SANDSTONE SPRING VALLEY
For profit - Limited Liability company
160 Beds
SANDSTONE HEALTHCARE GROUP
Data: November 2025
Trust Grade
25/100
#61 of 65 in NV
Photo by Meagan Ellis
Photo by Janice “Jan” Hartmann
Photo by Denise Foster
1 / 5 photos
Last Inspection: September 2024
Within standard 12-15 month inspection cycle. Federal law requires annual inspections.
Overview
Sandstone Spring Valley has received a Trust Grade of F, indicating significant concerns about the quality of care, which is considered poor. It ranks #61 out of 65 facilities in Nevada, placing it in the bottom half, and #40 out of 42 in Clark County, suggesting there are very few better options nearby. The facility is showing an improving trend, as the number of issues reported decreased from 18 in 2024 to 8 in 2025. Staffing is rated average with a turnover rate of 48%, which is comparable to the state average, and there have been no fines recorded, which is a positive sign. However, there are troubling incidents, such as residents not being informed about rules regarding leaving the facility, a failure to follow the meal menu, and a lack of proper hand hygiene by staff, raising concerns about overall resident care and safety.
- Trust Score
- F
- In Nevada
- #61/65
- Safety Record
- High Risk
- Inspections
- Getting Better
- Staff Stability ⚠ Watch
- 48% turnover. Above average. Higher turnover means staff may not know residents' routines.
- Penalties ✓ Good
- No fines on record. Clean compliance history, better than most Nevada facilities.
- Skilled Nurses ✓ Good
- Each resident gets 63 minutes of Registered Nurse (RN) attention daily — more than 97% of Nevada nursing homes. RNs are the most trained staff who catch health problems before they become serious.
- Violations ⚠ Watch
- 62 deficiencies on record. Higher than average. Multiple issues found across inspections.
25/100
Bottom 7%
Review needed
18 → 8 violations
★☆☆☆☆
1.0
Overall Rating
★★★☆☆
3.0
Staff Levels
★★★★☆
4.0
Care Quality
★☆☆☆☆
1.0
Inspection Score
↔
Stable
2024: 18 issues
2025: 8 issues
The Good
-
4-Star Quality Measures · Strong clinical quality outcomes
-
Full Sprinkler Coverage · Fire safety systems throughout facility
-
No fines on record
Facility shows strength in quality measures, fire safety.
The Bad
1-Star Overall Rating
Below Nevada average (3.0)
Significant quality concerns identified by CMS
Staff Turnover: 48%
Near Nevada avg (46%)
Higher turnover may affect care consistency
Chain: SANDSTONE HEALTHCARE GROUP
Part of a multi-facility chain
Ask about local staffing decisions and management
The Ugly 62 deficiencies on record
Aug 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
Safe Environment
(Tag F0921)
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 the air conditioning unit in 2 of 12 residen...
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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 the air conditioning unit in 2 of 12 resident room halls (1300 Hall and 2300 Hall) was maintained in good working condition. The deficient practice had the potential for the temperature to be at an uncomfortable level. Findings include: The Resident Council Meeting Minutes dated 06/10/2025, with ten residents in attendance, documented the residents had complained the air conditioning was not working in the Valley of Fire Unit and Mount [NAME] Unit. There were cooling fans throughout the building, but it did not alleviate the situation.Review of the facility map revealed the Valley of Fire Unit (located on the first floor of the building) consisted of resident rooms in 1100 Hall, 1200 Hall, and 1300 Hall. Mount [NAME] Unit (located on the second floor of the building) had the residents' rooms in 2100 Hall, 2200 Hall, and 2300 Hall.On 08/21/2025 at 12:15 PM, a Certified Nursing Assistant (CNA) revealed in June 2025 the air conditioning in some of the rooms on the first and second floor of the building was shut down and not working. The CNA indicated it was hot in the affected resident rooms. The CNA confirmed the residents were complaining about the hot room temperature.On 08/21/2025 at 2:44 PM, the Director of Nursing (DON) indicated Resident 181 (R181) was transferred from room [ROOM NUMBER] to room [ROOM NUMBER] on 05/28/2025 at 2:10 PM due to complaint of warm temperature in the room.R181 was admitted on [DATE] and discharged on 06/07/2025. The Nurse's Notes dated 05/28/2025 at 2:11 PM, documented room change to 2608 from 2201.On 08/22/2025 at 11:07 AM, the Administrator indicated in June 2025 an electric power surge in the building which shutdown the air conditioning unit in 1300 Hall and 2300 Hall. There were 12 private rooms in each hall or a total of 24 private rooms for the two halls. The facility called the contracted Heating, Ventilation, and Air Conditioning (HVAC) company immediately. The HVAC company came out servicing the air conditioning and was able to reset the system to make the air conditioning worked. The Administrator revealed after the repair, the system (air conditioning unit) was shutting down and needed to reset again. The Administrator explained the Maintenance Director kept on resetting the system every two hours to have the air conditioning work.The Administrator indicated electric fans and portable air conditioning units were provided to mitigate the situation. The Administrator confirmed the 1300 Hall, and 2300 Hall were closed on 07/12/2025 and had not been used since then.The Administrator acknowledged the temperature in the resident rooms should have been between 72 to 82 degrees Fahrenheit. The Administrator indicated the temperature in the resident rooms was 83 to 84 degrees Fahrenheit when the air conditioning was shut down.The Administrator explained the facility provided portable swamp coolers (evaporative coolers) in all affected rooms. The Administrator indicated it was an ongoing process and the needed parts for the repair of the air conditioning arrived yesterday (08/21/2025). The Administrator confirmed the contracted HVAC company was currently at the facility today and working to install the parts.On 08/22/2025 at 11:44 AM, the Maintenance Director indicated the residents remained in the affected rooms no longer than three days in June 2025 when the air conditioning was shut down and not working.On 08/22/2025 at 2:30 PM, the DON confirmed R181's room upon admission (room [ROOM NUMBER]) was affected by the air conditioning being shut down. The DON indicated there were individual rooms aside from the rooms in 1300 Hall and 2300 Hall which were affected.On 08/22/2025 at 2:48 PM, the Administrator indicated around 17 residents in 1300 Hall and 2300 Hall could have been affected by the hot room temperature when the air conditioning was not working and shut down in June 2025. The Administrator explained five residents opted to stay in the unit. The Administrator revealed 1300 Hall, and 2300 Hall had 12 private rooms each, or a total of 24 rooms, with 90-95% occupancy rate.The Administrator provided a timeline of events regarding the issue with the air conditioning unit which documented the following:- On approximately 06/01/2025, the facility experienced a power surge which damaged one indoor air unit. The contracted HVAC company was notified and was onsite the same day to review and provide repairs.- While repairing the individual unit, a communication error occurred causing one of six hallways on the first floor and one of six hallways on the second floor to experience intermittent outages.- System was able to be reset same day. The system worked for approximately ten days before a wiring issue caused the system to shut down.- Facility maintenance staff were on site and able to manually reset the air conditioning unit in question. This corrected the issue but only temporarily. The air conditioning system continued to shut down approximately every two hours. Maintenance staff stayed onsite and would manually reset the system as needed.- Approximately 06/10/2025, the contracted HVAC company identified a wiring issue in one of six hallways on the first floor and one of six hallways on the second floor. The wiring issue affected 12 rooms in 2300 Hall and seven rooms in 1300 Hall. 2300 Hall was closed at this time to allow for the air conditioning repairs to be completed without resident disruption. The air conditioning in rooms 1301 to 1305 continued to function and the residents remained in the rooms, while the remainder of 1300 hall was closed.- On 07/12/2025. all remaining rooms in 1300 Hall were closed to allow for HVAC wiring repairs to be completed.- One of six hallways on the first floor and one of six hallways on the second floor had remained closed since 07/12/2025 while HVAC repairs were being completed.During the onsite investigation on 08/19/2025 through 08/22/2025, the facility's correction of the past non-compliance related to the air conditioning not in good working condition occurred as evidenced by:- A tour of the facility revealed the resident rooms were not visibly hot. The room temperature ranged from 70.2 degrees Fahrenheit to79.0 degrees Fahrenheit. There were three portable air conditioning units on the first floor and two portable air conditioning units on the second floor.- The affected halls (1300 Hall and 2300 Hall) were closed.- During the onsite investigation, there were no residents who complained about the hot room temperature.- A CNA confirmed the resident room temperatures were okay now and the CNA had not received any complaints from the residents about the hot room temperature.- On 08/21/2025 at 1:57 PM, during the resident council meeting, the residents had no complaints about the room temperatures. Complaint 2289515
Jun 2025
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
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 abuse for 1 of...
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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 abuse for 1 of 6 sampled residents (Resident 1). The deficient practice had the potential for the resident to experience emotional distress and physical harm.
Findings include:
Resident 1 (R1)
R1 was re-admitted to the facility on [DATE] with diagnoses including type 2 diabetes mellitus, chronic obstructive pulmonary disease, end stage renal disease, and heart failure.
The facility reported incident (FRI) dated 02/03/2024 documented the following:
-On 02/01/2025 in the PM, R1 reported to the Nurse that on Saturday 2/1/2025, a Certified Nursing Assistant (CNA) took R1's room phone away because the resident kept calling the desk.
- Employee 1 (E1) was interviewed and admitted to taking the phone away from the resident because the resident had kept calling the front desk.
-Conclusion: The allegation of abuse by E1 against R1 was substantiated. The facility investigation documented R1 was upset with E1 due to E1 unplugging the phone in the room and putting it on the dresser across the room where R1 could not get to it and telling R1 to stop calling downstairs. E1 was suspended pending the investigation results. E1 was terminated on 02/06/2025 for abuse as the facility documented the employee willfully inflicted punishment to the resident which resulted in R1's mental anguish. The facility also reported E1 to the Board of Nursing on 02/06/2025.
The Social Services Coordinator's (SSC) investigative notes documented R1 thought E1 was upset with R1. R1 also stated E1 had been bossy and had given R1 attitude because E1 said R1 was putting the call light on too much and was calling downstairs constantly asking for things. R1 stated E1 unplugged the phone in the room and put it on the dresser across the room where R1 could not get to it and told R1 to stop calling downstairs. The SSC also documented R1 still had their cell phone and call light with them during this event.
A behavioral Care Plan revised 02/28/2025 documented R1 was demonstrating behavioral distress related to feeling powerless or out of control and utilizing ineffective coping mechanisms. Interventions included praising calm communication, walking to quiet areas, and staff to professionally and calmly communicate to the resident.
A behavioral Care Plan implemented on 02/28/2025 documented R1 was displaying behavioral symptoms of yelling and screaming out due to difficulty in adjusting to life in a Long-Term Care facility due to ineffective coping skills. Interventions were updated to include staff intervening when inappropriate behaviors were observed by using creative refocusing to alter the resident's behavior patterns.
On 06/05/2025 at 10:45 AM, R1 stated this incident happened a while ago. R1 said nothing like this had happened before or after this incident. R1 reported no psychosocial harm from the incident and reported also not experiencing any emotional distress from the incident. R1 stated felt safe and fine at this facility.
The facility policy titled Resident Rights, Abuse and Neglect, adopted 05/01/2024, documented it is the policy of this facility to provide professional care and services in an environment free from any type of abuse, corporal punishment, involuntary seclusion, and misappropriation of property, exploitation, neglect, or mistreatment.
During the onsite investigation on 06/05/2025, the facility's correction of the past non-compliance related to the incident occurred as evidenced by:
-Observation of resident interactions were respectful and courteous.
-Interviews with residents revealed they were happy with staff and were treated in a polite manner.
-E1 was terminated and reported to the Board of Nursing on 02/06/2025.
Facility Reported Incident #NV00073489
Complaint #NV00073457
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 6 sampled residents (Resident 1). The deficient practice had the potential to put residents at risk of physical or psychosocial harm.
Findings include:
Resident 1 (R1)
R1 was re-admitted to the facility on [DATE] with diagnoses including type 2 diabetes mellitus, chronic obstructive pulmonary disease, end stage renal disease, and heart failure.
The facility reported incident (FRI) dated 02/03/2024 documented the following:
-On 02/01/2025 in the PM, R1 reported to the nurse that on Saturday 2/1/2025, a Certified Nursing Assistant (CNA) took the resident's room phone away because the resident kept calling the desk.
- Employee 1 (E1) was interviewed and admitted to taking the phone away from the resident because the resident had kept calling the front desk.
The facility investigation documented the allegation of abuse by E1 against R1 was substantiated. The investigation also documented R1 was upset with E1 due to E1 unplugging the phone in the room and putting it on the dresser across the room where R1 could not get to it and telling R1 to stop calling downstairs. E1 was suspended pending the results of the investigation. E1 was terminated on 02/06/2025 for abuse as the facility documented the employee willfully inflicted punishment to the resident which resulted in R1's mental anguish. The facility also reported E1 to the Board of Nursing on 02/06/2025.
On 06/05/2025 at 1:37 PM, a CNA indicated staff have their trainings on the computer. The CNA stated thought had completed the Abuse and Neglect Annual Training last week.
On 06/05/2025 at 10:15 AM, a Licensed Practical Nurse (LPN) verbalized could not remember the last time the facility had training on resident abuse and neglect.
On 06/05/2025 in the afternoon, the Director of Nursing (DON) indicated ongoing abuse training should occur with an abuse allegation event. The DON stated would have expected staff education on abuse like they provide at hire and annually.
Employee training records indicated staff had not received additional abuse training related to the abuse event.
The facility policy titled Resident Rights, Abuse and Neglect, adopted 05/01/2024, documented ongoing training sessions were one of the seven steps for the prevention of abuse.
On 06/05/2025 at 3:07 PM, the Administrator acknowledged their policy and procedures bullet pointed steps which should be taken to prevent a future occurrence of the abuse. The administrator indicated abuse training related to the identified abuse, which was investigated, should have been a part of their action steps taken to prevent future occurrences. The Administrator stated an allegation of abuse should have initiated this type of ongoing abuse training.
FRI #NV00073349
Jan 2025
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
Resident Rights
(Tag F0550)
Could have caused harm · This affected 1 resident
**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observations and interview, the facility failed to ensure a resident was treated with dignity and respect by facility s...
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**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observations and interview, the facility failed to ensure a resident was treated with dignity and respect by facility staff directing the resident to urinate in their incontinence brief for 1 of 16 sampled residents (Resident 3). The deficient practice had the potential to negatively impact the resident's well-being.
Findings include:
Resident 3 (R3)
R3 was admitted on [DATE] with diagnoses including hypertension, end stage renal disease with hemodialysis, and congestive heart failure.
On 01/07/2025 at 9:22 AM, a Certified Nursing Assistant (CNA) verbalized the staff are not supposed to tell incontinent residents to go to the bathroom in their briefs, however it does occur.
On 01/07/2025 at 9:32 AM, Resident 5 (R5) verbalized having been told to urinate on themselves in the past. R5 verbalized feeling upset about it and has heard other residents have been told the same but cannot speak for them.
On 01/07/2025 at 3:52 PM, R3 verbalized one CNA on the night shift told the resident if had to wait for the CNA, then just go in the brief, that is why briefs are worn. R3 verbalized this makes the resident want to cry at night and makes the stay at the facility difficult.
On 01/07/2025 at 4:08 PM, the Director of Nursing (DON) verified it would not be appropriate for staff to direct a resident to urinate or defecate in their brief and staff would need to assist the resident to the bathroom as needed. The DON verbalized by directing a resident in this manner would result in dignity issues.
Complaint #NV00073092
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 F0660
(Tag F0660)
Could have caused harm · This affected 1 resident
**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on record review and interview, the facility failed to clarify discrepancies in the appeal decision resulting in a residen...
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**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on record review and interview, the facility failed to clarify discrepancies in the appeal decision resulting in a resident being discharged and lacked documented evidence of well-coordinated discharge planning for 1 of 16 sampled residents (Resident 4). The deficient practice had the potential for a resident not to receive the necessary skilled therapy to improve functional ability and provide the necessary provisions for continuation of care.
Findings include:
Resident 4 (R4)
R4 was admitted on [DATE] and discharged on 11/21/2024 with diagnoses including difficulty in walking, chronic osteomyelitis of right ankle and foot, contracture of muscle right lower leg, and limitations of activities due to disability.
The admission Minimum Data Set (MDS) dated [DATE] documented R4 had lower extremity (hip, knee, ankle, foot) functional limitations in range of motion with impairment on both sides.
The Physical Therapy Evaluation and Plan of Treatment dated 08/23/2024 documented 100+ degrees flexion contracture (knee is bent at a fixed angle preventing it to be straightened fully) of right and left knees with right side greater than left.
The Detailed Explanation of Non-coverage dated 11/09/2024 documented R4 was able to walk 100 feet without an assistive device, with one person watching the resident.
A Beneficiary and Family Centered - Quality Improvement Organization (BFCC-QIO) Determination letter dated 11/09/2024 documented a review of the medical records showed the resident is walking 100 feet without an assistive device with supervision. The documentation does not support the need for daily skilled therapy services. Continued Skilled Nursing Facility coverage is not needed because the resident does not require daily skilled therapies.
The Physician Discharge summary dated [DATE] documented gait (pattern of how a person walks) instability and continue physical therapy for gait training.
The Interdisciplinary Team (IDT) Functional Abilities Discharge document dated 11/25/2024 documented R4's discharge performance for ability to walk ten feet: once standing, the ability to walk at least ten feet in a room, corridor, or similar space as not attempted due to medical condition or safety concerns.
On 01/09/2025 at 9:24 AM, the Director of Rehabilitation (DOR) verbalized upon admission R4 was unable to walk due to bilateral lower extremity contractures, upon discharge R4 was still unable to walk. The DOR stated being unsure why the appeal decision would state R4 was able to walk 100 feet.
On 01/09/2025 at 9:37 AM, the Case Manager stated the facility process when a resident makes an appeal to the discharge decision, was as follows:
1) Submit the required records electronically to the insurance provider.
2) When the insurance determination was received, staff would review the decision and provide the resident with the information.
The Case Manager verified for R4 this review did not occur. The case manager verbalized providing R4 with the letter without reviewing the explanation for the decision.
On 01/09/2025 at 9:58AM, the Case Manager recalled discussing discharge with R4 and their spouse stating the spouse was concerned due to not being able to provide care for R4 resulting in a decision for hospice services. The Case Manager acknowledged the discharge discussion was not documented, and care giver training did not occur.
On 01/09/2025 at 12:00 PM, the Case Manager verbalized R4 was financially overqualified for Medicaid services and R4 declined additional placement options such as a group home. The Case Manager stated R4 was provided with care giver services information and agreed to discharge home with hospice services. The Case Manager acknowledged the medical record lacked documentation of the discussion.
On 01/09/2025 at 12:15 PM, the DOR verbalized upon admission R4 stated their spouse was able to provide care. However, when therapy contacted the spouse, the spouse indicated were not able to provide care therefore caregiver training did not occur. The DOR acknowledged the medical record lacked documentation regarding the discussion.
CONCERN
(D)
📢 Someone Reported This
A family member, employee, or ombudsman was alarmed enough to file a formal complaint
Potential for Harm - no one hurt, but risky conditions existed
ADL Care
(Tag F0677)
Could have caused harm · This affected 1 resident
**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, interview, record review and document review, the facility failed to ensure showers were provided as sched...
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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 showers were provided as scheduled for 1 of 16 sampled residents (Resident 14). The deficient practice had the potential to increase skin breakdown, infections, odor and bacteria buildup.
Findings include:
Resident 14 (R14)
R14 was admitted on [DATE], with diagnoses of major vascular neurocognitive disorder- dementia.
A Therapy to Nursing communication form dated 01/06/2024, documented the resident is front weight bearing with transfer and the resident had an assessed device of a rolling walker. The resident needed supervision for grooming, oral care, upper body dressing and footwear, moderate assistance with toileting, minimal assistance with showering and lower body dressing. The resident is independent with communication, vison and feeding.
On 01/07/2025 at 4:50 PM, Director of Medical records provided two shower sheets which documented on 01/08/2024, the resident had a bed bath and on 01/16/2024 the resident had a shower.
On 01/07/2025 at 2:38 PM, Employees 16 and Employee 17 (E16 and E 17) clarified if a resident would refuse a shower or bed bath, the CNAs would notify the nurse and document the event.
E16 provided the shower schedule for R14's unit which documented showers are scheduled for morning and evening shift. E16 voiced resident showers are two days a week. E16 voiced if a resident had an accident after ADL care and the family requested for incontinent care the care would be completed immediately.
On 01/09/2025 at 8:31 AM, an observation of the shower schedule on the unit where the resident was housed indicated showers are designated twice a week, which are on Mondays and Thursdays.
On 01/09/2025 at 8:50 AM, review of January 2024 calendar revealed R14 did not receive a shower or bed bath on the scheduled shower days. R14 had missed scheduled showers for the week of 01/11/24 through 01/15/24, a shower for 01/18/2024 and 01/22/2024. The documents, which were provided by the Director of Medical Records, indicated the resident received a bed bath on 01/08/2024, a shower on 01/16/2024, and a skin assessment on 01/22/2024.
On 01/09/2025 at 10:22 AM, Employee 18 (E18) clarified residents on the Mount [NAME] Unit receives showers twice a week. E18 stated the shower schedule is arranged between morning shift and evening shift. E18 expressed if a resident refused a shower or a bed bath the nurse would be notified and documentation on a shower sheet must be present, E18 expressed the resident would sign the shower sheet along with the CNA. E18 confirmed if the resident is unable to sign the shower sheet the assigned nurse would sign the shower sheet.
On 01/09/2025 at 12:20 PM, the Director of Nursing (DON), stated the expectation for resident's personal hygiene and showers are important and has scheduled shower days. The DON confirmed the facility does expect the staff to accommodate the resident's preferences if requested for a later shower or bed bath. The DON voiced the staff can provide bed baths if the residents refuse a shower on the scheduled day.
On 01/09/2025, facility policy titled Quality of life activities of daily living (ADL's) maintain abilities dated 11/2017, documented the facility provides the necessary care and services to support the resident's care needs. The policy clarified that residents are given the appropriate treatment and services to maintain the ability to carry out activities of daily living, including hygiene care of bathing, grooming, dressing and oral care. The policy also indicated if a resident is unable to carry out activities of daily living receives the necessary services to maintain good grooming, personal hygiene and oral hygiene.
On 01/09/2025, facility policy titled Bed and Shower, adopted on 05/01/2024, documented the facility policy is to promote cleanliness, stimulate circulation and assist in relaxation.
Complaint #NV00071075
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 observation, interview and document review, the facility failed to ensure two free standing portable oxygen cylinders w...
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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 two free standing portable oxygen cylinders were safely stored. The deficient practice had the potential to prevent avoidable accidents and increase concerns of potential harm to residents and the facility overall.
Findings include:
On 01/07/2025 at 8:42 AM in resident room [ROOM NUMBER], two free standing portable oxygen cylinders were left unattended.
On 01/07/2025 at 8:45 AM, the resident stated was not sure why the oxygen cylinders are in the resident's room. One oxygen cylinder was empty, and the other cylinder was half full.
On 01/07/2025 at 8:45 AM, a Certified Nursing Assistant (CNA) explained was not sure why the oxygen cylinders were inside the room. The CNA confirmed the oxygen cylinders were placed correctly but the oxygen cylinders should be placed in the closet with other oxygen cylinders. The CNA stated was not aware if the oxygen cylinders were empty.
On 01/07/2025 at 8:48 AM, a Registered Nurse (RN) expressed the oxygen cylinders should be on a stand or Respiratory Therapy (RT) would take the tanks to be stored in the closet with empty oxygen cylinders.
On 01/07/2025 at 9:00 AM, an RN explained oxygen cylinders are left in the oxygen storage room unless the resident is being transported. If the oxygen cylinder is kept in the resident's room for any reason the oxygen cylinder is placed on a stand for storage.
On 01/07/2025 at 8:59 AM, in resident room [ROOM NUMBER] an oxygen cylinder was stored on a stand with wheels in the corner of the resident's room.
On 01/07/2025 at 9:35 AM, in resident room [ROOM NUMBER] oxygen cylinders were not removed or stored in the oxygen storage room.
On 01/09/2025 at 11:20 AM, facility policy titled Oxygen Handling and Storage last revised 05/01/2024, documented oxygen cylinders must be stored in a safe manner. The policy clarified oxygen cylinders must be secured to a wall with a chain or cable or is in a stationary rack specifically for holding oxygen cylinders.
On 01/09/2025 at 12:20 PM, the Director of Nursing (DON), confirmed oxygen cylinders must be stored in a stationary rack, in an oxygen storage closet, or in a dolly with wheels. The DON stated that oxygen cylinders should never be left free standing inside a resident's room or hallway without the proper storage rack, contained rack or a dolly. The DON clarified if an oxygen tank must be stored in a resident's room it has to be on a dolly.
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 F0761
(Tag F0761)
Could have caused harm · This affected 1 resident
**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, interview, and record review, the facility failed to ensure medications were secured for 1 of 6 sampled re...
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**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, interview, and record review, the facility failed to ensure medications were secured for 1 of 6 sampled residents (Resident #19). This deficient practice had the potential to result in other residents having access to the medication.
Findings include:
Resident 19
Resident 19 was admitted to the facility on [DATE], with diagnoses including type II diabetes mellitus with diabetic neuropathy, surgery on the digestive system, dehydration, elevated white blood count, hypertension, hyperlipidemia, unspecified, acute kidney failure unspecified, chronic kidney disease stage three unspecified, and acute cholecystitis.
On 1/07/2025 at 9:00 AM, a white/pink cream in a medication cup was left on Resident 19's dresser, unattended.
On 1/07/2025 at 9:03 AM, the Registered Nurse verbalized the medication cup with the cream medication, should not have been placed and left in the resident's room.
On 1/09/2025 at 10:23 AM, the Registered Nurse verbalized Resident #19 had an order for Moisture Barrier cream with Zinc10%. The RN stated the Wound care nurse is the only staff member who would apply the Moisture Barrier Cream.
On 1/09/2025 at 12:10 PM, the Wound Care Nurse verbalized Resident 19 had moisture barrier cream with Zinc. The Wound Care Nurse stated only the wound care nurse can apply the moisture barrier cream for Resident 19 and the cream cannot be left in Resident 19's room.
Resident 19's treatment administration record revealed the Moisture barrier with Zinc 10% was applied on the coccyx after cleaning at 7:00am by the wound care nurse.
Sept 2024
17 deficiencies
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 clinical record review, document review and interview, the facility failed to ensure a resident or resident representat...
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**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on clinical record review, document review and interview, the facility failed to ensure a resident or resident representative was provided information about the right to formulate an advanced directive for 1 of 29 sampled residents (Resident #84). The deficient practice has the potential to deprive residents of their right for self-determination.
Findings Include:
Resident #84
Resident #84 was admitted to the facility on [DATE], with diagnoses including anoxic brain damage, acute respiratory failure with hypoxia, and severe persistent asthma with acute exacerbation.
Resident #84's clinical record lacked documented evidence of an advance directive or information provided to the resident or the resident's representative about the right to formulate an advanced directive.
On 09/26/2024 at 7:28 AM, the Director of Nursing confirmed the facility had not determined if Resident #84 had an advanced directive or if the resident or the resident's representative was provided information to formulate one.
The facility policy titled, Care and Treatment, Advance Directives, adopted 05/01/2024, documented upon admission, the resident and/or representative would be informed of advance directive options and documentation in the resident's record the information was provided would be completed.
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** Resident #15
Resident #15 was admitted to the facility on [DATE], and readmitted on [DATE], with a diagnosis of anxiety disorder...
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**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Resident #15
Resident #15 was admitted to the facility on [DATE], and readmitted on [DATE], with a diagnosis of anxiety disorder unspecified.
An active physician's order dated 08/13/2024, documented Hydroxyzine Pamoate capsule 25 milligrams(mg). Give one tablet via gastronomy tube every 12 hours as needed for anxiety.
A consent for psychotropic medication dated 08/13/2024, documented Hydroxyzine 25 mg with an expected duration of 14 days.
Resident #15's comprehensive care plan lacked a care plan for anxiety or Hydroxyzine Pamoate anxiety medication.
On 09/26/2024 at 11:34 AM, a Certified Nursing Assistant (CNA) verbalized the CNA knew to monitor residents with anxiety through verbal discussions with nurses and by looking at the resident's care plan. The CNA verbalized not monitoring for Resident #15's anxiety.
On 09/26/2024 at 4:35 PM, a Licensed Practical Nurse (LPN) verbalized Resident #15 had anxiety exhibited by staying up all night. The LPN confirmed Resident #15 took Hydroxyzine Pamoate to manage anxiety. The LPN verbalized care plans were sometimes used and the LPN would expect anxiety to be on a resident's care plan and confirmed anxiety was not on Resident #15's care plan.
On 09/26/2024 at 5:06 PM, the Director of Nursing (DON) verbalized psychotropics should be included in a care plan, and if not the psychotropic, a baseline care plan for the diagnosis and relating interventions should be on a care plan. The DON verbalized the resident had a care plan related to hoarding and disorganized thinking but was unable to provide a care plan for the Hydroxyzine Pamoate or anxiety diagnosis.Resident #69
Resident #69 was admitted to the facility on [DATE], with diagnoses including acute respiratory failure, unspecified whether with hypoxia or hypercapnia, pneumonia due to pseudomonas, and dependence on respirator (ventilator) status.
Resident #69's care plan last updated on 09/08/2024, lacked documented evidence the resident's respiratory failure and dependence on a respirator (ventilator), was developed and documented objectives, goals and interventions.
On 09/26/2024 at 4:02 PM, the DON confirmed a care plan for Resident #69's respiratory failure and respirator dependence had not been developed. The DON verbalized staff would not have been able to implement the care or services the resident required if a care plan was not developed.
The facility policy titled, Care and Treatment, Care Planning, adopted 05/01/2024, documented the interdisciplinary team would develop a comprehensive care plan for each resident, and would review and revise the plan as the resident's care needs changed.
Based on interview, clinical record review and document review, the facility failed to ensure a care plan was developed for 1) a resident receiving hospice services (Resident #57), 2) a resident dependent on a respirator (Resident #69), and 3) a resident with anxiety (Resident #15) for 3 of 29 sampled residents. This deficient practice has the potential to deprive residents of receiving appropriate care.
Findings include:
Resident #57
Resident #57 was admitted to the facility on [DATE], with diagnoses including psychotic disorder with hallucinations due to a known physiological condition, cognitive communication deficit and depression, unspecified.
On 09/24/2024 at 7:57 AM, Resident #57 verbalized being confused as to what care was being provided in the facility and could not verbalize if the resident was receiving hospice services.
A physician's order dated 09/18/2024, documented admit to hospice on 09/18/2024.
Resident #57's clinical record lacked documented evidence of a care plan for hospice.
On 09/26/2024 at 8:38 AM, the Director of Nursing (DON) verbalized all staff referred to resident care plans to determine care needs of each resident and to determine how to properly provide care and monitor a resident's care. Care Plans were developed and revised when care needs had changed for the resident, such as being put on hospice to receive end of life care. The DON confirmed Resident #57 lacked a care plan for hospice care and verbalized the lack of a care plan could have health consequences for the resident.
CONCERN
(D)
Potential for Harm - no one hurt, but risky conditions existed
Deficiency F0658
(Tag F0658)
Could have caused harm · This affected 1 resident
**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, interview, and document review the facility failed to meet professional standards of medication administra...
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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 meet professional standards of medication administration and ensure medications were not left, unsecured, at a resident's bedside for 1 of 4 residents observed for medication administration (Resident #82). The deficient practice placed the patient at risk for not receiving needed medication.
Findings include:
Resident #82
Resident #82 was admitted to the facility on [DATE], and readmitted on [DATE], with diagnoses including other acute osteomyelitis, left ankle and foot and chronic obstructive pulmonary disease, unspecified.
On 09/26/2024 at 9:04 AM, a Licensed Practical Nurse (LPN) began preparing medications for Resident #82. Included in the prepared medications was ClearLax 17 grams (gm), mixed in water, in a clear plastic cup.
On 09/24/2024 at 9:17 AM, the LPN entered Resident #82's room and placed the resident's medications on the bedside table. The LPN stood at the resident's bedside while the resident took the oral tablet medications. The LPN then explained the indication for ClearLax to Resident #82.
On 09/26/2024 at 9:19 AM, the LPN exited Resident #82's room. The ClearLax remained on the bedside table.
On 09/26/2024 at 9:21 AM, the LPN confirmed the ClearLax was left on Resident #82's bedside table when the LPN exited the resident's room. The LPN explained all medications should be taken/swallowed by the resident prior to the LPN leaving the resident's room.
On 09/27/2024 at 7:32 AM, the Director of Nursing (DON) explained it was the DON's expectation of nursing staff to remain with the resident until all medications were taken/swallowed by the resident. The DON explained if medications were left in a resident's room staff would not know if the resident took the medication and residents may not receive the therapeutic benefits the medication was prescribed for if the medication was not taken.
The facility policy titled Medication Access and Storage, adopted 05/01/2024, documented medication supply was to only be accessible to staff lawfully authorized to administer medications. All drugs and biologicals were to be stored in locked compartments under proper temperature controls.
CONCERN
(D)
Potential for Harm - no one hurt, but risky conditions existed
Deficiency F0678
(Tag F0678)
Could have caused harm · This affected 1 resident
**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Resident #40
Resident #40 was admitted to the facility on [DATE], and readmitted [DATE], with a primary diagnosis of other cereb...
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**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Resident #40
Resident #40 was admitted to the facility on [DATE], and readmitted [DATE], with a primary diagnosis of other cerebrovascular disease.
Resident #40's electronic chart documented the resident was a full code and was to receive CPR in an emergent event.
Resident #40's POLST, dated [DATE], documented the resident was a DNR to be on comfort-focused treatment without artificial nutrition or feeding tube.
A DNR Order for Resident #40 dated [DATE], documented no CPR would be undertaken, only palliative care to maintain comfort, full code for now was written underneath, and the document was unsigned.
Resident #347
Resident #347 was admitted to the facility on [DATE], with a primary diagnosis of encounter for surgical aftercare following surgery on the skin and subcutaneous tissue.
Resident #347's electronic chart documented the resident was a full code and was to receive CPR in an emergent event.
Resident #347's POLST, dated [DATE], documented the resident was a DNR.
On [DATE] at 2:10 PM, a Licensed Practical Nurse (LPN) verbalized POLSTs inform nurses what type of life sustaining treatment a resident wanted. The LPN explained in an emergent event, the LPN would look at what was documented in the resident's electronic health record to determine the resident's code status.
On [DATE] at 2:30 PM, the DON explained POLSTs helped the facility determine code status for residents. The DON confirmed resident POLSTs and what was documented on the electronic health record should match. The DON explained in an emergent event, staff should refer first to the signed document.
The DON confirmed Resident #347 was DNR status, however the electronic chart documented the resident was full code. The DON explained when Resident #40 began hospice, the resident's brother gave verbal confirmation Resident #40 was a full code. The DON confirmed Resident #40 was their own medical representative and the document was not signed and should have been. The DON confirmed Residents #40 and #347 were both DNR status per their POLSTs, however the electronic chart documented the residents were full code.
The facility policy titled Advance Directive, adopted [DATE], documented a resident's choice about advance directives would be respected and once a resident chose to be full code or DNR a discussion would be had, a physician signature obtained for a POLST and documented accurately in the resident's clinical record.
Based on interview, clinical record review and document review, the facility failed to ensure a code status of do not resuscitate (DNR) was not documented as full code in the electronic health record for 4 of 29 sampled residents (Resident #57, #75, #40, and #347). This deficient practice had the potential to result in a resident with DNR status being given life-saving measures during an emergent event.
Findings include:
Resident #57
Resident #57 was admitted to the facility on [DATE], with diagnoses including psychotic disorder with hallucinations due to a known physiological condition, cognitive communication deficit and depression, unspecified.
Resident #57's electronic chart documented the resident was a full code and was to receive cardio pulmonary resuscitation (CPR) in an emergent event.
Resident #57's Provider Order for Life-Sustaining Treatment (POLST) dated [DATE], documented the resident was on comfort-focused treatment and was a DNR.
Resident #75
Resident #75 was admitted to the facility on [DATE], and readmitted on [DATE], with diagnoses including anoxic brain damage, not elsewhere classified, tracheostomy status, gastrostomy status, and dependence on respirator (ventilator) status.
Resident #75's electronic chart documented the resident was a full code and was to receive CPR in an emergent event.
Resident #75's POLST dated [DATE], documented the resident was a DNR.
On [DATE] at 8:38 AM, the Director of Nursing (DON) explained a POLST documented what treatment wishes a resident may have. The wishes included CPR, which indicated a resident would like to receive CPR in the event CPR was needed and the other wish was to be a DNR. A DNR meant no life saving measures would be taken in the event a resident stopped breathing. The DON verbalized staff referred to a resident's electronic chart for code status.
The DON verbalized if a resident was to receive CPR and was a DNR status, that would be a violation of a resident right and go against the resident's right to choose. If a resident was DNR and received CPR, it would cause psychological harm to the resident. The DON confirmed Resident's #57 and #75 were both DNR status, however the electronic chart documented both residents were full code
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 observation, interview, clinical record review, and document review, the facility failed to ensure an ordered therapeut...
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**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, interview, clinical record review, and document review, the facility failed to ensure an ordered therapeutic diet was on the resident meal card and provided to 1 of 29 sampled residents (Resident #89). This deficient practice placed the resident at risk for not receiving an appropriate diet to maintain nutritional needs.
Findings include:
Resident #89
Resident #89 was admitted to the facility on [DATE], and readmitted on [DATE], with a diagnosis of type two diabetes mellitus without complications.
A physician order dated 08/06/2024, documented heart healthy consistent carbohydrate (CCHO) diet regular texture regular consistency.
Resident #89's care plan included an intervention revised 08/18/2024, documenting prescribed diet was heart healthy CCHO diet.
On 09/24/2024 at 10:19 AM, Resident #89 verbalized Resident #89 was diabetic. The facility served a lot of carbohydrates that did not taste very good, so Resident #89's family often brought meals Resident #89 liked better.
The Week At a Glance regular diet menu documented breakfast would include assorted juice, choice of hot or cold cereal, pancakes, sausage, fresh fruit cup, margarin or syrup, and milk or another beverage.
The Week At a Glance CCHO diet menu documented breakfast would include assorted juice, choice of hot or cold cereal unsweetened, a pancake, sausage, fresh fruit cup, margarin or diet syrup, and milk or another beverage.
On 09/26/2024 at 9:29 AM, Resident #89's breakfast plate included two pancakes, a sausage patty, oatmeal, and a banana.
On 09/26/2024 at 9:29 AM, a Certified Nursing Assistant (CNA) confirmed Resident #89's breakfast included two pancakes, a sausage patty, oatmeal, and a banana.
Resident #89's meal card for 09/26/2024, documented a regular diet regular texture.
On 09/26/2024 at 1:55 PM, the Dietary Manager (DM) explained resident diets were transferred to meal cards through an automated process between the electronic health record (EHR) and the kitchen's electronic system. Meal cards were updated as the diet order in the EHR was updated. The DM verbalized Resident #89 was on a regular diet and confirmed the meal card documented a regular diet regular texture. The DM confirmed Resident #89's diet order dated 08/06/2024, documented heart healthy CCHO diet.
The DM verbalized the kitchen's electronic system had an update approximately one month prior and the system did not update with diet orders. The kitchen staff manually entered diets into the kitchen's electronic system and Resident #89's therapeutic diet must have been missed on Resident #89's meal card. The DM was unsure how long Resident #89 was served a regular diet.
On 09/26/2024 at 2:28 PM, the Dietician verbalized it was important to ensure CCHO therapeutic diets were served to residents who needed them because it helped to stabilize sugar levels. The Dietician explained ordered diets were documented in the EHR and automatically changed in the kitchen's electronic system to be printed on cards. The Dietician verbalized Resident #89 should be on a Heart Healthy CCHO diet.
The facility policy titled Meal Identification, Resident Meal Card, undated, documented all residents should have a tray card on file indicating diet orders and would be used by dining services staff to identify and provide accurate meal service for the individual while honoring their dining needs. To ensure meal cards were kept accurate, the Dining Services Manager (Dietary Manager) would compare the meal card to the written physician diet order in the medical record on a regular basis, including verification of accurate diet order.
The facility policy titled Honoring Resident Choice and Self-Directed Living at Meals, undated, documented residents would be offered meals that provide nutritional adequacy and are consistent with their plan of care.
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 interview, clinical record review and document review, the facility failed to obtain Dialysis Communications forms for ...
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**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on interview, clinical record review and document review, the facility failed to obtain Dialysis Communications forms for a resident receiving hemodialysis for 1 of 29 sampled residents (Resident #198). This deficient practice potentially places residents at risk for not receiving continuity of care.
Findings include:
Resident #198
Resident #198 was admitted to the facility on [DATE], and readmitted on [DATE], with diagnoses including end stage renal disease, other specified abnormal findings of blood chemistry, and heart failure, unspecified.
A physician's order dated 09/22/2024, documented hemodialysis every Tuesday, Thursday, and Saturday.
Resident #198's Care Plan initiated on 09/24/2024, documented the resident required renal dialysis related to renal failure and was to receive dialysis every Tuesday, Thursday and Saturday.
Resident #198's clinical record lacked documented evidence dialysis communication forms were being sent with the resident to dialysis and obtained in the medical record.
On 09/25/2024 at 1:20 PM, the Director of Nursing (DON) explained the facility could not locate any dialysis communication forms for Resident #198 and the resident was sent out for dialysis with the dialysis binder, to include the communication forms, and did not return with the binder. A phone call was placed to the dialysis clinic, in an attempt to locate the communications forms, however, the dialysis clinic verbalized the resident did not bring a binder to dialysis and the binder could not be located.
A nursing progress note dated 09/25/2024, documented the resident was sent to dialysis with the resident's dialysis book and the resident did not return with the book. The resident was unable to verbalize to the nurse being sent with the dialysis book so a call was placed to the dialysis clinic. The dialysis clinic informed the nurse, the resident did not bring the dialysis book to the appointment on 09/24/2024.
On 09/25/2024 at 2:58 PM, the DON verbalized dialysis communication sheets were required to be sent with the resident to dialysis and sent back to the facility with the resident upon return from dialysis. The dialysis communications sheets would inform staff if there were any complications during the dialysis appointment needing to be monitored. The DON verbalized if the sheets were not returned with the resident, the health of the resident could be at risk because staff would not be aware of health concerns to monitor for the resident. The DON confirmed there were no dialysis communication sheets for the resident.
The facility policy titled Dialysis, adopted 05/01/2024, documented the facility staff would coordinate with the dialysis center for individual care and would obtain copies of communication sheets from the dialysis center after each appointment.
CONCERN
(D)
Potential for Harm - no one hurt, but risky conditions existed
Deficiency F0757
(Tag F0757)
Could have caused harm · This affected 1 resident
**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on interview, clinical record review, and document review the facility failed to discontinue a medication after receiving ...
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**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on interview, clinical record review, and document review the facility failed to discontinue a medication after receiving an order to discontinue the medication for 1 of 29 sampled residents (Resident #4). This deficient practice resulted in the resident receiving an unnecessary medication.
Findings include:
Resident #4
Resident #4 was admitted to the facility on [DATE], and readmitted on [DATE], with diagnoses including osteomyelitis of vertebra, sacral and sacrococcygeal region and neuromuscular dysfunction of bladder, unspecified.
An Order Summary Report for Resident #4, dated 09/26/2024, documented the following:
-Oxybutynin Chloride oral tablet, give one tablet by mouth BID for overactive bladder. The order date was 09/17/2024, with a start date of 09/18/2024.
-Tolterodine Tartrate (Detrol) two mg tablets, give one tablet by mouth BID for urinary frequency, urgency, and incontinence. The order date was 09/17/2024, the start date was 09/18/2024.
The September 2024 Medication Administration Record (MAR) for Resident #4 documented the following:
-Oxybutynin Chloride, give one tablet by mouth two times a day for overactive bladder. The start date was 09/18/2024. The medication was administered to the resident one to two times daily from 09/18/2024 through 09/25/2024.
-Tolterodine Tartrate two mg tablets, give one tablet by mouth two times a day for urinary frequency, urgency, and incontinence. The start date was 09/18/2024. The medication was administered to the resident two times per day from 09/18/2024 through 09/25/2024.
On 09/26/2024 at 11:57 AM, a Licensed Practical Nurse (LPN) verbalized the LPN was not sure why Resident #4 was prescribed two drugs from the same drug class, to treat the same diagnosis. The LPN explained when a resident was prescribed two drugs from the same class the nurse would hold the medications and contact the physician for clarification of which medication to continue.
The LPN retrieved the unit's mobile phone to contact Resident #4's physician. The LPN verbalized a previous message was in the phone indicating staff had contacted the physician on 08/29/2024, via the phone's text messaging function, regarding the two medications. The physician's response included instruction to discontinue Tolterodine and continue Oxybutynin. The LPN explained this was an order and the order should have been entered in the resident's record in addition to a progress note to detail the information. The LPN reviewed Resident #4's record and confirmed the record lacked a progress note related to the medications or an order to discontinue Tolertodine. The Tolterodine and Oxybutynin remained active on the resident's MAR.
On 09/26/2024 at 12:04 PM, the LPN called Resident #4's physician to report the incident.
A Progress Note dated 09/26/2024 at 12:26 PM, documented the LPN clarified with the physician to discontinue Tolterodine and continue Oxybutynin.
On 09/26/2024 at 4:19 PM, the DON explained staff could communicate with the physician via the unit's mobile phone and confirmed staff could receive orders via the unit phone's text messaging function. The DON explained the DON's expectation of staff when staff received an order from the physician was to enter the order in the resident's clinical record and carry out the order. The DON confirmed if staff continued to administer a medication to a resident after staff received an order from the physician to discontinue it, this would be considered an unnecessary medication and would not be following physician's orders.
The facility policy titled Administration of Drugs, adopted 05/01/2024, documented medications were to be administered as prescribed by the physician.
CONCERN
(D)
Potential for Harm - no one hurt, but risky conditions existed
Medication Errors
(Tag F0758)
Could have caused harm · This affected 1 resident
**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on interview, clinical record review, and document review, the facility failed to ensure a psychotropic medication's side ...
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**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on interview, clinical record review, and document review, the facility failed to ensure a psychotropic medication's side effects were monitored, a psychotropic medication's related behaviors were monitored, and an as needed psychotropic medication was limited to 14 days for 1 of 29 sampled residents (Resident #15). This deficient practice placed residents at risk for not receiving appropriate medications for their overall health status.
Findings include:
Resident #15
Resident #15 was admitted to the facility on [DATE], and readmitted on [DATE], with a diagnosis of anxiety disorder unspecified.
A consent for psychotropic medication dated 08/13/2024, documented Hydroxyzine 25 mg with an expected duration of 14 days.
An active physician's order dated 08/13/2024, documented Hydroxyzine Pamoate capsule 25 milligrams(mg). Give one tablet via gastronomy tube every 12 hours as needed for anxiety.
Resident #15's physician orders lacked evidence of side effect monitoring or behavior monitoring for Hydroxyzine Pamoate.
Resident #15's comprehensive care plan lacked a care plan for anxiety, Hydroxyzine Pamoate anxiety medication, side effect monitoring or behavior monitoring.
Resident #15's August and September 2024 Medication Administration Records documented the following:
-Hydroxyzine Pamoate was administered from 08/14/2024 through 09/15/2024, 20 days after the 14-day period, and the order continued to be active through 09/25/2024.
-No side effect monitoring for anxiety or Hydroxyzine Pamoate.
-No behavior monitoring for anxiety or Hydroxyzine Pamoate.
Resident #15's Progress Notes lacked documented evidence of Hydroxyzine Pamoate 25 mg side effect or behavior monitoring.
On 09/26/2024 at 11:34 AM, a Certified Nursing Assistant (CNA) verbalized the CNA knew to monitor residents with anxiety through verbal discussions with nurses and by looking at the resident's care plan. The CNA verbalized not looking out for Resident #15's anxiety.
On 09/26/2024 at 4:35 PM, a Licensed Practical Nurse (LPN) verbalized residents on psychotropic medications should have behavior monitoring, side effect monitoring, and a care plan related to the psychotropic. The LPN confirmed Resident #15's as needed Hydroxyzine Pamoate 25 mg order was used to treat Resident #15's anxiety and was an active order from 08/13/2024 through 09/26/2024. The LPN confirmed Resident #15 was last administered the Hydroxyzine Pamoate approximately one week prior. The LPN confirmed there was no order to monitor side effects or behaviors, nor a care plan related to Hydroxyzine Pamoate or anxiety.
On 09/26/2024 at 5:06 PM the Director of Nursing (DON) verbalized as needed psychotropic medications should have side effect monitoring, behavioral monitoring, a care plan for either the psychotropic or the diagnosis, and a 14-day active period. The Director of nursing confirmed Resident #15's Hydroxyzine Pamoate order was active from 08/13/2024 to 09/26/2024, and was last administered on 09/15/2024, 20 days after the end of the 14-day period. The DON verbalized believing the 14-day requirement for as needed psychotropic medications did not apply to long-term residents. The DON confirmed Resident #15's clinical record lacked documented evidence of side effect and behavior monitoring related to the Hydroxyzine Pamoate for anxiety.
The facility policy titled Psychoactive Drug Use, dated 05/01/2024, documented as needed psychotropic medication orders were limited to 14 days, results of behavior monitoring, and interventions would be included in assessments, and adverse reactions would be monitored according to the resident plan of care.
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, clinical record review, and document review the facility failed to ensure medications were admi...
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**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, interview, clinical record review, and document review the facility failed to ensure medications were administered with an error rate of less than 5 percent (%). There were 31 opportunities and 6 medication errors. The medication error rate was 19.35%.
Findings include:
Resident #48
Resident #48 was admitted to the facility on [DATE], and readmitted on [DATE], with diagnoses including acute respiratory failure with hypoxia and other seizures.
On 09/25/2024 at 7:47 AM, a Licensed Practical Nurse (LPN) explained medications were required to be administered within one hour before and one hour after the scheduled administration time on the Medication Administration Record (MAR).
On 09/25/2024 at 10:13 AM, a Registered Nurse (RN) began preparing to administer medications to Resident #48. Among the medications prepared were the following:
-Cholecalciferol D3 1000 units, two tablets were placed in a medication cup.
-Docusate Sodium 100 milligrams (mg), one tablet was placed in a medication cup.
-Enoxaparin Sodium 40 mg, one prefilled syringe.
-Keppra Levetiracetam 100 mg/milliliter (ml), 15 ml were placed in a medication cup.
-Valproic Acid 250 mg/ five ml, ten ml were placed in a medication cup.
-Metoprolol 25 mg, one half tablet was placed in a medication cup.
On 09/25/2024 at 11:04 AM, the RN administered the prepared medications to Resident #48, one at a time, through the resident's feeding tube.
The September 2024 MAR and an Order Summary Report for Resident #48 documented the following:
-Cholecalciferol tablet 1000 units, give two tablets enterally one time a day for supplement. The scheduled administration time was 9:00 AM.
-Docusate Sodium oral tablet 100 mg, give one tablet via G-Tube two times a day for constipation. The scheduled administration time was 9:00 AM.
-Enoxaparin Sodium injection solution prefilled syringe 40 mg/ 0.4 ml, inject 40 mg subcutaneously one time a day for anticoagulant. The scheduled administration time was 9:00 AM.
-Keppra solution 100 mg/ml, give 15 ml via G-Tube two times a day for seizure prevention. The scheduled administration time was 9:00 AM.
-Valproic Acid oral solution 250 mg/ five ml, give ten ml via G-Tube two times a day for seizures. The scheduled administration time was 9:00 AM.
-Metoprolol Tartrate, give 12.5 mg by mouth two times a day for hypertension. The scheduled administration time was 9:00 AM.
On 09/26/2024 at 4:16 PM, the Director of Nursing (DON) explained medications were to be administered within one hour before or one hour after the scheduled administration time. The DON confirmed medications administered after 11:00 AM, with a scheduled administration time of 9:00 AM, would be considered late.
The facility policy titled Administration of Drugs, adopted 05/01/2024, documented medications were to be administered in accordance with the written orders of the ordering/prescribing physician. Medications were to be administered within one hour before or after the prescribed time. Unless otherwise specified by the ordering/prescribing physician, routine medications were to be administered as scheduled.
CONCERN
(D)
Potential for Harm - no one hurt, but risky conditions existed
Medical Records
(Tag F0842)
Could have caused harm · This affected 1 resident
**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** The facility policy titled, Documentation, Charting and Documentation, adopted 05/01/2024, documented all services and care shal...
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**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** The facility policy titled, Documentation, Charting and Documentation, adopted 05/01/2024, documented all services and care shall be documented in the resident's record and documentation must be complete and accurate.
Based on interview, clinical record review and document review, the facility failed to ensure resident records were complete and accurate for 1 of 29 sampled residents (Resident #80). The deficient practice had the potential for the resident not receiving appropriate care and/or medications.
Findings include:
Resident #80
Resident #80 was admitted to the facility on [DATE], and readmitted on [DATE], with diagnoses including chronic kidney disease, unspecified, unspecified severe protein-calorie malnutrition, and muscle wasting and atrophy, not elsewhere classified, multiple sites.
Resident #80's weight record documented the following:
-04/01/2024: used a sitting scale
-04/08/2024: used a sitting scale
-04/16/2024: used a sitting scale
-04/23/2024: used a sitting scale
-04/29/2024: used a sitting scale
-05/06/2024: used a sitting scale
-06/04/2024: used a sitting scale
-07/03/2024: used a sitting scale
-07/10/2024: used a sitting scale
-07/12/2024: used weights taken during dialysis
-07/18/2024: used weights taken during dialysis
-07/20/2024: used weights taken during dialysis
-07/23/2024: used weights taken during dialysis
-07/24/2024: used weights taken during dialysis
-08/06/2024: used a sitting scale
-08/08/2024: used weights taken during dialysis
-08/10/2024: used weights taken during dialysis
-09/03/2024: used a sitting scale
-09/23/2024: used a wheelchair scale
Resident #80's Care Plan initiated on 04/07/2024, and revised 09/25/2024, documented:
-On 04/29/2024, the resident had a significant weight gain x one week
-On 05/06/2024, the resident had a significant weight gain x 30 days
-On 07/03/2024, the resident had significant weight loss x 30 days
-On 08/10/2024, the resident had significant weight gain x one week
-On 09/03/2024, the resident had significant weight gain x 30 and 90 days.
The resident was to be weight monthly,
On 09/26/2024 at 1:03 PM, the Registered Dietician explained there was one Certified Nursing Assistant (CNA) in the facility designated to take resident weights. The method used to weigh each resident needed to be consistent by using the same method each time the resident was weighed. The consistent method used to weigh each resident would determine if a resident was experiencing a significant weight loss or weight gain and if the same method was not used each time, the weights of each resident would not be accurate. The staff would not be able to honestly determine if a resident was experiencing significant weight loss or weight gain. The Registered Dietician confirmed Resident #80 was not weighed using a consistent method and the facility could not determine an accurate weight gain or weight loss for the resident.
On 09/26/2024 at 2:19 PM, the CNA designated to take resident weights could not be located in the facility.
The facility policy titled Nutrition Monitoring & Management Program, adopted 05/01/2024, documented the purpose of weighing residents was to ensure and maintain acceptable parameters of nutritional status, such as body weight and protein levels. Weights would be obtained using the same device on each weigh date.
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
Infection Control
(Tag F0880)
Could have caused harm · This affected 1 resident
**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, interview, clinical record review, and document review the facility failed to ensure Enhanced Barrier Prec...
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**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, interview, clinical record review, and document review the facility failed to ensure Enhanced Barrier Precautions (EBP) were in place for a resident with chronic wounds for 1 of 29 sampled residents (Resident #292) and hand hygiene was performed during medication administration for 1 of 4 residents observed during medication administration (Resident #82). The deficient practice had the potential for spreading infectious illnesses to all residents.
Findings include:
Resident #292
Resident #292 was admitted to the facility on [DATE], with diagnoses including localized swelling, mass and lump, lower limb, bilateral and chronic venous hypertension (idiopathic) with ulcer.
On 09/23/2024 at 2:00 PM, Resident #292 was lying in bed with bilateral lower legs wrapped with elastic bandages. The resident explained the resident was admitted to the facility for care of a wound on the resident's leg. The resident recalled the wound was present for approximately four to five months. Resident #292's room lacked EBP signage and a personal protective equipment (PPE) cart.
A progress note dated 09/21/2024, documented bilateral lower extremity venous stasis ulcers.
A physician's order dated 09/23/2024, with a start date of 09/25/2024, documented cleanse left leg with normal saline (ns), pat dry, apply honey gel, cover with wrap every day shift Monday, Wednesday, and Friday for 30 days.
A physician's order dated 09/23/2024, with a start date of 09/25/2024, documented cleanse right leg with ns, pat dry, apply honey gel, then abdominal (abd) pad, wrap with kerlix, every day shift Monday, Wednesday, Friday for 30 days.
On 09/26/2024 at 12:17 PM, a Licensed Practical Nurse (LPN) explained EBP was required when providing care to residents with chronic wounds. The LPN explained residents were evaluated for the need for EBP upon admission and an order was entered to implement EBP if the resident had a catheter or a chronic wound. EBP was intended to limit the spread of infections around the facility.
The LPN confirmed Resident #292 had wounds on the resident's right and left lower leg, the wounds were venous ulcers. The LPN explained Resident #292's record documented the wounds as most likely chronic. The LPN verbalized Resident #292 would require the implementation of EBP and confirmed EBP was not in place.
On 09/26/2024 at 4:24 PM, the Director of Nursing (DON) explained EBP was used for residents with indwelling medical devices and chronic wounds. The intent of EBP was to protect residents from infection.
The DON confirmed Resident #292 had chronic wounds and should have had EBP put in place upon admission. The DON reviewed the resident's record and confirmed EBP was not implemented upon admission to the facility.
The facility policy titled Enhanced Barrier Precautions, adopted 05/01/2024, documented residents with wounds and indwelling devices were at especially high risk of acquisition of and colonization with multi-drug resistant organisms (MDROs). Wounds generally included chronic wounds, example: venous stasis ulcers. Procedure included: 1) identifying residents requiring EBP, including residents with wounds that required dressings, 2) posting clear signage on the door/wall outside the resident room indicating the type of precaution and personal protective equipment required, and 3) placing a PPE cart immediately inside the resident's room.
Resident #82
Resident #82 was admitted to the facility on [DATE], and readmitted on [DATE], with diagnoses including other acute osteomyelitis, left ankle and foot and chronic obstructive pulmonary disease, unspecified.
On 09/26/2024 at 9:01 AM, LPN2 entered Resident #82's room and checked the resident's blood pressure.
On 09/26/2024 at 9:04 AM, LPN2 exited Resident #82's room, donned a pair of gloves, cleansed the blood pressure cuff with an antimicrobial wipe, doffed the pair of gloves and began preparing medications for Resident #82. LPN2 did not perform hand hygiene upon exiting the resident's room or after doffing gloves.
On 09/26/2024 at 9:17 AM, LPN2 entered Resident #82's room and administered medications to the resident.
On 09/26/2024 at 9:21 AM, LPN2 explained hand hygiene was required in between medications passes, when entering and exiting a resident's room, before donning gloves, and after doffing gloves. LPN2 confirmed the LPN2 did not perform hand hygiene upon exiting Resident #82's room, prior to donning gloves, or after doffing gloves.
On 09/26/2024 at 4:16 PM, the DON explained hand hygiene was required to be performed when hands were soiled and before and after nursing interventions. The DON confirmed hand hygiene was required to be performed after removing gloves.
The facility policy titled Hand Hygiene, adopted 05/01/2024, documented healthcare personnel were to use an alcohol-based hand rub or wash with soap and water for the following clinical indications: between all services to residents, after touching the resident's immediate environment, and immediately after glove removal.
The facility policy titled Standard Precautions, adopted 05/01/2024, documented standard precautions included washing hands after removing gloves. Gloves were to be removed promptly after use, before touching non-contaminated surfaces and items, before going to another resident, and hands were to be washed immediately to avoid transfer of microorganisms to other residents or environments.
CPT #NV00070408
CONCERN
(D)
Potential for Harm - no one hurt, but risky conditions existed
Deficiency F0943
(Tag F0943)
Could have caused harm · This affected 1 resident
Based on employee record review, document review and interview, the facility failed to ensure an employee completed training on preventing, identifying, and reporting abuse, neglect, misappropriation ...
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Based on employee record review, document review and interview, the facility failed to ensure an employee completed training on preventing, identifying, and reporting abuse, neglect, misappropriation of property, and exploitation (abuse training) for 1 of 35 sampled employees (Employee #8). The deficient practice had the potential to place residents at risk for abuse and neglect.
Findings Include:
Employee #8
Employee #8 with a title of Certified Nursing Assistant and a hire date of 10/17/2023. Employee #8's record lacked documented evidence abuse training had been completed.
On 09/25/2024 at 1:19 PM, the Director of Human Resources confirmed Employee #8 was hired on 10/17/2023 and had not completed abuse training since hire.
The facility policy titled, Freedom from Abuse, Neglect, and Exploitation, Preventing and Prohibiting Abuse, revised 09/13/2022, documented staff would receive training related to the prohibition and prevention, identifying and recognizing, and reporting of resident abuse, neglect, misappropriation of property, and exploitation.
CONCERN
(E)
Potential for Harm - no one hurt, but risky conditions existed
Safe Environment
(Tag F0584)
Could have caused harm · This affected multiple residents
**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, interview and document review, the facility failed to ensure 4 of 4 dining rooms maintained a comfortable ...
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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 4 of 4 dining rooms maintained a comfortable home-like environment by storing medical equipment in the dining areas. The deficient practice had the potential to affect all residents who wish to eat in the dining areas.
Findings include:
On 09/24/2024 at 7:54 AM, in the Lake [NAME] dining room, the following medical equipment was being stored:
-One hoyer lift,
-One vitals sign monitor, and;
-One wheelchair scale.
On 09/24/2024 at 8:06 AM, there was a resident eating breakfast in the Lake [NAME] dining room. The resident explained the medical equipment was always in the dining area, however, did not know how long the equipment had been there.
On 09/24/2024 at 8:11 AM, a Certified Nursing Assistant (CNA) explained the medical equipment was supposed to be put away in the cubbies, located in each hallway, however staff would put the equipment in the dining area after use. The CNA confirmed the medical equipment was stored in the dining room and verbalized the dining room was not a comfortable homelike environment for the residents who wished to eat in the dining room.
On 09/24/2024 at 9:15 AM, in the Red Rock dining room, the following medical equipment was being stored:
-One geri chair,
-One IV drip post,
-Three vital sign monitors,
-One IV hanger; and,
-One wheelchair scale.
On 09/24/2024 at 9:19 AM, a Registered Nurse (RN) explained the medical equipment was always stored in the dining room and the equipment should be stored somewhere other than the dining room. The RN verbalized there were residents who ate in the dining room with each meal and one resident who had family visit at every meal.
On 09/24/2024 at 9:21 AM, the Respiratory Therapist confirmed the dining room was being used to store medical equipment and explained there was an area available to store the equipment.
The room was located next to the dining room and was large enough to accommodate all medical equipment stored in the dining room.
The Respiratory Therapist confirmed the Red Rock dining room was being used to store the medical equipment and verbalized the dining room was not a comfortable, homelike environment.
On 09/25/2024 at 7:33 AM, in the Valley of Fire dining room, the following medical equipment was being stored:
-One wheelchair scale,
-One oxygen concentrator,
-One sliding weight scale,
-One shower chair,
-Two hoyer lifts,
-One vitals sign monitor; and,
_One three foot tall fan.
On 09/25/2024 at 7:42 AM, a CNA confirmed the Valley of Fire dining room was being used to store medical equipment and verbalized the dining room was not a safe, comfortable homelike environment for residents. The CNA explained working at the facility for the last three years and the medical equipment had always been stored in the dining room and staff was using the dining room to store the medical equipment for staff convenience.
On 09/25/2024 at 7:46 AM, located in the Mount [NAME] dining room, the following medical equipment was being stored:
-Two food carts,
-One wheelchair scale,
-One hoyer lift,
-One sliding weight scale; and,
-Three vital sign monitors,
On 09/25/2024 at 7:50 AM, the Director of Nursing (DON) confirmed the Mount [NAME] dining room was being used to store medical equipment and verbalized the dining room was not a comfortable homelike environment for residents wishing to eat in the dining room.
The DON explained there were various other areas to store the equipment, such as the nurses' stations and verbalized the dining room was for resident use and residents were not to be staring a medical equipment while eating a meal.
On 09/25/2024 at 8:39 AM, the Administrator explained storing of medical equipment in each dining room was a common practice for the facility and there were cubbies in each hallway designed to store medical equipment. The Administrator admitted not thinking anything about storing the medical equipment in dining areas was not conducive to a homelike environment for the residents.
The facility policy titled Resident Rights, adopted 05/01/2024, documented residents had the right to an environment that maintained and enhanced each resident's dignity and respect.
The facility policy titled Physical Environment: Space and Equipment, dated 07/2018, documented the facility would provide sufficient space and equipment in dining areas and storage of supplies elsewhere. The dining space would not restrict a resident's functional movement.
The facility policy titled Physical Environment: Dining and Resident Activity Rooms, dated 07/2018, documented the facility would provide comfortable areas for residents to engage in dining activities.
CONCERN
(E)
📢 Someone Reported This
A family member, employee, or ombudsman was alarmed enough to file a formal complaint
Potential for Harm - no one hurt, but risky conditions existed
Deficiency F0761
(Tag F0761)
Could have caused harm · This affected multiple residents
**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, interview, clinical record review and document review, the facility failed to ensure 1) expired medication...
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**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, interview, clinical record review and document review, the facility failed to ensure 1) expired medications were removed from 1 of 5 inspected medication carts and 1 of 2 inspected medication storage rooms, 2) an unsealed medication was removed from 1 of 5 inspected medication carts, and 3) discontinued medications were removed from 1 of 5 inspected medication carts. This deficient practice has the potential to place residents at risk of receiving medications that were no longer at a safe level of efficacy.
Findings include:
Expired Medication
On 09/24/2024 at 2:35 PM, during an inspection of the medication room on the Valley of Fire unit in the presence of Licensed Practical Nurse (LPN)1, the following items were found:
-Three intravenous (IV) solution bags containing Pantoprazole 40 milligrams (mg) in 100 milliliters (ml) of Normal Saline (NS). The use by date on the three IV solution bags was 09/06/2024. The IV solution bags were hanging on the wall of the medication room, with current IV medications for residents.
-One vial of Humalog Lispro. The expiration date printed on the vial was 05/2022. The vial was stored in the refrigerator in the medication room.
LPN1 confirmed the three IV solution bags of Pantoprazole and the vial of Humalog Lispro were past the best by and expiration dates printed on the medications. LPN1 explained when medications were expired or past the use by date, the medications should be placed in a box in the medication room. The box was intended to temporarily store expired or discontinued medications until the medications could be destroyed. LPN1 then moved the Pantoprazole and Humalog Lispro to the bin designated for expired or discontinued medications.
On 09/24/2024 at 3:17 PM, during an inspection of a medication cart on the Lake [NAME] unit in the presence of a Registered Nurse (RN), a bottle of Geri-Lanta, regular strength with an expiration date of 05/2024 printed on the bottle, was found.
The RN confirmed the bottle of Geri-Lanta had expired and should have been removed from the medication cart prior to the expiration date.
On 09/25/2024 at 4:15 PM, during an inspection of a medication cart on the Valley of Fire unit in the presence of LPN2, a bottle of Sodium Bicarbonate ten grams with an expiration date of 05/2024 printed on the bottle was found.
The LPN2 confirmed the bottle of Sodium Bicarbonate had expired and should have been removed from the medication cart prior to the expiration date. LPN2 explained it was important to remove expired medications from the cart as administering an expired medication to a resident could result in an adverse reaction for the resident.
Open Medication Package
On 09/25/2024 at 4:59 PM, during an inspection of a medication cart on the Mount [NAME] unit in the presence of LPN1, a syringe of Lovenox 40 mg/0.4 ml was found. The seal on the syringe's package was broken. Store in original carton or packaging until ready to use was printed on the container. LPN1 confirmed the package was no longer sealed and explained the medication should have been discarded.
Discontinued Medication
Resident #103
Resident #103 was admitted to the facility on [DATE], with diagnoses including displaced intertrochanteric fracture of left femur, subsequent encounter for closed fracture with routine healing and difficulty in walking, not elsewhere classified. Resident #103 was discharged from the facility on 09/13/2024.
On 09/24/2024 at 3:17 PM, during an inspection of a medication cart on the Lake [NAME] unit in the presence of a Registered Nurse (RN), the following items were found stored in the medication cart:
-Four doses of Morphine four mg/ml. The label attached to the Morphine indicated the medication belonged to
Resident #103.
A log to track dispensed doses was attached the package of Morphine with a rubber band. The log indicated the last dose was administered on 08/11/2024.
The RN explained the Morphine was discontinued and was being stored in the medication cart until it could be given to a unit manager to dispose of it. The RN denied a specific timeframe for when a discontinued medication should have been given to the unit manager and explained it was whenever the unit manager was not busy.
A physician's order dated 08/05/2024, documented Morphine Sulfate injection solution, four mg/ml. Use one ml IV every 24 hours as needed prior to wound care or dressing changes. The discontinue date was 08/13/2024.
On 09/26/2024 at 4:06 PM, the Director of Nursing (DON) explained it was the DON's expectation medication would be stored according to manufacturer guidelines. The DON verbalized an open package of Lovenox would not be appropriate to store in the medication cart and the medication should have been discarded as staff would no longer know if the medication was safe or had been contaminated.
The DON explained it was the facility's process to discard outdated, expired, or discontinued medications. Medications, including controlled substances, belonging to residents who were discharged from the facility should have been removed from the medication cart and discarded. The DON denied it would be appropriate for medication which had been discontinued the month prior to remain in the medication cart.
The facility policy titled Medication Access and Storage, adopted 05/01/2024, documented outdated, contaminated, or deteriorated medications and those in containers which were cracked, soiled, or without secure closures were immediately removed from stock, disposed of according to procedures for medication destruction and reordered from the pharmacy, if a current order existed.
The facility policy titled Discarding and Destroying Medications, adopted 05/01/2024, documented it was the policy of the facility for medications not able to be returned the dispensing pharmacy (controlled substances, non-unit-dose medications, medications refused by the resident, and/or medications left by residents upon discharge) should be destroyed.
CPT #NV00071985
CONCERN
(F)
📢 Someone Reported This
A family member, employee, or ombudsman was alarmed enough to file a formal complaint
Potential for Harm - no one hurt, but risky conditions existed
Deficiency F0572
(Tag F0572)
Could have caused harm · This affected most or all residents
**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, interview, clinical record review, and document review, the facility failed to ensure residents were infor...
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**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, interview, clinical record review, and document review, the facility failed to ensure residents were informed both orally and in writing prior to or upon admission of the rules related to leaving on pass. This deficient practice had the potential to affect the entire facility population of 129 residents.
Findings include:
Resident # 347
Resident #347 was admitted to the facility on [DATE], with a primary diagnosis of encounter for surgical aftercare following surgery on the skin and subcutaneous tissue.
On 09/23/2024 at 3:09 PM, Resident #347 verbalized the resident was unable to leave the premises. In the past, when Resident #347 wanted to go across the street for food or to the grocery store, Resident #347 was told by facility staff if the resident left, the facility would kick the resident out. Resident #347 verbalized being in the facility felt like being in a prison.
On 09/24/2024 at 2:34 PM, during a resident council interview, 5 of 5 residents reported wanting to leave the premises of the facility but all were told if they left, the residents would be considered against medical advice (AMA) and discharged . The residents verbalized to leave the property on pass, the physician would need to give the residents permission.
On 09/26/2024 at 9:27 AM, a Certified Nursing Assistant (CNA) verbalized residents who wanted to leave the facility property would need to reach out to a nurse and the nurse would get the residents a pass as residents were not allowed to walk out and go. If residents were to leave, residents would be considered AMA. The CNA verbalized residents complain all the time about wanting to leave the facility premises.
On 09/26/2024 at 10:06 AM, a Licensed Practical Nurse (LPN) verbalized residents who wanted to go out on pass would need to talk with the nurse and the nurse would talk with the physician to get permission. The LPN explained whether a resident was granted pass depended on a history of drug abuse, whether the resident came back to the facility within the required timeframe the last time, and some were just not allowed to leave.
The LPN verbalized residents used to want to leave on pass all the time, but recently the physicians stopped allowing residents to go. If a resident still wanted to leave without the Physician order, the physician would inform the resident it was considered AMA, and the resident would not be allowed to return to the facility.
On 09/26/2024 at 10:32 AM, the Director of Nursing (DON) explained if residents wanted to leave the facility on pass, the residents would need to get a physician order. The DON explained if a resident still wanted to leave the facility, or if the resident did not return within the timeframe, the resident may be considered AMA and not allowed to return to the facility. The DON verbalized many residents requested to go out on pass, but the order was not granted often. The DON explained disqualifying factors included a medically unstable resident, a resident not alert and oriented, a resident with an intravenous port, and a resident with a history of drug abuse.
On 09/27/2024 at 9:18 AM, the DON verbalized the decision to consider a resident AMA was left to the physician. The DON confirmed the policy documented both the physician and the interdisciplinary team determined whether a resident was fit to go out on pass and confirmed the facility was not following the policy for both the physician and the interdisciplinary team to be involved.
The DON verbalized residents should be informed by the physician at the first doctor appointment of the facility rules and policies related to going out on pass. The DON confirmed the facility did not have any documentation residents were informed of facility rules or processes related to going out on pass prior to or upon admission, including the risk of discharge if the resident did not return within the allotted timeframe. The DON confirmed the facility should inform residents in writing of the rules related to going out on pass.
The facility's admission packet lacked documented evidence residents were informed in writing of the facility rules and processes regarding going out on pass.
The facility policy titled Continuum of Care: Leave of Absence, dated 05/01/2024, documented nursing would obtain a physician's order for the resident to go out on pass. The decision of appropriateness of a leave was made by the Physician in conjunction with the interdisciplinary team. If a resident leaves on a leave of absence and does not return or contact the facility, the facility reserved the right to attempt to locate the resident, including calling the police.
CONCERN
(F)
Potential for Harm - no one hurt, but risky conditions existed
Menu Adequacy
(Tag F0803)
Could have caused harm · This affected most or all residents
Based on observation, interview, and document review, the facility failed to ensure the menu was followed for a breakfast service. This deficient practice had the potential to affect all residents in ...
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Based on observation, interview, and document review, the facility failed to ensure the menu was followed for a breakfast service. This deficient practice had the potential to affect all residents in the facility.
Findings include:
On 09/26/2024 at 8:31 PM, breakfast was delivered to residents in the Valley of Fire Unit to include cereal, fruit, pancakes and sausage.
The Week At a Glance menu documented breakfast for Thursday would include assorted juice, choice of hot or cold cereal, cheesy eggs, hashbrowns, banana, toast, margarine or jelly, and milk or another beverage. The breakfast for Friday would include assorted juice, choice of hot or cold cereal, pancakes, sausage, fresh fruit cup, margarin or syrup, and milk or another beverage.
On 09/26/2024 at 2:18 PM, the Dietary Manager (DM) verbalized breakfast on Thursday 09/26/2024 was swapped with the breakfast for Friday 09/27/2024 because the cook looked at the wrong day on the menu and began preparing for the breakfast for Friday instead of the breakfast for Thursday. The DM verbalized residents would be notified of this change by changing the menus in each unit hallway.
The facility policy titled Honoring Resident Choice and Self-Directed Living at Meals, undated, documented residents would be offered all food and beverage components planned in the approved menu.
CONCERN
(F)
📢 Someone Reported This
A family member, employee, or ombudsman was alarmed enough to file a formal complaint
Potential for Harm - no one hurt, but risky conditions existed
Food Safety
(Tag F0812)
Could have caused harm · This affected most or all residents
**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** 3. Hand Hygiene
On 09/25/2024 at 12:57 PM, the Dietary Aide entered the kitchen and donned gloves. The Dietary Aide did not wash...
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**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** 3. Hand Hygiene
On 09/25/2024 at 12:57 PM, the Dietary Aide entered the kitchen and donned gloves. The Dietary Aide did not wash hands prior to donning the gloves.
On 09/25/2024 at 12:57 PM, the Dietary Aide confirmed the Dietary Aide did not wash hands upon entering the kitchen and prior to donning gloves.
On 09/25/2024 at 12:59 PM, the DM confirmed the Dietary Aide did not was hands prior to donning gloves and should have.
4. Uncovered Beverages
On 09/24/2024 at 8:02 AM during a dining observation of meal service, the following occurred:
-Beverages were poured in the dining area, outside the satellite kitchen in the Valley of Fire Unit.
-Beverages were set on meal trays on an open meal cart.
-Four trays were transported down the hall and delivered to resident bedrooms.
-Process was repeated three times for the 1100 hallway with 18 uncovered beverages, and twice in the 1200 hallway with 13 uncovered beverages.
On 09/24/2024 at 8:40 AM, a Certified Nursing Assistant (CNA) confirmed the beverages were uncovered while being transported down the hallways. The CNA confirmed the open beverages risked the spread of bacteria between residents and staff.
On 09/24/2024 at 10:38 AM, the Dietary Manager (DM) verbalized food and beverages should be covered in the hallways because it presented a sanitation issue with people coughing in the hallways and bacteria being spread. The DM confirmed beverages were being served uncovered in the Vally of Fire Unit and should not have been.
5. Food Storage
On 09/25/2024 at 12:05 PM, the Dietary Aide entered the satellite kitchen in the Valley of Fire Unit and transferred beverages, pudding, and vanilla shakes into the refrigerator. The refrigerator's built-in thermometer was flashing between C46 and 88.8.
On 09/25/2024 at 12:21 PM, the Dietary Aide verbalized the Dietary Aide observed the refrigerator's temperature every shift and after each meal. The Dietary Aide confirmed the refrigerator's built-in thermometer was flashing and verbalized being unsure why but may be due to the refrigerator door being open.
The Dietary Aide removed beverage pitchers from the refrigerator and put them in the dining room to be served to residents.
After closing the door, the Dietary Aide confirmed the built-in thermometer was still flashing and verbalized the built-in thermometer may be flashing because the refrigerator was on defrost mode. The Dietary Aide verbalized there was a thermometer inside the refrigerator reading at 55 degrees Fahrenheit (F). The Dietary Aide verbalized food should be stored at 40 F.
On 09/25/2024 at 12:40 PM, the DM verbalized food should be stored at or below 41 F. The DM confirmed the refrigerator stored milk, cottage cheese, chocolate pudding, individual size yogurts, vanilla shakes, oatmeal, salads, and resident items to include tortillas, cheese slices, cooked ravioli, ham, smoothies, grapes, jelly jars, Greek yogurt and whipped cream.
On 09/25/2024 at 12:40 PM, the following items were assessed to be above 41 F and confirmed by the DM:
-Milk at 47.6 F.
-Cottage cheese at 50 F.
-Chocolate pudding at 50.1 F.
-Yogurt at 41.6 F.
-Vanilla pudding desserts at 54.5 F.
The facility policy titled Serving Temperatures for Hot and Cold Foods, undated, documented foods would be served to ensure a safe and appetizing dining experience at 41 F or below for cold beverages, fruits, desserts, salads, and dairy products.
6.Thermometer Sanitation
On 09/25/2024 at 12:51 PM, during lunch tray line observation, the Dietary Aide took the temperature of the chopped pork, wiped the thermometer with an alcohol swab, then wiped the thermometer with a stained, dirty appearing rag. The Dietary Aide used the same thermometer to take the temperature of the minced and moist pork, wiped the thermometer with a new alcohol swab, then wiped the thermometer with the stained, dirty appearing rag. The Dietary Aide took the same thermometer and took the temperature of the chopped pork, wiped the thermometer with an alcohol swab, and wiped the thermometer with the stained rag.
On 09/25/2024 at 12:59 PM, the DM confirmed the Dietary Aide used the rag to wipe the thermometer before taking the temperature of the other foods. The DM verbalized the Dietary Aide should have use the alcohol swab and let the thermometer air dry without using the rag because it contaminated the other foods the thermometer was placed in. The DM asked if the DM could reheat the food to kill bacteria or if the DM would need to serve all new food to the residents.
The facility policy titled Monitoring Food Temperatures for Meal Service, undated, documented alcohol swabs may be used to sanitize between uses while taking temperatures or if contamination of the thermometer occurs. If applicable, the manufacturer's recommendations for cleaning and sanitizing thermometers may be followed.
The facility policy titled Preventing Foodborne Illness-Food Handling, adopted 05/01/2024, documented food would be stored in a way to prevent the risk of foodborne illnesses and staff would handle food with practices of safe food handling to prevent foodborne illnesses.
CPT #NV00070408
2. Hair covering:
On 09/25/2024 at 12:38 PM, during an observation of the satellite kitchen on the Mount [NAME] unit, a Licensed Practical Nurse (LPN) entered the satellite kitchen. The LPN opened the refrigerator, removed a tray of desserts, set the tray aside and retrieved a yogurt. The LPN was not wearing a hairnet and did not perform hand washing upon entering the kitchen.
On 09/25/2024 at 12:40 PM, the LPN confirmed the LPN was not wearing a hairnet and did not perform hand washing upon entering the kitchen. The LPN confirmed staff were required to don a hairnet and hands were to be washed when entering the kitchen.
The facility policy titled Preventing Foodborne Illness - Employee Hygiene and Sanitary Practices, adopted 05/01/2024, documented employees must wash their hands whenever entering or re-entering the kitchen. Hair nets or caps must be worn to keep hair from contacting exposed food, clean equipment, utensils, and linens.Based on observation, interview, and document review, the facility failed to ensure 1) a dietary aide's purse was not being stored with resident food in the dry storage area of the kitchen, 2) a hairnet was donned prior to entering the kitchen, 3) hand washing was performed when entering the kitchen or prior to donning gloves, 4) beverages were covered when traveling down hallways, 5) food was stored at safe temperatures, and 6) thermometers were properly sanitized between foods during the taking of temperatures. This deficient practice placed residents at risk for food-borne infectious illnesses.
Findings include:
1. Storage of personal items:
On 09/23/2024 at 12:56 PM, located on a shelf containing food for residents, was a staff members purse.
On 09/23/2024 at 1:00 PM, the Dietary Aid confirmed the purse belonged to them and verbalized the Dietary Manager had previously spoke to the Dietary Aid on a few occasions about leaving the Dietary Aid's purse next to resident food. The Dietary Aid explained the purse was not to be stored with resident food because the food can get contaminants causing illnesses.
On 09/24/2024 at 10:38 AM, the Dietary Manager explained the Dietary Manager had previously warned the Dietary Aid about storing the purse with resident food and the Dietary Aid continued to place the purse with resident food. The Dietary Manager verbalized personal items were not to be stored with resident food because it could cause a bacteria outbreak should the residents consume the food.
On 09/25/2024 at 8:39 AM, the Administrator verbalized personal items were not to be stored with resident food to protect the resident's health and safety. The Administrator explained there were personal lockers available to the dietary staff to store the personal belongings.
The Administrator verbalized the facility did not have a policy regarding the storage of personal items in the kitchen and the facility followed best practices.
The facility policy titled Food Receiving and Storage, adopted 05/01/2024, documented the facility would store food in a manner that complied with safe food handling practices.
The facility policy titled Preventing Foodborne Illness-Food Handling, adopted 05/01/2024, documented food would be stored in a way to prevent the risk of foodborne illnesses and staff would handle food with practices of safe food handling to prevent foodborne illnesses.
Feb 2024
1 deficiency
CONCERN
(D)
📢 Someone Reported This
A family member, employee, or ombudsman was alarmed enough to file a formal complaint
Potential for Harm - no one hurt, but risky conditions existed
Deficiency 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 ensure pain medications were administ...
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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 pain medications were administered as prescribed for 1 of 15 sampled residents (Resident 1). This deficient practice had the potential to cause a resident to have uncontrolled pain and a diminished quality of life.
Findings include:
A facility policy titled Pain Assessment and Management revised in March 2020, documented interventions were developed to be consistent with the resident's goals and needs and to address the underlying causes of pain. The pain management interventions were required to be consistent with the resident's treatment goals, which were specially defined and documented. Implementing pain management strategies, including non-pharmacological interventions, may be appropriate alone, in conjunction with medications, or prescribed to manage pain. Implement the medication regimen as ordered, carefully documenting the results of the interventions.
A facility policy titled Pharmacy Services-Medication Administration dated 08/2018, documented medications were to be prepared and administered in accordance with the prescriber's order. The medications were to be administered within 1 hour before or after the scheduled administration time.
Resident 1 (R1) was admitted on [DATE], with diagnoses including absence of left leg above knee, difficulty walking and multiple fractures of the head of right radius, left pubis fifth metacarpal bone, right hand, left femur and lumbar vertebra upper end of left tibia.
The Brief Interview of Mental Status dated 12/12/2023, documented a score of 13/15, which indicated R1's cognitive status was intact.
A Physician Order dated 12/08/2023, documented Hydromorphone Hydrochloride 2 milligram (mg) by mouth every four (4) hours for severe pain (7-10 pain scale).
On 12/19/2023 at 9:30 AM during medication pass observation, a Licensed Practical Nurse (LPN) assigned to R1 indicated R1 had routine pain medication every 4 hours and as needed (PRN) for breakthrough pain. The LPN explained routine pain medication should be given as prescribed to effectively manage pain but was not consistently given on time. The LPN indicated medication should be administered within one (1) hour before or after the scheduled administration time. The LPN indicated the physician should have been notified if the order was not administered as prescribed.
The Administration History documented the scheduled Hydromorphone was not administered as prescribed on the following dates and times:
-12/14/2023: scheduled at 12:00 PM, administered at 1:34 PM
-12/14/2023: scheduled at 8:00 PM, administered at 10:54 PM
-12/15/2023: scheduled at 4:00 AM, administered at 5:14 AM
-12/15/2023: scheduled at 8:00 AM, administered at 10:23 AM
-12/15/2023: scheduled at 12:00 PM, administered at 1:57 PM
-12/16/2023: scheduled at 12:00 AM, administered at 2:14 AM
-12/16/2023: scheduled at 8:00 AM, administered at 11:06 AM
-12/16/2023: scheduled at 12:00 PM, administered at 3:51 PM
-12/16/2023: scheduled at 8:00 PM, administered at 10:32 PM
-12/17/2023: scheduled at 8:00 PM, administered at 4:29 AM
-12/17/2023: scheduled at 8:00 AM, administered at 9:38 AM
-12/17/2023: scheduled at 12:00 PM, administered at 2:02 PM
-12/17/2023: scheduled at 8:00 PM, administered at 10:57 PM
-12/18/2023: scheduled at 4:00 AM, administered at 5:11 AM
-12/18/2023 scheduled at 8:00 AM, administered at 9:45 AM
-12/18/2023 scheduled at 8:00 PM, administered at 11:33 PM
-12/18/2023 scheduled at 1200 AM, administered at 11:33 PM
-12/19/2023: scheduled at 4:00 AM, administered at 6:01 AM
On 12/19/2023 at 11:00 AM, R1 had been in a motorcycle accident resulting in multiple fractures and left leg amputation. R1 reported experiencing significant pain and had scheduled pain medication orders every 4 hours, including doses as needed. R1 expressed frustration regarding pain medication not being administered as prescribed. Instead, it was given more than 1 hour to three hours late, and R1 rated the pain as 9/10. R1 emphasized multiple times the medications were late.
On 12/19/2023 in the morning, the Assistant Director of Nursing (ADON) indicated the staff were expected to follow the orders and for any deviations the physician should have been notified and documented.
On 12/19/2023 at 12:05 PM, the Director of Nursing (DON) verified and confirmed the Hydromorphone was inconsistently given on time and lacked documented evidence the physician was notified. The DON indicated there should have been documentation as to why the medication was not given on time. The DON indicated the staff were expected to follow orders as prescribed to manage R1's pain.
On 12/19/2023 at 12:14 PM, a Physician Assistant (PA) indicated R1's pain medication should have been administered as prescribed to effectively manage the pain and prevent heightened pain and resident's anxiety.
Complaint # NV00069866
Complaint #NV00069832
Sept 2023
15 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 and interview the facility failed to inform a resident of the medical justification for placing the residen...
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**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation and interview the facility failed to inform a resident of the medical justification for placing the resident on transmission-based precautions (TBP) for 1 of 31 sampled residents (Resident 10). The deficient practice led to miscommunication, the lack of residents' knowledge of their care arrangements, and had the potential for psychosocial harm.
Findings include:
Resident 10 (R10)
R10 was admitted on [DATE] with diagnoses including bacteremia (bacteria in the bloodstream).
On 09/20/2023 at 10:04 AM, a contact precaution sign was posted outside of R10's door.
On 09/21/2023 at 1:15 PM, the contact precaution sign was no longer posted outside of R10's door.
On 09/21/2023 at 1:44 PM, R10 explained they noticed the contact precaution sign, labeled with Methicillin-resistant Staphylococcus aureus (MRSA) (type of bacteria that was resistant to several antibiotics), was placed outside of their door on 09/20/2023 and taken off on 09/21/2023. R10 inquired four times with various staff members and have yet to be informed nor provided with medical documentation as to why they were placed on isolation. R10 expressed frustration as other residents passed by the room and felt the label made them feel like you're a disease, you know. R10 felt embarrassed and upset saying it is my right to know, as they had yet to be informed of the medical reasoning as to why they were placed on isolation.
On 09/22/2023 at 11:29 AM, the Infection Preventionist Nurse verbalized the situation was a misunderstanding on their part for placing R10 on isolation. The Infection Preventionist Nurse acknowledged misinterpreting a physician's progress note documenting MRSA, but failed to see it was noted as a history of MRSA, until after the fact. The Infection Preventionist Nurse explained their process of verbally informing the floor nurse of a resident's status and the floor nurse would notify the resident. The Infection Preventionist Nurse did not believe a staff member had notified R10 as R10 approached them to discuss the matter.
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
Deficiency Text Not Available
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Deficiency Text Not Available
CONCERN
(D)
Potential for Harm - no one hurt, but risky conditions existed
Deficiency F0645
(Tag F0645)
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 facility had a process in ...
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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 facility had a process in place to identify and refer residents for pre-admission screening and resident review (PASARR) level two for 1 of 31 sampled residents (Resident 30). The deficient practice had the potential to deprive residents with appropriate behavioral health services.
Findings include:
The PASARR Screening Coordination policy dated July 2018, documented the facility would refer to the appropriate state-designated authority, any resident with newly evident or possible serious mental disorder, intellectual disability, or related condition.
Resident 30 (R30)
R30 was admitted on [DATE], with diagnoses including bipolar disorder and pneumonia.
R30's indicators included not having a PASARR level two with diagnoses.
On 09/20/2023 in the morning, R30 was awake in bed with a tracheostomy tube, but was able to verbalize needs.
A PASARR level one dated 07/31/2018, revealed R30 had no mental illness, no mental retardation, no dementia and was appropriate for nursing facility placement.
On 09/22/2023 at 8:47 AM, the Admissions Director indicated being familiar with the PASARR process and ensured all newly admitted residents had a PASARR level one at minimum and sometimes residents got admitted with a PASSAR level two. The Admissions Director indicated not being involved with other components of the PASARR process and indicated the social services department may be responsible for identifying residents who met the criteria for a referral for PASARR level two.
On 9/22/2023 at 8:58 AM, the Social Services Director (SSD) and the Social Services Assistant (SSA) indicated not being familiar with the facility's PASARR process and explained the former social services staff members used to be responsible for PASARR two referrals. The SSA indicated not being involved with the PASARR referral process and indicated the Minimum Data Set (MDS) nurses may be responsible. The SSD and the SSA indicated not having any idea on how to identify and refer residents for PASARR level two.
On 09/22/2023 at 9:07 AM, the MDS Director explained the purpose of PASARR was to ensure residents were appropriately placed in nursing facilities. The MDS Director and two other MDS nurses indicated the MDS team was not involved in any way with the facility's PASARR referral process.
On 09/22/2023 at 9:12 AM, the Administrator indicated the social services department was responsible for identifying residents who met the criteria for a PASARR level two referral whenever there was a change in psychiatric diagnoses. The Administrator indicated not being aware social services staff members were not knowledgeable on their expected involvement with the facility's PASARR process.
On 09/22/23 at 9:18 AM, the Regional Nurse Consultant indicated being familiar with PASSAR in terms of the regulatory requirement, but the Regional Nurse Consultant indicated not being aware the social services department was unfamiliar with the PASSAR referral process.
On 09/22/2023 at 9:23 AM, the SSD indicated the last resident who was referred for a PASSAR level two evaluation was referred by the former social worker on 04/21/2023. The SSD indicated no other residents had been identified or referred for PASARR level two since the former social worker left the facility in June 2023.
On 09/22/2023 at 2:19 PM, the Administrator indicated not being aware the last resident who was referred for a PASARR level two had occurred in April 2023 by the former social worker.
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:
1) The medication was availa...
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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) The medication was available during the medication pass for 1 of 31 sampled residents (Resident 341).
2) The Medication Administration Record (MAR) was not signed off before medication administration for 1 of 31 sampled residents (Resident 341) occurred.
These deficient practices had led to a missed medication dose, and the failure to accurately document the medication administration could potentially have resulted in medication errors, falsified medication records, altered therapeutic benefits, medication underdosing or overdosing, and adverse reactions.
Findings include:
Resident 341 (R341)
R341 was admitted on [DATE], with diagnoses including severe protein-calorie malnutrition and gastrostomy status.
1) A Physician order dated 09/06/2023, documented Folic acid tablet 1 milligram (mg) via percutaneous endoscopic gastrostomy (PEG) tube (a feeding tube used to deliver nutrition directly to the stomach).
On 09/21/2023 at 8:38 AM, a Licensed Practical Nurse (LPN) prepared and crushed R341's medications except for Folic acid. The LPN confirmed the Folic acid was not available because the ordered dose was not the same as what was available in the medication cart.
On 09/22/2023 at 4:24 PM, the Assistant Director of Nursing (ADON) indicated the nurses were expected to ensure R341's medications were available before passing medications to prevent a delay in administration. The ADON indicated the medication should have been administered one hour before and after the scheduled time.
2) On September 21, 2023, at 8:53 AM, during medication pass, the LPN prepared and crushed the medications. Afterward, the LPN promptly signed off on the Medication Administration Record (MAR), indicating the medications had already been administered. Following the documentation, the LPN administered the medications to R341 via a PEG tube.
On 09/22/2023 at 4:24 PM, the ADON indicated the Medication Administration Record should have been signed off after the medications were administered to the resident, not before administration to ensure the medications were successfully swallowed by the resident. The ADON indicated there could have been a circumstance during the administration, and the good practice was to document after the administration.
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
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 interview, record review, and document review, the facility failed to ensure a newly identified pressure ulcer was repo...
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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 newly identified pressure ulcer was reported to the physician and treatment orders were obtained and carried out for 1 of 31 sampled residents (Resident #437). The deficient practice placed the resident at risk for wound complications such as infection or worsening of the pressure ulcer.
Findings include:
Resident #437 was admitted on [DATE], with diagnosis including encounter for surgical aftercare following surgery of the circulatory system, heart failure, and limitation of activities due to disability.
A Wound Assessment Details Report dated 04/21/23, documented a facility acquired coccyx wound was identified on 04/21/23.
There was no documented evidence in the clinical record the physician was notified of the wound, the care plan was updated, skin assessments were completed, wound care orders were obtained, and the resident was provided treatment for the wound identified on 04/21/23.
On 09/21/23 at 2:30 PM, the Wound Nurse confirmed the clinical record lacked documented evidence of new orders, a treatment plan, care planning, progress notes and the wound had been reported to the physician. The wound care nurse explained when a wound is found, it needed to be reported and follow up care planned.
On 09/22/23 at 12:57 PM, the Assistant Director of Nursing, verified there was not a care plan related to the wound, no record of reporting from the wound team, no skin checks post identification of the wound, and no wound care was provided for the resident.
The facility policy Wound Care revised October 2010 documented the purpose was to provide guidelines for the care of wounds to promote healing. Preparation included verification of the physician's order and review of the resident's care plan. Documentation included recording in the medical record the type of wound care provided, date and time, changes in the resident's condition and assessment data.
Complaint# NV00068504
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 and document review, the facility failed to ensure a spray bottle of chemical cleaner, a bottle ...
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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 a spray bottle of chemical cleaner, a bottle of wound cleanser, and a portable oxygen cylinder were safely stored. The deficient practice had the potential to prevent avoidable accidents and increase concerns of potential harm to residents and the facility overall.
Findings include:
On 09/20/2023 at 11:30 AM, a spray bottle of Sani2 chemical cleaner was unattended in a cubby area across from the elevators, at the entry of the Valley of Fire unit. Three residents and a staff member walked past the area.
A Maintenance Assistance staff member walked by, confirmed the spray bottle of Sani2 chemical cleaner was unattended and advised the spray bottle of Sani2 chemical cleaner was not safe to leave unattended.
On 09/20/2023 at 12:55 PM, in resident room [ROOM NUMBER] was a bottle of wound cleanser on top of the dresser drawer.
On 09/20/2023 at 12:59 PM, a Unit Manager confirmed the bottle of wound cleanser was inside resident room [ROOM NUMBER] and reported the bottle of wound cleanser was supposed to be stored in the wound cart.
On 09/20/2023 at 11:11 AM, in resident room [ROOM NUMBER] was a portable oxygen cylinder leaning partially slanted against the left side wall and chair from the entry of the room.
On 09/20/2023 at 11:14 AM, a Certified Nursing Assistant (CNA) confirmed the position of the portable oxygen cylinder in resident room [ROOM NUMBER] and indicated it was not an appropriate way to store a portable oxygen cylinder. The CNA explained the unsecured portable oxygen cylinder had the potential if dropped, could be a projectile missile or explode and should have been securely stored on a rack or behind a wheelchair.
On 09/21/2023 at 1:17 PM, the resident from room [ROOM NUMBER] reported they did not normally have a portable oxygen cylinder behind their wheelchair and only used an oxygen continuous positive airway pressure (CPAP) machine at night. The resident indicated they did not place the portable oxygen cylinder against the wall in their room. At the time, the resident was sitting in a wheelchair and no portable oxygen cylinder was observed behind the wheelchair.
The facility policy titled Fire Safety and Prevention last revised May 2011, documented storing oxygen cylinders in racks with chains, sturdy portable carts, or approved stands; never leave oxygen cylinders free standing and do not store oxygen cylinders in any resident room.
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 physician orders for the util...
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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 physician orders for the utilization and size of an indwelling Foley catheter were obtained and transcribed for 1 of 31 sampled residents (Resident 23), and the correct Foley size order was verified and inserted as ordered for 1 of 31 sampled residents (Resident 47).
This deficient practice could potentially increase the risk of catheter-related complications, including urinary tract infections, patient discomfort, trauma, and pain.
Findings include:
Resident 23 (R23)
R23 was admitted on [DATE], with diagnoses including urinary tract infection and severe dementia with agitation.
A Care plan dated 09/08/2023, documented R23 had altered urinary function, requiring the use of an indwelling Foley catheter for obstructive neuropathy.
R23's medical record lacked documented evidence a physician order was obtained for the utilization of the indwelling Foley catheter, including specifying its size.
On 09/20/2023 at 11:01 AM, R23 lay in bed with eyes closed. R23's Foley catheter was draining dark-colored yellow urine with sediments. A Certified Nursing Assistant (CNA) confirmed R23's Foley catheter was in place with a 20 French (catheter size) catheter x (times) 10 ml.(balloon size, inflation required to secure catheter within the bladder)
On 09/20/2023 at 11:01 AM, a Licensed Practical Nurse (LPN) indicated R23 had wounds and required the use of a Foley catheter. The LPN verified there was no order in place for the insertion of R23's Foley catheter, and the Foley size had not been specified. The LPN indicated the utilization of the Foley required an order and should have been transcribed in the medication or treatment administration record.
On 09/22/2023 at 9:20 AM, the Assistant Director of Nursing (ADON) confirmed there was no indicated size for R23's Foley catheter. The ADON indicated the nurses were required to verify whether there was an order in place for the utilization of the Foley catheter, obtain the necessary justification, and ensure orders had been transcribed or documented in the resident's record.
On 09/22/2023 at 9:23 AM, the Director of Nursing (DON) confirmed there was no specified Foley catheter size indicated for R23. The DON indicated the nurses were required to adhere to the exact size specified in the order or, if uncertain, to obtain clarification for the order. The DON verbalized the importance of verifying and documenting the catheter size, as it is essential to ensure in the event of catheter dislodgement, there was a clear reference for the appropriate size to be used during reinsertion.
Resident 47 (R47)
R47 was admitted on [DATE], with diagnoses including dysphagia, diabetes mellitus, and chronic kidney disease.
The Brief Interview of Mental Status dated 08/03/2023, documented a score of 14/15, which indicated R47's cognitive status was intact.
A physician order dated 01/31/2023, documented Foley 16 French x 10 ml.
A Care Plan dated 05/15/2023, documented R47 had an indwelling catheter related to the neurogenic bladder. Monitor signs and/or symptoms of discomfort and pain due to the catheter. The goal was to keep R47 free from trauma.
On 09/21/2023 at 4:41 PM, a CNA and the LPN confirmed R47's Foley catheter in place was an 18 French Foley catheter x 10 cc. The LPN indicated R47 had wounds in the coccyx, requiring R47 to utilize a Foley catheter.
On 09/22/2023 at 9:20 AM, the ADON confirmed R47's Foley order was 16 Fr x 10 cc. The ADON indicated the nurses were expected to verify the Foley size order before insertion or clarify the order. The ADON indicated the ordered Foley size was a smaller size, but the Foley inserted was a bigger size.
On 09/22/2023 at 9:23 AM, the DON indicated the nurses were expected to adhere to the ordered size for the catheter, or the order should have been clarified. The DON explained the importance of verifying and indicating the size so, in case the Foley was dislodged, there would be clarity on the correct size for reinsertion.
A facility policy titled Urinary Catheterization dated 04/2021, documented to provide care and services to support residents in the management of a urinary catheter.
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 observation, interview, record review, and document review, the facility failed to complete timely assessments and inte...
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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 complete timely assessments and interventions addressing resident's weight loss and a physician was notified for one of the 31 sampled residents (Resident 47).
This deficient practice could have potentially led to a deprivation of essential care and a deterioration in overall health.
Findings include:
Resident 47 (R47)
R47 was admitted on [DATE], with diagnoses including dysphagia, diabetes mellitus and chronic kidney disease.
The Brief Interview of Mental Status dated 08/03/2023, documented a score of 14/15, which indicated R47's cognitive status was intact.
On 09/20/2023 at 10:51 AM, R47 indicated was diabetic and had wounds. R47 indicated the diabetic diet had been discussed but was not provided. R47 expressed concerns about significant weight loss, and nobody within the facility had discussed this concern. R47 indicated became aware of the weight loss during a weighing session and had to inquire with the CNA about the weight, comparing it to previous results independently.
The Weight Summary documented as follows:
-06/03/2023, 237.6 pounds (lbs.)
-07/06/2023, 224.0 lbs.
-08/09/2023, 215.0 lbs.
-08/15/2023, 217.0 lbs.
-09/04/2023, 215.0 lbs.
R47's medical records lacked documented evidence; the physician was notified regarding R47's significant weight loss of 13.6 lbs. on 07/06/2023, a nutritional assessment was completed, and interventions had been implemented.
On 09/22/2023 at 11:16 AM, the Registered Dietitian (RD) indicated R47's diet was regular with a soft, bite-sized texture and thin liquid consistency. The RD indicated R47 previously was on tube feeding but liberalized and eating orally. The RD indicated R47 was assessed with the previous RD who no longer worked at the facility. The RD acknowledged there was a change of condition on 07/06/2023, when R47 had a weight loss of 13.6 pounds or 5.7%, which was a significant weight loss over 30 days. The RD confirmed R47's weight loss was unplanned.
The RD explained the nutritional assessment would have been completed upon the resident's admission and as needed when there was a change of condition such as significant weight loss. The RD indicated the monthly weights were reviewed and submitted to the DON. The RD indicated when a significant weight loss was identified, a weekly weight should have been obtained to monitor the risk of losing more weight. The RD confirmed there was no documentation the physician was notified regarding R47's significant weight loss, there was no assessment done, and no timely interventions were implemented after a significant weight loss was identified on 07/06/2023.
On 09/22/2023 at 1:43 PM, a Certified Nursing Assistant (CNA) indicated one CNA, or a Restorative Nursing Assistant (RNA) was assigned to obtain the residents weights under the direction of the Registered Dietitian. The CNA indicated a CNA on the floor could be of help in obtaining weights if directed, but the RNA was responsible for weights.
On 09/22/2023 at 2:51 PM, during a telephone interview, the RNA explained the responsibilities, which included obtaining the weights of newly admitted residents on a daily basis and entering them into the computer system. The RNA explained the list of weekly weight schedules was obtained from the RD, and every week, had to perform tasks such as monitoring significant weight changes, addressing refusals, comparing the current weight to the previous one, and conducting reweighs.
The RNA clarified the monthly weights were obtained for all residents at the beginning of each month. The CNA explained a weight difference of more than 5 lbs. was considered a significant change, and was required to immediately notify the charge nurse and the Registered Dietitian before inputting the information into the computer system. The RNA confirmed the RD was aware of R47's significant weight loss on 07/06/2023.
The Wound, Weight, and Fall (WWF) committee minutes for June and July 2023, lacked documented evidence R47's significant weight loss was discussed.
On 09/22/2023 at 3:07 PM, the Assistant Director of Nursing (ADON), indicated the WWF committee would have been convening every Thursday. The ADON indicated R47's weight loss had not been addressed or communicated to the committee until 08/10/2023. The ADON indicated the physician was not notified because the nursing staff or the committee was unaware of R47's weight loss issue and had expected the RD to notify the committee promptly at least within a week.
The ADON explained the RD could have taken proactive steps by informing the nursing department to alert the physician for orders related to supplements and medication reconciliation if a resident exhibited a loss of appetite. The ADON acknowledged there had been a delay in implementing these necessary interventions for more than a month.
On 09/22/2023 at 2:01 PM, the Nurse Consultant acknowledged there was a delay in assessment and intervention when R47's significant weight loss of 5.7% occurred on 07/06/2023. The Nurse consultant indicated there should have been an assessment within a week after it was identified, and the physician and interdisciplinary team should have been notified during the weekly meeting.
A facility policy titled Nutritional assessment dated 10/2017, documented the dietitian, in conjunction with the nursing staff and healthcare practitioners, would conduct a nutritional assessment for each resident upon admission and as indicated by a change in condition that places the resident at risk for impaired nutrition.
A facility policy titled Nutrition/Unplanned Weight Loss-Clinical Protocol revised 11/2017, documented the staff would report to the physician any significant weight gain or loss.
CONCERN
(D)
Potential for Harm - no one hurt, but risky conditions existed
Tube Feeding
(Tag F0693)
Could have caused harm · This affected 1 resident
**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Resident 42 (R42)
R42 was admitted on [DATE] with diagnoses including anoxic brain damage, acute respiratory failure with hypoxi...
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**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Resident 42 (R42)
R42 was admitted on [DATE] with diagnoses including anoxic brain damage, acute respiratory failure with hypoxia, and dysphagia following cerebral infarction.
A physician's order dated 07/31/2023, documented Glucerna with Carbsteady 1.2 calories at 85 cubic centimeters (cc) per hour for 20 hours from 6:00 PM to 2:00 PM via percutaneous endoscopic gastrostomy (PEG) tube to provide 1700mL/2040kcal.
A quarterly Minimum Data Set (MDS) dated [DATE] documented a Brief Interview for Mental Status (BIMS) (screening measure for cognitive condition) score of 00, which meant R42 was severely impaired.
On 09/20/2023 at 11:27 AM, R42 was lying in bed with the head of bed elevated. The tube feed pump was on and running with a formula of Glucerna with Carbsteady 1.2 calories, infusing at 85 cc per hour.
A physician's order dated 09/20/2023, documented Glucerna with Carbsteady 1.2 calories at 90 cc per hour for 20 hours from 6:00 PM to 2:00 PM via PEG tube to provide 1800mL/2160kcal.
On 09/21/2023 at 9:05 AM, R42 was lying in bed with the head of bed elevated. The tube feed pump was on and running with a formula of Glucerna with Carbsteady 1.2 calories, infusing at 85 cc per hour.
On 09/21/2023 at 9:08 AM, a Certified Nursing Assistant (CNA) confirmed R42's tube feeding was set at 85 cc per hour with the tube feed formula of Glucerna with Carbsteady 1.2 calories.
On 09/21/2023 at 9:11 AM, a Licensed Practical Nurse (LPN) confirmed R42's tube feeding was set at 85 cc per hour with the tube feed formula of Glucerna with Carbsteady 1.2 calories and was not running at the new rate as ordered on 09/20/2023 at 2:24 PM by the Registered Dietitian (RD). The LPN indicated they were not aware the order had changed and indicated the importance of following the rate per order to control a resident's caloric intake for their weight.
On 09/21/2023 at 9:21 AM, the LPN confirmed R42's tube feeding started at 6:00 PM to 2:00 PM. The LPN acknowledged it had been an estimated 18 hours since the order was changed and R42's tube feeding rate was not increased to meet R42's caloric need during that time. The LPN indicated their plan to follow up with the RD and physician to inquire if an adjustment was needed following R42 missing their increased dosage.
On 09/22/2023 at 10:08 AM, the RD explained they were the responsibly party for making tube feed recommendations. Any changes in tube feed recommendations were communicated to the Unit Managers who would then communicate to the floor nurses. The RD confirmed increasing R42's rate to 90 cc on 09/20/2023 in the late afternoon. The RD verbally informed and sent a text message to a Unit Manager. The RD presented a text message time stamped at 2:55 PM. Note the Unit Manager the RD notified was not the Unit Manager of the Valley of Fire unit where R42 resided.
The RD explained they changed R42's order to increase the nutritional intake due to R42 being identified with weight loss. The RD explained they changed the order prior to the next scheduled feeding at 6:00 PM on 09/20/23 and therefore expected the new order to be implemented at that time. The RD was not aware R42's new order was not implemented or of the estimated 18 hours delay, which the RD indicated was not appropriate. The RD explained the current goal for R42 was to maintain their weight and considered the weekly monitoring to be stable at this time.
Based on observation, interview, record review, and document review, the facility failed to ensure the tube feeding rate was communicated and carried out as ordered for 2 of 31 sampled residents (Residents 338 and 42). This deficient practice could potentially lead to weight loss and severe complications, jeopardizing residents' health, and overall well-being.
Findings include:
The facility policy titled Quality of Care Tube Feeding Management/Restore Eating Skills, last revised in June 2018, documented the facility in collaboration with the Registered Dietician and Dietary Services, provided direction on how to determine whether the tube feedings met the resident's nutritional needs and when to adjust them accordingly, and validated the administration of enteral nutrition was consistent with and followed the practitioner's orders. The facility would have addressed actual or potential complications and notified the practitioner about evaluating and managing the care to address complications or risk factors.
Resident 338 (R338)
R338 was admitted on [DATE], with diagnoses including severe protein-calorie malnutrition, fluid and intake deficiency, and dependence on renal dialysis.
The Brief Interview of Mental Status, dated 09/20/2023, documented a score of 13/15, which indicated R338's cognitive status was intact.
A physician order dated 09/19/2022, documented Nepro at 85 cubic centimeters (cc) times (x) 12 hours from 6:00 PM to 6:00 AM, providing a total of 1020 milliliters (ml) equivalent to 1836 kilocalories (kcl) via percutaneous endoscopic gastrostomy (PEG) tube (a way of providing nourishment and hydration to people who cannot swallow or eat enough by mouth).
A Care Plan dated 09/18/2023, documented R338's altered nutritional state related to diabetes, protein-calorie malnutrition required enteral feeding, actual infection, actual wounds, and end-stage renal disease requiring dialysis. The intervention which included providing a diet as ordered.
A Care Plan dated 09/19/2023, documented R338 required enteral feedings as a supplement for oral feeding, which puts R338 at risk for malnutrition, dehydration, and intolerance. The interventions included providing enteral nutrition per physician's order.
The Dietitian Evaluation dated 09/19/2023, documented R338 was at risk for fluid shifts secondary to chronic kidney disease, on hemodialysis, increased needs secondary to wound healing, and mixed oral intake with supplemental nocturnal feeds. The goal was to achieve a stable weight and improved skin. To supplement with nocturnal feeding of Nepro at 85 cc for 12 hours to provide 1020 = 1,836 kcal and supplements.
On 09/20/2023 at 8:16 AM, R338 was in bed, alert, and verbally oriented. R338's tube feeding was infusing at 70 cc per hour via an enteral feeding pump.
On 09/21/2023 at 10:26 AM, R338's tube feeding (TF) was turned off, and no TF bag was hung. A Licensed Practical Nurse (LPN) confirmed R338's TF was Nepro at 70 cc/hour and was started the previous night at 6:00 PM for 12 hours. The LPN explained was unaware the TF order had been increased to 85 cc/hr.
The tube feeding (TF) enteral pump infusion record history was reviewed with the LPN and the Assistant Director of Nursing (ADON), which revealed the following readings:
-12 hours consumption, 840 cc was delivered (a difference of 180 cc)
-24 hours consumption, 996 cc was delivered (a difference of 1,044 cc)
The total volume required for R338 had not been completely delivered as ordered.
The ADON verified R338's TF orders and confirmed the TF rate was changed to 85 cc/hour by the Registered Dietitian on 09/19/2023. The ADON explained R338 should receive a total volume of 1020 for 12 hours and 2,040 for 24 hours, but the total volume requirement was not completely delivered per the history record of the enteral pump. The ADON explained when the order was changed, the RD would communicate with the nursing department to ensure the new order was carried out or reset the pump.
On 09/21/2023 at 11:06 AM, a Registered Dietitian (RD) confirmed R338's TF was changed on 09/19/2023 at 12:15 PM to 85 cc x 12 hrs. with a total volume of 1,020 cc for 12 hours and 2,040 cc for 24 hours. The RD indicated the assessment was completed, based on R338's estimated calculated needs, the average intake was 47% and nocturnal needs were at 75%. The RD acknowledged R338 nutritional needs were not met at 100%. The RD indicated a potential for weight loss if the total calories required were not completely delivered. The RD indicated the Unit Manager was notified on 9/19 through text message regarding R338's new TF order.
On 09/21/2023 at 12:37 PM, the Unit Manager (UM) explained the RD had not sent a text message but had instead made a phone call on 09/19/2023. During the call, the UM informed the RD to send the new order via fax to the unit and to notify the nurse assigned to R338. The UM noted it was evident the order had not been executed because the nurse was unaware of it. The UM also mentioned a similar incident had occurred in the past when an order was not adequately communicated, leading to a failure in its execution.
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 390 (R390)
R390 was admitted on [DATE], with diagnoses including osteomyelitis.
On 09/20/2023 at 9:43 AM, R390 was ale...
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**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Resident 390 (R390)
R390 was admitted on [DATE], with diagnoses including osteomyelitis.
On 09/20/2023 at 9:43 AM, R390 was alert in bed while eating breakfast. The resident had an intravenous (IV) access in the right upper arm with a transparent dressing dated 09/14/2023. The dressing had brownish dirt build-up on the edges and was starting to come loose at the ends. R390 pointed to right foot and explained R390 was receiving IV antibiotics related to a foot infection and the peripherally inserted central catheter (PICC) line was inserted at the hospital for antibiotic therapy. R390 indicated requesting the night nurse to change the PICC line dressing last night because the site was starting to itch. According to the resident, the night nurse administered the IV antibiotics, left the room, and did not return.
On 09/20/2023 at 9:49 AM, the Assistant Director of Nursing (ADON) entered R390's room and confirmed the resident's right upper arm PICC line dressing was dated 09/14/2023, was dirty and coming loose at the ends. R390 reported the night nurse to the ADON for ignoring the resident's request for a PICC line dressing change the evening prior on 09/19/2023.
On 09/20/2023 at 9:52 AM, the ADON explained the facility policy required nurses to assess and change all IV dressings upon admission or within 24 hours of admission and weekly thereafter and as needed when the dressing became soiled or loosened. The ADON indicated if R390 was receiving IV antibiotics twice a day, nurses had two opportunities per day to assess the resident's PICC line and identify the dressing was due to be changed.
A physician's order dated 09/20/2023, documented to change dressing one time on admission and every week by Sunday night shift and as needed when soiled or loose.
On 09/20/2023 at 10:13 AM, the ADON confirmed there were no care orders for R390's right upper arm PICC line prior to 09/20/2023 and emphasized R390's PICC line dressing should have been changed within 24 hours of admission.
Resident 79 (R79)
R79 was admitted on [DATE], with diagnoses including urinary tract infection and resistance to multiple antibiotics.
On 09/20/2023 at 11:52 AM, R79 laid in bed watching television. The resident was connected to a ventilator and could speak a few words but with difficulty. R79 had a left upper arm IV access with transparent dressing dated 09/13/2023. The resident's family member explained the resident had completed antibiotic therapy on 08/31/2023 but the physician had granted the family member's request to maintain the midline to prevent another insertion in the event of need. According to the family member, dressing changes were typically performed on Sunday nights but no one came to perform the task this past Sunday.
A physician's order dated 08/20/2023, documented to give Amikacin Sulfate 75 milligrams (mg) every 12 hours intravenously for Pseudomonas Pneumonia for 10 days.
A physician's order dated 08/20/2023, documented to insert a midline or peripherally inserted central catheter (PICC) line for pneumonia.
A Midline Procedural Note dated 08/20/2023, revealed a left upper extremity midline was inserted, unable to advance to axilla due to vein scarring. Do not draw labs from midline.
A physician's order dated 08/20/2023, documented to change dressing weekly or when soiled or loosened.
On 09/21/2023 at 8:45 AM, R79 and the family member were awake watching television. R79's left upper arm midline remained dated 09/13/2023. The family member indicated the night shift nurse came and looked at the resident's midline the evening prior on 09/20/2023 but did not return to perform any care, not even to flush the line.
On 09/21/2023 at 8:50 AM, a Licensed Practical Nurse (LPN) entered the resident's room and confirmed R79's left upper arm midline was dated 09/13/2023. The LPN indicated midline dressings were replaced every seven days or as needed when loose or soiled. The LPN indicated it had been past seven days since the last dressing change which was not in accordance with the facility's policy. The LPN emphasized IV lines which were not in use should be maintained in accordance with facility policy which included site assessments and flushing every shift and weekly dressing changes.
On 09/21/2023 at 9:00 AM, the Unit Manager indicated R79 was on antibiotic therapy from 08/20/2023 until 08/30/2023, but the physician had ordered the midline to be maintained since R79 was a hard stick. The Unit Manager indicated until the physician ordered the midline removal, care orders must be carried out to include site assessment and flushing every shift and weekly dressing changes. The Unit Manager verbalized consequences to not providing care to midlines or PICC lines may include infection and occlusion.
On 09/21/2023 at 11:45 AM, the Regional Nurse Consultant reviewed R79's medical record and confirmed R79's left upper arm midline dressing was due to be performed on 09/20/2023, but was not done.
The Midline Dressing Changes policy revised April 2016, documented to prevent catheter-related infections from occurring due to contaminated, loosened, or soiled catheter-site dressings, the midline or PICC line catheter dressings were to be changed every five to seven (5-7) days or when wet, dirty, not intact or compromised in any way.
Based on observation, interview, record review, and document review, the facility failed to ensure the peripherally inserted central catheter (PICC) or midline dressing was changed as scheduled for four sampled residents (Residents 8, 47, 79, and 390). This deficient practice could potentially lead to serious complications, such as bloodstream infections, clot formation, or other adverse health outcomes.
Findings include:
Resident 8 (R8)
R8 was admitted on [DATE], with diagnoses including diabetes mellitus and osteomyelitis of left ankle and foot.
The Brief Interview of Mental Status (BIMS) dated 09/01/2023, documented a score of 12/15, which indicated R8's cognitive status was intact.
On 09/20/2023 at 12:30 PM, R8 lay in bed, verbally alert and oriented. An empty bag of intravenous antibiotics hung at the bedside. R8's left arm had a PICC line inserted; the transparent dressing was soiled and dated 09/07/2023.
A Physician order dated 09/03/2023, documented changing the transparent dressing (every Sunday at night).
The Medication Administration Record (MAR) documented, R8's PICC line transparent dressing was changed on 09/10/2023 and 09/17/2023.
On 09/20/2023 at 3:30 AM, a Licensed Practical Nurse (LPN) confirmed R8's PICC line dressing was old and dated 09/07/2023. The LPN confirmed R8 was still receiving an antibiotic treatment for osteomyelitis. The LPN indicated the student nurses were responsible for changing the intravenous (IV) line dressings, but if they were not changed as scheduled, the nurses assigned to the resident were responsible. An LPN indicated the IV line dressing should have been changed weekly as scheduled to prevent infection.
On 09/21/2023 at 8:36 AM, the Assistant Director of Nursing (ADON) indicated the midline and PICC line dressing should have been changed weekly at night or as needed if it was soiled or loosened. The ADON confirmed R8's dressing was not changed as scheduled but was documented in the MAR as having been changed. The ADON indicated the staff were expected to document what had been completed.
Resident # 47 (R47)
R47 was admitted on [DATE], with diagnoses including dysphagia, diabetes mellitus and chronic kidney disease.
The Brief Interview of Mental Status dated 08/03/2023, documented a score of 14/15, which indicated R47's cognitive status was intact.
On 09/20/2023, at 10:32 AM, R47 was lying in bed. The PICC line dressing was dated 09/07/2023. R47 mentioned the PICC line was inserted in the facility but had not been changed for two weeks and had not been in use.
A Physician order dated 04/16/2023, documented to change transparent dressings (every Sunday at night).
The MAR documented R8's PICC line transparent dressing was changed on 09/10/2023 and 09/17/2023.
On 09/20/2023 at 11:11 AM, a Certified Nursing Assistant (CNA) confirmed the PICC line dressing was soiled and dated 09/07/2023. On 09/20/2023 at 3:30 AM, a Licensed Practical Nurse (LPN) confirmed R47's PICC line dressing was dated 09/07/2023, was old, and soiled.
On 09/22/2023 at 9:22 AM, the Director of Nursing (DON) indicated the PICC line or midline dressing should have been changed every 7 days and documented in the MAR if the task had been completed.
CONCERN
(D)
Potential for Harm - no one hurt, but risky conditions existed
Deficiency F0757
(Tag F0757)
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 an intravenous antibiotic was ...
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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 an intravenous antibiotic was administered as scheduled following a physician's order for 1 of 31 sampled residents (Resident 132). The deficient practice had the potential to cause adverse effects related to toxic levels of the medication.
Findings include:
Resident #132 (R132)
R132 was admitted on [DATE] with diagnoses including right mandible abscess and osteomyelitis.
On 09/20/2023 at 9:10 AM, R132 stated a nurse administered an intravenous (IV) antibiotic at the wrong time. The resident denied any adverse reaction after the administration.
A physician's order dated 09/04/2023, documented Zosyn (piperacillin sodium/tazobactam sodium 3-0.375 grams), intravenously every eight hours for osteomyelitis for 20 days.
A physician's order dated 08/31/2023, documented Cubicin (Daptomycin) 600 milligrams (mg) IV (Daptomycin) one time a day for facial cellulitis.
The Medication Administration Record (MAR) for September 2023, revealed Cubicin was scheduled to be administered every day at 10:00 AM and Zosyn was scheduled to be administered every eight hours at 6:00 AM, 2:00 PM, and 10:00 PM. The MAR revealed the IV antibiotics were administered as ordered. There was no documented evidence a medication error occurred for the administration of these medications. The MAR did not document the antibiotic Zosyn was administered on a wrong schedule at 10:00 AM, four hours apart from the previous dose administered at 6:00AM.
Nursing progress note dated 9/11/23, indicated the Infectious Diseases Nurse Practitioner agreed to administer Daptomycin IV daily as ordered. The note documented R132 tolerated IV antibiotic well, and did not report pain, redness at the administration site, or adverse reaction. The note did not mention the antibiotic Zosyn was administered on a wrong schedule at 10:00 AM, four hours apart from the previous dose administered at 6:00AM.
Incident report dated 09/11/2023, documented that around 10:00 AM, when the due antibiotic Cubicin was about to be administered to R132, the nurse saw another antibiotic being administered (Zosyn). R132 told the nurse that the medication had just been started by another nurse. The nurse did not stop the administration of the antibiotic Zosyn and inform the Director of Nursing (DON) about the incident. The note indicated the attending physician was notified and ordered to not administer Zosyn at 2:00 PM as scheduled since was administered early, instead Cubicin would be administered at 2:00 PM.
On 09/22/23 at 9:15 AM, the DON indicated a nurse reported an incident related to administration of Zosyn on a wrong schedule. The DON explained a nurse administered the antibiotic Zosyn on a wrong schedule and another nurse found the medication had been administered twice by mistake during the morning. According to the DON, the attending physician was notified about the incident and directed the nurse to finish the Zosyn and give Daptomycin at 2:00 PM. The DON indicated the nurse was re-educated and disciplined. The DON verbalized it was expected nurses followed the medication administration safety practice that included the verification of the right schedule time before the administration of the medication.
The facility policy titled Adverse Consequences and Medication Error dated April 2014, indicated a medication error was defined as the preparation or administration of drugs or biologicals which was not in accordance with the physician's order and included medication given in a wrong time.
CONCERN
(D)
Potential for Harm - no one hurt, but risky conditions existed
Infection Control
(Tag F0880)
Could have caused harm · This affected 1 resident
**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, interview, and document review, the facility failed to transport clean linen in a sanitary manner for one ...
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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 transport clean linen in a sanitary manner for one unsampled resident and follow their Transmission-Based Precaution (TBP) practice for 1 of 31 sampled residents (Resident 10). The deficient practice had the potential to contaminate clean linen and spread communicable infections or organisms that can affect the well-being of residents.
Findings include:
On 09/20/2023 at 8:39 AM, a Physical Therapy Assistant (PTA) was observed carrying clean folded linen in between their right arm and against their clothing/body down the 1100 hallway into a resident room [ROOM NUMBER]. The PTA was observed unfolding and fanning the linen over a resident in the B bed.
On 09/20/23 at 8:41 AM, the PTA verbalized it was probably not okay to transport clean linen against their body due to the concern of contamination of the clean linen. The PTA did not know the importance of not fanning linen over a resident after it was transported in such a manner.
On 09/22/2023 at 11:29 AM, the Infection Preventionist Nurse explained clean linen should be transported and handled in a manner away from one's body so as to not contaminate the clean linen and keep the linen as clean as possible. The Infection Preventionist Nurse indicated it was not appropriate to transport clean linen against one's body and proceed to fan the linen over a resident.
The facility policy titled Infection Prevention and Control Linen Handling last revised September 2018, documented the facility staff will handle, store, process, and transport linens so as to prevent the spread of infection and minimize the risk of contamination. The policy specified clean linen will be transported in a manner to maintain cleanliness and staff will not carry clean linen next to clothing.
Resident 10 (R10)
R10 was admitted on [DATE] with diagnoses including bacteremia (bacteria in the bloodstream).
On 09/20/2023 at 10:04 AM, a contact precaution sign was posted outside of R10's door, along with Personal Protective Equipment (PPE) supply.
On 09/21/2023 at 8:30 AM, a Certified Occupational Therapy Assistant (COTA) entered R10's room without donning Personal Protective Equipment (PPE).
The COTA explained the contact precaution sign was a precaution prior to entering the resident's room. It was expected to don the proper PPE when providing patient care, but not necessary if entering quickly to speak with a resident. The COTA indicated it was important to follow the precaution sign to prevent the spread of diseases. The COTA also confirmed another resident was visiting with R10 in the room.
On 09/21/2023 at 8:33 AM, the visiting resident was sitting in a wheelchair positioned at the bottom right edge of R10's bed, facing towards the direction of R10 and talking to R10. The visiting resident was not wearing PPE.
On 09/21/2023 at 8:34 AM, a Certified Nursing Assistant (CNA) indicated contact precaution required a mask, gloves, gown, and face shield for PPE. The CNA confirmed the visiting resident inside R10's room was not wearing PPE.
On 09/21/2023 at 8:42 AM, the Unit Manager reported R10 had Methicillin-resistant Staphylococcus aureus (MRSA) (type of bacteria that was resistant to several antibiotics) in the blood and was on droplet precaution which required a mask, glove, and gown for PPE. It was important to follow the precaution sign to stop the spread of infection and expected all staff members to don PPE upon entering the resident's room. The Unit Manager confirmed the visiting resident inside R10's room was not wearing appropriate PPE.
On 09/21/2023 at 1:44 PM, R10 indicated they noticed the contact precaution sign was placed outside their door on 09/20/2023. R10 verbalized they left and reentered their room multiple times since the sign was posted and no staff member had stopped them from leaving their room.
On 09/22/2023 at 11:29 AM, the Infection Preventionist Nurse verbalized the proper PPE for contact precaution was a gown and gloves. The Infection Preventionist Nurse explained residents who were in isolation were not allowed to leave their rooms. However, staff members are not allowed to force residents to stay in their room and should discuss the risk and benefits with the resident. The Infection Preventionist Nurse explained the importance of following precaution signs to avoid spreading the concerning organism. The Infection Preventionist Nurse indicated it was not appropriate for staff members or visitors to enter an isolation room without donning proper PPE.
The facility policy titled Infection Control: Standard Precautions, Enhanced Barrier Precautions, and Transmission-Based Precautions (TBP) published on 07/26/2022, documented TBP was used in addition to Standard Precautions for residents who may be infected or colonized with certain infectious agents for which additional precautions are needed to prevent infection transmission. TBP included Contact, Droplet, and Airborne precautions. Standard Precautions documented PPE (gloves, gown, mask/respirator, eye protection) was selected based on the interaction with the resident.
CONCERN
(E)
Potential for Harm - no one hurt, but risky conditions existed
Deficiency F0565
(Tag F0565)
Could have caused harm · This affected multiple residents
Based on interview and document review, the facility failed to ensure the views and recommendations of the resident group were acted upon, and the response and rationale were communicated back to the ...
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Based on 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 were communicated back to the resident group. The failed practice had the potential to affect the quality of life and health status of residents.
Findings include:
The Resident Right to Organize and Participate in Resident Groups in the Facility policy dated July 2018, documented the facility would consider views of the residents and act promptly upon the grievances and recommendations of resident group concerning issues of resident care and life in the facility. The facility should be able to demonstrate the facility's response and rationale for the response in relation to expressed grievances and recommendations from the group.
On 09/21/23 at 2:15 PM, eight residents attended the resident council meeting. The residents reported food concerns discussed in previous meetings had not been addressed and remained unresolved. Specifically, residents indicated food would sometimes be served late, cold, nasty, did not follow the published menu nor honor resident's preferences, alternatives were not offered, and snacks would not be available especially at night.
The resident council minutes dated 01/26/2023, documented residents raised concerns regarding cold food and residents not getting what was ordered or requested.
The resident council minutes dated 02/23/2023, documented residents were complaining of cold food and not getting what was on the menu and what they ordered. Residents also raised their concerns about snacks not being available, especially during nighttime.
The resident council minutes dated 03/23/2023, documented residents requested a kitchen representative to come to their room to obtain choice of meal and to bring back the alternative menu.
The resident council minutes dated 04/27/2023, documented residents complained of sausage with gravy which was nasty and should be removed from the menu.
The resident council minutes dated 05/18/2023, documented residents complaining of cold and nasty food. The administration and owners should look into this long-standing problem because nutrition plays a huge part in their recovery. A lot of residents have claimed to lose weight.
The resident council minutes dated 06/15/2023, documented same concerns with cold food, no alternative menu and water was nasty.
The resident council minutes dated 08/17/2023, documented requesting kitchen representative to come to resident's rooms to obtain preferred choice of meal and offer more alternative choices. Most meals were served cold, especially at night. Pork was often served which most residents do not want and had expressed requests for chicken, beef, salad, and fresh fruits because food plays a big role to their recovery.
The resident council minutes lacked documented evidence the documents had been reviewed by the Administrator. At the end of each document, the provision for Administrator's signature was unsigned on 01/26/2023, 02/23/2023, 03/23/2023, 04/27/2023, 05/18/2023, 06/15/2023, 07/20/2023, and 08/17/2023.
The resident council minutes lacked documentation of the facility's response and actions taken, if any, were communicated back to the resident group regarding food and dietary concerns.
On 09/22/2023 at 12:05 PM, two kitchen staff members provided copies of written complaints dated 08/17/2023 and 09/05/2023 addressed to Administration regarding kitchen issues such as insufficient food supplies, mistakes committed by the dietary manager on resident meal trays, and lack of training of new kitchen staff.
On 09/22/2023 at 2:57 PM, the Regional Nurse Consultant indicated being aware of food complaints which were discussed by Social Services during daily stand-up meetings, but the Regional Nurse Consultant indicated assuming the Social Services department were addressing the food concerns as independent grievances.
On 09/22/2023 at 3:10 PM, the Regional Nurse Consultant indicated being the facility's Director of Nursing (DON) from November 2021 until May 2023. The former DON indicated not being able to recall attending resident council meetings and was learning for the first time of persistent food concerns raised by the resident group.
On 09/22/2023 at 3:15 PM, the Administrator indicated not being aware of food concerns raised in resident council meetings.
On 09/22/23 at 3:39 PM, the Administrator acknowledged not reviewing resident council minutes on 01/26/2023, 02/23/2023, 03/23/2023, 04/27/2023, 05/18/2023, 06/15/2023, 07/20/2023, and 08/17/2023. The Administrator explained the Activities Director should have provided the resident council minutes to the Administrator for review, but the Activities Director had not done so. The Administrator indicated not requesting the resident council minutes from the Activities Director for review from January 2023 to present.
On 09/22/2023 at 4:42 PM, the Activities Director indicated food concerns were being shared by the former Social Worker almost daily during stand-up meetings, but the facility's leadership did not seem interested in resolving the food complaints. The Activities Director indicated after the Social Worker left in June 2023, the Activities Director stopped communicating food concerns with the Administrator. However, the Activities Director indicated speaking with the Administrator a week after the last resident council meeting held on 08/17/2023, regarding resident's complaints of cold and nasty food and the menu not being followed. According to the Activities Director, the Administrator told the Activities Director the Administrator needed proof the food was bad.
CONCERN
(E)
Potential for Harm - no one hurt, but risky conditions existed
Deficiency F0761
(Tag F0761)
Could have caused harm · This affected multiple residents
**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, interview and document review, the facility failed to securely store medication in the hallway and six res...
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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 securely store medication in the hallway and six resident rooms in 3 of 3 hallways in the Valley of Fire unit. The deficient practice had the potential for residents, visitors, and staff members to gain unauthorized access to medications and for residents to self-administer medication that could interact with facility prescribed medication, which can adversely affect a resident's health.
Findings include:
On [DATE] at 8:22 AM, an intravenous piggyback (Piperacillin and Tazobactam), was unattended on top of a locked medication cart stationed outside of resident room [ROOM NUMBER]. The staff member was inside resident room [ROOM NUMBER] and the medication cart was not within their sight.
A Licensed Practical Nurse (LPN) exited resident room [ROOM NUMBER] and explained the medication was an antibiotic and should not have been left unattended. The medication should have been stored inside the medication cart. The LPN verbalized someone could have walked by and grabbed the medication.
On [DATE] at 8:51 AM, in resident room [ROOM NUMBER] was an unwrapped syringe of normal saline flush (0.9 % sodium chloride). The syringe was wedged on top of the infusion pump.
On [DATE] at 9:02 AM, a Unit Manager confirmed the observation and the location of the unwrapped syringe of normal saline. The Unit Manager indicated it was not appropriate for the syringe of normal saline to be left on the infusion pump. The Unit Manager considered the syringe of normal saline to be a medication and all medications should be stored in the medication carts.
On [DATE] at 8:29 AM, in resident room [ROOM NUMBER] was a bottle of Soothe XP (eye protection therapy) on the bedside tray table and two syringes of normal saline flush (0.9 % sodium chloride) on top of the dresser.
On [DATE] at 8:44 AM, the LPN confirmed there was a bottle of eye drops, two syringes of normal saline flush syringes and seven individually wrapped tablets of Pepto-Bismol in resident room [ROOM NUMBER]. The LPN indicated the facility did not carry the brand of eyedrops or the type of Pepto-Bismol found in the resident's room. The LPN indicated the syringes of normal saline flush were okay to leave inside resident rooms.
On [DATE] at 9:01 AM, there were two syringes of normal saline flush on top of an unattended medication cart. The medication cart was out of the LPN's sight. At the time, a resident and another staff member walked past the medication cart.
On [DATE] at 9:18 AM, in resident room [ROOM NUMBER] was an inhaler of Albuterol sulfate 90 micrograms (mcg) on the resident's bed. On the bedside tray table there was a tube of ultra-moisturizing Hydrocortisone cream and two amber colored, unlabeled plastic medication bottles which contained two different pills. The resident indicated they had these medications with them since they came to the facility, used the medication as needed, and the staff were aware the resident had them.
On [DATE] at 9:27 AM, the LPN confirmed the resident in room [ROOM NUMBER] had an inhaler of Albuterol on the bed. The LPN identified the two different pills as Tums and Tylenol in the amber plastic medication bottles. The LPN confirmed the resident had an inhaler of Trelegy Ellipta and Hydrocortisone cream on the bedside tray table.
On [DATE] at 10:07 AM, in resident room [ROOM NUMBER] on top of the bedside dresser was a tube of Cortisone cream. The resident stated the nurse was aware they had Cortisone cream.
On [DATE] at 10:22 AM, a CNA confirmed on top of the dresser was a tube of Cortisone in resident room [ROOM NUMBER].
On [DATE] at 10:51 AM, in resident room [ROOM NUMBER] on top of a dresser were the following medications:
A bottle of Vitafusion multivitamins gummies (take one a day).
A bottle of BoneUp (take one a day).
A bottle of Iron 27 mg (take one a day).
A bottle of Potassium 99 milligrams (mg) (take one a day).
A bottle of Potassium 99 mg which was expired.
A bottle of Potassium gluconate.
A container of Metamucil.
A bottle of Nystop powder
The resident stated they were aware one of the medications had expired and did not take the expired medication.
On [DATE] at 11:16 AM, a Unit Manager confirmed the above listed medications were in resident room [ROOM NUMBER]. The Unit Manager re-stated all medications should be stored and locked away. The Unit Manager explained the residents were made aware outside medications were not allowed upon admission to the facility.
On [DATE] at 8:38 AM, in resident room [ROOM NUMBER], the container of Metamucil remained on top of the dresser.
On [DATE] at 8:47 AM, a Unit Manager confirmed the container of Metamucil was in resident room [ROOM NUMBER] and verbalized they must have missed the Metamucil supplement when removing the other medications.
On [DATE] at 12:55 PM, in resident room [ROOM NUMBER] was one syringe of normal saline flush on top of the dresser.
On [DATE] at 12:59 PM, a Unit Manager confirmed one syringe of normal saline flush was inside resident room [ROOM NUMBER].
A facility policy titled Pharmacy Services Labeling and Storage of Drugs and Biologicals revised [DATE], documented the facility stored drugs and biologicals in locked compartments and over the counter medication should have labels that contain the original manufacturers or pharmacy-applied label.
CONCERN
(F)
Potential for Harm - no one hurt, but risky conditions existed
Food Safety
(Tag F0812)
Could have caused harm · This affected most or all residents
**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, interview, and document review, the facility failed to ensure 1) the oven was maintained in sanitary condi...
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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 1) the oven was maintained in sanitary conditions, 2) an expired meal product was discarded, 3) open meal products were labeled, 4) nourishment room was maintained in sanitary conditions, and 5) nourishment room food items in the refrigerator were labeled, dated, and expired items were discarded. The deficient practice had the potential to affect the residents' health by exposing them to potentially hazardous foods.
Findings included:
09/20/23 07:50 AM, the following issues were identified during the initial tour to the kitchen:
The top surface of the oven was tacky to touch with collection of food debris and dust. The inside of the oven was visibly soiled with golden-brown like grime stains. A food service worker verbalized the oven was cleaned about two months ago and was not sure how often it had to be cleaned.
Expired meal products:
a 5 pounds (Lbs.) container of peeled garlic expired on 09/16/2023 was found in the walk-in refrigerator.
Unlabeled opened meal products in the walking refrigerator:
A bottle of heavy-duty mayonnaise 1 gallon.
A bottle of sweet pickle relish.
Unlabeled meal products in the refrigerator #2:
Two cups of chicken noodle soup.
Unlabeled opened meal products in the dry food storage:
A 5 Lbs. container of creamy peanut butter.
10 bags of potatoes chips snack size
A bag containing five dinner bread rolls.
A bag of sandwich bread.
A bag of raisin bran cereal.
A bag of rice crispy cereal.
A bag of cheerios cereal.
A food service worker confirmed the observation and indicated meal products should have been labeled with the date the items were opened.
09/20/23 09:08 AM, an inspection conducted in the nourishment room located at the Mount [NAME] Unit revealed the following issues:
A steam table was out of services.
A plate warmer was visibly soiled with food debris.
A refrigerator used to store resident's personal food was visibly soiled with meal-like product.
A gallon of 2 % reduced fat milk was open and not labeled with the date it was open.
A 16 ounces (oz) bottle of peanut butter was open and not labeled with the date it was open.
An 18 oz jar of seedless strawberry jam.
A cereal dispenser containing corn flakes was not labeled.
A cereal dispenser containing raisin bran was not dated.
A microwave used to warm resident's meals was visibly soiled with meal debris.
The floor was visibly soiled with food debris and a large brown spot of dried liquid.
The Nursing Manager of the unit confirmed the observations and indicated the food service staff were responsible for maintaining the sanitary conditions in the nourishment room.
On 09/20/2023 at 11:00 AM, the Kitchen Manager explained meal products should have been labeled with the date they were opened. The Manager indicated the food services department was responsible to keep nourishment rooms in good sanitary repair. The Manager acknowledged the nourishment room should have been clean. The Manager explained the kitchen equipment in the nourishment room were out of order and should have been removed from the room.
The facility policy titled Sanitization dated October 2008, documented food service area should be maintained in a clean and sanitary condition. The policy indicated all equipment should be kept clean, maintained and in good repair, free from litter and rubbish.
The facility policy titled Food Safety dated July 2018, stated food, including leftovers would be labeled and dated.
Feb 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
Deficiency F0658
(Tag F0658)
Could have caused harm · This affected 1 resident
**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Resident 3 (R3)
R3 was admitted on [DATE] with medical diagnoses including multiple sclerosis (nerve damage disrupting communic...
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**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Resident 3 (R3)
R3 was admitted on [DATE] with medical diagnoses including multiple sclerosis (nerve damage disrupting communication between the brain and body).
A Physician Order dated 07/31/2022 revealed an order for Tizanidine (muscle relaxant).
On 02/08/2023 in the morning, a [NAME] Specialist indicated their pharmacy stopped servicing the facility on 07/31/2022. The [NAME] Specialist explained they did receive an order for the Tizanidine, but their pharmacy did not dispense the medication.
On 02/08/2023 at 9:00 AM, a Pharmacy Technician indicated their pharmacy started servicing the facility on 08/01/2022. The Pharmacy Technician explained there was an order for the Tizanidine, but they did not dispense the medication.
A review of the Medication Administration Record revealed the resident of concern received the Tizanidine on the following dates:
-08/01/2022
-08/02/2022
-08/03/2022
-08/04/2022
On 02/08/2023 at 10:07 AM, Licensed Practical Nurse #1 (LPN1) explained there was a blue bin located in the medication storage room for discontinued medications. LPN1 indicated discontinued medication bottles were placed in the blue bin with resident labels still on them. LPN1 explained if a resident was admitted and their medications were not available in the pyxis or from pharmacy, they notified the physician to see if the physician wanted to make any changes to the current prescription. LPN1 indicated at the discretion of the Administrator, Director of Nursing, or a supervisor, if a medication was not available for a resident, but available in the discontinued pile, the medication could be used if it was an emergency.
On 02/08/2023 in the morning, Licensed Practical Nurse #2 (LPN2) indicated if a prescribed medication was not available, the physician was notified in case they wanted to order an alternative medication or discontinue the current order. LPN2 explained a medication belonging to one resident was not used on another resident as it was not appropriate practice.
A review of records lacked documented evidence the physician was informed the Tizanidine was not available.
On 02/08/2023 in the morning, a Unit Manager indicated if a medication had a resident label on it, then the medication belonged to the resident and the medication was not given to another resident.
On 02/08/2023 at 10:51 AM, the Director of Nursing (DON) indicated they were not allowed to give medications labeled for one resident to a different resident. The DON explained they were not able to say for certain, if a medication was not available for a resident and a nurse notified the physician, a physician had not authorized the use of a medication belonging to one resident to be used on another resident.
On 02/08/2023 in the afternoon, the DON indicated when it came to the standard practice for medication administration, they followed what was outlined on the facility policy for medication administration.
A review of the facility's policy titled Administering Medications last revised on 04/2019 revealed the individual administering medications checked labels to ensure the medication was given to the right resident. The policy indicated medications ordered for a particular resident were not administered to another resident.
Based on interview, record review and document review, the facility failed to ensure medications ordered for a particular resident were not administered to another resident for 2 of 8 sampled residents (Residents 2 and 3). The failed practice had the potential to lead to adverse reactions and drug-to-drug interactions.
Findings include:
Resident 2 (R2)
R2 was admitted on [DATE], with diagnoses including Hyperlipidemia.
A Clinical admission Evaluation dated 06/18/2022, documented R2 was alert and oriented.
The Hospital Discharge summary dated [DATE], documented Pancrelipase 24000 units by mouth three times a day with each meal and snack.
A Physician Order dated 06/18/2022, documented Pancrelipase 24000 unit by mouth with meals for pancreatic insufficiency.
A Physician Order dated 06/22/2022, documented Pancrelipase 36000 unit by mouth with meals for pancreatic insufficiency. Give with meals. Give 36000 units by mouth as needed for prior two snacks for two doses per day, a total of five doses per day.
The Medication Administration Record from 06/2022, documented R2 received doses of Pancrelipase during their stay at the facility.
On 02/07/2023 at 12:33 PM, a Registered Nurse conveyed the Pancrelipase would come from the pharmacy.
On 02/07/2023 at 1:22 PM, the Unit Manager confirmed the Pancrelipase was not a house stock and would come from the pharmacy.
On 02/08/2023 at 10:19 AM, a Pharmacy Technician acknowledged Pancrelipase would have been dispensed by the pharmacy. The Pharmacy Technician confirmed they received the Physician order for Pancrelipase, but it was not delivered and could not verbalize the reason why it was not delivered to the facility.
On 02/08/2023 at 10:30 AM, the Director of Nursing (DON) indicated Pancrelipase was not an over-the-counter medication, and it would have been a medication that would come from the pharmacy.
On 02/08/2023 at 11:35 AM, the DON conveyed prior to their current pharmacy, the facility had a house stock of Pancrelipase but did not have any at the time of survey. The DON was unable to provide a proof of purchase for the Pancrelipase.
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 a physician order for a resident's intraven...
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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 physician order for a resident's intravenous (IV) antibiotic was followed for 1 of 8 sampled residents (Resident 1). Failure to follow a physician order could potentially lead to further complications, such as delayed healing.
Findings include:
Resident 1 (R1)
R1 was admitted on [DATE], with diagnoses including aftercare following joint replacement surgery.
A Physician order dated 10/11/2022, documented Meropenem 1 gram intravenous (IV) every eight hours for right knee wound infection.
The Medication Administration Record from 10/2022, documented R1 received a dose of Meropenem on 10/11/2022 at 11:32 PM. The next dose was received on 10/13/2022 at 12:37 AM. R1 missed two doses of Meropenem on 10/12/2022 scheduled at 8:00 AM and 4:00 PM.
A Medication Administration Note dated 10/12/2022, documented R1's medication was on order and pharmacy was aware.
A Medication Administration Note dated 10/12/2022, documented the physician order was refaxed to the pharmacy and the facility was waiting for the medication. The Unit Manager (UM) was notified of the delay.
A Care Plan (undated) documented R1 was on antibiotic therapy related to right knee infection. Administer medication as ordered.
On 02/07/2023 at 1:03 PM, a UM acknowledged the facility had an emergency drug kit (a box containing prescription medications) the staff members could use to pull medications from such as Meropenem. The UM confirmed R1 had a physician order for Meropenem and R1 received a dose on 10/11/2022 at 11:32 PM and R1 missed two doses of Meropenem on 10/12/2022 due to unavailability.
On 02/07/2023 at 3:29 PM, a Pharmacy Technician indicated the facility's emergency drug kit contained two Meropenem and would have been re-stocked every week or whenever they were informed of a medication pull. The Pharmacy Technician conveyed a Meropenem was pulled on 10/11/2022 from the emergency kit for R1 and there should have been one left available for use. The Pharmacy Technician reported three doses of Meropenem were delivered on 10/11/2022 at 11:49 PM and was received by the facility's staff member. Fifteen doses were delivered on 10/12/2022, but there was no time indicated on the delivery receipt.
The pharmacy's Shipping List dated 10/11/2022, revealed three doses of Meropenem 1000 milligrams were delivered for R1 on 10/11/2022 at 11:49 PM.
On 02/08/2023 at 7:20 AM, a Registered Nurse (RN) indicated the nurses were trained to cross reference the medications being delivered against the pharmacy's delivery receipt prior to signing.
On 02/08/2023 at 8:00 AM, another RN reported IV medications would have been stored in the medication room and the nurses were responsible for hanging their own IV medications. The RN acknowledged the facility had an emergency drug kit they could pull medications from to prevent a resident from missing their medication.
On 02/08/2023 at 10:30 AM, the Director of Nursing (DON) conveyed the nurses were expected to ensure the medications on the delivery receipt matched the medications being delivered by the pharmacy prior to signing the delivery receipts. The DON indicated they do not believe the three doses of Meropenem delivered for R1 on 10/11/2022 were at the facility even if a staff member signed the delivery receipt.
The facility's Administering Medications revised 04/2019, documented medications were administered in a timely manner and as prescribed.
Aug 2022
19 deficiencies
CONCERN
(D)
Potential for Harm - no one hurt, but risky conditions existed
Deficiency F0557
(Tag F0557)
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 upper and lower b...
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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 upper and lower back was covered for 1 of 31 sampled residents (Resident #102) and a resident's catheter drainage bag was covered for 1 unsampled resident (Resident #83).
Findings include:
The facility's admission Packet (undated) documented a resident in a skilled nursing facility had the right to receive care in a manner and environment that maintained and enhanced each resident's dignity with respect to each resident's individuality.
Resident #102 (R102)
R102 was admitted on [DATE], with diagnoses including chronic obstructive pulmonary disease.
On 07/28/2022 at 1:09 PM, R102 was observed sitting at the edge of bed facing the room window while eating their lunch. R102's upper and lower back was uncovered and visible from the hallway.
On 07/28/2022 in the afternoon, the Director of Nursing (DON) conveyed a resident had the right to expose themselves if they wish to.
On 07/28/2022 at 1:11 PM, a Certified Nursing Assistance (CNA) confirmed the observation and conveyed R102 should have been covered and not exposed because their dignity was being violated. The CNA went in the room and covered R102's back. R102 had no concerns being covered.
On 07/29/2022 at 1:49 PM, R102 was observed sitting at the edge of bed facing the room window while eating their lunch. R102's upper and lower back was uncovered and visible from the hallway.
A Registered Nurse (RN) confirmed the observation and indicated R102's upper and lower back should have been covered and not exposed. The RN went in R102's room and covered their back with a blanket. R102 had no concerns being covered.
Resident #83 (R83)
R83 was admitted on [DATE], with diagnoses including cellulitis of groin.
A Physician order dated 04/05/2022, documented indwelling urinary catheter 18 French, 10 milliliters balloon for neurogenic bladder.
A Physician order dated 07/27/2022, documented indwelling urinary (foley) catheter would have been in a privacy bag and catheter leg strap would have been on at all times.
On 07/26/2022 at 2:22 PM, R83's catheter drainage bag was visible from the hallway. The catheter drainage bag was uncovered and was draining tea colored urine.
A unit clerk confirmed the catheter drainage bag was uncovered. The unit clerk indicated it was important to cover it and stated, I would not want to see it too if I was a visitor.
On 07/26/2022 at 2:28 PM, a Licensed Practical Nurse (LPN) confirmed the uncovered catheter drainage bag was visible from the hallway. The LPN conveyed R83's catheter drainage bag should have been covered for privacy.
On 07/28/2022 in the afternoon, the DON conveyed a resident had the right to leave their catheter drainage bag uncovered if they wish to.
On 07/29/2022 at 1:53 PM, R83 conveyed they had no problem with the facility covering their catheter drainage bag.
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
Deficiency Text Not Available
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Deficiency Text Not Available
CONCERN
(D)
Potential for Harm - no one hurt, but risky conditions existed
Grievances
(Tag F0585)
Could have caused harm · This affected 1 resident
Deficiency Text Not Available
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Deficiency Text Not Available
CONCERN
(D)
Potential for Harm - no one hurt, but risky conditions existed
Deficiency F0642
(Tag F0642)
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 assessment was ac...
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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 assessment was accurate for 1 of 31 sampled residents (Resident #36).
Findings include:
Resident #36 (R36)
R36 was re-admitted on [DATE], with diagnoses including end stage renal disease.
During the facility tour, R36 had a Minimum Data Set (MDS) indicator for tracheostomy.
On 07/26/2022 at 10:36 AM, no tracheostomy was observed on R36. R36 conveyed they did not have a tracheostomy.
R36's medical record lacked documented evidence of a tracheostomy.
The hospital Discharge Summaries dated 12/08/2021 and 12/16/2021, lacked documented evidence R36 had a tracheostomy prior to their arrival at the facility.
An MDS assessment dated [DATE], documented tracheostomy care under Section O.
On 07/28/2022 in the afternoon, a Wound Care Nurse conveyed R36 had been in the facility and did not have a tracheostomy.
On 07/28/2022 at 4:26 PM, the MDS Director reported the resident assessments were conducted between the fifth and eighth day of a resident's stay, quarterly, annually, and when there's a significant change in a resident's care. The MDS coordinators conducted the resident assessments by reviewing a resident's medical record.
The MDS Director would ensure the resident assessments were accurate prior to transmitting it to the Centers for Medicaid and Medicare Services (CMS). The MDS Department transmitted resident assessments daily.
The MDS Director explained the resident assessments determined the resource utilization group (RUG) level which was based on the care required by the resident. The RUG level determined the amount of reimbursement. The higher the level of assistance and level of care needed, the higher the RUG score. The higher the RUG score, the higher rate of reimbursement.
The MDS Director confirmed R36 was coded for tracheostomy care of 06/08/2022, but R36 did not have a tracheostomy. The MDS Director explained the facility meant to code for oxygen care and not tracheostomy care.
The staff member who completed Section O was not available for interview at the time of survey.
The facility's Resident Assessments Policy revised 11/2019, documented all persons who have completed any portion of the MDS resident assessment form must sign the document attesting to the accuracy of such information.
CONCERN
(D)
Potential for Harm - no one hurt, but risky conditions existed
Deficiency F0645
(Tag F0645)
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 assessed for Pre-admission S...
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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 assessed for Pre-admission Screening and Resident Review (PASARR) I for 1 of 31 sampled residents (Resident #62).
Findings include:
The facility admission Criteria revised 03/2019, documented all new admissions and readmissions were screened for mental disorders (MD), intellectual disabilities (ID) or related disorders (RD) per Medicaid PASARR.
Resident #62 (R62)
R62 was admitted on [DATE], with diagnoses including unspecified psychosis not due to a substance or known physiological condition.
The medical record lacked documented evidence of a PASSAR I. The medical record lacked documented evidence R62 was screened to determine if the resident may have had a MD, ID, or RD.
On 07/28/2022 in the afternoon, the Director of Nursing (DON) could not locate the PASSAR I in R62's medical record.
On 07/29/2022 at 11:02 AM, the Admissions Director reported the PASARR I for R62 could not be located.
The Admissions Director conveyed PASARRs were important in order to appropriately place a resident.
The Admissions Director explained it was the responsibility of the Admissions Department to ensure the PASARRs were obtained prior to a resident's arrival to the facility.
The Admissions Director indicated during chart review the Business Office Department would check for the PASARRs. In the event a resident does not have one, the Business Office Department would inform the Minimum Data Set (MDS) Department to obtain a PASARR for the resident through electronic mail (e-mail).
On 07/29/2022 at 12:16 PM, the MDS Director confirmed they would have been informed by the Business Office Department through e-mail if a PASARR I was needed for a resident.
The MDS Director conveyed they were not informed by the Business Office Department that R62 needed a PASARR I.
On 07/29/2022 at 12:42 PM, the Financial Coordinator reported it was the responsibility of the Admissions Department to notify the MDS Department to look at the portal to check if a PASARR I was issued for a resident.
CONCERN
(D)
Potential for Harm - no one hurt, but risky conditions existed
Quality of Care
(Tag F0684)
Could have caused harm · This affected 1 resident
**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, interview, and record review, the facility failed to follow a physician order for the use of PRAFO boots (...
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**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, interview, and record review, the facility failed to follow a physician order for the use of PRAFO boots (a device worn on the calf and foot used for patients who spend most of their time in bed to prevent bedsores or ulcers from developing on the back of the heel) for 1 of 31 sampled residents (Resident #64).
Findings include:
Resident #64 (R64)
R64 was admitted on [DATE], with diagnoses including dependence on respiratory status, and non-pressure chronic ulcers of the right and left lower leg.
A Physician Order dated 05/06/2021, documented to provide PRAFO boots on for 23 hours per day and one hour off during patient care to prevent skin breakdown.
On 07/26/2022 at 10:54 AM, R64 was in bed with eyes closed. There were no PRAFO boots observed used for the resident's bilateral lower extremities.
07/27/2022 at 11:13 am, R64 was in bed with eyes closed. There were no PRAFO boots observed used for the resident's bilateral lower extremities.
The medical record lacked documented evidence the physician order for the use of the PRAFO boots was discontinued.
On 07/27/2022 at 2:20 PM, a Licensed Practical Nurse (LPN) confirmed R64 did not have the PRAFO boots on. The PRAFO boots were not inside the resident's room. The LPN indicated not being aware why it was no longer used for the resident and the physician order was not followed. The resident would be at risk for developing sores in the bilateral lower extremities. Any existing sores could worsen if the PRAFO boots were no longer used.
On 07/28/2022 at 2:39 PM, the Director of Nursing indicated the physician order for the use of the PRAFO boots should have been followed. If the PRAFO boots were no longer appropriate for the resident per their assessment, the nurse should have contacted the physician to see if the PRAFO boots could be discontinued.
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
Deficiency Text Not Available
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Deficiency Text Not Available
CONCERN
(D)
Potential for Harm - no one hurt, but risky conditions existed
Deficiency F0687
(Tag F0687)
Could have caused harm · This affected 1 resident
Deficiency Text Not Available
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Deficiency Text Not Available
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 observation, interview, and record review, the facility failed to follow a physician order for using bilateral hand car...
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**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, interview, and record review, the facility failed to follow a physician order for using bilateral hand carrots (an orthosis device used to position the fingers away from the palm to protect the skin from excessive moisture, pressure, and the risk of nail puncture injuries) for 1 of 31 sampled residents (Resident #64).
Findings include:
Resident #64 (R64)
R64 was admitted on [DATE], with diagnoses including right upper arm, right hand, and left-hand contractures.
A Physician Order dated 05/06/2021, documented to provide bilateral hand carrots on for 23 hours per day and one hour off during patient care to prevent contractures.
On 07/26/2022 at 10:54 AM, R64 was in bed with eyes closed. There were no hand carrots used for the resident's hands.
On 07/27/2022 at 11:13 am, R64 was in bed with eyes closed. There were no hand carrots used for the resident's hands.
The medical record lacked documented evidence the physician order for the use of the bilateral hand carrots was discontinued.
On 07/27/2022 at 2:15 PM, a Physical Therapist indicated since R64 was no longer seen by the therapists, it was the nursing staff's responsibility to ensure the bilateral hand carrots were used if there was an order to continue using it. The resident would be at risk for having worsened contractures if the bilateral hand carrots were not used.
On 07/27/2022 at 2:20 PM, a Licensed Practical Nurse (LPN) confirmed R64 did not have the bilateral hand carrots. The bilateral hand carrots were not inside the resident's room. The LPN indicated not being aware why it was no longer used for the resident and the physician order was not followed.
On 07/28/2022 at 2:39 PM, the Director of Nursing indicated the physician order for the use of the bilateral hand carrots should have been followed. If the bilateral hand carrots were no longer appropriate for the resident per their assessment, the nurse should have contacted the physician to see if the bilateral hand carrots could be discontinued.
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** Resident #423 (R423)
The facility's Oxygen Administration policy revised 10/2010, documented to provide a safe oxygen administr...
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**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Resident #423 (R423)
The facility's Oxygen Administration policy revised 10/2010, documented to provide a safe oxygen administration, the portable oxygen cylinder should have been strapped to a stand.
R423 was admitted on [DATE], with diagnoses including fibromyalgia.
On 07/26/2022 at 1:49 PM, R423 was observed with an oxygen tubing connected to a free-standing oxygen cylinder.
On 07/26/2022 at 2:03 PM, a Certified Nursing Assistant (CNA) confirmed the free-standing oxygen cylinder in R423's room. The CNA conveyed the oxygen cylinder should have been in a stand because it could fall over and explode.
On 07/26/2022 at 2:47 PM, a Licensed Practical Nurse (LPN) indicated oxygen cylinders should have been secured and not free-standing because it could fall over and explode. The LPN conveyed the facility had oxygen cylinder stands available for use.
On 07/29/2022 at 8:33 AM, a Respiratory Therapist explained oxygen cylinders should have been secured because it could explode if knocked over.
Based on observations, interviews, record reviews, and document reviews, the facility failed to ensure: 1) a fall device was implemented to ensure safety for 1 of 31 sampled residents (Resident #91); 2) the care plan was followed for fall interventions for 2 of 31 sampled residents (Residents #23 and #91); and 3) an oxygen cylinder was secured for one unsampled resident (Resident #423).
Findings include:
A facility policy titled Fall Risk assessment dated 03/2018, indicated the facility staff would seek to identify and document resident risk factors for falls and establish a resident-centered falls prevention plan based on relevant assessment information.
Resident #91 (R91)
R91 was admitted on [DATE], with diagnoses including abnormalities of gait and mobility, hypertension, difficulty in walking, lack of coordination, and angina pectoris/chest pain.
The Brief Interview of Mental Status dated 07/10/2022, documented the score of 10/15 which indicated R91's cognitive status was moderately impaired.
The Fall Risk Evaluation dated 03/07/2022, documented R91 was at risk for a fall.
A physician order dated 07/04/2022, documented to provide R91 a fall mat for safety.
A Care Plan dated 07/05/2022, indicated to provide fall mats for safety.
The Nursing Progress Notes dated 07/11/2022, documented R91 was found on the floor and complaining of back pain.
The medical record documented an initial unwitnessed fall on 07/11/2022, with an intervention of floormat at the bedside.
On 07/27/2022 in the morning, R91 was in bed, alert, and oriented times 2-3. The floormat was leaning on the left side of the bed and not placed flat on the floor. The bed was in a high position. R91 indicated previous history of fall at the facility.
On 07/27/2022 at 2:36 PM, R91 was in bed, awake. The floormat was leaning on the bed and was not placed flat on the floor. The Unit Manager (UM) confirmed R91 was a fall risk, and the floor mat should be on the floor to prevent impact in the event of a fall. The UM confirmed the bed was not in the lowest position.
On 07/27/2022 at 3:20 PM, the Director of Nursing indicated staff members were expected to implement fall interventions to ensure the resident's safety.
Resident #23 (R23)
R23 was admitted on [DATE] and readmitted on [DATE], with diagnoses including seizures and diabetes.
A Care Plan for Actual Fall on 02/06/2022, documented to provide fall mats on each side of the bed.
A Nurse's Note dated 02/21/2022, documented R23 was found lying on the mat beside the bed.
On 07/26/2022 at 10:48 AM, R23 was observed in bed with eyes closed. There were no fall mats observed on the floor next to the bed. There were no fall mats observed inside the resident's room.
On 07/27/2022 at 8:38 AM, R23 was observed in bed with eyes closed. There were no fall mats observed on the floor next to the bed. There were no fall mats observed inside the resident's room.
On 07/27/2022 at 11:16 AM, R23 was observed in bed with eyes closed. There were no fall mats observed on the floor next to the bed. There were no fall mats observed inside the resident's room.
On 07/27/2022 at 2:38 PM, R23 was observed in bed with eyes closed. There were no fall mats observed on the floor next to the bed. There were no fall mats observed inside the resident's room.
The medical record lacked documented evidence the use of fall mats for R23 was discontinued.
On 07/27/2022 at 2:39 PM, a Registered Nurse (RN) confirmed there were no fall mats inside R23's room. The RN indicated the care plan was not followed.
On 07/28/2022 at 2:35 PM, the Director of Nursing indicated if the Interdisciplinary Team determined the use of the fall mats was necessary for R23 and placed as an intervention in the care plan, the nursing staff should have followed the intervention.
CONCERN
(D)
Potential for Harm - no one hurt, but risky conditions existed
Deficiency F0692
(Tag F0692)
Could have caused harm · This affected 1 resident
Deficiency Text Not Available
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Deficiency Text Not Available
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 a physician order was obtained...
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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 physician order was obtained for an oxygen treatment for 1 of 31 sampled residents (Resident #113) and one unsampled resident (Resident #423); and the oxygen nasal cannulas had dates of when they were last changed for 1 of 31 sampled residents (Resident 102) and four unsampled residents (Residents #5, #113, #424 and #429).
Findings include:
The facility's Oxygen Administration policy revised 10/2010, documented to provide for a safe oxygen administration, review and verify the physician's order for oxygen administration.
Resident #113 (R113)
R113 was admitted on [DATE], with diagnoses including enterocolitis due to clostridium difficile, recurrent.
On 07/26/2022 at 1:30 PM, R113 was observed with an oxygen nasal cannula in place.
The Clinical admission Evaluation dated 07/09/2022, documented R113 was receiving oxygen treatment via nasal cannula.
R113's medical record lacked documented evidence of a physician order for oxygen treatment and care.
On 07/28/2022 in the afternoon, a Unit Manager (UM) and a Wound Care Nurse confirmed R113 was receiving oxygen via nasal cannula.
On 07/29/2022 at 8:17 AM, a Unit Manager confirmed R113's medical record revealed a physician order for oxygen was placed on 07/28/2022 at 11:53 PM and there was no physician order prior to this.
Resident #423 (R423)
R423 was admitted on [DATE], with diagnoses including fibromyalgia.
On 07/26/2022 at 1:49 PM, R423 was observed with an oxygen nasal cannula in place.
The Clinical admission Evaluation dated 07/25/2022, documented R423 was receiving oxygen via nasal cannula.
R423's medical record lacked documented evidence of a physician order for oxygen treatment and care.
On 07/28/2022 at 12:32 PM, a Licensed Practical Nurse (LPN) confirmed R423 was receiving oxygen via nasal cannula. The LPN confirmed R423 had no order for the oxygen treatment. The LPN conveyed a physician order should have been obtained for oxygen treatment.
On 07/29/2022 in the morning, a UM explained it was the responsibility of the admission Nurse and Nurse Managers to ensure a physician order had been obtained for the use of an oxygen.
On 07/29/2022 at 8:33 AM, a Respiratory Therapist reported a physician order for oxygen was needed because it was considered as a drug.
On 07/28/2022 at 2:14 PM, the Director of Nursing (DON) explained residents with oxygen must have a physician order because a treatment was being administered. The DON conveyed it was important to obtain instructions from the provider in order to properly administer the treatment. The physician order should include an oxygen route, rate, and indication.
Resident #102 (R102)
R102 was admitted on [DATE], with diagnoses including chronic obstructive pulmonary disease.
On 07/26/22 at 11:27 AM, R102 was observed with a nasal cannula in place. There was no date on the nasal cannula to indicate the date it was changed. R102 could not recall the last time the nasal cannula was changed.
Resident #5 (R5)
R5 was admitted on [DATE], with diagnoses including chronic obstructive pulmonary disease.
On 07/26/2022 at 2:04 PM, R5 was observed with an oxygen nasal cannula in place. There was no date on the nasal cannula to indicate when it was last changed.
Resident #113 (R113)
R113 was admitted on [DATE], with diagnoses including enterocolitis due to clostridium difficile, recurrent.
On 07/26/2022 at 1:30 PM, R113 was observed with an oxygen nasal cannula in place. There was no date on the oxygen nasal cannula to indicate the date it was changed. R113 could not recall the last time their oxygen nasal cannula was changed or if it was changed at all.
Resident 424 (R424)
R424 was admitted on [DATE], with diagnoses including chronic obstructive pulmonary disease.
On 07/26/2022 at 11:12 AM, R424 was observed with an oxygen nasal cannula in place. There was no date on the nasal cannula to indicate the date it was changed.
Resident 429 (R429) was admitted on [DATE], with diagnoses including chronic obstructive pulmonary disease.
On 07/26/2022 at 11:39 AM, R429 was observed with an oxygen nasal cannula in place.
On 07/26/2022 at 2:47 PM, an LPN reported the oxygen nasal cannulas would have been changed as needed and weekly every Sunday night. The facility's process was to ensure the oxygen nasal cannulas were not broken and changed as part of infection control measures. The nurses were expected to put date whenever the oxygen nasal cannulas were changed.
The LPN confirmed the oxygen nasal cannulas of R5, R424, R102 and R429 had no dates to indicate the last time the nasal cannulas were changed.
On 07/26/2022 at 3:03 PM, another LPN confirmed the oxygen nasal cannula for R113 had no date to indicate the last time it was changed.
On 07/28/2022 at 2:14 PM, the DON conveyed the oxygen tubings were expected to have been changed weekly on Sundays and dated whenever they were changed.
On 07/29/2022 at 8:33 AM, a Respiratory Therapist conveyed it was important to change the oxygen tubing weekly or as needed to prevent a resident from possibly getting a respiratory infection.
On 07/29/2022 at 8:48 AM, the Assistant DON indicated as part of infection control measures the oxygen tubings were changed every Sunday and as needed by the nursing staff.
CONCERN
(D)
Potential for Harm - no one hurt, but risky conditions existed
Deficiency F0761
(Tag F0761)
Could have caused harm · This affected 1 resident
**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, interviews and document review, the facility failed to ensure 2 of 9 medication carts were free from expir...
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**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, interviews and document review, the facility failed to ensure 2 of 9 medication carts were free from expired biologicals and 1 of 4 medication rooms was free from discontinued medications.
Findings include:
On [DATE] at 8:55 AM, two bottles of eye saline with an expiration date of 11/2021 were in a drawer of medication cart 1 in the Mount [NAME] Unit.
A Licensed Practical Nurse (LPN) confirmed the two bottles of eye saline were expired. The LPN reported it was the responsibility of the unit managers to ensure the medication carts were free from expired biologicals.
On [DATE] at 9:04 AM, a box of Fluticasone with an expiration date of 04/2022 was in a drawer of medication cart 2 in the Mount [NAME] Unit.
A Registered Nurse (RN) confirmed the expired Fluticasone. The RN conveyed it was a joint effort between the nurses to ensure the medication carts were free from expired biologicals. The RN reported the nurses should check the medications carts daily for expired and discontinued medications.
On [DATE] at 9:14 AM, the following discontinued medications were observed in the Medication Room of Mount [NAME] Unit: four 1-liter bags of Dextrose 5% and 23 vials of Octreotide.
An LPN confirmed the discontinued medications were from discharged residents. The LPN explained it was the responsibility of the unit managers to ensure the medication rooms were free from discontinued medications.
On [DATE] at 8:42 AM, the Assistant Director of Nursing (ADON) expected the nursing staff members to check the expiration dates on the biologicals and discard the expired and discontinued medications daily.
The ADON explained it was the responsibility of the nurses and unit managers to ensure the medication carts and medication rooms were free from expired and discontinued medications. The discontinued medications should have been given to the Director of Nursing and pharmacist to dispose.
The facility's Storage of Medications policy revised 11/2020, documented discontinued drugs or biologicals were returned to the dispensing pharmacy or destroyed. The nursing staff were responsible for maintaining medication storage and preparation areas in a clean, safe, and sanitary manner.
CONCERN
(D)
Potential for Harm - no one hurt, but risky conditions existed
Food Safety
(Tag F0812)
Could have caused harm · This affected 1 resident
Based on observation, interview, and document review, the facility failed to ensure open food items in the kitchen were labeled with a date when it was first opened and a date until when it was good f...
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Based on observation, interview, and document review, the facility failed to ensure open food items in the kitchen were labeled with a date when it was first opened and a date until when it was good for.
Findings include:
07/26/2022 at 8:03 AM, a container of grape jelly, four cups of sliced apples, two cups of sliced oranges, a container of multiple slices of cucumbers, a container of multiple slices of different colored cheese, and a container with shredded vegetables were observed inside the refrigerator in the kitchen. There was no date labeled on the food items.
On 07/26/2022 at 8:06 AM, the Director of Culinary Services indicated the dietary staff were required to label any open food item as soon as it was opened. The label would indicate when the food was first opened and until when the food was good to use, which would be three days from the time it was opened.
07/27/2022 at 8:05 AM, a container of grapy jelly, and a container of corn mix were observed inside the refrigerator in the kitchen. There was no date labeled on the food items.
On 07/27/2022 at 8:06 AM, a Dietary Aide indicated the food should have been dated when it was first opened and used.
07/27/2022 at 8:07 AM, the Lead [NAME] indicated opened food items should be dated when it was first opened and until when it was good to use.
The facility policy Food Receiving and Storage revised October 2017, documented all food stored in the refrigerator would be labeled and dated a use by date.
CONCERN
(D)
Potential for Harm - no one hurt, but risky conditions existed
Deficiency F0825
(Tag F0825)
Could have caused harm · This affected 1 resident
**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on interview and record review, the facility failed to ensure physical therapy (PT) frequency of treatment was provided pe...
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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 physical therapy (PT) frequency of treatment was provided per the physician's order for one unsampled resident (Resident #C116).
Findings include:
Resident #C116 (C116)
Resident C116 was admitted on [DATE] and discharged on 06/13/2022, with diagnoses including other fracture of head and neck of right femur, other lack of coordination, and difficulty in walking.
The physician's order dated 05/13/2022, documented PT skilled services four to six times per week for 12 weeks.
The PT Treatment Encounter Note and Service Log Matrix for Resident C116 documented the resident received PT services on 06/03/2022, 06/08/2022, and 06/09/2022 or a total of three PT sessions (treatment) for the week of 06/03/2022 to 06/09/2022.
Resident C116's medical record lacked documented evidence the resident received a total of four to six PT sessions for the week of 06/03/2022 to 06/09/2022 per the physician's order.
On 07/28/2022 at 1:37 PM, the Rehabilitation (Rehab) Director revealed Resident C116 was evaluated by PT on 05/13/2022 which was a Friday. The Rehab Director explained the week for the resident's PT session started on Friday and ended on Thursday.
The Rehab Director confirmed Resident C116 received a total of three PT sessions during the fourth week of treatment or from 06/03/2022 to 06/09/2022. The Rehab Director acknowledged PT skilled services should have been provided to the resident four to six times per week in accordance with the physician's order.
On 07/29/2022 at 8:51 AM, the Interim Rehab Director verified the PT visit log for Resident C116 for the month of June 2022 under the new electronic system which transitioned on the said month. The Interim Rehab Director confirmed the resident received three PT sessions for the week of 06/03/2022 to 06/09/2022 instead of at least four sessions per the physician's order.
CONCERN
(D)
Potential for Harm - no one hurt, but risky conditions existed
Infection Control
(Tag F0880)
Could have caused harm · This affected 1 resident
**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Resident #423 (R423)
R423 was admitted on [DATE], with diagnoses including fibromyalgia.
On 07/26/2022 at 11:00 AM, a signage by...
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**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Resident #423 (R423)
R423 was admitted on [DATE], with diagnoses including fibromyalgia.
On 07/26/2022 at 11:00 AM, a signage by the resident's door indicated 7-day Observation off: 08/01/2022.
PPE required in hallway Surgical mask on top of N95.
PPE required upon entering the resident room - eye protection (face shield or goggles), Surgical Mask on top pf N95, gown, gloves. Wash hands with soap or hand sanitizer before exiting room. All PPE is discarded in the room.
A family member was in R423's room without gown, gloves, and eye protection.
On 07/26/2022 at 11:05 AM, a Certified Nursing Assistant (CNA) confirmed the family member had no gown, gloves, and eye protection. The CNA conveyed staff members and visitors must comply with the infection control measure. The CNA explained it was important to wear the appropriate PPE prior to entering R423's room to prevent cross contamination.
Resident #5 (R5)
R5 was admitted on [DATE], with diagnoses including chronic obstructive pulmonary disease.
On 07/26/2022 at 11:03 AM, a stop sign to check in with the nursing staff prior to entering the room was by the resident's door. A plastic bin with gowns was by the resident's door.
A Certified Nursing Assistant conveyed R5 was on transmission-based precaution for MRSA wound.
On 07/26/2022 at 11:06 AM, a vendor was observed entering R5's room without the appropriate PPE.
The vendor conveyed it was important to wear gown and gloves to prevent them from possibly getting the infection.
Based on observation, interview, record review, and document review, the facility failed to ensure visitors and vendors donned the appropriate personal protective equipment (PPE) prior to entering an isolation room for four residents (Residents #423, #5, #119 and #118).
Findings include:
Resident #119 (R119)
R119 was admitted on [DATE], with a diagnosis of wedge compression fracture of T11-T12 (thoracic) vertebra, subsequent encounter for fracture with routine healing.
On 07/26/2022 at 11:40 AM, a signage posted at the entrance door of R119's room documented the following:
- 7-day observation off on 7/30.
- PPE required in hallway: Surgical mask on top of N95.
- PPE required upon entering the resident room: Eye protection, place surgical mask on top of N95, gown and gloves. Wash hands with soap or hand sanitizer before exiting room. All PPE to be discarded in the room.
An isolation bin which contained disposable gowns and gloves was available upon entering the resident's room.
R119 was lying in bed and there were three visitors observed inside the room who were talking to the resident. One visitor was sitting in a chair placed by the resident's bedside and another one was sitting in a chair placed less than six feet from the resident. Another visitor was standing and less than six feet from the resident. The three visitors wore a mask but were not wearing gown and gloves while inside the room.
A Certified Nursing Assistant (CNA) was present during the observations and explained the visitors should have been wearing gown, gloves, and mask prior to entering R119's room. The CNA indicated R119 was on isolation for 7-day observation.
On 07/26/2022 at 11:46 AM, R119's visitor (family member) revealed coming to the facility daily to visit R119 and stayed inside the resident's room until lunch time. The visitor explained not being told to wear gown and gloves prior to entering the resident's room.
On 07/26/2022 at 12:53 PM, another CNA indicated R119 was a new admit and was placed on a 7-day observation which started from the day of admission. The resident should have been observed for COVID-19 symptoms for seven days and was placed on isolation. The CNA confirmed the resident's visitors should have worn mask, gown, and gloves to avoid the spread of infection.
Resident #118 (R118)
R118 was admitted on [DATE], with a diagnosis of heart failure.
On 07/26/2022 at 12:10 PM, a signage posted at the entrance door of R118's room documented the following:
- 7-day observation off on 7/29.
- PPE required in hallway: Surgical mask on top of N95.
- PPE required upon entering the resident room: Eye protection, place surgical mask on top of N95, gown and gloves. Wash hands with soap or hand sanitizer before exiting room. All PPE to be discarded in the room.
An isolation bin which contained disposable gowns and gloves was available upon entering the resident's room.
R118 was lying in bed and there was a visitor observed inside the room who was talking to the resident. The visitor was sitting in a chair placed by the resident's bedside. The visitor wore a mask but was not wearing gown and gloves while inside the room.
On 07/26/2022 at 12:55 PM, a CNA confirmed the observations and acknowledged R118's visitor should have worn gown and gloves while inside the resident's room. The CNA explained the appropriate PPE should have been worn inside the room because the resident was on isolation for observation of COVID-19 symptoms.
On 07/26/2022 at 1:39 PM, the Unit Manager explained R119 and R118 were on 7-day observation from the date of admission and were placed on isolation for COVID-19 precautions. The Unit Manager indicated the residents' visitors should have worn mask, gown, and gloves prior to entering the room to prevent transmission of infection.
The Unit Manager revealed the risks and benefits were explained to the visitors if they refused to wear the required PPE inside the room of residents on isolation (7-day observation). The visitors should have signed a waiver acknowledging the potential risks of noncompliance with the required PPE. The Unit Manager confirmed the visitors of R119 and R118 had no signed waiver for not wearing the required PPE prior to entering the room. The Unit Manager indicated not being aware the two residents had visitors.
On 07/29/2022 at 9:35 AM, the Infection Preventionist (IP) Nurse explained the residents were placed on 7-day observation for COVID-19 precautions upon admission. The residents would have been on contact and droplet precautions during the 7-day observation. The IP Nurse indicated the resident's visitors should have worn the proper PPE prior to entering the room such as mask, gown, and gloves. The staff members were required to wear a surgical mask on top of the N95 mask when doing resident care, in addition to gown and gloves.
The IP Nurse revealed the nursing staff should have explained to the visitors the risks and benefits if they refused to wear the required PPE. The visitors should have signed a waiver if they still refused to comply. The IP Nurse indicated the nurses and CNAs were expected to remind, educate, and monitor the visitors regarding compliance with wearing the appropriate PPE prior to entering the room of residents on 7-day observation. The IP Nurse acknowledged compliance with the required PPE was important to prevent transmission of infection.
CONCERN
(D)
Potential for Harm - no one hurt, but risky conditions existed
Safe Environment
(Tag F0921)
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 the temperature in a resident's room was adju...
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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 the temperature in a resident's room was adjusted according to their preference for 1 of 31 sampled residents (Resident #1).
Findings include:
Resident #1 (R1)
R1 was re-admitted on [DATE], with diagnoses including essential hypertension.
A Minimum Data Set (MDS) assessment dated [DATE], documented R1 had a Brief Interview of Mental Status score of 14, which indicated R1 was cognitively intact.
On 07/26/2022 at 10:11 AM, R1 indicated it was cold in the room and had asked the staff members to adjust the room temperature, but they could not. The thermostat was at 73 degrees.
R1's roommate, was observed sitting in their chair with a blanket on top of them. The roommate conveyed they were cold as well.
On 07/28/2022 at 9:27 AM, R1 reported being cold in the room and no one had come to adjust the thermostat. The thermostat was at 73 degrees.
On 07/28/2022 at 12:06 PM, R1 conveyed they were cold. The thermostat was at 73 degrees. A Licensed Practical Nurse (LPN) confirmed the thermostat was at 73 degrees. The LPN tried to adjust the thermostat but could not. The LPN reported the thermostat in other resident rooms could not be adjusted as well and would inform the Maintenance Department.
On 07/28/2202 at 1:40 PM, the Maintenance Director explained the air condition system in the resident rooms were not centralized and could have been adjusted to the resident's liking.
The Maintenance Director conveyed the staff members would inform them of the work order by writing the concern in the maintenance book located at the nurses' station. The Maintenance Director conveyed the staff members had not reported the thermostat in the resident rooms in Mount [NAME] Unit could not be adjusted.
The Maintenance Director confirmed the thermostat in R1 and R419's room was at 73 degrees, and it was locked and could not be adjusted. The Maintenance Director explained the air conditioning system was controlled electronically and the computer system must have locked the thermostats.
The Maintenance Director unlocked the thermostat and was able to adjust the temperature. The Maintenance Director checked the room across, and the thermostat was locked as well.
The facility's Homelike Environment policy revised 02/2021, documented the facility staff and management maximizes, to the extent possible, the characteristics of the facility reflect a personalized, homelike setting. These characteristics included comfortable and safe temperatures.
CONCERN
(E)
Potential for Harm - no one hurt, but risky conditions existed
Incontinence Care
(Tag F0690)
Could have caused harm · This affected multiple residents
**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Resident 367 (R367)
R367 was admitted on [DATE], with diagnoses including lack of coordination, difficulty in walking, enterocol...
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**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Resident 367 (R367)
R367 was admitted on [DATE], with diagnoses including lack of coordination, difficulty in walking, enterocolitis (inflammation in the digestive tract) due to clostridium difficile, and Crohn's disease (an inflammatory bowel disease).
The BIMS dated 07/21/2022, documented a score of 12/15, which indicated R367's cognitive status was moderately impaired.
On 07/26/2022 at 11:40 AM, Foley catheter was draining with approximately 150 milliliter (ml) yellow-colored urine. The Foley bag was left unattended on the floor.
On 07/27/22 at 9:59 AM, Foley catheter, not anchored, draining with 200 ml yellow-colored urine. R367 indicated the Foley was inserted because of urine retention.
R367's medical record lacked documented evidence a physician order for Foley catheter use, care and management were obtained.
On 07/28/22 in the morning, a Certified Nursing Assistant indicated they had no access to document the urine output, but the information was given to the nurse if asked.
On 07/28/22 at 9:28 AM, the LPN confirmed R367 had a Foley catheter on 07/26/2022. The LPN was uncertain if the Foley was inserted after resident's admission to the facility or was admitted with it. The LPN explained if a resident had a Foley catheter, there should have been an order for Foley use and the management and care plan. The LPN indicated there was no order in place and lacked documented evidence the Foley was monitored.
On 07/28/22 at 9:35 AM, the Unit Manager confirmed there was no order in place for R367's Foley catheter until 07/27/2022. The Unit Manager confirmed R367 was admitted with Foley. The Unit Manager explained after the Foley was identified, assessment should have been conducted, the physician contacted for the diagnosis, and a physician order should have been obtained. The Unit Manager explained the admitting nurse was responsible for obtaining an order for Foley use but lacked documented evidence an order was obtained, and a care plan was initiated.
On 07/28/22 at 11:00 AM, the Director of Nursing (DON) explained a Foley use required an order. The DON indicated If a resident was admitted with a Foley, the physician should be notified to obtain the justification. The DON indicated if the use of Foley was not justified, bladder training should be completed, and the Foley should be removed. The DON confirmed there were no Foley orders for R367 until 07/27/2022. The DON conveyed if there's no order in place, the task for documentation would not be populated for monitoring.
Resident #369 (R369)
R369 was admitted on [DATE], with diagnoses including urinary tract infection and extended-spectrum beta lactamase resistance (resistance to antibiotics).
On 07/27/22 in the morning, the resident was in bed with Foley catheter draining amber-colored urine.
The Clinical admission Evaluation dated 07/22/2022 indicated genitourinary documentation of the presence of a catheter.
The medical record lacked documented evidence a physician order was obtained for Foley use and the Foley was cared for and managed until 07/25/2022.
On 07/28/22 at 9:35 AM, the Unit Manager confirmed the order was not obtained when a Foley catheter was identified, and an order was placed three days after the resident's admission.
Based on observation, interview, and record review, the facility failed to ensure physician orders were obtained for the use of an external catheter for 1 of 31 sampled residents (Resident #52), residents were appropriately assessed for an acceptable indication for continued use of the indwelling catheter for 3 of 31 sampled residents (Resident #93, #49, and #64), and physician orders for the use of an indwelling (Foley) catheter was obtained for 2 of 31 sampled residents (Resident #24 and #367) and an unsampled resident (Resident #369).
Findings include:
Resident #52 (R52)
R52 was admitted on [DATE], with diagnoses including anoxic brain damage and dependence on ventilator status.
On 07/26/2022 at 10:11 AM, R52 was in bed with eyes closed. The resident had a catheter connected to a urinary drainage bag on the side of the bed.
On 07/27/2022 at 1:32 PM, R52 was in bed with eyes closed. The resident had a catheter connected to a urinary drainage bag on the side of the bed.
On 07/28/2022 at 11:00 AM, R52 was in bed with eyes closed. The resident had a catheter connected to a urinary drainage bag on the side of the bed.
On 07/28/2022 at 11:05 AM, a Licensed Practical Nurse explained R52 used an external (condom) catheter.
The medical record lacked documented evidence a physician order was obtained for R52's use of the external catheter and for care and management of the catheter.
On 07/28/2022 at 11:08 AM, the LPN and the Unit Manager confirmed there was no physician order for the use of the external catheter.
On 07/28/2022 at 2:46 PM, the Director of Nursing (DON) indicated a physician order should have been obtained for the use of the condom catheter and for its care and management.
Resident #93 (R93)
R93 was admitted on [DATE], with diagnoses including unspecified intracranial injury and dependence on ventilator status.
On 07/26/2022 at 1:44 PM, R93 was in bed with eyes closed. A catheter was observed connected to a urinary drainage bag on the side of the bed.
On 07/27/2022 at 2:56 PM, R93 was in bed with eyes closed. A catheter was observed connected to a urinary drainage bag on the side of the bed.
A Physician Order dated 07/03/2022, documented to use an indwelling (Foley) catheter size 16 French with a 30 milliliters balloon related to a wound.
On 07/27/2022 at 3:03 PM, a Wound Care Nurse indicated R93 had no current pressure ulcers. R93 currently had intact skin. The resident previously had stage 2 pressure ulcers on the bilateral buttocks which were resolved on 07/14/2022.
The medical record lacked documented evidence of any attempts to remove the indwelling catheter after the stage 2 pressure wounds were healed on 07/14/2022. There were no documented assessments to check if the continued use of the indwelling catheter was appropriate for R93. The medical record lacked documented evidence the facility identified a justification for the continued use of the indwelling catheter since R93 no longer had any open wounds.
On 07/28/2022 at 2:45 PM, the DON indicated the nurse should have called the physician and verified the indication for the continued use of the indwelling catheter. If there was no acceptable reason to keep the indwelling catheter, the nurse was expected to obtain an order to discontinue the catheter and to start bladder training for the resident and monitor if the resident was retaining urine post-removal of the catheter.
Resident #49 (R49)
R49 was admitted on [DATE] and readmitted on [DATE], with diagnoses including cerebral palsy and dependent on ventilator status.
On 07/26/2022 at 11:07 AM, R49 was observed in bed with eyes closed. A catheter was observed connected to a urinary drainage bag on the side of the bed.
On 07/28/2022 at 10:59 AM, R49 was observed in bed with eyes closed. A catheter was observed connected to a urinary drainage bag on the side of the bed.
A Physician Order dated 05/04/2022, documented to use an indwelling catheter 16 French with 10 milliliter balloon for wound management of a stage 3 pressure ulcer.
On 07/28/2022 at 10:57 AM, two Wound Care Nurses revealed R49 had no current open wounds and the resident's skin was intact. R49 previously had a stage 3 pressure wounds on the left buttock and left ischium. Both stage 3 pressure wounds were healed back in 2021.
The medical record lacked documented evidence of any attempts to remove the indwelling catheter after the stage 3 pressure wounds were healed in 2021. There were no documented assessments to check if the continued use of the indwelling catheter was appropriate for R49. The medical record lacked documented evidence the facility identified a justification for the continued use of the indwelling catheter since R49 no longer had stage 3 pressure wounds.
On 07/28/2022 at 11:02 AM, a Licensed Practical Nurse (LPN) confirmed the presence of the indwelling catheter and could not indicate a reason why R49 continued to need the indwelling catheter if there were no current open wounds. The LPN indicated the physician order should be verified.
On 07/28/2022 at 2:49 PM, the DON explained the nursing staff should have called the physician and verified the indication for the continued use of the indwelling catheter. If there was no acceptable reason to keep the indwelling catheter, the nurse was expected to obtain an order to discontinue the catheter, to start bladder training for the resident, and monitor if the resident was retaining urine post-removal of the catheter.
Resident #64 (R64)
R64 was admitted on [DATE] and readmitted on [DATE], with diagnoses including non-pressure chronic ulcer of the unspecified part of the right and left lower legs and dependence on ventilator status.
On 07/26/2022 at 10:54 AM, R64 was in bed with eyes closed. A catheter was observed connected to a urinary drainage bag on the side of the bed.
On 07/27/2022 at 11:13 am, R64 was in bed with eyes closed. A catheter was observed connected to a urinary drainage bag on the side of the bed.
On 07/28/2022 at 9:40 AM, a Certified Nursing Assistant (CNA) was observed draining the urinary bag. Dark orange urine with minimum red colored and cloudy sediments were observed inside the drainage bag. The CNA indicated the resident did not have Foley catheter before and just recently had it placed.
A Minimum Data Set (MDS) Quarterly assessment dated [DATE], revealed R64 did not have an indwelling catheter.
An MDS Quarterly assessment dated [DATE], revealed R64 did not have an indwelling catheter.
An MDS Annual assessment dated [DATE], revealed R64 did not have an indwelling catheter.
An MDS Quarterly assessment dated [DATE], revealed R64 did not have an indwelling catheter.
An MDS Quarterly assessment dated [DATE], revealed R64 did not have an indwelling catheter.
An MDS Quarterly assessment dated [DATE], revealed R64 did not have an indwelling catheter.
A Health Status Note dated 07/16/2022, documented R64 had a dry brief throughout the shift. Straight catheterization was performed with a urine output of 400 milliliters. The physician was notified and ordered to insert a 16 French indwelling (Foley) catheter.
A Nurse's Note dated 07/16/2022, documented a Foley catheter 16 French with 10 milliliter balloon was inserted and connected to a bag.
A Physician Order dated 07/16/2022, documented to insert a Foley Catheter 16 French.
A Nurse's Note dated 07/23/2022, documented R64 had blood in the urine and the physician was made aware. Eliquis (a blood thinner medication) would be held for two days.
The medical record lacked documented evidence of any attempts to remove the Foley catheter as soon as possible. There were no assessments made or post-void residual tests to check if the resident continued to have acute urinary retention.
A Physician's Progress Note dated 07/27/2022, documented a Foley catheter was in place to promote wound healing and prevention of new wounds and moisture control.
A Physician's Progress Note dated 07/27/2022, documented R64 had neurogenic bladder and wounds on lower extremity which required R64 to have a Foley catheter to monitor urine output, avoid contamination and prevent infections.
07/27/2022 at 3:12 PM, a Wound Care Nurse revealed R64 did not have any pressure ulcers. The resident currently had diabetic ulcers on the leg. The Wound Care Nurse indicated the diabetic ulcers on the legs would not be an acceptable justification to keep the resident's Foley catheter.
On 07/28/2022 at 2:45 PM, the DON confirmed R64 had diabetic wounds on the legs but had no open wounds on the sacrum, coccyx, buttocks, or gluteal areas. The DON explained a physician wanted to keep the Foley catheter for R64's bilateral lower extremity wounds. The DON indicated acceptable criteria for keeping a Foley catheter in the nursing home setting included having urinary retention secondary to a diagnosis of neurogenic bladder or obstructive uropathy, for comfort measures related to hospice status, or as a wound care intervention for a Stage 3 or higher-pressure ulcer on the buttocks, sacrum, or coccyx area. If the resident meets the criteria, the nurse would be expected to obtain orders from the physician to keep the Foley catheter, obtain the size of the Foley catheter to be used, and for the care and management of the catheter. If there was no acceptable reason to keep the Foley catheter, the nurse was expected to obtain an order to discontinue the catheter and to start bladder training for the resident and monitor if the resident was retaining urine post-removal of the catheter.
The medical record lacked documented evidence assessments were completed to see if the resident continued to retain urine. There was no referral obtained for a urologist to see R64 and perform cystoscopy and ultrasonography to visualize the bladder and ureters.
On 07/28/2022 at 3:00 PM, the DON acknowledged R64 did not have a Foley catheter for more than a year. The resident's previous wounds on the sacrum healed a long time ago without having to use a Foley catheter to heal those wounds. The DON indicated a urology referral should have been made to see what caused the urinary retention on 07/16/2022. There was currently no urologist going to the facility to assess residents on ventilator status and it was difficult to send out residents who were on ventilators to a urologist's office for evaluation.
Resident # 24 (R24)
R24 was admitted on [DATE] and readmitted on [DATE], with diagnoses including diabetes, hypertension, and chronic obstructive pulmonary disease.
On 07/26/2022 at 10:07 AM, R24 was in bed with eyes closed. The resident was observed with a Foley catheter connected to a urinary drainage bag.
On 07/27/2022 at 9:54 AM, R24 was in bed with eyes closed. The resident was observed with a Foley catheter connected to a urinary drainage bag.
A Clinical admission Evaluation Note dated 07/11/2022, documented a 16 French catheter was in place to prevent soiling of a stage 3 or 4 pressure ulcer.
A Health Status Note dated 07/16/2022, documented the Foley catheter was draining clear yellow urine.
The medical record lacked documented evidence a physician order was obtained for the use of a Foley catheter and for the care and management of the catheter.
On 07/27/2022 at 2:32 PM, a Registered Nurse confirmed there were no physician orders obtained for the use of the Foley catheter and for care and management of the catheter.
On 07/28/2022 at 2:45 PM, the DON indicated since R24 had a valid indication to keep the Foley catheter, the nurse should have obtained a physician order for the continued use of the Foley catheter and for its care and management.
CONCERN
(E)
Potential for Harm - no one hurt, but risky conditions existed
Deficiency F0694
(Tag F0694)
Could have caused harm · This affected multiple residents
**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Resident #106 (R106)
R106 was admitted on [DATE], with diagnoses including essential hypertension (high blood pressure), chronic...
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**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Resident #106 (R106)
R106 was admitted on [DATE], with diagnoses including essential hypertension (high blood pressure), chronic kidney disease, and sepsis.
On 07/26/2022 at 3:16 PM, R106 was observed with a midline catheter (intravenous/IV catheter) inserted in the right upper arm. The transparent dressing of the midline catheter was loose and coming off.
R106's medical record lacked documented evidence physician's orders were obtained for the resident's midline catheter care such as dressing changes, monitoring of the IV site, and flushes.
On 07/27/2022 in the morning, an observation of R106's midline catheter was conducted with a Licensed Practical Nurse (LPN). The LPN confirmed the dressing of the resident's midline catheter was loose and dated 07/18/2022.
On 07/27/2022 at 8:43 AM, the LPN indicated the transparent dressing of a midline catheter should have been changed upon admission, every seven days and as needed for loose or soiled dressing. The LPN acknowledged R106's midline catheter dressing should have been changed two days ago.
On 07/28/2022 at 10:52 AM, the Director of Nursing (DON) revealed R106's midline catheter was inserted on 07/18/2022. The DON explained the nurses were expected to obtain physician's orders for the midline catheter care such as dressing change every seven days and as needed for loose or soiled dressing, monitoring of the IV site every shift, and flushes.
The DON confirmed R106's medical record lacked documented evidence physician's orders were obtained for the resident's midline catheter care. The DON acknowledged such orders should have been obtained on 07/18/2022 when the resident's midline catheter was inserted.
Resident #113 (R113)
R113 was admitted on [DATE], with diagnoses including enterocolitis due to clostridium difficile, recurrent.
On 07/26/2022 at 1:30 PM, R113 was observed with an IV line in the left upper extremity (LUE) with a written date of 07/16/2022.
The Clinical admission Evaluation dated 07/09/2022, documented R113 had a PICC line in the LUE.
R113's medical record lacked documented evidence of medications to be infused intravenously. The medical record lacked documented evidence of a justification for R113's PICC line.
A physician order dated 07/09/2022, documented change dressing weekly every night shift every Sunday for IV maintenance.
The Medication Administration Record for 07/2022, lacked documented evidence the dressing was changed on 07/24/2022.
On 07/26/2022 at 3:03 PM, a Licensed Practical Nurse confirmed the IV dressing on R113 had a written date of 07/16/2022.
On 07/28/2022 at 3:39 PM, a third LPN confirmed the IV dressing of R113 had a written date of 07/16/2022 which meant the IV dressing was not changed the past Sunday, 07/24/2022.
Resident #111 (R111)
R111 was admitted on [DATE], with diagnoses including chronic kidney disease.
On 07/28/2022 in the afternoon, R111 was observed with an IV line in the right upper extremity (RUE).
The Clinical admission Evaluation dated 07/09/2022, documented R111 had a PICC line in the RUE.
R111's medical record lacked documented evidence of medications to be infused intravenously. The medical record lacked documented evidence of a justification for R111's PICC line.
On 07/29/2022 at 2:22 PM, the Infection Preventionist (IP) nurse confirmed R113 and R111 had no previous and current physician orders for IV medications. The IP nurse reported there was no justification to keep the PICC lines.
The IP nurse conveyed it was their responsibility to ensure the IV lines were discontinued for non-use as this could pose a risk for infection.
Resident 5 (R5)
R5 was admitted on [DATE], with diagnoses including chronic obstructive pulmonary disease.
A physician order dated 07/20/2022, documented midline insertion.
A physician order dated 07/27/2022, documented change dressing weekly every night shift every Sunday.
On 07/26/2022 at 2:04 PM, R5 was observed with an IV dressing in the RUE with a written date of 07/20/2022.
On 07/28/2022 at 12:28 PM, an RN confirmed R5's IV dressing had a written date of 07/20/2022.
On 07/26/2022 at 2:47 PM, another LPN indicated IV dressings were changed every Sunday night. The LPN conveyed it was important to ensure the IV dressings were changed weekly as part of the facility's infection control measure.
On 07/28/2022 at 12:28 PM, the RN conveyed the IV dressings would have been changed every Sunday. The RN indicated the date this past Sunday was 07/24/2022, which meant the IV dressing of R5 was not changed.
On 07/28/2022 at 2:19 PM, the Director of Nursing (DON) conveyed the IV dressings were expected to be changed weekly every Sunday. If a resident came after Sunday, the IV dressings would have been kept unchanged and changed the following Sunday. The DON indicated the IV dressings would have been dated at the time of change.
The facility Peripheral and Midline IV Dressing Changes policy revised 03/2022, documented the facility would change the dressing at least every seven days.
Based on observation, interview, record review and document review, the facility failed to ensure:
1) peripherally inserted central catheter (PICC) and Heplock intravenous line orders were obtained for 2 or 31 sampled residents (Residents #97 and #367),
2) dressing changes were done for 5 of 31 sampled residents (Residents #97, #366, #113, #316 and #105) and 1 unsampled resident (Resident 5) and,
3) resident's unused PICC lines were removed for 1 of 31 sampled residents (Resident #113) and 1 unsampled resident (Resident #111).
Findings include:
A facility policy titled Peripheral and Midline IV Dressing Changes, revised 03/2022, indicated need to perform site care dressing changes at established intervals or immediately if the integrity of the dressing is compromised (e.g., damp, loosened, or visibly soiled). Change the dressing at least every 7 days for Transparent Semipermeable Membrane (TSM) dressing, at least every 2 days for sterile gauze dressings. Assess the patency of the vascular access. Assess the peripheral/midline access device at least every 4 hours (every 1-2 hours for residents with cognitive impairment).
Resident #97 (R97)
R97 was admitted on [DATE], with diagnoses including dependence on renal dialysis, type 2 diabetes mellitus, and end-stage renal disease.
On 07/26/2022 at 2:00 PM, R97's transparent intravenous Heplock dressing on right upper arm (RUA) was soiled and undated. R97 could not remember when it was inserted.
The Brief Interview of Mental Status (BIMS) dated 07/13/2022, documented the score of 6/15, which indicated R97's cognitive status was severely impaired.
The medical record lacked documented evidence a physician order was obtained for R97's Heplock, care and management until 07/27/2022.
On 07/26/2022 at 3:35 PM, a Licensed Practical Nurse (LPN) confirmed R97's Heplock on the RUA was soiled and undated. The LPN indicated the dressing should have been changed weekly on Sundays at night and as needed. The IV-certified LPN confirmed there was no order in place for R97's IV access: no care and management.
On 07/27/2022 at 2:45 PM, the Director of Nursing (DON) indicated the IV access required an order and dressing changes was the responsibility of the RN and supervisors. The IV-certified LPNs could not take care of PICC lines except Heplocks. The DON indicated the staff were expected to follow orders and change the dressing as scheduled.
Resident #366 (R366)
R366 was admitted on [DATE], with diagnoses including after-care following surgery on the nervous system, lumbar region carrier or suspected carrier of Methicillin-susceptible staphylococcus aureus infection; and disruption (re-opened) external operation wound.
The BIMS dated 07/21/2022, documented the score of 15/15, which indicated R366's cognitive status was intact.
On 07/26/2022 at 11:00 AM, R366 was sitting at the bedside with an intravenous machine and a PICC line at RUA with transparent dressing dated 07/17/2022. R366 was receiving IV antibiotics and the PICC line dressing had not been changed for more than a week.
The Medication Administration Record, dated 07/24/2022, documented the dressing was not changed.
A physician order dated 07/15/2022, documented to change transparent dressing as needed for soiled or loosened dressing every Sunday night shift for PICC.
A care plan dated 07/15/2022, R366 was on IV medication with the goal to prevent complications related to IV therapy. The interventions included monitoring dressing at the site.
On 07/26/2022 at 3:31PM, an LPN confirmed R366's PICC line was not changed as scheduled. The LPN indicated R366 was receiving IV antibiotics and the dressing was more than a week old. The LPN indicated the dressing should have been changed weekly on Sundays and as needed by night-duty Registered Nurses.
Resident #367 (R367)
R367 was admitted on [DATE], with diagnoses including pneumonia, tobacco use and enterocolitis (inflammation in the digestive tract) due to clostridium difficile.
The BIMS dated 07/21/2022, documented a score of 12/15, which indicated R367's cognitive status was moderately impaired.
On 07/26/22 at 11:40 AM, R367 was in bed, PICC line in RUA was dated 07/15/2022. The PICC line's transparent dressing was soiled and peeling off at the edges. R367 indicated the PICC line was not in use for approximately two weeks. A Heplock in left upper arm and the transparent dressing was soiled and undated was also observed.
R367's medical records lacked documented evidence an order for R367's IV lines was obtained, and care was initiated.
The Clinical admission Evaluation dated 07/15/2022, documented R367 had a PICC line.
On 07/26/22 03:38 PM, an LPN confirmed the observation and indicated R367's PICC line was not changed as scheduled and was not in use. The LPN indicated the dressing should have been changed weekly on Sundays and as needed by night-duty RNs. The LPN indicated if there was no order in place the PICC line would not be cared and monitored.
On 07/28/22 at 10:25 AM, the UM verified and confirmed there was no order for R367's PICC line. The Unit Manager indicated R367 was admitted with a PICC line per R367's clinical admission evaluation. The UM explained if a resident was admitted with IV access, a physician order should have been obtained. The UM verified and confirmed R367 was admitted with a Heplock from the hospital per R367's clinical admission evaluation. The UM confirmed there was no order in place for R367's Heplock. The UM explained if a Heplock was not in use, it should have been removed.
Resident #316 (R316)
R316 was admitted on [DATE], with diagnoses including joint replacement surgery and difficulty in walking.
A Physician Order dated 07/18/2022, documented to insert a midline catheter for R316.
A Health Status Note dated 07/22/2022, documented R316 continues to receive intravenous antibiotics. The left arm midline catheter dressing was in place.
On 07/26/2022 at 9:03 AM, R316 was observed with a midline catheter in the left arm. The transparent dressing on the catheter was dated 07/18/2022.
On 07/27/2022 at 2:38 PM, R316 was observed with a midline catheter in the left arm. The transparent dressing on the catheter was dated 07/18/2022.
On 07/27/2022 at 2:41 PM, a Registered Nurse (RN) confirmed the date on the dressing was 07/18/2022 and should have been changed two days ago. The RN indicated the facility had an Intravenous (IV) nurse who came once a week to change the IV dressings. It was the facility's policy to have dressings on central vascular catheters changed every seven days.
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.
Concerns
- • Multiple safety concerns identified: Federal abuse finding. Review inspection reports carefully.
- • 62 deficiencies on record. Higher than average. Multiple issues found across inspections.
- • 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 Sandstone Spring Valley's CMS Rating?
CMS assigns SANDSTONE SPRING VALLEY an overall rating of 1 out of 5 stars, which is considered much 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 Sandstone Spring Valley Staffed?
CMS rates SANDSTONE SPRING VALLEY's staffing level at 3 out of 5 stars, which is average compared to other nursing homes. Staff turnover is 48%, compared to the Nevada average of 46%.
What Have Inspectors Found at Sandstone Spring Valley?
State health inspectors documented 62 deficiencies at SANDSTONE SPRING VALLEY during 2022 to 2025. These included: 62 with potential for harm. While no single deficiency reached the most serious levels, the total volume warrants attention from prospective families.
Who Owns and Operates Sandstone Spring Valley?
SANDSTONE SPRING VALLEY 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 SANDSTONE HEALTHCARE GROUP, a chain that manages multiple nursing homes. With 160 certified beds and approximately 153 residents (about 96% occupancy), it is a mid-sized facility located in LAS VEGAS, Nevada.
How Does Sandstone Spring Valley Compare to Other Nevada Nursing Homes?
Compared to the 100 nursing homes in Nevada, SANDSTONE SPRING VALLEY's overall rating (1 stars) is below the state average of 3.0, staff turnover (48%) is near the state average of 46%, and health inspection rating (1 stars) is much below the national benchmark.
What Should Families Ask When Visiting Sandstone Spring Valley?
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 Sandstone Spring Valley Safe?
Based on CMS inspection data, SANDSTONE SPRING VALLEY 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 1-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 Sandstone Spring Valley Stick Around?
SANDSTONE SPRING VALLEY has a staff turnover rate of 48%, 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 Sandstone Spring Valley Ever Fined?
SANDSTONE SPRING VALLEY 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 Sandstone Spring Valley on Any Federal Watch List?
SANDSTONE SPRING VALLEY 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.