Red Rocks Care Center
For profit - Limited Liability company
102 Beds
GENESIS HEALTHCARE
Data: November 2025
Trust Grade
63/100
#19 of 67 in NM
Last Inspection: July 2024
Within standard 12-15 month inspection cycle. Federal law requires annual inspections.
Overview
Red Rocks Care Center has a Trust Grade of C+, which means it is considered decent and slightly above average among nursing homes. It ranks #19 out of 67 facilities in New Mexico, placing it in the top half, but it is #2 out of 2 in McKinley County, indicating limited local options. The facility is improving, with a decrease in reported issues from 8 in 2024 to just 3 in 2025. Staffing is a concern, as it received a 2/5 rating with a 45% turnover rate, which is below the state average. However, the nursing home has a high amount of RN coverage, meaning more registered nurses are available than at 88% of other facilities, which is a positive aspect. Despite these strengths, there are significant weaknesses. The facility has been cited for serious issues, including failing to act on allegations of abuse by an employee, which caused harm to a resident. Additionally, there were concerns about maintaining a sanitary environment, as some ceiling tiles were found to be water-damaged and moldy, potentially exposing residents to health risks. Lastly, meal delivery times were inconsistent, leading to frustration and hunger among residents. Overall, families should weigh these factors carefully when considering Red Rocks Care Center for their loved ones.
- Trust Score
- C+
- In New Mexico
- #19/67
- Safety Record
- Moderate
- Inspections
- Getting Better
- Staff Stability ○ Average
- 45% turnover. Near New Mexico's 48% average. Typical for the industry.
- Penalties ✓ Good
- $7,443 in fines. Lower than most New Mexico facilities. Relatively clean record.
- Skilled Nurses ⚠ Watch
- Each resident gets only 21 minutes of Registered Nurse (RN) attention daily — below average for New Mexico. Fewer RN minutes means fewer trained eyes watching for problems.
- Violations ⚠ Watch
- 49 deficiencies on record. Higher than average. Multiple issues found across inspections.
63/100
Top 28%
Needs review
8 → 3 violations
★★★★☆
4.0
Overall Rating
★★☆☆☆
2.0
Staff Levels
★★★★☆
4.0
Care Quality
★★★★☆
4.0
Inspection Score
↔
Stable
2024: 8 issues
2025: 3 issues
The Good
-
4-Star Quality Measures · Strong clinical quality outcomes
-
Full Sprinkler Coverage · Fire safety systems throughout facility
-
No fines on record
-
Staff turnover below average (45%)
3 points below New Mexico average of 48%
Facility shows strength in quality measures, fire safety.
The Bad
Staff Turnover: 45%
Near New Mexico avg (46%)
Typical for the industry
Federal Fines: $7,443
Below median ($33,413)
Minor penalties assessed
Chain: GENESIS HEALTHCARE
Part of a multi-facility chain
Ask about local staffing decisions and management
The Ugly 49 deficiencies on record
1 actual harm
Jun 2025
3 deficiencies
CONCERN
(D)
📢 Someone Reported This
A family member, employee, or ombudsman was alarmed enough to file a formal complaint
Potential for Harm - no one hurt, but risky conditions existed
Investigate Abuse
(Tag F0610)
Could have caused harm · This affected 1 resident
Based on record review and interview, the facility failed to complete and submit a Five Day Report (a report sent to the State Survey Agency which includes the results of the facility's investigation ...
Read full inspector narrative →
Based on record review and interview, the facility failed to complete and submit a Five Day Report (a report sent to the State Survey Agency which includes the results of the facility's investigation into alleged violations) to the State Agency regarding allegations of neglect (the failure of the facility, its employees, or service providers to provide goods and services to a resident that are necessary to avoid physical harm, pain, mental anguish, or emotional distress) for 1 (R #5) of 1 (R #5) residents. If the facility does not submit follow-up reports, then the State Agency cannot assure the residents are safe and free of neglect. The findings are:
A. Record review of the facility's Reportable Incidents and Conditions policy, dated 06/01/15, revealed the following:
- Staff will report, review, and investigate all reportable incidents and conditions which occurred, or allegedly occurred, on the property and involved, or allegedly involved, a resident who received services.
- The Executive Director, Resident Care Director, or designee will review all reportable incidents and conditions to determine if:
-Required documentation has been completed; and
-Interventions to prevent further incident have been identified and implemented.
- When conduction and investigation, the Executive Director, Resident Care Director, or designee will:
- Monitor that all aspects of the reportable incident or condition and investigation are documented;
- Complete the investigation within five working days.
- The progress and outcome of investigation is communicated to appropriate leadership and to State Agencies, as indicated.
B. Record review of R #5's face sheet revealed an initial admission date of 07/21/22 with the following diagnoses:
- Dementia (a group of conditions characterized by impairment of at least two brain functions, such as memory loss and judgment),
- Dysphagia (difficulty or discomfort in swallowing).
C. Record review of the facility's Facility Reported Incident, dated 05/05/25, revealed R #5 sat across from the nursing station after activities concluded. A nurse noticed R #5 was unable to speak and had a flushed face and watery eyes. The nurse went to assist the resident and observed the crumbs of a sandwich on the floor around the chair of R #5.
D. Record review of the facility's records revealed the records did not contain documentation to show the facility submitted a Five Day Follow-Up Report to the State Survey Agency.
E. On 06/13/25 at 1:34 pm during an interview, the Director of Nursing (DON) stated staff were to investigate and start initial reporting for all reportable incidents within two hours and to complete the investigation in five days. She stated she expected for staff to complete the investigations of reportable incidents by the fifth day, to include the completion of the Five Day Follow-Up Report. The DON stated staff completed the investigation for R #5 within five days, but the facility failed to submit the Five Day Follow-Up Report to the State Survey Agency.
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 F0628
(Tag F0628)
Could have caused harm · This affected 1 resident
Based on record review and staff interview, the facility failed to provide a copy of the planned Involuntary Discharge Notice to the State Long-Term Care Ombudsman for 2 (R #3 and #4) of 3 (R #3, #4 a...
Read full inspector narrative →
Based on record review and staff interview, the facility failed to provide a copy of the planned Involuntary Discharge Notice to the State Long-Term Care Ombudsman for 2 (R #3 and #4) of 3 (R #3, #4 and #7) residents. This deficient practice could result in residents being discharged without necessary advocacy or support from the Ombudsman's office. The findings are:
R #3
A. Record review of R #3's Notice of Involuntary Discharge, dated 03/06/25, revealed the facility sent the resident's Involuntary Discharge Notice to the State Long-Term Care Ombudsman in another state. The facility did not send the discharge notice to the New Mexico Long-Term Care Ombudsman.
B. On 06/12/25 at 10:31 am during an interview, the New Mexico Long-Term Care Ombudsman stated she did not receive R #3's Notice of Involuntary Discharge, dated 03/06/25.
C. On 06/12/25 at 12:46 pm during an interview, the Social Services Director (SSD) stated she sent R #3's Notice of Involuntary Discharge, dated 03/06/25, to the Long-Term Care State Ombudsman in the wrong state.
R #4
D. Record review of R #4's Notice of Involuntary Discharge, dated 03/05/25, revealed the facility sent the resident's Involuntary Discharge Notice to the State Long-Term Care Ombudsman in another state. The facility did not send the discharge notice tot he New Mexico Long-Term Care State Ombudsman.
E. On 06/12/25 at 10:31 am during an interview, the New Mexico Long-Term Care Ombudsman stated she did not receive R #4's Notice of Involuntary Discharge, dated 03/05/25. She stated she had concerns residents did not receive the correct information to receive advocacy services should they appeal the discharge.
F. On 06/12/25 at 12:46 pm during an interview, the Social Services Director (SSD) stated she sent R #4's Notice of Involuntary Discharge, dated 03/05/25, to the Long-Term Care State Ombudsman in the wrong state. She stated she was not aware she sent the notice to the wrong entity. She stated she followed the instructions she received from the Corporate SSD,who advised her to use a template which included the contact information for an Ombudsman in a different state.
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
Medical Records
(Tag F0842)
Could have caused harm · This affected multiple residents
Based on observation and interview, the facility failed to safeguard residents' personal health information when the facility mailed a notice of involuntary discharge to an unauthorized entity for 2 (...
Read full inspector narrative →
Based on observation and interview, the facility failed to safeguard residents' personal health information when the facility mailed a notice of involuntary discharge to an unauthorized entity for 2 (R #3 and #4) of 3 (R #3, #4 and #7) residents. If the facility fails to ensure the confidentiality, security, and proper management of resident records, then residents are at risk of unauthorized persons accessing their personal and medical information. The findings are:
A. Record review of R #3's Notice of Involuntary Discharge, dated 03/06/25, revealed the facility sent the resident's notice to the State Long-Term Care Ombudsman in another state. The facility did not send the discharge notice to the State Long-Term Care Ombudsman in New Mexico.
B. Record review of R #4's Notice of Involuntary Discharge, dated 03/05/25, revealed the facility sent the resident's notice to the State Long-Term Care Ombudsman in another state. The facility did not send the discharge notice to the State Long-Term Care Ombudsman in New Mexico.
C. On 06/12/25 at 10:31 am during an interview, the New Mexico State Ombudsman (SO) stated she was made aware the facility sent R #3's and R #4's discharge information to the wrong state ombudsman when the ombudsman from the other state reached out to her. She stated the ombudsman from the other state reported they received two New Mexico Notices of Involuntary Discharge. The SO stated she reached out to the facility Administrator, because she had concerns with resident information being shared with unauthorized persons. She stated there was not a resolution to ensure discharge notices would be sent to the correct state ombudsman. The SO stated she was concerned residents might not realize they could appeal the involuntary discharge, and the resident would not have the correct contact information for the SO who could assist residents in the process.
D. On 06/12/25 at 12:46 PM during an interview, the Social Services Director (SD) stated she sent R #3's and R #4's Notice of Involuntary Discharge to the State Ombudsman in another state. She stated her Corporate Social Services Director (CSSD) provided her with a template for the notice that included ombudsman contact information, and the CSSD advised her to use the template. She stated she was not aware she sent the Notice of Involuntary Discharge to the incorrect state ombudsman.
Jul 2024
8 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** Based on record review, and interview, the facility failed to provide pressure ulcer interventions as ordered for R #10. This de...
Read full inspector narrative →
**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on record review, and interview, the facility failed to provide pressure ulcer interventions as ordered for R #10. This deficient practice could likely result in the resident not receiving appropriate and timely pressure ulcer relieving interventions, which could result in wounds becoming worse. The findings are:
Findings for R #10
A. Record review of R #10's electronic medical record showed the resident was admitted on [DATE] with a diagnosis of pressure ulcer of sacral region, Stage 4 (pressure injuries that extend to muscle, tendon, or bone). This is not an all inclusive list.
B. Record review of R #10's physician orders, dated 05/19/24, showed an order for a pressure-redistribution cushion to chair and a pressure-redistribution mattress to bed.
C. Record review of R #10's physician orders from the wound clinic, dated 07/16/24, showed orders to offload (reduction or redistribution of pressure on a specific area to promote healing and prevent complications) patient every two hours, order a pressure relieving wheel chair cushion, and order a pressure relieving mattress.
D. Record review of R #10's physician orders, dated 07/24/24, showed the record did not include an order to turn every two hours.
E. Record review of R #10's tasks for the Certified Nursing Aides (CNA) did not include a task to turn the resident every two hours.
F. On 07/23/24 at 8:25 am, during observation of R #10's room, a pressure relieving mattress was not on the resident's bed.
G. On 07/24/24 at 2:42 PM during an interview of the Director of Nursing (DON), she stated staff did not order the pressure relieving mattress, and she did not know why. She stated the resident did get his wheelchair cushion. The DON stated staff did not enter the order to turn the resident every two hours.
CONCERN
(D)
Potential for Harm - no one hurt, but risky conditions existed
Deficiency F0687
(Tag F0687)
Could have caused harm · This affected 1 resident
**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, interview, and record review, the facility failed to provide podiatry (the medical care and treatment of t...
Read full inspector narrative →
**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, interview, and record review, the facility failed to provide podiatry (the medical care and treatment of the human foot) services for 1 (R #65) of 1 ( R #65) resident reviewed for toenail care. This deficient practice could likely result in functional decline, pain, and infections. The findings are:
A. Record review of R #65's face sheet indicated she was admitted on [DATE]. She had a diagnosis of type 2 diabetes (when the body does not use insulin properly), morbid obesity (overweight), Guillan-Barre syndrome (a condition in which the body's immune system attacks the nerves. It can cause weakness, numbness or paralysis) and dementia (symptoms affecting memory, thinking and social abilities severely enough to interfere with daily life). This is not an all inclusive list.
B. On 07/21/24 at 6:45 pm, during an interview with R #65, she stated she needed her toenails cut and to see podiatry. She stated she requested this from the nursing staff for awhile now.
C. On 07/21/24 at 6:45 pm, an observation revealed bandages around R #65's feet and legs. She had a brace on one of her feet. Her toenails could not be observed.
D. Record review of the physician orders for R #65 indicated the following:
- An order, dated 07/01/24, to refer to podiatry.
- An order, dated 07/23/24, for an appointment for foot and ankle, and staff made the appointment on 09/26/24.
F. On 07/24/24 at 2:38 pm, during an interview with the Unit Manager (UM), she stated R #65 was a diabetic, and her blood sugars were uncontrolled. She stated podiatry had not seen the resident yet. She stated she did not see a past appointment for R #65. She stated podiatry should see diabetic residents monthly. The UM stated she would expect podiatry to have seen R #65 since she was admitted in November 2023.
CONCERN
(D)
Potential for Harm - no one hurt, but risky conditions existed
Accident Prevention
(Tag F0689)
Could have caused harm · This affected 1 resident
Based on observation and interview, the facility failed to put a resident in her bed when she was asleep, and the resident slumped forward in her wheelchair for 1 (R #13) of 1 (R #13) resident viewed ...
Read full inspector narrative →
Based on observation and interview, the facility failed to put a resident in her bed when she was asleep, and the resident slumped forward in her wheelchair for 1 (R #13) of 1 (R #13) resident viewed during random observation. This deficient practice could likely cause the resident to fall forward out of her wheelchair and get hurt. The findings are:
A. On 07/24/24 at 10:45 am, an observation of R #67 revealed the resident was asleep in her wheelchair in room off of the nursing station. She was slumped forward in her chair with one of her arms hanging off the side of the chair and appeared that she may fall out of the wheelchair.
B. On 07/24/24 at 11:00 am, observation of R #67 revealed the resident slumped forward and asleep in her wheelchair. Certified Nursing Assistant (CNA) #5 and CNA #6 sat in the room with R #67, but neither CNA assisted R #67.
C. On 07/24/24 at 11:03 am, during an interview and observation of CNA #5, the CNA did not answer any questions from the surveyor regarding R #67. CNA #5 got up and asked R #67 if she wanted to lay down in her bed. R #67 stated yes, she wanted to lay down.
CONCERN
(E)
Potential for Harm - no one hurt, but risky conditions existed
Deficiency F0552
(Tag F0552)
Could have caused harm · This affected multiple residents
Based on record review and interview, the facility failed to ensure residents or the guardians were aware of and understood the reason they took a medication, the risks, and the benefits of the medica...
Read full inspector narrative →
Based on record review and interview, the facility failed to ensure residents or the guardians were aware of and understood the reason they took a medication, the risks, and the benefits of the medication for 2 (R #19 and R #66) of 2 (R #19, R #66) residents reviewed for unnecessary medications. If the residents or their guardians are not informed of the risks of benefits of the medication, they are not able to make informed decisions. The findings are:
R #19
A. Record review of R #19's physician's orders revealed an order for quetiapine fumarate oral tablet (used to treat certain mental/mood disorders), 50 mg (milligrams). Give one tablet orally at bedtime for agitation. Start date: 05/09/24.
B. Record review of R #19's medical record revealed the record did not contain a consent form for quetiapine fumarate oral tablet, 50 mg.
C. On 08/29/23 at 2:30 pm, during an interview, the Director of Nursing (DON) stated R #19's medical record did not contain consent forms for quetiapine fumarate oral tablet, 50 mg, and staff did not monitor R #19's behaviors while taking the quetiapine from 05/09/24 thru 07/02/24.
R #66
D. Record review of face sheet for R #66 revealed an admission date of 03/25/24 and included the following diagnoses: Dementia (decline in cognitive abilities that affect memory, thinking, language, and behavior) and drug induced subacute dyskinesia (movement disorder that causes involuntary, repetitive body movements caused by long term use of certain medications).
E. Record review of Physicians Orders for R #66 revealed the following:
- Buspirone HCI oral tablet (medication used to treat anxiety), 5 mg. Give one tablet by mouth two times a day for anxiety. Start date: 03/25/24.
- Risperdal (medication used to treat certain mental/mood disorders) Oral Tablet 1 mg. Give one tablet by mouth two times a day for dementia/behaviors. Start date: 06/24/24.
F. Record review of medication administration records for R #66, dated 03/25/24 through 07/21/24, revealed staff administered buspirone and risperdal to R #66 daily.
G. Record review of electronic medical record for R #66 revealed the record did not contain a signed consent by R #66 or R #66's Power of Attorney (POA) to receive psychotropic medications.
H. On 07/24/24 at 10:15 am during an interview with the Director of Nursing, she stated R #66 or the resident's POA should have signed a consent for psychotropic medications on 03/25/24 or within a couple of days of his admission date, if the resident was admitted to the facility with orders for psychotropic medications. She verified a consent form was not completed until 07/22/24, when facility staff did a full sweep of residents who took psychotropic medications.
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** Curtains
E. On 07/22/24 at 9:50 am, a random observation of resident rooms revealed the following:
- room [ROOM NUMBER] - curta...
Read full inspector narrative →
**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Curtains
E. On 07/22/24 at 9:50 am, a random observation of resident rooms revealed the following:
- room [ROOM NUMBER] - curtains were inappropriately hanging and were falling off the curtain rods.
- room [ROOM NUMBER] - curtain were inappropriately hanging and were falling off the curtain rods.
F. On 07/22/24 at 9:54 am during an interview, the Housekeeper stated that housekeeping staff reported the broken curtain rods several times and requested the rods be fixed, but it never gets done.
G. On 07/24/24 at 10:02 am, random observations of resident rooms revealed the window curtains in resident rooms 43, 46, 47, 51, 64, 66 and 70 were falling off the rods and were missing clips that held the curtains in place. Further observation revealed curtains could not be closed.
H. On 07/24/24 at 12:08 pm during an interview and record review with the Administrator, he stated he was aware of the issue with the curtains, and they purchased extra clips to replace as needed. He stated he was not aware whether or not there were any maintenance requests for the curtain issues. He stated he expected all staff who were aware of any issues to put in maintenance requests. He stated he was not sure why the curtains in the resident rooms were not addressed. The Administrator provided one maintenance request for room [ROOM NUMBER] curtain issues.
I. Record review of facility maintenance requests for repairs to curtains in resident rooms revealed one work order, dated 07/22/24, for resident room [ROOM NUMBER] - window curtain rail was bent.
Shower room door findings:
J. On 07/24/24 at 10:55 am, during an observation of the shower room, the shower room door was broken. A large chunk of the door, which measured approximately 12 inches () by 3 at the widest part, was missing around the handle area, the door did not lock, and the keypad on the door did not work. Further observation revealed a handle on the inside of the door so staff and residents could get out of the shower room.
K. On 07/24/24 at 12:07 pm, during an interview with Administrator, he stated initially the door had an issue with latching, and then there was another issue with the door which he could not recall what it was. He stated measurements were taken for a new door, and a new door was ordered. The Administrator stated the issue with the shower room door had been like that for many months. He said it was a long process to get it replaced. He said they relied on outside companies, and it took a long time to get things done.
L. On 07/25/24 at 12:30 pm, during an interview with the Maintenance Director, he stated the door sagged, and he put a piano hinge on it to help with the sagging. He stated he was not sure how the door became so damaged, but he was aware the door had been sticking. The Maintenance Director stated it took a little bit of force to open the door. He stated he started to work on the door issue in May 2024. He said the facility tried to get someone local to replace the door, but it took too long for the vendor to get paid. He stated they now have to go through an outside company to get the door replaced.
Based on observation, interview, and record review, the facility failed to provide a homelike environment for 4 (R # 21, 63, 67 and 201) out of 4 (R # 21, 63, 67 and 201) residents reviewed when staff failed to replace the shower bed mattress that had a large hole all the way through the mattress which exposed the white pipe frame; to replace the curtain rods for multiple rooms; and to fix a broken door into the shower room. If residents do not have a homelike environment, they may become depressed and anxious about things in disrepair. The findings are:
Shower bed mattress findings:
A. On 07/22/24 at 2:02 pm, during an interview with R #67, she stated the shower bed she used for showers had a large hole in it. She stated the bed hurt her back when she lay on it, and the hole kept getting bigger. She stated it has been like that for months.
B. On 07/24/24 10:41 am, during an interview with Certified Nursing Assistant (CNA) #5, she stated the shower bed has been like this for probably a couple of months. She stated R #67 complained about the hole in the mattress. She stated that everyone (nurses and management) were aware of the condition of the shower bed mattress.
C. On 07/24/24 at 10:55 am, during an observation of the shower room, the shower bed had multiple cracks on the shower bed mattress. The shower bed also had a large hole that went all the way through the mattress and exposed the pipe frame.
D. On 07/24/24 at 11:10 am, during an interview with Administrator, he stated he was not aware the shower bed had a large hole in the mattress. He stated that it was not acceptable for residents to use the shower bed as it was. The Administrator stated the bed should not be used.
CONCERN
(E)
Potential for Harm - no one hurt, but risky conditions existed
Assessment Accuracy
(Tag F0641)
Could have caused harm · This affected multiple residents
Based on record review and interview, the facility failed to ensure comprehensive Minimum Data Set (MDS; a federally mandated assessment instrument completed by facility staff) assessments were accura...
Read full inspector narrative →
Based on record review and interview, the facility failed to ensure comprehensive Minimum Data Set (MDS; a federally mandated assessment instrument completed by facility staff) assessments were accurate for 2 (R #70 and #84) of 2 (R #70 and #84) residents reviewed for accurate MDS Assessments. If resident assessments are not complete and accurate, the facility could misidentify clinical complications and fail to provide adequate care to treat the resident's medical condition. The findings are:
A. Record review of R #70's admission MDS Assessment, dated 05/21/24, indicated the resident was not on dialysis.
B. Record review of R #84's admission MDS Assessment, dated 07/16/24, indicated the resident was not on dialysis.
C. On 07/22/24 at 12:11 pm, during an interview with the MDS Coordinator, she verified R #70 was on dialysis at admission, and staff coded his MDS Assessment inaccurately. She also verified R #84 was on dialysis at admission, and staff coded her MDS Assessment inaccurately.
CONCERN
(E)
Potential for Harm - no one hurt, but risky conditions existed
Comprehensive Care Plan
(Tag F0656)
Could have caused harm · This affected multiple residents
Based on interview and record review, the facility failed to ensure two (R #11 and R #66) of two (R #11 and R #66) residents had complete comprehensive care plans for their care, when staff failed to:...
Read full inspector narrative →
Based on interview and record review, the facility failed to ensure two (R #11 and R #66) of two (R #11 and R #66) residents had complete comprehensive care plans for their care, when staff failed to:
1. Include hospice on R #11's care plan.
2. Ensure R #66's care plans for delirium (a serious change in mental abilities that causes confused thinking and lack of awareness of surroundings), oral health, and use of psychotropic drugs (drugs that affect a person's mental state) were complete and included time frames.
This failure had the potential to adversely affect staff's ability to implement preventative measures for the residents' health and well-being.
Findings include:
Resident #11
A. Record review of R #11's comprehensive Minimum Data Set (MDS; a federally mandated assessment instrument completed by facility staff), dated 04/22/24, revealed the resident was on hospice.
B. Record review of R #11's comprehensive care plan, dated 05/30/24, did not include R #11 was on hospice.
C. Record review of R #11's physician orders showed R #11 started hospice on 04/12/24.
D. During an interview on 7/23/24 at 1:57 PM, the Director of Nursing (DON) stated staff did not care plan R #11's hospice until 07/22/24, and the DON did not know why it was not on 04/12/24. The DON expected hospice to be care planned the day it was ordered.
Resident #66
E. Record review of the care plans for R #66 revealed the following:
- Dated 03/25/24 - Focus: Resident/Patient was at risk for or exhibited symptoms of delirium related to: [this space left blank]. Goal: Resident/Patient will remain free of signs/symptoms of delirium with no unexplained or rapid changes for [blank] days. Further review revealed the care plan was revised on 07/05/24, but staff did not include time frames for goals to be achieved by.
- Dated 03/25/24 - Focus: Resident exhibited or was at risk for oral health or dental care problems as evidenced by [blank]. Goal: 1) The resident will maintain intact oral mucous membranes for [blank] days. 2) The resident will not have any discomfort or chewing problems in the next [blank] days. Further review revealed the care plan was revised on 07/05/24, but staff did not include time frames for goals to be achieved by.
- Dated 03/25/24 - Focus: Resident was at risk for complications related to the use of psychotropic drugs. Goal: Resident will have the smallest, most effective dose without side effects for [blank] days. Further review revealed the care plan was revised on 07/05/24, but staff did not include a reason/cause for R #66's delirium or time frames for goals to be achieved by.
F. On 07/24/24 at 10:15 am during an interview, the DON verified R #66's care plans were incomplete. She stated she was not sure why the care plans were incomplete, but it is her expectation staff completed the care plans to include a measurable time frame for goals.
CONCERN
(E)
Potential for Harm - no one hurt, but risky conditions existed
Infection Control
(Tag F0880)
Could have caused harm · This affected multiple residents
Based on observation, record review, and interview the facility failed to maintain proper infection prevention measures when the facility failed to ensure the shower bed was free of a hole and several...
Read full inspector narrative →
Based on observation, record review, and interview the facility failed to maintain proper infection prevention measures when the facility failed to ensure the shower bed was free of a hole and several other cuts that exposed the foam for 4 (R #21, 63, 67 and 201) of 4 ( R # 21, 63, 67 and 201) residents that used the shower bed. Failure to replace items that required cleaning multiple times per day for infection control purposes could likely cause the spread of infections and illness to the residents who use the shower bed equipment. The findings are:
A. On 07/22/24 at 2:02 pm, during an interview with R #67, she stated the shower bed she used for showers had a large hole in it, and it kept getting bigger. She stated it has been like that for months.
B. On 07/24/24 at 10:55 am, during an observation of the shower room, the shower bed had multiple cracks on the shower bed mattress. The shower bed also had a large hole that went all the way through the mattress and exposed the pipe frame. The foam in the mattress was exposed in several places. The foam was a pourous suface that absorbed water and any of other substance that touched it. It was not a smooth, washable surface.
C. On 07/24/24 at 11:10 am, during an interview with Administrator, he stated he was not aware the shower bed had a large hole in the mattress. He stated there was only one shower bed for showering, and only a few residents used it.
D. On 07/24/24 1:41 pm, during an interview with Certified Nursing Assistant (CNA) #5, she stated the shower bed has been like this for probably a couple of months. She stated management staff were aware of the issue with the shower bed. She stated it was hard to clean, because the foam was showing. The CNA stated they spray the shower chair down with an antibacterial spray and let it drip dry. She stated four or five residents used the shower bed.
E. On 07/25/24 at 10:45 am, during an interview with R #63, he stated the shower bed was like that for three months. R #63 stated he used the shower bed a couple of times per week.
F. On 07/25/24 at 10:50 am, during an interview with R #21, he stated he used the shower bed a couple of times per week. He stated he was not sure how long the hole in the shower bed had been there.
G. On 07/25/24 at 10:55 am, during an interview with R #201, he stated he used the shower bed, and it was like that for at least one month. He stated he thought everyone was aware the bed had a hole.
H. On 07/25/24 at 12:30 pm, during an interview with the Maintenance Director, he stated the shower mattress was reported to him by word of mouth and not through the system they typically used to report issues.
Dec 2023
4 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 F0657
(Tag F0657)
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 ensure the care plan was revised and updated for 1 (R #101) of 5 (R...
Read full inspector narrative →
**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on record review and interview, the facility failed to ensure the care plan was revised and updated for 1 (R #101) of 5 (R #101, R #102, R #103, R #104, R #105) residents reviewed for revised care plans. This deficient practice is likely to result in residents' care and needs not being addressed if care plans are not updated. The findings are:
A. Record review of R #101's face sheet revealed R #101 was admitted to the facility on [DATE] with the following diagnoses:
- Neoplasm (a new and abnormal growth of tissue in some part of the body, especially as a characteristic of cancer) of uncertain behavior of the brain, infratentorial (the area of the brain located below the tentorium cerebelli); obstructive hydrocephalus (fluid buildup in the brain);
- Adult failure to thrive;
- Constipation, unspecified;
- Unspecified astigmatism, bilateral (the front surface of the eye or the lens, inside the eye, is curved differently in one direction than the other in both eyes).
- A diagnosis which indicated progressive renal failure was not found in the resident's record.
B. Record review of R #101's electronic health record revealed emergency room discharge instructions, dated [DATE], related to a visit for edema (swelling). The discharge instructions indicated R #101 was diagnosed with progressive renal failure.
C. Record review of R 101's care plan, revision date of 11/29/23. revealed it did not contain care plan focus, goals, or interventions related to progressive renal failure.
D. On 12/28/23 at 4:15 pm, during an interview, the Minimum Data Set (MDS; a federally mandated assessment instrument completed by facility staff) Registered Nurse (RN) stated staff did not update R #101's care plan, but they should have updated the care plan to reflect his new diagnoses of progressive renal failure.
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
Medical Records
(Tag F0842)
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 ensure medical records were complete and accurate for 3 (R #101, R ...
Read full inspector narrative →
**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on record review and interview, the facility failed to ensure medical records were complete and accurate for 3 (R #101, R #102, and #103) of 3 (R #101, R #102 and R #103) residents reviewed for accuracy of documentation. This deficient practice has the potential to negatively impact the care staff provide to meet resident needs due to missing or inaccurate records. The findings are:
Findings for R #101:
A. Record review of R #101's face sheet revealed the following: R #101 was admitted to the facility on [DATE] on hospice care (a type of health care that focuses on the relief of a terminally ill patient's distress and symptoms and attending to their emotional and spiritual needs during the final stages of life) with the diagnoses of neoplasm (a new and abnormal growth of tissue in some part of the body, especially as a characteristic of cancer) of uncertain behavior of the brain, infratentorial (the area of the brain located below the tentorium cerebelli); obstructive hydrocephalus (fluid buildup in the brain); adult failure to thrive; constipation, unspecified; and unspecified astigmatism, bilateral (the front surface of the eye or the lens, inside the eye, is curved differently in one direction than the other in both eyes).
B. Record review of R #101's nursing progress notes, dated 09/20/23, revealed the doctor ordered Seroquel to calm the resident.
C. Record review of R #101's care plan revealed an intervention, initiation date of 09/20/23, related to falls, indicating that the medical doctor (MD) ordered Seroquel [an antipsychotic medication used to treat several kinds of mental health conditions] to calm the resident.
D. Record review of R #101's Medication Administration Record (MAR), dated September 2023, revealed the record did not contain orders for Seroquel or documentation to show staff administered Seroquel or its generic equivalent to the resident.
E. Record review of R #101's physician's medication orders revealed the record did not contain orders for Seroquel or its generic equivalent.
F. On 12/27/23 at 10:44 am, during an interview, the Assistant Director of Nursing (ADON) confirmed there was a note in R #101's progress note to order Seroquel, and the Seroquel was on R #101's care plan. She confirmed the resident's record did not contain a physician's order for Seroquel.
Findings for R #102:
G. Record review of R #102's face sheet revealed an initial admission date of 05/10/23 with the following relevant diagnoses:
- History of falling;
- Generalized muscle weakness;
- Difficulty in walking.
H. Record review of R #102's electronic health record revealed the following:
1. R #102 had falls on 11/03/23 and 12/23/23. Staff performed neurological evaluations (an assessment that consists of observations completed after a fall, that looks at level of consciousness, orientation, follows simple commands, sensation/response to pain, pupils, motor function, vital signs, and changes in the person's baseline condition to make sure the brain is working as it should) for both falls.
2. A Neurological Evaluation Flowsheet, start date 11/03/23, revealed the following:
- On 11/4/23 at 12:00 am, 1:00 am, 2:00 am, and 3:00 am, staff did not document the neurological evaluations of level of consciousness, orientation, follows simple commands, sensation/response to pain, pupils, motor function, vital signs and change from baseline to be completed
- On 11/04/23 at 11:00 am, and 7:00 pm staff did not document the neurological evaluations of level of consciousness, orientation, follows simple commands, sensation/response to pain, pupils, motor function, and change from baseline.
- On 11/05/23 at 3:00 am, 11:00 am, 7:00 pm and 11/06/23 for 3:00 am, 11:00 am, and 7:00 pm, staff did not document the neurological evaluations of level of consciousness, orientation, follows simple commands, sensation/response to pain, pupils, motor function, vital signs and change from baseline.
3. A Neurological evaluation flowsheet, start date 12/23/23, revealed the following:
- On 12/23/23 at at 6:00 pm, 6:15 pm, 6:30 pm, and 6:45 pm, staff did not document the neurological evaluations of level of consciousness, orientation, follows simple commands, sensation/response to pain, pupils, motor function, vital signs and change from baseline.
- On 12/25/23 at 1:15 am and 12/26/23 at 1:15 am, staff did not document the neurological evaluations.
I. On 12/29/23 at 10:51 am, during an interview, the Assistant Director of Nursing confirmed the Neurological Evaluation Flowsheets for R #102, dated 11/03/23 and 12/23/23 , were missing documentation, and staff should complete all areas or document the reason why the assessment was not completed.
Findings for R #103:
J. Record review of R #103's face sheet revealed the following relevant diagnosis: venous insufficiency (when the veins in the legs do not allow blood to flow back up to the heart) and edema (swelling caused by too much fluid trapped in the body's tissues).
K. Record review of R #103's progress note dated revealed that R #103 was readmitted to the facility on [DATE].
L. Record review of R #103's Treatment Administration Record (TAR), dated September 2023, revealed the following treatment: Thigh high compression stocking for vein procedures, elevate bilateral lower extremities (both legs) above heart 1 to 2 times daily, morning late afternoon, and remove stockings at hours of sleep , start date 07/06/23. Further review of the resident's TAR revealed staff did not document they administered the treatment to the resident on the following dates and times:
-09/21/23 at 8:00 pm,
-09/22/23 at 8:00 am and 8:00 pm,
-09/23/23 at 8:00 am and 8:00 pm,
-09/24/23 at 8:00 am and 8:00 pm,
-09/25/23 at 8:00 am and 8:00 pm,
-09/26/23 at 8:00 am and 8:00 pm.
M. On 12/23/2023 at 2:43 pm, during an interview, Wound Care Lead confirmed R #103 was out of the facility from 09/21/23 to 09/26/23, and the TAR did not contain documentation for those dates. She stated staff should document in the TAR to indicate the reason the treatment was not administered.
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
Safe Environment
(Tag F0584)
Could have caused harm · This affected multiple residents
Based on observation and interview, the facility failed to maintain a homelike environment in good condition for 2 (R #101 and R #102) of 4 (R #101, R #102, R #104, and R #105) residents reviewed for ...
Read full inspector narrative →
Based on observation and interview, the facility failed to maintain a homelike environment in good condition for 2 (R #101 and R #102) of 4 (R #101, R #102, R #104, and R #105) residents reviewed for homelike environment. This deficient practice could likely cause residents to feel they are not living in a comfortable environment, and they are not valued. The findings are:
A. On 12/20/23 at 5:24 pm, during an interview, R #101's family member stated the beds in R #101's room were old. The family member also stated the door to the bigger cabinet in R #101's room and to the little cabinet were broken. She stated on the little cabinet, the whole door was broken. She stated she had not been to the facility in a while because it was depressing.
B. On 12/27/23 at 9:00 am, an observation of R #101's and R #102's room, revealed the following:
1. A chest of drawers in the resident's room was missing a strip of the laminate veneer from the left, front face of the drawers, which measured approximately ¾ inch by 4 feet in size and left the press board beneath exposed. The chest of drawers was also missing a strip of laminate veneer from the lower, right face of the chest, which measured approximately ¾ inch by 18 inches. The right, back corner of the top shelf of the drawers was chipped and exposed the pressed wood underneath it.
2. A wooden nightstand in the resident's room was scratched in several areas.
3. The vinyl floor tiles, at the foot of R #101's bed, were warped in appearance, with one tile visibly curling up along a 12-inch edge.
4. The wall at the head of R #101's bed was missing the wooden wall protector and exposed a 10 inch by 4 foot rectangular section of the wall with a different color paint than the rest of the wall. The exposed wall area had small rectangular notches in the wall.
5. The wooden wall protector above R #102's was badly scratched along its 4 foot length and exposed different colors of paint under the scratched portions.
C. On 12/27/23 at 5:35 pm, during an observation of R #101's and R #102's room, a floor tile at the foot of R #101's bed was completely removed from the flooring.
D. On 12/27/23 at 5:35 pm, during an interview, the Maintenance Director confirmed the floor tile at the foot of R #101's bed needed repair. He confirmed the chest of drawers in R #101's and R #102's room was missing its laminate veneers and stated the chest of drawers should be replaced. He confirmed the wall protector above R #102's bed had a large quantity of scratches and the wall above R #101's bed was missing the wall protector. He stated the room could be more homelike.
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
Safe Environment
(Tag F0921)
Could have caused harm · This affected most or all residents
**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation and interview, the facility failed to provide a sanitary and comfortable environment for all 93 residents, ...
Read full inspector narrative →
**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation and interview, the facility failed to provide a sanitary and comfortable environment for all 93 residents, as identified by the facility census provided by the Administrator In Training (AIT) on 12/26/23, by failing to maintain and replace water damaged and stained ceiling tiles. This deficient practice is likely to cause all residents in this facility to be exposed to environmental hazards and to not feel comfortable, which could likely affect their psychosocial well-being. The findings are:
A. On 12/28/23 at 8:33 am, during an interview and observation, the Maintenance Director stated there was a ceiling tile that had mold. The tile was located at the nurses' station. During an observation of the ceiling tiles in the nursing station area, a ceiling tile was observed to have a circular stain approximately 2 feet in circumference. The center section of the stain was spongelike and black in appearance. The tile bowed out and curved towards the floor. During an observation, a 4 inch water stain on a ceiling tile, located in the hallway outside of room [ROOM NUMBER], was painted, and the water stain was visible through the paint. The Maintenance Director reported the water-stained ceiling tiles are painted once leaks in the pipes have been repaired.
B. On 12/28/23 at 8:40 am, observations in the resident hallways revealed the following:
A. Hallway A ceiling:
- Four ceiling tiles located next to each other with the following stains:
1. A tile with an 1 foot circular water stain, brown in color.
2. A tile with two circular water stains, each 1 foot in diameter and brown in color.
3. A tile with a 2 foot circular water stain, brown in color.
4. A tile with a 6 inch water stain, brown in color.
- A singular ceiling tile with a 6 inch stain, brown in color.
- Two ceiling tiles located next to each other:
1. One tile with a 6 inch water stain, brown in color.
2. One tile with two 18 inch water stains, brown in color and located near a facility fire sprinkler head.
B. Hallway B ceiling:
- A painted over stain, approximately 10 inches in diameter located on the ceiling in between rooms [ROOM NUMBERS]. The ceiling bracket around the tile and the stain had a rusty apearance.
- A 3 foot, half-circle stain, brown in color, located on the ceiling tile outside room [ROOM NUMBER].
- Two separate ceiling tiles with an one 6 inch, water stain, brown in color, triangular in appearance outside room [ROOM NUMBER].
Nov 2023
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
Incontinence Care
(Tag F0690)
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 provide Foley catheter (a flexible tube inserted into the bladder a...
Read full inspector narrative →
**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on record review and interview, the facility failed to provide Foley catheter (a flexible tube inserted into the bladder and anchored by a balloon to allow the free flow of urine into an attached bag) care for 2 (R #1 and 2) of 3 (R #s 1, 2 and 3) residents found to have an indwelling (fixed in a person's body for a long time) Foley catheter. This deficient practice is likely to result in a resident's catheter becoming unclean and unsanitary leading to urinary tract infections (an infection in any part of the urinary system) and other diseases. The findings are:
Resident #1
A. Record review of face sheet, dated 11/10/23, for R #1 revealed an initial admission date of 03/15/23 and included the following diagnoses:
- Paraplegia (the impairment in motor or sensory function of the lower extremities),
- Peritoneal abscess (a collection of pus or infected material in the abdomen),
- History of urinary tract infections (UTI - an infection of any part of the urinary tract),
- Neuromuscular dysfunction of bladder (when a person lacks bladder control due to brain, spinal cord or nerve problems),
- Need for assistance with personal care,
- Reduced mobility,
- Neurogenic bowel (loss of normal bowel function, inability to control bowel movements),
- Acute inflammatory disease of uterus (infection of the female reproductive tract),
- Latent syphilis (a sexually transmitted infection).
B. Record review of admission orders, dated 03/15/23, for R #1 revealed R #1 had a Foley catheter.
C. Record review of Minimum Data Set (MDS; an assessment tool used to assess the health and needs of nursing home residents), dated 03/22/23, for R #1 revealed she had an indwelling catheter, and she had an UTI within the last 30 days.
D. Record review of physicians' orders for R #1 revealed the following orders:
- Indwelling catheter, dated 08/07/23;
- Measure, record and monitor urine output every day and night shift, dated 05/05/23 through 08/10/23 and 08/10/23 through 10/18/23;
- Change the Foley catheter every two weeks, every day and night shift and as needed, dated 08/25/23 through 09/08/23 and 09/20/23 through 10/18/23;
- Change the indwelling catheter when occluded (blocked) or leaking, dated 04/18/23 through 08/10/23, 08/10/23 through 10/18/23, and 11/10/23;
- Empty the catheter drainage bag at least once every eight hours, when it becomes ½ to 2/3 full, as needed and every eight hours, dated 08/10/23 through 10/18/23, and 11/10/23;
- Perform indwelling catheter care as needed and every day and night shift, dated 08/10/23 through 10/18/23, and 11/10/23;
- Replace drainage system if disconnections or leakage occur, as needed, dated 04/18/23 through 08/10/23, and 08/10/23 through 10/18/23.
E. Record review of Treatment Administration Record (TAR), dated August 2023, for R #1 revealed the following:
- Measure and record urine output every shift and as needed . Start date: 05/05/23. End date: 08/10/23. Staff did not complete on 08/03/23.
- Measure and record urine output every shift and as needed .Start date: 08/10/23. End date: 10/18/23. Staff did not complete on 08/11/23 day shift, 08/12/23 through 08/14/23 night shift, 08/15/23 and 08/16/23 day shift, 08/17/23 through 08/20/23 night shift, and 08/29/23 night shift.
F. Record review of TAR, dated September 2023, for R #1 revealed the following:
- Empty catheter drainage bag at least once every eight hours, when it becomes 1/2 to 2/3 full, as needed and every 8 hours. Start date: 08/10/23. End date: 10/18/23. Staff did not complete for 6:00 am on 09/02/23 through 09/04/23, 09/09/23, and 09/19/23.
- Measure and record urine output every shift and as needed . Start date: 08/10/23. End date: 10/18/23. Staff did not complete on 09/01/23 through 09/3/23 night shift, 09/06/23 through 09/08/23 night shift, 09/10/23 morning shift, 09/15/23 through 09/17/23 morning shift, 09/18/23 night shift, 09/20/23 day shift, and 09/23/23 day and night shifts.
G. Record review of TAR, dated November 2023, for R #1 revealed, Perform Indwelling Catheter Care as needed and every day and night shift. Start date: 11/10/23. Staff did not complete on 11/17/23 night shift.
H. On 11/28/23 at 3:25 pm during an interview, R #1 stated the staff are supposed to change her Foley catheter out every two weeks and one time in September. She said it took them two weeks and three days to change the catheter out which caused an infection, and she had to go to the hospital.
I. On 11/29/23 at 12:58 pm, during an interview with the Director of Nursing (DON), she stated R #1 was sent out to the emergency room in September for a UTI, abnormal vital signs, nausea, and vomiting. She stated R #1 had chronic (recurring or long lasting) UTIs and was a chronic catheter patient. The DON further stated once in September, staff changed the Foley catheter out late. This was around the time R #1 was sent out to the ER (Emergency Room) in September.
J. On 11/29/23 at 1:38 pm during an interview with the DON, she stated if staff did not document anything in the TAR then she would assume it meant the task was not completed. The DON verified the TARs for R #1 for August, September, and November 2023 were missing documentation for some of the tasks/physician's orders.
Resident #2
K. Record review of face sheet dated 09/01/23 for R #2 revealed an initial admission date of 09/15/22 and included the following diagnoses:
- Alcoholic Liver Disease,
- Need for assistance with personal care,
- Reduced Mobility (reduction in a normal range of motion in the joints),
- Alcohol Abuse,
- Alcoholic Gastritis (a condition where there is inflammation, irritation or wasting away of the stomach lining caused by excessive alcohol use),
- Obstructive and Reflux Uropathy (a condition when urine cannot drain through the urinary tract),
- Chronic Kidney Disease (long-term condition where the kidneys gradually lose their ability to function properly),
- Benign Prostatic Hyperplasia [a condition in which the flow of urine is blocked due to an enlarged prostate (male reproductive gland)] with Lower Urinary Tract Symptoms.
L. Record review of MDS, dated [DATE], for R #2 revealed R #2 had urinary incontinence and an indwelling catheter.
M. Record review of Physicians Orders for R #2 revealed the following orders:
- Change Foley catheter monthly on the 24th day of each month, or when leaking/occluded, dated 11/24/22;
- Replace drainage system if disconnections or leakage occur, as needed, dated 02/04/23;
- Measure and record urine output every day and night shift for indwelling Foley catheter, dated 06/07/23.
N. Record review of Change in Condition Assessment, dated 08/24/23, for R #2 revealed a change in condition for bleeding was reported, and the nurse assessed R #2 after he requested to be sent to the hospital. The nurse checked his Foley catheter bag and observed fresh blood and no urine.
O. Record review of Change in Condition Assessment, dated 09/25/23, for R #2 revealed a change in condition for bleeding was reported. Resident complained of pain above the pubic bone, which measured four out of ten (scale of one through ten with one being the lowest level and ten being the highest level) and urinary retention (inability to voluntarily pass urine). Staff assessed the resident's urine. They noted it to be cola colored (brown), blood tinged, and the output minimal.
P. Record review of TAR, dated August 2023, for R #2 revealed, Urine Output: Measure and Record Urine Output every shift. Every day and night shift. Start date: 06/07/23. Staff did not complete on 08/01/23 day shift, 08/02/23 night shift, 08/05/23 night shift, 08/09/23 and 08/10/23 day shift, 08/14/23 night shift, and 08/24/23 night shift.
Q. Record review of TAR, dated September 2023, for R #2 revealed the following:
- Replace drainage system if disconnections or leakage occur. As needed. Staff did not complete for the month of September 2023.
- Urine Output: Measure and Record urine output every shift. Every day and night shift. Start date: 06/07/23. Staff did not complete as ordered 09/01/23 day shift, 09/14/23 night shift, 09/17/23 through 09/19/23 day shift, 09/21/23 night shift, and 09/27/23 night shift.
R. Record review of TAR, dated October 2023, for R #2 revealed, Urine Output: Measure and Record urine output every shift. Every day and night shift. Start date: 06/07/23. Staff did not complete as ordered 10/01/23 and 10/02/23 night shift, 10/05/23 night shift, 10/15/23 day shift, 10/20/23 day and night shift, 10/26/23 night shift, and 10/30/23 night shift.
S. Record review of TAR, dated November 2023, for R #2 revealed, Urine Output: Measure and record urine output every shift. Every day and night shift. Start date: 06/07/23. Staff did not complete as ordered 11/21/23 day shift, 11/24/23, 11/28/23 through11/30/23 night shift.
T. On 11/29/23 at 1:38 pm during an interview, the DON stated if staff did not document anything in the TAR then she would assume it meant the task was not completed.
May 2023
11 deficiencies
CONCERN
(D)
Potential for Harm - no one hurt, but risky conditions existed
Accident Prevention
(Tag F0689)
Could have caused harm · This affected 1 resident
Based on observation, record review, and interview the facility failed to ensure that 1 [R #195] of 2 [R #74 and 195] residents reviewed for falls were free from accident hazards by not providing suff...
Read full inspector narrative →
Based on observation, record review, and interview the facility failed to ensure that 1 [R #195] of 2 [R #74 and 195] residents reviewed for falls were free from accident hazards by not providing sufficient supervision for one resident. This deficient practice could likely result in injuries or hospitalizations. The findings are:
Resident #195
A. On 05/02/23 at 2:04 pm during a random interview, an unknown CNA (Certified Nursing Aide) stated that R #195 has fallen a couple of times since being in the facility and she is now on 1:1 (requires one on one supervision).
B. On 05/03/23 at 8:31 am during a random observation revealed R #195 was seated in her wheelchair. She was observed to have a C shaped bruise on the outer corner of her right eye. She was appropriately dressed and appeared clean and comfortable.
C. Record review of Face Sheet dated 04/23/23 for R #195 revealed this as an initial admission date and included the following diagnoses: Traumatic Subdural Hemorrhage (a type of bleed inside your head), Hypothyroidism (low thyroid hormone), Dementia (a group of symptoms affecting memory, thinking and social abilities severely enough to interfere with your daily life), Age-related Nuclear Cataract Right Eye (the clouding and hardening of the central part of the eye's lens), Nonexudative Age-related Macular Degeneration (irreversible vision loss), Sensorineural Hearing Loss Bilateral (inner ear hearing loss), Unilateral Primary Osteoarthritis Right Knee (degenerative joint disease that results from the breakdown of joint cartilage), Low Back Pain, and Age-related Osteoporosis.
D. Record review of Progress Notes dated 04/24/23 at 8:31 am for R #195 revealed, . Situation: The Change In Condition/s reported on this CIC (Change In Condition) Evaluation are/were: Fall .
E. Record review of Progress Notes dated 04/25/23 at 9:33 am for R #195 revealed, IDT (Interdisciplinary Team) NOTE: Reviewed fall from 04/24/23 .
F. Record review of Progress Notes dated 04/25/23 at 14:17 (2:17 pm) for R #195 revealed, Late Entry . Rsd (resident) high fall risk, continues to get out of bed. Rsd is on hospice. Due to fall, hematoma (bruising) above right eye. Rsd family request mattress to be on floor for safety precaution. D.O.N (Director of Nursing), ADON (Assistant Director of Nursing), and Hospice notified. Given approval for mattress to be placed on floor.
G. Record review of Progress Notes dated 04/30/23 at 16:33 94:33 pm) revealed, Note: Rsd continually tries slide out of wheelchair. Another rsd was yelling and screaming at staff. Nurse asked another Nurse to watch rsd while she went to get medication out of locked refrigerator [sic]. Nurse moved away from rsd and rsd slipped out of wheelchair down onto her buttocks then leaned over to right side.
H. Record review of Progress Notes date 05/01/23 at 21:20 (9:20 pm) for R #195 revealed, Note: Resident observed on floor on buttocks moving down hallway using scooting motion following shift change. Resident assisted into wheelchair . No injuries observed; resident reportedly has had this behavior recently. Resident brought to nursing station and sat in long seated chair . No attempts to exit chair at this time.
I. Record review of Progress Notes dated 05/03/23 at 10:30 am for R #195 revealed, This morning during activity @ (at) 10:20 am, Resident [name of R #195] fell out of her Wheelchair, Ithis [sic] Activity Director [name of] had just sat her back in her w/c (wheelchair), as I turned around I heard a thump and she was on the floor, Nurse was notified immediately toassess [sic] her.
J. Record review of Care Plan dated 04/25/23 for R #195 revealed, Focus: [name of R #195] is at risk for falls: cognitive loss, lack of safety awareness, cataract, macular degeneration. Goal: [name of R #195] will have no falls with injury throughout the next review. Interventions: 1) Fall mat on one side of bed, while resident is in bed. Family does not want the floor mat when they are here. They would like to take care of her when they are here. 2) Mattress on the floor. Family request. 3) Encourage resident to attend activities that maximize their full potential while meeting their need to socialize. 4) One side of the bed to be placed toward the wall due to resident being anxious while in bed.
K. On 05/04/23 at 3:25 pm during a random observation and interview revealed, R #195 was seated on the floor in her room, she was not wearing socks, there were no staff present in the room during this observation. This surveyor continued to observe resident and asked R #195 if she was ok and R #195 stated yes/ya and asked twice aren't you going to help me. Staff did not come to check on this resident until 3:37 pm. CNA #1 stated that R #195 is supposed to be a 1:1 but that the other person didn't show up today and they (the facility) have her working two halls, A & B and she was passing out snacks on both halls.
L. On 05/04/23 at 5:24 pm during a random observation revealed, R #195 was alone in her room, she is sitting on her mattress on the floor, she appeared to be attempting to get out of her bed, there are no staff present. A CNA entered the room at 5:26 pm.
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 record review and interview, the facility failed to conduct a urinary and bowel incontinence assessment for 1 (R #15) o...
Read full inspector narrative →
**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on record review and interview, the facility failed to conduct a urinary and bowel incontinence assessment for 1 (R #15) of 1 (R #15) residents reviewed for falls. This deficient practice could likely result in denying the resident of assessment and services that might restore normal bladder function and allow the resident to return to the highest practicable well being.
The findings are:
A. Record review of the facility's policy Continence Management, last revised 06/15/22, revealed the following: Patients will be assessed for the need for continence management as part of the nursing assessment process. A urinary incontinence assessment and/or bowel incontinence assessment will be completed upon admission or re-admission and with a change in condition or change continence status (the ability to control movements of the bowels and bladder). Continence status will be reviewed quarterly (every 3 months) as part of the care plan process .
1. Identify patient's continence status and need for continence management by conducting a nursing assessment. Assessment components include, but are not limited to:
1.1 Type of incontinence;
1.2 Prior history of bladder function .
1.3 Voiding patterns (patterns when urination actually occurs; e.g., if an individual consistently urinates in the morning after waking or shortly after a meal)
1.4 Physical and cognitive function and abilities;
1.5 Pertinent diagnosis;
1.6 Diagnostic testing;
1.7 Environmental factors (obstacles that may prevent the resident from practicing continent measures; e.g., temperature of room, furnature layout, path to the restroom, lighting, etc.)
1.8 Use of assistive devices (wheelchair, walker, cane, etc.)
2. Address transient causes for incontinence (other reasons that may prevent continent measures; e.g., fatigue, stroke, depression, infection, poor balance, poor muscle strength, etc.)
3. If urinary and/or fecal incontinence is not resolved after attempts to address transient causes, review three days of voiding data .
4. Develop individualized interventions and plan of care .
5. Implement revisions to the plan of care as needed .
B. Record review of R #15's EHR (Electronic Health Record) revealed that he was admitted to the facility on [DATE] for the following pertinent diagnosis: epilepsy (a disorder in which nerve cell activity in the brain is disturbed and causes seizures- temporary abnormalities in muscle tone or movements; stiffness, twitching or limpness, behaviors, sensations or states of awareness), unspecified, without epilepticus, repeated falls, flaccid hemiplegia (paralysis of one side of the body) affecting left nondominant side, and IBS (irritable bowel syndrome- a group of symptoms that occur together, including repeated pain in your abdomen and changes in your bowel movements, which may be diarrhea, constipation, or both).
C. Record review of care plan, last reviewed 04/14/23, revealed:
Focus: [Name of R #15] is incontinent of urine with potential for improved control or management of
urinary elimination. Date Initiated: 03/15/2023
Goal: [Name of R #15] will demonstrate improved urinary elimination control as evidenced by experiencing less than 1 episodes of urinary incontinence per day. Date Initiated: 03/15/2023
Intervention: Assist [Name of R #15] to the toilet at scheduled times i.e. upon rising, before meals, at
HS [night], and as needed. Date Initiated: 04/14/2023, Encourage [Name of R #15] to consume all fluids during meals. Offer/encourage fluids of choice. Date Initiated: 04/14/2023
D. Record review of physician orders, dated 03/24/23, revealed the following order Certified Nurse Assistant [CNA] to toilet resident before and after meals. Before meals for toileting and after meals for toileting
E. Record review of the EHR revealed that R #15 did not have any urinary or bowel incontinence assessments.
F. On 05/04/23 at 12:20 pm, during an interview with the ADON/IP (Assistant Director of Nursing/Infection Preventionist), when asked to explain R #15's care plan entry related urine incontinence, she stated The care plan should have triggered a urinary continence assessment. The results of the assessment are reviewed by the Director of Nursing (DON) and the provider and then a regimen is developed for the bowel & bladder program. He is on a toileting schedule [as ordered] and we did that due to his falls but we missed a step by not doing the assessment. I thought I did a urinary assessment for him. We did have an instance where one of our nurses erased all of our assessments and I don't know if that [R #15's] was one of them. We have since trained the nurses about assessments. After you go through the assessment it gives you a score of what the bowel and bladder program should look like. The physical therapist was worried about him needing to get to the bathroom and that would be an intervention for his fall. So we were planning on reviewing it to see if it was effective. We haven't evaluated him since though.
CONCERN
(D)
Potential for Harm - no one hurt, but risky conditions existed
Pharmacy Services
(Tag F0755)
Could have caused harm · This affected 1 resident
Based on observation, interview, and record review, the facility failed to properly document the administration of a narcotic medication (a drug that produces analgesia, narcosis, and addiction. It is...
Read full inspector narrative →
Based on observation, interview, and record review, the facility failed to properly document the administration of a narcotic medication (a drug that produces analgesia, narcosis, and addiction. It is also known to produce euphoria in some people) for 1 resident (R #81) of 1(R #81) residents record of compliance of record keeping in the controlled substance log (A book that allows on coming nurses to count narcotics medications in the nursing cart). If the facility is not ensuring that controlled drugs are not appropriately documented at the time of administration, it could cause a narcotic medication discrepancy. The findings are:
A. On 05/02/23 at 9:46 am, during an observation of med pass it was noted that the Controlled Substance book was missing a signature for 04/23/23 for R# 81.
B. Record Review for R #81 physicians order revealed an order for LORazapam (abenzodiazepine used to treat anxiety disorders) 0.5 MG (milligrams) 1 time a day for Anxiety (Feeling nervous or tense. impending doom).
C. On 05/02/23 at 09:26 am, during an interview with Certified Medication Assistant (CMA) #1, stated that another CMA failed to sign that the medication was given in the controlled substance book, and that they weren't in the facility at that time, however when they returned, they would sign the medication out. A post it note was left asking that the blank space be filled out, no signature of who wrote the note.
D. On 05/04/23 at 11:45 am, during an interview with the Center Nursing Executive (CNE) she stated her expectations for signing out a controlled substance is that they would catch it during count so that the individual wouldn't have to be called back to sign it back out. CNE stated that it could cause discrepancy at the time and could lead to a question of are they really count or just taking keys. Nursing staff would need to sign out the controlled substance ensuring that the count was correct, and that a drug diversion was not taking place. Nurses usually do the count of the controlled substance book when one nurse is leaving a shift, and the other one is coming on. At this time the keys are turned over from the nurse leaving their shift, to the one coming on to their shift.
E. Record review of the facility's policy and procedure titled: Controlled Drugs: Management of, last revision date 04/01/22 revealed the following: Ongoing inventory: A complete count of all Schedule ll-lV controlled substances (Schedule II drugs, substances, or chemicals are defined as drugs with a high potential for abuse, with use potentially leading to severe psychological or physical dependence. Schedule IV drugs, substances, or chemicals are defined as drugs with a low potential for abuse and low risk of dependence) is required at the change of shifts per state regulations or at any time in which narcotic keys are surrendered from one licensed nursing staff to another. The count must be performed by two licensed nurses and/or authorized nursing personal, per state regulations.
CONCERN
(D)
Potential for Harm - no one hurt, but risky conditions existed
Deficiency F0757
(Tag F0757)
Could have caused harm · This affected 1 resident
Based on record review and interview, the facility failed to ensure that the the pharmacist recommendations, which were documented as responded to by the Center Nursing Executive (CNE) were followed t...
Read full inspector narrative →
Based on record review and interview, the facility failed to ensure that the the pharmacist recommendations, which were documented as responded to by the Center Nursing Executive (CNE) were followed through for 1 (R #74) of 3 (R #s 74, 94 and 197) residents sampled for drug (medication) regimen review (thorough evaluation of the medication regimen of a resident, with the goal of promoting positive outcomes and minimizing adverse consequences [undesirable effects of medication]) by not completing a lab screening for INR levels (blood test that that determines how well a person is responding to Warfarin - a blood thinning medication).
This deficient practice could likely result in residents receiving medications that may have adverse consequences, receiving medications longer than needed or at a higher or incorrect dose. The findings are:
A. Record review of Face Sheet dated 08/13/22 for R #74 revealed this as an initial admission date and included the following diagnoses: Long Term Use of Anticoagulants (blood thinning medications) and Atherosclerotic Heart Disease (a condition where the arteries become narrowed and hardened due to buildup of plaque (fats) in the artery wall.)
B. Record review of Medication Regimen Review dated 11/16/22 - 11/17/22 for R #74 revealed, Comment: [Name of R #74] receives Warfarin (blood thinning medication) and the prescriber ordered an INR lab on 10/26/22. The result was not documented in the medical record at the time of this review. Recommendation: Please ensure that the INR was obtained, communicating the result to the prescriber and documenting the INR result and any additional notes in the medical record Director of Nursing Comments: Circled the note and had handwritten double exclamation marks and is signed and dated 11/21/22.
C. Record review of Physicians orders for R #74 revealed the following:
- Warfarin Sodium Tablet 4 MG (milligrams). Give 1 tablet by mouth one time a day for antiplatelet (medicines that reduce the ability of platelets [blood cells] to stick together and inhibit [prevent] the formation of blood clots) Start date: 08/14/22.
- Eliquis Oral Tablet 5 MG. Give 1 tablet by mouth 2 times a day for Atherosclerotic Heart Disease. Start date: 04/12/23.
D. Record review of electronic medical record revealed no documented results for INR levels until 03/21/23.
E. Record review of Medication Administration Record (MAR) dated October 2022 for R #74 revealed that Warfarin Sodium Tablet 4 MG was administered as ordered 10/01/22 - 10/31/22.
F. Record review of MAR dated November 2022 for R #74 revealed that Warfarin Sodium Tablet 4 MG was administered as ordered 11/01/22 - 11/30/22.
G. Record review of MAR dated April 2023 for R #74 revealed that Warfarin . D/C dated: 04/11/23. was administered as ordered on 04/01/23 - 04/10/23.
H. Record review of MAR dated April 2023 for R #74 revealed that Eliquis Oral Tablet 5 MG was administered as ordered on 04/12/23 - 04/30/23.
I. On 05/05/23 at 11:41 am during an interview, the Center Nursing Executive (CNE) stated that [name of R #74] was changed from Warfarin to Eliquis (medication used to reduce the risk of stroke and blood clots) so they wouldn't have to have the INR levels checked as often.
J. On 05/05/23 at 1:22 pm during an interview with the CNE, she stated that she called the hospital lab and they stated that there wasn't enough of a sample (a small part or quantity of something to show what the whole is like) on 10/26/22 to run the INR test on that date. [there is no documentation regarding communication between the hospital and facility regarding this.]
K. On 05/05/23 at 2:56 pm during an interview, the CNE and Center Executive Director (CED) stated that they contacted the hospital lab and were given documentation, today, showing that the INR test was not able to be run because there was not enough of a sample, they stated that the hospital told them they could not go that far back to check to see if there was any communication from the hospital to the facility requesting another draw for the test.
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 and interviews, the facility failed to:
1) Ensure that opened and accessed (if [NAME]-dose vial has been op...
Read full inspector narrative →
**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation and interviews, the facility failed to:
1) Ensure that opened and accessed (if [NAME]-dose vial has been opened or accessed {e.g needle puntered} the vial should be dated with the last date that the product should be used {expiration date} and discarded with in 28 days unless the manufacturer specifies a different use by date) multi-use vials (a vial of liquid medication that contains more than one dose of the medication) were dated as to when they were initially opened/assessed, by nursing staff.
2) Ensure that expired medications were not stored with unexpired medications, that were readily available for resident use; and
3) Ensure that treatment carts are kept locked when not in use.
These deficient practices have the likelihood to result in the 19 residents that were identified on daibetis list provided by the ADON on 05/05/02, to receive expired medications that have either lost their potency, or effectiveness; medications that were undated continued to be accessed and stored with active medications. The findings are:
A. Record review of the facility's policy and procedure/policy titled, Storage and Expiration Dating of Medications, Biologicals (are made from a variety of natural sources- humans, animals, or microorganisms. Biologicals are used to treat, prevent, or diagnose disease and medical conditions), last revision 07/21/22, revealed the following: Facility should ensure that medications and biologicals that (1) have an expired date on the label; (2) have been retained longer than recommended by manufacturer or supplier guidelines; or (3) have been contaminated or deteriorated, are stored separate from the other medications until destroyed or returned to the pharmacy or supplier. 5:3 If a multi dose vial of an injectable medication has been opened or accessed (e.g., needle-punctured), the vial should be dated and discarded within 28 days unless the manufacturer specifies a different (shorted or longer) date for that opened vial.
Opened and Labeled Medications:
B. On 05/02/23 at 8:12 am, during an observation of Nurses med cart revealed the following:
1. One (1) multi-dose vial of Levemir (is a long-acting insulin that can be taken once or twice daily to control high blood sugar) was opened and empty, vial was undated.
2. One (1) multi-dose vial of Novolin R (a type of insulin used to control blood sugar for many hours during the day) had an open date, however no use by date (that means users are supposed to mark the date they open a vial or begin using a pen, and then keep track and discard it after 28 days) was on the vail.
3. One (1) multi-dose vial of Lantus (is a man-made form of a hormone (insulin) that is produced in the body. Insulin is a hormone that works by lowering levels of glucose) had an open date on it however there was no use by date.
4. One (1) multi dose vial of Novolog (is a rapid-acting insulin that helps lower mealtime blood sugar spikes in adults and children with diabetes.) Vial had no open or use by date.
5. One (1) multi-dose vial of Novolin 70/30 (It is a mixture of 70% intermediate-acting insulin (isophane), and 30% short-acting insulin (regular) was opened and empty, vial was undated.
C. On 05/02/23 at 1:43 pm, during an observation of the nurse's medication storage room, the following was revealed:
1. One bottle of Naproxen 220 mg (milligrams), is used to relieve pain from various conditions such as headache, muscle aches, tendonitis, dental pain, and menstrual cramps) was expired on 01/23. This was observed in the storage unit with non-expired medications.
D. On 05/03/23 at 8:30 am, during an interview, Registered Nurse (RN) #3 confirmed the vials found were house stock (medications utilized by the entire facility) they use for residents, and they should be dated with both an open date and a use by date. She stated the dates must have been rubbed off during use and that is why they are not there. RN #3 also confirmed the boxes (original container they are kept in) must have been thrown away as they weren't in the med cart with the insulin vials.
Medication Storage:
E. On 05/02/23 at 1:43 pm, during an interview with the Assistant Director of Nursing (ADON) when asked about how expired medications are disposed of, she stated that if they are in the medication storage room then our central supply would take care of ensuring they are disposed of.
F. On 05/03/23 at 1:05 pm, during an interview with Central Supply (clerk) stated, I usually place the ones with the most recent expiration date in the front so they are used first As for the Naproxen, I just forgot to pull it on the first of the month. I am just learning to do the medicine room cabinets (where the house stock medications are kept) because I haven't been doing this job for very long.
Unlocked Treatment Carts:
G. On 05/02/23 at 9:49 am, during an observation of the Nurses treatment care, the cart was observed to be unlocked, with no authorized personnel around the cart.
H. On 05/02/23 at 9:49 am, during an interview with RN #1 confirmed the treatment cart was unlocked, with no authorized personnel around cart.
I. On 05/04/23 at 8:43 am, during an observation of the Nurses treatment cart, the cart was observed to be unlocked, with no authorized personnel around the cart.
J. On 05/04/23 at 8:45 am, during interview with RN #4 confirmed that the cart was unlocked. She stated her expectations are that anytime the nurse leaves the cart that it should be locked.
K. On 05/04/23 at 5:30 pm, during observation of the Nurses treatment cart, it was observed the Nurses treatment cart to be unlocked, with no authorized personnel around the cart.
L. On 05/04/23 at 5:30 pm, during the interview with RN #3 confirmed the cart was unlocked. She stated, Oh my gosh I will never let this happen again, and then she locked it.
M. On 05/05/23 at 9:21 am, during observation of the Nurses treatment cart, it was observed the Nurses cart to be unlocked, with no authorized personnel around the cart.
N. On 05/05/23 at 9:21 am during interview with the ADON, she confirmed the cart was unlocked. ADON stated, It should always be locked as soon as the nurse leaves the cart.
CONCERN
(E)
Potential for Harm - no one hurt, but risky conditions existed
Deficiency F0657
(Tag F0657)
Could have caused harm · This affected multiple residents
**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on record review and interview, the facility failed to update a residents care plan to reflect new diagnosis and treatment...
Read full inspector narrative →
**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on record review and interview, the facility failed to update a residents care plan to reflect new diagnosis and treatment plans for 2 (R #15 & R #92) of 2 (R #15 & R #92) residents reviewed for comprehensive care plans. This deficient practice could likely result in resident care not being closely monitored and managed to meet the needs of the resident.
The findings are:
A. Record review of the facility policy Person Centered Care Plan, last revised 10/24/22, revealed the following: 4. A comprehensive person-centered care plan must be developed for each patient and must describe the following: 4.1 Services that are to be furnished; . 6.1 The care plan must be customized to each individual patient's preferences and needs.
Findings for R #15:
B. Record review of R #15's EHR (Electronic Health Record) revealed that he was admitted to the facility on [DATE] for the following diagnosis: epilepsy (a disorder in which nerve cell activity in the brain is disturbed and causes seizures- temporary abnormalities in muscle tone or movements; stiffness, twitching or limpness, behaviors, sensations or states of awareness), unspecified, without epilepticus, repeated falls, and flaccid hemiplegia (paralysis of one side of the body) affecting left nondominant side.
C. Record review of physician orders, dated 04/21/23, revealed the following medication order: Phenobarbital (antiseizure medication) oral tablet 34.8 mg, [milligrams] give 1 tablet by mouth at bedtime
D. Record review of EHR revealed R #15 experienced a fall on the following dates:
01/02/23, 01/08/23, 01/24/23, and 03/19/23.
E. Record review of care plan, last reviewed 04/14/23, revealed that R #15 did not have information related to his seizure disorder, the prescribed use of Phenobarbital, or repeat falls.
F. On 05/04/23 at 10:57 am, during an interview with the ADON/IP (Assistant Director of Nursing/Infection Preventionist), when asked if R #15's care plan should include information related to his seizure disorder, the prescribed use of Phenobarbital, and repeat falls, she confirmed yes.
Findings for R # 92:
G. Record review of R #92's EHR revealed that R #92 was admitted to the facility on [DATE] with the pertinent diagnosis of: unspecified dementia without behavioral disturbance, and type 2 diabetes.
H. Record review of physician notes, dated 02/12/23, revealed that R #92 was sent to the hospital for symptoms of a UTI (Urinary Tract Infection).
I. Record review of physician notes, dated 03/05/23, revealed that after R #92 returned to the facility on [DATE], she (R #92) was found to be positive for C. diff (Clostridioides difficile- a bacteria that causes infection that results from the disruption of normal healthy bacteria in the colon, often from antibiotics. It can cause severe damage to the colon. C. difficile requires contact precautions, a gown and gloves must be worn when providing patient care, as it can be transmitted from person to person by spores) where the treatment plan included contact precautions and Fidaxomicin (an antibiotic often used to treat C. diff)
J. Record review of R #92's EHR revealed that she was sent to the hospital on [DATE].
K. Record review of hospital notes, dated 03/08/23 revealed that R #92 was being treated for the following pertinent diagnosis: sepsis (when an existing infection causes the body to have a chain reaction resulting in damage to multiple organ systems often leading to death) from HAP (Hospital acquired pneumonia), C.Diff, and DVT (deep vein thrombosis- a blood clot that forms in one or more of the deep veins in the body).
L. Record review of physician orders revealed the following:
Physician order, dated 03/03/23, order for Fidaxomicin Oral Tablet 200 MG (Fidaxomicin), give 200 MG by mouth two times a day for C. Diff until 03/07/2023.
Physician order, dated 03/03/23, order for Apixaban [an anticoagulant medication used to treat and prevent blood clots] oral tablet 5 MG, give 5 MG by mouth two times a day for DVT.
M. Record review of R #92's care plan, revealed that her care plan did not contain information related to her diagnosis of the following:
A new diagnosis of C. diff, which would require staff to follow specific infection control precautions and be familiar with the side effects of the antibiotic treatment.
A new diagnosis of DVT and the the signs and symptoms to be aware of along with the side effects of an anticoagulant.
N. On 05/04/23 04:24 pm, during an interview with the ADON/IP, she confirmed that R #92's care plan did not have information related to R #92's diagnosis of C. diff or DVT. She then confirmed that if a resident becomes positive for C. Diff, the care plan should reflect their new diagnosis of C. Diff and if a resident is prescribed an antibiotic, their care plan should reflect the use of an antibiotic. She also confirmed that if a resident is prescribed an anticoagulant, their care plan should reflect the use of an antibiotic.
CONCERN
(E)
Potential for Harm - no one hurt, but risky conditions existed
ADL Care
(Tag F0677)
Could have caused harm · This affected multiple residents
Based on record review and interview the facility failed to ensure residents maintained personal grooming for 2 (R #13 and 23) of 3 (R #13, 23 and 34) residents reviewed for Activities of Daily Living...
Read full inspector narrative →
Based on record review and interview the facility failed to ensure residents maintained personal grooming for 2 (R #13 and 23) of 3 (R #13, 23 and 34) residents reviewed for Activities of Daily Living (ADLs)/nail grooming. These deficient practices could likely affect the health of the residents, causing pain in their feet and issues with their shoes not being comfortable. The findings are:
R #13
A. On 05/01/23 at 11:30 am, during an interview with R #13, he stated that he is not diabetic but needs his toenails cut. They don't cut them here and they are too long and it hurts when I have my shoes on.
B. Record review of the physician orders indicated that an order on 10/21/22: Refer to Podiatry: Right Great toe nail dislocated.
C. Record review of R #13's medical chart did not reveal that an appointment was made for podiatry.
D. Record review of the physician orders indicated that an order on 01/03/23: Referral to Podiatry: to get toenails clipped.
E. Record review of R #13's medical chart did not reveal that an appointment was made for podiatry.
R #23
F. On 05/05/23 at 1:40 pm, during an interview with R #23 she indicated by pointing that her toenails hurt. When asked if they needed to be cut she nodded yes.
G. Record review of the podiatry list (a list of residents requiring podiatry services) for 01/17/23 indicated that she was on the list to be seen. There was no documentation in the medical record of R #23 being seen on the 17th.
H. On 05/05/23 at 8:26 am, during an interview with Assistant Director of Nursing (ADON), she stated that podiatry used to come in once per month and they would see diabetics first and anyone else would be seen or evaluated. They stopped coming because the business closed. The last time podiatry was out was in November 2022. Podiatry always looks at and cuts Diabetic residents toenails and will also look at other residents feet and toes if there is an issue or concern.
CONCERN
(E)
Potential for Harm - no one hurt, but risky conditions existed
Deficiency F0760
(Tag F0760)
Could have caused harm · This affected multiple residents
**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on record review and interview, the facility failed to notify the physician that nursing staff did not obtain and administ...
Read full inspector narrative →
**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on record review and interview, the facility failed to notify the physician that nursing staff did not obtain and administer medications for 2 (R #48 and #92) of 3 (R #15, #48, #92) residents reviewed for medication regimen. This deficient practice could likely result in residents not receiving medication as ordered for treatment of infection and disease. The findings are:
A. Record review of job aid titled 5 Step Medication Order Quick Reference Guide, not dated,
1. Determine Time Next Dose Due .
2. Determine Estimated Delivery Time (EDT)- . If EDT is > [later that] time dose is due, go to next step.
3. Pull From On-site Inventory (eKit/Omnicell)- Determine if the med [medicine] is available on-site in the eKit or Omnicell. If not, go to next step
4. Urgent Action Needed -Call the prescriber to get the med changed to something in the Omnicell/eKit or call the pharmacy to request the med be delivered STAT [immediately]. Be sure to inform the pharmacy when the next dose is due .
5. Enter RMS Pharmacy Alert [notification for pharmacist and physician]- If the medication was not available because it was not delivered before it was due, enter a RMS Pharmacy Alert. Be sure to provide details such as; patient, medications, who you spoke with and pharmacy response.
Findings for R #92
B. Record review of R #92's EHR (Electronic Health Record) revealed that R #92 was admitted to the facility on [DATE] with the pertinent diagnosis of: unspecified dementia without behavioral disturbance (a term for several diseases that affect memory, thinking, and the ability to perform daily activities), hypothyroidism [a condition in which the thyroid gland doesn't produce enough thyroid hormone] , and type 2 diabetes (a chronic condition that affects the way the body processes blood sugar).
C. Record review of EHR revealed that R #92 was sent to the hospital on [DATE] through 03/03/23.
D. Record review of hospital documentation, for encounter dates 02/22/23-03/03/23, revealed that R #92 was found to be positive for C. diff (Clostridioides difficile- a bacteria that causes infection that results from the disruption of normal healthy bacteria in the colon, often from antibiotics. It can cause severe damage to the colon) where the treatment plan included Fidaxomicin (an antibiotic) for 10 days, with the start date of 02/24/23 (end date of 03/05/23). Further review revealed a DVT (deep vein thrombosis- a blood clot that forms in one or more of the deep veins in the body) was found in her lower left extremity and apixaban [an anticoagulant medication used to treat and prevent blood clots] was started upon admission.
E. Record review of the facility's physician orders revealed the following:
Physician order, dated 03/03/23, Fidaxomicin [a type of antibiotic] Oral Tablet 200 MG [milligrams]), give 200 MG by mouth two times a day for C. Diff until 03/07/2023.
Physician order, dated 03/03/23, Apixaban [an anticoagulant medication used to treat and prevent blood clots] oral tablet 5 MG, give 5 MG by mouth two times a day for DVT.
Physician order, dated 05/18/22, Levothyroxine Sodium Tablet [a medication used to treat hypothyroidism] 50 MCG [micrograms], give 1 tablet by mouth one time a day for thyroid. Take on an empty stomach
F. Record review of the MAR (Medication Administration Record) for March of 2023 revealed that R #92 did not receive Fidaxomicin, Apixaban, or Levothyroxine Sodium on 03/03/23, 03/04/23, or 03/05/23.
G. Record review of nursing notes revealed that there was no documentation related to staff notifying the physician of the medication being unavailable or not administered.
H. On 05/05/23 at 8:28 am, during an interview with the Assistant Director of Nursing (ADON)/Infection Prevenionist (IP) and the Center Nursing Executive (CNE), they explained Fidaxomicin was ordered on the 4th [03/04/23]. It came in on the 5th. It was delivered in the morning but not before the morning med pass. The hospital documentation says that her C .Diff med was started on 02/24/23 and was ordered to be given for 10 days. Her order in the facility says to stop on 03/07/23 and I think it was extended due to an expectation of delay in acquiring the medication. They [nursing staff] then held the medication on the last dose because she was pocketing food and medications. When asked why Apixaban and Levothyroxine were not administered, they explained The nurses and med techs have been reeducated on access to resources. There were 2 nurses and a med aid that did not check the Omnicell [a back-up medication system that is automated to dispense medication] for the Apixaban or Levothyroxine. They were both available. I don't know why they didn't get it form the Omnicell. One of those nurses is a PRN [as needed] nurse and I don't know if she didn't think she had access to the Omnicell and the other nurse was an agency nurse [contracted to work in the facility for a certain amount of weeks]. The agency nurse is no longer with us and the PRN nurse has been educated.
I. On 05/05/23 at 1:26 pm, during an interview with the CNE, when asked if the nurses should notify the doctor if an ordered medication was not administered she replied Yes, they should always say if they are not able to get a medication and if they are not able to they should notify the CNE or the doctor
Findings R #48
J. Record review of the progress notes dated 4/20/23 indicated an order for Clindamycin HCl (an antibiotic) Capsule 150 mg (milligrams). Give 1 capsule by mouth three times a day for hand infection for 10 Days from 04/20/23 to 04/30/23.
K. Record review of the progress notes dated 4/21/23 indicated that the hospital notified the facility of microbiology (is the study of microorganisms) results for R #48's hand infection. The report indicated that resident had methicillin-resistant staphylococcus aureus (MRSA is a staph bacteria living on their skin or in their noses without it causing any problems. If staph bacteria get into a person's body through a cut, scrape, or rash, they can cause minor skin infections).
L. Record review of the physician orders indicated that an order for Clindamycin 150 mg to be given by mouth three times per day for hand infection for 10 days.
M. Record review of the Medication Administration Record (MAR) for the month of April 2023 indicated that the Clindamycin was not given on Friday 04/21/23 at 9 am and 1 pm. Monday 04/24/23 at 1 pm, Wednesday 04/26/23 at 1 pm and Friday 04/28/23 at 1 pm.
N. Record review of physician orders indicated that R #48 was going to dialysis (a blood purifying treatment given when kidney function is not optimum) on Monday, Wednesday and Friday chair time at 10:10 am. Resident was out of the facility at 1 pm on Monday, Wednesday and Friday (usually doesn't return until after 2:30 pm).
O. On 05/03/23 at 10:30 am during an interview with Certified Medication Assistant (CMA) #5, she stated that if a resident is out at an appointment when medications are scheduled she will mark the away code on the MAR. She stated that they have an hour before and after scheduled time to give a medication, it is is past that time it will be marked as a missed dose. Even if it is an antibiotic they will just mark it as a missed dose.
P. On 05/03/23 at 2:13 pm, during an interview with the Assistant Director of Nursing (ADON), she stated that they will always try to make sure that a resident is getting their antibiotics. They will schedule a time around the appointments if they have to. They can notify the physician and have orders changed if needed. She stated that no they should not be missing doses of antibiotics. She wasn't aware if the physician had been notified but she would guess that he hadn't because the order had never been changed.
Q. On 05/05/23 at 1:23 pm, during an interview with Center Nursing Executive (CNE) she stated that they don't want residents missing doses of antibiotics. They also don't want medications to be dialyzed out of their system. So they have to adjust times to give the antibiotics. She confirmed that R #48 should have had his antibiotics as ordered and not just missed doses because he was at his appointment.
R. On 05/05/23 at 1:31 pm, during an interview with the CNE, she stated that the way the physician ordered it, the antibiotic should have been given to the driver to give to the dialysis center. The dialysis center would have made sure to give it to the resident.
CONCERN
(E)
Potential for Harm - no one hurt, but risky conditions existed
Infection Control
(Tag F0880)
Could have caused harm · This affected multiple residents
Based on observation, interview, and record review the facility failed to ensure that glucometer's (a medical device to measure glucose {sugar} levels in the blood) utilized by the facility for more t...
Read full inspector narrative →
Based on observation, interview, and record review the facility failed to ensure that glucometer's (a medical device to measure glucose {sugar} levels in the blood) utilized by the facility for more than one resident, was disinfected per manufacturer's instructions after each time one is used, for 2 (R #5 and R #10) of 17 (R #4,R #5, R #10, R #20, R #26, R #35, R #36, R #37, R #39, R #56, R #67, R #68, R #92, R #197, R #200, R #204, and R #205) residents that receive capillary (small blood vessels) blood glucose (CBG capillary blood glucose) monitoring with glucometers. Nursing staff should be doing hand hygiene before and after each resident. This deficient practice may likely result in the spread of infection agents (viruses and bacteria) between residents and or staff who utilize glucometers. The findings are:
A. On 05/02/23 at 8:40 am, during an observation of Registered Nurse (RN) #1 checking R #5 CBG. RN #1 pulled glucometer from caddy without disinfect the glucometer before use. RN #1 did not perform hand hygiene prior to donning gloves (putting gloves on), and after the CBG test was completed for R#5, RN # 1 was observed placing the used glucometer #1 in a small caddy (this is where supplies {lancets, glucose strips, and alcohol pads} were stored to check residents CBG's while in R #5's room. RN #1 doffed (took off gloves) gloves and walked out of the residents room with the caddy. No hand hygiene was performed. RN #1 walked back to the nursing cart, wiped down glucometer #1 with a Moist Towelette (a wet wipe, also known as a wet towel, or a disposable wipe is a small to medium sized moistened piece of plastic or cloth that either comes folded and individually wrapped or, in a case of dispensers) before she placed the clean glucometer in a plastic cup. At no time was any hand hygiene performed. RN #1 stated they use two glucometers, located in the nursing cart on residents who need a glucometer check. They interchange them out every other resident to allow for the dry time (recommended length of time between using the disinfectant wipe, and they it can be used again).
B. On 05/02/23 at 9:11 am, during an observation of RN #1 checking R #10 CBG, prior to CBG test, RN #1 did not to perform hand hygiene prior to donning gloves. RN #1 pulled glucometer #2 from small caddy and did not disinfect the glucometer before use. After CBG test was completed RN #1 was observed placing glucometer #2 in a small caddy. RN #1 walked back to the nursing cart, wiped down the blood glucometer #2 with a Moist Towelette and placed the glucometer in a cup to dry.
C. On 05/02/23 at 9:53 am, during an interview with the Assistant Director of Nursing (ADON)/ Infection Preventionist (IP) nurse she was asked what expectations she had for glucometer use when checking CBG's. ADON/IP stated the process was to have two glucometers on the cart. They use one on a resident, clean it and allow it to dry while they grab the other one. ADON/IP nurse stated they should do hand hygiene before and after each use, and before they put on their gloves to complete the test. When questioned about what they use to clean the glucometers the ADON/IP nurse grabbed a purple top container [Medline Micro-kill disinfecting, deodorizing, cleaning wipes with alcohol (Micro-kill on Germicide is a durable, cloth that feature quaterney ammonium {a group of chemicals used for a variety of purposes including preservatives, surfactants, and as an active ingredient in disinfectants and sanitizers} and alcohol solution]. Per the ADON, nurses have been educated to only take the needed supplies in the room with them and not the whole caddy.
D. On 05/02/23 at 11: 28 am, during an interview with RN #1 she stated she was educated on the cleaning of glucometers and that an unknown nurse had instructed her to use the Moist Towelette so that the cleaners wouldn't cause the glucometers not to work. RN #1 confirmed that this is how she had been cleaning the glucometers prior to today's [05/02/23] observation.
E. Record review of the facility's policy titled, Glucose Meter, last revised 01/01/12, revealed the following procedure for cleaning and infection control standards. Policy: to ensure the accuracy and validity of blood glucose monitoring, Residential Care Facility-owned blood glucose meters will be cleaned according to manufacturer's guidelines. Purpose: To maintain the equipment at the optimal level of functioning, prolong the life of the meter, and maintain infection control standards.
F. Record review of the manufacturer's instructions titled, Caring for Meter. Cleaning and Disinfecting your Meter.
To disinfect your meter, clean the meter with one of the validated disinfecting wipes listed below. Other EPA registered wipes may be used for disinfecting the Even G2 system, however these other wipes have not been validated and could affect the performance of your meter.
Dispatch hospital cleaner Disinfectant Towels with Bleach (EPA Registration Number: 56392-8.
Medline Micro Kill Disinfecting, Deodorizing, Cleaning Wipes with Alcohol (EPA Registration Number 59894-10).
Clorox Healthcare Bleach Germicidal and Disinfectant Wipes (EPA Registration Number: 67619-12).
Medline Micro Kill Bleach Germicidal Bleach Wipes (EPA Registration Number: 69687-1).
Wipe all external areas of the meter including both front and back surfaces until visibly clean. Avoid wetting the meter test strip port. Allow the surface of the meter to remain wet at room temperature for the contact time listed on the wipe's directions for use.
G. Record review of the diagnosis report for Diabetes Melliitus dated 05/02/23, revealed 17 other residents (R #4,R #5, R #10, R #20, R #26, R #35, R #36, R #37, R #39, R #56, R #67, R #68, R #92, R #197, R #200, R #204, and R #205) whose CBG's are checked using shared glucometers in the building.
H. Record review of the infection control log dated 05/02/23, revealed R #197 had a diagnosis of Clostridioides difficile (is a bacterium that causes an infection in the large intestines {colon} causing diarrhea (loose stools) to life threatening damage to the colon).
CONCERN
(F)
Potential for Harm - no one hurt, but risky conditions existed
Deficiency F0809
(Tag F0809)
Could have caused harm · This affected most or all residents
Based on record review, observation, and interviews, the facility failed to deliver consistently, and timely (to be prompt, be on time, and follow the times provided to the facility) lunch meals to 89...
Read full inspector narrative →
Based on record review, observation, and interviews, the facility failed to deliver consistently, and timely (to be prompt, be on time, and follow the times provided to the facility) lunch meals to 89 residents that receive trays in the dining rooms, and room trays, as identified on the facility matrix provided by Center Executive Director on 05/01/23. This deficient practice could potentially lead to resident frustration and hunger. The findings are:
A. Record review of the facility posted times revealed that the following times for the meal pass.
1. Breakfast will be served at 7:30 am.
2. Lunch will be served at 12:30 pm.
3. Supper will be served at 5:30 pm.
B. On 05/04/23 during an observation of the lunch meal pass, the following was noted.
1. Meal trays passed in the South dining room at 12:50 pm for a 12:30 pm mealtime. (20 min delay)
2. Meal trays passed on the North side dining room at 12:56 pm for a 12:30 pm mealtime. (26 min delay)
3. Meal trays arrived in the hallway at 1:15 pm for at 12:30 pm mealtime. (45 min delay)
4. Meal tray pass completed for hallway A, B, C and D at 1:30 pm for a mealtime of 12:30 pm. (1 hour delay)
C. On 05/05/23 at 10:20 am, during an interview with the Dietary Manager (DM), when asked what the food services responsibilities were for the meals getting out on time; she stated if my cook starts to fall behind that she would step in and help them serve. DM stated they have a hour from 12:30 pm to 1:30 pm, of time to get everything out and that is the way they are educated in the kitchen. It is policy. We have an hour to get everything out. When asked what the order for getting trays out to the dining rooms, and to the residents that eat in their rooms, DM stated, we start with the dining rooms, then we go to the hallways. We start breakfast at 7:30 am and get them all out in 20 minutes. DM was asked if when the trays are passed out if the first tray should be passed out at 12:30 pm for lunch. DM responded saying, it would be closer to 12:40 pm would be their expectation to serve the first tray.
D. On 05/05/23 at 11:23 am, during an interview with the Assistant Director of Nursing (ADON), she was asked what her expectation was for meal serving times. ADON responded with breakfast should be served between 8:00 am and 8:30 am. Lunch would be served from 12:00 pm to 12:30 pm and supper would be served between 5:00 pm and 5:30 pm and that they shouldn't be served later than the times posted.
E. On 05/05/23 during an observation of lunch meal pass the following was noted:
1. Meal trays passed in the South dining room at 12:50 pm for a 12:30 pm mealtime. (20 min delay)
2. Meal trays passed in the North dining room at 12:57 pm for a 12:30 pm mealtime. (27 min delay)
3. Meal trays arrived in the hallway at 1:17 pm for a 12:30 pm mealtime. (47 min delay)
4. Meal tray pass completed for hallways A, B, C, D at 1:45 pm for a mealtime of 12:30 pm. (1 hour and 15 min delay)
F. Record review of the facility's policy titled, Frequency of Meals, revised 09/17 revealed The dining services Director will ensure that each meal is served within the designated time frame unless there is an emergency situation or a resident request.
CONCERN
(F)
Potential for Harm - no one hurt, but risky conditions existed
Food Safety
(Tag F0812)
Could have caused harm · This affected most or all residents
Based on observation, interview and record review, the facility failed to
1. Follow policy procedure for sanitizing (method of reducing or eliminating pathogenic agents, such as bacteria, on the surf...
Read full inspector narrative →
Based on observation, interview and record review, the facility failed to
1. Follow policy procedure for sanitizing (method of reducing or eliminating pathogenic agents, such as bacteria, on the surfaces of something) food preparation areas and;
2. Serve a room tray at safe food temperatures (hot foods should be held and served at 135 degrees Fahrenheit)
These deficient practices could likely result in residents receiving food that may be contaminated due to unsanitized prep surfaces and poor handling/serving of food trays served in resident rooms.
The findings are:
Findings related to sanitizing technique:
A. Record review of the facility policy Cleaning and Sanitizing, not dated, revealed the following; Sanitizer solution should be tested for correct PPM (parts per million- the ratio of chemical to water) frequently . You must change your sanitizing solution every two hours or when it becomes soiled [dark, cloudy, or with debri] .
B. On 05/01/23 at 11:05 am, during an observation of the kitchen prep area, sanitizer solution was observed in a bucket sitting on a nearby cart. The solution in the bucket was observed to be dark and cloudy. The kitchen Manager was asked to use a test strip to measure the PPM, the concentration of sanitizing solution, to ensure that it was within effective range (between 50 and 100). Before the Kitchen Manager tested the water, a kitchen staff member placed a rag into the bucket to saturate and use it to wipe down her prep area. The Kitchen Manager tested the solution in the bucket and it was found to be reading at 200.
C. On 05/01/23 at 11:05 am, during an interview, the Kitchen Manager explained that the solution in the bucket should have been replaced as it was visibly tainted and when tested, the solution was not within the required concentration range. When asked how often the solution in the bucket should be replaced, she stated every 2 hours or as needed. When asked how the 2 hour mark was tracked, she explained that her staff were educated on when to change the sanitizing solution. When asked if the kitchen staff member who saturated her rag before testing the solution should have done so, she confirmed that the staff member should not have used the solution as it was out of range.
Resident #48
D. On 05/01/23 at 12:55 pm, an observation was made of the food cart with a sign on it indicating the following: If residents are at an appointment/out on pass/hospital/etc. Please bring trays back to the kitchen. Do not put them in the carts with the rest of the dirty trays they will be thrown out
E. On 05/01/23 at 3:01 pm, observation of lunch tray is sitting at R #48's bedside table untouched. (room trays usually go out around 12:30 pm)
F. On 05/02/23 at 9:54 am, during an interview with R #48, he stated that when he goes out to dialysis (a blood purifying treatment given when kidney function is not optimum) at around 11:00 am he does not receive a sack lunch or a snack when he goes out. He stated that yes, he gets hungry and will eat his lunch when he gets back to the facility. Yesterday he got back at 4 pm and ate the lunch that was still sitting there. He said since he is usually hungry, he will eat the lunch even if the ice cream has melted.
G. On 05/03/23 at 1:38 pm, observation of the lunch tray sitting at R #48's bedside table.
H. On 05/03/23 at 1:55 pm, during an interview with the Dietary Manager, she stated that room trays are not supposed to be left at the bedside table, they are supposed to be brought down to the kitchen and put in the fridge. She stated that sack lunches are available if the resident wants one. She will usually give it to the driver.
I. On 05/03/23 at 2:05 pm, during an interview with the Assistant Director of Nursing, she stated that
sack lunches are being given. If their chair time is closer to lunch they will typically get their lunch an hour early and eat before they leave for dialysis. If they are gone before the tray comes out then it will be put it in the fridge and heated up when they return. She confirmed that the staff should not be leaving the lunch tray on the bedside table until the resident returns.
Feb 2023
6 deficiencies
1 Harm
SERIOUS
(G)
📢 Someone Reported This
A family member, employee, or ombudsman was alarmed enough to file a formal complaint
Actual Harm - a resident was hurt due to facility failures
Free from Abuse/Neglect
(Tag F0600)
A resident was harmed · This affected 1 resident
**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on record review and interview, that facility failed to ensure residents were free from abuse for 1 (R #4) of 7 (R #'s 4, ...
Read full inspector narrative →
**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on record review and interview, that facility failed to ensure residents were free from abuse for 1 (R #4) of 7 (R #'s 4, 6, 7, 8, 9, 10, and 11) residents reviewed for allegations of abuse, when the facility failed to act on a reasonable suspicion of an intoxicated employee that had been accused of physically assaulting R #4. This deficient practice likely resulted in R #4 experiencing physical and psychosocial harm when the Nurse Assistant (NA) attempted to put the resident to bed and change her clothes while R #4 resisted. The findings are:
A. Record review of a facility self report, dated 10/13/22, revealed that R #4, who has a history of fluctuating mood and false allegations of neglect and 'rough' treatment, informed the nurse that she was attacked by the NA (Nurse Assistant) when asked to be laid down in bed. In her allegation, she (R #4) claims that the NA threw her onto the bed and was rough with her. She also said that the NA put her hand over her nose and she couldn't breath. The resident was then appropriately assisted by her nurse and sent to the ER (Emergency Room) to be evaluated. Further review revealed Conclusion: [name of NA], the nurse aide (NA) entered into [name of resident] (resident) room on October 10, 2022 to put the resident to bed. [name of resident], the resident, alleged that NA physically abused her. She has a history of mood changes and making false allegations. The NA alleged that the resident was not cooperative when she tried to assist her. The nurse met the resident soon after and provided the necessary nursing care. The hospital noted that the resident had a red mark on right collarbone with no other specific evidence of trauma found. The allegation is not confirmed.
B. Record review of R #4's hospital documentation, dated 10/10/22, revealed the following; . You were seen in the Emergency Department for reported assault. Your heart rate was elevated but improved after fluid [a sterile solution containing isotonic concentrations of electrolytes in water] and Tylenol [a medication used to treat fever and mild to moderate pain]. You have what appear to be a bruise on your skin over left collar bone [the bone that joins the breast bone and shoulder blades] .
C. Record review of the facility's investigative interviews with the staff members who worked on the night of the incident (10/10/22) revealed the following:
1. Investigative interview dated 10/10/22, . [name of alleged NA] was pushing one of the residents [in wheelchair] too fast and she was talking too loud.
2. Investigative interview dated 10/10/22, . [name of alleged NA] was in the restorative room with a resident, [name of resident], stating the resident's weight was more than hers, talking loud .
3. Investigative interview dated 10/10/22, . I saw [name of alleged NA] who worked in C hall, pushing resident, [name of resident], through D hall. She was asking him questions that I didn't understand .
4. Investigative interview dated 10/14/22, . [name of alleged NA] was very happy and loud, was wearing heavy perfume.
D. Record review of the police report, dated 10/10/22 at 21:53 (9:53 pm), revealed that On October 10, 2022 at about 2153 hours (9:53 pm) I was dispatched to [address of facility] in reference to possible elderly abuse. Upon arrival at 2205 (10:05 pm) I made contact with the Registered Nurse [name of RN #1] who reported the following. [name of RN #1] stated that [name of R #4] one of the residents was complaining of shoulder pain and was being prepared for transport to [name of hospital] further review revealed that after R #4 had asked the alleged NA to help her to bed, that the alleged NA pushed her onto bed and then put her hand over her nose and squeezed it until she could not breath and placed her hands over her neck, holding it. RN #1 then explained that R #4 requires assistance from 2 people as she is paralyzed from the waist down. RN #1 noticed that when she checked R #4 she saw redness around her nose, her forehead, and to the left side of her neck R #4 also complained about pain in her right shoulder. RN #1 also noted blood in her hand but she could not find where it was coming from as she did not see any open cuts, and she checked [name of R #4's] nose, mouth, and ears but saw no indication of blood. Further review revealed that the alleged NA was sent home prior to law enforcement being contacted and therefor an interview was not conducted.
E. Record review of nursing notes, dated 10/10/22, revealed the nurse was notified to check on R #4 by her roommate and when she tended to her, she found, Upon entering the room, resident became emotionally upset, crying, shaking and stating (in Navajo) 'I was attacked by the lady working when I asked her to lay me down and change me and she threw me into bed and did not change me. She was being rough with me. Put her hand over my nose and squeezed it and I couldn't breath. Then she choked me. She tied up my light string.' Resident appeared very disheveled, red markings apparent to face under eyes and around nose. Scratches and redness around neck right side. Blood observed on resident's hands R [right] hand on 3 knuckles and L [left] hand on knuckles and palm of hand that resident reports is from her nose. Redness to middle of forehead. redness to R [right] shoulder that resident reports 'it hurts from when the lady threw me into bed' Resident's undergarment brief heavily saturated with urine and BM [bowel movement] that spread from abdomen to her back. Sweatpants were also saturated with urine. Tank top that resident was wearing was backwards and inside out with both straps on L [left] shoulder. Further review of nursing notes, dated 10/13/22, revealed Visit with [name of R #4] , she said she is doing ok, sore on L [left] shoulder.
F. On 02/01/22 at 1:24 pm, during an interview with RN (Registered Nurse) #1, when asked to describe the night of the incident (10/10/22), she explained I remember coming onto night shift and the alleged NA was driving round with a male resident [pushing a resident in a wheel chair around the halls] and she was being loud and different than what we would know [different from usual]. We [other staff and I] noticed her being different, I didn't recognize her . Later that evening, the NA went into see a resident who was in room [ROOM NUMBER] and she [the NA] was crying and having an emotional outburst. We asked the NA what was going on and she said 'They are all fine' and she said that she was worried about [name of R #4's roommate]. I didn't receive any issues for [name of R #4's roommate] during report [exchange of information regarding resident status]. I was confused and I asked why. She said 'Her condition is getting worse.' I again asked if everything was OK, she said 'yea, I am just feeling really bad.' We said OK, well it happens when you get attached to the people you work with. We told her to go get a breath of fresh air and come back when ready. She went out the back door of C wing which was odd because the door is locked for resident safety and the alarm was blaring. [Name of R #4's roommate] was at the nurse's station and asked me to go check on [name of R #4]. She said something was not right. I went to check on [name of R #4] and she (R #4) had a very scared look on her face. I noticed that her tank top was inside out and backwards, and I believe it was a spaghetti strap where both straps were on one side of her head, and she looked very disheveled. What I could gather form her Navajo was that she was saying 'The woman who works here attacked me.' There were red markings on her neck, chin, jaw area and ear. She had dry blood on her fingers. Her call light was tied up and away. She wasn't dressed for bed. She is usually very particular about how she likes things, and she explained that the lady didn't change her [change her brief]. When she (R #4) asked to get into bed, she (the NA) threw her. RN #1 found a translator and the translating CNA said that R #4 said that the NA had attacked her by putting her hand on R #4's nose and mouth and then placed the call light button out of reach by rolling up the call light cord. RN #1 then explained that the The alleged NA was saying 'who did it' all the CNAs did not know what she was talking about . The NA said that [name of R #4] was mad at her, and she [the NA] felt bad. Another nurse helped me do a skin assessment and change her. We found that that she was completely soaked with BM [bowel movement]. She was crying and scared. The NA was coming back inside, and we decided to send her home . I asked her to leave since she was having a hard time in emotional distress. She went home . Everyone noticed that she (the NA) was displaying odd behavior. Her (the NA's) mom then called and asked if she had gone to work and I told her that she did go into work but I had to send her home and her mom said 'Ugh, I know why, she has fallen off the wagon' we called the police and sent [name of R #4] to the hospital, she said that her nose felt like she was swelling and it was red and seemed likely swollen. When asked to explain the NA's behavior, she explained She is typically quiet. I have worked with her only a few times and she is usually very quiet and does her work. When asked if the NA had a particular smell or odor, she confirmed no. When asked if R #4 has made similar allegations in the past, she explained Yea, she would make allegations that people weren't changing her or not answering her call light or generally being mean to her. She was rooming with another resident who would have the same behaviors and they would say claims of neglect but I don't think there was any full report on it and it was never proven but I know that the CNAs would say that she would say things like that or that people were rough with her but she hasn't made claims like that in a very long time. When asked to explain the blood that was found on R #4's hands, she explained It was on her fingertips, and it was dry, and I wiped her face to see if there was any source but I didn't notice anything and I asked her where the blood came from and she just kept saying that she was attacked. She then explained that in the past, she thinks the CNAs were encouraged to provide care for R #4 with another CNA present to provide a witness for any type of allegation.
G. On 02/01/23 at 2:59 pm, during an interview with the roommate of R #4, when asked if she remembers the night of the incident, she replied, no.
H. On 02/01/23 at 3:56 pm, during an interview with R #4, When asked to recall the incident that occurred on 10/10/22, she stated Ever since that happened my mind is not the same as it used to be. My memory is not as good as it used to be . She [the alleged NA] didn't say anything she just grabbed my neck . I had a bloody nose maybe from when she chocked me. I stated bleeding because it [the blood] was on my hand. When asked if she feels safe, she explained Sometimes I do not feel safe. I'm afraid sometimes of my old roommate and the NA. She then explained that this is why she wants to transfer to another facility.
I. On 02/02/23 at 9:39 am, during an interview with CNA #2, when asked to explain the night of the incident, he explained The nurse asked me to be a translator because I'm bilingual. She [R #4] said that the young lady who was taking care of her threw her in bed and tried to choke her. Her tank top was halfway taken off, she had some scratches or red areas on her neck and a bloody nose. She had wiped it down on her face. She was crying, she was shook up. When asked to recall if the alleged NA seemed different that night, he explained I do remember, the minute I walked in I noticed that she was loud, this NA is usually quite.
J. On 02/02/23 at 10:27 am, during an interview with CNA #3 (the alleged NA), when asked to explain what occurred during the night of the incident, she explained She [R #4] said that I was trying to break her neck and throwing her around. I'm not too sure what was happening, I was trying to put her to bed and she was being really stubborn. She has to be lifted with a gait belt [an assistive device used to transfer residents form one surface to another] to be put in bed. I put the gait belt around her and I was trying to lift her and she was holding onto the wheelchair and I told her to let go and I put her in the bed and she probably thought I threw her on the bed. I tried to change her clothes and she wouldn't let me change her clothes. I kind of speak Navajo and I heard her saying 'damn you' in Navajo. She is usually cooperative. I've never had a problem with her at all. It threw me off and I got really emotional about it because she was nice and we got along. I laid her down and tried to cover her with her blanket. When asked if she often refuses care, she explained Her roommate had already told me before when I went into the room that she was being stubborn all day. That she has done this in the past with other CNAs. When asked if the CNA from the previous shift reported this behavior to her that day, she explained She didn't say anything about her being stubborn. When asked what she was wearing, she explained She wasn't in her pajamas and she needed a brief change but she wouldn't let me help her. When asked if she was upset about anything, she explained No, I tried to talk to her the way I usually do, and she wouldn't talk to me. She just kept nudging me away, like she just kept shrugging her shoulders. It was like she didn't even recognize me or something. When asked if she touched her neck or nose, she explained No. I don't know why she would say that. I asked the other CNAs if I did anything wrong, I usually don't get bad comments from the elders and they said that other CNAs have been accused by her for being thrown around and being talked badly about by her. When asked if she consumed any alcoholic beverages before coming to work, she stated, no.
K. On 02/02/23 at 11:08 am, during an interview with CNA #'s 4 and 5, when asked to explain how R #4 is transferred from wheelchair to bed, they explained We use the sit-to-stand [a mechanical device that assist a patient from a sitting position to a standing position] with her. She is a full assist. To get into bed she needs 2 people. Sometimes she can stand, sometimes she cannot. It's different everyday. When asked how staff are aware when to use 2 people for her transfers, they explained with the sit-to-stand, someone has to hold her in the back and someone else has to help her in the front. Sometimes she will stand but it all depends on her knees. We will ask if its ok for her to stand and she will say yes or no but she doesn't stand for long. It's usually 2 people to transfer because you need 2 people to use the sit-to-stand. When asked if a gait belt is used for her, they explained Yes, we do use a gait belt, when we put her to bed if were not using the sit-to-stand. Her preferred method of transfer is 50/50 [between using the sit-to-stand or the gait belt]. When asked if she is able to make her needs known, they confirmed yes. When asked if they have noticed her make false allegations, they explained Sometimes she tells the truth, sometimes she lies . It's better to have 2 people with her so that someone can be a witness. We always go in at the same time to have 2 people. When asked how often does she make allegations, they explained Before, she would say things everyday. She would say things about with the young and new staff or if she just doesn't like certain ones. When asked if she has ever made a claim about a staff member being rough and placing their hands on her neck or nose, they explained She was telling us 'A lady put her hand on my neck' and threw her in bed. It was a new claim, it was the first time she said that. When asked if they were present during the night of the incident, they explained That NA would usually come in quiet but that day she was really happy. We were ready to give report and she came in happy and acting different. When asked if R #4 was refusing care that day, they explained No, she didn't refuse anything, she was still sitting in the wheelchair [at the end of shift] and we passed that on to the next shift. Then the next morning she was saying that that happened last night. She doesn't normally refuse When asked if she is able to dress herself, they explained that she can help get herself dressed but is not able to dress herself alone.
L. On 02/02/23 at 11:37 am, during an interview with CNA #6, when asked if she remembers the night of the incident, she explained That NA, she's normally quiet and she doesn't say a lot. That night when she came in she was loud and heavily scented with perfume. She was very loud and happy. I thought it was weird. I came back the next day and they said what happened with [name of R #4]. When asked if she recalled any red markings on R #4, she explained She did have red marks on her upper nose [on the next day after the incident]. I worked with her that day and they were not there when I left at 7 pm. When asked if R #4 refuses care, she stated not normally.
M. On 02/02/23 at 11:57 am, during an interview with CNA #7, when asked if she was familiar with the claims that R #4 makes against staff, she explained I think she has her favorites because with the senior CNAs, she's really nice to them. The younger ones or the ones who just came on board, she's mean to them. A lot of them don't speak Navajo, and that's a communication barrier. When asked of she was familiar with the incident, she explained About a couple of days after it happened, I was giving her a shower and she told me that a couple nights ago one of the girls came in, she said I don't know her name but she is a new one who is heavier set and she came in and threw me on the bed and shocked her and put her hands around her neck and put a pillow on her head and she said she tried to scream and almost lost her breath. When asked if she was familiar with the alleged NA, she explained One night [a different night] she came in different. When we work with her on day shift, she was usually really quiet, she only spoke when you spoke to her but on this particular night . December 24th. I saw her briefly at the nurses station and she was being really loud and I didn't know what she was saying but later on that night she got really wild. She was skipping down the hall and waiving her hands. She said she got a new phone and she was showing it off and she was taking pictures of us without permission. I was thinking that maybe she was more comfortable with a smaller crew but later in the night she was passed out [asleep] in the D wing in one of the vacant resident rooms. When asked if a nurse was aware of her behavior, she explained, Nobody said anything to the nurse but that the DON was made aware of it on the next day.
N. On 02/02/23 at 12:20 pm, during an interview with CNA #8, when asked to explain the type of help R #4 usually needs, she explained She is cooperative, she usually likes to lay down at about 8 pm. She needs assistance from the bed to the chair and the back. We usually check on her throughout the night. She likes to get up at about 5 am. She likes a certain way to dress at night. She tells us that she likes to wear a tank top and a night gown. She is usually a 2 person assist. Sometimes in the morning if I can't find somebody to help me I will tell her to stand with me and she will do it but only for a couple seconds. When asked if she refuses, she explained No, by the time we come on shift, she likes to lay down. If she's up, then I will usually lay her down between 7:30 and 8 pm. When asked if R #4 ever shrugs her away, she responded No, she has never shrugged me away. She's usually happy to lay down. When asked if she could recall the night of the incident, she explained She [the alleged NA] was hyper, running around, and I don't know, she's usually quite but this time she was over happy and jumping up and down. She just looked happy and almost excited. It was off because she's usually quiet. When asked if she has displayed this behavior on additional nights, she explained It was just that one night. The other rest of the nights she has been working on another wing.
O. On 02/02/23 at 5:01 pm, during an interview with the facility DON (Director of Nursing), when asked if she was aware of the alleged NA (CNA #3) acting differently and sleeping in a vacant bed on December 24th, she explained A CNA told me [the next day] that she had suspicions of her being intoxicated and I said, hey, why didn't you tell me when she was working. If I knew about it when it was happening, I would of confronted her and dealt with it. I would of took it to HR [Human Resources]. I had nothing in writing, so I didn't confront her about it. I didn't have any substantial information, it was just hearsay at the time. If I knew about it at the time, then I could of done something about it. She then confirmed that no investigation was conducted regarding her suspicious behaviors.
P. On 02/03/23 at 8:33 am, during an interview with the Administrator, when asked to explain the incident, he explained Generally, from what I was told, she came into the building, they [staff] said that she [the alleged NA] was happy, talking out loud and then an incident happened with the resident. She was trying to change the resident's clothes and the resident was not happy with it so she left the resident with her clothes partially taken off. The roommate came to the nurse, before she [the NA] did. The nurse went there and calmed the resident down, she was upset about how the lady treated her. The nurse made a report. I talked to the resident but it was difficult to get the information from her so I had to depend on other staff to translate. She complained that the staff member was rough with her. She told the nurse that she was attacked by the NA. She said that the NA threw her and was rough with her. I think I collected the information the next day or maybe even in the same night. When asked to explain how the alleged NA explained the incident, he explained She told me that she was trying to change her [R #4's] clothes, but she was not cooperating and she was not able to calm her down. She was trying to change her clothes and the resident pushed her away and the resident landed on the bed, and she [the alleged NA] was feeling stressed because she was not able to calm her down. She then left the room and the nurse talked with her and later she was sent home. When asked if she was intoxicated, he explained She said she had taken [consumed] alcohol the day before but not that day. She was sent home because we wanted to protect the resident. When asked if the police officer interviewed the alleged NA, he confirmed no, as she had left the building prior to the arrival of the officer. When asked if it is expected that the police officer interview the alleged NA, he confirmed yes. When asked if he felt as though this incident would be considered abuse, he confirmed, yes.
Q. On 02/06/23 at 3:40 pm, during an interview with the Administrator, when asked how R #4 developed a bruise on her left collarbone that was noted by the ER staff, he explained We thought it was her clothes that were causing redness because there was a struggle between the NA and [name of R #4] trying to get the clothes changed. When asked how a clothes change would cause redness on the jawline, he explained They were trying to pull the clothes with the arm in the neck and it caused the clothes to become tight on her neck. The NA explained to me that the resident was pulling the clothes. She pulled them half way before she had to leave the resident. And that is how the resident was found. She said that the resident was being difficult but she didn't know why. When asked to explain how the NA transferred the resident to bed, he explained I would say most likely the resident was not cooperating with her to be transferred. When asked, why did the NA proceeded with the transfer, he explained That is what I tried to let the NA know, the residents have their rights- If you are having difficulty with the residents then the supervisor should be informed. When asked if when the NA transferred the resident into bed even though the resident was refusing, that the transfer was an act of abuse, he explained She didn't respect the rights of the resident. The resident has the right to say no. When asked why he was not able to substantiate this allegation of abuse, he explained At that time, I couldn't confirm that she was drunk even though they [staff] said she was shouting and happy but none of them could tell if she smelled like alcohol and no one could confirm if she was drunk. Also, the resident has had incidents of false allegations. When asked if the NA was penalized as a result of the incident on 10/10/22, he explained that she received training and was suspended and asked to earn her NA certificate and was not allowed to return until she was certified. When asked if he was aware of the suspicious behavior on 12/24/22, he confirmed that he was not aware.
CONCERN
(D)
📢 Someone Reported This
A family member, employee, or ombudsman was alarmed enough to file a formal complaint
Potential for Harm - no one hurt, but risky conditions existed
Investigate Abuse
(Tag F0610)
Could have caused harm · This affected 1 resident
Based on record review and interview, the facility failed to maintain a process to report suspicious behavior and conduct a comprehensive investigation for 1 (R #4) of 1 (R #4) residents reviewed for ...
Read full inspector narrative →
Based on record review and interview, the facility failed to maintain a process to report suspicious behavior and conduct a comprehensive investigation for 1 (R #4) of 1 (R #4) residents reviewed for abuse. This deficient practice could likely result in residents being exposed to possible abuse and not receiving quality care and staff not being offered training opportunities regarding incidents.
The findings are:
A. Record review of a facility self report, dated 10/13/22, revealed that R #4, who has a history of fluctuating mood and false allegations of neglect and 'rough' treatment, informed the nurse that she was attacked by the NA (Nurse Assistant) when asked to be laid down in bed. In her allegation, she (R #4) claims that the NA threw her onto the bed and was rough with her. She also said that the NA put her hand over her nose and she couldn't breath. The resident was then appropriately assisted by her nurse and sent to the ER (Emergency Room) to be evaluated. Further review revealed Conclusion: [name of NA], the nurse aide (NA) entered into [name of resident] (resident) room on October 10, 2022 to put the resident to bed. [name of resident], the resident, alleged that NA physically abused her. She has a history of mood changes and making false allegations. The NA alleged that the resident was not cooperative when she tried to assist her. The nurse met the resident soon after and provided the necessary nursing care. The hospital noted that the resident had a red mark on right collarbone with no other specific evidence of trauma found. The allegation is not confirmed.
B. Record review of the facility's investigative interviews with the staff members who worked on the night of the incident (10/10/22) revealed the following:
1. Investigative interview dated 10/10/22, . [name of alleged NA] was pushing one of the residents [in wheelchair] too fast and she was talking too loud.
2. Investigative interview dated 10/10/22, . [name of alleged NA] was in the restorative room with a resident, [name of resident], stating the resident's weight was more than hers, talking loud .
3. Investigative interview dated 10/10/22, . I saw [name of alleged NA] who worked in C hall, pushing resident, [name of resident], through D hall. She was asking him questions that I didn't understand .
4. Investigative interview dated 10/14/22, . [name of alleged NA] was very happy and loud, was wearing heavy perfume.
C. On 02/02/23 at 11:57 am, during an interview with Certified Nursing Assistant (CNA) #7, when asked if she was familiar with the claims that R #4 makes against staff, she explained I think she has her favorites because with the senior CNAs, she's really nice to them. The younger ones or the ones who just came on board, she's mean to them. A lot of them don't speak Navajo, and that's a communication barrier. When asked of she was familiar with the incident, she explained About a couple of days after it happened, I was giving her a shower and she told me that a couple nights ago one of the girls came in, she said I don't know her name but she is a new one who is heavier set and she came in and threw me on the bed and shocked her and put her hands around her neck and put a pillow on her head and she said she tried to scream and almost lost her breath. When asked if she was familiar with the alleged NA, she explained One night [a different night] she came in different. When we work with her on day shift, she was usually really quiet, she only spoke when you spoke to her but on this particular night . December 24th. I saw her briefly at the nurses station and she was being really loud and I didn't know what she was saying but later on that night she got really wild. She was skipping down the hall and waiving her hands. She said she got a new phone and she was showing it off and she was taking pictures of us without permission. I was thinking that maybe she was more comfortable with a smaller crew but later in the night she was passed out [asleep] in the D wing in one of the vacant resident rooms. When asked if a nurse was aware of her behavior, she explained, Nobody said anything to the nurse but that the DON was made aware of it on the next day.
D. On 02/02/23 at 5:01 pm, during an interview with the facility DON (Director of Nursing), when asked if she was aware of the alleged NA (CNA #3) was acting differently and sleeping in a vacant bed on December 24th, she explained A CNA told me [the next day] that she had suspicions of her being intoxicated and I said, hey, why didn't you tell me when she was working. If I knew about it when it was happening, I would of confronted her and dealt with it. I would of took it to HR [Human Resources]. I had nothing in writing, so I didn't confront her about it. I didn't have any substantial information, it was just hearsay at the time. If I knew about it at the time, then I could of done something about it. She then confirmed that no investigation was conducted regarding her suspicious behaviors.
E. On 02/03/23 at 8:33 am, during an interview with the Administrator, when asked if he was aware of the alleged NA's (CNA #3) suspicious behavior on December 24th (2022), he explained I'm not sure they [staff] told me. I did not receive information of this night. When asked if this type of suspicious should be reported, he explained I would expect to receive this information. I would expect that information to be delivered to me directly. My phone number is posted and I let them know I am available 24 hours. Retrospectively, now that I am aware of the night in December, it is possible that she may have been drunk that day, the day of the incident [10/10/22].
CONCERN
(D)
📢 Someone Reported This
A family member, employee, or ombudsman was alarmed enough to file a formal complaint
Potential for Harm - no one hurt, but risky conditions existed
Comprehensive Care Plan
(Tag F0656)
Could have caused harm · This affected 1 resident
**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on interview and record review the facility failed to update a care plan with interventions to:
1. Address behaviors relat...
Read full inspector narrative →
**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on interview and record review the facility failed to update a care plan with interventions to:
1. Address behaviors related to false allegations of abuse; and
2. Psychiatric services (type of treatment focused on the diagnosis, treatment and prevention of mental, emotional and behavioral disorders) after an allegation of abuse occurred for 1 (R #4) of 1 (R #4) residents reviewed for abuse. This deficient practice could likely result in residents not receiving personalized care according to their individual and behavioral needs.
A. Record review of the facility policy titled Person-Centered Care Plan, last revised on 10/24/22, revealed the following:
Person-centered care means to focus on the patient as the focus of control and support the patient in making their own choices and having control over their daily life . Further review revealed:
. Care plan includes measurable objectives and timetables to meet a patient's medical, nursing, nutritional, and mental and psychosocial needs that are identified in the comprehensive assessments.
The interdisciplinary team, in conjunction with the patient and/or patient representative, as appropriate, will establish the expected goals and outcomes of care, the type, amount, frequency, and duration of care, and any other factors related to the effectiveness of the plan of care.
Documentation will show evidence of:
-Patient's goals and preferences;
-Patient's status in triggered Care Area Assessments (CAAs);
- Development of care planning interventions for all CAAs triggered by the MDS [Minimum Data Set- a collection of medical information that reflects a resident's medical status and needs]; and
- Rationale for not care planning for a specific triggered CAA .
Purpose
- To attain or maintain the patient's highest practicable physical, mental, and psychosocial well being.
- To eliminate or mitigate triggers that may cause re-traumatization of the patient.
- To promote positive communication between patient, patient representative, and team to obtain the patient's and residents representative input into the plan of care, ensure effective communication, and optimize clinical outcomes.
Practice Standards
4. A comprehensive person-centered care plan must be developed for each patient and must describe the following:
4.1 Services that are to be furnished;
4.2 Any services that would otherwise be required but are not provided due to the patient's exercise of right, including the right to refuse treatment; .
6.1 The care plan must be customized to each individual patient's preferences and needs.
B. Record review of R #4's face sheet revealed that R #4 was admitted to the facility on [DATE] and is currently being treated for the following pertinent diagnosis: hemiplegia (paralysis of one side of the body) and hemiparesis (muscle weakness or partial paralysis on one side of the body) following nontraumatic subarachnoid hemorrhage (Bleeding in the space between the brain) affecting left non-dominant side, cognitive communication deficit (difficulty with thinking and how someone uses language as a result of neurological damage), muscle weakness, age-related osteoporosis (a condition where bones become weak and brittle) with current pathological fracture (a broken bone caused by disease)- vertebra (small back bones) sequela (relating to the expected path of a disease), other lack of coordination, unspecified lack of coordination, and other fracture of T9-T10 vertebra (the tiny bones of the thoracic spine), sequela.
C. Record review of R #4's care plan, dated 01/19/23, revealed the following:
1. Focus: [name of R #4] is at risk for distressed/fluctuating mood symptoms related to: Recent move into/within center and/or inability to return home. Date initiated: 03/02/2020.
2. Goal: . [Name of R #4] will exhibit decreased episodes of anger and false allegations of neglect and 'rough' treatment that are vague and unsubstantiated during the review period. Date initiated 03/02/2020
3. Interventions:
A. Observe for pain and effectiveness of current interventions. Attempt non-pharmacological interventions.
B. Administer pain medications as ordered and document effectiveness/side effects.
C. Observe for signs/symptoms of worsening sadness/depression/anxiety/fear/anger/agitation.
D. Encourage resident/patient with opportunities for choice during care/activities to provide a sense of control.
E. Social Service visits to provide support as needed. Seek input from family/support system regarding past mood, triggers and strategies.
F. Consider appropriate room/roommate placement if current roommate situation could contribute to symptoms of depressed mood. Date initiated 03/02/2020.
D. Record review of R #4's EHR (Electronic Health Record) revealed the following documentation related to R #4's episodes of anger and false allegations of neglect and 'rough' treatment:
1. Nursing note, dated 12/22/19, Resident's sister called the facility and stated that the resident tells sister that she is being neglected and that nobody in the facility checks on her. During meals they tell me that I have to walk to the dinning room myself . Upon several entries to resident's room from morning through the day, resident states in Navajo that she is complaint free and does not need anything. SSD [Social Services Director] did not voice any concerns to this RN (Registered Nurse) or CNA (Certified Nurse Assistant) through the day.
2. Nursing note, dated 09/03/20, Rsd [resident] states that her sister has been calling her and informed rsd that she is going to jail for a past offense and that the police department is going to come to the facility to arrest her. Writer asked resident which sister so that sister may be contacted and more information may be obtained and clarified. Rsd just states 'she said to get my stuff together because she told them I'm here. Now I'm going to get kicked out of here and go to jail.' Writer attempted to reassure rsd she is safe here and that more information would be needed before conclusions are made. Rsd states 'I'll call my sister' Rsd does not state which sister informed her of this information.
3. Grievance form, dated December 2022, resident states that she would like a room change because she stated that her roommate says she will shoot her with a gun.
E. Record review of EHR revealed that no documentation was found for psych services during her stay at the facility from 12/11/19-present.
F. On 02/01/22 at 1:24 pm, during an interview with RN#1, when asked if R #4 often makes false allegations, RN #1 explained Yea, she would make allegations that people weren't changing her or not answering her call light or generally being mean to her. She was with another resident who would have the same behaviors and they would say claims of neglect but I don't think there was any full report on it and it was never proven, but I know that the CNAs would say that she would say things like that or that people were rough with her but she hasn't made claims like that in a very long time. I know that previously when I worked there the CNAs were encouraged to go into her room [ROOM NUMBER] people at a time. I don't know if it was ordered, but they were encouraged to go in 2 at a time.
G. On 02/01/23, during an interview with CNA #1, when asked if R #4 often makes false allegations, CNA #1 explained She always tells the truth with me, because she likes me. Most of the CNAs say that she tells lies and tells stories. They said to be careful with her and have 2 people [staff members] when working with her
H. On 02/02/23 at 11:08 am, during an interview with CNA #4 and CNA #5, when asked if R #4 often makes false allegations, CNA #4 and CNA #5 explained It's better to have 2 people with her so that someone can be a witness. When asked how often does she make claims, CNA #4 and CNA #5 explained Before, she would say things everyday. She kind of complains about the young or new CNAs or if she just doesn't like certain ones.
I. On 02/02/23 at 11:37 am, during an interview with CNA #6, when asked if R #4 often makes false allegations, CNA #6 explained She can make up stories. Like she will say, for example when she used to have [name of resident] as a roommate, [name of resident] doesn't speak Navajo, and she would say that [name of resident] said this or that [in Navajo] which didn't really make sense since [name of R #4] only speaks Navajo.
J. On 02/02/23 at 11:57 am, during an interview with CNA #7, when asked if R #4 often makes false allegations, CNA #7 explained I think she has her favorites because with the senior CNAs, she's really nice to them, the younger ones or the ones who just came on board, she's mean to them. A lot of them don't speak Navajo, and that's a communication barrier. She will say 'the stupid one came in here and they are trying to talk to me but I don't know what they are saying'. So, I think she has her favorites. When asked if she says things that are not true, she replied Not really. I have heard stories about it but I have never seen it myself . I think maybe some of them might be true. She used to be in another room with another resident and she accused that resident of bringing in a gun but the other resident doesn't speak Navajo and how would she say that she wants to bring a gun to shoot her. I have heard other stories where staff have abused her and I don't know how true that is so I do but don't believe her.
K. On 2/3/23 at 8:33 am, during an interview with the Administrator, when asked if 2 staff members should be providing care for R #4 at all times and if that should be on her care plan, he explained The need for 2 people to care for her at all times is expected to be care planned however, I don't see it listed on the care plan.
L. On 02/06/23 at 3:40 pm, during an interview with the Administrator, when asked if a behavioral intervention was implemented after an allegation of abuse from October 2022, he explained we talked about her being reviewed by psych [psychiatric services- a type of mental health treatment]. When asked to confirm if she received psych services, he was not able to find a psych referral. When asked if R #4's episodes of anger and false allegations should be written as a Focus opposed to a Goal, he replied It would be better as a focus. When asked if the interventions listed have been found to be effective, he explained During the care plan meeting we have an IDT team [team members from different disciplines working collaboratively] who talks about the goal or the issue and the interventions. These are usually agreed with the resident or family member.
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 F0657
(Tag F0657)
Could have caused harm · This affected 1 resident
Based on record review and interview, the facility failed to revise the care plan for 1 (R #1) of 1 (R #1) resident reviewed for skin care when they failed to update the Focus, Goal, and Interventions...
Read full inspector narrative →
Based on record review and interview, the facility failed to revise the care plan for 1 (R #1) of 1 (R #1) resident reviewed for skin care when they failed to update the Focus, Goal, and Interventions for skin breakdown (damage to the skin). If the facility is not updating the care plan to reflect the resident's current care areas and treatment, then the facility may not be providing the appropriate care and treatment to meet the residents' needs. The findings are:
A. Record review of R #1's Face Sheet revealed admission date 09/14/22, diagnosis: pneumonia (lung inflammation caused by bacterial or viral infection), hypertensive heart disease (high blood pressure), respiratory failure with hypoxia (low levels of oxygen in your body tissues) end stage renal disease (disease of the kidneys in which they cannot remove wastes and fluids from the blood stream), type 2 diabetes mellitus (high blood sugars), gout (sudden, severe attacks of pain, swelling, redness and tenderness in one or more joints), edema (swelling caused by fluid in your body's tissues), muscle weakness (lack of strength in the muscles), difficulty in walking, stage 2 pressure ulcer [partial-thickness skin loss into, but no deeper than, the dermis which is the second layer of the skin, which is usually tender and painful] of sacral region (large triangular bone at the base of the spine between the hip bone), anemia (low blood iron), hyperlipidemia (abnormally high concentration of fats or lipids in the blood), dependence on real dialysis (the process of filtering the blood when the kidneys are not able to cleanse it).
B. Record review of R #1's Physicians orders dated 09/28/22, stated, Wound order for buttocks: clean with normal saline, pat dry with gauze, apply hydrogel [substance that quickly absorbs and retains water or other fluid used in wound care], then cover with optifoam [non-adhesive foam wound dressing], two times a day for stage 2 ulcer and needed for wound care.
C. Record review of R #1's Physicians orders dated 09/28/22, stated, Closed wound: location: left heel. Paint discoloration with betadine [topical antiseptic that provides infection protection]. Leave open to air. Off load heels while in bed as tolerated. Apply heel protectors to assist in offloading. Report an changes in status to wound. Every day shift for wound care and as needed for wound care.
D. Record review of R #1's Care Plan dated 09/14/22, revealed, that the care plan was not revised and up-dated when R #1 had developed skin breakdown as per physicians order dated 09/28/22.
E. On 02/09/23 at 9:59 am, during an interview with the Director of Nursing (DON) confirmed that R #1 care plan dated 09/14/22 was not revised and up-dated to include the focus, goal, and intervention for R #1's skin breakdown that developed on 09/28/22.
CONCERN
(D)
📢 Someone Reported This
A family member, employee, or ombudsman was alarmed enough to file a formal complaint
Potential for Harm - no one hurt, but risky conditions existed
Deficiency F0658
(Tag F0658)
Could have caused harm · This affected 1 resident
Based on record review and interview the facility failed to ensure that services were provided to meet professional standards for 1 (R #1) of 1 (R #1) resident by not documenting an initial skin check...
Read full inspector narrative →
Based on record review and interview the facility failed to ensure that services were provided to meet professional standards for 1 (R #1) of 1 (R #1) resident by not documenting an initial skin check when completing an admission assessment. If the facility are not ensuring skin checks is documented, then residents are likely not to receive the appropriate care and services needed to maintain optimal well-being. The findings are:
A. Record review of R #1's Face Sheet revealed, admission date 09/14/22.
B. Record review of R #1's Nursing Progress Notes: category: admission/readmission dated 09/14/22, revealed no documentation for skin checks.
C. Record review of facility statement dated 02/02/23 completed by Assistant Director of Nursing (ADON) stated, On 09/14/22 we (facility) received a new admission R #1. Upon admission Registered Nurse (RN #2) was R #1's nurse. RN #2 advised R #1 that she needed to do a skin check. R #1 stated, I do not have any skin issues, and refused a skin check. RN #2 signed her section. I locked the assessment (on residents efile) not checking to see if a note had been made about R #1's refusal (of having a skin check).
D. On 02/02/23 at 4:40 pm, during an interview with Director of Nursing (DON) confirmed that there was no skin check documented on the admission assessment, and that the skin check should have been documented.
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 F0728
(Tag F0728)
Could have caused harm · This affected 1 resident
Based on interview and record review, the facility failed to ensure that a Nurse Assistant (NA) completed a training and competency evaluation program while working with residents residing in the faci...
Read full inspector narrative →
Based on interview and record review, the facility failed to ensure that a Nurse Assistant (NA) completed a training and competency evaluation program while working with residents residing in the facility from 06/01/22-11/07/22. This deficient practice could likely result in residents not being cared for safely or as preferred.
A. Record review of the facility's policy titled Nurse Aide Training and Certification, last revised 10/24/22, revealed the following:
1. [name of company] will not use any individual as a nurse aides for more that four months on a full-time, temporary, per diem, or other basis unless that individual:
1.1 Is competent to provide nursing and nursing related services; and
1.2 Has completed a training and competency evaluation program or a competency evaluation program approved by the state; or
1.3 Has been deemed competent or determined competent.
3. Nurse aides who fail to become certified within state required timelines may be terminated from employment or may be reassigned to non-nursing related activities.
4. Before allowing an individual to serve as a nurse aide, the service location must receive registry verification that the individual has met competency evaluation requirements unless the individual:
4.1 Is a full-time employee in a training and competency evaluation program approved by the state; or
4.2 Can prove that they have recently successfully completed a training and competency evaluation program or competency evaluation program approved by the state and has not yet been included in the registry.
4.2.1 Service locations must follow-up to ensure that the individual actually becomes registered.
B. Record review of a facility incident report, dated 10/13/22, revealed that R #4, who has a history of fluctuating mood and false allegations of neglect and 'rough' treatment, informed the nurse that she was attacked by the NA (Nurse Assistant) when asked to be laid down in bed. In her allegation, she claims that the NA threw her onto the bed and was rough with her. She also said that the NA put her hand over her nose and she couldn't breath. The resident was then appropriately assisted by her nurse and sent to the ER (Emergency Room) to be evaluated. Further review revealed Conclusion: [name of NA], the nurse aide (NA) entered into [name of resident] (resident) room on October 10, 2022 to put the resident to bed. [name of resident], the resident, alleged that NA physically abused her. She has a history of mood changes and making false allegations. The NA alleged that the resident was not cooperative when she tried to assist her. The nurse met the resident soon after and provided the necessary nursing care. The hospital noted that the resident had a red mark on right collarbone with no other specific evidence of trauma found. The allegation is not confirmed. [please note, the referenced NA in this incident report became a CNA (Certified Nurse Assistant) in November of 2022 and is also referred to as CNA #3].
C. On 02/06/23 at 1:19 pm, during an interview with Certified Nurse Assistant (CNA #3), (date of hire 05/05/22) when asked if she was working with another CNA, she explained It was just me and her [R #4]. When asked if she had received her Nurse Assistant certification, she explained I did not have my Certificate. I was aware that I needed to work with a certified person. Over here, they don't have us with a certified person, they just have us on a wing. When asked why she is not working with another certified staff member, she explained That's just how the schedule is. I have been on my own since the day I started and basically, I have never been partnered with somebody I was always by myself and basically, we would just split the halls.
D. Record review of CNA #3's, Human Resource file revealed that CNA #3 completed a CNA training course on 06/01/22 however; she did not test to obtain her certificate unit 11/07/22.
E. On 02/03/23 at 8:33 am, during an interview with the facility's Administrator, when asked if a NA is allowed to provide patient care unaccompanied by other certified staff, he confirmed that she should not have been working alone and he also explained They [NAs] are supposed to be with Certified Nurses Assistants. When asked why CNA #3 was working alone the night of the incident, He explained I don't know why she was alone. She should have let someone else know when she had difficulty transferring the resident. She should have informed the nurse immediately. We recognized that she was still learning, but she had the responsibility of telling the nurse. When asked when CNA #3 received her certification, he stated that she didn't get certified until November of 2022.
F. On 02/06/23 at 3:40 pm, during an interview with the facility's Administrator, when asked why CNA #3 was not certified, he explained I asked the scheduler and HR [Human Resources] and they had not scheduled her test. They were having difficulty getting a test date.
Mar 2022
16 deficiencies
CONCERN
(D)
Potential for Harm - no one hurt, but risky conditions existed
Notification of Changes
(Tag F0580)
Could have caused harm · This affected 1 resident
**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on record review and interview, the facility failed to ensure that a Physician or Nurse Practitioner was informed of an Ab...
Read full inspector narrative →
**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on record review and interview, the facility failed to ensure that a Physician or Nurse Practitioner was informed of an Abnormal Involuntary Movement Assessment (AIMS is a 12-item clinician-rated scale to assess severity of orofacial, extremity and truncal movements) that had changed for 1 resident (R # 22) of 5 (R #'s 16, 22, 51, 67, 72) residents looked at for psychotropic medications (are medications that affect your central nervous system). This deficient practice likely caused this resident to go without treatment for newly identified involuntary movements that the resident was experiencing. The findings are:
A. Record review of the antipsychotic medications (are used to treat symptoms of psychosis such as delusions (for example, hearing voices), hallucinations, paranoia, or confused thoughts) for R #22 indicated that resident was taking:
Sertraline 150 mg (milligram) (medication for Depression)
Trazodone 50 mg (medication for Insomnia)
Risperdal 0.5 mg (medication for Dementia with Behaviors/Psychosis)
Bupropion 100 mg (medication for Depression)
B. Record review of the AIMS assessment dated [DATE] indicated that the following scoring system:
0 = None, 1 = minimal, maybe extreme normal, 2 = mild, 3 = moderate, 4 = severe. Category A. Facial and Oral Movements, R #22 was assessed to be 0 indicating no involuntary movements. B. Extremity Movements was assessed to be 0, Trunk Movements was 0, Global Judgements was a 0 and Dental Status on whether or not R #22 wore dentures or had teeth and gum problems, both questions were assessed to be no.
C. Record review of the AIMS assessment dated [DATE] was not filled in, indicating that R #22 was not assessed.
D. Record review of the AIMS assessment dated [DATE] indicated the following: A. Facial and Oral Movements, R #22 scored a 3 in both Movements occurring of the forehead, eyebrows, blinking, smiling, grimacing and in lips puckering, pouting and smacking. B. Extremity Movements, R #22 was assessed at a 0. Trunk Movements were a 0 and Global Judgements R #22 scored a 1 in the severity of abnormal movements overall and a 1 in the incapacitation due to abnormal movements and scored a 0 for R #22's awareness of the movements. E. Was answered no for any dental issues the resident might be having.
E. On 03/17/22 at 10:50 am during an interview with the Center Nurse Executive, when asked about the last AIMS assessment that she had completed for R #22, she agreed that she had filled it out and stated that she wasn't sure how long he had been having the movements but she did note them on the last assessment. She confirmed that the movements were not noted on the prior AIMS. When asked what she did after the assessment such as notifying the physician she stated no she didn't notify the physician about it.
F. On 03/17/22 at 4:15 pm, during an interview with Licensed Professional Nurse #1, she stated that if she identified an AIMS that noted extrapyramidal movements (is commonly referred to as drug-induced movement disorders) and was different than the last AIMS assessment that was done, she would notify the physician about it, make a note of it and make sure that the resident was seen by the physician next time the physician was in the building.
G. On 03/18/22 at 10:18 am, during an interview with Nurse Practitioner (NP) she stated that she would expect nursing staff to call her or the physician to notify them of an AIMS that had changed and was now indicating that a resident was having extrapyramidal movements so they could assess the resident.
CONCERN
(D)
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 record review and interview, the facility failed to ensure that resident needs related to urinary incontinence (the ina...
Read full inspector narrative →
**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on record review and interview, the facility failed to ensure that resident needs related to urinary incontinence (the inability to maintain control of one's bladder, resulting in the need to wear a brief) were being met for 1 (R #40) of 1 (R #40) resident reviewed for dignity. This deficient practice could likely result in the resident feeling ignored and at risk for developing moisture associated to skin damage. The findings are:
A. On 03/15/22 at 10:16 am, during an interview, R #40 stated at night, when I need a brief change, they don't clean me well enough. They just put a new brief on me. Night shift are rough with me. This happens mostly every night. I don't know who [which staff member] it is specifically. Night shift doesn't help, they turn off the light and walk out.
B. Record review of the Electronic Health Record (EHR) revealed that R #40 was admitted to the facility on [DATE] with the following pertinent diagnosis: major depressive disorder, recurrent severe without psychotic features (a loss of contact with reality), major depressive disorder, recurrent muscle weakness, other lack of coordination, other chronic pain, personal history of urinary (tract) infections, other constipation, spinal stenosis (a narrowing of the spaces within your spine, which can put pressure on the nerves that travel through the spine), lumbar region with neurogenic claudication (a symptom of spinal stenosis where patients experience leg pain), and type II diabetes mellitus with unspecified complications (a chronic condition where the body either doesn't produce enough insulin, or it resists insulin).
C. Record review of the care plan for R #40 revealed that she did not have an entry related to her dissatisfaction with the night shift staff members.
D. On 03/16/22 at 12:31 pm, during an interview with Certified Nursing Assistant (CNA) #7, when asked if R #40 was cooperative and what kind of care she needed, she explained, During the day, she is cooperative. I don't know about the night. When we do a brief change on her, we use the Hoyer lift [a mechanical device used to lift patients to transfer or move them form one surface to another]. Generally, she needs a brief change after every meal. In the morning, she does not have any particular preferences. Sometimes she says that 'there is a CNA in the night that ignores me, she doesn't clean me right, I don't want her working with me.' With [name of R #40], I don't know if her allegations are true. She says one thing and then another. [Name of R #40] always says 'I don't want her working with me' and I have reported it to nursing. We have also reported to Social Services. I don't know what the outcome was.
E. On 03/16/22 at 2:22 pm, during an interview with Social Services, when asked to explain her familiarity with R #40, she explained in the past year, she has been getting better. When her family comes around her mood is better, she is not as cranky. She has her moments sometimes. She is good about letting us know things. When asked if she was familiar with her dissatisfaction with the night shift CNAs, she replied She never complained about a CNA.
F. On 03/16/22 at 3:01 pm, during an interview with CNA #8, when asked to explain the care that R #40 needs, she stated She complains a lot. We do everything we can. She complains about night shift, that they are rough. She doesn't want certain CNAs to work with her. We have reported this to nursing and the Center Nurse Executive (CNE). She will say that they don't do what she asks them to do. When asked if, in the morning, it seems as if she was not wiped or cleaned well during a brief change, she explained,In the mornings, I put [Vitamin] A & [Vitamin] D ointment on her [during a brief change] and sometimes you can tell that nothing was applied, it is dry, dry. She is not oily from the ointment. She has like a skin tear on her brief area. The CNAs should put the ointment on it every time we change her.
G. On 03/17/22 at 1:44 pm, during an interview with LPN (Licensed Practical Nurse) #1, when asked if R #40 complains of anything, she stated I don't know specifically what she complains about. I know she goes through spells of depression where she says that no one is giving her attention. When asked if the residents have highly soiled briefs in the morning, she replied, I do receive report that in the morning, the residents are soaked.
H. On 03/17/22 at 2:52 pm, during an interview with the CNE, when asked to describe R #40, she stated, she came to us and there was a care plan meeting where she was very needy. At first she demanded that she be fed and that she eat in the main dinning room. She would not get along with other residents. We were looking for people who she could get a long with. When COVID [a highly contagious disease that is caused by a virus] started, we would have residents who required assistance eating in communal dinning. We would try to feed her but she started to feed herself. During a care plan meeting she was complaining because she said she couldn't move her arms but then she would move her arms, for example, she wiped her face. She demands a lot of attention. We told the family that we could not meet her needs and all of a sudden it changed. When COVID started is when the change occurred. Therapy and activities had problems with her. Its not that we aren't trying. When asked to describe the allegation against the night shift, she stated, she has complained about the night shift but she is unhappy with all staff members. She used to be in A hall but due to her beliefs, she did not want to be in a room where no one has passed. Staff would come to me and tell me about her allegations. I have done many investigations for her.
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 record review, observation, and interview, the facility failed to complete a comprehensive nutritional assessment for a...
Read full inspector narrative →
**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on record review, observation, and interview, the facility failed to complete a comprehensive nutritional assessment for a resident at risk for compromised nutrition for 1 (R #64) of 1 resident (R #64) reviewed for nutrional assessments. This deficient practice is likely to result in inconsistent delivery of interventions to avoid unplanned weight loss, and poor nutrional status of residents. The findings are:
A. Record review of R #64's medical record revealed R #64 was admitted to the facility on [DATE] with the following diagnoses: acquired absence of other specified parts of digestive tract; unspecified dementia (loss of memory, language, problem-solving and other thinking abilities that are severe enough to interfere with daily life) without behavioral disturbance; atherosclerotic (heart disease of native coronary artery buildup of fatty deposits along the walls of the main blood vessels supplying the heart with blood) without angina pectoris (chest discomfort or shortness of breath caused when heart muscles receive insufficient oxygen-rich blood); unspecified osteoarthritis (inflammation of one or more joints of the body) ; muscle weakness (generalized); difficulty in walking not elsewhere classified; unspecified protein-calorie malnutrition; hyperlipidemia (an abnormally high concentration of fats or lipids in the blood), unspecified; depression, unspecified; unspecified macular degeneration(a disease that affects a person's central vision) ; essential (primary) hypertension (high blood pressure); personal history of malignant carcinoid tumor (a type of slow-growing cancer) of small intestine; and personal history of other diseases of the digestive system.
B. Record review of R #64's medical record revealed R #64 was admitted to the facility for the purposes of surgical aftercare following surgery on the digestive system resulting in acquired absence of other specified parts of the digestive tract.
C. Record review of R #64's medical record revealed there was no record of a comprehensive nutritional assessment being completed for R #64.
D. On 04/18/22 at 3:52 PM, during an interview RD (Registered Dietician) confirmed he had not completed a dietary assessment for R #64.
E. On 04/18/22 3:59 PM, during an interview, MDS (Minimum Data Set Coordinator) stated that there had been a review of R # 64's laboratory work by the medical doctor on 3/4/22. After the laboratory tests were reviewed, the diagnosis of protein-malnutrition would have been effective upon R #64's admission. A doctor's order was signed on 3/18/22 for 3 times a day with meal protein supplement for R #64. MDS did not know why there was a gap between the time the doctor reviewed R #64's lab results and the time protein supplements were ordered for R #64.
F. Record review of the care plan for R #64 revealed no interventions had been care planned to address R #64's protein malnourishment.
G. On 03/18/22 at 9:29 AM, during an interview DM (Dietary Manager) reported that R #64 was not on any type of supplements. According to DM, a resident at risk of malnourishment usually will be put on a supplement as an intervention.
CONCERN
(D)
Potential for Harm - no one hurt, but risky conditions existed
Drug Regimen Review
(Tag F0756)
Could have caused harm · This affected 1 resident
**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on record review and interview, the facility failed to implement the licensed pharmacist's suggestion regarding the need f...
Read full inspector narrative →
**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on record review and interview, the facility failed to implement the licensed pharmacist's suggestion regarding the need for a lab sample and medication dosage reduction for 1 (R #72) of 3 (R #'s 20, 21, and 72) residents reviewed for drug irregularities. This deficient practice could likely result in a miscalculated dosage of medication as the lab sample (method of measuring and ensuring the medication is within therapeutic range) was not collected. The findings are:
A. Record review of the facility's policy titled Medication Regimen Review, last revised 11/01/19, revealed that When the Medication Regimen Review (MRR) Consultation Report is received from the Consultant Pharmacist, the Center Nurse Executive (CNE) will provide copies to the attending physician and Medical Director . Further review revealed The CNE or designee will ensure follow-up of the pharmacist recommendations.
B. Record review of the Electronic Health Record (EHR) revealed that the resident was admitted on [DATE] with the following pertinent diagnosis: generalized idiopathic epilepsy [seizure disorders where the brain functions normally when not experiencing seizure activity but when experiencing seizure activity, is brought on from abnormal electrical activity in the brain] and epileptic syndromes [the display of normal epileptic characteristics including the part of the brain, the genetic information and usual course], not intractable [controlled by medications], without status epilepticus [where seizure activity lasts less than 5 minutes or the patient may return to a normal level of consciousness between seizure episodes].
C. Record review of physician orders, dated 09/25/21, for R #72 revealed an order for Phenobarbital [a prescription medicine used to treat and prevent the symptoms of seizures] tablet 32.4 mg [milligrams], give 1 tablet by mouth two times a day for seizures [a sudden, uncontrolled electrical disturbance in the brain]. R #72 also also had a physician order dated, 9/20/21, for risperidone tablet 1 mg [milligram], give 1 mg by mouth two times a day for chronic (ETOH) [alcohol] induced psychosis [a mental disorder characterized by a disconnection from reality]. Further review of physician orders revealed that a lab order to determine if the level of prescription drugs is within the therapeutic range was not on file.
D. On 03/17/22 03:22 pm, during an interview with the facility's Center Nurse Executive (CNE), when asked if lab results should be on file for R# 72, she confirmed yes. When asked why R #72 does not have a lab result on file, she explained that R #72 experienced a fall about 2 weeks ago and as a result he was sent out to the hospital where lab samples were drawn and the facility was awaiting the results.
E. Record review of the pharmacy consultation report, dated 09/01/21, revealed that a recommendation to reduce risperidone to once daily was submitted. Further review of the consultation report revealed that the physician accepted the recommendation.
F. On 03/18/22 at 11:06 am, during an interview with the Contracted Registered Pharmacist, when asked if labs results would be requested for a resident who is prescribed Phenobarbital, he stated for Phenobarbital, yes, we would request to see those. When asked if lab results for R #72 were requested, he stated my colleague made that recommendation in November [2021]. When asked if a dose reeducation recommendation was issued for risperidone, he confirmed, yes, a recommendation was made in the past and last month [February 2022].
G. On 03/18/22 at 11:16 am, during an interview with the CNE, when asked what the process is for ensuring that the pharmacist orders are followed, she stated I sign them give them to the nurses and then I should check them to confirm that the change has occurred
CONCERN
(D)
Potential for Harm - no one hurt, but risky conditions existed
Deficiency F0761
(Tag F0761)
Could have caused harm · This affected 1 resident
Based on observations, interviews, and record review, the facility failed to:
1) Ensure that treatment/medication carts were kept locked when not in use;
2) Ensure that opened/accessed multi-dose via...
Read full inspector narrative →
Based on observations, interviews, and record review, the facility failed to:
1) Ensure that treatment/medication carts were kept locked when not in use;
2) Ensure that opened/accessed multi-dose vials (a vial of liquid medication that contains more than one dose of the medication) were dated as to when they were initially opened/accessed by the nursing staff, that were being accessed after the 28-day manufacturer's recommendation; and
3) Ensure that expired medications and medical supplies were not stored with unexpired medications or medical supplies that were readily available for resident use.
These deficient practices could likely result in affecting the 90 identified residents listed on the facility's Resident Alphabetical Census list provided by the Center Executive Director (CED) on 03/14/22, to allow residents and unauthorized staff access to unlocked treatment/medication carts and residents to receive medications that have either lost their potency, or effectiveness. The findings are:
Findings related to treatment/medication carts were kept locked when not in use:
A. On 03/16/22 at 12:00 pm, during an observation, the medication cart for halls B and D, was noted to be opened.
B. On 03/16/22 at 12:00 pm, during an interview, LPN (Licensed Practical Nurse) #3 when asked if the medication cart should be locked, she confirmed that it should be locked at all times.
Findings related to opened multi-dose vials that were dated when initially opened/or accessed, and findings related to expired medications and medical supplies were not stored with unexpired medications or medical supplies, that were readily available for resident use:
C. On 03/16/22 at 4:23 pm, during an observation of the medication storage room, the following was noted:
In the medication refrigerator the following was indicated:
1. An opened multi-vial of Tuberculin PPD (purified protein derivated) dated as having been opened on 11/11/21. This opened multi-vial of Tuberculin PPD was being accessed and administered to the residents, 97 days beyond the manufacturer's recommendation of 28 days, from the day that the multi-dose vial was first accessed.
2. Three (3) new unopened multi-vials of Tuberculin PPD, indicated an expiration date of 02/2022.
In the medication storage room, the following was indicated:
3. Seven (7) sterile dressing change trays, were noted to have expired on the following dates:
a. 1 - sterile dressing change tray expired 05/03/20;
b. 2 - sterile dressing change tray expired on 01/31/21;
c. 2 - sterile dressing change trays expired on 03-04-21; and
d. 2 - sterile dressing change trays expired on 06/03/21.
D. On 03/16/22 at 4:45 pm, during an interview, LPN #3, confirmed that the four vials of Tuberculin PPD should have been discarded at the end of the 28th day for the opened multi-dose vial (which was 12/09/21) and that the other 3 multi-dose vials should have been discarded the end of February 2022. LPN #3 also confirmed that the 7 sterile dressing change trays should have been discarded upon their expiration date.
E. Record review of the facility's policy and procedure titled Storage and Expiration Dating of Medications, Biologicals (are made from a variety of natural sources -- humans, animals or microorganisms (a microscopic organism which can be bacteria or fungus). Biological's are used to treat, prevent, or diagnose diseases and medical conditions), Syringes and Needles, last revision date of 10/31/16, revealed the following: .Facility should ensure that all medications and biological's, including treatment items are securely stored in a locked cabinet/cart or locked medication room that is inaccessible by residents and visitors .Facility should ensure that medications and biological's that (1) have an expired date on the label, (2) have been retained longer than recommended by manufacturer or supplier guidelines; or (3) have been contaminated or deteriorated, are stored separate from other medications until destroyed or returned to the pharmacy or supplier. Once any medication or biological package is opened, Facility should follow manufacturer/supplier guidelines with respect to expiration dates for opened medications. Facility staff should record the date opened on the medication container when the medication has a shortened expiration date once opened .Medication with a manufacturer's expiration date expressed in month and year (e.g. May 2019) will expire on the last day of the month .Facility personnel should inspect nursing station storage areas for proper storage compliance on a regularly scheduled basis .
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** Based on record review and interviews, the facility failed to ensure that the medical record contained complete and accurate inf...
Read full inspector narrative →
**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on record review and interviews, the facility failed to ensure that the medical record contained complete and accurate information for 1 (R #182) of 1 (R #182) resident reviewed for tube feedings. This deficient practice could likely cause confusion with the staff on how to properly care for residents and has the potential of causing harm to the residents when physician orders, care plans and the [NAME] don't match the care the resident should receive. The findings are:
A. Record review of the Nutrition assessment dated [DATE] indicated that R #182 was on tube feedings (Tube feeding: medical device used to provide nutrition to people who cannot obtain nutrition by mouth, are unable to swallow safely, or need nutritional supplementation) and was not taking anything by mouth.
B. Record review of the care plan dated 02/18/22 for R #182 indicated that R #182 was at risk for impaired swallowing related encephalopathy (used to describe a disease that affects brain structure or function. It causes altered mental state and confusion). For the Interventions: Monitor for signs/symptoms of aspiration i.e. coughing, watery eyes, chocking, moist sounding voice and R #182 is an absolute NPO (nothing by mouth).
C. Record review of the [NAME] (desktop file system that gives a brief overview of each patient and is used by the Certified Nursing Assistants). In the Eating Section it indicated that R #182 was to be encouraged to consume all fluids during meals and to offer a choice of fluids. Free H2O (water) as ordered. (this is not an all inclusive list)
D. On 03/18/22 at 11:30 am, during an interview with the Center Nurse Executive (CNE), she confirmed that R #182 was NPO and on tube feedings. She stated that she didn't feel that the free H2O could be confusing for a new Certified Nursing Assistant (CNA) who might be new to the facility or new to R #182.
E. On 03/18/22 at 12:59 pm, during an interview with Licensed Professional Nurse (LPN) #1, she stated that free water means that the resident can have as much water as they want and agreed it might be confusing for staff to see free water when R #182 is NPO.
F. On 03/18/22 at 1:00 pm, during an interview with Certified Nursing Assistant (CNA) #2 she stated that if the [NAME] had free water,she would interrupt that as they can have as much water as they want.
CONCERN
(E)
Potential for Harm - no one hurt, but risky conditions existed
Comprehensive Care Plan
(Tag F0656)
Could have caused harm · This affected multiple residents
**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on interview, observation, and record review the facility failed to ensure that a comprehensive person-centered care plan ...
Read full inspector narrative →
**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on interview, observation, and record review the facility failed to ensure that a comprehensive person-centered care plan was developed and implemented for 2 (R #'s 40, and 64 ) of 3 (R #'s 30, 40, and 64) resident reviewed for care plan accuracy. Focus areas consistent with measurable objectives and timeframes to meet a resident's respiratory medical needs that are identified in the Special Treatments, Procedures, and Programs section of the Minimum Data Set Resident Assessment and Care Screen were missing from the care plan along with resident perception and behavior, and swallowing/nutritional status. This deficient practice is likely to result in inconsistent delivery of interventions to residents in need of specialized care. The findings are:
Findings for R #64:
A. Record review of R #64's medical record revealed R #64 was admitted to the facility on [DATE] with the following diagnoses: acquired absence of other specified parts of digestive tract; unspecified dementia (loss of memory, language, problem-solving and other thinking abilities that are severe enough to interfere with daily life) without behavioral disturbance; atherosclerotic heart disease of native coronary artery buildup of fatty deposits along the walls of the main blood vessels supplying the heart with blood) without angina pectoris (chest discomfort or shortness of breath caused when heart muscles receive insufficient oxygen-rich blood); unspecified osteoarthritis (inflammation of one or more joints of the body); muscle weakness (generalized); difficulty in walking not elsewhere classified; unspecified protein-calorie malnutrition; hyperlipidemia (an abnormally high concentration of fats or lipids in the blood), unspecified; depression, unspecified; unspecified macular degeneration(a disease that affects a person's central vision) ; essential (primary) hypertension (high blood pressure); personal history of malignant carcinoid tumor (a type of slow-growing cancer) of small intestine; and personal history of other diseases of the digestive system.
B. Record review of the R #64's admission Minimum Data Set (MDS) dated [DATE] revealed the resident had a Brief Interview for Mental Status (BIMS) score of 7 indicating the resident had a severely impaired cognition status. Special Treatments, Procedures, and Programs of the resident's MDS also indicated R #64 had also recently received respiratory treatments in the form of oxygen treatment both while not as a resident of the facility and as a resident of the facility within the last 14 days of the MDS assessment. R #64's MDS also indicated she received a mechanically altered diet and a therapeutic diet.
C. Record review of the R #64's chart revealed the resident's care plan dated 02/18/22 did not have interventions developed to address respiratory treatment and oxygen therapy needs, mechanically altered diet, and therapeutic diet as identified on the resident's admission MDS dated [DATE]. No dietary assessment was observed in R #64's chart.
D. On 03/16/22 at 4:24 PM, during an observation and interview, R #64 was observed in her room. Her nasal cannula (a medical device to provide supplemental oxygen therapy to people who have lower oxygen levels by delivering oxygen directly into the nostrils) was observed to be on the floor. No date was observed on the nasal cannula tubing or on the water cannister on the oxygen concentrator (a type of medical device used for delivering oxygen to individuals with breathing-related disorders, by taking air from the room, compressing it and filtering the purified oxygen from it before delivering to the patient). During an interview with R #64, she stated she was unsure why the nasal cannula was on the floor. She stated that she thought she is supposed to wear it all the time, but she was unsure.
E. On 03/16/22 at 4:33 PM, during an interview, LPN (Licensed Practical Nurse) #3 stated R #64 had her nasal cannula in that morning. LPN reported she was an agency nurse, and this was her first time working R #64's floor. She was not sure why R #64 didn't have her nasal cannula in. She was not sure what oxygen treatment R #64 should be receiving. LPN #3 also stated she is not sure what oxygen equipment should be dated because the rules for dating the equipment vary state to state. She stated she thought the nasal cannula tubing should be changed every 24 hours but she was not sure.
F. On 03/16/22 at 4:40 PM, during an interview, CNA (Certified Nursing Assistant) #4, who was working R #64's floor, stated she was not sure if R #64 oxygen should be continuously on but that R #64 usually has it on when she sees her.
G. Record Review of the Medical Administration Record (MAR) for March 2022 for R #64 revealed the following:
O2 (Oxygen) at 1-2L (liters) continuous per nasal canula
two times a day for SOB (shortness of breath)
-Start Date-
02/18/2022 1700
H. On 03/18/22 at 8:38 AM, during an interview, RD (Registered Dietician) stated that if R #64 was missing a dietary assessment, she may have been overlooked and that her dietary assessment may not have been completed. He was unable to look at patient's files to verify complete, incomplete or missing dietary assessments, at the time of the interview due to being out of state for a family emergency.
I. On 03/18/22 09:29 AM during an interview DM (Dietary Manager) reported that R #64 was not currently on any type of supplements. She stated that historically any resident at risk of malnourishment will be put on a supplement as part of a therapeutic intervention. She will follow up with a nurse to reach out to the medical doctor to order a 3 time a day supplement for R #64, if it is appropriate.
J. On 04/18/22 03:59 PM, during an interview, MDSC (Minimum Data Set Coordinator) stated R #64 did have a dysphagia (a swallowing problem) diagnoses and that this should have been identified in the care plan by the coordinating team, which consists of nursing, the registered dietician and the dietary manager. R #64 was admitted to the facility with the dysphagia order by her medical doctor. MDSC stated a dietary supplement was ordered and was electronically signed by the medical doctor for 3 times a day protein supplement for R #64 on 03/18/22.
Findings for R #40:
L. Record review of the Electronic Health Record (EHR) revealed that R #40 was admitted to the facility on [DATE] with the following pertinent diagnosis: major depressive disorder, recurrent severe without psychotic features (a loss of contact with reality), major depressive disorder, recurrent, muscle weakness, other lack of coordination, other chronic pain, personal history of urinary (tract) infections, other constipation, spinal stenosis (a narrowing of the spaces within your spine, which can put pressure on the nerves that travel through the spine), lumbar region with neurogenic claudication (a symptom of spinal stenosis where patients experience leg pain), and type II diabetes mellitus with unspecified complications (a chronic condition where the body either doesn't produce enough insulin, or it resists insulin).
M. On 03/15/22 at 10:16 am, during an interview, R #40 stated at night, when I need a brief change, they don't clean me well enough. They just put a new brief on me. Night shift are rough with me. This happens mostly every night. I don't know who [which staff member] it is specifically. Night shift doesn't help, they turn off the light and walk out.
N. Record review of the care plan, dated 03/12/22, for R #40 revealed that she did not have an entry related to her dissatisfaction with the night shift staff members.
O. On 03/16/22 at 12:31 pm, during an interview with Certified Nursing Assistant (CNA) #7, when asked if R #40 was cooperative and what kind of care she needed, she explained, During the day, she is cooperative. I don't know about the night. When we do a brief change on her we use the Hoyer lift [a mechanical device used to lift patients to transfer or move them form one surface to another]. Generally, she needs a brief change after every meal. In the morning, she does not have any particular preferences. Sometimes she says that 'there is a CNA in the night that ignores me, she doesn't clean me right, I don't want her working with me.' With [name of R #40], I don't know if her allegations are true. She says one thing and then another. [Name of R #40] always says 'I don't want her working with me' and I have reported it to nursing. We have also reported to Social Services. I don't know what the outcome was.
P. On 03/16/22 at 2:22 pm, during an interview with Social Services, when asked to explain her familiarity with R #40, she explained in the past year, she has been getting better. When her family comes around her mood is better, she is not as cranky. She has her moments sometimes. She is good about letting us know things. When asked if she was familiar with her dissatisfaction with the night shift CNAs, she replied She never complained about a CNA.
Q. On 03/16/22 at 3:01 pm, during an interview with CNA #8, when asked to explain the care that R #40 needs, she stated She complains a lot. We do everything we can. She complains about night shift, that they are rough. She doesn't want certain CNAs to work with her. We have reported this to nursing and the Center Nurse Executive (CNE). She will say that they don't do what she asks them to do.
R. 03/16/22 at 4:56 pm, during an interview, when asked if she has received report of the night shift staff ignoring the needs of R #40, her family member stated I am going to go visit her on the 29th [of March 2022]. Ever since she moved in, she has been complaining about the night shift, about 2 years ago she started saying that they were ignore her.
S. On 03/17/22 at 1:44 pm, during an interview with LPN (Licensed Practical Nurse) #1, when asked if R #40 complains of anything, she stated I don't know specifically what she complains about. I know she goes through spells of depression where she says that no one is giving her attention.
T. On 03/17/22 at 2:52 pm, during an interview with the CNE, when asked to describe R #40, she stated, she came to us and there was a care plan meeting where she was very needy. At first she demanded that she be fed and that she eat in the main dinning room. She would not get along with other residents. We were looking for people who she could get a long with. When COVID [a highly contagious disease that is caused by a virus] started, we would have residents who required assistance eating in communal dinning. We would try to feed her but she started to feed herself. During a care plan meeting she was complaining because she said she couldn't move her arms but then she would move her arms, for example, she wiped her face. She demands a lot of attention. We told the family that we could not meet her needs and all of a sudden it changed. When COVID started is when the change occurred. Therapy and activities had problems with her. Its not that we aren ' t trying. When asked to describe the allegation against the night shift, she stated, she has complained about the night shift but she is unhappy with all staff members. She used to be in A hall but due to her beliefs, she did not want to be in a room where no one has passed. Staff would come to me and tell me about her allegations. I have done many investigations for her. When asked if R #40's behaviors that include false allegations should be in her care plan, she confirmed, yes.
U. Record review of the facility's policy titled Person-Centered Care Plan, last revised 07/01/19, revealed that A comprehensive, individualized care plan will be developed in 7 days after completion of the comprehensive assessment for each patient that includes measurable objectives and timetables to meet a patient's medical, nursing, nutritional, and mental and psychosocial needs that are identified in the comprehensive assessments.
The care plan will be prepared by the interdisciplinary team .
The interdisciplinary team, in conjunction with the patient and/or resident representative, as appropriate, will establish the expected goals and outcomes of care, the type, amount, frequency, and duration of care, and any other factors related to the effectiveness of the plan of care.
The documentation will show evidence of :
- Patient's goals and preferences;
-Patient's status in triggered Care Area Assessments (CAAs);
-Development of care planning interventions for all CAAs triggered by the MDS; and
-Rationale for not care planning for a specific triggered CAA.
The care plan will be reviewed and revised by the interdisciplinary team after each assessment.
CONCERN
(E)
Potential for Harm - no one hurt, but risky conditions existed
Deficiency F0685
(Tag F0685)
Could have caused harm · This affected multiple residents
**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on record review and interview, the facility failed to maintain a process that would allow residents to receive outside ap...
Read full inspector narrative →
**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on record review and interview, the facility failed to maintain a process that would allow residents to receive outside appointments for 1 (R #21) of 2 (R #21 and R #40) residents reviewed for vision, dental, and hearing services. This deficient practice could likely result in residents not receiving the specialized medical attention needed to maintain visual abilities.
A. On 03/14/22 at 1:06 pm, during an interview, R #21 stated I need an eye appointment.
B. Record review of R #21's nursing notes revealed R #21's pertinent diagnosis to be pterygium (a growth that starts on the clear tissue of the eye that can spread to the cornea). Further review of nursing notes read as follows:
Nursing note dated 12/29/21, . Resident's pterygium of right eye is continuing to bother patient and he is wondering when his next appointment with his eye doctor will be. Resident states his vision is blurry.
C. Record review of physician orders, dated 01/05/22, revealed an order to Refer to ophthalmologist to follow up on right eye pterygium (also known as surfer's eye) is an ocular surface disease characterized mainly by a wing-shaped growth.
D. Record review of nursing note, dated 01/17/22, revealed the Resident's pterygium of his right eye continues to bother him and referral was made for a visit to the ophthalmologist.
E. Record review of the resident's hard chart (physical binder) revealed that a follow-up appointment was needed for R #21.
F. On 03/16/22 at 1:57 pm, during an interview with Social Services, when asked if she is familiar with the order for an eye referral, she stated [Name of CNA (Certified Nursing Assistant) #6] would probably be aware of eye appointments needed or on file.
G. On 03/17/22 at 11:06 am, during an interview with CNA #6, when asked about the eye referral for R #21, she stated I will be setting him up. I just got an email letting me know that he needs an eye appointment. When asked to describe the process for setting up a resident for a referral, she stated Someone puts in orders or Social Services will confirm with me that the resident needs an appointment. He had an eye appointment at [Name of Provider] and they needed to schedule another eye appointment but that office here in [NAME] closed. They closed in about February. I was not aware of the need for a follow-up eye appointment. The order said to schedule the MRI [Magnetic Resonance Imaging, a medical imaging technique used in radiology to form pictures of the anatomy and the physiological processes of the body] and then go from there. Usually, I will get a follow-up call from [Name of provider] but they never did [provide a follow-up call]. When asked of there would be an internal method of notification used, she stated, Usually they will put in the orders and make a copy for me in my box. The clinic will send documentation back with them [the resident] and the nurses will put that in PCC [Point Click Care, name of electronic medical record software]. It should have been put in his chart electronically and then in his binder. From there, a nurse should of noticed that he needed a follow-up.
CONCERN
(E)
Potential for Harm - no one hurt, but risky conditions existed
Pressure Ulcer Prevention
(Tag F0686)
Could have caused harm · This affected multiple residents
**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on record review and interview, the facility failed to maintain skin integrity practices (to monitor and maintain the cond...
Read full inspector narrative →
**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on record review and interview, the facility failed to maintain skin integrity practices (to monitor and maintain the condition and health of the skin) by not;
1. Collecting wound measurements,
2. Preventing and identifying new skin concerns, and
3. Following physician orders for wound care, for 2 (R #'s 40 and 180) of 2 (R #'s 40 and 180) residents reviewed for pressure ulcers (injuries of the skin that usually result from prolonged pressure). This deficient practice could likely result in discomfort and a decline in the wound's status and condition. The findings are:
A. Record review of the facility policy titled Skin Integrity Management, last revised 06/01/21, revealed that Staff continually observes and monitors patients for changes and implements revisions to the plan of care as needed. Further review of the policy revealed that staff should Identify patient's skin integrity status and need for prevention intervention or treatment modalities through review of all appropriate assessment information . Perform skin inspection on admission/re-admission and weekly. Perform wound observations and measurements and complete Skin Integrity Report upon initial identification of altered skin integrity, weekly, and with anticipated decline of wound.
Findings for R #40:
B. Record review of the EHR (Electronic Health Record) revealed that R #40 was admitted to the facility on [DATE] with the following pertinent diagnosis: muscle weakness, other lack of coordination, spinal stenosis (a narrowing of the spaces within your spine, which can put pressure on the nerves that travel through the spine), and type II diabetes mellitus with unspecified complications (a chronic condition where the body either doesn't produce enough insulin, or it resists insulin).
C. On 03/15/22 at 10:16 am, during an interview, R #40 stated at night, when I need a brief change, they don't clean me well enough. They just put a new brief. Night shift are rough with me. This happens mostly every night. I don't know who [which staff member] it is specifically. Night shift doesn't help, they turn off the light and walk out.
D. On 03/16/22 at 3:01 pm, during an interview with CNA (Certified Nurse Assistant) #8, when asked if, in the morning, it seems as if she (R #40) was not wiped or cleaned well during a brief change, she explained, In the mornings, I put [Vitamin] A & [Vitamin] D ointment on her [during a brief change] and sometimes you can tell that nothing was applied, it is dry dry. She is not oily from the ointment. She has like a skin tear on her brief area. The CNAs should put the ointment on it every time we change her.
E. On 03/17/22 at 1:44 pm, during an interview with LPN (Licensed Practical Nurses) #1, when asked if the residents have highly soiled briefs in the morning, she replied, I do receive report that in the morning, the residents are soaked.
F. On 03/18/22 at 12:00 PM, during an interview with CNA #9, when asked how the shower sheets are used, she replied, We have shower sheets and we fill them out after every shower. If there has been a wound patch and it came off, we will let the nurse know and patch the area back up. Sometimes there are bruises and scratches. When asked what the shower sheets for R #40 would look like, she replied, She had a deep sore where you could see tissue. It has healed itself and now there's a bunch of skin in that area. She complains that it hurts. Lotion helps her feel better. She has a new wound, it has been going on for about 2-3 weeks. I don't know what type of wound it is . the nurses haven't put anything on it so I don't know if its much of a concern. She likes to lay flat. It looks like its kind of like a little bit of a bed sore kind where you can see some tissue on the bottom of her real skin. Its not deep to where you can see the tissue. It's pretty small, its probably like a quarter size. It's kind of in the middle where her tailbone is. When asked if this was reported to nursing staff, she replied, I put it on the shower sheet and let day shift know that we are turning her and applying barrier cream. We get her dressed and put her in the chair. If you don't put the barrier cream she will complain that it hurts.
G. On 03/18/22 at 1:10 pm, during an interview with LPN #1, when asked to conduct a skin assessment of R #40's brief area, she explained, Where the brief comes through [between her legs] she has redness and skin tears. It seems like she could be allergic to the brief. You can't tell if its a rash. I have to have the doctor look at it to determine what it is. I don't know if maybe if it was from the paste. They [the CNAs] say that the A&D ointment helps it. It could be a fungul [caused by a group of organisms] issue. I don't know how long it has been there. When asked if this should have been observed during her last skin assessment and when she had a shower, she confirmed, It should have been reported during those two opportunities. When asked how skin assessments are completed, she replied, When they [CNAs] do their showers, they are supposed to get the nurse and the nurse is supposed to do a skin assessment. When asked if skin assessments occur, she replied, There are multiple things that affect the skin assessment: the scheduled shower day, the way PCC [Point Click Care, the electronic health record software] prompts you to complete the shower assessment, if the resident refuses, if the resident refusal button is available in PCC. There are many things that are being juggled in the process to get the skin assessment done. When asked if R #40 should have at least one recent wound measurement, LPN #1 replied, Some responsibility to do get wound care completed falls short due to staffing integrity issues. Night shift sometimes does not complete nursing tasks.
H. On 03/18/22 at 2:34 pm, during an interview with the facility's Center Nurse Executive (CNE), when asked how often wound measurements should occur, she replied, Measurements should be occurring once a week. The same person should measure the wound. She then stated This is is a staffing issue, we may need another nurse to take the measurements. When asked if she was aware of the developing skin issue on R #40, she explained that R# 40 may only have a skin irritation that requires air, she then stated The nurses may not be able to tell the CNA's to leave the brief off because they get the shower sheets at the end of the shift. Someone should go look at it and remove the brief even if its the next brief. When asked if R #40 should have a wound measurement, she replied If the day shift can't do it, the night shift should do it .
Findings for R #180
I. Record review of the nursing progress notes dated 02/24/22 indicated the following: resident (R #180) arrived to facility in wheelchair . skin warm to touch, skin dry. Open wound to coccyx, bandage in place. Deep tissue injury (DTI is a pressure-related injury to subcutaneous tissues under intact skin. Initially, these lesions have the appearance of a deep bruise) to right heel.
J. On 03/16/22 at 4:20 pm during an interview with Licensed Professional Nurse #3 she stated that R #180 has a wound on right heel. They put betadine on it because it toughens up the skin. It is currently scabbed over and they are still treating it every three days. His skin is very fragile and they don't want to rip his skin so that is why the order is every three days. Every Friday they do measurements on the wounds.
K. Record review of the physician orders dated 02/26/22 indicated the following orders: Wound care to coccyx. 1. Cleanse with wound cleanser and pat dry. 2. Apply hydrocolloid dressing. 3. Change every three days and as needed if missing or until resolved. Every 3 days on dayshift for stage II decub
L. Record review of the Treatment Administration Record (TAR) indicated that on 02/27/22 R #180 did not receive wound care for his coccyx wound. There was no documentation for that day.
M. Record review of the TAR indicated that wound care was not completed on 03/08/22 or 03/14/22 for the coccyx wound.
N. Record review of the physician orders dated 02/26/22 indicated the following orders: Wound care to right heel. 1. Cleanse with wound cleanser and pat dry. 2. Paint with betadine. 3. Apply padded dressing daily and as needed, until resolved. Every day shift for DTI as.
O. Record review of the TAR indicated that from 02/26/22 - 02/28/22, R #180 did not receive wound care for right heal DTI. There was no documentation for those days.
P. Record review of the MAR (Medication Administration Record) indicated that for the DTI right heel wound R #180 did not receive wound care on March the 8th, 13th and 14th. This wound care was scheduled daily.
Q. The first measurement of the wounds for R #180 took place on 03/07/2022. 9 days from admit to the facility.
R. Record review of the Care Plan indicated in the Focus section:
R #180 has actual skin breakdown. Stage II decuitis to coccyx and DTI to right heel.
In the Interventions section: Palliative Goal: R #180's dressing changes will be managed at the appropriate minimum frequency to manage wound odor and exudate
CONCERN
(E)
Potential for Harm - no one hurt, but risky conditions existed
Respiratory Care
(Tag F0695)
Could have caused harm · This affected multiple residents
Based upon observation, record review, and interview, the facility failed to meet professional standards of care for 2 (R #64 and R #31) of 2 (R #64 and 31) residents reviewed for oxygen care by not p...
Read full inspector narrative →
Based upon observation, record review, and interview, the facility failed to meet professional standards of care for 2 (R #64 and R #31) of 2 (R #64 and 31) residents reviewed for oxygen care by not properly dating and monitoring the oxygen delivery tubing and dating the humidifier bottle (bottle of water that provides water to the oxygen to prevent the air from being too dry). This deficient practice could likely lead to tubing becoming clogged or dirty leading to reduced flow of oxygen or upper respiratory infections (an infection of the upper part of the respiratory system which is above the lungs). The findings are:
A.
On 03/15/22 at 10: 00 AM, during an observation, R #64 was observed to be on oxygen therapy. No date was observed on her nasal cannula tubing (oxygen delivery tubing that provides oxygen to the patient by the nose).
B.
On 03/15/22 at 4:10 PM during an observation, R #31 was observed to be on oxygen therapy. No date was observed on his nasal cannula tubing.
C.
On 03/16/22 at 4:24 PM, during an observation, R #31 was observed to be receiving oxygen therapy. No date was observed on his nasal cannula tubing or humidifier (water) bottle.
D.
On 03/16/22 at 4:47 PM, during an interview, R #31 reported water was backing up into his nasal cannula. CNA (Certified Nursing Assistant) #1 stated there should be a date on the water bottle and on the tubing but there was not. She will change out R #31's system.
E.
On 03/16/22 at 4:33 PM, during an interview, LPN (Licensed Practical Nurse) #3 stated she was a nurse from an out of state nursing agency. She was not sure what should be dated on the oxygen delivery equipment. She thought the nasal cannula tubing should be changed out every 24 hours, but she was unsure.
F.
On 03/16/22 at 4:40 PM, during an interview, CNA #4 stated the nasal cannula tubing was usually changed out for the residents every Sunday. If the nasal cannula tubing is on the floor or any other issues occur, the tubing will also be changed out. CNA #4 stated there should be a date on the humidifier bottle and the nasal cannula tubing.
G.
Record review of Facility's Oxygen: Nasal Cannula Policy, dated 01/01/04 and revised 06/01/21, 3.2, states .Nasal cannula labeled with date of initial set-up . Number 10 of the same policy states If humidifier is used: 10.1 Label with date . Number 16 of the policy states Replace disposable set-up every seven days .
CONCERN
(E)
Potential for Harm - no one hurt, but risky conditions existed
Pharmacy Services
(Tag F0755)
Could have caused harm · This affected multiple residents
**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on record review and interviews, the facility's contracted pharmacy, failed to ensure that prescribed routine medications,...
Read full inspector narrative →
**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on record review and interviews, the facility's contracted pharmacy, failed to ensure that prescribed routine medications, needing prior insurance authorization for dispensing were available to residents. This deficient practice has the potential to affect all 90 resident's listed on the facility's Resident Census provided by the Center Executive Director on 03/14/22, this likely resulted in a resident not receiving their prescribed medications more than 5 days in a row.
A. Record review of R #16's face sheet, indicated an original admission to the facility on [DATE], having the following diagnoses: Primary Respiratory Tuberculosis (is a contagious, infectious disease that attacks the lungs), Dementia (a group of thinking and social symptoms that interferes with daily living), protein-calorie malnutrition (a state of inadequate intake of food), pulmonary embolism (a sudden blockage in a lung artery) blood clot in the lungs), hypertension (having a high blood pressure), and muscle weakness.
B. Record review of R #16's March 2022 Medication Administration Record revealed the following:
1. Isoniazid (used to treat and prevent tuberculosis), which was ordered by the physician on 03/03/22. R #16 did not receive the medication until 03/08/22, five days later due to the unavailability of the medication in the facility that was to be dispensed by the pharmacy.
C. On 03/16/22 at 12:45 pm, during an interview, Certified Medication Aide (CMA) #1, when asked what was the process for ordering medications from the pharmacy. She stated that when the blister-pack containing the medications has only 5 days of medications left. There is a button in the software program for nursing staff to order the medication from the pharmacy. CMA #1 stated that there are prescribed medications that are needing prior authorization from the resident's insurance companies. When asked if there was anything written on the medication label that would indicate that the pharmacy would need a prior authorization to be dispensed from the pharmacy. She stated that she was not aware of anything to alert nursing staff of this. She continued that if the medication is needing a prior authorization from the insurance company, it can take a long period of time, in this case 5 (five) days 03/03/22 through 03/07/22, that R #16 did not receive her prescribed medication of Isoniazid.
D. On 03/18/22 at 10:15 am, during an interview, the Consultant Pharmacist when asked about what the process was regarding the re-filling a prescription of a medication that the resident had been receiving from the pharmacy, which now needs to be refilled and needing an authorization from the insurance company before the pharmacy can dispense to the facility. He stated, that he did not have any control over that kind of situation and provided phone numbers of the General Manager of the contracted pharmacy consultants.
E. On 03/18/22 at 11:20 am, a phone call was placed to the General Manager of the contracted pharmacy consultants, but never received a return call.
F. Record review of the contracted pharmacy's policy and procedure titled Medication Shortages/Unavailable Medications, last revised on 01/01/13, revealed the following: .If the medication is unavailable from pharmacy due to formulary coverage, contraindication, drug-drug interaction, drug-disease interaction, allergy or other clinical reason, facility should collaborate with pharmacy and physician/prescriber to determine a suitable therapeutic alternative .
CONCERN
(E)
Potential for Harm - no one hurt, but risky conditions existed
Deficiency F0757
(Tag F0757)
Could have caused harm · This affected multiple residents
**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Findings R #22
I. Record review of the antipsychotic medications (are used to treat symptoms of psychosis such as delusions (for...
Read full inspector narrative →
**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Findings R #22
I. Record review of the antipsychotic medications (are used to treat symptoms of psychosis such as delusions (for example, hearing voices), hallucinations, paranoia, or confused thoughts) for R #22 indicated that resident was taking:
Sertraline 150 mg (medication for Depression)
Trazodone 50 mg (medication for Insomnia)
Risperdal 0.5 mg (medication for Dementia with Behaviors/Psychosis)
Bupropion 100 mg (medication for Depression)
J. Record review of the AIMS assessment dated [DATE] indicated the following scoring system: 0 = None, 1 = minimal, maybe extreme normal, 2 = mild, 3 = moderate, 4 = severe. Category A. Facial and Oral Movements R #22 was assessed to be 0 indicating no involuntary movements. B. Extremity Movements was assessed to be 0, Trunk Movements was 0, Global Judgements was a 0 and Dental Status on whether or not R #22 wore dentures or had teeth and gum problems, both questions were assessed to be no.
K. Record review of the Pharmacist Consultation Report dated 09/08/21 indicated in the Comment Section: Repeated Recommendation from 08/02/21: Please respond promptly to assure facility compliance with Federal Regulations. R #22 receives Risperidone which may cause involuntary movements including tardive dyskinesia (TD is a loss of control of muscles, especially of face, arms, and legs. This results in repetitive involuntary movements like: Grimacing and eye blinking, Tongue jetting out, Puckering and pursing of lips, Lip smacking, Jerking of arms and legs) but an Abnormal Involuntary Movement Scale (AIMS) .assessment was not documented in the medical record within the previous 6 months. In the Recommendation Section: Please monitor for involuntary movements now and at least every 6 months .
L. Record review of the Pharmacist Consultation Report dated 10/07/21 indicated in the Comment Section: R #22 receives Risperidone which may cause involuntary movements including tardive dyskinesia but an Abnormal Involuntary Movement Scale (AIMS) .assessment was not documented in the medical record within the previous 6 months. In the Recommendation Section: Please monitor for involuntary movements now and at least every 6 months .
M. Record review of the AIMS assessment dated [DATE] was opened but none of the content was filled in, indicating that R #22 was not assessed.
N. Record review of the AIMS assessment dated [DATE] indicated the following: A. Facial and Oral Movements R #22 scored a 3 in both Movements occurring of the forehead, eyebrows, blinking, smiling, grimacing and in lips puckering, pouting and smacking. B. Extremity Movements R #22 was assessed at a 0. Trunk Movements were a 0 and Global Judgements R #22 scored a 1 in the severity of abnormal movements overall and a 1 in the incapacitation due to abnormal movements and scored a 0 for R #22's awareness of the movements. E. Was answered no for any dental issues the resident might be having.
O. Record review of the care plan revision dated 01/19/22 indicated in the FOCUS: R #22 is at risk for complications related to the use of psychotropic drugs for agitation/verbal outburst Medication: Risperidone. Interventions:
AIMS testing per protocol (the assessment grid indicated it should be completed every 6 months)
Gradual dose reduction as ordered
Monitor for side effects and consult physician and/or pharmacist as needed. (This list isn't all inclusive of the intervention).
P. On 03/17/22 at 10:50 am during an interview with the Center Nurse Executive (CNE), when asked about the last AIMS assessment that wasn't completed on 10/07/21 she did not know why it had not been filled out and completed. She confirmed that she had opened the assessment that wasn't completed.
Based on record review and interviews, the facility and the facility's contracted pharmacy, failed to ensure that Residents were free from significant medication errors, indicated by the following:
1. that prescribed routine medications, needing to be refilled and needing prior insurance authorization for dispensing to the facility, were available to residents; and
2. medications that had been discontinued by the physician in September 2021, were currently being administered to a resident, which could likely result in affecting all 90 residents listed on the facility's Resident Census obtained from the Center Executive Director on 03/14/22. These deficient medication practices of residents not receiving their routine prescribed medications that are needing insurance authorizations, and residents receiving discontinued medications, putting the resident at risk for experiencing potential unnecessary drug interactions or adverse side effects. The findings are
Findings for R #67:
A. Record review of R #67's admission Record dated 05/05/21, with the following diagnoses: Hypertension (having high blood pressure), diabetes mellitus (having too much sugar in the blood), depression (a mental health disorder that negatively affects how you feel, the way you think, and how you act), dementia (a chronic or persistent disorder of the mental processes caused by brain disease or injury and marked by memory disorders, personality changes, and impaired reasoning), chronic kidney disease (decrease in the production of urine), gastro-esophageal reflux disease (a digestive disease in which stomach acid washes back up the food pipe) and long-term use of insulin (a medication used to control blood sugar levels).
B. Record review of R #67's Physician Orders dated for the month of March 2022, indicated that R #67 was taking the following medications: Gabapentin (a medication used to treat nerve pain), Sertraline (an antidepressant used to treat mood swings), Famotidine (used to prevent and treat heartburn caused by stomach acids), Empagliflozin (Jardiance, used to treat blood sugar levels), acetaminophen (mild pain reliever), amlodipine (used to treat high blood pressure), refresh tears (used to moisten the eyes), Novolin R (Insulin Regular, used to rapidly treat high blood sugar levels), and Basalgar (used to treat as a long-acting insulin medication to treat high blood sugar levels).
C. Record review of the Pharmacy Consultation Report dated 09/08/21, indicated the following:
1. The medication Sertraline was reviewed by the Pharmacist on 09/08/21;
2. The Physician's Response was to discontinue the Sertraline dated 09/13/21; and
3. The Center Nurse Executive (CNE) signed the Consultation Report on 09/14/21.
R #67, continued to receive the Sertraline from 09/13/21 to 03/16/22, which would be 184 days the resident received the medication Sertraline after the medication had been discontinued by the physician.
D. Record review of the Pharmacy Consultation Report dated 09/08/21, indicated the following:
1. The medication Jardiance was reviewed by the Pharmacist on 09/08/21;
2. The Physician's Response was to discontinue the Jardiance dated 09/13/21;
3. The CNE signed the Consultant Report on 09/14/21.
R #67 continued to receive the Jardiance from 09/13/21 to 03/16/22, which would be 184 days the resident received the medication Jardiance after the medications had been discontinued by the physician.
E. Record review of the Physician Order Summary Report, indicated active orders as of 10/31/21, revealed that the Sertraline and Jardiance had not been discontinued as ordered the previous month.
F. On 03/16/22 at 10:20 am, during an interview, the CNE confirmed that she had signed the Pharmacy Consultant Reports for the medications Sertraline and Jardiance, after the physician had discontinued the medications back in September of 2021.
G. On 03/16/22 at 11:30 am, during an interview, the Consultant Pharmacist replied when asked about the follow-up or the monitoring of the medications Sertraline and Jardiance which R #67 was currently being administered, which had been discontinued by the physician on 09/13/21. He stated that he was not the consulting pharmacist at that time, but that the previous consulting pharmacist had noted the response from the physician from 09/13/21, and had re-issued another recommendation in October and again in November of 2021. The Consultant Pharmacist stated that there was a lack of communication between the Consultant Pharmacist at that time with the physician and the Director of Nursing.
H. Record review of the Consultant Pharmacy's policy and procedure titled Medication Regimen Review, dated 11/28/16, revealed the following: .The pharmacist will address copies of residents' MRRs (Medication Regimen Review) to the Director of Nursing and/or the attending physician and to the Medical Director. Facility should ensure that the attending physician, Medical Director, and Director of Nursing are provided with copies of the MRRs .Facility should alert the Medical Director when MRRs are not addressed by the attending physician in a timely manner. When the Consultant Pharmacist identifies an urgent medication irregularity during MRR that requires immediate action, the consultant pharmacist will notify the nurse and request the facility contact the attending physician to communicate the issue and obtain direction or new orders .
CONCERN
(E)
Potential for Harm - no one hurt, but risky conditions existed
Deficiency F0825
(Tag F0825)
Could have caused harm · This affected multiple residents
Based on interview and record review the facility failed to coordinate and provide ordered speech therapy for 2 (R #22 and 182) of 2 (R #22 and 182) residents looked at for speech evaluations. This de...
Read full inspector narrative →
Based on interview and record review the facility failed to coordinate and provide ordered speech therapy for 2 (R #22 and 182) of 2 (R #22 and 182) residents looked at for speech evaluations. This deficient practice could likely put the resident at risk of not reaching their highest potential in their recovery. The findings are:
Resident #22
A. Record review of an incident report dated 01/13/22 at 1:10 pm, an incident occurred with R #22. R #22 was in his room eating lunch when some food became lodged in his throat and required intervention from staff to clear airway. This nurse (CNE) (Center Nurse Executive) was walking down the hall when a Certified Nursing Assistant (CNA) called me into the resident's room. Resident was chocking on his meal. Heimlich attempted x (times) 2. Food was dislodged an second attempt. Resident VS (vital signs) were taken 135/85 blood pressure, 84 respirations, temperature was 98, pulse was 20 and oxygen saturation was 88%. (name of physician) notified, order received for Levaquin 500 (an antibiotic) mg (milligrams) daily for 10 days. Area hospitals are on crisis care status. Resident's diet changed to dysphagia puree (food that is placed in a blender or food processor) and ST (Speech Therapy) referral placed.
B. Record review of the care plan dated 01/16/22 indicated in Interventions to obtain an SLP (Speech and Language Pathology) evaluation as ordered.
C. Record review of the physician orders dated 02/18/22 indicated that an order was placed for Speech Therapy (ST)-Evaluation & Treatment.
D. On 03/17/22 at 10:50 am during an interview with CNE, the CNE stated that she was walking down the hall and a CNA who was in the room with R #22 called her in and told her that R #22 was chocking and she needed help. The CNA was doing the Heimlich and needed assistance. The CNE started to do the Heimlich but they couldn't get him out of this chair. They finally managed after she hit him on the chest to get all the food out. After that they checked vitals. His oxygen was low so they gave him some oxygen. She let the physician know what happened and his diet was downgraded and an order for an antibiotic was put in so he wouldn't get aspiration pneumonia (occurs when food, saliva, liquids, or vomit is breathed into the lungs or airways leading to the lungs, instead of being swallowed into the esophagus and stomach). He had been on a regular diet and he was downgraded to a puree. He was monitored and was not sent out to the hospital. She confirmed that a speech study was ordered and has not been completed. They do not have a speech therapist on staff at this time and he has not been out to one either.
E. On 03/17/22 at 10:35 am, during an interview with the Physical Therapist (PT), she stated that they don't have anyone working in speech right now. She stated that it has been this way for awhile. She is not aware of residents being sent out for speech therapy or speech assessments. She stated that they used to have as needed speech therapy coming out on the weekends but that also has stopped.
R #182
F. Record review of the physician orders indicated that R #182 was NPO (nothing by mouth) starting on 02/18/22, date of admission to the facility.
G. Record review of the Initial Nutrition Assessment:dated 02/21/22 indicated the following: recently hospitalized for altered mental status and found to have a Urinary Tract Infection (UTI) and aspiration pneumonia. R #182 is 100% nothing by mouth and on enteral feed (is a medical device used to provide nutrition to people who cannot obtain nutrition by mouth, are unable to swallow safely, or need nutritional supplementation). R #182 was seen by SLP prior to admission and was determined safest to remain NPO at the time and continue enteral feeds, recommend facility SLP re-eval.
H. On 03/17/22 at 10:30 am, during an interview with the CNE, she stated that R #182 probably isn't going to get much better but the family really wants him too and wants therapy to work with him and speech to do a swallow study with him. Physical therapy (PT) and Occupational therapy (OT) have evaluated him and he is a good candidate for therapy. He wasn't improving and they weren't able to keep him on their caseload. She told the family that he may not pass a swallow study and that they needed to be prepared for that. The CNE stated that he has been here one month and the family has stated that R #182 is starting to talk and they want more speech therapy.
I. On 03/17/22 at 1:30 pm, during a second interview with the PT, she stated that R #182 came into the facility in February and she worked with him the first week. She couldn't justify continuing to work with him because there wasn't good potential for improvement. She just re-evaluated him and the outcome was the same. The PT stated that he would have been a candidate for Restorative but they don't offer that anymore because the restorative person had to work the floor due to short staffing. She stated that R #182 needs to be in a facility where they can offer speech therapy.
J. On 03/18/22 at 3:14 pm, during an interview with Family Member #1, FM #1 stated that she has been waiting for a speech evaluation since he got here. She wants a swallow study done on him to see if he can come off tube feedings. They told her that they are going to request a speech evaluation but they haven't done that yet.
CONCERN
(F)
Potential for Harm - no one hurt, but risky conditions existed
Deficiency F0727
(Tag F0727)
Could have caused harm · This affected most or all residents
Based on record review and interview, the facility failed to ensure that the Center Nursing Executive[CNE] was scheduled to work as a charge nurse only when the resident census was below 60. This defi...
Read full inspector narrative →
Based on record review and interview, the facility failed to ensure that the Center Nursing Executive[CNE] was scheduled to work as a charge nurse only when the resident census was below 60. This deficient practice could likely indicate that the facility was short staffed and could potentially cause harm to all 90 residents identified on the resident census list provided by the Administrator on 03/14/22 due to the CNE not being able to oversee the duties and responsibilities of the clinical nursing staff while she was providing care to the residents. The findings are:
A. Record review of the staffing sheets for 01/01/22 to 01/31/22 indicated that the CNE was on the schedule to work the following days:
01/01/22, 01/03/22, 01/04/22, 01/06/22, 01/07/22, 01/10/22-01/16/22, 01/21/22-01/23/22 and 01/27/22-01/29/22. The census was above 60 residents the entire month of January.
B. Record review of the staffing sheets for 02/01/22 to 02/29/22 indicated that the CNE was on the schedule to work the following days: 02/01/22, 02/02/22, 02/26/22, 02/27/22. The census was above 60 residents the entire month of February.
C. On 03/15/22 at 2:01 pm, during an interview with the CNE, she stated that staffing has been hard and they do have days that there aren't enough nurses. She stated that she has worked the floor on numerous occasions because the residents deserve to be taken care of. She was aware that she wasn't supposed to be working with a census above 60 but she hasn't had a choice if she wanted the residents to get good care.
CONCERN
(F)
Potential for Harm - no one hurt, but risky conditions existed
Deficiency F0760
(Tag F0760)
Could have caused harm · This affected most or all residents
**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on record review and interviews, the facility and the facility's contracted pharmacy, failed to ensure that Residents were...
Read full inspector narrative →
**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on record review and interviews, the facility and the facility's contracted pharmacy, failed to ensure that Residents were free from significant medication errors, indicated by the following:
1. that prescribed routine medications, needing to be refilled and needing prior insurance authorization for dispensing to the facility, were available to residents; and
2. medications that had been discontinued by the physician in September 2021, were currently being administered to a resident.
These deficient medication practices of residents not receiving their routine prescribed medications that are needing insurance authorizations, and residents receiving discontinued medications, putting the resident at risk for experiencing potential unnecessary drug interactions or adverse side effects. The findings are:
Findings related to prescribed routine medications, needing authorization:
A. Record review of R #16's face sheet, indicated an original admission to the facility on [DATE], having the following diagnoses: Primary Respiratory Tuberculosis (is a contagious, infectious disease that attacks the lungs), Dementia (a group of thinking and social symptoms that interferes with daily living), protein-calorie malnutrition (a state of inadequate intake of food), pulmonary embolism (a sudden blockage in a lung artery) blood clot in the lungs), hypertension (having a high blood pressure), and muscle weakness.
B. Record review of R #16's March 2022 Medication Administration Record revealed the following:
1. Isoniazid (used to treat and prevent tuberculosis), which was ordered by the physician on 03/03/22. R #16 did not receive the medication until 03/08/22, five days later due to the unavailability of the medication in the facility that was to be dispensed by the pharmacy.
C. On 03/16/22 at 12:45 pm, during an interview, Certified Medication Aide (CMA) #1, when asked what was the process for ordering medications from the pharmacy. She stated that when the blister-pack containing the medications has only 5 days of medications left. There is a button in the software program for nursing staff to order the medication from the pharmacy. CMA #1 stated that there are prescribed medications that are needing prior authorization from the resident's insurance companies. When asked if there was anything written on the medication label that would indicate that the pharmacy would need a prior authorization to be dispensed from the pharmacy. She stated that she was not aware of anything to alert nursing staff of this. She continued that if the medication is needing a prior authorization from the insurance company, it can take a long period of time, in this case 5 (five) days 03/03/22 through 03/07/22, that R #16 did not receive her prescribed medication of Isoniazid.
D. On 03/18/22 at 10:15 am, during an interview, the Consultant Pharmacist when asked about what the process was regarding the re-filling a prescription of a medication that the resident had been receiving from the pharmacy, which now needs to be refilled and needing an authorization from the insurance company before the pharmacy can be dispensed to the facility. He stated, that he did not have any control over that kind of situation and provided phone numbers of the General Manager of the contracted pharmacy consultants.
E. On 03/18/22 at 11:20 am, a phone call was placed to the General Manager of the contracted pharmacy consultants, but never received a return call.
F. Record review of the contracted pharmacy's policy and procedure titled Medication Shortages/Unavailable Medications, last revised on 01/01/13, revealed the following: .If the medication is unavailable from pharmacy due to formulary coverage, contraindication, drug-drug interaction, drug-disease interaction, allergy or other clinical reason, facility should collaborate with pharmacy and physician/prescriber to determine a suitable therapeutic alternative .
Findings related to medications currently being administered that were to be discontinued in September 2021:
G. Record review of R #67's admission Record dated 05/05/21, with the following diagnoses: Hypertension (having high blood pressure), diabetes mellitus (having too much sugar in the blood), depression (a mental health disorder that negatively affects how you feel, the way you think, and how you act), dementia (a chronic or persistent disorder of the mental processes caused by brain disease or injury and marked by memory disorders, personality changes, and impaired reasoning), chronic kidney disease (decrease in the production of urine), gastro-esophageal reflux disease (a digestive disease in which stomach acid washes back up the food pipe) and long-term use of insulin (a medication used to control blood sugar levels).
H. Record review of R #67's Physician Orders dated for the month of March 2022, indicated that R #67 was taking the following medications: Gabapentin (a medication used to treat nerve pain), Sertraline (an antidepressant used to treat mood swings), Famotidine (used to prevent and treat heartburn caused by stomach acids), Empagliflozin (Jardiance, used to treat blood sugar levels), acetaminophen (mild pain reliever), amlodipine (used to treat high blood pressure), refresh tears (used to moisten the eyes), Novolin R (Insulin Regular, used to rapidly treat high blood sugar levels), and Basalgar (used to treat as a long-acting insulin medication to treat high blood sugar levels).
I. Record review of the Pharmacy Consultation Report dated 09/08/21, indicated the following:
1. The medication Sertraline was reviewed by the Pharmacist on 09/08/21;
2. The Physician's Response was to discontinue the Sertraline dated 09/13/21; and
3. The Center Nurse Executive (CNE) signed the Consultation Report on 09/14/21. R #67, continued to receive the Sertraline from 09/13/21 to 03/16/22, which would be 184 days the resident received the medication Sertraline after the medication had been discontinued by the physician.
J. Record review of the Pharmacy Consultation Report dated 09/08/21, indicated the following:
1. The medication Jardiance was reviewed by the Pharmacist on 09/08/21;
2. The Physician's Response was to discontinue the Jardiance dated 09/13/21;
3. The CNE signed the Consultant Report on 09/14/21. R #67, continued to receive the Jardiance from 09/13/21 to 03/16/22, which would be 184 days the resident received the medication Jardiance after the medications had been discontinued by the physician.
K. Record review of the Physician Order Summary Report, indicated active orders as of 10/31/21, revealed that the Sertraline and Jardiance had not been discontinued as ordered the previous month.
L. On 03/16/22 at 10:20 am, during an interview, the CNE confirmed that she had signed the Pharmacy Consultant Reports for the medications Sertraline and Jardiance, after the physician had discontinued the medications back in September of 2022.
M. On 03/16/22 at 11:30 am, during an interview, the Consultant Pharmacist replied when asked about the follow-up or the monitoring of the medications Sertraline and Jardiance which R #67 was currently being administered, which had been discontinued by the physician on 09/13/21. He stated that he was not the consulting pharmacist at that time, but that the previous consulting pharmacist had noted the response from the physician from 09/13/21, and had re-issued another recommendation in October and again in November of 2021. The Consultant Pharmacist stated that there was a lack of communication between the Consultant Pharmacist at that time with the physician and the Director of Nursing.
N. Record review of the Consultant Pharmacy's policy and procedure titled Medication Regimen Review, dated 11/28/16, revealed the following: .The pharmacist will address copies of residents' MRRs (Medication Regimen Review) to the Director of Nursing and/or the attending physician and to the Medical Director. Facility should ensure that the attending physician, Medical Director, and Director of Nursing are provided with copies of the MRRs .Facility should alert the Medical Director when MRRs are not addressed by the attending physician in a timely manner. When the Consultant Pharmacist identifies an urgent medication irregularity during MRR that requires immediate action, the consultant pharmacist will notify the nurse and request the facility contact the attending physician to communicate the issue and obtain direction or new orders .
CONCERN
(F)
Potential for Harm - no one hurt, but risky conditions existed
Infection Control
(Tag F0880)
Could have caused harm · This affected most or all residents
**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, record review, and interview, the facility failed to maintain transmission based precautions (a set of act...
Read full inspector narrative →
**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, record review, and interview, the facility failed to maintain transmission based precautions (a set of actions that include the use of personal protective equipment to prevent the spread of contagious organisms) related to COVID-19 (a highly contagious disease that is a result of a virus) for 3 (R#'s 230, 231, and 232) of 3 (R#'s 230, 231, and 232) residents reviewed for infection control practices. This deficient practice could likely result in a breach in infection control resulting in an outbreak in cases of COVID-19.
A. Record review of the facility's policy titled COVID-19, last revised 06/07/21, revealed that In addition to Standard Precautions, Contact and Airborne Precautions will be implemented for patients suspected or confirmed to have COVID-19 based on the Centers for Disease and Control (CDC) guidance. For the purpose of this policy, Airborne Precautions is defined as . keeping the door to the patient's room closed and .
B. Record review of the facility census, dated 03/13/22, revealed that recent admits were located in the following rooms: R #230 was located in room [ROOM NUMBER], R #231 was located in room [ROOM NUMBER], and R #232 was located in room [ROOM NUMBER].
C. On 03/16/22 at 3:01 pm, an observation of the recently admitted residents' rooms was made. The doors to the resident rooms were open and the curtains were pushed back against the wall.
D. On 03/17/22 at 2:26 pm, during an interview with LPN (Licensed Professional Nurse) #1, when asked if newly admitted residents should be placed on quarantine, she confirmed, yes.
E. Record review of the Electronic Health Record (EHR) revealed that R #230 was admitted on [DATE] with MRSA (Methicillin-Resistant Staphylococcus Aureus, a bacteria that causes an infection that is difficult to treat) bacteremia. Further review of the EHR revealed that R #230 is not vaccinated against COVID-19.
F. Record review of the EHR revealed that R #232 was admitted on [DATE] but was not fully vaccinated against COVID-19.
G. Record review of the EHR revealed that R #231 was admitted on [DATE] but was not vaccinated against COVID-19.
H. On 03/18/22 at 10:50 am, during an observation, the doors to the resident rooms were open. The curtains were not drawn. R #231 was noted to be out of his room and did not have a sign on his door which would alert the staff of the transmission based precautions and what type of PPE would be required before entering the room.
I. On 03/18/22 at 11:36 am, during an interview with the Center Nurse Executive (CNE), when asked what is expected for new admits who are not vaccinated, she explained that they offer all residents the opportunity to receive the vaccine. If they resident declines the vaccine, then, they will conduct COVID-19 tests for the first four days after being admitted . The residents are then kept on quarantine for fourteen days. When asked what the quarantine period should look like, she explained that the residents should remain in their room, the door should be closed, a sign should be on the door indicating what type of contact precautions are in place and the staff should use the appropriate PPE. When asked if the observations for R #'s 230, 231, and 232 were consistent with the quarantine expectations, she confirmed no.
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
- "Can I speak with families of current residents?"
- "What's your RN coverage like on weekends and overnight?"
Our Honest Assessment
Strengths
- • 45% turnover. Below New Mexico's 48% average. Good staff retention means consistent care.
Concerns
- • 49 deficiencies on record, including 1 serious (caused harm) violation. Ask about corrective actions taken.
Bottom line: Mixed indicators with Trust Score of 63/100. Visit in person and ask pointed questions.
✓ Report will be sent to your email
About This Facility
What is Red Rocks Care Center's CMS Rating?
CMS assigns Red Rocks Care Center an overall rating of 4 out of 5 stars, which is considered above average nationally. Within New Mexico, this rating places the facility higher than 99% of the state's 100 nursing homes. This rating reflects solid performance across the metrics CMS uses to evaluate nursing home quality.
How is Red Rocks Care Center Staffed?
CMS rates Red Rocks Care Center's staffing level at 2 out of 5 stars, which is below average compared to other nursing homes. Staff turnover is 45%, compared to the New Mexico average of 46%. This relatively stable workforce can support continuity of care. RN turnover specifically is 58%, which is notably high. RNs provide skilled clinical oversight, so turnover in this role can affect medical care quality.
What Have Inspectors Found at Red Rocks Care Center?
State health inspectors documented 49 deficiencies at Red Rocks Care Center during 2022 to 2025. These included: 1 that caused actual resident harm and 48 with potential for harm. Deficiencies causing actual harm indicate documented cases where residents experienced negative health consequences.
Who Owns and Operates Red Rocks Care Center?
Red Rocks Care Center 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 GENESIS HEALTHCARE, a chain that manages multiple nursing homes. With 102 certified beds and approximately 82 residents (about 80% occupancy), it is a mid-sized facility located in Gallup, New Mexico.
How Does Red Rocks Care Center Compare to Other New Mexico Nursing Homes?
Compared to the 100 nursing homes in New Mexico, Red Rocks Care Center's overall rating (4 stars) is above the state average of 2.9, staff turnover (45%) is near the state average of 46%, and health inspection rating (4 stars) is above the national benchmark.
What Should Families Ask When Visiting Red Rocks Care Center?
Based on this facility's data, families visiting should ask: "Can you walk me through typical staffing levels on day, evening, and night shifts?" "Can I visit during a mealtime to observe dining assistance and food quality?" "How do you handle medical emergencies, and what is your hospital transfer rate?" "Can I speak with family members of current residents about their experience?" These questions are particularly relevant given the below-average staffing rating.
Is Red Rocks Care Center Safe?
Based on CMS inspection data, Red Rocks Care Center has a clean safety record: no substantiated abuse findings (meaning no confirmed cases of resident harm), no Immediate Jeopardy citations (the most serious violation level indicating risk of serious injury or death), and is not on the Special Focus Facility watch list (a federal program monitoring the lowest-performing 1% of nursing homes). The facility has a 4-star overall rating and ranks #1 of 100 nursing homes in New Mexico. While no facility is perfect, families should still ask about staff-to-resident ratios and recent inspection results during their visit.
Do Nurses at Red Rocks Care Center Stick Around?
Red Rocks Care Center has a staff turnover rate of 45%, which is about average for New Mexico 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 Red Rocks Care Center Ever Fined?
Red Rocks Care Center has been fined $7,443 across 1 penalty action. This is below the New Mexico average of $33,153. While any fine indicates a compliance issue, fines under $50,000 are relatively common and typically reflect isolated problems that were subsequently corrected. Families should ask what specific issues led to these fines and confirm they've been resolved.
Is Red Rocks Care Center on Any Federal Watch List?
Red Rocks Care Center 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.