Pavilion Health Center at Brightmore
For profit - Limited Liability company
108 Beds
LIBERTY SENIOR LIVING
Data: November 2025
2 Immediate Jeopardy citations
Trust Grade
1/100
#272 of 417 in NC
Photo by The Pavilion Health Center at Brightmore
Photo by The Pavilion Health Center at Brightmore
Photo by CHANSON COOLEY
1 / 5 photos
Last Inspection: July 2025
Inspected within the last 6 months. Data reflects current conditions.
Overview
Pavilion Health Center at Brightmore currently holds a Trust Grade of F, indicating poor performance with significant concerns about care quality. It ranks #272 out of 417 in North Carolina, placing it in the bottom half of facilities in the state and #18 out of 29 in Mecklenburg County, suggesting limited local options for better care. Although the facility's trend is improving, having reduced issues from 19 in 2024 to 6 in 2025, it still faces challenges, including $86,450 in fines, which is higher than 82% of other North Carolina facilities. Staffing has a 3/5 average rating, with a 47% turnover rate, which is slightly below the state average. However, serious incidents have raised alarms, such as a critical failure to provide necessary nebulizer treatments for a resident with chronic obstructive pulmonary disease, leading to chest pain, and another instance where a resident felt neglected while waiting for incontinence care, resulting in emotional distress. Families should carefully weigh these strengths and weaknesses when considering this nursing home for their loved ones.
- Trust Score
- F
- In North Carolina
- #272/417
- Safety Record
- High Risk
- Inspections
- Getting Better
- Staff Stability ⚠ Watch
- 47% turnover. Above average. Higher turnover means staff may not know residents' routines.
- Penalties ⚠ Watch
- $86,450 in fines. Higher than 96% of North Carolina facilities. Major compliance failures.
- Skilled Nurses ⚠ Watch
- Each resident gets only 25 minutes of Registered Nurse (RN) attention daily — below average for North Carolina. Fewer RN minutes means fewer trained eyes watching for problems.
- Violations ⚠ Watch
- 30 deficiencies on record. Higher than average. Multiple issues found across inspections.
1/100
Bottom 35%
Review needed
19 → 6 violations
★★☆☆☆
2.0
Overall Rating
★★★☆☆
3.0
Staff Levels
★★★☆☆
3.0
Care Quality
★★☆☆☆
2.0
Inspection Score
↔
Stable
2024: 19 issues
2025: 6 issues
The Good
-
Full Sprinkler Coverage · Fire safety systems throughout facility
-
No fines on record
Facility shows strength in fire safety.
The Bad
2-Star Overall Rating
Below North Carolina average (2.8)
Below average - review inspection findings carefully
Staff Turnover: 47%
Near North Carolina avg (46%)
Higher turnover may affect care consistency
Federal Fines: $86,450
Well above median ($33,413)
Moderate penalties - review what triggered them
Chain: LIBERTY SENIOR LIVING
Part of a multi-facility chain
Ask about local staffing decisions and management
The Ugly 30 deficiencies on record
2 life-threatening 3 actual harm
Jul 2025
6 deficiencies
CONCERN
(D)
Potential for Harm - no one hurt, but risky conditions existed
Deficiency F0605
(Tag F0605)
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 ensure a resident had an indication and a diagnosis for the ...
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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 ensure a resident had an indication and a diagnosis for the use of an antipsychotic medication. This was for 1 of 5 residents for chemical restraints (Resident #49).
The findings included:
Resident #49 was admitted to the facility on [DATE] with diagnoses that included cerebral infarction (a medical emergency where blood flow to a part of the brain is interrupted, causing brain tissue damage due to lack of oxygen and nutrients), hemiplegia and hemiparesis of the left arm and leg (inability to move/use the left arm and leg), aphasia (a disorder that limits the ability to communicate) following cerebral infarction, benign neoplasm of cerebral meninges (a slow-growing tumor that originates surrounding the brain and spinal cord), adult failure to thrive, and vascular dementia/unspecified severity/with mood disturbance and anxiety.
Resident #49's Physician orders included:
-Seroquel 25 milligrams (MG) (Quetiapine Fumarate) dated 9/11/24 to give via gastric tube.
- Seroquel tablet 25 milligrams (MG) (Quetiapine Fumarate) dated 4/3/25, to give via gastric tube.
Resident #49's care plan was revised on 4/3/25 included that she received antipsychotic medication related to her diagnosis of dementia with behavioral disturbances with risk for adverse side effects. The interventions for taking an antipsychotic included consulting a pharmacist to review my psychotropic medications quarterly and as needed for possible changes or reductions. The care plan also included discussing possible side effects of medication with me and my responsible party (RP).
A quarterly Minimum Data Set (MDS) assessment dated [DATE] indicated Resident #49 rarely made herself understood and had severely impaired cognitive skills for daily decision making. She was not coded for potential indicators of psychosis. Resident #49 was coded for diagnosis that included Alzheimer's Disease, cerebrovascular accident/stroke and Non-Alzheimer's Dementia. Resident #49 was coded as currently taking an antipsychotic (high risk medication) on a routine basis and an indication for use was noted. She was coded with impaired extremities on one side and needing functional assistance for less than half of each care activity. Resident #49 had contractures of the left extremities and was unable to use the right extremities.
On 6/23/25 at 10:12 AM, Resident #49 was observed asleep in bed and did not respond to verbal stimuli.
Observations on 6/24/25 at 11:00 AM and 1:18 PM were completed. The resident was asleep sitting in a chair. She did not awake with her name or voice commands.
Observed Resident #49 on 6/25/25 at 9:00 AM while Nurse Aide (NA) #1 provided a bed bath. The resident did not have control of her body and began to lean to the right side. NA #1 had to ask for assistance to complete Resident #49's bed bath.
The pharmacy recommendation dated 5/2/25 addressed Seroquel tablet 25 milligrams (MG) order dated 4/3/25 stated that Resident #49 was receiving antipsychotic agent Quetiapine 25 daily but lacks an allowable diagnosis to support its use. The pharmacy recommendation stated the Seroquel 4/3/25 order stated Seroquel use was for squirming. The pharmacist recommended the following diagnosis: Schizophrenia, Delusional disorder, Mood Disorder, Psychosis in the absence of dementia, Tourette's disorder, Hiccups (not induced by other medications), Nausea and vomiting associated with cancer and chemotherapy, Behavioral or psychological symptoms of dementia and Medical illness/delirium with psychotic symptoms. The provider selected the agree with pharmacist indication box. The recommendation form was signed by provider on 5/6/25 with hiccups and nausea associated with cancer circled.
Resident #49's Seroquel (Quetiapine Fumarate) orders included:
- Seroquel tablet 25 milligrams (MG) dated 6/7/25 included, to give 1 tablet via gastric tube one time a day for nausea and vomiting, hiccups.
- Seroquel tablet 25 milligrams (MG) dated 6/13/25 to give Seroquel tablet 25 milligrams (MG) 1 tablet via percutaneous endoscopic gastrostomy (PEG) tube one time a day for dementia with behavioral disturbance.
An interview on 6/25/25 at 11:38 AM with Nurse Aide (NA) #1 revealed she had not observed Resident #49 speak or have any movement of her extremities. She stated that she had observed Resident #49 grind her teeth and had not observed hiccups. The NA could not confirm that Resident #49 exhibited behavioral disturbances.
The Unit Manager stated on 6/25/25 at 8:37 AM that she had not observed Resident #49 move her extremities. The Unit Manager reported she had observed Resident #49 grind her teeth and had not observed Resident #49 with hiccups. The Unit Manager stated she had not observed Resident #49 exhibit behaviors such as yelling, hitting or pulling PEG-tube. The Unit Manager could not confirm that Resident #49 exhibited behavioral disturbances.
Phone interview with Nurse Consultant on 7/3/25 at 4:43 PM revealed that Resident #49 original Seroquel order was dated 9/11/24. The Nurse Consultant stated that Seroquel was reordered every time Resident #49 was readmitted to the facility. She stated that the admitting nurse would select the medications in the electronic medical record (EMR) and the providers would review and make changes as needed.
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** 2. Resident #92 was admitted to the facility on [DATE].
A review of a social service progress note dated 05/07/2025 at 10:11 AM ...
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**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** 2. Resident #92 was admitted to the facility on [DATE].
A review of a social service progress note dated 05/07/2025 at 10:11 AM stated Resident #92 had a planned discharge to an assisted living facility.
A review of the discharge MDS assessment dated [DATE] revealed that the discharge status had been coded as discharge to hospital.
An interview on 06/25/2025 at 11:15 AM with the MDS Coordinator indicated she received a resident's discharge information through progress notes, discussions with the Social Worker or weekly utilization review meetings. The interview revealed she was newer to the role of MDS Coordinator and had just coded Resident #92 went to the hospital by mistake. She stated it should have reflected the resident was discharged to an assisted living facility.
An interview on 06/25/2025 at 3:41 PM with the Director of Nursing (DON) indicated the MDS should be coded accurately. She was not sure why Resident #92's discharge MDS had been coded incorrectly.
An interview conducted with the Administrator on 6/26/25 at 11:39 AM revealed the resident MDS assessments should be coded accurately.
Based on record review and staff interviews, the facility failed to accurately code the Minimum Data Set (MDS) assessment in the areas of hospice (Resident #345), discharge status (Resident #92), and oxygen use and functional abilities (Resident #49). This deficient practice occurred for 3 of 21 residents reviewed for accuracy of assessments.
The findings included:
1. A review of Resident #345's medical record indicated she was admitted to hospice services on 5/29/25.
Resident #345 was admitted to the facility on [DATE].
The admission MDS assessment dated [DATE] revealed Resident #345 was not coded for receiving hospice services.
During an interview with MDS Coordinator #1 on 6/26/25 at 10:56 AM she revealed Resident #345 was receiving hospice services prior to being admitted to the facility. MDS Coordinator #1 stated Resident #345 was not coded for receiving hospice services on the admission MDS due to an oversight on her part.
An interview with the Director of Nursing on 6/26/25 at 11:37 AM indicated Resident #345 was receiving hospice services and the MDS assessment should have been coded accurately.
An interview conducted with the Administrator on 6/26/25 at 11:39 AM revealed the resident MDS assessments should be coded accurately.
3. Resident #49 was originally admitted to the facility on [DATE] with diagnoses that included cerebral vascular accident (CVA), hemiplegia, left hip contracture, and dependence on supplemental oxygen.
Resident #49 physician orders dated 6/7/25 included to administer oxygen at 2 liters continuously via nasal cannula at bedtime for oxygen supplement for hypoxia at bedtime.
A quarterly Minimum Data Set (MDS) assessment dated [DATE] indicated Resident #49 rarely made herself understood and had severely impaired cognitive skills for daily decision making. She was coded as needing functional assistance for less than half of each care activity. The MDS assessment was not coded for oxygen use.
Resident #49 was observed with oxygen at 2 liters via nasal cannula on 6/24/25 at 8:15 AM and 6/25/25 at 8:40 AM.
An interview on 6/25/25 at 11:38 with Nurse Aide (NA) #1 revealed that she had never observed Resident #49 move on her own or assist with any of her care. NA #1 stated that Resident #49 was dependent in all care areas and required at least 2 people to provide total care. NA #1 reported that Resident #49 used oxygen when in bed sleeping.
An interview on 6/25/25 at 9:10 AM with the Unit Manager revealed that Resident #49 was total care and dependent in all areas of activities for daily living (ADLs) and required oxygen at bedtime.
The MDS Coordinator was interviewed on 6/25/25 at 4:01 PM. The MDS Coordinator stated she collected resident status information from medical records and clinical staff in the daily team meetings which she used to code the MDS assessment. The MDS Coordinator confirmed that Resident #49 used oxygen. She stated Resident #49's oxygen usage was coded in error and the functional status for Resident #49 was coded incorrectly.
The Administrator was interviewed on 6/26/25 at10:42 AM. The Administrator stated the MDS Coordinator should collect information regarding a resident from therapy and clinical nursing, and orders should be reviewed for MDS coding. The Administrator reported she would have expected the coding to accurately represent the resident and orders for treatment.
CONCERN
(D)
Potential for Harm - no one hurt, but risky conditions existed
Comprehensive Care Plan
(Tag F0656)
Could have caused harm · This affected 1 resident
**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on record review and staff interviews, the facility failed to develop personalized comprehensive care plans in the areas o...
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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 personalized comprehensive care plans in the areas of oxygen therapy (Resident #16) and include accurate interventions in a care plan (Resident #41) for 2 of 21 residents reviewed for comprehensive care plans.
The findings included:
1. Resident #16 was admitted to the facility on [DATE] with diagnoses of congestive heart failure, pneumonia, and dependence on supplemental oxygen.
A review of the admission Minimum Data Set (MDS) dated [DATE] showed Resident #16 was coded for oxygen therapy.
A review of Resident #16's medical record revealed a current physician order dated 6/13/25 for two liters of continuous oxygen via nasal cannula.
A review of Resident #16's June 2025 Medication Administration Record (MAR), for the period of 6/1/25 through 6/30/25, revealed she had been receiving the oxygen as ordered.
An observation on 6/23/25 at 2:44 PM revealed Resident #16 in her room receiving oxygen via nasal cannula from concentrator.
A review of Resident #16's care plan as of 5/30/25 revealed there was no care area in place for continuous oxygen use.
An interview with MDS Coordinator #1 on 6/25/25 at 3:54 PM revealed the information in each care plan was gathered in their interdisciplinary meetings and from nurse and clinical notes and nurse aide charting. The MDS nurses complete each resident care plan. MDS Coordinator #1 stated Resident #16 used continuous oxygen since she was admitted , and it was an oversight oxygen use was not included in her care plan.
An interview with the Director of Nursing (DON) on 6/26/25 at 11:39 AM revealed the MDS Coordinators were tasked with completing the comprehensive care plans. He had the expectation Resident #16's care plan would include oxygen therapy.
An interview with the Administrator on 6/26/25 at 11:43 AM revealed she had the expectation all care plans should be updated.
2. Resident #41 was admitted to the facility on [DATE] with diagnoses of chronic respiratory failure with hypoxia, diabetes and epilepsy.
A review of Resident #41's medical record revealed a current physician order dated 6/2/25 for wearing an abdominal binder for protection due to pulling at feeding tube. May remove for care and replace when finished. Assess skin integrity every shift. There were no other current or discontinued orders for hand mitts for Resident #41 in his medical record.
A review of the admission Minimum Data Set (MDS) dated [DATE] showed Resident #41 was not coded for restraints.
A review of Resident #41's June 2025 Medication Administration Record (MAR), for the period of 6/1/25 through 6/30/25, revealed the abdominal binder was in place each shift.
Resident #41's current care plan dated 6/23/25 revealed there was a care problem area use of bilateral mitts to hands and abdominal binder due to pulling at feeding tube with increased risk for associated complication and injuries. Interventions included administering abdominal binder as ordered and monitor and document for side effects and effectiveness, ensuring there is a physician's order for device, and ensuring correct positioning with proper body alignment while using device.
An interview was completed with Nurse #2 on 6/25/25 at 2:20 PM and revealed Resident #41 never used bilateral mitts on his hands. She stated the abdominal binder was in place to keep him from pulling at his feeding tube.
An interview with MDS Coordinator #1 on 6/25/25 at 3:57 PM revealed Resident #41 never used hand mitts, just the abdominal binder and the hand mitts were included in the care plan by mistake.
An interview with the DON on 6/26/25 at 11:43 AM revealed the Unit Managers complete the baseline care plans when residents were admitted and the MDS Coordinators were tasked with completing the comprehensive care plans. He noted when Resident #41 came to the facility he was in and out of the hospital and he kept taking out his feeding tube. The hand mitts were never used, and the abdominal binder had been sufficient.
An interview with the Administrator on 6/26/25 at 11:45 AM revealed she had the expectation the hand mitts would be taken off the care plan for Resident #41.
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 interviews the facility failed to develop a comprehensive care plan within 7 days of completing...
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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 a comprehensive care plan within 7 days of completing a comprehensive assessment for 1 of 21 residents (Resident #56) reviewed for care plans.
The findings included:
Resident #56 was admitted to the facility on [DATE] with diagnoses that included fracture of the left humerus (upper arm bone), falls, and urinary tract infection.
The admission minimum data set (MDS) assessment dated [DATE] indicated Resident #56 had upper extremity impairment to one side, required partial to moderate assistance with activities of daily living (ADL), was frequently incontinent of bowel and bladder, was at risk for developing pressure ulcers and coded for falls. The MDS assessment was signed on 6/17/25 verifying it was completed.
Resident #56's Care Area Assessment (CAA) Summary dated 6/10/25 revealed the triggered care areas included ADL functional/rehabilitation potential, urinary incontinence, falls, pressure ulcers and nutritional status. The care plan decision completion date for all the care areas was 6/11/25.
A review of Resident #56's medical record revealed the care plan dated 6/05/25 included focus areas and interventions related to discharge planning, mood disorder and activities. The care plan did not include focus areas or interventions related to the triggered care areas on the CAA related to ADL function, falls, urinary incontinence, pressure ulcers and nutrition.
An interview conducted with MDS Coordinator #1 on 6/26/25 at 11:02 AM MDS Coordinator #1 stated the day after admission, or if on a weekend, the following Monday she developed and completed the resident's comprehensive care plan. She revealed the comprehensive care plan was revised after the admission MDS was completed to include any additional care areas triggered on the CAA. MDS Coordinator #1 indicated Resident #56 was admitted to the facility due to a fall with a fracture, was incontinent and requiring assistance with ADL and her admission MDS assessment was completed on 6/10/25. MDS Coordinator #1 revealed she was unaware that Resident #56's comprehensive care plan had not been completed and it was an oversight on her part.
During an interview with the Administrator on 6/26/25 at 11:40 AM she stated the MDS Coordinators were responsible for developing and completing the residents' comprehensive care plans and a comprehensive care plan should have been completed for Resident #56.
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, the facility failed to use sterile gloves and failed to perform han...
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**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observations, record reviews, and staff interviews, the facility failed to use sterile gloves and failed to perform hand hygiene while providing tracheostomy care to Resident #62. This deficient practice occurred for 1 of 1 resident observed for tracheostomy care (Resident #62).
The findings included:
Resident #62 was originally admitted to the facility on [DATE] with diagnoses that included acute respiratory failure with hypoxia and tracheostomy.
A quarterly Minimum Data Set (MDS) assessment dated [DATE] indicated Resident #62 was coded for tracheostomy and tracheostomy care.
The care plan dated 2/7/24 included Resident #62 had a tracheostomy with risk for complications including decreased oxygenation, infection, nutritional imbalance, anxiety, and decreased ability to communicate. The interventions included providing trach care as ordered and observing tracheostomy site for redness, drainage, signs of infection each shift and report to nurse or provider.
Resident #62's physician orders included:
- Change the disposable inner cannula every shift and as needed every shift. (8/15/24)
- Respiratory therapist to change tracheostomy tube every month. (8/15/24)
Nurse #1 was observed on 6/25/25 at 10:49 AM performing trach care for Resident #62. Nurse #1 set up a table with a white paper barrier on top of table. Next, Nurse #1 placed tracheostomy care supplies on the barrier which included: one trach drainage gauze, one trach inner cannula, and six pairs of gloves. She did not use a tracheostomy kit. Nurse #1 donned a clean gown and 2 pairs of non-sterile clean gloves. She then removed the dirty dressing and placed the dirty dressing in the trash. Nurse #1 doffed her gloves and without sanitizing her hands, donned 2 pairs of non-sterile gloves and applied a clean gauze to Resident #62's trach site. Using the same gloves, Nurse #1 removed the trach inner cannula and disposed of the inner cannula in the trash. Nurse #1 removed her gloves, then donned a new pair of non-sterile gloves without sanitizing her hands and inserted a new inner cannula in Resident #62's trach site. Nurse #1 doffed her gloves and gown and washed her hands at the sink in Resident #62's room.
An interview conducted on 6/25/25 at 2:10 PM with Nurse #1 revealed she was aware that she had not sanitized her hands each time she had doffed her gloves. She stated she should have had hand sanitizer with her supplies or should have washed her hands at the sink before donning a new pair of gloves. Nurse #1 stated that a respiratory therapist used sterile trach kits when providing trach care. She was not aware that she needed sterile gloves for trach care.
An interview conducted on 6/25/25 at 2:43 PM with the Infection Preventionist/ Assistant Director of Nursing (ADON) revealed her expectation was that every nurse would sanitize their hands every time that they removed their gloves and before putting on clean gloves during wound and trach care. The ADON further stated staff received education on infection control annually and multiple times during the year.
An interview on 6/26/25 at 12:23 AM with the Director of Nursing (DON) revealed he was not aware of Nurse #1's errors during trach care. The DON stated it was his expectation that Nurse #1 followed the best practices infection control to avoid introducing microorganisms into the trach site. The DON stated that the respiratory therapist visited Resident #62 to complete sterile trach care the previous day.
CONCERN
(D)
Potential for Harm - no one hurt, but risky conditions existed
Unnecessary Medications
(Tag F0759)
Could have caused harm · This affected 1 resident
**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observations, staff interviews, and record reviews, the facility failed to have a medication error rate of less than 5%...
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**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observations, staff interviews, and record reviews, the facility failed to have a medication error rate of less than 5% as evidenced by 5 medication errors out of 27 opportunities, resulting in a medication error rate of 18.52% for 1 of 4 residents (Resident #49) observed during the medication administration observation.
The findings included:
Resident #49 was originally admitted to the facility on [DATE]. Her diagnosis included presence of a percutaneous endoscopic gastrostomy (PEG) tube. A PEG-tube is a feeding tube inserted through the skin and the stomach wall to provide nutrition and a route for medication administration.
A review of Resident #49's active physician orders included an order dated 6/7/25:
-Enteral Feed Order every shift flush with 30ml (milliliters) of water then administer each medication separately. Dissolve each medication in 10-15 ml of water and flush with 5 ml water after each medication. Flush with 30ml water as final flush.
On 6/25/25 at 8:37 AM, the Unit Manager was observed as she began to prepare medications for administration to Resident #49 via PEG-tube. The medications included: 81mg (milligrams) aspirin (used for stroke prevention)- 1 tablet, 25 mg metoprolol (used blood pressure management) - 1 tablet, 25mg Seroquel (used for hiccups) -1 tab, and 4 mg silodosin (used relax urethra to prevent urine retention)- 1 capsule. All four medications were placed in a 30 ml medication cup. The Unit Manager poured the medication tablets in a clear plastic sleeved and crushed the medication. Next, she opened the medication capsule and emptied the medication in the mix of crushed medications. Then the Unit Manager poured 5mg/ml of Metoclopramide (used for nausea) into a medication cup for a total of 10 ml. Next, she poured 30 ml of ProStat (protein supplement) into a medication cup.
The Unit Manager was observed on 6/25/25 at 8:48 AM as she [NAME] the medications for administration into Resident #49's room. After the nurse connected a syringe to the resident's PEG- tube, she flushed the tube with 30 ml of water. The crushed medications were mixed with 60 ml of water in a cup and the solution was poured into the syringe connected to Resident #49's PEG-tube. The Unit Manager then combined the Metoclopramide and Prostate with 20 ml of water for a total of 60 ml of solution. She then administered the solution into the syringe and then the PEG-tube. The Unit Manager completed the medication administration by flushing the resident PEG-tube with 60 ml of water.
An interview was conducted with the Unit Manager on 6/25/25 at 2:11 PM. The Unit Manager reported she was nervous and did not routinely work with Resident #49. The Nurse Manager stated that her normal practice was to combine all medications and administer in the PEG- tube at once as a cocktail. The Unit Manager stated that she had not reviewed the medication administration order for Resident #49 prior to administering the medications.
An interview was conducted on 6/26/25 at 10:29 AM with the facility's Director of Nursing (DON). During the interview, the DON stated he would expect that orders are followed for all medications administered to a resident.
Mar 2024
19 deficiencies
2 IJ
CRITICAL
(J)
📢 Someone Reported This
A family member, employee, or ombudsman was alarmed enough to file a formal complaint
Immediate Jeopardy (IJ) - the most serious Medicare violation
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, resident interviews, family interviews and staff interviews the facility failed to protect Resident #28 ...
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**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on record review, resident interviews, family interviews and staff interviews the facility failed to protect Resident #28 from neglect when he was not administered scheduled nebulizer treatments (medical device that delivers liquid directly into the lungs) as ordered by Hospice despite repeated requests. Resident #28 had a diagnosis of chronic obstructive pulmonary disease with oxygen use and had orders for nebulizer treatments at 9:00 am, 11:00 am, 1:00 pm and 5: 00 pm during the 7:00 am to 7:00 pm (day shift). Resident #28 reported he was only administered one nebulizer treatment during the day shift on 3/9/24 and 3/10/24 and experienced chest pain on 3/9/24. In addition, Resident #28 stated during the day shift on 3/9/24 when he requested a dietary supplement he was told there were not any. No vital signs were documented on the day shift on 3/9/24. Resident #28 reported he experienced chest pain on 3/9/24, felt belittled and that staff were retaliating against him because he had filed a complaint about care. In addition, on 3/10/24 the facility neglected to provide incontinence care and assistance with activities of daily living for Resident #17 when requested by a family member. Resident #17 had severe cognitive impairment and when the family member arrived had a wet brief, was wearing a t-shirt and was partially covered by a blanket. Care was not provided until later in the afternoon when a second family member arrived and requested assistance. This deficient practice occurred for 2 of 3 residents reviewed for neglect (Resident #28 and Resident #17).
Immediate jeopardy began on 3/9/24 when the facility neglected to provide necessary care and services for Resident #28. Immediate jeopardy was removed on 3/19/24 when the facility provided and implemented an acceptable credible allegation of Immediately Jeopardy removal. The facility remains out of compliance at a lower scope and severity of G (actual harm that is not Immediate Jeopardy) for example # 2 and to complete education and ensure monitoring systems put into place are effective related to neglect.
The findings included:
1. Resident #28 was admitted to the facility on [DATE] with diagnoses inclusive of chronic obstructive pulmonary disease (COPD), gastroesophageal reflux disease (GERD), heart failure, hypertension, and anxiety.
An admission MDS assessment dated [DATE] indicated Resident #28 was cognitively intact, was receiving hospice care and required maximal assistance with toileting, showering, and dressing. The assessment further indicated rejection of care 1-3 times and use of oxygen.
A care plan dated 2/26/24 indicated Resident #28 was care planned for the following:
-altered respiratory status/ difficulty breathing related to anxiety, COPD history of respiratory failure with intervention to provide oxygen as ordered.
-continuous oxygen therapy for CHF and COPD with interventions to give medications as ordered, monitor/ document side effects and effectiveness, observe for symptoms of respiratory distress and report to physician as needed (restlessness, pulse oximetry, increased heart rate, headaches, lethargy, confusion, cough, accessory muscle usage and skin color.
-altered cardiovascular status, arrythmia, CHF and hypertension with interventions to assess shortness of breath and cyanosis, diet consult as necessary, oxygen as ordered, monitor/document/report changes in lung sounds (crackles), edema, and changes in weight; vital signs as ordered/as needed and report abnormal readings to physician.
-acid reflux with an intervention for medications to be given as ordered, monitor/ document side effects and effectiveness.
-hospice services related to COPD, with an intervention to administer pain medications as prescribed, assess frequently and provide additional pain relief as necessary; coordinate care with hospice team; invite hospice staff to participate in resident care planning conferences; promote comfort by repositioning, adding more pillows, massage, reading, and aromatherapy.
A review of the March 2024 Medication Administration Record revealed Resident #28 was to receive the following during the 7am- 7pm shift:
-Omeprazole- give one tablet in evening for GERD (4pm)
-Prostat- (Protein supplement) 30 milliliters one time a day for additional protein (9am)
-Budesonide inhalation suspension (nebulizer treatment)- 2 times a day for COPD (9am)
-Formoterol fumerate inhalation solution 2 times a day (every 12 hours) for COPD (1pm)
-Tamsulosin- one capsule by mouth 2 times a day (Flomax) (9am)
-Ensure (dietary supplement)- 3 times a day (10am, 2pm)
-Oxgyen 3 liters continuous nasal canular for shortness of breath- every shift O2
-Vital signs every shift
-Ipratropium-albuterol inhalation solution #60 vial-(nebulizer) inhale 4 times a day for COPD (11am, 5pm)
-Fluticasone propionate suspension- spray each nostril one time a day for allergies (9am)
-Observe or ask resident if shortness of breath (SOB) occurs when lying flat down or is resident avoiding lying flat due to SOB; every shift signs of SOB: interrupted speech pattern (only able to say a few words before taking a breath); increased respiratory rate
During an interview on 3/11/24 at 11:10 AM Resident #28 revealed he received a nebulizer treatment once on Saturday 3/9/24 and once on Sunday 3/10/24 during the 7:00 am to 7:00 pm shift (day shift), although he was supposed to receive nebulizer treatments four times during the day shift. He also stated he did not receive any of his other medications that were in pill form. Resident #28 stated he had chest difficulty on 3/9/24 and requested a breathing (nebulizer) treatment on several occasions but did not receive it until late afternoon. He revealed he told Nurse Aide (NA) #1 he needed a breathing treatment each time she came into his room to check on him or answer his call bell throughout the day and NA #1 told him that she informed Nurse #10 of his requests. Resident #28 indicated on 3/9/24 he called his daughter to complain of chest pain and that he had been asking for a breathing treatment for 3 hours. The Resident explained NA #1 was trying to be helpful when she spoke with his daughter on the phone while she was in the room and stated she was doing all she could by reporting the Resident's need for a breathing treatment. The Resident stated when the Medication Aide (later identified by the Resident as Med Aide #1) finally came in to give him his breathing treatment later in the day, she stated in a hostile manner here is your breathing treatment. The Resident stated he had not reported his concerns that occurred over the weekend to nursing management.
During a follow up interview on 3/14/24 at 12:42 pm Resident #28 revealed he did not receive any medications by mouth, and he received one breathing treatment during the day shifts on 3/9/24 and 3/10/24. He stated on 3/9/24, Med Aide #1 stated in a hostile manner you push your bell every 5 minutes, then she activated his call bell so that he could not use it and it stayed on for the remainder of the shift. The Resident further explained since Med Aide #1 pressed the call bell, there was no way for him to press it if he needed something. Resident #28 also revealed he felt belittled when he asked Med Aide #1 for his scheduled dietary supplement, and she stated in a hostile tone there is none! The Resident did not state if this occurred on 3/9/24 or 3/10/24. He further revealed he asked Nurse #11 on the next shift (7:00 pm- 7:00 am) for the dietary supplement and he received it. The interview further revealed Resident #28 stated he felt two staff, including Med Aide #1, were retaliating against him by acting mean, because he filed a complaint about not receiving care a few weeks prior, when he was first admitted to the facility. The Resident stated management handled the issue and that he had not seen that staff person since then.
A review of video footage from camera #14 on 3/9/24 from 7:00 am to 7:00 pm and the Medication Administration Audit (indicates the date and time medications were initialed as administered on the Medication Administration Record) report for 3/9/24 revealed following:
-8:05 am- NA #1 entered Resident #28's room and exited at 8:08 am.
-8:12 am to 8:13 am- two unidentified NAs deliver breakfast trays to Resident #28 and his roommate.
-8:35 am- Nurse #10 (supervised Med Aide #1 on 3/9/24) arrived on 200- hall with med cart and begins med pass.
-8:40 am- NA #1 approached Nurse #10 at med cart and they had a conversation then NA #1 leaves the hall.
-8:44 am- 9:00 am Nurse #10 continued with med pass in other resident rooms but never entered Resident #28's during this time.
-9:06 am- NA #1entered Resident #28's room, collected one breakfast tray and exited the room.
-9:14 am- Nurse #10 relocated med cart to the end of 200-hall and continued med pass.
-9:33 am- Nurse #10 left 200-hall without the med cart
-9:44 am- Nurse #10 returned to the med cart on 200-hall.
-10:00 am- NA #1 entered Resident #28's room
-10:01 am- NA #1 exited Resident #28's room, spoke to Nurse #10 who was at the other end of the hall and performed a hand motion as she was speaking. Nurse #10 then turned around and left the hall.
-10:19 am- NA #1 entered Resident #28's room. NA #1 exited Resident #28's room at 10:24 am and walked across the hall to enter another resident's room.
-10:22 am- Med Aide #1 entered Resident #28's room with what appeared to be a small plastic cup. It was not clear if Med Aide #1 medicated Resident #28 or his roommate. Med Aide #1 exited Resident #28's room at 10:25 am with something in her hand.
-10:22 am- Per the Med Administration Audit report, Med Aide #1 signed that she administered Budesonide inhalation suspension (nebulizer) and Fluticasone propionate suspension (nasal spray) to Resident #28.
-10:23 am- Per the Med Administration Audit report, Med Aide #1 signed that she administered Ensure and Tamsulosin to Resident #28.
-10:24 am Per Med Administration Audit report, Med Aide #1 signed that she administered Prostat to Resident #28.
-10:25 am- Per the Med Administration Audit report, Med Aide #1 signed that she conducted a pain assessment (0 of 10 scale), obtained vital signs, checked oxygen at 3 liters continuous nasal canular for shortness of breath for Resident #28.
-10:25 am- Per the Medication Administration Audit report, Med Aide #1 signed that she observed or asked Resident #28 if shortness of breath (SOB) occurred when lying flat down or was resident avoiding lying flat due to SOB; monitored for signs of shortness of breath such as interrupted speech pattern (only able to say a few words before taking a breath) and increased respiratory rate.
-10:31 am- NA #1 entered Resident #28's room.
-10:32 am- NA #1 exited Resident #28's room with water pitcher and box of gloves.
-10:33 am- NA #1 entered Resident #28's room with water pitcher the exits a few seconds later at 10:33 am.
-10:33 am- Nurse #10 moved medication cart near middle of hallway/ closer to Resident #28's room and had a conversation with NA #1.
-10:34 am- Med Aide #1 went to Nurse #10's cart while Nurse #10 was still talking to NA#1.
-10:35 am- Med Aide #1 and Nurse #10 conversing at med cart and they both leave 200-hall with the med cart.
-10:35 am- Per the Med Administration Audit report, Med Aide #1 signed that she administered Ipratropium-albuterol inhalation solution (nebulizer) to Resident #28.
-11:03 am- Med Aide #1 returns to 200-hall with med cart.
-11:15 am- NA #1 entered Resident #28's room.
-11:16 am- NA #1 exited Resident #28's room and takes linen cart from linen closet and leaves the hallway.
-11:18 am- NA #1 returned to hall and entered Resident #28's room.
-11:19 am- NA #1 exited Resident #28's room and walked past Med Aide #1 at the med cart.
-11:19 am- Med Aide #1 entered Resident #28's room with a small plastic cup in hand. It was unclear if Med Aide #1 medicated Resident #28 or his roommate.
-11:20 am- Med Aide #1 exited Resident #28's room and returned to med cart.
-11:28 am- NA #1 returned to 200-hall, removed something from the hallway floor, said something in Med Aide #1's direction and Med Aide #1 looked at NA #1 then NA #1 left the hall.
-11:55 am- Med Aide #1 left med cart, exited the hall and returned to the med cart at 11:56 am.
-12:13 pm- Resident # 28's roommate left the room.
-12:34 pm- Per the Medication Administration Audit report, Med Aide #1 signed that she administered Formoterol fumerate inhalation solution to Resident #28.
-12:55 pm- Med Aide #1 entered Resident #28's room with a lunch tray and immediately exited with lunch tray.
-1:11 pm- Resident #28's roommate returned to their room.
-1:51 pm- Per the Medication Administration Audit report, Med Aide #1 signed that she administered Ensure Plus to Resident #28.
-1:33 pm- NA #1 entered Resident #28's room and exited at 1:36 pm then converses with another Aide in the hall.
-1:52 pm- NA #1 entered Resident #28's room and exited at 1:53 pm.
-2:00 pm- Med Aide #1 in hall talking with another NA.
-2:03 pm- Unit Manager #1 entered Resident #28's room and exited at 2:04 pm.
-2:09 pm- Unit Manager #1 re-entered Resident #28's room with a 4-ounce plastic cup in her hand and exited at 2:10 pm.
During an interview on 3/17/24 Unit Manager #1 indicated she answered Resident # 28's call bell and he requested acid reflux medication. She stated Resident #28 did not appear short of breath and he did not request a nebulizer treatment. She left the Resident's room then returned and administered the acid reflux medication, which was a standing order.
-2:21 pm NA #1 returns to 200-hall, removes her coat, places it out of camera shot and leaves hall.
-2:22 pm NA #1 entered Resident #28's room and exited at 2:22 pm.
-2:58 pm- Med Aide #1 returns to 200-hall with no cart and entered another resident's room.
-3:08 pm- Nurse #10 arrived on 200-hall with dirty linen bag and placed in dirty linen closet next to Resident #28's room but does not go into his room and leaves 200-hall.
-3:20 pm Nurse #10 returned to 200-hall with med cart.
-3:59 pm NA #1 entered Resident #28's room and exited at 3:59 pm with blue gloves in hand and spoke with someone out of camera footage then left 200-hall.
-4:30 pm NA #1 entered Resident #28's room and exited at 4:31 pm.
-4:34 pm Med Aide #1 arrived on 200-hall with med cart and started med pass.
-4:48 pm NA #1 returned to 200 hall and entered Resident #28's room and exited at 4:48 pm with dirty linen bag.
-4:49 pm NA #1 entered Resident #28's room.
-4:50 pm NA #1 exited Resident #28's room and spoke to Med Aide #1 at the med cart as she was pointing toward Resident #28's room, then walked to med cart and continued to speak with Med Aide #1. NA #1 walked away from Med Aide #1, put her hands up in the air and re-entered Resident #28's room.
-4:51 pm NA #1 exited Resident #28's room.
-4:51 pm Med Aide #1 left med cart with something in hand and walked past Resident #28's room as she left 200-hall.
-4:53 pm Med Aide #1 returned to 200-hall.
-4:54 pm NA #1 entered Resident #28's room with incontinence supplies and exited at 4:54 pm.
-5:00 pm- Med Aide #1 on the 200-hall with med cart.
-5:01 pm- Med Aide #1 entered Resident #28's room (something in hand) and exited at 5:03 pm. It was unclear if Med Aide #1 medicated Resident #28 or his roommate.
-5:03 pm- Med Aide #1 exited Resident #28's room and left 200-hall.
-5:04 pm- Per the Med Administration Audit report, Med Aide #1 signed that she administered Ipratropium-albuterol inhalation solution (nebulizer) to Resident #28.
-5:12 pm NA #1 in hall with Med Aide #1 for brief conversation.
-5:16 pm Med Aide #1 entered Resident #28's room with a small plastic cup in hand and exited at 5:16 pm. It was unclear if Med Aide #1 if she medicated Resident #28 or his roommate.
- 5:42 pm Med Aide #1 placed med cart trash bag in dirty linen closet and exited at 5:43 pm.
-5:46 pm- Med Aide #1 entered Resident #28's room after leaving dirty linen closet and exited Resident #28's room at 5:46 pm.
-5:47 pm- Med Aide #1 exited 200-hall with med cart.
-6:00 pm- Med Aide #1 returned to 200-hall without the med cart.
A review of video footage from camera #14 on 3/10/24 from 7:00 am to 7:00 pm and the Medication Administration Audit report for 3/10/24 revealed following:
-7:02 am Med Aide #1 entered Resident #28's room with the mobile vitals machine and exited at 7:04 am.
-7:55 am- NA #1 entered Resident #28's room and exited at 7:57 am.
-8:00 am- NA #1 entered Resident 28's room, exited at 8:02 and left 200-hall.
-8:18 am- NA #1 and NA #14 entered Resident #28's room with breakfast trays and exited at 8:19 am.
-8:18 am- Med Aide #1 entered Resident #28's room with a small plastic cup, unwrapped straw, and another item in hand and exited at 8:21 am with an unwrapped straw and a plastic bottle. It was unclear if Med Aide #1 medicated Resident #28 or his roommate.
-8:32 am- Nurse #13 (supervised Med Aide #1 on 3/10/24) arrived on the 200-hall with med cart.
-9:03 am- NA #14 re-entered Resident #28's room with a cup of coffee and exited with another breakfast tray.
-9:57 am Nurse #13 left hall with med cart laptop.
-10:01 am Nurse #13 returned to hall and resumed med pass.
-10:46 am- Med Aide #1 arrived on the hall without med cart and went to Nurse #13's med cart and exited hall at 10:52 am.
-11:27 am Per the Med Administration Audit report, Med Aide #1 signed that she administered Budesonide inhalation suspension and Fluticasone propionate suspension (nasal spray), Ipratropium-albuterol inhalation solution (nebulizer) and Prostat to Resident #28.
-11:28 am Per the Med Administration Audit report, Med Aide #1 signed that she administered Tamsulosin to Resident #28.
-11:29 am Per the Med Administration Audit report, Med Aide #1 signed that she administered Ensure Plus, conducted a pain assessment (0 of 10 scale), obtained vitals, checked oxygen, and asked/ assessed for shortness of breath of Resident #28.
-11:52 am- Med Aide #1 returned briefly to the med cart, picked up a small plastic cup, entered Resident #28's room and exited at 11:52 am. It was unclear if Med Aide #1 medicated Resident #28 or his roommate.
-12:13 pm- Resident #28's roommate (Resident #60) in bed A leaves the room via wheelchair, with a family member.
-12:23 pm- Med Aide #1 transported/ parked the med cart to dirty linen closet outside of Resident #28's room, discarded a bag of trash in the dirty linen closet, exited the dirty linen closet, returned to med cart and picked up a small plastic cup with spoon and entered Resident #28's room with the plastic cup in hand. Med Aide #1 then exited the room with cup in hand, placed it on med cart at 12:24 pm and exited 200-hall with the med cart.
-12:29 pm- Med Aide #1 returned to 200-hall without med cart, stood outside Resident #28's room then left the hall.
-12:32 pm- NA #14 and unidentified unknown NA entered Resident #28's room with lunch trays.
-12:56 pm- Per the Med Administration Audit report, Med Aide #1 signed that she administered formoterol fumerate inhalation solution to Resident #28.
-1:02 pm- Med Aide #1 arrived on 200-hall and left the hall at 1:05 pm.
-from 2:00 pm to 4:26 pm- No staff entered Resident #28's room.
-4:24 pm- Med Aide#1 arrived on 200-hall with medication cart and began med pass.
-4:26 pm- NA #14 entered linen closet, retrieved linen, and entered Resident #28's room.
-4:27 pm- NA #14 exited Resident #28's room and into one of the rooms across the hall from Resident #28, then leaves the hall a few minutes later.
-4:53 pm- Med Aide #1 entered Resident #28's room with something in hand. It was not clear if Med Aide #1 medicated Resident #28 or his roommate.
-4:54 pm Med Aide #1 exited Resident #28's room.
-4:57 pm Med Aide #1 re-entered Resident #28's room.
-4:58 pm Med Aide #1 exited Resident #28's room.
-4:59 pm- Per the Med Administration Audit report, Med Aide #1 signed that she administered omeprazole and Ipratropium-albuterol inhalation solution (nebulizer) to Resident #28.
-5:00 pm- Med Aide #1 at med cart and Nurse #13 at med cart on opposite end of hall.
-5:05 pm- NA #14 and an unknown NA delivered dinner trays to Resident #28's room and exited at 5:06 pm.
-5:08 pm- Med Aide #1 entered Resident #28's room and exited a few seconds later then left the hall.
-5:09 pm- Med Aide #1 returned to 200-hall and the med cart.
-5:51 pm- Med Aide #1 left 200-hall with med cart.
-6:31 pm- NA #14 entered Resident #28's room with a bag of linens, left the room seconds later and placed bag in dirty linen closet.
Attempts to interview Nurse #13 were not successful.
Attempts to interview NA #14 were not successful.
A review of video footage from camera #7 on 3/09/24 from 7:00 am to 7:00 pm showed a hall's length view but did not show a view of the Resident #28's room. The view shows blurry parts of Med Aide #1 standing at the med cart, sometimes showing only the bottom half of her legs, leaving the med cart, returning to the med cart around similar or the same footage times that were viewed on camera #14.
During a phone interview on 3/14/24 at 11:21 am Resident #28's family member, indicated she resided out of state and received several phone calls from the Resident on 3/9/24. She stated she was a nurse and was working when the Resident left her a voice mail message about 1:58 pm about how he pressed his call bell, NA #1 responded, and he told her he needed a breathing treatment and he had not received it. She returned his call about 5:15 pm to see if the Resident received his treatment. Resident #28 told her that he was experiencing chest pains and had been requesting his scheduled breathing treatments for at least 3 hours. The family member further indicated at one point during the day (about 5:15 pm) when she spoke to the Resident, she also spoke with the NA #1, on the Resident's cell phone when the NA went in to check on the Resident. The family member stated NA #1 told her she had reported to Nurse #10 on several occasions the Resident needed a breathing treatment and at one point Nurse #10 stated she was on break and that the NA needed to find someone else. The family member stated she was so upset, she demanded to know what was going on and NA #1 attempted to have a nurse who was out in the hall come into the Resident's room to talk to her, but the nurse would not come to the phone. The family member further indicated every time she spoke with the Resident, he seemed out of breath as evidenced by speaking in a reserved manner to preserve his breath and she could tell he was short of breath. The family stated she was so upset she called the hospice phone number and left a voice mail message for the Hospice Administrator at 5:05 pm and left messages about the Resident's report of difficulty breathing. When the family member called the Resident about 6:00 pm, the Resident stated he had just received a nebulizer treatment from the nurse and that he was feeling better. The family member also stated the Resident was only confused when he needed breathing treatment, and she truly believed him when he stated he was having difficulty. The family member stated she spoke with the Resident on 3/10/24 after she came from church, and he stated he was ok. She stated when she spoke with the Resident on Tuesday 3/12/24, he stated Sunday was a little rough, but he did not go into detail, then said it was ok.
During an interview on 3/14/24 at 12:21 pm Med Aide #1 stated she was assigned to Resident #28 on the 7:00 am- 7:00 pm shift on 3/9/24 and 3/10/24 and was responsible for administering his medications and breathing treatments. She further stated on 3/9/24 NA #1 did not inform her that Resident #28 needed a breathing (nebulizer) treatment on 3/9/24 during the 7am- 7pm shift. Med Aide #1 indicated she administered a breathing treatment to Resident #28 three times during her shift (morning, afternoon, and before evening) on 3/9/24 and 3/10/24. Med Aide #1 denied being hostile towards Resident #28, activating his call bell so he could not use it, or telling him there was no dietary supplement to give him when he asked for one during her shift on 3/9/24.
During a phone interview on 3/14/24 at 4:36 pm NA #1 revealed she was assigned to Resident #28 on day shift on 3/9/24 and each time she answered his call bell or checked on him from the morning through the afternoon, the Resident requested a breathing treatment. She further revealed she informed Nurse #10 on at least three occasions that the Resident was requesting his breathing treatment. The third time she informed Nurse #10 of the Resident's request for his breathing treatment, Nurse #1 stated she was on break and that NA #1 should ask Med Aide #1. NA #1 stated she located Med Aide #1 in another resident's room watching a soccer game and informed her of the Resident's request for medication. NA #1 stated Med Aide #1 replied ok. NA #1 further revealed when she went to check on the Resident during the afternoon, the Resident was on his cell phone with a family member and gave NA #1 the phone. NA #1 spoke with the family member on the phone and apologized that there was nothing else she could do but keep telling the nurse that the Resident was requesting a nebulizer treatment. NA #1 stated she returned to the Resident's room later in the afternoon and the Resident stated he still had not received his breathing treatment, then asked her did you see the nurse? when is the nurse coming. The NA further stated the Resident was not gasping for air and she could not determine whether he was short of breath because he seemed frustrated and was trying to maintain his composure. NA #1 stated her assignment kept changing on 3/9/24, the communication was horrible, and the attitudes and disposition of the nurses were awful.
A follow-up call to NA #1 was placed on 3/17/24 at 4:09 pm and the voice mail box was full.
During a follow-up interview on 3/17/24 at 1:53 pm Unit Manager #1 indicated she was the Unit Manager for the entire building on Saturday 3/9/24 and Sunday 3/10/24 and that Nurse #1 oversaw the Med Aide #1. She further indicated she was not aware that the Resident did not receive nebulizer treatments and medications as ordered and scheduled.
During an interview on 3/14/24 at 12:02 pm Nurse #10 revealed she supervised Med Aide #1 on 3/9/24 who was assigned to Resident #28, and she was never informed the Resident reported chest pains or difficulty breathing and requested a breathing treatment. She further revealed she had no conversations with NA #1 about Resident #28 during the day shift on 3/9/24.
During an interview on 3/14/24 at 10:44 am Nurse #11 indicated he worked 7:00 pm to 7:00 am on 3/9/24 and 3/10/24 and was assigned to Resident #28. Nurse #11 stated Resident #28 did not complain about being mistreated by staff or not receiving his medication as scheduled on 3/9/24 or 3/10/24 during the 7:00 am to 7:00 pm shift. Nurse #11 further indicated he administered breathing treatments as ordered to Resident #28's, on both nights that he worked, and the off-going staff did not mention any concerns with the Resident.
A hospice nurse progress note dated 3/11/24 revealed the Resident #28 reported to the hospice social worker that he was not administered breathing treatments as ordered over the weekend and specifically complained about treatment from an evening nurse or med aide. He further reported that facility staff activated his call light so that he could not press it. The note further read that the hospice administrator was contacted by Resident #28's family member about the Resident receiving medications on 3/9/24.
During a phone interview on 3/15/24 at 8:16 pm the Hospice Nurse revealed she visits Resident #28 on Monday/Friday every week and that the Resident was very upset when he reported to her on 3/11/24 that his scheduled nebulizer treatments were not given on time on 3/9/24 and 3/10/24. She stated that the Resident did not give specific times he did not receive his nebulizer treatments but that he only received one treatment during 7am to 7pm shifts and should have received 4 treatments during those shifts. She stated the Resident had high anxiety and she believed what he was telling her because the hospice nurse heard similar stories from other patients related to not receiving their medications. She also stated the Resident should have received scheduled breathing treatments 4 times per day and not receiving those treatments could cause psychological stress which would affect his breathing, cardiac status, and increase his heart rate. The Hospice Nurse stated over the weekend, she received a voice mail from the Resident's family member stating the Resident was having chest pains and that the family member also contacted the hospice administrator and left a message about the Resident's unanswered requests for breathing treatments. She also stated his symptoms would have resolved faster than they did, had the Med Aide administered the medications and nebulizer treatments as ordered. The nebulizer treatments should have been spread throughout the day so he could avoid the spikes in anxiety, since he was already nervous due to the albuterol which could cause the heart rate to increase.
During an interview on 3/12/24 at 2:35 pm Unit Manager #2 agreed to follow-up with Resident #28 after the Surveyor informed Unit Manager #2 the Resident had concerns from the weekend (3/9/24 and 3/10/24) regarding the call bell incident, Med Aide #1 interactions related to not getting his medications, and dietary concerns.
During an interview on 3/14/24 at 1:10 pm Unit Manager #2 revealed she spoke with Resident #28 on Monday or Tuesday (3/11/24 or 3/12/24), after the [State Surveyor] informed her Resident #28 had concerns about incidents that occurred over the weekend (3/9/24 and 3/10/24), related to not receiving his nebulizer treatments, call bell being activated so the Resident could not activate it and wanting to speak with the dietician about menu concerns. Unit Manager #2 further revealed the Resident did not mention he did not receive his breathing treatments but that he did not get his medications on time over the weekend and his call bell was not being answered in a timely manner. Unit Manager #2 stated she informed the Director of Nursing (DON) of the concerns after she spoke to the resident.
During an interview on 3/14/24 at 1:00 pm the DON indicated he was not made aware of Resident #28's concerns until 3/14/24 related to not receiving medications or that Med Aide #1 activated the Resident's call bell so that the Resident could not use it. The DON further indicated he expected all residents to receive their medications as prescribed and call bells to be answered in a timely manner.
During an interview on 3/14/23 at 1:10 pm, with the Corporate Nurse, Unit Manager #2 and the DON present, the Corporate Nurse spoke on behalf of Unit Manager #2 and stated Resident #28 did not report to Unit Manager #2 that he did not receive his nebulizer treatment or that the Med Aide #1 pressed his call bell so he couldn't use it. The DON indicated Unit Manager #2 made him aware of the call bell concerns on 3/14/24.
During a phone interview on 3/14/24 at 5:00 pm the facility Nurse Practitioner (NP) indicated scheduled breathing treatments could have helped Resident #28's symptoms if he received them. She further indicated the Resident was probably upset and became more air hungry, anxious, and bronchioles constricted despite receiving oxygen at 3 liters. The NP indicated her expectation was for Resident #28 to receive all his scheduled medications as ordered.
During a phone interview on 3/14/24 at 5:27 pm the Medical Director revealed he took over as Medical Director in January 2024 and was not yet familiar with Resident #28. He further revealed the Resident could have had a significant decline when he did not receive his breathing treatments as ordered and not receiving breathing trea
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 resident, family member, staff interviews, Hospice Nurse, Nurse Practitioner (NP), and Medical Direct...
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**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on record review and resident, family member, staff interviews, Hospice Nurse, Nurse Practitioner (NP), and Medical Director interviews the facility failed to prevent a significant medication error when Resident #28 was not administered scheduled nebulizer treatments (medical device that delivers liquid directly into the lungs) as ordered by Hospice despite repeated requests. Resident #28 had a diagnosis chronic obstructive pulmonary disease with oxygen use and had orders for nebulizer treatments at 9:00 am, 11:00 am, 1:00 pm and 5: 00 pm during the 7:00 am to 7:00 pm (day shift). Resident #28 reported he was only administered one nebulizer treatment during the day shift on 3/9/24 and 3/10/24 and experienced chest pain on 3/9/24. This had the high likelihood of a serious adverse outcome including psychological stress which would affect his breathing, cardiac status, and increase his heart rate. The deficient practice occurred for 1 of 1 resident reviewed for significant medication errors.
Immediate jeopardy began on 3/9/24 when Resident #28 was not administered scheduled nebulizer treatments despite repeated requests. The immediate jeopardy was removed on 3/19/24 when the facility provided and implemented an acceptable credible allegation of Immediately Jeopardy removal. The facility remains out of compliance at a lower scope and severity of D (no actual harm with potential for more than minimal harm that is not Immediate Jeopardy) to complete education and ensure monitoring systems put into place are effective related to preventing a significant medication error.
The findings included:
Resident #28 was admitted to the facility on [DATE] with diagnoses inclusive of chronic obstructive pulmonary disease (COPD), heart failure, hypertension, and anxiety.
An admission MDS assessment dated [DATE] indicated Resident #28 was cognitively intact, was receiving hospice care and required maximal assistance with toileting, showering, and dressing. The assessment further indicated rejection of care 1-3 times and use of oxygen.
A care plan dated 2/26/24 indicated Resident #28 was care planned for the following:
-altered respiratory status/ difficulty breathing related to anxiety, COPD history of respiratory failure with intervention to provide oxygen as ordered.
-continuous oxygen therapy for CHF and COPD with interventions to give medications as ordered, monitor/ document side effects and effectiveness, observe for symptoms of respiratory distress and report to physician as needed (restlessness, pulse oximetry, increased heart rate, headaches, lethargy, confusion, cough, accessory muscle usage and skin color.
-altered cardiovascular status arrythmia, CHF and hypertension with interventions to assess shortness of breath and cyanosis, diet consult as necessary, oxygen as ordered, monitor/document/report changes in lung sounds (crackles), edema, and changes in weight; vital signs as ordered/as needed and report abnormal readings to physician.
-hospice services related to COPD, with an intervention to administer pain medications as prescribed, assess frequently and provide additional pain relief as necessary; coordinate care with hospice team; invite hospice staff to participate in resident care planning conferences; promote comfort by repositioning, adding more pillows, massage, reading, and aromatherapy.
A review of the March 2024 Medication Administration Record revealed Resident #28 was to receive the following during the 7am- 7pm shift:
-Budesonide inhalation suspension- 2 times a day for COPD (9am)
-Formoterol fumerate inhalation solution 2 times a day (every 12 hours) for COPD (1pm)
-Oxgyen 3 liters continuous nasal canular for shortness of breath- every shift O2
-Ipratropium-albuterol inhalation solution #60 vial-(nebulizer) inhale 4 times a day for COPD (11am, 5pm)
During an interview on 3/11/24 at 11:10 AM Resident #28 revealed he received a nebulizer treatment once on Saturday 3/9/24 and once on Sunday 3/10/24 during the 7:00 am to 7:00 pm shift (day shift), although he was supposed to receive nebulizer treatments four times during the day shift. Resident #28 stated he had chest difficulty on 3/9/24 and requested a breathing (nebulizer) treatment on several occasions but did not receive it until late afternoon. He revealed he told Nurse Aide (NA) #1 he needed a breathing treatment each time she came into his room to check on him or answer his call bell throughout the day and NA #1 told him that she informed Nurse #10 of his requests. Resident #28 indicated on 3/9/24 he called his daughter to complain of chest pain and that he had been asking for a breathing treatment for 3 hours. The Resident explained NA #1 was trying to be helpful when she spoke with his daughter on the phone while she was in the room and stated she was doing all she could by reporting the Resident's need for a breathing treatment. The Resident stated when the Medication Aide (later identified by the Resident as Med Aide #1) finally came in to give him his breathing treatment later in the day, she stated in a hostile manner here is your breathing treatment. The Resident stated he had not reported his concerns that occurred over the weekend to nursing management.
A review of video footage from camera #14 on 3/9/24 from 7:00 am to 7:00 pm and the Medication Administration Audit (indicates the date and time medications were initialed as administered on the Medication Administration Record) report for 3/9/24 revealed following:
-8:05 am- NA #1 entered Resident #28's room and exited at 8:08 am.
-8:35 am- Nurse #10 (supervised Med Aide #1 on 3/9/24) arrived on 200- hall with med cart and begins med pass.
-8:40 am- NA #1 approached Nurse #10 at med cart and they had a conversation then NA #1 leaves the hall.
-8:44 am- 9:00 am Nurse #10 continued with med pass in other resident rooms but never entered Resident #28's during this time.
-9:14 am- Nurse #10 relocated med cart to the end of 200-hall and continued med pass.
-9:33 am- Nurse #10 left 200-hall without the med cart
-9:44 am- Nurse #10 returned to the med cart on 200-hall.
-10:00 am- NA #1 entered Resident #28's room
-10:01 am- NA #1 exited Resident #28's room, spoke to Nurse #10 who was at the other end of the hall and performed a hand motion as she was speaking. Nurse #10 then turned around and left the hall.
-10:19 am- NA #1 entered Resident #28's room. NA #1 exited Resident #28's room at 10:24 am and walked across the hall to enter another resident's room.
-10:22 am- Med Aide #1 entered Resident #28's room with what appeared to be a small plastic cup. It was not clear if Med Aide #1 medicated Resident #28 or his roommate. Med Aide #1 exited Resident #28's room at 10:25 am with something in her hand.
-10:22 am- Per the Med Administration Audit report, Med Aide #1 signed that she administered Budesonide inhalation suspension (nebulizer) to Resident #28.
-10:23 am- Per the Med Administration Audit report, Med Aide #1 signed that she administered Ensure and Tamsulosin to Resident #28.
-10:24 am Per Med Administration Audit report, Med Aide #1 signed that she administered Prostat to Resident #28.
-10:31 am- NA #1 entered Resident #28's room.
-10:32 am- NA #1 exited Resident #28's room with water pitcher and box of gloves.
-10:33 am- Nurse #10 moved medication cart near middle of hallway/ closer to Resident #28's room and had a conversation with NA #1.
-10:34 am- Med Aide #1 went to Nurse #10's cart while Nurse #10 was still talking to NA#1.
-10:35 am- Med Aide #1 and Nurse #10 conversing at med cart and they both leave 200-hall with the med cart.
-10:35 am- Per the Med Administration Audit report, Med Aide #1 signed that she administered Ipratropium-albuterol inhalation solution (nebulizer) to Resident #28.
-11:03 am- Med Aide #1 returns to 200-hall with med cart.
-11:18 am- NA #1 returned to hall and entered Resident #28's room.
-11:19 am- NA #1 exited Resident #28's room and walked past Med Aide #1 at the med cart.
-11:19 am- Med Aide #1 entered Resident #28's room with a small plastic cup in hand. It was unclear if Med Aide #1 medicated Resident #28 or his roommate.
-11:20 am- Med Aide #1 exited Resident #28's room and returned to med cart.
-11:28 am- NA #1 returned to 200-hall, removed something from the hallway floor, said something in Med Aide #1's direction and Med Aide #1 looked at NA #1 then NA #1 left the hall.
-11:55 am- Med Aide #1 left med cart, exited the hall and returned to the med cart at 11:56 am.
-12:13 pm- Resident # 28's roommate left the room.
-12:34 pm- Per the Medication Administration Audit report, Med Aide #1 signed that she administered Formoterol fumerate inhalation solution to Resident #28.
-12:55 pm- Med Aide #1 entered Resident #28's room with a lunch tray and immediately exited with lunch tray.
-1:52 pm- NA #1 entered Resident #28's room and exited at 1:53 pm.
-2:00 pm- Med Aide #1 in hall talking with another NA.
-2:22 pm NA #1 entered Resident #28's room and exited at 2:22 pm.
-2:58 pm- Med Aide #1 returns to 200-hall with no cart and entered another resident's room.
-3:20 pm Nurse #10 returned to 200-hall with med cart.
-3:59 pm NA #1 entered Resident #28's room and exited at 3:59 pm with blue gloves in hand and spoke with someone out of camera footage then left 200-hall.
-4:30 pm NA #1 entered Resident #28's room and exited at 4:31 pm.
-4:34 pm Med Aide #1 arrived on 200-hall with med cart and started med pass.
-4:50 pm NA #1 exited Resident #28's room and spoke to Med Aide #1 at the med cart as she was pointing toward Resident #28's room, then walked to med cart and continued to speak with Med Aide #1. NA #1 walked away from Med Aide #1, put her hands up in the air and re-entered Resident #28's room.
-4:51 pm NA #1 exited Resident #28's room.
-4:51 pm Med Aide #1 left med cart with something in hand and walked past Resident #28's room as she left 200-hall.
-4:53 pm Med Aide #1 returned to 200-hall.
-5:00 pm Med Aide #1 on the 200-hall with med cart.
-5:01 pm- Med Aide #1 entered Resident #28's room (something in hand) and exited at 5:03 pm. It was unclear if Med Aide #1 medicated Resident #28 or his roommate.
-5:03 pm- Med Aide #1 exited Resident #28's room and left 200-hall.
-5:04 pm- Per the Med Administration Audit report, Med Aide #1 signed that she administered Ipratropium-albuterol inhalation solution (nebulizer) to Resident #28.
-5:12 pm NA #1 in hall with Med Aide #1 for brief conversation.
-5:16 pm Med Aide #1 entered Resident #28's room with a small plastic cup in hand and exited at 5:16 pm. It was unclear if Med Aide #1 if she medicated Resident #28 or his roommate.
-5:46 pm- Med Aide #1 entered Resident #28's room after leaving dirty linen closet and exited Resident #28's room at 5:46 pm.
-5:47 pm- Med Aide #1 exited 200-hall with med cart.
-6:00 pm- Med Aide #1 returned to 200-hall without the med cart.
A review of video footage from camera #14 on 3/10/24 from 7:00 am to 7:00 pm and the Medication Administration Audit report for 3/10/24 revealed following:
-8:18 am- Med Aide #1 entered Resident #28's room with a small plastic cup, unwrapped straw, and another item in hand and exited at 8:21 am- with an unwrapped straw and a plastic bottle. It was unclear if Med Aide #1 medicated Resident #28 or his roommate.
-8:32 am- Nurse #13 (supervised Med Aide #1 on 3/10/24) arrived on the 200-hall with med cart.
-9:57 am- Nurse #13 left hall with med cart laptop.
-10:01 am- Nurse #13 returned to hall and resumed med pass.
-10:46 am- Med Aide #1 arrived on the hall without med cart and went to Nurse #13's med cart and exited hall at 10:52 am.
-11:27 am- Per the Med Administration Audit report, Med Aide #1 signed that she administered Budesonide inhalation suspension and Ipratropium-albuterol inhalation solution (nebulizer) to Resident #28.
-11:52 am- Med Aide #1 returned briefly to the med cart, picked up a small plastic cup, entered Resident #28's room and exited at 11:52 am. It was unclear if Med Aide #1 medicated Resident #28 or his roommate.
-12:13 pm- Resident #28's roommate (Resident #60) in bed A leaves the room via wheelchair, with a family member.
-12:23 pm- Med Aide #1 transported/parked the med cart to dirty linen closet outside of Resident #28's room, discarded a bag of trash in the dirty linen closet, exited the dirty linen closet, returned to med cart and picked up a small plastic cup with spoon and entered Resident #28's room with the plastic cup in hand. Med Aide #1 then exited the room with cup in hand, placed it on med cart at 12:24 pm and exited 200-hall with the med cart.
-12:29 pm- Med Aide #1 returned to 200-hall without med cart, stood outside Resident #28's room then left the hall.
-12:56 pm- Per the Med Administration Audit report, Med Aide #1 signed that she administered formoterol fumerate inhalation solution to Resident #28.
-from 2:00 pm to 4:26 pm- No staff entered Resident #28's room.
-4:24 pm- Med Aide#1 arrived on 200-hall with medication cart and began med pass.
-4:53 pm- Med Aide #1 entered Resident #28's room with something in hand. It was not clear if Med Aide #1 medicated Resident #28 or his roommate.
-4:54 pm- Med Aide #1 exited Resident #28's room.
-4:57 pm- Med Aide #1 re-entered Resident #28's room.
-4:58 pm- Med Aide #1 exited Resident #28's room.
-4:59 pm- Per the Med Administration Audit report, Med Aide #1 signed that she administered Ipratropium-albuterol inhalation solution (nebulizer) to Resident #28.
-5:00 pm- Med Aide #1 on the 200- hall with med cart and Nurse #13 at med cart on opposite end of hall.
-5:08 pm- Med Aide #1 entered Resident #28's room and exited a few seconds later then left the hall.
-5:51 pm- Med Aide #1 left 200-hall with med cart and was not observed returning with the med cart before 7:00 pm.
A review of video footage from camera #7 on 3/09/24 from 7:00 am to 7:00 pm showed a hall's length view but did not show a view of the Resident #28's room. The view shows blurry parts of Med Aide #1 standing at the med cart, sometimes showing only the bottom half of her legs, leaving the med cart, returning to the med cart around similar or the same footage times that were viewed on camera #14.
During a phone interview on 3/14/24 at 4:36 pm NA #1 revealed she was assigned to Resident #28 on day shift on 3/9/24 and each time she answered his call bell or checked on him from the morning through the afternoon, the Resident requested a breathing treatment. She further revealed she informed Nurse #10 on at least three occasions that the Resident was requesting his breathing treatment. The third time she informed Nurse #10 of the Resident's request for his breathing treatment, Nurse #1 stated she was on break and that NA #1 should ask Med Aide #1. NA #1 stated she located Med Aide #1 in another resident's room watching a soccer game and informed her of the Resident's request for medication. NA #1 stated Med Aide #1 replied ok. NA #1 further revealed when she went to check on the Resident during the afternoon, the Resident was on his cell phone with a family member and gave NA #1 the phone. NA #1 spoke with the family member on the phone and apologized that there was nothing else she could do but keep telling the nurse that the Resident was requesting a nebulizer treatment. NA #1 stated she returned to the Resident's room later in the afternoon and the Resident stated he still had not received his breathing treatment, then asked her did you see the nurse? when is the nurse coming. The NA further stated the Resident was not gasping for air and she could not determine whether he was short of breath because he seemed frustrated and was trying to maintain his composure.
During an interview on 3/14/24 at 12:21 pm Med Aide #1 stated she was assigned to Resident #28 on the 7:00 am- 7:00 pm shift on 3/9/24 and 3/10/24 and was responsible for administering his medications and breathing treatments. She further stated on 3/9/24 NA #1 did not inform her that Resident #28 needed a breathing (nebulizer) treatment on 3/9/24 during the 7am- 7pm shift. Med Aide #1 indicated she administered a breathing treatment to Resident #28 three times during her shift (morning, afternoon, and before evening) on 3/9/24 and 3/10/24.
During an interview on 3/14/24 at 12:02 pm Nurse #10 revealed she supervised Med Aide #1 on 3/9/24 who was assigned to Resident #28, and she was never informed the Resident reported chest pains or difficulty breathing and requested a breathing treatment. She further revealed she had no conversations with NA #1 about Resident #28 during the day shift on 3/9/24.
During a phone interview on 3/14/24 at 11:21 am Resident #28's Family Member, indicated she resided out of state and received several phone calls from the Resident on 3/9/24. She stated she was a nurse and was working when the Resident left her a voice mail message about 1:58 pm about how he pressed his call bell, NA #1 responded, and he told her he needed a breathing treatment and he had not received it. She returned his call at about 5:15 pm to see if the Resident received his treatment. Resident #28 told her that he was experiencing chest pains and had been requesting his scheduled breathing treatments for at least 3 hours. The family member further indicated at one point during the day (about 5:15 pm) when she spoke to the Resident, she also spoke with the NA #1, on the Resident's cell phone when the NA went in to check on the Resident. The family member stated NA #1 told her she had reported to Nurse #10 on several occasions the Resident needed a breathing treatment and at one point Nurse #10 stated she was on break and that the NA needed to find someone else. The family member stated she was so upset, she demanded to know what was going on and NA #1 attempted to have a nurse who was out in the hall come into the Resident's room to talk to her, but the nurse would not come to the phone. The family member further indicated every time she spoke with the Resident, he seemed out of breath as evidenced by speaking in a reserved manner to preserve his breath and she could tell he was short of breath. The family stated she was so upset she called the hospice phone number and left a voice mail message for the Hospice Administrator at 5:05 pm and left messages about the Resident's report of difficulty breathing. When the family member called the Resident about 6:00 pm, the Resident stated he had just received a nebulizer treatment from the nurse and that he was feeling better. The family member also stated the Resident was only confused when he needed breathing treatment, and she truly believed him when he stated he was having difficulty. The family member stated she spoke with the Resident on 3/10/24 after she came from church, and he stated he was ok. She stated when she spoke with the Resident on Tuesday 3/12/24, he stated Sunday was a little rough, but he did not go into detail, then said it was ok.
During a phone interview on 3/15/24 at 8:16 pm the Hospice Nurse revealed she visits Resident #28 on Monday/Friday every week and that the Resident was very upset when he reported to her on 3/11/24 that his scheduled nebulizer treatments were not given on time on 3/9/24 and 3/10/24. She stated that the Resident did not give specific times he did not receive his nebulizer treatments but that he only received one treatment during 7:00 am to 7:00 pm shifts and should have received four nebulizer treatments each day during those shifts. The Hospice Nurse stated the Resident had high anxiety and she believed what he was telling her because she had heard similar stories from other residents related to not receiving their medications.
During an interview on 3/14/24 at 1:10 pm Unit Manager #2 revealed she spoke with the Resident #28 on Monday or Tuesday (3/11/24 or 3/12/24), after the State Surveyor informed her Resident #28 had concerns about incidents that occurred over the weekend (3/9/24 and 3/10/24), related to not receiving his nebulizer treatments. Unit Manager #2 further revealed the Resident did not mention he did not receive his breathing treatments but that he did not get his medications on time over the weekend. Unit Manager #2 stated she informed the Director of Nursing (DON) of the concerns after she spoke to the resident.
During an interview on 3/14/24 at 1:00 pm the DON indicated he was not made aware of Resident #28's concerns until 3/14/24 related to not receiving medications over the weekend (3/9/24 and 3/10/24). The DON further indicated he expected all residents to receive their medications as prescribed and call bells to be answered in a timely manner.
During a phone interview on 3/14/24 at 5:00 pm the facility Nurse Practitioner (NP) indicated scheduled breathing treatments could have helped Resident #28's symptoms if he received them. She further indicated the Resident was probably upset and became more air hungry, anxious, and bronchioles constricted despite receiving oxygen at 3 liters. The NP indicated her expectation was for Resident #28 to receive all his scheduled medications as ordered.
During a phone interview on 3/14/24 at 5:27 pm the Medical Director revealed he took over as Medical Director in January 2024 and was not yet familiar with Resident #28. He further revealed the Resident could have had a significant decline when he did not receive his breathing treatments as ordered and not receiving breathing treatments may have caused the symptoms that included: increased shortness of breath, wheezing and increased stress. The Medical Director stated the Resident's symptoms caused him to contact his family member who called hospice when he could not get assistance from the facility. The Medical Director indicated his expectation was for staff members to administer medications as ordered.
The Administrator was notified of immediate jeopardy on 3/16/24 at 6:00 pm.
The facility provided the following credible allegation of immediate jeopardy removal.
Identify those recipients who have suffered, or are likely to suffer, a serious adverse outcome as a result of the noncompliance.
On 3/9/24 and 3/10/24 the facility failed to prevent a significant medication error when Resident # 28, who has diagnoses including COPD with respiratory failure and CHF, was not administered scheduled nebulizer treatments as ordered by the physician at 9 AM (Budesonide), 11 AM (Ipratropium-Albuterol), 1 PM (Formoterol Fumarate) and 5 PM (Ipratropium-Albuterol) despite repeated requests.
On 3/11/2024, Resident #28 was seen by the Nurse Practitioner at the request of Hospice nurse for shortness of breath and chest pain. He reported these symptoms to the Hospice Nurse on 3/11/24. Per Nurse Practitioner, Resident #28 to continue Morphine for pain and restlessness and new order for Hydromet Syrup 5-1.5 MG/5ML (Hydrocodone-Homatropine) 5ml every 6 hrs. for cough/congestion. Resident #28 reported to the Hospice Nurse on 3/11/24 that he only received one nebulizer treatment for the 7am to 7pm shifts on 3/9/24 and 3/10/24 was having shortness of breath and chest pain. Hospice nurse reports resident does have anxiety regarding not receiving medications and a combination of the anxiety and trouble breathing is triggering his PTSD per the hospice progress note.
The resident was interviewed by the Administrator on 3/14/24 about 3/9/24 and 3/10/24 and not receiving nebulizer treatments. The resident reported he suffered from chest pain as a result of not receiving the scheduled nebulizer medication. The resident continues to have assessments (respiratory, pain assessments) to assess for any serious adverse outcome including any significant decline or respiratory distress. Resident # 28 is receiving routine vital signs every shift including pulse ox (documented in the medical record) and daily nursing assessments of his respiratory status.
On 3/14/2024, Medication Aide #1 was immediately suspended pending investigation.
On 03/14/2024, the Director of Nursing notified the provider of the significant medication error when Resident #28 was not administered his scheduled nebulizer treatments as ordered by the physician which included the 9 AM (Budesonide), 11 AM (Ipratropium-Albuterol), 1 PM (Formoterol Fumarate) and 5 PM (Ipratropium-Albuterol) despite repeated requests.
On 3/14/2024, the Director of Nursing and Unit Managers completed medication administration audit by reviewing the electronic record for 3/9/2024 to 3/10/2024 for all shifts. The results were: All scheduled medications documented as administered.
On 03/14/2024, the DON and the ADON conducted interviews that were completed on current residents with BIMs of 13 or higher indicating no cognitive impairment and they were asked if they have any concerns with medication administration and if they had received all of their scheduled medications. This included residents on the 200 halls where Resident #28 resides. The results included that there were no residents who reported any concerns with their medications being administered and they had no significant decline or respiratory distress and reported receiving their scheduled medications. All residents with a BIMs of 12 or below with cognitive impairment were assessed observing for any acute distress (shortness of breath verbal/nonverbal indicators of pain) by Unit Managers for any significant decline or respiratory distress. This included residents on the 200 halls. The results were no other residents identified with any significant decline or respiratory distress.
The Director of Nursing determined on 3/15/24 that no other residents were impacted by the medication error when no other current alert residents with a Brief Interview of Mental Status (BIMs) of 13 or greater reported any concerns with having received their medications and when all other current residents with a BIMs of 12 or less indicating cognitive impairment were assessed for any change in condition including any significant decline, pain or respiratory distress with none noted and all vital signs were at baseline.
On 03/15/2024 the Director of Nursing (DON) and Assistant Director of Nursing initiated random medication observations of the licensed nurses and the medication aides to ensure that all residents received their scheduled medication and that the 6 rights of medication administration were followed including documenting administration of medications that were administered. This was completed on 03/15/2024 and there were no negative findings.
Director of Nursing, and /or Assistant Director of Nursing and/or Unit Managers and /or Nurse Managers completed Medication Pass Observations using a Medication Observation Tool, on 5 licensed nurses, and 1 medication aid with no concerns identified. This was completed on 03/15/2024.
Specify the action the entity will take to alter the process or system failure to prevent a serious adverse outcome from occurring or recurring, and when the action will be complete.
On 03/15/2024, the Administrator and Director of Nursing conducted a root cause analysis and determined that the root cause of the alleged error was that Medication Aide #1 failed to follow facility policy related to medication administration and 6 rights of medication administration and disregard of resident's rights by ignoring request by Nurse Aide #1 for administration of Resident #28's nebulizer treatment. Video footage revealed Medication Aide #1 did not administer nebulizer treatments as ordered. The video was reviewed for the 7a-7p shifts on 3/9/24 and 3/10/24.
All Full Time and Part Time and as needed (PRN) Nursing (Registered Nurses, Licensed Practical Nurses) and Medication aides will be educated on the following preventing medication errors, the 6 rights of medication administration (right medication right patient, right dose, right time, right route, and right documentation) and following medication safety practices by the Director of Nursing, Nurse Managers and Staff Development Nurse. Education began on 03/14/2024. In person training was completed and the in-service topics included preventing medication errors, the 6 rights of medication administration (right medication right patient, right dose, right time, right route, and right documentation-signing MAR after administering medication). The Director of Nursing will review staffing schedules daily to ensure that anyone that did not receive the in-service training by 03/15/2024 will not be allowed to work until the training is complete. This training will be incorporated into the general orientation program and education for agency staff. The education was provided in person both days on 3/14/24 and 3/15/24 by the Assistant Director of Nursing in the facility.
The Administrator and Director of Nursing will communicate with all nursing staff beginning 3/18/24 via meeting, phone, and nursing huddles to reiterate that Resident #28 and all other residents, are not to be neglected, retaliated against and all residents receive the ordered care and services. The Director of Nursing will ensure any staff not communicated with will not be able to work until communication is complete. All new staff will be trained during orientation by nursing leadership.
The Interdisciplinary Team (Administrator, Director of Nursing, Nurse Managers, Minimum Data Set Coordinators, Unit Manager, Support nurse, Therapy, Health Information Management, Dietary Manager, Medical Director, Pharmacist), were notified of the significant medication error by 03/15/2024 and were involved in the removal plan. DON will be responsible for ensuring the removal plan is implemented. Immediate Jeopardy Removal Date: 03/19/2024
F760 - Date of immediate jeopardy removal: 03/19/2024.
On 03/26/24, the facility's immediate jeopardy removal plan effective 03/19/24 was validated by the following: Nursing staff interviews revealed they had received education on the 6 rights of medication administration. Administrative staff interviews revealed they had completed audits of nurses and medication aides during medication pass. The facilities medication error rate was 0% during the medication pass facility task completed by the survey team.
The immediate jeopardy removal date of 3/19/24 was 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
Deficiency F0557
(Tag F0557)
Could have caused harm · This affected 1 resident
**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observations, resident and staff interviews and record review, the facility failed to honor a resident's right to keep ...
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**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observations, resident and staff interviews and record review, the facility failed to honor a resident's right to keep personal equipment in his room per his preference. This failure occurred for 1 of 2 sampled residents reviewed for personal property (Resident #36).
The findings included:
Resident #36 was admitted to the facility on [DATE]. Resident #36 was his own responsible party.
A quarterly Minimum Data Set (MDS) assessment dated [DATE] assessed Resident #36 with intact cognition, adequate hearing, adequate vision, clear speech, understood by others and able to understand others.
Resident #36 was interviewed and observed on 3/11/24 at 11:48 AM. He stated that he ordered an ice cream maker online about one to two months ago and that he used it to make ice and ice cream for himself and his roommate. During the interview, an ice cream maker was observed in his room available for use.
Nurse #8 documented in a progress note dated 3/11/24 that around 11:30 PM, she responded to a call for help from Resident #36 after a fall. The NP was contacted, and Resident #36 was sent to the emergency room (ER) for further evaluation.
Unit Manager #2 recorded a progress note dated 3/12/24 at 2:23 PM that Resident #26 returned to the facility from the ER with no new orders.
During a follow up interview with Resident #36 on 3/13/24 at 1:10 PM, Resident #36 stated that he returned from the ER on [DATE] and when he got back to his room, his ice cream maker was gone. Resident #36 further stated They just took it, no one told me, and I don't know why they took it and stated that he wanted his ice cream maker back.
An interview with the Maintenance Director occurred on 3/13/24 at 2:00 PM and revealed that Resident #36 had an ice cream maker in his room that he used for about 1 month. The Maintenance Director stated he checked the ice cream maker before it was used to make sure it was safe to operate in the facility. The Maintenance Director further stated that Resident #36 went to the ER and returned to the facility on 3/12/24. While Resident #36 was gone, the Maintenance Director stated that he removed the ice cream maker from his room as part of a decluttering plan the Resident agreed to and placed it in storage. The Maintenance Director stated that Resident #36 did not identify the ice cream maker as an item he wanted removed from his room as part of the declutter plan, and that he did not ask his permission before it was removed. The Maintenance Director further stated that he thought it was best to remove the ice cream maker while Resident #36 was gone. The Maintenance Director stated that he should have asked Resident #36 first before removing the ice maker from his room while he was away from the facility.
A phone interview with the Administrator and Regional Quality Assessment and Assurance Nurse Consultant occurred on 3/16/24 at 5:01 PM. The Administrator stated that Resident #36 had a conversation with staff about organizing his room and that she thought that while he was in the ER recently that staff should remove it to determine if the ice cream maker was a fire hazard. She stated that she was not aware that the Maintenance Director had already assessed the ice cream maker before it was used and determined that it was not a fire hazard. After further thought, the Administrator stated that she was not in support of removing the ice cream maker from Resident #36's room without his permission. The Administrator further stated that staff should have given Resident #36 a call to notify him that the ice cream maker was being removed since it was removed from his room while he was in the ER.
CONCERN
(D)
📢 Someone Reported This
A family member, employee, or ombudsman was alarmed enough to file a formal complaint
Potential for Harm - no one hurt, but risky conditions existed
Safe Environment
(Tag F0584)
Could have caused harm · This affected 1 resident
Based on observation and staff interviews, the facility failed to ensure residents wheelchairs were in good repair for 2 of 2 residents reviewed for environmental concerns (Residents #54 and #94).
Th...
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Based on observation and staff interviews, the facility failed to ensure residents wheelchairs were in good repair for 2 of 2 residents reviewed for environmental concerns (Residents #54 and #94).
The findings included:
A. An observation was made on 3/11/24 at 11:30 AM of Resident #54 seated in her wheelchair in her room. The right armrest of the wheelchair had a two inch piece of orange tape with 1 inch of yellow foam exposed.
B. An observation was made on 3/11/24 at 10:15 AM of Resident #94 while she was lying in bed. Her wheelchair was observed pulled up next to her bed. The left armrest of the wheelchair had two inches of exposed yellow foam.
On 3/13/24 at 8:31 AM, an interview occurred with the Maintenance Director, who stated he was responsible for the maintenance of wheelchairs. If staff found a problem, they were to fill out the maintenance work orders, and he addressed it. He observed Resident #54 and #94's wheelchair armrests with the exposed foam. The Maintenance Director stated if he had been aware of the condition of the armrests, he would have switched them out.
The Administrator was interviewed on 3/14/24 at 12:31 PM and stated it was her expectation for wheelchairs to be in good repair.
CONCERN
(D)
📢 Someone Reported This
A family member, employee, or ombudsman was alarmed enough to file a formal complaint
Potential for Harm - no one hurt, but risky conditions existed
Deficiency F0602
(Tag F0602)
Could have caused harm · This affected 1 resident
**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on record review, family interview, staff interviews and video observation, the facility failed to protect a resident's ri...
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**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on record review, family interview, staff interviews and video observation, the facility failed to protect a resident's right to be free from misappropriation of resident property when a housekeeper staff member#1 (floor tech) used a resident's credit card and made multiple unauthorized purchases that included, the facility vending machine, grocery stores, gas stations, vape stores, shopping stores, restaurants and liquor stores. This occurred for 1 of 4 residents (Resident #98) reviewed for misappropriation of resident property.
The findings included:
Resident #98 was admitted to the facility on [DATE] and discharged on 12/28/23 at 5:45am. Resident #98 passed away later the same day in the hospital.
A review of the admission Minimum Data Set (MDS) dated [DATE] indicated Resident #98 was cognitively intact.
Review of the initial report to the state read in part incident date was 12/28/23, The facility became aware of the incident on 01/02/2024 at 12:45pm when Resident #98's family member called the facility and reported Resident #98's missing credit card and driver's license.
An interview was conducted with the Administrator on 03/14/24 at 8:15am, she indicated she received a call from Resident #98's family member on 01/02/24 and the family stated Resident #98's credit card and driver's license had been stolen at the facility. The Administrator indicated that she informed the family that she would be following the facility's abuse protocol for the allegation of the missing items. The Administrator also indicated she called the family back on 01/03/24 and provided an update on the investigation about what was observed on the video camera of the housekeeping staff member #1 observed to enter Resident #98's room and then go to the vending machine after exiting the Resident's room. The administrator indicated she had informed the family member the police were notified of this information, and they informed her they would escalate the information to the fraud department.
On 03/14/23 at 8:30am a review of the bank credit transaction forms received from the bank was received by the facility on 01/02/24 from Resident #98's family member. The bank credit transaction forms revealed several unauthorized purchases made on 12/28/23 through 12/31/23 that included multiple charges from the facility vending machine, grocery store, gas stations, vape stores, food restaurants, shopping stores, and liquor stores.
Attempted to contact Resident #98's family was made on 03/14/24 at 8:45am and was unsuccessful.
Attempted to contact housekeeping staff member #1 on 03/14/24 at 8:55am, however voice mail indicated it was not a working number.
Attempted to contact the Police officer was made on 03/14/23 at 9:00am and again on 03/15/24 and was unsuccessful.
An interview was conducted with the Social Worker (SW) on 03/14/24 at 9:30am and she indicated the Housekeeping Supervisor came to her on 12/28/23, (she was unsure of the time) with Resident #98's purse. The SW indicated she directed the Housekeeping Supervisor to give the purse to the Administrator or to the Business Office. SW indicated she never touched the purse, but she knew Resident #98 had been sent out to the hospital earlier that morning.
An observation of the facility's video camera was done on 3/14/24 at 11:12am, and the video camera revealed on 12/28/23 at 12:30pm the housekeeping staff member #1 entered Resident #98 room. He left the room around 12:35pm and was observed going to the facility's vending machine near the 300 and 400 halls around 12:37pm. Housekeeping staff member #1 was observed to make two purchases from the vending machine.
An interview was conducted with Resident #98's family member on 03/15/24 at 9:00am, and he indicated they canceled the credit card, contacted the police department, and called the facility once they reviewed Resident #98's accounts. The family member indicated the police had not reached out to him since he made the report, but stated he was informed it could take 3 to 6 months or longer before the case would be closed. The family member indicated the Administrator had reached out to the family and explained the process of the investigation.
An interview was conducted with housekeeping staff member #2 on 03/15/24 at 9:30am. Housekeeping staff member #2 indicated she did not see Resident #98's purse in her room on 12/28/23. She indicated she had been informed to clean up Resident #98's room because she had left to go to the hospital early that morning. Housekeeping staff member #2 indicated the room was clean, and she only mopped over the floor because there were footprints on the floor. Housekeeping staff member #2 indicated she had no knowledge of any missing items at the time.
An interview with the Housekeeping Supervisor on 03/15/24 at 9:45am occurred and she indicated she retrieved Resident #98's purse from her room and was informed by the SW to take it to the Business Office. The Housekeeping Supervisor indicated that she gave the purse to the Business Office Manager on 12/28/23. She indicated she never opened the purse.
Review of statement from the Business Office Manager dated 01/08/24 read in part To Whom It May Concern, Regarding Resident #98's personal belongings (purse). Upon Resident #98's discharge to the hospital, the Housekeeping Supervisor came to the business office and gave her Resident #98's purse. The Business Office Manager indicated she locked the purse in the closet in the business office until the family picked up the purse.
A review of the investigation report dated 01/09/24 read in part, Resident # 98 's family member reported on 01/02/24 Resident #98's credit card and driver's license were missing out of her purse. The facility contacted the police and Adult Protective Services (APS). The facility interviewed alert and oriented residents regarding misappropriation of resident property with no concerns. They audited grievances made of missing monies/items and found no issues. They collected statements from staff members who were also in the room on the day of the incident, and no one had observed the credit card or driver's license. The facility reviewed the cameras from 12/28/23 the day Resident #98 went to the hospital and the cameras showed the housekeeping staff member #1 entering the Resident's room, after the Resident had discharged and was showed to leave the Resident's room and go to the vending machine at 12:37pm. The family provided a charge of five dollars on 12/28/23 at 12:39pm from the facility's vending machine. The police were in contact with the family and informed them an investigation was ongoing. The video footage determined a reason to substantiate.
An interview was conducted with the Director of Nursing (DON) on 03/15/24 at 12:42pm and he revealed he had not been made aware of Resident #98's missing property until the family called the facility on 01/02/24. The DON indicated the facility had a zero tolerance of abuse, neglect, and misappropriation of resident's property.
An interview was conducted with the Administrator on 03/15/24 at 1:15pm, she indicated she followed the facility's abuse policies and procedures for the investigation for Resident #98's missing credit card and driver's license and the facility had zero tolerance of misappropriation of resident's property. She also indicated that the facility completed a full plan of correction.
The facility provided the following corrective action plan with a completion date of 01/06/24.
Corrective action for resident involved:
On 1/2/2024, Resident #98 son notified facility of charges made to resident's credit card following discharge from facility on 12/28/2023 to hospital. On 1/2/2024, Administrator submitted an initial allegation report for misappropriation of resident property and notified police and APS. On 1/2/2024, the Administrator suspended interviewed Housekeeper#1 pending investigation. On 1/2/2024, Administrator reviewed video footage for 12/28/2023 and noted housekeeper#1 entering and exiting resident#1 room following discharge to hospital on [DATE] and using card to purchase items from vending machine in dining room between 300 and 400 halls. On 1/2/2024, Administrator provided [[NAME]] police department with investigation findings and completed report of incident. On 1/2/24, Resident's son notified Administrator that Citi Bank would be reimbursing resident's account for fraudulent charges. On 1/5/2024, Administrator concluded investigation and substantiated allegation related to misappropriation and based on investigation findings the root cause of incident was due to housekeeper#1 failing to follow facility policy related to abuse to include misappropriation. On 1/5/2024, a Quality Assurance and Performance Improvement meeting was held with the Interdisciplinary Team to review findings of investigation with no additional findings. On 1/9/2024, the Administrator completed an investigation report and submitted an investigation report to the Department of Health and Human Services.
Corrective action for potentially impacted residents:
Beginning 1/2/2024, the Administrator and Director of Nursing identified residents that would be potentially impacted by the alleged deficient practice by completing resident interviews for all current resident with BIMS of 13 or higher and asked if they had any concerns with misappropriation of property. Grievances/concerns were reviewed for the last 30 days to identify any concerns related to misappropriation of property for residents with BIMS of 12 or less. This was completed by 1/3/2024.
Results included: No other residents identified with issues related to misappropriation of property.
On 1/5/2024, after concluding investigation, the Quality Assurance Committee convened to discuss the misappropriation of resident property and the status of the investigation.
There were no additional findings at that time.
Systemic Changes:
On 1/2/2024, the Administrator began servicing all full-time, part-time and PRN (as needed) staff (including agency) on ABUSE (Misappropriation of Resident Property) policy. This training will include all current staff including the agency. This training included: ABUSE (Misappropriation of Resident Property). On 1/3/2024, the Administrator and Director of Nursing verbally reeducated residents and family regarding policy related to Inventory List, Resident Personal Items.
As of 1/4/2024, 20 % of staff members have not attended the in-service. The Administrator will ensure that any of the above-identified staff who do not complete the in-service training by 1/5/2024 will not be allowed to work until the training is completed.
Quality Assurance:
Beginning the week of 1/8/2024, The Administrator or designee will monitor misappropriation of resident property using the QA Tool for Misappropriation. The Administrator will monitor Misappropriation of Residents Property using the QA Tool for Misappropriation by interviewing 4 residents weekly regarding missing money or personal items and monitor any concerns daily for 4 weeks. This will be completed weekly for 4 weeks and 8 Residents monthly for 2 months and all newly admitted Residents. Reports will be presented to the weekly QA committee by the Administrator or Director of Nursing to ensure corrective action initiated as appropriate. Compliance will be monitored, and the ongoing auditing program reviewed at the weekly QA Meeting. The weekly QA Meeting is attended by the Administrator, Director of Nursing, MDS Coordinator, Social Worker, Therapy Manager, Health Information Manager, and the Dietary Manager.
Compliance date: 1/06/2024
The facility's corrective action plan was validated on 03/15/24 when staff interviews revealed they received education on the Abuse policy and procedures, residents' rights to be free from physical abuse, neglect, and misappropriation of resident property . The education included documentation and reporting to management immediately when they become aware of reported, suspected abuse, misappropriation and/or injury. Nurse's Aides must submit the reports of misappropriation of resident property, and/or abuse issues daily to the Nurse/Unit Manager immediately. The Unit Manager will review information and submit it to the Director of Nursing and the Administrator. Facility documentation revealed staff were trained on the following topics and additional training: abuse policy and procedures, residents' rights education, misappropriation of resident property and interviewing for abuse, nurse notification and assessment, the residents. Attestations related to the abuse training were signed by trained staff for the verbal education that was provided. Staff indicated they were trained prior to working their next shifts. Newly hired staff received an in-service service prior to working and this was verified by the facility trainers and orientation form. The completion/compliance date of 01/06/24 was 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
Deficiency F0604
(Tag F0604)
Could have caused harm · This affected 1 resident
**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observations, record review, Nurse Practitioner, and staff interviews, the facility failed to recognize the use of an a...
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**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observations, record review, Nurse Practitioner, and staff interviews, the facility failed to recognize the use of an abdominal binder (a wide compression belt that encircles the abdomen) as a physical restraint for 1 of 1 resident (Resident #400) reviewed for physical restraints.
The findings included:
Resident #400 was admitted to the facility on [DATE] with diagnoses that included intracranial hemorrhage, presence of a gastrostomy tube (G-tube), and dementia.
Resident #400's admission Minimum Data Set (MDS) assessment was still in progress.
Review of Resident #400's baseline care plan did not include a care plan for the use of an abdominal binder as a restraint.
A review of Resident #400's active physician orders did not include an order for the use of an abdominal binder.
Review of Resident #400's medical record did not reveal documented evidence of a consent for the use of a restraint or restraint assessment.
A nursing progress note dated 3/13/24 read in part: resident pulls at G-tube, abdominal binder in place.
On 3/13/24 at 1:30 PM, an interview was conducted with Nurse #1. She explained that Resident #400 had the abdominal binder present when he arrived from the hospital and it had been kept in place to prevent him from pulling out the feeding tube. She was unaware the abdominal binder could be considered a restraint. Nurse #1 further stated that the abdominal binder was unfastened when she provided tube feeding care, medications, and nutrition, otherwise it was secured in place with Velcro. She stated Resident #400 was unable to remove the abdominal binder.
An interview occurred with Assistant Director of Nursing (ADON) on 3/13/24 at 1:35 PM who explained that Resident #400 was admitted to the facility with the abdominal binder in place to prevent pulling him from pulling out the feeding tube. The abdominal binder was removed during bathing, care to the feeding tube, and when medications and nutrition was provided via the feeding tube. She explained she felt the abdominal binder was used for safety and had not considered it a restraint.
The Director of Nursing (DON) was interviewed on 3/13/24 at 1:45 PM who confirmed there was no documentation of a restraint consent or restraint assessment in the medical record for Resident #400. The DON stated the binder was being used to prevent Resident #400 from pulling out the feeding tube and was unaware it could be considered a restraint.
On 3/13/24 at 2:10 PM, an interview occurred with Nurse Practitioner #1, who stated she was aware Resident #400 was using an abdominal binder but felt it was being used as an intervention to prevent him from pulling on the feeding tube.
Nurse Aide (NA) #2 was interviewed on 3/13/24 at 3:20 PM and cared for Resident #400 on the 3:00 PM to 11:00 PM shift. She explained an abdominal binder had been present since he arrived at the facility and stated, he becomes agitated with personal care. He has very spastic movements with his hands and tries to pull out the feeding tube when the abdominal binder isn't there. She added she had not observed him trying to remove the abdominal binder.
On 3/14/24 at 6:33 AM, an interview was conducted with Nurse #2 who cared for Resident #400 on the 7:00 PM to 7:00 AM shift. She explained the abdominal binder had been utilized since he was admitted to the facility and was unfastened during medication and nutrition administrations.
An interview was completed with NA #3 on 3/14/24 at 6:50 AM. She was assigned to care for Resident #400 on the 11:00 PM to 7:00 AM shift and stated that Resident #400 had an abdominal binder in place since his admission to the facility. She explained the abdominal binder was released during personal care and that although Resident #400 becomes combative with personal care he was unable to release the abdominal binder.
An observation was conducted on 3/14/24 at 8:37 AM with Nurse #1. She lifted Resident #400's shirt and a white colored abdominal binder, approximately 10-12 inches wide that extended around his abdomen and secured with Velcro was observed. Nurse #1 asked Resident #400 to attempt to remove the abdominal binder. After several prompts it was evident that Resident #400 could not follow commands and made no visible effort to touch the binder. She then proceeded to unfasten the abdominal binder and provide Resident #400 with his medications and nutrition via the feeding tube.
In an interview with the Administrator on 3/14/24 at 12:31 PM, she stated Resident #400's abdominal binder was medically necessary but was unaware it could be considered a restraint.
CONCERN
(D)
📢 Someone Reported This
A family member, employee, or ombudsman was alarmed enough to file a formal complaint
Potential for Harm - no one hurt, but risky conditions existed
Comprehensive Care Plan
(Tag F0656)
Could have caused harm · This affected 1 resident
**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on record review, observations, and staff interviews, the facility failed to develop an individualized, person-centered co...
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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 develop an individualized, person-centered comprehensive care plan in the areas of wound care (Resident #399) and splints (Resident #11). This deficient practice was for 2 of 26 residents whose comprehensive care plans were reviewed.
The findings included:
1. Resident #399 was admitted to the facility on [DATE] with diagnoses that included a periprosthetic fracture of the left hip, chronic embolism (a block in the artery), and thrombosis (blood clot) of deep veins of the lower extremities, and dementia. Resident #399 was discharged from the facility on 1/2/2023.
A review of Resident #399's admission Minimum Data Set (MDS) dated [DATE] revealed Resident #399 had severe cognitive impairment and required extensive 2-person assistance with activities of daily living (ADL). The MDS revealed no presence of wounds or wound care.
Review of the care plan dated 12/21/2023 revealed Resident #399 was care planned for being at risk for pressure ulcer development due to decreased ability to assist with repositioning with interventions to observe skin for redness and open areas and inform nurse if any areas noted and utilize pressure reducing mattress. Resident #399's care plan did not address the presence of any actual wounds and Resident #399's care plan had not been updated or revised.
Review of the admission nursing assessment completed on 12/20/2023 by Nurse #4 revealed no documented alterations in skin integrity.
Review of the Nurse Practitioner (NP#1) acute visit on 12/26/2023 revealed:
#1. Right great toe necrotic (dead tissue with black, dry, and leathery appearance) wound.
#2. Right great toe and second toe were crossed over each other
#3. Right heel wound with skin coming off
An interview was conducted with NP #1on 03/14/2024 at 11:14 AM. NP #1 revealed Resident #399 presented to the facility with a wound on his right foot. She further stated that when she evaluated Resident #399 on 12/26/2023, his right great toe was necrotic, and the right great toe and the second toe were crossed over each other. She also stated Resident #399 also had a wound to his right heel which was opened. NP #1 further indicated that wound care was ordered and a consult for the wound care doctor was made on 12/26/2023.
An interview was conducted with the MDS Nurse #1 on 03/14/2024 at 1:39 PM. MDS Nurse #1 revealed he used the admission nursing assessment to complete Resident #399's MDS (Minimum Data Set) and care plans. MDS Nurse #1 also stated that there was no documentation in Resident #399 medical record related to wounds therefore Resident #399 was only care planned for being at risk for skin breakdown. The MDS nurses also revealed that Resident #399's care plan had not been revised or updated.
An interview was conducted with the Administrator on 03/14/2023 at 2:00 PM. The administrator stated she expected the care plan to be reflective of the resident's current clinical condition including skin issues and presence of wounds.
2. Resident #11 was admitted to the facility on [DATE] with diagnoses that included contractures to the right and left knee and dementia.
A review of the annual Minimum Data Set (MDS) assessment dated [DATE], revealed Resident #11 had severe cognitive impairment with no behaviors.
Review of Resident #11's Physical Therapy Discharge summary dated [DATE] indicated she was discharged from therapy with bilateral knee splints for limited range of motion to her knees.
Review of a Restorative or Maintenance Form dated 1/20/24 indicated Resident #11 was to wear bilateral knee splints for five to six hours as tolerated when in bed.
A review of Resident #11's active care plan, last reviewed 2/21/24, included a focus area for limited physical mobility related to contractures but did not address the use of bilateral knee splints.
On 3/14/24 at 3:39 PM, an interview occurred with MDS Nurse #1 who reviewed Resident #11's active care plan and confirmed the therapy recommendation for bilateral knee splints was not present. Stated he felt it was an oversight.
The Director of Nursing was interviewed on 3/14/24 at 4:58 PM and stated it was his expectation for the care plan to be comprehensive and should have included the bilateral knee splints.
CONCERN
(D)
📢 Someone Reported This
A family member, employee, or ombudsman was alarmed enough to file a formal complaint
Potential for Harm - no one hurt, but risky conditions existed
Deficiency F0657
(Tag F0657)
Could have caused harm · This affected 1 resident
**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on record review and staff interviews, the facility failed to revise the care plan for an intravenous (IV) medication (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 revise the care plan for an intravenous (IV) medication (Resident #22). This was for 1 of 26 active resident care plans reviewed.
The findings included:
Resident #22 was initially admitted to the facility on [DATE] with diagnoses that included diabetes and retention of urine.
The medical record for Resident #22 was reviewed and indicated she received Vancomycin (an antibiotic) 1250 milligrams (mg) per 250 milliliters (ml). Use 1250 mg intravenously one time a day from 2/1/24 until 2/12/24.
A review of the February 2024 Medication Administration Record (MAR) revealed Resident #22 received Vancomycin via IV as ordered from 2/1/24 to 2/12/24.
A practitioner progress note dated 2/14/24 indicated the midline (a type of IV catheter) was removed from Resident #22.
Resident #22's active care plan, last reviewed 3/5/24, included a focus area for I am receiving IV fluids via midline with risk for complications such as infection and infiltration.
A review of the March 2024 MAR revealed Resident #22 did not receive any type of IV antibiotics or fluids.
On 3/14/24 at 11:50 AM, an interview occurred with the Minimum Data Set (MDS) Nurse #1 . After reviewing Resident #22's active care plan and medical record he confirmed the IV antibiotics were discontinued on 2/12/24 and the IV catheter was discontinued on 2/14/24. He stated this care plan focus area should have been resolved when it was reviewed on 3/5/24 and felt like it was an oversight.
The Administrator was interviewed on 3/14/24 at 12:31 PM and indicated it was her expectation for the care plan to be accurate representation of the resident.
CONCERN
(D)
📢 Someone Reported This
A family member, employee, or ombudsman was alarmed enough to file a formal complaint
Potential for Harm - no one hurt, but risky conditions existed
Deficiency F0658
(Tag F0658)
Could have caused harm · This affected 1 resident
**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on record review, Nurse Practitioner, and staff interviews, the facility failed to transcribe the correct medication admin...
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**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on record review, Nurse Practitioner, and staff interviews, the facility failed to transcribe the correct medication administration route for 1 of 3 residents reviewed for gastric feeding tube (Resident #400).
The findings included:
Resident #400 was admitted to the facility on [DATE], with diagnoses that included intracranial hemorrhage and presence of a gastrostomy tube.
Review of the baseline care plan included a focus area initiated on 3/6/24 revealed Resident #400 required tube feeding for all nutrition, fluids, and medications.
The active March 2024 physician orders included an order dated 3/5/24 for Labetalol 200 milligrams (mg) one table by mouth two times a day for hypertension. All other medications were written to be provided through the gastric feeding tube. The physician's orders indicated Resident #400 was to have nothing by mouth (NPO).
On 3/13/24 at 11:25 AM, an interview occurred with Nurse Practitioner #1 who stated that Resident #400 was NPO and received all his medications via the feeding tube.
An interview occurred with Nurse #1 on 3/13/24 at 1:30 PM who was working the medication cart for Resident #400's hall and had administered his medications earlier. The nurse confirmed Resident #400 did not receive any medications by mouth and that she had provided the morning dose of Labetalol through the feeding tube. Nurse #1 was also the nurse that entered the order for Resident #400 into the Electronic Medical Record (EMR). Nurse #1 explained she entered the medication, dose, and frequency into the EMR but failed to change the medication route to gastrostomy tube (G-tube). Stated the default route was by mouth.
The Director of Nursing (DON) was interviewed on 3/14/24 at 12:41 PM. He reviewed Resident #400's physician orders and confirmed the route for the Labetalol was entered as oral instead of via G-tube. He further explained that when entering the medication into the EMR the default route was oral and he felt it was an oversight that the nurse failed to change the route to G-tube. The DON stated it was his expectation for all medication administration routes to be entered correctly when the order was transcribed.
CONCERN
(D)
📢 Someone Reported This
A family member, employee, or ombudsman was alarmed enough to file a formal complaint
Potential for Harm - no one hurt, but risky conditions existed
Quality of Care
(Tag F0684)
Could have caused harm · This affected 1 resident
**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observations, resident, staff and Nurse Practitioner interviews, the facility failed to accurately assess and failed to...
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**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observations, resident, staff and Nurse Practitioner interviews, the facility failed to accurately assess and failed to obtain wound care orders for skin condition of the right great toe and the right heel (Resident #399). The facility also failed to follow a physician order to remove staples from a surgical wound (Resident #93). The deficient practice was for 2 of 4 sampled residents for wound care (Resident #93 and Resident #399).
The findings included:
1. Review of Resident #399's hospital Discharge summary dated [DATE] revealed Resident #399 would be discharged to the facility but had no documentation regarding Resident #399 right foot wound or wound care orders.
Resident #399 was admitted to the facility on [DATE] with diagnoses that included a periprosthetic fracture of the left hip, chronic embolism (a block in the artery), and thrombosis (blood clot) of deep veins of the lower extremities, and dementia. Resident #399 was discharged from the facility on 1/2/2024.
Review of the Nurse Practitioner's (NP #1) hospital discharge summary review of an incoming new admission note dated 12/20/2023 at 5:57 PM revealed no notation regarding Resident #399's right foot wounds or wound care orders.
Review of the facility's admission skin assessment completed on 12/20/2023 at 6:48 PM by Nurse #4 revealed Resident #399 had intact skin with no skin issues identified.
Review of the facility's admission nursing assessment completed on 12/20/2023 at 6:54 PM by Nurse #4 revealed an initial skin assessment was completed with no skin abnormalities observed.
An interview was completed on 03/13/2024 at 2:14 PM with Nurse #4 who admitted Resident #339 to the facility on [DATE]. Nurse #4 revealed that she completed the admission nursing assessment on Resident #399. She also stated that she did a head-to-toe skin assessment, and her documentation would reflect her assessment, but she did not remember much about Resident #399.
Review of Resident #399's care plan dated 12/21/2023 revealed Resident #399 was care planned for being at risk for pressure ulcer development due to decreased ability to assist with repositioning with interventions to observe skin for redness and open areas and inform nurse if any areas noted and utilize pressure reducing mattress. Resident #399's care plan did not address the presence of any actual wounds.
Review of a nursing note dated 12/23/2024 at 2:18 PM completed by Nurse #3 revealed the occupational therapist (OT #1) informed Nurse #3 that resident #399 was bleeding from his right heel. Nurse #3 removed Resident #399's sock and observed the right heel to have had a skin tear. The right heel wound was cleaned with normal saline (NS) and steri-strips were applied and covered with dry dressing. There were no orders written for wound care.
An interview was conducted with occupational therapist (OT #1) on 03/14/2024 at 3:11 PM. OT #1 stated that she was assisting Resident #399 on 12/23/2024 with ambulation and noticed his right sock was wet and red. She assisted Resident #399 to a sitting position and immediately went and got Resident #399's nurse (Nurse #3) to assess Resident #399's heel.
Several unsuccessful attempts were made to contact and interview Nurse #3.
Review of a nursing note dated 12/24/2024 at 6:37 PM by Nurse #3 revealed Resident #399 was alert with some confusion and was compliant of all medications. Resident #399 was observed with a right heel skin tear. Nurse #3 applied a dry dressing and wrapped the right heel with Kerlix. An entry was also placed in the physician's communication book for Resident #399 to be seen and evaluated by the wound physician for right heel skin tear.
Review of NP #1 visit on 12/26/2023 at 12:03 PM revealed NP #1 noted a right heel wound with skin coming off and the right great toe with a necrotic wound with right the great toe and the second toe crossed. NP #1 ordered a wound physician consult for the right heel and the right great toe. NP #1 also ordered to paint Resident #399's right great toe with betadine twice a day.
Review of a subsequent weekly skin assessment dated [DATE] completed by Nurse #12 revealed no new skin concerns and no documentation of the right heel wound or the right great toe wound.
Several unsuccessful attempts were made to contact and interview Nurse #12.
A review of Resident #399's admission Minimum Data Set (MDS) dated [DATE] revealed Resident #399 had severe cognitive impairment and required extensive 2-person assistance with activities of daily living (ADL). The MDS revealed no presence of wounds or skin issues.
Review of the physician orders revealed on 12/28/2023 an order was placed to clean Resident #399's right heel with normal saline (NS), apply betadine, and wrap with Kling daily.
Review of Resident #399's December 2023 Treatment Administration Record revealed all treatments were completed as ordered by the physician.
Review of Resident #399 electronic medical record revealed no facility wound measurements were documented for Resident #399's right heel or right great toe.
An interview was conducted with the NP on 03/14/2024 at 11:14 AM and on 03/19/2024 at 3:30 PM. NP #1 stated Resident #339 was admitted to the facility with a necrotic right toe. NP#1 also stated from her clinical assessment and discussion with Resident #399's wife, who told the NP #1 that Resident #399 had issues with his right great toe for over 10 years. NP #1 stated the necrotic toe was not a new finding as Resident #399 had severe peripheral artery disease (PAD) and both lower legs and feet were discolored from lack of circulation to the lower extremities. She further stated that when she evaluated Resident #399 on 12/26/2023 his right great toe was black, and the right great toe and the second toe were crossed. Resident #399 also had a skin tear on his right heel which had started to open. NP#1 indicated she thought the right heel wound had opened because Resident #399 was walking to and from the bathroom with a walker and that caused the skin tear to open. NP #1 also stated that she ordered the right great toe painted with betadine twice a day, the right heel to be cleansed with normal saline and wrapped with gauze daily and a consult for the wound care physician to evaluate both wounds. She stated she changed the right heel wound care orders on 12/28/2024 to clean the right heel with normal saline (NS), apply betadine, and wrap with Kling daily. NP#1 also revealed it was unlikely that Resident #399's wounds on his right feet would heal due to the severity of the PAD. She further stated the wound care doctor was scheduled to see Resident #399 on 01/02/2024 but Resident #399 was transferred to the hospital before the wound care doctor saw him.
An interview was conducted with the Director of Nursing (DON) 03/14/2024 at 1:51 PM who stated he was not familiar with Resident #399, but he expected an accurate head to toe skin assessment be performed on all residents and the skin assessment should be documented completely and accurately.
2. Resident #93 was admitted to the facility on [DATE] with a diagnosis of displaced intertrochanter fracture to the right femur repair.
A hospital Discharge summary dated [DATE] revealed a physician order to remove the staples post operative day #14. The hospital discharge summary revealed Resident #93 had surgery to repair the right femur on 02/12/24.
An admission Minimum Data Set (MDS) assessment dated [DATE] revealed Resident #93 was moderately cognitively impaired. Resident #93 was coded as having a surgical wound.
The active physician's orders for February 2024 for Resident #93 included no orders to remove the resident's staples post operatively.
On 03/11/24 at 10:36 AM an interview was conducted with Resident #93's Responsible Party (RP)#1. During the interview she stated the resident had a right hip surgery repair approximately 4 weeks prior and that her surgical site was looking good with the staples still intact.
On 03/12/24 at 2:10 PM an observation was conducted with Nurse #6 of Resident #93's surgical site to the right hip. During the observation 3 incision sites were noted to the right hip with a total of 17 staples present in the surgical site. Nurse #6 stated, the site looks great.
On 03/12/24 at 2:15 PM an interview was conducted with Nurse #6. During the interview the surveyor asked Nurse #6 to review Resident #93's hospital discharge summary orders. She stated she saw an order to remove the resident's surgical staples post operatively on day 14 which should have been 02/26/24. The interview revealed Unit Manager #1 had completed the resident's admission and should have entered the order into the system for it to show up onto the Treatment Administration Record for the nurse to remove the staples. Nurse #6 stated the order was never entered into the system. She stated she typically worked third shift and did not realize when Resident #93's surgical staples needed to be removed.
On 03/12/24 at 2:30 PM an interview was conducted with Unit Manager #1. During the interview she stated once a resident was admitted into the facility, she would take the hospital discharge summary and input the physician orders into the electronic system. She stated the order had been missed by her when she was completing the resident's admission. Unit Manager #1 stated the resident's staples should have been removed on 02/26/24 and she would have to notify Nurse Practitioner #1.
On 03/12/24 at 2:45 PM an interview was conducted with Nurse Practitioner #1. During the interview she stated she stated she had just given Unit Manager #1 a verbal order to remove the surgical staples immediately. She stated the staples should have been removed per the physician orders on the hospital discharge summary but since it had only been two weeks past the 14th day that it shouldn't be an issue to remove the staples. She stated she would evaluate the resident's incision site the following day.
An observation was conducted on 03/12/24 at 3:02 PM of Unit Manager #1 removing Resident #93's staples from the surgical incision located on her right hip. Unit Manager #1 removed a total of 17 staples from the surgical site without difficulty. Resident #93 fell asleep during the procedure.
On 03/12/24 at 3:50 PM an interview was conducted with the Director of Nursing (DON). During the interview he stated the nurses should follow the orders listed on the hospital discharge summary. He stated the staples should have been removed post operatively on day 14 and it should have been caught during the weekly skin assessments.
On 03/12/24 at 4:20 PM an interview was conducted with Wound Physician #1. During the interview he stated he had not seen Resident #93 but that he often had to tell staff when he saw staples in surgical wounds, that they needed to be removed.
CONCERN
(D)
📢 Someone Reported This
A family member, employee, or ombudsman was alarmed enough to file a formal complaint
Potential for Harm - no one hurt, but risky conditions existed
Deficiency F0688
(Tag F0688)
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 apply bilateral knee splints according to ther...
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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 apply bilateral knee splints according to therapy recommendations for 1 of 1 resident reviewed for limited range of motion (Resident #11).
The findings included:
Resident #11 was admitted to the facility on [DATE] with diagnoses that included contractures to the right and left knee and dementia.
A Physical Therapy (PT) initial evaluation dated 1/5/24 indicated Resident #11 would receive therapy for decreased range of motion to her bilateral knees.
A PT Discharge summary dated [DATE] indicated Resident #11 received therapy for limited range of motion to her bilateral knees. She was discharged to nursing to don/doff the braces when in bed.
The Rehab Director was interviewed on 3/14/24 at 2:54 PM and explained that Resident #11 was under PT therapy caseload for decreased range of motion to her knees. When she was discharged , nursing would continue to apply the bilateral knee splints when she was in bed.
The Rehab Director was interviewed again on 3/14/24 at 4:09 PM and explained that upon discharge from therapy, nursing staff were educated and trained on the application of the bilateral knee splints for Resident #11. The Rehab Director added the therapy department typically did not enter orders into the resident's chart regarding splinting devices but would have provided a referral form to nursing when the resident was discharged . Together an observation occurred of Resident #11's room and the bilateral knee splints were not present.
Review of Restorative or Maintenance Record (referral form) dated 1/20/24, indicated nursing staff was educated on the bilateral knee splints for Resident #11. The record indicated that bilateral knee extensor braces were to be worn for five to six hours as tolerated when in bed.
A review of Resident #11's active care plan, last reviewed 2/21/24, included a focus area for limited physical mobility related to contractures. The interventions did not include the use of bilateral knee splints.
An annual Minimum Data Set (MDS) assessment dated [DATE] indicated Resident #11 had severe cognitive impairment and was coded inaccurately with no limited range of motion.
A review of the February 2024 and March 2024 Medication Administration Record (MAR) and Treatment Administration Record (TAR) did not include an entry for Resident #11's bilateral knee splint application or removal.
On 3/13/24 at 3:28 PM, Nurse Aide (NA) #5 was interviewed and stated she cared for Resident #11 on the 7:00 AM to 7:00 PM shift. She explained that Resident #11 used her hands to self-propel in the wheelchair. She stated she has not seen Resident #11 with bilateral knee splints on nor has she been asked to apply or remove them.
NA #6 was interviewed on 3/13/24 at 5:18 PM and stated she has not seen bilateral knee splints on Resident #11 during the 7:00 AM to 7:00 PM shift.
Nurse #12 was interviewed on 3/14/24 at 7:10 AM and stated he cared for Resident #11 during the 7:00 PM to 7:00 AM shift. He stated Resident #11 didn't wear bilateral knee splints and was unaware she was supposed to.
An observation of Resident #11 occurred on 3/14/24 at 3:45 PM. She was lying in bed and did not have knee splints on.
Nurse #5 was interviewed on 3/14/24 at 3:54 PM, who was assigned to care for Resident #11 on the 7:00 AM to 7:00 PM shift. She stated she had not applied any knee splints to her and did not see an order for this on the administration records.
The Director of Nursing was interviewed on 3/14/24 at 4:58 PM and explained the order for Resident #11's bilateral knee splints did not show up on the NA flow record or nursing MAR/TAR because when the order was put in it was put in under an auxiliary tab which did not go anywhere. He further stated there was a drop down box when the order was put in and the TAR box should have been checked so the order would show up for the nursing staff to put on and remove the bilateral knee splints.
CONCERN
(D)
📢 Someone Reported This
A family member, employee, or ombudsman was alarmed enough to file a formal complaint
Potential for Harm - no one hurt, but risky conditions existed
Deficiency F0692
(Tag F0692)
Could have caused harm · This affected 1 resident
**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observations, interviews with the Registered Dietitian (RD), the Nurse Practitioner (NP) #1 and NP #2, staff, and recor...
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**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observations, interviews with the Registered Dietitian (RD), the Nurse Practitioner (NP) #1 and NP #2, staff, and record review, the facility failed to follow a recommendation from the RD to reweigh Resident #36 for further evaluation after an assessment of significant weight loss. Additionally, the facility failed to implement a plan from NP #2 in response to subtherapeutic total protein lab results for Resident #11. This failure occurred for 2 of 7 sampled residents reviewed for nutritional status.
The findings included:
1. Resident #36 was admitted to the facility on [DATE]. Diagnoses included severe obesity, lymphedema, peripheral arterial disease, resistant hypertension, chronic cellulitis of right/left lower limbs, supplemental oxygen dependency, obstructive sleep apnea, hypercholesterolemia, gastro-esophageal reflux disease, and type 2 diabetes mellitus, among others.
A quarterly Minimum Data Set assessment dated [DATE] assessed Resident #36 with intact cognition, no behaviors, and no rejection of care. He weighed 326 pounds with no significant weight loss/gain. He received a therapeutic diet and diuretic therapy.
A care plan revised on 1/9/24 revealed he had the potential for nutritional decline due to severe obesity, receipt of a therapeutic diet, diuretic therapy, and a history of weight gain. Interventions included RD evaluations and recommendations.
The electronic medical record for Resident #36 recorded the following weights:
- 1/2/24, 326 pounds
- 2/2/24, 305 pounds (21pound loss)
Review of the electronic medical record for Resident #36 revealed his last recorded weight was obtained on 2/2/24.
A RD progress note dated 2/6/24, recorded a weight warning of 6.4% weight change in 30 days with a recommendation to obtain a reweight due to a large discrepancy from the previous weight.
Electronic mail (email) communication dated 3/11/24 was provided to the surveyor by the RD for review. The subject was recorded as, Weight list has been reviewed and documented a request from the RD to the Unit Manager (UM) #2 to obtain a monthly weight for Resident #36 for March 2024.
A 3/11/24 NP #1 progress note recorded Resident #36 was assessed for chronic left lower extremity edema, chronic cellulitis, and weeping. NP#1 ordered antibiotic therapy for 10 days.
At the request of the surveyor, staff obtained a current weight for Resident #36 on 3/13/24 of 349 pounds, a gain of 44 pounds, or 14.4%, in 30 days.
A 3/13/24 nurse progress note written by Unit Manager (UM) #2 recorded the NP (NP #1) was notified of Resident #36's weight gain and a new physician (MD) order was written to give extra Lasix 40 mg once daily for three days due to significant weight gain.
Review of MD orders for Resident #36 revealed the following medications were prescribed:
- A MD order dated 11/15/23, Furosemide (diuretic for removing excess fluid) 20 milligrams (mg) give one tablet by mouth two times a day.
- A MD order dated 3/11/24, Doxycycline Monohydrate Capsule (antibiotic) 100 mg, give 1 capsule by mouth two times a day for chronic cellulitis, for 10 days.
- A MD order dated 3/13/24, Furosemide 40 mg, give one tablet by mouth in the afternoon for increased weight for 3 days.
Resident #36 was interviewed and observed on 3/11/24 at 11:48 AM in his recliner in his room. His right and left lower extremities were observed swollen, red, and peeling. He stated that for the past month, he had increased pain in his left lower leg due to the swelling. He stated that he received pain medication daily for his pain, and that it usually relieved his pain, but for the past month, due to the increased swelling, the pain medication had not worked as well. He also stated that he had not reported this concern to staff.
Resident #36 was interviewed and observed on 3/13/24 at 5:08 PM. During the interview, he was eating dinner. His right and left lower extremities were both observed swollen, red, and peeling. He stated that he was weighed monthly at the facility and received diuretic therapy for his legs. He stated his last weight was obtained once in February 2024 and reflected weight loss.
The Unit Manager (UM) #2 was interviewed on 3/14/24 at 1:53 PM and stated that the facility received electronic mail (email) communication from the RD when she had residents, she wanted reweighed. The UM #2 stated she did recall receiving an email from the RD requesting a reweight for Resident #36 and that she was responsible for obtaining reweights for the RD. The UM #2 stated she could not recall if she obtained a reweight for Resident #36 at the request of the RD, but that she would obtain his weight. A follow up interview with the UM #2 on 3/14/24 at 2:45 PM revealed the current weight for Resident #36 was 349 pounds.
The RD was interviewed on 3/14/24 at 1:01 PM. The RD stated she sent an email on 2/6/24 to the facility to request a reweight for Resident #36 because of the significant weight loss in 30 days. The RD stated she sent a second email to the facility on 3/11/24 to follow up on her request, but that she had not yet received a response. The RD provided copies of the emails for review. In a follow up interview with the RD on 3/14/24 at 3:00 PM she stated the current weight for Resident #36 was 349 pounds, which was a 14.4% gain. The RD stated that a gain of that amount, was likely fluid, and that he should be evaluated by the provider due to the significant increase for a possible decline in his cardiac status and the risk of exacerbating his diagnoses of lymphedema and chronic cellulitis.
A 3/14/24 RD progress note recorded Resident #36 was noted with a significant weight gain of 14.4% in 30 days which was discussed with the Unit Manager (UM #2) to notify the provider of the significant weight gain.
A phone interview with the NP #1 on 3/14/24 at 4:00 PM revealed she received notification on 3/14/24 of the current weight for Resident #36 and due to his significant weight gain, she ordered diuretic therapy for three days. The NP stated that Resident #36 required intermittent diuretic therapy a lot, due to diagnoses of lymphedema, severe obesity, and chronic cellulitis, but that in her current assessment, he did not present clinically with signs or symptoms of distress because of the current weight gain. NP #1 stated she saw Resident #36 asleep in his recliner during her clinical rounds on Friday, 3/8/24, but because he was asleep, she did not talk to him. She stated that his legs were swollen, but were not elevated, and that on 3/11/24 when she saw him during clinical rounds, his legs were noted with increased swelling, more swollen than they were on Friday, 3/8/24 so she ordered antibiotic therapy to address his chronic cellulitis. The NP #1 stated that she would expect the RD recommendation to obtain a reweight to be completed within a week or so for further evaluation of the clinical risks associated with significant weight changes.
A phone interview with the Administrator and Regional Quality Assessment and Assurance Nurse Consultant occurred on 3/16/24 at 5:01 PM. The Administrator stated that if the RD recommends a reweight, it should be obtained within one week. She further stated that if the weight results reflected a significant loss/gain, the results were discussed during clinical meetings and the provider was notified for further evaluation.
2. Resident #11 was admitted to the facility on [DATE]. Diagnoses included protein calorie malnutrition (PCM), dementia, chronic kidney disease (CKD) stage 3, abnormality of albumin (a protein made in the liver), and adult failure to thrive, among others.
Review of the electronic medical record for Resident #11 recorded a physician order dated 12/9/21 for a pureed textured diet.
Continued review revealed lab results for Resident #11 dated 7/26/23 from a Comprehensive Metabolic Panel (CMP) (a blood test) which indicated total protein results of 5.9 grams/deciliter (g/dl). The normal range was recorded as 6.0 - 8.3 g/dl.
The nutrition care plan revised 1/9/24 identified Resident #11 was at risk for nutritional decline due to receipt of a mechanically altered diet. Interventions included obtaining and monitoring lab/diagnostic work as ordered, reporting results to the provider, and following up as indicated.
A quarterly Minimum Data Set assessment dated [DATE] assessed Resident #11 with severely impaired cognition, and receipt of a mechanically altered diet.
A 2/16/24 progress note written by NP #2 recorded lab results were reviewed regarding her diagnoses of CKD, PCM and a history of subtherapeutic total protein lab results (5.9 g/dl on 7/26/23). The NP #2 wrote a plan for PCM, to continue a (brand name) protein supplement and update labs.
Review of the medical record for Resident #11 revealed there was no active physician order for a protein supplement.
A CMP for Resident #11 dated 2/21/24 indicated total protein results were 5.8 g/dl (low).
A NP #2 progress note dated 3/6/24 recorded NP #2 assessed Resident #11 for a monthly visit and reviewed labs from February 2024 and noted her total protein results were 5.8 g/dl (low). NP #2 did not record any new orders or changes regarding the lab results.
Resident #11 was observed in her room on 3/13/24 at 5:30 PM eating her dinner meal independently. She received a pureed meal per diet order and ate 100% of her meal.
The Assistant Director of Nursing (ADON) stated in an interview on 3/14/24 at 11:44 AM that Resident #11 did not have a current order for a protein supplement. The ADON stated that it was not typical practice for nursing staff to review the NP progress notes to obtain orders, but that the NP usually wrote their own orders or gave nursing a verbal/written order to implement. The ADON stated she was not aware of a verbal/written order for a protein supplement for Resident #11.
The RD stated in an interview on 3/14/24 at 12:45 PM that she completed dietary assessments on admission, quarterly, annually and with a significant change, but that these assessments did not include a review of lab results. The RD stated that she would receive a request for a consultation if the provider identified a nutrition concern after admission that required RD intervention. The RD reviewed the electronic record for Resident #11 and stated that the last protein supplement order was because of low albumin lab results for Resident #11 and that the order was discontinued on 3/12/23. The RD further stated Resident #11 did not have a current order for a protein supplement.
A phone interview with NP #2 occurred on 3/14/24 at 11:24 AM. NP #2 stated that she was new to the facility, and when she completed her assessment of Resident #11 on 2/16/24 she reviewed her lab results history and noted Resident #11 had a history of total protein lab results that was slightly subtherapeutic, and that a protein supplement was effective for her in the past. NP #2 stated that since Resident #11 had been successful with receiving a protein supplement in the past, NP #2 wrote in her plan to continue the protein supplement because she thought the order for the protein supplement was still active. NP #2 stated that she thought Resident #11 was already receiving a protein supplement, so she wrote a plan to continue it. NP #2 stated it was her usual practice to write her own orders, but that in the case of Resident #11, she did not write a new order for the protein supplement because her plan was to continue a supplement that she thought Resident #11 currently received.
A phone interview with the Administrator and Regional Quality Assessment and Assurance (QAA) Nurse Consultant occurred on 3/16/24 at 5:01 PM. The Regional QAA Nurse Consultant stated that NP #2 wrote in her progress note on 2/16/24 for Resident #11 a plan to continue the protein supplement, but the physician order should have been relayed to nursing to implement the order or NP #2 should have written and implemented the order. The Administrator stated that she expected all physician orders to be reviewed and followed.
CONCERN
(D)
📢 Someone Reported This
A family member, employee, or ombudsman was alarmed enough to file a formal complaint
Potential for Harm - no one hurt, but risky conditions existed
Medical Records
(Tag F0842)
Could have caused harm · This affected 1 resident
**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** 3. Resident #198 was admitted to the facility on [DATE].
A physician order dated 2/27/24 specified Remedy nutrashield cream to ...
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**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** 3. Resident #198 was admitted to the facility on [DATE].
A physician order dated 2/27/24 specified Remedy nutrashield cream to buttock every shift and as needed for wound healing/prevention. Resident #198's physician orders did not indicate a cream ordered as needed to other areas of the skin.
A review of the Minimum Data Set assessment dated [DATE] revealed Resident #198 was moderately cognitively impaired.
An interview on 03/14/24 at 6:22 AM revealed Resident #198 was hurting and burning between her legs.
Nurse #12 was informed 3/14/24 at 6:34 AM by this surveyor that Resident #198 was burning and hurting between her legs. Nurse #12 indicated he would go get cream for her.
An observation with Nurse #12 of Resident #198 on 3/14/24 at 6:48 AM revealed Nurse #12 applied cream from a small tube to Resident #198's affected area.
A review of the standing orders 3/15/24 revealed orders for pressure ulcers and skin tears, but not for skin irritation.
A review of the nurse's progress notes dated 3/14/24 and 3/15/24 did not indicate any documentation regarding the skin assessment or the application of cream to the pink areas at the inguinal creases by Nurse #12.
Nurse #12 could not be reached for interview.
An interview with the Director of Nursing on 3/15/24 at 4:00 PM indicated his expectations would be for the staff to always document any treatment in the MAR and to document in the notes what treatment was for.
Based on record review and staff interviews the facility failed to maintain accurate electronic records for Resident #28 (1 of 6 sampled for administration of medications), Resident #71 (1 of 4 sampled for nutrition), and Resident #198 (1 of 1 resident sampled for the application of a medicated cream) who were reviewed for accuracy of resident records.
1. During an interview on 3/17/24 Unit Manager #1 indicated she answered Resident # 28's call bell and he requested acid reflux medication. Unit Manager #1 further indicated she left the Resident's room, retrieved an acid reflux medication, then returned and administered the acid reflux medication, which was a standing order. She stated since the Resident was not due for his scheduled omeprazole medication, she administered an acid reflux medication from the standing orders. Unit Manager #1 stated she was assisting Medication Aide #1 by administering the acid reflux medication to Resident #28 and expected Medication Aide #1 to sign off that the medication was given. Unit Manager #1 further indicated 3/9/24 was a very busy day and there was a lot going on. Unit Manager #1 stated she should have checked the Resident's Medication Administration Record (MAR) and entered that she had administered the medication.
A review of the MAR and Medication Administration Review audit report (indicates the date and time medications were initialed as administered on the Medication Administration Record) did not indicate the acid reflux medication was given on 3/9/24.
An interview with the Director of Nursing on 3/15/24 at 4:00 PM indicated his expectations would be for the staff to always document any medication administered on the MAR.
Medication Aide #1 was not available for an interview.
2. A physician's order dated 3/1/24 revealed weekly weights times 4 weeks, then monthly and as needed on day shift every 7 days were ordered for Resident #71.
Further review of the medical record revealed the most recent documented weight of 146 pounds on 2/23/24. There were no weights documented as ordered weekly from 3/1/24 through 3/13/24.
During an interview on 3/13/24 at 2:35 pm Nurse #10 revealed she kept a report sheet where she recorded Resident #71's weight from 3/1/24 as 145.5 pounds. Nurse #10 further revealed she weighed Resident #71 via geriatric wheelchair on 3/9/24 and could not locate the report sheet showing a weight for that day but could recall the Resident weighed 145 pounds. Nurse #10 stated she had not entered the Resident's weights for 3/1/24 and 3/9/24 into the electronic medical record.
CONCERN
(D)
📢 Someone Reported This
A family member, employee, or ombudsman was alarmed enough to file a formal complaint
Potential for Harm - no one hurt, but risky conditions existed
Deficiency F0919
(Tag F0919)
Could have caused harm · This affected 1 resident
**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observations, staff interviews, and record review, the facility failed to provide Resident #11 with a functional call l...
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**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observations, staff interviews, and record review, the facility failed to provide Resident #11 with a functional call light to request staff assistance for 3 of 3 days. This failure occurred for 1 of 2 sampled residents reviewed for a decline in activities of daily living.
The findings included:
Resident #11 was admitted to the facility on [DATE]. Diagnoses included moderate dementia with agitation.
The care plan revised 2/21/24 identified Resident #11 was at risk for decline in activities of daily living due to diagnoses of dementia, incontinence, and receipt of palliative services. Interventions included assisting with incontinence care, encouraging Resident to call for staff assistance prior to transfers, and keeping the call light within the Resident's reach.
An annual Minimum Data Set assessment dated [DATE] assessed Resident #11 with severely impaired cognition, adequate hearing, adequate vision with corrective lenses, clear speech, understood, understands, no impairment in range of motion, required extensive staff assistance with toileting and frequently incontinent of bowel/bladder.
Resident #11 was observed in her room and interviewed on 3/11/24 at 12:19 PM. Resident #11 was dressed in clothing, seated in her wheelchair, wearing gloves on both hands with a box of facial tissue next to her on the bed. Her call light was in reach. Her pants and brief were both pulled down to her knees and her right hand was inside the front section of her brief. Resident #11 stated that there was no toilet tissue in her bathroom, so she had to use this tissue (facial tissue) and that she needed toilet tissue. Resident #11 stated I need some tissue to wipe myself and there is none in here. Resident #11 was asked by the surveyor if she used her call light in her room to ask for staff assistance and she replied, I am not dumb you know, I know how to use my call bell, I pressed it, but no one came, so I am doing it myself. The surveyor observed that neither the wall panel light nor the light outside the room door were on when the Resident's call light in her room was engaged. Resident #11 stated she last used her call light yesterday, to request staff assistance and staff responded.
Nurse #6 was notified by the surveyor on 3/11/24 at 12:25 PM that Resident #11 needed staff assistance. Nurse #6 entered the Resident's room on 3/11/24 at 12:26 PM, observed Resident #11 and stated that she was wearing gloves with her brief and pants pulled down to her knees. Nurse #6 asked Resident #11 what she was doing, and the Resident stated that she needed toilet tissue to wipe herself. Nurse #6 reminded Resident #11 to use her call light when she needed staff assistance. The Resident replied, I did, but you didn't come, so I had to wipe myself. Nurse #6 stated to the Resident that her call light in her room was not on. Nurse #6 pressed the Resident's call light in her room, looked at the wall panel and the light outside the room door and said she would notify the Maintenance Director that her call light in her room did not work. Resident #11 received assistance from staff with incontinence care.
An observation occurred on 3/13/24 at 10:42 AM of the call light engaged for Resident #11 but the light on the wall panel in her room and the light outside the room door did not turn on.
Nurse #6 was interviewed on 3/13/24 at 10:45 AM and she stated that she reported to the Maintenance Director on Monday, 3/11/24 that the call light in the room for Resident #11 was not working. She did not recall what time she reported the call light to the Maintenance Director, but said she reported it as soon as she left the Resident's room on Monday, 3/11/24.
Nurse Aide (NA) #5 was interviewed on 3/13/24 at 3:28 PM. NA #5 stated she was assigned to care for Resident #11 at times on the 7 AM to 7 PM shift for the past five to six months. NA #5 described Resident #11 as alert, oriented with confusion, used her call light in her room frequently throughout the shift, but would also propel herself in her wheelchair into the hallway with her brief below her knees to wait for staff to come answer her call light. NA #5 stated Resident #11 required more assistance now with her care.
An interview with NA #6 occurred on 3/13/24 at 5:18 PM. NA #6 stated she was the assigned NA for Resident #11 routinely on the 7 AM to 7 PM shift. NA #6 stated Resident #11 required limited to extensive staff assistance with her nursing care due to dementia. NA #6 stated Resident #11 would use her call light in her room to ask for staff assistance and sometimes she would transfer herself to the toilet without requesting assistance. NA #6 stated that for the last couple of days Resident #11 did not use her call light as much.
Nurse #12 stated in an interview on 3/14/24 at 7:15 AM that he was the assigned Nurse routinely for Resident #11 on the 7 PM to 7 AM shift. He stated Resident #11 used her call light in her room all the time. He described that when she turned on her call light in her room, she then came into the hallway to see if staff were coming to see what she wanted.
An interview with the Maintenance Director occurred on 3/13/24 at 11:34 AM. He stated that Nurse #6 told him Yesterday, Tuesday, 3/12/24 that the call light in room [ROOM NUMBER] - B was not working. He stated, I repaired it today, I know that since it is a call light, it should be repaired immediately. He stated that when he went to room [ROOM NUMBER] - B, he identified that the call light cord in the room was burned out, so he replaced it. He further stated that the call light cord can burn out without notice and would not be identified until the call light was pressed, and staff noticed that the wall light in the room and the hall light outside the room door did not light up. The Maintenance Director further stated that he conducted room rounds daily and call light audits weekly checking randomly to identify any call lights that needed repair. He stated that he checked all call lights in the facility monthly and that his last monthly check was conducted on 2/29/24. He provided documentation of his last monthly call light audit dated 2/29/24 for review.
A phone interview with the Administrator and Regional Quality Assessment and Assurance Nurse Consultant occurred on 3/16/24 at 5:01 PM. The Administrator stated that maintenance staff should ensure all call lights were functional for residents who used them.
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
Assessment Accuracy
(Tag F0641)
Could have caused harm · This affected multiple residents
**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observations, staff interviews, and record reviews the facility failed to code the Minimum Data Set (MDS) assessment ac...
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**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observations, staff interviews, and record reviews the facility failed to code the Minimum Data Set (MDS) assessment accurately in the areas of wounds (Resident #399), hospice services (Resident #22), range of motion (Resident #11), and tube feeding (Resident #57). This deficient practice was identified for 4 of 18 sampled residents.
The findings included:
1. Resident #399 was admitted to the facility on [DATE] with diagnoses that included a periprosthetic fracture of the left hip, chronic embolism (a block in the artery), and thrombosis (blood clot) of deep veins of the lower extremities, and dementia. Resident #399 was discharged from the facility on 1/2/2023.
Review of the admission nursing assessment completed on 12/20/2023 by Nurse #4 revealed no alterations in skin integrity including skin conditions or wounds.
Review of NP #1 visit on 12/26/2023 at 12:03 PM revealed NP #1 evaluated and noted a right heel wound with skin coming off and the right great toe with a necrotic wound with right great toe and second toe crossed. NP #1 ordered a wound physician consult for right heel and right great toe and to paint right great toe with betadine twice a day.
A review of Resident #399's admission Minimum Data Set (MDS) dated [DATE] revealed Resident #399 had severe cognitive impairment. The MDS revealed no presence of wounds.
An interview was conducted with NP #1 on 03/14/2024 at 11:14 AM. NP #1 revealed Resident #339 presented to the facility with a wound on his right great toe. She further stated that when she evaluated Resident #399, his right great toe was necrotic, and the right great toe and the second toe were crossed. She also stated Resident #399 also had a wound on his right heel which was opened. NP #1 also stated that wound care was ordered and a consult for the wound care doctor was made on 12/26/2023.
An interview was conducted with the MDS Nurse #1 on 03/14/2024 at 12:39 PM. MDS Nurse #1 revealed he reviewed the admission nursing assessment to complete Section M (Skin Conditions) on the MDS. MDS Nurse #1 also stated that there was no nursing documentation in Resident #399 medical record related to wounds or skin conditions.
An interview was conducted with the DON on 03/14/2024 at 1:20 PM. The DON stated that he expected all MDS's be completely accurately based on the resident's clinical status.
An interview was conducted with the Administrator on 03/14/2023 at 2:00 PM. The administrator stated that her expectation was for the MDS to be reflective of the resident's clinical condition and completed accurately.
2. Resident #22 was originally admitted to the facility on [DATE] with diagnoses that included venous insufficiency and type 2 diabetes.
A care plan was initiated on 3/28/23, indicating Resident #22 was to receive palliative care, no terminal diagnosis was noted.
A physician's order dated 6/23/23 indicated Resident #22 received palliative care services.
Review of Resident #22's medical record did not reveal hospice service documentation.
A modified Significant Change in Status Minimum Data Set (MDS) assessment dated [DATE] revealed Resident #22 was coded with hospice care.
During an interview with the MDS Nurse #1 on 3/14/24 at 2:23 PM, he reviewed Resident #22's MDS assessment dated [DATE] as well as her medical record information and stated hospice care was marked in error.
The Administrator was interviewed on 3/14/24 at 12:31 PM and stated it was her expectation for the MDS assessments to be coded accurately.
3. Resident #11 was admitted to the facility on [DATE] and had diagnoses that included contractures to the right and left knee and dementia.
A Physical Therapy (PT) Discharge summary dated [DATE] indicated Resident #11 received therapy for limited range of motion to her bilateral knees. She was discharged to nursing to don/doff bilateral knee braces when in bed.
A review of Resident #11's active care plan, last reviewed 2/21/24, included a focus area for limited physical mobility related to contractures.
An annual Minimum Data Set (MDS) assessment dated [DATE] indicated Resident #11 had severe cognitive impairment and was not coded for any limited range of motion to the lower extremities.
On 3/14/24 at 2:53 PM, an interview occurred with the Rehab Director who explained that Resident #11 had decreased range of motion to her knees and was unable to fully straighten them out.
An observation of Resident #11 was conducted on 3/14/24 at 3:45 PM while she was lying in bed. She was unable to fully straighten out her legs when asked to do so.
During an interview with MDS Nurse #1 on 3/15/24 at 9:22 AM, he reviewed Resident #11's MDS assessment dated [DATE] as well as her medical record information and stated limited range of motion should have been marked for the lower extremities.
The Administrator was interviewed on 3/14/24 at 12:31 PM and stated it was her expectation for the MDS assessments to be coded accurately.
4. Resident #57 was admitted to the facility 5/20/22.
Diagnoses included nothing by mouth and attention to percutaneous endoscopic gastrostomy (PEG) tube, among others.
A physician (MD) order dated 7/13/23, recorded NPO (nothing by mouth) diet, and NPO texture.
A quarterly Minimum Data Set (MDS) assessment dated [DATE] assessed Resident #57 required extensive staff assistance with eating and received 51% or more of her calories from a tube feeding.
The MDS Coordinator was interviewed on 3/18/24 at 9:21 AM and reviewed Resident #57's quarterly MDS dated [DATE]. He stated that he did not complete this MDS, and that the MDS Coordinator who completed it no longer worked at the facility. In review of the MDS, he stated that Resident #57 had a NPO MD order dated 7/13/23 and that the 10/18/23 quarterly MDS should have assessed Resident #57 required total staff assistance for eating. He stated that the MDS was assessed incorrectly.
The Administrator and Regional Quality Assessment & Assurance (QAA) Nurse were interviewed together via phone on 3/16/24 at 5:01 PM. During the interview, the Regional QAA Nurse stated that the quarterly MDS assessment dated [DATE] for Resident #57 stated that the assessment of extensive assistance with eating was inaccurate because Resident #57 was totally dependent on staff to provide all her nutrition from an enteral product via a PEG tube. The QAA Nurse stated the MDS should have been coded as requiring total staff assistance. The QAA Nurse stated that the MDS was completed by prn (as needed) MDS staff who no longer worked at the facility.
CONCERN
(E)
📢 Someone Reported This
A family member, employee, or ombudsman was alarmed enough to file a formal complaint
Potential for Harm - no one hurt, but risky conditions existed
Deficiency F0679
(Tag F0679)
Could have caused harm · This affected multiple residents
**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on record review, resident, responsible party (RP) and staff interviews, the facility failed to ensure group activities we...
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**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on record review, resident, responsible party (RP) and staff interviews, the facility failed to ensure group activities were planned for rehabilitation residents to meet the needs of the residents who expressed that it was important to them to attend group activities for 3 of 3 residents reviewed for activities (Resident #37, Resident #85 and Resident #88).
The findings included:
A review of the March 2024 activity calendar revealed activities for inside of the facility during the week and on the weekends. Activities were scheduled daily at 11:00 AM and 2:00 PM for the duration of the month. The calendar revealed an ice cream social dated 03/01/24 and bingo twice a week on Tuesdays and Thursdays.
On 03/13/24 at 10:25 AM an interview was conducted with the Activities Assistant. During the interview she stated the activities were planned by the residents during a meeting held each month. The interview revealed most activities were held in the activity room on the long-term side of the building and events were usually held at 2:00 PM daily. She stated she would normally remind residents the day before the event and on the day of the event 30 minutes prior to start time would go to the rooms of the residents that she knew would want to participate and assist them to the activity. The interview revealed she and the Activities Director would typically split the building meaning she would ask the residents on the long-term care side of the building and the Activities Director would ask residents on the rehabilitation side of the building. She stated the Activities Director had been out of the facility since the beginning of March on leave. The Activities Assistant stated she had not gone to the rehabilitation side of the facility and asked residents if they wanted to attend activities scheduled. She stated she also assisted with resident admissions into the facility as part of her job duties assigned by the Administrator. She stated she only had 30 minutes to gather residents to attend activities and did not have time to go room to room to ask residents if they wanted to attend. The interview revealed she assisted the residents that needed to be pushed via wheelchair to the activities and if there was a large activity the Nurse Aides (NA) on the hall would assist. She stated she would ask the NA's on the hall for assistance getting the residents to the activity room.
1. Resident #37 was admitted to the facility on [DATE] and most recently readmitted on [DATE].
An admission Minimum Data Set (MDS) dated [DATE] indicated Resident #37 felt that it was very important to have activities that included doing things in a group setting. The assessment further indicated Resident #37 was moderately cognitively impaired.
A care plan dated 02/06/24 revealed a focus area for Resident #37's interest in group bingo events. The goal was for Resident #37 to participate in group bingo events when offered. Interventions included providing reminders and assistance to group activity of interest.
On 03/11/23 at 11:39 AM an interview was conducted with Resident #37's Responsible Party (RP) #1. During the interview she stated Resident #37 had been discharged to the hospital and recently readmitted back to the facility (2/22/24). She stated since he had returned, he was moved to the 400 hall on the rehabilitation side of the facility. The interview revealed no staff members had come to the room and asked Resident #37 if he wanted to attend the bingo activity that the facility had twice a week. She stated on 03/01/24 the facility had an ice cream social; the interview revealed the resident had observed a staff member walk down the hall with a bowl of ice cream and told her he would like to have some ice cream. RP #1 stated she had to push the resident in his wheelchair and go find where the facility was having the ice cream social event for him to attend. She stated activities were very important to the resident and sometimes she wasn't in the building to take him. RP #1 stated all residents should be included in the activities not just the residents on the long-term side of the building.
On 03/13/24 at 10:13 AM a follow up interview was conducted with RP #1. During the interview she stated according to the March activity Calendar the facility had bingo at 2:00 PM on 03/12/24. She stated she was in the resident's room on the afternoon of 3/21/24 and no one had come to the room and asked Resident #37 if he wanted to attend the activity.
On 03/13/24 at 10:50 AM an interview was conducted with Nurse Aide (NA) #2. During the interview NA #2 stated she had taken care of Resident #37 on a regular basis. NA#2 stated she had never asked Resident #37 if he wanted to attend any of the activities in the facility. NA#2 stated she thought she had seen someone from activities ask the residents if they wanted to attend.
On 03/13/24 at 10:59 AM an interview was conducted with Nurse #2. During the interview she stated she was regularly assigned to Resident #37. She indicated typically she observed someone from the Activities Department come to the hall and ask the residents if they would like to attend activities during the first week of their admission. She stated if the residents said no, then sometimes they were not asked again. She stated she had not seen anyone ask Resident #37 if he wanted to attend an activity.
On 03/13/24 at 10:35 AM an interview was conducted with the Director of Nursing (DON). During the interview he stated the Activities Director had been out of the facility on leave since the beginning of March. He stated he had not received any complaints of residents not being asked to attend activities. The interview revealed he felt the nursing staff were assisting residents to attend the activities that were scheduled.
On 03/13/24 at 11:48 AM an interview was conducted with the Administrator. During the interview she stated Resident #37's RP had never voiced any concerns to her of staff not asking if he wanted to attend activities. She stated the Activities Director had been out of the facility since the beginning of March and she was not aware of the arrangement between the Activities Director and her Assistant. The interview revealed she did not know why Resident #37 had not been asked to attend the activities in the facility.
2. Resident # 85 was admitted to the facility on [DATE] with diagnoses that included diabetes and a history of a stroke. She resided on the 300 hall, which was one of the two rehab halls.
An Activity Assessment completed by the Activity Director and dated 1/3/24 indicated the assessment was completed with Resident #85 who indicated she wanted to be invited to out of room activities.
The admission Minimum Data Set (MDS) assessment dated [DATE] indicated Resident #85 had severe cognitive impairment and displayed no behaviors. She was able to make herself understood and usually understood others. Preferences for Customary Routine and Activities (section F) indicated group activities were very important to her. A wheelchair was used for mobility.
On 3/13/24 at 10:25 AM, the Activities Assistant was interviewed. She explained that on a typical day when an activity is scheduled at 2:00 PM, she would remind residents the day prior and an hour before the activity by going to the rooms of the residents that she knew would participate. She added that the Activity Director normally went to the rehab side to do this task. The Activities Assistant stated that the Activity Director had been out of the facility since 3/5/24 and she had not been going to the rehab side of the building to inquire if residents wanted to go to any group activities because she didn't have enough time.
An observation and interview were conducted with Resident #85 on 3/13/24 at 1:33 PM. She was sitting in her wheelchair watching television (TV) in her room and stated she couldn't recall being asked to go to activities but, I love being around people and it would be nice to be asked.
A review of Resident #85's medical record from 12/28/23 to 3/14/24 didn't reveal any activity notes.
Activity logs for resident #85's participation in activities were not available for review.
On 3/14/24 at 8:32 AM, an interview occurred with Nurse Aide #13 who was assigned to care for Resident #85. She stated the activity calendars were in resident rooms and that sometimes activities will come and ask residents if they wanted to go to whatever was scheduled. She could not recall if Resident #85 was asked or assisted to attend group activities.
The Administrator was interviewed on 3/14/24 at 12:31 PM and stated she was not aware Resident #85 was not being included in group activities. The Administrator stated she didn't know the arrangement that was made by the Activity Director and Activities Assistant prior to the Activities Director leaving the facility on 3/5/24 regarding resident activity participation. She added it was her expectation that Resident #85 be invited and assisted as desired to group activities.
3. Resident #88 was admitted to the facility on [DATE] with recent left shoulder fracture. She resided on the 300 hall, which was one of the two rehab halls.
An Activity Assessment completed by the Activity Director and dated 2/1/24 indicated the assessment was completed with Resident #88 who indicated she wanted to be invited to out of room activities.
The admission MDS assessment dated [DATE] indicated Resident #88 had moderately impaired cognition and displayed no behaviors. Preferences for Customary Routine and Activities (section F) indicated group activities were very important to her.
Resident #88's care plan included a focus area for an interest in group activities and a willingness to participate. One of the interventions included to provide reminders and assistance to group activities of interest before they start.
On 3/13/24 at 10:25 AM, the Activities Assistant was interviewed. She explained that on a typical day when an activity was scheduled at 2:00 PM, she would remind residents the day prior and an hour before the activity by going to the rooms of the residents that she knew would participate. She added that the Activity Director normally went to the rehab side to do this task. The Activities Assistant stated that the Activity Director had been out of the facility since 3/5/24 and she had not been going to the rehab side of the building to inquire if residents wanted to go to any group activities because she didn't have enough time.
An observation and interview were conducted with Resident #88 on 3/13/24 at 1:39 PM. She was sitting in her wheelchair watching television (TV) and stated she hadn't been asked or told anything about the activities going on for the day but would like to be given a choice of attending or not.
A review of Resident #88's medical record from 1/25/24 to 3/14/24 did not include any activity notes.
Activity logs for resident #88's participation in activities were not available for review.
On 3/14/24 at 8:32 AM, an interview occurred with Nurse Aide #13 who was assigned to care for Resident #88. She stated activity calendars were in resident rooms and that sometimes activities will come and ask residents if they wanted to go to whatever was scheduled. She could not recall if Resident #88 was asked or assisted to attend group activities.
The Administrator was interviewed on 3/14/24 at 12:31 PM and stated she was not aware Resident #88 was not being included in group activities. The Administrator stated she didn't know the arrangements that were made by the Activity Director and Activities Assistant prior to her leaving the facility on 3/5/24 regarding resident activity participation. She added it was her expectation that Resident #88 was invited and assisted as desired to group activities.
CONCERN
(E)
📢 Someone Reported This
A family member, employee, or ombudsman was alarmed enough to file a formal complaint
Potential for Harm - no one hurt, but risky conditions existed
QAPI Program
(Tag F0867)
Could have caused harm · This affected multiple residents
Based on observations, record review, and staff interviews, the facility's Quality Assessment and Assurance (QAA) Committee failed to maintain implemented procedures and monitor the interventions that...
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Based on observations, record review, and staff interviews, the facility's Quality Assessment and Assurance (QAA) Committee failed to maintain implemented procedures and monitor the interventions that the committee put into place following the recertification and complaint investigation survey of 9/29/22. This failure occurred for four repeat deficiencies cited for resident's rights, accuracy of assessments, maintenance of nutrition and hydration status, and infection prevention and control that was subsequently recited on the current recertification and complaint investigation survey of 3/26/24. The continued failure of the facility during two federal surveys of record shows a pattern of the facility's inability to sustain an effective QAA Program.
The findings included:
This tag is cross referenced to:
F550 (Resident's Rights): Based on record review, observations, resident, and staff interviews, the facility failed to treat a resident (Resident #198) with dignity and respect when Nurse Aide #12 treated her roughly during personal care, causing her to cry. Resident #198 was observed to have pinkened areas at the creases of the thighs where the brief comes up between the legs. The facility also failed to provide care for 1 of 1 resident (Resident #17) in a dignified manner by leaving her uncovered in bed, in a soiled brief after being made aware of care needs. This was for 2 of 13 residents reviewed for dignity.
During the recertification and complaint survey of 9/29/22, the facility failed to provide incontinence care when requested to 1 of 6 sampled residents reviewed for dignity. This failure caused the resident to cry, expressing she felt worthless, horrible, bad and did not deserve this treatment.
F641 (Accuracy of Assessments): Based on observations, staff interviews, and record reviews the facility failed to code the Minimum Data Set (MDS) assessment accurately in the areas of wounds (Resident #399), hospice services (Resident #22), range of motion (Resident #11), and tube feeding (Resident #57). This deficient practice was identified for 4 of 18 sampled residents.
During the recertification and complaint survey of 9/29/22, the facility failed to code range of motion status accurately on the MDS for 1 of 19 residents reviewed for accuracy of assessments.
F692 (Maintenance of Nutrition and Hydration Status): Based on observations, interviews with the Registered Dietitian (RD), the Nurse Practitioner (NP) #1 and NP #2, staff, and record review, the facility failed to follow a recommendation from the RD to reweigh Resident #36 for further evaluation after an assessment of significant weight loss. Additionally, the facility failed to implement a plan from NP #2 in response to subtherapeutic total protein lab results for Resident #11. This failure occurred for 2 of 7 sampled residents reviewed for nutritional status.
During the recertification and complaint survey of 9/29/22, the facility failed to follow the recommendation of the Registered Dietitian to reweigh a resident with significant weight loss to determine the accuracy of the weight status. This failure occurred for 1 of 6 sampled residents reviewed for maintenance of nutrition status.
F880 (Infection Prevention and Control): Based on observations, staff interviews and record reviews the facility failed to implement their infection control policy when Nurse Aide (NA #4) did not perform hand hygiene between residents during meal delivery and meal assistance and Nurse Aide (NA #12) failed to doff soiled gloves and perform hand hygiene before exiting Resident #57's room to obtain incontinence care supplies. This deficient practice was observed for 2 of 2 nursing assistants observed for hand hygiene and had the potential to result in the cross contamination of microorganisms between residents and environmental surfaces.
During the recertification and complaint survey of 9/29/22, the facility failed to follow manufacturer guidelines for cleaning and disinfection of a glucose meter, stored in the medication cart that was used for a resident but was not designated for individual resident use.
The Administrator and the Regional QAA Nurse Consultant were interviewed by phone on 3/16/24 at 5:01 PM. During the interview, the Administrator stated that repeat deficiencies were reviewed during quarterly QA meetings which included a review of the QA plan to ensure that monitoring of the deficiency continued to prevent a reoccurrence of the same deficient practice. The Administrator also stated that during monitoring, if QAA committee identified that the deficiency was ongoing, staff received re-education and the concern was discussed during QAA meetings to identify any trends for continued monitoring. The Administrator stated that she was aware of the deficiencies from the 9/29/22 survey. The Regional QAA Nurse Consultant stated that the repeat deficiencies were related to staff taking shortcuts, the use of agency staff, MDS staffing changes and staff oversight despite continued efforts to re-educate staff.
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
Infection Control
(Tag F0880)
Could have caused harm · This affected multiple residents
Based on observations, staff interviews and record reviews the facility failed to implement their infection control policy when Nurse Aide (NA #4)) did not perform hand hygiene between residents durin...
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Based on observations, staff interviews and record reviews the facility failed to implement their infection control policy when Nurse Aide (NA #4)) did not perform hand hygiene between residents during meal delivery and meal assistance and Nurse Aide (NA #12) failed to doff soiled gloves and perform hand hygiene before exiting Resident #57's room. This deficient practice was observed for 2 of 2 nursing assistants observed for hand hygiene and had the potential to result in the cross contamination of microorganisms between residents and environmental surfaces.
The findings included:
1. Review of the facility's policy titled Hand Hygiene dated July 2002 and last revised on July 2023, stated in part, It is the policy of this facility that hand hygiene be regarded as the single most important means of preventing the spread of infections. 1. Specific Indications for hand hygiene included before resident contact, and after direct contact with the resident's skin and touching equipment or furniture near a resident.
On 03/11/2024 from 1:08 PM to 1:14 PM a continuous observation of the lunch tray meal delivery service was conducted in the facility on the 300 hall. Hand sanitizing dispensers were observed in place at intervals on the wall of the 300 hall. During this continuous observation, NA #4 removed a meal tray from the meal cart, entered Resident #88's room, placed the meal tray on Resident #88's overbed table and repositioned the resident's overbed table in front of the resident. NA #4 was then observed to exit the room and returned to the meal cart without performing hand hygiene. NA #4 pushed the meal cart further down the 300 hall and removed Resident #404's meal tray from the cart. NA #4 served the lunch tray to Resident #404 and assisted the Resident #404 with tray set up. NA #4 exited Resident #404's room and returned to the meal cart without performing hand hygiene. NA #4 removed Resident #405's meal tray from the cart. NA #4 served the lunch tray to Resident #405. NA#4 exited Resident #405's room without performing hand hygiene.
An interview was conducted with the Assistant Director of Nursing (ADON) on 03/11/2024 at 1:15 PM who was also serving lunch trays on the 300 Hall. The ADON stopped NA #4 and asked NA #4 to perform hand hygiene after NA #4 served Resident 405's meal tray. The ADON also provided hand hygiene education to NA #4 specific to meal delivery and entering and exiting resident rooms. The ADON further stated that all staff should clean their hands between each resident. She also revealed that NA #4 had been educated in proper hand hygiene.
An interview was conducted with NA #4 on 03/13/2024 at 10:45 AM. NA#4 stated that he thought he performed hand hygiene after serving meal trays and exiting resident's rooms. He also stated that he had received hand hygiene education specific to meal delivery and when entering and exiting resident rooms.
An interview was conducted with the ADON on 03/13/2024 at 11:23 AM. The ADON stated that she was the facility's Infection Preventionist and was responsible for the Infection Prevention Program for the facility. She further stated that all staff had received hand hygiene education on hire and yearly thereafter. She also stated that throughout the year there are several Infection Control educational sessions for employees including hand hygiene. She also stated that NA #4 had received hand hygiene education and was aware of the indications for hand hygiene during meal delivery.
On 03/13/2024 at 9:15 AM an interview was conducted with the Director of Nursing (DON). The DON revealed that staff were expected to perform hand hygiene after caring for each resident including during meal delivery.
On 03/13/2024 at 2:25 PM an interview was conducted with the Administrator. The Administrator indicated NA #4 should have performed hand hygiene in accordance with the facility's policy. She also revealed that all staff had received hand hygiene education.
2. Review of the facility policy, Hand Hygiene, revised October 2022, recorded in part, Specific Indications for Hand Hygiene, after contact with bodily fluids, excretions, urine, or feces. Review of the facility policy, Perineal Care, revised October 2011, recorded in part, if gloves become soiled anytime during the care, change gloves and perform hand hygiene.
Resident #57 was observed on 3/14/24 at 6:50 AM in bed alert, awake, nonverbal and lying on her back. Nurse Aide (NA) #12 donned gloves pulled the covers back and rolled Resident #57 onto her right side to observe Resident #57 for signs of incontinence. Resident #57 was observed wearing a night gown and a disposable brief. NA #12 was asked by the surveyor if she saw any signs of incontinence, NA #12 stated, No, but I don't usually check like that. NA #12 then rolled Resident #57 onto her back, unfastened the disposable brief, placed both gloved hands inside the opened brief and reached toward the Resident's buttocks until both gloved hands were observed to contact bowel movement. NA #12 then asked Resident #57 if she could change her brief and Resident #57 smiled. NA #12 said to the resident, Ok, I am going to go get some wipes and change your brief. NA #12 exited the Resident's room but did not remove the gloves that had contacted bowel movement in the Resident's disposable brief. NA #12 then walked to the clean linen closet that was to the right of the Resident's room, opened the closet door, removed a package of disposable wipes, and opened the lid of the disposable wipes while wearing the same soiled glove. NA #12 was interviewed prior to going back into the Resident's room and asked if she realized that she still had on the same gloves she used to check Resident #57 for incontinence? NA #12 sighed and stated that she did have on the same gloves she used to check Resident #57 for incontinence, and that she received infection control and hand hygiene in-services often. NA #12 stated that according to the training she received, she should have removed the soiled gloves and washed her hands before exiting the Resident's room. She further stated, I know that.
Unit Manager (UM) #2 was interviewed on 3/14/24 at 11:44 AM. UM #2 stated NA #12 did not follow infection control practices and would need re-education on incontinence care and hand hygiene. UM #2 further stated that NA #12 should have removed the soiled gloves, and performed hand hygiene before she left the Residents' room.
The Assistant Director of Nursing (ADON)/Infection Preventionist (IP), was interviewed on 3/14/24 at 11:20 AM and stated once the gloves become soiled, staff should remove the soiled gloves in the room, and perform hand hygiene before exiting the room. The ADON/IP also stated staff should not exit a resident's room with soiled gloves and then use the same soiled gloves to contact other items or surfaces. The ADON/IP stated NA #12 and other nursing staff would need re-education regarding the proper way to provide incontinence care and when to perform hand hygiene.
A phone interview with the Administrator and Regional Quality Assessment and Assurance Nurse Consultant occurred on 3/16/24 at 5:01 PM. The Administrator stated that when NA #12 assessed Resident #57 to see if she needed incontinence care, NA #12 should have removed the soiled gloves, performed hand hygiene, obtained the needed supplies, and then put on new gloves.
MINOR
(C)
Minor Issue - procedural, no safety impact
Staffing Information
(Tag F0732)
Minor procedural issue · This affected most or all residents
Based on observations and staff interviews the facility failed to post daily nurse staffing in a prominent location that was readily accessible to residents on 5 of 5 days during the survey (03/11/202...
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Based on observations and staff interviews the facility failed to post daily nurse staffing in a prominent location that was readily accessible to residents on 5 of 5 days during the survey (03/11/2024, 03/12/2024, 03/13/2024, 03/14/2024, and 03/15/2024).
The findings included:
An observation on 03/11/2024 at 9:45 AM revealed the daily nurse staff posting was located on the ledge of the receptionist's desk in the front lobby which was accessible to staff and visitors. The daily nurse staffing sheet was a white, 8 X 10-inch piece of paper enclosed in a hard plastic display holder. The lobby was only accessible to the residents by entering through a closed double door access which had to be manually opened. The daily nurse staff posting was not readily visible or accessible for residents to view.
Additional observations on 03/12/2024 at 8:00 AM, 03/13/2024 at 7:45 AM, 03/14/2024 at 7:25 AM, and 03/15/2024 at 8:13 AM of the facility's daily nurse staff posting revealed it was located on the ledge of the receptionist's desk in the front lobby and was not readily visible or accessible for residents to view.
An interview was conducted with the Director of Nursing (DON) on 03/13/2024 at 10:21 AM. The DON revealed that the residents could view the daily staff posting if they entered the lobby. He further stated the residents would have had to manually open the double doors and enter the lobby in order to view the daily staff posting. The DON also stated this is where the daily staff posting had been located for quite a long while.
An interview was conducted with the Administrator on 03/14/2024 at 11:13 AM. The Administrator revealed the facility's daily staff posting should be placed in an area that was readily accessible and visible for residents to view. She also stated the staff daily staff posting had been displayed in this area since she had been with the facility.
Sept 2022
5 deficiencies
3 Harm
SERIOUS
(G)
Actual Harm - a resident was hurt due to facility failures
Resident Rights
(Tag F0550)
A resident was harmed · This affected 1 resident
**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, resident and staff interviews and record review, the facility failed to provide care in a manner to mainta...
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**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, resident and staff interviews and record review, the facility failed to provide care in a manner to maintain the resident's dignity by not providing incontinence care when requested. This resulted in Resident #37 crying while waiting for incontinence care and she reported it made her feel worthless, horrible, bad and didn't deserve to be treated that way. This was evident for 1 of 6 residents who were reviewed for dignity and respect (Resident #37).
Findings included:
Resident #37 was admitted to the facility on [DATE].
A review of the admission Minimum Data Set (MDS) dated [DATE] revealed that Resident #37 was cognitively intact. Resident #37 needed extensive assisted with all activities of daily living with the exception of eating.
While touring the 100 hall on 09/26/22 at 11:00 am Resident #37 was observed to call out for assistance and the call light was activated, upon entering Resident's room, the room had a noticeable odor of urine. Resident #37 indicated she was wet and had not been changed since the night shift. Resident #37 indicated that she had informed Nursing Assistant (NA) #1 that she needed to be changed when she came in to deliver the breakfast meal between 8:30 am and 8:45 am. Resident #37 indicated that NA #1 told her she would be back, and she never returned. Resident #37 voiced she had to eat her breakfast while she was soaked and wet and it was not a good feeling. While in the room it was observed Resident #37's breakfast was still in front of her during this tour at 11:15 am. Resident #37 indicated that she had been waiting for assistance for over 3 to 4 hours. Resident #37 stated that this made her feel horrible, worthless, and bad. Resident #37 knew what time it was because she had called her daughter her family for help.
During an observation at 11:37 am on 09/26/22, it was observed Resident #37 was double briefed and both briefs were saturated with urine. During care Resident #37 started to cry and stated, I know I'm fat and I'm hard to move but I don't deserve to be treated this way. NA #1 indicated she was working in the kitchen from 7:00 am until she passed the trays on the hall around 8:45 am, and she had not provided care for Resident #37 since she got to work at 7:00 am. NA #1 stated that this was because the kitchen needed help.
A phone interview was attempted on 09/27/22 at 10:00 am with NA #11 who worked with Resident #37 on the third shift that began on 09/25/22 and ended on 09/26/22.
An interview was conducted with the Director of Nursing on 09/28/22 at 7:47 am, and he indicated the Nursing Department was staffing challenged and he had knowledge of staff doing double work at the facility. The DON indicated his expectation was for all residents in the facility to be treated with dignity and respect and no resident should have to wait over 30 minutes for care and treatment.
An interview was conducted with the Administrator on 09/29/22 at 3:15pm. She indicated that her expectation was for staff to always treat residents with respect and dignity.
SERIOUS
(G)
Actual Harm - a resident was hurt due to facility failures
ADL Care
(Tag F0677)
A resident was harmed · This affected 1 resident
**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observations, resident and staff interviews, and record review, the facility failed to provide incontinence care when r...
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**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observations, resident and staff interviews, and record review, the facility failed to provide incontinence care when requested for 1 of 6 residents (Resident #37) reviewed for activities of daily living (ADL).
Findings included:
Resident #37 was admitted to the facility on [DATE].
A review of the admission Minimum Data Set (MDS) dated [DATE] revealed that Resident #37 was cognitively intact. Resident #37 needed extensive assisted with all activities of daily living with the exception of eating. No issues of refusals of care noted.
A review of an ADL care plan dated 09/02/22 revealed Resident #37 required assistance with ADL care and was incontinent of bowel and bladder. Interventions included instructions to check on her frequently and provide incontinence care as needed.
An observation on 09/26/22 at 11:00 am revealed Resident #37's call light was activated.
On 09/26/22 at 11:15 am, Resident #37 was observed call out verbally for staff's assistance and the call light was activated. Resident #37's room had a noticeable odor of urine. Resident #37 indicated she was wet and had not been changed since the night shift. Resident #37 indicated that she had informed Nursing Assistant (NA) #1 that she needed to be changed when she came in to deliver the breakfast meal between 8:30 am and 8:45 am. Resident #37 indicated that NA #1 told her she would be back, turned her call light off, and never returned. Resident #37 voiced she had to eat her breakfast while she was soaked and wet and it was not a good feeling. While in the room it was observed Resident #37's breakfast was still in front of her during at 11:15 am. Resident #37 indicated that she had been waiting for assistance for over 3 to 4 hours. Resident #37 stated that this made her feel horrible, worthless, and bad. Resident #37 indicated she knew what time it was because she used her phone call to call her daughter for help.
During an observation at 11:37 am on 09/26/22 care was provided to Resident #37 by NA #1. It was observed Resident #37 was double briefed and both briefs were saturated with urine. During care Resident #37 started to cry and stated, I know I'm fat and I'm hard to move but I don't deserve to be treated this way. NA #1 indicated she was working in the kitchen from 7:00 am until she passed the trays on the hall around 8:45 am, and she had not provided care for Resident #37 since she got to work at 7:00 am. NA #1 also indicated that she turned the call light off at 8:45 am. NA #1 stated this was because the kitchen needed help.
During an interview with Nurse #1 on 09/27/22 at 9:00 am she revealed she had no knowledge of Resident #37 not receiving care on 09/26/22 until 11:30 am. Nurse #1 also indicated that sometimes the NAs had to work in the kitchen during the morning and they tried to cover the hall to meet the needs of the residents.
A phone interview was attempted on 09/27/22 at 10:00 am with NA #11 who worked with Resident #37 on the third shift that began on 09/25/22 and ended on 09/26/22.
An interview was conducted with the Director of Nursing (DON) on 09/28/22 at 7:47 am, and he indicated the Nursing Department was staffing challenged and he had knowledge of staff doing double work at the facility. The DON indicated that all resident's incontinence care needed to be done during the morning round when first shift staff came on duty. The DON indicated his expectation was for all residents in the facility to be assisted with incontinence care every 2 hours and whenever needed. He also indicated no residents in the facility should wait over 15 to 20 minutes for care to be provided. The DON indicated he was not aware a resident had to wait 3 to 4 hours for incontinence care to be provided.
An interview was conducted with the Administrator on 09/29/22 at 3:15 pm. She indicated that her expectation was for staff to provide care and treatment for all residents in a timely manner. The Administrator stated residents should not have to wait for hours at a time to have care provided.
SERIOUS
(G)
Actual Harm - a resident was hurt due to facility failures
Deficiency F0692
(Tag F0692)
A resident was harmed · This affected 1 resident
**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observations, record review, staff interviews, and Registered Dietician (RD) interview, the facility failed to follow t...
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**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observations, record review, staff interviews, and Registered Dietician (RD) interview, the facility failed to follow the RD's recommendation to reweigh a resident identified with significant weight loss to determine if the change in weight status was accurate for 1 of 5 residents reviewed for nutrition (Resident #26).
The findings included:
Resident #26 was admitted on [DATE] with diagnoses that included contusion and laceration of right cerebrum without loss of consciousness, traumatic subarachnoid hemorrhage without loss of consciousness.
The admission Minimum Data Set (MDS) dated [DATE] revealed Resident #26 had moderate cognitive impairment with no behaviors or rejection of care. Resident #26 weighed 210 pounds (lbs) on admission and had no or unknown significant weight loss. He had a mechanically altered diet and supplemental tube feedings.
Resident #26's care plan initiated on 7/26/22 revealed he had a potential nutritional problem related to receiving mechanically altered diet and tube feedings. The interventions included, in part: RD to evaluate and make diet change recommendations as needed. Weigh the resident at same time of day, using the same scale and record the weight. The care plan further revealed Resident #26 required tube feeding to assist in maintaining or improving his nutritional status. The interventions included, in part: consult the RD as needed and weigh as ordered.
Resident #26's electronic medical record (EMR) revealed the following recorded weights:
-On 08/15/2022 Resident #26's weight was recorded as 208 lbs.
-On 09/19/2022 Resident #26's weight was recorded as 186 lbs (10.58% weight loss).
Review of the RD note dated 9/21/22 revealed Resident #26 was noted to have a weight discrepancy of 22 lbs less than his previous weight. The RD recommended staff reweigh Resident #26.
During an interview on 9/29/22 at 2:06 PM the RD revealed Resident #26 was weighed monthly per facility protocol. When there was a weight discrepancy, she created a reweigh list and emailed it to the Unit Manager. The DON and the Administrator were also copied in this e-mail. The RD further revealed she sent two emails requesting that Resident #26 be reweighed, but it was not done. The RD stated reweighs should be done as soon as possible so she could add the appropriate interventions for the resident.
An interview was conducted with the Director of Nursing (DON) on 9/28/22 at 12:30 PM which revealed he was unaware of Resident #26's weight loss and would have him reweighed.
During an interview with Nurse Aide (NA) #7 on 9/28/22 at 3:45 PM she revealed she had been asked by the Director of Nursing to reweigh Resident #26 on that day and his reweigh was 186 lbs. She further revealed when she weighed residents, she reported the weights to the nurse and the Unit Manager.
An interview was conducted with Nurse #3 on 9/29/22 at 11:45 AM that revealed weights were completed for residents on admission then monthly. If there was an issue with weight/nutrition the resident would have an order for weekly weights. She further revealed weights were followed by the Unit Manager.
During an interview on 9/29/22 at 2:52 PM the Unit Manager indicated she thought she had reweighed Resident #26 but explained she had been very busy and she may have overlooked it.
During an interview on 9/29/22 at 4:07 PM the Administrator explained resident weights were recorded in the electronic medical record and the RD then reviewed those weights. A list of residents that needed reweighed were communicated by e-mail. The Administrator revealed she was included in those emails, and she thought the Unit Manager or DON had ensured Resident #26 was reweighed. She further revealed reweighs should occur on the same day.
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 interviews with facility staff, the facility failed to follow the manufacturer guidelines for cleaning and disinfection of a blood glucose meter that was stored...
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Based on observation, record review and interviews with facility staff, the facility failed to follow the manufacturer guidelines for cleaning and disinfection of a blood glucose meter that was stored in the medication cart prior to use for 1 of 1 resident observed (Resident #38). The blood glucose meter was stored in the medication cart and was not designated as an individual resident meter.
Findings included:
Review of the Facility Policy 'Glucometers' revised on 01/2011, noted 'to utilize individual glucometers for each resident' and the glucometer was to 'be cleaned and disinfected per manufacturer's guidelines.'
Review of the blood glucose meter manufacturer guidelines, provided by the Unit Manager revealed the meter should be cleaned and disinfected after use on each resident. The meter was only to be used on multiple patients when the manufacturer's disinfection procedures were followed. Clorox Healthcare Bleach Germicidal Wipes, Dispatch Hospital Cleaner Disinfectant Towels with Bleach, CaviWipes1 and PDI Super Sani-Cloth Germicidal Disposable Wipes were approved for disinfection. 70% alcohol was not listed as approved for disinfection.
During an observation of medication administration on 09/28/22 at 9:19 AM Nurse #1 stated all residents were supposed to have their own blood glucose meters, but Resident #38 was a new admission and did not have his own meter.
Nurse #1 was observed on 9/28/22 at 9:25 AM as she walked into Resident #38's room with the blood glucose meter she had removed from the medication cart. She had gathered the required supplies and went to his bedside.
Nurse #1 was interviewed on 09/28/22 at 9:26 AM in Resident #38's room and asked how she knew the meter had been cleaned prior to use at this time. She said, I don't know if it was cleaned, I have my own Lysol wipes on top of the cart and I would like to use those now. She returned to the medication cart outside the room. She was asked if Lysol wipes were approved to use and stated, I haven't used them before on the meters. Nurse #1 then noted I would like to use the alcohol wipe to clean the strip insertion site and proceeded to clean only the insertion site with a 70% alcohol pad. When asked how long the meter needed to stay wet to be effective, she noted I am not sure, I am just going to clean the whole meter with alcohol now. Nurse #1 cleaned the entire blood glucose meter with another 70% alcohol pad.
Nurse #1 was observed going back into Resident #38's room on 09/28/22 at 9:29 AM and performed a blood glucose check on Resident #38 with the meter she had cleaned with 70% alcohol.
An interview was conducted with Nurse #1 on 09/28/22 at 9:31 AM and she was asked if she had an orientation to the facility regarding the blood glucose meter disinfection. Nurse #1 stated honestly no and I go to different facilities and learn as I go.
Unit Manager (UM) #1 was interviewed on 09/28/22 at 12:15 PM regarding the process for blood glucose meters. She stated every resident that required blood glucose checks should have their own meter and supplies. The UM went to the supply room, revealed the area where the supplies were kept and how the kit should have been put together. She provided the blood glucose meter instruction guide for the meter used.
On 09/28/22 at 12:43 PM the Director of Nursing (DON) provided an orientation checklist for Nurse #1 with her signature and the Staff Development Coordinator's (SDC) signature. Review of the 'Agency Nurse Orientation' packet indicated for 'blood sugar meters, they were never to be shared between residents, when cleaning/disinfecting to use the facility approved bleach/product, and alcohol wipes were not effective in cleaning meters and were not to be used to clean/disinfect blood sugar meters.' The packet was signed and dated by Nurse #1 on 08/15/22.
On 09/28/22 at 3:07 PM Nurse #1 verified it was her signature on the agency nurse competency form for blood sugar meters and stated she must have forgotten the orientation.
A follow-up interview was done with Unit Manager #1 on 09/29/22 at 4:07 PM. She stated for blood glucose meters, every resident should have their own meter in their room, and if they did not, the nurse should get a meter for the resident. The UM noted the meter should always be cleaned with the approved disinfectant wipe and the manufacturer guidelines followed, keeping it wet according to the guidelines and cleaning before and after use.
The DON was interviewed on 09/29/22 at 4:13 PM about the blood glucose meters. He said every resident was to have their own meter. The DON noted Nurse #1 should have disinfected the meter with the appropriate cleaning agent before and after use.
An interview was conducted on 09/29/22 at 4:56 PM with the Administrator regarding blood glucose meters. She stated each resident should have their own meter and when Nurse #1 took the meter out of the medication cart, she should have cleaned it. She said the manufacturer guidelines should have been followed and the meter was to be cleaned before and after use.
MINOR
(B)
Minor Issue - procedural, no safety impact
Assessment Accuracy
(Tag F0641)
Minor procedural issue · This affected multiple residents
**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on record reviews and staff interviews, the facility failed to accurately code a Minimum Data Set (MDS) assessment for 1 o...
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**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on record reviews and staff interviews, the facility failed to accurately code a Minimum Data Set (MDS) assessment for 1 of 19 MDS assessments reviewed (Resident #64).
Findings included:
Resident #64 was readmitted to the facility 12/30/2021 with diagnoses to include heart failure and Parkinson's disease.
The quarterly MDS dated [DATE] it was documented Resident #64 had limited range of motion of one side of her lower extremities.
Resident #64 was observed on 9/29/2022 at 10:00 AM standing beside her wheelchair. Resident #64 was not holding onto anything and was standing independently.
An interview was conducted with the Director of Rehabilitation on 9/28/2022 at 10:19 AM. The Director of Rehabilitation reported Resident #64 had stretching exercises to her lower extremities, but she did not have limited range of motion.
Physical Therapist #1 (PT) was interviewed on 9/28/2022 at 10:42 AM. PT #1 reported he had provided care to Resident #64 several times, and she did not have limited range of motion of either lower extremity.
An interview was conducted with PT #2 on 9/28/2022 at 10:56 AM. PT #2 reported she had provided rehabilitation services to Resident #64 several times and she did not have any joint limitation, contracture, or impairment in her lower extremities.
Resident #64 was interviewed on 9/29/2022 at 10:13 AM. Resident #64 reported she had received therapy in the past to help with strengthening. Resident #64 demonstrated full range of motion of her lower extremities and reported she had no impairment of her lower legs. Resident #64 lifted each leg and demonstrated full range of motion of her ankles, knees, and hips and then kicked her legs out in front of her. Resident #64 stated, I don't have any problems with my legs. Resident #64 concluded by reporting she was able to take a few steps without assistance but required the wheelchair when she needed to go longer distances.
The MDS nurse was interviewed on 9/29/2022 at 2:08 PM. The MDS nurse reported she was not certain why limited range of motion of one side of lower extremities was documented for Resident #64. The MDS nurse reported it may have been an error.
The Administrator was interviewed on 9/29/2022 at 5:19 PM. The Administrator reported that she expected MDS assessments to be coded accurately.
Understanding Severity Codes (click to expand)
Life-Threatening (Immediate Jeopardy)
J - Isolated
K - Pattern
L - Widespread
Actual Harm
G - Isolated
H - Pattern
I - Widespread
Potential for Harm
D - Isolated
E - Pattern
F - Widespread
No Harm (Minor)
A - Isolated
B - Pattern
C - Widespread
Questions to Ask on Your Visit
- "What changes have you made since the serious inspection findings?"
- "Can I speak with families of current residents?"
- "What's your RN coverage like on weekends and overnight?"
Our Honest Assessment
Strengths
- • Licensed and certified facility. Meets minimum state requirements.
Concerns
- • Multiple safety concerns identified: 2 life-threatening violation(s), 3 harm violation(s), $86,450 in fines. Review inspection reports carefully.
- • 30 deficiencies on record, including 2 critical (life-threatening) violations. These warrant careful review before choosing this facility.
- • $86,450 in fines. Extremely high, among the most fined facilities in North Carolina. Major compliance failures.
- • Grade F (1/100). Below average facility with significant concerns.
Bottom line: Trust Score of 1/100 indicates significant concerns. Thoroughly evaluate alternatives.
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About This Facility
What is Pavilion Health Center At Brightmore's CMS Rating?
CMS assigns Pavilion Health Center at Brightmore an overall rating of 2 out of 5 stars, which is considered 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 Pavilion Health Center At Brightmore Staffed?
CMS rates Pavilion Health Center at Brightmore's staffing level at 3 out of 5 stars, which is average compared to other nursing homes. Staff turnover is 47%, compared to the North Carolina average of 46%. RN turnover specifically is 64%, which is notably high. RNs provide skilled clinical oversight, so turnover in this role can affect medical care quality.
What Have Inspectors Found at Pavilion Health Center At Brightmore?
State health inspectors documented 30 deficiencies at Pavilion Health Center at Brightmore during 2022 to 2025. These included: 2 Immediate Jeopardy (the most serious level, indicating potential for serious harm or death), 3 that caused actual resident harm, 23 with potential for harm, and 2 minor or isolated issues. Immediate Jeopardy findings are rare and represent the most serious regulatory concerns. They require immediate corrective action.
Who Owns and Operates Pavilion Health Center At Brightmore?
Pavilion Health Center at Brightmore 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 LIBERTY SENIOR LIVING, a chain that manages multiple nursing homes. With 108 certified beds and approximately 96 residents (about 89% occupancy), it is a mid-sized facility located in Charlotte, North Carolina.
How Does Pavilion Health Center At Brightmore Compare to Other North Carolina Nursing Homes?
Compared to the 100 nursing homes in North Carolina, Pavilion Health Center at Brightmore's overall rating (2 stars) is below the state average of 2.8, staff turnover (47%) is near the state average of 46%, and health inspection rating (2 stars) is below the national benchmark.
What Should Families Ask When Visiting Pavilion Health Center At Brightmore?
Based on this facility's data, families visiting should ask: "What changes have been made since the serious inspection findings, and how are you preventing similar issues?" "Can I visit during a mealtime to observe dining assistance and food quality?" "How do you handle medical emergencies, and what is your hospital transfer rate?" "Can I speak with family members of current residents about their experience?" These questions are particularly relevant given the facility's Immediate Jeopardy citations.
Is Pavilion Health Center At Brightmore Safe?
Based on CMS inspection data, Pavilion Health Center at Brightmore has documented safety concerns. Inspectors have issued 2 Immediate Jeopardy citations (the most serious violation level indicating risk of serious injury or death). The facility has a 2-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 Pavilion Health Center At Brightmore Stick Around?
Pavilion Health Center at Brightmore has a staff turnover rate of 47%, which is about average for North Carolina nursing homes (state average: 46%). Moderate turnover is common in nursing homes, but families should still ask about staff tenure and how the facility maintains care continuity when employees leave.
Was Pavilion Health Center At Brightmore Ever Fined?
Pavilion Health Center at Brightmore has been fined $86,450 across 1 penalty action. This is above the North Carolina average of $33,943. Fines in this range indicate compliance issues significant enough for CMS to impose meaningful financial consequences. Common causes include delayed correction of deficiencies, repeat violations, or care failures affecting resident safety. Families should ask facility leadership what changes have been made since these penalties.
Is Pavilion Health Center At Brightmore on Any Federal Watch List?
Pavilion Health Center at Brightmore 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.