Charlotte Health & Rehabilitation Center
For profit - Limited Liability company
90 Beds
LIFEWORKS REHAB
Data: November 2025
5 Immediate Jeopardy citations
Trust Grade
0/100
#324 of 417 in NC
Photo by Charlotte Health & Rehabilitation Center
Photo by Sandra Stone
Photo by Charlotte Health & Rehabilitation Center
1 / 5 photos
Last Inspection: October 2024
Within standard 12-15 month inspection cycle. Federal law requires annual inspections.
Overview
Charlotte Health & Rehabilitation Center has received a Trust Grade of F, indicating significant concerns about the facility's care and operations, which places it in the lowest category. In North Carolina, it ranks #324 out of 417 facilities, meaning it is in the bottom half of all nursing homes in the state, and #22 out of 29 in Mecklenburg County, indicating only a few local options are worse. The facility is reportedly improving, with issues decreasing from 13 in 2024 to 4 in 2025, but it still has a concerning staffing rating of 2 out of 5 stars and a high turnover rate of 60%, above the state average. Moreover, it has accumulated a staggering $177,170 in fines, which is higher than 95% of nursing homes in North Carolina, indicating serious compliance issues. While it has average RN coverage, the facility has faced critical incidents, including a failure to promptly address a resident's significant change in condition, which ultimately led to the resident's death, and a serious medication error involving a resident who was given a medication they were allergic to. These findings highlight both critical weaknesses in care and oversight that families should consider when evaluating this facility.
- Trust Score
- F
- In North Carolina
- #324/417
- Safety Record
- High Risk
- Inspections
- Getting Better
- Staff Stability ⚠ Watch
- 60% turnover. Above average. Higher turnover means staff may not know residents' routines.
- Penalties ○ Average
- $177,170 in fines. Higher than 66% of North Carolina facilities. Some compliance issues.
- Skilled Nurses ⚠ Watch
- Each resident gets only 28 minutes of Registered Nurse (RN) attention daily — below average for North Carolina. Fewer RN minutes means fewer trained eyes watching for problems.
- Violations ⚠ Watch
- 39 deficiencies on record. Higher than average. Multiple issues found across inspections.
0/100
Bottom 23%
Review needed
13 → 4 violations
★☆☆☆☆
1.0
Overall Rating
★★☆☆☆
2.0
Staff Levels
★☆☆☆☆
1.0
Care Quality
★☆☆☆☆
1.0
Inspection Score
↔
Stable
2024: 13 issues
2025: 4 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 North Carolina average (2.8)
Significant quality concerns identified by CMS
Staff Turnover: 60%
14pts above North Carolina avg (46%)
Frequent staff changes - ask about care continuity
Federal Fines: $177,170
Well above median ($33,413)
Significant penalties indicating serious issues
Chain: LIFEWORKS REHAB
Part of a multi-facility chain
Ask about local staffing decisions and management
Staff turnover is elevated (60%)
12 points above North Carolina average of 48%
The Ugly 39 deficiencies on record
5 life-threatening 2 actual harm
Mar 2025
1 deficiency
1 Harm
SERIOUS
(G)
📢 Someone Reported This
A family member, employee, or ombudsman was alarmed enough to file a formal complaint
Actual Harm - a resident was hurt due to facility failures
Deficiency F0660
(Tag F0660)
A resident was harmed · This affected 1 resident
**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on record review, and staff, resident and family member interviews, the facility failed to develop and implement effective...
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**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on record review, and staff, resident and family member interviews, the facility failed to develop and implement effective discharge planning that ensured a resident would have the necessary durable medical equipment when she was discharged home to include a hospital bed, gel bed overlay with mattress, half side rails, a trapeze bar, and oxygen supplies for 1 of 4 residents reviewed for discharge (Resident #1). Resident #1 stated she was not provided with equipment for oxygen therapy and would get short of breath, and it would wake her up. Resident #1 reported she would cough, and it made her throw up at night. In addition, Resident #1 indicated that the hospital bed was not delivered, and she was sleeping in a recliner due to the shortness of breath which resulted in edema in her ankles and worsening of gastroesophageal reflux disease (GERD) symptoms.
The findings included:
Resident #1 was admitted to the facility on [DATE] with diagnoses including GERD, sleep apnea, and rhabdomyolysis (a serious condition caused by a direct or indirect muscle injury and could lead to serious complications such as kidney failure).
A review of physician order dated 1/22/25 revealed Resident #1 received oxygen therapy at two liters per minute via nasal cannula, every day and night shift.
An admission Minimum Data Set (MDS) on 1/29/25 revealed Resident #1 was cognitively intact. Resident #1 was not coded for oxygen use. The MDS was coded for Resident #1 to discharge back to the community.
A review of Resident #1's Treatment Administration Record (TAR) revealed she received oxygen at two liters per minute via nasal cannula, every day and night shift from 1/22/25 to 2/5/25.
A review of a physician order/note dated 2/5/25 and signed by the previous Medical Director revealed Resident #1 needed the use of durable medical equipment (DME) in her home. The equipment included a semi-electric hospital bed, a gel overlay for the mattress and a trapeze bar. The order described Resident #1 as having severe back pain and needed frequent changes in body position to alleviate the pain caused by arthritis. Resident #1 was described in the note as having a compromised circulatory status, therefore requiring pressure reducing support surface to treat and prevent skin breakdown. Resident #1 also needed a trapeze bar to get in and out of bed. The order did not include oxygen supplies.
A review of an itemized physician's order form dated 2/5/25 and signed by the previous Medical Director included a semi-electric hospital bed, wheelchair, gel overlay, a mattress, half bed rails, and a trapeze bar. The order did not include oxygen supplies.
A review of a nursing progress note written by Nurse #1 dated 2/6/25 revealed Resident #1 was given patient discharge instructions. Nurse #1 reviewed medications with Resident #1 who voiced understanding. She was discharged with medications and prescriptions.
A review of the Discharge summary dated [DATE] and signed by Nurse #1 revealed Resident #1 was discharged home with home health services and needs for a hospital bed and walker. The discharge summary did not include the need for any oxygen supplies and did not indicate Resident #1's use of oxygen at the facility. The discharge summary did not have contact information for the durable medical equipment provider and listed a bed and walker as the equipment needed by Resident #1.
A telephone interview with Nurse #1 on 3/19/25 at 2:39 PM revealed she discharged Resident #1 home on 2/6/25. She stated the SW would order any durable medical equipment for any residents discharging home. She stated she printed a discharge summary for Resident #1 and went through her medications with her. Nurse #1 stated if oxygen was listed on the summary, she would have discussed it with Resident #1. She stated nursing would typically fill out the device section of the assessment. Nurse #1 explained if oxygen was not checked off on the discharge summary list for Resident #1, it would not have been ordered for the discharge.
A telephone interview with a DME Company Representative on 3/19/25 at 12:47 PM revealed Resident #1 had not received her equipment in her home after her discharge. She stated Resident #1's family had called the equipment company many times inquiring why the bed and other equipment had not been delivered.
A second telephone interview with a DME Company Representative on 3/20/25 at 9:08 AM revealed she spoke to Resident #1's family member for the first time on 3/10/25 but the family member had placed many calls to the call center requesting information about Resident #1's equipment. She stated the facility originally did not fax over the needed information to complete the DME order to include the medical need for the supplies requested. The DME Company Representative explained the DME requested was for the bed and the bed accessories. She did not know Resident #1 needed oxygen therapy, but added they would be able to get her the supplies she needed if the facility would send over an order and medical need for the oxygen. The DME Company Representative stated no DME, or supplies had been delivered to Resident #1 yet as they were waiting on the documents requested from the facility.
A telephone interview was conducted with Resident #1's family member on 3/19/25 at 1:50 PM. She stated Resident #1 had not yet received the hospital bed or any equipment that came with the bed. The Family Member indicated Resident #1 did receive a walker and a bedside commode when she was discharged from the facility. She understood from the DME company that the correct information needed for the DME including oxygen supplies was not given by the facility during the discharge process. The Family Member stated she called the call center at the durable medical equipment company many times. She stated the DME Company Representative was helping her to get the documentation needed for the equipment from the facility.
A second telephone interview with Resident #1's family member on 3/19/25 at 2:12 PM. She stated Resident #1 had continuous oxygen in the hospital prior to her admission at the facility. She revealed the facility did not provide Resident #1 a portable oxygen tank after discharge, and she wore oxygen every day during her stay at the facility.
A telephone interview with Resident #1 on 3/20/25 at 10:03 AM revealed she did not have her hospital bed, the gel overlay, the trapeze bar, or oxygen as of 3/20/25. She stated when she was in the facility, she had oxygen because when she was sleeping, her oxygen level would go down. Resident #1 stated she was not sent home with any oxygen equipment from the facility, and when she slept, she would get short of breath, and it would wake her up. Resident #1 reported she would cough, and it made her throw up at night. Resident #1 explained she had been sleeping in a recliner because of her shortness of breath and her GERD. She stated that because she has been in her recliner to sleep, her ankles were swollen, and they were not before when she was sleeping in an adjustable bed at the facility. Resident #1 stated her GERD has worsened because of not being able to sleep in an adjustable bed. Resident #1 indicated she had not been hospitalized since her discharge from the facility.
An interview with the Social Worker (SW) on 3/19/25 at 2:19 PM revealed Resident #1 discharged home on 2/6/25 with orders for home health services and equipment that included a hospital bed and accessories to include a trapeze bar, mattress and overlay and side rails. She stated Resident #1's discharge plan included a bed with other accessories and a walker. The SW indicated she created the DME order on 2/5/25 and sent over the paperwork in the ordering portal to start the ordering process with the DME company. The SW recalled on 3/10/25, Resident #1's family member called and stated they had not received the bed. The SW stated the DME company needed documentation that explained the necessity of the bed to fulfill the order. She stated she sent the information to the durable medical equipment company on 3/17/25 and she received a message from the contact at the durable medical equipment company on 3/19/25 that the documentation was approved. The SW explained she was not aware Resident #1 had an order for oxygen in the facility or needed oxygen therapy after discharge. The SW revealed she did not review residents' orders before discharge and nursing would have been responsible for alerting her to Resident #1's need for oxygen. She stated discharges were discussed during the morning meeting at the facility. The SW further stated she did not follow up with Resident #1 after her discharge from the facility. She explained she made the official request for DME supplies based on the reports given to her from other departments during the morning meeting.
An interview with the Unit Manager on 3/20/25 at 9:51 AM revealed he could not recall specifics about Resident #1's care but stated typically discharges were discussed in the morning meeting. He stated supplies needed for a resident's discharge would be discussed and the SW would order anything needed for the discharge. The Unit Manager indicated nursing would typically inform the SW if oxygen was needed.
A telephone interview with the previous Medical Director on 3/20/25 at 11:55 AM revealed he had written the discharge orders for Resident #1 but explained he did not specially recall Resident #1 as he was temporally filling in as Medical Director for the facility. He stated if a resident used oxygen in a facility and still had the need for oxygen, then oxygen therapy should have been part of the discharge plan. The previous Medical Director explained that if he signed a physician's order for DME for a resident before discharge, then the equipment was necessary.
An interview with the Administrator on 3/20/25 at 11:04 AM occurred. She stated Resident #1 did not receive her bed and DME due to the need for additional information to document Resident #1's need for the equipment to fulfill the order. The Administrator indicated the facility reviewed discharges during the clinical part of their morning meeting but did not recall Resident #1's discharge discussion. She stated during this meeting all DME was reviewed for each resident discharging. The Administrator stated Resident #1's needs for oxygen should have been reviewed before she was discharged from the facility. She explained the SW should have followed up with Resident #1 before she left the faciity on her needs. The Administrator explained the facility had implemented a plan in response to the discharge concerns with Resident #1 to improve coordination with DME and home health services for residents discharging home from the facility.
The facility presented a plan of correction that was not accepted by the State Survey Agency. The facility failed to provide evidence of the audits being completed at the time the plan was completed. The interview with the SW on 3/19/25 revealed that she was not calling all discharges as stated she would in the plan but only called the residents who left against medical advice or had a lot of concerns and indicated that she was just recently been given this directive from her Regional Consultant. Furthermore, the ongoing monitoring failed to include the names of the residents that were audited upon discharge and what equipment was needed and verified to have been delivered to the discharged resident.
Feb 2025
3 deficiencies
1 Harm
SERIOUS
(G)
📢 Someone Reported This
A family member, employee, or ombudsman was alarmed enough to file a formal complaint
Actual Harm - a resident was hurt due to facility failures
Free from Abuse/Neglect
(Tag F0600)
A resident was harmed · This affected 1 resident
**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on record reviews, and Psychiatric Mental Health Nurse Practitioner, Resident Representative (RR) and staff interviews, th...
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**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on record reviews, and Psychiatric Mental Health Nurse Practitioner, Resident Representative (RR) and staff interviews, the facility failed to protect a resident's right to be free from resident-to-resident abuse. In January 2025, Resident # 2 was observed touching Resident # 1's breasts. On Saturday, 2/1/25 Resident #1 was positioned in a reclining wheelchair in the dayroom when Resident #2 was observed sitting next to Resident #1 with his right arm on her reclining wheelchair in the day room. Nurse Aide (NA) #1 intervened asking Resident #2 to give Resident #1 space and observed the blanket used to cover Resident #1 had been removed, Resident #1's pants and brief were pulled down, the brief was torn on the right-side exposing Resident #1's private area. Resident #1 was severely cognitively impaired and her ability to speak was rare according to the most recent Minimum Data Set (MDS). Resident #1's Representative stated Resident #1 would feel completely violated. A reasonable person would expect to be free from abuse in their own home and could experience trauma, fear and anxiety. This affected 1 of 3 residents reviewed for abuse (Resident #1).
The findings included:
Resident #1 was admitted to the facility on [DATE]. Diagnoses included Alzheimer's disease and degeneration of nervous system. Resident #1 was under Hospice care.
The quarterly Minimum Data Set (MDS) dated [DATE] indicated Resident #1 was severely cognitively impaired and her ability to speak was coded as rare or never understood and her ability to understand speech was coded as rare or never understood. Resident #1 was dependent on staff for all Activities of Daily Living (ADL).
A review of Resident #1's care plan revised on 2/26/24 indicated she was at risk for complications related to communication impairment due to impaired cognition and was rarely or never understood. Interventions included anticipating needs and observing for nonverbal cues which may indicate care needs.
Resident #2 was admitted to the facility on [DATE]. Diagnoses included hemiplegia and hemiparesis following cerebral infarction affecting left side, cognitive communication deficit, and hypertension.
The admission MDS dated [DATE] indicated Resident #2 was cognitively intact and used a wheelchair for mobility.
A review of Resident #2's care plan revised 12/2/24 indicated he required assistance with Activities of Daily Living (ADL) and the interventions included two-person assistance for bed mobility, mechanical lift for all transfers. Resident #2's care plan did not indicate any problem areas pertaining to behaviors.
An interview with Housekeeper #1 on 2/19/25 at 2:55 PM revealed she saw Resident #2 touching Resident #1's chest area in the day room. She stated that she could not remember the exact date but stated it was the beginning to middle of January 2025. She stated she immediately let the nursing staff, which included NA #3, at the nurse's desk know and the residents were separated. She stated she never saw Resident #2 touching Resident #1 after this incident but stated Resident #2 stared at Resident #1 quite often. Housekeeper #1 stated she watched out for Resident #1 after this incident.
A second telephone interview with Housekeeper #1 occurred on 2/20/25 at 3:52 PM. She stated when she witnessed Resident #2 touching Resident #1 in early to mid-January, he touched her on the outside of her shirt with his left hand rubbing across her chest and breasts. She explained Resident #1 was sitting next to a table in the day room and Resident # 2 was sitting next to her.
A telephone interview with NA #3 on 2/20/25 at 2:14 PM revealed she was standing at the nurse's desk when Housekeeper #1 alerted them to Resident #2 touching Resident #1's breasts. NA #3 responded and went down to the dayroom. She could not recall the date but stated it occurred the beginning or middle of January 2025. NA #3 did not indicate if she reported this incident or not. She stated she kept an eye on Resident #2 and would often tell him to leave Resident #1 alone when they were in common areas.
A review of a Psychiatric Mental Health Nurse Practitioner's note on 1/16/25 revealed Resident #2 exhibited increased sexual behaviors towards female peers and he had touched a female peer's breasts.
A telephone interview with the Psychiatric Mental Health Nurse Practitioner on 2/18/25 at 3:36 PM revealed she visited Resident #2 on 1/16/25 for sexual misconduct as he had touched a female resident's breasts and exposed himself to female staff at the facility. The Psychiatric Mental Health Nurse Practitioner suggested supervision and an increase in medication to address Resident #2's depression.
A telephone interview with the Psychiatric Nurse Practitioner occurred on 2/18/25 at 4:54 PM. She stated on her visit to Resident #2 on 1/16/25, a nurse verbally told her about Resident #2's sexually inappropriate behaviors directed at another female resident. She could not recall who told her and she was not aware of the name of the female resident.
A review of the initial allegation report submitted by the facility to the Division of Health Service Regulation (DHSR) revealed an allegation type of resident abuse on 2/1/25. The allegation details noted Nurse Aide (NA) #1 observed Resident #2 sitting next to Resident #1 in the day room with his hand in her lap. NA #1 removed Resident #2 immediately. Resident #2 was placed on one-to-one supervision. Resident #1 was sent to the hospital for further evaluation.
A written statement from NA #1 written on 2/1/25 from the facility's investigation submitted to DHSR on 2/5/25 was reviewed. The statement read, in part, that NA #1 walked past the day room on 2/1/25 and saw Resident #2 sitting close to Resident #1 with his hand resting on the right side of her reclining wheelchair. NA #1 stated she asked Resident #2 to back up and when she walked closer to Resident #1, she noted her pants were pulled down some and her incontinence brief tabs on the right side were undone and she was exposed.
A telephone interview with NA #1 on 2/18/25 at 2:21 PM revealed she was walking down the hallway when she noticed Resident #2 sitting next to Resident #1 with his right arm on the left side of her reclining wheelchair. She stopped and asked Resident #2 to back up and give Resident #1 some space. Resident #2 backed away and she noticed Resident #1's pants were pulled down and her incontinence brief tab closure was undone on the right side. NA #1 noted that Resident #1 was completely asleep and was unable to move any aspects of her clothes or blanket. NA #1 stated she immediately reported the incident to Nurse #1 and Resident #1 was sent to the hospital for evaluation.
A written statement from NA #2 written on 2/1/25 from the facility's investigation submitted to DHSR on 2/5/25 was reviewed. The statement read, in part, that NA #2 had assisted Resident #1 to transfer to her reclining wheelchair earlier on 2/1/25 and was asleep in the chair in the day room. She was called into the day room and Resident #2 exited the room stating that he did nothing. NA #2 stated when she walked towards Resident #1, her pants appeared disheveled, and her brief was open on the right side and her private area was exposed. She also noted the sheet Resident #1 was covered with, was pulled away from her lap. NA #2 stated Resident #1's clothing and sheet covering her were not left that way 20 minutes prior when Resident #1 was transferred to her reclining wheelchair.
A telephone interview with NA #2 on 2/18/25 at 1:49 PM revealed she fed Resident #1 lunch in the day room and she transferred her to a reclining wheelchair after lunch so she could rest in the day room. NA #2 indicated she covered Resident #1, who was fully dressed, with a blanket. NA #2 stated NA #1 called her to the day room approximately 20 minutes later and found Resident #2 leaving promptly saying he didn't do anything. NA #2 stated Resident #1's incontinence brief was pulled down, torn on the side and her pubic hair was visible. NA #2 stated she did not see Resident #2 touch Resident #1 when she arrived to the day room.
A telephone interview with Nurse #1 occurred on 2/20/25 at 12:51 PM. She stated she was at the nurse's station on 2/1/25 when she was alerted by NA #1 of the incident. She noted she did not see Resident #2 do anything, but stated Resident #1's pants were pulled down and incontinence brief was open, and Resident #2 exited the day room. She stated Resident #1 was sent to the hospital immediately for evaluation and Resident #2 went back to his room. She stated Resident #2 was placed with a one-on-one sitter on 2/1/25 after the incident. Nurse #1 stated she was not aware of any previous inappropriate sexual behaviors toward female residents or staff exhibited by Resident #2.
A review of the staffing schedules was conducted and revealed Resident #2 was placed under one-to-one supervision from staff from 2/1/25 after the incident until his transfer to the hospital on 2/3/25.
A review of a progress note written by the Psychiatric Mental Health Nurse Practitioner, dated 2/3/25 read, in part that Resident #2 was no longer appropriate to live at the facility after recent inappropriate sexual behavior with Resident #1. She further wrote that Resident #2 was a threat to female peers and to facility staff due to recent and past inappropriate behaviors. The Psychiatric Mental Health Nurse Practitioner indicated Resident #2 would be more appropriate in an all-male facility wherein other patient's safety would not be a factor.
A telephone interview with the Psychiatric Mental Health Nurse Practitioner occurred on 2/18/25 at 3:36 PM. She stated she wrote a progress note on 2/3/25 that Resident #2 was not appropriate for the facility due to the incident involving Resident #2 exhibiting inappropriate sexual behaviors towards Resident #1 on 2/1/25. She suggested Resident #2 be discharged to the hospital for psychological evaluation.
A nursing progress note dated 2/3/25 written by the Director of Nursing (DON) revealed Resident #2 was sent to the hospital for evaluation and management per Psychiatric Mental Health Nurse Practitioner's recommendation on 2/3/25.
The DON was not available to interview during the survey.
A telephone interview with Resident #1's Representative occurred on 2/20/25 at 2:51 PM. She stated Resident #1 was very modest and would often try to cover herself when care was being provided. Resident #1's Representative stated if Resident #1 was able to speak for herself, she would feel completely violated if she knew about the incident where Resident #2 allegedly touched her. She further indicated Resident #1 was very protective of her private areas.
An interview with the Administrator on 2/18/25 at 4:57 PM revealed she was not aware of any inappropriate sexual behaviors directed to female residents by Resident #2 before the incident on 2/1/25. She stated she was not aware of the Psychiatric Mental Health Nurse Practitioner's note dated 1/16/25 until after the incident on 2/1/25 when she was compiling her investigation to submit to the state agency. The Administrator also added that she could not determine who reported Resident #2's inappropriate sexual behaviors to the Psychiatric Mental Health Nurse Practitioner on 1/16/25.
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
Transfer Notice
(Tag F0623)
Could have caused harm · This affected 1 resident
**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on record review, and staff, Adult Care Home admission Director, and Ombudsman interviews, the facility failed to provide ...
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**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on record review, and staff, Adult Care Home admission Director, and Ombudsman interviews, the facility failed to provide a complete written notice of transfer/discharge including a statement of the resident's appeal rights for 1 of 3 residents (Resident #2) reviewed for discharge.
The findings included:
Resident #2 was admitted to the facility on [DATE].
The admission Minimum Data Set, dated [DATE] indicated Resident #2 was cognitively intact.
A nursing progress note dated 2/3/25 revealed Resident #2 was discharged to the hospital on 2/3/25. Resident #2 did not return to the facility.
A review of Resident #2's medical record revealed a notice of transfer/discharge form was completed by the Administrator on 2/3/25 with the discharge location of a local adult care home, not the hospital. The form was issued without the second page entitled Nursing Home Hearing Request form which included instructions for Resident #2 to request an administrative hearing to appeal the discharge.
A review of an email from the Ombudsman to the Social Worker (SW) dated 2/5/25 revealed the second page of the notice of transfer/discharge entitled Nursing Home Hearing Request Form was attached and sent to the SW. The Ombudsman indicated both forms would need to be issued together to Resident #2 and she stated the facility would need to reissue the notice of Transfer/Discharge.
A telephone interview was conducted with the Ombudsman on 2/21/25 at 2:10 PM. She stated she received an email from the Social Worker on 2/4/25 with the notice of transfer/discharge for Resident #2 and the second page was missing. The Ombudsman explained to SW that the second page was the Hearing Request form and contained the instructions to request an administrative hearing to appeal the discharge. She informed the SW that both pages were required and without the second page Resident #2 would not be able to appeal the notice. The Ombudsman stated she asked the SW to reissue the notice of transfer/discharge to Resident #2.
An interview with the SW occurred on 2/20/25 at 5:33 PM. She stated the notice of transfer/discharge was written before Resident #2 was sent to the hospital. The SW explained she delivered the notice to Resident #2 and the staff at the hospital on 2/3/25. She stated the notice of transfer/discharge did not include the second page. The SW was not aware she needed to include the second page until she received the email from the Ombudsman. She stated the Ombudsman was supposed to send the second page to her. The SW explained the notice was not reissued to Resident #2. The SW stated someone at the facility started a conversation with the adult care home listed on the notice as the discharge location, but she did not know who it was.
A telephone interview with the admission Director at the adult care home listed on the notice of transfer/discharge on [DATE] at 4:54 PM revealed Resident #2's name was not in their system as a possible resident. They had not received any referrals with his name.
A telephone interview was conducted with the Administrator on 2/20/25 at 3:58 PM. The Administrator stated Resident #2 was sent to the hospital due his inappropriate behaviors and putting female residents at risk. She stated the Psychiatric Mental Health Nurse Practitioner stated Resident #2 was not appropriate for the facility.
A second telephone interview with the Administrator on 2/20/25 at 5:42 PM revealed she was aware of the notice of transfer/discharge given to Resident #2 by the SW who typically handled these notices. She stated the adult care home listed on the notice of transfer/discharge given to Resident #2 did not currently have a bed open for him. She was not aware Resident #2 did not receive the second page of the notice of transfer/discharge.
CONCERN
(D)
📢 Someone Reported This
A family member, employee, or ombudsman was alarmed enough to file a formal complaint
Potential for Harm - no one hurt, but risky conditions existed
Safe Transfer
(Tag F0626)
Could have caused harm · This affected 1 resident
**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on record review, and Hospital Case Manager, Resident Representative, and staff interviews, the facility failed to allow a...
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**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on record review, and Hospital Case Manager, Resident Representative, and staff interviews, the facility failed to allow a resident to return to the facility after being sent to the hospital for evaluation using the resident's inappropriate sexual behaviors prior to discharge as a basis for their decision for 1 of 3 residents reviewed for transfer and discharge (Resident #2).
The findings included:
Resident #2 was admitted to the facility on [DATE]. Diagnoses included hemiplegia and hemiparesis following cerebral infarction affecting left side and hypertension.
The admission Minimum Data Set, dated [DATE] indicated Resident #2 was cognitively intact.
Resident #2 was discharged to the hospital on 2/3/25 and did not return to the facility.
A review of Resident #2 electronic medical record (EMR) revealed he had a Resident Representative listed as a contact.
A review of a progress note written by the Psychiatric Mental Health Nurse Practitioner, dated 2/3/25 read, in part that Resident #2 was no longer appropriate to live at the facility after recent inappropriate sexual behavior with Resident #1. She further wrote that Resident #2 was a threat to female peers and to facility staff due to recent and past inappropriate behaviors. The Psychiatric Mental Health Nurse Practitioner indicated Resident #2 would be more appropriate in an all-male facility wherein other patient's safety would not be a factor.
A telephone interview with the Psychiatric Mental Health Nurse Practitioner occurred on 2/18/25 at 3:36 PM. She stated she wrote a progress note on 2/3/25 that Resident #2 was not appropriate for the facility due to the incident involving Resident #2 exhibiting inappropriate sexual behaviors towards Resident #1 on 2/1/25. She suggested Resident #2 be discharged to the hospital for psychological evaluation.
A nursing progress note dated 2/3/25 written by the Director of Nursing revealed Resident #2 was sent to the hospital for evaluation and management per Psychiatric Mental Health Nurse Practitioner's recommendation on 2/3/25.
A telephone interview occurred with Resident #2's Resident Representative on 2/20/25 at 11:27 AM. He stated he was told by the facility he would have a 30-day notice for his discharge, but stated Resident #2 was still in the hospital and the facility would not let him return. He stated many other facilities have come to the hospital to evaluate Resident #2, but there have been no offers for placement.
A telephone interview with the Hospital Case Manager on 2/20/25 at 2:30 PM revealed hospital case management called the facility on 2/3/25 immediately after Resident #2 was sent to the hospital emergency room. She stated the facility Social Worker (SW) dropped off a notice of transfer/discharge to Resident #2. The facility was called about the readmission of Resident #2 on 2/3/25 at 6:38 PM and the facility refused to readmit Resident #2.
An interview with the facility SW on 2/20/25 at 5:33 PM revealed she delivered the notice of transfer/discharge to Resident #2 on 2/3/25 at the hospital.
A telephone interview with the facility admission Liaison on 2/20/25 at 4:24 PM revealed the hospital case manager reached out for the facility to readmit Resident #2. She stated the facility would not readmit him per the Psychiatric Nurse Practitioner stating he was not appropriate for the facility due to his behaviors,
The Director of Nursing was not available during the survey to interview.
A telephone interview with the Administrator on 2/20/25 at 3:58 PM revealed she did not speak to the hospital case managers regarding Resident #2. She stated the admission Liaison spoke to the hospital and they pushed to have Resident #2 readmitted . She stated Resident #2 was sent out due to his inappropriate sexual behaviors and the Psychiatric Mental Health Nurse Practitioners stated he was not appropriate for their facility. The Administrator understood from the case managers that they would look for placement in another facility for him.
The Administrator was notified by the survey team by telephone on 2/20/25 at 5:41 PM there was an expectation Resident #2 would be readmitted to the facility with appropriate supervision.
The Administrator notified the survey team by email on 2/20/25 at 5:57 PM that the facility would readmit Resident #2 to the facility when a male bed was available.
Dec 2024
6 deficiencies
5 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
Notification of Changes
(Tag F0580)
Someone could have died · This affected 1 resident
**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on record review and interviews with staff, Nurse Practitioner and Medical Director, the facility failed to immediately co...
Read full inspector narrative →
**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on record review and interviews with staff, Nurse Practitioner and Medical Director, the facility failed to immediately consult with the on-call Nurse Practitioner on [DATE] when Resident #1 had a significant change in condition. Resident #1 showed signs of restlessness, agitation, crawling onto the floor and verbally expressed to staff that she had experienced difficulty breathing. The facility also failed to notify the provider that Resident #1 had received a medication for anxiety for which she had a documented allergy on [DATE] at 7:44 AM. On [DATE] at 8:13 AM Resident #1 was found in her room unresponsive with seriously abnormal vital signs. Resident #1 was pronounced deceased by Emergency Medical Services (EMS) staff at 8:30 AM on [DATE]. The deficient practice affected 1 of 3 residents reviewed for physician notification (Resident #1).
The findings included:
Resident #1 was readmitted to the facility on [DATE] with diagnoses of chronic obstructive pulmonary disease (COPD) and respiratory failure.
A review of Resident #1's quarterly Minimum Data Set assessment dated [DATE] revealed she was cognitively intact. The resident had no behaviors during the assessment period.
On [DATE] at 11:27 AM an interview was conducted with Nurse Aide (NA) #2. NA #2 stated she had cared for Resident #1 on [DATE] during the 3:00 PM to 7:00 PM shift. Resident #1 was very anxious when she came on shift at 3:00 PM and did not eat her supper meal. NA #2 recalled Resident #1 had flipped over her bedside table and had thrown her supper meal onto the floor. The interview revealed Resident #1 would not stay in the bed and NA #2 had to keep repositioning the resident so she was sitting up because Resident #1 said to her, I can't breathe. NA #2 stated, I sat her up to calm her down, I would give her the call light and she would immediately hit the light again asking me to come back saying she couldn't breathe. The interview revealed she told Nurse #2 and Nurse #1 about the resident's condition; however they just told her the resident was anxious. Resident #1 continued to use her call light throughout the shift and if she did not call out, she would yell out the door stating, I can't breathe, I can't breathe. NA #2 had not cared for Resident #1 prior to that day and was not familiar with the resident to know if that was typically how Resident #1 acted.
On [DATE] at 12:30 PM an interview was conducted with Nurse #2. During the interview she stated she had taken care of Resident #1 on [DATE] during the 7:00 AM to 7:00 PM shift. Nurse #2 stated Resident #1 seemed fine during her shift and did not seem anxious or short of breath. She did not recall NA #2 coming to her and stating the resident had not eaten her supper meal or thrown over the bedside table. Nurse #2 did not recall hearing Resident #1 yell out that she could not breathe during the shift. She gave report to Nurse #1 and left the facility at 7:00 PM.
On [DATE] at 1:20 PM an interview was conducted with NA #5. NA #5 was responsible for Resident #1 on [DATE] during the 7:00 PM to 11:00 PM shift. She stated she had a hard time assisting Resident #1 with incontinence care because she needed to sit up and seemed very anxious. NA #5 notified Nurse #1 of the resident's behavior however she stated Nurse #1 was already aware of how the resident was acting. At 11:00 PM she gave report to NA #6 and was assigned another hall. During the night she saw Resident #1's call light on so she went back into the room (but could not recall the time) to assist in changing the resident's brief. Once she lifted the bed up, Resident #1 would not stop moving and trying to get off of the bed. She stated she cleaned the resident as best as she could but Resident #1 would not lay down long enough, so she had a difficult time placing the new brief back onto the resident. NA #5 stated she had taken care of Resident #1 before, and she had never been that way. NA #5 indicated she once again let Nurse #1 know Resident #1 seemed very anxious, wanting to sit up and could not be still. Nurse #1 stated to her she was aware of the resident's condition. NA #5 then went back to her assigned hall.
On [DATE] at 9:05 AM an interview was conducted with NA #6. NA #6 was responsible for Resident #1 on [DATE] during the 11:00 PM to 7:00 AM shift. She stated at 11:00 PM she received a report that the resident was very anxious. Resident #1 was up and down all night and would not stay in bed. During the shift she would sit in the room with her because if she didn't then Resident #1 would end up lying on the floor. Resident #1 was talking but seemed confused. NA #6 stated Resident #1 was having difficulty breathing, was wheezing and did not want to lay down. She would assist the resident to sit up in the bed and sit on the side of the bed during the night. Resident #1 kept saying, Help me so she went and got Nurse #1 to go to the room to look at the resident. NA #6 stated at one point Nurse #1 said she was going to notify a physician and send her to the hospital. However, shortly after she changed her mind and said there was nothing the hospital could do for the resident because they were aware of her condition. Resident #1 was constantly moving from the bed to the floor on her fall mat during the shift, sitting up on the fall mat. Nurse #1 did not ask her to obtain vital signs. She stated she had taken care of Resident #1 before and had never seen her in the state she was in. NA #6 stated Resident #1 seemed like she was in distress. At 6:30 AM she gave a report to NA #1 and stated the resident had a change of condition and did not get any sleep during the night. She told NA #1 to keep a close eye on Resident #1 because she did not seem like herself.
Nurse #1 was assigned to Resident #1 on [DATE] - [DATE] during the 7:00 PM to 7:00 AM shift. A nursing note written by Nurse #1 as a late entry dated [DATE] at 8:30 PM revealed Resident #1 was very restless during the shift and had continued to attempt to place herself onto the floor and pull cords from the wall and wrap them around various body parts. At 10:15 PM Resident #1 was assisted to the chair and stated she wanted to get back into bed. When she was assisted back into bed, she then stated she wanted to get back on the floor. The note revealed at 10:30 PM staff were sitting in the room with Resident #1 for a duration of 30 minutes to try and calm her down. At 12:00 AM on [DATE], Resident #1 was noted to rest for brief periods of time and then become very restless again. Resident #1 was documented to continue being restless and staff assisted the resident back and forth from the bed to the chair and to the floor per her request at 2:00 AM. At 7:45 AM Resident #1 continued to be restless and a standing order for Ativan was given. At 8:10 AM Resident #1 had respiratory distress and Emergency Medical Services (EMS) was called.
A nursing note written by Nurse #1 as a late entry dated [DATE] at 7:48 AM revealed Nurse #1 was made aware by the NA that Resident #1 had attempted to get out of the bed several times and had pulled down multiple items in her room. The resident stated she felt warm and thirsty. Resident #1's temperature decreased, and she was provided with water. Resident #1 continued to thrust herself forward to get out of bed. She was redirected and remained in bed. The incident occurred on [DATE] at 9:00 PM.
On [DATE] at 3:56 PM an interview was conducted with Nurse #1. Nurse #1 stated when she received a report from Nurse #2 at 7:00 PM the nurse had stated the resident was up and down from the bed to the floor, very anxious and moving around a lot. The anxious behavior continued throughout the night. Nurse #1 said she was not familiar with the resident. Nurse #1 stated she didn't know the process for notification to the physician because she was new to the facility. She stated she assumed since a Nurse Practitioner (NP) was in the building daily that the NP knew what was going on with Resident #1 and would be back in the facility the next day to see the resident. Nurse #1 stated because she assumed the Nurse Practitioner was aware of Resident #1's condition and wasn't concerned, then the condition was probably the resident's baseline. She stated, I would rather talk to the physician in the morning than at 3:00 AM in the middle of the night. It seems like something day shift would tell them.
A nursing note written by Nurse #1 as a late entry dated [DATE] at 8:10 AM revealed Nurse #1 was made aware by Nurse #2 that Resident #1 was in possible distress after being discovered by NA #1 after medication administration. Upon entering the room, the resident was faced up and slow to respond. Nurse #1 requested vital signs and to call emergency medical services. Resident #1's vital signs were blood pressure 94/60 (normal blood pressure reading 120/80), pulse 111(normal pulse range 60-100), respiratory rate 4 (normal respiratory rate 12-20) and oxygen saturation level 54% (normal oxygen saturation level greater than 92%), Nurse #1 continued to call Resident #1's name with no response, the nurse requested oxygen saturation levels again with an oxygen saturation reading of 30% with supplemental oxygen (amount unspecified). EMS arrived on scene and were able to take over the resident's care.
On [DATE] at 12:53 PM an interview was conducted with Nurse #3. Nurse #3 worked on [DATE] -[DATE] during the 7:00 PM to 7:00 AM shift with Nurse #1 but was not responsible for Resident #1. Nurse #3 stated Nurse #1 asked her what to do regarding the resident because she was very anxious and kept getting in and out of bed. Nurse #1 seemed overwhelmed with the situation so Nurse #3 went to the resident's room with her to see what she could do. Nurse #3 stated Resident #1 was screaming out, crawling out of the bed and very anxious. At approximately 3:00 AM Nurse #1 again came to her and stated she did not know what to do with Resident #1. Nurse #3 did not instruct Nurse #1 to notify the on-call physician because she felt that Resident #1 had a diagnosis of COPD and was just excited like most residents with the diagnosis and the Ativan would help calm her.
A nursing note written by Nurse #2 dated [DATE] at 12:14 PM as a late entry revealed she had received report from Nurse #1 who stated Resident #1 was restless all evening and attempted to get out of bed multiple times throughout the night. Nurse Aide #1 alerted Nurse #2 the resident was unresponsive. Upon assessment Resident #1 was noted to be hypoxic (low levels of oxygen) with an oxygen saturation of 60% (normal level greater than 92%) on 4 liters of supplemental oxygen via nasal cannula. Emergency Medical Services (EMS) was notified, Resident #1 was noted to have a do no resuscitate (DNR) order in place. EMS took over in administering life saving measures without success. Resident #1 was pronounced deceased by EMS at 8:30 AM.
On [DATE] at 12:30 PM an interview was conducted with Nurse #2. Upon return to the facility on [DATE], she came in at 7:00 AM. Nurse #1 was giving her report and stated Resident #1 had been anxious during the night and they had tried to give the resident Ativan but did not have access to the An automated system for medication management, an automated system for medication management. Nurse #2 was getting a report from Nurse #1 when Unit Manager #1 arrived at the nurses station. Nurse #3 and Unit Manager #1 then went to pull the Ativan from the An automated system for medication management machine for Resident #1 while Nurse #2 finished getting report and began to start her medication pass. Unit Manager #1 then brought her a cup with a 0.5mg Ativan in it for Resident #1 and stated to her to administer the medication. Nurse #2 stated she did not ask any questions or look at the resident's allergies prior to administering the Ativan 0.5 mg along with the resident of Resident #1's morning medication around 7:44 AM. When she went into the resident's room, she was sitting up on the floor on her fall mat. Nurse #2 and NA #1 assisted the resident to get up to the side of the bed to take her medication. Nurse #2 administered the medication and stated the resident drank water provided and Nurse #2 left the room. She was then alerted by NA#1 approximately 5-10 minutes later that something was wrong with Resident #1. Nurse #2 and Nurse #1 went into the resident's room to find her lying on the bed with her eyes open and fixed, mouth open and a faint pulse. EMS were called and vital signs were obtained. Nurse #2 stated Resident #1 was pronounced deceased by EMS at 8:30 AM.
On [DATE] at 12:07 PM an interview was conducted with Nurse Aide (NA) #1. During the interview she stated she came on shift around 6:30 AM on [DATE] to find Resident #1 lying on her fall mat in the floor. Resident #1 looked at NA #1 and stated, I can't take this no more. She went to Nurse #1 who told her not to get the resident off the floor because she had been back and forth from the bed to the floor all night. NA #1 told Nurse #1 she did not feel comfortable leaving the resident lying on her fall mat in the floor but since she was wanting to be on the fall mat she proceeded to clean Resident #1 up and change her brief while she was lying on the fall mat. NA #1 then assisted Resident #1 up to the side of her bed and began fixing her oxygen tubing cord which was tangled. NA #1 was in the room with the resident when Nurse #2 entered the room and administered the resident's medication around 7:44 AM. NA #1 said Resident #1 acted like she did not want to take the medication, but she had her back to the resident untangling oxygen tubing. Nurse #2 then left the room as NA #1 continued to untangle the resident's oxygen tubing cord. NA #1 then heard the resident call out her name. When she turned around Resident #1 was lying flat on her back with her eyes fixed up at the ceiling and mouth open. Resident #1 would not respond to her, so she yelled out for Nurse #2 who was in the hallway outside of the resident's room. NA #1 stayed with the resident until Nurse #1 and Nurse #2 entered the room. Nurse #1 was doing a sternal rub on the resident to try and get her to respond however she did not. EMS was called and took over the resident's care once they arrived. She stated she had taken care of Resident #1 the day prior on [DATE] during the 7:00 AM to 3:00 PM shift and she was in no distress and was not anxious during the shift.
On [DATE] at 10:19 AM an interview was conducted with Unit Manager #1. During the interview she stated she had come in on [DATE] as the manager on call to orient Nurse #2 during the 7:00 AM to 7:00 PM shift. The interview revealed she arrived to the facility around 7:12 AM and noticed Resident #1 lying on her fall mat on the floor. She asked Nurse #1 if she was aware the resident was on the fall mat and Nurse #1 stated it was the safest place the resident could be. She was told Resident #1 had been very restless, agitated and had been throwing herself out of bed during the night. She was then notified by a Nurse Aide (name she could not recall) that Resident #1 was coding. Resident #1 was a DNR, so she went to the room to find Nurse #1, Nurse #2 and NA #1 in the room with the resident. EMS had already been contacted and were enroute to the facility. She left the room to print the resident's paperwork and gave EMS the resident's DNR paperwork upon their arrival to the facility.
EMS records dated [DATE] revealed they were notified at 8:13 AM, dispatched to the facility at 8:18 AM, arrived on scene at 8:29 AM and to the resident at 8:30 AM with a chief complaint of cardiac/ respiratory arrest. Upon EMS arrival Resident #1 was found lying in bed. The resident was apneic (without breathing) and pulseless. Resident #1 had no heart tones with a valid do not resuscitate order (DNR). She was pronounced deceased at 8:30 AM.
On [DATE] at 2:24 PM an interview was conducted with the former Director of Nursing (DON). The DON stated Unit Manager #1 called her on [DATE] to notify her Resident #1 had expired. The nurses were new to the facility and did not notify the on-call provider that Resident #1 had experienced a change of condition. The DON stated all nurses involved should have followed the facility protocol if a resident had experienced a change of condition and notified the physician.
On [DATE] at 11:28 AM an interview was conducted with the Administrator and Regional Nurse Consultant. The interview revealed on [DATE] around 7:30 AM, Nurse #2 administered Ativan 0.5 mg to Resident #1 due to behaviors of restlessness and agitation. Nurse #2 administered Ativan to Resident #1 at 7:44 AM and Resident #1 was then found unresponsive with a low oxygen saturation level. EMS was called to the facility, and the resident was pronounced as deceased . At 11:30 AM the Former Director of Nursing (DON) was reviewing the documentation, and they immediately suspended the nurses involved and completed an investigation into the incident. Nurse #1 was responsible for the resident during the 7:00 PM to 7:00 AM shift and had needed guidance from Nurse #3 who told her about the standing order for Ativan 0.5mg. None of the 4 nurses involved in the incident notified a provider that Resident #1 had experienced difficulty breathing, restlessness or increased anxiety.
On [DATE] at 1:34 PM an interview was conducted with the on-call Nurse Practitioner. During the interview she stated she was not contacted on [DATE] or [DATE] regarding Resident #1. She stated that was unusual because the facility typically would let her know if anything acute happened but if a resident was having trouble breathing, she would have immediately sent the resident to the hospital for an evaluation.
On [DATE] at 1:38 PM an interview was conducted with the Medical Director (MD). The MD stated the DON notified him of an incident that happened on [DATE] when a nurse administered Ativan to a resident with a documented allergy to the medication. The interview revealed the first time he was contacted was on [DATE] at 1:00 PM and told a medication error had occurred. He wasn't notified Resident #1 had experienced a change of condition starting at approximately 3:00 PM on [DATE]. The MD stated the on-call Nurse Practitioner would have been notified if it happened after 5:00 PM. The MD stated the facility should have sent Resident #1 to the hospital for an evaluation because from review of the nursing progress notes she had a respiratory episode and could have had increased carbon dioxide (A waste product produced during metabolism. It is transported through the bloodstream to the lungs, where it is exhaled as a gas.) in the blood. He stated the result of increased CO2 levels would be psychotic behavior such as getting up and down out of bed along with confusion. The MD stated if they had contacted the Nurse Practitioner, she would have sent the resident to the hospital for an evaluation because the resident was likely having an acute exacerbation of COPD as she had experienced in the past and needed to be on a BiPap (non-invasive ventilation therapy).
The Administrator was notified of the immediate jeopardy on [DATE] at 6:30 PM.
The facility provided the following corrective action plan with a completion date of [DATE].
Address how corrective action will be accomplished for those residents found to have been affected by the deficient practice;
The facility failed to notify the on-call medical provider that Resident #1 had experienced a change of condition. Based on staff interviews on [DATE] during the 3:00 PM to 7:00 AM shift, Resident #1 showed signs of restlessness, agitation, crawling onto the floor and verbally expressed to staff that she was experiencing difficulty breathing. At 8:13 AM Resident was noted in her room unresponsive with a blood pressure of 94/60, pulse rate of 111, respiratory rate of 4 and oxygen saturation level of 54%. The staff applied a non-rebreather mask then called Emergency Medical Services (EMS). Resident #1 was pronounced deceased by EMS staff at 8:30 AM.
Address how the facility will identify other residents having the potential to be affected by the same deficient practice;
Current residents are at risk of this occurring.
An audit was completed by the Director of Nursing and designee to review the last 7 days of nursing notes to ensure any noted changes in residents' condition were noted and the physician had been notified. This was completed by the Director of nursing on [DATE]. The audit included a review of nursing notes and 24-hour shift to shift reports.
Address what measures will be put into place or systemic changes made to ensure that the deficient practice will not recur;
Education started by the Director of Nursing on [DATE] for the change in condition and physician notification related to change in condition to include providing comprehensive assessments, that required medical attention, obtain vital signs, signs of restlessness, agitation, oxygen saturations, and any breathing issues. Any licensed nurse and medication aides not receiving this education will not be able to work until receiving the education. New licensed nurses and medication aides will receive education during the orientation process. Director of Nursing ensured all licensed nurses and medication aides were educated prior to working their next scheduled shift as of [DATE]. Director of nursing reeducated all certified nursing assistants on verbally reporting any noted change in condition such as altered mental status, abnormal behaviors, abnormal vital signs, etc. to the nurse for assessment as of [DATE].
All nursing note reviews, and 24-hour reports reviews were completed by the Director of Nursing or designee by [DATE] to ensure noted changes in condition were addressed, vitals taken and physician notified. Nursing note reviews will be completed by the Director of Nursing or Designee on 5 residents weekly x 12 weeks.
New changes in conditions will be reviewed by the nursing clinical team during morning clinical meetings for any noted change in condition and physician notification. This occurs 5 times weekly and is ongoing as of [DATE]. New changes in condition from the weekend will be reviewed by the nursing clinical team during the Monday clinical meeting. The nursing team was notified of this responsibility on [DATE] by the facility administrator.
Indicate how the facility plans to monitor its performance to make sure that solutions are sustained;
As of [DATE] the results of the monitoring will be reviewed by the Administrator or Director of Nursing in the weekly Risk meeting and during the monthly Quality Assurance Performance Improvement (QAPI) meeting with the Interdisciplinary Team (IDT) as of [DATE] for 3 months. Changes will be made to the plan as necessary to maintain compliance with resident safety. The IDT team will consist of the Administrator, Director of Nursing, Medical Director, Social Worker, Activities Director and Minimum Data Set (MDS) nurse.
Alleged date of compliance and the immediate jeopardy removal date is [DATE].
On [DATE], the corrective action plan was validated by onsite verification through facility staff interviews. The interviews revealed all nursing staff had received education on the change in condition and physician notification related to change in condition to include providing comprehensive assessments, that required medical attention, obtain vital signs, signs of restlessness, agitation, oxygen saturations, and any breathing issues. Nurse Aides were interviewed regarding notification to the nursing staff if they see a resident with a change of condition. The facility's in-service log, monitoring results and training material was reviewed.
The immediate jeopardy was removed on [DATE]. The completion date of [DATE] for the corrective action plan was validated.
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
Free from Abuse/Neglect
(Tag F0600)
Someone could have died · This affected 1 resident
**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on record review, and facility staff, Nurse Practitioner (NP), and Medical Director (MD) interviews, the facility failed t...
Read full inspector narrative →
**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on record review, and facility staff, Nurse Practitioner (NP), and Medical Director (MD) interviews, the facility failed to protect Resident #1's right to be free of neglect when the facility failed to: 1) immediately consult with the on-call Nurse Practitioner on [DATE] when a resident had a significant change in condition during the 3:00 PM to 11:00 PM shift that included signs of restlessness, agitation, crawling onto the floor and verbally expressing to staff that she had difficulty breathing; 2) complete ongoing thorough assessments for the change in condition that continued through the 11:00 PM to 7:00 AM shift; 3) prevent a significant medication error when staff deliberately disregarded an electronic medical record (EMR) system alert when Ativan (a benzodiazepine, used as a sedative medication) was entered into the EMR and administered to a resident who had a documented allergy to the medication; 4) notify the physician that Ativan was administered to a resident with a documented allergy; and 5) recognize the seriousness of a significant change in condition and identify the urgent need for medical attention. On [DATE] at 8:13 AM EMS were contacted when Resident #1 was found in her room unresponsive. Upon EMS arrival, Resident #1 was apneic (without breathing) and pulseless and Resident #1 was pronounced deceased at 8:30 AM. This deficient practice affected 1 of 3 sampled residents reviewed for neglect (Resident #1).
The findings included:
This tag is cross referenced to:
F580: Based on record review and interviews with staff, Nurse Practitioner and Medical Director, the facility failed to immediately consult with the on-call Nurse Practitioner on [DATE] when Resident #1 had a significant change in condition. Resident #1 showed signs of restlessness, agitation, crawling onto the floor and verbally expressed to staff that she had experienced difficulty breathing. The facility also failed to notify the provider that Resident #1 had received a medication for anxiety for which she had a documented allergy on [DATE] at 7:44 AM. On [DATE] at 8:13 AM Resident #1 was found in her room unresponsive with seriously abnormal vital signs. Resident #1 was pronounced deceased by Emergency Medical Services (EMS) staff at 8:30 AM on [DATE]. The deficient practice affected 1 of 3 residents reviewed for physician notification (Resident #1).
F684: Based on observations, record review, and resident, staff, Nurse Practitioner (NP), and Medical Director (MD) interviews, the facility failed to identify the seriousness of a significant change in condition, complete ongoing thorough assessment and identify the urgent need for medical attention for a resident with a history of chronic obstructive pulmonary disease who reported she could not breathe. On [DATE] during the 3:00 PM to 11:00 PM shift, Resident #1 was restless, agitated, crawling onto the floor and verbally expressed to staff she could not breathe. During the night shift (11:00 PM to 7:00 AM) the difficulty breathing, anxiety and agitation continued and Resident #1 asked staff repeatedly to help her. On [DATE] at 8:13 AM Resident was noted in her room unresponsive with a blood pressure of 94/60, pulse rate of 111, respiratory rate of 4 and oxygen saturation level of 54%. Resident #1 was pronounced deceased by Emergency Medical Services (EMS) staff at 8:30 AM. This deficient practice occurred for 1 of 3 sampled residents reviewed for quality of care (Resident #1).
F760: Based on record review, and interviews with staff, Medical Director and Pharmacist, the facility failed to prevent a significant medication error when Resident #1 received a dose of Ativan (a benzodiazepine, used as a sedative medication) as a one-time dose. Resident #1 had an allergy to Ativan documented on the Allergy List in the electronic medical record (EMR) on [DATE]. The medication order was entered into the electronic health record by Nurse #3. She stated the electronic medical record flagged the order due to the allergy, but she bypassed the alert and entered the order in the EMR, which was then pulled from an automated system for medication management. Nurse #2, a nurse who was orienting under the supervision of the Unit Manager, administered the medication on [DATE] at 7:44 AM. On [DATE] at 8:13 AM Resident #1 became unresponsive with seriously abnormal vital signs. Resident #1 was pronounced deceased by Emergency Medical Services (EMS) staff at 8:30 AM. This deficient practice occurred for 1 of 3 sampled residents reviewed for medication errors.
The Administrator was notified of the immediate jeopardy on [DATE] at 6:30 PM.
The facility provided the following corrective action plan with a compliance date of [DATE].
Address how corrective action will be accomplished for those residents found to have been affected by the deficient practice;
The facility neglected to act upon the system alert for Resident #1's allergy to Ativan when ordering a one-time dose on [DATE]. Nurse #3 entered the order for Ativan and when the system flagged the order due to a documented allergy for Resident #1, Nurse #3 by passed the alert, continued to enter the order which was then pulled from the Omnicell and given to Resident #1 on [DATE] at approximately 7:35 AM. At approximately 8:15 AM Resident #1 was found in her room unresponsive with vital signs: b/p: 94/60, Pulse: 111, Respirations: 4, Oxygen saturation level of 54%. Emergency Medical Services (EMS) was called and pronounced Resident #1 deceased at 8:30 AM. The facility failed to provide comprehensive assessments, failed to identify a significant change in condition that required medical attention, failed to obtain vital signs and ongoing oxygen saturations during the evening and night on [DATE] through [DATE]. On [DATE] during the 3:00 PM to 11:00 PM shift, Resident #1 showed signs of restlessness, agitation, crawling onto the floor and verbally expressed to staff that she was experiencing difficulty breathing which continued from 11:00 PM to 7:00 AM. The facility failed to notify the on call medical provider that a resident had experienced a change of condition on [DATE].
On [DATE], the Director of Nursing was notified at 11:13 am by Nurse #1 that Resident #1 had an allergy to Ativan. Nurses involved in the incident were suspended on [DATE] pending investigation. Nurse #1, and Nurse #3 were terminated and reported to the Board of Nursing as of [DATE]. Nurse # 2 turned in a resignation letter on [DATE]. The Unit Manger was initially terminated and appealed the termination. She was brought back on 12/16 and placed back into the training program. She resigned effective immediately on 12/28. Medical Director was notified of Residents #1 change in condition and medication allergy at around 1:00 pm on [DATE] by the Director of Nursing. The Nurse Practitioner was notified around 8:30 AM of a change in condition and an allergy to Ativan.
Address how the facility will identify other residents having the potential to be affected by the same deficient practice;
Current residents are at risk of this occurring.
An audit of medication allergy alerts, change in condition and physician notification in the electronic medical records was completed by the Director of Nursing and designee on [DATE] to ensure that medications were not ordered with the listed allergies.
An audit on [DATE] completed by the Director of Nursing and designee to review nursing notes, 24 hour reports, vital sign logs in the electronic healthcare record to ensure any noted changes in residents' condition were noted and physician notified. The audit also included that residents' vital signs were taken and noted in the electronic record.
Audits included all current residents who could be affected by this deficient practice of neglect were reviewed to ensure any change in condition and physician notification as well as bypassing the allergy alert which would result in neglect were reviewed by the director of nursing. No negative findings noted following the audit on [DATE].
Address what measures will be put into place or systemic changes made to ensure that the deficient practice will not recur;
Education started by the Director of Nursing on [DATE] for the process for medication order entry in regard to alerts related to allergies and acknowledgement of alerts. Education also included physician notification of known allergies.
Education started by the Director of Nursing on [DATE] for the change in condition and included providing comprehensive assessments that require medical attention, obtaining vital signs, signs of restlessness, agitation, oxygen saturations, and any breathing issues and notification of physician of change in condition. Education also included the documentation of comprehensive assessment into the electronic medical record.
Education also addressed failure to follow above processes results in neglect which is a form of abuse.
.
Director of nursing educated all certified nursing assistants on reporting any noted change in condition to the nurse verbally for assessment as of [DATE].
Any licensed nurse and medication aides not receiving this education will not be able to work until receiving the education. Director of Nursing ensured all licensed nurses and medication aides were educated prior to working their next scheduled shift as of [DATE].
New licensed nurses will receive education during the orientation process by the Director of Nursing until a Staff Development Coordinator is hired.
Medication Observations on current licensed nurses and medication aides will be completed by the Director of Nursing or designee by [DATE] to ensure no medications are given related to a resident allergy. Med pass observations will be completed by Director of Nursing or Designee on 5 licensed nurses and/or medication aides weekly x 12 weeks.
New medication alerts will be reviewed by the director of nursing and the clinical team during morning clinical meetings. This occurs 5 times weekly and is ongoing as of [DATE]. Any allergy alerts will be addressed at the time.
All nursing notes and 24-hour reports will be reviewed by the nursing clinical team during morning clinical meetings for any noted changes in condition to ensure vital signs and oxygen saturation were done for change in condition. This occurs 5 times weekly and is ongoing as of [DATE]. Director of Nursing or designee will review nursing notes over the weekend to ensure any change in condition is addressed. Nursing note reviews will be completed by the Director of Nursing or Designee on 5 residents weekly x 12 weeks.
As of [DATE] the Director of nursing or designee will interview 5 nurse aides weekly for 12 weeks to ensure they are reporting any change in condition to their charge nurse verbally.
Until a Staff Development Coordinator is hired, the Director of Nursing will complete monthly training on abuse and neglect for 3 months and then quarterly ongoing. Education will ensure abuse and neglect is explained to all staff per federal guidelines, Neglect as defined at 483.12, the failure of the facility, its employees or service providers to provide goods and services to a resident that are necessary to avoid physical harm, pain, mental anguish or emotional distress.
Indicate how the facility plans to monitor its performance to make sure that solutions are sustained;
As of [DATE] the results of the monitoring will be reviewed by the Administrator or Director of Nursing in the weekly Risk meeting and during the monthly Quality Assurance Performance Improvement (QAPI) meeting with the Interdisciplinary Team (IDT) as of [DATE] for 3 months. Changes will be made to the plan as necessary to maintain compliance with resident safety. The IDT team will consist of the Administrator, Director of Nursing, Medical Director, Social Worker, Activities Director and Minimum Data Set (MDS) nurse.
Alleged date of IJ removal: [DATE]
On [DATE], the corrective action plan was validated by onsite verification through facility staff interviews. The interviews revealed all nursing staff had received education on the process for medication order entry in regard to alerts related to allergies and acknowledgement of alerts. Education also included physician notification of known allergies. The education also included change in condition and included providing comprehensive assessments that require medical attention, obtaining vital signs, signs of restlessness, agitation, oxygen saturations, and any breathing issues. Education also included the documentation of comprehensive assessment into the electronic medical record. Education also addressed failure to follow above processes results in neglect which is a form of abuse. Nurse Aides were interviewed regarding notification to the nursing staff if they see a resident with a change of condition. The facility's in-service log, monitoring results and training material was reviewed.
The immediate jeopardy removal date of [DATE] and the compliance date of [DATE] for the corrective action plan were validated.
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
Quality of Care
(Tag F0684)
Someone could have died · This affected 1 resident
**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observations, record review, and resident, staff, Nurse Practitioner (NP), and Medical Director (MD) interviews, the fa...
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**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observations, record review, and resident, staff, Nurse Practitioner (NP), and Medical Director (MD) interviews, the facility failed to identify the seriousness of a significant change in condition, complete ongoing thorough assessments and identify the urgent need for medical attention for a resident with a history of chronic obstructive pulmonary disease who reported she could not breathe. On [DATE] during the 3:00 PM to 11:00 PM shift, Resident #1 was restless, agitated, crawling onto the floor and verbally expressed to staff she could not breathe. During the night shift (11:00 PM to 7:00 AM) the difficulty breathing, anxiety and agitation continued and Resident #1 asked staff repeatedly to help her. On [DATE] at 8:13 AM Resident #1 was noted in her room unresponsive with a blood pressure of 94/60 (normal blood pressure reading 120/80), pulse 111(normal pulse range 60-100), respiratory rate 4 (normal respiratory rate 12-20) and oxygen saturation level 54% (normal oxygen saturation level greater than 92%). Resident #1 was pronounced deceased by Emergency Medical Services (EMS) staff at 8:30 AM. This deficient practice occurred for 1 of 3 sampled residents reviewed for quality of care (Resident #1).
The findings included:
Resident #1 was readmitted to the facility on [DATE] with diagnoses of chronic obstructive pulmonary disease (COPD) and respiratory failure. Resident #1 was [AGE] years old.
An allergy list in the electronic medical record (EMR) updated on [DATE] included the medication Ativan. Resident #1's allergy reaction was documented as unspecified.
A physician order dated [DATE] revealed Resident #1 required continuous supplemental oxygen via 2 liters/minute to maintain oxygen saturation levels greater than 92 %.
A physician order dated [DATE] revealed Resident #1 was prescribed formoterol fumarate inhalation nebulization solution (breathing treatment) to inhale orally via nebulizer two times a day related to COPD with acute exacerbation.
A review of Resident #1's quarterly Minimum Data Set assessment dated [DATE] revealed she was cognitively intact. The resident had no behaviors during the assessment period. Resident #1 received antianxiety medication during the assessment period and continuous oxygen therapy.
On [DATE] at 11:27 AM a telephone interview was conducted with Nurse Aide (NA) #2. NA #2 stated she had cared for Resident #1 on [DATE] during the 3:00 PM to 7:00 PM shift. Resident #1 was very anxious when she came on shift at 3:00 PM and did not eat her supper meal. NA #2 recalled Resident #1 had flipped over her bedside table and had thrown her supper meal onto the floor. The interview revealed Resident #1 would not stay in the bed and NA #2 had to keep repositioning the resident so she was sitting up because Resident #1 said to her, I can't breathe. NA #2 stated, I sat her up to calm her down, I would give her the call light and she would immediately hit the light again asking me to come back saying she couldn't breathe. NA #2 recalled she told Nurse #2 and Nurse #1 about the resident's condition; however they just told her the resident was anxious. Resident #1 continued to use her call light throughout the shift and if she did not call out, she would yell out the door stating, I can't breathe, I can't breathe. NA #2 had not cared for Resident #1 prior to that day and was not familiar with the resident to know if that was typically how Resident #1 acted. Resident #1 was wearing supplemental oxygen during the shift. NA #2 stated Resident #1 continued to be anxious and have behaviors throughout her shift and reported the behaviors to the oncoming NA (NA#5).
A nursing note dated [DATE] at 6:39 PM documented by Nurse #2 revealed Resident #1's vital signs taken on [DATE] with readings of blood pressure 135/72, temperature 97.6, pulse 67, respiratory rate 14 and O2 96%. Resident #1 was receiving oxygen therapy at 2 liters per minute. No signs or symptoms of distress were noted.
On [DATE] at 12:30 PM a telephone interview was conducted with Nurse #2. During the interview she stated she had taken care of Resident #1 on [DATE] during the 7:00 AM to 7:00 PM shift. Nurse #2 stated Resident #1 seemed fine during her shift and did not seem anxious or short of breath. She did not recall NA #2 coming to her and stating the resident had not eaten her supper meal or thrown over the bedside table. Nurse #2 did not recall hearing Resident #1 yell out that she could not breathe during the shift. Nurse #2 stated she had administered Resident #1's medication around 5:00 PM and she was able to swallow her medication and did not seem to be in any distress. She gave report to Nurse #1 that Resident #1 was using her call light repeatedly, but the nurses said that was normal for the resident. Nurse #2 indicated she left the facility at 7:00 PM. Nurse #2 stated she was new to the facility and was not very familiar with Resident #1.
Review of Resident #1's medical record revealed no vital signs were documented for Resident #1 on [DATE] during the 7:00 AM to 7:00 PM shift.
On [DATE] at 1:20 PM a telephone interview was conducted with NA #5. NA #5 stated she was responsible for Resident #1 on [DATE] during the 7:00 PM to 11:00 PM shift. NA #5 indicated she received report from NA #2 who had stated Resident #1 was very anxious and having difficulty breathing. NA #5 stated she had a hard time assisting Resident #1 with incontinence care because she needed to sit up and seemed very anxious. NA #5 notified Nurse #1 of the resident's behavior around 10:00 PM however she stated Nurse #1 was already aware of how the resident was acting because she had been in and out of the room during the shift. NA #5 revealed she gave report to NA #6 at 11:00 PM and she (NA #5) was assigned to another hall. During the night (could not recall what time) she saw Resident #1's call light on so she went back into the room to assist NA #6 with changing the resident's brief. Once she raised the bed up, Resident #1 would not stop moving and trying to get off the bed. She stated she cleaned the resident as best as she could, but Resident #1 would not lay down long enough, so she had a difficult time placing the new brief back onto the resident. NA #5 stated she had taken care of Resident #1 before, and she had never been that way. Resident #1 was wearing supplemental oxygen during the shift. NA #5 indicated she once again let Nurse #1 know Resident #1 seemed very anxious, wanting to sit up and could not be still. Nurse #1 stated to her she was aware of the resident's condition. NA #5 then went back to her assigned hall.
On [DATE] at 9:05 AM a telephone interview was conducted with NA #6 who was responsible for Resident #1 on [DATE] during the 11:00 PM to 7:00 AM shift. She stated at 11:00 PM she received a report NA #5 that the resident was very anxious. Resident #1 was up and down all night and would not stay in bed. NA #6 recalled she sat in the room with Resident #1 during the shift because if she didn't then Resident #1 would end up lying on the floor. Resident #1 was talking but seemed confused. NA #6 stated Resident #1 was having difficulty breathing, was wheezing and did not want to lay down. She assisted the resident to sit up in the bed and sit on the side of the bed during the night. Resident #1 kept saying, Help me so she went and got Nurse #1 to go to the room to look at the resident (could not recall what time). Nurse #1 went into the room and looked at Resident #1 and said she was going to notify a physician and send her to the hospital. However, shortly after Nurse #1 changed her mind and said there was nothing the hospital could do for the resident because they were aware of her condition. Resident #1 was constantly moving from the bed to the floor on her fall mat during the shift, sitting up on the fall mat. Resident #1 was wearing supplemental oxygen during the shift. Nurse #1 did not ask her to obtain vital signs, so she did not get them. She stated she had taken care of Resident #1 before and had never seen her in the state she was in, and it seemed like she was in distress. At 6:30 AM she gave a report to NA #1 and stated the resident had a change of condition and did not get any sleep during the night. She told NA #1 to keep a close eye on Resident #1 because she did not seem like herself.
Review of Resident #1's Medication Administration Record dated [DATE] revealed an order for nebulization solution (breathing treatment) to inhale orally via nebulizer at bedtime related to Chronic Obstructive Pulmonary Disease with Acute Exacerbation. On [DATE] the medication was scheduled for 9:00 PM. Nurse #1 documented a (2) for the [DATE] 9:00 PM dose. Review of the legend located at the bottom of the MAR dated [DATE] revealed documentation of a (2) meant the medication was refused.
A statement written and signed by Nurse #1 on [DATE] obtained by the facility revealed she was assigned Resident #1 during the 7:00 PM to 7:00 AM shift on [DATE] through [DATE]. The statement revealed Resident #1 kept getting out of the bed and laying on the floor during the shift. Nurse #3 asked her if the resident had any Ativan available and Nurse #1 stated she wasn't sure. Nurse #3 then told her the facility had standing orders for Ativan, and it could be pulled from the automated medication dispensing system. Nurse #1 was unable to access the automated medication dispensing system. and had to wait until the next shift to be able to obtain the Ativan. When the next shift arrived at 7:00 AM Nurse #1 gave report to Nurse #2. NA #1 came to the office after Nurse #3's medication pass and stated something was wrong with Resident #1. Nurse #3 asked if she would go to the resident's room for support, so Nurse #1 did. Upon arrival to the resident's room Resident #1 was face up, lying in bed with a slow response to communicate. She asked for vital signs and for someone to call EMS after feeling a weak pulse on the resident. Nurse #1 continued to do a sternal rub on the resident until EMS arrived. After EMS arrived, she was told Resident #1 had expired. Nurse #1 was later told Resident #1 had received by mouth Ativan and that she had an allergy to the medication. Nurse #1 noted in her statement she did not administer the medication but had signed off on the resident's MAR because she was the nurse responsible for the resident and had initiated the process of Resident #1's need for the medication.
Nurse #1 was assigned to Resident #1 on [DATE] at 7:00 PM through [DATE] at 7:00 AM. A nursing note written by Nurse #1 as a late entry dated [DATE] at 8:30 PM revealed Resident #1 was very restless during the shift and had continued to attempt to place herself onto the floor and pull cords from the wall and wrap them around various body parts. At 10:15 PM Resident #1 was assisted to the chair and stated she wanted to get back into bed. The note read, vital signs completed WNL (within normal limits). When she was assisted back into bed, she then stated she wanted to get back on the floor. The note revealed at 10:30 PM staff were sitting in the room with Resident #1 for a duration of 30 minutes to try and calm her down. At 12:00 AM on [DATE], Resident #1 was noted to rest for brief periods of time and then become very restless again. Resident #1 was documented to continue being restless and staff assisted the resident back and forth from the bed to the chair and to the floor per her request at 2:00 AM. At 7:45 AM ([DATE]) Resident #1 continued to be restless and a standing order for Ativan was given. At 8:10 AM Resident #1 had respiratory distress and Emergency Medical Services (EMS) was called.
A nursing note written by Nurse #1 as a late entry dated [DATE] at 7:48 AM revealed Nurse #1 was made aware by the NA that Resident #1 had attempted to get out of bed several times and had pulled down multiple items in her room. The resident stated she felt warm and thirsty. Resident #1's temperature decreased, and she was provided with water. Resident #1 continued to thrust herself forward to get out of bed. She was redirected and remained in bed. The incident occurred on [DATE] at 9:00 PM.
A nursing note written by Nurse #1 as a late entry for [DATE] dated [DATE] at 8:10 AM revealed Nurse #1 was made aware by Nurse #2 that Resident #1 was in possible distress after being discovered by NA #1 after medication administration. Upon entering the room, the resident was face up and slow to respond. Nurse #1 requested vital signs and to call emergency medical services. Resident #1's vital signs were blood pressure 94/60 (normal blood pressure reading 120/80), pulse 111(normal pulse range 60-100), respiratory rate 4 (normal respiratory rate 12-20) and oxygen saturation level 54% (normal oxygen saturation level greater than 92%), Nurse #1 continued to call Resident #1's name with no response, the nurse requested oxygen saturation levels again with an oxygen saturation reading of 30% with supplemental oxygen (amount unspecified). EMS arrived on scene and were able to take over the resident's care.
On [DATE] at 3:56 PM a telephone interview was conducted with Nurse #1. She confirmed she was responsible for Resident #1 on [DATE] through [DATE] for the 7:00 PM to 7:00 AM shift. Nurse #1 stated when she received a report from Nurse #2 at 7:00 PM on [DATE] the nurse had stated the resident was up and down from the bed to the floor, very anxious and moving around a lot. Nurse #1 recalled the anxious behavior continued throughout the night for her entire shift. Nurse #1 said she was not familiar with the resident. Nurse #1 stated she didn't know the process for notification to the physician because she was new to the facility. She stated she assumed since a Nurse Practitioner (NP) was in the building daily that the NP knew what was going on with Resident #1 and would be back in the facility the next day to see the resident. Nurse #1 stated because she assumed the Nurse Practitioner was aware of Resident #1's condition and wasn't concerned, then the condition was probably the resident's baseline. Nurse #1, who was no longer employed by the facility, stated she wanted to use her initial statement to the facility as a response to any more questions asked.
On [DATE] at 12:07 PM an interview was conducted with Nurse Aide (NA) #1. During the interview she stated she came on shift around 6:30 AM on [DATE] to find Resident #1 lying on her fall mat in the floor with supplemental oxygen on via nasal cannula. Resident #1 looked at NA #1 and stated, I can't take this no more. She went to Nurse #1 who told her not to get the resident off the floor because she had been back and forth from the bed to the floor all night. NA #1 told Nurse #1 she did not feel comfortable leaving the resident lying on her fall mat on the floor but since she was wanting to be on the fall mat she proceeded to clean Resident #1 up and change her brief while she was lying on the fall mat. NA #1 then assisted Resident #1 up to the side of her bed and began fixing her oxygen tubing cord which was tangled. NA #1 was in the room with the resident when Nurse #2 entered the room and administered the resident's medication. NA #1 then heard the resident call out her name. When she turned around Resident #1 was lying flat on her back with her eyes fixed up at the ceiling and with her mouth open. Resident #1 would not respond to her, so she yelled out for Nurse #2 who was in the hallway outside of the resident's room. NA #1 stayed with the resident until Nurse #1 and Nurse #2 entered the room. Nurse #1 was doing a sternal rub on the resident to try and get her to respond, however she did not. EMS was called and took over the resident's care once they arrived. She stated she had taken care of Resident #1 the day prior on [DATE] during the 7:00 AM to 3:00 PM shift and she was in no distress and was not anxious during the shift.
An undated After-Hours Standing Physician Orders revealed for aggression or agitated behavior the nurse may administer Ativan 0.5 milligram (mg) by mouth. The nurse could repeat the action in 20 minutes if the resident did not respond to the medication. The orders read to notify the primary care physician in the AM for further orders.
A medication administration note in the electronic medical record dated [DATE] at 7:43 AM revealed Nurse #3 entered an order for Ativan oral tablet 0.5 mg. Give 0.5 mg by mouth one time only related to COPD with acute exacerbation. The medication order triggered an alert for a system identified drug allergy.
Resident #1's Medication Administration Record (MAR) for [DATE] revealed an order for Ativan oral tablet 0.5 mg by mouth on time only related to COPD with acute exacerbation. The medication was administered on [DATE] at 7:44 AM and signed off by Nurse #1.
A nursing note written by Nurse #2 dated [DATE] at 12:14 PM as a late entry revealed she had received report from Nurse #1 who stated Resident #1 was restless all evening and attempted to get out of bed multiple times throughout the night. Nurse Aide #1 alerted Nurse #2 the resident was unresponsive. Upon assessment Resident #1 was noted to be hypoxic (low levels of oxygen) with an oxygen saturation of 60% (normal level greater than 92%) on 4 liters of supplemental oxygen via nasal cannula. Emergency Medical Services (EMS) was notified, Resident #1 was noted to have a do no resuscitate (DNR) order in place. EMS took over in administering life saving measures without success. Resident #1 was pronounced deceased by EMS at 8:30 AM.
On [DATE] at 12:30 PM a telephone interview was conducted with Nurse #2. Nurse #2 stated she returned to the facility on [DATE] at 7:00 AM and Nurse #1 gave her report and stated Resident #1 had been anxious during the night and they had tried to give the resident Ativan but did not have access to the automated medication dispensing system. Nurse #2 recalled she was getting a report from Nurse #1 when Unit Manager #1 arrived at the nurse's station. Nurse #3 and Unit Manager #1 then went to pull the Ativan for Resident #1 while she (Nurse #2) finished getting report and began to start her medication pass. Unit Manager #1 brought her a cup with a 0.5mg Ativan in it for Resident #1 and stated to her to administer the medication. Nurse #2 stated she did not ask any questions or look at the resident's allergies prior to administering the Ativan 0.5 mg along with Resident #1's morning medication. When she went into the resident's room, Resident #1 was sitting up on the floor on her fall mat. Nurse #2 and NA #1 assisted the resident to get up to the side of the bed to take her medication. Nurse #2 administered the medication and stated the resident drank water provided and Nurse #2 left the room. She was then alerted by NA#1 approximately 5-10 minutes later that something was wrong with Resident #1. Nurse #2 and Nurse #1 went into the resident's room to find her lying on the bed with her eyes open and fixed, mouth open and a faint pulse. EMS were called and vital signs were obtained. Nurse #2 stated Resident #1 was pronounced deceased by EMS at 8:30 AM.
On [DATE] at 12:53 PM a telephone interview was conducted with Nurse #3. Nurse #3 worked on [DATE] through [DATE] during the 7:00 PM to 7:00 AM shift with Nurse #1 but was not responsible for Resident #1. Nurse #3 stated Nurse #1 asked her what to do regarding the resident because she was very anxious and kept getting in/ out of bed. Nurse #1 seemed overwhelmed with the situation so Nurse #3 went to the resident's room with her to see what she could do. Nurse #3 stated Resident #1 was screaming out, crawling out of bed and very anxious. At approximately 3:00 AM on [DATE], Nurse #1 again came to her and stated she did not know what to do with Resident #1. Nurse #3 then told her the facility had standing orders for Ativan, she stated she told her it was okay to give the resident Ativan because the resident was all over the place by screaming, pulling on her oxygen tubing and crawling out of bed. The interview revealed Nurse #3 had access to the automated medication dispensing system. but Nurse #1 did not. The two nurses waited until the day shift arrived and asked Unit Manager #1 to be a second witness to pull the Ativan out of the automated medication dispensing system. machine. Nurse #3 and Unit Manager #1 then pulled Ativan 0.5 mg from the automated medication dispensing system for Resident #1 and Unit Manager #1 took the medication and gave it to Nurse #2 to administer. The interview revealed there were no alerts that popped up in the automated medication dispensing system. machine. However, when Nurse #3 put the Ativan order in the electronic charting system an allergy alert did pop up and she bypassed the alert in the system. At that time Nurse #3 did not know if they had administered the medication or not and left the facility after entering the medication order. Nurse #3 recalled she received a call after leaving the facility from the DON that Resident #1 had an allergy to the medication, and Nurse #3 had put the standing order into the Medication Administration Record (MAR). Nurse #3 stated she knew she should not have bypassed the allergy alerts in the system but was not thinking clearly about the situation and just clicked the button. She stated she felt that Resident #1 had a diagnosis of COPD and was just excited like most residents with the diagnosis and the Ativan would help calm her. Nurse #3 stated she did not review the resident's allergy list. The interview revealed looking back on the situation, the nurses should have contacted the on-call Nurse Practitioner regarding Resident #1's change in behavior.
On [DATE] at 10:19 AM an interview was conducted with Unit Manager #1. During the interview she stated she had come in on [DATE] as the manager on call to orient Nurse #2 during the 7:00 AM to 7:00 PM shift. The interview revealed she arrived at the facility around 7:12 AM and noticed Resident #1 lying on her fall mat on the floor. She asked Nurse #1 if she was aware the resident was on the fall mat and Nurse #1 stated it was the safest place the resident could be. The interview revealed she was touching base with Nurse #2 when Nurse #3 asked her to be a second witness to remove Ativan 0.5mg from the automated medication dispensing system. for Resident #1 due to agitation. She was told Resident #1 had been very restless, agitated and had been throwing herself out of bed during the night and Nurse #1 did not have access to the automated medication dispensing system. to pull the medication. Unit Manager #1 indicated she went with Nurse #3 and removed the medication from the automated medication dispensing system. as the second witness. She took the medication and gave it to Nurse #2 and instructed her to administer the medication to Resident #1. She was then notified by a nurse aide (name she could not recall) that Resident #1 was coding. Resident #1 was a DNR, so she went to the room to find Nurse #1, Nurse #2 and NA #1 in the room with the resident. EMS had already been contacted and were enroute to the facility. The interview further revealed Unit Manager #1 was new to the facility and was not familiar with Resident #1. Unit Manager #1 stated if Resident #1 had a change of condition and experienced difficulty breathing the nurses on duty should have notified the on-call Nurse Practitioner of the resident's condition.
EMS records dated [DATE] revealed they were notified at 8:13 AM, dispatched to the facility at 8:18 AM, arrived on scene at 8:29 AM and to the resident at 8:30 AM with a chief complaint of cardiac/ respiratory arrest. Upon EMS arrival Resident #1 was found lying in bed. The resident was apneic (without breathing) and pulseless. Resident #1 had no heart tones with a valid do not resuscitate order (DNR). She was pronounced deceased at 8:30 AM.
On [DATE] at 2:24 PM a telephone interview was conducted with the former Director of Nursing (DON). The DON stated Unit Manager #1 called her on [DATE] to notify her Resident #1 had expired. The DON indicated nurses were new to the facility and did not notify the on-call provider that Resident #1 had experienced a change of condition, and the nurses should have completed an assessment on the resident. The interview revealed she instructed Nurse #1 to go back into the system and document nursing notes for the night of [DATE] through [DATE] because the nurse had not originally documented the resident's change of condition. The DON stated all nurses involved should have followed the facility protocol if a resident had experienced a change of condition and notified the physician. The DON revealed looking through documentation she saw Resident #1 had a documented allergy to the medication Ativan she was administered at 7:44 AM on [DATE]. The DON stated it was around 11:00 AM on [DATE] when she was notified of Resident #1 being administered a medication she had a documented allergy to and she immediately suspended the nurses involved. She notified the Medical Director on [DATE] at 1:00 PM Resident #1 had received the medication Ativan with a documented allergy. The interview revealed the facility had standing orders to use Ativan if a resident was having agitation which was to administer 0.5mg of Ativan as a one-time dose. The nurses were new to the facility and the nurse who administered the medication (Nurse #2) was still in orientation and did not ask any questions prior to giving it to the resident because she was told to do so by Unit Manager #1, who was her preceptor. The DON stated all nurses involved should have followed the facility protocol for administration of medication which included review of the resident's allergies. She stated Nurse #3 should have never bypassed the allergy alerts in the EMR system. All nurses were suspended pending the investigation.
On [DATE] at 11:28 AM an interview was conducted with the Administrator and Regional Nurse Consultant. The interview revealed on [DATE] around 7:30 AM, Nurse #2 administered Ativan 0.5 mg to Resident #1 due to behaviors of restlessness and agitation based off of standing physician orders the facility had in place. The Regional Nurse Consultant stated Nurse #2 administered Ativan to Resident #1 at 7:44 AM and Resident #1 was then found unresponsive with a low oxygen saturation level. EMS was called to the facility, and the resident was pronounced as deceased . At 11:30 AM the Former Director of Nursing (DON) was reviewing the documentation, and they immediately suspended the nurses involved and completed an investigation into the incident. Nurse #1 was responsible for the resident during the 7:00 PM to 7:00 AM shift on [DATE] through [DATE] and needed guidance from Nurse #3 who told her about the standing order for Ativan 0.5mg. The Administrator stated none of the four nurses involved in the incident notified a provider or documented assessments when Resident #1 had experienced difficulty breathing, restlessness or increased anxiety and should have identified Resident #1 had experienced a change of condition during the night. Resident #1 was noted to have a documented allergy to the medication Ativan administered at 7:44 AM. None of the four nurses involved in the incident verified Resident #1 had no allergies to the medication. Nurse #3 bypassed the alerts in the electronic medical record when entering the medication order into the resident's MAR. The Administrator stated the nurses were responsible for verifying that the resident did not have an allergy to the medication, and they did not. The Regional Nurse Consultant stated nurses should be documenting the resident assessments and vital signs throughout the shift especially if there were changes to the resident's condition.
On [DATE] at 1:34 PM a telephone interview was conducted with the on-call Nurse Practitioner. During the interview she stated she was not contacted on [DATE] or [DATE] regarding Resident #1. She stated that it was unusual because the facility typically would let her know if anything acute happened but if a resident was having trouble breathing, she would have immediately sent the resident to the hospital for an evaluation.
On [DATE] at 1:38 PM a telephone interview was conducted with the Medical Director (MD). The MD stated the DON notified him of an incident that happened on [DATE] when a nurse administered Ativan to a resident with a documented allergy to the medication. The interview revealed the first time he was contacted was on [DATE] at 1:00 PM and told a medication error had occurred. He wasn't notified Resident #1 had experienced a change of condition starting at approximately 3:00 PM on [DATE]. The MD stated the on-call Nurse Practitioner would have been notified if it happened after 5:00 PM. The MD stated the facility should have sent Resident #1 to the hospital for an evaluation because from review of the nursing progress notes she had a respiratory episode and could have had increased carbon dioxide (A waste product produced during metabolism. It is transported through the bloodstream to the lungs, where it is exhaled as a gas.) in the blood. He stated the result of increased CO2 levels would be psychotic behavior such as getting up and down out of bed along with confusion. The MD stated if they had contacted the Nurse Practitioner, she would have sent the resident to the hospital for an evaluation because the resident was likely having an acute exacerbation of COPD as she had experienced in the past and needed to be on a BiPap (non-invasive ventilation therapy).
The Administrator was notified of the immediate jeopardy on [DATE] at 6:30 PM.
The facility provided the following corrective action plan with a compliance dated of [DATE].
Address how corrective action will be accomplished for those residents found to have been affected by the deficient practice;
The facility failed to provide comprehensive assessments, failed to identify a significant change in condition that required medical attention, failed to obtain vital signs and ongoing oxygen saturations during the evening and night on [DATE] through [DATE]. On [DATE] during the 3:00 PM to 11:00 PM shift, Resident #1 showed signs of restlessness, agitation, crawling onto the floor and verbally expressed to staff that she was experiencing difficulty breathing which continued from 11:00 PM to 7:00 AM. At 8:13 AM Resident was noted in her room unresponsive with a blood pressure of 94/60, pulse rate of 111, respiratory rate of 4 and oxygen saturation level of 54%. Resident #1 was pronounced deceased by Emergency Medical Services (EMS) staff at 8:30 AM.
On the evening of [DATE], Resident #1 showed signs of restlessness and agitation according to the licensed nurses' statements. Licensed nurses made multiple attempts to make resident #1 comfortable. Nurse #2 continued to assist Resident #1 throughout the night moving her from bed to chair to help the resident to become more comfortable. Nurse #2 obtained Resident #1's oxygen saturations at 98% at approximately 2:00 AM. Resident #1 needed one on one supervision periodically during the night by nursing staff for safety. Nurse #2 failed to properly assess the resident.
Address how the facility will identify other residents having the potential to be affected by the same deficient practice;
Current residents are at risk of this occurring.
As of [DATE] an audit was completed by the Director of Nursing and designee to review nursing notes, 24-hour reports, and vital sign logs in the electronic healthcare record to ensure any noted changes in residents' condition were noted and the physician notified from [DATE] forward. The audit also included a review to ensure that residents' vital signs were taken and noted in the electronic record. This was completed by the Director of nursing and designees on [DATE]
Address what measures will be put into place or systemic changes made to ensure that the deficient practice will not recur;
Education started by the Director of Nursing on [DATE] for the change in condition and included providing comprehensive assessments that
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
Deficiency F0726
(Tag F0726)
Someone could have died · This affected 1 resident
**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on record review, and interviews with staff, Medical Director and Pharmacist, the facility failed to provide effective tra...
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**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on record review, and interviews with staff, Medical Director and Pharmacist, the facility failed to provide effective training and orientation for new hires including preceptorship, skills validations and specific training related to pharmacy services and resident allergies in the electronic medical record (EMR) system alerts. On [DATE] Unit Manager #1, who had not received a complete orientation, was scheduled to precept Nurse #2. Under Unit Manager #1's direction Nurse #2 administered Ativan to Resident #1 who had a documented allergy to Ativan. At 8:13 AM Resident #1 was noted in her room unresponsive and vital signs were blood pressure 94/60 (normal blood pressure reading 120/80), pulse 111(normal pulse range 60-100), respiratory rate 4 (normal respiratory rate 12-20) and oxygen saturation level 54% (normal oxygen saturation level greater than 92%). Resident #1 was pronounced deceased by Emergency Medical Services (EMS) staff at 8:30 AM. The incomplete orientation and training for Unit Manager #1 put all residents at risk for a serious adverse outcome.
For example b. the facility failed to provide complete orientation and training for Nurse #1 before she worked independently. This is cited at D (no actual harm with potential for more than minimal harm that is immediate jeopardy).
The deficient practice occurred for 2 of 4 nurses reviewed for competencies.
The findings included:
This tag is cross-referred to:
F760: Based on record review, and interviews with staff, Medical Director and Pharmacist, the facility failed to prevent a significant medication error when Resident #1 received a dose of Ativan (a benzodiazepine, used as a sedative medication) as a one-time dose. Resident #1 had an allergy to Ativan documented on the Allergy List in the electronic medical record (EMR) on [DATE]. The medication order was entered into the electronic health record by Nurse #3. She stated the electronic medical record flagged the order due to the allergy, but she bypassed the alert and entered the order in the EMR, which was then pulled from an automated system for medication management. Nurse #2, a nurse who was orienting under the supervision of the Unit Manager, administered the medication on [DATE] at 7:44 AM. On [DATE] at 8:13 AM Resident #1 became unresponsive with seriously abnormal vital signs. Resident #1 was pronounced deceased by Emergency Medical Services (EMS) staff at 8:30 AM. This deficient practice occurred for 1 of 3 sampled residents reviewed for medication errors.
a. Review of Unit Manager #1's employee file revealed she had been hired on [DATE]. An undated, incomplete skills validation record titled, Unit Manager revealed Unit Manager #1 had not received training on facility equipment, supervising Nurse Aides (NA), clinical processes, pharmacy services, EMR documentation, or clinical skills competencies. She also had not completed nursing competencies under the heading, Unit Manager Responsibilities.
On [DATE] at 10:19 AM an interview was conducted with Unit Manager #1. Unit Manger #1 stated she was hired on [DATE] and received three days of class orientation with the facility Scheduler. The training included introducing her to the company, discussing the schedule, discussing the facility policy regarding attendance and paid time off. On the second day she met with the Staff Development Coordinator (SDC) going over infection control, contact isolation, enhanced barrier precautions and watching informative videos. Unit Manager #1 was given a skills validation packet and told she would be placed with a preceptor and the preceptor would assist her in completing the nursing competencies. Unit Manager #1 stated nothing else happened after that, she was never placed with a preceptor or received any more training after the in-class training. She stated she asked the Former Director of Nursing about receiving education or training and she would say okay, but never followed back up with Unit Manager #1. When Nurse #1 and Nurse #2 were hired the facility did not have a SDC and their orientation wasn't even half of what she had received. Nurse #3 would state to her that she hadn't received any on-the-floor training. Unit Manager #1 stated on [DATE] she was scheduled to precept Nurse #2. However, she had not even received orientation herself but was told by the Scheduler that Nurse #2 just needed support because she really did not need orientation. Unit Manager#1 stated she had her skills validation sheet however it wasn't completed other than the three days of classroom orientation. Unit Manager #1 stated no one from the facility had gone over verifying residents allergies prior to administration of medication or system alerts related to resident allergies. She stated she knew she should have verified the residents' allergies but thought Nurse #1 had already done so. She was not the primary nurse and was just signing as a witness. The interview revealed no one from the facility had gone over medication rights or change of condition with her until after the incident on [DATE].
On [DATE] at 10:56 AM an interview was conducted with the Scheduler. The interview revealed she assisted during the orientation process and provided each newly hired Nurse Aide or Nurse with a skills check off sheet. She stated the newly hired staff received an orientation lasting three days and then were placed with a preceptor on the units that would sign off the newly hired staff member was competent in the area on the checklist. The interview revealed once the checklist was completed it would be returned to herself or the Staff Development Coordinator who placed it into the employee's file. The Scheduler stated the facility had a period of time with no SDC in the building from [DATE] until [DATE] and the Former Director of Nursing had been responsible for gathering the completed checklist and oversight of newly hired staff. The Scheduler stated she had not seen a completed skills checklist from Nurse #1 and Unit Manager #1. She stated Nurse #2 was still in orientation and Nurse #3 had a completed skills checklist.
On [DATE] at 9:24 AM an interview was conducted with the Staff Development Coordinator (SDC). She stated she had left the facility at the end of October and not returned until [DATE]. The SDC stated the Former DON was responsible for all nursing orientation during that time. Orientation in the facility consists of 3-4 days in person class time for the Nurses and Nurse Aides (NA). After the class orientation nurses were typically placed with a preceptor for at least a week or two after the in-class orientation. The interview revealed Nurses received access to the automated medication dispensing system during the class orientation. The SDC stated she was unaware if Nurse #1, and Unit Manager #1 had completed their skills validation record or received a precepted orientation because she had only been back into the building for one day. The SDC verified that part of the orientation training included reviewing residents allergies prior to administration of medication.
An interview conducted on [DATE] at 2:24 PM with the Former Director of Nursing (DON) revealed Unit Manager #1 called her on [DATE] to notify her Resident #1 had expired. After looking through documentation she saw Resident #1 had a documented allergy to the medication Ativan she was administered at 7:44 AM. The DON stated it was around 11:00 AM when she was notified, and she immediately suspended the nurses involved. She notified the Medical Director at 1:00 PM. The interview revealed the facility had standing orders to use Ativan if a resident was having agitation which was to administer 0.5mg of Ativan as a one-time dose. The nurses were new to the facility and the nurse who administered the medication (Nurse #2) was still in orientation and did not ask any questions prior to giving it to the resident because she was told to do so by Unit Manager #1 who was her preceptor. The DON stated all nurses involved should have followed the facility protocol for administration of medication which included review of the resident's allergies. She stated Nurse #3 should have never bypassed the allergy alerts in the EMR system. The Former DON stated verifying resident's allergies and acknowledging system alerts were covered during orientation to the facility by the Staff Development Coordinator (SDC) or nursing preceptor assigned to newly hired employees.
On [DATE] at 11:23 AM an interview was conducted with the Administrator. During the interview she stated immediately following the incident on [DATE] through [DATE] the facility put a plan of correction in place regarding orientation. The facility realized the biggest mistake was during the orientation process and their Corporate Clinical Educator put together a structured orientation process of what the facility should be doing for newly hired staff. Education was completed for every staff member that was still in the orientation process. The Administrator stated the staff members had not received the clinical preceptorship to meet her expectations, and each staff member had voiced they felt they were not properly trained by the facility.
The Administrator was notified of the immediate jeopardy on [DATE] at 4:15 PM.
b. Review of Nurse #1's employee file revealed she had been hired on [DATE]. An undated, incomplete skills validation record titled, Charge Nurse revealed Nurse #1 did not receive training on Pharmacy Services, Electronic Medical Record (EMR) clinical documentation for allergies or clinical skills competencies.
An interview conducted on [DATE] at 3:56 PM with Nurse #1 revealed she was hired by the facility on [DATE] and received an in-person class training for 2 days. She stated following the class training she was assigned with a nurse that was as needed (PRN) in the facility and was only with her for a duration of two days before being placed on her own because the staff member wasn't working in the facility. Nurse #1 stated she had come from a hospital setting where she had received 8 weeks' training, and she felt like the long-term care training was not adequate. The interview revealed the training was incomplete because she had not received an actual precepted orientation and no one from the facility had provided training on resident allergies or EMR system alerts.
The facility submitted the following corrective action plan:
Address how corrective action will be accomplished for those residents found to have been affected by the deficient practice;
While interviewing 4 nurses involved in the incident occurring on [DATE], It was mentioned that they did not feel as if they received proper orientation from the facility. The facilities failure to have a proper orientation and training program in place, led to an undesirable resident outcome.
Address how the facility will identify other residents having the potential to be affected by the same deficient practice;
On [DATE] the Administrator identified that current clinical staff hired on or after [DATE] were not properly orientated, onboarded, and thoroughly trained to completely fulfill their role.
Address what measures will be put into place or systemic changes made to ensure that the deficient practice will not recur;
As of [DATE] it was decided by the Administrator to have identified employees return for a corrected orientation, onboarding, and training process beginning on [DATE]. Licensed Nurses completed Medication Pass Observations with the Director of Nursing starting on [DATE] after medication error on [DATE]. Nurses who did not complete this Medication Pass Observation before their next scheduled shift, were not allowed to work until it was completed. Skills Validations were started on [DATE] for Licensed Nurses by the Director of Nursing or designee after incident on [DATE]. All Licensed Nurses hired on [DATE] or after participated in the training program on [DATE]. Those who did not attend were not allowed to return until they went through the training program. Nurses involved in the incident were suspended on [DATE] pending investigation. Nurse #1, and Nurse #3 were terminated and reported to the Board of Nursing as of [DATE]. Nurse # 2 turned in a resignation letter on [DATE]. The Unit Manger was initially terminated and appealed the termination. She was brought back on 12/16 and placed back into the training program. She resigned effective immediately on 12/28. This training program was held by the Administrator, Director of Nursing and Human Resources Director. Training included prior to accepting responsibility for an assignment without preceptor supervision, the Director of Nursing or designee must validate successful completion of the Skills Validation Record, Medication Pass Observation, and Treatment Observation. Skills Validation Record, Medication Pass Observation, and Treatment Observation was completed by designated preceptor or supervisor.
The Director of Clinical Education and Regional Director of Clinical Services provided detailed training on company expectations in the area of appropriate orientation, onboarding, and thorough training on Wednesday, [DATE] to the Administrator, Director of Nursing, and Human Resources Director. Once a Staff Development Coordinator is hired, they will be educated by the administrator on the expected orientation process.
The Administrator, Director of Nursing or designee, and Human Resources Director will ensure that company expectations for appropriate orientation, onboarding, and thorough training for newly hired clinicians are implemented beginning [DATE]. The Director of Nursing will complete this training until an SDC is hired.
Company expectations are as follows: 5 days of classroom orientation adhering to the company-specific orientation agenda, followed by no less than 2 weeks of on-the-floor 1:1 onboarding and training with a center-designated clinical preceptor.
Prior to accepting responsibility for an assignment without preceptor supervision, the Director of Nursing or designee must validate successful completion of the Skills Validation Record, Medication Pass Observation, and Treatment Observation. Skills Validation Record, Medication Pass Observation, and Treatment Observation will be completed by designated preceptor or supervisor. Effective [DATE], the Administrator will be ultimately responsible for ensuring implementation of this corrective action plan.
Indicate how the facility plans to monitor its performance to make sure that solutions are sustained;
As of [DATE], HR will interview new hire employees weekly x 12 weeks to ensure that they are receiving proper orientation and feel comfortable with the training that is being provided.
As of [DATE] Medication pass observations will be completed by the Director of Nursing or Designee on 5 licensed nurses weekly x 12 weeks to ensure residents do not receive medications with listed allergies on the EMAR. Allergies are listed on the EMAR and show up when the EMAR is pulled up or displayed in the electronic health record.
As of [DATE] The results of the monitoring will be discussed by the Administrator during the monthly QAPI meeting with the Interdisciplinary Team. Changes will be made to the plan as necessary to maintain compliance with resident safety.
IJ removal date: [DATE]
On [DATE], the corrective action plan was validated by onsite verification through facility staff interviews. The interviews revealed the facility staff were provided with company expectations of the following: 5 days of classroom orientation adhering to the company-specific orientation agenda, followed by no less than 2 weeks of on-the-floor 1:1 onboarding and training with a center-designated clinical preceptor. Prior to accepting responsibility for an assignment without preceptor supervision. The facility's in-service log, monitoring results and training material was reviewed. The IJ removal date of [DATE] and the compliance date of [DATE] for the corrective action plan were validated.
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
Deficiency F0760
(Tag F0760)
Someone could have died · This affected 1 resident
**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on record review, and interviews with staff, Medical Director and Pharmacist, the facility failed to prevent a significant...
Read full inspector narrative →
**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on record review, and interviews with staff, Medical Director and Pharmacist, the facility failed to prevent a significant medication error when Resident #1 received a dose of Ativan (a benzodiazepine, used as a sedative medication) as a one-time dose. Resident #1 had an allergy to Ativan documented on the Allergy List in the electronic medical record (EMR) on [DATE]. The medication order was entered into the electronic health record by Nurse #3. She stated the electronic medical record flagged the order due to the allergy, but she bypassed the alert and entered the order in the EMR, which was then pulled from the automated system for medication management. Nurse #2, a nurse who was orienting under the supervision of the Unit Manager, administered the medication on [DATE] at 7:44 AM. On [DATE] at 8:13 AM Resident #1 became unresponsive with seriously abnormal vital signs. Resident #1 was pronounced deceased by Emergency Medical Services (EMS) staff at 8:30 AM. This deficient practice occurred for 1 of 3 sampled residents reviewed for medication errors.
The findings included:
An undated After-Hours Standing Physician Orders revealed for aggression or agitated behavior the nurse may administer Ativan 0.5 milligram (mg) by mouth. The nurse could repeat the action in 20 minutes if the resident did not respond to the medication. The order read to notify the primary care physician in the AM for further orders.
Resident #1 was readmitted to the facility on [DATE] with diagnoses of chronic obstructive pulmonary disease (COPD) and respiratory failure.
An allergy list in the electronic medical record updated on [DATE] included the medication Ativan. Resident #1's allergy reaction was documented as unspecified.
A review of Resident #1's quarterly Minimum Data Set assessment dated [DATE] revealed she was cognitively intact.
A review of the facility's medication error report dated [DATE] at 11:20 AM by the Director of Nursing (DON) revealed Resident #1 was ordered and administered Ativan 0.5 mg for a one-time dose with a documented allergy to the medication by Nurse #2. The result of the incident was documented as Resident #1 experienced an unresponsive event. The medication error was reported to the Medical Director.
A medication administration note in the electronic medical record dated [DATE] at 7:43 AM revealed Nurse #3 entered an order for Ativan oral tablet 0.5 mg. Give 0.5 mg by mouth one time only related to Chronic Obstructive Pulmonary Disease with Acute Exacerbation until [DATE] at 9:00 AM. The medication order triggered an alert for a system identified drug allergy.
Resident #1's Medication Administration Record (MAR) for [DATE] revealed an order for Ativan oral tablet 0.5 mg by mouth on time only related to COPD with acute exacerbation. The medication was administered on [DATE] at 7:44 AM and signed off by Nurse #1.
On [DATE] at 3:56 PM an interview was conducted with Nurse #1, who was no longer employed by the facility. During the interview she stated she wanted to use her initial statement to the facility as a response to questions asked.
A statement written and signed by Nurse #1 on [DATE] obtained by the facility revealed she was assigned Resident #1 during the 7:00 PM to 7:00 AM shift on [DATE] - [DATE]. The statement revealed Resident #1 kept getting out of the bed and laying on the floor during the shift. Nurse #3 asked her if the resident had any Ativan available and Nurse #1 stated she wasn't sure. Nurse #3 then told her the facility had standing orders for Ativan, and it could be pulled from the automated system for medication management. Nurse #1 was unable to access the automated system for medication management and had to wait until the next shift to be able to obtain the Ativan. When the next shift arrived at 7:00 AM Nurse #1 gave a report to Nurse #2. NA #1 came to the office after Nurse #3's medication pass and stated something was wrong with Resident #1. Nurse #3 asked if she would go to the resident's room for support, so Nurse #1 did. Upon arrival to the resident's room Resident #1 was face up, lying in bed with a slow response to communicate. She asked for vital signs and for someone to call EMS after feeling a weak pulse on the resident. Nurse #1 continued to do a sternal rub on the resident until EMS arrived. After EMS arrived, she was told Resident #1 had expired. Nurse #1 was later told Resident #1 had received by mouth Ativan and that she had an allergy to the medication. Nurse #1 noted in her statement she did not administer the medication but had signed off on the resident's MAR because she was the nurse responsible for the resident and had initiated the process of Resident #1's need for the medication.
On [DATE] at 12:53 PM an interview was conducted with Nurse #3. Nurse #3 worked on [DATE] - [DATE]. during the 7:00 PM to 7:00 AM shift with Nurse #1 but was not responsible for Resident #1. Nurse #3 stated Nurse #1 asked her what to do regarding the resident because she was very anxious and kept getting in/ out of bed. Nurse #1 seemed overwhelmed with the situation so Nurse #3 went to the resident's room with her to see what she could do. Nurse #3 stated Resident #1 was screaming out, crawling out of the bed and very anxious. At approximately 3:00 AM on [DATE], Nurse #1 again came to her and stated she did not know what to do with Resident #1. Nurse #3 then told her the facility had standing orders for Ativan, she stated she told her it was okay to give the resident Ativan because the resident was all over the place by screaming, pulling on her oxygen tubing and crawling out of bed. The interview revealed Nurse #3 had access to the automated system for medication management, but Nurse #1 did not. The two nurses waited until the day shift arrived and asked Unit Manager #1 to be a second witness to pull the Ativan out of the automated system for medication management. Nurse #3 and Unit Manager #1 then pulled Ativan 0.5 mg for Resident #1 and Unit Manager #1 took the medication and gave it to Nurse #2 to administer. The interview revealed there were no alerts that popped up in the automated system for medication management. However, when Nurse #3 put the Ativan order in the electronic charting system an allergy alert did pop up and she bypassed the alert in the system. At that time Nurse #3 did not know if they had administered the medication or not and left the facility after entering the medication order. She then received a call after leaving the facility from the DON that Resident #1 had an allergy to the medication, and Nurse #3 had put the standing order into the Medication Administration Record (MAR). Nurse #3 stated she knew she should not have bypassed the allergy alerts in the system but was not thinking clearly about the situation and just clicked the button. She stated she felt that Resident #1 had a diagnosis of COPD and was just excited like most residents with the diagnosis and the Ativan would help calm her. Nurse #3 stated she did not review the resident's allergy list.
On [DATE] at 10:19 AM an interview was conducted with Unit Manager #1. During the interview she stated she had come in on [DATE] as the manager on call to orient Nurse #2 during the 7:00 AM to 7:00 PM shift. The interview revealed she arrived at the facility around 7:12 AM and was touching base with Nurse #2 when Nurse #3 asked her to be a second witness to remove Ativan 0.5mg from the automated system for medication management for Resident #1 due to agitation. She was told Resident #1 had been very restless, agitated and had been throwing herself out of bed during the night and Nurse #1 did not have access to the automated system for medication management to pull the medication. Unit Manager #1 went with Nurse #3 and removed the medication from the as the second witness. After, she took the medication and gave it to Nurse #2 whom she was orienting and instructed her to administer the medication to Resident #1.
On [DATE] at 12:07 PM an interview was conducted with Nurse Aide (NA) #1. During the interview she stated she came on shift around 6:30 AM on [DATE] to find Resident #1 lying on her fall mat on the floor. She went to Nurse #1 who told her not to get the resident off the floor because she had been back and forth from the bed to the floor all night. NA #1 was in the room with the resident when Nurse #2 entered the room and administered the resident's medication around 7:44 AM. NA #1 said Resident #1 acted like she did not want to take the medication, but she had her back to the resident untangling oxygen tubing. Nurse #2 then left the room as NA #1 continued to untangle the resident's oxygen tubing cord. NA #1 then heard the resident call out her name. When she turned around Resident #1 was lying flat on her back with her eyes fixed up at the ceiling and mouth open. Resident #1 would not respond to her, so she yelled out for Nurse #2 who was in the hallway outside of the resident's room. NA #1 stayed with the resident until Nurse #1 and Nurse #2 entered the room. Nurse #1 was doing a sternal rub on the resident to try and get her to respond, however she did not. EMS was called and took over the resident's care once they arrived.
On [DATE] at 12:30 PM an interview was conducted with Nurse #2. During the interview she stated she worked the 7:00 AM to 7:00 PM shift on [DATE]. The interview revealed when she came in at 7:00 AM Nurse #1 was giving her report and stated Resident #1 had been anxious during the night and they had tried to give the resident Ativan but did not have access to the automated system for medication management. Nurse #2 was getting a report from Nurse #1 when Unit Manager #1 arrived at the nurses station. Nurse #3 and Unit Manager #1 then went to pull the Ativan for Resident #1 while Nurse #2 finished getting report and began to start her medication pass. Unit Manager #1 then brought her a cup with a 0.5mg Ativan in it for Resident #1 and stated to her to administer the medication. Nurse #2 stated she did not ask any questions or look at the resident's allergies prior to administering the Ativan 0.5 mg along with the resident of Resident #1's morning medication around 7:44 AM. When she went into the resident's room, she was sitting up on the floor on her fall mat. Nurse #2 and NA #1 assisted the resident to get up to the side of the bed to take her medication. Nurse #2 administered the medication and stated the resident drank water provided and Nurse #2 left the room. She was then alerted by NA #1 approximately five to ten minutes later that something was wrong with Resident #1. Nurse #2 and Nurse #1 went into the resident's room to find her lying on the bed with her eyes open and fixed, mouth open and a faint pulse. EMS were called and vital signs were obtained. Nurse #2 stated Resident #1 was pronounced deceased by EMS at 8:30 AM.
A nursing note written by Nurse #1 dated [DATE] at 8:10 AM as a late entry revealed she was made aware by Nurse #2 that Resident #1 was in possible distress after being discovered by NA #1 after the morning medication pass. Upon entering the room, the resident was slow to respond. Nurse #1 requested vital signs to be obtained and to call EMS. Resident #1's blood pressure was 94/60 (normal blood pressure reading 120/80), pulse 111 (normal pulse range 60-100), respiratory rate 4 (normal respiratory rate 12-20) and oxygen saturation level 54% (normal oxygen saturation level greater than 92%), she was noted to be receiving an undocumented amount of supplemental oxygen via nasal cannula. Nurse #1 continued to call the resident's name without a response. Resident #1's oxygen saturation was checked for a second time with a reading of 30%. EMS then arrived on scene and were able to take over the resident's care.
EMS records dated [DATE] revealed they were notified at 8:13 AM, dispatched to the facility at 8:18 AM, arrived on scene at 8:29 AM and to the resident at 8:30 AM with a chief complaint of cardiac/ respiratory arrest. Upon EMS arrival Resident #1 was found lying in bed. The resident was apneic (without breathing) and pulseless. Resident #1 had no heart tones with a valid do not resuscitate order (DNR). She was pronounced deceased at 8:30 AM. Allergies listed on the EMS report for Resident #1 included Ativan.
On [DATE] at 2:24 PM an interview was conducted with the former Director of Nursing (DON). The DON stated Unit Manager #1 called her on [DATE] to notify her Resident #1 had expired. After looking through documentation she saw Resident #1 had a documented allergy to the medication Ativan she was administered at 7:44 AM. The DON stated it was around 11:00 AM when she was notified, and she immediately suspended the nurses involved. She notified the Medical Director at 1:00 PM. The interview revealed the facility had standing orders to use Ativan if a resident was having agitation which was to administer 0.5mg of Ativan as a one-time dose. The nurses were new to the facility and the nurse who administered the medication (Nurse #2) was still in orientation and did not ask any questions prior to giving it to the resident because she was told to do so by Unit Manager #1 who was her preceptor. The DON stated all nurses involved should have followed the facility protocol for administration of medication which included review of the resident's allergies. She stated Nurse #3 should have never bypassed the allergy alerts in the EMR system.
On [DATE] at 11:28 AM an interview was conducted with the Administrator and Regional Nurse Consultant. The interview revealed on [DATE] around 7:30 AM Nurse #2 administered Ativan 0.5 mg to Resident #1 due to behaviors of restlessness and agitation. At 7:30 AM Nurse #3 and Unit Manager #1 pulled Ativan 0.5 mg out of the automated system for medication management based on standing orders the facility had. The facility had a standing order to give Ativan 0.5 mg as needed for agitation. Nurse #2 administered Ativan to Resident #1 at 7:44 AM and Resident #1 was then found unresponsive with a low oxygen saturation level. EMS was called to the facility, and the resident was pronounced as deceased . At 11:30 AM the Former Director of Nursing (DON) was reviewing the documentation and noted the resident had a allergy to the medication and notified the Regional Nurse Consultant who then called the Administrator. The interview revealed they immediately suspended the nurses involved and completed an investigation into the incident. Nurse #1 was responsible for the resident during the 7:00 PM to 7:00 AM shift and had needed guidance from Nurse #3 who told her about the standing order for Ativan 0.5mg however they did not have access to the automated system for medication management to pull the medication. They waited until the next shift arrived at 7:00 AM on [DATE] and had Unit Manager #1 be the second witness to pull the medication with Nurse #3. Nurse #2 was working the day shift on [DATE] and was asked to administer the medication to Resident #1 in which she did and did not ask any questions. None of the 4 nurses involved in the incident verified Resident #1 had no allergies to the medication. Nurse #3 bypassed the alerts in the electronic medical record when entering the medication order into the resident's MAR. The Administrator stated the nurses were responsible for verifying that the resident did not have an allergy to the medication and they did not.
On [DATE] at 1:38 PM an interview was conducted with the Medical Director (MD). The MD stated the DON notified him of an incident that happened on [DATE] when a nurse administered Ativan to a resident with a documented allergy to the medication. He stated it happened because the facility had standing orders for the medication for agitation as needed. The nurse involved did not check the resident's allergies and just gave the medication. The interview revealed he was contacted around 1:00 PM on [DATE] and the medication error occurred earlier in the morning. The MD stated he knew the resident had expired but it did not sound like she had an anaphylactic reaction to the medication, however, would not know unless an autopsy was performed, and to his knowledge it had not been done. Resident #1 was not noted to have any rash or hives by the nursing staff. The MD stated there was no justification for the staff members to administer Ativan to the resident with a documented allergy.
On [DATE] at 2:18 PM an interview was conducted with the Pharmacist. During the interview he stated a true medication allergy would result in anaphylaxis (severe, life-threatening allergic reaction that can occur within minutes of exposure to an allergen) and a rash. After reviewing Resident #1's medication orders he stated there were no active physician orders for Ativan 0.5mg from the pharmacy for the resident but he did see an allergy listed for Ativan. The interview revealed if the facility initiated a standing order for the medication, it would not have come from the pharmacy, but they would have pulled it from the automated system for medication management located at the facility. The staff would not have been alerted to the resident's allergy in the sytem when pulling the medication. He stated he completed a system report that showed on [DATE] the medication Ativan 0.5mg was removed from the machine under Resident #1's name. The Pharmacist stated the allergy error would have shown when the nurses were putting the order into the electronic medical record and the nurses would have had to click off on the allergy alert to get the error screen to remove and move forward in the system. The interview revealed the nurse would have to bypass the alert. The pharmacist stated no resident should receive medication with a documented allergy. That is why alerts were put in place for staff to recognize prior to administration of the medication.
The Administrator was notified of the immediate jeopardy on [DATE] at 12:31 PM.
The facility provided the following corrective action plan.
Address how corrective action will be accomplished for those residents found to have been affected by the deficient practice;
The facility failed to prevent a significant medication error when Resident #1 received a dose of Ativan 0.5 milligram (mg) as a one-time dose. Resident #1 had a documented allergy to Ativan on [DATE]. The medication order was entered into the electronic health record by Nurse #3 who said that the Electronic Health record electronic order entry flagged the order due to the allergy but she bypassed the alert and entered the order which was then pulled from the automated system for medication management. Nurse #2 Administered the medication on [DATE] at 7:44 AM. At 8:13 AM Resident #1 was noted in her room unresponsive with a blood pressure of 94/60, pulse rate of 111, respiratory rate of 4 and oxygen saturation level of 54%. Resident #1 was pronounced deceased by Emergency Medical Services (EMS) staff at 8:30 AM.
On the evening of [DATE], Resident #1 showed signs of restlessness and agitation according to the licensed nurses' statements. Licensed nurses made multiple attempts to make Resident #1 comfortable. Licensed nurses repositioned residents many times, changed the room temperature, and offered fluids and snacks. Resident #1 tried to crawl onto the floor and roll around in the bed. Staff provided Resident #1 with one on one supervision periodically throughout the night, due to Resident #1 trying to crawl out of the bed related to agitation and restlessness. The morning of [DATE], at approximately 7:00 am, the day shift nursing staff came on duty. At about 7:15 am, the standing order for Ativan 0.5 mg tablet was pulled from the automated system for medication management. The medication was provided to Nurse #2 to give to Resident #1. Ativan 0.5 mg was given by mouth to Resident #1 at approximately 7:35 am. The medication order was placed into the electronic health record system at 7:43 am by Nurse #3. The electronic medication administration record (EMAR) was signed off as medication given at 7: 44 am by Nurse #3. This information was obtained through interviews with the above-mentioned nurses.
On [DATE], after the occurrence, all licensed nurses were given access to the automated system for medication management by the Director of Nursing.
At 8:13 am Resident # 1 was in her room and unresponsive with Vital Signs as follows: BP 94/60, Pulse 111, Resp 4, Oxygen sat level 54. EMS was called for transport. Resident #1 was Do Not Resuscitate. EMS arrived on scene and resident #1 was pronounced deceased at approximately 8:30am.
Upon review of the chart by the Director of Nursing on [DATE], it was noted that Resident #1 had an allergy to Ativan. The severity of the allergy was unknown. The Medical Director was notified that Resident #1 expired and Ativan was given with a documented allergy on [DATE].
Nurse #3 and Nurse #1 were terminated [DATE] by the facility Administrator.
Address how the facility will identify other residents having the potential to be affected by the same deficient practice;
Current residents are at risk of this occurring.
An audit of current resident's allergy listing and current medication list was completed by the Director of Nursing and designee to ensure that medications were not ordered or given with the listed allergies. This was completed by the Director of nursing on [DATE].
Address what measures will be put into place or systemic changes made to ensure that the deficient practice will not recur;
On [DATE], Director of Nursing was notified at 11:13 am by Nurse #1 that Resident #1 had an allergy to Ativan. The Director of Nursing started an investigation.
Education started [DATE] by the Director of Nursing for all licensed nurses and medication aides on alerts in the electronic health record order entry in the MAR. Education was also conducted for pulling medications from the automated system for medication management to ensure there is order in place and allergies are checked prior to withdrawing medication. All flagged notifications will be reviewed when flagged as an alert when entering the order in the electronic health record by the nurse, and the nurse will notify the physician for direction. Any licensed nurse not receiving this education will not be able to work until receiving the education. New licensed nurses will receive education during the orientation process. Director of Nursing ensured all licensed nurses and medication aides were educated prior to working their next scheduled shift as of [DATE].
Medication observations on current licensed nurses and medication aides will be completed by the Director of Nursing or designee to ensure residents are not receiving medication with listed allergies on their EMAR by [DATE]. Allergies are listed on the EMAR and show up when the EMAR is pulled up or displayed in the electronic health record.
Medication pass observations will be completed by the Director of Nursing or Designee on 5 licensed nurses weekly x 12 weeks to ensure residents do not receive medications with listed allergies on the EMAR. Audits begin as of [DATE]. Allergies are listed on the EMAR and show up when the EMAR is pulled up or displayed in the electronic health record.
Education was provided to all licensed nurses that before activating a standing order, allergies must be reviewed to ensure the resident does not have a listed allergy for the medication by the Director of Nursing on [DATE].
All new orders are reviewed during the morning clinical meeting by the nursing clinical team to ensure no new medications are ordered that residents have an allergy too. This will be completed in 5x weeks x 12 weeks.
As of [DATE], Regional Clinical Nurse or designee will review medication allergy alerts in the electronic health record by reviewing the progress notes for allergy alerts weekly to ensure no allergy alerts were bypassed. These audits will be completed weekly x 12 weeks.
Indicate how the facility plans to monitor its performance to make sure that solutions are sustained;
As of [DATE] the results of the monitoring will be reviewed by the Administrator or Director of Nursing in the weekly Risk meeting and during the monthly Quality Assurance Performance Improvement (QAPI) meeting with the Interdisciplinary Team (IDT) as of [DATE]. Changes will be made to the plan as necessary to maintain compliance with resident safety. The IDT team will consist of the Administrator, Director of Nursing, Medical Director, Social Worker, Activities Director and Minimum Data Set (MDS) nurse. This meeting lasted for 1 hour.
IJ removal date: [DATE].
On [DATE], the corrective action plan was validated by onsite verification through facility staff interviews and record review. The interviews revealed all nursing staff had received education on alerts in the electronic health record order entry in the MAR. Education was also conducted for pulling medications from the automated system for medication management to ensure there was an order in place and allergies were checked prior to withdrawing medication. All flagged notifications will be reviewed when flagged as an alert when entering the order in the electronic health record by the nurse, and the nurse will notify the physician for direction. Education was provided to all licensed nurses that before activating a standing order, allergies must be reviewed to ensure the resident does not have a listed allergy for the medication. The facility's in-service log, audits and training material were reviewed.
The immediate jeopardy removal date of [DATE] and the compliance date of [DATE] for the corrective action plan were validated.
CONCERN
(D)
📢 Someone Reported This
A family member, employee, or ombudsman was alarmed enough to file a formal complaint
Potential for Harm - no one hurt, but risky conditions existed
Resident Rights
(Tag F0550)
Could have caused harm · This affected 1 resident
**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on record review and resident and staff interviews, the facility failed to treat a resident in a dignified manner while pr...
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**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on record review and resident and staff interviews, the facility failed to treat a resident in a dignified manner while providing incontinent care and failed to effectively respond to a call light for 1 of 3 residents reviewed for dignity (Resident #3). Resident #3 stated that she felt disrespected and upset that she was ignored and made to stay in a soiled brief.
The findings included:
Resident #3 was admitted to the facility on [DATE] with diagnoses of contracture of left hand, overactive bladder, and chronic obstructive pulmonary disease.
The care plan dated 11/12/2024 was reviewed. The problem stated the resident is incontinent of bladder and bowels and is not a candidate for toileting program due to inability to control bowel and bladder due to severe physical impairment. The goal stated that Resident #3 would remain as clean and dry as possible. The interventions included the resident required 2 staff assistance for bed mobility, 1 person assist with toileting, check and change briefs frequently.
The quarterly Minimum Data Set (MDS) assessment dated [DATE] revealed that Resident #3 was cognitively intact, required extensive assistance with toileting, and was always incontinent with bowel and bladder. No refusal of care was noted during the assessment reference period.
Resident #3 was interviewed on 12/16/2024 at 2:14 PM. During the interview Resident #3 stated that NA #3 had changed her on 12/13/2024 at 4:30 PM. The resident did not state how she knew what time it was, but it was observed that Resident #3 had her cell phone within reach. Resident #3 stated NA #3 seemed frustrated with her request not to use soap for urinary incontinence due to reoccurring urinary tract infections. Resident #3 stated NA #3 went back in the bathroom to rinse the soap out of the cloth and slammed the bathroom door. Resident #3 voiced when NA #3 came back, NA #3 rolled her eyes. Resident #3 stated I felt hurt, because I had done nothing to be treated that way. Resident #3 reported her concerns regarding NA #3's attitude towards her during 4:30 PM incontinence care to Nurse #4 around 8:45 PM. Resident #3 stated she felt confident that Nurse #4 would take care of the situation because the nurses have always resolved issues in past in a timely manner. Resident #3 stated when she placed her call light on around 9:00 PM to receive incontinence care, NA #3 entered the room and Resident #3 stated she needed to be changed. Resident #3 reported NA #3 did not speak to her, turned the call light off, and exited the room. Resident #3 stated that she felt disrespected and upset that she was ignored and made to stay in a soiled brief. No one entered the room until NA #4 entered around 10:45 PM. Resident #3 stated the urine in her brief had soaked through her clothing, and she was concerned about her buttocks that was being treated with barrier cream (protective skin cream).
On 12/17/2024 an interview was conducted at 9:40 AM with NA #3. NA #3 was assigned to Resident #3 on 12/13/2024 during the 3:00 PM to 11:00 PM shift. NA #3 reported she provided incontinence care for Resident #3 once at the beginning of her shift around 4:45 PM. NA #3 stated that when she returned from her smoke break around 8:45 PM, some of her assigned residents' call lights were on. NA #3 stated she began to answer call lights for the residents; however, she did not start with Resident #3. NA #3 reported she entered Resident #3's room around 9:00 PM to answer the call light. NA #3 stated she asked Resident #3 if she needed anything, and Resident #3 did not say anything. NA #3 reported she turned Resident #3's call light off and left the room. NA #3 stated Nurse #4 told her around 9:40 PM not to go back in Resident #3's room and the assignment for the 11:00 PM to 7:00 AM shift would be changed so that NA #3 would not be assigned to Resident #3. NA #3 stated that was her first time caring for Resident #3 and Resident #3 wanted things done a certain way that NA #3 was not aware of. NA #3 stated she had not routinely rounded on Resident #3 because Resident #3 was alert enough to call when she needed assistance.
On 12/18/2024 at 9:43 AM an interview was conducted with Nurse #4. Nurse #4 reported when she started her shift on 12/13/2024 at 7:00 PM and completed rounds on the residents around 8:30 PM, Resident #3 reported to Nurse #4 that her brief had not been changed since 4:30 PM and that NA #3 had an attitude and acting like she didn't want to care for her. Nurse #4 stated that she contacted Unit Manager #2 regarding NA #3 not providing incontinence care to Resident #3. She stated she contacted Unit Manager #2 around 9:30 PM after she observed NA #3 enter Resident #3's room, turning the light out and exiting the room around 9:00pm. Nurse #4 stated Unit Manager #2 requested Nurse #4 change the schedule for the 11:00 PM to 7:00 AM shift and not allow NA #3 back in Resident #3's room. Nurse #4 stated she changed the schedule around 10:00 PM and asked NA #3 around 9:40 PM not to go back in Resident's #3's room. Nurse #4 stated that she and NA #4 provided incontinence care to Resident #3 at 10:30 PM and Resident #3 was soiled with urine that had leaked through the incontinence brief on to Resident #3's clothing.
On 12/17/2024 at 12:00 PM an interview was conducted with NA #4. NA #4 stated that Nurse #4 approached her around 10:30 PM when she arrived for her 11:00 PM to 7:00 AM shift. NA #4 stated she and Nurse #4 provided incontinence care to Resident #3 around 10:45 PM and found Resident #3's clothes were soaked with urine. NA #4 stated Resident #3 said, I don't know what I did to make her treat me that way.
On 12/17/2024 at 10:22 AM an interview was conducted with Unit Manager #2. Unit Manager #2 stated Nurse #4 reported by telephone the behavior of NA #3 as being disrespectful and not providing incontinence care at 9:33 PM. Unit Manager #2 stated he asked Nurse #4 to change assignments and not allow NA #3 back in Residents #3's room. Unit Manager #2 reported that he then sent a text to NA #3 at 9:45 PM, asking NA #3 not to return to Resident #3's room due to her poor treatment towards Resident #3.
On 12/17/24 at 8:55 AM an interview was conducted with the Administrator. She stated NA #3 should have provided care when Resident #3 asked. The Administrator stated Resident #3 should never feel disrespected and wait until the next shift for incontinence care.
Oct 2024
7 deficiencies
CONCERN
(D)
Potential for Harm - no one hurt, but risky conditions existed
Deficiency F0583
(Tag F0583)
Could have caused harm · This affected 1 resident
**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on record review, observations and staff interviews, the facility failed to maintain a resident's privacy by not providing...
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**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on record review, observations and staff interviews, the facility failed to maintain a resident's privacy by not providing full visual privacy during tracheostomy (hole that surgeons make through the front of the neck and into the windpipe) care for 1 of 1 resident (Resident #187) reviewed for personal privacy. The reasonable person concept was applied as a reasonable person would expect privacy in their home when being cared for.
The findings included:
Resident #187 was admitted to the facility on [DATE].
Review of the admission Minimum Data Set (MDS) assessment dated [DATE] revealed he had severe cognitive impairment and was coded for tracheostomy care.
During a continuous observation of tracheostomy care from inside Resident #187's room on 10/23/2024 from 11:00 AM until 11:18 AM, Nurse # 1 and Nurse # 2 left Resident #187's door open to the hallway while they were cleaning the tracheostomy site, performing suctioning, and changing the tracheostomy cannula. Resident #187 was in a private room and there was no privacy curtain in the room. While standing at Resident #187's bedside, observing Nurse #1 and Nurse #2 provide care for the resident the hallway could easily be visualized. There was nothing in the room that would obstruct the view of the resident receiving care from the hallway.
An interview was completed on 10/23/2024 at 11:21 AM with Nurse # 1 where she reported Resident #187's door should have been closed for his privacy. Nurse # 1 went on to say she was not sure why she did not close the door except that she just forgot.
During an interview with Nurse #2 on 10/23/2024 at 11:23 AM he reported the door to Resident #187's room should not have been opened while they were providing care, but he forgot to close it or even remind Nurse #1 to close it.
An interview was conducted on 10/23/2024 at 11:32 AM with the Director of Nursing (DON) where she explained there were no privacy curtains in the private room, but she expected the resident's door to be closed any time care was being provided to maintain their privacy.
On 10/23/2024 at 12:33 PM an interview was completed with the Administrator. During the interview the Administrator reported she expected staff to close the door when providing care to maintain resident privacy.
CONCERN
(D)
Potential for Harm - no one hurt, but risky conditions existed
Assessment Accuracy
(Tag F0641)
Could have caused harm · This affected 1 resident
**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based upon observation, record review, and staff interviews, the facility failed to accurately code the Minimum Data Set (MDS) a...
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**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based upon observation, record review, and staff interviews, the facility failed to accurately code the Minimum Data Set (MDS) assessment for 1of 1 resident (Resident #187) reviewed for special services.
Findings included:
Resident #187 was admitted to the facility on [DATE] with the following diagnoses: respiratory failure with hypoxia, pneumonia, and tracheostomy status.
A review of Resident #187's admission Minimum Data Set (MDS) dated [DATE] showed the resident had severe cognitive impairment, aphasia and respiratory failure. The MDS also revealed Resident #187 was receiving oxygen, needed tracheostomy care, and was on invasive mechanical ventilation.
Review of Resident #187's care plan dated 10/18/2024 revealed he was at risk for complications secondary to a tracheostomy related to respiratory failure. Interventions included: tracheostomy care as needed, notify the Physician of any respiratory complications, and suction as needed. There was no care plan for invasive mechanical ventilation.
A review of Physician orders dated 10/7/2024 through 10/20/2024 revealed there were no orders for invasive mechanical ventilation.
On 10/20/2024 at 2:21 PM Resident #187 was observed lying in bed, alert with eyes open. A tracheostomy was in place with oxygen running. There was no evidence of invasive mechanical ventilation.
An interview was completed with Nurse #3 on 10/22/2024 at 2:22 PM. During the interview Nurse #3 looked at Resident #187's electronic medical record and reported while he was in the hospital he did receive invasive mechanical ventilation, but was weened down from the ventilator prior to admission to the facility.
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 observations, record reviews, and staff interviews, Nurse #1 failed to follow the procedure for tracheostomy (hole that...
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**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observations, record reviews, and staff interviews, Nurse #1 failed to follow the procedure for tracheostomy (hole that surgeons make through the front of the neck and into the windpipe) care when she did not use the sterile gloves from the sterile tracheostomy kit when cleaning the tracheostomy site and changing the inner canula. In addition, the facility failed to have a physician order for continuous oxygen for Resident #187. This deficient practice occurred for 1 of 1 resident requiring tracheostomy care (Resident #187).
The findings included:
a. Review of the facility's procedure guide for Tracheostomy Care read in part, perform hand hygiene and apply clean /sterile gloves for suctioning and other Personal Protective Equipment (PPE) if not already completed. Hyper-oxygenate resident for 30 seconds or ask resident to take 5-6 deep breaths then suction tracheostomy. Before removing gloves, remove the soiled dressing and discard. Perform hand hygiene again and prepare equipment on the bedside table as follows: Open sterile tracheostomy kit and prepare dressings and cleaning supplies. Open sterile tracheostomy dressing package. Unwrap sterile basin and pour normal saline into it. Open small sterile brush package and place aseptically into sterile basin. Prepare tracheostomy fixation device. Open inner cannula package. Apply sterile gloves and keep dominant hand sterile throughout procedure.
Resident #187 was admitted on [DATE] with the following diagnoses: respiratory failure with hypoxia, pneumonia and tracheostomy status.
Review of orders dated 10/7/2024 showed the following, tracheostomy care every shift and as needed. Clean or change the inner cannula as applicable. Suction tracheostomy as needed for excess secretions.
A review of the admission Minimum Data Set (MDS) assessment dated [DATE] revealed Resident #187 had severe cognitive impairment and required tracheostomy care.
Review of the care plan dated 10/18/2024 showed a problem that the Resident was at risk for complications secondary to a tracheostomy related to respiratory failure. There was a goal for the Resident to be free from complications related to having a tracheostomy. Interventions included, observe for signs and symptoms of respiratory complications including infection and or respiratory blockage or mucous plug, refer to pulmonologist as needed, suction as needed, and tracheostomy care per order.
A continuous observation of tracheostomy care was conducted on 10/23/2024 from 11:00 AM to 11:21 AM. Before the procedure, Nurse #1 performed hand hygiene and applied gloves. Nurse #1 proceeded to open the sterile tracheostomy cleaning kit and while opening the kit an item fell to the floor. Nurse #1 retrieved another tracheotomy cleaning kit from the PPE container hanging on the Resident's door. Nurse #1 failed to remove gloves, perform hand hygiene, or apply new gloves before continuing to open the rest of the items in the tracheostomy kit. Prior to cleaning the tracheostomy site and changing the inner cannula, Nurse #1 failed to apply the sterile gloves from the tracheostomy kit or keep one hand sterile through the procedure.
An interview was completed on 10/23/24 at 11:22 AM with Nurse #1. During the interview Nurse #1 stated the sterile gloves should have been applied and changed anytime the sterile field was broken.
During an interview on 10/23/24 at 11:32 AM with the Director of Nursing (DON) she reported she expected Nurse #1 to follow the policy and procedures, including using the sterile gloves provided in the tracheostomy kit when performing tracheostomy care.
On 10/23/24 at 12:06 PM an interview was completed with the Infection Preventionist (IP). During the interview the IP stated Nurse #1 should have followed the policy and procedure for tracheostomy care as well as changed her gloves and washed her hands after getting a new tracheostomy cleaning kit. The IP further explained there would be additional education on proper tracheostomy care and hand hygiene.
An interview was completed with the Administrator on 10/23/24 at 12:33 PM where she reported she expected staff to follow policies and procedures for tracheostomy care.
b. A review of Resident #187's physician orders dated 10/7/2024 through 10/21/2024 revealed orders were in place for tracheostomy care. There were no orders for oxygen use.
An observation on 10/20/2024 at 2:21 PM showed Resident #187 was lying in bed with oxygen set to 3 liters (L)/minute.
On 10/22/2024 at 8:53 AM Resident #187 was observed lying in bed with oxygen flowing into the tracheostomy and set on 3L/minute.
An interview was completed on 10/22/2024 at 2:22 PM with Nurse #3. During the interview Nurse #3 looked at Resident #187's orders and was unable to find any orders related to oxygen flow rate, however she was able to find the oxygen settings in Resident #187's discharge paperwork. Nurse #3 went on to say if there was no order in place the Nurse Practitioner (NP) or Physician needed to be called for clarification orders.
During an interview with the 200 Hall Unit Manager on 10/22/2024 at 2:32 PM she looked at the Physician orders and electronic medical record (eMAR) for Resident #187 and was not able to find orders for oxygen use. The Unit Manager stated there should have been orders in place for the oxygen flow rate.
An interview was completed with the Director of Nursing (DON) on 10/22/2024 at 2:43 PM. During the interview the DON looked through Resident #187's eMAR and was not able to find orders for oxygen use, including flow rate. The DON reported there should be orders in the system for oxygen flow rate and the humidifier on the O2 concentrator. The DON further explained Resident #187 was a newly admitted resident and new admission orders were reviewed by several members of the nursing team, including the Unit Managers, but somehow the orders for Resident #187's oxygen had been missed.
During an interview with the Administrator on 10/23/2024 at 12:33 PM she reported her expectation was for all orders for any newly admitted residents to be discussed during clinical meetings and any discrepancies needed to be discussed and the Physician notified. The Administrator went on to say there should have been orders in place for Resident #187's oxygen.
CONCERN
(D)
Potential for Harm - no one hurt, but risky conditions existed
Garbage Disposal
(Tag F0814)
Could have caused harm · This affected 1 resident
Based on observations and staff interviews the facility failed to remove loose garbage, food, and debris from around 2 of 2 trash receptacles located outdoors behind the kitchen. This practice had the...
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Based on observations and staff interviews the facility failed to remove loose garbage, food, and debris from around 2 of 2 trash receptacles located outdoors behind the kitchen. This practice had the potential to impact sanitary conditions and attract pests/rodents.
The findings included:
An observation of the outdoor trash receptacle area on 10/20/24 at 10:52 AM revealed eight sets of used disposable gloves and one used sandwich bag with food debris in it on the ground outside of the receptable. One garbage bag was found on the sidewalk leading to the trash receptacle area that was open with debris and spaghetti noodles. During the observation the receptacle door on one trash receptacle was noted to be open and the lid of the trash receptacle caved into the dumpster, weighed down by garbage bags.
An interview with Maintenance Assistant on 10/22/24 09:28 AM revealed the housekeeping and maintenance departments were responsible for keeping the trash receptacle area clean. He stated the area was cleaned each morning and trash and debris was removed from night shift.
An interview with the Administrator on 10/23/24 at 12:35 PM revealed she expected the trash receptacle area to be maintained according to the facility's policies and procedures.
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
Menu Adequacy
(Tag F0803)
Could have caused harm · This affected multiple residents
**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observations, record review, review of Resident Council minutes, and resident and staff interviews, the facility failed...
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**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observations, record review, review of Resident Council minutes, and resident and staff interviews, the facility failed to follow their planned menus for 1 of 1 sampled resident reviewed for preferences (Resident #65). The deficient practice had the potential to affect other residents who received food from the kitchen.
The findings included:
Resident #65 was admitted to the facility on [DATE], discharged and readmitted on [DATE] with the following diagnoses: end stage renal disease (ESRD), dependence upon dialysis, vitamin deficiency, and gastroesophageal reflux disease (GERD).
A review of the admission Minimum Data Set (MDS) dated [DATE] revealed that Resident #65 was cognitively intact. The MDS also indicated Resident #65 only needed set-up assistance from staff with eating.
Review of #65's Physician orders dated 10/8/2024 showed a dietary order for a renal diet with regular texture and thin liquids.
A review of Resident #65's most recent care plan dated 8/16/2024 revealed Resident #65 was at risk for weight loss or malnutrition related to chronic diseases including GERD, ESRD, and dependence upon dialysis. The goal in place was for Resident #65 to have optimal nutrition and hydration status through the review period. Interventions included therapeutic diet as ordered, encourage to eat, and monitor meal intakes.
Review of Resident Council minutes dated 5/7/2024 showed residents did not feel like the menus were being followed and they were not receiving what they ordered.
An additional review of Resident Council minutes dated 7/3/2024 revealed residents were concerned that they were not being informed when substitutions were being made to meals.
Resident Council notes dated 8/13/2024 indicated residents were concerned because they were not getting what they were selecting on their menus.
On 10/20/2024 at 10:40 AM an interview was completed with a [NAME] Aide where she reported food was delivered on Mondays and sometimes the facility received what they ordered and sometimes they did not. She went on to say the Dietary Manager placed the orders and then someone above her changed the order due to the budget.
An interview with Resident #65 on 10/20/2024 at 12:23 PM revealed meal tickets did not usually match what was served. The interview further revealed Resident #65 felt as if she did not ever receive enough protein as she rarely received any meat at breakfast. Resident #65 went on to say she was not always offered the chance to make choices regarding the menu, because staff would serve what they wanted to serve.
An observation of Resident #65's lunch tray on 10/20/2024 at 12:27 PM showed she had mixed greens, black eyed peas, a meat that the resident reported as baked chicken, and pineapple tidbits. An observation of Resident #65's lunch meal ticket indicated she should have received buttered green beans, black eyed peas, baked chicken, and apple pie.
An additional observation was completed on 10/22/2024 at 8:45 AM of Resident #65's meal ticket and breakfast tray. Resident #65's tray had oatmeal and scrambled eggs. A review of the meal ticket revealed there should have also been a sausage patty and a cup of milk on the tray. Resident #65 reported she received neither of those items.
An observation of the breakfast menu outside of the dining room on 10/23/2024 at 8:27 AM showed there was supposed to be a sausage patty with biscuit and country gravy and a side of grits.
Observation and interview of Resident #65's breakfast meal ticket on 10/23/2024 at 8:30 AM revealed the resident had received eggs, toast, and cereal. Resident #65 reported she did not receive a sausage patty or gravy for breakfast.
During an interview on 10/22/2024 at 10:39 AM with Nurse Aide (NA) #1 she explained resident menus were supposed to be filled out the day before and the only time they were informed of any changes in the menu was when they would open the resident's meal tray during set-up.
An interview was completed on 10/22/2024 at 10:59 AM with NA #2 where she reported staff would not be told about any menu changes and would learn about the changes when the meal tray was opened. NA #2 further explained that some residents would receive breakfast meats, and others would not because the kitchen did not always have protein available.
An interview with the Registered Dietician (RD) was completed on 10/22/2024 at 8:59 AM. During the interview the RD reported she signed off on a log after the fact for any substitutions. She went on to say the Dietary Manager was able to make the substitutions if the kitchen was out of what they were supposed to have. The RD also reported any substitutions that were made to the menu had to be posted outside of the dining room. The RD further explained the kitchen did not have anything that could have been substituted for the sausage because the company that delivered the food order was out of sausage.
An interview was conducted on 10/22/2024 at 9:28 AM with the Dietary Manager. During the interview the Dietary Manager reported the meal tickets were not changed to show substitutions and the only way a resident would know if there had been a change would be for them to come to the dining room to look at the menu.
An interview was completed on 10/23/2024 at 12:35 AM with the Administrator where she explained her expectations were that the residents be informed of any menu changes and the kitchen to follow their policies and procedures.
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
Food Safety
(Tag F0812)
Could have caused harm · This affected multiple residents
Based on record review, observations and staff interviews, the facility failed to label and date leftover food items stored for use, keep a food storage area clean and orderly, and failed to dry servi...
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Based on record review, observations and staff interviews, the facility failed to label and date leftover food items stored for use, keep a food storage area clean and orderly, and failed to dry serving trays prior to stacking. These practices occurred in 1 of 7 reach-in coolers, 1 of 1 walk-in freezer, 1 of 1 dry goods storage area, and had the potential to affect food served to residents.
The findings included:
An initial tour of the main kitchen occurred 10/20/24 at 10:26 AM. The following concerns were identified:
a. A bag of leftover frozen French fries was observed in the walk-in freezer not dated.
b. Food items in the reach-in coolers that were open and not labeled with a use by date included:
-three resealable plastic bags of cut watermelon
-one gallon tub of sweet pickle relish
-gallon tub of blue cheese dressing
-five-pound tub of sour cream
-14 ounce can of whipped cream
c. Four disposable bowls of vanilla pudding on a tray, not covered or dated in the reach-in cooler were observed.
d. Three bags of hamburger buns with manufacturer's best by of 9/14/24 were observed in the dry storage room.
e. 51 clean serving trays were observed wet-nested in the dishwashing area on a tray-holding cart. All 51 trays were visibly wet and wet to the touch.
An interview with [NAME] Aide #1 on 10/20/24 at 10:40 AM revealed the trays were stacked wet due to limited space in the dishwashing area.
An interview with the Dietary Manager (DM) on 10/22/24 at 9:28 AM revealed she had been in the DM role for about a month. She stated she was not aware of the wet nested trays, the items that were not labeled, and items stored past the use by date.
An interview with the Administrator on 10/23/24 at 12:35 PM revealed she had the expectation that the kitchen staff and managers followed their policies and procedures.
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
Room Equipment
(Tag F0908)
Could have caused harm · This affected multiple residents
Based on observations and staff interviews, the facility failed to maintain the food steamer, which leaked water onto the floor in the main kitchen, in safe operating condition.
Findings included:
An ...
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Based on observations and staff interviews, the facility failed to maintain the food steamer, which leaked water onto the floor in the main kitchen, in safe operating condition.
Findings included:
An observation made on 10/20/24 at 10:43 AM revealed a large puddle of water under the food steamer next to the gas stove adjacent to the food preparation area. Water was observed dripping out a plastic pipe on the back of the appliance. The pipe was not located above the floor drain and a large puddle of water was observed on the kitchen floor.
An interview with [NAME] Aide #1 on 10/20/24 at 10:42 AM revealed the kitchen staff verbally reported the leaking pipe from the food steamer to Maintenance staff multiple times in the previous weeks and the water was still leaking on the kitchen floor.
An interview with Dietary Manager (DM) on 10/22/24 at 9:28 AM revealed she was not aware of the leaking pipe from the food steamer.
An interview with the Maintenance Assistant on 10/23/24 at 9:48 AM revealed he was not aware of the leaking pipe from the food steamer. He stated the facility used an online maintenance tracking system. He stated staff knew to enter a concern in the system, and Maintenance staff would respond to the need. He stated if there was an urgent need, staff knew to verbally alert the Maintenance staff, and they would immediately respond.
An interview with the Administrator on 10/23/24 at 12:35 PM revealed she was not aware of the leaking pipe under the steamer appliance, and she had the expectation that the kitchen staff and managers followed their policies and procedures to maintain equipment and report any concerns to Maintenance staff.
Aug 2023
8 deficiencies
CONCERN
(D)
Potential for Harm - no one hurt, but risky conditions existed
Deficiency F0558
(Tag F0558)
Could have caused harm · This affected 1 resident
**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, record review and interviews with resident and staff, the facility failed to ensure a dependent resident c...
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**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, record review and interviews with resident and staff, the facility failed to ensure a dependent resident could access the light switch located behind the bed for 1 of 1 resident reviewed for accommodation of needs. (Resident #48)
Resident #48 was admitted to the facility on [DATE].
Review of Resident #48's medical records revealed she had moved to her current bedroom (room [ROOM NUMBER]A) on 06/27/23.
The quarterly Minimum Data Set (MDS) dated [DATE] assessed Resident #48 with intact cognition. The MDS indicated walking between locations inside or outside the room did not occur for Resident #48 during the assessment periods.
During an observation conducted on 08/07/23 at 1:25 PM, the switch for the light fixture behind Resident #48's bed was attached with a broken cord approximately 3 inches in length. The switch located on the wall was approximately 5 feet from the floor and around 4 feet from Resident #48's bed. Resident #48 was unable to reach the cord connected to the light switch from the bed if needed.
An interview was conducted with Resident #48 on 08/07/23 at 1:31 PM. She stated she did not know how long the cord attached to the light switch behind the bed had been broken. She added she was bed bound and non-ambulatory. She did not have any control of the lights behind her bed as she could not reach the switch on the wall from her bed. She had to rely on nursing staff to control the light each time and it was very inconvenient to her. She added it would be great if she could have full control of the light switch behind her bed.
During a subsequent observation conducted on 08/08/23 at 10:00 AM, the cord attached to the light switch behind Resident #48's bed remained in disrepair.
During a joint observation conducted with Nurse #1 and Nurse Aide (NA) #1 on 08/08/23 at 2:11 PM, the access cord to the light switch for the light behind the bed remained inaccessible from Resident #48's bed.
A joint interview was conducted with Nurse #1 and NA #1 on 08/08/23 at 2:14 PM. Both nursing staff confirmed Resident #48 was bed bound and acknowledged that the switches on the wall were unreachable for Resident #48 from the bed. They had provided care for Resident #48 frequently in the past 2 weeks but did not notice the access cord for the light switch behind the bed was broken.
An interview was conducted with the Maintenance Director on 08/08/23 at 2:58 PM. He acknowledged that the cord to control the switch for the light behind Resident #48's bed was in disrepair, and it needed to be fixed immediately. He stated he did a walk through of the facility daily to identify repair needs but he rarely walked into resident's rooms unless there were repair issues. He depended heavily on staff to report repair or maintenance needs via work order system in the computer. He reported he checked the work order system at least twice daily to ensure all the repair needs were addressed in timely manner. He was not aware the access cord for the light switch behind the bed was broken as he had never received any report from the staff.
An interview was conducted with the Director of Nursing (DON) on 08/09/23 at 9:21 AM. She expected nursing staff to pay more attention to residents' home and reported repair needs to Maintenance Director in timely manner. It was her expectation for all the residents to have accessibility and full control of the light fixtures to accommodate their needs.
An interview was conducted on 08/10/23 at 11:06 AM with the Administrator. She stated the cord to control the light switch for the light fixture behind Resident #48's bed should be in good repair. It was her expectation for all the residents to have full access and control of their light fixture all the time.
CONCERN
(D)
Potential for Harm - no one hurt, but risky conditions existed
Deficiency F0583
(Tag F0583)
Could have caused harm · This affected 1 resident
**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observations, record review, staff interview, and resident interview the facility failed to provide privacy for a resid...
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**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observations, record review, staff interview, and resident interview the facility failed to provide privacy for a resident when the resident was transferred in a common area with their brief exposed. This occurred for one of one resident reviewed for personal privacy. (Resident #50)
The findings included:
Resident #50 was admitted to the facility on [DATE].
A quarterly Minimum Data Set for Resident #50 dated 5/9/23 revealed she was cognitively intact.
On 8/7/23 at 10:31 AM upon exiting a resident's room, Resident # 50 was observed being brought out of her room in a mechanical lift by Nurse Aide (NA) #2 and NA #3. NA #2 was positioned to the side of the resident guiding the resident in the sling. NA #3 was positioned behind the mechanical lift pushing it out of the room. Resident #50 was in the sling with her legs slightly upward, Resident #50's incontinence brief was exposed. A shower bed was positioned against the wall outside of Resident #50's room, Resident #50 was transferred to the shower bed. After the transfer was complete, NA #3 went into Resident #50's room, retrieved a sheet and covered the resident. During this transfer there were staff members on the hall and multiple residents' room doors were open.
During an interview on 8/7/23 at 12:02 PM NA #2 revealed she assisted NA #3 transfer Resident #50 to the shower bed. She stated they could not complete the transfer inside the resident's room because there was not enough room for the lift and shower bed. NA #2 revealed they usually covered Resident #50 with a sheet before bringing her into the hall. She further revealed she was guiding the resident out of the room while NA #2 was pushing the mechanical lift. When she noticed the resident was uncovered, they were already in the hall, so they just completed the transfer. She stated they should have covered the resident before exiting the room.
An interview conducted with NA #3 on 8/7/23 at 12:13 PM revealed she was assigned to care for Resident #50 on that day. She further revealed when she and NA #2 were transferring Resident #50 to the shower bed she was rushing and forgot to cover the resident with a sheet before exiting the room. She stated she usually ensured residents that needed to be transferred in the hallway were covered.
During an interview with Resident #50 on 8/7/23 at 2:10 PM she indicated she did not recall being uncovered during the transfer to the shower bed. She stated the staff usually covered her before they left the room. She preferred to be covered during transfers.
During an interview on 8/7/23 at 2:27 PM the Director of Nursing revealed in some instances staff had to complete transfers in the hall. If a resident needed to be transferred in the hall staff should ensure that the resident was covered. She further stated staff should have covered Resident #50 prior to exiting the room.
CONCERN
(D)
Potential for Harm - no one hurt, but risky conditions existed
Safe Environment
(Tag F0584)
Could have caused harm · This affected 1 resident
**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, record review, and interviews with resident and staff, the facility failed to maintain a wheelchair in goo...
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**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, record review, and interviews with resident and staff, the facility failed to maintain a wheelchair in good repair for 1 of 2 residents reviewed for mobility device (Resident #18).
The findings included:
Resident #18 was admitted to the facility on [DATE].
Review of weekly skin assessment from 06/02/23 through 08/03/23 revealed Resident #18's skin was intact without any issues.
Review of the quarterly Minimum Data Set (MDS) dated [DATE] assessed Resident #18 with severe impairment in cognition and her primary mobility device was wheelchair.
During an observation conducted on 08/07/23 at 10:24 AM, Resident #18 was seen sitting in her wheelchair next to her bed in her room. The left armrest of Resident #18's wheelchair was in disrepair with multiple torn spots, ripped edges, and cracked lines. In addition, some the bolts and nuts to hold the right armrest to the wheelchair were missing. Leaving the right armrest partially attached to the wheelchair and at risk of falling off. Resident #18 was wearing short sleeves sitting in the wheelchair and both of her arms were in contact with the broken armrests during the observation.
An interview was conducted with Resident #18 on 08/07/23 at 10:27 AM. She said I don't know repeatedly when the surveyor attempted to interview her.
During a joint observation conducted on 08/08/23 at 2:06 PM with Nurse #1 and Nurse Aide (NA) #1, Resident #18 was wearing short sleeves sitting in the wheelchair with her both arms in contact with the broken armrests. Nurse #1 assessed Resident #18's left arm and deteermined her skin was intact without any redness or rashes.
A joint interview was conducted on 08/08/23 at 2:09 PM with Nurse #1 and NA #1. Both nursing staff acknowledged that the bilateral armrests for Resident #18's wheelchair were broken and needed to be fixed immediately. They provided care for Resident #18 frequently in the past couple weeks but had not noticed the armrests were in disrepair. The nurse stated she was going to file a work order to the maintenance department immediately.
During a joint observation conducted on 08/08/23 at 2:41 PM with the Maintenance Director, Resident #18 was seen sitting in the wheelchair wearing short sleeves and the skin of her bilateral arms were in contact with the broken armrests.
An interview was conducted on 08/08/23 at 02:43 PM with the Maintenance Director. He acknowledged that the armrests for Resident #18's wheelchair were in disrepair, and needed to be fixed immediately. He stated he walked through the facility daily to identify repair needs but he rarely went into resident's rooms unless there were repair issues. He depended heavily on staff to report repair needs via work order system in the computer and he would check the work order system at least twice daily to ensure all the repair needs were addressed in timely manner. He was not aware of Resident #18's broken armrests as he had not received any report from the staff.
An interview was conducted on 08/09/23 at 9:23 AM with the Director of Nursing. She expected the staff to be more attentive to resident's mobility devices and reported repair needs to maintenance department in timely manner. It was her expectation for all the mobility devices to be in good repair all the time.
An interview was conducted with the Administrator on 08/10/23 at 11:06 AM. She expected the staff to report repair needs to maintenance department in timely manner. It was her expectation for all the mobility devices included wheelchair to be in good repair all the time.
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 observations, record review, resident interview and staff interviews the facility failed to review and revise the care ...
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**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observations, record review, resident interview and staff interviews the facility failed to review and revise the care plan for 1 of 2 residents reviewed for comprehensive resident centered care plans (Resident #239).
The findings included:
Resident #239 was admitted to the facility on [DATE] with diagnoses inclusive of stroke and dementia.
An admission Minimum Date Set (MDS) assessment dated [DATE] indicated Resident #239 had an indwelling urinary catheter.
A Care Plan dated 7/20/23 indicated the presence of an indwelling catheter.
A review of a physician's order dated 7/31/23 revealed the indwelling foley catheter was discontinued for Resident #239.
A review of a nursing progress note dated 7/31/23 indicated Resident #239's indwelling catheter was removed at 11:00 AM.
A review of physician orders dated 7/31/23 through 8/7/23 revealed no order for a condom catheter for Resident #239.
A review of nursing progress notes dated 8/1/23, 8/5/23, 8/8/23 revealed Resident #239 had a condom catheter.
During a phone interview on 8/8/23 at 2:06 PM a family member indicated Resident #239 was incontinent at night and preferred to wear a condom catheter instead of a diaper. She further indicated she purchased the supplies, left them in his room, and visited daily to change the condom catheter. When she was unable to visit on 8/6/23, she informed staff, who told her they needed a doctor's order and would ask the nurse practitioner. When she called back on 8/7/23, the order had not been written and she continued to change the condom catheter herself.
During an interview on 8/10/23 at 9:45 AM the MDS nurse indicated she did not review and update Resident #239's care plan to reflect the presence of a condom catheter because she did not see an order for one and did not realize the indwelling catheter had been discontinued.
During an interview on 8/10/23 at 4:32 PM the Director of Nursing (DON) revealed the indwelling catheter was discontinued on 7/31/23 and an order for a condom catheter for Resident #239 should have been entered, followed by a care plan update to reflect the change from an indwelling catheter to condom catheter.
CONCERN
(D)
Potential for Harm - no one hurt, but risky conditions existed
ADL Care
(Tag F0677)
Could have caused harm · This affected 1 resident
**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observations, record review, resident and staff interviews the facility failed to provide nail care for 1 of 2 resident...
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**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observations, record review, resident and staff interviews the facility failed to provide nail care for 1 of 2 residents ( Resident #77) reviewed for activities of daily living (ADLs).
The findings included:
Resident #77 was admitted to the facility on [DATE] with diagnoses inclusive of dysphagia, stroke, epilepsy, and acute respiratory failure.
An admission Minimum Data Set assessment dated [DATE] revealed Resident #77 had moderate cognitive impairment and required limited assistance with bed mobility, dressing, and personal hygiene; extensive assistance with toileting and transfers; supervision with eating and physical help with bathing. The MDS further revealed Resident #77 did not reject care such as ADL assistance.
A review of August 2023 progress notes did not reveal Resident #77 refused care.
A review of shower sheets dated 7/29/23 and 8/5/23 indicated Resident #77 did not need toes nails or fingernails cut.
An observation and interview with Resident #77 on 8/7/23 at 9:01 AM revealed untrimmed and jagged fingernails extending beyond the tips of his fingers on both hands and three fingernails on right hand had brown matter under the nailbeds. The Resident stated no one asked him if he wanted his nails trimmed or cleaned and he wanted them done.
A second observation on 8/9/23 at 11:45 AM revealed Resident #77 had untrimmed fingernails extending beyond the tips of his fingers on both hands and three fingernails on right hand had brown matter under the nailbeds.
During a phone interview on 8/9/23 at 1:10 pm Nurse Aide #5 revealed she normally provided nail care on assigned shower days and as needed. She further revealed she provided Resident #77 with a bed bath instead of a shower on 8/8/23 (2nd shift, since his shower days were Tues/Th/Sat), recognized that his fingernails needed care but forgot to complete nail care during her shift. She also stated she documented the Resident's ADLs in the medical record and did not regularly complete shower sheets.
During an interview on 8/9/23 at 12:29 PM Nurse Aide #4 indicated she was assigned to Resident #77 on first shift (8/9/23) and did not recognize his nails needed to be trimmed or cleaned until the Surveyor observed them, then made her aware. She further indicated she would complete nail care before her shift ended.
During an observation and interview on 8/9/23 at 12:37 PM, Nurse #5 accompanied by the Surveyor, observed Resident #77's nails. Nurse #5 revealed the Resident's nails were overgrown and had brown matter under the nailbeds. She further revealed she would make sure a Nurse Aide provided nail care before the end of the shift.
During an interview on 8/10/23 at 3:55 PM, Unit Manager #2 indicated she was made aware and observed Resident #77's nails on 8/9/23 before she was later made aware that the Activities assistant performed nail care after the Surveyor made another observation. She expected nail care to be performed as needed and on shower days.
During an interview on 8/10/23 at 4:32 PM the Director of Nursing (DON) indicated she expected nail care to be performed on shower days and as needed.
CONCERN
(D)
Potential for Harm - no one hurt, but risky conditions existed
Deficiency F0761
(Tag F0761)
Could have caused harm · This affected 1 resident
Based on observations and staff interviews the facility failed to secure a controlled substance in a permanently affixed compartment of the refrigerator in one of two facility medication rooms. (200 h...
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Based on observations and staff interviews the facility failed to secure a controlled substance in a permanently affixed compartment of the refrigerator in one of two facility medication rooms. (200 hall medication room)
The findings included:
On 8/8/23 at 3:13 PM an observation and interview were conducted with Nurse #3. The refrigerator in the 200-hall medication room was not locked and had a clear permanently affixed lock box that was locked and empty. In an unlocked drawer below the lock box was a medication, Lorazepam/Intensol (a controlled substance) oral concentrate 2 milligrams/milliliter. Nurse #3 stated the medication should have been in the lock box, and she was unsure of why the medication was not secured. She further stated she did not have a key to the lock box, but she would ask the Unit Manager (UM) #2 for the key.
During an interview on 8/8/23 at 3:30 PM the UM #2 revealed the Lorazepam was a controlled substance and should have been in the locked box. She stated she did not know where the key to the lock box was, and she would follow up with the Director of Nursing (DON).
During an interview with the DON on 8/8/23 at 4:31 PM she revealed the key to the lock box had been lost for about a week, and a new lock box had been ordered from the pharmacy. She stated staff were supposed to store their controlled medications in the lock box on the 100-hall until the new lock box was installed in the 200-hall refrigerator.
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 observations and staff interviews the facility failed to maintain ceiling vents in the kitchen free from accumulation of fuzzy grayish matter and failed to clean 2 of 3 ice machines (the kitc...
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Based on observations and staff interviews the facility failed to maintain ceiling vents in the kitchen free from accumulation of fuzzy grayish matter and failed to clean 2 of 3 ice machines (the kitchen ice machine and 200 Hall nourishment room ice machine). These practices had the potential to affect food and beverages served to residents.
Finding included:
1. During the initial tour of the kitchen on 08/07/2023 at 8:25 AM an observation of 2 ceiling vents located beside the dairy refrigerator revealed an accumulation of thick, fuzzy, grayish matter. No air was blowing from the ceiling vents. The tray line was located to the left of the ceiling vents.
On 08/08/2023 at 1:15 PM an interview was conducted with the Dietary Manager (DM). He stated the ceiling vents should be free of any debris and needed to be cleaned. He also stated that he did not know when the last time the ceiling vents were cleaned. He further stated the maintenance department was responsible for cleaning the ceiling vents.
2. On 08/08/2023 at 2:15 PM an observation of the kitchen ice machine was conducted with the DM. The observation revealed a black substance located on the white plastic seal under the ice machine lids. The black substance was not in contact with the ice in the ice machine.
On 08/08/2023 at 2:25 PM an observation of the 200 Hall nourishment room ice machine was conducted with the DM. The observation revealed a black substance located on the white plastic seal under the ice machine lids. The black substance was not in contact with the ice in the ice machine.
An interview was conducted with the DM on 08/08/2023 at 2:25 PM. The DM stated the ice in both ice machines needed to be discarded and the ice machines thoroughly cleaned. He also stated the maintenance department was responsible for cleaning and maintaining the ice machines.
During an interview with the Maintenance Supervisor on 08/09/2023 at 08:30 AM, he stated the ice machines are cleaned and sanitized by an outside contract company every 6 months. He stated the ice machines were last cleaned on 03/22/2023.
During an interview with the Administrator on 08/10/2023 at 8:00 AM, she stated her expectations were for the ice machines and ceiling vents to be cleaned routinely.
CONCERN
(E)
Potential for Harm - no one hurt, but risky conditions existed
QAPI Program
(Tag F0867)
Could have caused harm · This affected multiple residents
Based on observation, record review and interviews the facility's Quality Assessment and Assurance (QAA) committee failed to maintain implemented procedures and monitor interventions the committee put...
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Based on observation, record review and interviews the facility's Quality Assessment and Assurance (QAA) committee failed to maintain implemented procedures and monitor interventions the committee put into place following the complaint survey and recertification conducted on 4/14/22. Four repeat deficiencies were originally cited on the 4/14/22 survey under the areas of Resident Rights (F558), Comprehensive Resident Centered Care Plan (F657), Pharmacy Services (F761), and Food and Nutrition Services (F812) and were subsequently recited on the current recertification and complaint survey of 8/10/23. These repeat deficiencies during the 2 federal surveys show a pattern of the facility's inability to sustain an effective QAA Program.
The findings included:
This citation is cross referenced to:
F558: Based on observation, record review and interviews with resident and staff, the facility failed to ensure a dependent resident could access the light switch located behind the bed for one of one resident reviewed for accommodation of needs. (Resident #48)
During the recertification and complaint survey completed on 4/14/22 the facility failed to provide the correct size briefs for one of four residents reviewed for accommodation of needs.
F657: Based on observations, record review, resident interview and staff interviews the facility failed to review and revise the care plan for one of two residents reviewed for comprehensive resident centered care plans. (Resident #239)
During the recertification and complaint survey completed on 4/14/22 the facility failed to invite a resident to participate in the development and revision of their care plan for one of eight residents reviewed for care plan meetings.
F761: Based on observations and staff interviews the facility failed to secure a controlled substance in a permanently affixed compartment of the refrigerator in one of two facility medication rooms. (200 hall medication room)
During the recertification and complaint survey completed on 4/14/22 the facility failed to remove expired medications from two of two medication carts, remove expired medications from one of two medication storage rooms, and date and refrigerate a probiotic after opening in one of two medication carts.
F812: Based on observations and staff interviews the facility failed to maintain ceiling vents in the kitchen free from accumulation of fuzzy grayish matter and failed to clean 2 of 3 ice machines (the kitchen ice machine and 200 Hall nourishment room ice machine). These practices had the potential to affect food and beverages served to residents.
During the recertification and complaint survey completed on 4/14/22 the facility failed to discard food products on or before their expiration date and hold foods at a temperature of at least 135 degrees Fahrenheit on the steam table.
During an interview on 8/10/23 at 3:48 PM the Administrator revealed their QAA committee met monthly. During the meetings the committee reviewed their current process improvements, and discussed items that may need a process improvement. The administrator stated the repeat citations were in the same category but in a different area. She revealed from the previous survey the facility had citations related to expired foods, palatability, and preferences. The facility put a lot of focus on correcting those areas and gave less attention to the areas that were cited on the current survey. The Administrator indicated this was the case for all the repeat citations.
Apr 2022
14 deficiencies
CONCERN
(D)
Potential for Harm - no one hurt, but risky conditions existed
Deficiency F0558
(Tag F0558)
Could have caused harm · This affected 1 resident
**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on resident and staff interviews, and record review, the facility failed to provide Resident #87 with the correct size bri...
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**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on resident and staff interviews, and record review, the facility failed to provide Resident #87 with the correct size briefs for 1 of 4 sampled residents reviewed for accommodation of needs.
The findings included:
Resident #87 was admitted to the facility on [DATE] and discharged home on 3/3/22.
An admission Minimum Data Set assessment dated [DATE] revealed Resident #87's cognition was intact, required extensive 2-person assistance with bed mobility, toileting and had frequent incontinence of bowel and bladder.
A care plan 3/1/22 revealed Resident #87 had bladder incontinence related to impaired mobility and activity intolerance.
A telephone interview with the Resident #87 on 4/11/22 at 3:07 pm revealed he brought 48 bariatric briefs with him when he arrived at facility on 2/4/22 and ran out of the briefs within two weeks. He further revealed an unknown staff person showed him the order form showing the facility ordered and received bariatric briefs in a timely manner. Resident #87 could not recall the day he was shown the order form. He indicated he did not receive the bariatric briefs until two (2) days before he discharged from the facility and until then staff provided him with briefs that were too small and uncomfortable. He further indicated he asked a Nurse Aide (unknown) for the briefs and was told the supply clerk was out of the facility and supplies were not being distributed. Resident #87 indicated he saw a pallet of supplies outside the back of the building and was told by an unknown staff member that the supply clerk was the only one who could unload and distribute the supplies. He further indicated he was told that the supply clerk was out of the facility for almost 2 weeks. He also spoke with a unit manager who no longer worked at the facility. Resident #87 revealed he had skin irritations prior to wearing the briefs that were too small, although wearing the too small briefs did not improve skin irritation.
An interview with Central Supply Clerk on 4/12/22 at 2:11 pm indicated she started working at the facility in February 2022 and could not recall the issue regarding Resident #87 not receiving the correct briefs. She further indicated if needed supplies were on back order, the facility would normally contact a Medline liaison for assistance or contact a nursing home affiliate to obtain needed supplies such as briefs. The Central Supply Order notebook was reviewed during the interview and revealed bariatric briefs were ordered on 2/10/22 and 2/18/22. Further review of the notebook did not indicate order received dates. The Central Supply Clerk indicated she was in training and could not recall if she ordered the briefs on 2/10/22 and 2/18/22.
An interview with Nurse Aide (NA) #4 on 4/13/22 at 3:32 PM revealed she cared for Resident #87 during his nursing home stay. She recalled Resident #87 requested bariatric briefs, but his correct size was unavailable. NA #4 further revealed Resident #87 stated he was running out of the bariatric briefs he brought with him at the time of admission to facility. NA #4 indicated she asked the staff person in central supply if the requested briefs were ordered and available. NA #4 could not recall the date she went looking for the larger briefs and could only recall the correct size briefs were not available for Resident #87, therefore, she used the largest size the supply room had available.
Interviews with other nursing staff revealed they did not work with Resident #87 or were not familiar with his situation.
An interview with the Administrator on 4/12/22 at 4:28 pm revealed Resident #87 brought his own bariatric briefs into the facility upon admission. When Resident #87 was about to run out of bariatric briefs, the facility placed an order for bariatric briefs on 2/18/22 and the order was received on 2/21/22. An additional order was placed on 2/25/22 and delivered on 2/28/22. The Administrator provided an email copy of the Medline Proof of Delivery receipt that indicated bariatric briefs (1 carton of 32 briefs) were received at the facility on 2/14/22. No other Proof of Delivery receipts could not be located. The Administrator was unaware Resident #87 did not receive the briefs for at least 2 weeks after facility received the order.
CONCERN
(D)
Potential for Harm - no one hurt, but risky conditions existed
Deficiency F0578
(Tag F0578)
Could have caused harm · This affected 1 resident
**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** 2. Resident #70 admitted to the facility on [DATE].
A review of a Significant Change Minimum Data Set assessment dated [DATE] c...
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**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** 2. Resident #70 admitted to the facility on [DATE].
A review of a Significant Change Minimum Data Set assessment dated [DATE] completed for Resident #70 revealed he was cognitively intact.
Resident #70's Care Plan with a revision date of 4/1/2022 was reviewed and there was not a care plan in place for Resident #70's advanced directives.
A medical record review revealed Resident #70 had advanced directives and his Do Not Resuscitate form was dated 8/19/2021.
During an interview with the Director of Nursing on 4/13/2022 at 3:07 pm she stated she was the Minimum Data Set (MDS) Nurse and the interim Director of Nursing. She stated advanced directives are not care planned by the facility and it is a company policy. She stated the facility does put a copy of the resident's advanced directives in a book at the nurse's station and they upload the advanced directives into the electronic record.
An interview was conducted with the Administrator on 4/13/2022 at 5:04 pm and he stated the facility does not include the advanced directives in the resident's care plan. The Administrator stated the facility was in the process of reviewing the regulations regarding advanced directives to see if they need to include the advanced directives in the care plan.
Based on record review and staff interviews the facility failed to determine, on admission, if 1 of 3 sampled residents had an advance directive (Resident #77) and failed to develop a care plan for advanced directives for 1 of 3 sampled residents reviewed for advanced directives (Resident #70).
The findings included:
1. Resident #77 was admitted on [DATE] from the hospital.
An admission Minimum Data Set assessment dated [DATE] assessed Resident #77 with no speech or spoken words, rarely able to understand or be understood and severely impaired cognition.
A hospital Discharge summary, dated [DATE], a progress note dated 3/30/22 by the Discharge Planner and a care plan, revised 4/4/22 revealed no advanced directive was documented. The progress note, written by the Discharge Planner dated 3/30/22 documented Resident #77 did not have an advance directive indicated.
The medical record for Resident #77 did not document an advance directive until 4/11/22, 16 days after admission.
An interview on 04/12/22 at 6:33 PM with the Discharge Planner revealed when he completed the social services assessment for Resident #77 on 3/30/22, he did not see advanced directives documented in the medical record. He stated this information was to be obtained by nursing and input in the medical record.
An interview on 04/13/22 at 11:27 AM with Nurse #3 revealed she processed the admission for Resident #77. Nurse #3 stated that when a resident was admitted from the hospital, the nurse was responsible to review the hospital records for advanced directives and to provide this documentation to medical records to be included in the electronic medical record. Nurse #3 stated if advance directives was not in the hospital records, the nurse should ask the resident, or responsible party (RP), to provide or clarify and relay this to the manager. Nurse #3 stated she could not recall if she reported to the manager that Resident #77 did not have advanced directives indicated in the hospital records or if she contacted the RP to clarify.
An interview with the Interim Director of Nursing (IDON) occurred on 04/13/22 at 12:45 PM. The IDON stated that the admitting nurse should capture the code status from the admission packet, on admission, and if not documented, the nurse should talk to the resident or the RP and enter the code status into the medical record during the admission processes.
A telephone interview with the Regional Nurse Consultant occurred on 4/13/22 at 12:50 PM and revealed a resident's advance directive should be completed as part of the admission process and documented in the medical record.
CONCERN
(D)
Potential for Harm - no one hurt, but risky conditions existed
Notification of Changes
(Tag F0580)
Could have caused harm · This affected 1 resident
**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on record review, staff interviews and legal guardian interview the facility failed to notify a resident's legal guardian ...
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**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on record review, staff interviews and legal guardian interview the facility failed to notify a resident's legal guardian of a hospital admission for 1 of 1 resident reviewed for notification of changes (Resident #76).
Findings included:
Resident #76 was admitted to the facility on [DATE].
A progress note written by Nurse #12 on 3/14/22 read this writer contacted on call, awaiting triage to call for further instruction.
A progress note dated 3/19/22 revealed Resident #76 had arrived back to the facility. There was no additional documentation showing the guardian was contacted.
A phone interview was completed with Resident #76's guardian on 4/11/22 at 9:14 PM who stated she became aware of Residents #76 admission to the hospital on 3/16/22 from the hospital needing some additional information from the guardian. The guardian stated that she had not received a voicemail or any phone call from the facility. The guardian stated she had called the facility on 3/16/22 requesting to speak to the Interim Director of Nursing but was unable to reach her.
A telephone interview was completed with Nurse #12 on 4/12/22 at 10:35 AM who stated that she was the one working with Resident #76 on 3/14/22 and notified the physician and stated she did notify the responsible party and left a message. Nurse #12 stated she had filled out a E-interact transfer form (A form used as communication for SBAR; situation, background, assessment, and recommendation) which would have the emergency contact information. Nurse #12 stated that if there was not a note in the record then she had not put one in the record, but a note was supposed to be put in the record.
A review of the E-interact form was reviewed, and name of family/health care agent notified was blank for the name, date and time but was signed below by Nurse #12.
An interview was completed with the interim Director of Nursing (DON) on 4/12/22 at 2:25 PM who stated that if the resident had a guardian, the nurse would leave a message for them regarding the notification of change in condition.
An interview was completed with the Administrator on 4/12/22 at 5:15 PM who stated that he would expect that staff notify the responsible party or guardian if a resident is sent to the hospital.
CONCERN
(D)
Potential for Harm - no one hurt, but risky conditions existed
Comprehensive Assessments
(Tag F0636)
Could have caused harm · This affected 1 resident
**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on record review and staff interviews, the facility failed to complete an admission Minimum Data Set (MDS) assessment (Res...
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**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on record review and staff interviews, the facility failed to complete an admission Minimum Data Set (MDS) assessment (Resident #235) within the required time frames for 1 of 3 comprehensive MDS assessments reviewed.
Findings Included:
Resident #235 was admitted to the facility on [DATE].
Review of Resident #235's admission Minimum Data Set (MDS) revealed the assessment reference date (ARD) was 4/5/22. The assessment was not complete and revealed a status of 'in progress' as of 4/12/22.
An interview was completed on 4/12/22 at 2:33 PM with the Interim Director of Nursing (DON) and former MDS Coordinator who stated that Resident #235's admission MDS assessment was in progress, and it was due on 4/5/22 and was late. The interim DON stated that she had been doing both jobs by herself, both the MDS Coordinator job duties and the DON duties as the reason for being late. The interim DON stated that she had been training a nurse to learn the MDS job responsibilities.
An interview was completed with the Administrator on 4/13/22 at 7:22 PM who stated that his expectation is that the MDS assessments are to be done as soon as possible and to be timely.
CONCERN
(D)
Potential for Harm - no one hurt, but risky conditions existed
Deficiency F0655
(Tag F0655)
Could have caused harm · This affected 1 resident
**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on record review and staff interviews the facility failed to develop and implement a baseline care plan for 1 of 3 residen...
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**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on record review and staff interviews the facility failed to develop and implement a baseline care plan for 1 of 3 residents, Resident #83, reviewed for care plans initiated within 48 hours of admission.
Findings included:
Resident #83 admitted to the facility on [DATE] with diagnoses of stroke and communication deficits. She discharged from the facility on 3/4/2022.
A review of Resident #83's electronic record revealed there was not a care plan in her record.
An interview was conducted with the Director of Nursing (DON) on 4/12/2022 at 3:57 pm. The DON stated she did not see a care plan for Resident #83 in the electronic system. She stated if the baseline care plan was completed when Resident #83 was admitted it would be in the electronic record so it must not have been completed. The DON further stated the baseline care plan should be completed within 48 hours of admission.
During an interview with the admission Nurse on 4/13/2022 she stated the baseline care plans are in the electronic record under the care plan tab. She further stated it did not look like Resident #83 had a baseline care plan because there were no care plans in the electronic record for Resident #83. The admission Nurse stated if she does the an admission she completed the baseline care plan while she is doing the admission, but she did not do Resident #83's admission.
On 4/13/2022 at 5:04 pm the Administrator stated the nurse who is responsible for a resident on admission should do the baseline care plan when they are admitted . The Administrator also stated the facility plans to re-educate the nurses regarding what is expected when a resident is admitted to the facility.
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 and staff and resident interviews the facility failed to invite a resident to participate in the developm...
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**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on record review and staff and resident interviews the facility failed to invite a resident to participate in the development and revision of their care plan for 1 of 8 residents reviewed for care plan meetings (Resident # 20).
Findings Included:
Resident #20 was admitted to the facility on [DATE] with a diagnosis including end stage renal disease.
Resident #20's quarterly Minimum Data Set assessment dated [DATE] revealed the resident was assessed as cognitively intact.
An interview was conducted on 4/10/22 at 2:46 PM with Resident #20 who stated that he never knows when he is having a care plan meeting, had not received an invitation, and had not attended his care plan meetings.
A record review revealed care plan invitations were sent to the resident's responsible party for 8/12/21, 11/17/21, and 2/21/22.
An interview was completed with the with the Interim Director of Nursing (DON) who was the former MDS Coordinator on 4/12/22 at 2:11 PM who stated the MDS coordinator was responsible for sending out the care plan invitations. The interim DON stated that Resident #20's care plan invitation would be sent to the responsible party and would not include Resident #20 because he had a responsible party. The interim DON stated even though a resident may be alert and oriented, if they have a responsible party then the responsible party is included for the care plan but not the resident. The Interim DON stated that she would go by who is the residents own responsible party and not on whether they are assessed as being cognitively intact, but most of the residents who are alert and oriented are responsible for themselves and therefore would get an invite, but Resident #20 did have a responsible party and therefore they would not include Resident #20 in the care plan meeting. The interim DON stated that some families would have the resident attend the care plan meeting if the family wanted to have the resident participate and stated that Resident #20's responsible party had not attended the care plan meetings.
An interview was completed with the Administrator on 4/13/22 at 7:24 PM who stated that his expectation is that residents should be involved in their care plan.
CONCERN
(D)
Potential for Harm - no one hurt, but risky conditions existed
Deficiency F0761
(Tag F0761)
Could have caused harm · This affected 1 resident
Based on record review, observations and staff interviews the facility failed to remove expired medications from 2 of 2 medication carts (100 hall and 200 hall); failed to remove expired medications f...
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Based on record review, observations and staff interviews the facility failed to remove expired medications from 2 of 2 medication carts (100 hall and 200 hall); failed to remove expired medications from 1 of 2 medication storage rooms (200 hall); and failed to date and refrigerate a probiotic after opening in 1 of 2 medication carts (200 hall).
The findings included:
1. An observation (Nurse #1 present during observation) on 4/13/22 at 9:00 AM of the medication cart for the 100-hall revealed Nitroglycerine tablets expired (EXP) 2/20/22.
An interview with Nurse #1 (100 hall) 4/13/22 at 9:00 AM revealed she mistakenly overlooked the expired medication. Nurse #1 further revealed she usually reviews the medication cart for expired medications each shift she works.
2. An observation on 4/13/22 at 9:27 AM of the medication cart for the 200-hall revealed:
- Vitamin C tablets EXP 2/22
- Calcium 600 mg Vitamin D tablets EXP 9/21
- Multivitamin One Daily tablets EXP 3/22
- Ferrex CAPS EXP 3/22
3. An observation on 4/13/22 at 9:45 AM revealed Acidophilus probiotic 1 billion 100 CAPS; 26 CAPS remaining; label directions indicated store at room temperature and refrigerate after opening (no date when opened).
4. An observation on 4/13/22 at 9:50 AM of the medication storage room for the 200-hall revealed:
- Adult Aspirin, unopened EXP 2/22
- Antiseptic Wound & Skin Cleanser EXP 7/20
An interview with Nurse #2 (200 hall) on 4/13/22 at 9:27 AM revealed she was returning from days off and was unaware of the expired medications. She further revealed each shift nurse should review the cart for expired medications and remove them. Nurse #2 also indicated she was unaware of who was responsible for reviewing the medication storage room for expired medications.
An interview with the Administrator on 4/12/22 at 4:48 PM revealed each shift nurse is responsible for reviewing the cart and medication storage room for expired medications and removing them.
CONCERN
(D)
Potential for Harm - no one hurt, but risky conditions existed
QAPI Program
(Tag F0867)
Could have caused harm · This affected 1 resident
Based on record review and staff interviews the facility's Quality Assessment and Performance Improvement (QAPI) Committee failed to maintain implemented procedures and monitor these interventions tha...
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Based on record review and staff interviews the facility's Quality Assessment and Performance Improvement (QAPI) Committee failed to maintain implemented procedures and monitor these interventions that the committee put into place following the complaint investigation survey of 12/01/2021. This was for the deficiency originally cited in December 2021 and subsequently recited on the current recertification and complaint survey of 04/14/2022 in Infection Prevention and Control (F880). The continued failure of the facility during two federal surveys of record shows a pattern of the facility's inability to sustain an effective Quality Assurance (QA) Program.
The findings included:
This tag is cross-referenced to: F880 Infection Prevention and Control - Based on observation, record review, and staff interviews the facility failed to post an enhanced droplet precautions sign for 1 of 3 residents, Resident # 133, reviewed for quarantine when admitted after a hospitalization.
During the complaint investigation survey of 12/01/2021, the facility failed to implement their infection control policy when a Nurse Aide (NA) failed to perform hand hygiene after handling soiled meal trays on the COVID-19 unit and prior to entering 3 resident rooms and when a NA failed to wear a N95 mask when entering a resident room with enhanced droplet precautions in place.
The Administrator was interviewed on 4/13/22 at 5:52 PM. During the interview, he stated that the facility addressed the infection control concerns cited during the December 2021 complaint survey during the QAPI Committee monthly and quarterly meetings to maintain compliance, but that the current concerns with posting precaution signage was a new concern related to infection control that had not previously been identified by the facility.
CONCERN
(D)
Potential for Harm - no one hurt, but risky conditions existed
Infection Control
(Tag F0880)
Could have caused harm · This affected 1 resident
Based on observation, record review, and staff interviews the facility failed to post an enhanced droplet precautions sign for 1 of 3 residents, Resident # 133, reviewed for quarantine when admitted a...
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Based on observation, record review, and staff interviews the facility failed to post an enhanced droplet precautions sign for 1 of 3 residents, Resident # 133, reviewed for quarantine when admitted after a hospitalization. The facility was not in outbreak status at the time of the survey.
Finding included:
Resident #133 admitted to the facility from the hospital on 4/8/2022 with a history of stroke. A review of Resident #133's immunization record revealed he had not received a vaccination for COVID 19.
A Physician's Order dated 4/11/2022 stated Resident #133 should have Enhanced Droplet Precautions until 4/18/2022.
An observation of Resident #133 on 4/10/2022 at 3:30 pm revealed he did not have an Enhanced Droplet Precautions sign on his door. The Enhanced Droplet Precautions sign was observed on Resident #133's door on 4/11/2022 at 11:33 am.
During an interview with Nurse #1 on 4/13/2022 at 2:03 pm she stated she cared for Resident #133 on Sunday, 4/10/2022, and he did not have an Enhanced Droplet Precautions sign on his door when she worked. Nurse #1 stated the Admissions Nurse should place the Enhanced Droplet Precautions sign on a resident's door when they were admitted . Nurse #1 stated the Infection Preventionist would also place the Enhanced Droplet Precautions sign on residents that were from the hospital. Nurse #1 stated she had not been told to place the Enhanced Droplet Precautions sign on the door when the Infection Preventionist and the Admissions Nurse were not available. Nurse #1 stated Resident #133 had an Enhanced Droplet Precautions sign on his door when she came into work this morning.
The Director of Nursing was interviewed on 4/13/2022 at 3:25 pm and stated the nurse assigned to a resident when they were admitted was responsible for ensuring the resident's immunization status was documented and if they have not been immunized for COVID 19 then Enhanced Droplet Precautions should be put into place and the nurse should place a sign on the door.
An interview was conducted with the Admissions Nurse on 4/13/2022 at 2:33 pm and she stated she completed admission assessments when residents were admitted and the Infection Preventionist checks the resident's immunization status and then puts the Enhanced Droplet Precautions sign on their door if they have not been immunized for COVID 19. The admission Nurse stated the nurse who was responsible for the resident on admission should place the Enhanced Droplet Precautions sign on the door if the Admissions Nurse and Infection Preventionist were not available. The Admissions Nurse stated she did not admit Resident #133 to the facility and the Infection Preventionist was not available when Resident #133 was admitted .
The Infection Preventionist was interviewed on 4/13/2022 at 5:58 pm and stated she does check each admissions immunization status and places the Enhanced Precautions Sign on their door if they have not been immunized when she was in the facility. The Infection Preventionist further stated the nurse assigned to the resident was responsible for ensuring each resident's immunizations were checked and the Enhanced Droplet Precautions sign was placed on the door if the resident has not been immunized.
An interview was conducted with the Administrator on 4/13/2022 at 5:04 pm and he stated the Nurse that cared for Resident #133 on admission should have ensured his immunization status was checked and he was placed under Enhanced Droplet Precautions. The Administrator stated the Infection Preventionist does make sure the immunizations of each new admission are checked and helps with putting the Enhanced Droplet Precautions signs in place but the nurse on admission was responsible.
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 a review of Resident Council (RC) Minutes (February 2022 and March 2022), a RC Meeting (April 2022), and interviews with staff, the facility failed to document resolution to RC concerns (Febr...
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Based on a review of Resident Council (RC) Minutes (February 2022 and March 2022), a RC Meeting (April 2022), and interviews with staff, the facility failed to document resolution to RC concerns (February 2022), and resolve concerns voiced by residents during RC Meetings for 3 of 5 months reviewed (February 2022, March 2022, and April 2022).
The findings included:
1 a. A review of RC Minutes for February 2022 and March 2022, revealed Residents who attended the meetings voiced the following concerns:
·February 1, 2022 - 6 of 6 residents voiced nursing did not consistently return menus to residents for selection of their menu choices. There was no documentation of follow up to this concern.
·March 1, 2022 - 4 of 4 residents voiced they were not getting menus to select their menu choices on a regular basis. Documentation for follow up recorded that the new system would have assigned dietary and nursing staff hand out and collect all menus.
1 b. During a RC meeting held on 4/12/22 at 10:47 AM, 6 of 6 residents voiced that their previous concerns, from the February 2022 and March 2022 RC meetings, regarding receiving menus consistently to choose their menu items, still was not resolved. Residents who attended the 4/12/22 RC Meeting expressed this concern occurred as recently as Saturday, 4/9/22 and Sunday, 4/10/22.
The Dietary Manager (DM) was interviewed on 04/12/22 at 1:05 PM and stated he was the DM since 3/3/22. He stated that he was made aware that before he started, residents stated during RC meetings that they did not like the menu selection system in place so now he printed the menus, gave them to nursing so that nursing could take the menus to residents to let them make their menu choices. The DM stated that sometimes nursing staff collected and returned the resident select menus and sometimes dietary staff had to go get them, especially on the weekends. He stated that if nursing did not return the select menus, dietary had to go to residents and ask them what they wanted to eat. The DM further stated that since he implemented this system in March 2022, there were still a few residents who said they still did not get to select their menus, especially on the weekend.
An interview with the Interim Director of Nursing (IDON) on 04/12/22 at 1:18 PM revealed she started in this role in March 2022, and she was aware that residents have stated they did not consistently get a menu to select their choices. She stated that when this concern was brought to management attention, the plan was to have dietary staff bring the menus to nursing, an assigned nurse aide would take the menus to residents and return the completed menus to dietary. The IDON further stated that this concern continued to come up a few times during morning management meetings, as unresolved since some residents expressed it was still a problem.
The Administrator was interviewed on 04/12/22 at 04:52 PM and stated that the resident concern regarding not getting their menus was brought up during RC, but a plan was put in place and this plan was documented as follow up on the March 2022 RC meeting minutes. The Administrator stated this plan was discussed during morning management meetings and dietary stated that a couple of residents still expressed this was not resolved but that most residents expressed that this concern had improved. The Administrator further stated that he was not aware that residents still had concerns will not getting their menus. The Administrator stated that he expected resolution to this concern with the plan that was put into place. The Administrator stated that he and the DM were responsible for monitoring the plan.
CONCERN
(E)
Potential for Harm - no one hurt, but risky conditions existed
Deficiency F0804
(Tag F0804)
Could have caused harm · This affected multiple residents
**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on record review, observations, resident interviews, and staff interviews, the facility failed to provide meals that were ...
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**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on record review, observations, resident interviews, and staff interviews, the facility failed to provide meals that were palatable and at an appetizing temperature to 2 of 2 sample residents (Resident #283 and #35).
The findings included:
a. Resident #283 was admitted to the facility on [DATE]. An admission Minimum Data Set (MDS) assessment dated [DATE], assessed Resident #283 with clear speech, adequate hearing/ vision, able to understand and be understood, intact cognition and independent with eating after tray set up.
On 4/10/22 at 5:42 PM Resident #283 was observed during his dinner meal, attempting to eat a pork steak with his fork. He stated the potatoes were hard and meat was inedible to a point he had a hard time getting a fork through them.
b. Resident #35 was readmitted to the facility on [DATE]. An annual MDS assessment dated [DATE] indicated Resident #35 was cognitively intact and required extensive one-person assistance with bed mobility, speech was clear, hearing/ vision was adequate, and she was independent with eating, able to understand and be understood.
On 4/11/22 at 9:55 AM Resident #35 indicated lunch and dinner are horrible meals and she cannot eat them at times.
A test tray was requested on 4/13/22 at 5:40 PM for a regular dinner meal tray. The meal was plated at 5:44 PM with French fries, mashed potatoes, cubed steak, carrots, and chicken strips. The Registered Dietician (RD) left the kitchen at 5:46 PM with the test tray and arrived on the 200 Hall at 5:48 PM. All residents on the 200 Hall were served 5:58 PM and the test tray was sampled. Margarine and salt were added to the hot foods and the margarine remained congealed. The RD and surveyor sampled the foods and observed the following: the chicken strips were without visible steam, while the cubed steak and mashed potatoes were room temperature. The RD stated the chicken strips and French fries were a little dry and slightly warm. She further stated the cubed steak and carrots had a good flavor and were slightly warm.
An interview with the Dietary Manager (DM) on 4/12/22 at 1:05 PM revealed he was aware of resident concerns about the chicken and baked French fries being too dry, as well as the fish being distasteful. The DM further revealed since the French fries are baked, it is harder to keep the temperature and they won't taste as good.
An interview with the Administrator on 4/12/22 at 4:55 PM indicated he was aware of resident concerns about food and that the facility was not allowed to have a fryer to fry foods like chicken and French fries. The Administrator further indicated he plans to discuss plans with management and residents to have fast food orders delivered monthly.
CONCERN
(E)
Potential for Harm - no one hurt, but risky conditions existed
Deficiency F0806
(Tag F0806)
Could have caused harm · This affected multiple residents
**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observations, staff interviews, resident interviews, and record reviews, the facility failed to provide menu choices fo...
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**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observations, staff interviews, resident interviews, and record reviews, the facility failed to provide menu choices for 2 of 2 sampled residents (Resident #283 and #67).
The findings included:
1a. Resident #283 was admitted to the facility on [DATE]. An admission Minimum Data Set (MDS) assessment, dated 2/27/22, assessed Resident #283 with clear speech, adequate hearing/vision, able to understand and be understood, intact cognition and independent with eating after tray set up.
On 04/10/22 at 5:42 PM, Resident #283 was observed with his dinner meal. Resident #283 stated the foods he received were not what he wanted. He stated that residents were supposed to get a menu each day to make menu selections from and when he did not get a menu, the dietary staff just sent you anything. He stated this had occurred four times already that week. He stated that when he asked nursing staff for his menu he was told, they could not deliver a menu to him if the menus were not provided from dietary. On 4/12/22 at 1:36 PM, Resident #283 indicated he ordered cubed steak and gravy but received meatballs for lunch.
1b. Resident #67 was admitted to the facility on [DATE]. An admission MDS assessment, dated 3/15/22, assessed Resident #67 with clear speech, adequate hearing/vision, able to understand and be understood, moderately impaired cognition and independent with eating after tray set up. Resident #67 was observed with his dinner meal on 4/10/22 at 5:50 PM. He stated during the observation that he had not been able to make menu choices for a while now. He stated that he used to get a menu to select the foods he wanted, he asked about the menu, but still did not get a menu, so now, he just ate whatever he got.
The Dietary Manager (DM) was interviewed on 04/12/22 at 1:05 PM and stated he was the DM since 3/3/22. He stated that he was made aware that before he started, residents voiced concerns during Resident Council that they did not like the menu selection system in place so now he printed the menus, gave them to nursing so that nursing could take the menus to residents to let them make their menu choices. The DM stated that sometimes nursing staff collected and returned the resident select menus and sometimes dietary staff had to go get them, especially on the weekends. He stated that if nursing did not return the select menus, dietary had to go to residents and ask them what they wanted to eat. He stated that on weekends he typically had 2 dietary staff to prepare and deliver foods and this did not allow time for dietary staff to go to residents and ask them what they wanted to eat. He stated that as a result, there were still a few residents who said they still did not get to select their menus, especially on the weekend.
An interview with NA #3 on 4/12/22 at 4:17 PM indicated Resident #283 did not receive a menu on multiple occasions and received random food items he would not have ordered if he had completed a menu.
An interview with the Interim Director of Nursing (IDON) on 4/12/22 at 1:18 PM revealed she was aware that residents reported they did not consistently get a menu to select their choices. She further revealed as a result, management implemented a plan to have dietary staff bring the menus to nursing and an assigned NA would take the menus to residents and return the completed menus to dietary. The IDON stated this concern continued to come up a few times during morning management meetings, since some residents expressed it was still a problem.
An interview with the Administrator on 4/12/22 at 4:52 PM revealed resident concerns regarding not receiving their menus was discussed during Resident Council and a plan was put in place per minutes from March 2022 Resident Council Meeting. The Administrator further indicated the plan was also discussed during morning management meetings, whereas dietary reported a couple of residents continued to report the issue was unresolved but that most residents reported the process had improved. The Administrator expressed he and the DM were responsible for monitoring the plan.
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 observations, record review, and staff interviews, the facility failed to discard food products (boiled eggs, raw shredded cabbage, and shredded cheese) on or before the expiration date and h...
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Based on observations, record review, and staff interviews, the facility failed to discard food products (boiled eggs, raw shredded cabbage, and shredded cheese) on or before the expiration date and hold French fries at least 135 degrees Fahrenheit on the steam table. This had the potential to affect 22 of 86 residents.
The findings included:
1a. An observation with the Dietary Manager (DM) of the walk-in refrigerator occurred on 4/10/22 at 3:40 PM with the following concerns identified:
-A box of boiled eggs, with 6 unopened packages, of 12 eggs per package, recorded a manufacture's expiration date of 3/22/22.
-An unopened bag of shredded cabbage with a manufacture's expiration date of 3/22/22.
An interview with the DM on 4/10/22 at 3:30 PM revealed he began working at the facility on 3/3/22. He stated that refrigerated food items should have a label with 2 dates, the date opened and the use by date. He further revealed he was not aware that there were expired foods in the refrigerator and no one person was assigned to check the expiration date on refrigerated foods.
An interview with [NAME] #1 and [NAME] #2 on 4/13/22 at 7:15 PM revealed one package of boiled eggs was taken out of the refrigerator every morning for breakfast and any unused boiled eggs from the package were discarded. They further revealed no one person was assigned to check refrigeration for expired foods.
1b. An observation with the Regional Dietary Manager (RDM) of the walk-in refrigerator on the follow-up visit to the kitchen began on 4/13/22 at 10:55 AM with the following concerns identified:
- There were 3 large plastic bags of parmesan cheese with a written use by date of 4/10/22
An interview with the Regional Director on 4/13/22 11:45 AM revealed he oversaw eleven food service accounts and acquired oversight of the facility food account last year. He visited the facility at least twice since October and usually performed sanitation audits, food tray audits and financial audits. He further revealed he was unaware there were expired foods in the refrigerator. He provided no explanation on why the parmesan cheese was not used or discarded by the use by date.
2. An observation of temperatures for dinner items on the steam table began on 4/11/22 at 5:03 PM with [NAME] #1 who obtained the food temperatures via a digital thermometer. She revealed the French fries had a holding temperature of 121 degrees Fahrenheit.
An interview with [NAME] #1 on 4/11/22 at 5:30 PM indicated she prepared the French fries in the oven before placing them on the steam table. She further indicated the French fries were not prepared in a fryer and may lose their temperature when placed on the steam table.
An interview with the DM on 4/11/22 at 5:45 PM revealed the French fries were usually baked in the oven for about 15 minutes before they were placed on the steam table, prior to serving. He further revealed hot foods should have a holding temperature of no less than 135 degrees Fahrenheit, to conserve nutritive value, flavor, appearance and texture.
An interview with the Administrator on 4/12/22 at 4:48 PM indicated he was not aware of the dietary process for food temperatures since the contracted food service provider handled the dietary contract.
MINOR
(C)
Minor Issue - procedural, no safety impact
Staffing Information
(Tag F0732)
Minor procedural issue · This affected most or all residents
Based on staff interviews and record review, the facility failed to record the resident census for 3 of 6 days reviewed (1/5/22, 1/6/22, and 1/7/22), record nurse staffing data for 1 of 6 days reviewe...
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Based on staff interviews and record review, the facility failed to record the resident census for 3 of 6 days reviewed (1/5/22, 1/6/22, and 1/7/22), record nurse staffing data for 1 of 6 days reviewed (1/16/22) and record accurately licensed and unlicensed nursing staff on the Daily Nurse Staffing Summary for 4 of 6 days reviewed (1/3/22, 1/5/22, 1/6/22, and 1/7/22).
The findings included:
A review of the Daily Nurse Staffing Summary for 1/3/22, 1/5/22, 1/6/22, 1/7/22, 1/16/22, and 1/20/22 revealed the following:
1. The resident census was not recorded per shift on 3 of 6 days reviewed; 1/5/22, 1/6/22, and 1/7/22.
The staffing scheduler was interviewed on 4/13/22 at 6:01 PM and stated she started training in her role on 1/20/22 and was responsible for posting the nurse staffing data in lobby area. She reviewed the nurse staffing records and stated that the nurse staffing data should have been recorded correctly.
An interview with the Administrator on 4/13/22 at 6:36 PM revealed he expected the nurse staffing data to be posting daily with the current census and should accurately reflect the staffing in the facility.
2. There was no record of the Daily Nurse Staffing Summary for 1/16/22.
The staffing scheduler was interviewed on 4/13/22 at 6:01 PM and stated she started training in her role on 1/20/22 and was responsible for posting the nurse staffing data in lobby area. She reviewed the nurse staffing records and stated that the nurse staffing data should be posted.
An interview with the Administrator on 4/13/22 at 6:36 PM revealed he expected the nurse staffing data to be posting daily with the current census and should accurately reflect the staffing in the facility.
3. The Daily Nurse Staffing Summary was not recorded accurately for licensed and unlicensed nursing staff for the following:
·1/3/22, 7 AM to 3 PM shift recorded 15 nurse aides (NA); staffing assignment sheets recorded 10 NA had worked.
·1/3/22, 3 PM to 11 PM shift recorded 6 NA; staffing assignment sheets recorded 7.5 NA had worked.
·1/5/22, 7 AM to 3 PM shift recorded 2 Registered Nurses (RN), and 8 NA; staffing assignment sheets recorded 1 RN and 10 NA had worked.
·1/5/22, 3 PM to 11 PM shift recorded 7 NA; staffing assignment sheets recorded 5 NA had worked.
·1/6/22, 7 AM to 3 PM shift recorded .5 RN, 3.5 Licensed Practical Nurses (LPN), and 16 NA; staffing assignment sheets recorded 1 RN, 4 LPN, and 10 NA had worked.
·1/6/22, 3 PM to 11 PM shift recorded 1.5 LPN and 5 NA; staffing assignment sheets recorded 3.5 LPN and 7 NA had worked.
·1/6/22, 11 PM to 7 AM shift recorded 3 LPN and 7 NA; staff assignment data recorded 2 LPN and 8 NA had worked.
·1/7/22, 3 PM to 11 PM shift recorded 7 NA; staffing assignment sheets recorded 8 NA had worked.
·1/7/22, 11 PM to 7 AM shift recorded 2 LPN; staffing assignment sheets recorded 3 LPN had worked.
The staffing scheduler was interviewed on 4/13/22 at 6:01 PM and stated she started training in her role on 1/20/22 and was responsible for posting the nurse staffing data in lobby area. She reviewed the nurse staffing records and stated that the nurse staffing data should have been recorded correctly.
An interview with the Administrator on 4/13/22 at 6:36 PM revealed he expected the nurse staffing data to be posting daily with the current census and should accurately reflect the staffing in the facility.
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?"
- "What safeguards are in place to prevent abuse and neglect?"
- "Why is there high staff turnover? How do you retain staff?"
- "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: Federal abuse finding, 5 life-threatening violation(s), 2 harm violation(s), $177,170 in fines, Payment denial on record. Review inspection reports carefully.
- • 39 deficiencies on record, including 5 critical (life-threatening) violations. These warrant careful review before choosing this facility.
- • $177,170 in fines. Extremely high, among the most fined facilities in North Carolina. Major compliance failures.
- • Grade F (0/100). Below average facility with significant concerns.
Bottom line: This facility has a substantiated abuse finding. Extreme caution advised. Explore alternatives.
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About This Facility
What is Charlotte Health & Rehabilitation Center's CMS Rating?
CMS assigns Charlotte Health & Rehabilitation Center an overall rating of 1 out of 5 stars, which is considered much below average nationally. Within North Carolina, 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 Charlotte Health & Rehabilitation Center Staffed?
CMS rates Charlotte Health & Rehabilitation Center's staffing level at 2 out of 5 stars, which is below average compared to other nursing homes. Staff turnover is 60%, which is 14 percentage points above the North Carolina average of 46%. High turnover can affect care consistency as new staff learn residents' individual needs. RN turnover specifically is 81%, which is notably high. RNs provide skilled clinical oversight, so turnover in this role can affect medical care quality.
What Have Inspectors Found at Charlotte Health & Rehabilitation Center?
State health inspectors documented 39 deficiencies at Charlotte Health & Rehabilitation Center during 2022 to 2025. These included: 5 Immediate Jeopardy (the most serious level, indicating potential for serious harm or death), 2 that caused actual resident harm, 31 with potential for harm, and 1 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 Charlotte Health & Rehabilitation Center?
Charlotte Health & Rehabilitation 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 LIFEWORKS REHAB, a chain that manages multiple nursing homes. With 90 certified beds and approximately 84 residents (about 93% occupancy), it is a smaller facility located in Charlotte, North Carolina.
How Does Charlotte Health & Rehabilitation Center Compare to Other North Carolina Nursing Homes?
Compared to the 100 nursing homes in North Carolina, Charlotte Health & Rehabilitation Center's overall rating (1 stars) is below the state average of 2.8, staff turnover (60%) is significantly higher than the state average of 46%, and health inspection rating (1 stars) is much below the national benchmark.
What Should Families Ask When Visiting Charlotte Health & Rehabilitation 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?" "What safeguards and monitoring systems are in place to protect residents from abuse or neglect?" "How do you ensure continuity of care given staff turnover, and what is your staff retention strategy?" "Can you walk me through typical staffing levels on day, evening, and night shifts?" These questions are particularly relevant given the facility's Immediate Jeopardy citations, the substantiated abuse finding on record, the facility's high staff turnover rate, and the below-average staffing rating.
Is Charlotte Health & Rehabilitation Center Safe?
Based on CMS inspection data, Charlotte Health & Rehabilitation Center has documented safety concerns. The facility has 1 substantiated abuse finding (meaning confirmed case of resident harm by staff or other residents). Inspectors have issued 5 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 North Carolina. Families considering this facility should ask detailed questions about what corrective actions have been taken since these incidents.
Do Nurses at Charlotte Health & Rehabilitation Center Stick Around?
Staff turnover at Charlotte Health & Rehabilitation Center is high. At 60%, the facility is 14 percentage points above the North Carolina average of 46%. Registered Nurse turnover is particularly concerning at 81%. RNs handle complex medical decisions and coordinate care — frequent RN changes can directly impact care quality. High turnover means new staff may not know residents' individual needs, medications, or preferences. It can also be disorienting for residents, especially those with dementia who rely on familiar faces. Families should ask: What is causing the turnover? What retention programs are in place? How do you ensure care continuity during staff transitions?
Was Charlotte Health & Rehabilitation Center Ever Fined?
Charlotte Health & Rehabilitation Center has been fined $177,170 across 3 penalty actions. This is 5.1x the North Carolina average of $34,851. Fines at this level are uncommon and typically indicate a pattern of serious deficiencies, repeated violations, or failure to correct problems promptly. CMS reserves penalties of this magnitude for facilities that pose significant, documented risk to resident health or safety. Families should request specific documentation of what issues led to these fines and what systemic changes have been implemented.
Is Charlotte Health & Rehabilitation Center on Any Federal Watch List?
Charlotte Health & Rehabilitation 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.