Silver City Care Center
For profit - Limited Liability company
100 Beds
GENESIS HEALTHCARE
Data: November 2025
2 Immediate Jeopardy citations
Trust Grade
6/100
#65 of 67 in NM
Photo by Silver City Care Center
Photo by Silver City Care Center
Photo by Silver City Care Center
1 / 5 photos
Last Inspection: September 2024
Within standard 12-15 month inspection cycle. Federal law requires annual inspections.
Overview
Silver City Care Center received a Trust Grade of F, indicating poor performance and significant concerns about the care provided. It ranks #65 out of 67 nursing facilities in New Mexico, placing it in the bottom tier, and #2 out of 2 in Grant County, meaning there is only one other option locally. The facility is showing signs of improvement, having reduced issues from 22 in 2024 to 12 in 2025. However, it has a concerning history with critical incidents, including staff using a deceased resident to play a prank on another staff member, which is both disrespectful and dehumanizing. Staffing is slightly below average with a 54% turnover rate, and while the facility has an average level of RN coverage, the overall findings suggest families should proceed with caution.
- Trust Score
- F
- In New Mexico
- #65/67
- Safety Record
- High Risk
- Inspections
- Getting Better
- Staff Stability ⚠ Watch
- 54% turnover. Above average. Higher turnover means staff may not know residents' routines.
- Penalties ○ Average
- $32,615 in fines. Higher than 59% of New Mexico facilities. Some compliance issues.
- Skilled Nurses ⚠ Watch
- Each resident gets only 23 minutes of Registered Nurse (RN) attention daily — below average for New Mexico. Fewer RN minutes means fewer trained eyes watching for problems.
- Violations ⚠ Watch
- 75 deficiencies on record. Higher than average. Multiple issues found across inspections.
6/100
Bottom 3%
Review needed
22 → 12 violations
★☆☆☆☆
1.0
Overall Rating
★★☆☆☆
2.0
Staff Levels
★★★☆☆
3.0
Care Quality
★☆☆☆☆
1.0
Inspection Score
↔
Stable
2024: 22 issues
2025: 12 issues
The Good
-
Full Sprinkler Coverage · Fire safety systems throughout facility
-
No fines on record
Facility shows strength in fire safety.
The Bad
1-Star Overall Rating
Below New Mexico average (2.9)
Significant quality concerns identified by CMS
Staff Turnover: 54%
Near New Mexico avg (46%)
Higher turnover may affect care consistency
Federal Fines: $32,615
Below median ($33,413)
Moderate penalties - review what triggered them
Chain: GENESIS HEALTHCARE
Part of a multi-facility chain
Ask about local staffing decisions and management
The Ugly 75 deficiencies on record
2 life-threatening 1 actual harm
Aug 2025
4 deficiencies
CONCERN
(D)
📢 Someone Reported This
A family member, employee, or ombudsman was alarmed enough to file a formal complaint
Potential for Harm - no one hurt, but risky conditions existed
ADL Care
(Tag F0677)
Could have caused harm · This affected 1 resident
**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on record review, interview, and observation the facility failed to provide activities of daily living (ADL; activities re...
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**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on record review, interview, and observation 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 1 (R #1) of 1 (R #1) resident reviewed for ADL care when staff failed to cut R #1's fingernails. This deficient practice is likely to negatively affect the dignity and health of the residents. The findings are: A. Record review of R #1's admission record, no date, revealed R #1 was admitted to the facility on [DATE]. B. On 08/25/25 at 1:16 PM, during an observation, some of R #1's fingernails were overgrown, some were jagged and uneven from breaking off. C. On 08/25/25 at 1:16 PM, during an interview, R #1 stated staff had not offered to cut her fingernails. R #1 said she did not have any clippers to cut them herself. D. Record review R #1's Quarterly MDS dated [DATE] revealed R #1 needs partial to moderate assistance with personal hygiene. E. On 08/25/25 at 2:25 PM, during an interview, CNA #8 confirmed R #1's fingernails were long and had not been cut.
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 F0657
(Tag F0657)
Could have caused harm · This affected multiple residents
**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on record review and interview, the facility failed to ensure care plan revisions occurred for 2 (R #3 and R #8) of 6 (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 care plan revisions occurred for 2 (R #3 and R #8) of 6 (R #1, R #2, R #3, R #4, R #8, and R #9) residents reviewed for care plan accuracy when the staff failed to revise the care plan with the most current resident information. This deficient practice could likely result in the care plan not being updated with the most current resident conditions and appropriate interventions, staff being unaware of changes in care provided, and residents not receiving the care related to changes in their health status or healthcare decisions. The findings are:
R #3
A. Record review of R #3’s admission record (no date) revealed R #3 was admitted to the facility on [DATE].
B. Record review of R #3’s progress notes revealed the following:
1. Nurse note dated 05/06/25 at 6:12 PM: “Guardian in to visit with resident. Resident voiced concerns of wanting to go home or possible assisted living. Guardian stated she educated resident that it is a process and will assist in process for resident.”
2. Care plan meeting note dated 07/02/25 at 1:47 PM: “Plan is to move to assisted living in Las [NAME].”
C. Record review of R #3’s care plan dated 07/02/24 revealed the following:
Focus: R #3 is not expected to be discharged related to inability to care for self at home.
Goal: R #3 will be accepting of and appropriate for long-term placement through next review.
Interventions: (actions taken by facility staff): Identify, discuss and document resident/patient desires and concerns/barriers regarding discharge.
D. On 08/27/25 at 4:32 PM, during an interview with the DON, the following was confirmed:
1. R #3 expressed the desire to be discharged from the nursing facility to an assisted living facility.
2. R #3’s care plan was not updated to reflect the change in his discharge plan.
R #8
E. Record review of R #8’s admission documents, no date, revealed she was admitted to the facility on [DATE].
F. Record review of R #8's physician's orders, multiple dates, revealed the following:
1. An order dated 06/10/25, for trazodone (prescription antidepressant medication that belongs to the class of drugs known as serotonin antagonist and reuptake inhibitors) 100 mg 1 tablet by mouth once a day for circadian rhythm disorder (a sleep disorder that occurs when your body's internal clock, known as the circadian rhythm, is out of sync with your environment or your desired schedule).
2. An order dated 07/15/25, for mirtazapine (is an atypical tetracyclic antidepressant used primarily to treat major depressive disorder) 15 mg give one tablet at bedtime for depression.
G. Record review of R #8’s care plan, dated 07/08/25, revealed the care plan did not contain any interventions or goals for trazadone or mirtazapine.
H. On 08/26/25 at 1:39 PM, during an interview, the DON confirmed R #8’s care plan did not have interventions or goals for R #8’s trazodone or mirtazapine. The DON stated her expectation is that there should be interventions and goals for all psychotropic medications.
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 F0687
(Tag F0687)
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 provide foot care for 1 (R #1) of 1 (R #1) resident r...
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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 foot care for 1 (R #1) of 1 (R #1) resident reviewed for foot care when staff failed to provide nail care for R #1's toenails or make an appointment to a podiatrist for foot care. This deficient practice could likely cause podiatric complications (foot and ankle health issues, often arising from underlying systemic diseases like diabetes or poor circulation, that can lead to problems such as ulcers, infections, nerve damage (neuropathy), and, in severe cases, amputation in residents with diabetes). The findings are: A. Record review of R #1's admission record, no date, revealed the following: 1. R #1 was admitted to the facility on [DATE]. 2. R #1 has a diagnosis of type 2 diabetes mellitus (a chronic metabolic condition characterized by insulin resistance, where the body's cells don't respond to insulin properly, and a gradual decline in the pancreas's ability to produce enough insulin) without complications. B. On 08/25/25 at 1:16 PM, during an observation, R #1's toenails were overgrown, and her feet were callused (a thickened and hardened part of the skin or soft tissue). C. On 08/25/25 at 1:16 PM, during an interview, R #1 stated staff had not offered to cut her toenails and that she had not seen a podiatrist (a person who treats the feet and their ailments) since her admission. R #1 stated she had lost a toenail but that it was growing back. D. Record review of R #1's progress note, dated 07/11/25, revealed R #1 resident's nail fell off with no pain or blood. There was a recommendation from the provider to cleanse with wound cleanser pat dry apply triple antibiotic ointment, cover with dry gauze and secure with tape until healed. E. On 08/25/25 at 2:25 PM, during an interview, CNA #8 confirmed R #1's toenails were long and had not been cut. F. On 08/25/25 at 2:29 PM, during an interview, LPN #8 confirmed R #1 had a diagnosis of type 2 diabetes mellitus. LPN #8 stated that if a resident has a diagnosis of diabetes that a podiatrist will provide foot care for residents. LPN #8 stated the facility does not have a podiatrist that comes to the facility. G. On 08/25/25 at 3:31 PM, during an interview, RN #8 stated she had not seen R #1's toenails and that she had not made any referrals for R #1 to be seen by a podiatrist. RN #8 stated that residents' nails should be checked once a week. RN #8 confirmed R #1 is a diabetic. RN #8 confirmed that R #1's toenails are long and callused. H. On 08/26/25 at 2:46 PM, during an interview, the Schedular (staff who schedules appointments) stated he had scheduled an appointment last week for R #1 to see a podiatrist.
CONCERN
(E)
📢 Someone Reported This
A family member, employee, or ombudsman was alarmed enough to file a formal complaint
Potential for Harm - no one hurt, but risky conditions existed
Medical Records
(Tag F0842)
Could have caused harm · This affected multiple residents
**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on record review and interview, the facility failed to ensure medical records were complete and accurate for 2 (R #1 and 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 medical records were complete and accurate for 2 (R #1 and R #8) of 6 (R #1, R #2, R #3, R #4, R #8 and R #9) residents reviewed for documentation accuracy when staff failed to: 1. Document blood pressure and heart rate readings for R #1. 2. Document the correct diagnosis on the medication administration record for R #8. This deficient practice has the potential to have a negative impact on the care staff provide to residents due to missing or inaccurate records and resident information. The findings are:
R #1
A. Record review of R #1's admission record (no date) revealed the following:
1. R #1 was admitted to the facility on [DATE].
2. R #1 diagnoses included:
a. Essential primary hypertension (HTN, abnormally high blood pressure that is often influenced by lifestyle factors and not the result of a medical condition).
b. Paroxysmal atrial fibrillation (A FIB, episodes of rapid and irregular heartbeats that can last from a few minutes to several days).
B. Record review or R #1’s Physicians orders revealed the following:
1. Order dated 01/20/25; metoprolol (medication used to treat blood pressure) 25 mg give half tablet by mouth one time a day for HTN/A FIB, hold (do not give medication) for systolic blood pressure (SBP, top number of blood pressure reading) less than 100, diastolic blood pressure (DBP, bottom number of blood pressure reading) less than 50 or heart rate less than 60.
2. Order dated 03/18/25; lisinopril (medication used to treat high blood pressure) give 30 mg by mouth one time a day for hypertension hold for SBP less than 100 or DBP less than 50.
3. Order dated 07/20 25; furosemide (diuretic medication that helps the body get rid of excess fluid) give 20 mg by mouth one time a day for lower extremity edema (swelling of the legs) hold SBP less than 100 or DBP less than 50
C. Record review of R #1's MAR dated August 2025, revealed the following:
1. Staff did not document R #1’s blood pressure or heart rate when administering metoprolol.
2. Staff did not document R #1’s blood pressure when administering lisinopril.
3. Staff did not document R #1’s blood pressure when administering furosemide.
D. Record review of R #1’s vital signs (measurements of basic functions of the body that are essential for life including blood pressure, heart rate, body temperature and respiratory rate) for August 2025 revealed the following:
1. Staff did not document R #1’s blood pressure on August 6th, 7th, 14th, 15th, 16th, 17th, 19th, 20th, 21st, 22nd, 23rd and 24th.
2. Staff did not document R #1’s heart rate on August 4th, 6th, 7th, 14th, 15th, 16th, 17th, 19th, 20th, 21st, 22nd, 23rd and 24th.
E. On 08/27/25 at 4:22 PM, during an interview with the DON, the following was confirmed:
1. Staff should document the required vital signs when administering medications if the MAR has that option.
2. If staff do not have the option to document vital signs on the MAR they should document them in the vital signs section of the resident’s medical record.
3. Her expectation is that staff will document the vital signs in the medical record as indicated on the physician’s orders.
R #8
F. Record review of R #8’s admission documents, no date, revealed she was admitted to the facility on [DATE] with a diagnosis of circadian rhythm sleep disorder.
G. Record review of R #8's MAR for the month of August 2025 revealed, mirtazapine 15 mg give one tablet at bedtime for depression.
H. Record review of a psychiatric provider progress note, dated 07/15/25, revealed mirtazapine was prescribed for circadian rhythm disorder (a sleep disorder that occurs when your body's internal clock, known as the circadian rhythm, is out of sync with your environment or your desired schedule).
I. On 08/26/25 at 1:39 PM, during an interview, the DON stated R #8’s prescription for mirtazapine is for circadian rhythm disorder and that depression is the indication. The DON stated that staff entered the order wrong.
Jan 2025
8 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
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 thoroughly investigate an allegation of abuse/mistreatment for 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 thoroughly investigate an allegation of abuse/mistreatment for 1 (R #16) of 3 (R #1, R #16, and R #17) residents reviewed when they failed to:
1. Identify that staff using a deceased resident to carry out a prank/joke on another staff member was abuse/mistreatment of the resident.
2. Thoroughly investigate all components of the allegation.
2. Prevent further abuse/mistreatment by not removing RN #1 [initiator of the prank] from resident care.
3. Initiate corrective action to ensure staff are not dehumanizing residents and continue to treat residents with respect even after they are deceased .
If the facility is not adequately investigating allegations of abuse, then corrective action is not implemented to prevent other residents from similar abuse which puts residents at risk of adverse serious outcomes. The findings are:
Cross Reference findings from F550
A. Record review the admission record revealed R #16 was initially admitted on [DATE].
B. Record review of Physician Orders revealed R #16 was full code (medical term indicating patient wishes to receive all possible life saving measures in the event of a medical emergency).
C. Record review of R #16's progress notes dated [DATE] revealed:
1. 2205 (10:05 pm) resident assessed during hourly rounds. Semifowler (reclining position with head and torso raised between 30-45 degrees) in bed, room in good order no issues whatsoever resident unresponsive to when called out attempting to arouse. Assess results radial pulse weak faintly palpable (to be felt). Visible respiration inadequate to sustain life due to rate of 4 -8 per minute. Code blue initiated. Code blue called out, crash cart obtained, 911 call for assistance from emergency response teams. CPR (cardiopulmonary resuscitation) protocol breaths and chest compression provided 2208 (10:08 pm). 2211(10:11 pm) patient assessment resulting in no detectable heart beat, respirations, CPR resumption at which time ems entered room and immediately deployed team in rendering/continuing care. At this time care center employees and this nurse removed ourselves from that role.
2. Progress note identified notification to next of kin (Son #1) and he indicated that he would need to contact Son #2 to get funeral information. Per progress note dated [DATE] at 5:44 am, still waiting on funeral information.
D. On [DATE] at 4:36 PM, during an interview, NA #1 stated she got to work on [DATE] at 6:00 am. NA #1 said that she noticed R #16's door was closed, and the door being closed was unusual. NA #1 said that at 6:30 AM, RN #1 [night shift manager] asked her to take R #16's vital signs. NA #1 stated when she went into R #16's room, the room was cold. NA #1 said R #16 would usually respond to her right away when entering the room. NA #1 said R #16's dentures did not seem to be sitting right in her mouth. NA #1 further stated that she nudged R #16 and noticed at that time she was cold. NA #1 stated she realized R #16 had passed, so she left the room to let staff know and RN #1 was standing outside the room laughing. NA #1 stated RN #1 said it was a cruel rookie joke that he was playing and RN #1 told NA #1 not to say anything because he wanted to play the joke on another staff member. NA #1 said that she was so distraught that emergency medical services had to be called to check her out because she was having a panic attack.
E. On [DATE] at 12:07 PM, during an interview, the Administrator said she is the abuse coordinator. The Administrator stated R #16 passed during the night on [DATE] at 10:56 PM. The Administrator said RN #1 told NA #1 to go check vitals on R #16 who had already passed. The Administrator said RN #1 used the passing of R #16 as a teaching opportunity to teach NA #1 what to do when someone passes away. The Administrator further stated she was not told what happened to NA #1 was a joke/prank and she did not report the incident to the state because she thought it was a staff thing. The Administrator stated she received an email from [Name of NA #1's] family member [on 01/0925] informing her that NA #1 was sent to R #16's room after she had passed away, was a joke and only after she received the email did she initiate an investigation [[DATE]]. The Administrator investigated the incident as the facility not performing proper postmortem care because the emailed mentioned that when NA #1 entered the room to take vitals, she noticed that R #16's dentures were free floating in her mouth. The Administrator further stated that RN #1 was not suspended because he was scheduled to be off the days following the incident (RN #1 was still working in the facility until [DATE]. See plan of removal.) RN #1 received a written reprimand for sending NA # 1, to get vitals on a deceased resident (R #16). The Administrator did not document any reprimand for disrespecting a deceased resident. During the interview, the Administrator reported that she did not believe that there was any effect to R #16 because she was already deceased when it happened. The Administrator confirmed that there was not any education for RN #1 or other staff regarding respecting deceased residents.
F. Record review of the facility's self report dated [DATE] identified Care concerns have been reported for this resident [R #16]. Investigation started.
G. Record review of the follow-up report dated [DATE] revealed On [DATE] an email was sent to [Corporate name] legal department about allegations of possible mistreatment of a resident after she passed. The lady writing the email claimed to be the mother of one of our nursing assistants and this lady made accusations that her daughter told her that the residents dentures didn't look quite right when she was sent in the room by her charge nurse. Her daughter worked here as a nursing assistant and was working that AM shift after [Name of R #16] had passed away. An investigation was started and the NOC (night) shift were interviewed about the post mortem care done for [Name of R #16] after she passed away on the NOC shift. The nurse on shift and the CNA on shift both stated they did the care together and [Name of R #16]'s dentures were removed during this care and placed in a denture cup to be sent to the mortuary with her. An AM shift CNA that helped the mortuary staff transfer her to their gurney supported their statement and said she gave the mortuary staff her dentures that had been sitting on the bedside table. Future Preventative Actions included Spot checks performed by the charge nurses to ensure the CNA's are performing proper postmortem care. No additional evidence was provided to include acknowledgement of the prank, any reprimand to the staff member who initiated the prank or any staff education to staff involved or aware of the incident related to mistreatment of the resident.
H. Record review of the individual performance improvement plan date [DATE] revealed that the policy violation was RN #1 should not have told NA #1 to do vitals on a dead resident. It states that NA #1 could not handle it and that some people cannot handle, especially a young person that has not dealt with death before. The expected result was to not do it again. The developmental process was that death is a serious thing for people to deal with and it's not something that comes naturally. The measurement of expected results were that this will not happen again. Target date for the improvement was immediately.
I. Record review of the Abuse Prohibition Policy dated [DATE], revealed the following:
1. Suspected abuse will be reported to immediately.
2. The employee alleged to have committed the act of abuse will be immediately removed from duty, pending investigation.
J. On [DATE], three attempts were made to contact RN #1 for an interview. RN #1 did not answer, voicemails were left, and RN #1 did not return any of the calls.
The above findings resulted in an Immediate Jeopardy that was called on [DATE] at 4:55 PM.
The facility submitted a final plan of removal on [DATE] at 4:45 PM and the IJ was lifted, implementation was verified onsite. Training was reviewed, staff were interviewed and policy verified. Abuse Prohibition Policy was obtained and reviewed. Scope and Severity was reduced to level 2, D.
Plan of Removal .The following identification/corrections will be completed by [DATE]:
-The Administrator and DON were re-educated on [DATE] through [DATE] by the Market level staff, including the Market President special projects, Market Operation Advisor, Market Clinical Advisor, The training was on the policy and procedures for resident abuse and neglect with an emphasis on allegations of abuse being identified, immediate interventions put in place to prevent reoccurrence, immediately reporting to the appropriate state agencies, thorough investigation, and resident rights.
-A full investigation occurred within the facility to ensure no other residents have been mistreated or have felt they were treated undignified was completed by [DATE]. Residents that are alert and able to answer questions were asked if they felt they had been treated in an undignified manner. The residents that are unable to answer appropriately or fully, their families/POA's (Power of Attorney the authority to act for another person in specified or all legal or financial matters) or guardians were called and asked the same question. If any further mistreatment or undignified treatment is identified, the facility will remove any resident from the situation, and proper monitoring and interventions will be initiated immediately upon notification. No new allegations were identified or alleged during the interview process.
-If any staff are identified in an allegation of abuse, neglect, undignified behavior or mistreatment, the staff member will be removed from the situation to ensure resident safety and dignity, and the staff member will immediately be placed on administrative leave until the investigation is completed.
-On [DATE] the identified RN of concern was placed on administrative leave pending the investigation. The RN's last scheduled work day in the facility was on [DATE] and on [DATE] RN was placed on Admin leave. Should the RN be allowed to return to work following the investigation; additional retraining will be offered by the Administrator and DON along with New Mexico Market level clinical leads under the guidance of corporate legal/risk/compliance staff on ensuring resident dignity and treating co-workers with respect and with a monitoring plan in place to ensure this does not recur.
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
Administration
(Tag F0835)
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 have an effective administration that maintained the highest practi...
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**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on record review and interview, the facility failed to have an effective administration that maintained the highest practicable well-being of residents for 1 (R #16) of 3 (R #1, R #16, and R #17) residents reviewed when the administration failed to recognize the mistreatment, dehumanization (the process of depriving a person or group of positive human qualities) and disrespect to R #16 when she was used by staff to prank another staff member after she was deceased . If the administration is unable to adequately identifying the mistreatment of residents, even of deceased residents still under the care of the facility and establish a standard of practice by implementing adequate corrective action when failures are identified, then residents remain at risk of serious adverse outcomes. The findings are:
Cross reference findings from F550 and F610
A. On [DATE] at 4:36 PM, during an interview, NA #1 stated she got to work on [DATE] at 6:00 am. NA #1 said that she noticed R #16's door was closed, and the door being closed was unusual. NA #1 said that at 6:30 AM, RN #1 asked her to take R #16's vital signs. NA #1 stated when she went into R #16's room, the room was cold. NA #1 said R #16 would usually respond to her right away when entering the room. NA #1 said R #16's dentures did not seem to be sitting right in her mouth. NA #1 further stated R #16 did not respond to her, she nudged R #16 and noticed at that time she was cold. NA #1 stated she realized R #16 had passed, so she left the room to let staff know and RN #1 was standing outside the room laughing. NA #1 stated RN #1 said it was a cruel rookie joke that he was playing and RN #1 told NA #1 not to say anything because he wanted to play the joke on another staff. NA #1 said that she was so distraught that emergency medical services had to be called to check her out because she was having a panic attack.
B. Record review of a written statement dated [DATE], from CMA #1 revealed there was another staff member that was going to be asked to take vital signs on the deceased resident as a friendly joke but that staff member did not report to work. CMA #1 wrote NA #1 was the one sent into the room [to be pranked].
C. On [DATE] at 12:07 PM, during an interview, the Administrator said she is the Abuse Coordinator and she is the one that took the lead on the investigation of R #16 not the DON. The Administrator said R #16 passed away during the night on [DATE] at 10:56 am, and she was not at the facility. The Administrator said the morning after R #16 passed away, she was told that RN #1 told NA #1 to go check vital signs on R #16. The Administrator said she was not told checking the vitals was a joke that was being played on NA #1. The Administrator said RN #1 used the passing of R #16 as a teaching opportunity to teach NA #1 what to do when a resident passes. The Administrator said when she arrived to the facility on [DATE], NA #1 was passing trays. The Administrator said NA #1 became upset and started breathing heavy and NA #1 said she had a rough morning. The Administrator said they called an ambulance to come check NA #1. The Administrator said NA #1 ended up going home for the day. The Administrator said she did not submit a report to the state because she thought it was a staff thing. The Administrator stated she received an email from [Name of NA #1's] family member informing her that NA #1 was sent to R #16's room after she had passed away, was a joke and only after she received the email did she initiate an investigation [[DATE]]. The Administrator said NA #1 was not interviewed because she did not return the phone calls. The Administrator said RN #1 was not suspended because he was already scheduled to be off the days following the incident on [DATE] (RN #1 was still working in the facility until [DATE]. See plan of removal.) The Administrator said RN #1 received a written reprimand and was told not to do anything like that again without running it by herself or the DON. The Administrator said that RN #1 should not have told NA #1 to do vitals on a dead resident because NA #1 was young and could not handle it. The Administrator confirmed that the incident involving R #16 was not reported to the state as a staff to resident incident because she did not understand how this incident would have affected R #16 because she was already deceased . The Administrator confirmed that there was not any education or correction provided for RN #1 or other staff regarding respecting deceased residents. The Administrator never acknowledged that the prank was inappropriate.
D. Record review of a written statement, no date (the Administrator did not date her statement), from the Administrator [detailing the events as she recalled them. The statement was made as part of the facility's investigation.], revealed NA #1 told her a joke had been played on her when RN #1 sent her into the resident's room do vitals on a dead lady.
E. Record review of the facility's investigation report dated [DATE], revealed no written statement from the DON. The Administrator did not document DON's involvement in the investigation or the incident or as it related to the oversight of RN #1 and other nursing staff involved.
F. Record review of the individual performance improvement plan for RN #1 dated [DATE], revealed RN #1 was given a written reprimand for sending NA #1 to get vitals on a deceased resident [due to NA #1 being inexperienced]. The Administrator did not document any reprimand related to the mistreatment of a deceased resident.
G. On [DATE], three attempts were made to contact RN #1 for an interview. RN #1 did not answer, voicemails were left, and RN #1 did not return any of the calls.
The above findings resulted in an Immediate Jeopardy that was called on [DATE] at 4:55 PM
The facility submitted a final plan of removal on [DATE] at 4:45 PM and the IJ was lifted, implementation was verified onsite. Training was reviewed, staff were interviewed and policy verified. Scope and severity was reduced to level 2, D.
Plan of Removal .The following identification/corrections will be completed by [DATE]:
-The Administrator and DON were re-educated on [DATE] - [DATE] on numerous calls by the Market level staff, including the Market President special projects, Market Operation Advisor, Market Clinical Advisor, on the policy and procedures on Resident abuse and neglect with emphasis on dignity, respect and mistreatment, allegations of abuse being identified, immediate intervention put in place to prevent reoccurrence, immediate reporting to the appropriate state agencies and thorough investigation and resident rights.
-The Market Operations Advisor and Market Clinical Advisor will have oversight of the Administration of the facility effective immediately. Current Administrator and Director of Nursing to be placed on administrative leave pending additional retraining by New Mexico Market level and facility National legal/risk staff on thorough investigations, federal definitions of abuse/neglect and facility policy. All aspects of all investigations will be reviewed by the Market Ops Advisor and/or Market Clinical Advisor, and reviewed to ensure the investigation is complete and thorough.
-The Senior Operation resource lead and the Market Clinical resource lead will monitor and run the operational and clinical affairs of the facility to ensure quality care is provided to the residents at the facility. The Senior Operation resource lead also will assume the role of the facility abuse coordinator and will receive reports on all alleged abuse/neglect concerns.
-A full investigative audit occurred within the facility from [DATE] through [DATE] to ensure no other current residents have been mistreated or have felt they were treated undignified. Residents that are alert and able to answer questions were asked if they felt they have been treated undignified and for the residents not able to answer, their families/POA's (Power of Attorney the authority to act for another person in specified or all legal or financial matters) /guardians were called and asked the same question. and if any further mistreatment or undignified treatment comes forward, the facility will remove any resident from the situation, and proper monitoring and interventions will be initiated immediately upon notification. No new allegations of abuse have been provided.
-If any staff are identified in an allegation of abuse, neglect, undignified behavior or mistreatment, the staff member will be removed from the situation to ensure resident safety and dignity, and the staff member will immediately be placed on administrative leave pending the investigation completion.
-On [DATE] the identified RN of concern was placed on administrative leave pending the investigation. The RN's last scheduled day of work was [DATE].
SERIOUS
(G)
📢 Someone Reported This
A family member, employee, or ombudsman was alarmed enough to file a formal complaint
Actual Harm - a resident was hurt due to facility failures
Resident Rights
(Tag F0550)
A resident was harmed · 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 residents had a right to a dignified existence and were trea...
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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 had a right to a dignified existence and were treated with respect and dignity for 1 (R #16) of 3 (R #1, R #16, and R #17) residents when facility staff used R #16 (without consent) to play a prank/joke on another staff member after R #16 was deceased . This deficient practice was disrespectful and dehumanizing to R #16 and her family. The findings are:
A. Record review the admission record revealed R #16 was initially admitted on [DATE].
B. Record review of Physician Orders revealed that R #16 was full code (medical term indicating patient wishes to receive all possible life saving measures in the event of a medical emergency).
C. Record review of R #16's progress notes dated [DATE] revealed:
1. 2205 (10:05 pm) resident assessed during hourly rounds. Semifowler (position of laying in bed on back with head and torso raised between 30-45 degrees) in bed, room in good order no issues whatsoever resident unresponsive to when called out attempting to arouse. Assess results radial pulse weak thready faintly palpable (to be felt). Visible respiration inadequate to sustain life due to rate of 4 -8 per minute. Code blue initiated. Code blue called out, crash cart obtained, 911 call for assistance from emergency response teams. CPR (cardiopulmonary resuscitation) protocol breaths and chest compression provided 2208 (10:08 pm). 2211(10:11 pm) patient assessment resulting in no detectable heart beat, respirations, CPR resumption at which time ems entered room and immediately deployed team in rendering/continuing care. At this time care center employees and this nurse removed ourselves from that role.
2. Progress note identified notification to next of kin (Son #1) and he indicated that he would need to contact Son #2 to get funeral information. Per progress note dated [DATE] at 5:44 am, still waiting on funeral information.
D. On [DATE] at 4:36 PM, during an interview, NA #1 said she arrived at work on [DATE] at 6:00 AM and at 6:30 AM, RN #1 asked her to go take R #16's vital signs (measurements of the body's essential functions). NA #1 said when she went into R #16's room and usually R #16 would respond to her right away when entering her room but this time she did not. NA #1 said R #16's dentures did not seem to be sitting right in her mouth and R #16 did not respond to her. NA #1 stated she nudged R #16 and noticed she was cold. NA #1 said she realized R #16 had passed away. NA #1 said she thought R #16 had just passed away, so she left the room to let staff know, and RN #1 was standing outside R #16's room laughing. RN #1 stated that it was a cruel rookie joke that he was playing on her. RN #1 told NA #1 not to say anything because he wanted to play the same joke on another staff. NA #1 said that she was so distraught after the incident that eventually emergency medical services had to be called because she was having a panic attack.
E. On [DATE] at 6:57 PM, during an interview, CNA #1 stated R #16 passed away on [DATE] at 10:56 PM. CNA #1 said RN #1 wanted to play a joke on NA #1 (RN #1 is the night shift manager on the unit). CNA #1 said that when NA #1 got to work on [DATE], RN #1 told NA #1 to go take R #16's vital, knowing that R #16 was deceased . CNA #1 confirmed that she did not try to prevent the prank.
F. On [DATE] at 7:16 PM, during an interview, NA #2 said that R #16 had passed away and RN #1 wanted to play a joke on staff. NA #2 said when NA #1 got to work around 6:00 am on [DATE], she heard RN #1 ask NA #1 to go take R #16's vital signs. NA #2 said the joke was supposed to be played on another coworker too, but that the other coworker did not report to work.
G. On [DATE] at 12:01 PM, during an interview, Unit Manager (UM) #1 said she arrived at work on [DATE] at 6:00 am. UM #1 said she did not witness the prank that was played on NA #1, but was told about the joke after it happened. UM #1 did not remember who told her. UM #1 said she did not know whose idea it was to play the joke. UM #1 said she was told that someone was told to take vitals on a resident that was deceased .
H. On [DATE] at 12:07 PM, during an interview, the Administrator said R #16 passed away during the night. The Administrator said that the morning ([DATE]) after R #16 passed, RN #1 told NA #1 to go check vitals on a resident that had already passed. The Administrator said RN #1 wanted to use the passing of R #16 as a teaching opportunity to see what NA #1 would do if a resident passed away. The Administrator said that she was not told that it was meant to be a joke. The Administrator said that she received an email from NA #1's family member later on [received on [DATE]] informing her of what was done to NA #1 was a joke. During the interview, the Administrator reported that she did not believe that there was any effect to R #16 because she was already deceased when it happened.
I. Record review of CMA #1's written statement dated [DATE], revealed NA #1 was asked to take R #16's vitals and R #16 had already passed away and checking the vital signs was as a friendly joke.
J. Record review of SSD's written statement dated [DATE], revealed NA #1 told her that she was asked to get R #16's vitals, and R #16 was already dead. SSD said that NA #1 stated she was freaked out really bad by what had happened.
K. On [DATE], three attempts were made to contact RN #1 for an interview. RN #1 did not answer, voicemails were left, and RN #1 did not return any of the calls.
L. On [DATE] at 4:13 PM, during an interview with R #16's son (Son #2), he said that R #16 would have been horrified that a staff member was sent into her room after she had passed away to check her vitals as a prank. Son #2 said it was disgusting that they [staff] did that to his mother.
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
Transfer Notice
(Tag F0623)
Could have caused harm · This affected multiple residents
Based on record review and interview, the facility failed to ensure residents, their representatives, and the Ombudsman received a written notice of transfer as soon as practicable for 4 (R #8, R #9, ...
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Based on record review and interview, the facility failed to ensure residents, their representatives, and the Ombudsman received a written notice of transfer as soon as practicable for 4 (R #8, R #9, R #11 and R #13) of 4 (R #8, R #9, R #11 and R #13) residents reviewed for hospitalization. This deficient practice could likely result in the resident and/or their representative not knowing the reason or location the resident was discharged . The findings are:
R #8
A. Record review of R #8's medical record revealed the following:
1. On 12/07/24, the facility transferred R #8 to the hospital for a fall.
2. On 12/08/24, the facility transferred R #8 to the hospital for evaluation of abdominal wound and fever
3. The record did not contain any written transfer notices.
R #9
B. Record review of R #9's medical record revealed the following:
1. On 12/09/24, R #9 was sent to the hospital for abnormal lab results.
2. The record did not contain a written transfer notice.
R #11
C. Record review of R #11's medical record revealed the following:
1. On 12/22/24, R #11 was sent to the hospital for fall.
2. The record did not contain a written transfer notice.
R #13
D. Record review of R #13's medical record revealed the following:
1. On 09/14/24, R #13 was sent to the hospital for altered mental status.
2. The record did not contain a written transfer notices.
E. On 01/08/25 at 2:55 PM, during an interview, the DON confirmed R #8, R #9, R #11, and R #13 did not have any transfer notices. The DON said that transfer notices should be done at the time of transfer or as soon as practicable.
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 F0625
(Tag F0625)
Could have caused harm · This affected multiple residents
Based on record review and interview, the facility failed to ensure residents or their representatives received a written notice of the bed hold policy which indicated the duration the bed would be he...
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Based on record review and interview, the facility failed to ensure residents or their representatives received a written notice of the bed hold policy which indicated the duration the bed would be held for 4 (R #8, R #9, R #11 and R #13) of 4 (R #8, R #9, R #11 and R #13) residents reviewed for hospitalization. This deficient practice could likely result in the resident and/or their representative being unaware of the bed hold policy upon return from the hospital. The findings are:
R #8
A. Record review of R #8's medical record revealed the following:
1. On 12/07/24, the facility transferred R #8 to the hospital for a fall.
2. On 12/08/24, the facility transferred R #8 to the hospital for evaluation of abdominal wound and fever.
3. R #8's record did not contain a written notices of the bed hold notice.
R #9
B. Record review of R #9's medical record revealed the following:
1. On 12/09/24, R #9 was sent to the hospital for abnormal lab results.
2. R #9's record did not contain a written notice of the bed hold notice.
R #11
C. Record review of R #11's medical record revealed the following:
1. On 12/22/24, R #11 was sent to the hospital for fall.
2. R #11's record did not contain a written notice of the bed hold notice.
R #13
D. Record review of R #13's medical record revealed the following:
1. On 09/14/24, R #13 was sent to the hospital for a change in mental status.
2. R #13's record did not contain a written notice of the bed hold notice.
E. On 01/08/25 at 2:55 PM, during an interview, the DON confirmed that she did not see any bed holds for R #8, R #9, R #11, and R #13. The DON did not remember when the bed hold should be provided to the resident.
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 F0657
(Tag F0657)
Could have caused harm · This affected multiple residents
**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on record review and interview, the facility failed to ensure care plans were reviewed and revised for 3 (R #1, R #14 and ...
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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 care plans were reviewed and revised for 3 (R #1, R #14 and R #17) of 4 (R #1, R #2, R #14, and R #17) residents reviewed for care plans when they failed to revise the care plan with the most current resident information. This deficient practice could likely result in the care plan not being updated with the most current resident conditions and appropriate interventions, staff being unaware of changes in care provided, and residents not receiving the care related to changes in their health status or healthcare decisions. The findings are:
R #1
A. Record review of R #1's admission Record (no date) revealed the following:
1. R #1 was admitted to the facility on [DATE].
2. R #1 had a diagnosis of need for assistance with personal care (providing or assisting in performing daily living tasks and maintaining personal hygiene).
B. On 01/22/25 at 7:29 PM, during an interview, CNA #1 stated that R #1 sometimes refuses her showers.
C. Record review of R #1's care plan revised on 12/17/24 revealed:
1. R #1 had a history of refusing showers.
2. R #1's care plan did not include any interventions (actions taken by facility staff) on how staff is to assist or encourage R #1 when she refuses to shower.
R #14
D. Record review of R #14's admission Record revealed R #14 was admitted into the facility on [DATE]. R #14 is diagnosed with type 2 diabetes mellitus without complications.
E. Record review of R #14's progress note dated 01/10/25 revealed R #14 continued to refuse blood glucose checks and insulin. R #14 stated I'm not diabetic, the hospital said so.
F. Record review of R #14's care plan dated 09/17/24, revealed the care plan did not contain any documentation of R #14 being noncompliant with her insulin. There are no interventions for R #14's refusals documented.
G. On 01/10/25 at 11:54 AM, during an interview, the DON said she was aware that R #14 is refusing blood glucose checks and insulin. The DON said R #14 believes she has been cured of diabetes. The DON confirmed R#14's noncompliance was not care planned and that there were no interventions for her noncompliance. The DON said R #14's care plan should document that she is refusing insulin and what should be done when R #14 refuses.
R #17
H. Record review of R #17's admission Record (no date) revealed the following:
1. R #17 was admitted into the facility on [DATE].
2. R #1 had a diagnosis of need for assistance with personal care.
I. On 01/22/25 at 2:22 PM, during an interview, NA #3 said R #17 does not like having his teeth brushed and refuses sometimes.
J. Record review of R #17's care plan dated 10/20/24, revealed the care plan did not contain any documentation of R #17 refusing assistance and any interventions on how staff will assist or encourage R #17 when he refuses having his teeth brushed.
K. On 01/22/25 at 3:11 PM, during an interview, the DON confirmed staff did not document that R #17 was not compliant with brushing his teeth on his care plan. The DON said that resident's refusals should be documented and that interventions should be care planned.
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, observation, and interview, the facility failed to provide activities of daily living (ADL; activities r...
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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 provide activities of daily living (ADL; activities related to personal care such as bathing, showering, dressing, walking, toileting, and eating) assistance for oral care, baths and showers for 3 (R #1, R #2, and R #17) of 3 (R #1, R #2, and R #17) residents reviewed for ADL care. This deficient practice is likely to affect the dignity and health of the residents. The findings are:
R#1
A. Record review of R #1's admission record revealed R #1 was admitted into the facility on [DATE].
B. Record review of R #1's MDS Quarterly Minimum Data Set (a federally mandated assessment instrument completed by facility staff) dated 12/13/24 indicated R #1 required substantial/maximal assistance (staff lifts or holds trunk or limbs and provides more than half the effort) for showers.
C. Record review of the facility's shower schedule revealed R #1 was scheduled for showers on Tuesdays and Fridays on the night shift.
D. On 01/22/25 at 11:35 am, during an interview with R #1's family member (FM), she stated she visited R #1 on 12/17/24 (Tuesday) and R #1 was supposed to be showered that day, but she was not showered. R #1's FM stated she was told R #1 would be showered on 12/18/24. FM returned on 12/18/24 and R #1 was not assisted with a bath or shower on that day either.
E. Record review of R #1's documentation survey report (ADL tracking form on electronic health record- EHR) dated 12/01/24 through 12/31/24 revealed:
1. R #1 was offered/given four (4) baths/showers out of nine (9) opportunities.
2. R #1 did not receive a shower from 12/01/24 until 12/13/24.
3. On 12/17/24 facility staff documented R #1's shower as not applicable.
4. Facility staff did not document why R #1 did not receive a shower on 12/18/24.
F. Record review of R #1's documentation survey report dated 01/01/25 through 01/31/25 revealed R #1 was offered/given four (4) baths/showers out of six (6) opportunities.
G. On 01/22/25 at 7:29 PM, during an interview, CNA #1 stated R #1 sometimes refuses her shower. CNA #1 stated R #1 was not offered another shower until her next scheduled shower day, but if she asks for a shower in between shower days then the CNA's will try to shower her.
R#2
H. Record review of R #2's admission record revealed R #2 was admitted into the facility on [DATE].
I. Record review of R #2's MDS Quarterly Minimum Data Set, dated [DATE] indicated R #2 was dependent (staff does all the effort to complete the task) on staff assistance for showers.
J. Record review of the facility's shower schedule revealed R #2 was scheduled for showers on Mondays and Thursdays on the night shift.
K. Record review of R #2's documentation survey report dated 12/01/24 through 12/31/24 revealed R #2 was offered/given three (3) baths/showers out of nine (9) opportunities.
L. Record review of R #2's documentation survey report dated 01/01/25 through 01/31/25 revealed R #1 was offered/given four (4) baths/showers out of six (6) opportunities.
M. On 01/22/25 at 7:20 PM, during an interview, CNA #1 stated R #2 was cooperative with her showers and does not refuse. CNA #1 did not say why R #2 was not being showered.
R #17
N. Record review of R #2's admission record revealed R #17 was admitted into the facility on [DATE].
O. Record review of R #17's MDS Quarterly Minimum Data Set, dated [DATE] indicated R #17 was dependent on staff assistance for showers.
P. Record review of the facility's shower schedule revealed R #17 was scheduled for showers on Wednesdays and Saturdays on the day shift.
Q. Record review of R #17's documentation survey report dated 12/01/24 through 12/31/24 revealed R #17 was offered/given one (1) baths/showers out of nine (9) opportunities.
R. Record review of R #17's documentation survey report dated 01/01/25 through 01/31/25 revealed R #17 was offered/given two (2) baths/showers out of six (6) opportunities.
S. On 01/22/25 at 4:13 PM, during an interview, the DON confirmed that documentation for R #17 received only one (1) bath/shower for the month of December 2024. The DON confirmed R #17's documentation showed R #17 received two (2) bath/showers for the month of January 2025. The DON said R #17 should get two (2) bath/showers a week according to the schedule. The DON said R #17 refuses showers.
T. On 01/22/25 at 2:00 PM, during an observation of R #17 and interview, R #17's breath smelled horrible. R #17 was shaved and his hair was cut short. R #17 said staff does not brush his teeth and he is not able to brush his own teeth. R #17 said he does get showers.
U. Record review of R #17's documentation survey report dated 12/01/24 through 12/31/24 for mouth care-cleaning of teeth/dentures/mouth revealed the following:
1. R #17's teeth were brushed two (2) times out of the 31 opportunities on the day shift.
2. R #17's teeth were brushed 25 times out of the 31 opportunities on the night shift.
V. Record review of R #17's documentation survey report dated 01/01/25 through 12/31/25 for mouth care-cleaning of teeth/dentures/mouth revealed the following:
1. R #17's teeth were brushed four (4) times out of the 31 opportunities on the day shift.
2. R #17's teeth were brushed 10 times out of the 31 opportunities on the night shift.
W. On 01/22/25 at 2:22 PM, during an interview, NA #3 said she brushes R #17's teeth for him when he asks. NA #3 said R #17 does not like his teeth to be brushed.
X. On 01/22/25 at 3:11 PM, during an interview, the DON said R #17 should get his teeth brushed two times a day. The DON confirmed the documentation revealed R #17 was not getting his teeth brushed regularly in the mornings and the night shift was more consistent at documenting that his teeth are being brushed.
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
Quality of Care
(Tag F0684)
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 that facility staff followed physician's order for 2 (R #1 a...
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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 that facility staff followed physician's order for 2 (R #1 and R #13) of 5 (R #1, R #2, R #8, R #11 and R #13) residents reviewed for quality of care. Failure to follow physician orders could likely lead to facility staff and physician being unaware of changes in resident condition and could likely lead to worsening of resident's condition. The findings are:
R #1
A. Record review of R #1's admission record (no date) revealed R #1 was admitted to the facility on [DATE].
B. Record review of R #1's physician orders revealed an order date 08/30/2024: Weight every day shift every seven (7) days, scheduled every Saturday for monitoring.
C. Record review of R #1's Nutritional assessment dated [DATE] revealed the following:
1. Weight gain would be beneficial given very low body mass index (BMI;a tool that healthcare providers use to estimate the amount of body fat by using height and weight measurements and helps assess risk factors for certain health conditions).
2. R #1 was underweight for age. R #1 weighed 83.2 pounds.
D. Record review of R #1's weights log dated 01/22/25 revealed the following:
1. October 2024, R #1 was only weighed twice out of four (4) opportunities.
2. November 2024, R #1 was only weighed twice out of five (5) opportunities.
3. December 2024, R #1 was only weighed once out of four (4) opportunities.
4. January 2025, R #1 was only weighed once out of three (3) opportunities.
E. On 01/23/25 at 12:16 PM, an interview, LPN #1 confirmed R #1 did have a physician's order in place to be weighed weekly and staff did not weigh R #1 weekly as ordered.
R #13
F. Record review of R #13's admission record, no date, revealed R #13 was admitted to the facility on [DATE].
G. Record review of the R #13's order summary, dated 02/29/24, revealed the following:
1. Humalog (insulin medication used to help lower blood sugar), inject three (3) units subcutaneously (beneath the skin) before meals, hold if blood glucose is less than 100.
2. Lantus (long acting insulin) inject 15 units subcutaneously in the morning. Call physician prior to administration if blood glucose is less than 90.
H. Record review of R #13's MAR dated 09/01/24 through 09/30/24 for Humalog revealed the following:
1. On 09/09/24 R #13's blood glucose was not documented.
2. On 09/01/24 R #13's blood glucose was not documented.
3. On 09/01/24 R #13's blood glucose was not documented.
4. On 09/02/24 before breakfast, R #13's blood glucose was 104 and humalog was not given.
5. On 09/02/24 before lunch, R #13's blood glucose was 129 and humalog was not given
6. On 09/04/24 before lunch, R #13's blood glucose was 120 and was humalog was not given
7. On 09/04/24 before dinner, R #13's blood glucose was 134 and humalog was was not given.
8. On 09/05/24 before breakfast, R #13's blood glucose was 101 and humalog was not given.
9. On 09/05/24 before lunch, R #13's blood glucose was 101 and humalog was not given.
10. On 09/05/24 before dinner, R #13's blood glucose was 188 and humalog was not given.
11. On 09/09/24 before lunch, R #13's blood glucose was 145 and humalog was not given.
12. On 09/13/24 before breakfast, R #13's blood glucose was 121 and humalog was not given.
13. On 09/05/24 before dinner, R #13's blood glucose was 134 and humalog was not given.
what was the reason for holding the medication?
I. Record review of R #13's MAR dated 09/01/24 through 09/30/24 for Lantus revealed the following:
1. On 09/07/24 R #13's blood glucose was 78, lantus was held.
2. On 09/09/24 R #13's blood glucose was 98 and lantus was not given.
3. On 09/10/24 R #13's blood glucose was 84, lantus was held.
4. The MAR did not contain any documentation that the physician was notified when the insulin was not given.
J. On 01/10/25 at 11:55 AM, during an interview, the DON stated R #13 was not always compliant with blood glucose checks and taking her insulin. The DON confirmed that the physician was not notified when R #13's insulin was being held or when R #13 was noncompliant. The DON said that if R #13 is refusing insulin, after three attempts, the physician should be notified and it should be documented in R #13's medical record that the provider was notified.
K. On 01/13/25 at 1:24 PM, during an interview, DR #1 confirmed that if R #13's humalog was being held when her blood glucose levels are above 100 that the order was not being followed. DR #1 confirmed R #16's lantus was being held when her blood glucose was above 90, the order was not being followed. DR #1 said he does not recall being notified when R #13's insulin was being held. DR #1 said that he does not know why the orders were not being followed.
Sept 2024
7 deficiencies
CONCERN
(D)
Potential for Harm - no one hurt, but risky conditions existed
Deficiency F0638
(Tag F0638)
Could have caused harm · This affected 1 resident
Based on interview, record review, and review of the Resident Assessment Instrument (RAI) Manual, the facility failed to ensure one (R #28) of 33 residents reviewed for Minimum Data Set (MDS) had a qu...
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Based on interview, record review, and review of the Resident Assessment Instrument (RAI) Manual, the facility failed to ensure one (R #28) of 33 residents reviewed for Minimum Data Set (MDS) had a quarterly assessment successfully transmitted and accepted within the allotted time frame.
Findings include:
Review of the October 2023 RAI Manual, page 2-35, showed: The Quarterly assessment is a .non-comprehensive assessment for a resident that must be completed at least every 92 days following the previous .assessment of any type. It is used to track a resident's status between comprehensive assessments to ensure critical indicators of gradual change in a resident's status are monitored. As such, not all MDS items appear on the Quarterly assessment. The ARD .must be not more than 92 days after the ARD of the most recent .assessment of any type.
Review of R28's admission Record, from the electronic medical record (EMR) under the Profile tab, showed a facility admission date of 01/11/20.
Review of R28's annual MDS, with an Assessment Reference Date (ARD) of 01/21/24, showed medical diagnoses that included hypertension and diabetes type II.
Review of R #28's EMR MDS tab indicated the 01/21/24 annual assessment with a status of Accepted. A quarterly MDS with an ARD of 04/22/24 had a status of Accepted. Further review of R #28's EMR MDS tab indicated the quarterly MDS assessment with a potential ARD of 07/23/24 was not completed.
During an interview on 09/17/24 at 12:30 PM, MDS Coordinator (MDSC) reviewed R #28's EMR MDS tab status for the 07/23/24 assessment and stated the MDS Assessments are on an Automatic schedule on the Point Click Care System. The MDS Coordinator further stated the MDS assessment for R#28 had not been completed and confirmed, the MDS quarterly assessment was past 120 days, and the quarterly assessment should have completed on 07/23/24.
CONCERN
(D)
Potential for Harm - no one hurt, but risky conditions existed
MDS Data Transmission
(Tag F0640)
Could have caused harm · This affected 1 resident
Based on interview, record review, and review of the Resident Assessment Instrument (RAI) Manual, the facility failed to ensure one (R #28) of 33 sampled residents reviewed for Minimum Data Set (MDS) ...
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Based on interview, record review, and review of the Resident Assessment Instrument (RAI) Manual, the facility failed to ensure one (R #28) of 33 sampled residents reviewed for Minimum Data Set (MDS) assessment had a quarterly assessment successfully transmitted and accepted within the allotted time frame.
Findings include:
Review of the October 2023 RAI Manual, page 2-35, showed: The Quarterly assessment is an .non-comprehensive assessment for a resident that must be completed at least every 92 days following the previous .assessment of any type. It is used to track a resident's status between comprehensive assessments to ensure critical indicators of gradual change in a resident's status are monitored. As such, not all MDS items appear on the Quarterly assessment. The ARD .must be not more than 92 days after the ARD of the most recent .assessment of any type.
Review of R28's admission Record, from the electronic medical record (EMR) under the Profile tab, showed a facility admission date of 01/11/20.
Review of R28's annual MDS, with an Assessment Reference Date (ARD) of 01/21/24, showed medical diagnoses that included hypertension and diabetes type II.
Review of R28's EMR MDS tab indicated the 01/21/24 annual assessment with a status of Accepted. A quarterly MDS with an ARD of 04/22/24 had a status of Accepted. Further review of the EMR MDS tab indicated the quarterly MDS assessment with a potential ARD of 07/23/24 was not completed.
During an interview on 09/17/24 at 12:30 PM, MDS Coordinator (MDSC) reviewed R28's EMR MDS tab status for the 07/23/24 assessment and stated the MDS Assessments are on an Automatic schedule on the Point Click Care System. The MDS Coordinator further stated the MDS assessment for R28 was not completed and confirmed the MDS quarterly assessment was 120 days past due, and the quarterly assessment should have completed on 07/23/24.
CONCERN
(D)
Potential for Harm - no one hurt, but risky conditions existed
Deficiency F0645
(Tag F0645)
Could have caused harm · This affected 1 resident
Based on interview and record review, the facility failed to ensure an accurate Level 1 Pre-admission Screening and Resident Review (PASARR) was completed after a new diagnosis for one of one sampled ...
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Based on interview and record review, the facility failed to ensure an accurate Level 1 Pre-admission Screening and Resident Review (PASARR) was completed after a new diagnosis for one of one sampled resident (R21) reviewed for PASARR.
Findings include:
Review of R21's admission Record, from the electronic medical record (EMR) under the Profile tab, indicated a facility admission date of 02/06/24, re-admission date of 07/19/24 for R21, and included diagnoses of anxiety, bipolar disorder, and major depressive disorder.
Review of R21's PASARR Level 1 Screening Form, dated 02/06/24, revealed R21's diagnosis of anxiety was included on the screening. There were no recommendations related to the diagnosis.
Review of R21's Diagnosis Record, from the electronic medical record (EMR) under the Diagnosis tab, indicated R21 had a diagnosis of bipolar disorder, unspecified dated 02/06/24, major depressive disorder recurrent moderate, dated 02/6/24, and anxiety disorder dated 02/06/24.
On 09/18/24 at 11:55 AM during an interview , the Admissions Coordinator stated she was unaware the resident's diagnosis had changed and the bipolar diagnosis major depressive disorder had been added as a diagnosis. The Admissions Coordinator further stated the Director of Nurses (DON) will alert her during their morning meeting if a residents diagnosis changes and if a PASSRR needs to be completed.
On 09/18/24 at 1:15 PM during an interview with the Admission's Coordinator and telephone conversation with the New Mexico PASSRR personnel, the Admissions Coordinator was informed that a PASSR Level 1 re-screening should have been completed with the addition of the bipolar and major depressive disorder. The Admissions Coordinator confirmed the facility should of completed a PASSR level 1 after the residents diagnosis of bipolar disorder and major depressive disorder had been added as a diagnosis.
CONCERN
(D)
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, interview, and policy review, the facility failed to revise the care plan (CP) of one resident out of si...
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**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on record review, interview, and policy review, the facility failed to revise the care plan (CP) of one resident out of six residents (R8) reviewed for accidents/falls out of a total sample of 29 residents. This failure to revise the care plan of R8 by implementing interventions to prevent future falls has the potential to lead to serious adverse consequences.
Findings include:
Review of R8's Census tab located in the electronic medical record (EMR) revealed R8 was originally admitted on [DATE].
Review of R8's Medical Diagnoses tab located in the EMR revealed R8 had diagnoses including dementia, weakness, and unsteadiness on feet.
Review of R8's quarterly Minimum Data Set (MDS) with an assessment reference date (ARD) of 92/24/24 and located in the EMR revealed R8 had a Brief Interview for Mental Status (BIMS) score of nine out of 15 indicating a moderate cognitive decline and no falls since admission in Section J. Review of the quarterly MDS with an ARD of 05/26/24 revealed R8 had a BIMS score of six out of 15 indicating a severe cognitive decline and one fall since admission in Section J.
Review of R8's note located under the Progress Note tab in the EMR revealed R8 was found on the floor by his bed on 05/05/24.
Review of R8's Fall incident report, dated 05/05/24 and supplied by the Administrator, revealed R8 was found on the floor by his bed on 05/05/24. The immediate action taken by the facility was to care for the resident and await transport to the hospital for evaluation. The predisposing environmental, physiological, and situation factors were considered and indicated in the investigation. Aside from the immediate actions taken and predisposing factors investigated, no preventative interventions are indicated in the investigation or on the form.
Review of the facility's Complaint Narrative Investigation Report (5 day), completed 05/05/24 and supplied by the Administrator, revealed the facility placed a mattress at R8's bedside, initiated frequent checks on R8 by the staff, and neuro checks were initiated after his fall. There was no indication of interventions to implement, or other preventative measures indicated on the form.
Review of R8's Progress Note, located under the Prog Note tab located in the EMR, revealed R8 was involved in an unwitnessed fall from his wheelchair in the dining room on 05/16/24. The note stated a confused resident both assisted R8 back to his wheelchair and alerted the staff to the fall.
Review of R8's incident report, dated 05/16/24 and provided by the Administrator, revealed R8 was involved in an unwitnessed fall from his wheelchair. The immediate action taken by the facility was to assess R8 and initiate neuro checks. The predisposing physiological and situation factors were considered and indicated in the investigation. Aside from the immediate actions taken and predisposing factors investigated, no preventative interventions are indicated in the investigation or on the form.
Review of R8's Fall incident report, dated 05/16/24 and provided by the Administrator revealed R8 was observed walking through a doorway and falling to his knee. Immediate actions taken including assessing R8 and notifying the responsible parties. The predisposing physiological, including previous falls, and situation factors were considered and indicated in the investigation. Aside from the immediate actions taken and predisposing factors investigated, no preventative interventions are indicated in the investigation or on the form.
Review of R8's progress note located under the Prog Note tab located in the EMR revealed R8 was walking through a resident's door and fell to his knee on 07/12/24.
Review of R8's Initial Incident Report, dated 07/13/24 and provided by the Administrator, revealed R8 later complained of knee pain and was sent to the hospital for evaluation. There were no preventative interventions indicated in the investigation or on the form.
Review of R8's Care Plan located in the EMR revealed R8 had Focus(es) related to falls initiated on 08/09/22 with interventions including observing for changes in mental status and for Social Services to provide support as needed. The Focus was updated to include the falls on 05/05/24 and 07/12/24 with no corresponding interventions listed.
In an interview on 09/19/24 at 8:15 AM the Director of Nursing (DON) verified R8 had not had a care plan update related to fall interventions since August 2022. The DON stated after R8's fall on 05/05/24 the staff began using a fall mat while R8 was in bed. The DON was not sure why the care plan had not been updated after each fall but verified that it had not been updated. She stated the process is to update care plans with new interventions when needed.
An observation and interview on 09/19/24 at 10:15 AM revealed R8 sitting with other residents in the day-area. R8 was wearing his knee brace on his left knee and showed no signs or symptoms of distress or discomfort. Certified Nursing Assistant (CNA) 1 stated R8 walks when he wants to, but the staff try to get him to use a wheelchair for safety and the staff use a fall mat by R8's bed while he is in it. There was no observation that the floor mat was in place.
Review of the facility's Falls Management policy, revised 03/15/24 and provided by the Administrator revealed, Interventions to reduce risk and minimize injury will be implemented as appropriate. The policy continued the staff would .adjust and document individualized intervention strategies as patient condition changes.
Review of the facility's Accidents/Incidents policy, revised 03/01/24 and provided by the Administrator, revealed the licensed nurse will Implement appropriate interventions based on conclusions of an incident or accident.
Review of the facility's Care Plan Clinical System Process, version 06/2024 and provided by the DON revealed, Ongoing evaluations and revisions will be documented as they occur utilizing the care plan progress note and or the Care plan Evaluation note.
CONCERN
(D)
Potential for Harm - no one hurt, but risky conditions existed
Respiratory Care
(Tag F0695)
Could have caused harm · This affected 1 resident
**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, interview, record review, and facility policy review, the facility failed to ensure the oxygen (O2) concen...
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**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, interview, record review, and facility policy review, the facility failed to ensure the oxygen (O2) concentrators had dust free filters on the inlet where the air came into the machine for two of three residents (R29 and R43) of 25 sample residents. This deficient practice had the potential to allow an increased chance of infection and unnecessary respiratory treatment.
Findings include:
Review of the facility policy titled Respiratory Equipment/Supply Cleaning/Disinfecting revised 07/15/21 revealed, . In addition to surface cleaning and disinfecting, perform the following.Oxygen Concentrators: Rinse and dry the external filter weekly and PRN [as needed] when visibly dusty.
1. Review of R29's undated admission Record, located in the electronic medical record (EMR) under the Profile tab, revealed an admission date of 03/29/19, a readmission date of 04/09/24, and indicated a diagnosis of heart failure.
Review of R29's Physician Orders, dated 04/10/24 and located in R29's EMR under the Orders tab, indicated Oxygen at 2 L/min [at 2 liters per minute] via nasal cannula continuously.
Review of R29's Care Plan, revised on 04/24/24 and located in R29's EMR under the Care Plan tab, indicated [R29] is at risk for respiratory complications related to CHF [congestive heart failure]. O2 as ordered via nasal cannula.
During an observation on 09/16/24 at 11:11 AM, R29's oxygen concentrator was located in R29's room and was observed to have a black oxygen filter on the back of the concentrator. It was observed to be full of a buildup of heavy debris and was observed to be very dirty.
During an observation on 09/18/24 at 9:23 AM, R29's oxygen concentrator filter was again observed to have a very thick buildup of debris on the filter.
During observations and interview on 09/19/24 at 10:30 AM, the Unit Manager (UM) and the Director of Nursing (DON) were shown the filter on R29's concentrator. Both agreed it should not look like that. They were asked who would be responsible for cleaning the filters. The DON stated it was a duty of the certified nursing aides and it should be done when they change out the tubing. The UM stated I think it is on the TAR for the nurses to do it. The DON stated, Yes, it is the duty of the nurse, and it should be done weekly.
2. Review of R43's undated admission Record located in the electronic medical record (EMR) under the Profile tab, revealed an admission date of 05/21/24 and a readmission date of 08/12/24 and indicated diagnoses of chronic obstructive pulmonary disease (COPD) and shortness of breath.
Review of R43's Physician Orders, dated 08/12/24 and located in R43's EMR under the Orders tab, indicated Oxygen at 0-2 L/min [at 2 liters per minute] via Nasal Cannula as needed for sats [a measure of the amount of oxygen in the blood] less than 88% on RA [room air].
Review of R43's Care Plan, revised on 06/05/24 and located in R43's EMR under the Care Plan tab, indicated [R43] is at risk for respiratory complications related to COPD and heart failure. O2 as ordered via nasal cannula.
During an observation on 09/16/24 at 10:39 AM, R43's oxygen concentrator was located in R43's room and was observed to have a black oxygen filter on both sides of the concentrator. It was observed to be full of a buildup of heavy debris and was observed to be very dirty.
During an observation on 09/18/24 at 11:13 AM, R43's oxygen concentrator located in R43's room and was observed to have a black oxygen filter on both sides of the concentrator. It was observed to be full of a buildup of heavy debris and was observed to be very dirty.
During an interview on 09/19/24 at 3:00 PM, the DON was asked if she felt the filters on R43's concentrator was appropriate. The DON stated, No, they needed to be cleaned.
CONCERN
(F)
Potential for Harm - no one hurt, but risky conditions existed
Food Safety
(Tag F0812)
Could have caused harm · This affected most or all residents
Based on observation, interview, and facility policy review, the facility failed to ensure food items were dated when initially opened, failed to ensure staff wore beard covers or hair nets while in t...
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Based on observation, interview, and facility policy review, the facility failed to ensure food items were dated when initially opened, failed to ensure staff wore beard covers or hair nets while in the kitchen, and failed to ensure staff performed handwashing between glove use. These failures had the potential to affect 56 residents who consumed food prepared by the facility's kitchen.
Findings include:
Review of the facility's policy titled, Food Handling revised 06/15/18 revealed, .Once a product has been prepared or portioned, a new use by date is established.
Review of the policy titled, Staff Attire revised 10/20/23 revealed, Policy: All employees wear approved attire for the performance of their duties. Procedures, 1. All staff will have their hair off the shoulders, confined in a hair net or cap, and facial hair properly restrained .
Review of the facility policy titled, Hand Washing revised 10/01/19 revealed, Critical Elements.8. Uses clean, dry paper towel or air dryer to dry surfaces of fingers and hands. 9. Uses clean, dry paper towel to turn off faucet, without contaminating hands.
Review of the undated facility policy titled, Glove Usage revealed, Purpose: To educate all new hires and current employees on the safety and procedure of proper glove usage. Proper Glove Usage, Gloves are not meant to be used as a replacement for handwashing. They are only effective if proper handwashing is completed.When to change or remove your gloves. Before taking ONE Step away from your work area. When changing tasks, Prior to leaving kitchen. Remember to always wash your hands in between glove changes.
During the initial tour of the kitchen on 09/16/24 at 9:20 AM, a gallon jug of milk was in the refrigerator and had been open with no open date on the jug. During an interview, the District Dietary Manager (DS)4 was asked if an open date should be on the milk jug when it was opened and placed back in the refrigerator. DS4 stated, Yes.
Further observations during the initial tour on 09/16/24 at 9:25 AM, revealed Dietary Staff (DS)3 was observed to be making burritos. DS3 had facial hair with no cover. DS3 was asked if he should be wearing a cover over his beard. DS3 left the work area with gloves on and went over to get a beard cover. DS4 was asked if DS3 should have been wearing a beard cover. DS4 stated, Yes.
During an observation on 09/19/24 at 7:25 AM, the following observations were observed:
DS1 was observed to be wearing gloves at the steam table setting up plates. DS1 left the steam table and went to get a pan off the rack and a can of cooking spray. She placed the items on the stove. DS1 returned to the steam table and set up additional plates and then began to place scrambled eggs on the plates touching the eggs to keep them on the plates. DS1 placed her gloved fingers in the scoop to pull out the scrambled eggs. DS1 served five plates this way. She picked up five slices of raisin toast with the same gloved hands and sliced the toast in half and placed them on the same five plates. DS1 failed to change gloves as well as perform hand hygiene during the tasks.
During an observation on 09/19/24 at 7:30 AM, the Dietary Manager (DM) was observed to wash his hands up to his elbows. The DM rinsed off the soap and turned the faucet off with his elbows and then retrieved a paper towel and dried his hands. He then picked up the lid of the trash can with the paper towel and threw it away as the lid touched his hand.
During an observation on 09/19/24 at 7:33 AM, DS3 brought a loaf of raisin bread over to the toaster wearing gloves. DS3 reached into the loaf of bread with the same gloves as he had on when he retrieved the bread and placed several slices on the toaster.
During an observation on 0919/24 at 7:37 AM, the DM completed washing his hands again using the same technique of turning the faucet off with his elbow and retrieving the paper towel to dry his hands. Open the trash can touching the lid with the paper towel and the lid coming back down on his hand. He took a pair of gloves out of the box and dropped on the floor. He picked it up and threw it away and reached in the box to retrieve another glove. The DM did not perform hand hygiene prior to retrieving and donning a new glove.
During an observation on 09/19/24 at 7:40 AM, DS2 washed her hands and turned off the faucet by touching her elbow to the handles and then retrieved a paper towel to dry her hands. The trash can lid was touched as she threw the paper towel away.
During an observation on 09/19/24 at 7:44 AM, DS1 using the gloved hands pulled a pen out of her back pocket and then proceeded to went to the trash and touched the lid with the gloved hand. DS1 then retrieved a pan and spatula from the clean area. DS1 set the pan and spatula on the stove and went into the refrigerator touching the handles and brought out a bowl of pancake mix. DS1 took off the gloves and threw them away by touching the lid o the trash can. She went over and got another pair of gloves. No handwashing was observed between the glove change.
During an observation on 09/1924 at 7:48 AM, the following spices were set on the shelf without open dates: freeze dried chilies, ground black pepper, ground cinnamon, Italian seasoning and whole bay leaves.
During an observation on 09/19/24 at 7:53 AM, DS1 was getting coffee for a staff member that came to the door. DS1 left the kitchen with gloved hands. She returned to the kitchen with the same gloves and began to remove items from the steam table.
During an interview on 09/19/24 at 7:55 AM, DS1 was asked about the different times she was observed wearing the same gloves performing multiple tasks. DS1 stated, I should have changed gloves with each new task and washed hands in between. DS1 did not recall touching the trash lid with gloved hands or walking out of the kitchen with gloved hands.
During an interview on 09/19/24 at 8:01 AM, DS3 was asked about the spices that were not dated. DS3 stated, They should have been dated when they were opened. I just started Monday and had not gotten that far. DS3 was also asked about changing gloves and washing hands. DS3 stated, Gloves should be changed with each new task and handwashing in between.
During an interview on 09/19/24 at 8:15 AM, the DM and DS2 were asked about the proper technique for handwashing. The DM demonstrated hand washing in which he turned the faucet off with his elbows. DS2 stated that was the way she was taught. DS4 came into the kitchen and was asked what the proper technique was to turn off the faucet when washing hands, DS4 stated, Take the paper towel and dry the hands and then take another paper towel and turn off the faucet. There should also be an open trash can next to the sink that way staff do not have to open the trash can by taking off the lid and recontaminating their hands.
During an observation on 09/19/24 at 11:59 AM, DS5 walked into the kitchen and picked up a hair net and walked through the kitchen without placing the hair net over her hair and carrying her personal belongs with her.
During an observation on 09/19/24 at 12:03 PM, the DM was making puree with his beard cover under his chin and not cover the hair on his face.
During an interview on 09/19/24 at 12:09 PM, DS5 was asked why she walked through the kitchen without a hair net and carrying her purse. DS5 stated, I wanted to go to the back and put it on while looking in the mirror. Also, there is no other way to the office to put my purse up.
During an interview on 09/19/24 at 12:24 PM, DS4 and the DM were asked about the staff walking to the back without wearing the hair net and carrying personal belongings. The DM stated that was not appropriate, she should have placed the hair net on before walking to the back. She should also not have brought personal items into the kitchen. DS4 and the DM was asked about the beard cover not being worn correctly. The DM stated it should have been over the beard.
MINOR
(C)
Minor Issue - procedural, no safety impact
Staffing Information
(Tag F0732)
Minor procedural issue · This affected most or all residents
Based on daily nursing staff report review and interview, the facility failed to indicate the daily census in the space provided on the daily posted form. This failure had the potential for resident f...
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Based on daily nursing staff report review and interview, the facility failed to indicate the daily census in the space provided on the daily posted form. This failure had the potential for resident family, friends, or other visitors not to know the ratio of nursing staff to residents causing uncertainty of ability and availability of the staff for residents' needs.
Findings include:
Review of the facility's GenSTAR Daily Nurse Staffing Form(s), for 08/01/24 through 09/17/24 and provided by the Administrator, presented a space, but the facility census information was not filled in.
An observation on 09/17/24 at 10:20 AM revealed the daily staff posting to be in a conspicuous area. However, while the form contained a space for the daily resident census to be filled in, the form lacked having the daily census indicated.
An observation on 09/18/24 at 10:45 AM revealed the daily staff posting still lacked having the facility census space filled in with the resident census.
During an interview on 09/19/24 at 12:30 PM, the Administrator verified that the GenSTAR Daily Nurse Staffing Form(s) posted daily in the front of the facility should have had the census indicated in the space provided so visitors would know the ratio of staff to residents.
Jul 2024
1 deficiency
CONCERN
(D)
📢 Someone Reported This
A family member, employee, or ombudsman was alarmed enough to file a formal complaint
Potential for Harm - no one hurt, but risky conditions existed
Medical Records
(Tag F0842)
Could have caused harm · This affected 1 resident
Based on record review and interview, the facility failed to ensure medical records were complete and accurate for 1 (R #14) of 3 (R #12, R #14, and R #15) residents reviewed for abuse. This deficient...
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Based on record review and interview, the facility failed to ensure medical records were complete and accurate for 1 (R #14) of 3 (R #12, R #14, and R #15) residents reviewed for abuse. This deficient practice has the potential to negatively impact the care staff provide to meet residents' needs due to missing or inaccurate records and resident information. The findings are:
A. On 07/23/24 at 12:10 PM, during an interview, CNA #11 stated that R #14 had not had anything to eat for lunch or breakfast. CNA #11 said that R #14 had not eaten breakfast or lunch for a week. CNA #11 said that she had documented that R #14 was not eating.
B. Record review of the CNA's documentation for ADL's (Activities of Daily Living) (meal task) dated 07/23/24 for R #14, revealed the following:
1. On 07/16/24 at 8:44 AM, staff did not document the amount of the meal intake.
2. On 07/16/24 at 1:07 PM, staff did not document the amount of the meal intake.
3. On 07/16/24 at 5:52 PM, staff did not document the amount of the meal intake.
4. On 07/17/24 at 8:44 AM, staff did not document the amount of the meal intake.
5. On 07/17/24 at 2:06 PM, staff did not document the amount of the meal intake
6. On 07/17/24 at 6:04 PM, staff did not document the amount of the meal intake.
7. On 07/18/24 at 8:59 AM, staff did not document the amount of the meal intake.
8. On 07/22/24 at 8:40 AM, staff did not document the amount of the meal intake.
9. On 07/22/24 at 2:13 PM, staff did not document the amount of the meal intake.
10. On 07/22/24 at 5:59 PM, staff did not document the amount of the meal intake.
11. On 07/23/24 at 8:02 AM, staff did not document the amount of the meal intake.
12. On 07/23/24 at 12:11 PM, staff did not document the amount of the meal intake.
C. Record review of R #14's medical record revealed the record did not contain any documentation that R #14 was not eating.
D. On 07/23/24 at 2:56 PM, during an interview, the DON confirmed that CNA #11 did not document that R #14 was not eating. She said that it should be documented that R #14 was not eating.
May 2024
10 deficiencies
CONCERN
(D)
📢 Someone Reported This
A family member, employee, or ombudsman was alarmed enough to file a formal complaint
Potential for Harm - no one hurt, but risky conditions existed
Deficiency F0661
(Tag F0661)
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 have a discharge summary that includes a summary of the resident's ...
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**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on record review and interview, the facility failed to have a discharge summary that includes a summary of the resident's stay at the facility for 1 (R #22) of 3 (R #21, R #22, and R #23) residents reviewed for discharge. Failure to provide a complete discharge summary that includes a description of the resident's stay at the facility could likely result in the receiving facility or home health or home health agency not having the most current information to provide care to the residents. The findings are:
A. Record review of the progress notes revealed that R #22 was discharged on 04/22/24.
B. Record review of R #22's Discharge summary, dated [DATE], revealed staff did not complete the following areas of the form:
1. Dietary recommendation.
2. Skin condition.
3. Current infections.
4. Hearing ability.
5. Vision ability.
6. Dental concerns.
7. Speech pattern.
8. Bowel and bladder continence.
9. Assistance levels.
10. Signs and symptoms of a change in condition for the resident.
11. Therapy services that were received at the facility.
12. Medication reconciliation.
13. Any education provided and to whom it was provided.
14. Other attachments.
15. The form was not signed off by staff.
C. On 05/07/24 at 12:17 PM, during an interview the DON confirmed the following:
1. R #22's discharge summary was incomplete.
2. Staff are expected to complete the entire discharge summary document prior to the resident being discharged .
3. Staff are expected to complete a medication reconciliation (process of comparing a patient's medication orders to all of the medications that the patient has been taking).
4. Staff are expected to provide a copy of the discharge summary document and medication reconciliation to the resident, their representative, and/or the home health agency prior to the resident leaving the facility.
CONCERN
(D)
📢 Someone Reported This
A family member, employee, or ombudsman was alarmed enough to file a formal complaint
Potential for Harm - no one hurt, but risky conditions existed
Deficiency F0741
(Tag F0741)
Could have caused harm · This affected 1 resident
Based on record review and interview, the facility failed to ensure that staff received the appropriate behavioral health training and have the skills to provide behavioral health services for 1 (R #2...
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Based on record review and interview, the facility failed to ensure that staff received the appropriate behavioral health training and have the skills to provide behavioral health services for 1 (R #21) of 1 (R #21) residents reviewed for behavioral health concerns. This deficient practice is likely to result in residents not getting the care and assistance they need. The findings are:
A. Record review of R #21's progress notes, revealed the following:
1. On 01/26/24, R #21 was attempting to break into the ashtray in the smoking area using a metal fork, knife, and toenail clippers. R #21 was found taking things from other residents rooms and staff belongings. When staff discussed with R #21, he stated, I hate it here and want to leave, just let me leave out the door. Resident yelled at staff, you're a bitch and just want to keep me here for the money. When the nurse asked for the silverware, resident reluctantly gave it to the nurse and stated, I'm not going to stop, I plan on making everyone's life a living hell here.
2. On 01/27/24, R #21 was stuffing trash in the toilet. When asked why, R #21 told staff, I hate this place and everyone in it, I don't want to be here. I have a gun at home and I just want to shoot up this place. I hope you die here and everyone, I wish my wife was here so she could kick your ass, all of you. I'm going to call the police. I was a golden glove in the military, and I will kick you're ass and your workers, I also know how to use stuff to stab you guys if I wanted to. Resident was placed on one-to-one for the safety of everyone. Nurse began to give R #21 plastic utensils for safety.
3. On 01/31/24, R #21 took eating utensils from the kitchen. R #21 refused to give staff the utensils.
4. On 02/01/24, R #21 is having a lot of behaviors related to smoking and stealing. R #21 was informed that he had been denied admission into all skilled nursing facilities due to his behaviors. R #21 said, I'll just go home with my wife. R #21 was told that his wife was unwilling to take him home due to his behaviors. R #21 said he will have his wife send his gun and he will shoot up the place.
5. On 02/01/24, R #21 was writing on the walls and yelling curse words at staff.
6. On 02/01/24, R #21 was stealing belongings from other residents, taking utensils from the kitchen, and stuffing his commode with trash, gloves, trash bags, sugar, and creamer wrappers.
7. On 02/01/24, R #21 threw down ashtrays and was attempting to get cigarettes with two small sticks. When told to stop, R #21 told staff, You are a cunt bitch, I wish you were dead, you are violating my rights, I am a veteran, I am going to call my wife to kick you're ass. After the nurse picked up the ashtray, R #21 said, I'm just going to come back out here and do it again, I am going to make everyone's life a living hell around here, I hate this fucken place and everyone in it, I wish this place would burn down. R #21 was documented to possibly have a lighter.
8. On 02/02/24, R #21 attempted to use the phone at the nurses' station. When told to put the phone back, R #21 threw the phone on the floor.
9. On 02/06/24, R #21 tipped over the ashtray and was using utensils to get cigarette butts out of ashtray. R #21 denied trying to get cigarette butts. R #21 was reeducated on infection prevention and smoking policies.
10. On 02/06/24, R #21 was banging the back of his wheelchair into the door. R #21 was educated not to destroy company property. R #21 became agitated and asked why they keep him there. Staff asked R #21 if he didn't want to be in the facility. R #21 told staff he has been wanting to get out. Staff asked R #21 if he would like to be discharged to the local homeless shelter. R #21 said, yes, get me out of here.
11. On 02/06/24, R #21 was yelling at staff, fuck you bastards, I'll kick you're ass. R #21 threatened staff and other residents. R #21 was caught stealing from other residents, hoarding spoons, forks, and knives.
12. On 02/06/24, R #21 threw a large amount of silverware, sugar packets, and other items at RN #21. RN #21 had reddened marks across her right ear, cheek, and neck. RN #21 called the police. When questioned by the police, R #21 denied allegations, until shown red marks on RN #21's face, and R #21 said, Oh that . well, I didn't want to hurt her. The police determined R #21 had committed battery against a medical professional and arrested R #21.
B. Record review of R #21's entire medical record revealed the record did not have any documentation that the provider was notified about R #21's behaviors.
C. On 05/07/24 at 11:13 AM, during an interview with RN #21, she stated the following:
1. R #21 would go into other residents rooms and would take things.
2. Staff would have to redirect R #21 and get the items to give back to the other residents.
3. R #21 was constantly throwing things at staff and other residents.
4. R #21 was becoming very aggressive and was trying to leave the facility.
5. Intervention for R #21's behaviors was to redirect and remove anything that could be over stimulating.
6. R #21 would talk to himself and have full conversations and argue with himself.
7. R #21 did not receive any mental health services in the facility.
8. The facility had not provided her with any training on dealing with residents with behavioral health issues or aggressive behaviors.
D. Record review of RN #21's trainings revealed RN #21 had not completed any trainings related to behavioral health and dealing with aggressive residents.
E. On 05/08/24 at 10:55 AM, during an interview with the DON, she confirmed the following:
1. The Social Services Director (SSD) completed a training with several CNA's.
2. The training included how to handle residents with dementia and how to handle behavioral health issues.
3. The rest of the facility has not received the behavioral health training.
4. Staff did not receive behavioral health training when R #21 was becoming physically and verbally aggressive.
5. Staff do not complete any skills competencies for dealing with behavioral health and verbal and assaultive behaviors.
6. RN #21 did not have behavioral health training.
F. On 05/08/24 at 11:08 AM, during an interview with the SSD, she confirmed the following:
1. The training she provided was an 8-hour training to CNA's for the management of aggressive behaviors and teaches de-escalation of aggressive behavior (training was on multiple dates).
2. The training on management of aggressive behaviors provides staff with the skills they need to handle a resident with physical and verbally aggressive behaviors.
4. She has provided the training on management of aggressive behaviors to some of the CNA's on multiple dates.
5. She has not provided the training on the management of aggressive behaviors to the nurses or other clinical staff.
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 F0808
(Tag F0808)
Could have caused harm · This affected 1 resident
Based on observation, record review, and interview the facility failed to provide a therapeutic diet (a diet ordered by a physician or delegated registered or licensed dietitian as part of treatment f...
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Based on observation, record review, and interview the facility failed to provide a therapeutic diet (a diet ordered by a physician or delegated registered or licensed dietitian as part of treatment for a disease or clinical condition, or to eliminate or decrease specific nutrients in the diet) as ordered by a physician for 1 (R #11) of 3 (R #11, R #12, R #13) residents reviewed for dietary services. If the facility fails to provide a diet as ordered, then residents are likely to experience weight loss due to not receiving their prescribed nutritional caloric intake and may be at risk for choking. The findings are:
A. Record review of R #11's physician order dated 01/25/24, revealed an order for regular/liberalized diet, dysphagia advanced texture (bite sized foods that are moist with the exception of crunchy, sticky or very hard foods).
B. On 05/07/24 at 11:59 AM, during an observation, R #11's was served whole chicken nuggets, whole French fries (not chopped).
C. On 05/07/24 at 12:15 PM, during an interview, CNA #11 confirmed that R #11 was served whole chicken nuggets and whole French fries.
D. On 05/07/24 at 12:40 PM, during an interview, the DON confirmed that R #11 is on a dysphagia advanced diet. The DON said R #11 should be served mechanical soft, chopped bite size, and soft fruit and vegetables. The DON confirmed that R #11's chicken nuggets and French fries should have been chopped.
CONCERN
(E)
📢 Someone Reported This
A family member, employee, or ombudsman was alarmed enough to file a formal complaint
Potential for Harm - no one hurt, but risky conditions existed
Report Alleged Abuse
(Tag F0609)
Could have caused harm · This affected multiple residents
**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on record review and interview, the facility failed to report to the State Survey Agency within five (5) days of the incid...
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**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on record review and interview, the facility failed to report to the State Survey Agency within five (5) days of the incident for 1 (R #21) of 1 (R #21) residents sampled for abuse. If the facility fails to report abuse to the State Agency, then corrective action may not be taken, and residents could likely continue to be abused and/or suffer serious bodily injury. The findings are:
A. Record review of R #21's medical record revealed R #21 was admitted on [DATE] and discharged on 02/06/24.
B. Record review of R #21's progress note, dated 01/27/24, revealed R #21 was stuffing trash in the toilet. When asked why, R #21 told staff, I hate this place and everyone in it, I don't want to be here. I have a gun at home and I just want to shoot up this place. I hope you die here and everyone, I wish my wife was here so she could kick you're ass, all of you. I'm going to call the police. I was a golden glove in the military, and I will kick you're ass and your workers, I also know how to use stuff to stab you guys if I wanted to. Resident was placed on one-to-one (staff observing resident one staff to one resident) for the safety of everyone. The nurse began to give R #21 plastic utensils for safety. Staff did not document how long R #21 remained on one-to-one.
C. Record review of R #21's progress note, dated 02/01/24, revealed R #21 dumping out ashtrays and attempted to get cigarettes with two small sticks. When staff told R #21 to stop, R #21 told staff, You are a cunt bitch, I wish you were dead, you are violating my rights, I am a veteran, I am going to call my wife to kick you're ass. After the nurse picked up the ashtray, R #21 said, I'm just going to come back out here and do it again, I am going to make everyone's life a living hell around here, I hate this fucken place and everyone in it, I wish this place would burn down. It was documented that R #21 may have a lighter.
D. Record review of R #21's progress note, dated 02/06/24, revealed R #21 threw a large amount of silverware, sugar packets, and other items at RN #21. RN #21 had reddened marks across her right ear, cheek, and neck. RN #21 called the police. When questioned by the police, R #21 denied allegations, until shown red marks on RN #21's face. R #21 said, Oh that . well, I didn't want to hurt her. The police determined R #21 had committed battery against a medical professional and arrested R #21.
E. On 05/07/24 at 11:13 AM, during an interview with RN #21, she stated the following:
1. R #21 was becoming very aggressive and was trying to leave the facility.
2. R #21 was constantly throwing things like cups at staff and sometimes other residents.
3. When R #21 threw the silverware at her face, she felt assaulted and believed that R #21 was creating an unsafe environment for other residents, so she decided to call the police. She was worried that the other residents would not be able to get away if R #21 did that to them.
4. Other people saw R#21 throwing silverware at her. However, she was unsure who actually witnessed the incident.
F. On 05/07/24 at 12:17 PM, during an interview, the DON confirmed that the facility had not reported R #21's assault on the nurse and arrest to the State Agency because the corporate quality clinical nurse said it did not meet criteria to make a report to the state agency since R #21 assaulted a staff.
G. On 05/08/24 at 10:31 AM, during an interview with the Administrator, she confirmed that she was responsible for reporting to the state agency and she did not complete reports to the State Agency regarding R #21's threats, R #21 throwing things at other residents, or his assault on the nurse leading to R #21's arrest.
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 F0657
(Tag F0657)
Could have caused harm · This affected multiple residents
**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on record review and interview, the facility failed to revise the care plan for 2 (R #11 and R #21) of 4 (R #11, R #12, 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 revise the care plan for 2 (R #11 and R #21) of 4 (R #11, R #12, R #13, and R #21) residents reviewed for care plans when they failed to:
1. Revise R #11's care plan to include her regular/liberalized dysphagia advanced diet (moist foods in bite-sized pieces).
2. Have the required Interdisciplinary Team (IDT, team members from different disciplines working collaboratively, with a common purpose to set goals, make decisions, and share resources and responsibilities) members participate in the care plan meeting for R #21.
This deficient practice could likely result in staff being unaware of changes in care provided and residents not receiving the care related to changes in their health status or healthcare decisions. The findings are:
R #11
A. Record review of R #11's Speech Therapy (therapeutic treatment of impairments and disorders of speech, voice, language, communication, and swallowing) Evaluation dated 01/16/24 revealed dysphagia advanced diet due to endentulous (lacking teeth) state and poor cognition for safety with swallow.
B. Record review of R #11's medical record dated 01/25/24 revealed an order for regular/liberalized diet, dysphasia advanced texture (moist foods in bite-sized pieces).
C. Record review of R #11's care plan date 03/08/24, revealed that R #11's Dysphagia Advance diet was not included in R #11 care plan.
D. On 05/07/24 at 12:40 PM, during an interview, the DON confirmed that R #11's dysphagia advanced diet was not documented in the care plan. R #11 should have their diet orders care planned according to the DON's expectation.
R #21
E. Record review of R #21's face sheet revealed he was admitted to the facility on [DATE].
F. Record review of R #21's care plan meeting note, dated 08/29/23, revealed the following:
1. R #21's wife attended the care plan meeting.
2. The staff in attendance were the MDS coordinator, the Social Services Director (SSD), and the Activities Director.
G. Record review of R #21's care plan meeting note, dated 11/28/23, revealed:
1. The resident or his family did not attend.
2. The staff in attendance were the MDS coordinator, the Memory Care Director (current Social Services Director (SSD)), and the Activities Director.
H. On 05/08/24 at 11:40 AM, during an interview with the SSD, she stated the following:
1. The MDS coordinator schedules the Care Plan meetings.
2. Staff that attended the care plan meetings were the SSD, Activities Director, the MDS Coordinator, and the Administrator.
3. The resident and/or resident representative attend the care plan meetings.
4. The provider does not attend care plan meetings.
5. Nurses providing patient care do not attend care plan meetings.
6. CNA's providing care for the residents do not attend care plan meetings.
7. During care plan meetings, they review medications, code status, weight, diet, when physician visit took place, ADL's (Activites of Daily Living), continence, falls, skin, restraints, behaviors, activities, pain, psych medication, and if they want to transfer.
I. On 05/08/24 at 11:49 AM, during an interview with the MDS coordinator, she confirmed the following:
1. She schedules the care plan meetings.
2. Staff that attend care plan meetings are the MDS Coordinator, the SSD, and the Activities Director. If the resident is receiving therapy, she invites therapy to attend.
3. She is a nurse.
4. She does not provide care for the residents. She would not be able to say what the resident's behaviors are like other than what is noted in the progress notes.
5. She gets information for the care plan meeting from the MDS assessment.
6. She confirmed the MDS assessment is only a 7 day look back and does not cover all information that occurred during the quarter.
7. She does not invite a nurse that provides care for the residents to the care plan meeting.
8. She does not invite a CNA that provides care for the residents to the care plan meeting.
9. She does not invite the provider to the care plan meeting.
10. She is unsure how the providers are aware of what occurred during the care plan meeting.
11. She does not contact the physician for input prior to the care plan meeting.
12. She does not contact the nurses or CNA's for input prior to the care plan meeting.
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 F0740
(Tag F0740)
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 metal health services for 1 (R #21) of 1 (R #21) residents ...
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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 metal health services for 1 (R #21) of 1 (R #21) residents reviewed for mental health concerns, when the facility failed to provide metal health services for R #21 after the provider placed an order for mental health services.
This deficient practice could likely result in worsening of behaviors and worsening of behavioral or mental health conditions causing increased depression and anxiety. The findings are:
A. Record review of R #21's face sheet revealed R #21 was admitted on [DATE].
B. Record review of R #21's medical diagnoses revealed R #21 had a diagnosis of dementia, depression, and anxiety.
C. Record review of R #21's admission referral from hospital, dated 05/06/23, revealed the following:
1. R #21 took Depakote Sprinkles (medication used to treat mental/mood conditions) 125 milligram (mg, unit of measure) twice a day.
2. R #21 took Escitalopram (antidepressant medication used to treat depression and anxiety) 10 mg once a day.
D. Record review of R #21's Physician's orders, multiple dates, revealed the following:
1. An order dated 05/10/23, for Depakote 125 mg twice a day for mood stabilizer.
2. An order dated 05/10/23, for Escitalopram Oxalate 10 mg once a day for mood stabilizer.
3. An order dated 05/15/23, for Medi-tele care (online service that allows residents to see healthcare provider from home) to evaluate and treat for psychiatric and psychological health.
E. Record review of R #21's entire medical record revealed R #21 did not receive mental or behavioral health services.
F. On 05/07/24 at 11:13 AM, during an interview with RN #21, she stated the following:
1. R #21 would go into other residents rooms and would take things.
2. Staff would have to redirect R #21 and get the items to give back to the other residents.
3. R #21 was constantly throwing things at staff and other residents.
4. R #21 was becoming very aggressive and was trying to leave the facility.
5. R #21 lost his smoking privileges at least twice, due to R #21 not following the smoking policy.
6. Intervention for R #21's behaviors was to redirect and remove anything that could be over stimulating.
7. R #21 would talk to himself and have full conversations and argue with himself.
8. R #21 did not receive any mental health services in the facility.
G. On 05/07/24 at 9:23 AM, during an interview with the DON, she confirmed the following:
1. Medi-Teli care stopped providing services at the facility last year, she was unsure of the date.
2. She was unsure if R #21 ever received behavioral health services in the facility.
3. There was no documentation that R #21 received behavioral health services while at the facility.
H. On 05/07/24 at 11:41 AM, during an interview with the Medical Director (resident #21's primary physician), she stated the following:
1. She was unsure what mental health services are being provided to residents at the facility.
2. She did not remember R #21.
3. She did not remember if she had ever been notified about R #21's behaviors.
4. If a resident was having increasing behaviors, it would depend on what services are available at facility, but the staff can notify on-call about increased behaviors.
5. If she was notified about increasing behaviors, she would order labs and UA, would look into medications, and social services concerns, and would start medications if the resident was not hurting self or others.
6. If resident was showing signs of aggressions that would put residents or staff at risk she would send the resident out for psychiatric evaluation.
I. On 05/07/24 at 12:17 PM, during an interview with the DON, she confirmed the following:
1. R #21 was never sent to the hospital due to behavioral health issues.
2. R #21 was never referred to behavioral health hospitals.
3. She was aware that resident would talk to himself.
4. She was unsure if a discussion had taken place about R #21 being referred to a psychiatric facility for evaluation.
5. The community does not have anyone that can provide psychiatric services to the facility's residents.
J. On 05/07/24 at 12:56 AM, during an interview with the Administrator, she stated the following:
1. R #21 was grumpy and mean.
2. R #21 would take things off the walls and throw them at people and curse at people.
K. On 05/07/24 at 3:17 PM, during an interview with the DON and administrator, they stated the following:
1. R #21 was never sent to an off-site psychiatric provider for evaluation.
3. R #21 was never sent to the hospital for behavioral health.
4. R #21 made multiple threats to staff.
5. R #21 did not receive psychiatric services while at the facility.
L. On 05/08/24 at 10:31 AM, during an interview with the Administrator, she confirmed the following:
1. R #21 would frequently tell her that he was going to kill her.
2. R #21 would say that he was going to shoot or stab her.
3. She never took R #21's threats seriously.
4. She stated that she called [name of behavioral health hospital in another town], but they said they do not take people based off threats and R #21 did not have any psychosis diagnosis.
5. She did not document this phone conversation.
6. The facility did not send a referral packet to any behavioral health hospitals.
7. The facility does not have behavioral health services in the facility.
8. The town does not have any behavioral facilities to send residents to.
9. The facility has not had any medi-tele behavioral health services since sometime last year.
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 F0745
(Tag F0745)
Could have caused harm · This affected multiple residents
**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on interview and record review, the facility failed to provide social services for 1 (R #21) of 1 (R #21) residents review...
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**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on interview and record review, the facility failed to provide social services for 1 (R #21) of 1 (R #21) residents reviewed for behavioral/emotional health, when they failed to provide timely referrals for R #21 to other long term nursing facilities after R #21 requested to be transferred.
This deficient practice could likely lead to residents to feel that their wishes are not important and not attaining, or maintaining, their highest practicable mental and psychosocial well-being. The findings are:
A. Record review of R #21's face sheet revealed he was admitted to the facility on [DATE].
B. Record review of R #21's progress note, dated 06/05/23, revealed R #21 stated that R #21 wanted to be moved to [name town] near his wife.
C. Record review of R #21's progress note, dated 08/07/23, revealed the following:
1. R #21 stated that he wanted to leave the facility.
2. R #21 stated that he wanted to go home and live with his wife.
3. R #21 stated that if he could not live with his wife he would like to go to a veterans nursing facility.
4. R #21's wife told the Social Service Director (SSD), that she did not want R #21 moving in with her, but it was okay if they found another facility in [name of town] where she lived.
D. Record review of R #21's progress note, dated 09/18/23, revealed the following:
1. Staff spoke with R #21's wife.
2. R #21's wife said she could not take R #21 in.
3. The facility said they would send referrals to other nursing home facilities.
E. Record review of R #21's progress note, dated 09/25/23, revealed R #21 wanted to go to a facility in [name of town] where his wife lives because they will help him get a leg. Staff said they would send referrals.
F. Record review of R #21's progress note, dated 10/17/23, revealed staff and family had a discharge meeting and discussed sending referrals close to where R #21's wife and daughter lived.
G. Record review of R #21's physician's orders, dated 10/19/23, revealed an order to transfer R #21 to a long-term care facility closer to R #21's home.
H. Record review of R #21's progress note, dated 11/28/23, revealed the following:
1. R #21 wanted to go home.
2. R #21's wife and daughter determined that it was not possible for R #21 to return home.
3. R #21's wife and daughter said they wanted R #21 to be moved to a nursing home closer to them.
I. Record review of R #21's referral packet, dated 01/17/24, revealed a referral packet was faxed to a long-term care facility for veterans that was 148 miles away from [name of town] where R #21's wife and daughter lived.
J. Record review of R #21's DON progress note, dated 02/01/24, revealed facility said they had contacted multiple SNF facilities to have R #21 transferred, but had been denied due to his behaviors. The progress note did not specify which facilities had been contacted.
K. Record review of progress note, dated 02/06/24, revealed the local homeless shelter was contacted and they did not have any beds available for R #21.
L. On 05/08/24 at 9:59 AM, during an interview with the SSD, she confirmed the following:
1. She was responsible for making referrals for transfers to other long term care facilities if the resident or their family requested to be transferred.
2. She was aware that R #21 wanted to go home or be transferred to a long-term care facility closer to his wife and daughter.
3. She provided one referral packet for R #21, dated 01/17/24, to a long-term care facility.
4. She was unable to find any other referral packets for R #21 to other long term care facilities.
5. She was unable to specify what other facilities she had sent referral packets for R #21 to transfer to.
M. Record review of R #21's entire medical record revealed the record did not contain any documentation that R #21 had been referred to other nursing facilities prior to the one referral made on 01/17/24.
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
Medication Errors
(Tag F0758)
Could have caused harm · This affected multiple residents
Based on record review and interview, the facility failed to ensure residents did not receive psychotropic medications unless the medication was necessary to treat a specific psychiatric diagnosis and...
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Based on record review and interview, the facility failed to ensure residents did not receive psychotropic medications unless the medication was necessary to treat a specific psychiatric diagnosis and was documented in the medical record for 1 (R #12) of 3 (R #11, R #12 and R #13) residents reviewed for unnecessary psychotropic medications. This deficient practice could likely result in residents receiving medications without a medical reason and being at a higher risk of adverse side effects (unwanted, harmful, or abnormal result). The findings are:
A. Record review of R #12's admission record, not dated, revealed an admission date of 10/15/21 for R #12.
B. Record review of R #12's Physician's orders revealed an order, dated 02/05/24, for Risperidone (an antipsychotic medication used to treat schizophrenia and bipolar disease) tablet, 0.5 mg two times a day for psychosis (a collection of symptoms that affect the mind, where there has been some loss of contact with reality).
C. Record review of R #12's Medical Administration Record (MAR) for April 2024, documented R #12 was taking Risperidone as prescribed.
D. Record review of R #12's care plan dated 03/20/24, revealed to monitor R #12 for changes in mental status and functional level and report to MD as indicated.
E. Record review of R #12's entire medical record revealed R #12 does not have a documented diagnosis of psychosis or a psychiatric diagnosis to indicate the need for an antipsychotic.
F. On 05/07/24 at 12:26 PM, during an interview, the DON confirmed R #12 does not have a documented diagnosis of psychosis. The DON said that R #12 was sent out for a psychiatric evaluation on 01/20/22 and that R #12 was prescribed Risperidone at that time. The DON stated that that based on the psychiatric evaluation that the medication was needed. The DON confirmed that the psychiatric evaluation did not document a diagnosis of psychosis. The DON confirmed that R #12 did not have a psychiatric diagnosis on documented for the antipsychotic medication.
CONCERN
(F)
📢 Someone Reported This
A family member, employee, or ombudsman was alarmed enough to file a formal complaint
Potential for Harm - no one hurt, but risky conditions existed
Food Safety
(Tag F0812)
Could have caused harm · This affected most or all residents
Based on observation and interview, the facility failed to store, and serve food under sanitary conditions in accordance with professional standards of food service safety for 77 residents that eat fo...
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Based on observation and interview, the facility failed to store, and serve food under sanitary conditions in accordance with professional standards of food service safety for 77 residents that eat food prepared in the kitchen in the facility (residents were identified on the resident matrix provided by the Administrator on 09/11/23), when they failed to:
1. Wear facial hair coverings and hairnets in the kitchen.
2. Store food in a sanitary manner.
If the facility fails to adhere to safe food handling practices, hygiene practices, and safe food storage, residents could likely to be exposed to foodborne illnesses (illness caused by food contaminated with bacteria, viruses, parasites, or toxins). The findings are:
A. On 05/06/24 at 12:41 PM, during an observation of the kitchen revealed the following:
1. Six frozen hamburger patties sitting on top of a microwave. The hamburger patties were not in a wrapper, or on a plate or in a container.
2. The Dietary Manager (DM) #11 did not have a facial net covering his moustache and he did not have a hairnet on.
B. On 05/06/24 at 12:42 PM, during an interview, the DM confirmed that the hamburger patties should not be left out without being in a container or on a plate. The DM said that the cook had put the hamburger patties there because she was about to cook them. The DM confirmed that he was not wearing hair coverings. The DM confirmed that hair should be covered in the kitchen.
MINOR
(C)
📢 Someone Reported This
A family member, employee, or ombudsman was alarmed enough to file a formal complaint
Minor Issue - procedural, no safety impact
Accident Prevention
(Tag F0689)
Minor procedural issue · This affected most or all residents
Based on observation, and interview the facility failed to keep the residents free from accidents for all 61 residents on the 100 and 200 Units (Residents were identified by the resident Census provid...
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Based on observation, and interview the facility failed to keep the residents free from accidents for all 61 residents on the 100 and 200 Units (Residents were identified by the resident Census provided by the Administrator on 05/6/24), when they failed to keep treatment carts (a movable piece of equipment used in healthcare facilities to store, transport, and dispense treatment supplies and tools) locked when not supervised by staff. This deficient practice could likely result in injury to residents obtaining medical equipment which can cause injury/death. The findings are:
A. On 05/06/24 at 2:30 PM, during an observation of the 100 Unit, the treatment cart was unlocked and opened, the cart had hydrocortisone lotions (medicated lotion, ointment or solution that treats eczema and other skin conditions, scissors, and lancets (a small sharp object used to prick the skin). Staff were not present.
B. On 05/06/24 at 2:34 PM, during an interview, LPN #1 confirmed the treatment cart was unlocked and opened.
C. On 05/07/24 at 8:58 AM, during an observation of the 200 Unit, the treatment cart was unlocked and opened, the cart had hydrocortisone lotions, scissors, and lancets. Staff were not present.
D. On 05/07/24 at 9:00 AM, during an interview, the Unit Manager confirmed the treatment cart was unlocked and opened, even though it is supposed to be locked.
E. On 05/07/24 at 12:19 PM, during an interview, the Administrator confirmed that the expectation is that treatment carts should be locked when they are not in use.
Feb 2024
4 deficiencies
CONCERN
(D)
📢 Someone Reported This
A family member, employee, or ombudsman was alarmed enough to file a formal complaint
Potential for Harm - no one hurt, but risky conditions existed
Assessment Accuracy
(Tag F0641)
Could have caused harm · This affected 1 resident
Based on record review and interview, the facility failed to ensure the MDS assessment accurately reflected the resident's status at the time of the assessment for 1 (R #3) of 4 (R #1, R #2, R #3, and...
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Based on record review and interview, the facility failed to ensure the MDS assessment accurately reflected the resident's status at the time of the assessment for 1 (R #3) of 4 (R #1, R #2, R #3, and R #4) residents sampled for MDS accuracy. This deficient practice could likely result in residents not receiving the care and treatment they need. The findings are:
A. Record review of R #3's physician's orders revealed an order for Humalog (insulin) inject 10 units with meals for diabetes with a start date 01/03/24. Order discontinue date 01/04/24.
B. Record review of R #3's admission MDS assessment, Section N: Medication, dated 01/08/24 revealed:
Question N0350 Insulin: Record the number of days the physician changed the resident's insulin orders during the last 7 days was answered 0.
C. On 02/07/2024, at 1:45 PM, during an interview with the MDS coordinator, she confirmed that the insulin had been discontinued and that the MDS assessment was not accurate because there were changes to R #3's insulin orders.
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
Notification of Changes
(Tag F0580)
Could have caused harm · This affected multiple residents
**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on record review and interview, the facility failed to notify the provider of a change in condition for 1 (R #1) of 3 (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 notify the provider of a change in condition for 1 (R #1) of 3 (R #1, R #3, and R #4) residents reviewed for change of condition, when they failed to notify the facility provider about R #1's low blood pressure, low temperature, and abdominal pain. This deficient practice could likely result in residents not receiving necessary care or a delay in treatment. The findings are:
A. Record review of R #1's admission record revealed R #1 was readmitted to the facility on [DATE], with the following diagnoses:
1. Sepsis (life-threatening medical emergency caused by your body's overwhelming response to an infection).
2. Urinary tract infection (UTI)
3. Dehydration
B. Record review of facility's sepsis screening policy (review date 08/07/23) revealed: Patients with suspected or known infections will be monitored for signs and symptoms of possible sepsis, refer to sepsis algorithm (process of evaluating symptoms, vital signs, changes in patient condition to determine possible sepsis) for adults.
C. Review of sepsis screening algorithm revealed:
1. Sepsis is a clinical syndrome that is caused by an abnormal host response to infection. Sepsis can lead to multi-organ dysfunction (two or more of your organ systems are failing to support your body's needs) and death.
2. Does patient have suspected/actual infection? Hypotension (blood pressure reading below the specified limit of 100/60).
3. Does patient have 2 or more of the following? Temperature less than 96.8, systolic blood pressure (top number of blood pressure reading) less than 100, respiratory rate greater than 20? If yes, notify provider of advance directive (legal document that tells healthcare providers and loved ones what type of medical care is wanted if the patient/resident is not able to) and positive sepsis screening using SBAR (Situation, Background, Assessment, Recommendation, is a technique to facilitate prompt and appropriate communication regarding a patients change in condition)
D. Record review of R #1's care plan, dated 10/09/23, revealed the following:
- Focus: R #1 exhibits or is at risk for dehydration as evidenced by recent infection
sepsis related to UTI.
- Interventions: Monitor for signs/symptoms of dehydration (increase temperature, decrease output [decreased urination], mental status changes, dry mucous membranes, orthostatic hypotension [form of low blood pressure that happens when standing after sitting or lying down], tachycardia [increased heart rate])
E. Record review of R #1's Electronic Medical Record (EMR) revealed:
1. Low blood pressure readings as follows:
-01/09/24 at 7:30 AM 84/68
-01/10/24 (day shift) 84/68
2. Low temperature readings as follows:
-01/04/24 at 8:41 AM 96.1
-01/05/24 at 1:21 AM 95.4
-01/09/24 at 7:00 AM 95.3
-01/12/24 at 8:22 AM 96.4
-01/13/24 (day shift) 96.4
-01/14/24 (day shift) 96.4
-01/17/24 (day shift) 96.4
-01/18/24 at 12:19 PM 96.3
-01/23/24 at 8:42 AM 96.5
3. High respiration rate as follows:
-01/24/24 at 09:30 AM 22
-01/26/24 (day shift) 22
-01/27/24 (day shift) 22
-01/27/24 (day shift) 22
F. Record review of communication binder (binder where nursing staff communicate non-emergent information with facility provider) revealed:
1. Physician Notifications: 01/27/24 at 1130, R #1 complains of pain, abdominal distention (a sense of increased abdominal pressure that can be caused by urinary retention, gas and/or constipation), overall appearance is poor.
G. Record review of R #1's progress notes revealed:
1. Nurse's note dated 01/28/23 at 3:13 PM, The resident continues to deteriorate in her condition. The resident also continues to yell out intermittently throughout the day and night, she complains of pain often, although she has scheduled pain medication. The resident refused to eat today and has refused other times to eat. This nurse attempted to encourage the resident to eat and was unsuccessful.
2. The record did not contain any documentation of the facility provider being notified of the resident's abnormal vital signs or complaints of abdominal pain.
3. Nurse note dated 01/29/23, at 3:04 PM, revealed the in-house provider (Physician's Assistant; PA) reported resident (R #1) had a change in mental status and complained of abdominal pain. The provider requested R #1 be sent out to the local hospital via emergency medical services.
H. On 02/06/24, at 3:45 PM, during an interview with the Physician's Assistant (PA), he said that he saw R #1 for the first time on 01/29/24. The PA said she (R #1) was pale and moaning, appeared septic and that is why he sent her out to the hospital. The PA confirmed the facility failed to communicate the resident's abnormal vital signs or complaints of abdominal pain to him prior to him seeing her on 01/29/24. The PA stated that his expectation is that the facility nurses would have reported her blood pressure levels dropping under 100.
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 F0658
(Tag F0658)
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 meet professional standards of quality for 1 (R #3) of 4 (R #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 meet professional standards of quality for 1 (R #3) of 4 (R #1, R #2, R #3, and R #4) residents reviewed for professional standards of care when the facility staff failed to monitor R #3's blood sugar. If the facility is not monitoring the resident and reporting to the provider, it may lead to a delay in treatment or changes in residents' health status may go untreated. The findings are:
A. Record review of R #3's admission record revealed he was admitted to the facility on [DATE]. Further review of the admission record revealed diagnosis of type 2 diabetes (condition that happens because of a problem in the way the body regulates and uses sugar) with hyperglycemia (condition in which an excessive amount of glucose circulates in the blood, generally a blood sugar level higher than 200).
B. Record review of R #3's physician's orders revealed an order for Humalog (insulin) inject 10 units with meals for diabetes (order included treatment of checking blood sugar before each meal) with a start date 01/03/24. Order discontinue date 01/04/24.
C. Record review of R #3's Treatment Administration Record (TAR) for January 2024 revealed:
1. On 01/04/24 for time of 1130 AM, R #3's blood glucose level was 83.
2. The TAR did not contain any other documentation of R #3's blood glucose levels.
D. Record review of R #3's nurses' progress notes revealed:
1. Nurse note dated 01/04/23 at 11:23 AM, bgl (blood glucose level) 83, too low for nurse comfort zone to
give 10 units of Humalog. Resident also did not want insulin.
2. The record did not contain any documentation of communication with the facility provider regarding
discontinuation of Humalog or need for blood glucose monitoring.
E. Record review of R #3's lab results revealed: On 01/05/24 Hemoglobin A1C (blood test used to monitor how well blood sugar levels are being managed) result was 9.1 (lab result indicating that average blood glucose level is 212 and diabetes is not well controlled).
F. On 02/07/24 at 3:04 PM, during and interview with the DON, she confirmed that when the Humalog order was discontinued the blood glucose monitoring was also discontinued.
G. On 02/07/24 at 2:19 PM, during an interview with the Physician Assistant, he said that he would expect the blood glucose levels to be monitored for residents on insulin to determine if changes to treatment are necessary. PA was not aware of R #3's Hemoglobin A1C results for 01/05/24.
CONCERN
(E)
📢 Someone Reported This
A family member, employee, or ombudsman was alarmed enough to file a formal complaint
Potential for Harm - no one hurt, but risky conditions existed
Medical Records
(Tag F0842)
Could have caused harm · This affected multiple residents
**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on record review and interview, the facility failed to ensure medical records were complete and accurate for 3 (R #1, R #2...
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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 medical records were complete and accurate for 3 (R #1, R #2, and R #3) of 3 (R #1, R #2, and R #3) residents reviewed for accuracy of documentation. This deficient practice has the potential to negatively impact the care staff provide to meet residents' needs due to missing or inaccurate records. The findings are:
R #1
A. Record review of R #1's admission record revealed R #1 was readmitted to the facility on [DATE].
B. Record review of R #1's Treatment Administration Record (TAR), dated January 2024, revealed: Vital signs daily, every day shift, start date 06/20/23. Further review of the resident's TAR revealed staff did not document the resident's vital signs during day shift on the following dates:
-01/06/24
-01/07/24
-01/11/24
-01/16/24
-01/25/24
-01/29/24
R #2
C. Record review of R #2's admission record revealed R #1 was readmitted to the facility on [DATE].
D. Record review of R #2's TAR, dated January 2024, revealed: Lantus (insulin) inject 15 units one time a day for diabetes, start date 12/27/23. Further review of the resident's TAR revealed staff did not document that insulin was given to R #2 on the following dates and times:
-01/02/24 at 8:00 AM
-01/03/24 at 8:00 AM
-01/06/24 at 8:00 AM
-01/07/24 at 8:00 AM
-01/13/24 at 8:00 AM
-01/21/24 at 8:00 AM
-01/22/24 at 8:00 AM
-01/26/24 at 8:00 AM
-01/30/24 at 8:00 AM
-01/31/24 at 8:00 AM
R #3
E. Record review of R #3's admission record revealed R #3 was admitted to the facility on [DATE].
F. Record review of R #3's TAR, dated January 2024, revealed: Lantus (insulin) inject 15 units in the morning for diabetes, start date 01/03/24. Further review of the resident's TAR revealed staff did not document that insulin was given to R #3 on the following dates and times:
-01/03/24 at 5:00 AM
-01/04/24 at 5:00 AM
-01/06/24 at 5:00 AM
-01/07/24 at 5:00 AM
-01/08/24 at 5:00 AM
-01/09/24 at 5:00 AM
-01/10/24 at 5:00 AM
-01/15/24 at 5:00 AM
-01/17/24 at 5:00 AM
-01/21/24 at 5:00 AM
-01/22/24 at 5:00 AM
-01/29/24 at 5:00 AM
-01/30/24 at 5:00 AM
-01/31/24 at 5:00 AM
G. On 02/07/2024, at 3:04 PM, during an interview with the DON, she stated that she can not determine whether the treatments for R #1, R#2, and R #3 were completed due to lack of documentation. The DON stated that her expectation is that the TAR is documented on to determine whether the treatments were completed or not.
Sept 2023
19 deficiencies
CONCERN
(D)
Potential for Harm - no one hurt, but risky conditions existed
Deficiency F0661
(Tag F0661)
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 a discharge summary that included a recapitulation (a summar...
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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 a discharge summary that included a recapitulation (a summary describing the resident's course of treatment while residing in the facility) was completed for 1 (R #75) of 1 (R #75) residents sampled for discharge from the facility. This deficient practice could likely lead to the receiving facility or hospital not knowing what the current care needs and significant medical history are for the resident. The findings are:
A. Record review of R #75's Electronic Medical Record (EMR) revealed:
1. R #75 was transferred to the hospital on [DATE] due to abnormal vital signs (blood pressure, heart rate, temperature, respiratory rate and/or oxygen levels that deviate from the normal range and can indicate a possible health problem) and altered mental status (change in mental function that can stem from illness or injury and leads to changes in awareness, movement and/or behaviors).
2. As of 09/13/23, #75 had not returned to the facility.
3. Recapitulation of residents stay at the facility, or a discharge summary were not found in the EMR.
B. On 09/19/23 at 2:25 PM, during an interview, the DON confirmed that R #75 did not return to the facility and that no discharge summary had been completed for R #75. Per DON the nursing department was unaware that a discharge summary was required.
CONCERN
(D)
Potential for Harm - no one hurt, but risky conditions existed
Deficiency F0712
(Tag F0712)
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 require that physician visits were made by the physician personally...
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**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on record review and interview, the facility failed to require that physician visits were made by the physician personally for 1 (R #59) of 1 (R #59) residents reviewed for pressure ulcer/injury when R #59 was seen by the attending physician via telemedicine (the remote diagnosis and treatment of patients by means of telecommunications technology) and not face to face. This deficient practice could likely result in residents not receiving the required medical assessment and review resulting in resident receiving less than optimal care. The findings are:
A. Record review of R #59's face sheet revealed R #59 was admitted into the facility on [DATE].
B. Record review of R #59's History and Physical dated 05/25/23, revealed that this was the initial visit and care was provided by the physician utilizing telemedicine.
C. On 09/19/23 at 3:45 PM, during an interview, the DON confirmed R #59's initial visit was done via telemedicine. The DON stated physician comes to the facility once a month and if there is an initial visit and the physician is not in the facility, the visit will be done by telemedicine.
CONCERN
(D)
Potential for Harm - no one hurt, but risky conditions existed
Dental Services
(Tag F0791)
Could have caused harm · This affected 1 resident
Based on record review and interview the facility failed to schedule an appointment for dental services for 1 (R #42) of 3 (R #32, R #42 and R #68) residents sampled for dental services. This deficien...
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Based on record review and interview the facility failed to schedule an appointment for dental services for 1 (R #42) of 3 (R #32, R #42 and R #68) residents sampled for dental services. This deficient practice could likely result in residents' continued dental pain. The findings are:
A. Record review of R #42's admission record revealed an admission date of 12/20/22.
B. On 09/12/23 at 8:47 AM, during an interview, R #42 stated he had a dental appointment the following day on 09/13/23 in [name of town]. The resident did not know if he was going to the appointment, because the facility was having transportation issues.
C. On 09/13/23 at 1:45 PM, during an interview, Social Services stated staff did not take R #42 to his dental appointment due to the transportation issues, and staff have not rescheduled the appointment .
D. On 09/19/23 at 2:25 PM during an interview, the Administrator confirmed that resident should be going to their appointments regularly.
CONCERN
(E)
Potential for Harm - no one hurt, but risky conditions existed
Safe Environment
(Tag F0584)
Could have caused harm · This affected multiple residents
**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation and interview, the facility failed to maintain a safe and clean environment by not maintaining the facility...
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**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation and interview, the facility failed to maintain a safe and clean environment by not maintaining the facility's odor in the 200 Unit between room [ROOM NUMBER] and 208 and between 213 and 217. This has the potential to affect all 40 residents in the facility's 200 Unit (residents were identified by the Census provided by the Administrator on 09/11/23). This deficient practice could likely result in residents not maintaining their highest practicable well being in the facility. The finding are:
A. On 09/11/23 at 1:07 PM, during an observation of the 200 Unit revealed a very strong odor of urine.
B. On 09/12/23 at 9:29 AM, during an observation the 200 Unit revealed an odor of urine.
C. On 09/18/23 at 10:36 AM, during an interview R #1 reported the strong smell of urine on the 200 Unit.
D. On 09/18/23 at 3:40 PM, during an interview Housekeeper #22 stated the urine odor is from residents that remove their own brief and throw it in the trash can or throw it on the floor next to their bed.
E. On 09/19/23 at 12:40 PM, during an observation the 200 Unit revealed an odor of urine.
CONCERN
(E)
Potential for Harm - no one hurt, but risky conditions existed
Deficiency F0625
(Tag F0625)
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 provide a written notice of the bed hold policy at the time of the tra...
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**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on record review and interview, the facility failed provide a written notice of the bed hold policy at the time of the transfer to the resident and their representative(s) for 2 (R #68 and R #178) of 2 (R #68 and R #178) residents sampled for hospitalizations. This deficient practice could likely result in the resident and their representative being unaware that the resident is permitted to return and resume residence in the nursing facility upon discharge from the hospital. The findings are:
R #68
A. Record review of R #68's Electronic Medical Record (EMR) revealed:
1) R #68 was transferred to the hospital on [DATE] due to critical laboratory results (laboratory test results that are significantly outside the normal range and may indicate a life-threatening situation).
2) No notice of bed hold policy notice was found.
R #178
B. Record review of R #178's EMR revealed:
1) R #178's was transferred to the hospital on [DATE] per his request due to uncontrolled pain.
2) No notice of bed hold policy notice was found.
C. On 09/29/23 at 1:45 PM, during an interview, the administrator confirmed that there was no bed hold notice provided to R #68 and R #178 at the time of the transfer to the hospital. The administrator stated the bed hold policy was not being provided to any residents when they are sent to the hospital.
CONCERN
(E)
Potential for Harm - no one hurt, but risky conditions existed
Deficiency F0638
(Tag F0638)
Could have caused harm · This affected multiple residents
Based on record review and interview, the facility failed to ensure that a Minimum Data Set (MDS) assessment was completed every three months for 1 (R #37) of 1 (R #37) residents reviewed for MDS asse...
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Based on record review and interview, the facility failed to ensure that a Minimum Data Set (MDS) assessment was completed every three months for 1 (R #37) of 1 (R #37) residents reviewed for MDS assessments. This failed practice is likely to result in resident assessments being outdated and residents not receiving care and treatment that meets their current needs. The findings are:
A. Record review of R #37's Electronic Medical Record (EMR) completed on 09/14/23 revealed, R #37's most recent MDS was completed on 05/06/23.
B. On 09/14/23 at 1:45 PM, during an interview, the MDS Coordinator confirmed that R #37's Quarterly MDS was past due and was completed more than 3 months ago. The MDS Coordinator stated she recently had computer issues and that may be the reason she had not been prompted to complete an MDS for R #37.
CONCERN
(E)
Potential for Harm - no one hurt, but risky conditions existed
Deficiency F0658
(Tag F0658)
Could have caused harm · This affected multiple residents
Based on observation, record review, and interview, the facility failed to meet professional standards of quality for 1 for (R #63) of 4 (R #1, R #58, R #63, and R #181) residents observed during medi...
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Based on observation, record review, and interview, the facility failed to meet professional standards of quality for 1 for (R #63) of 4 (R #1, R #58, R #63, and R #181) residents observed during medication administration, when CMA #1 held R #63's blood pressure medication without specific parameters (numerical or another measurable factor) from the medical provider. This deficient practice could likely lead to the resident having adverse (unwanted, harmful, or abnormal result) side effects or not receiving the desired therapeutic effect of the medication due to it not being administered. The findings are:
A. On 09/14/23 at 8:16 AM, during observation of medication pass and interview CMA #1 did not administer Lisinopril (medication used to treat high blood pressure) 20 mg. CMA #1 stated he was holding the medication because R #63's blood pressure is 94/53 (number for blood pressure reading). Per CMA #1, he holds blood pressure medications if the blood pressure top number is lower than 110 or if the heart rate is 60 or lower. CMA #1 stated that he had already informed the Unit Manager that the blood pressure was low, and that the medication was being held.
B. Record review of R #63's Physician's orders revealed: Order Date 07/27/23; Lisinopril Oral Tablet 20 MG, give 20 mg by mouth one time a day for HTN (Hypertension-high blood pressure) there were no parameters in the order to indicate when medication is to be held.
C. Record review of R #63's Electronic Medical Record revealed that Lisinopril was held on:
1. 09/11/23 No documentation as to why the medication held
2. 09/12/23 No documentation as to why the medication held
3. 09/14/23 Not administered below parameters 94/53 nurse notified.
D. On 09/15/23 at 10:41 AM, during an interview, the DON confirmed that R #63's medication should not be held without an order to hold. The DON stated if there are parameters to hold then the medication can be held and if there are no parameters set then the provider needs to be notified to determine parameters and whether the medication should be held or given.
CONCERN
(E)
Potential for Harm - no one hurt, but risky conditions existed
Deficiency F0679
(Tag F0679)
Could have caused harm · This affected multiple residents
Based on record review and interview, the facility failed to provide an ongoing activity program for 2 (R #1 and R #55) of 4 (R #1, R #43, R #55 and R #179) resident reviewed for activities. If the fa...
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Based on record review and interview, the facility failed to provide an ongoing activity program for 2 (R #1 and R #55) of 4 (R #1, R #43, R #55 and R #179) resident reviewed for activities. If the facility does not ensure that all residents are receiving an ongoing activity program, documenting resident refusals, and making in-room activity accommodations, then residents are likely to demonstrate an increase in isolation and depression. The findings are:
A. On 09/13/23 at 12:05 PM, during an interview, R #1 stated that there is only about four group activities offered in the activity room and the rest are resident room activities or room visits. She stated there are no out of the facility outings and some of the activities listed do not include everyone and no alternatives offered.
B. On 09/12/23 at 9:09 AM, during an interview, R #55 stated he would like to have more group activities It's mostly just bingo and room visits are not really an activity they (activities staff) just come and check on us and see if we are okay and then they leave. Some card games, listening to music or reading some daily news would be nice activities for room visits.
C. Record review of the Activity calendar revealed on 09/13/23:
1. 8:30 AM Daily Chronicles and Daily Activity IR (in room)
2. 9:00 AM- 10:00 AM Coffee Bar AR- (activity room)
3. 9:00 AM Walmart shopping (done by staff once a month)
4. 10:00 AM Prayer of Rosary AR
5. 10:30 Smoke Break CY (court yard for nine smokers)
6. 1:00-11:45 PM One on one room visits IR
7. 2:00 PM Resident council meeting DR (dining room done once a month)
8. 4:00 PM Activity of choice IR
9. 5:30- 6:00 PM Connect 4 game DR (dining room)
C. On 09/19/23 at 2:47 PM during an interview, the Administrator confirmed that Walmart orders are only once a month, Activity room is closed during smoke breaks. The Administrator confirmed that more activities need to be done.
CONCERN
(E)
Potential for Harm - no one hurt, but risky conditions existed
Deficiency F0685
(Tag F0685)
Could have caused harm · This affected multiple residents
Based on record review and interview, the facility failed to ensure residents received adequate and timely transportation to each vision appointment for 3 (R #18, R #25, and R #28) of 3 (R #18, R #25,...
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Based on record review and interview, the facility failed to ensure residents received adequate and timely transportation to each vision appointment for 3 (R #18, R #25, and R #28) of 3 (R #18, R #25, and R #28) residents reviewed for timely transport to vision appointments. If the facility is not assisting residents in accessing treatment to maintain their vision, then residents are likely to lose their ability to see, which will compromise their quality of life. The findings are:
R #18
A. On 09/12/23 at 10:35 AM during and interview, R #18 stated he was not able to go to his eye appointment due to issues with the facility's transportation van's air conditioner not working.
B. Record review of R #18's Care Plan revealed: [name of resident] has vision impairment related to needing glasses to read fine prints.
C. On 09/13/23 at 12:57 PM, during an interview Social Services (SS) stated that she was not aware of an appointment for R #18. SS stated that they are not doing transportation to [name of town] because of the van's broken air conditioner. She stated that she will call the eye clinic and also arrange transportation through Medicaid.
R #25
D. On 09/12/23 at 2:00 PM, during an interview, R #25 stated that he needs an eye appointment and he has told them (staff) several times since his admission. He does not remember the names of the staff he told.
E. Record review of R #25's care plan revealed: Monitor conditions that may contribute to ADL (activities of daily living) decline, including .hearing or vision impairment .
F. On 09/13/23 at 12:34 PM during an interview, SS reported that the previous SS did not schedule R #25's appointment. She also reports that many appointments for residents have been canceled due to the transportation issue.
R #28
G. On 09/12/23 at 1:25 PM, during an interview, R #28 stated she is having issues with her eyes, seeing spots. She stated that she told staff and no appointment has been set due to the transportation van not having air conditioner.
H. Record review of R #28's Care plan revealed:
1. Monitor conditions that may contribute to ADL decline, including: metabolic causes poor nutrition, hearing or vision impairment .
2. Monitor medical conditions that may contribute to major depression, including: hearing or vision impairment .
I. On 09/13/23 at 12:43 PM, during an interview with SS confirmed that she was waiting on an order to make an appointment for R #28.
CONCERN
(E)
Potential for Harm - no one hurt, but risky conditions existed
Deficiency F0688
(Tag F0688)
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 that resident's received appropriate treatment...
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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 that resident's received appropriate treatment and services to prevent further decrease in range of motion for 2 (R #19 and R #59) of 2 (R #19 and R #59) residents reviewed for restorative therapy, when they failed to initiate restorative nursing care (nursing service that often follows skilled rehabilitation services provided by physical or occupation therapists with the goal to maximize function and prevent functional decline in residents dependent on staff for certain actions). This deficient practice could likely result in decreased mobility or a decrease in residents' abilities to participate or perform their own ADL's (activities of daily living). The finding are:
R #19
A. Record review of R #19's MDS (Minimum Data Set; comprehensive assessment) dated 06/30/23 revealed R #19's declined with bed mobility, transfers and toileting and now required extensive assistance as compared to MDS dated [DATE] in which she required only supervision for bed mobility and transfers and limited assistance for toileting.
B. Record review of R #19's Occupational Therapy (OT) Discharge summary dated [DATE] revealed: Discharge recommendations: Restorative Nursing Program (RNP) and 24-hour care.
C. On 09/19/23 at 2:00 PM, during an interview, the DON confirmed that R #19 did not receive Restorative Nursing services (RNP). Per DON she was not made aware of the referral for RNP services, and they (therapy department and the DON) are working on tracking these referrals.
R #59
D. On 09/12/23 at 3:12 PM, during an observation and interview, R #59 was having difficulty placing left leg on wheelchair leg rest. R #59 stated that he is unable to move his left leg. R #59 stated he was in therapy but was discharged . R #59 stated that he thinks he would benefit from therapy.
E. Record review of R #59's Physicians Orders dated 07/10/23 revealed, PT (physical therapy) Clarification order discharge from skilled PT for reaching highest maximum potential effective 08/02/23.
F. Record review of R #59's PT (Physical Therapy) Discharge summary dated [DATE] revealed discharge recommendations RNP continue with the omnicycle bike x (for) 165 minutes to maintain the current ROM (range of motion) of both knees.
G. Record review of R #59's OT Discharge summary dated [DATE] revealed that discharge recommendations for R #59 RNP with a prognosis to Maintain CLOF (current level of functioning) = Good with consistent staff follow-through.
H. Record review of R #59's PT Progress and Discharge summary dated [DATE] revealed, Discharge plans and instructions: D/C (discharge) to same SNF (skilled nursing facility) with RNP.
I. Record review of R #59's Care Plan dated 08/22/23 revealed the following:
1. No Care Plan for R #59's restorative nursing program.
J. On 09/13/23 at 3:06 PM, during an interview, the DON stated the facility doesn't have a Restorative Program with certified restorative aids. The DON confirmed that R #59 has a recommendation for restorative therapy, but that R #59 has not been receiving restorative therapy.
CONCERN
(E)
Potential for Harm - no one hurt, but risky conditions existed
Incontinence Care
(Tag F0690)
Could have caused harm · This affected multiple residents
Based on observation, interview, and record review, the facility failed to ensure appropriate treatment and services for Foley Catheter tubing/Collecting bag (soft plastic or rubber tube that is inser...
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Based on observation, interview, and record review, the facility failed to ensure appropriate treatment and services for Foley Catheter tubing/Collecting bag (soft plastic or rubber tube that is inserted to the bladder to drain the urine and is connected to a collecting bag) care for 1 (R #8) of 1 (R #8) residents sampled for Urinary Catheter, when they failed to keep R #8's Foley catheter and tubing off the floor. This deficient practice could likely result in residents getting infections. The findings are:
A. On 09/12/23 at 9:27 AM, during an observation of 100 Unit revealed R #8's catheter tubing was dragging on the floor while sitting in her wheelchair near the nurse's station.
B. On 09/12/23 at 9:28 AM, during an interview, the Unit Manager (UM) #11 confirmed that R #8's foley tubing was dragging on the floor and that the tubing should not be on the floor.
C. On 09/13/23 at 10:09 AM, during an observation of the Restorative Dining Room, R #8's catheter tubing was dragging on the floor while sitting in her wheelchair.
D. On 09/13/23 at 10:11 AM, during an interview, RN #11 confirmed R #8's catheter tubing was on the floor and that the tubing should not be on the floor.
E. Record Review of R #8's Care Plan dated 06/30/23 revealed R #8 requires an indwelling foley catheter and to keep catheter off the floor.
F. On 09/15/23 at 8:49 AM, during an interview, the DON confirmed that catheter tubing is not supposed to be on the floor.
CONCERN
(E)
Potential for Harm - no one hurt, but risky conditions existed
Deficiency F0745
(Tag F0745)
Could have caused harm · This affected multiple residents
Based on interview and record review, the facility failed to provide social services for 1 (R #3) of 1 (R #3) residents reviewed for behavioral/emotional health, when they failed to refer R #3 to vete...
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Based on interview and record review, the facility failed to provide social services for 1 (R #3) of 1 (R #3) residents reviewed for behavioral/emotional health, when they failed to refer R #3 to veterans facility after he requested to be transferred. This deficient practice could likely result in a resident experiencing anxiety and depression because their concerns with the facility have not been addressed or resolved. The findings are:
A. On 09/12/23 at 1:17 PM, during an interview, R #3 stated that he wants out. He said he is a Veteran and wants to go to a Veterans Home.
B. Record Review of R #3's Care Plan dated 07/08/22 revealed [Name of R #3] is unsure if he will be staying in facility long-term or transitioning back to the community . Make referrals to community-based agencies, providers, and services communicating the residents/patients needs and barriers to care.
C. Record review of a Social Services Assessment and Documentation revealed the following:
1. 01/12/23, Section E Discharge Planning revealed R #3 asked about a possible transition to a Veterans Home but is unable to transition at this time.
2. 04/03/23, Section E Discharge Planning revealed R #3 asked about a possible transition to a Veterans Home but is unable to transition at this time.
3. 06/29/23, Section E Discharge Planning revealed R #3 asked about a possible transition to a Veterans Home but is unable to transition at this time.
D. Record review of Progress Note dated 06/30/23 created by the Nurse Practitioner revealed that R #3 would like a referral for the Veterans nursing home.
E. Record review of R #3's medical records revealed no referrals found.
F. On 09/15/23 at 8:56 AM, during an interview, the DON stated she is aware that R #3 wants to leave. The DON stated R #3 wants to go to a Veterans facility. The DON said they have sent referrals and they haven't found anyone to accept him. The DON stated that Social Services would have the referrals.
G. On 09/15/23 at 9:06 AM, during an interview, the Social Services (SS) stated she has been in the position since the end of July 2023. She said she had not sent any referrals for R #3. She said she was not aware that R #3 was asking to be transferred. SS was not able to find any referrals for R #3, in social services records or R #3's medical record.
H. On 09/15/23 at 9:18 AM, during an interview, the Administrator stated that she knows R #3 wants to leave and stated they have done referrals to facilities. The Administrator said she has talked to R #3 and knows he wants to go to a Veterans Facility. The Administrator stated that SS should have the referrals, and that she would look for them personally.
I. On 09/15/23 at 9:55 AM, during an interview, R #3 stated that the facility had not done any referrals to other facilities.
J. On 09/19/23 at 4:30 PM, during the exit conference the facility was asked to provide any additional documents if found. No referrals were provided.
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
Pharmacy Services
(Tag F0755)
Could have caused harm · This affected multiple residents
**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on record review and interview, the facility failed to ensure pharmaceutical services (the direct, responsible provision o...
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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 pharmaceutical services (the direct, responsible provision of medication-related care) were met for 1 (R #178) of 1 (R #178) residents reviewed for medications when they failed to provide routine medications to residents. This deficient practice could likely lead to unresolved infections, worsening of infection or uncontrolled pain. The findings are:
A. Record review of R #178's Physician's orders revealed: Order date 03/16/23, order start date 03/17/23 vancomycin (antibiotic medication used to treat serious bacterial infections) intravenous (antibiotic given through the vein) use 1.25 gram every 12 hours for MRSA (methicillin-resistant staphylococcus aureus; infection caused by specific bacteria that are resistant to commonly used antibiotics) septicemia (serious blood stream infection) and osteomyelitis (infection in the bone) R (right) BKA (below knee amputation) stump (the end of a body part after the rest is removed) until 04/17/2023
B. Record review of R #178's Electronic Medical Record (EMR) revealed missed doses for vancomycin antibiotic as follows:
1) 03/17/23 at 11:45 AM Vanco (vancomycin) not available from [name of pharmacy]
2) 03/17/23 at 8:51 PM med not available
4) 03/18/23 at 9:00 AM H (medication held)
5) 03/18/23 at 9:00 PM H (medication held)
6) 03/19/23 at 12:06 AM Someone has placed a hold on his (R #178's) vancomycin and is asking for clarification.
7) 03/19/23 at 9:00 AM vancomycin was started and administered.
C. On 09/19/23 at 2:12 PM, during an interview, the DON confirmed that R #178's medication was not started until two days after the order start date. Per the DON the resident was admitted on [DATE] and the pharmacy did not process the order for the antibiotic until 03/18/23 at 10:05 AM so the medication was not delivered until 03/19/23.
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 pharmacy recommendations were followed after the Physician accepted them for 3 (R #19, R #28 and R #68) of 5 (R #19, R #28, R #...
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Based on record review and interview, the facility failed to ensure that pharmacy recommendations were followed after the Physician accepted them for 3 (R #19, R #28 and R #68) of 5 (R #19, R #28, R #48, R #55 and R #68) residents reviewed for unnecessary medications. This deficient practice could likely result in residents being at a higher risk of adverse side effects. The findings are:
R #19
A. Record review of Pharmacy Consultation Report Recommendation, dated 07/31/23, revealed:
1.Please monitor valproic acid [medication is used to treat mental/mood conditions such as manic phase (over-the-top level of activity or energy, mood or behavior) of bipolar disorder (serious mental illness characterized by extreme mood swings)] trough concentration (lowest concentration of medication in blood just prior to the administration of the next dose)
2. Please monitor a fasting lipid panel (lipid panel is a panel of blood tests used to find abnormalities in lipids, such as cholesterol and triglycerides) .
3. The form was marked I accept the recommendation .
4. The form was signed by the physician
B. Record review of R #19's Electronic Medical Record (EMR) revealed no valproic acid level and no lipid panel laboratory work had been completed.
C. On 09/19/23 at 4:45 PM, during an interview, the DON confirmed R #19's recommended lab work had not been completed after the physician accepted the pharmacist's recommendation, and had actually been drawn that morning (09/19/23).
R #28
D. Record review of R #28's admission sheet revealed an admission date of 06/18/19.
R #28's Consultation Report (Pharmacy review), dated June 2023, revealed:
1. Comment: [name of resident] receives Simvastatin (treat high cholesterol and triglyceride (fat) levels in the blood) and does not have a fasting lipid panel (a panel of blood tests used to find abnormalities in lipids, such as cholesterol and triglycerides) documented in the medical records in the previous 12 months. Please monitor a fasting lipid panel .
2. Physician response: I accept the recommendations.
E. Record review of R #28's Physician's Orders as of 09/14/23 revealed: No current order for Lipid panel.
R #68
F. Record review of Pharmacy Consultation Report Recommendation, date 07/31/23, revealed:
1.[name of R #68] receives three or more CNS (Central nervous system which included brain and spinal cord) active medications (medication which can slow brain activity, making them useful for treating anxiety, panic and acute stress reactions) cause an increased risk for falls and fractures Please reevaluate this combination.
2. The form was marked I accept the recommendation with the following modification: D/C (discontinue) hydroxyzine (an antihistamine that can treat anxiety and especially insomnia).
3. The form was signed by the physician
G. Record review of R #68's Physician's Orders revealed the following hydroxyzine orders:
1. Order date 07/25/23, order end date 08/08/23: hydroxyzine Tablet 50 mg Give 1 tablet by mouth every 8 hours as needed for ANXIETY for 14 Days.
2. Order date 08/08/23, order discontinue date 08/18/23: hydroxyzine Tablet 50 mg Give 1 tablet by mouth every 8 hours as needed for ANXIETY for 14 Days.
3. Order date 09/04/23, order end date 09/18/23: hydroxyzine Tablet 50 mg Give 1 tablet by mouth every 8 hours as needed for ANXIETY for 14 Days.
H. On 09/19/23 at 2:51 PM, during an interview, the DON confirmed that R #68's hydroxyzine had been reordered after the physician had accepted the pharmacy recommendation. The DON confirmed there was no documentation of increased behaviors or anxiety in R #68's EMR to indicate the need for the medication to be restarted.
CONCERN
(E)
Potential for Harm - no one hurt, but risky conditions existed
Medication Errors
(Tag F0758)
Could have caused harm · This affected multiple residents
Based on record review and interview, the facility failed to ensure residents did not receive antipsychotic medications unless the medication was necessary to treat a specific psychiatric condition or...
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Based on record review and interview, the facility failed to ensure residents did not receive antipsychotic medications unless the medication was necessary to treat a specific psychiatric condition or diagnosis and was documented in the medical record for 1 (R #19) of 5 (R #19, R #28, R #48, R #55, and R #68) residents reviewed for unnecessary medications.
This deficient practice could likely result in residents receiving medications without a clinical indication (medical reason) and being at a higher risk of adverse side effects (unwanted, harmful, or abnormal result). The findings are:
A. Record review of R #19's physician's orders revealed: Order start date 06/06/22, Risperdal (antipsychotic medicine that works by changing the effects of chemicals in the brain used to treat mental/mood disorders such as schizophrenia or bipolar disorder) solution (liquid form of medication) Give 0.5 ml by mouth two times a day for dementia with behaviors (condition that causes problems with thinking, memory and reasoning that can include behaviors of confusion, sleep deprivation and wandering).
B. Record review of R #19's Medical Record revealed no psychiatric diagnosis to indicate the need for an antipsychotic.
C. On 09/19/23 at 4:45 PM, during an interview, the DON confirmed R #19 did not have a psychiatric diagnosis on file for the antipsychotic medication. The DON stated the physician ordered the antipsychotic medication for R #19's dementia and behaviors.
CONCERN
(E)
Potential for Harm - no one hurt, but risky conditions existed
Deficiency F0761
(Tag F0761)
Could have caused harm · This affected multiple residents
Based on observation and interview, the facility failed to properly store medications, when they failed to:
1. Dispose of loose tablets stored in the medication carts for the 100, 200, and Memory Care...
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Based on observation and interview, the facility failed to properly store medications, when they failed to:
1. Dispose of loose tablets stored in the medication carts for the 100, 200, and Memory Care Units.
2. Ensure medication was not expired in the medication refrigerator.
3. Document temperatures for the 100 Unit medication refrigerator.
This could affect all 81 residents in the facility (Residents were identified by the resident matrix provided by the Administrator on 09/11/23). These deficient practices could likely result in residents obtaining medications that are no longer effective or that are not prescribed to them resulting in adverse side effects. The findings are:
100 Unit Medication Cart
A. On 09/18/23 at 10:47 AM, during an observation of the 100 Unit Medication Cart revealed the following:
1. Ten loose tablets in the medication cart,
2. One loose capsule in the medication cart.
B. On 09/18/23 at 10:54 AM, during an interview, CMA #1 confirmed the there were ten loose tablets and one loose capsule in the medication cart.
100 Unit medication storage room
C. On 09/18/23 at 11:03 AM, during an observation of the 100 Unit medication storage room refrigerator revealed the following:
1. Influenza vaccine Fluzone High Dose expired 06/30/23,
2. Influenza Vaccine Fluzone Quadrivalent expired 06/30/23,
3. Infuvite adult multiple vitamins injection 01/23.
D. On 09/18/23 at 11:07 AM, during an interview, CMA #1 confirmed the two Fluzone vaccines and the Infuvite adult multiple vitamins injection were expired.
200 Unit Medication Cart
E. On 09/18/23 at 2:27 PM, during an observation of 200 Unit Medication Cart, two surveyors observed the medication cart drawer with tightly packed meditation sheets and revealed two tablets loose in the medication cart.
F. On 09/18/23 at 2:28 PM, during an interview, CMA #11 confirmed the loose tablets.
Memory Care Unit Cart
G. On 09/18/23 at 2:45 PM, during an observation of the Memory Care Unit Cart, one loose tablet in the medication cart.
H. On 09/18/23 at 2:46 PM, during an interview, the DON confirmed the loose tablet in the cart.
I. On 09/18/23 at 2:52 PM, during an interview, the DON confirmed loose medications should not be in the medication carts, and staff should check the medication carts daily. The DON also confirmed staff should remove expired medications from the refrigerator and destroy them.
Medication Refrigerator
J. Record review of the medication refrigerator temperature logs on the 100 Unit revealed the following:
1. 09/02/23, was blank,
2. 09/03/23, was blank,
3. 09/10/23, was blank,
4. 09/16/23 was blank,
5. 09/17/23 was blank.
K. On 09/18/23 at 2:37 PM, during an interview CMA #1 confirmed the missing dates on the temperature logs for 100 Unit refrigerator.
L. On 09/18/23 at 2:52 PM, during an interview, the DON confirmed that there were blank dates on the temperature log and was not sure if the temperatures were taken on those days or not and stated that the medication refrigerator temperatures should be checked daily and documented.
CONCERN
(E)
Potential for Harm - no one hurt, but risky conditions existed
Food Safety
(Tag F0812)
Could have caused harm · This affected multiple residents
Based on observation and interview, the facility failed to store and serve food under sanitary conditions in accordance with professional standards of food service safety for 80 residents that eat foo...
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Based on observation and interview, the facility failed to store and serve food under sanitary conditions in accordance with professional standards of food service safety for 80 residents that eat food prepared in the kitchen in the facility (residents were identified on the resident matrix provided by the Administrator on 09/11/23), when they failed to:
1. Keep the deep freezer and kitchen floors clean,
2. Wear facial hairnets in the kitchen,
3. Failed to keep the stoves and surrounding areas clean from grease,
4. Ensure that spices in the kitchen are labeled and dated,
5. Ensure that food and spices are sealed properly after opening.
If the facility fails to adhere to safe food handling practices, hygiene practices, and safe food storage, residents could likely to be exposed to foodborne illnesses (illness caused by food contaminated with bacteria, viruses, parasites, or toxins). The findings are:
A. On 09/11/23 at 11:03 AM, during an observation of the kitchen revealed the following:
1. The floors in the freezer and kitchen had food particles, paper, fluids, and were sticky,
2. One bag of tater tots not sealed or dated in the freezer,
3. Ricotta cheese, with unreadable open date and expiration date, was in the refrigerator. The container of ricotta cheese had mold on the outside and inside on the cheese.
4. The Dietary Assistant (DA) #11 did not have a facial hairnet covering his moustache.
B. On 09/11/23 at 11:10 AM, during an observation of the dry storage revealed the following:
1. One large plastic container of sugar with a warped lid that did not stay sealed. The container had a date of 08/21 (no year provided),
2. One large plastic container of panko bread crumbs with a warped lid that did not stay sealed. The container had a date of 08/14 (no year provided),
3. Three bags of cereal not sealed and no expiration date,
4 One bag of elbow pasta was not sealed, no open dates, and no expiration dates,
5. Two bags of wheat penne pasta not sealed, no open dates, and no expiration dates.
C. On 09/11/23 at 11:17 AM, during an observation of the spice shelf revealed the following:
1. One container of chicken flavored spice did not have an open date,
2. One container of beef flavored spice not sealed and no expiration date,
3. One open, small bowl with an unknown white granular substance, not dated or sealed.
D. On 09/11/23 at 11:16 AM, during an interview, the Dietary Manager confirmed the floors were dirty in the kitchen and the liquid spills and crumbs in the freezer. The Dietary Manager also said staff should always wear facial hairnets in the kitchen if they have a beard or moustache. The Dietary Manager confirmed the open bags of cereal and noodles with no expiration and no dates and said all food should be sealed and labeled with received, opened, and expiration dates. The Dietary Manager confirmed the spices on the shelf without dates and not sealed. The Dietary Manager said staff should properly seal all spices and there should not be any spices in an open bowl without labels and not sealed.
E. On 09/11/23 at 11:18 AM, during an interview the DA #11 confirmed he did not wear a facial hairnet.
F. On 09/15/23 at 10:19 AM, during an observation of the kitchen revealed the following:
1. Stoves and griddle were heavily covered in oil and flour and burnt crumbs of food,
2. The floor under and around the appliances on the walls and sides of appliances were covered in old built-up oil,
3. The floors in the kitchen had food and were sticky.
G. On 09/15/23 at 10:37 AM, the Dietary Manager confirmed there was oil, crumbs, and build up on the stoves, griddle, and surrounding areas. The Dietary Manager also confirmed that the floors were not clean.
CONCERN
(E)
Potential for Harm - no one hurt, but risky conditions existed
Medical Records
(Tag F0842)
Could have caused harm · This affected multiple residents
Based on record review and interview, the facility failed to ensure documents were complete and accurate for 1 (R #43) of 1 (R #43) residents who were reviewed for documentation, when they failed to a...
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Based on record review and interview, the facility failed to ensure documents were complete and accurate for 1 (R #43) of 1 (R #43) residents who were reviewed for documentation, when they failed to accurately document R #43's participation in activities. This deficient practice could likely result in staff not having the information they need to provide competent, comprehensive care and services if vital information is missing from the documents. The findings are:
A. Record review of R #43's Care Plan, revision date 09/07/23, revealed the following:
1. Encourage R #43's participation in activities,
2. Provide R #43 with opportunities for choice during care/activities to provide a sense of control.
B. Record Review of R #43's Activity Participation Log, dated September 2023, revealed the following:
1. Independent engagement for 09/14/23, staff documented as limited involvement,
2. Individual Engagement for 09/14/23, staff documented as minimal to no response,
3. Room to Room for 09/14/23, staff documented as sleeping,
4. Independent Engagement for 09/15/23, staff documented as minimal to no response,
5. Room to Room for 09/15/23, staff documented as sleeping.
C. On 09/13/23 at 1:54 PM, during an interview, the Director of Activities confirmed staff documented future dates on R #43's Activity Participation Log. The Director of Activities stated it is not acceptable to chart or document in the future when it hasn't happened yet.
CONCERN
(F)
Potential for Harm - no one hurt, but risky conditions existed
Room Equipment
(Tag F0908)
Could have caused harm · This affected most or all residents
Recite from 08/10/22
Based on observation and interview, the facility failed to ensure essential equipment (vitally important; absolutely necessary) was in safe operating condition when the facility f...
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Recite from 08/10/22
Based on observation and interview, the facility failed to ensure essential equipment (vitally important; absolutely necessary) was in safe operating condition when the facility failed to ensure:
1. The transportation vehicle (transportation van used by facility to transport residents to and from appointments as needed) had a working air conditioner,
2. The kitchen stove had knobs used to control the gas burners.
If essential equipment is not in working order then residents could likely not be able to achieve the highest practicable well being because they are unable to go to medical appointments or get food prepared on the stove. The findings are:
Facility Van
A. On 09/12/23 at 8:47 AM, during an interview, R #42 reported he had a dental appointment tomorrow in town. R #42 stated he did not know if he was going to go because the facility is having transportation issues due to the van not having an operating air conditioner.
B. On 09/12/23 at 10:35 AM, during and interview, R #18 reported he did not go to an eye appointment, because the van's air conditioner did not work.
C. On 09/12/23 at 2:00 PM, during an interview, R #25 stated he needed an eye appointment, and he told the staff several times since his admission. R #25 stated he has not had an appointment due to the van issues.
D. On 09/12/23 at 1:25 PM, during an interview, R #28 stated she had issues seeing spots, and she told staff about it. R #28 stated staff have not made an appointment due to transportation issues.
E. On 09/13/23 at 2:00 PM, during a resident council meeting with R #18, R #37, R #38, R #40, R #42, R #46, and R #54, the residents expressed a concern regarding the facilities van issues not being addressed. The residents also stated the van issues caused them to miss or cancel appointments and not go on social outings.
F. On 09/19/23 at 3:01 PM, during an interview, the Administrator stated she was aware of the issues with the van's air conditioner (does not work) and window issues (do not roll down). The Administrator reported she followed up with her Corporate office weekly for updates on resolving the van's issues. In the meantime, staff scheduled the resident's appointments before 11:00 AM due to the summer temperatures. The Administrator also stated residents should go to their appointments regularly.
Kitchen
G. On 09/15/23 at 10:37 AM, during an observation of the facility kitchen revealed five out of eight knobs on the gas stove were missing.
H. On 09/15/23 at 10:40 AM, during an interview, the Dietary Manager confirmed that the knobs were missing.
Aug 2022
22 deficiencies
CONCERN
(D)
Potential for Harm - no one hurt, but risky conditions existed
Deficiency F0637
(Tag F0637)
Could have caused harm · This affected 1 resident
Based on interview and record review the facility failed to complete a significant change Care Area Assessment MDS (Minimum Data Set assessment) for 1 (R #74) of 1 (R #74) residents reviewed for death...
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Based on interview and record review the facility failed to complete a significant change Care Area Assessment MDS (Minimum Data Set assessment) for 1 (R #74) of 1 (R #74) residents reviewed for death when the resident had a Change In Condition ([CIC] decline or improvement in a resident's overall status that impacts more than one area of the resident's health status; and requires interdisciplinary review) and was placed on palliative care (medical caregiving approach aimed at optimizing quality of life and mitigating suffering among people with serious, complex, and often terminal illnesses). This deficient practice could likely result in resident not receiving the care they need due to the change of condition. The findings are:
A.
Record review of R #74'S Progress Notes revealed 04/06/22 resting unable to stay awake, color pale, Blood Pressure (pressure of the blood in the circulatory system [system of organs that includes the heart, blood vessels, and blood which is circulated throughout the entire body of a human] often measured for diagnosis due to being closely related to the force [strength of movement that occurs as blood pumps out of the heart] and rate [number of times your heart beats per minute] of the heartbeat) 75/43-69/35 [numbers indicating the residents low blood pressure reading; normal blood pressure is 120/70] Pt [abbreviation for patient] states she is unable to stay awake .pt. understands instruction but unable to stay awake. Pt. has become incontinent of urine[loss of bladder control resulting in one urinating on themselves]).
B.
Record review of R #74'S Progress Notes revealed 04/06/22 Family has requested that (name of resident) be placed on hospice due to decline in condition.
C.
Record review of R #74's Physician's Orders revealed, Order Date 04/12/22 Hospice to evaluate and treat.
D.
Record review of R #74's medical records revealed that a hospice evaluation was completed on 04/12/22 but the resident was not admitted to hospice.
E.
Record review of R #74's Progress Notes revealed 04/19/22 IDT (professionals from diverse fields who work in a coordinated fashion toward a common goal for the patient) met recently had a decline and her family changed her code status to palliative care [comfort care]
F.
On 08/09/22 at 3:14 PM, during an interview, the MDS Nurse stated that R #74's bed mobility fluctuated from limited to extensive assistance and she (R #74) declined in toileting from independent to extensive assistance. She (R #74) would fluctuate in her assistance that month (April 2022) just prior to her death (05/06/22) there was not an overall decline. I didn't trigger for a CIC.
CONCERN
(D)
Potential for Harm - no one hurt, but risky conditions existed
Deficiency F0660
(Tag F0660)
Could have caused harm · This affected 1 resident
Based on record review and interview, the facility failed to develop and implement an effective discharge planning process that had resident's discharge goals for 1 (R #72) of 1 (R #72) resident revie...
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Based on record review and interview, the facility failed to develop and implement an effective discharge planning process that had resident's discharge goals for 1 (R #72) of 1 (R #72) resident reviewed for discharge planning. This deficient practice has the potential to complicate or prevent smooth and safe transitions from the facility to the residents' post-discharge settings. The findings are:
A. Record review of R #72's Face Sheet revealed admission date of 07/15/22.
B. Record review of R #72's Progress Notes revealed no documentation on a Discharge Plan.
C. Record review of R #72's Care Plan revealed the following:
1. 07/21/22 . [name of the resident] has potential for discharge, or is expected to be discharged .
D. On 08/03/22 at 9:43 AM, during an interview, the Director of Social Services confirmed that no Discharge Plan was in place for R #72 upon admission. She stated, we had a meeting yesterday [08/02/22] about his discharge, prior to that we did not talk to him about his discharge plan.
CONCERN
(D)
Potential for Harm - no one hurt, but risky conditions existed
Drug Regimen Review
(Tag F0756)
Could have caused harm · This affected 1 resident
Based on interview, and record review, the facility failed to keep resident free from unnecessary psychotropic mediations (any medication capable of affecting the mind, emotions, and behavior) for 1 (...
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Based on interview, and record review, the facility failed to keep resident free from unnecessary psychotropic mediations (any medication capable of affecting the mind, emotions, and behavior) for 1 (R #8) of 2 (R #8, and R #46) residents reviewed for unnecessary medications, when they failed to:
Follow the pharmacy recommendations and initiate a Gradual Dose Reduction (attempt to lower the dose of medication) (GDR) for R #8's Quetiapine (medication to treat bipolar disorder) (episodes of mood swings ranging from low to high) medication.
This deficient practice could likely result in residents receiving medication without an appropriate clinical indication (reason), and for longer than needed, resulting in adverse side effects. The findings are:
A. Record review of R #8's Pharmacy Consultation Report dated 05/26/22 revealed the following:
1. Comment:
. repeated recommendation from 03/31/22. [name of the R #8] has received Quetiapine 25 mg QHS (every night) for dementia (A group of symptoms that affects memory, thinking and interferes with daily life) since 12/29/21. She also received Mirtazapine (medication to treat depression).
2. Recommendation:
For the initial attempt at a GDR, please reduce Quetiapine to 12.5 mg QHS with the end goal of discontinuation.
3. Physician's Response:
I accept the recommendation above, please implement as written.
4. 04/11/22 Nurse Practitioner declined GDR related to unsuccessful attempts previously.
5. 05/31/21 Spoke with residents Power of Attorney (POA), does not agree with GDR.
B. Record review of R #8's Face Sheet no date revealed the following diagnosis of:
1. Unspecified dementia (chronic disorder of mental process, can cause personality changes, impaired reasoning, and memory problem) without behavioral disturbances.
2. Restlessness and agitation.
C. Record review of R #8's Physician's Orders revealed the following:
1. 12/29/21 . Quetiapine 25 milligram, give one tablet by mouth at bedtime .
2. 10/30/21 . Mirtazapine 15 mg, give one tablet by mouth every evening .
D. Record review of R #8's Medication Administration Record (MAR) for August 2022 revealed the following:
1. Quetiapine 25 mg was documented as given at bedtime as ordered.
2. Mirtazapine 15 mg was documented as given every evening as ordered.
E. On 08/09/22 at 12:56 PM, during an interview with DON about not following the pharmacy recommendations, performing GDR, and decreasing R #8's medication, she stated at first Medical Director (MD) accepted the pharmacy recommendations, but R #8's POA refused and did not agree with the changes. They believed changing the dose of medication could affect the resident's mental health. We notified the MD, and no changes were made in the dose of the medication Quetiapine. She confirmed that facility failed to document the MD's rationale for declining the pharmacy recommendation and performing the GDR.
CONCERN
(D)
Potential for Harm - no one hurt, but risky conditions existed
Medication Errors
(Tag F0758)
Could have caused harm · This affected 1 resident
Based on interview, and record review, the facility failed to keep resident free from unnecessary psychotropic mediations (any medication capable of affecting the mind, emotions, and behavior) for 1 (...
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Based on interview, and record review, the facility failed to keep resident free from unnecessary psychotropic mediations (any medication capable of affecting the mind, emotions, and behavior) for 1 (R #8) of 2 (R #8, and R #46) residents reviewed for unnecessary medications, when they failed to:
Follow the pharmacy recommendations and initiate a Gradual Dose Reduction (attempt to lower the dose of medication) (GDR) for R #8's Quetiapine (medication to treat bipolar disorder) (episodes of mood swings ranging from low to high) medication.
This deficient practice could likely result in residents receiving medication without an appropriate clinical indication (reason), and for longer than needed, resulting in adverse side effects. The findings are:
A. Record review of R #8's Pharmacy Consultation Report dated 05/26/22 revealed the following:
1. Comment:
. repeated recommendation from 03/31/22. [name of the R #8] has received Quetiapine 25 mg QHS (every night) for dementia (A group of symptoms that affects memory, thinking and interferes with daily life) since 12/29/21. She also received Mirtazapine (medication to treat depression).
2. Recommendation:
For the initial attempt at a GDR, please reduce Quetiapine to 12.5 mg QHS with the end goal of discontinuation.
3. Physician's Response:
I accept the recommendation above, please implement as written.
4. 04/11/22 Nurse Practitioner declined GDR related to unsuccessful attempts previously.
5. 05/31/21 Spoke with residents Power of Attorney (POA), does not agree with GDR.
B. Record review of R #8's Face Sheet no date revealed the following diagnosis of:
1. Unspecified dementia (chronic disorder of mental process, can cause personality changes, impaired reasoning, and memory problem) without behavioral disturbances.
2. Restlessness and agitation.
C. Record review of R #8's Physician's Orders revealed the following:
1. 12/29/21 . Quetiapine 25 milligram, give one tablet by mouth at bedtime .
2. 10/30/21 . Mirtazapine 15 mg, give one tablet by mouth every evening .
D. Record review of R #8's Medication Administration Record (MAR) for August 2022 revealed the following:
1. Quetiapine 25 mg was documented as given at bedtime as ordered.
2. Mirtazapine 15 mg was documented as given every evening as ordered.
E. On 08/09/22 at 12:56 PM, during an interview with DON about not following the pharmacy recommendations, performing GDR, and decreasing R #8's medication, she stated at first Medical Director (MD) accepted the pharmacy recommendations, but R #8's POA refused and did not agree with the changes. They believed changing the dose of medication could affect the resident's mental health. We notified the MD, and no changes were made in the dose of the medication Quetiapine. She confirmed that facility failed to document the MD's rationale for declining the pharmacy recommendation and performing the GDR.
CONCERN
(D)
Potential for Harm - no one hurt, but risky conditions existed
Dental Services
(Tag F0791)
Could have caused harm · This affected 1 resident
Based on interview and record review the facility failed to schedule an appointment for dental services for 1 (R #23) of 2 (R #23 and R #47) residents reviewed for dental services. This deficient prac...
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Based on interview and record review the facility failed to schedule an appointment for dental services for 1 (R #23) of 2 (R #23 and R #47) residents reviewed for dental services. This deficient practice could likely lead to unnecessary dental pain. The findings are:
A.
On 08/02/22 at 9:47 AM during an interview with R #23's son, when asked if he had any concerns regarding her teeth or gums stated she (R #23) had some dental pain a while back I'm not sure if she ever went to the dentist to get the bad tooth out or not.
B.
Record Review of R #23's progress notes revealed 05/09/22 2:10 PM (Name of Medical Director) notified, POA (Power of Attorney; person who is responsible for making health care decisions) called, and message left for call back. Resident asked if in pain she replied yes but couldn't not tell me where most of her teeth are missing or broken down to gumline. Awaiting call back from resident POA
C.
Record review of R #23's Progress Notes revealed 05/09/2022 2:42 PM An oral health evaluation was completed lost tooth during mealtime today Pt (patient) has no verbal or non-verbal signs of dental pain. Pt care plan has been initiated including obtaining a dental consult as needed based on evaluation results.
D.
Record review of R #23's Progress Notes revealed nutrition note 05/14/2022 1:19 PM Intakes recently diminished, 25-50% some meals refused. Resident recently lost a tooth, has indicated dental pain Dental consult pending.
E.
On 08/10/22 at 3:32 PM, during an interview, the Administrator confirmed that the resident had not been to the dentist this year.
CONCERN
(E)
Potential for Harm - no one hurt, but risky conditions existed
Resident Rights
(Tag F0550)
Could have caused harm · This affected multiple residents
Based on observation, interview, and record review the facility failed to ensure that residents were treated with respect and dignity for 3 (R #14, R #19, and R #223) of 3 ( R #14, R #19, and R #223) ...
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Based on observation, interview, and record review the facility failed to ensure that residents were treated with respect and dignity for 3 (R #14, R #19, and R #223) of 3 ( R #14, R #19, and R #223) residents randomly sampled for dignity, when the facility failed to:
1)Provide a dignity cover for R # 14's Foley catheter bag (soft plastic or rubber tube that is inserted to the bladder to drain the urine and is connected to a collecting bag).
2)Change R #19's clothing after he spilled food on his shirt at mealtime and
3) Knock on R #223's door prior to entering.
If the facility is not treating residents with respect and dignity, then residents are likely to feel embarrassed and that their feelings and preferences are unimportant to facility staff. The findings are:
R #14
A. On 08/02/22 at 10:11 AM during observation in the 200 Unit, R #14's catheter bag was observed laying on top of R #14's bed without a dignity cover (a bag or cover used to conceal the urine in the catheter bag).
B. On 08/02/22 at 10:14 AM during an interview, R #14 confirmed that her catheter bag did not have a dignity cover.
C. On 08/04/22 at 11:15 AM during an interview with DON, she confirmed that all catheters must have a dignity cover.
R # 19
D. On 08/01/22 at 2:08 PM, during an observation of R #19's room, revealed he was sitting on the side of his bed with a large yellow stain (food stains) on his shirt (the last meal/lunch was served around 12:00 pm).
E. On 08/01/22 at 2:10 PM, during an interview with RN #21 she confirmed that resident's clothes should be clean and free from any stain. RN #1 stated, sometimes he refuses to change his clothes, but I had not personally offered to help him change his shirt.
F. On 08/08/22 at 12:18 PM, during an interview with the DON, she confirmed that R #19's shirt was not changed after his meal and staff did not offer to help him change it. She stated resident's clothes should be clean with appropriate appearance.
R #223
G. On 08/04/22 at 9:50 AM, during an observation of R #223's room, RN #22 was observed walking into R #223's room to medicate the resident. RN #22 did not knock on the door prior to entering the room.
H. On 08/04/22 at 9:51 AM, during and interview, RN #22 confirmed that he should have knocked on the residents' door before entering.
I. On 08/08/22 at 12:20 PM, during an interview, the DON confirmed that staff should knock before entering resident's rooms.
J. Record review of the facility policy for Resident Rights Under Federal Law revision date 03/01/22 revealed the following:
Purpose:
.To treat each resident with respect and dignity and care for each resident in a manner and in an environment that promotes maintenance or enhancement of his/her self esteem and self worth.
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 give resident council feedback on their concerns for 5 (R #9, R #14, R #22, R #52, and R #66) of 8 (R #2, R #9, R #14, R #22, R #52, R #57, R #61, and R #66)...
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Based on interviews the facility failed to give resident council feedback on their concerns for 5 (R #9, R #14, R #22, R #52, and R #66) of 8 (R #2, R #9, R #14, R #22, R #52, R #57, R #61, and R #66) residents reviewed for the Resident Council Meeting. If the facility does not ensure that the Resident Council grievances are responded to and resolved, then residents are likely to feel that their issues and/or concerns are not taken seriously. The findings are:
A.
On 08/08/22 at 1:52 PM, during a meeting with the Resident Council, when asked if the facility responded and acted promptly to grievances/issues and recommendations, the response from some of the members present (R #9, R 14, R #22, R #52, and R #66) was that they don't have anyone get back to them regarding their grievances.
B.
On 08/08/22 at 1:52 PM, during the meeting R #9 stated that, For example, The air conditioner on the transportation van has not been working for 2 months. We don't know what is going to happen to fix it. We are just being told that we will go to our appointments in the morning.
C.
On 08/09/22 at 12:44 PM, during an interview with the Social Services Director (SSD), when asked about grievances she stated that grievances are taken by the person that the resident speaks to, there is no specific person that is assigned to handle grievances. The SSD confirmed that the air conditioner on the van has not been working for approximately 2 months and she has been rescheduling all of the appointments for the morning.
CONCERN
(E)
Potential for Harm - no one hurt, but risky conditions existed
Deficiency F0576
(Tag F0576)
Could have caused harm · This affected multiple residents
Based on interview the facility failed to ensure that residents received unopened mail for 2 (R #14 and R #66) of 8 (R #2, R #9, R #14, R #22, R #52, R #57, R #61, and R #66) residents reviewed for Re...
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Based on interview the facility failed to ensure that residents received unopened mail for 2 (R #14 and R #66) of 8 (R #2, R #9, R #14, R #22, R #52, R #57, R #61, and R #66) residents reviewed for Resident's Right to privacy when they send or receive mail. This deficient practice could likely result in residents feeling like their privacy is not important. The findings are:
A.
08/08/22 at 2:18 PM, during a meeting with the Resident Council, when asked if the facility delivered their mail unopened to them, the response from some of the members present (R #14 and R #66) was that they have received their mail opened sometimes.
B.
On 08/08/22 at 2:22 PM, during the meeting, R #14 stated, My mail was sitting here on the table in the activities room, another resident was going through my mail. The activities staff said they hadn't had time to get around to delivering the mail yet.
C.
On 08/08/22 at 2:24 PM, during the meeting R #66 stated, My mail has been opened before it is given to me, especially my letters from the Social Security office.
D.
On 08/09/22 at 3:05 PM, during an interview, the Administrator stated that resident's mail should not be opened but she doesn't handle the mail. Administrator told me to speak with the receptionist, she is the one who hands out resident's mail.
E.
On 08/09/22 at 3:47 PM, during an interview, the receptionist stated that she assists with handing out resident's mail and confirmed that mail is opened if the Business office Manager needs a copy, it is then given to the resident opened.
CONCERN
(E)
Potential for Harm - no one hurt, but risky conditions existed
Deficiency F0583
(Tag F0583)
Could have caused harm · This affected multiple residents
Based on observation and interview the facility failed to protect the resident's privacy when they failed to replace the broken blinds covering R #50's window. This deficient practice could likely res...
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Based on observation and interview the facility failed to protect the resident's privacy when they failed to replace the broken blinds covering R #50's window. This deficient practice could likely result in residents experiencing embarrassment or humiliation. The findings are:
A. On 08/01/22 at 11:36 AM, during an observation of R #50's room revealed the blinds covering resident's window were broken and resident may be exposed from outside during personal care. R #50's bed was located against the window with broken blinds.
B. On 08/01/22 at 11:38 AM, during and interview RN #21 confirmed that the blinds were broken and missing several sections. She stated, Per Maintenance Director, the blinds are in back order.
C. On 08/08/22 at 12:25 PM, during an interview, the DON confirmed that the facility failed to replace the broken blinds covering R #50's window and stated, to protect the resident's privacy the blinds should not be broken or missing sections.
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 interviews the facility failed to ensure that residents were aware of the process to file a grievance. This deficient practice has the potential to affect all 75 residents (Identified by the ...
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Based on interviews the facility failed to ensure that residents were aware of the process to file a grievance. This deficient practice has the potential to affect all 75 residents (Identified by the Resident Matrix provided by the administrator on 08/01/22) If the facility does not ensure that residents are not sure how to file grievances, then residents are likely to feel that their issues and/or concerns are not taken seriously. The findings are:
A.
On 08/08/22 at 1:52 PM, during an interview, when asked if they (R #2, R #9, R #14, R #22, R #52, R #57, R #61, and R #66) knew how to file a grievance, R #14, R #22 and R #66 stated that they could speak to any staff member. R #2, R#9, R #52, R#57 and R #61 stated they were unsure of the process or the person to speak to in order to file a grievance.
B.
On 08/08/22 at 1:55 PM, during an interview R #14 and R #66 stated that the facility did not have a specific person in charge of grievances, and they did not get responses or updates on their grievances.
C.
On 08/09/22 at 12:44 PM, during an interview with the Social Services Director (SSD), when asked about grievances stated that grievances are taken by any person that the resident speaks to. The SSD confirmed that there is not a specific person that handles grievances.
CONCERN
(E)
Potential for Harm - no one hurt, but risky conditions existed
Free from Abuse/Neglect
(Tag F0600)
Could have caused harm · This affected multiple residents
Based on observation, interview, and record review the facility failed to keep residents free from neglect for 1 (R #223) of 1 (R #223) resident reviewed for neglect when resident was left on bed soak...
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Based on observation, interview, and record review the facility failed to keep residents free from neglect for 1 (R #223) of 1 (R #223) resident reviewed for neglect when resident was left on bed soaked through his depend (adult diaper), clothes, and bed sheet for an extended period because no one was available to change him.
This deficient practice could likely result in resident suffering from lack of care and feel embarrassed. The findings are:
A. On 08/04/22 at 10:05 AM, an observation of R#223's room revealed, resident was laying down of his bed, soaked in his urine and feces, contaminated all the way to his back.
B. On 08/04/22 at 10: 08 AM, during an interview, R #223 stated I have not been changed since last night.
C. On 08/04/22 at 10:09 AM, during an interview, RN #22 confirmed R #223 was left soaked through his depend, clothes, and bed sheet and stated, this is not acceptable to leave the resident in this condition.
D. On 08/04/22 at 2:54 PM, during an interview with R #223, he stated, when they [staff] left me soaked in my urine and did not get me up since the night before, I felt awful, being in that situation made me feel very depressed and anxious. I have pain to my back and pelvic area, all my body hurts. I do not want to be here, but I have no choice because I cannot take care of myself anymore, so I guess I have to get used to this environment.
E. Record review of R #223's Face Sheet, no date, revealed the admission date of 07/28/22 with medical diagnosis of Parkinson's Disease (A chronic and progressive movement disorder that initially causes tremor in one hand, stiffness or slowing of movement), muscle weakness, unsteady on feet, abnormality of gait and difficulty walking.
F. Record review of R #223's Care Plan revealed the following:
1. 08/05/22 . [name of the resident] requires assistance/is dependent for ADL (Activities of Daily Living) care in all areas (specify: bathing, grooming, personal hygiene, dressing, eating, bed mobility, transfer, locomotion (movement) and toileting) related to: Chronic disease/condition:(specify disease or condition: Parkinson's disease, and limited mobility .
G. On 08/08/22 at 12:41 PM, during an interview DON confirmed R #223 was left soaked through his depend, clothes and bed sheet and stated, leaving the resident contaminated with urine and feces for several hours in his bed can emotionally and physically affect him. She also stated, if we didn't do the job we were supposed to, we have to accept it and try to prevent it from happening again.
H. On 08/08/22 at 2:18 PM, during an interview with Medical Director (MD), when asked about the effect of leaving the resident soaked in his urine for a long period of time, she stated leaving a resident in his bed, soaked in his urine for extended time can affect the resident emotionally and cause him anxiety and distress.
I. On 08/08/22 at 3:07 PM, during an interview with the Administrator regarding R #223 being left soaked in his urine for a long period of time, she stated, the way resident can be affected depends on his/her cognitive level (level of understanding), but if they feel being in that situation makes them feel awful it probably will.
J. Record review of the facility's policy for Abuse Prohibition revision date 07/01/19 revealed the following:
Federal Definitions:
Neglect: is defined as the failure of the centers, its employees or service providers to provide good and services to a patient that are necessary to avoid physical harm, pain, mental anguish or emotional distress.
CONCERN
(E)
Potential for Harm - no one hurt, but risky conditions existed
Transfer Notice
(Tag F0623)
Could have caused harm · This affected multiple residents
Based on record review and interview, the facility failed to ensure residents, or their representatives received a written notice of transfer as soon as practicable for 5 (R #14, R #36, R #46, R #53, ...
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Based on record review and interview, the facility failed to ensure residents, or their representatives received a written notice of transfer as soon as practicable for 5 (R #14, R #36, R #46, R #53, R #67) of 5 (R #14, R #36, R #46, R #53, R #67)
residents reviewed for hospitalizations. This deficient practice could likely result in the resident and/or their representative not knowing the reason that the resident was sent to the hospital. The findings are:
R #14
A. On 08/02/22 at 11:18 AM during an interview, R #14 reported being in the hospital in January 2022 and did not receive a written notice of transfer.
B. Record review of R #14's Progress notes in the Electronic Medical Record revealed, no documentation of a written notice of transfer was found to be provided to the resident or the resident's family.
R #36
C. Record review of R #36's Progress notes in the Electronic Medical Record revealed:
1. On 7/26/22 Resident was very hot to the touch .family agreed to send out. DON informed .Report by ER nurse is that resident has UTI (Urinary tract infection). Other diagnosis may be upcoming .
2. No documentation of a written notice of transfer was found to be provided to the resident or the resident's family.
R #46
D. Record review of R #46's Progress notes in the Electronic Medical Record revealed:
1. R #46 was transferred to the hospital in June 2022.
2. No documentation of a written notice of transfer was found to be provided to the resident or the resident's family.
R #53
E. Record review of R #53's Progress notes in the Electronic Medical Record revealed:
1. On 1/20/2022 Resident left facility with facility staff to go to [Name of hospital] in [name of city]. Spouse aware of transfer and is in agreement.
Resident left without any issues or concerns.
2. No documentation of a written notice of transfer was found to be provided to the resident or the resident's family.
R #67
F. Record review of R #67's Progress notes in the Electronic Medical Record revealed:
1. R #14 had a hospitalized stay on 03/18/22
2. No documentation of a written notice of transfer was found to be provided to the resident or the resident's family.
G. On 08/09/22 at 2:17 PM, during an interview, the Administrator stated the facility was not doing the transfer notices.
CONCERN
(E)
Potential for Harm - no one hurt, but risky conditions existed
Deficiency F0625
(Tag F0625)
Could have caused harm · This affected multiple residents
Based on record review and interview, the facility failed to ensure residents, or their representatives received a written notice of their bed hold policy indicating the duration that the bed would be...
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Based on record review and interview, the facility failed to ensure residents, or their representatives received a written notice of their bed hold policy indicating the duration that the bed would be held for 5 (R #14, R #36, R #46, R #53, R #67) of 5 (R #14, R #36, R #46, R #53, R #67) residents reviewed for transfers to hospital. This deficient practice could likely result in the resident and/or their representative being unaware of the resident being able to return to their previous room upon return from the hospital. The findings are:
R #14
A. On 08/02/22 11:18 AM during an interview, R #14 reported being in the hospital in January 2022 and did not receive a written notice of transfer.
B. Record review of R #14's Progress notes in the Electronic Medical Record revealed, no written notice of the facilities bed hold policy.
R #36
C. Record review of R #36's Progress notes in the Electronic Medical Record revealed:
1. On 7/26/22 Resident was very hot to the touch .family agreed to send out. DON informed .Report by ER nurse is that resident has UTI (urinary tract infection).
Other diagnosis may be upcoming .
2. Review of R #36's medical record revealed no written notice of the facilities bed
hold policy.
R #46
D. Record review of R #46's Progress notes in the Electronic Medical Record revealed:
1. R #46 was transferred to the hospital in June 2022.
2. Review of R #46's medical record revealed no written notice of the facilities bed
hold policy.
R #53
E. Record review of R #53's Progress notes in the Electronic Medical Record revealed:
1. On 1/20/2022 Resident left facility with facility staff to go to [Name of hospital] in
[name of city]. Spouse aware of transfer and is in agreement. Resident left without any
issues or concerns.
2. Review of R #53's medical record revealed no written notice of the facilities bed
hold policy.
R #67
F. Record review of R #67's Progress notes in the Electronic Medical Record revealed:
1. R #14 had a hospitalized stay on 03/18/22
2. Review of R #67's medical record revealed no written notice of the facilities bed
hold policy.
G. On 08/09/22 at 2:17 PM, during an interview, the Administrator confirmed that the bed hold policies would be done by the business office manager but the facility has not had one for a month.
CONCERN
(E)
Potential for Harm - no one hurt, but risky conditions existed
Deficiency F0655
(Tag F0655)
Could have caused harm · This affected multiple residents
Based on record review and interview, the facility failed to develop a baseline care plan within the first 48 hours of admission that included the instructions needed to provide effective and person-c...
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Based on record review and interview, the facility failed to develop a baseline care plan within the first 48 hours of admission that included the instructions needed to provide effective and person-centered care of the resident that meets professional standards of quality care for 1 (R #223) of 1 (R #223) resident sampled for peg tube (feeding tubes, deliver nutrition directly to your stomach) and oxygen care plan documentation. This deficient practice could likely result in residents not receiving optimal care and treatment in a timely manner, which affects resident's safety and places the resident at risk for adverse events that could occur right after admission. The findings are:
A. Record Review of R #223's Face Sheet revealed admission date of 07/28/22.
B. Record review of R # 223's Nurses Notes revealed R #223 arrived at the facility on 07/28/22 at 11:10 PM.
C. Record review of R #223's Baseline Care Plan revealed it was initiated on 08/23/22.
D. On 08/08/22 at 12:40 PM, during an interview, DON confirmed that the facility failed to initiate the baseline care plan within 48 hours of R #223's admission for his peg tube and oxygen use.
CONCERN
(E)
Potential for Harm - no one hurt, but risky conditions existed
Deficiency F0657
(Tag F0657)
Could have caused harm · This affected multiple residents
Based on record review and interview, the facility failed to ensure that the care plan was updated for 2 (R #72, and R #223) of 2 (R #72, and R #223) by failing to:
1. Schedule a care plan meeting for...
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Based on record review and interview, the facility failed to ensure that the care plan was updated for 2 (R #72, and R #223) of 2 (R #72, and R #223) by failing to:
1. Schedule a care plan meeting for R #72,
2. Care plan R #223's Oxygen order and,
3. Care plan R #223's Peg tube (feeding tubes, deliver nutrition directly to your stomach) order.
If the facility is not updating the care plan to reflect residents current status and interventions, residents may not get the care and assistance they need. The findings are:
R #72
A. On 08/01/22 at 11:43 AM, during an interview, R #72 stated, I never been in a care plan meeting. I don't know when I am going home, they have not talk to me about my plan of care.
B. Record review of R #72's Nurses Notes revealed no documentation for care plan meeting was found.
C. Record review of R #72's Social Services Notes revealed no documentation for care plan meeting was found.
D. On 08/03/22 at 9:46 AM, during an interview with Social Services director, she stated as what I can see on my documents, and I can remember we did not have any care plan meeting for this resident since the day of his admission. We are supposed to have a post admission meeting, we did not have a post admission meeting 72 hours after his admission. She confirmed the facility failed to schedule a care plan meeting for R #72.
R #223
E. Record review of R #223's Face Sheet, no date, revealed admission date of 07/28/22 with diagnosis of Parkinson's Disease (A chronic and progressive movement disorder that initially causes tremor in one hand, stiffness or slowing of movement) and Dysphagia oropharyngeal phase (difficulty in moving the secretions from the mouth to the esophagus (tube that carries food and liquid from throat to the stomach).
F. Record review of R #223's Physician Orders revealed the following:
1. 07/27/22 . Oxygen 3 litter via nasal canula (tube to deliver oxygen through the nose) .
2. 07/27/22 .Enteral Feed (administering food via tube to the stomach) Order three times a day for nutrition .
G. Record review of R #223's Care Plan last revision date 08/05/22 revealed no documentation for Oxygen and peg tube orders were found.
H. On 08/08/22 at 11:45 AM, during an interview, DON confirmed that R #223's care plan was not revised for his oxygen and peg tube orders.
CONCERN
(E)
Potential for Harm - no one hurt, but risky conditions existed
Medical Records
(Tag F0842)
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 documents in resident records were complete and accurate for...
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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 documents in resident records were complete and accurate for 2 (R #8, and R #72) of 9 (R #1, R #8, R #19, R #35, R #45, R #50, R #60, R #72, and R #223) residents reviewed for advanced directives, by not ensuring Medical Orders for Scope of Treatment (MOST) forms were completed. This deficient practice is likely to result in staff not knowing the medical intervention wishes of residents during an emergency, or current status when giving care. The findings are:
R #8
A. Record review of R #8's face sheet revealed she was admitted into the facility on [DATE].
B. Record review of R #8's MOST form dated 11/23/21 revealed section Resident/ representative signature was not completed.
R #72
C. Record review of R #72's face sheet revealed he was admitted into the facility on [DATE].
D. Record review of R #72's MOST form dated 07/20/22 revealed section D: Discussed with was not completed.
E. On 08/08/22 at 12:4 PM, during an interview with the DON, she confirmed that the MOST form should be filled out completely.
CONCERN
(E)
Potential for Harm - no one hurt, but risky conditions existed
Infection Control
(Tag F0880)
Could have caused harm · This affected multiple residents
Based on observation, interview, and record review the facility failed to ensure they maintained an Infection Prevention and Control Program (IPCP; a program with policies and procedures that is imple...
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Based on observation, interview, and record review the facility failed to ensure they maintained an Infection Prevention and Control Program (IPCP; a program with policies and procedures that is implemented to help prevent residents and health workers from being harmed by avoidable infections) when they failed to:
1. Ensure that residents oxygen tubing was kept free of contamination
2. Ensure R #14's CPAP (continuous positive airway pressure) masks were covered when not in use.
3. Ensure that staff disposed of their PPE (Personal Protective Equipment) prior to exiting the room of a resident on airborne/contact precautions (Airborne Precautions for patients known or suspected to be infected with pathogens transmitted by the airborne route, Contact precautions prevent the spread of bacteria, parasites, and viruses from one person to another).
4. Provide Process Surveillance (techniques of observation, monitoring and tracking infections to help evaluate infection control practices) for tracking infections. The findings are:
Oxygen tubing
A. On 08/01/22 at 2:00 PM, during an observation of R #19's room revealed resident's oxygen tube was on the floor.
B. On 08/01/22 at 2:05 PM, during an interview, RN #21 confirmed the oxygen tube was on the floor and stated, we will get him a new tube.
CPAP mask
C. On 08/02/22 at 11:21 AM during an observation of R #14's room revealed her CPAP mask not covered.
PPE
D. On 08/03/22 at 9:54 AM, during an observation of 200 Hallways, CNA #21 was observed walking out of R # 39's room with a contaminated gown, donning off the gown and placing it in the trash can outside the door [airborne/contact precautions].
E. On 08/03/22 at 9:56 AM, during an interview CNA #21 stated we remove our gowns outside of the room and leave them inside of the trash can right by the door.
F. On 08/08/22 at 12:41 PM, during an interview DON stated, when staff care for residents under special precautions, they are supposed to step out of the resident's room and take out their contaminated gown. this has been our practice for a long time . She confirmed the oxygen tubes should not touch the floor to prevent contamination and nebulizer masks should be covered when is not in use.
Process Surveillance
G. On 08/09/22 at 1:57 PM, during an interview, the DON (Director of Nursing) confirmed that she is the current IP (Infection Preventionist the person(s) designated as responsible for the infection control program that is to help minimize or prevent the spread of infection) as of 07/05/22 and confirmed that no mapping (tracking of infections by resident room and type of infections to determine potential problems with infection control practices) of infections has been completed since March 2022.
CONCERN
(E)
Potential for Harm - no one hurt, but risky conditions existed
Room Equipment
(Tag F0908)
Could have caused harm · This affected multiple residents
Based on interview the facility failed to ensure essential equipment was in safe operating condition when the facility failed to ensure that the transportation vehicle (transportation van used by faci...
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Based on interview the facility failed to ensure essential equipment was in safe operating condition when the facility failed to ensure that the transportation vehicle (transportation van used by facility to transport residents to and from appointments as needed) had a working air conditioner for 3 (R #9, R #14, and R #22) of 8 (R #2, R #9, R #14, R #22, R #52, R #57, R #61, and R #66) residents reviewed for care equipment. This deficient practice could likely result in a greater risk of feeling uncomfortable due to elevated temperatures inside the vehicle and feelings of frustration due to having to have appointments rescheduled to a later date. The findings are:
A.
On 08/01/22 at 12:20 PM, during an interview, R #9 stated that she missed an appointment with the Orthopedic Doctor (a doctor who specializes in the diagnosis, treatment of injuries, disorders, and diseases of the body's musculoskeletal system [relates to the muscles and the skeleton of the body]) in July [2022] because the van air conditioner was broken. R #9 stated she still doesn't know what date her appointment is being rescheduled for.
B.
On 08/08/22 at 1:52 PM, during an interview, R #9 stated that The air conditioner on the transportation van has not been working for 2 months, we don't know what is going to happen to fix it. We are just being told that we will go to our appointments in the morning.
C.
On 08/08/22 at 2:25 PM, during an interview, R #14 stated her appointment at (name of dental clinic) had to be rescheduled from August 2022 until October 2022.
D.
On 08/08/22 at 2:27 PM, during an interview, R #22 stated that he has to wait to go to an appointment with the ear doctor in another city because of the distance/time it will take to go to the appointment.
D.
On 08/09/22 at 12:44 PM, during an interview with the Social Services Director (SSD), when asked about appointments, SSD confirmed that several appointments have been requiring rescheduling due to the facilities plan to schedule morning appointments to avoid the resident being in the heat.
E.
On 08/09/22 at 3:02 PM, during an interview, the Administrator confirmed that the van air conditioner is not working. She stated they have attempted to get it fixed but have been unable to. When asked if there was a plan to acquire a new transportation vehicle, the administrator stated that was not the plan at this time, the only plan in place was to have all resident appointments in the morning to avoid higher temperatures later in the day.
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 ensure the facility was adequately staffed for all 75 residents in the facility (residents were identified on the census list ...
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Based on observation, record review and interview, the facility failed to ensure the facility was adequately staffed for all 75 residents in the facility (residents were identified on the census list provided by the Administrator on 08/01/22) reviewed for sufficient nursing staff. This deficient practice could result in the residents' needs not being met, leaving them at risk for incontinence, falls, skin tears or broken bones. The findings are:
A. On 08/01/22 at 12:10 PM, during an observation of R #35 's room, resident pressed the call light (device used by patients to request help from staff) to request staff for assistance.
B. On 08/01/22 at 12:15 PM, during an interview when asked how long it takes for staff to respond to her call light requests, R #35 stated, it depends on the shift and the time of the day, some days they [facility] are short staffed so it takes longer.
C. On 08/01/22 at 12:29 PM, during an observation of R #35's room, 100 Hallway's Unit Manager (UM) responded to residents call light and request for assistance.
D. On 08/01/22 at 12:30 PM, during an interview with UM , when asked about the reasonable time for staff to respond to the resident's call for assistance UM stated, we usually respond to the call lights as soon as possible, but my expectation is 1 to 2 minutes at least to acknowledge resident is asking for help. He confirmed that R #35 waited for 19 minutes to get help.
E. On 08/04/22 at 9:30 AM, during an observation of 200 Hallway, R #56 pressed the call light to request for assistance.
F. On 08/04/22 at 9:40 AM, during an observation of 200 hallway's UM responded to R #56's call light. (10 minutes of wait time).
H. On 08/04/22 at 9:45 AM, during an interview with UM, when asked about the reasonable time for staff to respond to the resident's call for assistance UM stated, I don't have expectations for answering the call lights, as soon as we see the call light is on, we try to answer it.
I. On 08/04/22 at 10:05 AM, during an observation of R#223's room revealed, resident was laying down of his bed, soaked in his urine and feces, contaminated all the way to his back.
J. On 08/04/22 at 10: 08 AM, during an interview R #223 stated I have not been changed since last night.
K. On 08/04/22 10:09 AM, during an observation of R #223's room revealed staff responded to the resident's request for assistance and helped him get out of his bed at 10:10 AM.
L. On 08/04/22 at 10:37 AM, during an interview, CNA #22 stated, I started my shift with another CNA, but they [facility] pulled her to another unit, so I have been working by myself. I did not get a chance to clean R #223 and get him out of the bed since start of the shift.
M. On 08/08/22 at 12:41 PM, during an interview DON confirmed R #223 was left on his bed, soaked in his urine for an extended period of time because Memory care unit did not have sufficient staffing to assist the residents on timely manner and only one CNA was working that morning covering the whole unit.
N. Record review of the facility's weekly schedule revealed on 08/06/22, four CNAs were scheduled and worked during the night shift.
O. On 08/08/22 at 3:37 PM, during an interview DON confirmed on 08/06/22 night shift did not have sufficient staffing to assist the residents throughout the night and only four CNAs were working that night. she stated we usually have five CNAs work during nights, but that shift we only had four staff.
CONCERN
(F)
Potential for Harm - no one hurt, but risky conditions existed
Deficiency F0761
(Tag F0761)
Could have caused harm · This affected most or all residents
**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, interview, and record review, the facility failed to:
1) ensure medication cart is not left unlocked and ...
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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:
1) ensure medication cart is not left unlocked and unattended.
2) ensure that medication refrigerator temperatures were monitored daily,
3) ensure that expired medication was not stored with unexpired medications and,
This has the potential to negatively impact the health of all 75 residents (residents were identified by the Resident Matrix provided by the Administrator on 08/01/22) and could likely result in residents obtaining medications not properly stored, or expired, resulting in adverse side effects. The findings are:
Medication Cart
A. On 08/03/22 at 2:22 PM during an observation in the 200 Unit revealed the medication cart was left unlocked and unattended.
B. On 08/03/22 at 2:24 PM during an interview, RN #11 confirmed that he left the medication cart unattended and unlocked.
C. On 08/04/22 at 11:30 AM during an interview, the DON confirmed that all medication carts should not be left unlocked and unattended.
Storage of Medication
D. On 08/02/22 at 1:17 PM, during an observation of 200 Hallway, RN #24 left one capsule of medication fluoxetine hcl (used to treat depression, panic attacks, and eating disorder)10 mg unattended on top of the medication cart.
E. On 08/02/22 at 1:18 PM, during an interview RN #24 confirmed he failed to properly secure the medication and left the capsule unattended on top of the medication cart while residents were present.
F. On 08/02/22 at 1:35 PM, during an observation of the 100 Hallway medication cart, four loose tablets were found in the cart.
G. On 02/02/22 at 1:37 PM, during an interview, RN #21 confirmed four loose tablets were in the cart.
H. On 08/02/22 at 1:45 PM, during an observation of 200 Hallways treatment cart, one container of Distilled water (purified water) for bipap (bilevel positive airway pressure) machine (is a form of non-invasive ventilation therapy used to help you breathe) found opened and dated on 5/1/22.
I. On 08/02/22 at 1:50 PM, during an interview DON confirmed the Distilled water was expired and stated, we should discard it 60 days after initial opening date.
Medication Refrigerator Temperatures
J. Record review of the temperature binders for the refrigerator that is used to store medications and vaccines, was not fully documented for July 2022 and [DATE]. The Temperature Log for refrigerator indicated the following:
1. The temperatures for the medication and Vaccine refrigerator were not documented for 07/02/22, 07/03/22, 07/09/22, 07/10/22, 07/14/22, 07/15/22, 07/16/22, 07/23/22, 07/24/22 and 07/30/22.
2. No documentation for [DATE] was found.
K. Record review of Medication Room Temperature Log dated July 2022 revealed the following:
1. The temperatures for medication room were not documented for 07/02/22, 07/03/22, 07/09/22, 07/10/22, 07/14/22, 07/15/22, 07/16/22, 07/23/22, 07/24/22 and 07/30/22.
2. No documentation for [DATE] was found.
L. On 08/03/22 at 1:47 PM, during an interview RN #23 confirmed that the temperature logs for medication/vaccine refrigerator and medication room were not properly documented and were missing dates.
M. Record review of the facility policy for Medication and Vaccine Refrigerator/Freezer Temperature, revision date of 01/30/17 revealed the following:
Policy
.refrigerators and freezers used to store medications and vaccines will be checked twice a day for proper temperature .
CONCERN
(F)
Potential for Harm - no one hurt, but risky conditions existed
Food Safety
(Tag F0812)
Could have caused harm · This affected most or all residents
Based on observation, interview, and record review the facility failed to:
1. Ensure that food items in the kitchen were labeled and dated after they were open, and
2. Discard the expired food items. ...
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Based on observation, interview, and record review the facility failed to:
1. Ensure that food items in the kitchen were labeled and dated after they were open, and
2. Discard the expired food items.
These deficient practices could lead to foodborne illnesses that could affect all 75 residents in the facility (residents were identified on the census list provided by the Administrator on 08/01 /22) who eat food prepared in the kitchen. The findings are:
A. On 08/05/22 at 11:10 AM, during an observation of the kitchen revealed the following:
1. One pancake syrup container with no open date, no expiration or use by date.
2. One open bag of chopped potatoes with no open date, no expiration or use by date, located inside of the refrigerator.
3. One Cocoa Powder container expired on 06/02/22.
4. One ground ginger container expired on 02/11/22.
5. One Rubbed sage container expired on 07/01/22.
B. On 08/05/22 at 11:34 AM, during an interview with the Dietary Manager confirmed that all food should be labeled with expiration or use by date and all the expired food should be discarded.
C. Record review of the facility policy for Food Storage (Cold Food and Dry Goods) revision date 09/01/17 revealed the following:
Cold Foods:
.All foods will be stored wrapped or in covered containers, labeled and dated .
Dry Goods:
.Storage areas will be neat, and date marked as appropriate .
CONCERN
(F)
Potential for Harm - no one hurt, but risky conditions existed
Deficiency F0882
(Tag F0882)
Could have caused harm · This affected most or all residents
Based on interview the facility failed to provide a qualified, trained, and certified Infection Preventionist (IP) (IP; The person(s) designated as responsible for the infection control program that i...
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Based on interview the facility failed to provide a qualified, trained, and certified Infection Preventionist (IP) (IP; The person(s) designated as responsible for the infection control program that is to help minimize or prevent the spread of infection). This deficient practice has the potential to affect all 75 residents (Identified by the Resident Matrix provided by the administrator on 08/01/22) and could likely result in a greater risk for infections. The findings are:
A.
On 08/09/22 at 1:57 PM, during an interview, the DON (Director of Nursing) confirmed that she is the current IP and confirmed that she has started but has not completed the required IP training and does not have the training certificate yet.
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: 2 life-threatening violation(s), 1 harm violation(s), $32,615 in fines, Payment denial on record. Review inspection reports carefully.
- • 75 deficiencies on record, including 2 critical (life-threatening) violations. These warrant careful review before choosing this facility.
- • $32,615 in fines. Higher than 94% of New Mexico facilities, suggesting repeated compliance issues.
- • Grade F (6/100). Below average facility with significant concerns.
Bottom line: Trust Score of 6/100 indicates significant concerns. Thoroughly evaluate alternatives.
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About This Facility
What is Silver City Care Center's CMS Rating?
CMS assigns Silver City Care Center 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 Silver City Care Center Staffed?
CMS rates Silver City Care Center's staffing level at 2 out of 5 stars, which is below average compared to other nursing homes. Staff turnover is 54%, compared to the New Mexico average of 46%.
What Have Inspectors Found at Silver City Care Center?
State health inspectors documented 75 deficiencies at Silver City Care Center during 2022 to 2025. These included: 2 Immediate Jeopardy (the most serious level, indicating potential for serious harm or death), 1 that caused actual resident harm, 70 with potential for harm, and 2 minor or isolated issues. Immediate Jeopardy findings are rare and represent the most serious regulatory concerns. They require immediate corrective action.
Who Owns and Operates Silver City Care Center?
Silver City Care Center is owned by a for-profit company. For-profit facilities operate as businesses with obligations to shareholders or private owners. The facility is operated by GENESIS HEALTHCARE, a chain that manages multiple nursing homes. With 100 certified beds and approximately 73 residents (about 73% occupancy), it is a mid-sized facility located in Silver City, New Mexico.
How Does Silver City Care Center Compare to Other New Mexico Nursing Homes?
Compared to the 100 nursing homes in New Mexico, Silver City Care Center's overall rating (1 stars) is below the state average of 2.9, staff turnover (54%) 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 Silver City Care Center?
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 Silver City Care Center Safe?
Based on CMS inspection data, Silver City Care Center has documented safety concerns. Inspectors have issued 2 Immediate Jeopardy citations (the most serious violation level indicating risk of serious injury or death). 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 Silver City Care Center Stick Around?
Silver City Care Center has a staff turnover rate of 54%, which is 8 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 Silver City Care Center Ever Fined?
Silver City Care Center has been fined $32,615 across 1 penalty action. This is below the New Mexico average of $33,405. While any fine indicates a compliance issue, fines under $50,000 are relatively common and typically reflect isolated problems that were subsequently corrected. Families should ask what specific issues led to these fines and confirm they've been resolved.
Is Silver City Care Center on Any Federal Watch List?
Silver City Care Center is not on any federal watch list. The most significant is the Special Focus Facility (SFF) program, which identifies the bottom 1% of nursing homes nationally based on persistent, serious quality problems. Not being on this list means the facility has avoided the pattern of deficiencies that triggers enhanced federal oversight. This is a positive indicator, though families should still review the facility's inspection history directly.