Casa Maria Healthcare
For profit - Limited Liability company
118 Beds
OPCO SKILLED MANAGEMENT
Data: November 2025
4 Immediate Jeopardy citations
Trust Grade
0/100
#58 of 67 in NM
Last Inspection: September 2024
Within standard 12-15 month inspection cycle. Federal law requires annual inspections.
Overview
Casa Maria Healthcare in Roswell, New Mexico has received a Trust Grade of F, which indicates significant concerns about the quality of care provided. Ranked #58 out of 67 facilities in the state, this places them in the bottom half of nursing homes, and #2 out of 3 in Chaves County, meaning only one local option is better. While the facility is reportedly improving, going from 26 issues in 2024 to just 2 in 2025, the staffing rating is concerning with a score of 1 out of 5, and a high turnover rate of 52%. They have also accumulated $99,368 in fines, which is higher than 75% of New Mexico facilities, suggesting ongoing compliance issues. There are critical incidents that are alarming, including a failure to regularly check the blood sugar levels of diabetic residents, leading to one resident being hospitalized due to high blood sugar levels. Additionally, one resident suffered multiple falls due to inadequate preventative measures, ultimately resulting in their death shortly after. The facility also failed to report incidents of alleged abuse for two residents, raising serious concerns about safety and oversight. Overall, while there are some positive trends, the weaknesses in care and safety cannot be overlooked.
- Trust Score
- F
- In New Mexico
- #58/67
- Safety Record
- High Risk
- Inspections
- Getting Better
- Staff Stability ⚠ Watch
- 52% turnover. Above average. Higher turnover means staff may not know residents' routines.
- Penalties ○ Average
- $99,368 in fines. Higher than 56% of New Mexico facilities. Some compliance issues.
- Skilled Nurses ⚠ Watch
- Each resident gets only 20 minutes of Registered Nurse (RN) attention daily — below average for New Mexico. Fewer RN minutes means fewer trained eyes watching for problems.
- Violations ⚠ Watch
- 54 deficiencies on record. Higher than average. Multiple issues found across inspections.
0/100
Bottom 14%
Review needed
26 → 2 violations
★☆☆☆☆
1.0
Overall Rating
★☆☆☆☆
1.0
Staff Levels
★★★★☆
4.0
Care Quality
★☆☆☆☆
1.0
Inspection Score
↔
Stable
2024: 26 issues
2025: 2 issues
The Good
-
4-Star Quality Measures · Strong clinical quality outcomes
-
Full Sprinkler Coverage · Fire safety systems throughout facility
-
No fines on record
Facility shows strength in quality measures, fire safety.
The Bad
1-Star Overall Rating
Below New Mexico average (2.9)
Significant quality concerns identified by CMS
Staff Turnover: 52%
Near New Mexico avg (46%)
Higher turnover may affect care consistency
Federal Fines: $99,368
Well above median ($33,413)
Moderate penalties - review what triggered them
Chain: OPCO SKILLED MANAGEMENT
Part of a multi-facility chain
Ask about local staffing decisions and management
The Ugly 54 deficiencies on record
4 life-threatening 1 actual harm
Sept 2025
2 deficiencies
CONCERN
(D)
📢 Someone Reported This
A family member, employee, or ombudsman was alarmed enough to file a formal complaint
Potential for Harm - no one hurt, but risky conditions existed
Report Alleged Abuse
(Tag F0609)
Could have caused harm · This affected 1 resident
Based on record review and interview, the facility failed to report a suicide attempt where a potential for serious bodily injury can occur within 24 hours to the State Agency (SA) for 1 (R #2) of 1 (...
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Based on record review and interview, the facility failed to report a suicide attempt where a potential for serious bodily injury can occur within 24 hours to the State Agency (SA) for 1 (R #2) of 1 (R #2) resident reviewed for abuse. If the facility fails to report these incidents to the State Agency, then the State Agency cannot ensure the residents' safety is protected. The findings are: 1. Record review of the facility's Initial Incident Report for R #1's suicide attempt on 09/01/25 revealed the initial report was submitted to the SA on 09/10/25. 2. On 09/11/25 at 2:15 pm during an interview with the Regional Nurse Consultant, she confirmed that the report was not submitted timely within 24 hours.
CONCERN
(E)
📢 Someone Reported This
A family member, employee, or ombudsman was alarmed enough to file a formal complaint
Potential for Harm - no one hurt, but risky conditions existed
ADL Care
(Tag F0677)
Could have caused harm · This affected multiple residents
**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on record review and interview, the facility failed to provide activities of daily living (ADL; activities related to pers...
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**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on record review and interview, the facility failed to provide activities of daily living (ADL; activities related to personal care such as bathing, showering, dressing, walking, toileting, and eating) assistance for baths or showers for 3 (R #1, R #2, and R #3) of 3 (R #1, R #2, and R #3) residents reviewed for ADL care. This deficient practice is likely to affect the dignity and health of the residents. The findings are:R #1A. Record review of R #1's admission Record revealed R #1 was admitted to the facility on [DATE] with the following diagnoses:1. History of falling,2. Seizures (convulsions),3. Lack of coordination,4. Cognitive communication deficit (communication problems caused from cognitive impairment),5. Traumatic subdural hemorrhage (a collection of blood between the outer layer and middle layers of the brain's covering due to a traumatic brain injury),6. Generalized muscle weakness (the body's inability to contract muscles properly), 7. Reduced mobility,8. Muscle wasting,9. Difficulty in walking.B. Record review of R #1's admission Minimum Data Set (MDS; a federally mandated assessment instrument completed by facility staff) dated 07/18/25, revealed a Brief Interview for Mental Status (BIMS; a screening for cognitive impairment) score of 15, cognitively intact.C. Record review of R #1's care plan dated 04/24/25 revealed that R #1 requires supervision or touching assistance from staff to shower or bathe.D. On 09/11/25 at 12:46 am during an interview with R #1, he stated he has not been receiving his shower or bath on his regular scheduled times. R #1 stated he remembers getting a shower today, but he had not been getting his showers three times a week as ordered.E. Record review of the facility's POC ADL charting (Point of care activities of daily living care provided during shift), no date, revealed R #1 is scheduled for a shower on Mondays, Wednesdays, and Fridays.F. Record review of R #1's survey documentation report for the month of August 2025 revealed the following:1. R #1 received showers on 08/07/25, 08/15/25, and 08/23/25.2. No documentation to show R #1 was offered or assisted with a bath or shower for six days from 08/01/25 to 08/07/25.3. No documentation to show R #1 was offered or assisted with a bath or shower for seven days from 08/08/25 to 08/17/25.4. No documentation to show R #1 was offered or assisted with a bath or shower for seven days from 08/18/25 to 08/23/25.G. Record Review of R #1's survey documentation report for the month of September 2025 revealed the following:1. R #1 received showers on 09/06/25 and on 09/08/25.2. No documentation to show R #1 was offered or refused a bath or shower for six days from 09/01/25 to 09/06/25.R #2H. Record review of R #2's admission Record revealed R #2 was admitted to the facility on [DATE] with the following diagnoses:1. Metabolic Encephalopathy (brain dysfunction),2. Fracture of superior rim of left pubis, subsequent encounter for fracture with routine healing (fracture of the pelvis),3. Unspecified fracture of the T7-T8 Vertebra, subsequent encounter for fracture with routine healing (fracture of the spine),4. Difficulty in walking,5. Generalized muscle weakness.I. Record review of R #2's quarterly Minimum Data Set, dated [DATE], revealed the following:1. BIMS score of 15, cognitively intact.2. R #2 requires partial/moderate assistance to shower or bathe.J. Record review of the facility's shower schedule, no date, revealed R #2 is scheduled for a shower on Mondays, Wednesdays, and Fridays.K. Record review of R #2's survey documentation report for the month of August 2025 revealed the following:1. Resident #2 was showered with total dependence as a one-person physical assist on 08/18/25, 08/20/25, and 08/29/25.2. The survey documentation report did not contain any documentation to show R #2 was offered or assisted with a bath or shower for five days from admission, days from 08/13/25 to 08/18/25.3. The survey documentation report did not contain any documentation to show R #2 was offered or assisted with a bath or shower for seven days from 08/22/25 to 08/29/24.R #3L. Record review of R #3's admission Record revealed R #3 was admitted to the facility on [DATE] with the following diagnoses:1. Unspecified dementia (a group of conditions characterized by impairment of at least two brain functions, such as memory loss and judgment),2. Muscle weakness,3. Lack of coordination,4. Difficulty in walking.M. Record review of R #3's quarterly Minimum Data Set, dated [DATE] revealed the following:1. BIM score of 00, severe impairment.2. R #3 is totally dependent with maximum assistance to shower or bathe.N. Record review of the facility's shower schedule, no date, revealed R #3 is scheduled for a shower on Mondays, Wednesdays, and Fridays.O. Record review of R #3's survey documentation report for the month of August 2025 revealed the following:1. R #3 was showered on 08/06/25, and 08/25/25 with total dependence and one-person assist.2. The survey documentation report did not contain any documentation to show R #3 was offered or assisted with a bath or shower for five days from admission, days from 08/01/25 to 08/06/25.3. The survey documentation report did not contain any documentation to show R #3 was offered or assisted with a bath or shower for eighteen days, from 08/07/25 to 08/25/25.4. The survey documentation report did not contain any documentation to show R #3 was offered or assisted with a bath or shower for six days from 08/26/25 to 08/31/25.5. The survey documentation report revealed R #3 refused a bath or shower on 08/26/25.P. On 09/02/25 at 11:02 am during an interview with the Regional Nurse Consultant (RNC #1), she stated her expectation is for the shower schedule to be followed and confirmed it was not for R #1, R #2, and R #3.
Sept 2024
19 deficiencies
CONCERN
(D)
Potential for Harm - no one hurt, but risky conditions existed
Resident Rights
(Tag F0550)
Could have caused harm · This affected 1 resident
Based on observation and interview, the facility failed to promote care with dignity and respect for 4 (R #3, R #44, R #56, and R #70) of 6 (R #3, R #12, R #44, R #56, R #64, and R #70) residents revi...
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Based on observation and interview, the facility failed to promote care with dignity and respect for 4 (R #3, R #44, R #56, and R #70) of 6 (R #3, R #12, R #44, R #56, R #64, and R #70) residents reviewed during a random dining observation when the facility failed to serve lunch at the same time to all the residents who sat at the same dining table. This deficient practice could likely result in residents feeling frustrated and disappointed.
The findings are:
A. On 09/16/24 at 12:04 pm, during a lunch observation in the dining room, revealed the following:
1. R #12 and R #56 sat at the same table waiting for lunch to be served:
a. R #12 was served his meal at 12:22 pm and R #56 watched R #12 eat his meal.
b. R #56 was served his meal at 12:29 pm.
2. R #3, R #44, R #64, and R #70 sat at the same table waiting for lunch to be served:
a. R #64 was served his meal at 12:34 pm and R #3, R #44, and R #70 watched R #64 eat his meal.
b. R #3 was served her meal at 12:36 pm and R #44 and R #70 watched R #3 eat her meal.
c. R #70 was served his meal at 12:40 pm and R #44 watched R #70 eat his meal.
d. R #44 was served her meal at 12:46 pm.
B. On 09/16/24 at 12:26 pm, during an interview with R #12, he stated that he would prefer to have his meal served at the same time his friend's meal is served so they can eat together.
C. On 09/16/24 at 12:37 pm, during an interview with R #3, R #44, R #64, and R #70, they all agreed that they prefer to have their meals served at the same time as those sitting at the same table.
D. On 09/18/24 at 11:12 am, during an interview with the Dietary Manager (DM), he confirmed that residents having to wait from seven to twelve minutes to be served is too long. He stated his expectation is to have residents seated at the same table to be served at the same time or within a few minutes of each other.
CONCERN
(E)
Potential for Harm - no one hurt, but risky conditions existed
Deficiency F0553
(Tag F0553)
Could have caused harm · This affected multiple residents
**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on record reviews and interviews, the facility failed to ensure the resident's right to participate in the care planning p...
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**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on record reviews and interviews, the facility failed to ensure the resident's right to participate in the care planning process for 3 (R #24, R #30, and R #96) of 5 (R #24, R #30, R #90, R #96, and R #294) residents reviewed for care plans. If the facility fails to ensure resident's participation in the care planning process, then residents are likely to feel unimportant and uninformed. The findings are:
R #24
A. Record review of R #24's admission Record revealed R #24 was admitted to the facility on [DATE] with multiple diagnosis including:
1. Unspecified Sequelae of Unspecified Cerebrovascular Disease (conditions that impact blood vessels in the brain).
2. Bipolar Disorder (a disorder associated with episodes of mood swings ranging from depressive lows to manic highs).
3. Anxiety Disorder.
4. Anoxic Brain Damage (damage to the brain from lack of oxygen), not elsewhere classified.
6. Difficulty in walking
B. Record review of R #24's admission Minimum Data Set Assessment (MDS; a federally mandated assessment instrument completed by facility staff), dated 06/30/24, revealed a Brief Interview of Mental Status (BIMS; a screening for cognitive impairment. Scores range from 00 to 15, with 15 - 13 is cognitively intact, 12 - 8 is moderately impaired, 7 - 00 is severe impairment) score of 15.
C. On 09/17/24 at 8:45 am, during an interview with R #24, she stated that she does not have a Power of Attorney (POA; legal authorization for a designated person to make decisions about another person's property, finances, or medical care) in place, and she has not had a care plan meeting since being admitted to the facility.
D. Record review of R #24's Electronic Health Record revealed the record did not contain any evidence of a care plan meeting.
E. On 09/19/24 at 10:16 am, during an interview with the Regional Social Services Consultant (RSSC), he confirmed there has not been a care plan meeting for R #24 since she was admitted to the facility and stated, she should have had a care plan meeting already.
R #30
F. Record review of R #30's admission Record revealed R #30 was admitted to the facility on [DATE] and readmitted to the facility on [DATE] with multiple diagnoses including:
1. Acute and Chronic Respiratory Failure with Hypercapnia (a condition that requires long-term regular care that can become an emergency with too much carbon dioxide in the blood).
2. Muscle weakness, generalized.
3. Difficulty in walking.
4. Polyneuropathy, unspecified (a condition where a person's nerves located outside of the brain and spinal cord are damaged).
5. Hypertensive Heart Disease with heart failure.
G. On 09/16/24 at 2:12 pm, during an interview with R #30, he stated that he is not invited to attend his care plan meetings, and he does not have a POA in place.
H. On 09/16/24 at 10:16 am, during an interview with the RSSC, he stated the facility had a care plan meeting for R #30 on 07/18/24, but the resident was in the hospital. He confirmed the meeting should not have occurred stating it defeats the purpose to have a care plan meeting while the resident is not present.
R #96
I. Record review of R #96's admission Record revealed R #96 was admitted to the facility on [DATE] with multiple diagnosis including:
1. Malignant Neoplasm of Colon, unspecified (Colon Cancer).
2. Type 2 Diabetes, Mellitus without complications.
3. Acute Respiratory Failure with Hypoxia.
4. Difficulty in walking.
5. Encounter for surgical aftercare following surgery on the digestive system.
J. Record review of R #96's Minimum Data Set Assessment, dated 08/27/24, revealed a BIMS score of 13.
K. On 09/17/24 at 10:21 am, during an interview with R #96, she stated that she couldn't remember having a care plan meeting since being admitted to the facility. She stated that she would like to attend her care plan meetings because it's important for her to know everything she can about her care.
L. Record review of R #96's NM Care Plan Conference (the facility's form to document care plan meetings), dated 07/18/24, revealed her POA attended but R #96 Did not want to attend.
M. Record review of R #96's NM Care Plan Conference, dated 08/01/24, revealed R #96's POA attended the meeting, but R #96 Allows POA/daughter [R #96's daughter's name] to handle her affairs.
N. Record review of R #96's NM Care Plan Conference, dated 08/21/24, revealed that R #96's POA attended the meeting, but R #96 Has a POA, low BIMS.
O. On 09/18/24 at 10:56 am, during a follow-up interview with R #96, she stated the following:
1. She has never told the facility that she did not want to attend her meetings.
2. She has not been invited to attend a care plan meeting since being admitted to the facility.
3. She did sign POA to her daughter, but it's still important for her to participate in her care planning process.
P. On 09/19/24 at 10:09 am, during an interview with the RSSC, he stated his expectation is for all residents, regardless of their BIMS score to be invited to participate in every step of the care planning process including attending care plan meetings.
CONCERN
(E)
Potential for Harm - no one hurt, but risky conditions existed
Deficiency F0561
(Tag F0561)
Could have caused harm · This affected multiple residents
**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on record review, observations, and interviews, the facility failed to promote residents' choices for 2 (R #28 and R#96) o...
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**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on record review, observations, and interviews, the facility failed to promote residents' choices for 2 (R #28 and R#96) of 2 (R #28 and #96) residents reviewed for choices when staff failed to:
1. Announce themselves prior to entering R #28's room.
2. Accommodate R #96's choice to have her oxygen tube attached to the rail of her bed.
These deficient practices are likely to result in the resident's needs, choices and preferences not being honored. The findings are:
R #28
A. Record review of R #28's current physician orders, R #28 was admitted to the facility on [DATE] with multiple diagnosis including:
1. Acute and Chronic Respiratory Failure.
2. Other reduced mobility.
3. Muscle wasting and Atrophy.
4. Morbid obesity.
5. Unspecified Osteoarthris.
B. On 09/16/24 at 2:28 pm, during an interview with R #28, she stated that she is frustrated because staff enters her room without knocking. R #28 stated she has reported her concerns to the Administrator, but it continues to occur.
C. On 09/19/24 at 10:14 am, during an interview with the Regional Social Services Consultant (RSSC), he stated his expectation is for all employees to knock on the door first, if the resident does not answer employees, they should look in to the room to ensure the resident is safe while verbally announcing themselves. He stated that residents should be alerted to people entering their rooms because it is a dignity issue as well.
R #96
D. On 09/17/24 at 9:23 am, during an observation of R #96, she had her oxygen tube (a tube that is connected to the oxygen concentrator that supplies oxygen for one to breathe) loosely attached to the rail on her bed with a white fabric. Licensed Vocational Nurse (LVN) #1 started to untie the white fabric from the tube while R #96 was repeatedly asking her to stop. R #96 stated to LVN #1 she prefers the tube to be attached to her bed, so it's not on the floor. R #96 explained to LVN #1 that she did not want the germs on the floor to get on the oxygen tube. LVN #1 proceeded to untie the white fabric allowing the oxygen tube to fall to the floor and then threw the white fabric in the trash can. R #96 was visibly upset and said, I don't know why they treat us like little kids, I don't want the tube on the floor, and she (LVN #1) thinks she can do whatever she wants to.
E. On 09/20/24 at 9:26 am, during an interview with the Regional Nurse Coordinator, she stated her expectation would be for the nurse to listen to the resident and promote her choice, especially if there was not a health reason behind untying the fabric.
CONCERN
(E)
Potential for Harm - no one hurt, but risky conditions existed
Deficiency F0565
(Tag F0565)
Could have caused harm · This affected multiple residents
Based on interviews, the facility failed to ensure the grievances identified by the Resident Council (RC) were resolved and the resolutions communicated back to the RC committee. This deficient practi...
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Based on interviews, the facility failed to ensure the grievances identified by the Resident Council (RC) were resolved and the resolutions communicated back to the RC committee. This deficient practice could likely affect all 95 residents who reside at the facility. If the staff is not ensuring RC grievances are responded to and resolutions are communicated back to the RC group, then residents are likely to feel that their concerns do not matter, and do not have any influence over changing issues identified by residents. The findings are:
A. On 09/17/24 at 10:00 am, during an interview with the Resident's Council members [R #10, R #34, R #40, R #44, R #45, R #55, R #64, and R #70], they stated the facility discourages them from filing grievances and when they do file grievances the facility does not respond timely, if at all.
B. On 09/18/24 at 11:25 am, during an interview with the Activity Director (AD), she stated she fills out the grievance forms and submits the forms to the appropriate department head for completion. She stated that she informs the residents of the outcome of the grievances but stated she cannot do that until she gets the forms back which has at times taken up to several weeks.
C. On 09/19/24 at 10:24 am during an interview with the Regional Social Services Consultant (RSSC), he stated his expectation is for staff to:
1. Assist residents to write a grievance if requested by a resident and submit to the Social Services department so the grievance can be logged for internal tracking purposes.
2. Social Services should then submit the grievance to the appropriate department head to be completed and submitted to the Administrator.
3. Residents involved with the grievance should be notified in writing and in a manner that they understand.
4. Then the grievance should be placed in the binder.
The RSSC stated that he was unsure if grievances or outcomes are discussed during resident council meetings, but stated they should be.
CONCERN
(E)
Potential for Harm - no one hurt, but risky conditions existed
Assessment Accuracy
(Tag F0641)
Could have caused harm · This affected multiple residents
**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, interview and record review, the facility failed to complete an accurate comprehensive assessment for 2 (R...
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**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, interview and record review, the facility failed to complete an accurate comprehensive assessment for 2 (R #22 and R #75) of 2 (R #22 and R #75) residents reviewed for assessments. This deficient practice is likely to result in residents not receiving an accurate assessment which could result in the residents receiving less than optimal care and treatment. The findings are:
R #22
A. On 09/17/24 at 11:30 AM during an interview and observation with R #22, she stated she needed dental care but, she has not been offered a dental appointment. R #22 had missing teeth and discoloration.
B. Record review of the Minimum Data Set (MDS) assessment dated [DATE], Section L: Oral and Dental Status indicated R #22 did not have any dental problems.
C. On 09/20/24 at 1:52 PM during an interview with the MDS coordinator, he confirmed R #22's dental information was entered incorrectly.
R #75
D. On 09/17/24 at 9:43 AM during an interview with R #75, he stated he would like dentures, he further stated he has not had a dental appointment since prior to admission to the facility and would like dentures. He stated he might eat a little better if he did have dentures.
E. Record review of the Minimum Data Set (MDS) assessment Quarterly dated 07/31/24, Section L: Oral and Dental Status revealed the section was not completed and left blank.
F. On 09/20/24 at 1:52 PM during an interview with the MDS coordinator, he confirmed R #75 dental section was not completed.
CONCERN
(E)
Potential for Harm - no one hurt, but risky conditions existed
Deficiency F0679
(Tag F0679)
Could have caused harm · This affected multiple residents
**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on record review and interview, the facility failed to provide an ongoing program of activities designed to meet the inter...
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**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on record review and interview, the facility failed to provide an ongoing program of activities designed to meet the interests for 4 (R #22, R #24, R #30, and R #90) of 6 (R #22, R #24, R #30, R #90, R #242, and R #294) residents reviewed for activities by not providing meaningful individualized activities based upon residents' interests. If residents are not provided or encouraged to attend/participate in activities that meets their interests, then they are likely to experience an increase in boredom, isolation, and depression. The findings are:
R #22
A. Record review of R #22's admission Record revealed R #22 was admitted to the facility on [DATE] with multiple diagnoses including:
1. Type 2 Diabetes Mellitus without complications (DM2, a condition results from insufficient production of insulin, causing high blood sugar).
2. Schizophrenia, unspecified (a disorder that affects an individual's ability to think, feel, and behave clearly).
3. Bipolar Disorder, unspecified (a disorder associated with episodes of mood swings ranging from depressive lows to manic highs).
4. Depression, unspecified (a mood disorder that causes a persistent feeling of sadness and loss of interest).
5. Persistent Mood [Affective] Disorder (continuous, long-term form of depression).
6. Anxiety Disorder, unspecified (a feeling of worry, nervousness, or unease, typically about an imminent event or something with an uncertain outcome).
7. Cerebral Palsy, unspecified (a disorder of movement, muscle tone, and posture).
B. On 09/16/24 at 2:45 pm, during an interview with R #22, she stated she does not know anything about the activities the facility offers. She stated the facility has not offered any activities or even discussed activities with her.
C. Record review of R #22's Electronic Health Record (EHR) revealed the record did not contain any documentation of her participation in activities since she was admitted to the facility.
D. On 09/18/24 at 11:30 am, during an interview with the Activity Director (AD), she confirmed she has not offered R #22 any activities, especially in room activities, since she knows that R #22 enjoys spending time in her room.
R #24
E. Record review of R #24's admission Record revealed R #24 was admitted to the facility on [DATE] with multiple diagnosis including:
1. Unspecified Sequelae of Unspecified Cerebrovascular Disease (conditions that impact blood vessels in the brain).
2. Bipolar Disorder (a disorder associated with episodes of mood swings ranging from depressive lows to manic highs).
3. Anxiety Disorder.
4. Anoxic Brain Damage (damage to the brain from lack of oxygen), not elsewhere classified.
5. Difficulty in walking
F. On 09/17/24 at 8:40 am, during an interview with R #24, she stated that she does not attend activities because she has recently lost weight and does not have any clothes that fit her. She stated the facility has never offered activities for her to do in her room.
G. On 09/18/24 at 11:04 am during an interview with the AD, she confirmed R #24 does not come out of her room very often. The AD stated R #24 does participate in room activities and stated all activities would be documented in R #24's Electronic Health Record.
H. Record Review of R #24's EHR revealed the following:
1. Note dated 07/08/24 stated R #24 was watching TV program in her room.
2. Note dated 07/18/24 stated R #24 was enjoying TV programs in her room.
3. Note dated 08/09/24 stated R #24 enjoyed activities in the dining room.
4. The EHR did not contain any additional documentation of R #24 participating in activities.
I. On 09/18/24 at 2:16 pm, during an interview with the AD, she stated that her expectation is for R #24 to participate in a wider variety of activities more often than she has. She stated that she expects more individualized activities be offered to residents.
R #30
J. Record review of R #30's admission Record revealed R #30 was originally admitted to the facility on [DATE] and readmitted to the facility on [DATE] with multiple diagnoses including:
1. Acute and Chronic Respiratory Failure with Hypercapnia (a condition that requires long-term regular care that can become an emergency with too much carbon dioxide in the blood).
2. Muscle weakness, generalized.
3. Difficulty in walking.
4. Polyneuropathy, unspecified (a condition where a person's nerves located outside of the brain and spinal cord are damaged).
5. Hypertensive Heart Disease with heart failure.
K. On 09/17/24 at 8:40 am during an interview with R #30, he stated he does not like to attend group activities, but would like to be offered activities that he can do in his room. He stated you [residents] have to go to activities, or you do not get activities at all.
L. On 09/18/24 at 11:04 am during an interview with the AD, she confirmed R #30 has not been offered any activities since his readmission to the facility.
R #90
M. Record review of R #90's admission Record revealed R #90 was admitted to the facility on [DATE] with multiple diagnosis including:
1. Cellulitis of right lower limb.
2. Chronic Viral Hepatitis C.
3. Type 2 Diabetes Mellitus with Diabetic Chronic Kidney Disease.
4. Depression, unspecified.
5. End Stage Renal Disease.
N. On 09/17/24 at 9:05 am, during an interview with R #90, he stated he has not participated in any activities since he was admitted to the facility. He stated he did not know there were any activities offered and confirmed that nobody from the facility has talked with him about activities.
O. Record review of R #90's EHR revealed the record did not contain any documentation of R #90 participating in activities.
P. On 09/18/24 at 11:37 am during an interview with the AD, she confirmed she is the only staff member at the facility that meets with residents regarding activities, and she has not interacted with R #90 since his admission.
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 ensure residents received proper treatment to maintain vision for 1...
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**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on record review and interview, the facility failed to ensure residents received proper treatment to maintain vision for 1 (R #24) of 2 (R #24 and R #106) residnets reviewed for vision. This deficient practice could likely result in residents losing some independence if they cannot see, and compromising their quality of life. The findings are:
A. Record review of R #24's admission Record revealed R #24 was admitted to the facility on [DATE] with multiple diagnosis including:
1. Unspecified Sequelae of Unspecified Cerebrovascular Disease (conditions that impact blood vessels in the brain).
2. Bipolar Disorder (a disorder associated with episodes of mood swings ranging from depressive lows to manic highs).
3. Anxiety Disorder.
4. Anoxic Brain Damage (damage to the brain from lack of oxygen), not elsewhere classified.
5. Difficulty in walking
B. On 09/17/24 at 8:51 am, during an interview with R #24, she stated she needs eyeglasses because she can not see very well. R #24 further stated the previous Social Services Director told her an appointment would be scheduled but she is still waiting. R #24 stated this conversation with the previous Social Services Director happened a couple weeks after she was admitted but could not remember the date.
C. On 09/19/24 at 10:43 am, during an interview with the Regional Social Services Consultant (RSSC), he confirmed he could not find anything regarding a vision appointment in R #23's Electronic Health Record. He stated, Now that we know, it will be scheduled.
CONCERN
(E)
Potential for Harm - no one hurt, but risky conditions existed
Unnecessary Medications
(Tag F0759)
Could have caused harm · This affected multiple residents
Based on observation, record review, and interview, the facility failed to ensure the medication error rate was 5% or less when six medication errors occurred out of 43 opportunities, which resulted i...
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Based on observation, record review, and interview, the facility failed to ensure the medication error rate was 5% or less when six medication errors occurred out of 43 opportunities, which resulted in an error rate of 13.95% for 4 (R #19, R #24, R #55, and R #76) of 7 (R #19, R #24, R #38, R #41, R #55, R #62, and R #76) residents observed during medication administration. This deficient practice could likely result in the residents receiving the incorrect medication, not receiving the desired therapeutic effect, and exposing the resident to a higher risk of side effects. The findings are:
Incorrect Administration
A. Record review of the physician's order dated 09/17/24 for R #55, revealed an order for Lantus Subcutaneous solution (long-acting insulin that starts to work several hours after injection and keeps working evenly for 24 hours and is used to improve blood sugar control) 100 UNIT/ML (100 units of insulin per milliliter of solution) (insulin glargine [bioengineered (man-made) injectable form of long-acting insulin that is used to regulate sugar/glucose levels]) Inject 46 units subcutaneously (method of administering medication by injection into the tissue layer between the skin and the muscle) one time a day for DM 2 (DM 2, a condition results from insufficient production of insulin, causing high blood sugar), hold (medication) if blood glucose level is below <120 (A blood glucose test measures the level of glucose (sugar) in your blood in milligrams per deciliter. The test can involve a finger prick or a blood draw from your vein). [The preferred blood sugar range should be 70-100 mg/dl].
B. On 09/18/24 at 7:58 AM, during an observation, Licensed Vocational Nurse (LVN) #2 withdrew 46 units of insulin from the insulin vial and administered the dose to R #55. LVN #2 did not hold insulin or blood glucose level below 120 mg/dl .
Sanitizing hands Appropriately
C. On 09/18/24 at 8:10 AM, during an observation of medication administration, License Practical Nurse (LPN) #1 failed to sanitize hands prior to preparing medications for R #19 and LPN #1 failed to sanitize hands after administration of medications to R #19.
D. On 09/18/24 at 8:18 AM, during an observation of medication administration LPN #1 failed to sanitize hands prior to preparing and administering medications for R #76 and failed to sanitize hands after administration of medications.
E. On 09/18/24 at 8:20 AM, during an observation of medication administration, LPN #1 failed to sanitize hands after administering medications to R #24.
F. Record review of the Medication-Administration policy (not dated), provided by the Administrator (ADM) on 09/18/24, under the heading Procedure point number 2, wash hands before and after medication administration.
G. On 09/20/24 at 9:22 AM, during an interview with Regional Nurse Coordinator (RNC), she stated staff should follow the physician orders and facility policy on how medications are given to residents, including washing hands before and after resident interactions
CONCERN
(E)
Potential for Harm - no one hurt, but risky conditions existed
Deficiency F0760
(Tag F0760)
Could have caused harm · This affected multiple residents
Based on record review, observation and interview, the facility failed to ensure a resident was free of a significant medication error by not administering medications as ordered for 1 (R #55) of 1 (R...
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Based on record review, observation and interview, the facility failed to ensure a resident was free of a significant medication error by not administering medications as ordered for 1 (R #55) of 1 (R #55) resident reviewed for administration of insulin (hormone produced in the pancreas which regulates the amount of glucose in the blood). This deficient practice could likely have severe negative effects on the resident, such as hypoglycemia (too little sugar in the blood) and lead to symptoms of trouble talking, confusion, loss of consciousness, seizures, or death. The findings are:
A. Record review of R #55's admission Record (no date) revealed the diagnosis of Type 2 Diabetes Mellitus (condition characterized by high blood glucose levels caused by either a lack of insulin or the body's inability to use insulin efficiently) with foot ulcer.
B. Record review of R #55's Physician's Orders revealed an order dated 09/17/24 at 8:00 am Lantus Subcutaneous solution (long-acting insulin that starts to work several hours after injection and keeps working evenly for 24 hours and is used to improve blood sugar control) 100 UNIT/ML (100 units of insulin per milliliter of solution) (insulin glargine [bioengineered (man-made) injectable form of long-acting insulin that is used to regulate sugar/glucose levels]) Inject 46 units subcutaneously (method of administering medication by injection into the tissue layer between the skin and the muscle) one time a day for DM II (Type 2 Diabetes Mellitus), hold (medication) if below < (less than)120. [A blood glucose test measures the level of glucose (sugar) in your blood in milligrams per deciliter. The test can involve a finger prick or a blood draw from your vein]. [The preferred blood sugar range should be 70-100 mg/dl].
C. On 09/18/24 at 7:58 AM, during an observation. Licensed Vocational Nurse (LVN) #2 withdrew 46 units of insulin from the insulin vial and administered 46 units to R #55. LVN #2 did not hold R #55's insulin as ordered when blood sugar levels are less than 120 mg/dl.
D. On 09/18/24 at 7:58 AM, during an interview, LVN #2 confirmed that R #55's blood sugar level was 118 mg/dl when checked prior to giving the insulin.
E. On 09/20/24 at 9:22 AM, during an interview with Regional Nurse Coordinator (RNC), she stated staff should follow the physician orders and facility policy on how medications are given to residents.
CONCERN
(E)
Potential for Harm - no one hurt, but risky conditions existed
Dental Services
(Tag F0791)
Could have caused harm · This affected multiple residents
**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, record review, and interview, the facility failed to ensure residents obtained routine dental care for 3 (...
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**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, record review, and interview, the facility failed to ensure residents obtained routine dental care for 3 (R #22, R #24 and R #75) of 3 (R #22, R #24 and R #75) residents reviewed for dental services. This failure is likely to result in the resident experiencing pain, embarrassment over condition of teeth, and potential weight loss. The findings are:
R#22
A. Record review of R #22's face sheet revealed R #22 was admitted into the facility on [DATE].
B. On 09/17/24 at 11:30 AM during an observation and interview with R #22, she had missing teeth, tooth decay and discoloration on the remaining teeth. R #22 stated, she had not been offered dental care. She stated she had some of her teeth pulled in the past and she wanted to get dentures.
C. On 09/18/24 at 2:36 PM during an interview with Medical Records/Scheduler, she stated she schedules specialty services only and Social Services will make all other appointments for needs that are requested during care plan meetings or interdisciplinary team (IDT) meetings.
D. On 09/19/24 at 10:08 AM during an interview with Regional Social Services Consultant (RSSC) confirmed R #22 had not been offered a dental appointment, but would get her scheduled.
R #24
E. On 09/17/24 at 8:50 AM during an interview with R #24, she started my dentures were taken to be fitted about four weeks ago and I haven't heard anything about them.
F. On 09/19/24 at 10:45 AM during an interview with the RSSC, she stated R #24's dentures should have been delivered during an appointment on 08/14/24. RSSC stated the medical records/scheduler (MR) should have followed up on that.
G. Record review of R #24's Electronic Health Record revealed the record did not contain any documentation of a dental appointment on 08/14/24.
H. On 09/19/24 at 2:46 pm during an interview with MR, she confirmed R #24 should have had a dental appointment to get her dentures in August 2024 and it did not occur. She stated I should have followed up on this appointment sooner and I didn't, I'll take the blame for it. I usually follow-up once a week.
R#75
I. Record review of R #75's face sheet revealed R #75 was admitted into the facility on [DATE] with a history of muscle wasting (weaking of muscle) and atrophy (decrease in size of muscle).
J. On 09/17/24 at 9:43 AM during an observation and interview with R #75, he had missing teeth. R #75 stated, he had not had a dental appointment since he was admitted . He stated he has stomach problems which has caused weight loss but stated that if he had dentures, he may be able to eat better
K. On 09/19/24 at 10:08 AM during an interview with the RSSC, he confirmed that an email dated 07/15/24 had been sent requesting a dental appointment for R #75, but confirmed that a follow up to that referral had not been completed and an appointment had never been made
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, record review, the facility failed to administer medications in a manner to prevent cross contamination for 3 (R #19, R #24, and R #76) of 7 (R #19, R #24, R #38, R #4...
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Based on observation, interview, record review, the facility failed to administer medications in a manner to prevent cross contamination for 3 (R #19, R #24, and R #76) of 7 (R #19, R #24, R #38, R #41, R # 55, R #62, and R #76) residents. The failure has the potential to cause residents to be exposed to pathogens (organisms that can cause disease) and increased risk of infection.
The findings are:
A. On 09/18/24 at 8:05 am, during an observation of the medication administration pass, Licensed Practical Nurse (LPN) #1 prepared and gave R #19's medication and went back to the medication cart after administering medications. LPN #1 did not sanitize or wash her hands before or after resident contact.
B. On 09/18/24 at 8:18 AM, during continued medication administration observation, LPN #1 prepared medications for R #76. R #76's medications included a subcutaneous (just under the skin) injection. LPN #1 entered the resident's room, donned (to put on) gloves and administered the resident her medications. LPN #1 removed gloves and exited the room. LPN #1 went back to the medication cart without sanitizing or washing her hands prior to or after the medication administration.
C. On 09/18/24 at 8:20 AM, during continued medication administration observation, LPN #1 prepared medications for R #24. LPN #1 prepared and administered R #24 medications. LPN #1 went back to the medication cart without sanitizing or washing her hands after medication administration.
D. On 09/18/24 at 9:43 AM, during an interview with the Director of Nursing (DON), she stated hand sanitizer should be used before and after contact with each resident. She stated that medications should be administered according to the facility policy. The DON stated if injections are given her expectation is to wear gloves and use good hand hygiene before and after injection administration.
E. Review of the facility's policy titled, Medication-Administration (no date indicated), stated under the heading Procedure:
1. Assemble the necessary equipment.
2. Wash hands before and after medication administration.
3. Gloves will be worn to administer medications when contact with blood or potentially infectious body fluid is anticipated.
CONCERN
(E)
Potential for Harm - no one hurt, but risky conditions existed
Deficiency F0883
(Tag F0883)
Could have caused harm · This affected multiple residents
**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on record review the facility failed to ensure the medical records contained documentation that each resident received, or...
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**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on record review the facility failed to ensure the medical records contained documentation that each resident received, or staff offered the pneumococcal (a bacteria that can cause pneumonia infection of the respiratory tract) or influenza (flu) vaccines for 1 (R #74) of 6 (R #2, R #17, R #22, R #39, R #74, and R #75) residents reviewed for immunizations. If residents are not vaccinated as appropriate against pneumonia and influenza, they have a higher likelihood of contracting that illness and spreading it to other 95 residents on the census list provided by Administrator (ADM) on 09/16/24 and staff in the facility.
The findings are:
A. Record review of R #74's medical record revealed the following:
1. admission record for R #74 indicated she was admitted to the facility on [DATE].
2. Review of the EHR (Electronic Health Record) did not contain consent forms or declination forms for either vaccination.
3. Record review of the facility's policy titled Influenza Prevention and Control (no date) are to be offered to the residents after education is received.
B. Record review of the facility's police titled Pneumococcal Disease Prevention (no date) are to be offered to residents after education is received.
CONCERN
(E)
Potential for Harm - no one hurt, but risky conditions existed
Deficiency F0947
(Tag F0947)
Could have caused harm · This affected multiple residents
Based on record review and interview, the facility failed to ensure Certified Nurse Aides (CNAs) received the required in-service training of 12 hours per year for 1 (CNA #1) of 2 (CNA #1 and CNA #2) ...
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Based on record review and interview, the facility failed to ensure Certified Nurse Aides (CNAs) received the required in-service training of 12 hours per year for 1 (CNA #1) of 2 (CNA #1 and CNA #2) CNAs reviewed for required in-service training. This deficient practice is likely to result in the CNAs not receiving the necessary training to meet the care needs of the residents. The findings are:
A. Record review of CNA #1's personnel file revealed CNA #1 was hired on 06/27/23.
B. Record review of CNA #1's in-service training Transcript Report revealed CNA #1 did not complete any of the required 12 hours trainings from 06/27/23 to 09/20/24.
C. On 09/20/24 at 11:55 am, during an interview with the Human Resources Director (HRD), she confirmed CNA #1 has not completed any trainings during her employment at the facility. She confirmed CNA #1 continues to work shifts providing care for residents in the facility even though she has not completed any of the trainings. The HRD stated she expected all CNAs to complete at least 12 hours of training per year.
CONCERN
(F)
Potential for Harm - no one hurt, but risky conditions existed
Deficiency F0567
(Tag F0567)
Could have caused harm · This affected most or all residents
Based on interviews the facility failed to ensure residents have ready and reasonable access to their money. This deficient practice could likely affect all 95 residents who reside at the facility. If...
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Based on interviews the facility failed to ensure residents have ready and reasonable access to their money. This deficient practice could likely affect all 95 residents who reside at the facility. If the facility is not ensuring residents have access to their money, then residents are likely to feel undignified and unworthy. The findings are:
A. On 09/17/24 at 8:42 am, during an interview with R #24, she stated she recently received a check for a large amount of money, but the facility will not give her any money. She stated the facility tells the residents that they've [the facility] ran out of money when money is requested. R #24 stated that the facility never gives out money on the weekends.
B. On 09/17/24 at 10:00 am, during an interview with the Resident Council members [R #10, R #34, R #40, R #44, R #45, R #55, and R #64], they stated on weekdays, when they request money, staff have constantly told them that the money is not available. The residents further stated that they are never allowed to get money on the weekends.
C. On 09/18/24 at 9:50 am, during an interview with the Business Office Manager (BOM), she stated the facility did receive a check for R #24 on 09/04/24, and the check was deposited the same day, and cleared (funds were available) on 09/05/24. The BOM confirmed R #24 requested money on 09/06/24 and the request was denied due to the facility not have any money available at that time. The BOM confirmed the facility did not have any cash on hand for the resident's use for a total of thirteen days (from September 5, 2024, to September 17, 2024).
D. On 09/18/24 at 10:19 am, during an interview with the Regional Business Office Manager (RBOM), she stated her expectation is for the facility to have cash on hand for residents use at all times.
CONCERN
(F)
Potential for Harm - no one hurt, but risky conditions existed
Deficiency F0576
(Tag F0576)
Could have caused harm · This affected most or all residents
Based on interviews, the facility failed to ensure that residents are able to receive mail on Saturdays for all 95 residents residing at the facility. This deficient practice is likely to result in re...
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Based on interviews, the facility failed to ensure that residents are able to receive mail on Saturdays for all 95 residents residing at the facility. This deficient practice is likely to result in residents not receiving timely communication which could result in feelings of isolation. The findings are:
A. On 09/17/24 at 10:00 am, during the Resident's Council Meeting [R #10, R #34, R #40, R #44, R #45, R #55, R #64, and R #70], the residents stated mail is not delivered on Saturdays and they would like to receive their mail when it is delivered to the facility. R #44 stated she has never received her mail on a Saturday, even when she is waiting for a package. R #44 stated she has had to wait up to two days to receive packages that contain personal incontinence supplies.
B. On 09/18/24 at 11:25 am, during an interview with the Activities Director (AD) she confirmed the mail is not delivered on the weekends. She stated she is the only staff at the facility that delivers the mail to residents. so if she is not at work, the mail does not get delivered.
C. On 09/19/24 at 10:24 am during an interview with the Regional Social Services Consultant (RSSC), he stated he expects residents mail to be delivered daily.
CONCERN
(F)
Potential for Harm - no one hurt, but risky conditions existed
Deficiency F0728
(Tag F0728)
Could have caused harm · This affected most or all residents
Based on record review and interview, the facility failed to provide documentation confirming on Nurse Aide (NA) #1, employed by the facility, had completed a Nurse Aide Training and Competency Evalua...
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Based on record review and interview, the facility failed to provide documentation confirming on Nurse Aide (NA) #1, employed by the facility, had completed a Nurse Aide Training and Competency Evaluation Program (NATCEP) or a Competency Evaluation Program (CEP) within four months of being employed at the facility. This deficient practice is likely to affect all 95 residents residing in the facility. Residents are likely to experience substandard care because of the use of untrained or unqualified aides providing direct care to residents. The findings are:
A. Record review of NA #1's personnel record reviewed the following:
1. NA #1's hire date was 07/17/23.
2. NA #1's date of Certified Nurse Aide certification was 12/08/23.
B. On 09/20/25 at 11:55 am, during an interview with the Human Resources Director (HRD), she confirmed NA #1 received her certification late and continued to work shifts during that time. She stated her expectation is for all nurse aides to become certified within four months.
CONCERN
(F)
Potential for Harm - no one hurt, but risky conditions existed
Deficiency F0804
(Tag F0804)
Could have caused harm · This affected most or all residents
Based on interview and observation, the facility failed:
1. Ensure meals were attractive when served to residents.
2. Ensure foods were palatable (pleasant to taste) and to the resident's satisfactio...
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Based on interview and observation, the facility failed:
1. Ensure meals were attractive when served to residents.
2. Ensure foods were palatable (pleasant to taste) and to the resident's satisfaction.
3. Ensure cold and hot foods were served at the appropriate temperatures to prevent scalding and burning.
4. Ensure foods were served timely to each resident and those sharing tables.
These deficient practices have the potential to affect all 95 residents' ability to eat and enjoy meals, may decrease their quality of life, and could likely lose weight.
The findings are:
Food Attractiveness
A. On 09/16/24 at 3:51 pm, during an observation of R #90 in his room, he had a partially eaten hamburger on his bedside table. The meat was visibly red in the middle and appeared undercooked.
B. On 09/16/24 at 3:51 pm, during an interview, R #90 stated he was asked during breakfast what he wanted for lunch and was offered chicken fried steak. When he arrived for lunch, they served him spaghetti. He was told by the staff that he could not have chicken fried steak, because it is not included on the anytime menu, but was offered a hamburger instead. R #90 stated he doesn't mind getting a hamburger, but it was too raw to eat.
Food palatability
C. On 09/16/24 at 12:36 pm during an interview with R #3, she stated she did not want to eat lunch because it's too hard. She stated she didn't like what was being served and was offered a grilled cheese, but the crust was too hard. So I told her (CNA who served her) to forget it. R #3 stated she is not offered an alternative meal choice and will purchase Nutra grain bars for when she doesn't like what is served.
D. On 09/16/24 at 12:46 pm during an observation and interview with R #44, she was served grilled cheese sandwich and stated the cheese was not melted.
E. On 09/17/24 at 8:41 am, during an interview with R #65, she stated the food is too spicy to her a lot of the time and she won't eat it like that. She stated she doesn't like to complain.
F. On 09/17/24 at 8:47 am during an interview with R #24, she stated the food, it's not good. I'm supposed to be on weight gain program. If you ask for the alternate meal a sandwich is all you get.
G. On 09/17/24 at 9:11 am, during an interview with R #34, she stated the food taste is okay, but it depends on how the food is cooked and who is the cook. The food is either too cold or the meat is too tough.
H. On 09/17/24 at 9:48 am, during an interview with R #75, he stated he doesn't tolerate the food when it is too spicey but doesn't like to complain and will eat what he can.
I. On 09/17/24 at 12:43 pm, during an interview with R #242, he stated the food does not taste good and stated he does not eat it the food when it is too spicy.
J. On 09/19/24 at 11:43 am, during an interview with Dietary Manager (DM), he stated he was not aware the residents complained the food is too spicy. He stated when he is made aware of any issues, he will make those adjustments. He stated, for example, he did have complaints about the sausage being spicey and he changed the sausage to the mild brand. The DM stated he can and will make adjustments if needed, as long as he is made aware.
K. On 09/19/24 at 11:30 am during an interview with the DM, he stated meal choices should be made clear to the residents including the optional sides [hamburger with fries, vegetables, or chips].
L. On 09/20/24 at 12:33 am, during an on observation of a test tray, the test tray was brought from the kitchen. The meal was shredded chicken, white bread, green beans, and mashed potatoes with gravy. The temperature of chicken was 95F degrees. Food tasted good, potatoes were unsalted and bland without the gravy.
Food Temperature
M. On 09/17/24 at 9:11 am, during an interview with R #34, she stated the food taste depends on who cooked the food, whether the food is too cold or the meat is too tough.
N. On 09/17/24 at 12:43 pm, during an interview with R #242, he stated the food is always cold and does not taste good.
O. On 09/19/24 at 4:51 pm, during an observation of kitchen staff preparing to move hot foods on a heated transport carrier to the pilot kitchen. The temperature of the tomato soup was 115 degrees Fahrenheit and had to be reheated. When the tomato soup was returned to heat cart the soup was 200 degrees Fahrenheit. Kitchen Staff (K) #3, was asked what proper holding temperatures should be and he was unable to provide the appropriate holding food temperatures.
P. On 09/19/24 at 11:30 am, during an interview with the DM, he stated his expectation is for the individual food items should be temperature checked before being served and food should have been cooked correctly and held at the correct temperature.
Food Timing
Q. Record review of posted mealtimes on 09/16/24 at 12:30 pm indicated lunch was to be served starting at 11:30 am through 1:30 pm.
R. On 09/16/24 at 12:04 pm, during the lunch dining observation, the first meal was served at 12:22 pm to R #12, at the same table R #56 was served his meal at 12:29 pm, R #64 received his meal at 12:34 pm and R #70 received meal at 12:40 pm.
S. On 09/16/24 at 12:30 pm, during lunch dining observation, staff served the meal trays to the table where R #2 and R #27 sat, and they were served their meal at the same time. R #58, who was also at the same table, received their meal at 12:45 pm, 15 minutes after the first two residnets were served.
T. On 09/16/24 at 12:35 pm, during a lunch dining observation, R #1 was served his meal at 12:35 pm and R #40, who was also at the same table, received their meal at 12:50 pm, 15 minutes after the first person at the table was served their meal.
U. On 09/19/24 at 11:12 am, during an interview with DM, he confirmed that residents who are sitting at the same table should be served at or around the same time, he stated that 13 minutes is too long. The timing for last resident at 13 minutes apart would receive their meal almost an hour after the first resident at the table received their meal.
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 and interview, the facility failed to ensure the nutritional needs and preferences were met for all 95 residents listed on the facility census provided by the Administrator on 0...
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Based on record review and interview, the facility failed to ensure the nutritional needs and preferences were met for all 95 residents listed on the facility census provided by the Administrator on 09/16/24 by not having an alternative meal available for residents.
If the facility is not providing an alternative meal or offering an alternate meal menu to residents, then residents are likely to experience weight loss, frustration, and depression. The findings are:
A. Record review of the posted menu for September 2024, indicated only one meal option for breakfast, lunch and dinner. The facility did not offer an alternative meal/choice (second meal option) for each meal, that is equal in nutritional value to the primary meal being served to all residents.
B. On 09/19/24 at 11:17 am during an interview with the VPN (Vice President of Nutrition) she stated there is an always available menu. When asked if it was equivalent to the nutritional value of the main scheduled meal, she stated she feels the everyday menu may have different calories, but feels the resident has the choice to eat to peanut butter sandwich. She then stated the always available menu is not equal in nutritional value to the main meal served.
C. On 09/19/24 at 11:43 am during an interview with the Dietary Manager (DM), he stated. There should be two meal options. One would be the meal offered and the other would be the alternative meal. An always available menu [ie. grilled cheese, peanut butter and jelly sandwich, salad, hamburger, etc .] is offered, but it is not like the main meal that is served.
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 record review, observation and interview, the facility failed to store and serve food under sanitary conditions by not ensuring:
1. Kitchen was clean and sanitary.
2. Food items labeled and d...
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Based on record review, observation and interview, the facility failed to store and serve food under sanitary conditions by not ensuring:
1. Kitchen was clean and sanitary.
2. Food items labeled and dated
3. Refrigeration unit was clean.
5. Food storage and handling.
6. Maintenance of kitchen equipment and plumbing
These deficient practices are likely to affect all 95 residents listed on the resident census list provided by the Administrator on 09/16/24 and could likely lead to foodborne illnesses in residents if food is not being stored properly, safe food handling practices are not adhered to and sanitation of equipment preparation areas are not cleaned appropriately.
The findings are:
A. On 09/16/24 at 12:03 pm, during an observation of the initial tour of the kitchen and pilot kitchen from 12:03 pm through 12:33 pm, the following was revealed:
1. The floor was sticky.
2. The kitchen sink near preparation area had hard water deposits around the spicket.
3. The ice machine had hardwater stains on the outside near door opening.
4. A visibly soiled rag laid in the corner of dishwasher area.
5. A visibly soiled area on the floor by the wall between ice machine and mobile shelving unit and also the corners of kitchen floor.
6. In the dishwashing room, off of the kitchen, contained 2 large sinks; the sink closest to the wall the floors were very wet and had large solid food pieces underneath the sink.
7. The eye wash station was soiled with a dark brown substance on inside and the outside.
8. A transfer cart near the clean dishes was dirty with food particles.
9. Sanitation buckets used for cleaning prep areas had dirty water and lacked sanitizing solution.
B. On 09/16/24 at 12:03 pm, during observation and interview with Dietary Manager (DM), he was asked to check the sanitizer bucket with the approved test strips to ensure they had sanitizer in the buckets to wash the counter tops and any preparation food areas. The DM tested the sanitizer levels with the approved test strips the buckets and the bucket did not have any sanitizer present. DM confirmed that there should always be sanitizer present in the buckets used to wipe down any food prep areas and the buckets should be changed every two hours.
C. On 09/16/24 at 12:05 pm, during observation of dishwashing area, the faucets add hard water deposits around the faucet, the faucet also to had a small steady flow. DM attempted to turn off the faucet completely and confirmed the faucet closed tightly. Plastic piping under the sink poured contents from the sink directly onto the floor and was supported by plastic container.
D. On 09/16/24 at 12:08 pm, during an observation of the DM, he went to janitor closet to retrieve sanitizer for cleaning buckets, he found the 5-gal refill container of sanitizer was empty and dry. The DM stated at that time those conditions were unacceptable.
E. On 09/19/24 at 4:32 pm, during an interview with the kitchen staff (KS) #3 and #4, they were asked to check the sanitizing solution contents of the red cleaning bucket. KS #3 and KS #4 attempted to check the solution in the cleaning bucket, when they were unsuccessful the DM informed them they were using the wrong testing strips, the DM at that point took over and tested the contents and confirmed that there was no sanitizing solution in the cleaning bucket.
F. On 09/19/24 at 4:32 pm, during an interview with the DM, he confirmed the cleaning bucket did not contain the appropriate amount of sanitizing solution.
G. Record review on of the Service Opening and Closing monitoring logs [AM/PM checklist facility uses to check refrigerator temps, turn on equipment, prepare sanitizing solution for prep areas, sanitize ice scoop, empty trash, sweep and mom floors, daily cleaning, label, date and store ingredients, empty and clean 3-compartment sink, empty and clean sanitizer buckets, place all soiled linens in appropriate receptacle], were not competed for 09/15/24 morning and evening and 09/16/24 am shift.
Food Items Labeled and dated.
H. On 09/16/24 at 12:06 pm, during observation of the kitchen food prep area, food items on the transportation racks of mobile cart were not labeled and dated.
I. On 09/16/24 at 12:11 pm, during an interview with the DM, he confirmed Everything in the fridge should be labeled and dated.
J. On 09/19/24 at 4:40 pm, during an observation of the kitchen refrigerator, the evening snacks were not dated and labeled.
Refrigerator Clean and Sanitary
K. On 09/16/24 at 12:11 pm, during an observation of the refrigerator the inside of the refrigerator had a blue plastic elevated platform that was covered with soiled dark substance.
L. On 09/16/24 at 12:11 during an interview the DM confirmed the blue platform is used to store food items off the floor and should be cleaned. He further confirmed the refrigerator, freezer and kitchen were not clean.
Food Storing and Handling Properly
M. On 09/16/24 at 12:21 pm, during an observation of the of pilot kitchen located in dining room, uncovered and unwrapped ham and cheese sat on the counter to the left of the steam table, ham and cheese was at room temperature.
N. On 09/16/24 at 12:21 pm during an interview with KS #2 confirmed the ham and cheese should be kept on ice.
O. On 09/16/24 at 12:27 pm, during continued observation of pilot kitchen, KS #1 dropped a resident's food ticket into the contents of the chicken on the steam table and proceeded to serve the chicken.
P. On 09/16/24 at 12:27 pm, during an interview with KS #1, he was asked, if it is okay to serve the chicken now that it is contaminated. KS #1 stated he was unsure and contacted the DM. The DM arrived to confirm it was not fit to serve the chicken.
Maintaining Faucets, Pipes, and Dishwasher
Q. On 09/19/24 at 4:35 pm, during an observation of the kitchen, the middle sink by dishwasher had a red plumbing line leaking heavily onto the floor and created a large wet area throughout dishwashing area.
R. On 09/19/24 at 4:36 pm, during an observation of the dishwasher, the dishwasher temperature wash cycle was 115 degrees Fahrenheit. The temperature should be 120 degrees Fahrenheit. The sanitizing solution measured less than 50 parts per million (PPM) should be 150-200 PPM, the sanitizing solution in use under dishwasher was visibly low.
Sept 2024
2 deficiencies
1 IJ
CRITICAL
(J)
📢 Someone Reported This
A family member, employee, or ombudsman was alarmed enough to file a formal complaint
Immediate Jeopardy (IJ) - the most serious Medicare violation
Accident Prevention
(Tag F0689)
Someone could have died · This affected 1 resident
**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on record review and interviews, the facility failed to prevent an accident for 1 (R #1) of 3 (R #1, R #2, and R #3) resid...
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**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on record review and interviews, the facility failed to prevent an accident for 1 (R #1) of 3 (R #1, R #2, and R #3) residents reviewed for falls when:
1. R #1 sustained (14) falls in a 6.5 month period.
2. The facility did not implement adequate interventions to prevent falls
3. Neurochecks for unwitnessed falls and falls in which the resident hit her head were incomplete per policy.
4. One- to-one staffing was assigned to R #1, however staff were assigned other duties and R #1 had 3 falls during the time she was ordered to have one-to-one staffing in which she sustained injury to her head.
These deficient practices likely resulted in R #1 sustaining multiple acute subarachnoid hemorrhage (bleeding between the space between the brain and tissue covering the brain) and passing away (6) days after her last fall at the facility. The findings are:
A. Record review of R #1's face sheet revealed R #1 was admitted to the facility on [DATE] with multiple diagnoses including:
- Unspecified dementia without behavioral disturbance,
- Psychotic disturbance,
- Mood disturbance,
- Anxiety,
- Unspecified fracture of right ilium (the large broad bone forming the upper part of each half of the pelvis), subsequent encounter for fracture with routine healing.
- Urinary tract infection, site not specified.
- Essential hypertension (high blood pressure.)
- Other reduced mobility.
- Need for assistance with personal care.
- Specified sequelae of cerebral infarction (symptoms that occur after a stroke.)
- Unspecified dementia, unspecified severity.
- Age-related osteoporosis with current pathological fracture, right pelvis.
- Repeated falls.
B. Record review of R #1's quarterly Minimum Data Set (MDS; a federally mandated assessment instrument completed by facility staff), dated [DATE], revealed the following:
1. A Brief Interview for Mental Status (BIMS; a screening for cognitive impairment) score of 04, severe impairment,
2. Wandered daily,
3. Utilized a wheelchair for mobility,
4. Required substantial to maximal assistance when walking up to 50 feet,
5. Functional limitation in range of motion on one side of lower extremities (legs),
6. Had shortness of breath when lying flat,
7. Had two or more falls without injury since admission, reentry, or prior assessment,
8. Took an anticoagulant and indication was noted,
9. Did not receive any physical, occupational, or restorative therapy.
10. Signed by the Registered Nurse (RN)/MDS and the Social Worker.
11. Assessment marked completed on [DATE].
C. Record review of R #1's Physician Orders revealed an order for Eliquis (blood thinner to prevent/treat blood clots) 2.5 milligram tablet to be given twice daily and started on [DATE].
D. Record review of R #1's Care Plan, dated [DATE], revealed R #1 was a high risk for falls and included the following interventions:
1. Dated [DATE], review information on past falls and attempt to determine cause of falls. Record possible root causes. Alter remove any potential causes if possible.
2. Dated [DATE], Physical Therapy (PT) to evaluate and treat as ordered or as needed (PRN).
3. Dated [DATE], intervention related to fall risk included R #1 had frequent urinary track infections (UTI) which resulted in behavior changes. Consider UTI with each fall and get a urology consult as soon as possible.
4. The care plan did not address the resident's use of Eliquis or the risk associated with use.
E. Record review of the facility's Neurological Assessments policy, dated 02/2019, revealed nursing staff to perform neurological assessments as follows:
1. Upon Attending Physician order.
2. Following an unwitnessed fall.
3. Following a fall or other accident/injury involving head trauma.
4. When indicated by resident's condition.
5. To be completed every 30 minutes four times (a check to be completed every 30 minutes for two hours), then every hour four times (a check to be completed every hour for four hours), then every four hours four times (a check to be completed every four hours for 16 hours), and then every shift for a combined total of 72 hours.
F. Record review of R #1's Fall with Injury report, R #1's Electronic Health Record (EHR), R #1's progress notes and R #1's neurocheck evaluation revealed the following:
1. Progress noted dated [DATE], R #1 was on the floor behind door. Resident noted to have blood on face, gown, and floor, large bump and abrasion noted to forehead, bump and bruising noted to right forearm. Resident unable to give description of fall. For fall dated [DATE], the facility did not complete 15 out of sixteen required neurochecks (a brief neurological assessment performed by staff repeatedly to monitor a resident's neurological status).
2. Progress note dated [DATE], an unknown Certified Nursing Assistant (CNA) notified the nurse that R #1 was on the floor. For fall dated [DATE], the facility did not complete four out of sixteen required neurochecks. Care Plan revised [DATE], intervention related to fall risk included anticipate and meet the resident needs and be sure R #1's call light is within reach and encourage R #1 to use it for assistance as needed. R #1 needs prompt response to all requests for assistance.
3. Progress Note dated [DATE], the nurse heard a loud bang and saw the CNA at back door on 100 hall. Resident lay supine on the floor.
Dated [DATE], a hospital emergency room After Visit Summary - the reason for the visit was a fall. Diagnoses listed were unspecified fall and closed head injury. The EHR did not contain a Fall with Injury report for [DATE]. For fall dated [DATE], the facility did not complete 12 out of sixteen required neurochecks.
4. Progress note dated [DATE], R #1 was crawling on floor. For fall dated [DATE], the facility did not complete 12 out of sixteen required neurochecks. Care Plan revised [DATE], intervention related to fall risk included offer to assist R #1 to the toilet to avoid impulsiveness.
5. Progress note dated [DATE], R #1 reported she slipped out of her wheelchair. The EHR had no other record of this fall, injury to resident or new interventions. Care Plan revised [DATE] (9 days after the slip), intervention related to fall risk included apply Dycem (a non-slip material) to wheelchair. For fall dated [DATE], the facility did not complete eight out of sixteen required neurochecks.
6. Progress note dated [DATE], the author of the note went into the resident's room and saw the resident on floor next to the bed. For fall dated [DATE], the facility completed a total of sixteen neurochecks, but none of the checks were completed on [DATE] (within the 72 hours that neurochecks are supposed to be completed). There were no updates to the care plan following this fall.
7. Progress note dated [DATE], R #1 was on the floor between the wheelchair and the bed. For fall dated [DATE], the facility did not complete four out of sixteen required neurochecks. Care Plan revised [DATE], intervention related to fall risk included increased rounding (a practice where nursing staff periodically check on residents) on resident.
8. Progress note dated [DATE], another resident, name unknown, reported there was a woman on the floor in his room. Staff found R #1 on the floor when they entered his room. For fall dated [DATE], the facility failed to complete any neurochecks after the first day. Care Plan revised [DATE], intervention related to fall risk included treat resident clinically with medications as ordered.
9. Progress note dated [DATE], R #1 was on the floor in bedroom. For fall dated [DATE], the facility did not complete one out of of sixteen required neurochecks. No updates to the care plan.
10. Progress note dated [DATE], R #1 stood up and her legs gave out. R #1 was taken to the hospital for chest pain. For fall dated [DATE], the facility did not complete 13 out of sixteen required neurochecks. EHR did not identify if there were any injuries as it related to the fall.
11. Progress note dated [DATE], R #1 was found laying on the floor by (unknown initials). R #1's wheelchair was inside the facility door, and the resident was on the floor. Fall with Injury report dated [DATE], revealed staff found resident lying on the ground. Resident pushed open side door and attempted to walk out of facility. Resident fell to floor and acquired a wound to left eyebrow and bruising to left cheekbone. For fall dated [DATE], the facility did not complete six out of sixteen required neurochecks.
G. Record review of R #1's progress notes dated [DATE], identified Elopement Risk - updated care plan. Resident was one-to-one (staffing ratio of one employee to one resident) for 14 days to monitor for triggers and daily routine.
H. Record review of R #1's Care Plan related to high risk for falls dated [DATE] revealed Resident to be 1 on 1 when awake and Resident will be supervised when in observation areas when 1 on 1 is not available.
I. Record review of the R #1's EHR dated [DATE] and [DATE], handwritten notes which described what R #1 did throughout the day while one-to-one staffing was provided. The EHR did not contain additional documentation for other dates of one-on-one staffing, such as notes which described what R #1 did throughout the day while the one-to-one staffing would have been provided.
J. Record review of R #1's EHR, R #1's progress notes and R #1's neurocheck evaluation revealed the following:
1. Fall with Injury report dated [DATE], revealed staff saw resident lying on her back holding on to her head. Staff assessed resident. Resident had a quarter size hematoma to back of head. No other injuries noted. Progress notes dated [DATE], R #1 lay on the ground, on her back, and held her head. For fall dated [DATE], the facility did not complete seven out of sixteen required neurochecks.
2. Progress note dated [DATE] at 12:52 am, Change of Condition: R #1 hit her head which caused a subarachnoid hemorrhage (bleeding in the space between the brain and the tissue covering the brain) during an unwitnessed fall. Fall with Injury report dated [DATE], revealed an aide found the resident on floor in bedroom. The resident walked from restroom back to bed and fell to floor. Resident sustained large hematoma to left side of head which caused pain to patient. Resident had skin tear to left elbow and bruise to the left hip and right inner knee. Emergency Services was called, and resident was transported to the hospital. Progress noted dated [DATE] at 7:37 am revealed spoke with daughter after return from ER, per daughter all scans and labs were normal. For fall dated [DATE] at 12:52 am, the facility did not complete 15 out of sixteen required neurochecks.
K. Record review of R #1's hospital emergency room (ER) Physician's Documentation, dated [DATE], revealed .This patient has been recently seen in this Emergency Department today. The patient has been recently seen in this Emergency Department, this week, last week, a couple of weeks ago, last month, for similar complaints. Patient returns to the ED [Emergency Department] via EMS [Emergency Medical Services]. She resides at a local ECF [Extended Care Facility]. She has had increasing frequency of falls. She was here earlier in the evening for a fall. Imaging studies were without traumatic abnormality. She was returned to the ECF. Once there, she fell again. Staff state that she was found on the floor. Now she has AMS [Altered Mental Status], staring off to the right. She is not speaking to me, she is agitated. HPI [History of Present Illness] obtained from daughter.
L. Record review of R #1's hospital discharge documentation, dated [DATE], revealed the following.
1. Computed tomography (CT scan; a noninvasive diagnostic imaging procedure that uses a computer to take data from several X-ray images of structures inside a human and converts them into pictures on a monitor) head without contrast showed multiple acute subarachnoid hemorrhage in the pontine, parietal, and frontal parietal areas (areas of the brain).
2. Multiple acute subarachnoid hemorrhage secondary to anticoagulation with Eliquis, status post multiple mechanical falls.
M. Record review of R #1's Nursing Note, dated [DATE], revealed R #1 returned to the facility from hospital, status post (status after an intervention) subarachnoid hemorrhage from fall.
N. Record review of R #1's Clinical Physician Order, dated [DATE], revealed an order for hospice with a diagnosis of subarachnoid hemorrhage.
O. Record review of R #1's Minimum Data Set, dated [DATE] identified that R #1 was deceased .
P. On [DATE] at 9:25 am and [DATE] at 9:11 am, during an interview with R #1's daughter, she stated her mother passed away on [DATE] due to injuries she sustained from a fall at the facility, which never should have happened. She stated her mother fell a total of 11 times from [DATE] to [DATE]. She stated her concern was, each time her mother fell, the facility did not do anything to mitigate the falling or to prevent it from happening. She stated four or five of her mother's falls resulted in trips to the emergency room. R #1's daughter stated she had to ask for a care plan meeting, because the facility did not schedule one to put interventions in place. She explained that during the last meeting on [DATE], it was agreed that her mother would have one-to-one staffing. She stated the one-to-one only lasted two days. R #1's daughter stated if the facility would have done their part, then her mother probably would not have had the fall that cost her life. R #1's daughter also stated her mother was not able to use a call light appropriately due to the decline in her mental abilities. She stated her mother did not know what it was for or when to push the button.
Q. On [DATE] at 10:04 am, during an interview with the Director of Nursing (DON), she stated R #1's team met and placed R #1 on a one-on-one staffing intervention on [DATE]. The DON stated she would not expect for a resident to continue to have falls if one-to-one staffing was provided. The DON stated the staff that provided one-on-one staffing should have documented what occurred while the one-on-one staffing was provided, but she was not able to provide additional documentation that one-on-one staffing was scheduled beyond [DATE] and [DATE].
R. On [DATE] at 8:42 am, during an interview with CNA #1, she stated she was the one-on-one staff assigned to R #1 during her second fall on [DATE]. CNA #1 stated she was assigned other duties, such as answering call lights and passing out drinks to other residents, while assigned as R #1's one-on-one staff.
S. On [DATE] at 8:51 am, during an interview with CNA #2, she stated that she was assigned to work two shifts as R #1's one-on-one staff, but she could not remember the dates. CNA #2 stated on the first day she was assigned as R #1's one-on-one staff, R #1 fell and went to the hospital before she arrived at work. CNA #2 stated she remembered walking into work on the second day she was assigned to be R #1's one-on-one staff and saw the bruises to R #1's face and arms. CNA #2 stated she was assigned to answer call lights for other residents while assigned as R #1's one-on-one staff.
Based on record review and interviews, Immediate Jeopardy was identified in person to the Administrator on [DATE] at 10:35 am. The facility took corrective action by providing an acceptable Plan of Removal (POR) on [DATE] at 11:06 am. The facility's implementation of the POR was verified onsite on [DATE] at 12:00 pm with completion of the following:
1. A re-evaluation of all residents fall risks and care plans.
2. An audit of previous falls in the past 30 days to ensure new interventions were put in place and neurological checks were completed.
3. Reeducation of staff regarding one-on-one staffing expectations and completing neurological checks.
After removal of the Immediate Jeopardy, the deficiency remained at a G scope and severity for a pattern of harm.
CONCERN
(F)
📢 Someone Reported This
A family member, employee, or ombudsman was alarmed enough to file a formal complaint
Potential for Harm - no one hurt, but risky conditions existed
Deficiency F0761
(Tag F0761)
Could have caused harm · This affected most or all residents
Based on observation and interviews, the facility failed to ensure all treatment carts were locked while unattended. This deficient practice had the potential to affect all 94 people residing in the f...
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Based on observation and interviews, the facility failed to ensure all treatment carts were locked while unattended. This deficient practice had the potential to affect all 94 people residing in the facility by allowing unauthorized persons access to their medical supplies and personal health information.
The findings are:
A. On 08/23/24 at 8:23 am, during a random observation of the facility, the treatment cart located in the short hallway between the dining room and the nurse's station was unlocked, and facility employees were not in the area.
B. On 08/23/24 at 8:24 am, during an interview with Certified Nursing Assistant (CNA) #1, she confirmed the treatment cart was unlocked, and facility employees were not in the area.
C. On 08/23/24 at 8:26 am, during an interview with Assistant Director of Nursing (ADON) she stated the treatment cart should be locked and secured while not in use.
Apr 2024
2 deficiencies
CONCERN
(E)
📢 Someone Reported This
A family member, employee, or ombudsman was alarmed enough to file a formal complaint
Potential for Harm - no one hurt, but risky conditions existed
Deficiency F0676
(Tag F0676)
Could have caused harm · This affected multiple residents
Based on record review, and interview, the facility failed to ensure the residents' ability to perform activities of daily living (ADLs) was maintained for 2 (R #10 and R #11) of 4 (R #1, R #4, R #10 ...
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Based on record review, and interview, the facility failed to ensure the residents' ability to perform activities of daily living (ADLs) was maintained for 2 (R #10 and R #11) of 4 (R #1, R #4, R #10 and R #11) residents reviewed for restorative therapy (Restorative services refers to nursing interventions that promote the resident ' s ability to adapt and adjust to living as independently and safely as possible). If the facility does not ensure that residents receive restorative services, then the residents are likely to experience a decrease in their ability to walk, transfer, and do other activities of daily living. The findings are:
A. Record review of R #10's Therapy Records indicated that R #10 was discharged from physical therapy (PT), occupational therapy (OT), and speech therapy (ST) on 04/10/2024.
B. Record review of care plan for R #10 dated 04/10/24 revealed that PT was to evaluate for fall prevention.
C. Record review of R #11's Therapy Records indicated that R #11 was discharged from PT and OT services on 04/03/2024 and was discharged from ST on 03/27/2024.
D. Record review of R #11's care plan dated 04/10/24, revealed PT to evaluate for fall prevention and has a self-care deficit (patient who is not adequately performing the activities of daily living (ADLs)) related to confusion and limited mobility.
E. On 04/25/24 at 9:01 AM, during an interview, R #11 stated, Don't go to therapy anymore. I don't need it. I liked it when I went, met max potential (Rehabilitation potential refers to a projection about the future status of a patient based on present observable behaviors) in therapy.
F. On 04/24/24 at 6:00 pm, during an interview with the Administrator, she stated the facility does not have a restorative nursing program. We're waiting to put the right person in the position. So, it is in the works right now.
G. On 04/24/2024 at 9:10 am, during an interview with the Director of Rehabilitation (DOR), he stated the facility does not have a restorative program. Currently we will encourage basic activities like walk to dine if they need contact assistance, meaning a Certified Nursing Assistant (CNA) would need to walk with them so they don't fall over on the way. It would be good to have a restorative program it would benefit the residents.
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
Grievances
(Tag F0585)
Could have caused harm · This affected most or all residents
**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on interview and record review, the facility failed to ensure grievances (complaints over something believed to be wrong o...
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**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on interview and record review, the facility failed to ensure grievances (complaints over something believed to be wrong or unfair) were acted upon for 3 (R #3, R #6, and R #12) of 3 (R #3, R #6, and R #12) residents reviewed for grievances. This deficient practice could likely result in residents feeling unimportant and unsatisfied with the results of the grievance process. The finding are:
R #3
A Record review of R #3's face sheet revealed that R #3 was admitted to the facility on [DATE].
B. On 04/24/25 at 3:15 pm during an interview with R #3, she stated that the facility continues to
1. Send cold food.
2. Send improper eating utensils (fork for oatmeal, spoon for pork chops).
3. Sends bread on her tray when she asks for no carbs.
4. During church service on Sunday's its very noisy and loud in the kitchen.
R #3 stated these complaints have been brought up at the Resident Council meetings and they have not been addressed with her or the Resident Council. The dates of the Resident Council meetings took place on 03/14/23, 07/11/23, 08/08/23, 01/09/24, and 03/12/24.
R #6:
C. Record review of R #6's face sheet revealed R #6 was admitted to the facility on [DATE].
D. Record review of the Resident Council minutes on 01/09/24, revealed R #6 addressed issues with the cold food at the Resident Council meeting.
E. Record review of grievances dated 03/14/23, 07/11/23, 08/08/23, 01/09/24, and 03/12/24, revealed staff did not initiate any of the grievances or staff did not follow up with any response to the issues that were discussed in Resident Council.
R #12:
F. Record review of R #12's face sheet revealed R #12 was admitted to the facility on [DATE].
G. Record review of Concern/Grievance report dated 03/14/24, revealed R #12 requested more food, due to his broken jaw, his diet is liquid consistency and the resident was feeling hungry after each meal. R #12 had weight loss due to broken jaw. Staff did not document any follow-up for this concern.
H. Record review of the Resident Council minutes for the months of July 2023, August 2023, January 2024, and March 2024 had dietary issues, or noise issues documented. Several grievances staff did not have any response to the issues posed. The facility, Administrator and Department Directors did not respond or offer any resolution to the grievances.
I. On 04/25/24 at 9:45 am, during an interview with the Administrator, she confirmed that grievances or complaints were not submitted after the Resident Council meetings. The Grievances were not submitted to the Department Directors or to the Administrator. The Administrator confirmed that staff did not follow up on the grievances and staff did not resolve any of the Old Business issues for the months of July 2023, August 2023, January 2024, and March 2024 and there should be some kind of response.
Mar 2024
3 deficiencies
2 IJ
CRITICAL
(J)
📢 Someone Reported This
A family member, employee, or ombudsman was alarmed enough to file a formal complaint
Immediate Jeopardy (IJ) - the most serious Medicare violation
Report Alleged Abuse
(Tag F0609)
Someone could have died · This affected 1 resident
**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on record review and interview, the facility staff failed to report incidents of alleged abuse for 2 (R #1 and R #2) of 2 ...
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**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on record review and interview, the facility staff failed to report incidents of alleged abuse for 2 (R #1 and R #2) of 2 (R #1 and R #2) residents sampled. If the staff failed to report allegations of abuse to the facility administration then corrective measures may not be acted on, and the facility would be unable to assure residents are free from abuse and neglect. The findings are:
R #1
A. Record review of R #1's face sheet revealed she was admitted to the facility on [DATE]. R #1 was dependent on care on activities of daily living. Her diagnoses included but were not limited to:
- Reduced mobility (severe chronic illness that requires immobilization in bed),
- Need for assistance with personal care,
- Spinal stenosis (narrowing of the spine) lumbar region,
- Morbid severe obesity (overweight), and
- Sepsis (life threatening condition that arises when the body's response to infection causes injury to its own tissues and organs).
B. Record review of the Minimum Data Set (MDS; a federally mandated assessment instrument completed by facility staff), dated 11/30/23, identified R #1's Brief Interview for Mental Status (BIMS; tool to screen and identify the cognitive condition of long-term care residents 0 being the lowest and 15 being the highest) score was 15, cognitively intact.
C. On 02/10/24 at 2:15 pm during an interview, R #1 stated she woke up startled in the early morning hours on 01/23/24 and found Certified Nursing Assistant (CNA) #1 standing by her bedside table. R #1 asked CNA #1 what he was doing in her room in the dark, and he left her room without responding. The next morning (01/24/24), R #1 told Registered Nurse (RN) #1 that CNA #1 was in her room the night prior and it scared her. R #1 asked that CNA #1 not be allowed back into her room. CNA #1 continued to work with the resident, which R #1 stated traumatized her emotionally.
D. Record review of the facility's staffing scheduled revealed CNA #1 was assigned to work with R #1 on the following shifts:
- On 01/23/24, 6 pm-11:59 pm,
- On 01/24/24, 12 am-6:00 am,
- On 02/01/24, 6:00 pm-11:59 pm,
- On 02/02/24, 12 am-6 am.
E. Record review of the facility's staff schedule, dated 01/23/25 and 02/01/24, verified CNA #1 was assigned to work with R #1
F. On 02/10/24 at 4:12 pm during an interview, RN #1 stated R #1 reported to him (on 01/24/24) that she woke up on the night of 01/23/24 and was startled by CNA #1 standing in the dark near her bed. He said R #1 told him that she was upset and did not wish for CNA #1 to be allowed back in her room. RN #1 stated he did not have the ability to change the schedule, and he did not report the incident to anyone.
G. On 02/10/24 at 4:30 pm during an interview, CNA #2 stated R #1 previously told her that CNA #1 made her (R #1) uncomfortable and was standing in her room in the dark. CNA #2 stated she was aware of another resident (R #2) who expressed that she was afraid of CNA #1. The CNA stated that R #2 told her that she was scared of CNA #1. CNA #2 was unable to give the exact date R #2 said this, but she thought it occurred between 02/04/24 through 02/10/24. CNA #2 stated she did not tell anyone that R #2 reported being afraid of CNA #1.
R #2
H. Record review of R #2's face sheet revealed she was admitted on [DATE]. Her diagnoses included but were not limited to the following: Cerebral ischemia (a condition in which there is insufficient blood flow to the brain to meet metabolic demand), need for assistance with personal care, other reduced mobility, and weakness.
I. Record review of the MDS, dated [DATE], identified R #2's BIMS score was 9, moderately impaired.
J. Record review of the facility's staff schedule, dated 02/04/24 through 02/07/24, revealed CNA #1 worked on the hall where R #2's room was located and provided care for R #2. CNA #1 was the only male that had worked with R #2 during that time.
Based on interview and record review, Immediate Jeopardy was identified on 03/15/24 at 4:20 pm to the administrator, in person.
The facility took corrective action by proving an acceptable Plan of Removal (POR) on 03/14/24 at 4:31 pm. Implementation of the POR was verified onsite on 03/13/24 by interviewing staff regarding the education that had been given, and offsite on 03/14/24 with the completion of the resident audits regarding if any of the residents felt safe or felt abused.
Plan of removal:
The Nurse was educated on abuse reporting on 02/26/24.
The CNA was educated on abuse reporting on 03/13/24.
The facility conducted a safety audit of all residents in the building was completed on 03/14/24.
The facility has begun to conduct random staff questionaries on abuse and reporting. Date started 03/13/24. Total number of staff interviewed = 27.
Have you heard of a resident being abused in our facility?
What did you do about it?
Do you know who to report it to?
There are no grievances identified that abuse or neglect was indicated or required further reporting.
CRITICAL
(J)
📢 Someone Reported This
A family member, employee, or ombudsman was alarmed enough to file a formal complaint
Immediate Jeopardy (IJ) - the most serious Medicare violation
Investigate Abuse
(Tag F0610)
Someone could have died · This affected 1 resident
**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on record review and interview, the facility failed to complete a thorough investigation regarding allegations of sexual 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 complete a thorough investigation regarding allegations of sexual abuse for 1 (R #1) of 1 (R #1) residents that CNA #1 worked with. This failure could likely lead to other residents' being sexully abused. The findings are:
R #1
A. Record review of R #1's face sheet revealed she was admitted to the facility on [DATE]. R #1 was dependent on care for activies of daily living. Her diagnoses included but were not limited to:
- Reduced mobility (severe chronic illness that requires immobilization in bed),
- Need for assistance with personal care,
- Spinal stenosis (narrowing of the spine) lumbar region,
- Morbid severe obesity (overweight), and
- Sepsis (life threatening condition that arises when the body's response to infection causes injury to its own tissues and organs).
B. Record review of the Minimum Data Set (MDS; a federally mandated assessment instrument completed by facility staff), dated 11/30/23, identified R #1's Brief Interview for Mental Status (BIMS; tool to screen and identify the cognitive condition of long-term care residents 0 being the lowest and 15 being the highest) score was 15, cognitively intact.
C. On 02/10/24 at 12:15 pm during an interview, R #1 revealed she woke up startled in the early morning hours on 01/23/24 and found Certified Nursing Assistant (CNA) #1 standing by her bedside table. R #1 asked CNA #1 what he was doing in her room in the dark, and he left her room without responding. The next morning (01/24/24), R #1 told Registered Nurse (RN) #1 that CNA #1 was in her room the night prior and it scared her. R #1 asked that CNA #1 not be allowed back into her room. CNA #1 continued to work with the resident, which R #1 stated traumatized her emotionally. R #1 further reported that on 02/02/24, CNA #1 entered R #1's room and began to apply Desitin cream (diaper rash cream) to her pubic area. R #1 stated that CNA #1 began to apply the Desitin cream inside her vagina and touched her clitoris [the sensitive area located on the top of the vulva (the global term that describes all the structures that make the female external genitals] in a sensual manner. R #1 stated the incident happened so quickly, and it was over before she could tell CNA #1 to stop. CNA #1 put R #1's brief back on and left the room without saying anything. R #1 stated she was so terrified that CNA #1 would come back to her room that she did not use her call light for the rest of the night, even though she woke up with her bedding saturated with urine. R #1 stated she reported this to CNA #2.
D. Record review of the facility's staffing scheduled revealed CNA #1 was assigned to work with R #1 on the following shifts:
- On 01/23/24, 6 pm-11:59 pm,
- On 01/24/24, 12 am-6:00 am,
- On 02/01/24, 6:00 pm-11:59 pm,
- On 02/02/24, 12 am-6 am.
E. Record review of R #1's Trauma Informed Assessment, dated 02/02/24 and completed by Social Services, and answered by R #1 revealed:
1. Is abuse, violence, or sexual assault been an event in your life that has caused or causes a problem for you in any way?
a. A black man broke into her apartment in 1976 and tried to rape her. (R #1 had an event in her life in 1976 in which a black male broke into her apartment.
2. R #1 answered yes to the question Has there been a sudden event that made you feel very scared, helpless, or horrified?
a. After CNA #1 she was sleeping, and that she woke up suddenly.
3. R #1 answered yes to the question Have you had nightmares or thoughts about it happening when you did not want to?
a. R #1 expressed concern about CNA #1 in her room and asked RN #1 to please make sure that she had a female CNA. CNA #1 returned, and R #1 felt CNA #1 was anxious but aware of what he was doing when administering Desitin around her private area. He placed the Desitin inside the vaginal area, internally. R #1 did not feel he had any business in that area, because this was not where the medication was stood in her room in the dark and stared at her while upposed to go.
4. R #1 answered yes to the question Have you tried hard to not think about an event or went out of your way to avoid situations that reminded you of it?
a. R #1 requested of staff several times for a female attendant.
b. If yes, please describe: R #1 was watchful and guarded. Resident went 12 hours without allowing the male CNA to change her. The incident (sexual abuse) happened around 9:00 pm. R #1 allowed the morning nurse to change her at shift change, because the morning nurse was a female.
5. The assessment directed the assessor to evaluate for occurrence of trauma. The assessor documented no occurrence of trauma as resident would not allow herself to be touched by CNA #1 or any other male CNA. The resident only wanted a female in her room at this time.
F. On 02/10/24 at 4:12 pm during an interview, RN #1 stated R #1 reported to him [on 01/24/24] that she woke up on the night of 01/23/24 and was startled by CNA #1 standing in the dark near her bed. He said R #1 told him that she was upset and did not wish for CNA #1 to be allowed back in her room. RN #1 stated he did not have the ability to change the schedule, and he did not report the incident to anyone.
G. On 02/10/24 at 4:30 pm during an interview, CNA #2 stated R #1 was initially hesitant to discuss the incident between R #1 and CNA #1, but eventually the resident opened up about what happened (on 02/02/24). CNA #2 stated when she went into R #1's room the morning of 02/02/24, she found R #1 in a puddle of urine and the resident urinated through her brief. CNA #2 stated she asked R #1 why no one had changed her throughout the night, and R #1 told her CNA #1 touched her sexually during first rounds. CNA #2 stated R #1 said she did not want to call CNA #1 back into the room so she urinated on herself until the morning shift came in. CNA #2 stated R #1 previously told her that CNA #1 made her (R #1) uncomfortable and was standing in her room in the dark. CNA #2 stated she reported the incident to the facility's administrator on 02/02/24.
H. On 02/10/24 at 5:23 pm during an interview with the Director of Nursing (DON), she stated Desitin cream should have only been placed on the outside of R #1's groin area and not placed internally.
I. On 02/12/24, at 10:41 am during an interview with the Administrator, she stated the facility offered to send R #1 to the emergency room on [DATE], but the resident declined. She stated that during the facility's investigation of the incident, they did the random safe survey with five residents on the same hall as R #1. The Administrator said the hall did not have a large female population. The Administrator said the police were called on 02/02/24, and she spoke with the police officer. The Administrator said R #1 told the police officer there was no wrongdoing. The Administrator stated, Mostly, our decision [to unsubstantiate the allegation] was based on [Name of R #1] saying there was no wrongdoing [to the police officer], and we attributed [the allegation] to her past trauma. The Administrator stated CNA #1 was suspended pending results of the investigation, and CNA #1 returned to work a few days later.
J. Record review of the police report, dated 02/02/24, revealed law enforcement was called to the facility for possible elder abuse. The police report stated an officer was dispatched to the facility on [DATE], and the officer made contact with R #1. R #1 told the officer that about two weeks ago around 2:00 am and 3:00 am, she woke up to CNA #1 standing next to her bed just staring at her. R #1 told the officer she did not call CNA #1, and the CNA left the room when R #1 asked what he wanted. R #1 told the officer that she told RN #1 about the incident and asked for a different person to care for her. R #1 told the officer that on 02/01/24 CNA #1 took care of her again, and while CNA #1 applied medication to her vaginal area, he began to rub her clitoris. R #1 told the officer it made her feel uncomfortable to the point she did not call CNA #1 back to her room for care the rest of the night. R #1 told the officer she just laid there in a pool of urine until a female staff arrived. R #1 stated she did not want to press charges, but she was upset with how the facility handled the situation.
Based on interview and record review, Immediate Jeopardy was identified on 03/15/24 at 4:20 pm to the administrator, in person.
The facility took corrective action by proving an acceptable Plan of removal (POR) on 03/14/24 at 4:31 pm. Implementation of the POR was verified offsite on 03/14/24 with completion of resident audits regarding if any of the residents felt safe or felt abused.
Plan of removal:
The center has implemented a new process to identify residents who may also be affected by an allegation of abuse. The process change includes widening the interview pool to include residents with a BIMS <11 that was not previously in place to ensure the identification of others.
To continue compliance each state reportable that includes an allegation of abuse or neglect will be reviewed by a corporate partner to ensure interviews were conducted on all residents residing in the center prior to the 5 day being submitted.
If an employee has an allegation of abuse or neglect against them, the IDT will meet, including Social Services, Human Resources, Director of Nursing, and and Administrator, (or their designee) and make a decision to keep or terminate the employee based on the investigation.
This process will start on 03/13/24 when the RNC ([NAME] nurse consultant) educated the Administrator and Director of Nursing on performing interviews with all residents that could be at risk of an alleged incident.
SERIOUS
(H)
📢 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 multiple residents
**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on record review and interviews, the facility failed to prevent staff to resident sexual abuse and to protect other reside...
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**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on record review and interviews, the facility failed to prevent staff to resident sexual abuse and to protect other residents from ongoing sexual behaviors for 2 (R #1 & R #2) of 2 (R #1 and R #2) residents reviewed for abuse. This deficient practice likely resulted in psychosocial distress (unpleasant emotions associated with a highly stressful situation) for the residents who were subject to this behavior. The findings are:
R #1
A. Record review of R #1's face sheet revealed she was admitted to the facility on [DATE]. R #1 was dependent on care on activities of daily living. Her diagnoses included but were not limited to:
- Reduced mobility (severe chronic illness that requires immobilization in bed),
- Need for assistance with personal care,
- Spinal stenosis (narrowing of the spine) lumbar region,
- Morbid severe obesity (overweight), and
- Sepsis (life threatening condition that arises when the body's response to infection causes injury to its own tissues and organs).
B. Record review of the Minimum Data Set (MDS; a federally mandated assessment instrument completed by facility staff) dated 11/30/23 identified R #1's Brief Interview for Mental Status (BIMS; tool to screen and identify the cognitive condition of long-term care residents 0 being the lowest and 15 being the highest) score was 15, cognitively intact.
C. On 02/10/24 at 12:15 pm during an interview, R #1 stated she woke up startled in the early morning hours on 01/23/24 and found Certified Nursing Assistant (CNA) #1 standing by her bedside table. R #1 asked CNA #1 what he was doing in her room in the dark, and he left her room without responding. The next morning (01/24/24), R #1 told Registered Nurse (RN) #1 that CNA #1 was in her room the night prior and it scared her. R #1 asked that CNA #1 not be allowed back into her room. CNA #1 continued to work with the resident, which R #1 stated traumatized her emotionally. R #1 further reported that on 02/02/24, CNA #1 entered R #1's room and began to apply Desitin cream (diaper rash cream) to her pubic area. R #1 stated that CNA #1 began to apply the Desitin cream inside her vagina and touched her clitoris [the sensitive area located on the top of the vulva (the global term that describes all the structures that make the female external genitals] in a sensual manner. R #1 stated the incident happened so quickly, and it was over before she could tell CNA #1 to stop. CNA #1 put R #1's brief back on and left the room without saying anything. R #1 stated she was so terrified that CNA #1 would come back to her room that she did not use her call light for the rest of the night, even though she woke up with her bedding saturated with urine. R #1 stated she reported this to CNA #2. During the interview R #1 started to cry when she explained CNA #1 had touched her sexually when he rubbed Desitin on her, and she stated she feared him.
D. Record review of the facility's staffing scheduled revealed CNA #1 was assigned to work with R #1 on the following shifts:
- On 01/23/24, 6 pm-11:59 pm,
- On 01/24/24, 12 am-6:00 am,
- On 02/01/24, 6:00 pm-11:59 pm,
- On 02/02/24, 12 am-6 am.
E. Record review of the facility's staff schedule, dated 01/23/24 and 02/02/24, verified CNA #1 was assigned to work with R #1.
F. Record review of R #1's Trauma Informed Assessment, dated 02/02/24 and completed by Social Services, revealed:
1. Is abuse, violence, or sexual assualt been an event in your life that has casued or cuases a problem for you in anyway?
a. A black man broke into her apartment in 1976 and tried to rape her. (R #1 had an event in her life in 1976 in which a black male broke into her apartment.)
2. R #1 answered yes to the question Has there been a sudden event that made you feel very scared, helpless, or horrified?
a. After CNA #1 stood in her room in the dark and stared at her while she was sleeping, and that she woke up suddenly.
3. R #1 answered yes to the question Have you had nightmares or thoughts about it happening when you did not want to?
a. R #1 expressed concern about CNA #1 in her room and asked RN #1 to please make sure that she had a female CNA. CNA #1 returned, and R #1 felt CNA #1 was anxious but aware of what he was doing when administering Desitin around her private area. He placed the Desitin inside the vaginal area, internally. R #1 did not feel he had any business in that area, because this was not where the medication was supposed to go.
4. R #1 answered yes to the question Have you tried hard to not think about an event or went out of your way to avoid situations that reminded you of it?
a. R #1 requested of staff several times for a female attendant.
b. If yes, please describe: R #1 was watchful and guarded. Resident went 12 hours without allowing the male CNA to change her. The incident (sexual abuse) happened around 9:00 pm. R #1 allowed the morning nurse to change her at shift change, because the morning nurse was a female.
5. The assessment directed the assessor to evaluate for occurrence of trauma. The assessor documented no occurrence of trauma as resident would not allow herself to be touched by CNA #1 or any other male CNA. The resident only wanted a female in her room at this time.
G. On 02/10/24 at 4:12 pm during an interview, RN #1 stated R #1 reported to him (on 01/24/24) that she woke up on the night of 01/23/24 and was startled by CNA #1 standing in the dark near her bed. He said R #1 told him that she was upset and did not wish for CNA #1 to be allowed back in her room. RN #1 stated he did not have the ability to change the schedule, and he did not report the incident to anyone.
H. On 02/10/24 at 4:30 pm during an interview, CNA #2 stated R #1 was initially hesitant to discuss the incident between R #1 and CNA #1, but eventually the resident opened up about what happened (on 02/02/24). CNA #2 stated when she went into R #1's room the morning of 02/02/24, she found R #1 in a puddle of urine, and the resident urinated through her brief. CNA #2 stated she asked R #1 why no one had changed her throughout the night, and R #1 told her CNA #1 touched her sexually during first rounds. CNA #2 stated R #1 said she did not want to call CNA #1 back into the room so she urinated on herself until the morning shift came in. CNA #2 stated R #1 previously told her that CNA #1 made her (R #1) uncomfortable and was standing in her room in the dark. CNA #2 stated she reported the incident to the facility's administrator on 02/02/24. CNA #1 stated there was another resident (R #2) who expressed that she was afraid of CNA #1. CNA #2 could not ellbvorate on what she was afraid of, just that she was afraid. CNA #2 stated R #2 told her that she was scared of CNA #1, but CNA #2 was unable to give an exact date R #2 said this. CNA #2 stated she thought R #2 told her between 02/04/24 through 02/10/24. CNA #2 stated she did not tell anyone that R #2 reported being afraid of CNA #1.
I. On 02/10/24, at 5:23 pm, during an interview with the Director of Nursing (DON), she confirmed the Desitin cream should have only been placed on the outside of R #1's groin area and not placed internally.
J. On 02/12/24, at 10:41 am during an interview with the Administrator, she stated the facility offered to send R #1 to the emergency room on [DATE], but the resident declined. She stated that during the facility's investigation of the incident, they did the random safe survey with five residents on the same hall as R #1. The Administrator said the hall did not have a large female population. The Administrator said the police were called on 02/02/24, and she spoke with the police officer. The Administrator said R #1 told the police officer there was no wrongdoing. The Administrator stated, Mostly, our decision [to unsubstantiate the allegation] was based on [Name of R #1] saying there was no wrongdoing [to the police officer], and we attributed [the allegation] to her past trauma. The Administrator stated CNA #1 was suspended pending results of the investigation, and CNA #1 returned to work a few days later.
K. Record review of the police report, dated 02/02/24, revealed law enforcement was called to the facility for possible elder abuse. The police report stated an officer was dispatched to the facility on [DATE], and the officer made contact with R #1. R #1 told the officer that about two weeks ago around 2:00 am and 3:00 am, she woke up to CNA #1 standing next to her bed just staring at her. R #1 told the officer she did not call CNA #1, and the CNA left the room when R #1 asked what he wanted. R #1 told the officer that she told RN #1 about the incident and asked for a different person to care for her. R #1 told the officer that on 02/01/24 CNA #1 took care of her again, and while CNA #1 applied medication to her vaginal area, he began to rub her clitoris. R #1 told the officer it made her feel uncomfortable to the point she did not call CNA #1 back to her room for care the rest of the night. R #1 told the officer she just laid there in a pool of urine until a female staff arrived. R #1 stated she did not want to press charges, but she was upset with how the facility handled the situation.
R #2
L. Record review of R #2's face sheet revealed she was admitted on [DATE]. Her diagnosis included but were not limited to: Cerebral ischemia (a condition in which there is insufficient blood flow to the brain to meet metabolic demand), need for assistance with personal care, other reduced mobility, and weakness.
M. Record review of the MDS, dated [DATE], identified R #2's BIMS score was 9, moderately impaired.
N. On 02/10/24, at 4:45 pm during an interview, R #2 provided a physical description of CNA #1 and said the CNA attempted to touch her twice. R #2 was unable to give dates. R #2 pointed to her genitals. R #2 stated, I told him it [her body] was mine and to leave it alone. I am afraid of him. I am afraid of him around me, because he touched me. I didn't know who to tell. I am afraid of him. It happened the other night.
O. Record review of the facility's staff schedule, dated 02/04/24 through 02/07/24, revealed CNA #1 worked on the hall where R #2's room was located and provided care for R #2. Further review revealed CNA #1 was the only male that worked with R #2 during that time.
P. Record review of R #2's Trauma Informed Assessment, dated 02/10/24, completed by social services revealed:
1. R #2 reported a male staff member came in and tried to feel her up. The resident stated the staff member did not wear a badge, and she never saw him before. The assessor documented, He tried to play with her privates.
2. The assessor left questions 2 through 6 blank on the form.
3. R #2 stated she did not want that staff member to come to her room. The assessor documented, She is very horrified and on guard after what happened in her room. He should have been changing her but instead was touching down there.
Q. On 02/12/24 at 10:41 am during an interview with the Administrator regarding R #2, she said they offered to have a physician examine R #2 on 02/10/24, but the resident declined. The administrator said they were currently doing an investigation and CNA #1 was suspended pending results of the investigation, CNA #1 had not returned to work at this time, and the facility filed a state report.
Dec 2023
2 deficiencies
1 IJ (1 affecting multiple)
CRITICAL
(K)
📢 Someone Reported This
A family member, employee, or ombudsman was alarmed enough to file a formal complaint
Immediate Jeopardy (IJ) - the most serious Medicare violation
Quality of Care
(Tag F0684)
Someone could have died · This affected multiple residents
**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on record review and interview, the facility failed to ensure residents received treatment and care in accordance with pro...
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**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on record review and interview, the facility failed to ensure residents received treatment and care in accordance with professional standards of practice when staff did not routinely check the blood sugar levels of residents with diabetes for 4 (R #'s 1, 2, 3, and 4) of 4 (R #'s 1, 2, 3, and 4) residents reviewed for diabetes mellitus [DM; an impaired ability of the body to produce or respond to insulin (a naturally occurring hormone made by your pancreas that helps your body use sugar for energy) to maintain proper sugar levels (glucose) in the blood.] This deficient practice resulted in R #1's blood sugar not being routinely checked or checked when R #1 experienced a change in condition (changes from a persons normal baseline status), which likely resulted in R #1 being hospitalized with high blood sugar levels and in a diabetic coma (life threatening complication resulting from very high blood sugar). This deficient practice is also likely to result in residents not receiving the appropriate diabetic medical care and leading to an exacerbation (to make worse) of current medical conditions and/or death. The findings are:
Findings for R #1:
A. Record review of R #1's face sheet and most recent Care Plan revealed an original admission date of 11/21/2019 with the following diagnosis:
- Type 2 diabetes mellitus (DM2) without complications (a disease that occurs when a person's body does not use insulin effectively),
- Diabetes mellitus due to underlying condition with diabetic nephropathy (a progressive disease that affects your kidneys).
B. Record review of R #1's Physician Order, dated 03/09/23, revealed metformin HCL tablet (an oral drug used to control and balance blood sugar levels), 500 milligrams (MG). Give 1 tablet by mouth two times a day for diabetic management.
C. Record review of R #1's Electronic Medical Record (EMR) indicated the record did not contain physician orders for diabetes management.
D. Record review of R #1's progress note, dated 10/01/23, indicated R #1 did not eat and required assistance from staff. The note stated staff did not check R #1's blood glucose level (BGL) at this time.
E. Record review of R #1's progress note, dated 10/04/2,3 indicated R #1 barely ate. The note stated staff did not check R #1's BGL at this time.
F. Record review of R #1's progress note, dated 10/12/23 at 11:28 am, revealed R #1 was lethargic and barely opened her eyes. The note stated R #1's BGL read high on the glucometer, but staff did not document a number. The high BGL resulted in R #1 being sent to the emergency room (ER). This was the first time staff documented R #1's BGL in the resident's progress notes since her admission on [DATE].
G. Record review of R #1's hospital admission documentation, dated 10/12/23, revealed the hospital staff documented R #1's BGL measured 1030 mg/di (milligrams per deciliter; a unit of measure that showed the concentration of a substance in a specific amount of fluid. Normal BGL is 80 to 100) and the resident's urinary analysis ( a test of your urine used to detect and manage a wide range of disorders) was positive for a bacterial infection. Hospital records identified R #1 was in a diabetic coma. The resident's A1C (a blood test that measured average blood glucose over the past two to three months) at the hospital measured 12 (very high).
H. On 12/20/23 at 1:24 pm during an interview with R #1's son, he stated he had several complaints about his mother's care while at the facility. He said R #1 fell, lost a lot of weight, and the resident's diabetes was off track. He said the facility staff called and told R #1's family they needed to come to the facility and feed their mother. The facility staff told them the resident did not want to eat and was losing weight. He said staff also told them to bring her shakes and come sit with her.
I. On 12/21/23 at 1:00 pm during an interview with R #1's daughter, she stated the family filed a complaint with the New Mexico Department of Health, because their mother was sent to the emergency room and ended up in the intensive care in a diabetic coma. She stated the facility knew R #1 was a diabetic. The daughter said the facility called the family on the day the resident went to the hospital, and the staff told them their mother was very lethargic.
J. On 12/21/23 at 8:47 pm during an interview with Licensed Practical Nurse (LPN) #1, she stated residents who take metformin for diabetes have their blood sugar checked once a day. The LPN said R #1 was on metformin, but she did not know if staff checked the resident's blood sugar.
K. On 12/21/23 at 9:08 pm during an interview with Director of Clinical Services (DCS), she stated R #1 took metformin. The DCS said the doctor saw the resident on 10/06/23 and did not assess the resident's blood sugar or DM. The DCS said some physicians order staff to check a resident's blood sugar, and other physicians do not. The DCS said she would expect nursing staff to use their judgment on when to check a resident's blood sugar level.
L. On 12/22/23 at 9:31 am during an interview with Medical Doctor (MD) #1, he stated he would expect the facility staff to notify him when R #1 did not eat and became lethargic, prior to the day she went to the ER. He said the professional standard was for anyone with diabetes and took insulin or Metformin should have their BGL checked. MD #1 confirmed staff should have check R #1's BGL frequently, especially in the days prior to R #1 going to the ER when she was not eating. The MD said the facility's diabetic management was not conducted according to his expectations.
N. On 12/22/23 at 9:52 am during an interview with MD #2, she stated the professional standard was if a resident took metformin then staff should check that resident's blood sugar once a day. The MD said her expectation was for staff to inform the doctor if a resident's blood sugar was very low or over 400. She said it was expected the doctors would look at a resident's blood sugar at each visit to identify any trends in the resident's BGL. MD #2 said it was expected the facility nurses would notify her or the on-call doctor immediately if a resident had a change of condition, and that the nurses would let them know the resident was on diabetic medication. MD #2 stated staff should check a resident's blood sugar levels anytime the resident had a change in condition.
O. On 12/22/23 at 10:53 am during an interview with Registered Nurse (RN) #1, she stated she checked R #1's blood sugar when the resident did not eat. RN #1 stated she did not document the results of that test in the resident's record. The RN said staff have to make a judgement call whether or not to check a resident's blood sugar when the resident took metformin. RN #1 stated R #1 was lethargic and did not eat prior to going to the ER on [DATE]. The RN said she informed the doctor the resident was not doing well.
Findings for R #2:
P. Record review of R #2's face sheet/admission record revealed an original admission date of 09/29/2023 with a diagnosis of type 2 diabetes mellitus without complications.
Q. Record review of R #2's care plan, dated 10/14/23, revealed,
- Focus: The resident had diabetes mellitus.
- Interventions: Fasting serum blood sugar (FSBS; a medical test that measured the amount of glucose in a person's blood after an overnight fast) as ordered by doctor.
R. Record review of R #2's physician orders, dated 11/21/23, revealed R #2 received 12 units of insulin one time a day, every day, for diabetes.
S. Record review of R #2's physician orders, dated 09/29/23 through 12/21/23, revealed the record did not contain an order to check R #2's blood sugar level.
T. Record review of R #2's Vitals- Blood Sugar Summary, dated 11/01/23 through 11/30/23, revealed staff documented they checked R #2's blood sugar level 15 times out of 30 opportunities.
U. Record review of R #2's Vitals- Blood Sugar Summary, dated 12/01/23 through 12/21/23, revealed staff documented they checked R #2's blood sugar level once on 12/16/23.
V. On 12/21/23 at 7:00 pm during interview, the Regional Nurse Consultant (RNC) stated R #2 received finger sticks without a doctor's order, and the resident received a long acting insulin. The RNC said blood sugar checks were built into the insulin order.
Findings for R #3:
W. Record review of R #3's face sheet revealed R #3 was admitted into the facility on [DATE] with a diagnosis of type 2 diabetes mellitus with hyperglycemia (high blood sugar).
X. Record review of R #3's physician orders revealed the following:
- An order, dated 12/09/23, for capillary blood glucose- blood sugar level (CBG): For blood glucose (BG) less than 70, give 15 grams carbohydrates, wait 15 minutes, and recheck BG. If still less then 70 then give another 15 grams carbohydrates, wait 15 minutes, and recheck BG again. If still less than 70, notify the Medical Doctor (MD). Once BG at 70, give snack containing protein.
- An order, dated 12/09/23, for Basaglar KwikPen Subcutaneous Solution Pen-injector, 100 UNIT/milliliter (ml), insulin glargine. Inject 10 units subcutaneously (under the skin) in the morning for diabetes mellitus.
- The record did not contain orders for nursing staff to check R #3's blood sugar to know if R #3's blood sugar was less than 70.
Y. Record review of R #3's Blood Sugar Summary, dated 12/09/23 through 12/21/23, revealed staff documented they checked R #3's blood sugar once on 12/09/23.
Z. On 12/21/23 at 8:49 pm during an interview with LPN #1, she stated staff checked R #3's blood sugar level at bedtime to see if there was a change. LPN #1 confirmed staff should check R #3's blood sugar levels regularly, because he received insulin.
AA. On 12/22/23 at 9:35 am during an interview with MD #1, he stated if a resident's diabetes was under control then staff could conduct blood sugar checks daily or weekly. The MD said it was not acceptable for staff not to perform daily blood sugar checks for residents who receive insulin, including R #3.
Findings for R #4:
BB. Record review of R #4's face sheet revealed R #4 was admitted into the facility on [DATE] with a diagnosis of type 2 diabetes mellitus with hyperglycemia.
CC. Record review of R #4's physician order, dated 11/27/23, revealed metformin HCI oral tablet, 500 MG (not extended release). Give one tablet by mouth two times a day for DM2. The record did not contain a physician order for blood sugar checks.
DD. Record review of R #4's care plan, dated 12/06/23, revealed the following:
- Focus: Diabetic potential to develop hyperglycemia (high blood sugar) and hypoglycemia (low blood sugar).
- Interventions: Check fasting serum blood sugar as ordered.
EE. Record review of R #4's Vitals-Blood Sugar Summary, dated 11/27/23 through 12/21/23, revealed staff did not document they checked R #4's blood sugar.
FF. On 12/22/23 at 9:40 am during an interview with MD #1, he stated staff should check R #4's blood sugar levels daily or at least weekly. He said staff need to know if the resident's blood sugar levels were controlled or uncontrolled. MD #1 confirmed there should be an order to check R #4's blood sugar levels, and staff should check R #4's blood sugar regularly and according to her care plan.
These deficient practices resulted in Immediate Jeopardy identified on 12/22/23.
The facility Administrator was first notified of the Immediate Jeopardy on 12/22/23 at 1:44 pm.
Plan Of Removal Accepted on 12/22/23 at 4:17 pm and indicated the following:
1. Residents with a diagnosis of diabetes were reviewed for blood glucose check orders, and intervention with the medical director on 12/22/23. Reviewed with (MD #2) on 12/22/23. Orders that needed to be updated with the new medical director's standards were completed on 12/22/23.
2. The new standard regarding diabetic monitoring included: those residents with a hypoglycemic by mouth medication would receive blood sugar checks three times a week, those with insulin orders would be checked with his/her insulin dose, and those who are unstable will have a HgAlc ordered and depending on the result would receive a new lab either in 3 months or in 6 months. Licensed nurses were educated on the standards set by the new medical director on or before 12/27/23.
3. Residents with a diagnosis of diabetes had a blood sugar taken on 12/22/23 to determine if blood sugar is outside of the acceptable range. Two residents identified were reviewed with the provider on 12/22/23.
4. The medical director put in a standard for residents with a change in condition that any resident with a high blood sugar to be taken along with oxygen saturation. This new directive was presented to the licensed nursing staff on 12/22/23. The education will be continued through the shift changes to ensure licensed nurses entering a shift are aware of the new changes in directive for blood sugar monitoring and change of condition.
Implementation of the Plan of Removal was validated on 12/22/23 onsite through observation and interview.
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 staff revised and updated the care plan for 1 (R #5) of 1 (R...
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**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on record review and interview, the facility failed to ensure staff revised and updated the care plan for 1 (R #5) of 1 (R #5) residents reviewed for care plans when staff failed to add R #5's behavior to refuse diabetic management practices (insulin and blood sugar level checks). 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 #5's face sheet revealed R #5 was admitted into the facility on [DATE] with a diagnosis of type 2 diabetes mellitus with hyperglycemia (high blood sugar).
B. Record review of R #5's physician order, dated 08/28/23, revealed Insulin Lispro Injection Solution 100 unit/milliliter (ml), insulin lispro.
- Inject as per the following sliding scale, subcutaneously (under the skin) before meals and at bedtime for diabetes mellitus:
- If blood glucose level is 70 to149, give 0 units;
- 150 to 199, give 2 units;
- 200 to 249, give 3 units;
- 250 to 299, give 4 units;
- 300 to 349, give 5 units;
- 350 to 999, give 6 units;
- Greater than 349, give 6 units and call the Medical Doctor.
C. Record review of R #5's care plan, dated 10/15/23, revealed the following:
- Focus: The resident had diabetes mellitus.
- Interventions:
Diabetes medication as ordered by doctor.
Monitor and document for side effects and effectiveness.
Dietary consult for nutritional regimen and ongoing monitoring.
Educate regarding medications and importance of compliance and have resident verbally state an understanding.
Fasting serum blood sugar (a test that measures the amount of glucose in your blood) as ordered by doctor.
Identify areas of non-compliance or other difficulties in resident diabetic management.
Modify the problem area so that it may be more manageable for the resident and family.
Provide and document teaching to resident/family/caregiver.
Address identified roadblocks to compliance, and if infection is present, consult doctor regarding any changes in diabetic medications.
- R #5's care plan did not indicate the resident was non-compliant with diabetic management and refused diabetic care.
D. Record review of R #5's Medication Administration Record (MAR), dated 11/01/23 to 12/21/23, revealed staff documented R #5's blood sugar (BS) as 1 and the units of insulin administered as a 2.
E. On 12/21/23 at 8:53 pm during an interview with Licensed Practical Nurse (LPN) #1, she stated R #5 refused her blood sugar checks.
G. On 12/21/23 at 9:04 pm during an interview with LPN #2, she stated R #5 refused insulin, because the resident would say she was not a diabetic. LPN #2 said R #5 would not let the nursing staff prick her finger to check her blood sugar level.
H. On 12/22/23 at 11:05 am during an interview with Registered Nurse (RN) #1, she stated R #5 refused her blood sugar check everyday. LPN #2 said R #5 ate and did not get insulin. The LPN said the administrative staff told the nursing staff to put 1 and 2 on R #5's MAR to show R #5 did not get insulin.
I. On 12/23/23 at 12:07 pm during an interview the Director of Nursing (DON), he confirmed R #5's care plan did not indicate the resident constantly refused diabetic care, and staff should have updated R #5's care plan to reflect the refusals.
Jul 2023
8 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 #18) of 1 (R #18) resident reviewed for falls was free from accidents and hazards by not providing the neces...
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Based on observation, record review, and interview, the facility failed to ensure that 1 (R #18) of 1 (R #18) resident reviewed for falls was free from accidents and hazards by not providing the necessary equipment. This deficient practice could likely result in injuries and/or hospitalizations.
The findings are:
A. Record review of facility face sheet for R #18, dated 06/01/23, revealed admitting diagnoses which included: Fracture Of Left Femur (broken upper left leg), Heart Failure, Hypothyroidism (underactive thyroid), Extended Spectrum Beta Lactamase (ESBL) Resistance (difficulty in resistance to certain infections), Presence Of Left Artificial Hip Joint (new left hip), Urinary Tract Infection (bladder infection), Dementia (memory loss), Chronic Kidney Disease (low functioning kidneys), Hypertension (high blood pressure), Blindness in Left Eye, and History Of Falling.
B. On 06/26/23 at 9:26 am, during an observation of R #18 revealed that she had a small bandage to the left upper forehead/temple area.
C. Record review of R #18's 5 day Minimum Date Set (MDS) assessment, dated 06/04/23, revealed she was a fall risk.
D. Record review of nursing progress notes for R #18 revealed the following:
1. 06/11/2023 at 14:30 (2:30 pm) Nursing Note: Overhear resident crying out help on entering room was found sitting on floor next to wheelchair. Assisted up to wheelchair and instructed on call light use and verbalized understanding. States to this nurse, I didn't fall. I slid.
2. 06/23/2023 at 14:58 (2:58 pm), Progress Note: Reported resident had a fall in room. Resident reports she hit her head on the floor. Resident reports the wheelchair went out from under me. Resident has laceration (cut) to left side of forehead. Bleeding control with gauze. Wound cleansed with wound cleanser and sterile 4 x (by) 4 gauze. Laceration secured with steri-strips (small strips of adhesive tape) per providers orders.
3. 06/28/2023 at 9:57 pm Interdisciplinary team (IDT) Note: IDT met today to review resident for a fall on 06/23/23. The resident fell when her wheelchair rolled out from underneath her. Will request self locking brakes to be added to wheelchair. The resident did sustain a laceration to the head.
E. Record review of the fall care plan for R #18 dated 06/21/23 revealed that it had not been revised to reflect any of the resident's falls, or the intervention of self locking brakes, as noted in the IDT team note.
F. On 06/29/23 at 9:45 am, during an interview with the Director of Nursing, she acknowledged that R #18's wheelchair did not have self locking brakes.
CONCERN
(D)
Potential for Harm - no one hurt, but risky conditions existed
Deficiency F0727
(Tag F0727)
Could have caused harm · This affected 1 resident
Based on record review and interview, the facility failed to provide services of a Registered Nurse (RN) for at least 8 consecutive hours a day, 7 days a week. This deficient practice could affect all...
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Based on record review and interview, the facility failed to provide services of a Registered Nurse (RN) for at least 8 consecutive hours a day, 7 days a week. This deficient practice could affect all 71 residents, as identified on the facility census list provided by the Administrator on 06/25/23, if the residents cannot maintain their highest achievable status of health, mobility, and mental functioning. The findings are:
A. Record review of the posted nursing staff schedule for 07/05/23, revealed that the facility failed to schedule an RN to provide nursing care for that day.
B. On 07/06/23 at 1:30 pm, during an interview with the Director of Nursing (DON), she stated that there was RN coverage for 07/05/23 but that the facility had failed to document that on the posted nursing staff schedule. DON was unable to provide documentation to support this.
CONCERN
(E)
Potential for Harm - no one hurt, but risky conditions existed
Drug Regimen Review
(Tag F0756)
Could have caused harm · This affected multiple residents
Based on record review and interview, the facility failed to ensure that the consultant pharmacist reviewed each resident's drug regimen for irregularities on a monthly basis for 5 (R #15, 34, 44, 48 ...
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Based on record review and interview, the facility failed to ensure that the consultant pharmacist reviewed each resident's drug regimen for irregularities on a monthly basis for 5 (R #15, 34, 44, 48 and 172) of 5 (R #15, 34, 44, 48 and 172) residents reviewed for unnecessary medications. If the facility fails to conduct monthly reviews, there is potential for residents to experience unnecessary drug interactions and potentially adverse side effects. The findings are:
Resident #15:
A. Record review of R #15's facility face sheet, dated 07/05/22, indicated the following diagnoses: Muscle Wasting And Atrophy (loss of muscle), Hypotension (low blood pressure), Lack Of Coordination, Seizures (involuntary muscle spasms), Iron Deficiency Anemia (low iron and red blood cell count), Type 2 Diabetes Mellitus (high blood sugar), Hyperlipidemia (high cholesterol), Dementia (memory loss), Depressive Episodes (feeling of sadness), Hypertensive (high blood pressure) With Heart Failure (heart attack), Heart Failure, Gastro-Esophageal Reflux Disease (acid reflux), Gastrointestinal Hemorrhage (bleeding in intestines), Gout (joint pain caused by acid buildup), Benign Prostatic Hyperplasia (enlarged prostate), Dysphagia (difficulty swallowing), Cognitive Communication Deficit (difficulty thinking of words), Pain, Personal History Of Transient Ischemic Attack (TIA), And Cerebral Infarction (stroke), Dependence On Renal Dialysis (machine used to clean blood toxins from the body), End Stage Renal Disease (nonfunctioning kidneys), and Obstructive And Reflux Uropathy (difficulty urinating).
B. Record review of facility Pharmacist Regimen Review/Reports from revealed there was no available review completed for the month of May 2023.
Resident #34:
C. Record review of facility face sheet, dated 06/04/21, revealed admitting diagnoses which included: Pain, Muscle Wasting And Atrophy, Altered Mental Status, Hypotension, Type 2 Diabetes Mellitus, Major Depressive Disorder (Severe) (feeling of sadness), Anxiety Disorder (feeling of fear), Paranoid Personality Disorder (feeling of someone or something is after you), Extrapyramidal And Movement Disorder (involuntary movements caused by drug use), Insomnia (difficulty sleeping), Gastro-Esophageal Reflux Disease (acid reflux), Arthritis (swollen joints), Auditory Hallucinations (hearing things), Hypertensive Heart Disease (high blood pressure), Dementia (memory loss), and Reduced Mobility.
D. Record review of facility Pharmacist Regimen Review/Reports revealed there was no available review completed for the month of May 2023.
Resident #44:
E. Record review of facility face sheet, dated 05/30/23, for R #44 revealed admitting diagnoses which included: Dysphagia (difficulty swallowing), Sepsis (blood infection), Fracture Of Shaft Of Humerus, Left Arm, (broken upper left arm), Muscle Weakness, Difficulty In Walking, Methicillin Resistant Staphylococcus Aureus Infection (drug resistant infection), Hypertension (high blood pressure), Type 2 Diabetes Mellitus, Epilepsy (seizure disorder), Morbid (Severe) Obesity (overweight), Hypothyroidism (underactive thyroid), Hyperlipidemia (high cholesterol), Chronic Obstructive Pulmonary Disease (difficulty breathing), Edema (swelling), and Personal History Of Traumatic Brain Injury.
F. Record review of facility Pharmacist Regimen Review/Reports from revealed there was no available review completed for the month of May 2023.
Resident #48:
G. Record review of the facility face sheet, dated 06/26/23, for R#48 revealed admitting diagnosis which included: Traumatic Brain Injury, Type 2 Diabetes Mellitus, Polyneuropathy(nerve disease), Hypertension(high blood pressure), Hypothyroidism(low thyroid), Cognitive Communication Deficit (trouble communicating), Anxiety (stress), Protein Malnutrition (trouble processing proteins), Iron Deficiency Anemia (low iron), Edema (swelling), Pressure Ulcer (tissue damage caused by prolonged pressure).
H. Record review of facility Pharmacist Regimen Review/Reports revealed there was no available review completed for the month of May 2023.
Resident #172:
I. Record review of facility face sheet, dated 06/05/23, for R #172 revealed admitting diagnosis which included: Acute Heart Failure (heart attack), Urinary Tract Infection (bladder infection), Pneumonitis (lung infection), Hypokalemia (low potassium), Iron Deficiency Anemia (low red blood cell), Type 2 Diabetes Mellitus, Long Term Use Of Anticoagulants (blood thinners), Chronic Kidney Disease, Stage 3b (low functioning kidneys), Acute Kidney Failure (nonfunctioning kidneys), Presence Of Cardiac Pacemaker (internal device to keep heart pumping), Influenza (viral lung infection), Longstanding Persistent Atrial Fibrillation (irregular heartbeat), Atherosclerotic Heart Disease Of Native Coronary Artery (hardening of the arteries), Dysphagia (difficulty swallowing), Hyperlipidemia, and Hypothyroidism.
J. Record review of facility Pharmacist Regimen Review/Reports revealed there was no available review completed for the month of May 2023.
K. On 07/06/23 at 3:00 pm, during an interview the Director of Nursing (DON) confirmed that the pharmacy review for the month of May 2023 had still not been received by the facility. She stated the facility had switched to a different pharmacy group and the new pharmacy group had not provided the May 2023 reviews.
CONCERN
(F)
📢 Someone Reported This
A family member, employee, or ombudsman was alarmed enough to file a formal complaint
Potential for Harm - no one hurt, but risky conditions existed
Deficiency F0725
(Tag F0725)
Could have caused harm · This affected most or all residents
Based on observation, record review, and interview, the facility failed to provide enough Nurses and Certified Nursing Assistants (CNA's) to provide care to the residents. This failure has the potenti...
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Based on observation, record review, and interview, the facility failed to provide enough Nurses and Certified Nursing Assistants (CNA's) to provide care to the residents. This failure has the potential to affect all 71 residents as listed on the census provided by the Administrator on 06/25/23. This deficient practice could likely affect patient care and limit the residents abilities to obtain optimal well-being while in the facility.
The findings are:
A. On 06/25/23 at 11:00 am during the initial tour of the facility, it was observed that there were only two nurses and three Certified Nursing Assistants (CNA's) to care for all 71 residents spread throughout four separate hallways (100, 200, 300 and 400). One nurse and two CNA's were assigned to the 300 hall (20 residents) and 400 hall (31 residents) and one nurse and one CNA were assigned to the 100 hall (4 residents) and 200 hall (15 residents).
B. Record review of the Nurse Schedule for June 2023 revealed the following:
1. Day shift, 6:00 am to 6:00 pm, on 06/12/23: 1 nurse short. On 06/13/23: 1 nurse short. On 06/20/23: 2 nurses short. On 06/25/23, 1 nurse short.
2. Night shift, 6:00 pm to 6:00 am, on 06/12/23 through 06/18/23: 1 nurse short. On 06/18/23: 2 nurses short. On 06/19/23: 2 nurses short.
C. On 06/26/23 at 10:30 am at the Resident Council meeting, residents stated that often between 6:00 pm and 6:00 am, there was only one CNA working per hallway and call light wait times were up to an hour.
D. On 06/29/23 at 10:00 am during an interview with the Administrator, she stated that staff had difficulty completing assignments because low staffing of the facility overall was a problem.
CONCERN
(F)
Potential for Harm - no one hurt, but risky conditions existed
Staffing Information
(Tag F0732)
Could have caused harm · This affected most or all residents
Based on observation, record review, and interview, the facility failed to post Nurse Staffing Information in an accurate manner and at the beginning of each shift, This deficient practice could likel...
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Based on observation, record review, and interview, the facility failed to post Nurse Staffing Information in an accurate manner and at the beginning of each shift, This deficient practice could likely prevent the 71 residents on the facility census list provided by the Administrator on 06/25/23, and any visitors to have access to accurate daily staffing information. The findings are:
A. On 07/06/23 at 8:00 am during an observation the facility, the posted nurse staffing daily schedule at both nurses stations was dated 07/05/23, and the Registered Nurse (RN) staffing section was left blank. An additional posted nursing staff daily schedule located on the 200 hallway was dated 06/29/23.
B. Record review of the prior two months of posted nursing staff schedules revealed the following:
1. Posted nursing staff schedule dated 06/01/23 had two different postings for the same date, with different numbers of staff posted
2. Posted nursing staff schedule dated 06/02/23 had two different postings for the same date, with different numbers of staff posted
3. Posted nursing staff schedule dated 06/03/23 had three different postings for the same date, with different numbers of staff posted
4. Posted nursing staff schedule dated 06/05/23 had two different postings for the same date, with different numbers of staff posted
5. Posted nursing staff schedule dated 06/06/23 had two different postings for the same date, with different numbers of staff posted
6. Posted nursing staff schedule dated 06/10/23 had two different postings for the same date, with different numbers of staff posted
7. Posted nursing staff schedule dated 06/25/23 had two different postings for the same date, with different numbers of staff posted
8. Posted nursing staff schedule dated 06/26/23 had two different postings for the same date, with different numbers of staff posted
9. There was not a posted nursing staff schedule for 06/09/23 or 06/28/23.
C. During an interview with the Director of Nursing (DON) on 07/06/23 at 1:30 pm, she reviewed the posted nursing staff schedule records and acknowledged that they did not match up and the numbers of staff were different on several postings.
CONCERN
(F)
📢 Someone Reported This
A family member, employee, or ombudsman was alarmed enough to file a formal complaint
Potential for Harm - no one hurt, but risky conditions existed
Deficiency F0806
(Tag F0806)
Could have caused harm · This affected most or all residents
Based on observation, record review, and interview, the facility failed to provide an alternate meal menu for residents that preferred not to eat the meal served on the menu. By failing to post an alt...
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Based on observation, record review, and interview, the facility failed to provide an alternate meal menu for residents that preferred not to eat the meal served on the menu. By failing to post an alternate meal, all 71 residents listed on the census provided by the Administrator, may not be aware that they have choices. This deficient practice could lead to residents having less than optimal nutritional health outcomes, and suffer unwanted weight loss.
The findings are:
A. On 06/25/23 at 11:30 am, during observation of the facility it was noted that the menu displayed in the hallways bulletin boards did not show an alternate meal choice.
B. On 06/25/23 at 12:00 pm, during observation of the main dining room, the displayed menus for breakfast, lunch, and dinner did not list an alternate meal choice.
C. On 06/26/23 at 11:50 am, during observation of the main dining room, it was noted that the displayed menus did not contain an alternate menu listing.
D. Record review of the facility meal menu revealed that the facility did not offer alternate meal choices for breakfast, lunch, or dinner.
E. On 06/29/23 at 11:35 am, during an interview with Director of Dietary Services (DDS), she revealed that the facility menus are approved through the Registered Dietician. She stated that the facility offers an all-the-time menu, which included things like grilled cheese sandwiches, hamburgers, and pizza. She stated that the facility did not offer an alternate meal menu of the same nutritional value.
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 and interview, the facility failed to ensure food was labeled and dated in the refrigerators and dry storage areas. This deficient practice could affect the 71 residents, as liste...
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Based on observation and interview, the facility failed to ensure food was labeled and dated in the refrigerators and dry storage areas. This deficient practice could affect the 71 residents, as listed on the facility census provided by the Administrator on 06/25/23, that receive food or meals from the kitchen. If the facility does not ensure food storage is conducted using proper procedures, residents have the potential to receive food that is expired, or potentially exposed to food contamination resulting in foodborne illness.
The findings are:
A. On 06/25/23 at 9:08 am, the following items were observed during the kitchen tour:
Preparation Area:
1. (1) tortilla chips bag was open and sitting on top of a preparation table
2. (1) egg carton containing eggs was left on preparation counter/table uncovered and unrefrigerated
3. (1) marshmallow bag was opened and unlabeled laying on shelf under the preparation table
4. (4) eggs left in bowl on table with yellow substance on/under them
5. (1) container of basil leaves, only labeled with FIFO (first in first out) date
6. (1) container of cinnamon, only labeled with FIFO (first in first out) date
7. (1) container of taco seasoning, only labeled with FIFO (first in first out) date
8. (1) container of mustard powder, only labeled with FIFO (first in first out) date
9. (1) container of quick oats, opened and only labeled with FIFO (first in first out) date
Walk-In cooler:
1. (1) meat in clear container, unlabeled
2. (1) container with jalapenos, unlabeled
3. (1) peaches in container, unlabeled
4. (3) unopened monster energy drinks left in cooler (staff use)
5. (1) opened sweet and sour sauce, without open and use by date
6. (1) whipped topping, undated
7. (1) opened package of tortillas containing only one date (06/24/23)
8. (2) beef base containers, manufacturers best by date of 13 June 2023
B. On 06/25/23 at 9:50 am, during an interview, [NAME] #1 acknowledged that the food items discussed above were not labeled correctly.
C. On 06/29/23 at 11:00 am, during a follow-up observation of the kitchen the following was observed:
1. (1) container of donuts, in an untied plastic bag, in a box, and stored in the freezer
2. (1) container of California mixed vegetables (cauliflower, broccoli, peppers) in an unsealed bag
3. (1) container of apple juice had been opened and used during the breakfast meal, was sitting on shelf in the dining/service area and not refrigerated, as outlined on the manufacturer's labeling.
D. On 06/29/23 at 11:48 am, during an interview with the Director of Dietary Services (DDS), she acknowledged that the items outlined in the initial tour were not labeled correctly. She also acknowledged that the items outlined in the follow-up observation were not stored correctly.
CONCERN
(F)
Potential for Harm - no one hurt, but risky conditions existed
Garbage Disposal
(Tag F0814)
Could have caused harm · This affected most or all residents
Based on observation and interview, the facility failed to ensure trash/garbage cans were closed and in good repair. This deficient practice has the potential to affect all 71 residents, as listed on ...
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Based on observation and interview, the facility failed to ensure trash/garbage cans were closed and in good repair. This deficient practice has the potential to affect all 71 residents, as listed on the facility census provided by the Administrator on 06/25/23, by attracting insects, rodents and animals to the facility. The findings are:
A. On 06/25/23 at 9:08 am, during observation of the kitchen, four garbage cans (located outside of the kitchen) were observed to be without lids.
B. On 06/29/23 at 11:00 am, during observation of the kitchen, the following was observed:
1. Three garbage cans had only partial lids, with part of the lid broken off.
2. One garbage can had no lid.
3. One rolling garbage can, contained a plastic liner that was filled to the top and untied, had no lid.
C. On 06/29/23 at 11:18 am, during an interview with the Director of Dietary Services (DDS), she acknowledged that the garbage cans listed above were missing lids or had broken lids and unable to be closed completely.
Aug 2022
16 deficiencies
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
Based on record review, observation, and interview the facility failed to address safety concerns for 1 (R #57) of 1 (R #57) resident reviewed for abuse by not conducting an Interdisciplinary Team (ID...
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Based on record review, observation, and interview the facility failed to address safety concerns for 1 (R #57) of 1 (R #57) resident reviewed for abuse by not conducting an Interdisciplinary Team (IDT) meeting and develop a care plan for that resident. Failing to conduct IDT meetings addressing safety concerns and develop a care plan for residents could likely result in residents being involved in or subject to abusive situations (verbal, physical, or psychosocial). The findings are:
A. Record review of facility face sheet for R #57 revealed admitting diagnosis which included: Cerebral ischemia (stroke), 2019-nCoV acute respiratory disease (viral lung infection), Post-Traumatic Stress Disorder (feeling of fear caused by person being in similar situation of trauma), Depression (feeling of sadness), Muscle weakness, Dysphagia (difficulty swallowing), Cognitive communication deficit (difficulty communicating), Cellulitis of left upper limb (skin infection), and Anxiety disorder (feeling of fear).
B. Record review of facility progress notes for R #57 revealed:
06/16/2022 10:35 (Police) notified that spouse was in facility, intoxicated. Waiting for (Police) to arrive. Resident is being monitored in her room. This SSA (Social Services Administrator) has left 3 messages with (name), Ombudsman, awaiting reply. This SSA also attempted to reach emergency contacts this am, no answer. Social Services
06/27/2022 12:18 Husband in facility stating he wants to take (R #57) home AMA (against medical advise). This SSD (Social Services Director) explained the difference btwn (between) a safe dc (discharge) vs unsafe dc. In (R #57) room she agrees with him; however this morning during her shower (R #57) stated to CNA (Certified Nurse Assistant) Please don't let him take me home. This SSD notified Ombudsman (name). Who advised SS (Social Services) and CNA, she trusts to assess her in private when husband not in facility. Social Services
07/06/2022 09:36 Resident's spouse in facility this AM (morning) to visit. While spouse was here resident came out into the hallway crying and shaking stating he's leaving. This nurse attempted to calm resident down and redirected her attention to eating breakfast. A few minutes later resident came back into the hallway again crying saying he's moving to Colorado. This nurse tried explaining to resident that she would need to stay in facility until she was discharged . Resident replied by saying ok that's good. At that time spouse came out into hallway demanding resident be released. This nurse explained to spouse that resident has not been discharged by therapy or by Dr. (name). Spouse became agitated requesting to speak to the administrator. Administrator not in facility at that time so (name), SS came and spoke to spouse. (SSD) to notify Administrator of spouses request to speak with him.
Licensed Nurse
07/11/2022 06:30 Previous nurse reported to this nurse that CNA overheard husband telling resident to shut the fuck up. CNA went into resident's room at that time and redirected situation and resident was monitored closely. Per previous nurse, CNA also heard husband ask resident what she has told everyone. This nurse will report incident to management and SS if it hasn't already been reported Licensed Nurse
07/11/2022 12:01 (R #57) communicated to this SSD (Social Services Director) she did not want to go home with her husband. She fears him; however, (R #57) will allow him to visit her at this time.
Social Service
07/15/2022 12:50 Residents spouse (name) was in facility to visit resident. Floor nurse notified this Nurse(.) spouse was demanding discharge and he was talking her home regardless of what anyone said. This nurse spoke with spouse and he was admit (adamant) on taking patient regardless if she needed more therapy or not. I told (spouse) I would speak with resident and ask if she still wanted to continue therapy or go home. I assisted resident back to her room. Resident was in tears and states my husband is really angry. Resident sat in the chair in her room. I asked resident if she wanted to go home or continue to receive her therapy. Resident stated I want to stay but my husband is so angry and he is going to get mad at me. I also asked resident if she felt safe at home or if she would be taken care of if she went home. Resident stated I do not know because he gets so mad at me, I just do not know. I assisted resident to bed to take a nap. Bed left in lowest position with call light in reach. I notified residents spouse she did not want to leave and with that being said she will be staying. Spouse began to yell at this nurse cussing and walking down away. He stopped at the nurses station and yelled (in) her face calling her a bitch he proceeded down the hall way. I informed him he needed to leave the building and can not be acting this way. He continued to yell and cuss. Spouse then got close to this nurse and raised his hand to hit me while cussing. Spouse also called this nurse a bitch. Spouse threw his mask in the hallway and kicked a sign that was up in hall. I assisted spouse out the side door and informed him, he was no longer allowed in the building. Local police department was contact and report filled. Spouse notified of criminal trespassing. Event report # (case number) filled by Officer (name).
Licensed Nurse (sic)
C. Record review of care plan for R #57 revealed that there was no care plan developed for resident safety from abusive spouse.
D. Record review of Progress notes for R #57 revealed that there was no IDT meeting addressing abusive spouse.
E. On 08/08/22 at 10:00 am, an observation of the receptionist counter and sliding window revealed a note indicating that the spouse (by name) to R #57 was not allowed in the facility and to notify law enforcement if he entered facility.
F. On 08/10/22 at 3:00 pm, during an interview the DON (Director of Nursing) stated that she did not have a good reason why there was not something done in the care plan regarding the spouse (of R #57) and the potential for abuses (verbal, psychosocial, and physical).
CONCERN
(D)
Potential for Harm - no one hurt, but risky conditions existed
Deficiency F0655
(Tag F0655)
Could have caused harm · This affected 1 resident
**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on record review, observation, and interview, the facility failed develop a Baseline Care Plan for 1 (R #33) of 1 (R #33) ...
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**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on record review, observation, and interview, the facility failed develop a Baseline Care Plan for 1 (R #33) of 1 (R #33) resident reviewed for baseline care plans. If the facility fails to develop care, treatment, services, and goals the residents may not receive the appropriate care. This deficient practice could potentially result in residents not being able to achieve their highest practical abilities, a decline in their general health and wellbeing, and staff not being aware of the residents needed care. The findings are:
A. Record review of facility face sheet for R #33 revealed admitted on [DATE] with admitting diagnosis which included: Toxic encephalopathy (toxins in the brain), Delirium due to known physiological condition (temporary state of confusion, Bacterial pneumonia (bacterial lung infection), Urinary tract infection (bladder infection), Diabetes mellitus (high blood sugar), Hypoglycemia (low blood sugar), Major depressive disorder (feeling of sadness), Insomnia (difficulty sleeping), Hyperlipidemia (high cholesterol), Phlebitis and thrombophlebitis of lower extremity (inflamed veins), Hypertension (high blood pressure), Constipation, Muscle weakness, Unsteadiness on feet, Cognitive communication deficit (difficulty communicating), and Dysphagia (difficulty swallowing).
B. Record review of progress notes for R #33 revealed the following:
06/22/2022 14:02 (2:02 pm) Physical-OT therapy (therapy used to help resident gain strength) had taken resident to therapy, resident in a bad mood calling therapy staff names, was brought back to nurses desk. Resident then went to room where she tried to transfer self to bed and fell to sitting position in the middle of the floor. Resident states they made me so damn mad, I decided to do it myself. Resident denies any pain. When staff came in to help resident up, resident cannot bear any weight on legs, has not been able to do so since arriving at facility. Resident verbalized understanding to not try to transfer self since unable to bear weight. No injuries, or redness noted on resident, and resident denies any pain at this time. Dr. (name) notified, message left for legal guardian to call facility, ADON (Assistant Director of Nursing) notified.
07/11/2022 06:15 I meet the Resident (R #33) on the floor, Resident assisted back to bed, neurological (memory and motor skills) and physical assessed with no changes. Verbalized no dizziness. Doctor notified. Vitals taken and documented. No one answer me from her Family. Bed placed on the lowest position , NURO (neurological) evaluation started. (sic)
C. Record review of facility Electronic Health Record (EHR) for R #33 revealed no baseline care plan was completed.
D. Record review of comprehensive fall care plan for R #33, who admitted on [DATE], revealed the following:
Problem: Falls; Resident at risk for falling R/T (related to) encephalopathy (brain disease); Fall in room on 6/22/22
Goal: Resident will remain free from injury.
Approach(es): Give resident verbal reminders not to ambulate/transfer without assistance. 06/23/2022
Keep bed in lowest position with brakes locked. 06/23/2022
Keep call light in reach at all times. 06/23/2022
Keep personal items and frequently used items within reach. 06/23/2022
Receiving skilled services for therapy. 06/23/2022
E. On 08/03/22 at 3:00 pm, during an interview R #33 stated that she has not had anymore falls for a while. (last fall noted on 07/11/22)
F. On 08/04/22 at 2:00 pm, during an interview the DON (Director of Nursing) stated that a baseline care plan was not completed for R #33.
CONCERN
(D)
Potential for Harm - no one hurt, but risky conditions existed
Comprehensive Care Plan
(Tag F0656)
Could have caused harm · This affected 1 resident
**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on record review, observation, and interview, the facility failed to implement a comprehensive person-centered care plan f...
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**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on record review, observation, and interview, the facility failed to implement a comprehensive person-centered care plan for 1 (R #33) of 2 (R #11 and R #33) residents reviewed for falls. Failure to implement a resident centered care plan is likely to result in staff's failure to understand and implement the needs and treatments for residents to achieve their highest level of well-being. The findings are:
A. Record review of facility face sheet for R #33 revealed admitted on [DATE] with admitting diagnosis which included: Toxic encephalopathy (toxins in the brain), Delirium due to known physiological condition (temporary state of confusion), Bacterial pneumonia (bacterial lung infection), Urinary tract infection (bladder infection), Diabetes mellitus (high blood sugar), Hypoglycemia (low blood sugar), Major depressive disorder (feeling of sadness), Insomnia (difficulty sleeping), Hyperlipidemia (high cholesterol), Phlebitis and thrombophlebitis of lower extremity (inflamed veins), Hypertension (high blood pressure), Constipation, Muscle weakness, Unsteadiness on feet, Cognitive communication deficit (difficulty communicating), and Dysphagia (difficulty swallowing).
B. Record review of progress notes for R #33 revealed the following:
06/22/2022 14:02 (2:02 pm) Physical-OT (therapy used to help resident gain strength) therapy had taken resident to therapy, resident in a bad mood calling therapy staff names, was brought back to nurses desk. Resident then went to room where she tried to transfer self to bed and fell to sitting position in the middle of the floor. Resident states they made me so damn mad, I decided to do it myself. Resident denies any pain. When staff in to help resident up, resident cannot bear any weight on legs, has not been able to do so since arriving at facility. Resident verbalized understanding to not try to transfer self since unable to bear weight. no injuries, or redness noted on resident, and resident denies any pain at this time. Dr. (name) notified, message left for legal guardian to call facility, ADON (assistant director of nursing)notified.
07/11/2022 06:15 I meet the Resident (R #33) on the floor. Resident assisted back to bed neurological (memory and motor skills) and physical assessed with no changes. Verbalized no dizziness. Doctor notified. Vitals taken and documented. No one answer me from her Family. Bed placed on the lowest position , NURO (-logical) evaluation started.
C. Record review of facility Electronic Health Record (EHR) for R #33 revealed no baseline care plan was completed.
D. Record review of comprehensive fall care plan for R #33, who admitted on [DATE], revealed the following:
Problem: Falls; Resident at risk for falling R/T (related to) encephalopathy ( brain disease) fall in room on 6/22/22
Goal: Resident will remain free from injury.
Approach(es): Give resident verbal reminders not to ambulate/transfer without assistance. 06/23/2022
Keep bed in lowest position with brakes locked. 06/23/2022
Keep call light in reach at all times. 06/23/2022
Keep personal items and frequently used items within reach. 06/23/2022
Receiving skilled services for therapy. 06/23/2022
E. On 08/04/22 at 10:00 am, an observation of R #33's bed position revealed that it was in a higher than Lowest position with the resident laying in bed.
F. On 08/04/22 at 10:15 am, during an interview the DON (Director of Nursing) stated that resident R #33's bed was not in the lowest position as it should be.
CONCERN
(D)
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 timely revise and update a care plan for 1 (R #11) of 2 (R #11 and R #33) residents reviewed for falls. This deficient practice could likel...
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Based on record review and interview, the facility failed to timely revise and update a care plan for 1 (R #11) of 2 (R #11 and R #33) residents reviewed for falls. This deficient practice could likely cause staff to be unaware of current resident needs and/or behaviors, and impair the safety of residents. The findings are:
A. Record review of facility face sheet for R #11 revealed admitting diagnosis which included: 2019-nCoV acute respiratory disease (viral lung infection), Asthma (breathing difficulty), Peripheral vascular disease (circulation difficulty), Psychotic disorder with delusions (fixed false conviction that something is real, not shared by others), Alzheimer's disease (memory loss), Dementia (memory loss), Dehydration (not enough liquids), Acute kidney failure (non-functioning kidneys), Major depressive disorder (feeling of sadness), Anxiety disorder (feeling of fear), Hypertension (high blood pressure), Hyperlipidemia (high cholesterol), Gastro-esophageal reflux disease (acid reflux), Shortness of breath, Dry eye syndrome (loss of eye lubricants), Pain, Insomnia (difficulty sleeping), Lack of coordination, Muscle weakness, and Difficulty in walking.
B. Record review of fall care plan initiated on 06/18/19 for R #11 revealed the following:
Problem: ; Falls; R #11 is at risk for injuries due to generalized muscle weakness as evidenced by falls and inability to stabilize self without assistance. 04/07/22 - Found on floor-no injuries; 05/20/22 - Found on floor beside bed - no injuries. Revised: 06/18/2019
Goal: R #11 will remain free from injury r/t (related to) falls and injury for the next 90 days.
Approach(es):
1. Dysom (non-slip material) to Wheelchair to prevent R #11 from sliding from w/c (wheelchair)
to floor Twice A Day; 06:00 - 18:00 (6 am to 6 pm), 18:00 - 06:00 (6 pm to 6 am); (revised) 05/24/2022
2. Fall mat at bedside bed in lowest position (revised) 04/06/2022
3. R #11 to be referred to Therapy for evaluation of strength and balance (revised) 10/04/2021
4. Staff educated on passing out snacks promptly and regularly. (revised) 04/13/2020
5. Scoop mattress (high sided) to be applied to bed so R #11 can be aware of where the edge of the bed is when available. (revised) 11/05/2019
6. Licensed staff will observe R #11 frequently and she will allow placement in supervised area when out of bed. (revised) 09/18/2019
7. R #11 will allow licensed staff to clear her room and environment of clutter. (revised) 06/18/2019
8. R #11 will allow licensed staff to keep call light within reach at all times while she is in her room. (revised) 09/18/2019.
C. Record review of nursing progress notes for R #11 revealed the following:
06/06/2022 21:34 (9:34 pm) I found the resident on the floor, resident was put on the bed, all neurological and physical assessment (test of memory and motor skills) was applied , No changes observed , Skin Evaluation (skin check) was done and no changes observed (No bruises, injuries(y) related to fall), Vital signs . no pain, DR. (name) was informed, there is no family Number to tell them about the incident, paper work done, (ADON) (assistant director of nursing) informed. Registered Nurse (RN). (sic)
D. Record review of fall care plan for R #11 revealed that the last noted fall as indicated in progress notes was on 06/06/22, which was prior to last care plan update (06/18/22) which should have reflected the newest fall and intervention/approach to care for resident.
E. On 08/08/22 at 3:03 pm, during an interview DON (Director of Nursing) acknowledged that a revision should have taken place, but was unable to give a reason why, It must have been missed.
CONCERN
(D)
Potential for Harm - no one hurt, but risky conditions existed
ADL Care
(Tag F0677)
Could have caused harm · This affected 1 resident
Based on observation and interview the facility failed to provide for the needed personal hygiene for 1 (R #27) of 1 (R #27) residents reviewed for ADL (Activities for Daily Living) care. This deficie...
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Based on observation and interview the facility failed to provide for the needed personal hygiene for 1 (R #27) of 1 (R #27) residents reviewed for ADL (Activities for Daily Living) care. This deficient practice may likely lead to residents feeling uncomfortable as well as put them at increased risk for not being able to maintain their optimal levels of well-being. The findings are:
A. On 08/01/22 at 2:00 pm, during an observation it was observed R #27 had a soiled diaper. There was an overwhelming smell of feces and no Certified Nurse Aide (CNA) appeared to be concerned. After initially bringing the situation of R #27 to the attention of a Certified Nurse Assistant (CNA #9), she stated that the resident was fine. Once surveyor insisted that CNA #9 check on R #27, CNA #9 found that the resident had soiled herself.
B. On 08/04/22 at 1:10 pm, during an interview RN (Registered Nurse) #1 stated that she has noticed that staffing at this facility has not been enough. RN#1 further stated that some days there are enough staff and some days there are poor staffing levels, and that a big concern of her is staffing that do come to work do not know the residents. RN #1 stated that this impacts patient care.
C. On 08/04/22 at 1:40 pm, during an interview with CNA #1, he stated that he felt staffing at this facility was less than adequate and he feels the residents would do better if there were more staff.
D. On 08/08/22 at 2:10 pm during an interview, the Director of Nursing (DON) stated that the facility was short on staffing and that it was a concern.
CONCERN
(D)
Potential for Harm - no one hurt, but risky conditions existed
Deficiency F0679
(Tag F0679)
Could have caused harm · This affected 1 resident
**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, record review, and interview, the facility failed to provide activities to promote the mental and psychoso...
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**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, record review, and interview, the facility failed to provide activities to promote the mental and psychosocial (combined psychological factors and physical environment related to a resident) well being for 1 (R #1) of 1 (R #1) reviewed for activities. This deficient practice has the potential to result in all 64 residents, identified on the facility matrix as presented by the Administrator on 08/01/22, becoming depressed and feel like they have no quality of life. The findings are:
A. Record review of facility face sheet for R #1 revealed admitting diagnosis which included: 2019-nCoV acute respiratory disease (viral lung infection), Acute infarction of spinal cord (stroke within the spinal cord), Paraplegia (partial paralysis), Shortness of breath, Hypertension (high blood pressure), Pain, Muscle weakness, insomnia (difficulty sleeping), Muscle wasting and atrophy (loss of muscle), Dysphagia (difficulty swallowing), Unsteadiness on feet, Lack of coordination, Cognitive communication deficit (difficulty communicating), Limitation of activities due to disability and reduced mobility.
B. Record review of facility census for R #1 revealed he was moved to room [ROOM NUMBER]-A from 308-B, due to Covid Positive test on 07/19/22.
C. On 08/01/22 at 4:02 pm, during an observation of R #1's area revealed a TV mounted on the wall in front of his bed space (112-A), but no remote to use. The other bed space (112-B) had a TV mounted on the wall with a working remote, which was not easily seen from 112-A bed's angle. The room did not have an activities calendar to inform the resident of events taking place or an activity request form.
D. On 08/01/22 at 4:05 pm, during an interview R #1 stated that he was very bored in his room. He stated that he has a TV to watch in front of his bed, but the remote does not work and it only gets one channel. He stated that the other TV and remote works (mounted at 112-B), but it's hard to see at the angle he has to watch it at. He said he isn't able to move around easily due to his paralysis. He stated that he hasn't seen anyone from the activities department and doesn't know what was available for activities, but he may get a paper once in a while if the nurse brings one in.
E. Record review of facility Activity Policies and Procedures revealed the following:
.Procedures: .5. Those who cannot participate in a group setting are provided one on one/individual programming., who are in isolation for medical reasons, who are on physician ordered bed rest or those who were not able to attend due to no more than the number of residents where 6-foot distancing among residents has been maximized. One to one programming can occur in person, via telephone or live video chat on approved facility devices.7. Programs take place mornings and afternoons, 7 days/week, and include holidays and evenings. 8. Programs take place in various areas, including but not limited to Activity rooms, .in-house TV channels, virtually through live video feeds/conferencing on facility owned devices .etc.
F. On 08/01/22 at 2:00 pm, during an interview the Administrator (ADM) stated that the activities person was not going to be at the facility during the survey due to illness. No alternate was given.
CONCERN
(D)
Potential for Harm - no one hurt, but risky conditions existed
Quality of Care
(Tag F0684)
Could have caused harm · This affected 1 resident
**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, record review, and interview, the facility failed to assess a chest surface wound on 1 (R #46) of 1 (R #46...
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**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, record review, and interview, the facility failed to assess a chest surface wound on 1 (R #46) of 1 (R #46) residents reviewed for quality of care. This deficient practice has the potential for residents to be uncomfortable and to increase the risk of skin breakdown and infection. The findings are:
A. Record review of diagnosis for R #46 include: Metabolic encephalopathy (Unable to think clearly) Urinary tract infection, unspecified severe protein-calorie malnutrition (unable to effectively digest calories and protein) Other intervertebral disc degeneration, lumbar region (spacing between spinal discs lessening due to ageing) Pressure ulcer sacral region unstageable. (Sore on lower center back close to buttocks cleft) Unspecified atrial fibrillation (Heart dysrhythmia) Ileus, unspecified (partial bowel blockage) Atherosclerotic heart disease of native coronary artery without angina pectoris (Clogged cardiac artery without chest pain) Dehydration, Pain unspecified, Gastro-esophageal reflux disease without esophagitis ([NAME] without heartburn) Nausea, repeated falls, Dysphagia, oral phase ( difficulty speaking) Muscle weakness generalized, Other abnormalities of gait and mobility (Difficulty walking) Cognitive communication deficit (Difficulty thinking and speaking at the same time) Dysphagia (Difficulty forming words).
B. On 08/01/22 at 10:51 am, during an observation an unattached/loose 4 inches by 4 inches bandage was seen on R #46's center chest, which had been removed from a 1X1 chest surface wound. R #46 was observed playing with a 4X 4 bandage and then holding it up and saying Where does this go?
C. Record review of physicians orders for R #46 revealed there was no order for wound care for R #46.
D. On 08/01/22 at 1:30 pm, during an interview the DON (Director of Nursing) acknowledged that there was no order for wound care and that she would have the Wound Care Nurse assess R#44's wound.
CONCERN
(D)
Potential for Harm - no one hurt, but risky conditions existed
Deficiency F0726
(Tag F0726)
Could have caused harm · This affected 1 resident
Based on record review and interview the facility failed to review and complete competencies for 2 of 6 Certified Nurse Aides (CNA) reviewed for competencies. This failure is likely to cause residents...
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Based on record review and interview the facility failed to review and complete competencies for 2 of 6 Certified Nurse Aides (CNA) reviewed for competencies. This failure is likely to cause residents to suffer from lack of proper care and lead to their less than optimal well-being. The findings are:
A. Record review of Certified Nurse Aides (CNA) training files for 2 (CNA #3 and CNA #4) of 6 (CNA#'s 3, 4, 5, 6, 7, and 8) revealed competencies were not completed.
B. On 08/10/22 at 12:28 pm, during an interview the Infection preventionist (IP)/Staff Development Coordinator (SDC) stated he did not have competency information for 2 of the 6 CNA's reviewed.
CONCERN
(E)
Potential for Harm - no one hurt, but risky conditions existed
Deficiency F0559
(Tag F0559)
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 residents of a room change by not giving written notificatio...
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**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on record review and interview, the facility failed to notify residents of a room change by not giving written notification prior to moving resident's room/location for 3 (R #'s 20, 59, and 63,) of 3 (R #'s 20, 59,and 63 ) residents reviewed for notification of room change. This deficient practice could likely result in a resident being unprepared for the room change and may lead to feelings of helplessness, anxiety, and uncertainty. The findings are:
A. On 08/08/22 a new facility matrix was provided showing changes to resident locations within the facility from the previous week (08/01/22). Noted residents included R #'s 20, 59, 63.
Resident #20
B. On 08/09/22 at 8:00 am, during an interview, R #20 stated that she was given written notice of room transfer on 08/08/22, not on 08/05/22 the day of transfer. She stated that she was not given the reason for the transfer.
C. Record review of facility advance notification of room transfer for R #20 revealed that R #20 signed a transfer advance notification document on 08/08/22. No reason was annotated on the form.
D. Record review of facility Electronic Health Record (EHR) census for R #20 revealed she was transferred from Rm (Room)-201 to RM [ROOM NUMBER] on 08/05/22 at 4:00 pm.
Resident #59
E. On 08/10/22 at 11:15 am, during an interview, R #59 stated that he was given written notice of transfer to another room a couple days ago and could not remember if notice was given before the transfer. He stated he did not know why he was transferred.
F. Record review of facility advance notification of room transfer for R #59 revealed that R #59 signed a transfer advance notification document, but it was undated. No reason was annotated on the form.
G. Record review of facility EHR census for R #59 revealed he was transferred from Rm-207 to RM [ROOM NUMBER] on 08/05/22 at 4:00 pm.
Resident #63
H. On 08/09/22 at 3:05 pm, during an interview, R #63 stated that he was given written notice of transfer to another room a couple days ago and could not remember if notice was given before the transfer. He stated he was not given a reason for the transfer.
I. Record review of facility advance notification of room transfer for R #63 revealed that R #63 signed a transfer advance notification document, but it was undated. No reason annotated on the form.
J. Record review of facility EHR census for R #63 revealed he was transferred from Rm-204 to RM [ROOM NUMBER] on 08/05/22 at 4:00 pm.
K. On 08/08/22 at 3:00 pm, during an interview the Director of Nursing (DON) stated that the residents (inclusive of R #20, R #59, and R #63, ) were moved to other parts of the facility due to staffing shortages.
L. On 08/09/22 at 3:00 pm during an interview the SSD (Social Services Director) stated that she did not provide written notice to R #20, R #59 and R #63 before the transfer of these residents.
CONCERN
(E)
Potential for Harm - no one hurt, but risky conditions existed
Grievances
(Tag F0585)
Could have caused harm · This affected multiple residents
Based on record review and interview the facility failed to make residents aware of the grievance process and providing responses to those identified concerns. This is likely to affect all 64 resident...
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Based on record review and interview the facility failed to make residents aware of the grievance process and providing responses to those identified concerns. This is likely to affect all 64 residents as noted on the facility census provided by the Administrator on 08/01/22. Failing to make residents aware of how to file a grievance and providing a response is likely to cause residents to feel isolated, unable to be understood and unwanted, all of which impact their psychosocial well-being. The findings are:
A. On 08/02/22 at 10:56 am, during a resident council meeting the following was relayed:
1. Some residents stated that the shower chairs were too high, making them feel afraid to get out of them due to fear [anxiety (of falling and causing injuries)].
2. Residents stated that the food is not good, and that the kitchen has been out of bread and other items such as breakfast meats (bacon and sausage).
3. The always available menu items are not always available such as grilled cheese, hot dogs, and those things do not come with/have vegetables.
4. Hot food is never hot, room trays are late, and constantly have to wait on trays in dining room.
5. Residents stated that there is not enough staff at night, and if there are call-ins no one comes in to replace that staff member.
6. Residents in attendance stated they have waited up to an hour for a call light to be answered.
7. Resident initiated grievances are not acted on. Residents in attendance stated, I have filled out grievances, and have not heard anything back; I don't even get a copy of it.
8. Showers scheduled for twice a week may happen sometimes if there is enough staff.
9. Residents stated that no snacks are available or made known to them at bedtime
10. Toenails have not been cut. (diabetic residents)
11. Residents stated that the Physician does not respond to requests.
12. R #2 stated that he needs a Psychiatrist, but no response to his request has been received by him.
13. Residents in attendance stated that they did not know how to file a complaint with the State Survey Agency.
B. Record review of facility Complaints and Grievance Process, dated 10/01/20, revealed the following:
Policy: The facility's leadership will support the patient and resident right to communicate complaints and grievances to the facility or other agencies or entities that hear grievances, regarding services and treatments receive including , but not limited to:
A. Treatment
B. Care and services .
Procedures: .
5. The facility honors the patient and the resident's right to obtain a written decision regarding the filed grievance .
7. The facilities leadership will accept complaints and grievances from patients, residents, family members or visitors according to state-specific statutes and regulations.
8. Grievances and complaints are generally directed to facility leaders which include but are not limited to:
A. Administrator
B. Department manager or designee
C. Supervisor
D. Unit Manager
9. Facility leadership acts promptly to understand and resolve complaints and grievances.
10. Facility leadership maintains communication with the complainant to provide updates and information on progress towards resolution
Documentation: Written Decisions:
1. Written grievance decisions include:
A. Date a grievance was received
B. Summary statement of the grievance
C. Investigation methods
D. Summary of pertinent findings and conclusions
E. Statement whether the grievance was confirmed, and the facility corrective actions taken or to be taken
2. Date the decision was issued .
Documentation: Complaint or Grievance Intake
1. The receiver of a complaint or grievance will instruct the complainant to complete the appropriate sections of a Complaint and Grievance Report. If the complainant is unable, the appropriate facility staff will provide assistance with the documentation.
3. Upon complaint or grievance resolution, the Administrator reviews and signs the
report or the monthly log indicating a review of the complaints and grievances
4. The completed Complaint/Grievance Report is filed in the Facility Grievance Binder.
5. Complaints and grievances are recorded on the grievance log. Grievance Logs may be electronic or hardcopy .
C. On 08/01/22 at 1:00 pm, during an interview, R #24 stated that the food is awful, sometimes it is cooked all the way through and sometimes it is not. I did not receive breakfast today, and they have not been serving sausage or bacon like on the menu for the last three days. She further stated that she has asked that she receive the same breakfast all the time (eggs, bacon and a slice of toast), and that several times the kitchen has been out of bacon as requested and she has not received a breakfast meal at all at times. (no grievance initiated by staff)
D. On 08/01/22 at 3:53 pm, during an interview, R #14 stated that he has asked the kitchen that he not be brought chicken. He said he has had nothing but chicken lately, and that he told them several times that he is not able to chew the chicken chunks without his dentures. (no grievance initiated by staff)
E. On 08/01/22 at 4:00 pm, during an interview, R #1 stated that the kitchen served way too much chicken all the time, I'm tired of chicken. They (kitchen) don't send an alternative if I send my meal back, they (kitchen staff/CNA (Certified Nurse Assistant) don't ask us what we want before (the served) meal, they (kitchen staff/CNA) did when I was on the other hall (resident's original hall). There is no posted meal menu to let us know what is being served either over here (covid/quarantine hall). (no grievance initiated by staff)
F. On 08/02/22 at 9:44 am, during an interview R #10 stated that the facility gave her a grilled cheese sandwich for lunch on 08/01/22, and the bread that was used was a hamburger bun due to them (kitchen) being out of regular bread. She stated that the bread was so thick that by the time they got the cheese to melt the bread was too hard for her to eat it. She stated that the facility has not had sausage or bacon for the past 3 days for the breakfast meals as scheduled on the menus. (no grievance initiated by staff)
G. On 08/10/22 at 1:18 pm, during an interview with the Dietary Manager (DM) she stated that snacks are prepared and left in the kitchen refrigerators for (the) residents at bedtime. She continued that nursing has to go to kitchen to pick up (the) snacks; I am not surprised the residents do not know about (the) snacks (being) available at bedtime.
H. Record review of the grievance log revealed that several grievances that did not have a timely response to the issue posed, revealing a failing of the facility to follow its policy of the facility leadership acting promptly to understand and resolve.
I. On 08/09/22 at 3:50 pm, during an interview with the Administrator, he acknowledged a problem with the grievance system. He stated that he understands that there are several issues with the facility right now and plans to address them within the six months.
CONCERN
(E)
Potential for Harm - no one hurt, but risky conditions existed
Drug Regimen Review
(Tag F0756)
Could have caused harm · This affected multiple residents
Based on record review and interview the facility failed to ensure monthly drug regimen reviews were conducted and records maintained by the consultant pharmacist for 3 Residents (R #'s 11, 28, and 33...
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Based on record review and interview the facility failed to ensure monthly drug regimen reviews were conducted and records maintained by the consultant pharmacist for 3 Residents (R #'s 11, 28, and 33) of 3 (R #'s 11, 28, and 33) residents reviewed for unnecessary medications. This failure could likely cause irregularities (a potential problem related to taking a specified prescription) to occur with resident's medication and recommendations to be unresolved. The findings are:
Resident #11
A. Record review of facility face sheet for R #11 revealed admitting diagnosis which included: 2019-nCoV acute respiratory disease (viral lung infection), Asthma (breathing difficulty), Peripheral vascular disease (circulation difficulty), Psychotic disorder with delusions (fixed false conviction that something is real, not shared by others), Alzheimer's disease (memory loss), Dementia (memory loss), Dehydration (not enough liquids), Acute kidney failure (non-functioning kidneys), Major depressive disorder (feeling of sadness), Anxiety disorder (feeling of fear), Hypertension (high blood pressure), Hyperlipidemia (high cholesterol), Gastro-esophageal reflux disease (acid reflux), Shortness of breath, Dry eye syndrome (loss of eye lubricants), Pain, Insomnia (difficulty sleeping), Lack of coordination, Muscle weakness, and Difficulty in walking.
B. Record review of physician orders for R #11 revealed the following:
Colace (docusate sodium) [OTC (over the counter)]; capsule; 100 milligram (mg); amt (amount): 1 tablet (tab); oral; Twice A Day 09:00 am, 21:00 (9:00 pm); Constipation.
Famotidine [OTC]; tablet; 20 mg; amt: 1 tab; oral; At Bedtime 20:00 (8:00 pm); Gastro-esophageal reflux disease.
Fluticasone [OTC]; spray,suspension; 50 mcg/actuation (micrograms per spray/pump); amt (amount): one spray each nostril; nasal Once A Morning 09:00, allergies.
Labetalol; tablet; 100 mg; amt: 1 tab; oral; Special Instructions: hold for SBB (static/resting blood pressure) LESS THAN 110 OR HR (heart rate) less than 65; Twice A Day 08:00 am, 20:00 (8:00 pm); hypertensive.
Miralax (polyethylene glycol 3350) [OTC]; powder in packet; 17 gram; amt: 1 packet; oral; Special Instructions: Mix with water; Once A Day 09:00; Constipation.
Mirtazapine; tablet; 7.5 mg; amt 1; oral; At Bedtime 20:00; Anxiety disorder
Paroxetine HCl; tablet; 10 mg; amt: 1 TAB; oral; Once A Day 09:00; Major depressive disorder with violent behaviors.
Quetiapine; tablet; 25 mg; amt: 1 tab; oral; At Bedtime 20:00; Psychotic disorder with delusions.
Rivastigmine tartrate; capsule; 4.5 mg; amt: 1 capsule; oral; Once A Morning 09:00; Alzheimer's disease.
C. Record review of pharmacy Medication Regimen Review (MRR) revealed the following:
October 2021 - Recommendation: No assessment noted of renal function over past 6 months; next available lab monitor BMP (basic metabolic panel) over next 6 months.
November 2021 - No record.
December 2021 - receives Lisinopril, no recent serum creatine or electrolyte evaluation in matrix. Oked.
January 2022 - Receives Paroxetine 10 mg QD for major Depressive Disorder on 01/17/22; was 20 mg QD (every day) prior; also receives Quetiapine. Attempt a GDR (gradual dose reduction) of Paroxetine to 5 mg QD. Oked.
February 2022 - H2RA (H2 inhibitor/acid reducer) Famotidine 20 mg BID; estimated CrCl (creatine clearance/how kidneys are functioning) of 28 ml/min (mililiters per minute) on 02/16/22; consider decrease Famotidine to 20 mg QHS (every day at bedtime). Oked by physician.
March 2022 Through June 2022 - No records.
Resident #28
D. Record review of facility face sheet For R #28 revealed admitting diagnosis which included: 2019-nCoV acute respiratory disease (viral lung disease), Major depressive disorder (feeling of sadness), Extrapyramidal and movement disorder (uncontrolled muscle twitching and movements), Dementia (memory loss), Anxiety disorder (feeling of fear), Arthritis (joint pain), Type 2 diabetes mellitus (high blood sugar), Paranoid personality disorder (feeling of mistrust) , Auditory hallucinations (hearing things), Insomnia (difficulty sleeping), Hypertensive heart disease (excessive thickening of the heart wall), Gastro-esophageal reflux disease (acid reflux), Dry eye syndrome (lack of eye lubrication), Chronic pain, Muscle weakness, Difficulty in walking, Altered mental status (memory loss), and Cognitive communication deficit (difficulty communicating).
E. Record review of physician orders for R #28 revealed the following:
Amantadine HCl; tablet; 100 mg; amt: 1; oral; Once A Day; 08:00; Extrapyramidal and movement disorder.
Famotidine [OTC]; tablet; 20 mg; amt: 1; oral; Once A Day; 08:00; Gastro-esophageal reflux disease without esophagitis
Gabapentin; capsule; 100 mg; amt: 2 tablet; oral; Three Times A Day; 08:00, 14:00, 20:00; Major depressive disorder, recurrent, severe with psychotic symptoms
Humalog KwikPen Insulin (insulin lispro); insulin pen; 100 unit/mL [portion of drug (insulin) per mililiter]; amt: Per Sliding Scale; If Blood Sugar is less than 60, call MD If Blood Sugar is greater than 400, call MD. (Medical Doctor); subcutaneous (under the skin); Twice A Day; 08:00, 20:00; Type 2 diabetes mellitus with unspecified complications
Lisinopril; tablet; 10 mg; amt: 1; oral; Once A Day; 08:00 am; Hypertensive heart disease
Melatonin; tablet; 10 mg; amt: 1 TAB; oral; At Bedtime; 20:00 (8:00 pm); Insomnia
Memantine; tablet; 10 mg; amt: 1; oral; Once A Day; 08:00; Extrapyramidal and movement disorder
Risperidone; tablet; 0.25 mg; amt: 1 tab; oral; Once A Day; 08:00; Paranoid personality disorder
Sertraline; tablet; 100 mg; amt: 1; oral; Once A Day; 08:00; Major depressive disorder, recurrent, severe with psychotic symptoms
F. Record review of Pharmacy Regimen Review for R #28 revealed the following:
September 2021 - No record
October 2021 - Recommendation: No A1C (blood test for diabetes) in matrix noted; conduct an A1C next lab day and every 6 months thereafter. Okayed per physician.
November 2021 - No record
December 2021 - Recommendation: No recent serum creatine (test to see creatine levels) in matrix noted; order BMP every 6 months to assess CrCl and GFR (kidney filtration rate). Okayed per physician.
January 2022 - No recommendation.
February 2022 - Receives 3 or more CNS (central nervous system) active medications Sertraline, Risperidone, and Gabapentin. Recommended decrease Risperidone from 0.5 mg BID to 0.25 mg QAM (every morning) + 0.5 mg QHS. Okayed per physician.
March 2022 - No recommendation
April 2022 through June 2022 - No Records
Resident #33
G. Record review of facility face sheet for R #33 revealed admitting diagnosis which included: Toxic encephalopathy (toxins in the brain), Delirium due to known physiological condition (temporary state of confusion, Bacterial pneumonia (bacterial lung infection), Urinary tract infection (bladder infection), Diabetes mellitus (high blood sugar), Hypoglycemia (low blood sugar), Major depressive disorder (feeling of sadness), Insomnia (difficulty sleeping), Hyperlipidemia (high cholesterol), Phlebitis and thrombophlebitis of lower extremity (inflamed veins), Hypertension (high blood pressure), Constipation, Muscle weakness, Cognitive communication deficit, and Dysphagia (difficulty swallowing).
H. Record review of physician orders for R #33 revealed:
Atorvastatin tablet; 20 mg; 1 Tablet; oral; At Bedtime; Hyperlipidemia
Docusate Sodium [OTC] tablet; 100 mg; 1 tablet; oral; Once A Day; Constipation,
hydrochlorothiazide tablet; 12.5 mg; 1 Tablet; oral; Once A Day; Hypertension
Lantus Solostar U-100 Insulin (insulin glargine) insulin pen; 100 unit/mL (3 mL); Amount to Administer: 35; subcutaneous; Once A Day; Diabetes mellitus
Lisinopril tablet; 20 mg; amt: 1; oral; Once A Day 08:00; Hypertension
Metoprolol tartrate tablet; 50 mg; amt: 1; oral; Once A Day; 08:00; Hypertension
Novolog Flexpen U-100 Insulin (insulin aspart u-100); insulin pen; 100 unit/mL (3 mL); amt: Per Sliding Scale; If Blood Sugar is less than 50, call MD. If Blood Sugar is greater than 450, call MD. Subcutaneous; Before Meals and At Bedtime 07:30 am, 11:30 am, 16:30 (11:30 pm), 20:00 (8:00 pm); Diabetes mellitus
Olanzapine tablet; 2.5 mg; amt: 1; oral; At Bedtime 20:00; depression
Sertraline tablet; 25 mg; amt: 1; oral; Once A Morning 08:00 am; depression
Xarelto (rivaroxaban) tablet; 20 mg; amt: 1; oral; Once A Day 08:00 am; phelebitis
I. Record review of pharmacy medication regimen review for R #33 revealed the following:
September 2021 - No record available
November 2021 - No record available
April 2022, May 2022, and June 2022 - No Records available
J. On 08/03/22 at 2:54 pm, during an interview the DON (Director of Nursing) stated, I am looking for April's (2022) medication drug regime review. June's (2022) would have gone to the previous DON's email address. I don't have June's of 2022. I met with the consultant pharmacist last week.
CONCERN
(E)
Potential for Harm - no one hurt, but risky conditions existed
Menu Adequacy
(Tag F0803)
Could have caused harm · This affected multiple residents
Based on record review, observation, and interview, the facility failed to provide nutritionally adequate alternate menu choice menus to 3 (R #1, R #14, and R #24) of 3 (R #1, R #14, and R #24) reside...
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Based on record review, observation, and interview, the facility failed to provide nutritionally adequate alternate menu choice menus to 3 (R #1, R #14, and R #24) of 3 (R #1, R #14, and R #24) residents reviewed for menu alternate/resident preference meals. Failure to have an alternate menu to ensure the needs were met for 62 of the 64 residents listed on the facility census that could consume meals from the kitchen as provided by the Administrator on 08/01/22 is likely to result in resident weight loss and not meeting their nutritional needs, and overall well-being. The findings are:
A. Record review of facility menu revealed the following:
Monday Lunch: 08/01/22
1. Crispy Oven Baked Chicken 1 Ea (each)
2. Sweet potato fries 11/2 Cup
3. Seasoned Broccoli 4 Oz (ounces)
4. Fresh Baked Roll 1 Oz - Margarine 1 Ea
5. Cream Pie (1/10) 1 Slice
6. Iced Tea 8 Oz Ice Water 8 Oz
B. Record review of current facility menus revealed no alternate menu choice for residents to equal the same nutritional values as the main menu. An All the time menu was available to residents, if they did not want the main proposed meal, but nutritional value was not equal in comparison, as items such as a grilled cheese sandwich was all that was on the plate. A grilled cheese sandwich could replace the main portion of the meal, however the vegetable and desert portions were excluded.
C. On 08/01/22 at 1:00 pm, during an interview R #24 stated, The food is awful, sometimes it is cooked all the way through and sometimes it is not. I did not receive breakfast today, and they have not been serving sausage or bacon like on the menu for the last three days. She further stated that she asked that she receive the same breakfast all the time (eggs, bacon and a slice of toast), and that several times the kitchen has been out of bacon and she has not received a breakfast meal at all for some of those times.
D. On 08/01/22 at 3:53 pm, during an interview R #14 stated that he has asked the kitchen that he not be brought chicken, as he has had nothing but chicken lately, and that he is not able to chew the chicken chunks without his dentures.
E. On 08/01/22 at 3:55 pm, during an observation of R #14's room it was observed that there were no menus in the rooms for the residents to know what is being served for the day. (This was observed the same for all quarantine rooms)
F. On 08/01/22 at 4:00 pm, during an interview R #1 stated that the kitchen served way too much chicken all the time. He said, I'm tired of chicken. They (kitchen) don't send an alternative if I send my meal back, they [kitchen/CNA (Certified Nurse Aide)] don't ask us what we want before (the served) meal, they (kitchen/CNA) did when I was on the other hall (resident's original hall). There is no posted meal menu to let us know what is being served either over here (covid/quarantine hall).
G. On 08/02/22 at 9:44 am, during an interview, R #10 stated that the facility gave her a grilled cheese sandwich for lunch on 08/01/22, and the bread that was used was a hamburger bun due to them being out of regular bread. She stated that the bread was so thick that by the time they got the cheese to melt the bread was too hard for her to eat it. She stated that the facility has not had sausage or bacon for the past 3 days for the breakfast meal as scheduled on the menus.
H. On 08/04/22 at 3:10 pm, during an interview with the Dietary Manager, she was asked how the facility gets its food supplies; and why were they out of regular (sandwich) bread? The Dietary Manager stated that the facility orders food from (an approved source) and that they were waiting on a delivery. She stated that she was informed after the fact (that the sandwich had already been made) and that there is nothing that should have or would have prevented the (kitchen) staff from going to a local market and purchasing regular bread or other items if needed. She stated that she was going to be working with the dietician to fix the menus. She stated that the current facility menus came about due to food waste. No further comment was given.
CONCERN
(E)
Potential for Harm - no one hurt, but risky conditions existed
Deficiency F0804
(Tag F0804)
Could have caused harm · This affected multiple residents
Based on record review, observation, and interview the facility failed to provide meals that tasted good and with the requested resident preferences for 4 (R #1, R #10, R #14, and R #24) of 4 (R #1, R...
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Based on record review, observation, and interview the facility failed to provide meals that tasted good and with the requested resident preferences for 4 (R #1, R #10, R #14, and R #24) of 4 (R #1, R #10, R #14, and R #24) residents reviewed for food quality. This failed practice has the potential to affect the 62 residents identified on the resident census list provided by the administrator on 08/01/22 that were able to eat meals from the kitchen. This deficient practice has the potential for residents to not wanting to eat meals, which could lead to significant weight loss. The findings are:
Resident #1
A. Record review of facility face sheet for R #1 revealed admitting diagnosis which included: 2019-nCoV acute respiratory disease (viral lung infection), Acute infarction of spinal cord (stroke within the spinal cord), Paraplegia (partial paralysis), Shortness of breath, Hypertension (high blood pressure), Pain, Muscle weakness, insomnia (difficulty sleeping), Muscle wasting and atrophy (loss of muscle), Dysphagia (difficulty swallowing), Unsteadiness on feet, Lack of coordination, Cognitive communication deficit (difficulty communicating), Limitation of activities due to disability, and reduced mobility.
B. Record review of progress notes for R #1 revealed the following:
07/21/2022 17:01 (5:01 pm) RD (Registered Dietician) Note: triggered to (R #1) due to annual nutritional assessment. Wt (weight) has remained stable through the past 6 months. Skin has remained intact. Intakes have remained consistently good and sufficient to meet estimated nutritional needs. No new dietary concerns noted. Dietary plan is appropriate. Continue dietary plan. RD will continue to monitor.
C. On 08/01/22 at 4:00 pm, during an interview R #1 stated that the kitchen served way too much chicken all the time, I'm tired of chicken. They (kitchen) don't send an alternative if I send meal back, they [kitchen/CNA (Certified Nurse Assistant)] don't ask us what we want before (the served) meal, they (kitchen/CNA) did when I was on the other hall (resident's original hall). There is no posted meal menu to let us know what is being served either over here (covid/quarantine hall).
Resident #10
D. Record review of facility face sheet for R #10 revealed admitting diagnosis which included: End stage renal disease (low/non-working kidneys), Acute kidney failure, Pneumonia (bacterial lung disease), Hypokalemia (low potassium), Heart failure (heart attack), Type 2 diabetes mellitus (high blood sugar), 2019-nCoV acute respiratory disease (viral lung infection), Acute respiratory failure (stop breathing) with hypoxia (loss of oxygen to the brain), Cirrhosis of liver (low functioning liver), Chronic viral hepatitis C (liver disease), Atrial fibrillation (irregular heartbeat), Depressive episodes (feeling of sadness), Bed confinement status, Hypertension (high blood pressure), Hypotension (low blood pressure), Gastro-esophageal reflux disease (acid reflux), Chronic pain, and Muscle wasting (loss of muscle).
E. Record review of nutritional care plan for R #10 revealed the following:
Problem: Nutritional Status; R #10 is at risk for weight fluctuations related to Diabetes, congestive heart failure, bed confinement and end stage renal disease aeb (as evidenced by) irregular weights. 05/15/2022
Goal: (R #10) will maintain an appropriate weight for her body size through next review. 08/28/2022
Approach(es): She states she 'chokes on lettuce, rice, and beans'. SLP (Speech Language Therapy) to screen for swallow deficit. 05/18/2021
Encourage oral intake of food and fluids. Monitor skin turgor (skin elasticity) and for leg cramps - report abnormal findings to MD (Medical Doctor). 03/21/2019
Monitor and record intake of food. 03/21/2019
Monitor lab work. 03/21/2019
Monitor skin turgor, vital signs, weight and labs. 03/21/2019
F. Record review of progress notes for R #10 revealed the following:
05/17/2022 10:24 CBW (corrected body weight) 262.6 # (pounds) (-0.4% x 1 mo, -5.0% x 3 mo, -5.3% x 6 mo), BMI (body mass index) 49.61. Diet order is CCHO (consistent carbohydrate diet), ground meats, and meal intakes are mostly 51-75% at this time. Weight has been relatively stable over the past month. Continue current nutrition plan at this time. Will continue to monitor for changes.
G. On 08/02/22 at 9:44 am, during an interview R #10 stated that the facility gave her a grilled cheese sandwich for lunch on 08/01/22, and the bread that was used was a hamburger bun due to them being out of regular bread. She stated that the bread was so thick that by the time they got the cheese to melt the bread was too hard for her to eat it (nothing else was on the plate). She stated that the facility has not had sausage or bacon for the past 3 days for the breakfast meal as scheduled on the menus.
Resident #14
H. Record review of facility face sheet for R #14 revealed admitting diagnosis which included: 2019-nCoV acute respiratory disease (viral lung disease), Heart failure (heart attack), Chronic kidney disease (low/non-functioning kidneys), Alzheimer's disease (memory loss), Morbid (severe) obesity, Bipolar disorder (mood swings), Depressive episodes (feeling of sadness), Anxiety disorder (feeling of fear), Osteoarthritis (swollen joints), Hypertension (high blood pressure), Gastro-esophageal reflux disease (acid reflux), Retention of urine, Dysphagia (difficulty swallowing), Obstructive sleep apnea (stop breathing during sleep), Insomnia (difficulty sleeping), Acute respiratory failure (stop breathing), Long term (current) use of anticoagulants (blood thinners), Edema (swelling), and Orthostatic hypotension (low blood pressure upon sitting up or standing).
I. Record review of progress notes for R #14 revealed the following:
03/24/2022 05:35 CBW (corrected body weight) 275.6 # (-1.9% x 1 mo, -3.1% x 3 mo), BMI (body mass index) 43.16. Diet order is regular, minced/moist. Meal intakes are in the 75-100% range. Continue current nutrition plan due to good meal intakes. Will continue to monitor for changes. Dietary
J. Record review of the nutritional care plan for R #14 revealed the following:
Problem: Nutritional Status; (R #14) is at risk for potential weight fluctuations. He has had nutritional education from the physician on choosing healthier meals. 05/14/2022
Goal: He will remain or progress to a healthy weight through the next review. 08/16/2022
Approach(es): 11/14/2017
1. Provide a regular diet, soft foods per resident request as ordered with his food preferences
as feasible.
2. Monitor and encourage intake of meals.
3. Offer snacks between each meal and at bedtime.
4. Encourage resident to try new foods when offered. (Revised) 03/17/2019
K. On 08/01/22 at 3:53 pm, during an interview R #14 stated that he has asked the kitchen that he not be brought chicken, as he has had nothing but chicken lately, and that he is not able to chew the chicken chunks without his dentures.
L. On 08/01/22 at 3:55 pm, an observation of the resident R #14 room revealed that there was no menus in the rooms for the residents to know what is being served for the day.
Resident #24
M. Record review of facility face sheet for R #24 revealed admitting diagnosis which included: Cerebral infarction (stroke), Hemiplegia and hemiparesis (partial paralysis) following cerebral infarction affecting right dominant side, Transient cerebral ischemic attack (stroke), Chronic obstructive pulmonary disease (difficulty breathing), unspecified, Atherosclerotic heart disease (hardening of the arteries), Hyperlipidemia (high cholesterol), Type 2 diabetes mellitus (high blood sugar), Hypokalemia (low potassium), Diverticulitis of intestine (inflammation of the intestines), Cerebral cysts (brain tumors), Major depressive disorder (feeling of sadness), Restless legs syndrome, Sleep apnea (stop breathing during sleep), Shortness of breath, Chronic pain, Osteoarthritis (inflamed joints), Ulcerative colitis (inflamed colon with sores) with rectal bleeding, Gastro-esophageal reflux disease (acid reflux), and Hypertension (high blood pressure).
N. Record review of nutritional care plan for R #24 revealed the following:
Problem: Nutritional Status; (R #24) is at risk for potential weight fluctuations related to poor nutritional status, poor dental status, and diuretic therapy. She also has a diagnosis of GERD (acid reflux), diverticulitis (iinflamed bowels) and CHF (chronic heart failure). She has an elevated BMI. 03/28/2019 (Revised) 06/14/2022
Goal: (R #24) will remain or progress to a healthy weight through the next review. 10/01/2022
Approach(es): (R #24) wishes to lose weight safely. Dietitian was consulted. Dietary changes made - diet CCHO (controlled carbohydrate diet), NAS (no added salt), small portions. 10/14/2021
1. Provide diet as ordered with resident food preferences as feasible.
2. Encourage fluid intake.
3. Monitor and encourage intake of meals.
4. Offer snacks as ordered. Provide assistance with meals/snacks as necessary. Edited: 03/28/2019 (Revised) 09/02/2019
O. On 08/01/22 at 1:00 pm, during an interview R #24 stated that the food is awful, sometimes it is cooked all the way through and sometimes it is not. I did not receive breakfast today, and they have not been serving sausage or bacon like on the menu for the last three days. She further stated that she has asked that she receive the same breakfast all the time (eggs, bacon and a slice of toast), and that several times the kitchen has been out of bacon as requested and she has not received a breakfast meal at all some of those times.
P. Record review of current facility menus revealed no alternate menu choice for residents to equal the same nutritional values as the main menu. An all the time menu was available to residents if they did not want the main proposed meal, but nutritional value was not equal in comparison, as items such as a grilled cheese sandwich was all that was on the plate.
Q. On 08/04/22 at 3:10 pm, during an interview with the Dietary Manager, she was asked how the facility gets its food supplies; and and why it was out of regular (sandwich) bread? The Dietary Manager stated that the facility orders food from (an approved source) and that they were waiting on a delivery. She stated that she was informed after the fact (that the sandwich had already been made on a hamburger bun) and that there is nothing that should have or would have prevented the (kitchen) staff from going to a local market and purchasing regular bread or other items if needed. She stated that the bread should have been resealed after any prior use to keep it from drying out. She stated that she was going to be working with the dietician to fix the menus.
CONCERN
(E)
Potential for Harm - no one hurt, but risky conditions existed
Food Safety
(Tag F0812)
Could have caused harm · This affected multiple residents
Based on record review, observation, and interview, the facility failed to follow facility Nutrition Policies and Procedures (08/01/2020), for food storage by not ensuring food in refrigerators and dr...
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Based on record review, observation, and interview, the facility failed to follow facility Nutrition Policies and Procedures (08/01/2020), for food storage by not ensuring food in refrigerators and dry storage were properly stored and dated. This could affect 62 residents as listed on the facility matrix provided by the Administrator (ADM) on 08/01/22 that could eat from the kitchen. If the facility does not ensure food storage is conducted using proper procedures, residents have the potential to receive food that is expired, past it's Use By date, or exposed to potentially hazardous food contamination resulting in foodborne illness. The findings are:
A. On 08/01/22 at 8:15 am, during the initial tour the following was observed:
1. Chicken breasts and chicken tenders were observed to be uncovered on cooking sheets sitting in a rack to the right of the oven.
2. Sweet potato fries were observed to be on cooking sheets uncovered sitting on preparation table.
3. Walk-in cooler had an opened cheddar cheese package with only a single date of 07/27/22 it was unknown if it was opened date or use by date.
4. Walk-in freezer had 2 unlabeled water bottles sitting on top shelf it was unknown if they were for residents or staff had placed them there.
5. A beef patties box was sitting on the middle shelf and was left opened with the plastic inner packaging left open as well.
B. On 08/01/22 at 8:45 am, during an interview the Dietary Manager acknowledged the findings and stated that she would address the discovered/found issues.
C. On 08/04/22 at 2:50 pm, during a follow-up kitchen visit the following was observed:
1. Walk-in freezer had a beef patties box was sitting on the middle shelf and was left opened with the plastic inner packaging left open as well.
2. Walk-in cooler had a pan with cheese slices and sliced turkey meat stored together and unlabeled; green chili was in a container and labeled with a single date of 07/31/30 (past 72 hour storage limit); jalapeno slices were in a container and labeled with a single date of 07/30/22 (past the 72 hour storage limit); individual styrofoam cups of Jell-o were on a storage rack only partially covered with lids allowing possibility of contamination.
3. Preparation table had a partially opened loaf of bread lying on it with the plastic left open (allowing it to dry out or become hardened)
4. Bread rack contained 2 loaves of bread (1 partial loaf) and and a partial bag of buns, the partial loaf of bread and the bag of buns were left opened allowing the bread to become dry and/or hardened.
5. A metal storage rack near the entrance contained a dirty shop vac floor attachment and emergency light left on the top shelf (allowing any residual debris to fall on anything stored below).
6. The drain in front of the ovens and prep table was dirty and contained dark brown/black substance.
7. The wall and floor behind the stove and ovens was dirty and contained dark substances.
D. Record review of current (08/01/2020) facility Nutrition Policies and Procedures revealed the following:
Receiving guidelines:
.
3.
Keep receiving area clean and well lighted.
.
6. Check expiration dates and use-by dates to assure the dates are within acceptable parameters.
.
9. When adding newly delivered food into current inventory, use the FIFO (First In, First Out) method so old stock is rotated to the front and utilized first.
Refrigerated food guidelines:
.
9.
Prevent meat and poultry juices from getting into other foods.
.
12.
Refrigerated, ready to eat Time Temperature Control for Safety Foods (TCS) are properly covered, labeled, dated with a use-by date, and refrigerated immediately. [NAME] them clearly to indicate the date by which the food shall be consumed or discarded. The day of preparation or day original container is opened shall be considered day 1. Discard after three days unless otherwise indicated. Refer to Cold Storage Chart.
13.
In the case of commercially processed food, the date marked by the facility may not exceed a manufacturer's use-by date.
E. On 08/04/22 at 3:10 pm, during an interview with the Dietary Manager, acknowledged that there were problems with the labeling of the food items. She stated that the walls and floor (to include the drains) were supposed to have been deep cleaned monthly, but hadn't been cleaned this month (August) yet. She stated that the cheese and turkey should not have been stored together (due to possibility of cross-contamination) and the bread should have been resealed after the prior use to keep it from drying out. She did not have an explanation for the attachment and emergency light found on the rack.
CONCERN
(F)
Potential for Harm - no one hurt, but risky conditions existed
Deficiency F0725
(Tag F0725)
Could have caused harm · This affected most or all residents
Based on observation, record review, and interview the facility failed to maintain appropriate staffing levels. This failure has the potential to affect all 64 residents as provided by the Administrat...
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Based on observation, record review, and interview the facility failed to maintain appropriate staffing levels. This failure has the potential to affect all 64 residents as provided by the Administrator on 08/01/22. This deficient practice could likely affect direct patient care and limit the residents abilities to obtain optimal well-being while in the facility. The findings are:
A. On 08/03/22 at 9:00 pm, an observation of the facility revealed that there were just two (2) nurses and five (5) CNA's (Certified Nurse Assistants) to care for all 64 residents spread across 4 (100, 200, 300, and 400) hallways. Each nurse took care of 2 hallways (100 and 400) and (200 and 300), and there was 1 CNA assigned to 100 hall, 1 CNA assigned to 200 hall, 2 CNA's assigned to 300 hall until 10:00 pm when it dropped to 1, and 2 assigned to 400 hall.
B. Record review of facility staffing on 08/08/22 to 08/09/22 for the 6 pm to 6 am shift of Nursing revealed two (2) nurses (1) Registered Nurse; (1) Licensed Practical Nurse to cover the 64 residents in all 4 (100, 200, 300, and 400) hallways.
C. Record review of facility staffing on 08/08/22 to 08/09/22 for the 6 pm to 6 am shift of there were 6 CNA's in total assigned to care for the residents. 1 in 100 hallway, 1 in 200 hallway, 2 in 300 hallway, and 2 in 400 hallway. (none signed, in only 5 in facility during observation)
D. On 08/03/22 at 9:40 pm, during an interview Licensed Practical Nurse (LPN) #3 stated that staffing has been very short and it is hard to work both areas at times.
E. On 08/08/22 at 2:10 pm, during an interview Director of Nursing stated that staffing levels were concerning to her. She was asked if she thought staffing levels were at an emergency level based on resident movements and such, she stated Yes, I believed so.
CONCERN
(F)
Potential for Harm - no one hurt, but risky conditions existed
Staffing Information
(Tag F0732)
Could have caused harm · This affected most or all residents
Based on observation and interview the facility failed to post Nurse Staffing Information in a timely manner. This deficient practice could likely prevent the 64 residents on the facility census list ...
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Based on observation and interview the facility failed to post Nurse Staffing Information in a timely manner. This deficient practice could likely prevent the 64 residents on the facility census list provided by the Administrator on 08/01/22, and any visitors to have access to accurate staffing information. The findings are:
A. On 08/01/22 at 8:40 am, an observation during the initial tour of the facility revealed the facility Nurse Staffing 24 Hour Posting was dated 07/28/22; 4 days prior to entry.
B. On 08/01/22 it was observed that there was no posting made for the day.
C. On 08/02/22 at 7:40 am, the 24 Hour Posting was completely filled in for all the shifts that were supposed to work for that day.
D. On 08/08/22 at 12:00 pm, an observation revealed the facility Nurse Staffing 24 Hour Posting was dated 08/05/22; 3 days prior to reentry to the facility.
E. On 08/09/22 at 11:00 am, during an interview the DON acknowledged the Posted Staffing (24 Hour Posting) was being posted incorrectly.
Understanding Severity Codes (click to expand)
Life-Threatening (Immediate Jeopardy)
J - Isolated
K - Pattern
L - Widespread
Actual Harm
G - Isolated
H - Pattern
I - Widespread
Potential for Harm
D - Isolated
E - Pattern
F - Widespread
No Harm (Minor)
A - Isolated
B - Pattern
C - Widespread
Questions to Ask on Your Visit
- "What changes have you made since the serious inspection findings?"
- "Can I speak with families of current residents?"
- "What's your RN coverage like on weekends and overnight?"
Our Honest Assessment
Strengths
- • Licensed and certified facility. Meets minimum state requirements.
Concerns
- • Multiple safety concerns identified: 4 life-threatening violation(s), Special Focus Facility, 1 harm violation(s), $99,368 in fines. Review inspection reports carefully.
- • 54 deficiencies on record, including 4 critical (life-threatening) violations. These warrant careful review before choosing this facility.
- • $99,368 in fines. Extremely high, among the most fined facilities in New Mexico. Major compliance failures.
- • Grade F (0/100). Below average facility with significant concerns.
Bottom line: This facility is on CMS's Special Focus list for poor performance. Consider alternatives strongly.
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About This Facility
What is Casa Maria Healthcare's CMS Rating?
CMS assigns Casa Maria Healthcare an overall rating of 1 out of 5 stars, which is considered much below average nationally. Within New Mexico, this rating places the facility higher than 0% of the state's 100 nursing homes. A rating at this level reflects concerns identified through health inspections, staffing assessments, or quality measures that families should carefully consider.
How is Casa Maria Healthcare Staffed?
CMS rates Casa Maria Healthcare's staffing level at 1 out of 5 stars, which is much below average compared to other nursing homes. Staff turnover is 52%, compared to the New Mexico average of 46%. RN turnover specifically is 67%, which is notably high. RNs provide skilled clinical oversight, so turnover in this role can affect medical care quality.
What Have Inspectors Found at Casa Maria Healthcare?
State health inspectors documented 54 deficiencies at Casa Maria Healthcare during 2022 to 2025. These included: 4 Immediate Jeopardy (the most serious level, indicating potential for serious harm or death), 1 that caused actual resident harm, and 49 with potential for harm. Immediate Jeopardy findings are rare and represent the most serious regulatory concerns. They require immediate corrective action.
Who Owns and Operates Casa Maria Healthcare?
Casa Maria Healthcare 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 OPCO SKILLED MANAGEMENT, a chain that manages multiple nursing homes. With 118 certified beds and approximately 97 residents (about 82% occupancy), it is a mid-sized facility located in Roswell, New Mexico.
How Does Casa Maria Healthcare Compare to Other New Mexico Nursing Homes?
Compared to the 100 nursing homes in New Mexico, Casa Maria Healthcare's overall rating (1 stars) is below the state average of 2.9, staff turnover (52%) is near the state average of 46%, and health inspection rating (1 stars) is much below the national benchmark.
What Should Families Ask When Visiting Casa Maria Healthcare?
Based on this facility's data, families visiting should ask: "What changes have been made since the serious inspection findings, and how are you preventing similar issues?" "Can you walk me through typical staffing levels on day, evening, and night shifts?" "Can I visit during a mealtime to observe dining assistance and food quality?" "How do you handle medical emergencies, and what is your hospital transfer rate?" These questions are particularly relevant given the facility's Immediate Jeopardy citations and the below-average staffing rating.
Is Casa Maria Healthcare Safe?
Based on CMS inspection data, Casa Maria Healthcare has documented safety concerns. Inspectors have issued 4 Immediate Jeopardy citations (the most serious violation level indicating risk of serious injury or death). The facility is currently on the Special Focus Facility watch list (a federal program monitoring the lowest-performing 1% of nursing homes nationwide). The facility has a 1-star overall rating and ranks #100 of 100 nursing homes in New Mexico. Families considering this facility should ask detailed questions about what corrective actions have been taken since these incidents.
Do Nurses at Casa Maria Healthcare Stick Around?
Casa Maria Healthcare has a staff turnover rate of 52%, which is 6 percentage points above the New Mexico average of 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 Casa Maria Healthcare Ever Fined?
Casa Maria Healthcare has been fined $99,368 across 3 penalty actions. This is above the New Mexico average of $34,073. Fines in this range indicate compliance issues significant enough for CMS to impose meaningful financial consequences. Common causes include delayed correction of deficiencies, repeat violations, or care failures affecting resident safety. Families should ask facility leadership what changes have been made since these penalties.
Is Casa Maria Healthcare on Any Federal Watch List?
Casa Maria Healthcare is currently an SFF Candidate, meaning CMS has identified it as potentially qualifying for the Special Focus Facility watch list. SFF Candidates have a history of serious deficiencies but haven't yet reached the threshold for full SFF designation. The facility is being monitored more closely — if problems continue, it may be added to the official watch list. Families should ask what the facility is doing to address the issues that led to this status.