and could not recall the CNA offering the service. The CNA indicated identifying the abnormal appearance of the resident's Foley catheter and urine during morning rounds and had intended to inform the nurse, but the breakfast carts arrived for meal distribution.
On 08/31/2023 at 9:36 AM, the LPN indicated the CNA should have communicated the resident's dirty catheter and purulent drainage to the nurse for timely interventions. According to the LPN, although R132 was afebrile and denied pain at the catheter insertion site, other signs and symptoms of a UTI were already present such as purulent drainage at insertion site, dirty catheter tubing and abnormal urine characteristics.
On 08/31/2023 at 9:39 AM, the LPN reviewed the resident's medication administration record (MAR) which revealed nursing staff have been documenting catheter care specifically, washing catheter site with soap and warm water every shift and site assessment every shift as being completed with the exception of two dates - 07/23/2023 and 08/02/2023. The LPN verbalized there were two possibilities: 1) nursing staff were documenting the service as completed without providing the care, or 2) nursing staff provided care but not meticulously in accordance with facility practice because according to the LPN, the heavy buildup of dirt around the catheter site would have accumulated over time and not overnight.
On 08/31/2023 at 9:57 AM, the Registered Nurse (RN) Clinical Manager reviewed R132's medical record and confirmed there were two missed catheter care administrations on 07/23/2023 and 08/02/2023. The RN Clinical Manager indicated Foley care must be provided meticulously in accordance with facility policy every shift. The RN Clinical Manager expressed agreement with the LPN who indicated it was possible staff were documenting for unprovided care or catheter care was being provided poorly.
On 08/31/2023 at 10:12 AM, the RN Clinical Manager indicated the CNA who offered to do R132's perineal care this morning should have stressed the importance of cleansing the site and described the abnormalities identified to the resident. The RN Clinical Manager indicated the CNA should have also informed the nurse of the purulent drainage, dirty tubing, and cloudy urine with sediments immediately since these were all signs and symptoms of a UTI process.
A nursing note dated 08/31/2023, documented R132's catheter site with purulent drainage from penis. Foley catheter tubing tube noted to be dirty with dried up matter of unknown origin. Urine bag contained cloudy urine with sediments. Physician and RN Supervisor notified.
A physician's order dated 08/31/2023, documented to change out Foley with Fr 18 five cc balloon. Do urinalysis and culture and sensitivity.
On 08/31/2023 at 11:47 AM, the Director of Nursing (DON) indicated care orders were in place for R132's Foley catheter when the resident was admitted with on 07/17/2023. Care included assessment every shift by a licensed nurse and perineal care every shift by a CNA. The DON expressed agreement with the LPN and RN Clinical Manager who indicated it was possible site assessment and perineal care were being documented as completed but not provided and it was also possible catheter care was being provided but not meticulously in accordance with the facility's procedure for catheter care. The DON indicated the lack of care provided to R132's Foley catheter potentially resulted in an unconfirmed UTI.
The Urinary Catheter Care policy revised September 2014, documented to wash the resident's genitalia with soap and water, rinse very well and dry. Observe the resident for signs and symptoms of UTI. Document the date and time catheter care was provided to include assessment data such as urine characteristics. Report findings to the Supervisor and Physician immediately.
Resident 116 (R116)
R116 was admitted on [DATE] and readmitted on [DATE], diagnoses included stage three pressure ulcers and dementia.
On 8/29/2023 at 9:42 AM, R116 lay in bed and non-interviewable. A Foley catheter 16 French (Fr) times (x) 10 cc (centimeters) balloon, newly changed and dated 08/28/2023, draining with yellow-colored urine at 300 cc with no sediments.
The History and Physical dated 09/13/2022, documented R116 had a Foley catheter for neurogenic bladder.
The Nursing admission Evaluation dated 04/18/2023, documented R116 had a Foley catheter 16 Fr. The Foley balloon size was not indicated.
A Care Plan dated 04/26/2023, documented R116 had a Foley catheter 16 Fr x 30 cc balloon and was at risk for catheter-related trauma.
A physician order dated 07/03/2023, documented indwelling catheter 16 Fr x 30 cc and monitor intake and output.
On 08/29/2023 at 4:43 PM, a Licensed Practical Nurse (LPN) explained R116 had a stage three pressure wound which justified the use of a Foley catheter. An LPN confirmed the Foley order specified a Foley catheter of 16 Fr with a 30 cc balloon, but the Foley catheter in place was a 16 Fr with a 10 cc balloon, indicating the order had not been followed. An RN explained the correct size might not have been available, which could explain why the inserted Foley catheter did not match the order.
On 09/29/2023 at 4:45 PM, the Unit Manager (UM) indicated the Foley size order should have been followed because the 10 cc balloon was smaller and had the potential for dislodgement and subsequent reinsertion. The UM verbalized the nurses were expected to verify the Foley orders properly to prevent any potential trauma. The UM indicated if the Foley size order was not available, the physician should have been notified to clarify the order.
CONCERN
(D)
Potential for Harm - no one hurt, but risky conditions existed
Deficiency F0694
(Tag F0694)
Could have caused harm · This affected 1 resident
**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, interview, record review and document review, the facility failed to ensure a resident's midline intraveno...
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**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, interview, record review and document review, the facility failed to ensure a resident's midline intravenous dressing change was performed in accordance with facility policy and physician's orders for 1 of 28 sampled residents (Resident 130). The deficient practice placed the resident at risk for phlebitis (site infection).
Findings include:
Resident 130 (R130)
R130 was admitted on [DATE], with diagnoses including end-stage renal disease and osteomyelitis of the foot.
On 08/29/2023 at 10:37 AM, R130 was seated on the left side of the bed, an intravenous (IV) access with purple port was observed on R130's left upper arm. The IV access was covered in transparent dressing with a soiled gauze pad underneath. The IV dressing was dated 08/28/2023 and was coming loose on all ends, a strip of plastic tape reinforced the right side of the dressing. R130 pointed to an IV pole on the left side of the bed and indicated receiving IV antibiotics for a foot infection. According to R130, the IV dressing had not been changed in more than a week but a nurse entered the resident's room earlier in the morning to write the date 08/28/2023 without providing care to the resident's IV access.
On 08/29/2023 at 10:42 AM, a Licensed Practical Nurse (LPN) and a Registered Nurse (RN) entered the resident's room and described R130's left upper arm IV access as dirty, gauze soiled with brownish matter and the dressing was coming loose at all ends. The LPN indicated the brown matter appeared to be old blood. The LPN and RN were in the room when R130 emphasized the IV site had not been cleaned nor the dressing changed in more than a week, but a tall nurse came in to write the date 08/28/2023 on the IV dressing. The LPN and RN explained IV dressing changes were performed weekly and when needed when the IV site was soiled or loose. The LPN and RN verbalized R130's IV site did not appear to have been cleaned and changed on 08/28/2023 but could not speak to why the dressing was dated as if care was provided on 08/28/2023.
On 08/29/2023 at 10:49 AM, the RN Clinical Manager entered the resident's room and R130 identified the RN Clinical Manager as the nurse who wrote the date 08/28/2023 on the resident's IV dressing earlier in the morning. The RN Clinical Manager admitted to writing 08/28/2023 on R130's IV dressing. The RN Clinical Manager acknowledged not providing care to R130's IV line when the RN wrote the date 08/28/2023 on R130's midline dressing. The RN Clinical Manager stated it was the wrong thing to do and went against the facility's practice for midline care.
On 08/29/2023 at 11:00 AM, the Director of Nursing (DON) entered the resident's room and described R130's left upper arm midline dressing was dirty, gauze soiled with brownish matter of unknown origin, dressing coming loose at all ends with date written 08/28/2023. The LPN, RN and RN Clinical Manager were in the room when the DON explained IV dressing changes were performed weekly and as needed when soiled or coming loose. The DON verbalized R130's midline did not appear to have been cleaned or changed on 08/28/2023 as the date suggested. The DON indicated when the RN Clinical Manager was making morning rounds, the RN Clinical Manager should have identified the site as dirty, soiled, and loose and should have cleaned and replaced the midline dressing prior to affixing the date. The DON indicated consequences to not providing proper midline care included phlebitis (site infection).
A consent for midline catheter dated 08/20/2023, revealed a single lumen midline catheter was inserted into R130's left arm.
A physician's order dated 08/20/2023, documented to give Merrem reconstituted solution 500 milligrams intravenously at bedtime for 14 days.
A physician's order dated 08/24/2023, documented to perform midline dressing change every Mondays by night shift nurse. Cleanse insertion site with Betadine times three swabs, alcohol wipes times three swabs, air dry and cover with transparent dressing.
The Medication Administration Record (MAR) for August 2023, documented the resident's midline dressing change was scheduled for 08/28/2023 by Monday night shift. The MAR revealed the dressing change for R130's midline was not provided as scheduled.
On 08/30/2023 at 7:15 AM the DON assessed R130's midline and described the site as clean, dry, intact with date 08/29/2023. The DON emphasized this was how a one-day old dressing should look like. The DON confirmed R130's midline care specifically cleaning the insertion site and dressing change was not performed in accordance with facility policy and the physician's orders. According to the DON, it was not acceptable for the RN Clinical Manager to write a date on R130's midline dressing without providing care to the midline.
The Midline Dressing Changes policy revised April 2016, revealed midline catheter dressing must be performed 24 hours after catheter insertion, every five to seven days, or when wet, soiled, dirty, not intact or compromised in any way. The purpose of the procedure was to prevent catheter-related infections associated with contaminated, loosened, or soiled catheter-site dressings.
CONCERN
(D)
Potential for Harm - no one hurt, but risky conditions existed
Respiratory Care
(Tag F0695)
Could have caused harm · This affected 1 resident
**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, interview, record review, and document review, the facility failed to ensure the Oxygen (O2) order was fol...
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**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, interview, record review, and document review, the facility failed to ensure the Oxygen (O2) order was followed for 1 of 28 sampled residents (Resident 91). This deficient practice could lead to serious health complications, incorrect dosages, or adverse reactions.
Findings include:
Resident 91 (R91)
R91 was admitted on [DATE] and readmitted on [DATE], with diagnoses including chronic obstructive pulmonary disease (COPD) with exacerbation, dependence on supplemental Oxygen and obstructive sleep apnea.
The Brief Interview of Mental Status dated 07/12/2023, documented a score of 15/15, which indicated R91's cognitive status was intact.
The Minimum Data Sheet dated 07/12/2023, documented R91 was on Oxygen therapy.
A Care Plan dated 04/28/2023, documented R91 had altered respiratory status due to COPD and smoking. The interventions included administering the medication and treatment as ordered.
A physician order dated 07/18/2023, documented the administration of O2 inhalation at 2 liters per minute via nasal cannula continuously.
On 08/29/2023 at 8:30 AM, R91 lay in bed, alert and verbally responsive. O2 was flowing at 4 LPM via nasal cannula. R91 indicated was on O2 for two years continuously after being positive for COVID-19. R91 had no signs or symptoms of respiratory distress.
On 08/29/2023 at 10:53 AM, R91 lay in bed, and O2 was on at 4 LPM via nasal cannula. R91 indicated the staff administered the O2. The O2 tubing was dated 08/28/2023.
The Medication Administration Record dated 08/29/2023, documented R91's O2 was administered at 2 LPM when the actual O2 delivered was at 4 LPM.
On 08/30/2023 at 12:24 PM, R91's O2 was on at 4 LPM via nasal cannula. A Licensed Practical Nurse confirmed R91's O2 was on at 4 LPM, but the order indicated 2 LPM. The LPN indicated the nurses were responsible for ensuring the O2 order was administered as ordered or to notify the physician to clarify the order.
On 08/30/2023 at 10:00 AM, a Unit Manager (UM) indicated with the resident's O2 the order should have been verified to match the actual 02 administered. The UM indicated the nurses were expected to follow the orders and, if clarification was needed, notify the physician.
A facility policy titled Oxygen Administration revised 2010, documented to verify there was a physician order for the procedure. Review the physician orders or facility protocol for O2 administration. Review the resident's care plan to assess any special needs.
CONCERN
(D)
Potential for Harm - no one hurt, but risky conditions existed
Deficiency F0697
(Tag F0697)
Could have caused harm · This affected 1 resident
**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Resident 101 (R101)
R101 was admitted on [DATE] with diagnoses including muscle spasm and fibromyalgia.
The Brief Interview of M...
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**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Resident 101 (R101)
R101 was admitted on [DATE] with diagnoses including muscle spasm and fibromyalgia.
The Brief Interview of Mental Status dated 06/13/2023, documented a score of 15/15, which meant R101's cognitive status was intact.
On 08/29/2023 at 8:58 AM, R101 indicated they endured pain due to having fibromyalgia and their scheduled muscle relaxer medication was sometimes administered late which made them feel frustrated.
R101's medical record revealed a physician had an order on dated 03/13/2023 for Tizanidine HCL tablet, four milligrams (mg); give one tablet by mouth three times a day related to other muscle spasm.
The August 2023 Medication Administration Record (MAR) revealed Tizanidine was administered three times a day as ordered, however, the MAR lacked documentation of the actual time the medication was administered.
On 08/31/2023 at 2:48 PM, a Unit Manager explained the facility's window for administering medication was within one hour before and after the scheduled time. The Unit Manager reviewed R101's medical record and indicated Tizanidine was administered at 9 AM, 1 PM, and 5 PM. The Unit Manager reported the following late administration of Tizanidine between 08/08/2023 through 08/31/2023 (23 days):
08/11/2023- scheduled at 9:00 AM, given at 10:08 AM (eight minutes late).
08/11/2023- scheduled at 1:00 PM- given at 2:09 PM (nine minutes late).
08/13/2023- scheduled at 9:00 AM, given at 10:14 AM (14 minutes late).
08/15/2023- scheduled at 9:00 AM, given at 10:34 AM (34 minutes late).
08/19/2023- scheduled at 1:00 PM, given at 2:32PM (32 minutes late).
08/20/2023- scheduled at 9:00 AM, given at 10:52 AM (52 minutes late).
08/27/2023- scheduled at 9:00 AM, given at 10:35 AM (35 minutes late).
08/28/2023- scheduled at 9:00 AM, given at 10:56 AM (56 minutes late).
The medical record revealed Tizanidine was administered late on eight occasions in a 23-day period. The Unit Manager confirmed this information.
The Unit Manager explained it was important to follow the scheduled time of medication administration and if medications were administered late, it can be considered double dosing which can impact the interaction of medications.
R101's care plan for pain management included an intervention to administer medications as ordered.
A facility policy titled Medication Administration Schedule revised November 2020, documented scheduled medications are administered within one hour of their prescribed time.
Based on observation, interview, record review, and document review, the facility failed to ensure a pain medication was not administered late for 1 of 28 sampled residents (Resident 101). This deficient practice placed the resident at risk for inadequate pain relief, potential discomfort and compromised quality of life.
CONCERN
(D)
Potential for Harm - no one hurt, but risky conditions existed
Deficiency F0698
(Tag F0698)
Could have caused harm · This affected 1 resident
**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, interview, record review and document review, the facility failed to ensure 1) dialysis communication reco...
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**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, interview, record review and document review, the facility failed to ensure 1) dialysis communication records were completed for 1 of 28 sampled residents (Resident 130) and 2) an agreement was obtained with the dialysis provider for 1 of 28 sampled residents (Resident 130) and one unsampled resident (Resident 343). The deficient practice potentially placed the residents at risk for improper coordination of care between the facility and the dialysis provider.
Findings include:
Resident 130 (R130)
R130 was admitted on [DATE], with diagnoses including end-stage renal disease (ESRD), diabetes mellitus and osteomyelitis of the foot.
On 08/29/2023 at 10:37 AM, R130 pulled down shirt which revealed a right central venous catheter (CVC) dressed in white gauze. R130 explained the CVC was used for dialysis (renal replacement therapy).
A physician's order dated 07/17/2023, revealed R130 was scheduled to receive dialysis at a dialysis clinic on Tuesdays, Thursdays, and Saturdays with a prescribed run time of three hours and 30 minutes.
On 08/30/2023 in the morning, the Medical Records (MR) Director provided R130's hemodialysis communication sheets from admission on [DATE] which revealed dialysis communication sheets were not completed on 07/18/2023, 07/20/2023, 07/22/2023, 07/25/2023, 07/29/2023, 08/03/2023, 08/10/2023, 08/12/2023, and 08/17/2023.
Resident 343 (R343)
R343 was admitted on [DATE], with diagnoses including ESRD and sepsis.
On 08/29/2023 in the morning, R343 laid alert in bed. R343 indicated being newly admitted the evening prior and was just getting settled in the resident's room. A blue bag bearing the name of the dialysis provider was observed in the room containing the resident's personal belongings.
A physician's order dated 08/28/2023, documented R343 was scheduled to receive dialysis at a dialysis clinic on Tuesdays, Thursdays, and Saturdays.
On 08/30/2023 at 12:14 PM, the Administrator and the Business Office Manager confirmed the facility currently did not have a signed agreement with the dialysis provider who provided dialysis treatments for R130 and R343.
On 08/30/2023 at 12:20 PM, the Director of Nursing (DON) explained the hemodialysis communication sheets were to be utilized by the facility and the dialysis provider when coordinating care for dialysis residents, specifically for R130 and R343. The DON indicated expecting a two-way communication between the facility and the dialysis provider which may include pertinent information regarding the resident's ESRD care such as vascular access appointment and care, medications, laboratory orders, infection status and vital signs, etc.
On 08/30/2023 at 12:30 PM, the Clinical Manager at the dialysis clinic confirmed R130 was a dialysis patient at the clinic and indicated there was no signed agreement between the dialysis provider and the skilled nursing facility.
The Care of a Resident with End-Stage Renal Disease (ESRD) policy revised September 2010, revealed an agreement between the facility and the contracted ESRD facility would include all aspects of how care would be managed, including how information would be exchanged between the facilities, how the care plan should be developed and implemented which must reflect the resident's needs related to ESRD dialysis care.
CONCERN
(D)
Potential for Harm - no one hurt, but risky conditions existed
Pharmacy Services
(Tag F0755)
Could have caused harm · This affected 1 resident
**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, interview, record review and document review, the facility failed to ensure a sufficient supply of a presc...
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**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, interview, record review and document review, the facility failed to ensure a sufficient supply of a prescribed medication for 1 of 28 sampled residents (Resident 124). The deficient practice resulted in an omitted dose and placed the resident at risk for hypertension.
Findings include:
Resident 124 (R124)
R124 was admitted on [DATE], with diagnoses including essential hypertension.
On 08/30/2023 at 9:10 AM, a Licensed Practical Nurse (LPN) was observed preparing and administering R124's routine morning medications.
A physician's order dated 08/18/2023, documented to give Amlodipine Besylate 10 milligrams (mg) one tablet by mouth once daily for hypertension. Hold for systolic blood pressure (BP) less than 110 millimeters of Mercury (mmHg).
On 08/30/2023 at 9:13 AM, the LPN indicated R124's anti-hypertensive medication Amlodipine was scheduled to be administered and the resident met the criteria with a recorded BP of 120/99 mmHg. The LPN held the empty medication blister pack of the resident's Amlodipine and indicated the medication could not be administered due to being unavailable. The LPN explained it was the LPN's first shift for the week and the nurse who worked the previous shift should have ordered the medication to prevent the omitted dose. The LPN explained the facility had reminded nurses to place medication orders when supply was running low, when there was about three to seven days left. According to the LPN, pharmacy made three deliveries daily and a routine medication could be delivered within the same shift or day for as long as they were ordered timely.
On 08/30/2023 in the morning, an inspection of two medication rooms revealed the facility did not have a medication-dispensing system. An LPN indicated not relying on a medication-dispensing system for routine medications because medication orders were easy to place by telephone or facsimile and the contracted pharmacy was efficient with fulfilling deliveries. The LPN indicated nurses were reminded to place orders when medications were running on low supply, about three to seven days to prevent omitted doses.
A nursing note dated 08/30/2023, documented Amlodipine Besylate 10 mg not given due to medication unavailability.
On 08/30/2023 in the afternoon, the Director of Nursing (DON) indicated there was no excuse for the missed administration of R124's scheduled anti-hypertensive medication because any nurse who identified the medication was running in low supply should have followed the facility practice of placing a pharmacy order for R124's Amlodipine Besylate.
On 08/30/2023 at 2:21 PM, the Consultant Pharmacist indicated Amlodipine Besylate was a routine drug which could easily be supplied within the same shift or day if the order was placed timely. The Pharmacist indicated nurses were reminded to place orders when medications had about three days left. The Pharmacist stated it was inexcusable for R124's Amlodipine to have been missed due to a failure in following the facility's medication ordering policy.
The Medication Ordering and Receiving from Pharmacy policy revised November 2011, revealed reordering of medications was done in accordance with the order and delivery schedule developed by the pharmacy provider. Reorder medications three to four days in advance of need, to assure an adequate supply is on hand. The Licensed Nurse who received the medication verified medications received and promptly reported discrepancies and omissions to the pharmacist and charge nurse/Supervisor.
CONCERN
(D)
Potential for Harm - no one hurt, but risky conditions existed
Unnecessary Medications
(Tag F0759)
Could have caused harm · This affected 1 resident
**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, interview, record review and document review the facility failed to ensure it was free from a medication e...
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**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, interview, record review and document review the facility failed to ensure it was free from a medication error rate of five percent (%) or greater for three unsampled residents (Residents 32, 3 and 124). The deficient practice placed residents at risk for medication errors.
Findings include:
On 08/30/2023 in the morning, a Medication Administration Pass observation was performed with 28 opportunities observed and revealed three errors. The medication error rate was 10.71 %.
Resident 32 (R32)
R32 was admitted on [DATE], with diagnoses including heart failure and epilepsy.
On 08/30/2023 at 8:43 AM, a Licensed Practical Nurse (LPN) prepared and administered the following medications to R32:
- Ferrous Sulfate 325 milligrams (mg) one tablet
- Folic acid 400 micrograms (mcg) one tablet
- Gabapentin 100 mg one tablet
- Apixaban 5 mg one tablet
- Levetiracetam 500 mg one tablet
- Divalproex 250 mg extended release three tablets
- Cephalexin 500 mg one tablet
- Metoprolol succinate 250 mg extended release one tablet
A physician's order dated 08/11/2023, documented to give Folic Acid one mg one tablet by mouth for supplement.
On 08/30/2023 at 1:49 PM, the Licensed Practical Nurse (LPN) confirmed the Folic acid order was for one milligram, but the actual dose administered was Folic acid 400 mcg which was an over-the-counter supply because the facility did not have Folic acid one milligram available.
On 08/30/2023 in the afternoon, the Director of Nursing (DON) indicated Folic acid 400 mcg strength was not the same as Folic acid 1 milligram. The DON indicated if there was no Folic acid one milligram on stock, the nurse could contact the physician to possibly modify the order to Folic acid 400 mcg until a Folic acid one milligram could be obtained.
Resident 3 (R3)
R3 was admitted on [DATE], with diagnoses including chronic pain syndrome.
On 08/30/2023 at 8:50 AM, an LPN prepared and administered the following medications to R3:
- Lidocaine ointment 5 %
- Levetiracetam 500 mg one tablet
- Apixaban 5 mg one tablet
- Venlafaxine 75 mg extended release (ER) one tablet
- Macrobid 100 mg one tablet
- Vitamin D 50 micrograms (mcg) 2,000 international units (IU) one tablet
- Aspirin 81 mg delayed release one tablet
- Ascorbic acid 500 mg one tablet
- Lisinopril 5 mg one tablet
- Clonazepam 0.05 mg one tablet
- Lacosamide 50 mg one tablet
- Pregabalin 100 mg one tablet
A physician's order dated 07/04/2023, documented to give Aspercreme Lidocaine 4% apply to lower back two times a day.
On 08/30/2023 at 1:52 PM, the LPN confirmed Lidocaine 5% was applied to R3's lower back this morning instead of the physician's order Aspercreme Lidocaine 4% because pharmacy delivered Lidocaine 5% instead of Aspercreme Lidocaine 4%.
On 08/30/2023 in the afternoon, the DON indicated Aspercreme 4% was not the same as Lidocaine 5%. The DON indicated when nurses identified discrepancies between the physician's order and the actual medication delivered by pharmacy, a clarification must be obtained from the physician and final orders communicated to pharmacy to ensure medication orders match what was being administered to the residents.
Resident 124 (R124)
R124 was admitted on [DATE], with diagnoses including essential hypertension.
On 08/30/2023 at 9:10 AM, an LPN prepared and administered the following medications to R124:
- Ascorbic acid 500 mg one tablet
- Docusate Sodium 100 mg one tablet
- Januvia 50 mg one tablet
- Lurasidone 60 mg one tablet
- Benztropine 1 mg one tablet
- Aspirin chewable 81 mg one tablet
- Doxazosin 2 mg one tablet
A physician's order dated 08/18/2023, documented to give Amlodipine Besylate 10 mg one tablet by mouth once daily for hypertension. Hold for systolic blood pressure (BP) less than 110 millimeters of Mercury (mmHg).
On 08/30/2023 at 9:13 AM, the LPN indicated R124's BP was 120/99 and the anti-hypertensive medication Amlodipine was scheduled to be administered at 9:00 AM but the nurse who worked the previous shift failed to re-order the medication which could not be administered due to being unavailable. The LPN held the empty medication blister pack with hands and indicated when supply was running low, nurses should re-order the medication by phone. According to the LPN, pharmacy made three deliveries daily and a routine medication could be delivered within the same shift or day for as long as they were ordered timely.
On 08/30/2023 at 2:02 PM, an LPN was present during inspection of the medication storage room where no medication-dispensing system was observed. The LPN indicated medication orders were easy to place by telephone or facsimile and nurses were reminded to place orders when medications were running on low supply, about three to seven days to make sure.
On 08/30/2023 in the afternoon, the DON indicated omitted doses counted as medication errors since the medication was not administered in accordance with physician's order. The DON indicated there was no excuse for the missed administration of R124's scheduled anti-hypertensive medication because any nurse who identified the medication was running in low supply should have followed the facility practice of placing a pharmacy re-order.
On 08/30/2023 at 2:21 PM, the DON was present during the interview with the Consultant Pharmacist. The Consultant Pharmacist explained:
1. Folic acid 400 mcg was the highest available dose sold over the counter for Folic acid. Folic acid one milligram was prescription strength, required a physician's order and provided by pharmacy. The Consultant Pharmacist indicated Folic acid 400 mcg and Folic acid one milligram were not the same and a nurse should have sought clarification from R32's physician.
2. Aspercreme Lidocaine 4% was not the same as Lidocaine 5%. According to the Consultant Pharmacist, medication nurses should contact the physician for clarification when discrepancies were identified between the physician's order and the actual medication delivered for the resident. The Consultant Pharmacist indicated it was common practice for pharmacy to dispense generic version for brand name medications but in this case the medication strength was not the same and a clarification should have been obtained from the physician.
3. Amlodipine Besylate was a routine drug which was not backordered. According to the Consultant Pharmacist, facility nurses have been reminded multiple times to place medication orders when medications were running in low supply, preferably when there were three days left in stock. According to the Pharmacist, R124's missed Amlodipine dose on 08/30/2023 was preventable if the nurse followed the facility's practice for re-ordering medications since the medication could be delivered right away within the same shift or day if ordered timely.
On 08/30/2023 at 2:31 PM, the Consultant Pharmacist indicated physician's orders must match the medications administered and discrepancies must be clarified with the physician and communicated to pharmacy. The Consultant Pharmacist indicated it was fair to consider R32's Lidocaine ointment, R3's Folic acid and R124's Amlodipine as medication errors.
The Medication Ordering and Receiving from Pharmacy policy revised November 2011, revealed reordering of medications was done in accordance with the order and delivery schedule developed by the pharmacy provider. Reorder medications three to four days in advance of need, to assure an adequate supply is on hand. The Licensed Nurse who received the medication verified medications received and promptly reported discrepancies and omissions to the pharmacist and charge nurse/Supervisor.
CONCERN
(D)
Potential for Harm - no one hurt, but risky conditions existed
Deficiency F0804
(Tag F0804)
Could have caused harm · This affected 1 resident
**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, interview, and document review, the facility failed to ensure food was palatable, attractive, and served a...
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**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, interview, and document review, the facility failed to ensure food was palatable, attractive, and served at an appetizing temperature when hot cereal was prepared and served with a solid consistency rather than the customary semi-liquid consistency; and not served at an appetizing temperature (too cold), for one sampled resident (Resident 89) and two unsampled residents. The deficient practice had the potential to decrease the amount of nutrients consumed by residents, and also the resident's perception of their quality of life.
Findings:
On 08/31/2023 at 8:10 AM, Resident 89 (R89) was alert and answered questions appropriately. R89 verbalized having been served cream of wheat in the form of one large cold lump in the bowl. R89 reported having to ask staff for assistance in breaking up the lump so it could be consumed.
On 08/29/2023, in the morning, one unsampled resident complained of being served hard (congealed) cream of wheat with today's breakfast.
On 8/31/2023 at 8:00 AM, one unsampled resident's breakfast tray included a bowl of hot cereal. The resident showed the surveyor the cereal in the bowl. The cereal was observed in a large lump. The resident indicated the cereal lump was hard and it came cold. The resident verbalized not wanting to eat the cereal. The resident reported having been served cold hard cereal on a frequent basis.
On 08/30/20233 at 2:00 PM, a meeting with the five residents including the Resident Council President was conducted. All five residents reported having been served hard cream of wheat cereal.
Resident Council Minutes from May and June of 2023 listed concerns with hard cream of wheat, and lacked documentation the concern had been addressed.
On 08/31/2023, in the morning, oatmeal served to an unsampled resident in the [NAME] Hall unit had the approximate consistency of potato salad and maintained a rounded semi-spherical shape in the bowl.
On 08/31/2023, in the morning, the Dietary Supervisor (DS) verbalized hot cereal such as oatmeal and cream of wheat were customarily served hot and with a semi-liquid consistency. The DS verified the oatmeal observed was a solid lump rather than a semi-liquid consistency and verbalized this was not a palatable or attractive presentation for hot cereal. The DS verbalized the cook should have added more liquid to the oatmeal to ensure the correct consistency, and the same would hold true for the cream of wheat.
CONCERN
(E)
Potential for Harm - no one hurt, but risky conditions existed
Deficiency F0565
(Tag F0565)
Could have caused harm · This affected multiple residents
Based on observation, interview, and document review, the facility failed to ensure the views and recommendations of the resident group were acted upon, and the response and rationale communicated bac...
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Based on observation, interview, and document review, the facility failed to ensure the views and recommendations of the resident group were acted upon, and the response and rationale communicated back to the resident group. The failed practice had the potential to affect the quality of life and health status of some residents.
Findings:
The policy and procedure titled Resident Council, Revised February 2021, indicated the purpose of the resident council was to provide a forum for residents to have input on the operation of the facility, including discussions of concerns and suggestions for improvement. The policy indicated the Resident Council Response Form was utilized to track issues and their resolutions. The facility department which was related to any specific issues was responsible for addressing the item(s) of concern.
Resident council meeting minutes documented the following:
On 02/22/2023, 16 residents and five staff had attended a resident council meeting.
New Business notes indicated issues of Breakfast, chicken and pork terrible tasting. Want to discuss menu changes and condiments on trays, CNA- not good attitudes when working with residents. Maintenance -walking into room unannounced. And contractors.
The meeting minutes indicated the Dietary Supervisor met with the resident council and expressed an intention to work with resident requests in accordance with dietary requirements.
Under the heading of Department Response, the meeting minutes lacked documented evidence of a facility response to address the resident council concerns with dietary, nursing and maintenance services.
The meeting minutes lacked evidence the document had been reviewed by the Administrator or designee.
On 05/29/2023, 10 residents and three staff had attended a resident council meeting.
New business included a concern with hard cream of wheat cereal and running out of wheat bread.
Under the heading of Department Response, the meeting minutes lacked documented evidence of a facility response to address the resident council concerns regarding hard cream of wheat and running out of wheat toast.
The meeting minutes lacked evidence the document had been reviewed by the Administrator or designee.
On 06/23/2023, one resident (the Resident Council President) and seven staff had attended a resident council meeting.
The section titled Old Business - Review of Previous Meeting, Outstanding Issues and Resident Council Departmental Response Form included concerns with hard cream of wheat and running out of wheat toast.
Under the heading of Department Response, the meeting minutes lacked documented evidence of a facility response to address the resident council concerns regarding hard cream of wheat and running out of wheat toast.
The meeting minutes lacked evidence the document had been reviewed by the Administrator or designee.
On 07/27/2023, 13 residents and two staff had attended a resident council meeting.
The section titled Old Business - Review of Previous Meeting, Outstanding Issues and Resident Council Departmental Response Form included a concern regarding night-shift staff not responding to call lights.
Under the heading of Department Response, the meeting minutes lacked documented evidence of a facility action taken to address the concern regarding call light response.
On 08/25/2023, 20 residents and seven staff had attended a resident council meeting.
The section titled Old Business - Review of Previous Meeting, Outstanding Issues and Resident Council Departmental Response Form included a concern about a specific maintenance staff entering the resident room with other staff without asking for permission from the resident first.
New Business notes indicated there were unspecified food concerns.
Under the heading of Department Response, the meeting minutes lacked documented evidence of a facility response to address the resident council concerns regarding the privacy and food.
In summary, the Resident Council meeting minutes lacked documented evidence there had been facility actions taken to address resident council concerns regarding food, call light response, and privacy/dignity issues.
On 08/30/20233 at 2:00 PM, a meeting with the five residents including the Resident Council President was conducted. All five of the residents reported concerns including the following:
-Dietary: Menu had too much chicken, food was too salty, tough meat, over-cooked vegetables, cold food, overly congealed and hard cream of wheat cereal, stale bread, and food causing diarrhea after being consumed.
-Nursing: One of the residents reported being left wet for an extended period of time due to delayed response to their call light. Four other residents verbalized having also experienced significant delays in staff response to call lights and all felt concerned about the situation. The residents thought the facility needed more staff particularly on night shift and weekends.
-Privacy/Dignity: One female resident reported having been caught undressed in their room by a hearing impaired maintenance staff person who entered without warning. This concern was reported but the resident felt it had not been addressed.
All five residents reported staff, including the Activity Director, had been informed of these resident council concerns. The residents reported having had multiple conversations with the Dietary Supervisor, the Director of Nursing, and the Maintenance Director regarding the issues, however the facility had not communicated back to the group what actions had been taken. The residents expressed the issues remained unresolved.
On 08/29/2023, in the morning, one unsampled resident verbalized having eaten a meatball served the prior Sunday which had a bad taste. The resident stated they had developed diarrhea after eating the meatball.
On 08/29/2029, in the morning, two unsampled residents verbalized the facility food lacked variety, was bland and did not taste good.
On 08/29/2023 at 9:41 AM, one unsampled resident complained of bland food which was served cold, not having sufficient variety on the menu, and with breakfast today, had received a burnt sausage which was hard and inedible.
On 08/29/2023, in the morning, one unsampled resident complained of being served hard (congealed) cream of wheat with today's breakfast.
On 8/31/2023 at 8:00 AM, an unsampled resident's breakfast tray included a bowl of hot cereal. The resident showed the surveyor the cereal in the bowl. The cereal was observed in a large lump. The resident indicated the cereal lump was hard and it came cold. The resident indicated they were not planning to eat the cereal. The resident indicated being served hard cereal on a frequent basis.
On 08/31/23 at 9:08 AM the Administrator (ADM) was notified of the concerns identified from the resident council meeting minutes and resident interviews. The ADM verbalized attending some of the resident council meetings, and at the meetings having been aware of food concerns voiced by residents. The ADM reported believing the Dietary Supervisor (DS) had resolved the concerns to each resident's satisfaction, with the exception of several residents who habitually complained about the food no matter what was offered. The ADM verbalized having been made aware of resident concerns about staffing and call bells response time and believed the Director of Nursing (DON) had addressed and resolved those concerns. The ADM was not sure if measures taken to address the concerns were documented. The ADM verbalized the department heads should be documenting what had been done to resolve resident issues.
On 08/31/20233 at 9:25 AM, the DS verbalized in response to resident food concerns and suggestions, the DS had implemented corrective measures such as seasonal menu changes and alternate menu items. The DS verbalized having spoken to individual residents with food concerns and felt the issues had been resolved except for several residents who were very difficult to please. The DS was not sure if these corrective measures had been documented and planned to look at dietary documents to confirm.
On 08/31/2023 at 10:34 AM, the DS reviewed the resident council Department Responses forms regarding resident food issues and verified actions the DS had taken to resolve the concerns had not been documented. The DS verbalized thinking the Activities Director (AD) may have documented the interventions but was not sure. The DS verbalized having met with residents and resolved food issues but was unable to provide documented evidence of the resolution.
On 08/31/20233 at 10:47 AM, the AD revealed their job duties included organizing and attending all resident council meetings and acting as a scribe. The AD reported after each meeting, dietary concerns mentioned by the residents were referred to DS, nursing concerns to the DON, and maintenance concerns to the Maintenance Director to follow up on. The AD did not document what was done to address the resident concerns, but was only documenting what the residents had said. The AD verified the resident council meeting form had a section where the response was to be documented. The AD did not know why the facility responses had not been documented on the form. The AD verbalized thinking it would be a good idea for someone to start documenting the responses made by the facility.
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 document review, the facility failed to safely secure hazardous items and medications. The deficient practice had the potential to increase concerns about resident ...
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Based on observation, interview and document review, the facility failed to safely secure hazardous items and medications. The deficient practice had the potential to increase concerns about resident safety within the facility and potential harm.
Findings include:
On 08/30/2023 at 12:10 PM, outside of resident room W04 was an unattended maintenance tool cart with items to include chemicals (professional sprayer in a spray bottle), screws, a hammer, wrenches, screw drivers, caulking material, and a 4.5 gallon of joint compound.
On 08/30/2023 at 12:12 PM, a Certified Nursing Assistant (CNA) verified the maintenance tool cart was unattended and indicated the unattended maintenance tool cart was not safe and posed a hazard for residents.
Shortly after, a Plant and Maintenance staff member exited resident room W04. The Plant and Maintenance staff member indicated the maintenance tool cart should not be left unattended as someone could have gotten items from the cart.
On 08/30/2023 at 12:40 PM, a second Plant and Maintenance staff member verbalized a maintenance tool cart should not be unattended as it was possibly dangerous, may result in injury to a resident, or obstruct the hallway.
On 08/30/2023 at 12:48 PM, inside resident room S03 was a wound cleanser spray bottle and sodium chloride irrigation bottle on the bedside dresser.
On 08/30/2023 at 12:50 PM, the Director of Staff Development (DSD) verified a wound cleanser spray bottle and sodium chloride irrigation bottle was on the bedside dresser. The DSD was not sure about the sodium chloride irrigation bottle, but indicated the wound cleanser spray bottle should not be kept inside a residents' room and should be kept in the wound care cart. The DSD indicated removing the two items and following up with the wound care team.
On 08/30/2023 at 9:42 AM, on top of an unattended medication cart parked in the hallway between resident rooms W01 and W03, were two individually wrapped normal saline flush injectable syringes. One resident was observed walking by the medication cart.
On 08/30/2023 at 9:45 AM, a Licensed Practical Nurse (LPN) verified there were two individually wrapped normal saline flush injectable syringes on the medication cart parked between resident rooms W01 and W03. The LPN explained the saline flush should not have been left on top of the unattended medication cart and should have been locked as it was considered a medication. The LPN verbalized there were confused residents nearby who can accidentally get a hold of and ingest the medication.
On 08/30/2023 at 12:18 PM, there were multiple plastic bags of medications on top of a locked medication cart parked at the nurse's station between the 100 and north halls. A nurse was sitting at the nurse's station at the time.
On 08/30/2023 at 12:30 PM, the plastic bags of medications were on top of the same locked medication cart parked at the nurse's station between the 100 and north halls. On top of the cart were four different plastic bags with medications for four different residents. The medications in the plastic bags included Lorazepam, Risperdal, and Levothyroxine. There was no nurse in the area at the time.
On 08/30/2023 at 12:33 PM, a second LPN was observed walking up the hallway. The LPN had indicated it was their medication cart, but they were just coming back from lunch and stated the pharmacy must have just made a delivery. The LPN indicated the medications should not be on top of the cart due to the Health Insurance Portability and Accountability Act (HIPPA) and residents could have gotten the medications.
On 08/31/2023 at 8:20 AM, the door to the central supply storage room was opened, no staff were in the room and the keys were in the door lock. There was no staff observed in the hallways or at the nursing station. The central supply storage room contained multiple shelves with stocked medications such as acetylsalicylic acid 81 milligram, fish oil, stool softener, Loratadine and Naproxen.
At 8:25 AM, a Registered Nurse (RN) was observed coming down the hallway and verified the door to the central supply room was opened with the keys inside the lock. The RN indicated it was not okay for the central supply storage room to be open as someone could harm themselves if they got the medication. The RN verbalized there were confused residents on the unit.
A facility policy titled Storage of Medication revised February 2015, documented medications were stored safely, securely, and properly and the medication supply was accessible only to licensed nursing personnel, pharmacy personnel, or staff members lawfully authorized to administer medications.
A facility policy titled Controlled Substance Storage revised November 2011, documented medications in the classification as controlled substances are subject to special handling and storage in the facility and only authorized licensed nursing and pharmacy personnel have access to controlled substances.
Jun 2023
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
Investigate Abuse
(Tag F0610)
Could have caused harm · This affected 1 resident
Based on observation, interview, record review and document review, the facility failed to ensure it provided documented evidence of thorough investigations for 4 of 4 internal and self-reported incid...
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Based on observation, interview, record review and document review, the facility failed to ensure it provided documented evidence of thorough investigations for 4 of 4 internal and self-reported incidents (Residents #1, #2 and #3) and failed to report an incident within 5 working days of the incident for 1 of 3 residents (Resident #2).
Findings include:
Resident #1
On 10/13/2022, the facility admitted Resident #1 with unspecified dementia, mood disorder and psychosis.
On 6/1/2023, the facility reported an elopement incident.
Both the facility's internal investigation report and the facility reported incident failed to identify how and why the resident exited the building, what the video review identified and where the resident was found outside.
On 6/7/2023 at 12:20 PM, the Licensed Practical Nurse who documented the report indicated video was reviewed, but no other witnesses were captured by video when the resident exited. The Licensed Practical Nurse indicated the video revealed where the resident exited, but this was not documented.
Resident #2
On 4/8/2022, the facility admitted Resident #2 with unspecified dementia, psychosis, and schizophrenia.
On 3/26/2023, Resident #2 had an elopement incident.
The facility lacked documented evidence of a completed internal investigation report.
The resident was never care-planned for elopement risk until after this incident, despite multiple documented indicators in the chart, such as minimum data set assessments and progress notes predating the incident, identifying the resident as repeatedly wandering. The facility reported incident revealed the resident wandered aimlessly and attempts to leave facility.
The facility failed to submit an initial and final report to the bureau within 5 working days, as the initial/final report was received 4/2/2023 and attached 4/3/2023.
On 6/6/2023 in the afternoon, the Social Worker confirmed the above findings.
Resident #3
On 3/21/2023, the facility admitted Resident #3 with unspecified dementia with agitation, impulse disorder, and anxiety disorder.
On 4/2/2023, the facility reported an elopement incident.
Both the facility's internal investigation report and the facility report were incomplete, documenting only that the resident was an active exit seeker and there were no witnesses. There was no documented evidence of employee statements when the resident was last seen or where the resident exited. The resident had several pre-disposing physiological factors, none of which were checked off. The resident was never care-planned for elopement risk until after this incident, despite multiple documented indicators in the chart, such as minimum data set assessments and progress notes predating the incident, identifying the resident as repeatedly wandering.
On 6/7/2023 at 1:45 PM, a Licensed Practical Nurse indicated items were checked which applied to the resident on the incident report.
On 4/22/2023, Resident #3 exited the facility through an open window, fell on some landscaping outside the window and lacerated the face, which had to be treated at an emergency department.
The facility completed progress notes and a communication note, but the facility did not document an investigation report, facility report or any investigation as to how and why the resident attempted to leave the facility. There was a progress note, but the facility relied upon the word of a roommate who summoned help while Resident #3 was injured and discovered outside the building.
On 6/7/2023 at 12:05 PM and 1:45 PM, two Licensed Practical Nurses indicated the facility completed incident reports for elopements, falls and resident injuries.
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
Comprehensive Care Plan
(Tag F0656)
Could have caused harm · This affected 1 resident
Based on record review and interview, the facility failed to ensure 3 of 3 residents (Resident #1, #2 and #3) were care-planned for elopement risk and/or with measurable objectives and timeframes.
Fin...
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Based on record review and interview, the facility failed to ensure 3 of 3 residents (Resident #1, #2 and #3) were care-planned for elopement risk and/or with measurable objectives and timeframes.
Findings include:
Resident #1
On 10/13/2022, the facility admitted Resident #1 with unspecified dementia, mood disorder and psychosis.
On 1/19/2023, the facility care-planned the resident for elopement risk.
On 4/5/2023, the facility renewed the elopement care plan. None of the interventions had measurable objectives or timeframes. The chart lacked documented evidence these objectives were being addressed/monitored on a regular basis.
On 6/1/2023, the facility reported an elopement incident.
On 6/1/2023, the facility's report revealed a wanderguard in place with weekly checks. The chart lacked documented evidence of a physician order for a wanderguard. The last order was discontinued because of the resident's refusals to wear the wanderguard as of 3/13/2023.
On 6/7/2023 in the late morning, the floor was contacted, and it was revealed there was no wanderguard in place. The Central Supply Technician indicated the resident refused the wanderguard, without realizing there was no physician order.
On 6/2/2023, the facility revised the elopement care plan. Two new interventions added included a care conference, which was pending at the time of the onsite visit, and frequent visual monitoring. There was no documented evidence of monitoring or a frequency of monitoring.
Resident #2
On 4/8/2022, the facility admitted Resident #2 with unspecified dementia, psychosis, and schizophrenia.
On 4/2/2023, the facility reported an elopement incident.
The resident was never care-planned for elopement risk until after this incident, despite multiple documented indicators in the chart, such as minimum data set assessments and progress notes predating the incident on 3/26/2023, identifying the resident as repeatedly wandering. The facility report revealed the resident wandered aimlessly and attempts to leave facility.
On 4/7/2023, the facility first initiated an elopement risk care plan. None of the interventions had measurable objectives or timeframes. The chart lacked documented evidence these objectives were being addressed/monitored on a regular basis.
Resident #3
On 3/21/2023, the facility admitted Resident #3 with unspecified dementia with agitation, impulse disorder, and anxiety disorder.
On 4/2/2023, the facility reported an elopement incident.
The resident was never care-planned for elopement risk until after this incident, despite multiple documented indicators in the chart, such as minimum data set assessments and progress notes predating the incident, identifying the resident as repeatedly wandering.
On 4/7/2023, the facility first initiated an elopement risk care plan. None of the interventions had measurable objectives or timeframes. The chart lacked documented evidence these objectives were being addressed/monitored on a regular basis.
In addition to the above, the interventions in all three elopement risk care plans were virtually identical with rare exception, so they were not individualized. Each of the three care plans had as one of the first interventions listed to discuss with the resident if he/she left the facility, he/she would be considered leaving against medical advice (AMA).
On 6/7/2023 in the afternoon, the Director of Nursing confirmed the findings, and that the AMA intervention should not be listed in the care plans.
Mar 2023
4 deficiencies
2 Harm
SERIOUS
(G)
📢 Someone Reported This
A family member, employee, or ombudsman was alarmed enough to file a formal complaint
Actual Harm - a resident was hurt due to facility failures
Deficiency F0658
(Tag F0658)
A resident was harmed · This affected 1 resident
**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on interview and record review, the facility failed to ensure professional standards were followed for a choking resident ...
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**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on interview and record review, the facility failed to ensure professional standards were followed for a choking resident by administering emergency first aid such as abdominal thrust, for 1 of 8 sampled residents (Resident #1). The deficient practice resulted in the resident being unable to expel the foreign object from their airway.
Resident #1 (R1)
R1 was originally admitted on [DATE] and re-admitted on [DATE], with diagnoses including cerebral vascular accident (CVA), vascular dementia, aphasia (disorder that affects the ability to communicate), dysphagia (swallowing difficulties), and esophageal stricture (an abnormal narrowing of the esophageal lumen).
R1's history and physical dated 03/14/2017, documented R1 had history of CVA with aphasia and dysphagia. R1 was on mechanical soft diet with thin liquids.
Medical record revealed R1 was under hospice care and had a physician order for life-sustaining treatment (POLST) dated 11/28/2018 that indicated to allow natural death, do not attempt resuscitation, no intubation, no mechanical ventilation, and no defibrillation. The order indicated when not in cardiopulmonary arrest, life-sustaining treatment could be ordered for a trial period to determine if there was benefit to the patient.
A physician order dated 10/13/2019, documented a Registered Nurse (RN) may pronounce the resident deceased and release the body to mortuary. The order was effective for 120 days and expired on 02/10/2020. The medical record did not document a new RN to pronounce order.
Nursing SBAR (Situation, Background, Assessment, Recommendation) note dated 08/24/2022 documented R1 was choking at the nursing station and was unable to expel dislodged food from throat. The SBAR note stated R1 was a hospice patient and had orders for do not resuscitate (DNR). The documented action requested or recommended to solve R1's choking situation, R1 was taken to their room from wheelchair to lay in bed and notify the Hospice agency. The SBAR note did not document if a physician or emergency medical services were called to provide R1 with emergency treatment to clear their airway. There is no documented evidence first aids were provided to R1.
Nursing progress note dated 08/24/2022, revealed R1 did not have sign of pulse, respiration, heartbeat, and pupil reaction. Resident was pronounced at 5:50 PM by the Director of Staff Development (DSD). The nursing progress note lacked documented evidence emergency treatment was administered to R1.
The medical record lacked documented evidence about the details of the choking incident, the exact time when occurred, the type of food the resident was consuming, and the type of first aid dispensed.
Care Plan for dysphagia initiated on 10/11/2021, revealed R1 was at risk for aspiration. Interventions included staff to be informed of R1 special dietary and safety needs, alternate small bites, and sips, using a teaspoon for eating, monitor for shortness of breath, choking, labored respirations.
On 03/30/2023 at 2:30 PM, the Medical Director explained residents in hospice care were treated to have comfortable end of life. If a resident was choking with food, the situation was not comfortable and required immediate interventions to dislodge the food. If the nurses were not able to dislodge the food by encouraging cough or by abdominal thrusts, the emergency medical services should have been activated regardless of whether the patient was in hospice care or had order for do not resuscitate. The Medical Director verbalized a resident choking should not be put on a bed as it makes it difficult to apply lifesaving measures. The medical Director agreed a resident choking was not close to dying from a natural cause, and there was an obvious problem that required an emergency intervention.
On 03/30/2023 at 3:40 PM, a Licensed Practical Nurse (LPN), explained if a resident was choking on food, first aid should be provided immediately including abdominal thrusts maneuver to attempt to dislodge the food. If the maneuver was unsuccessful, 911 should be called to activate the emergency medical services regardless of the resident code status or hospice care.
On 03/30/2023 at 4:00 PM, an LPN outlined the first aid protocol for a resident who was choking included performing abdominal thrusts method to dislodge the food. If the maneuver was unsuccessful, the resident's code status or hospice care status made no difference and 911 must be contacted to summon emergency medical help. The LPN verbalized residents had the right for care and choking on food was far from being a comfortable situation.
On 03/30/2022 at 4:15 PM, the Director of Nursing (DON) indicated choking on food was an uncomfortable event that required immediate lifesaving intervention provided in the place where the incident occurred. The DON explained whether a resident is in a DNR status or receiving hospice care, a call to 911 should be made to activate emergency medical services if the first aids applied were unsuccessful. The DON confirmed the medical record did not document the interventions implemented during the event and the details of the incident.
On 03/30/2023 at 4:30 PM, the DSD explained the day of the incident R1 was receiving assistance with dinner at the nursing station in the rehabilitation unit. The DSD reported seeing a Certified Nursing Assistant (CNA) assisting R1 with the meal on their walk to the office of the House Supervisor. After around 10 to 15 minutes, the DSD was summoned to R1's room. The DSD found R1 unresponsive in bed. After the DSD assessed the resident, it was determined that R1 had no vital signs and proceeded to pronounce R1's death. The DSD was unaware of any life-saving measures implemented by the staff during the incident prior to arrival to R1's room. The DSD verbalized emergency medical services should have been activated to provide medical care to the resident regardless of whether the resident was receiving hospice care or a DNR status.
On 03/30/2023 at 4:40 PM, an attempt to contact the CNA who was assisting R1 with the dinner the day the incident occurred via phone call. The CNA was not available, and a message was left. The phone call was performed by the DSD.
On 03/30/2023 at 5:00 PM, an on-call nurse representative of the hospice agency was contacted via phone call. The nurse confirmed if a resident choked on food, first aid should be administered immediately, including abdominal thrust maneuvers to dislodge the food. If the maneuver fails, call 911 to activate emergency medical services regardless of whether the resident was receiving hospice care or a code status.
The facility policy titled Emergency Procedure- Choking, dated August 2018, documented choking residents would be helped by trained staff to remove the foreign body from the throat. If the resident was aware, standing or seated, check the resident for choking and ask the resident to cough to eliminate any foreign item if they can.
The policy indicated to execute abdominal thrusts if the resident could not cough and continue thrusting until the foreign body was evacuated or the resident lost consciousness. If the resident was unconscious, gently lower the resident and call for aid if needed. Place the resident on their back with arms at their sides and perform abdominal thrusts by putting one hand's heel on the resident's upper mid-abdomen, below the rib cage and above the navel, with fingers directed toward the chest, overlap the other hand, and quickly push your hands inside the resident's upper abdomen. Check for foreign bodies with the finger sweep. If unable to clear the foreign body from obstructing the airway, arrange emergency transport of the resident to the nearest acute care medical facility.
The policy revealed documentation should be included in the resident's medical record by the individual performing this procedure that included the date and time the procedure was carried out, the name and title of the person or persons who performed the treatment, the exact time the choking started, the exact timing of any unconsciousness, all assessment information gathered during the operation, the beginning and ending times of the process, the resident's response to the treatment, and the signature and position of the individual recording the data.
Complaint #NV00067675
SERIOUS
(G)
📢 Someone Reported This
A family member, employee, or ombudsman was alarmed enough to file a formal complaint
Actual Harm - a resident was hurt due to facility failures
Quality of Care
(Tag F0684)
A resident was harmed · This affected 1 resident
**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on interview and record review, the facility failed to ensure emergency medical services were activated to transport a cho...
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**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on interview and record review, the facility failed to ensure emergency medical services were activated to transport a choking resident to an acute care facility when staff were unable to clear the foreign body obstructing the airway, for 1 of 8 sampled residents (Resident #1). The deficient practices resulted in the deprivation of emergency procedures to clear the resident's airway.
Findings include:
Resident #1 (R1)
R1 was originally admitted on [DATE] and re-admitted on [DATE], with diagnoses including cerebral vascular accident (CVA), vascular dementia, aphasia (disorder that affects the ability to communicate), dysphagia (swallowing difficulties), and esophageal stricture (an abnormal narrowing of the esophageal lumen).
R1's history and physical dated 03/14/2017, documented R1 had history of CVA with aphasia and dysphagia. R1 was on mechanical soft diet with thin liquids.
Medical record revealed R1 was under hospice care and had a physician order for life-sustaining treatment (POLST) dated 11/28/2018 that indicated to allow natural death, do not attempt resuscitation, no intubation, no mechanical ventilation, and no defibrillation. The order indicated when not in cardiopulmonary arrest, life-sustaining treatment could be ordered for a trial period to determine if there was benefit to the patient.
A physician order dated 10/13/2019, documented a Registered Nurse (RN) may pronounce the resident deceased and release the body to mortuary. The order was effective for 120 days and expired on 02/10/2020. The medical record did not document a new RN to pronounce order.
Nursing SBAR (Situation, Background, Assessment, Recommendation) note dated 08/24/2022 documented R1 was choking at the nursing station and was unable to expel dislodged food from throat. The SBAR note stated R1 was a hospice patient and had orders for do not resuscitation (DNR). The documented action requested or recommended to solve R1's choking situation was R1 was taken to their room from wheelchair to lay in bed and notify the Hospice agency. The SBAR note did not document if a physician or emergency medical services were called to provide R1 with emergency treatment to clear their airway. There is no documented evidence first aids were provided to R1.
Nursing progress note dated 08/24/2022, revealed R1 did not have sign of pulse, respiration, heartbeat, and pupil reaction. Resident was pronounced at 5:50 PM by the Director of Staff Development (DSD). The nursing progress note lacked documented evidence emergency treatment was administered to R1.
The medical record lacked documented evidence about the details of the choking incident, the exact time when occurred, the type of food the resident was consuming, and the type of first aid dispensed.
Care Plan for dysphagia initiated on 10/11/2021, revealed R1 was at risk for aspiration. Interventions included staff to be informed of R1 special dietary and safety needs, alternate small bites, and sips, using a teaspoon for eating, monitor for shortness of breath, choking, labored respirations.
On 03/30/2023 at 2:30 PM, the Medical Director explained residents in hospice care were treated to have comfortable end of life. If a resident was choking with food, the situation was not comfortable and required immediate interventions to dislodge the food. If the nurses were not able to dislodge the food by encouraging cough or by abdominal thrusts, the emergency medical services should have been activated regardless of whether the patient was in hospice care or had order for do not resuscitate. The Medical Director verbalized a resident choking should not be put on a bed as it makes it difficult to apply lifesaving measures. The medical Director agreed a resident choking was not close to dying from a natural cause, and there was an obvious problem that required an emergency intervention.
On 03/30/2023 at 3:40 PM, a Licensed Practical Nurse (LPN), explained if a resident was choking on food, first aid should be provided immediately including abdominal thrusts maneuver until able to dislodge the food. If the maneuver was unsuccessful, 911 should be called to activate the emergency medical services regardless of the resident code status or hospice care.
On 03/30/2023 at 4:00 PM, an LPN outlined the first aid protocol for a resident who was choking included performing abdominal thrusts method to dislodge the food. If the maneuver was unsuccessful, the resident's code status or hospice care status made no difference and 911 must be contacted to summon emergency medical help. The LPN verbalized residents had the right for care and choking on food was far from being a comfortable situation.
On 03/30/2022 at 4:15 PM, the Director of Nursing (DON) indicated choking on food was an uncomfortable event that required immediate lifesaving intervention provided in the place where the incident occurred. The DON explained whether a resident is in a DNR status or receiving hospice care, a call to 911 should be made to activate emergency medical services if the first aids applied were unsuccessful. The DON confirmed the medical record did not document the interventions implemented during the event and the details of the incident.
On 03/30/2023 at 4:30 PM, the Director of Staff Development (DSD) explained the day of the incident R1 was receiving assistance with the dinner at the nursing station in the rehabilitation unit. The DSD reported seeing a Certified Nursing Assistant (CNA) assisting R1 with the meal on their walk to the office of the House Supervisor. After around 10 to 15 minutes, the DSD was summoned to R1's room. The DSD found R1 unresponsive in bed. After the DSD assessed the resident, it was determined that R1 had no vital signs and proceeded to pronounce R1's death. The DSD was unaware of any life-saving measures implemented by the staff during the incident prior to arriving at R1's room. The DSD verbalized emergency medical services should have been activated to provide medical care to the resident regardless of whether the resident was receiving hospice care or a DNR status.
On 03/30/2023 at 4:40 PM, an attempt was made to contact the CNA who was assisting R1 with the dinner the day the incident occurred via phone call. The CNA was not available, and a message was left. The phone call was performed by the DSD.
On 03/30/2023 at 5:00 PM, an on-call nurse representative of the hospice agency was contacted via phone call. The nurse confirmed if a resident choked on food, first aid should be administered immediately, including abdominal thrust maneuvers to dislodge the food. If the maneuver fails, call 911 to activate emergency medical services regardless of whether the resident was receiving hospice care or a code status.
The facility policy titled Emergency Procedure- Choking, dated August 2018, documented choking residents would be helped by trained staff to remove the foreign body from the throat. If unable to clear the foreign body from obstructing the airway, arrange emergency transport of the resident to the nearest acute care medical facility.
Complaint #NV00067675
CONCERN
(D)
📢 Someone Reported This
A family member, employee, or ombudsman was alarmed enough to file a formal complaint
Potential for Harm - no one hurt, but risky conditions existed
Accident Prevention
(Tag F0689)
Could have caused harm · This affected 1 resident
**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on interview, record review, and document review, the facility failed to ensure an elopement risk assessment was completed...
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**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on interview, record review, and document review, the facility failed to ensure an elopement risk assessment was completed for a resident who experienced exit seeking behaviors, for 1 of 8 sampled residents (Resident #2). Failure to complete the risk assessment resulted in the inability to establish and implement a plan of care to prevent the resident from leaving the facility unsupervised.
Findings include:
The facility's Elopement/Wandering/Exit-Seeking, Unsafe Resident policy stipulated:
-If a resident began to attempt to leave the facility, the unit nurse would conduct a new Risk of Elopement/Wandering Evaluation.
-A Care Plan would be written for each resident, detailing risk-reduction measures to be implemented.
-Residents who posed a risk for elopement/wandering or exit seeking would wear a green or yellow wristband to alert all staff members that they posed a danger for such behaviors.
Resident #2 (R2)
R2 was admitted on [DATE], with diagnoses including metabolic/hepatic encephalopathy, alcohol dependence with withdrawal.
Minimum Data Set quarterly assessment dated [DATE], revealed a brief interview for mental status (BIMS) with a score of 8 out of 15, indicating a moderately impaired cognition.
admission wandering risk evaluation dated 07/14/2022, documented R2 was alert with confusion, bed bound, no signs of agitation, impaired decision-making skills, and was not frequently pacing or wandering. R2 did not have desire to leave the facility. The assessment revealed a care plan was not initiated due to the low risk at the time of admission.
Nursing progress note dated 08/21/2022, documented R2 was noted walking out the door that leads to the laundry room. The Nurse Supervisor and the Director of Nursing (DON) were notified. The medical record lacked documented evidence an elopement/wandering risk assessment was performed to evaluate R2's exit seeking behavior.
Nursing progress note dated 09/09/2022, documented the resident wandered thorough out the shift. The note indicated the resident was previously packed bag with belongings and wandered hall attempting to open doors. The note indicated the resident was re-directed. The medical record lacked documented evidence an elopement/wandering risk assessment was performed to evaluate R2's exit seeking behavior.
Nursing progress note dated 09/10/2022, documented resident wandering in hall with bag with belongings. The resident verbalized to nurse they were leaving the facility. Resident was redirected. Another nursing progress note written 2 hours later documented resident was again wandering. RN was notified. The medical record lacked documented evidence an elopement/wandering risk assessment was performed to evaluate R2's exit seeking behavior.
Nursing progress note dated 09/14/2022, documented resident was noted to be missing from unit between 1:30 PM through 2:20 PM. R2 was found at a bus stop located on a street adjacent to the center. A wander guard was placed, and the attending physician notified.
Incident note dated 09/15/2022, documented the assessment for root cause was pending. Interventions included wander guard and photo, put on list of residents with risk of elopement.
A wandering risk assessment dated [DATE] at 1:04 PM, documented the resident had history of wandering with diagnoses of dementia. The assessment indicated the resident was agitated at times. The resident had recently changed rooms. The assessment indicated the resident had a wander guard on the right wrist for elopement risk. The resident was located outside the facility at a bus stop. Resident was assessed and no injuries noted.
Physician order dated 09/14/2022, documented for wander guard to be worn at all times and check every shift for placement.
On 03/30/2023 at 12:20 PM, the Director of Nursing (DON) verbalized an elopement risk should have been conducted after the resident initially exhibited exit seeking behaviors on 08/21/2022. The DON acknowledged if the risk assessment had been conducted, a care plan would have been developed and implemented to prevent the resident from eloping.
On 03/30/2023 at 4:00 PM, Licensed Practical Nurse (LPN) explained elopement was a Code Pink. Staff were trained to secure all exits while two people searched the outside perimeter. Each unit does a head count of residents. Notifications would later follow for family, ADON, DON and physician.
The LPN indicated even if the resident was cognitively intact, the facility was still responsible for the resident although this lessens the risk of harm.
On 03/30/2023 at 4:28 PM, another LPN indicated when a missing resident was identified, the nurse informs the nurse supervisor and calls a Code Pink. A search is initiated inside and outside the facility. The LPN indicated the facility was responsible for the resident unless the resident wishes to leave AMA.
Facility Reported Incident #NV00067044
CONCERN
(E)
📢 Someone Reported This
A family member, employee, or ombudsman was alarmed enough to file a formal complaint
Potential for Harm - no one hurt, but risky conditions existed
Report Alleged Abuse
(Tag F0609)
Could have caused harm · This affected multiple residents
**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Resident #8 (R8)
R8 was admitted on [DATE] and had a previous incident of elopement in 2020.
A facility reported incident docume...
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**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Resident #8 (R8)
R8 was admitted on [DATE] and had a previous incident of elopement in 2020.
A facility reported incident documented R8 was missing, and a facility code was called to search for resident in surrounding areas. Security cameras were reviewed and found the resident had used the keypad for secure unit and input the correct code to open the doors. The facility reported incident was documented as having occurred on 01/20/2023.
The state agency received the facility reported incident on 02/01/2023.
On 05/26/2023 at 10:00 AM, staff approached keypad and resident was walking unit floor, staff member blocked view of resident to keypad by placing body in between keypad and resident and cupped hand over keypad surface. The LPN stayed at the door until it was closed and secured.
On 05/26/2023 at 10:10 AM, a Licensed Practical Nurse (LPN1) indicated residents were assigned to secure unit based on conditions such as history of wandering, and high-level dementia care needs. The LPN verbalized there were some with mental health diagnosis however most are in unit for wandering behaviors or dementia care needs. LPN1 explained all staff received training in dementia care at hire and annually. The LPN explained no residents were given a code to secure doors and all staff should protect keypad from being seen while entering code to open door by blocking with body and cupping hand over keypad while entering code.
On 05/26/2023 at 11:30 AM, a Licensed Practical Nurse (LPN2) verbalized residents getting a wander guard would have a physician order and would have been assessed as a safety risk to themselves or others when wandering. LPN2 indicated when there was an incident of a resident eloping, new codes would be established for the keypad and education provided by the maintenance staff who was responsible for entering new code. The resident wander guard would be checked to make sure they were in proper working order. The supervisor of Central supply was responsible for the maintenance and inventory of the wander guards.
On 05/26/2023 at 1:15 PM, the Central Supply Supervisor explained when a resident had an incident of elopement, and the wander guard did not alert the staff when approaching the doors, they would be replaced with a new unit and the new unit would be tested prior to application. The supply supervisor indicated a nurse would assess the resident and obtain physician order and then contact them to request a wander guard. Depending on the needs of the resident the wander guard bracelet could be placed on the wrist or around the ankle.
The Central supply supervisor does remember the specific incident with the resident and there was a malfunction with the wander guard alerting. The supervisor revealed when a resident with a properly functioning wander guard wandered closer than 12 feet the alarm would start going off and would increase in intensity as the resident walked closer to the doors. The supervisor verbalized all wander guards were tested weekly and battery was changed. All exit doors to the outside were equipped with sensors for the wander guards and were also checked weekly.
The central supply supervisor verbalized the code to the doors in the secure unit were changed monthly and after any incident of elopement. The director of maintenance was responsible for changing the code and providing education to nursing staff about safety awareness when entering the code.
05/26/2023 at 11:54 am, the Clinical Manager verbalized they were instructed by administrator to send report for all incidents involving any residents. The Clinical Manager indicated the incident should have been investigated and reported to the state agency immediately or within 24 hours with a final report within five days. The Clinical Manager acknowledged based on reporting guidelines the facility report was sent to the state agency 12 days after incident occurred and did not include a final report.
Resident #7 (R7)
R7 was admitted on [DATE] with diagnosis of mood affective disorder.
A Brief Interview of Mental Status dated 01/27/2023, documented a score of 15/15 which indicated R7's cognitive status was intact.
A progress note dated 12/21/2021 documented a new care plan was initiated with interventions for wandering behavior.
A facility report was received by the state agency on 12/23/2022.
The facility report documented R7 was found wandering outside off the facility grounds on 12/21/2021.
On 05/26/2023 at 10:00 AM approximately 10-12 residents sitting in hallway near the nurse's station were engaged with staff in activities and being supervised by two additional staff members. Nursing staff were interacting with residents in calm, professional manner. The staff provided redirection to residents as needed.
On 05/26/2023 at 3:51 PM, R7 indicated being in the facility for three years and had no issues with staff who took good care of the resident. The resident indicated preferring to eat meals in the room but occasionally attended activities where the resident socialized with other residents.
On 05/26/2023 at 3:55 PM, a Licensed Practical Nurse (LPN) indicated the resident did not have wandering behaviors and was not an elopement risk. The incident where the resident was found outside the 200-hall entrance (nurse pointed to double doors at the end of the 200-Hall) a few months ago, was an isolated incident. The LPN recalled the resident had a bad day and seemed to go out for some fresh air as opposed to an intent to leave the facility. The LPN indicated this was an isolated incident which had not recurred.
Complaint #NV00068335
Facility Reported Incidents #NV00068081, NV00067318, NV00067656, and NV00067902
Based on interview, record review, and document review, the facility failed to ensure incidents of physical abuse, neglect, wandering, and resident-to-resident altercations were reported to the state agency in a timely manner, or a final report was completed within five days (5 days) following occurrence per policies and regulations for 5 of 10 sampled residents (Residents 1, 5, 6, 7 and 8). This deficient practice could potentially lead to serious harm to the residents, undermine their rights, compromise their safety, and jeopardize their well-being.
Findings include:
A facility policy titled Abuse Investigation and Reporting dated July 2017, documented an alleged violation of abuse, neglect, exploitation, or mistreatment and/or injuries of unknown source (abuse) and misappropriation of resident property would be reported immediately but not later than two hours if the alleged violation involved abuse or twenty hours if the alleged violation did not involve abuse and had not resulted in serious bodily injury. Findings from the abuse investigation would also be reported. The administrator, or designee, would provide the appropriate agencies or individuals listed above with a written report of the findings of the investigation within five (5) working days of the incident's occurrence.
Resident 1 (R1)
R1 was admitted on [DATE] and readmitted on [DATE], with diagnoses including anemia, chronic embolism, and thrombosis.
The Brief Interview of Mental Status dated 02/26/2023, documented a score of 15/15, which indicated R1's cognitive status was intact.
The Situation Background Assessment and Recommendation (SBAR) dated 03/01/2023, documented R1 noted a skin discoloration on the left elbow with a purplish, greenish, or yellowish color. No swelling or pain were noted. Recommendations: monitor the resident; issue new testing orders; issue intervention orders.
The Nursing Progress Note dated 03/02/2023, documented the skin discoloration noted on R1's left elbow, which was purplish, greenish, or yellowish in color. No swelling was noted. R1 stated it happened one and a half weeks ago at 10 a.m. when the caregiver grabbed R1 on the left elbow.
The facility report dated 03/01/2023, documented a Certified Nursing Assistant (CNA) had tried to get R1 out of bed for the day but resident refused. The CNA roughly grabbed R1's arm and insisted had to go on break, leaving the resident puzzled as to why the CNA could not come back later to assist R1. After the CNA released R1's arm, the resident felt a momentary numbness in the arm. Later that evening, another CNA helped R1 undress and prepare for bed and asked how the bruise on R1's left arm was acquired. R1 could not recall which CNA had assisted R1 but suggested it might have been the one from the morning.
On 05/26/2023 at 9:50 AM, R1 was in bed, alert and verbally responsive. R1 indicated the incident with a CNA had occurred a long time ago. R1 did not believe the CNA acted maliciously and there was no recurrence. R1 stated the facility had investigated the incident, and the CNA had not been observed taking care of the resident after the incident. R1 indicated had been residing in the facility for a long time and felt safe with no issues.
On 05/25/2023 at 11:12 AM, a CNA who was assigned to R1 denied R1 had been grabbed, stated R1 had been pleasant and calm, and there was no reason to engage in a physical altercation. R1 was capable of standing independently but required assistance with transfers from the bed to the chair. The CNA indicated had been suspended during the investigation and reinstated later. The CNA had received in-service training regarding abuse.
On 05/26/2023 at 11:46 AM, the Nursing Supervisor indicated when the allegation of physical abuse had been received, the incident should have been investigated and reported immediately to the state agencies. The Nursing Supervisor indicated the report's findings should have been completed within five (5) days. The Nursing Supervisor confirmed the report was submitted after nine days by the social worker.
On 05/26/2023 at 2:00 PM, the Director of Staff Development (DSD) explained the abuse allegation reporting should be reported immediately upon receiving the allegation of abuse, and the final report should have been completed or submitted to the state or federal agencies within 5 days. The DSD confirmed the final report was not reported timely within 5 days. The DSD explained the social worker was responsible for reporting and was unavailable for an interview due to being off schedule.
On 05/26/2023 at 2:30 PM, the administrator indicated the final report of abuse allegations should have been completed within 5 days per policy.
Resident 5 (R5)
R5 was admitted on [DATE], with diagnoses including dementia, mood disorder and psychosis.
The facility's initial report dated 10/31/2022, documented resident-to-resident altercation involving two residents. R5 had been injured when R6 struck R5 in the face. R6 had been meddling with R5's belongings. R5 had attempted to maneuver to the side of the room, leading to a physical struggle which concluded with R6 striking R5 in the face and causing R5's face to bleed. R6 was sent out to the acute care facility via Legal 2000.
The State agency received the initial report on 10/31/2022, but lacked documented evidence, a final report was completed and submitted.
Resident 6 (R6)
R6 was admitted on [DATE] and readmitted on [DATE], with diagnoses including dementia with psychotic disturbance.
The Nursing Progress Notes dated 10/26/2023, documented R6 had a physical altercation with R5, who was R6's roommate. R6 attempted to bother R5 all day. R6 attempted to take something from R5's stuff. R6 struck R5's face and caused bleeding. A Physician order to transfer R6 to the acute via Legal 2000 received.
On 05/26/2023 at 11:46 AM, the Nursing Supervisor indicated the responsible staff for the reporting was the social worker. The Nursing Supervisor indicated there should have been a final report completed or submitted within five (5) days, but there was none.
On 05/26/2023 at 2:00 PM, the DSD explained the social worker was responsible for reporting and was unavailable for an interview due to being off schedule. The DSD confirmed there was no final report submitted.
On 05/26/2023 at 2:30 PM, the administrator indicated the final report of the altercation incident should have been completed within 5 days per policy.
Jan 2023
5 deficiencies
CONCERN
(D)
📢 Someone Reported This
A family member, employee, or ombudsman was alarmed enough to file a formal complaint
Potential for Harm - no one hurt, but risky conditions existed
Deficiency F0558
(Tag F0558)
Could have caused harm · This affected 1 resident
**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on interview, record review, and document review, the facility failed to ensure the request for an electric wheelchair was...
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**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on interview, record review, and document review, the facility failed to ensure the request for an electric wheelchair was appropriately communicated, documented, and assessed for 1 of 12 sampled residents (Resident 1). Failure to communicate and provide necessary services could lead to the residents' psychological effects, which include depression, anxiety, and a feeling of deprivation.
Findings include:
Resident 1 (R1)
R1 was admitted on [DATE] and readmitted on [DATE], with diagnoses including palliative care muscular dystrophy, contracture of muscle, malignant neoplasm of the bronchus or lung, constipation, low back pain and muscle spasm.
The Brief Interview of Mental Status dated 03/08/2022, documented a score of 14/15, which indicated R1's cognitive status was intact.
R1's functional status dated 03/08/2022, documented the bed mobility, transfer dressing, eating, toileting and personal hygiene required extensive assistance and one person's assistance.
R1's medical records lacked documented evidence R1 did have an electric wheelchair in the facility.
On 11/17/2023 at 2:44 PM, the social worker indicated R1 was alert and oriented, hard to please, had control issues with unrealistic demands and accommodating everything would not be enough. The social worker explained R1 had an electric wheelchair at home but not in the facility.
The social worker recalled R1 had requested an electric wheelchair three times. The social worker indicated the said request was communicated verbally to the Director of Rehabilitation Services. The social worker indicated there was no documentation regarding a request had been made or communicated.
On 01/17/2023 at 3:02 PM, the Director of Rehabilitation Services confirmed no request for an electric wheelchair from social services had been received. R1 received physical therapy and occupational therapy from 11/23/2021 to 11/29/2021, before being discharged for hospice care.
The Director of Rehabilitation Services confirmed no written request for an electric wheelchair was on record and requests should be submitted in written form, either handed out or placed in the rehab box, but no evidence of a request was found.
The Director of Rehabilitation Services explained that if a request had been made, R1 would have been evaluated to determine eligibility for an electric wheelchair. The Director or Rehabilitation Services confirmed R1 was not evaluated.
On 01/17/2023 at 3:30 PM, the Assistant Director of Nursing (ADON) indicated the resident's request would be communicated in writing to the department of concern and should be documented to appropriately address the needs of the residents. The ADON indicated even though R1 was not eligible for an electric wheelchair, the request should have been appropriately communicated, evaluated, discussed with the resident, and documented.
A facility policy titled Accommodation of Needs dated 01/2020, indicated the resident's individual needs and preferences would be accommodated to the extent possible.
Complaint ##NV00066981
CONCERN
(D)
📢 Someone Reported This
A family member, employee, or ombudsman was alarmed enough to file a formal complaint
Potential for Harm - no one hurt, but risky conditions existed
ADL Care
(Tag F0677)
Could have caused harm · This affected 1 resident
**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on interview, record review, and document review, the facility failed to ensure a shower or bed bath was provided as sched...
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**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on interview, record review, and document review, the facility failed to ensure a shower or bed bath was provided as scheduled to a dependent resident for 1 of 12 sampled residents (Resident #4). Failure to provide showers and bed baths for the resident could lead to poor personal hygiene, decline in overall health and well-being.
Findings include:
The Activities of Daily Living (ADL) Policy revised 03/2018, documented resident would be provided with care, treatment, and services as appropriate to maintain or improve their ability to carry out activities of daily living. Appropriate care and services would be provided for residents who are unable to carry out ADLs independently, with the consent of the resident and in accordance with the plan of care, including appropriate support and assistance with: hygiene (bathing, dressing, grooming, and oral care), mobility, elimination, dining; and communication.
Resident #4 (R4)
R4 was admitted on [DATE] and discharged [DATE], with diagnoses including injury of nerve root of cervical spine, pressure ulcer of right buttock stage 4, quadriplegia, contracture of right elbow, and chronic pain syndrome.
The Quarterly Minimum Data Set, dated [DATE], documented R4's Brief Interview for Mental Status score of 12/15 which meant the cognitive status was moderately impaired. R4 required extensive assistance with two-person physical assistance for personal hygiene.
The Census Document documented R4 was in room [ROOM NUMBER] from 12/30/2021-04/30/2022, 05/16/2022-06/16/2022, and 06/24/2022-07/06/2022.
The Rehabilitation Shower Schedule 2022, documented room [ROOM NUMBER]'s scheduled shower days were Wednesday and Saturday, day shift.
The Documentation Survey Report for showers revealed the following showers/bed baths were provided for R4:
-January 2022: 01/03/2022, 01/05/2022, 01/07/2022, 01/08/2022, 01/26/2022, 01/31/2022
-February 2022: 02/16/2022, 02/23/2022
-March 2022: 03/02/2022, 03/05/2022, 03/09/2022, 03/23/2022, 03/26/2022, 03/30/2022
-April 2022: 04/06/2022, 04/09/2022, 04/13/2022, 04/16/2022, 04/20/2022, 04/27/2022, 04/30/2022, 04/23/2022 (refused)
The Medical Record lacked documented evidence R4 was provided a shower or bed bath on the scheduled days on 01/12/2022, 01/15/2022, 01/19/2022, 01/22/2022, 01/29/2022, 02/02/2022, 02/05/2022, 02/09/2022, 02/12/2022, 02/19/2022, 02/26/2022, 03/12/2022, 03/16/2022, 03/19/2022, and 04/02/2022.
On 01/17/2023 in the morning, four Certified Nursing Assistants (CNAs) indicated residents were provided a shower or bed bath twice a week based on the shower schedule. The CNAs indicated the type of shower or bed bath, bathing support, and bathing self-performance, and refusals would be documented in the Activities of Daily Living (ADL) Point of Care.
On 01/18/2022 at 12:04 PM, the Lead CNA indicated the residents were provided a shower or bed bath based on the shower schedule. The Lead CNA confirmed R4 was not provided showers or bed baths according to the shower schedule of Wednesday and Saturday and did not get two showers a week as scheduled.
On 01/18/2022 in the afternoon, the Assistant Director of Nursing (ADON) indicated residents were provided showers twice a week based on the schedule. The ADON confirmed R4 was not provided showers or bed baths following the shower schedule.
CONCERN
(D)
📢 Someone Reported This
A family member, employee, or ombudsman was alarmed enough to file a formal complaint
Potential for Harm - no one hurt, but risky conditions existed
Quality of Care
(Tag F0684)
Could have caused harm · This affected 1 resident
**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on interview, record review, and document review, the facility failed to ensure medications were administered per the phys...
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**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on interview, record review, and document review, the facility failed to ensure medications were administered per the physician prescribed administration time for 1 of 12 sampled residents (Resident #3).
The failure to administer the medications as ordered had the potential for the residents' treatment plan to be ineffective.
Findings include:
Resident #3 (R3)
R3 was admitted on [DATE] and discharged on 09/20/2022, with diagnoses including chronic obstructive pulmonary disease, type 2 diabetes, and obesity.
A Physician Order dated 07/21/2022, documented Apixaban tablet 2.5 milligram (mg) two times a day by mouth at 8:00 AM and 4:00 PM for deep vein thrombosis (DVT) prophylaxis.
A Physician Order dated 05/13/2022, documented Aspirin tablet 81 mg by mouth at 8:00 AM for cerebral vascular accident (CVA) prophylaxis.
A Physician Order dated 05/13/2022, documented Doxazosin Mesylate tablet 2 mg by mouth at 8:00 AM for hypertension.
A Physician Order dated 05/13/2022, documented Furosemide tablet 40 mg by mouth at 8:00 AM for heart failure.
A Physician Order dated 05/13/2022, documented Lisinopril tablet 40 mg by mouth at 9:00 AM for hypertension.
A Physician Order dated 08/28/2022, documented Macrobid capsule 100 mg by mouth once a day at 9:00 AM for chronic urinary tract infection.
A Physician Order dated 09/01/2022, documented Gabapentin tablet 600 mg by mouth three times a day at 9:00 AM, 1:00 PM, and 5:00 PM for myopathy.
A Physician Order dated 06/10/2022, documented Novolog Solution 100 unit/milliliter (mL) Insulin Aspart inject subcutaneously before meals and at bedtime at 6:00 AM, 11:00 AM, 4:00 PM, and 8:00 PM per sliding scale: if 0-150 = no insulin,151-200 = 2 units, 201-250 = 4 units, 251-300 = 6 units, 301-350 = 8 units, 401-450 = 12 units. Call physician if blood sugar below 70, and above 451 for diabetes mellitus
The Medication Administration Audit Report for September 2022, documented R3's Apixaban tablet 2.5 mg medication scheduled at 8:00 AM per the above-mentioned physician's orders were documented as administered late on the following days:
-09/03/2022 at 9:40 AM
-09/06/2022 at 9:24 AM
-09/07/2022 at 11:50 AM
-09/10/2022 at 9:34 AM
-09/13/2022 at 10:07 AM
-09/14/2022 at 12:24 PM
-09/15/2022 at 9:50 AM
The Medication Administration Audit Report for September 2022, documented R3's Aspirin tablet 81 mg medication scheduled at 8:00 AM per the above-mentioned physician's orders were documented as administered late on the following days:
-09/03/2022 at 9:30 AM
-09/06/2022 at 9:24 AM
-09/07/2022 at 11:50 AM
-09/10/2022 at 9:34 AM
-09/13/2022 at 10:07 AM
-09/14/2022 at 12:23 PM
-09/15/2022 at 9:45 AM
The Medication Administration Audit Report for September 2022, documented R3's Doxazosin Mesylate tablet 2 mg medication scheduled at 8:00 AM per the above-mentioned physician's orders were documented as administered late on the following days:
-09/03/2022 at 9:40 AM
-09/06/2022 at 9:24 AM
-09/07/2022 at 11:50 AM
-09/10/2022 at 9:34 AM
-09/13/2022 at 10:07 AM
-09/14/2022 at 12:24 PM
-09/15/2022 at 9:50 AM
The Medication Administration Audit Report for September 2022, documented R3's Furosemide tablet 40 mg medication scheduled at 8:00 AM per the above-mentioned physician's orders were documented as administered late on the following days:
-09/03/2022 at 9:41 AM
-09/06/2022 at 9:24 AM
-09/07/2022 at 11:50 AM
-09/10/2022 at 9:34 AM
-09/13/2022 at 10:07 AM
-09/14/2022 at 12:24 PM
-09/15/2022 at 9:50 AM
The Medication Administration Audit Report for September 2022, documented R3's Lisinopril tablet 40 mg medication scheduled at 9:00 AM per the above-mentioned physician's orders were documented as administered late on the following days:
-09/03/2022 at 12:09 PM
-09/04/2022 at 10:47 AM
-09/07/2022 at 11:50 AM
-09/13/2022 at 10:07 AM
-09/14/2022 at 12:25 PM
The Medication Administration Audit Report for September 2022, documented R3's Macrobid capsule 100 mg medication scheduled at 9:00 AM per the above-mentioned physician's orders were documented as administered late on the following days:
-09/04/2022 at 10:46 AM
-09/07/2022 at 11:52 AM
-09/14/2022 at 12:26 PM
The Medication Administration Audit Report for September 2022, documented R3's Gabapentin tablet 600 mg medication scheduled at 9:00 AM per the above-mentioned physician's orders were documented as administered late on the following days:
-09/04/2022 at 10:46 AM
-09/07/2022 at 11:51 AM
-09/13/2022 at 10:08 AM
-09/14/2022 at 12:27 PM
The Medication Administration Audit Report for September 2022, documented R3's Gabapentin tablet 600 mg medication scheduled at 1:00 PM per the above-mentioned physician's orders were documented as administered late on the following days:
-09/10/2022 at 3:42 PM
-09/13/2022 at 2:18 PM
The Medication Administration Audit Report for September 2022, documented R3's Novolog Solution 100 unit/milliliter (mL) medication scheduled at 11:00 AM per the above-mentioned physician's orders were documented as administered late on the following days:
-09/01/2022 at 12:07 PM
-09/06/2022 at 1:53 PM
-09/07/2022 at 1:35 PM
-09/09/2022 at 12:29 PM
-09/12/2022 at 1:18 PM
-09/13/2022 at 2:18 PM
On 01/17/2023 at 11:11 AM, the Licensed Practical Nurse (LPN) indicated the nurses were to follow the physician orders and administer medication on time. The LPN indicated the nurses were required to administer medication within one hour before or after the scheduled time. The LPN indicated the nurses would try their best to administer resident medications within the time frame.
On 12/01/2022 in the afternoon, the Nurse Practitioner indicated the licensed nurses were expected to follow physician orders and administer medications timely.
On 01/18/2023 in the morning, the Director of Staff Development indicated the licensed nurses were to follow the physician order and administer medication within one hour before or after the prescribed time. The DSD indicated the licensed nurses were expected to check off the medication in the Medication Administration Record immediately after the medication was administered.
On 01/18/2023 at 10:10 AM, the Assistant Director of Nursing (ADON) confirmed R3 did not receive their medication as ordered by the physician. The ADON explained medications were to be administered within one hour before or after the prescribed time following the physician order.
The Administering Medication Policy revised April 2019, documented medications were to be administered within one hour of their prescribed time, unless otherwise specified.
Complaint #NV00067062
CONCERN
(D)
📢 Someone Reported This
A family member, employee, or ombudsman was alarmed enough to file a formal complaint
Potential for Harm - no one hurt, but risky conditions existed
Accident Prevention
(Tag F0689)
Could have caused harm · This affected 1 resident
**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Resident #5 (R5)
R5 was admitted to the facility on [DATE] with diagnosis including Cognitive Loss/Dementia, Epilepsy, unsteadi...
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**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Resident #5 (R5)
R5 was admitted to the facility on [DATE] with diagnosis including Cognitive Loss/Dementia, Epilepsy, unsteadiness on the feet, legal blindness, unspecified hearing loss, and Osteoporosis.
The resident's medical record documented R5 had been assessed for falls and had no history of falls. There was no physician's order for fall precautions. A Care Plan initiated on 05/11/2022, documented R5 had a communication problem. One intervention to avoid isolation was to have the bed in the lowest position.
Progress noted dated 09/18/2022, documented a Certified Nursing Assistant (CNA) nonchalantly stated the resident fell to the floor. The CNA was outside of resident's door.
On 01/18/2023 at 9:32 AM the ADON described R5 with a short stature and had the ability to walk on their own, noting their feet would touch the floor if the bed was in a lowered position and their feet would not touch the floor if the bed was in a higher position.
On 01/18/2023 at 2:53 PM, a Licensed Practical Nurse (LPN's) reported R5's bed was at waist height and a fall mat was in place at the time of incident. The Housekeeping Supervisor indicated during R5's stay, the lowest setting for the two types of beds at that time would have been either 20 or 12 inches.
The CNA was no longer employed by the facility for interview.
Accommodations of Needs Policy, revised on 01/2020, documented accommodating individual needs and preferences, with examples to include providing a variety of types, sizes (height and depth) and arranging of furniture in rooms, for independent mobility to a standing position.
Complaints #NV00067052 and #NV00066981
Based on interview, record review, and document review, the facility failed to ensure:
1) A fall risk assessment was performed timely for a resident who had repeated falls and neurological evaluations (neurochecks) and monitoring were completed post-fall incidents for 1 of 12 sampled residents (Resident 1).
2) The facility failed to adjust a resident's bed to the lowest position so the resident could get out from bed safely for 1 of 12 sampled residents (Resident 5).
Failure to perform fall risk assessments, neurological evaluations, monitoring and bed height adjustments had the potential to cause neurological injuries and harm to residents.
Findings include:
A facility policy titled Falls-Clinical Protocol revised 03/2018, documented the nurse should assess and monitor the resident following a fall incident.
Resident 1 (R1)
R1 was admitted on [DATE] and readmitted on [DATE], with diagnoses including palliative care muscular dystrophy, contracture of muscle, malignant neoplasm of the bronchus or lung, constipation, low back pain and muscle spasm.
The Brief Interview of Mental Status dated 03/08/2022, documented a score of 14/15, which indicated R1's cognitive status was intact. R1's functional status dated 03/08/2022, documented the bed mobility, transfer dressing, eating, toileting, and personal hygiene required extensive assistance and one person's assistance.
A Care Plan dated 03/25/2020, documented R1 was at risk for falls related to weakness, polyneuropathy, pain, incontinence, and medication side effects. The interventions included conducting neurochecks. R1 had an actual fall on 05/28/2022 and 06/04/2022.
The Fall Risk Evaluation dated 05/28/2022, documented R1 had an actual fall but lacked documented evidence an intervention was recommended or implemented.
The Fall Risk Evaluation dated 06/05/2022, documented R1 was bed-bound with a score of 21, which indicated R1 was at high risk for falling. R1 had repeated falls but lacked documented evidence an intervention was recommended or implemented.
Neurocheck flowsheets on 05/28/2022 and 06/05/2022, were initiated but not completed. The medical record lacked documented evidence R1 was being monitored and interventions were being implemented.
The Therapy Screening Form dated 05/30/2022, documented the reason for screening: Fall, the resident was found on the floor; Comments: R1 rolled out of bed, reaching for the television remote. Hospice was notified.
The Therapy Screening Form dated 06/06/2022, documented the reason for screening: falling out of bed. Attempting to reach for a libation. Hospice was notified. R1's medical records lacked documented evidence the 72-hour neuro checks were completed following an unwitnessed fall incident.
On 01/17/2023 at 2:24 PM, a Licensed Practical Nurse (LPN) recalled R1 was alert and oriented, bed bound with bouts of anxiety and high risk for fall. The LPN explained when a resident was assessed as being at fall risk, floor mats should be placed if the resident was bed-bound, the bed should be in the low position, a call light should be within reach, and the resident would be checked on at least every 30 minutes. The LPN explained could not remember what interventions R1 had in place during the fall.
On 01/18/2023 at 9:52 AM, the Assistant Director of Nursing (ADON) confirmed R1's unwitnessed fall incidents occurred on 05/28/2022 and 06/04/2022. The ADON confirmed R1 was alert, bed-bound, anxious, and could make movements to reach for something.
The ADON indicated the staff were expected to follow fall prevention protocol, including the monitoring and neurochecks for 72 hours. The ADON indicated there should have been neurological checks following the post-fall incident, but they were not completed.
The ADON indicated the nurses assigned to R1 did not complete the required documentation. The DON acknowledged incomplete documentation and assessment related to an unwitnessed fall could have delayed the provision of appropriate interventions.
On 01/18/2023 at 1:00 PM, the Director of Staff Development (DSD) indicated the facility utilized a checklist following a post-fall incident and staff were expected to comply using the tool. The DSD indicated following a fall incident; a Neurological Evaluation Flow Sheet would be performed immediately within 72 hours. The DSD confirmed that no orders for fall interventions were in place.
The Fall Documentation Requirements dated 08/23/2022, indicated to complete the following post fall incident:
-Complete Risk Management can be found under Clinical-PCC.
-Complete Health Status Change: SBAR (located under Progress Notes)
-Start and complete Neurochecks for (unwitnessed fall or if resident hits head) Located under Evaluation-Neurocheck for Falls/Facility Protocol-PCC
-Complete the E-Interact condition change; located under Evaluations: PCC
-Start and complete the Fall note for 72 hours under Progress Notes.
-Complete fall risk evaluation (located under evaluations): PCC
-Complete Fall packet-including Fall investigation-paper documentation
-The care plan must be completed.
-Notify family members, public guardians, or representative using the phone numbers on the face sheet, notify the physician and the DON.
R1's medical records lacked documented evidence that post-fall incident fall prevention and management protocols were consistently followed.
CONCERN
(D)
📢 Someone Reported This
A family member, employee, or ombudsman was alarmed enough to file a formal complaint
Potential for Harm - no one hurt, but risky conditions existed
Deficiency F0697
(Tag F0697)
Could have caused harm · This affected 1 resident
**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Resident #5 (R5)
R5 was admitted to the facility on [DATE] with diagnosis including Cognitive Loss/Dementia, Epilepsy, unsteadin...
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**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Resident #5 (R5)
R5 was admitted to the facility on [DATE] with diagnosis including Cognitive Loss/Dementia, Epilepsy, unsteadiness on the feet, legal blindness, unspecified hearing loss, and Osteoporosis.
A Nurse Progress note dated 09/18/2022 at 10:21 PM, documented R5 fell to the floor. Progress notes dated 09/19/2022 documented bruising and swelling developed on the left clavicle, and the resident expressed pain.
A Situational-Background-Assessment Recommendation tool (SBAR) dated 09/18/2022 at 10:25 PM lacked documentation a pain status evaluation was conducted.
On 01/18/2023 at 2:53PM, a Licensed Practical Nurse (LPN), informed the SBAR had been completed, but could not explain why the pain assessment evaluation section was blank. The LPN indicated another LPN conducted the pain assessment on R5. The medical record lacked documented evidence a pain assessment had been completed for R5. The other LPN was not available for interview.
Pain Assessment and Management Policy, revised on 3/2020, indicated as a procedure to help identify pain in a resident. Comprehensive pain assessments would be conducted . whenever there is a significant change in condition, or onset of new pain or worsening of existing pain.
Complaint #NV00066981 and #NV00067052
Based on interviews, record review, and document review, the facility failed to ensure:
1) a resident's pain medication was administered timely as ordered and the pain level was assessed for 1 of 12 sampled residents (Resident #1).
2) a pain assessment was conducted and documented post-fall incident for 1 of 12 sampled residents (Resident #5).
Failure to timely administer pain medication and assess resident pain levels could affect a resident's psychological state, prolong the stress response, adversely affect the residents' recovery, lead to depression or anxiety, or result in further harm or injury.
Findings include:
A facility policy titled Pain Assessment and Management revised 03/2020, indicated the pain management program was based on a facility-wide commitment to appropriate assessment and treatment of pain. Pain management was defined as the process of alleviating the resident's pain based on the resident's clinical condition and established treatment goals, including the assessment and monitoring of the effectiveness of the interventions.
A facility policy titled Administering Medication revised 04/2019, documented medications be administered in a safe and timely manner and in accordance with prescriber orders, including the required time frame. Medications were administered within one (1) hour of the prescribed time.
Resident 1 (R1)
R1 was admitted on [DATE] and readmitted on [DATE], with diagnoses including palliative care muscular dystrophy (progressive weakness and loss of muscle mass), contracture of muscle, malignant neoplasm of bronchus or lung, low back pain and muscle spasm.
The Brief Interview of Mental Status dated 03/08/2022, documented a score of 14/15, which indicated R1's cognitive status was intact.
R1's functional status dated 03/08/2022, documented the bed mobility, transfer, dressing, eating, toileting, and personal hygiene required extensive assistance and required one person's assistance.
A Care Plan dated 03/25/2020, documented R1 was on pain medication related to polyneuropathy (simultaneous malfunction of many peripheral nerves throughout the body) and generalized body pain. The interventions included was to administer the medication as ordered, monitor, observe for adverse reactions and review for pain medication efficacy.
The Nursing Progress Notes dated 05/17/2022, documented R1 was alert and continued on hospice services with scheduled pain medications and anti-anxiety medications.
A Physician order dated 03/23/2022, documented Oxycodone Hydrochloride tablet 5 milligram to be administered by mouth every 8 hours for pain due at 6 AM, 2:00 PM and 10:00 PM.
R1's Oxycodone was administered more than one (1) hour late or more than 1 hour early on the following occasions:
06/01/2022 at 4:04 PM (due at 2:00 PM)
06/08/2022 at 3:44 PM (due at 2:00 PM)
06/01/2022 at 8:38 PM (due at 10:00 PM)
06/04/2022 at 11:08 PM (due at 10:00 PM)
06/08/2022 at 7:30 PM (due at 10:00 PM)
R1's medical records lacked documented evidence R1's pain level was assessed and monitored to determine if the medication was effective or if the pain was appropriately managed.
On 01/18/2023 in the afternoon, Licensed Practical Nurse 1 (LPN1) indicated R1 was bed-bound, verbally alert and oriented, contracted and had a lot of pain due to bone infection. R1 was on routine pain medication every 8 hours. The LPN explained the pain level should have been assessed to determine if the pain medication was too little, too much, or effective, but there was no pain assessment in place.
On 01/18/2023 at 11:45 AM, Licensed Practical Nurse 2 (LPN2) confirmed R1 was on hospice services and Oxycodone was administered late on 06/01/2022. LPN2 indicated the Oxycodone was due at 2:00 PM and was administered late at 4:04 PM which was more than two hours.
LPN2 explained the pain medication should have been administered 1 hour in advance or 1 hour late, but it was administered beyond the allowed time frame. LPN2 indicated if the medication was administered late, the physician should have been notified and documented, but this was not done.
On 01/18/2023 at 11:54 AM, a Registered Nurse (RN) confirmed was assigned to R1, and on 06/01/2022, during the shift, the Oxycodone was due at 10:00 PM but was documented as being administered at 8:38 PM. The RN indicated could not remember why it was administered outside the prescribed time frame.
RN2 indicated the pain medication should have been administered as ordered and the pain level should have been assessed prior to administration and post-administration to check if the pain was effectively controlled. RN2 confirmed there was no pain assessment performed.
On 01/18/2023 at 12:18 PM, the Assistant Director of Nursing (ADON) confirmed the Oxycodone was not given within the prescribed time. The ADON indicated the protocol for the medication administration was to be administered 1 hour in advance or 1 hour late.
The ADON confirmed there was no pain assessment performed and no documentation as to why the medication was administered outside the ordered timeframe.
On 01/18/2023 at 1:23 PM, a pain doctor indicated the staff were expected to follow the orders and if there were any changes, the provider should have been notified and documented the changes.
The pain doctor indicated it would be beneficial to assess the resident's pain, even on hospice services, to assess the location of pain, the activity, level of consciousness and the effectiveness of the pain medication. The pain doctor indicated the hospice was responsible for ensuring pain was managed or controlled.
Jun 2022
19 deficiencies
CONCERN
(D)
Potential for Harm - no one hurt, but risky conditions existed
Resident Rights
(Tag F0550)
Could have caused harm · This affected 1 resident
**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, interview, record review, and document review, the facility failed to ensure a resident's dignity and priv...
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**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, interview, record review, and document review, the facility failed to ensure a resident's dignity and privacy by not covering a urinary catheter drainage bag for 1 of 33 sampled residents (Resident 116).
Findings include:
Resident 116 (R116) was admitted on [DATE], with diagnoses including kidney failure and morbid obesity.
On 06/14/2022 at 10:35 AM, R116 was in bed, asleep. R116's urinary bag was hanging at the bedside, uncovered and visible from the door entrance of R116's room. The urinary catheter bag was transparent with 300 milliliters of amber-colored urine.
On 06/14/2022 in the afternoon, R116 was lying in bed alert and verbally oriented. R116 indicated bed confinement and dependence on activities of daily living. R116 was admitted three weeks ago with a Foley catheter. R116 was not aware the urinary bag was uncovered and visible by the entrance door. R116 indicated embarrassment regarding uncovered urine bag that others might see.
A Care Plan dated 06/14/2022, documented the position of the urinary catheter bag and tubing below the level of the bladder and away from the entrance room door.
On 06/15/2022 at 1:50 PM, the urinary bag was hanging at the bedside uncovered. A Certified Nursing Assistant (CNA) confirmed the observation the urinary bag was visible from the entrance of the room. The CNA indicated the urinary bag should have been covered by a dignity bag.
On 06/15/2022, a Licensed Practical Nurse said that a urinary bag should have been covered to protect the dignity of the resident.
On 06/15/2022 at 2:15 PM, the Nurse Supervisor indicated the Foley bag was from the hospital but should have been covered and placed on the other side of the bed for the resident's privacy. The Nurse Supervisor indicated the facility's urinary bags had a cover attached to them.
On 06/15/2022 at 3:00 PM, the Director of Staff Development (DSD) indicated the urinary bag should have been covered for the resident's dignity.
A facility policy titled Dignity revised 02/2021, revealed each resident shall be cared for in a manner that promotes and enhances the resident's sense of well-being, level of satisfaction with life, and feeling of self-worth and self-esteem, helping the resident to keep urinary catheter bags covered.
CONCERN
(D)
Potential for Harm - no one hurt, but risky conditions existed
Notification of Changes
(Tag F0580)
Could have caused harm · This affected 1 resident
**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on interview, record review and document review the facility failed to 1) report a resident's COVID positive status, 2) ro...
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**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on interview, record review and document review the facility failed to 1) report a resident's COVID positive status, 2) room change and 3) change in condition to the family for 1 of 33 sampled residents (Resident 275).
Findings include:
Resident 275 (R275) was admitted on [DATE], with diagnoses including cerebral atrophy and psychosis.
1) R275's medical record documented a positive COVID - 19 test result dated 01/20/2022. The progress notes had no notes from nursing and physicians as to why the resident was tested for COVID.
2) R275's medical record documented a room change from S10 to 307 on 01/22/2022. The progress notes had no notes from nursing as to why the resident was transferred to another room.
3) R275's progress notes dated 01/27/2022, revealed the Nurse Practitioner (NP) documented nurses had reported a decrease in R275's food & fluid intake. The NP ordered the resident to be started on intravenous fluids (IVF) until diet improved. Blood work in the morning, nutrition supplement and dietitian consult. The NP ordered additional as needed dose of the blood pressure increasing medication of R275 due to hypotension (low blood pressure).
The medical record lacked documented evidence R275's family was notified of the indicated incidences.
On 06/15/2022 in the afternoon, three nurses indicated family should be notified for positive COVID test results and room changes. The nurses verbalized initiation of IVF and new medication or changes with medication dosing - especially blood pressure increasing medication or medications that affects vital signs was considered as a change of condition and family should be informed.
On 06/15/2022 at 2:30 PM, the charge nurse indicated family should be notified for any room change, COVID testing and results. Medication initiation and dosing changes can be considered as change in health status.
06/15/2022 at 3:30 PM, the Director of Nursing (DON) reviewed the medical record and agreed with the findings. The DON indicated the facility was already aware of the incident and was already discussed with the administrator.
The facility policy titled Change in a Resident's Status or Condition revised February 2021, documented unless instructed by the resident, a nurse will notify the resident's representative when: There is a significant change in physical, mental, or psychosocial status. There is a need to change the resident's room assignment.
The facility policy titled Coronavirus Disease - Reporting Facility data to Residents and Families dated May 2020, documented resident and families were kept informed of the current COVID-19 situation of a resident and facility.
Complaint #NV00065930
CONCERN
(D)
Potential for Harm - no one hurt, but risky conditions existed
Abuse Prevention Policies
(Tag F0607)
Could have caused harm · This affected 1 resident
On 06/16/2022, the list of nursing staff for the day revealed four CNAs were from agency staffing.
A review of the personnel records for the four CNAs revealed, Employees 9, 10, 11 and 12 were from t...
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On 06/16/2022, the list of nursing staff for the day revealed four CNAs were from agency staffing.
A review of the personnel records for the four CNAs revealed, Employees 9, 10, 11 and 12 were from the internet-based staffing agency.
Employee 9's personnel filed lacked documented evidence of a completed criminal background check, previous employment references check, and abuse and neglect training.
Employee 10's personnel record lacked documented evidence of a completed criminal background check, previous employment references check and abuse and neglect training.
Employee 11's personnel record lacked documented evidence of a completed criminal background check, previous employment references check and abuse and neglect training.
Employee 12's personnel record lacked documented evidence of a completed criminal background check, previous employment references check and abuse and neglect training.
On 06/16/2022 at 2:30 PM, the Director of Human Resources (DHR) and Staffing Coordinator indicated the facility had the impression the internet-based staffing agency would perform all the necessary background checks and the facility was not screening for criminal background and job references. The DHR assumed the agency staff had completed the abuse and neglect training prior being allowed to work with residents in the facility.
On 06/17/2022 at 2:00 PM, the Administrator and director of nursing (DON) were not aware of the terms and agreement where the internet-based staffing agency relinquished the sole responsibility in assuring all facility requirements regarding training and background checks and placed the responsibility with the facility. The DON acknowledged the importance of performing such checks to ensure the safety of the residents.
A document titled Terms of Service, signed by the facility's Administrator, disclosed that the internet-based staffing application did not represent or guarantee the truth or accuracy of any healthcare professional (HCP), the facility's postings, or other user content on the Site. The agreement specified that the signing customer (the facility's Administrator) accepted, agreed, and understood the internet-based staffing application in no way supervised, directed, controlled, or evaluated HCPs or their work and was not liable for any Project or Work Product. The document indicated that the internet-based staffing application made no assurances on the quality, safety, or legality of HCP Services, the qualifications, background, or identities of HCPs, or their capacity to provide HCP Services. The document indicated the facility should provide orientation on policies and procedures including patient's rights.
The facility policy titled Abuse Prevention Program dated December 2016, documented the facility's administration would conduct employee background checks and required staff training and orientation as part of the resident abuse prevention.
Facility Reported Incident #NV00066075
Based on interview, record review and document review, the facility failed to ensure employees contracted through an internet-based app that links healthcare workers with available shifts in healthcare facilities were screened for criminal background and job references and received abuse and neglect training prior being allowed to work alone with residents for 5 of 12 reviewed personnel files (Employee 8, 9, 10, 11 and 12).
Findings include:
On 06/17/2022 in the afternoon, employee's files were reviewed.
Employee 8 (E8)
E8's personnel records revealed the employee was contracted to perform duties as a Certified Nursing Assistant (CNA) through an internet-based app that linked healthcare workers with available shifts in healthcare facilities. The record documented the employee worked at the facility on 02/09/2022, 02/10/2022, 02/11/2022, 02/12/2022, 02/14/2022, 02/15/2022, 02/17/2022, 02/19/2022, 02/20/2022, 02/21/2022, 02/22/2022, 02/23/2022, 04/04/2022, and 04/05/2022. E8's personnel record lacked documented a completed background check was performed and previous employment references were checked prior to be assigned to provide care to residents.
E8's personnel record documented the employee completed elder abuse training on 04/29/2022. The personnel record lacked documented evidence E8 received abuse and neglect training prior being allowed to work alone with residents. E8 first day at work was 02/09/2022.
On 06/15/2022 at 3:00 PM, the Staffing Coordinator explained staffing needs were covered using an internet-based app that linked healthcare workers with available shifts in healthcare facilities. The Staffing Coordinator indicated the facility posted the shifts available and the healthcare workers responded with the availability to cover the shift. The Staffing Coordinator confirmed the facility did not verify the staff qualifications since it was the responsibility of the agency who runs the app.
On 06/17/2022 at 12:00 PM, the Director of Staff Development (DSD) explained regular staff received abuse and neglect training upon hire, annually and as needed. The DSD indicated the training for the staff contracted from nursing agencies or through the internet-based staffing app was performed by their agencies and not by the facility. The DSD stated Human Resources verified job references and completed the criminal background check for the regular staff but not for agency nurses. The DSD acknowledged it was important to verify the staff qualifications to ensure resident safety.
On 06/17/2022 at 12:30 PM, the Director of Human Resources (DHR) explained the facility utilized an internet-based staffing app that linked healthcare workers with available shifts as a staffing resource when a nurse was needed. The DHR indicated the facility published the nursing shifts available in the staffing app. The nurse was chosen by Human Resources from a pool of nurses interested in the shift. The chosen nurse came to work the assigned shift and the facility paid the staffing website for the nursing services.
The DHR explained it was the duty of the nursing agency that runs the internet-based staffing app to verify criminal background, job references, and training, and upload all documents related to qualifications, licenses, and certificates. The DHR indicated that, under normal circumstances, a criminal background check was one of the prerequisites for hiring a new employee. The candidate for employment consented to enrollment in the Nevada Automated Background Check System (NABS). After obtaining permission, fingerprints were taken, and the information was submitted to the NABS website. The DHR acknowledged the facility did not complete a criminal background check, job reference verification, training and qualifications for nurses contracted through the internet-based staffing app.
CONCERN
(D)
Potential for Harm - no one hurt, but risky conditions existed
Comprehensive Care Plan
(Tag F0656)
Could have caused harm · This affected 1 resident
**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on interview, record review, and document review, the facility failed to develop a person-centered comprehensive care plan...
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**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on interview, record review, and document review, the facility failed to develop a person-centered comprehensive care plan for a nutritional concern for 2 of 33 sampled residents (Resident 59 and Resident 106).
Findings include:
Resident 59 (R59) was admitted on [DATE] and readmitted on [DATE], with diagnoses including injury of nerve root of cervical spine, contracture of right elbow, stage 4 pressure ulcer of right buttock, unstageable pressure ulcer of left heel, and chronic pain.
A Nutritional Comprehensive assessment dated [DATE], documented R59 had a stage 4 pressure ulcer to the right buttock. The nutritional diagnoses revealed R59's increased nutrient needs related to metabolic demand for increased nutrients as evidenced by stage 4 sacral pressure ulcer. R59's nutritional intervention was to start Arginaid one packet twice a day for wound healing.
A Nutritional Care Plan revised 05/18/2022, documented R59 had a nutritional problem or potential nutritional problem related to diet restrictions for a reduced concentrated sweets diet. R59's goal was to maintain adequate nutritional status by consuming at least three meals daily, not develop complications related to obesity, and to provide ease with self-feeding.
The medical record lacked documented evidence of a person-centered nutritional care plan for R59's increase nutrient needs for the stage 4 sacral pressure ulcer.
On 06/17/2022 at 11:20 AM, the Registered Dietitian (RD) indicated resident nutritional care plans would be updated and personalized to address the nutritional concerns of the resident. The RD explained R59 required additional protein to promote wound healing for the stage 4 pressure ulcer to the right buttock. The RD indicated the nutritional comprehensive assessment on 05/20/2022 addressed the concern of R59's stage 4 pressure ulcer and need for increased nutrients. The RD confirmed R59's care plan did not reflect the nutritional needs of the resident and should have been revised.
Resident 106 (R106) was admitted on [DATE], with diagnoses including dysphagia, dementia, and signs and symptoms concerning food and fluid intake.
The Quarterly Minimum Data Set (MDS) dated [DATE] and 05/20/2022, revealed R106 had significant weight loss of 5% or more in the last month or loss of 10% or more in last 6 months and was not on prescribed weight loss regimen.
Physician Order Progress Note dated 04/04/2022, documented the physician was notified and to follow Registered Dietitian (RD) dietary recommendation for weight loss and suboptimal oral intake.
The Nutrition Quarterly Review dated 05/18/2022, documented R106 had 25-50% oral intake. R106 had lost 3 pounds since last RD follow up and continued with weight loss in the last six months. R106 had lost 12.6 pounds (11.4%).
A Nutritional Care Plan dated revised 05/27/2022, documented R106 was at risk of altered nutritional status due to dementia/cognitive impairment, and mechanically altered diet due to difficulty swallowing. Intervention for R106 were to encourage adequate food and fluid intake, offer nutritional supplements per RD recommendation, RD referral for nutritional needs, and weight weekly as needed.
The medical record laced documented evidence of a person-centered nutritional care plan for R106's significant weight loss.
On 06/17/2022 at 11:25 AM, the RD indicated R106's had nutritional concerns related significant weight loss. The RD acknowledged the comprehensive care plan for R106 was not person-centered and did not address the resident's weight loss concern. The RD explained R106's nutritional care plan should have been revised.
On 06/17/2022 at 1:40 PM, the Director of Nursing (DON) indicated resident care plans should be person-centered to reflect the care needed for the resident. The DON confirmed R59's and R106's nutritional care plan were not person-centered to reflect the nutritional concerns of the resident.
The Comprehensive Person-Centered Care Plan Policy revised 12/2016, documented a comprehensive person-centered care plan includes measurable object and timetables to meet the resident's physical, psychosocial, and functional needs would be developed and implemented for each resident. The care plan interventions were to be derived from a thorough analysis of the information gathered as part of the comprehensive assessment.
CONCERN
(D)
Potential for Harm - no one hurt, but risky conditions existed
ADL Care
(Tag F0677)
Could have caused harm · This affected 1 resident
**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, interview, record review, and document review, the facility failed to ensure a shower or bed bath was prov...
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**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, interview, record review, and document review, the facility failed to ensure a shower or bed bath was provided as scheduled for 2 of 33 sampled residents (Resident 422 and Resident 428).
Findings include:
1) Resident 422 (R422) was admitted on [DATE], with diagnoses including type 2 diabetes and end stage renal disease.
On 06/14/2022 at 11:37 AM, R422 was in bed watching television. R422's hair was unkempt, messy, and had an unshaven face. R422 indicated nobody had offered or helped the resident shave and had not showered since arriving at the facility over a week ago. R422 indicated they would like their beard shaved, showered, and to feel clean when going out the dialysis clinic.
The Nursing Admission/readmission Evaluation dated 06/07/2022, documented R422 required total dependence for bath or shower.
The 5-Day Minimum Data Set (MDS) dated [DATE], documented the Brief Interview for Mental Status (BIMS) score of 15/15 which meant the cognitive status was intact. R422 required extensive assistance for personal hygiene bathing activity did not occur within the last 7-day period.
The Shower Schedule revealed R422's showers were scheduled on Tuesdays and Fridays during the night shift.
The Point of Care Documentation History for bath/shower documented R422 was not provided a shower or bed bath since admission on [DATE].
The Medical Record lacked documented evidence R422 was provided a shower or bed bath since arriving at the facility on 06/07/2022.
On 06/15/2022 at 2:18 PM, Certified Nursing Assistant 1 (CNA1) indicated residents were provided a shower or bed bath twice a week based on the shower schedule. CNA1 indicated the nurse would be informed if the resident refused a shower, and the refusal would be documented in the Activities of Daily Living (ADL) Point of Care. CNA1 indicated R422 was scheduled to receive showers every Tuesdays and Fridays in the evening. CNA1 indicated they were unsure why R422 was not provided showers on the scheduled shower days.
On 06/15/2022 at 2:23 PM, a Licensed Practical Nurse (LPN) indicated residents were provided showers based on the shower schedule twice a week or more frequently if needed. R422 should have been provided a shower or bed bath on the scheduled days of Tuesday and Friday in the evening. The LPN confirmed R422 was not provided a shower or bed bath since arriving at the facility on 06/07/2022 and should have at least received shower or bed baths in the past week.
2) Resident 428 (R428) was admitted on [DATE], with diagnoses including chronic obstructive pulmonary disease, type 2 diabetes mellitus, and morbid obesity.
On 06/14/2022 at 3:55 PM, R428 was in bed watching television. R428's hair was messy, greasy, and had not been washed in a while. R428 indicated the staff had not offered a shower or washed their hair since being at the facility a week ago. R428 indicated they would like a shower and needed assistance from the nursing staff with the shower. R428 indicated they have notified the staff, but they did not receive a shower.
On 06/15/2022 at 2:01 PM, R428 indicated the nursing staff did not come to assist for a shower after telling them yesterday.
The Nursing Admission/readmission Evaluation dated 06/09/2022, documented R428 required setup assistance for bath or shower.
The 5-Day MDS dated [DATE], documented R428's BIMS score of 15/15 which meant the cognitive status was intact. R428 required supervision with setup help for personal hygiene and bathing activity did not occur within the last 7-day period.
The Shower Schedule revealed R428's showers were scheduled on Tuesdays and Fridays during the day shift.
The Point of Care Documentation History for bath/shower documented R428 was not provided a shower or bed bath since admission on [DATE].
The Medical Record lacked documented evidence R428 was provided a shower or bed bath since arriving at the facility on 06/09/2022.
On 06/15/22 at 2:11 PM, CNA2 indicated residents were provided bed baths or showers twice a week following the shower schedule or when the resident requests. CNA2 indicated they had taken care of R428 the past few days and provide a shower for the resident. CNA2 indicated they did not check the shower schedule so R428's scheduled shower was missed. CNA2 remembered R428 asking for a shower yesterday but was busy and forgot to provide the shower.
On 06/15/2022 at 2:13 PM, an LPN confirmed R428 was not provided a shower or bed bath since arriving at the facility on 06/09/2022 and the CNA should have provided a shower on the assigned shower days or when the resident requested.
On 06/15/2022 at 3:18 PM, the DON indicated showers were to be provided twice a week. The DON confirmed the showers were not provided and should have been provided.
On 06/15/2022 at 3:18 PM, the Director of Nursing (DON) indicated the CNAs were expected to provide a shower or bed bath twice a week following the shower schedule or when the resident requests.
The Activities of Daily Living (ADL) Policy revised 03/2018, documented resident would be provided with care, treatment, and services as appropriate to maintain or improve their ability to carry out activities of daily living. Appropriate care and services would be provided for residents who are unable to carry out ADLs independently, with the consent of the resident and in accordance with the plan of care, including appropriate support and assistance with: hygiene (bathing, dressing, grooming, and oral care), mobility, elimination, dining; and communication.
CONCERN
(D)
Potential for Harm - no one hurt, but risky conditions existed
Quality of Care
(Tag F0684)
Could have caused harm · This affected 1 resident
**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, interview, record review, and document review, the facility failed to ensure the intravenous (IV) antibiot...
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**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, interview, record review, and document review, the facility failed to ensure the intravenous (IV) antibiotic medication to treat a leg infection was administered as ordered for 1 of 33 sampled residents (Resident 116).
Findings include:
R116 (R116) was admitted on [DATE], with diagnoses including kidney failure, diabetes mellitus, and leg infection.
On 06/14/2022 at 10:25 AM, R116 was in bed asleep. Ceftriaxone was given through an IV in the right upper arm.
On 06/15/2022 at 1:55 PM, R116 indicated the Ceftriaxone should be administered daily but was inconsistently given. R116 expressed requests were made, but the staff did not regularly give the IV antibiotic for unexplained reasons. R116 had spoken to the nursing supervisor and the issue was reported.
The Brief Interview of Mental Status dated 06/04/2022, documented the score of 15/15, which indicated R116's cognitive status was intact.
A physician order dated 06/10/2022, documented Ceftriaxone Sodium Solution 2 gram (gm) IV to be administered at 9:00 AM, daily for right foot infection-Proteus mirabilis until 06/16/2022.
The Medication Administration Records lacked documented evidence the Ceftriaxone was administered on 06/08/2022, 06/10/2022, 06/13/2022 and 06/15/2022.
R116's medical records lacked documented evidence the physician was notified of the missed doses and the reason why they were missed.
On 06/16/2022 at 2:40 PM, the pharmacy technician indicated R116's Ceftriaxone was ordered. The pharmacy technician indicated there were 13 doses delivered at the facility and no IV medication pulled from the emergency dispenser. The pharmacy technician indicated the Ceftriaxone was ordered on 06/04/2022 at 4:59 PM and was delivered on the following dates: 06/05/2022, 3 doses, 06/07/2022, 3 doses, 06/09/2022, four doses and 06/14/2022, 3 doses were delivered.
On 06/16/2022 at 3:30 PM, the nurse supervisor confirmed R116 reported missed doses of Ceftriaxone. The nurse supervisor confirmed the Ceftriaxone was inconsistently administered. The nurse supervisor confirmed the staff was expected to administer the medications as ordered and if the dose was missed the physician should have been notified and documented. The nurse supervisor confirmed there was no documented evidence as to why the Ceftriaxone was not administered.
The nurse supervisor confirmed Ceftriaxone IV was completed that day at 9 AM (06/16/2022), but doses of R116's Ceftriaxone were found in the medication room at the time of the survey. The nurse supervisor indicated there was no personnel assigned to monitor and oversee the IV medications if they were administered or not. The nurse supervisor indicated the LPNs assigned to the resident were not IV certified and should call for nursing staff to administer the IV.
On 06/15/2022 at 3:45 PM, the physician assistant (PA) who attended to R116 indicated the facility staff was expected to give the IV antibiotic as ordered to achieve the therapeutic effect and prevent sepsis. The PA was not informed of the missed doses of IV Ceftriaxone.
A facility policy titled Medication Administration Schedule, Revised 11/2020, indicated the scheduled medications should be administered within one hour of their prescribed time. The exact time of medication administration is documented in the MAR. If medication is administered early, late, or is omitted, the reason is also documented.
CONCERN
(D)
Potential for Harm - no one hurt, but risky conditions existed
Pressure Ulcer Prevention
(Tag F0686)
Could have caused harm · This affected 1 resident
**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, interview, record review and document review, the facility failed to ensure heel protection devices were a...
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**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, interview, record review and document review, the facility failed to ensure heel protection devices were applied to prevent pressure ulcer for 1 of 33 sampled residents (Resident 172).
Findings included:
Resident 172 (R172) was admitted on [DATE], with diagnoses including down syndrome, morbid obesity.
A Braden Scale dated 03/15/2022, documented the resident had moderate risk for pressure ulcer development.
A Nursing Progress Note dated 03/24/2022, documented on assessment R172 was found having an unstageable pressure ulcer to right lateral ankle. The progress note indicated the attending physician was called and ordered wound consult with the wound care physician and wound care team, and the treatment for the pressure ulcer including to cleanse the injury with normal saline solution, pat dry, apply Iodosorb ointment, cover with dry dressing, change every Tue, Thu, Sat and as needed for soiled and dislodgement until 04/21/2022.
A Wound Care Physician assessment dated [DATE], revealed the physician assessed the resident and ordered treatment.
On 06/17/22 at 10:00 AM, the Wound Care Nurse (WCN) indicated R172 rubbed the feet in bed and the dried skin possibly contributed to the ulcer development. At the time the skin injury was discovered on 03/24/2022, an assessment was performed, and the injury was identified as an unstageable with dimensions of 2.0 X 2.0 x 0.1 centimeter (cm). The WCN indicated bilateral heel protectors were ordered to prevent further skin ulcers.
On 06/17/2022 at 10:20 AM, R172 was lying in bed and did not have heel protectors on. The right foot was covered with a sock and the left foot was uncovered. R172 was moving the lower extremities and rubbing the feet against bed.
On 06/17/2022 at 10:25 AM, a Licensed Practical Nurse (LPN) confirmed R172 was not wearing the heel protectors. The LPN examined R172 left ankle and found a redness area. The LPN described the finding as a blister caused by shearing the foot with the mattress surface. The LPN acknowledged heel protectors should have been placed to prevent skin injuries.
A Physician Order dated 02/08/2019, documented bilateral heel protectors on at all times while in bed.
A care plan dated 03/15/20222 indicated R172 had potential for tissue breakdown or pressure ulcer related to extensive assistance required with bed mobility and had urinary and bowel incontinence, pruritus. Interventions included bilateral heel protectors on at all times while in bed for pressure relief and turning/repositioning every 2 hours.
The facility policy titled Prevention of Pressure Injuries dated April 2020, documented staff should review resident's care plan and identify the interventions designed to reduce or eliminate the risk factors. The policy indicated appropriate support surface should be selected based on the risk factors.
CONCERN
(D)
Potential for Harm - no one hurt, but risky conditions existed
Deficiency F0688
(Tag F0688)
Could have caused harm · This affected 1 resident
**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on interview, record review, and document review, the facility failed to provide restorative services for 1 of 33 sampled ...
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**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on interview, record review, and document review, the facility failed to provide restorative services for 1 of 33 sampled residents (Resident 93).
Findings include:
Resident 93 (R93) was admitted on [DATE], and readmitted on [DATE], with diagnoses including monoplegia of lower limb following cerebral infarction, and chronic obstructive pulmonary disease.
On 06/15/2022 at 8:31 AM, R93 indicated their left leg was paralyzed and was not receiving therapy or restorative services to get stronger. R93 indicated it had been a few weeks since receiving restorative services and did not receive therapy or restorative services since returning to the facility. R93 would like to get stronger working with therapy or restorative services.
The 5-Day Minimum Data Set (MDS) dated [DATE], documented R93's Brief Interview for Mental Status (BIMS) score of 15/15 which meant the cognitive status was intact.
The Nursing Admission/readmission Evaluation dated 05/13/2022, documented R93 had permanent physical impairment due to contractures.
The Therapy Screening Form dated 05/16/2022, revealed R93 was re-admitted and had no recent changes or deficits noted. R93 was at prior level of function.
The Function Abilities and Goal assessment dated [DATE], documented R93 had not attempted sit to lying, lying to sitting on bed side, sit to stand, chair/bed-to chair transfer, toilet transfer, and walk due to medical condition or safety concerns.
On 06/16/2022 at 8:52 AM, the Director of Rehabilitation indicated newly admitted , long-term, and readmitted residents would be screened by therapy to determine if the resident would benefit from physical therapy or occupational therapy. The resident would be referred to restorative services for maintenance if the resident was at prior level of function. The Director of Rehabilitation indicated R93 was screened on 05/16/2022 after readmission to facility and was at prior level of function. R93 was referred to restorative services to maintain range of motion for maintain upper and lower extremity joints.
On 06/16/2022 at 9:08 AM, the Restorative Service Supervisor and the Minimum Data Set Licensed Practical Nurse indicated readmitted and newly admitted residents would be screened by restorative services. Restorative services would be provided for the resident if the resident was not on therapy services for 90 days. The Restorative Service Supervisor indicated R93 was screened on 05/18/2022 but restorative service was not provided at that time due to the resident being in the person under investigation (PUI) observation unit for 7-days after admission. The Restorative Service Supervisor indicated they would provide restorative services to residents once they were no longer in the PUI unit. The Restorative Service Supervisor and the Minimum Data Set Licensed Practical Nurse indicated R93 was not on restorative services because R93 returned from the hospital and was in the PUI observation unit. Restorative Service Supervisor indicated R93 was overlooked and should have been on restorative services after the 7-day observation period ended.
On 06/17/2022 at 10:21 AM, the Director of Nursing (DON) confirmed R93 should have been placed on restorative services because the therapy services did not pick up the resident due to the resident was at prior level of function when screened on 05/16/2022. The DON indicated restorative services should have provided services starting 05/21/2022, the day after R93 was no longer in the PUI observation unit.
The Restorative Nursing Services Policy revised 07/2017, documented residents would receive restorative nursing care as need to help promote optimal safety and independence. Residents may be started on a restorative nursing program upon admission, during the course of stay or when discharged from rehabilitative care.
CONCERN
(D)
Potential for Harm - no one hurt, but risky conditions existed
Accident Prevention
(Tag F0689)
Could have caused harm · This affected 1 resident
**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, interview, record review, and document review, the facility failed to ensure a power cord was safely plugg...
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**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, interview, record review, and document review, the facility failed to ensure a power cord was safely plugged-in to prevent a tripping hazard for 1 of 33 sampled residents (Resident 10).
Findings include:
Resident 10 (R10) was admitted on [DATE], with diagnoses including psychosis, lack of coordination, absence of left leg below the knee, and history of falling.
On 06/14/2022 at 1:30 PM, the Oxygen (O2) concentrator was running and plugged into a power cord, and the power cord was plugged into an electrical outlet across R10's room.
On 06/15/22 in the morning, R10 and staff members were observed going in and out of the room. A power cord was plugged across R10's room. R10 was able to transfer independently from bed to a wheelchair.
On 06/15/2022 at 2:30 PM, R10 was in bed. A Certified Nursing Assistant (CNA) confirmed the power cord was plugged right across R10's room entrance. The CNA indicated the power cord was a tripping hazard.
On 06/15/2022 at 2:35 PM, the nurse supervisor indicated the use of a power cord and plug across R10's room was unacceptable and a safety hazard. The nurse supervisor indicated anyone could trip, including the resident.
On 06/15/2022 at 2:40 PM, the Housekeeping Supervisor indicated the environmental services were responsible for ensuring the safety plugging of the power cords.
On 06/17/2022 at 4:30 PM, the Director of Environmental Services (EVS) indicated was not aware a power cord was used for the concentrator that was plugged into the electrical outlet across the resident's room. The Director of EVS indicated a power cord was a safety hazard and anybody could trip.
CONCERN
(D)
Potential for Harm - no one hurt, but risky conditions existed
Incontinence Care
(Tag F0690)
Could have caused harm · This affected 1 resident
**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, interview, record review, and document review, the facility failed to ensure a resident was appropriately ...
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**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, interview, record review, and document review, the facility failed to ensure a resident was appropriately assessed for the use of a Foley catheter, a physician order was obtained, and urine output was monitored for 1 of 33 sampled residents (Resident 116).
Findings include:
Resident 116 (R116) was admitted on [DATE], with diagnoses including kidney failure, morbid obesity, anemia, and diabetes mellitus.
On 06/14/2022 at 10:35 AM, R116's urine drainage bag was hanging next to the bed, uncovered, and could be seen from the doorway of the room.
06/14/22 in the afternoon, R116 was in bed. The Foley bag was beside the bed, draining 250 ml of amber-colored urine. R116 was in bed, alert and verbally oriented. R116 indicated bed confinement and dependence on activities of daily living. R116 was admitted three weeks ago with a Foley catheter. R116 indicated the Foley was inserted in the hospital but was previously able to control bladder function.
The admission Evaluation dated 05/25/2022, lacked documented evidence R116's Foley catheter was identified, assessed, and monitored until 06/14/2022.
The facility checklist indicated the nursing staff responsibilities on the day of admission included bowel and bladder program screening every 72 hours.
On 06/15/2022 at 1:50 PM, a Certified Nursing Assistant (CNA) indicated uncertainty if R116 was admitted with a Foley catheter. The CNA indicated if a resident had a Foley catheter, the intake/urine output would be monitored and documented.
On 06/15/2022 at 2:01 PM, a Licensed Practical Nurse indicated a Foley catheter required an assessment, physician order, and monitoring.
The LPN confirmed R116's Foley catheter did not have an order in place and was not monitored until 06/14/2022.
On 06/15/2022 at 2:15 PM, the nurse supervisor indicated R116 was admitted with a Foley catheter. The nurse supervisor indicated residents with Foley catheters should have been assessed with justification for use of a catheter. The Foley required an order including the care and management, output monitoring, checking for kinks, and changing once a month. If the use of the Foley catheter was not justified, the physician would be notified to obtain orders. The nurse supervisor confirmed since there was no assessment in place and no physician order was obtained, R116's Foley was not monitored from 05/25/2022 to 06/13/2022.
On 06/15/2022 at 3:00 PM, the Director of Staff Development (DSD) indicated staff members were provided education regarding Foley catheter use. The DSD explained the resident's Foley catheter should have an assessment, justification, and monitoring in place. The DSD indicated the Foley catheter required an order and a care plan.
On 06/17/2022 at 12:15 PM, the Nurse Practitioner indicated the facility was expected to assess a resident with a Foley catheter upon admission. The NP indicated R116 was bed-bound and the skin on R116's buttock was intact. The NP indicated there was a discussion with the family at bedside regarding the desire for Foley catheter removal with a goal of discharging home with the family.
A facility policy titled Foley Catheter (undated), indicated a Foley catheter should have an order.
A facility policy titled Catheter Care, Urinary revised 09/2014 indicated to review the resident's care plan to assess and monitor the Foley catheter, monitor urine output, and maintain an accurate record, observe the resident for complications associated with urinary catheters and manage obstructions.
CONCERN
(D)
Potential for Harm - no one hurt, but risky conditions existed
Deficiency F0692
(Tag F0692)
Could have caused harm · This affected 1 resident
**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on interview, record review, and document review, the facility failed to 1) provide nutritional assessments for 2 of 33 sa...
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**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on interview, record review, and document review, the facility failed to 1) provide nutritional assessments for 2 of 33 sampled residents (Residents 106 and 422), and 2) Registered Dietitian (RD) recommendations were communicated to the physician and processed for 2 of 33 sampled residents (Residents 59 and Resident 106).
Findings include:
1) Nutritional Assessments
Resident 106 (R106) was admitted on [DATE], with diagnoses including dysphagia, dementia, and signs and symptoms concerning food and fluid intake.
The Quarterly Minimum Data Set (MDS) dated [DATE], documented R106 had significant weight loss of 5% or more in the last month or loss of 10% or more in the last six months. R106 was not on a physician-prescribed weight-loss regimen.
The medical record lacked documented evidence a quarterly nutritional assessment and progress note was done to address R106's weight loss.
On 06/15/2022 at 3:05 PM, the RD indicated nutritional assessments were completed within seven days after admission, quarterly, and annually following the MDS schedule. The RD acknowledged the quarterly nutritional assessment was not completed for R106 on 02/18/2022. The RD indicated the previous RD may have missed the quarterly nutritional assessment and should have completed the quarterly nutritional assessment.
Resident 422 (R422) was admitted on [DATE], with diagnoses including type 2 diabetes and end stage renal disease.
The medical record lacked documented evidence of an admission nutritional assessment was completed.
On 06/15/2022 at 3:05 PM, the RD indicated newly admitted residents would be assessed by the RD within seven days of admission. The RD confirmed the admission nutritional assessment for R422 was not completed and should have been completed within seven days of admission.
On 06/16/2022 at 12:04 PM, the Director of Nursing (DON) indicated the RD was expected to complete nutritional assessments following the MDS schedule. The DON indicated they were not aware the quarterly nutritional assessment for R106 was not completed and the new admission assessment for R422 was not done within seven days.
The Nutritional Quarterly Review Policy revised 07/02/2018, documented the quarterly review would need to correlate with the quarterly MDS. A quarterly progress note review would be acceptable unless the resident was on a tube feeding, on dialysis, on ventilator, experienced significant weight loss, pressure injury, nutritional pertinent abnormal labs, or other serious nutritional concerns, then the Medical Nutrition Quarterly Review would be used.
The Nutritional Care Planning Process Policy revised 04/30/2021, documented the initial nutritional risk review were completed seven-days from admission and a seven-day look-back period should be utilized. In order to establish a Dietary Plan of Care, a MDS and Initial Nutritional Risk Review, a Quarterly MDS and Quarterly Nutritional Risk Review, and an Annual MDS and Nutritional Risk Review were completed for every resident.
2) Recommendations
Resident 59 (R59) was admitted on [DATE] and readmitted on [DATE], with diagnoses including injury of nerve root of cervical spine, contracture of right elbow, stage 4 pressure ulcer of right buttock, unstageable pressure ulcer of left heel, and chronic pain.
On 06/14/2022 at 10:39 AM, R59 indicated there was a wound on their buttocks for a long time and the wound care team was providing treatment. R59 was not sure if a nutritional supplement was provided to help with the wound healing.
A Nutritional Comprehensive assessment dated [DATE], documented R59 had a stage 4 pressure ulcer to the right buttock. The nutritional diagnoses revealed R59's increased nutrient needs related to metabolic demand for increased nutrients as evidenced by stage 4 sacral pressure ulcer. R59's nutritional intervention was to start Arginaid one packet twice a day for wound healing.
The medical record lacked documented evidence the RD recommendation was communicated to the physician and implemented.
On 06/16/2022 at 11:04 AM, the Wound Care Nurse indicated the RD would recommend nutritional supplements for wound healing if the resident had stage 3 or stage 4 wound. The Wound Care Nurse indicated R59 would benefit from the nutritional supplements to promote wound healing for the stage 4 pressure injury to the buttocks. The Wound Care Nurse confirmed there was no nutritional supplement ordered for R59.
On 06/17/2022 at 11:20 AM, the RD indicated a resident with stage 3 or stage 4 would be prescribed supplements to promote wound healing. The RD confirmed the RD recommendation from the Nutritional Assessment on 05/20/2022 to start Arginaid twice a day for wound healing was not implemented. The RD indicated they forgot to notify the DON of the RD recommendation, therefore the Arginaid supplement was not implemented. The RD indicated the RD recommendation would be sent to the DON who would notify the physician and process the recommendation. The RD indicated the RD recommendation should have been processed within 72 hours of the nutritional assessment.
On 06/17/2022 at 12:04 PM, the DON indicated the RD recommendations should be processed within 24 hours after receiving the order from the RD. The DON indicated the RD did not submit the RD recommendation for the Arginaid which was why the physician was not notified and the recommendation was not processed.
Resident 106 was admitted on [DATE], with diagnoses including dysphagia, dementia, and signs and symptoms concerning food and fluid intake.
The Quarterly Minimum Data Set (MDS) dated [DATE] and 05/20/2022, revealed R106 had significant weight loss of 5% or more in the last month or loss of 10% or more in last 6 months and was not on prescribed weight-loss regimen.
A Dietary Progress Note dated 04/03/2022, documented R106 weighed 101.6 pounds. The oral intake varied with an average of 50%. R106 received Resource 2.0 supplement four times a day and had an order for diabetic health shake three times a day. The RD would continue Resource 2.0 supplement, discontinue diabetic health shake, start Magic Cup twice a day with lunch and dinner, and recommended appetite stimulant.
The medical record lacked documented evidence the RD recommendation for appetite stimulant was implemented after 04/03/2022.
Nutrition Quarterly Review Quarterly dated 05/18/2022, documented R106 had lost 3 pounds since last RD follow-up. R106 continued with weight loss. Resident had lost 12.6 pounds (11.4%) in the last six months. RD recommended the provider to consider an appetite stimulant for 30 days.
The medical record lacked documented evidence the RD recommendation for appetite stimulant was implemented after 05/18/2022.
On 06/17/2022 at 11:25 AM, the RD indicated the RD recommendations should be processed within 72-hours. The RD confirmed R106 did not have orders for appetite stimulant and the RD recommendation should have been processed.
On 06/17/2022 at 1:47 PM, the Physician indicated the facility did not notify them the RD's recommendation of an appetite stimulate for R106. The Physician indicated R106 would benefit for the appetite stimulant due to weight loss.
On 06/17/2022 at 1:50 PM, the DON indicated the RD recommendation was not communicated, processed, and was overlooked on 05/18/2022 when the RD notified the DON. The DON indicated the RD recommendation should have been processed within 24 hours once the RD notified the DON of the recommendation.
The Recommendation to Nursing Fax Consultation and Telephone Orders Policy revised 06/30/2018, documented dietary recommendations were given to the Charge Nurse and Director of Nursing. Nursing was to return the completed recommendation form within 72 hours.
The Criteria for Completion of RD's Quarterly Report Nutritional Assessment for Long-Term Care Policy revised 04/30/2021, documented appropriate nutritional recommendations were to be made and followed through in a timely manner. Check to be sure there were no outstanding and overdue recommendations.
CONCERN
(D)
Potential for Harm - no one hurt, but risky conditions existed
Deficiency F0694
(Tag F0694)
Could have caused harm · This affected 1 resident
**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Resident 422 (R422) was admitted on [DATE], with diagnoses including type 2 diabetes and end stage renal disease.
On 06/14/2022...
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**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Resident 422 (R422) was admitted on [DATE], with diagnoses including type 2 diabetes and end stage renal disease.
On 06/14/2022 at 11:37 AM, R422 was observed with a midline catheter in the left upper arm. The midline catheter had a dressing dated 06/06/2022. R422 indicated the midline catheter dressing had not been changed since arriving at the facility and the current dressing was done at the hospital over a week ago.
The Nursing Admission/readmission Evaluation dated 06/07/2022, documented R422's midline on left upper arm dressing was clean, dry, and intact with no complication. There was no drainage, bleeding, or swelling noted.
A Physician Order dated 06/07/2022, documented midline dressing change: cleanse insertion site with betadine swab, cleanse with alcohol wipes, air dry, and cover with transparent dressing every 7 days.
On 06/15/2022 at 2:13 PM, the Licensed Practical Nurse (LPN) indicated midline dressings were changed weekly for residents on Sunday. The LPN indicated R422 was receiving a daily midline flush and should have had a dressing change on Sunday by the day shift nurse at 8:00 AM per the physician orders. The LPN indicated the nurse would clean the insertion site, cover the site with transparent dressing, and date the dressing of when it was changed. The LPN confirmed R422's midline catheter to the left upper arm dressing was dated 06/06/2022 and should have been changed on Sunday 06/12/2022 as ordered by the physician. The LPN was not sure why the day shift nurse on Sunday did not change the midline dressing.
On 06/15/2022 at 3:18 PM, the Director of Nursing (DON) indicated there was a facility protocol for midline care. The DON confirmed R422 should have the midline dressing change every 7-days on Sunday and the nurse should have followed the physician order for midline dressing change as indicated on the treatment administration record.
Based on observation, interview, record review, and document review, the facility failed to ensure an intravenous (IV) midline dressing was changed within 24 hours upon insertion and weekly thereafter per policy for 2 of 33 sampled residents (Residents 116 and 422).
Findings include:
A facility policy titled Midline Dressing Changes, revised 11/2016, indicated the midline catheter dressings would be changed at specific intervals, or when needed, to prevent catheter-related infections associated with contaminated, loosened, or soiled catheter-site dressings. Change midline catheter dressings every 24 hours after catheter insertion, every 5 days, or if they are wet, dirty, not intact, or compromised in any way.
Resident 116 (R116) was admitted on [DATE], with diagnoses including kidney failure, cellulitis (deep infection of the skin), diabetes mellitus, and leg infection.
The Brief Interview of Mental Status dated 06/04/2022, documented the score of 15/15, which indicated R116's cognitive status was intact.
On 06/14/22 at 10:25 AM, the resident was in bed asleep. The Ceftriaxone IV antibiotic was infused via IV midline access in the right upper arm. The midline transparent dressing was dated 06/02/2022 and soiled with reddish-brownish matter.
A physician's order dated 06/02/2022, documented a midline dressing change to cleanse the insertion site and cover it with transparent dressing every seven days by Sunday.
On 06/15/2022 at 1:55 PM, R116 was alert, oriented, and verbally responsive. R116 indicated the midline IV access was inserted within the facility on 06/02/2022 and received an IV antibiotic for leg infection. R116 indicated the midline dressing had not been changed since insertion on 06/02/2022.
The Medication Administration Record (MAR) documented the midline dressing was changed on 06/05/2022 and 06/12/2022. The midline dressing was not changed as documented.
On 06/15/2022 at 2:01 PM, a Licensed Practical Nurse (LPN) confirmed observation R116's dressing was soiled and dated 06/02/2022. The LPN indicated the registered nurse (RN), or IV certified nurse should have changed the dressing every Sunday.
On 06/15/2022 at 2:10 PM, the Nurse Supervisor confirmed the midline dressing was not changed weekly as scheduled but documented it was done. The nurse supervisor indicated the staff should not document the dressing was changed when it was not.
On 06/16/2022 at 11:50 AM, the Director of Nursing indicated the IV certified LPNs, RNs, and supervisors were responsible for the dressing changes every 5 days or weekly on Sundays at night. The staff were expected to inspect the IV lines as a standard of care prior to administering the IV antibiotic and should document the outcome.
CONCERN
(D)
Potential for Harm - no one hurt, but risky conditions existed
Deficiency F0697
(Tag F0697)
Could have caused harm · This affected 1 resident
**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, interview, record review, and document review, the facility failed to monitor the resident's pain level fo...
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**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, interview, record review, and document review, the facility failed to monitor the resident's pain level for 1 of 33 sampled residents (Resident 422).
Findings include:
Resident 422 (R422) was admitted on [DATE], with diagnoses including type 2 diabetes and end stage renal disease.
On 06/14/2022 at 11:37 AM, R422 indicated the pain medication provided would last three to four hours then the pain in their hands and feet would increase to a pain level of 9 out of 10. R422 indicated the nurses were not monitoring their pain and they would have to wait till the next pain pill was brought to them. R422 indicated they had notified the nurse of the pain returning after a few hours, but they explain the next pain pill was not due yet.
On 06/15/2022 at 2:00 PM, R422 indicated the pain in their hands and feet were currently at level 9 out of 10 and needed pain medication. R422 indicated the nurse provided pain medication in the morning but did not ask if they were in any pain. R422 indicated the nurse had not returned since the morning and had notified a staff of the pain during lunch.
A Physician Order dated 06/07/2022, documented Pregabalin Capsule 75 milligrams (mg) two times a day for pain.
The Nursing: Pain Evaluation dated 06/07/2022, documented R422 had no complaint of pain or discomfort.
The Weight and Vital Summary document, reveled the following pain level summary:
-06/07/2022 at 9:00 PM; pain level 0
-06/13/2022 at 2:32 PM; pain level 0
-06/14/2022 at 10:00 PM; pain level 0
The Medical Record lacked documented evidence R422's pain level was monitored twice a day.
On 06/15/2022 at 2:13 PM, the Licensed Practical Nurse (LPN) indicated they were aware R422's pain medication was ineffective and provided relief for a short period of time. The LPN indicated the pain in R422's hands and feet would be constant and needed the physician to adjust or change the pain medication for the resident. The LPN indicated R422 was currently receiving Pregabalin for pain at 8:00 AM and 4:00 PM daily which was not enough for pain relief. The LPN indicated there was no parameters for pain administration, but the nurse would ask the resident if they were in pain when administering the pain medication. The LPN indicated R422 was half asleep when the pain medication was administered in the morning, so they were not able to ask the resident what their pain level was at before to administering the medication. The LPN indicated there was no pain level parameter indicated in R422's medication administration record order therefore they did not have to document R422 pain level. The LPN confirmed there was no documentation for pain levels in R422 orders. The LPN indicated they were not sure why some nurses documented R422's pain level under the weight and vital section and confirmed there were three entries of R422's pain level since admission.
On 06/15/2022 at 3:18 PM, the Director of Nursing (DON) indicated pain medication should have parameters based on the type of pain medication provided. The DON expected the nurses to know the resident's pain level prior to administering their pain medication in order to know if the medication would be effective or not. The DON indicated the nurses were required to monitor the resident's vital signs which included pain level every shift. The DON confirmed the nurses were not monitoring R422's pain level every shift and should have monitored their pain at least twice a day.
The Clinical Pain Protocol revised 03/2018, documented the staff would assess the individual's pain and related consequences at regular intervals, at least each shift for acute pain or significant changes in level of chronic pain.
CONCERN
(D)
Potential for Harm - no one hurt, but risky conditions existed
Deficiency F0698
(Tag F0698)
Could have caused harm · This affected 1 resident
**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, interview, record review and document review, the facility 1) failed to complete necessary dialysis commun...
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**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, interview, record review and document review, the facility 1) failed to complete necessary dialysis communication records and 2) ensure dialysis related medication was administered per physician orders for 1 of 33 sampled residents (Resident 53).
Findings include:
Resident 53 (R53) was admitted on [DATE] with diagnoses including type II diabetes and end stage renal disease requiring dialysis.
1) A physician order dated 04/27/2022, documented dialysis three times per week (Monday, Wednesday, and Friday), pick up at 9:00 AM.
The medical record from May of 2022 to current, lacked dialysis communication on the following dates:
05/04/2022, 05/09/2022, 05/11/2022, 05/13/2022, 06/08/2022, 06/10/2022, and 06/15/2022.
On 06/16/22 at 4:00 PM, the nurse caring for R53 indicated the dialysis communication record should be sent to the dialysis center with the resident and received from the dialysis center every time the resident goes for dialysis treatment. The nurse indicated if the resident returns from dialysis treatment without the communication form, the nurse was expected to call the dialysis center and have the form faxed back to the facility.
2) On 06/16/22 at 3:09 PM, R55 indicated getting medications at different times and not always with meals.
On 06/17/22 at 8:50 AM, R55 was observed sitting in the wheelchair dressed and ready to be to be picked up by transportation for dialysis. R55 indicated being finish with breakfast and had not yet received morning medication.
On 06/17/22 at 09:06 AM, The nurse caring for R55 was observed passing out medication close to R55's room. The nurse indicated medications will be given to R55 shortly.
On 06/17/22 at 09:07 AM, the certified nursing aide (CNA) confirmed breakfast trays were delivered between 7:00 AM to 7:30 AM.
A physician order dated 06/08/2022, documented Renvela tablet 800 milligrams give two tablets with meals.
On 06/17/22 at 09:25 AM, the medication administration record (MAR) was reviewed and revealed the Renvela medication timed for 7:00 AM was not signed off as given during the breakfast meal as prescribed by the physician.
On 06/17/22 at 11:12 AM, the dietary manager indicated breakfast was served in R55's unit at around 7:15 AM.
On 06/17/22 at 10:22 AM, the Director of Staff Development (DSD) indicated the Renvela medication should have been administered with the meals to aid the absorption of minerals in the stomach not digested by kidney failure residents. The DSD reviewed the medical record and confirmed the missing dialysis communication records and indicate dialysis communication should be completed every dialysis treatment to aide coordination of care between the two facilities.
The facility policy titled Care of a Resident with End-stage Renal Disease revised September 2010, documented arrangements between the facility and the contracted dialysis include all aspects of how the resident's care will be managed, including how information will be exchanged between the facilities.
The facility policy titled Administering Medications revised April 2019, documented medications were administered in accordance with the prescribers' orders, including any required time frame.
CONCERN
(D)
Potential for Harm - no one hurt, but risky conditions existed
Pharmacy Services
(Tag F0755)
Could have caused harm · This affected 1 resident
**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, interview, record review and document review, the facility failed to ensure medications were available dur...
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**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, interview, record review and document review, the facility failed to ensure medications were available during medication pass to ensure timely administration per policy for 2 of 33 sampled residents (Residents 116 and 43).
Findings include:
1) Resident 116 (R116) was admitted on [DATE], with diagnoses including diabetes mellitus with foot ulcer and cellulitis of the right lower limb.
On 06/16/2022 at 9:30 AM, a medication pass observation was conducted in the Retirement Unit. Licensed Practical Nurse 2 (LPN2) prepared and administered R116 morning medications, except IV Lactobacillus capsule. LPN2 explained the Lactobacillus was not available. LPN2 explained the Lactobacillus order was different from the one available in the medication cart and would be ordered by central supply.
A physician order dated 05/31/2022, documented to give Lactobacillus capsule by mouth three times a day for gastrointestinal prophylaxis.
On 06/16/2022 at 11:30 AM, the Director of Central Supply indicated the facility did not carry the Lactobacillus capsule and had not received a request. The Director of Central Supply indicated the Lactobacillus capsule should have been ordered by the pharmacy.
On 06/16/2022 at 2:00 PM, LPN2 indicated central supply did not carry the Lactobacillus capsule and it should be ordered by the pharmacy. LPN2 explained the availability of the medications should have been checked prior to administration to ensure availability.
On 06/16/2022 at 3:55 PM, the Nurse Supervisor confirmed R116 missed the Lactobacillus capsule due to unavailability. The nurse supervisor indicated the medication should have been ordered to by the pharmacy prior to administration to avoid delay of administration.
On 06/16/2022 in the afternoon, the Director of Nursing (DON) indicated staff were expected to ensure the medications were available before the medication administration to ensure timely administration.
2) Resident 43 (R43) was admitted on [DATE], with diagnoses including dementia and pressure ulcer.
On 06/16/2022 at 7:30 AM, a medication pass observation was conducted in the Rehabilitation Unit. Licensed Practical Nurse 1 (LPN1) crushed R43's morning medications, except Oyster Shell Calcium.
A physician order dated 05/01/2022, documented to give Oyster Shell Calcium tablet by mouth twice daily for electrolyte imbalance.
A physician order dated 03/29/2022, documented to give multi vitamin 5 milliliter (ml) liquid via gastrostomy (GT) for wound management.
On 06/16/2022 at 7:55 AM, after crushing the six medications, LPN1 indicated the Oyster Shell Calcium tablet 500 milligram (mg) could not be given because it was not available. LPN1 indicated the process was to obtain a new supply of medication when there were a few left to ensure the medications were available. LPN1 indicated the Oyster Shell Calcium was a house stock. LPN1 was unsure when was the last time the Oyster Shell Calcium was available.
On 06/16/2022 at 11:00 AM, the Nurse Supervisor acknowledged the Oyster Shell Calcium was not administered as ordered. The Nurse Supervisor indicated the Oyster Shell Calcium was a house stock and should have been requested prior to the administration had started to avoid delay of administration.
On 06/16/2022 at 11:30 AM, the Director of Central Supply indicated there was no request filed by the LPN. The Director explained a request should have been filled out and could have been provided immediately. The Director of Central Supply showed bottles of Oyster Shell Calcium were available.
CONCERN
(D)
Potential for Harm - no one hurt, but risky conditions existed
Unnecessary Medications
(Tag F0759)
Could have caused harm · This affected 1 resident
**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, interview, record review, and document review, the facility failed to ensure their medication error rate w...
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**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, interview, record review, and document review, the facility failed to ensure their medication error rate was not five percent or greater when four errors were identified with 29 opportunities observed calculating an error rate of 13.79%.
Findings include:
A facility policy titled Adverse Consequences and Medication Errors, revised 04/2014, revealed listed medication errors like not giving a drug that was ordered, giving the wrong drug, or giving it at the wrong time.
A facility policy titled Medication Administration Schedule, Revised 11/2020, documented the scheduled medications were administered within one hour of their prescribed time. The exact time of medication administration is documented in the MAR. If medication is administered early, late, or is omitted, the reason is also documented.
1) Resident 2 (R2) was admitted on [DATE], with diagnoses including chronic obstructive pulmonary disease (COPD) with acute exacerbation and acute chronic respiratory failure with hypoxia.
On 06/16/2022 at 8:19 AM, a medication pass observation was conducted in the Rehabilitation Unit. Licensed Practical Nurse 2 (LPN2) prepared four morning medications including the breathing treatment, and administered to R2, except for Pulmicort Suspension.
A physician order dated 06/03/2022, documented Pulmicort Suspension 0.5 milligrams (mg) inhaled orally every 12 hours at 9 AM and 9 PM for COPD.
A physician order dated 06/03/2022, documented Ipratropium-Albuterol Solution 3 mL inhaled orally every 8 hours at 6 AM, 2 PM, and 10 PM for COPD.
On 06/16/2022 at 2:55 PM, LPN2 verified and confirmed the Ipratropium-Albuterol Solution was administered instead of the Pulmicort Suspension. LPN2 indicated the resident had a lot of breathing medications and might be confused during medication pass. LPN 2 indicated did not double check the right medicine and the right time.
On 06/16/2022 at 4:00 PM, the Nurse Supervisor confirmed LPN2 administered the wrong breathing medication. The nurse supervisor indicated the right medication should have been checked prior to administration to avoid error.
On 06/16/2022, the Director of Staff Development indicated the staff were educated to observe the basic rights of medication administration. The right drug at the right time should have been verified prior to administration to prevent error.
2) Resident 43 (R43) was admitted on [DATE], with diagnoses including dementia, bone density disorder, scoliosis, and dehydration.
On 06/16/2022 at 7:30 AM, a medication pass observation was conducted in the Rehabilitation Unit. Licensed Practical Nurse 1 (LPN1) crushed R43's morning medications, except Oyster Shell Calcium.
On 06/16/2022 at 7:55 AM, after crushing the six medications, LPN1 indicated the Oyster Shell Calcium was not available. LPN1 indicated the Oyster Shell Calcium was house stock. LPN1 indicated the Oyster Shell Calcium was missed due to unavailability.
A physician order dated 05/01/2022, documented to give Oyster Shell Calcium tablet by mouth twice daily for electrolyte imbalance.
On 06/16/2022 at 10:55 AM, LPN1 indicated that any medication with only a few tablets left should have been reordered or refilled to make sure it could be given on time.
On 06/16/2022 at 11:00 AM, the Nurse Supervisor acknowledged the Oyster Shell Calcium was not administered as ordered. The Nurse Supervisor indicated the Oyster Shell Calcium was a house stock and should have been requested prior to medication pass to avoid delay of administration.
On 06/16/2022 at 11:30 AM, the Director of Central Supply indicated LPN1 did not request Oyster Shell Calcium. The Director of Central Supply explained a request should have been filled out and medication could have been provided immediately. The Director of Central Supply showed bottles of Oyster Shell Calcium were available on the medication shelves.
3) Resident 116 (R116) was admitted on [DATE], with diagnoses including diabetes mellitus with foot ulcer and cellulitis (bacterial skin infection) of the right lower limb.
On 06/16/2022 at 9:30 AM, a medication pass observation was conducted in the Retirement Unit. LPN2 prepared and administered R116's morning medications, except Lactobacillus capsule. LPN2 explained the Lactobacillus order was different from the one available in the medication cart and would be ordered from central supply.
A physician order dated 05/31/2022, documented to give Lactobacillus capsule by mouth three times a day for gastrointestinal prophylaxis.
On 06/16/2022 at 11:30 AM, the Director of Central Supply indicated the facility did not carry the Lactobacillus capsule and should have been ordered from the pharmacy.
On 06/16/2022 at 3:55 PM, the nurse supervisor confirmed the facility had no stock with Lactobacillus capsule and R116 missed the doses due to unavailability. The nurse supervisor explained the Lactobacillus capsule should have been ordered from the pharmacy prior to medication pass to avoid delay of administration.
On 06/16/2022 in the afternoon, the Director of Nursing indicated the staff were expected to administer the ordered medications within one hour of their prescribed time. The DON indicated staff were expected to observe and implement the rights of the medication administration. The DON indicated any medication should have been checked prior medication pass to avoid delay of administration.
4) On 06/16/2022 at 9:30 AM, a medication pass observation was conducted in the Retirement Unit. LPN2 prepared and administered R116 morning medications. LPN2 explained the IV Ceftriaxone could not be administered because was not an IV certified. LPN2 indicated would ask an IV certified to administer the Ceftriaxone.
A physician order dated 06/04/2022, documented Ceftriaxone 2 gram intravenous (IV) daily at 9:00 AM for right foot infection-proteus mirabilis until 06/16/2022.
The Medication Administration Record dated 06/16/2022, documented the Ceftriaxone was administered late.
On 06/17/2022 at 1:54 PM, LPN3, an IV certified nurse indicated the Ceftriaxone was administered late because she was informed late. LPN3 indicated the physician assistant was notified the IV Ceftriaxone was administered late.
On 06/16/2022 at 3:45 PM, the physician assistant indicated the facility staff were expected to administer the IV Ceftriaxone as scheduled to gain the therapeutic effect and prevent sepsis.
On 06/16/2022 at 4:00 PM, the Nurse Supervisor confirmed R116 missed the IV Ceftriaxone at 9:00 AM. The IV Ceftriaxone was available, but it was given late. The nurse supervisor indicated the ordered medication should have been administered within the prescribed time.
CONCERN
(D)
Potential for Harm - no one hurt, but risky conditions existed
Deficiency F0806
(Tag F0806)
Could have caused harm · This affected 1 resident
**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, interview, record review and document review, the facility failed to ensure a residents food allergy was h...
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**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, interview, record review and document review, the facility failed to ensure a residents food allergy was honored and not served for 1 of 33 sampled residents (Resident 422).
Findings include:
Resident 422 (R422) was admitted on [DATE], with diagnoses including type 2 diabetes and end stage renal disease.
On 06/14/2022 at 3:36 PM, R422 indicated the staff were providing peanut butter and chicken which the resident was allergic to. R422 indicated anaphylactic shock would occur if they consumed chicken and peanut/peanut butter which had occurred a few years ago. R422 indicated they would check the food to ensure it was something they could have so they would not have to be hospitalized for eating foods they were allergic to. R422 indicated the nurses would provide a peanut butter and jelly sandwich as a snack during the night and they would need to send it back for a sandwich without peanut butter.
The Diet Order slip dated 06/07/2022, documented R422 was a new admission on a cardiac/renal dialysis diet.
The Diet Order slip lacked documented evidence food allergies were relayed to the kitchen staff.
The Electronic Medical Record Allergy documented R422 was allergic to Heparin, Morphine, Nifedipine, Lovenox, Wellbutrin, chicken, and fish.
The resident's Meal Ticket for breakfast, lunch, and dinner, revealed R422 did not have a food allergy listed.
The Week at a Glance Menu dated 06/15/2022, documented balsamic glazed chicken, creamy tri-color pasta, California blend vegetables, and baked apples was served for lunch.
On 06/15/2022 at 12:48 PM, R422 indicated the kitchen served chicken for lunch which they were allergic to. R422 indicated they had to tell the certified nursing assistant (CNA) to send the meal tray back to the kitchen and get something else other than chicken. R422 indicated the CNA took the meal tray and provided two turkey sandwiches for lunch.
On 06/15/2022 at 1:18 PM, the CNA indicated they were not aware R422 was allergic to chicken because the meal ticket indicated the resident was not allergic to any foods. The CNA indicated the nursing staff would check the food on the tray before taking the meal tray into the resident room to ensure it was the correct diet, texture and if any listed allergic foods were not provided. The CNA indicated R422 told them they were not able to eat the chicken due to a food allergy and needed something else to eat for lunch. The CNA indicated they called the kitchen to tell them R422 was allergic to the chicken served for lunch and needed an alternate menu item. The CNA indicated the kitchen staff said to give the resident a turkey sandwich instead which was stocked in the nursing nourishment refrigerator.
On 06/15/2022 at 1:42 PM, the Dietary Manager (DM) indicated resident food preferences were completed within 72 hours of admission and the meal tickets were updated with the resident's likes, dislikes, preferences, and allergies. The DM indicated they were not aware of R422's food allergies which was why the meal ticket was not updated with R422's food allergies. The DM indicated R422's food preference screening was completed on 06/08/2022, the day after admission and did not note any food allergies. The DM confirmed R422's chicken and fish allergy was listed in the electronic medical record allergy section and should have been listed on the meal ticket for the kitchen and nursing staff to follow.
On 06/15/2022 at 2:13 PM, the Licensed Practical Nurse (LPN) indicated they were not aware R422 was allergic to chicken and peanut/peanut butter. The LPN indicated they were not aware R422 was provided chicken for lunch. The LPN indicated CNA should have notified the licensed nurse of what occurred, so they were able to communicate with the kitchen of the resident's food allergies. The LPN acknowledged R422 had chicken and fish allergy listed in the electronic medical record, but the meal ticket and diet order slip did not indicate the resident had any food allergies.
The Resident Rights-Food and Nutrition Service Policy revised 08/31/2018, documented a food preference list would be obtained during the Initial Nutritional Screen by the Certified Dietary Manager (CDM), Registered Diet Technician (DTR), or other clinically qualified nutrition professional.
The Initial Resident Visitation/Nutritional Screening Policy revised 09/22/2021, documented the CDM, DTR, or other clinically qualified nutrition professional, or designated associate should visit each resident within approximately 72 hours or in the first week following admission and complete a dietary interview and prescreen. Obtain food preferences, allergies, or intolerances and note designated form and tray card.
Complaint #NV00066365
CONCERN
(E)
Potential for Harm - no one hurt, but risky conditions existed
Food Safety
(Tag F0812)
Could have caused harm · This affected multiple residents
Based on observation, interview, and document review, the facility failed to ensure 1) expired items were discarded, 2) opened food items were labeled and dated, 3) cleanliness of the kitchen, 4) Ice ...
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Based on observation, interview, and document review, the facility failed to ensure 1) expired items were discarded, 2) opened food items were labeled and dated, 3) cleanliness of the kitchen, 4) Ice build-up in the freezers, 5) kitchen logs were completed, 6) dishwasher was at correct temperature, 7) food items were covered during meal delivery, and 8) food temperatures were taken prior to meal service.
Findings include:
On 06/14/2022 at 8:21 AM, during the initial kitchen tour of the kitchen revealed the following:
1) Expired items:
Dry Storage:
-Cream of Wheat packets with expired date of 09/22/2021
-Stevia sugar packets with expired date of 04/26/2021
2) Opened items unlabeled and undated included:
Reach-in refrigerator next to juice station:
-Three containers of soup base
Storage Shelf above toaster:
-Container of seasoned salt
3) Cleanliness:
-Freezer 1, Freezer 2, and Freezer 3 had food particles and food pieces on the bottom of shelf
-Shelf under the steam table had dried up food debris
4) Ice build-up in the freezers
-Freezer 2 pipe near the top shelf was covered in ice build-up around four inches by three inches. There was a frozen streak of water on the back wall of the freezer coming from the frozen pipe and dripped down the bottom of the freezer.
-Freezer 3 had a frozen puddle water on bottom of shelf.
5) Kitchen logs
-Reach-in refrigerator 1 June temperature log was not completed on 06/13/2022 PM shift
-Reach-in refrigerator 4 June temperature log was not completed on 06/11/2022 and 06/12/2022 for both AM and PM shift
-Milk refrigerator June temperature log was not completed on 06/12/2022 and 06/13/2022 PM shift.
-Pot and pan test strip/sanitation bucket June log was not completed on 06/13/2022 for lunch and dinner.
-Refrigerator 4 June temperature log was not completed on 06/11/2022 and 06/12/2022 for AM and PM shift
-Freezer 1 June temperature log was not completed on 06/11/2022 and 06/12/2022 for AM and PM shift
-Freezer 2 June temperature log was not completed on 06/11/2022 and 06/12/2022 for AM and PM shift
-Freezer 3 June temperature log was not completed on 06/11/2022 and 06/12/2022 for AM and PM shift
-Dry storage June temperature log was not completed on 06/13/2022 PM shift
On 06/14/2022 at 8:39 AM, the Dietary Manager (DM) confirmed the expired items in the kitchen should have been disposed. The opened items should be labeled and dated. The soiled areas should have been cleaned but had not.
The DM confirmed the ice covering the inside pipe and the accumulation of frozen water inside the freezer. The DM indicated the freezer should be free of ice build-up.
The DM confirmed the equipment temperature logs were not monitored, documented, and should have been completed to ensure the equipment were working properly at correct temperatures and the food stored inside the refrigerator/freezer were at proper temperature.
6) Dishwasher temperature
-The low temperature dishwasher was running at the highest of 116 degrees Fahrenheit after the kitchen staff had run four loads of dishes continuously.
On 06/14/2022 at 8:41 AM, the Dietary Aide indicated the dishwasher temperature, and the sanitizer were checked and recorded on the dish machine temperature log for breakfast, lunch, and dinner. The Dietary Aide indicated the temperature and sanitizer solution was checked around 7:00 AM this morning and had recorded 120 degrees Fahrenheit. The Dietary Aide was not aware the dish machine was not washing/rinsing at 116 degrees Fahrenheit currently because it was checked earlier this morning. The Dietary Aide indicated if the machine was not running at correct temperatures or if the sanitizer was malfunctioning, they would notify the DM and the maintenance department.
On 06/14/2022 at 8:43 AM, the DM confirmed the dish machine was not operating at the correct temperature and the temperature should be above 120 degrees Fahrenheit to properly wash and rinse the dishes. The DM was not aware the dish machine was not running at the correct temperature and was unsure when the machine started to malfunction.
7) Uncovered food
On 06/14/2022 at 12:35 PM, observed a Certified Nursing Assistant (CNA) pour approximately 14 beverages in foam cups and placed them on the utility cart in front of the nursing station in the 100, 200, and 300-hall. The beverages were uncovered. The CNAs placed an uncovered beverage on a meal tray and walked down the hall to deliver the food to the resident room.
On 06/14/2022 at 12:36 PM, CNA1 indicated the beverage cart was brought to the unit with the meal cart. The CNAs would have to pour the beverage in a cup and delivery it to the resident rooms with the meal tray. The CNA indicated they would pre-pour 10-15 beverages so it would be easier to grab and place on the meal tray for faster delivery. The CNA indicated the kitchen did not provide lids for the cups. The CNA confirmed there were no lids for the beverage cups while delivering the meal trays.
On 06/14/2022 at 12:38 PM, observed CNA2 in the 400-unit passing out meal trays with uncovered beverages. There was a utility cart with five meal trays parked at the end of the 400-hall with the juice and coffee uncovered.
On 06/14/2022 at 12:41 PM, observed two construction workers pulling and cutting wires out of the wall in the hallway where the utility cart with uncovered beverages with five meal trays were parked. Two family members were observed standing next to the utility cart waiting for a staff member to assist a resident.
On 06/14/2022 at 12:45 PM, the CNAs in the 400-unit would place their meal trays on the utility cart and push it down the hall for delivery. CNA2 indicated there were no lids for the beverages and they would place it on the meal tray and push it down the hall on the utility cart. CNA2 confirmed the beverages on the meal utility cart were uncovered and there was construction being done next to the utility cart with meal trays on it which could have contaminated the uncovered beverages on the utility cart.
On 06/14/2022 at 12:51 PM, observed CNA3 in the 410-hall walk from the nurse's station to the 410 hall to deliver a meal tray with a beverage uncovered. CNA3 confirmed the beverage on the meal tray was uncovered and indicated the kitchen did not provide lids for the cups so the CNAs would deliver uncovered beverages. The CNA indicated the beverages should have been covered to avoid the risk of contamination while delivery the meal tray to the resident rooms.
On 06/14/2022 at 12:59 PM, the Dietary Aide indicated the beverage cart in each unit should have assorted beverages, cups, and lids. The Dietary Aide confirmed the beverage carts sent to the units for lunch did not have lids and forgot to check the cart before it was delivered the units.
On 06/14/2022 at 1:11 PM, the Dietary Manager (DM) indicated the dietary aide preparing the beverage carts of the units should have placed the lids on the cart for the nursing staff to use. The DM indicated all food items on the meal tray should be covered during transportation and delivery to avoid food contamination and ensure food was safe for the residents to consume. The DM was not aware lids for the beverage cups were not provided and should have been provided by the kitchen.
On 06/14/2022 at 2:33 PM, the Director of Nursing (DON) and the Infection Preventionist Assistant indicated all food items on the meal tray should be covered to avoid food contamination during the delivery process and to ensure the food was safe for residents to consume.
8) Food temperatures
On 06/16/2022 at 11:26 AM, the cook was observed setting up the steam table with the food served for lunch. The cook indicated the different texture (puree, mechanical soft) and additional alternate menu item temperatures were not required to be temped and were not documented. The cook explained the temperature log required regular textured menu items to be temped before meal service and there was no place to document temperature of other food items on the temperature log.
On 06/16/2022 at11:38 AM, [NAME] 2 indicated regular textured items required temperatures and were to be documented on the temperature log. [NAME] 2 indicated the temperature log did not have a place for the cook to document the food temperature of the pureed, mechanical soft and alternate menu items.
On 06/16/2022 at 11:43 AM, the DM indicated all food items served should be recorded on the food temperature log including the modified textures. The DM was not aware the cooks did not record food temperatures of other food items other than the regular textured items on the menu. The DM indicated the cooks should have documented the temperature of all items service to ensure food safety before serving food to the residents.
On 06/16/22 12:00 PM, the DON expects the kitchen staff take the temperature of the food served to ensure the food safety for the resident and possibility of food borne illness.
The Food Storage Policy revised 03/09/2020, documented any expired or outdated food products should be discarded. Label and date all food items.
The Cleaning Schedule Policy revised 08/31/2018, documented the Food and Nutrition Services staff should maintain the sanitation of the Food and Nutrition Services Department. The department would be responsible for maintain the cleanliness of the kitchen.
The Record of Refrigeration Temperatures Policy revised 08/08/2019, documented a daily temperature record would be kept of refrigerated items. Record temperatures from the internal thermometers. The freezer must be clean, and food must be frozen soil with no indication of thawing and must be frost free. The refrigerator must be clean, and temperatures must be 41 degrees Fahrenheit or less. Temperatures greater than these areas were to be reported to the Director of Food and Nutrition Services.
The Recording of Dish machine temperature policy (undated), documented to ensure that the wash and rinse temperatures were properly monitored and controlled, a log must be competed. Read the temperature gauge on the machine and record temperatures each meal. The wash temperature of the low temperature dish machine should be at 120-150 degrees Fahrenheit. Any inaccurate temperatures must be brought to the attention of the Director of Food and Nutrition Services or other clinically qualified nutrition professional immediately.
The Food Temperature Policy revised 03/19/2020, documented food should be served at proper temperature to ensure food safety and palatability. Record reading of the food temperature record or other designated form at the beginning of tray line and the end of tray line. If temperatures do not meet acceptable serving temperatures, reheat the product or chill the product to proper temperature. Take the temperature of each pan of product before serving.
The Accident Prevention in Food Transport Policy revised 09/01/2018, documented rood should remain covered when in transit.
CONCERN
(F)
Potential for Harm - no one hurt, but risky conditions existed
Deficiency F0761
(Tag F0761)
Could have caused harm · This affected most or all residents
**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, interview, record review, and document review, the facility failed to ensure expired medications were remo...
Read full inspector narrative →
**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, interview, record review, and document review, the facility failed to ensure expired medications were removed from the active medications and discarded for 4 of 4 medication rooms.
Findings include:
On 06/16/2022 at 10:10 AM, an inspection was conducted in four medication rooms accompanied by the nurse supervisor. The medication refrigerator in each medication room was locked and temperatures were monitored. Expired medications were found inside the refrigerator together with the active medications in the following units:
1) Rehab Medication Room
-Aplisol injection, expiry date 05/23/2022
-Hemorrhroidal Prep, expiry date 08/2021
-Acephen suppositories 650 mg, 12 suppositories, expiry date 08/2021
-Influenza vaccine, expiry date 09/2019
-Prochlorperazine 25 milligram suppositories, expiry date 01/13/2021
2) Retirement Medication Room
-Magnesium Citrate Laxative, date opened 09/12/2021, expiry date 03/2022
-Pneumonia vaccine, 2 vials, expiry date 05/2021
-Insulin Lispro Injection 1 vial (10 ml), dated 02/06/22, expiry date 03/04/2022
-Pneumonia vaccine, 7 vials, expiry date 02/11/2021
-Prochlorperazine 25 mg, 8 suppositories, expiry date 05/2022
-Pneumonia vaccine syringe injection, expiry date 05/26/2022
-Acetaminophen 650 mg suppositories, expiry date 04/2020
-Bisacodyl 10 mg, 14 suppositories, expiry date 05/2022
3) North Southwest Medication Room
-Bisacodyl Suppositories 10 mg, 100 suppositories, expiry date 05/2022
-Bisacodyl Suppositories 10 mg 88 suppositories, no packaging box, expiry date 05/2022
4) [NAME] medication room (secured unit)
-Influenza vaccine: 5 boxes, expiry date 06/10/2022
-Influenza vaccine, 6 boxes, expiry date 06/15/2022
-Acetaminophen 650 mg 10 suppositories, expiry date 04/2020
-Bisacodyl 10 mg 100 suppositories, expiry date 05/2022
On 06/16/2022 at 11:00 AM, the nurse supervisor indicated the supervisors were responsible for checking the medication expiry dates. The nurse supervisor confirmed the expired medications were stored in the refrigerator together with the active medications. The nurse supervisor indicated the expired medications should be removed and discarded to prevent erroneous administration.
On 06/16/2022 at 11:37 AM, the Director of Nursing indicated the supervisors were responsible for checking the expiry dates randomly. The DON indicated the expired medications should have been returned to the pharmacy or discarded to ensure expired medications were not administered to residents. The DON explained the expired medications near expiry dates should be taken out as a precautionary measure.
On 06/16/2022 at 11:50 AM, the Director of Staff Development indicated the staff was expected to ensure medications were not expired upon administration and expired medications should have been properly discarded for the residents' safety.
A facility policy titled Storage Medications revised 11/2020, indicated the facility stored all drugs in a safe, secure, and orderly manner. The discontinued, outdated, or deteriorated drugs are returned to the dispensing pharmacy or destroyed.
Understanding Severity Codes (click to expand)
Life-Threatening (Immediate Jeopardy)
J - Isolated
K - Pattern
L - Widespread
Actual Harm
G - Isolated
H - Pattern
I - Widespread
Potential for Harm
D - Isolated
E - Pattern
F - Widespread
No Harm (Minor)
A - Isolated
B - Pattern
C - Widespread
Questions to Ask on Your Visit
- "What safeguards are in place to prevent abuse and neglect?"
- "Can I speak with families of current residents?"
- "What's your RN coverage like on weekends and overnight?"
Our Honest Assessment
Strengths
- • No fines on record. Clean compliance history, better than most Nevada facilities.
- • 44% turnover. Below Nevada's 48% average. Good staff retention means consistent care.
Concerns
- • Multiple safety concerns identified: Federal abuse finding, 2 harm violation(s). Review inspection reports carefully.
- • 58 deficiencies on record, including 2 serious (caused harm) violations. Ask about corrective actions taken.
- • Grade F (25/100). Below average facility with significant concerns.
Bottom line: This facility has a substantiated abuse finding. Extreme caution advised. Explore alternatives.
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About This Facility
What is El Jen Skilled Care's CMS Rating?
CMS assigns EL JEN SKILLED CARE an overall rating of 2 out of 5 stars, which is considered below average nationally. Within Nevada, 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 El Jen Skilled Care Staffed?
CMS rates EL JEN SKILLED CARE's staffing level at 4 out of 5 stars, which is above average compared to other nursing homes. Staff turnover is 44%, compared to the Nevada average of 46%. This relatively stable workforce can support continuity of care.
What Have Inspectors Found at El Jen Skilled Care?
State health inspectors documented 58 deficiencies at EL JEN SKILLED CARE during 2022 to 2025. These included: 2 that caused actual resident harm and 56 with potential for harm. Deficiencies causing actual harm indicate documented cases where residents experienced negative health consequences.
Who Owns and Operates El Jen Skilled Care?
EL JEN SKILLED CARE 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 EMPRES OPERATED BY EVERGREEN, a chain that manages multiple nursing homes. With 144 certified beds and approximately 137 residents (about 95% occupancy), it is a mid-sized facility located in LAS VEGAS, Nevada.
How Does El Jen Skilled Care Compare to Other Nevada Nursing Homes?
Compared to the 100 nursing homes in Nevada, EL JEN SKILLED CARE's overall rating (2 stars) is below the state average of 3.0, staff turnover (44%) is near the state average of 46%, and health inspection rating (2 stars) is below the national benchmark.
What Should Families Ask When Visiting El Jen Skilled Care?
Based on this facility's data, families visiting should ask: "What safeguards and monitoring systems are in place to protect residents from abuse or neglect?" "Can I visit during a mealtime to observe dining assistance and food quality?" "How do you handle medical emergencies, and what is your hospital transfer rate?" "Can I speak with family members of current residents about their experience?" These questions are particularly relevant given the substantiated abuse finding on record.
Is El Jen Skilled Care Safe?
Based on CMS inspection data, EL JEN SKILLED CARE has documented safety concerns. The facility has 1 substantiated abuse finding (meaning confirmed case of resident harm by staff or other residents). The facility has a 2-star overall rating and ranks #100 of 100 nursing homes in Nevada. Families considering this facility should ask detailed questions about what corrective actions have been taken since these incidents.
Do Nurses at El Jen Skilled Care Stick Around?
EL JEN SKILLED CARE has a staff turnover rate of 44%, which is about average for Nevada nursing homes (state average: 46%). Moderate turnover is common in nursing homes, but families should still ask about staff tenure and how the facility maintains care continuity when employees leave.
Was El Jen Skilled Care Ever Fined?
EL JEN SKILLED CARE has no federal fines on record. CMS issues fines when nursing homes fail to meet care standards or don't correct problems found during inspections. The absence of fines suggests the facility has either maintained compliance or corrected any issues before penalties were assessed. This is a positive indicator, though families should still review recent inspection reports for the full picture.
Is El Jen Skilled Care on Any Federal Watch List?
EL JEN SKILLED CARE 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.