What is HIGHLAND OAKS HEALTH CENTER's CMS rating?

HIGHLAND OAKS HEALTH CENTER has a one-star overall rating from CMS (Centers for Medicare & Medicaid Services), based on health inspections, staffing levels, and quality measures.

Does HIGHLAND OAKS HEALTH CENTER have any serious inspection findings?

Yes, HIGHLAND OAKS HEALTH CENTER has 1 Immediate Jeopardy citation on record, which represent the most serious type of deficiency. The facility has 97 total deficiencies from recent inspections.

What are the staffing levels at HIGHLAND OAKS HEALTH CENTER?

HIGHLAND OAKS HEALTH CENTER has a four-star staffing rating from CMS with 0.51 RN hours per resident per day. This rating is based on registered nurse (RN), licensed practical nurse (LPN), and nurse aide staffing hours.

Where is HIGHLAND OAKS HEALTH CENTER located?

HIGHLAND OAKS HEALTH CENTER is located in MCCONNELSVILLE, OH. It is a Medicare and Medicaid certified skilled nursing facility.

How many beds does HIGHLAND OAKS HEALTH CENTER have?

HIGHLAND OAKS HEALTH CENTER has 99 certified beds.

Who owns HIGHLAND OAKS HEALTH CENTER?

HIGHLAND OAKS HEALTH CENTER is a for profit - limited liability company facility and is part of the TRILOGY HEALTH SERVICES chain.

Is HIGHLAND OAKS HEALTH CENTER safe?

HIGHLAND OAKS HEALTH CENTER has documented safety concerns including a substantiated abuse finding on record, 1 immediate jeopardy citation, placement on the CMS Special Focus Facility list. Families should ask about corrective actions taken.

Do nurses at HIGHLAND OAKS HEALTH CENTER stick around?

HIGHLAND OAKS HEALTH CENTER has average staff turnover at 48%, which is typical for the nursing home industry.

Was HIGHLAND OAKS HEALTH CENTER ever fined?

Yes, HIGHLAND OAKS HEALTH CENTER has been fined $51,951 by federal regulators. Fines are issued for serious violations of Medicare and Medicaid requirements.

Is HIGHLAND OAKS HEALTH CENTER on any federal watch list?

HIGHLAND OAKS HEALTH CENTER is currently an SFF Candidate, meaning CMS is monitoring it for potential placement on the Special Focus Facility list due to a history of serious quality issues.

What have inspectors found at HIGHLAND OAKS HEALTH CENTER?

Medicare inspectors have found 97 deficiencies at HIGHLAND OAKS HEALTH CENTER: 1 critical, 6 serious, 87 moderate, 3 minor. Each deficiency represents a violation of federal nursing home requirements.

How does HIGHLAND OAKS HEALTH CENTER compare to other nursing homes?

HIGHLAND OAKS HEALTH CENTER has a 1-star overall rating, which is below average compared to other nursing homes in OH. Families should carefully review inspection findings and consider alternatives.

HIGHLAND OAKS HEALTH CENTER

4114 NORTH STATE ROUTE 376 NW, MCCONNELSVILLE, OH 43756 · (740) 962-3761

For profit - Limited Liability company 99 Beds TRILOGY HEALTH SERVICES Data: November 2025 1 Immediate Jeopardy citation

Trust Grade

0/100

#867 of 913 in OH

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HIGHLAND OAKS HEALTH CENTER nursing home in MCCONNELSVILLE, OH - Photo 1 of 2

HIGHLAND OAKS HEALTH CENTER nursing home in MCCONNELSVILLE, OH - Photo 2 of 2

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Last Inspection: January 2025

Within standard 12-15 month inspection cycle. Federal law requires annual inspections.

Overview

Highland Oaks Health Center has received a Trust Grade of F, indicating significant concerns about the care provided, which is classified as poor. This facility ranks #867 out of 913 in Ohio, placing it in the bottom half of nursing homes in the state, and it is the second of only two facilities in Morgan County, meaning there is only one other local option available. The situation seems to be worsening, with the number of issues rising from 12 in 2024 to 42 in 2025. While staffing is rated 4 out of 5 stars, showing good performance with a turnover rate slightly below the state average at 48%, the facility has also incurred $51,951 in fines, which is concerning as it reflects compliance issues that are higher than 83% of other facilities in Ohio. Additionally, there have been serious incidents, including a failure to protect a resident from sexual abuse and multiple medical complications leading to severe health issues. These findings highlight both a critical lack of supervision and serious medical concerns that families should weigh carefully when considering this facility.

Trust Score: F
In Ohio: #867/913
Safety Record: High Risk
Inspections: Getting Worse
Staff Stability: 48% turnover. Above average. Higher turnover means staff may not know residents' routines.
Penalties: $51,951 in fines. Lower than most Ohio facilities. Relatively clean record.
Skilled Nurses: Each resident gets 30 minutes of Registered Nurse (RN) attention daily — about average for Ohio. RNs are the most trained staff who monitor for health changes.
Violations: 97 deficiencies on record. Higher than average. Multiple issues found across inspections.

★☆☆☆☆

1.0

Overall Rating

★★★★☆

4.0

Staff Levels

★★★★☆

4.0

Care Quality

★☆☆☆☆

1.0

Inspection Score

↔

Stable

2024: 12 issues

2025: 42 issues

The Good

4-Star Staffing Rating · Above-average nurse staffing levels
4-Star Quality Measures · Strong clinical quality outcomes
Full Sprinkler Coverage · Fire safety systems throughout facility
No fines on record

Facility shows strength in staffing levels, quality measures, fire safety.

The Bad

1-Star Overall Rating

Below Ohio average (3.2)

Significant quality concerns identified by CMS

Staff Turnover: 48%

Near Ohio avg (46%)

Higher turnover may affect care consistency

Federal Fines: $51,951

Above median ($33,413)

Moderate penalties - review what triggered them

Chain: TRILOGY HEALTH SERVICES

Part of a multi-facility chain

Ask about local staffing decisions and management

The Ugly 97 deficiencies on record

1 life-threatening 6 actual harm

Jan 2025 42 deficiencies 1 IJ

CRITICAL (J)

Immediate Jeopardy (IJ) - the most serious Medicare violation

Free from Abuse/Neglect (Tag F0600)

Someone could have died · This affected 1 resident

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**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, record review, review of the facility Abuse and Neglect policy and procedure, and interviews, the facility failed to provide adequate and necessary supervision and intervention to protect Resident #27's right to be free from sexual abuse by Resident #21. This resulted in Immediate Jeopardy and the potential for actual harm beginning on 11/16/24 when Certified Nursing Assistant (CNA) #300 observed Resident #21, who was positive for Hepatitis C engaging in non-consensual sexual intercourse with Resident #27, a cognitively impaired and non-interviewable male resident who lacked the cognition to consent to the interaction. CNA #300 reported the incident to CNA #203 and Registered Nurse (RN) #188 but no investigation was completed, and no interventions were initiated to prevent potential recurrence. On 11/21/24 staff again observed Resident #21 in Resident #27's room with her shirt lifted up in front of the resident. This affected one resident (#27) of two residents reviewed for abuse. The facility census was 85. On 01/15/25 at 4:00 P.M., the Administrator and Director of Nursing (DON) were notified Immediate Jeopardy began on 11/16/24 when the facility failed to protect Resident #27's right to be free from sexual abuse by Resident #21. In addition to failing to prevent the incident from occurring, following the incident, the facility failed to timely intervene, thoroughly investigate and implement measures to prevent additional incidents of sexual abuse from occurring. The Immediate Jeopardy was removed on 01/16/25 when the facility implemented the following corrective actions: • On 01/15/25 at 4:00 P.M. the facility initiated an investigation related to the incident of sexual abuse involving Resident #27. The investigation process included speaking to Resident #21 and Resident #27 regarding the alleged incident, interviewing all residents, or assessing residents if they were not cognitively intact including skin assessments, pain assessments. The investigation process also included interviewing staff who worked on 11/16/24 for potential knowledge of any abuse incidents, as well as educating all staff on the abuse policy and procedure, notifying family and physician. • On 01/15/25 at 4:35 P.M. Resident #21 was placed on one-on-one supervision. Resident #21 would remain on one-on-one services until seen by psychiatric services. Facility staff would complete the one-on-one supervision which would be tracked through documentation. • On 01/15/25 at 5:15 P.M. Resident #21 and Resident #27's guardians were notified of the sexual abuse incident by the DON/Designee. • On 01/15/25 at 5:30 P.M. a Quality Assurance Assessment (QAA) meeting was held which included the Administrator/Executive Director, DON, two unit managers, social worker, regional nurse consultant, and medical director. The team discussed a plan to mitigate the sexual abuse concern identified including an immediate intervention to keep all residents safe, the investigation including all education needed, interviews, assessments, discussions with all physicians, any medications that needed ordered or clarified, notifying family and the next steps including notifying the police department and filing a self-reported incident (SRI). • On 01/15/25 at 5:30 P.M. Resident #21 and Resident #27's physician was notified of the sexual abuse incident by the Administrator/Designee. • On 01/15/25 at 5:30 P.M. the DON/Designee assessed Resident #21 with no negative findings. • On 01/15/25 at 5:58 P.M. the Administrator/Designee notified the police department of Resident #21 and Resident #27 allegedly having sexual intercourse in November 2024 and that the facility had started an internal investigation. • On 01/15/25 at 5:58 P.M. the Administrator/Designee reported the allegation of sexual abuse involving Resident #27 to the State Agency and began a thorough investigation. • On 1/15/25 at 6:00 P.M. the DON/Designee assessed 23 of 23 non-interviewable residents on the memory care unit to ensure no signs or symptoms of sexual abuse were identified. • On 01/15/25 at 6:10 P.M. the DON/Designee assessed Resident #27. • On 01/15/25 at 6:10 P.M. Social Service Designee (SSD)/Designee #190 assessed Resident #21 for psychosocial well-being. • On 01/15/25 at 6:13 P.M. a local Police Department (PD) Officer arrived at the facility to take a report. The DON informed the officer there was an allegation of (sexual) intercourse between two memory impaired residents (#27 and #21) and that the facility was investigating the allegation. • On 01/15/25 at 6:15 P.M. SSD #190 spoke with Resident #21's guardian. As a result of the conversation, the guardian agreed to transfer Resident #21 to another facility that could accommodate her sexual behaviors. Discharge planning was started. Resident #21 would remain on increased supervision as recommended by psychiatric services. Supervision was changed to every 15 minutes checks on 01/16/25 at 12:30 P.M. • On 01/15/25 at 6:20 P.M. SSD #190/Designee assessed Resident #27 for psychosocial well-being. • On 01/15/25 at 6:30 P.M. SSD #190/Designee interviewed or assessed 89 of 89 current residents and interviewed 123 of 123 staff members with no additional allegations of sexual abuse identified. • On 01/15/25 at 7:00 P.M. SSD #190/Designee assessed 23 of 23 residents on the memory care unit for psychosocial well-being. • On 01/15/25 at 7:15 P.M. the DON/Designee reviewed the orders and care plans for 23 of 23 residents on the memory care unit to ensure interventions for sexually inappropriate behaviors were in place. • 01/15/25 at 9:00 P.M. the Administrator/Designee educated 123 of 123 staff members on the Abuse policy including Sexual abuse and reporting and investigating abuse. • On 01/16/25 at 1:30 P.M. bloodwork was drawn for a Hepatitis panel for Resident #27. • On 01/16/25 at 8:15 A.M. the DON/Designee spoke with the Nurse Practitioner regarding Resident #21. Orders were obtained for birth control pills. The resident had been started on the medication, Tagamet (a medication used to decrease libido) on 12/26/24. The resident's guardian was notified of these orders on 01/16/25. • On 01/17/25 at 11:00 A.M. Resident #21's plan of care was updated to include the following non-pharmacological interventions to deter potentially sexually inappropriate behaviors: activities of choice, offer other activities to participate in with the activities department, leave the unit with supervision to participate in other activities and socialize, going on outings when able, family trips when able and counseling with Psychiatric Nurse Practitioner. • Beginning on 01/16/25 the facility implemented audits for the Administrator/Designee to interview three staff members weekly times four weeks to ensure no concerns of sexual abuse were identified, then as determined by the QAA Committee. • Beginning on 01/16/25 the facility implemented audits for the DON/Designee to assess three non-interviewable residents weekly times four weeks to ensure no signs or symptoms of sexual abuse were identified, then as determined by the QAA Committee. Although the Immediate Jeopardy was removed on 01/16/25, the facility remained out of compliance at Severity Level 2 (no actual harm with potential for more than minimal harm that is not Immediate Jeopardy) as the facility was still in the process of implementing their corrective action and monitoring to ensure on-going compliance. Findings include: Record review revealed Resident #27 admitted to the facility on [DATE] with diagnoses including dementia, hypertension, angina pectoris, attention and concentration deficit following cerebral infarction, and personal history of a traumatic brain injury. Record review revealed Resident #27 had a court appointed legal guardian of person and estate as of 05/14/24 related to being deemed an incompetent adult in the probate court. Resident #27 resided on the facility secured memory care unit. Review of a care plan dated 07/22/24 revealed Resident #27 may demonstrate inappropriate behaviors including agitation. The care plan was not specific to what the inappropriate behaviors were and did not include evidence of sexually inappropriate behaviors for the resident. In addition, there was no evidence in the medical record or plan of care that the resident was sexually active with other residents in the facility. Review of Resident #27's Minimum Data Set (MDS) assessment dated [DATE] revealed the cognitive assessment was incomplete. The assessment revealed Resident #27 refused care one to three days of the seven-day assessment reference period. Review of a psychiatric consult note documented in Resident #21's medical record, dated 11/21/24 at 1:40 P.M. revealed Resident #21 was caught on 11/16/24 having sexual relations with a gentleman (identified to be Resident #27) on the unit. The note indicated staff were being diligent at trying to keep them apart. Record review revealed no documentation of this incident was included in Resident #27's medical record. Following the incident, there was no evidence Resident #27 was assessed for injury, assessed related to his ability to consent to a sexual relationship with another resident/resident #21 or evidence the resident's legal guardian was notified. Review of a nursing note dated 11/21/24 at 1:27 P.M. by RN #188 revealed Resident #27 was found with Resident #21 in his room with her shirt pulled slightly up and the female resident was redirected out of Resident #27's room. There was no evidence that the provider or legal guardian were notified of the incident. Review of a handwritten, unsigned note dated 11/21/24 revealed Resident #27's guardian was alerted of a relationship with a resident, and noted the resident does not like to be told to stay out of the female resident's room. Staff were educated to assist with socializing in the common area. Record review revealed there was no evidence Resident #27 was assessed related to his ability to consent to a sexual relationship with another resident/Resident #21 at this time. Record review revealed Resident #21 admitted to the facility on [DATE] with diagnoses including anoxic brain damage, unspecified dementia, opioid use with opioid-induced psychotic disorder, bipolar disorder, major depression, chronic viral Hepatitis C, [NAME] (an eating disorder in which a person eats things not usually considered food), and acute Hepatitis C without hepatic coma. Record review revealed Resident #21 had a court appointed legal guardian of person and estate as of 05/02/22 related to being deemed an incompetent adult in probate court. Resident #21 resided on the facility secured memory care unit. Review of a care plan dated 04/15/24 revealed Resident #21 demonstrated inappropriate behaviors including making false accusations about peers and staff. There was no evidence of a care plan related to sexually inappropriate behaviors or that the resident was sexually active with other residents in the facility. Review of a MDS assessment completed on 11/15/24 revealed Resident #21 had severe cognitive impairment. The MDS revealed the resident had no behaviors. Review of a nursing note dated 11/21/24 at 1:17 P.M. by RN #188 revealed Resident #21 was found in Resident #27's room with her shirt up. Resident #21 was redirected out of the male resident's room. There was no evidence Resident #21's physician or legal guardian were notified of the incident. In addition, there was no evidence the facility implemented additional interventions to prevent continued sexual behaviors from occurring. Review of a psychiatric consult note documented in Resident #21's medical record, dated 11/21/24 at 1:40 P.M. revealed Resident #21 was caught on 11/16/24 having sexual relations with a gentleman (identified to be Resident #27) on the unit. The note indicated staff were being diligent at trying to keep them apart. The note indicated Resident #21 was not on birth control and a pregnancy test was ordered. Review of orders revealed Resident #21 had an order entered by LPN #165 dated 11/21/24 for a pregnancy test to be completed on 12/02/24. Review of a handwritten, unsigned note dated 11/21/24 revealed Resident #21's guardian was notified of sexual behaviors and stated, that's how she is. The note indicated Resident #21 was spoken to about appropriate and inappropriate behaviors. However, there was no evidence the facility implemented additional interventions to prevent continued sexual behaviors at this time. Review of the medical record revealed a progress note dated 12/22/24 at 10:46 A.M. by RN #212 that included Resident #21 wanders ad lib and is very friendly with male resident (Resident #27). Review of an addendum to a psychiatric consult note dated 12/26/24 at 1:37 P.M. revealed after speaking with staff, a pattern of Resident #21's behavior was that she tended to be more sexual with any new male resident. A recommendation for Tagamet 400 milligrams (mg) twice daily was provided in addition to a recommendation Resident #21 be placed on birth control if appropriate clinically. Record review revealed no evidence the facility implemented any additional non-pharmacological interventions and/or supervision to timely identify and/or prevent continued sexual behaviors by Resident #21 at this time. Review of orders revealed Resident #21 received an order dated 12/26/24 for Tagamet 200 mg two tablets twice daily by mouth. Interview on 01/14/25 at 10:28 A.M. with SSD #190 revealed she was involved on the memory care unit, but stated not as much as she would like to be. She stated Resident #21 had a boyfriend (Resident #27), the staff tried to keep them apart and staff were attempting interventions. However, SSD #190 did not specify what type of interventions and stated she does not document in care plans because the MDS nurse entered care plans for behaviors. She stated Resident #21 and Resident #27's families were aware of their interest in each other, and the SSD revealed she did not think they were concerned. Interview on 01/14/25 at 2:36 P.M. with RN #188 revealed there had been an incident where Resident #21 was in a room with a male resident (Resident #27) and pulled her shirt up, but the resident stated she only showed the male resident her belly button. Resident #21 was then started on Tagamet to lessen behaviors and sex drive, which the RN stated she believed were working. The RN also indicated staff were to ensure Resident #21 and Resident #27 were not alone in the same room together. Interview on 01/15/25 at 8:26 with CNA #153 revealed she believed Resident #21 and Resident #27 were boyfriend and girlfriend and stated they had been caught a few times together behind closed doors. She stated the residents were caught lying in bed together, but one time it was more than that, although the CNA stated she was not working at the time of this incident. The CNA revealed staff were to make sure the residents were not alone behind closed doors. Interview on 01/15/25 at 8:50 A.M. with CNA #202 revealed she had seen Resident #21 holding hands with and kissing Resident #27 more on the evening shift. The CNA stated she tried to redirect and separate the residents when this occurred. Interview on 01/15/25 at 8:55 A.M. with LPN #165 revealed she had observed Resident #21 holding hands with Resident #27 but denied knowledge of any type of sexually inappropriate behaviors being reported to her. An additional interview on 01/15/25 at 9:02 A.M. with LPN #165 revealed (in November 2024) Resident #21 told Psychiatrist #305 that she needed a pregnancy test, and Psychiatrist #305 ordered the test. LPN #165 stated she just entered the test in the computer but did not inquire why it was necessary. Interview on 01/15/25 at 9:03 A.M. with Psychiatrist #305 revealed he was informed by staff (unable to state which staff) Resident #21 had sexual relations with a male resident on the unit. He stated Resident #21 still menstruated, so after being made aware of the sexual activity, a pregnancy test was ordered (the test was negative). Psychiatrist #305 revealed if the resident continued to have sex, she should be started on birth control. During the interview, Psychiatrist #305 revealed he confirmed with Resident #21 she had sex with another resident, and stated the resident was quite proud. However, there was no evidence the psychiatrist discussed with staff the other resident involved in the sexual activity to ensure the resident was able to and had consented to the sexual activity. Interview on 01/15/25 at 10:16 A.M. with Licensed Social Worker (LSW) #313 revealed she worked with Psychiatrist #305 for any consults in the facility. She stated she was contacted (unable to recall by which facility staff member) because Resident #21 had allegedly been having sex with a male resident (Resident #27). The LSW revealed since the resident still had menses, there was a possibility of her becoming pregnant, so Psychiatrist #305 ordered a pregnancy test, then eventually started her on Tagamet. However, there was no evidence the LSW discussed with staff the other resident involved in the sexual activity to ensure the resident was able to and had consented to the sexual activity. Interview on 01/15/25 at 10:26 A.M. with MDS Nurse #139 revealed social service staff were expected to develop and document care plans related to resident behaviors. Interview on 01/15/25 at 10:35 A.M. with Resident #21 revealed she had a boyfriend and identified him as Resident #27. Resident #21 stated they had already had sex (including penetration) without protection, and they got in trouble because she could still get pregnant. Resident #21 stated she sees Resident #27 every day. During the interview Resident #21 stated all the staff know about her sex life. Resident #21 stated I have tried to hide myself, but I'm not hideable due to having a loud voice and Resident #27 is able to find her. Interview on 01/15/25 at 10:39 A.M. with RN #188 revealed she had heard CNA #300 allegedly witnessed Resident #21 and Resident #27 having sex. During the interview, Resident #21 approached RN #188 and stated she needed condoms so she could have safe sex. Interview on 01/15/25 at 11:42 A.M. with SSD #190 revealed she had spoken with Resident #21 about her interactions with Resident #27 as she felt Resident #21 was able to remember a little more than Resident #27 could. SSD #190 revealed she cautioned Resident #21 about the relationship because of the age difference between the two residents and the resident's memory impairment. During the interview, she confirmed Resident #21 had a diagnosis of Hepatis C and having unprotected sex with another person would not be safe. Interview on 01/15/25 at 1:12 P.M. with CNA #300 revealed (on 11/16/24) she was about to provide incontinence care to another resident, but there were no gloves in the room, so she went to Resident #27's room because she recalled seeing gloves in there. She stated upon entering the room, she observed Resident #21 lying with her back on the bed with her buttocks towards the edge and her legs spread while Resident #27 was standing in front of her penetrating her. Both residents were completely naked. She stated she was new to the facility and did not know what to do, and she noticed the residents became nervous with her presence as well. She stated she closed the door and walked to the nurse's station to ask what to do. She was informed by CNA #203 the residents needed to be separated, and a statement needed to be written. CNA #300 stated CNA#203 took her statement. Interview on 01/15/25 at 1:53 P.M. with Resident #21's guardian revealed the resident was very forward and talked about sex often. The resident's guardian stated the facility had not contacted her or made her aware of any type of relationship between Resident #21 and Resident #27. The guardian stated it was her preference that the resident does not have sexual interactions. She stated she wanted Resident #21 to be safe, and she did not feel Resident #21 should be sexually active due to cognition and hygiene concerns. Interview on 01/15/25 at 2:40 P.M. with Resident #27's guardian revealed at the last care conference she had with the facility she was made aware Resident #27 was having sexualized types of behaviors. However, she was not aware of actual sexual activity, the extent of the sexualized behaviors or that the resident was involved in any type of relationship with another resident. During the interview, the guardian revealed Resident #27 was not able to provide consent (to sexual activity) due to his cognitive impairment. The guardian revealed she had not been notified that the sexual activity that had occurred had placed Resident #27 at risk for contracting Hepatitis C (as the sexual intercourse was unprotected). She stated the last phone call she received from the facility was on 11/14/24. Interview on 01/15/25 at 3:09 P.M. with the DON revealed she was aware Resident #21 and Resident #27 would hold hands, and she was aware there was human contact where some upper body contact was attempted or did happen. However, she stated she was not aware of any invasive contact (eluding to sexual intercourse). The DON verified Resident #27, due to cognitive impairment would not be able to consent to sexual activity. The DON revealed she was unaware of pregnancy testing for Resident #21 until 01/13/25. The DON revealed she was aware Tagamet had been ordered for Resident #21 to decrease her libido and deter potential attempts at sex. The DON indicated it was her expectation if two residents were observed having sex that the staff would call her and the Administrator, not leave until they were interviewed, and an investigation and self-reported incident (SRI) would be completed immediately. During the interview, the DON indicated she was unaware of this incident involving Resident #27 in 11/2024 until interview with the State agency surveyor. Interview on 01/15/25 at 4:17 P.M. with CNA #108 revealed she had previously observed Resident #21 kissing Resident #27 and had observed the resident's holding hands. While the CNA did not report witnessing Resident #21 having sexual activity with Resident #27, she stated she had heard from a lot of staff that had witnessed Resident #21 having sex with Resident #27. Interview on 01/15/25 at 4:34 P.M. with CNA #300 revealed additional staff present during the incident (on 11/16/24) included the scheduler, CNA #203, and a higher up lady. CNA #300 stated it was her second week at work, and following the incident, she placed a written statement in a folder next to the computer. She stated the incident had occurred after lunch but before 2:00 P.M. She stated, the higher up lady who shared the same name as the DON, stated there was nothing that could be done about it. Interview on 01/15/25 at 4:41 P.M. with CNA #201 revealed Resident #21 believed she was in a relationship with Resident #27 and staff had to remind them of their age gap. Interview on 01/16/25 at 8:16 A.M. with RN #188 revealed she could not recall working at the time Resident #21 and Resident #27 were observed having sex, despite being on the schedule to work on this date (11/16/24). During the interview, the RN was unable to recall information from this time period. During the interview, RN #188 revealed she was also unaware Resident #21 had Hepatitis C and the potential for spreading it during sex. Interview on 01/16/25 at 8:18 A.M. with CNA #203 revealed she was working at the facility (on 11/16/24) when CNA #300 informed her Resident #21 and Resident #27 were in Resident #27's room having sex and she was unsure what to do. CNA #203 stated she told CNA #300 the resident's needed separated, so she went to split them up, but they had already separated themselves and were getting their clothes back on. Both residents were naked at that time. CNA #203 stated she told RN #188 about the incident, but she was passing medications, so she told CNA #300 to write a witness statement and place it on the medication cart. Interview on 01/16/25 at 8:23 A.M. with SSD #190 revealed she was not clinical, so she did not think to inquire why Resident #21 needed a pregnancy test ordered. SSD #190 revealed she did not know Resident #21 had Hepatitis C and could potentially transmit it sexually. During the interview, SSD #190 provided no evidence the sexual activity between Resident #21 and Resident #27 was consensual, that Resident #27 had the ability to consent to the interaction or that the incident had been investigated as possible sexual abuse with Resident #27 being the victim. Interview on 01/16/25 at 8:34 A.M. with the DON revealed no one inquired why the pregnancy test was ordered for Resident #21 in November 2024. The DON verified the lack of written documentation of the sexual intercourse incident in the resident's medical records at the time of the incident, lack of responsible party/guardian notification and physician notification. The DON verified the incident was not reported to the State agency and/or investigated as an incident of sexual abuse. The DON also verified the lack of comprehensive assessments and care plans related to the ability to consent to sexual activity for Resident #27. During the interview, the DON denied knowledge of CNA #300 writing a statement following the observed incident on 11/16/24. Attempts to interview Resident #27 throughout the survey were unsuccessful due to the resident's impaired cognitive status. During the survey, the resident was observed on the secured memory care unit often times sweeping the carpet and participating in activities. On 01/16/25 the facility provided a root cause analysis indicating the incidents of sexual abuse had occurred due to Resident #21's age and being very impulsive due to medical diagnoses including memory impairment, anoxic brain damage, unspecified dementia, history of opioid use, bipolar disorder and not recognizing socially appropriate boundaries. The root cause analysis revealed a nursing home had been determined to not be the least restrictive environment for Resident #21 and that Resident #21 would likely be served in a group home setting or all female facility/unit. However, there was no evidence the facility had identified this or addressed this for the resident prior to the State agency being onsite for the annual survey. Upon further questioning of the root cause analysis, the facility updated the analysis to only note the incidents of sexual abuse had occurred due to Resident #21's age and being very impulsive due to medical diagnoses including memory impairment, anoxic brain damage, unspecified dementia, history of opioid use, bipolar disorder and not recognizing socially appropriate boundaries. During the onsite survey, staff reported their belief was that Resident #21 and Resident #27 were boyfriend and girlfriend and were aware physical contact (i.e. hand holding and kissing) between the residents had and was occurring (as noted in the staff interviews above). However, the facility failed to identify these behaviors as potentially inappropriate, failed to ensure an interdisciplinary comprehensive assessment of each resident's ability to consent to the relationship or sexual activity, or provide adequate supervision and intervention (staff reported simply re-directing when the residents were observed together) to prevent Resident #21 from engaging in unprotected sexual intercourse with Resident #27 on 11/16/24 placing Resident #27 at risk for contracting Hepatitis C and placing Resident #21 at risk for becoming pregnant. Review of a policy titled Abuse, Neglect, Exploitation & Misappropriation of Resident Property, dated 2016, revealed sexual abuse was non-consensual contact of any type with a resident. When an issue was identified, the resident involved should be protected from reoccurrence, the incident should be reported to the state, and an investigation should be completed and be thorough. All residents and witnesses should be interviewed. In the case of a resident-to-resident incident, the interdisciplinary team will determine appropriate interventions.

SERIOUS (G)

Actual Harm - a resident was hurt due to facility failures

Quality of Care (Tag F0684)

A resident was harmed · This affected 1 resident

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**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** 4. Medical record review revealed Resident #31 was admitted to the facility on [DATE] at 5:05 P.M., with diagnoses including diffuse traumatic brain injury with loss of consciousness, hemiplegia, deformity of the head, atrial fibrillation, chronic pain, and iron deficiency anemia. Review of Resident #31's hospital records dated 12/04/24 to 12/18/24 revealed the resident was admitted for a cranial wound dehiscence and purulence. The resident had a craniectomy in 2019 complicated by chronic draining scalp wound and was treated with long term antibiotics. The resident had been having ongoing purulent drainage and exposed hardware. She was taken to neurosurgery and plastics on 12/04/24 for excision of skull bone infection with craniectomy, removal of prior cranial hardware, debridement of bone and scalp and dermal tissue, and implantation of dura matrix. The infection disease was consulted to assist with intravenous antibiotics. Their recommendation at discharge included intravenous meropenem two grams every eight hours for six weeks and vancomycin (pharmacy to dose) for six weeks. The stop date would be 01/16/25. A left tunneled internal jugular central line was placed on 12/12/24. The resident will need oral antibiotics therapy at the end of the parenteral therapy based on the follow up MRI. Review of Resident #31's hospital discharge orders dated 12/18/24 revealed to obtain Vancomycin tough and a basic metabolic profile (BMP) 30-60 minutes before the scheduled dose on Monday and Thursday for two weeks and then weekly on Mondays. Obtain a complete blood count (CBC) and hepatic function panel weekly on Monday. The resident's vancomycin trough range goal was 15-20 micrograms (mcg) per milliliter (ml). Fax laboratory results to the infection disease physician (name and fax number was provided on discharge paperwork). Further review revealed to administer meropenem two grams intravenously every eight hours (last dose was administered on 12/18/24 at 10:56 A.M.) and vancomycin 750 milligrams (mg) every 12 hours intravenously (last dose was administered on 12/18/24 at 5:42 A.M.). A. Review of Resident #31's current orders dated 01/2025 revealed meropenem two grams intravenous every eight hours (6:00 A.M., 2:00 P.M., and 10:00 P.M.) and vancomycin 750 mg intravenous every 12 hours (goal trough range 15-20 mcg/ml) at 8:00 A.M. and 8:00 P.M. Review of Resident #31's medication administration records (MAR) dated 12/18/24 to 01/15/25 revealed the resident didn't receive meropenem on 12/18/24 10:00 P.M., 12/19/24 at 6:00 A.M., 12/29/24 at 2:00 P.M. due to the medication was not available. The vancomycin was not administered on 12/18/24 8:00 P.M., 12/19/24 at 8:00 A.M., 12/23/24 at 8:00 A.M., 12/29/24 at 8:00 P.M., 12/30/24 at 8:00 A.M. and 8:00 P.M. and 12/31/24 at 8:00 A.M., due to the medication was not available. The physician was notified on 12/31/24 that the vancomycin was not available. The medication was on hold on 01/09/25 for the 8:00 A.M. and 8:00 P.M. awaiting trough to be drawn, however the trough (blood work to check medication level) was never collected on 01/09/25. B. Review of Resident #31's orders revealed vancomycin trough was ordered on 12/19/24 on Tuesday and Thursday for two weeks (discontinued on 12/31/24). On 12/27/24 and 01/06/25 vancomycin trough was ordered every Monday and was discontinued on 01/19/25 and 01/09/25 a vancomycin trough was ordered and discontinued the same day. Further review revealed on 12/27/24 a BMP, CBC, CMP, and hepatic function was ordered every Monday and discontinued on 01/19/25. Review of Resident #31's laboratory results revealed the only laboratory results in the medical record were dated 01/10/25. Review of Resident #31's medical record revealed no evidence the laboratory test was faxed to the infectious disease physician per the hospital discharge orders. Review of the laboratory results dated [DATE] to 1/20/25 revealed: -12/19/24 (Thursday) only the vancomycin trough was completed. There was no evidence the BMP was collected per the hospital discharge orders. The vancomycin trough was collected at 10:22 A.M. Per the MAR the resident had missed the 8:00 P.M. dose on the 12/18/24 and the 8:00 A.M., dose on 12/19/24. The trough level was 10.7 microgram (mcg)/ milliliter and the resident's goal were 15-20. -12/23/24 and 12/26/24 (Monday and Thursday) There was no evidence laboratory results were obtained. -12/30/24 (Monday) the blood was collected at 1:45 P.M. (Vancomycin was not administered on 12/29/24 at 8:00 P.M., or on 12/30/24 at 8:00 A.M., due it was not available). The trough level was 5.5 mcg/ml. The BMP, hepatic, and CBC was collected. -01/06/25 (Monday) There was no evidence lab testing was collected. -01/07/25 (Tuesday) The trough level was 26.3 mcg/ml. The BMP, hepatic, and CBC was collected. The trough level was collected at 11:36 A.M., which would have been after the administration of the vancomycin (order was to collect 30-60 minutes prior to administration of vancomycin). New orders were to hold to hold morning dose on 01/09/25 and recollect vancomycin's trough due to the 01/07/25 bloodwork was not collected properly. -01/09/25 there was no evidence the vancomycin trough was collected; however, the resident did not receive either dose of vancomycin on 01/09/25. -01/10/25 the vancomycin trough was collected at 1:44 P.M. and the trough was 4.0 mcg/ml. The MAR indicated the 8:00 A.M., dose was held until the lab was drawn. -01/13/25 (Monday) the vancomycin trough was 13.0 mcg/ml and was collected at 1:47 P.M. The MAR indicated the vancomycin was held until the trough was collected. The other labs were obtained per orders. Review of Resident #31's progress notes dated 01/08/25 revealed the vancomycin trough was reported to pharmacy. The results were 26.3. The dose of vancomycin was administered before the labs were drawn on 01/07/25 so the trough was not a true draw. Recommendation received to redraw trough tomorrow 01/09/25 and hold the 8:00 A.M., dose of Vancomycin until after labs have been drawn. Interview on 01/21/25 at 10:53 A.M., with Licensed Practical Nurse (LPN)/Unit Manger #177 confirmed Resident #31's laboratory results were not in the resident medical record except for the laboratory testing that was completed on 01/10/25. The LPN verified she called and had the hospital fax over all the laboratory results today (01/21/25) from admission to present. The laboratory person comes to the facility on Monday and Thursday to collect labs. LPN #177 reported she called the infection disease physician office today, and they confirmed they had received the laboratory results. The LPN confirmed the troughs should have been drawn 30-60 minutes prior to administering the vancomycin, however the vancomycin troughs on 12/26/24, 12/30/24, and 01/07/25 were collected after the administration of the vancomycin. The LPN confirmed the resident had missed seven doses of the vancomycin and three doses of the meropenem because they were not available to administer from pharmacy, which has been an issue for the facility. LPN #177 confirmed the BMP was not collected on 12/19/24 nor was the trough or BMP collected on 12/23/24, or 12/26/24 per the hospital discharge orders. The laboratory staff did not come on 01/06/25 due to weather but came on 01/07/25. LPN #177 confirmed the resident lab work should have been collected via the central line by the facility's nursing staff; however, it was not collected because the facility depends on the lab to transport specimens. The labs were not done on 01/09/25 and staff should have (but did not) contacted the physician and not held the two doses. 5. Medical record review revealed Resident #54 was admitted to the facility on [DATE] with diagnoses including malignant neoplasm of liver, type two diabetes, urinary tract infection, anemia, paroxysmal atrial fibrillation, congestive heart failure, cardiomegaly, hyperlipidemia, anxiety, history of acute kidney, ileus, acute pulmonary edema, conjunctival hemorrhage, severe sepsis with septic shock, sepsis, encephalopathy, bacteriuria, liver disease, diarrhea, gastroenteritis and colitis, muscle weakness, difficulty walking, need for assistance with personal care. Review of Resident #54's face sheet revealed the resident primary payer was hospice Medicaid. Review of Resident #54' Minimum Data Set (MDS) dated [DATE] revealed the resident was receiving hospice services. A. Review of Resident #54's current and discontinued orders dated 12/19/24 to 01/15/25 revealed no evidence of orders for hospice. Review of Resident #54's medical record revealed no evidence of hospice notes. Review of Resident #54's care plans revealed no evidence of a plan of care for hospice. B. Review of Resident #54's orders dated 12/16/24 to 01/15/25 revealed to check the resident's blood glucose twice a day and notify hospice if greater than 450 mg/dL. Review of Resident #54's MAR dated 12/2024 revealed the resident's blood glucose on 12/18/24 was 509. Review of Resident #54's medical record revealed no evidence hospice was notified of the blood glucose of 509 mg/dL on 12/28/24. C. Review of Resident #54's hospice orders dated 12/10/24 and 01/22/25 revealed the resident was ordered Humalog insulin 10 units prior to meals. Review of Resident #54's facility orders dated 12/11/24 to 01/16/25 revealed the resident was ordered Humalog 15 units three times a daily. Review of Resident #54's MAR dated 12/16/24 to 01/15/25 revealed the resident was receiving 15 units of Humalog three times daily. Interview on 01/22/25 at 9:45 A.M., with RN #139 confirmed Resident #54 did not have a plan of care for hospice. Interview on 01/22/25 at 10:59 A.M. and 2:20 P.M. with LPN #177 confirmed she had called hospice and reviewed Resident #54's medical record and there was no evidence hospice was notified of the blood sugar of 509 mg/dL on 12/18/24. LPN #177 confirmed the facility's physician had increased the resident's Humalog to 15 units on 12/10/24, however hospice was not updated. Originally LPN #177 confirmed the facility had to call hospice to obtain notes, however later reported the facility staff was not aware, however hospice confirmed there was a binder they have been leaving notes in for the staff. Interview on 01/22/25 2:16 P.M. with Hospice RN #340 revealed there has been communication issues with the facility not notifying hospice of changes in resident conditions/orders. The night shift nurses were worse than day shift. For example, Resident #54 has been yelling out at night. No one had called and updated hospice. Hospice RN #340 stated she usually gets information from the chart during her visits, the resident, and sometimes she gets information from other residents. Resident #54 had had an as needed order for Ativan and the facility was not utilizing the as needed medication or notifying hospice. There has been concerns with medication not being administered timely as well. If medications are ordered from the facility, it may take 2-3 days before the medications are started. Hospice RN#340 reported she brings notes in every two weeks and places in the binders for staff. Review of the facility's policy titled Hospice (dated 06/2022) revealed the facility policy was to coordinate end-of-life care with hospice agency of a resident/resident representative choice. The facility would coordinate care with the hospice agency. Facility would notify hospice agency upon resident/resident representative request, or a change in resident condition. Facility would document the coordination of care and treatment that was given to the resident. 6. Medical record review revealed Resident #191 was admitted to the facility on [DATE] with diagnoses including chronic obstructive pulmonary disease, acute respiratory failure with hypoxia, sepsis, tracheostomy, gastrostomy, hypertension, atrial fibrillation, acute kidney failure, protein-calorie malnutrition, anxiety, hyperlipidemia, and tobacco use. Review of Resident #191's progress note dated 01/13/25 at 9:41 A.M., revealed the resident had noted with swelling and bruising to right arm. Area noted to be warm and tender to touch. New orders received to obtain a venous duplex and laboratory testing. Review of Resident #191's progress note dated 01/14/25 revealed no evidence the venous duplex was completed. Review of Resident #191's progress note dated 01/15/25 at 11:54 A.M., revealed the resident had a Doppler completed to the right upper extremity per orders. Review of Resident #191's Doppler results dated 01/15/25 revealed the reason for the right upper extremity Doppler was for pain and swelling to the right arm. The impression included no findings of the right upper extremity deep vein thrombosis. Review of the facility's imaging services agreement (dated 10/01/22) revealed the imaging service was to respond within a reasonable timeframe to request for services, usually within a few hours. Doppler exams are scheduled services, although every effort is made to prioritize emergent venous Doppler studies to be performed within 24 hours. Interview and observation on 01/13/25 at 10:19 A.M., with Resident #191 revealed she had had swelling in her right arm/hand since admission and had not been able to move it. The resident reported she had voiced concerns to the facility staff and wanted an x-ray, but no one had gotten back to her, and she didn't know what the holdup was. At 10:28 A.M., during the interview with the resident an unknown staff member had walked into the resident's room and reported she had spoken to the Nurse Practitioner, and she had ordered a venous Doppler and blood work. Interview on 01/15/25 at 10:16 A.M., with Resident #191 revealed the venous Doppler still had not been completed and she still had the swelling in her right arm and hand. Interview on 01/15/25 at 10:20 A.M., with Licensed Practical Nurse (LPN)/Unit Manger #177 confirmed the resident had not had the venous Doppler at this time. Interview on 01/15/25 at 10:33 A.M., with the Director of Nursing (DON) revealed she was not aware the Doppler was not done and her expectation would be the Doppler would have been done within 24 hours of the order, if not, the facility would transport the resident to the hospital to have the test completed. Interview on 01/16/25 at 10:56 A.M., with the Nurse Practitioner (NP) #315 confirmed her expectations would be the venous Doppler be done within 24 hours from when it was ordered. The NP confirmed staff did not update her that the Doppler was not completed within the 24 hours. Interview on 01/16/25 at 11:06 A.M., with LPN #177 revealed it was the facility's expectation to have a venous Doppler completed within 24 hours from the order. The LPN reported she thought the contracted company was having staff issues. Based on observations, record reviews, and interviews, the facility failed to monitor and administer Resident #31's vancomycin per standards of care, failed to address edema and obtain Doppler testing timely for Residents #59, #85, and #191, failed to communicate orders and care plan with hospice for continuity of care for Resident #54, and failed to address a change in condition for Resident #41 following a fall. This affected six sampled residents (#31, #41, #54, #59, #85, #191) of 20 residents reviewed for quality of care. The facility census was 85. Actual Harm occurred to Resident #41 beginning on 12/20/24 when Registered Nurse (RN) #213 documented the resident had inflammation of left foot and toes after a fall on 12/19/24, with no evidence the resident's medical provider was notified of the resident's change in condition delaying any orders for treatment of the resident's change in condition. On 12/21/24, Resident #41's left foot continued to be edematous and red, with the resident exhibiting facial grimacing with repositioning and generalized discomfort; the resident's wife verbalized he had been sleepier and had a poor appetite since his fall on 12/19/24. An order was received on 12/21/24 at 11:42 A.M. for an x-ray of the left foot and hip, and a venous Doppler to right foot. Resident #41 continued to show signs of discomfort including facial grimacing and moaning aloud with care, and as needed pain medication was administered. The left foot and hip x-rays were delayed and not completed until the following day (12/22/24) at 2:00 P.M., the x-ray results were received, the resident was transferred to the hospital for additional testing that identified the resident had an acute mildly impacted subcapital right femoral neck fracture. Findings include: 1. Record review revealed Resident #41 was admitted to the facility on [DATE] with diagnoses including atherosclerotic heart disease without angina pectoris, hypo-osmolality and hyponatremia, anemia, hypertension, and heart failure. Resident #41 was recently readmitted to the facility on [DATE] after a brief stay in the hospital. Review of a nursing note dated 12/19/24 at 2:30 P.M. by RN #188 revealed Resident #41 was noted to have fallen from his wheelchair on his right side in the dining room attempting to throw away an apple core. Resident #41 was assessed with no injuries noted, he did not complain of pain or discomfort, but stated this floor is hard. Resident #41 was assisted into his wheelchair without difficulty. The resident's responsible party was notified. Review of a nursing note dated 12/20/24 at 8:00 P.M. by RN #213 revealed Resident #41 had inflammation noted to his left foot and toes. There was no evidence the resident's medical provider was notified of the resident's change in condition after his fall on 12/19/24. Review of a nursing note dated 12/21/24 at 11:42 A.M. by RN #202 revealed Resident #41's left foot was noted to be slightly edematous and red, with pedal pulses palpable and no increased warmth. Resident #41 had grimacing with positioning and generalized discomfort, and as needed Tylenol was administered. Resident's wife was present and stated he had a poor appetite and was sleepier since his fall on 12/19/24. A new order was received for an x-ray to the left hip and foot due to pain, and a venous Doppler to the right foot. Wife present and agreeable. Review of a nursing note dated 12/21/24 at 9:41 P.M. by RN #216 revealed the mobile imaging company called and stated the x-ray would not be able to come in as scheduled but would come sometime tomorrow. Review of a nursing note on 12/22/24 at 11:22 A.M. by RN #202 revealed Resident #41 continued to show signs of discomfort, facial grimacing and moaning aloud with care, and as needed Tylenol was administered as ordered. Review of a nursing note dated 12/22/24 at 2:00 P.M. by RN #202 revealed the mobile imaging company was in-house for exam of Resident #41. Review of a medication administration record for December 2024 revealed on 12/22/24 Resident #41 received an x-ray of his left foot and hip. Review of a nursing note dated 12/22/24 at 2:10 P.M. by RN #202 revealed x-ray results were received, and the on-call provider was notified and gave new orders to send to the emergency department for further evaluation. A squad was notified of need for transfer and family notified. Review of a nursing note dated 12/22/24 at 3:59 P.M. by RN #202 revealed Resident #41 was transported to the hospital. Review of a hospital note dated 12/23/24 revealed Resident #41 presented to the emergency department (ED) following a fall at a facility. Upon presentation, Resident #41's blood pressure was 190/71 and other vitals were within normal limits. An x-ray of the pelvis showed a previous internal fixation of the left femoral neck and due to a nondisplaced fracture of the right femoral neck, and fecal impaction. A CT scan of the pelvis showed an acute mildly impacted subcapital right femoral neck fracture. Interview on 01/16/25 at 2:43 P.M. with Director of Nursing (DON) revealed there have been concerns with the mobile imaging company not showing up to complete STAT imaging. The DON confirmed Resident #41 began to complain of pain on 12/20/24, with no new intervention in place until the imaging services were ordered on 12/21/24, which were not completed until 12/22/24. The DON stated if the company does not show up within four hours, a resident should be sent to the hospital. 2. Record review revealed Resident #59 admitted to the facility on [DATE] with diagnoses including dementia, metabolic encephalopathy, type II diabetes, and hypertension. Review of a minimum data set (MDS) completed on 10/09/24 revealed Resident #59 had impaired cognition and no behaviors. Review of a nursing note dated 11/30/24 by RN #188 revealed Resident #59 complained of discoloration to her left foot. Her foot was noted to be dark purple/black, and swelling was noted with capillary refill of less than three seconds. Resident #59 denied pain, the medical provider was notified, and new orders were received for an x-ray and a venous Doppler. The mobile imaging company stated they would not be able to complete the Doppler until next week. Review of a progress note dated 12/02/24 by Nurse Practitioner (NP) #315 revealed she was asked to see Resident #59 due to discoloration of the left foot. An x-ray was completed and negative and the venous duplex was not yet completed. There was one-two pitting edema to the left foot with purple discoloration to the left foot dorsal aspect, non-tender palpation and 2+ DPPT pulse. No new orders were given. Review of a note dated 12/10/24 at 2:20 P.M. revealed the mobile imaging company was in-house to complete Resident #59's ultrasound (Doppler). Results were negative. Review of a Doppler report dated 12/10/24 revealed there was no evidence of left lower extremity deep venous thrombosis. Interview on 01/16/25 at 1:47 P.M. with RN #188 revealed she entered Resident #59's order for a stat venous Doppler and she faxed the information six times before the mobile imaging completed the ultrasound. RN #188 stated she notified the NP (#315) of the situation but the Medical Director (MD) #340 came in and evaluated the resident and was not worried. Her family did not want her sent out for evaluation and were okay with waiting until the scan could be done in house. Interview on 01/16/25 at 10:56 A.M., with the Nurse Practitioner (NP) #315 confirmed her expectations would be the venous Doppler be done within 24 hours from when it was ordered. Interview on 01/16/25 at 2:43 P.M. with Director of Nursing (DON) revealed there have been concerns with the mobile imaging company not showing up to complete STAT imaging. The DON confirmed Resident #59 waited from 11/30/24 to 12/10/24 to receive the venous Doppler. The DON stated if the company does not show up within four hours, a resident should be sent to the hospital. 3. Record review revealed Resident #85 admitted to the facility on [DATE] with diagnoses including vascular dementia, post-traumatic stress disorder, and idiopathic gout. Review of a MDS completed on 11/29/24 revealed Resident #85 had moderately impaired cognition and wandered daily. Review of orders revealed Resident #85 had an order in place to receive a venous duplex (Doppler) to his left lower extremity due to pain and swelling dated 01/02/25. The order was discontinued on 01/02/25. Review of a nursing note dated 01/02/25 at 9:54 A.M. by Licensed Practical Nurse (LPN) #177 revealed new orders were received for Resident #85 for a CBC, Chem 8, ESR, CRP, and uric acid level, obtain an x-ray of left knee due to pain and swelling, and a venous duplex of the left lower extremity. Review of a nursing note dated 01/05/25 at 10:03 A.M. by LPN #211 revealed Resident #85 had +1 putting edema to the right foot with minimal movement and grimacing when attempting to move. The resident's medical provider was notified and new order was received for right lower extremity venous duplex. Review of a nursing note dated 01/05/25 at 6:40 P.M. for late entry from 9:28 A.M. by LPN #211 revealed she called the mobile imaging company to schedule a Doppler for Resident #85 and was told a face sheet and order needed sent prior to scheduling. Information was sent. Review of orders revealed Resident #85 had an order in place for a venous duplex of right lower extremity dated 01/05/25. The order was discontinued on 01/08/25. Review of a nursing note dated 01/08/25 at 9:29 A.M. by LPN #211 revealed she called the mobile imaging company to ask if the venous Doppler had been completed and the scheduler requested a new order with updated symptoms. Review of orders revealed Resident #85 had an order in place dated 01/08/25 for a venous duplex of right lower extremity due to pain and edema. The order was discontinued on 01/16/25. Review of a nursing note dated 01/10/25 at 10:44 A.M. by LPN #165 revealed a face sheet and orders were faxed to the mobile imaging company for a venous duplex of the right lower extremity due to pain and swelling and will call back to schedule exam. Review of a patient report (for Resident #85) for venous Doppler dated 01/15/25 revealed there was no deep venous thrombosis evident on the right lower extremity. Interview on 01/16/25 at 10:56 A.M., with the Nurse Practitioner (NP) #315 confirmed her expectations would be the venous Doppler be done within 24 hours from when it was ordered. Interview on 01/16/25 at 2:43 P.M. with the DON revealed there have been concerns with the mobile imaging company not showing up to complete STAT imaging. The DON confirmed Resident #85 received an initial order on 01/02/25 and waited until 01/15/25 to have a venous Doppler completed. The DON stated if the company does not show up within four hours, a resident should be sent to the hospital.

SERIOUS (G)

Actual Harm - a resident was hurt due to facility failures

Pressure Ulcer Prevention (Tag F0686)

A resident was harmed · This affected 1 resident

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**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** 2. Review of Resident #1's medical record revealed she was admitted to the facility on [DATE]. Her diagnoses included paraplegia, neurogenic bowel, colostomy status, neuromuscular dysfunction of the bladder, supra-pubic catheter status, peripheral vascular disease, chronic pain syndrome, muscle weakness, and a stage IV pressure ulcer (full-thickness skin and tissue loss with exposed fascia, muscle, tendon, ligament, cartilage, or bone in the ulcer) on her buttocks. Review of Resident #1's annual Minimum Data Set (MDS) assessment dated [DATE] revealed the resident did not have any communication issues and was cognitively intact. She was known to display verbal behaviors directed at others during the seven day assessment period, but was not known to reject care. She had a functional limitation in her range of motion of her bilateral lower extremities. She was dependent on staff for bed mobility and transfers and used a motorized wheelchair for mobility. She was identified as being at risk for pressure ulcers and had two unhealed pressure ulcers that were stage IV pressure ulcers that were present upon admission. Pressure reduction for her bed and chair, turning and repositioning, pressure ulcer care, application of medications/ ointments/ and dressings were all indicated to have been used for skin/ ulcer treatment. Review of Resident #1's active care plans revealed she had a care plan in place for having pressure ulcers on her her buttocks. The care plan was initiated on 02/24/23. The goal was for the resident's pressure ulcers to heal without complications. The interventions included the use of a pressure reducing mattress and to provide treatment per the physician's orders. Further review of Resident #1's active care plans revealed she also had a care plan in place for being at risk for skin breakdown related to paraplegia, existing pressure ulcers, bowel incontinence, and decreased mobility. That care plan was initiated on 02/24/23. The goal was for the resident's skin to remain intact. Interventions included avoiding shearing of the skin during positioning/ turning/ transferring, encourage and assist the resident with turning and repositioning for comfort and as needed, float heels as needed, and pressure reducing mattress to bed. Review of Resident #1's physician's orders revealed she had a treatment in place to cleanse her wounds daily with normal saline, pat dry, lightly pack the wound with 1/4 inch Iodoform packing gauze, cover with a Mepilex border dressing or an equivalent, and they could continue to use an ABD pad and tape to cover. The physician's orders also included the use of an low air loss alternating mattress with directions to check the function every shift, encourage the resident to float heels when in bed, and a trapeze bar to her bed to assist the resident with bed mobility. On 01/14/25 at 10:30 A.M., an observation of Resident #1 noted her to be lying in bed in a supine position. The low air loss (LAL) alternating mattress on her bed was under-inflated as the resident was sunk down into the mattress. The settings on the pump that was attached to the foot of her bed revealed it was set on the softest setting with only the first green light of eight illuminated. The more lights illuminated the firmer the mattress was. There were setting guidelines on a label stuck to the top of the pump that indicated what the bed setting should be set on based on the resident's weight. The resident reported she was around 150 pounds (163 pounds was her actual weight recorded in her EMR when last weighed in January 2025), which both weights indicated the softness/ firmness setting of her mattress should have been set between two and four. The resident was asked at the time of the observation who adjusted the settings on her LAL mattress. The resident reported the maintenance employee had changed the settings on her bed when she last complained that the bed was not comfortable. The maintenance employee stated he wanted to try that softer setting before he proceeded with having to replace her mattress. She was not observed to have a trapeze bar in place over her bed as ordered to assist her with bed mobility. The resident was asked if staff were providing her encouragement or assistance with turning and repositioning. She denied that they were regularly coming in to encourage or assist her with turning and repositioning, as per her orders and plan of care. She reported there had been times she had been asleep in her bed and she would wake up four or five hours later in the same position. On 01/14/25 at 2:20 P.M., an interview with Certified Nursing Assistant (CNA) #199 revealed Resident #1 was known to have two wounds to her buttocks area that had dressings on them. She reported the wounds had been there since her admission and the nurses took care of the wounds. They tried to keep the resident on her side. She liked to be on her side, unless she was eating or up in her wheelchair. She claimed the resident would let them know when she wanted to be turned. It was typically maybe twice a shift (eight hour shifts) that the resident would ask to be turned and repositioned. She denied that they offloaded the resident's heels when she was in bed. The resident had the use of an air mattress and she had heard the resident complain there were areas on her bed that were hard on her back. She denied that the aides messed with the settings on the resident's mattress. If the bed beeped, they called the bed company to come in and fix it. She denied the resident had a trapeze over her bed to assist with bed mobility. On 01/14/25 at 2:30 P.M., an interview with RN #162 revealed Resident #1 had pressure ulcers on her bilateral buttocks that had tunneling. She was aware they were pressure ulcers but was not sure what stages they were classified as. The resident was being followed by the local hospital's wound clinic and the facility's visiting nurse practitioner. She confirmed the pressure ulcers were present upon the resident's admission. Tunneling had decreased according to the report the resident gave them following her last wound clinic appointment. She verified the resident had the use of a LAL mattress. She claimed the resident was able to turn and reposition herself, but the aides would assist as needed. She denied the resident had the use of a trapeze to assist with bed mobility that she was aware of. On 01/14/25 at 3:10 P.M., observations made during a treatment observation of Resident #1's pressure ulcers revealed her LAL mattress remained on the softest setting and not according to her known weight. She also did not have a trapeze bar over her bed as ordered and per her plan of care. After the completion of her wound treatments, Resident #1 informed RN #162 that the surveyor had concerns with her LAL mattress not being properly inflated based on her known weight and what the settings called for based on that weight. LPN #165, who was in the room assisting RN #162 with the treatment, verified the resident's LAL mattress was set on the first setting (softest) and should have been set between two and four based on the resident's weight. She was observed to raise the setting to three and informed the resident that they would try that setting since it was in the middle of what was called for based on her weight. They would then adjust it between two and four as needed until the desired comfort was achieved. On 01/14/25 at 3:30 P.M., a follow up interview with RN #162, after she left Resident #1's room following the completion of her dressing changes. She acknowledged skin prevention interventions were not being followed for the resident as per her plan of care as a trapeze bar was not in place over the resident's bed to assist her with bed mobility and her heels were not being offloaded as ordered. She further acknowledged the LAL mattress should have been inflated to the proper setting based on the resident's known weight. She further acknowledged inconsistencies in the information provided by the nursing staff and the resident on how often the resident was to be encouraged and assisted with turning and repositioning. The aides reported they turned and repositioned the resident twice a shift and not every two hours as per her plan of care and the nurse had indicated the resident was able to turn and reposition herself when the resident denied being able to do so. Based on observations, record reviews, and interviews, the facility failed to develop and implement a comprehensive and individualized pressure ulcer prevention program to ensure skin assessments/skin checks were completed and to ensure skin integrity issues were reported to the medical provider. In addition, the facility failed to provide treatment to newly developed pressure ulcers for Resident #41 and failed to implement skin interventions for Resident #1 per the resident's plan of care. This affected two residents (#1 and #41) of two residents reviewed for pressure ulcers. The facility census was 85. Actual Harm occurred beginning on 01/01/25 when Resident #41, who was assessed to be at high risk for the development of pressure ulcers, was re-admitted to the facility from the hospital with mushy heels and the facility failed to comprehensively assess or implement interventions to prevent pressure ulcer development. On 01/09/25 prevlon boots were ordered to both feet without documentation regarding the reason the boots were ordered. On 01/12/25 an initial assessment revealed had a pressure ulcer to his left heel that measured 4.5 (did not specify inches or centimeters) in diameter and was brown in color (with no staging included). The facility failed to implement new pressure ulcer interventions at this time resulting in a decline and identification of bilateral heel pressure ulcers that were Stage III (full-thickness loss of skin, in which subcutaneous fat may be visible in the ulcer and granulation tissue and epibole (rolled wound edges) are often present. Slough and/or eschar may be visible but does not obscure the depth of tissue loss due to the eschar and coloring of the wound) pressure ulcers. Findings include: 1. Record review revealed Resident #41 admitted to the facility on [DATE] with diagnoses including atherosclerotic heart disease without angina pectoris, hypo-osmolality and hyponatremia, anemia, hypertension, and heart failure. Resident #41 recently re-admitted to the facility on [DATE] after a brief stay in the hospital. Review of a care plan initiated 12/26/23 revealed Resident #41 was at risk for skin breakdown related to decreased mobility and incontinence. Interventions (all dated 06/28/24) included avoiding shearing skin during positioning, turning and transferring; conduct a weekly skin assessment and pay particular attention to bony prominences; encourage and assist to turn and reposition for comfort and as needed; floats heels as needed; keep linens clean and dry as possible, minimize skin exposure to moisture; pressure reducing cushion to chair; pressure reducing mattress to bed; use lifting device as needed for bed mobility; and use moisture barrier product to perineal area as needed. The care plan was last reviewed on 01/02/25 with no new interventions. Record review revealed no documented evidence care planned interventions, including turning and repositioning and floating the resident's heels, were implemented and completed. Review of a hospital wound care note dated 12/24/24 revealed Resident #41 had a traumatic wound to the second toe of his right foot. There were no additional wounds listed. Review of a nursing note dated 01/01/25 at 3:42 P.M. by Licensed Practical Nurse (LPN) #211 revealed Resident #41 was re-admitted to the facility, with pain noted to hip, scattered bruising to bilateral arms and right leg was yellow and purple in color. There was an incision to his right hip measuring 10 centimeters (cm) in length by 0.01 cm in width and 0 cm in depth. Review of an admission Observation and Data Collection assessment dated [DATE] revealed Resident #41's skin color was normal, warm in temperature, normal turgor, and skin impairment was identified and to be assessed on a Wound Event Assessment. Resident #41 was determined to be at high risk for developing pressure ulcers. Review of a progress note dated 01/02/25 by Nurse Practitioner (NP) #315 revealed Resident #41's skin was warm, dry, and the dressing to the right hip was dry and intact with surrounding ecchymosis. Review of an order dated 01/09/25 revealed Resident #41 was to have prevlon boots on when in bed. Review of a nursing note dated 01/12/25 at 9:23 A.M. by Registered Nurse (RN) #213 revealed wound on Resident #41's left heel was now approximately 4.5 (did not specify inches or centimeters) in diameter and had become brown in color. There was no staging including in the note. No drainage was noted, and soft boots were in place to elevate foot and heel off the bed. Review of a nursing note dated 01/16/25 at 7:20 P.M. by RN #213 revealed the heel of Resident #41's left foot had approximately 4 centimeter (cm) area of light brown coloration, was soft to touch, and soft booties were in place to both feet. Review of a nursing note dated 01/20/25 at 11:05 A.M. by RN #213 revealed Resident #41 had a Stage I (intact skin with a localized area of non-blanchable erythema) pressure ulcer to his left heel, which was darker brown than previously noted and padded boots were in place to each foot. Review of an order dated 01/22/25 revealed Resident #41's heels should be monitored and notify nurse practitioner of any changes due to deep tissue injury. Measurements provided to the surveyor on 01/22/25 of bilateral heel pressure ulcers revealed an ulcer to the left heel was five centimeters by three centimeters and an ulcer to the right heel was three centimeters by 1.5 centimeters. Eschar noted to be present was not measured. Interview on 01/21/25 at 10:21 A.M. with Registered Nurse (RN) #188 revealed Resident #41 had a wound to his right second toe, which the resident was admitted with from the hospital, and a wound to the left and right heels. RN #188 stated the bilateral heels were hard and brown. Interview on 01/21/25 at 2:25 P.M. with Licensed Practical Nurse (LPN) #165 revealed she completes wound rounds with the NP, NP #315 when she comes in. LPN #165 stated they had not looked at Resident #41's heels during the wound rounds on 01/20/25 because the last they heard, the heels were just soft and prevlon boots had been added as a preventative measure. LPN #165 confirmed there was no documentation in the medical record regarding where the wounds to Resident #41's heels came from or information about the right heel at all. Interview and observation on 01/21/25 at 2:40 P.M. with Director of Nursing (DON) revealed the wound to Resident #41's left heel was approximately the size of a fifty-cent piece, was purple and brown in color, with approximately 25% eschar (dead or devitalized tissue that is hard or soft in texture; usually black, brown, or tan in color, and may appear scab-like). The wound to the right heel was approximately the size of a nickel, brown in color and had about 5% eschar. Resident #41's wife was present at the time of the observation and stated the resident's heels were soft upon return to the facility from the hospital (on 01/01/25). Observation on 01/22/25 at 10:36 A.M. of Resident #41's heels revealed the right heel was a healing blister the size of a nickel with blanchable skin and the skin was intact and wound edges approximate. The left heel had 30% eschar in the corner of the wound and was dry. Fascia, muscle, tendon, ligament, cartilage and/or bone were not exposed indicating a potential Stage 3 pressure injury. Interview on 01/22/25 at 11:18 A.M. with LPN #165 revealed she was unable to locate any documented evidence Resident #41 had mushy heels upon readmission to the facility on [DATE], however, LPN #165 stated the floor nurse knew but failed to document it. LPN #165 confirmed there was nothing regarding pressure ulcers/wounds to Resident #41's heels in the care plan, nursing notes, or hospital documentation to indicate the resident's heels had started to have wounds in the hospital. Interview on 01/22/25 at 11:40 A.M. with Medical Director (MD) #340 revealed he does not specialize in wound care and was not comfortable with staging the wounds to Resident #41's heels. MD #340 stated the NP took care of wounds for the facility. MD #340 stated the wounds looked like a blister, but he was not sure. He stated if new wounds arise, staff should contact the NP to let her know so she can assess and give interventions as soon as the wound is noticed. Interview on 01/22/25 at 12:53 P.M. with the DON revealed nursing notes, hospital notes, the NP note, assessments, and orders did not address potential deep tissue injuries or pressure ulcers to Resident #41's heels until 01/09/25 for the prevlon boots. The DON stated she assessed Resident #41's heels upon his return to the facility (01/01/25) but failed to document. After observing wounds on 01/21/25 (at 2:40 P.M. with the surveyor), the DON did not contact a medical provider, complete an assessment, or measure the wounds to Resident #41's bilateral heels. The DON acknowledged eschar was present in both wounds. Interview on 01/22/25 at 3:16 P.M. with RN #213 revealed she had assessed Resident #41's left heel the other day and it was about a Stage II pressure ulcer (partial-thickness loss of skin with exposed dermis, presenting as a shallow open ulcer. The wound bed is viable, pink or red, moist, and may also present as an intact or open/ruptured blister), and she reported to the unit manager, LPN #165, to have the NP look at Resident #41's heels. RN #213 went to observe Resident 41's heels with surveyor present and stated the wound to Resident #41's left heel appeared to be a Stage Three (full-thickness loss of skin, in which subcutaneous fat may be visible in the ulcer and granulation tissue and epibole (rolled wound edges) are often present. Slough and/or eschar may be visible but does not obscure the depth of tissue loss due to the eschar and coloring of the wound). Review of the National Pressure Ulcer Advisory Panel Pressure Injury Stages (dated 2018) revealed a deep tissue injury in intact or non-intact skin with localized area of persistent, non-blanchable deep red, maroon, purple discoloration or epidermal separation revealed a dark wound bed or blood filled [NAME]. If necrotic tissue (eschar), subcutaneous tissue, granulation tissue, fascia, muscle or other underlying structures are visible, this indicates a full-thickness pressure injury (unstageable, stage 3 or 4). A stage 3 pressure injury is full-thickness loss of skin, in which adipose is visible in the ulcer and granulation tissue and epibole are often present. Slough and eschar may be visible. If slough or eschar obscure the extent of tissue loss, it is an unstageable pressure injury. An unstageable pressure injury is when the extent of tissue damage cannot be confirmed because it is obscured by slough or eschar. If slough or eschar are removed, stage 3 or 4 will be revealed. Stable eschar (dry, adherent, intact without erythema or fluctuance) on the heels should not be removed. Review of a Pressure Ulcer/Injury Risk Assessment policy (last revised in 2017) revealed the following information should be documented in the medical record: - The type of assessment - The date, time, and type of skin care provided - The name and title (or initials) of the person completing the assessment - Any change in the resident's condition if identified - The condition of the resident's skin - How the resident tolerated to procedure - Any problems or complaints made by the residents - If treatment/assessment were refused - Initiation of a form related to the type of alteration if a new skin alteration is noted - Addressing the MD notification if new alteration is noted - And notification to responsible party.

SERIOUS (G)

Actual Harm - a resident was hurt due to facility failures

Accident Prevention (Tag F0689)

A resident was harmed · This affected 1 resident

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**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, record review and interview, the facility failed to develop and implement comprehensive, individualized and effective interventions to prevent a fall and wandering behavior resulting in Resident #71 exiting the facility. Actual harm occurred on 07/31/24 when the facility failed to prevent Resident #71 from exiting the building to the patio after the resident reported he was aware he could exit after pushing on the door for 15 seconds to get out. Following this incident on this date, the facility failed to implement additional/new interventions for Resident #71's safety and five hours later, Resident #71 exited the building again, and sustained a fall. The resident complained of pain and was transported to the emergency department where he was diagnosed with a fracture of the shaft of the left femur. In addition, a concern not rising to the level of actual harm, was identified when the facility failed to ensure medications were stored properly on the memory care unit. This affected one resident (#71) of three residents reviewed for falls and had the potential to affect 18 residents (#5, #17, #21, #24, #27, #34, #37, #39, #58, #59, #62, #66 #71, #72, #76, #79, #83, and #85) of 85 resident's residing in the facility. Findings include: 1. Record review revealed Resident #71 was admitted to the facility on [DATE] with diagnoses including atrial fibrillation, dementia, memory deficit following cerebral infarction, and history of a transient ischemic attack. Review of the Minimum Data Set (MDS) assessment completed 06/27/24 revealed Resident #71 had moderately impaired cognition and wandered daily. Review of a nursing note dated 07/31/24 at 3:31 A.M. revealed Resident #71 was awake all night, asking repetitive questions of where the bathroom was and where to go. He had verbal agitation with redirection. Review of a nursing note dated 07/31/24 at 10:04 A.M. revealed Resident #71 got out of the facility into the courtyard area and stated he knew if he pushed on the door long enough it would open. Staff accompanied Resident #71 until he wanted to go back into the facility. No additional interventions were implemented to keep Resident #71 from exiting the building following this incident. Review of a nursing note dated 07/31/24 at 3:10 P.M. revealed Resident #71 went out the locked door, started to run, slipped on the sidewalk and hit his head on the white plastic fence and then hit the ground with his left hip. Resident #71 had a laceration to the left side of his head; he was complaining of hip pain in his right leg area. An emergency squad was called, and the resident left the facility at 3:56 P.M. (to go to the hospital). Review of a nursing note dated 07/31/24 at 5:24 P.M. recorded as a late entry for 3:25 P.M. revealed staff stated Resident #71 was pushing on the exit door and when staff tried to redirect him, he raised his fists to her so she stepped back, and the resident forced the door open falling forward to the pavement. Outward rotation of the left lower extremity was noted and Resident #71 complained of pain and was sent to the emergency department. Review of the fall investigation revealed no evidence of statements from staff were obtained as part of the investigation. Review of a care plan initiated on 08/14/24 revealed Resident #71 wanders without purpose. Interventions included assessing cognition quarterly; encourage resident to participate in brief periods of structured activity; encourage resident's family to visit on a schedule that meets the needs of the resident as appropriate; maintain routine in the resident's day including meal time, activity, family visits, etcetera; monitor cognitive function for significant fluctuations and refer to physician as needed; observed wandering patterns and escort away from other residents or other resident rooms as needed; and provide meaningful leisure activity as appropriate. Review of a care plan initiated on 08/14/24 revealed Resident #71 was at risk for falls related to dementia, impaired gait, and medication side effects. Interventions included to assure the floor is free of liquids and foreign objects; encourage and assist resident to assume a standing position slowly; keep call light in reach; keep personal items and frequently used items in reach; provide non-skid footwear; therapy evaluation and treatment as needed; and increase frequency of visual reminders. Interview on 01/15/25 with CNA #202 revealed she was not present when Resident #71 broke his hip. Interview on 01/15/25 at 2:30 P.M. with the Director of Nursing (DON) revealed Resident #71 had been exit seeking prior to his fall with fracture, but she was not aware of any additional interventions to stop him from continued exit seeking. The DON also confirmed two separate nursing notes had different descriptions of the event. Interview on 01/21/25 at 8:04 A.M. with the DON revealed a hand-written statement was completed the same day with a staff member who worked the day of Resident #71's fall. The DON stated a statement had been written at the time of the incident, but it could not be located. The DON stated the facility does utilize a 15-minute check form, but there was no evidence it was completed for the resident at the time of this incident. The DON stated she just found out today it was standard for the unit to use heightened checks but they do not enter orders for it. The DON stated the second note entered was the correct version of the incident. The DON stated in her mind, heightened checks means the resident is in line of sight, but not one-on-one. Review of a statement received at the time of the survey on 01/21/25 by Certified Nursing Assistant (CNA) #202 revealed Resident #71 was having increased behaviors and exit seeking. Heightened checks and frequent re-direction were initiated. 2. Observation on 01/13/25 at 8:55 A.M. on the memory care unit in the living room revealed two residents seated in the living room area with no staff supervision. A closet was unlocked and revealed multiple medications, a credit card, and a dull knife. The medications included: - a full bottle of probenecid - a full bottle of sodium bicarbonate, opened and unlabeled - a bottle of vitamin D - an open bottle of aspirin 325 milligrams (mg), unlabeled - two boxes of fluticasone propionate and salmeterol powder 250 micrograms (mcg)/50 mcg - a bottle of multi-vitamins opened on 12/12/24 - unopened box of anti-diarrheal 24 2 mg capsules - a pill organizer for Sunday-Saturday morning and evening medications; morning pills were in container for Wednesday through Saturday and Sunday through Saturday for evening medications. The organizer was not labeled with the medication information or who they belonged to. - ondansetron four 4 mg tablets - one 21 mg nicotine patch - half a bottle vitamin B6 50 mg opened on 03/17/24 - a bottle opened on 12/31/22 with an expiration date of 04/2024 of geri-kot 8.6 mg - megesterol - cyclosprorine 0.05% eye drops - albuterol sulfate one inhaler with the label ripped off - finestreride 5 mg tablets - escitalopram 20 mg tablets - memantine 10 mg 136 tablets - two bottles of calcium 250 mg - carboxymethylcellulose gel - mucus-ER 40 tablets unopened - sodium chloride half bottle - unopened, unlabeled box of Tagamet 200 mg 30 tablets - estradiol 0.1 mg vaginal cream - nyastatin 100,000 units/gram powder - tacrolimus ointment 0.1% - clobetasol 0.05% cream - silver sulfadiazine 1% cream - megestrol acetate 40 mg half a bottle Interview on 01/13/25 at 9:25 A.M. with Licensed Practical Nurse (LPN) #165 confirmed the medication findings and the door being unlocked. LPN #165 stated she noticed over the weekend the door would be locked but wasn't latching. LPN #165 confirmed the door handle was not locked at the time of the observation. A list provided by the Director of Nursing (DON) on 01/13/25 at approximately 10:45 A.M. revealed the memory care unit residents were all confused and 18 residents (#5, #17, #21, #24, #27, #34, #37, #39, #58, #59, #62, #66 #71, #72, #76, #79, #83, and #85) residing on the memory care unit wandered throughout the memory care unit independently.

CONCERN (D)

Potential for Harm - no one hurt, but risky conditions existed

Resident Rights (Tag F0550)

Could have caused harm · This affected 1 resident

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**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on medical record review, review of the concern log, review of personnel files, interviews, and policy reviews the facility failed to ensure residents were treated with respect and dignity by nursing staff. This affected one resident (#9) of six residents interviewed on 300 halls. Findings included: Medical record review revealed Resident #9 was admitted to the facility on [DATE] with diagnoses including anxiety, depression, respiratory disease, diabetes, difficulty walking, and was currently under hospice care. Interview on 01/13/25 at 9:15 A.M., and 01/21/25 at 1:58 A.M., with Resident #9 revealed Registered Nurse (RN) #126 was rude and rough with care such as pulling on her arms when administering insulin. Resident #9 reported several residents had voiced complaints about RN #126 and she had observed RN #126 make another staff member cry. The RN works on 3rd shift. Interview on 01/13/25 at 11:10 A.M., with Resident #78 revealed there's a nurse on nightshift, but she could not recall her name, that doesn't treat her with respect and dignity. The nurse just doesn't like her and yells at her if she tries to ambulate on her own. The nurse was always in a hurry. Interview on 01/16/25 at 11:14 A.M., with Licensed Practical Nurse (LPN)/Unit Manger #177 revealed she had heard other staff members having issues with RN #126, however she had not heard anything related to residents. The LPN reported she had just started as the Unit Manager last Friday. Interview on 01/16/25 at 11:26 A.M., with LPN/Unit Manger #165 revealed RN #126 had a dry personality but was a good nurse. She had also just started as the Unit Manger last Friday and been off for a few months. LPN #165 reported she was unaware of any concerns regarding RN#126 and residents. Interview on 01/16/25 at 11:49 A.M., with the Director of Nursing (DON) revealed there had been concerns with RN#126, however she thought she had provided education to the RN and placed the education in her personnel files. The DON reported she had just recently received a complaint from a resident that RN #126 rushes when providing care. The DON reviewed the concerns forms with the surveyor and could not recall which concerns were related to RN #126 and she would have to look into them a little deeper. Interview on 01/16/25 at 3:07 P.M., with the Administrator revealed the DON had found some education for RN #126 on her computer and handed the surveyor a one-page typed letter from the DON that was signed at the bottom and undated. The letter indicated on 08/23/24 and 09/11/24 RN #126 was provided verbal education accordingly. On 11/20/24 the DON had met with RN #126 and explained there had been concerns with her in the past and explained if there were any further complaints that they would result in a suspension. The Administrator reported there had been no further concerns since 11/20/24. Interview on 01/22/25 at 2:14 P.M., with Hospice RN #340 revealed she had reported on at least three occasions Resident #9's concerns regarding RN #126 to the Social Service Director (SSD) #190. The SSD #190 told her she wrote up concern forms and reported the incidents to the Administrator. The RN could not recall the dates she had reported the residents concerns to the SSD. Interview on 01/22/25 at 3:54 P.M. with SSD #190 confirmed there had been other resident besides Resident #9 that had voiced concerns regarding RN #126. SSD #190 verified that the Hospice RN #340 had reported concerns related to RN #126, however she cannot recall the dates or information, and she could not locate the concerns forms she had started regarding the concerns. The SSD reported she starts the concern form and then gives the form to the department responsible and she must have not received the form back. The SSD verified she does not document on the form in the space that indicates the resolution was communicated to the person filing the concern. Review of resident concern forms dated 08/20/24 to 01/07/25 revealed: On 07/23/24 Resident #9 had reported RN #126 the nurse was yelling and hollering. The resolution was to speak to the nurse regarding volume when speaking. There was no evidence the resident was notified of the resolution, or the nurse was educated. On 08/22/24 Resident #14 (not interviewable) was upset that the nurse (RN #126) told her to get rid of her snacks and was rude. The resident was crying. The resolution was the nurse would be addressed. There was no evidence the nurse was addressed, or the resident was notified of the resolution. On 09/10/24 a former resident reported staff (RN #126) was rude when asking for medications. The resolution was staff would be re-educated on attitude. There was no evidence the resolution was discussed with the resident or staff was re-educated. On 11/19/24 a family member had voiced concerns that she had called into the building for an update on her husband (no longer a current resident at the facility during the annual survey) and RN #126 was extremely rude. The form indicated the nurse was educated on customer service. The resolution was blank. There was no evidence the family member was notified of the outcome of the concern, or the nurse was educated. Further review of the concern log/forms dated 07/15/24 to 01/07/25 revealed no evidence there were any concerns reported, or forms completed for Resident #9 regarding RN #126. Review of RN #126's personnel file revealed the RN was hired on 09/26/23 and there was no evidence the RN had any verbal education/disciplinary actions. The surveyor had requested the file include any disciplinary actions. Review of the facility policy titled Grievances/Complaints (dated 04/2017) revealed the administrator and staff would make prompt efforts to resolve grievances to the satisfaction of the resident and or representative. The resident or person filing the grievance and/or complaint on behalf of the resident, would be informed (verbally and in writing) of the findings of the investigation and the actions that would be taken to correct any identified problems. Review of the facility's policy titled Dignity (dated 08/2009) revealed each resident shall be cared for in a manner that promotes and enhances quality of life, dignity, respect and individuality. Residents should be treated with dignity and respect at all times. Staff shall promote, maintain and protect resident privacy, including bodily privacy during assistance with personal care and during treatment procedures.

CONCERN (D)

Potential for Harm - no one hurt, but risky conditions existed

Deficiency F0551 (Tag F0551)

Could have caused harm · This affected 1 resident

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**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on medical record review, review of the probate court local rules of practice, and interview the facility failed to ensure a resident had a legal guardian when the resident no longer had the ability to maintain capacity. This affected one resident (#19) of one resident reviewed for notification. The facility census was 85. Findings Include: Review of the medical record for Resident #19 revealed an initial admission date 03/08/16 of secondary Parkinsonism, diabetes mellitus, aphasia, hyperlipidemia, bipolar disorder, depressive episodes, schizoaffective disorder, bipolar type, anxiety disorder, schizophreniform and dementia. Review of the letter of guardianship dated 10/03/14 revealed the resident was deemed incompetent. A family member of the resident was named the resident's guardian of person only indefinitely. Review of the removal of guardianship dated 11/14/17 revealed the resident's family member was removed as the resident's guardian for failure to file guardianship reports. Review of the resident's facehseet revealed the resident's family member was listed as emergency contact, responsible party, other legal oversight, family member responsible and primary financial contact. Review of the medical record revealed no evidence of power of attorney (POA) paperwork for the family member listed on the face sheet. Review of the resident's quarterly Minimum Data Set (MDS) assessment dated [DATE] revealed the resident had a severe cognitive deficit. The assessment indicated dementia, anxiety disorder, depression, bipolar disorder and schizophrenia were active diagnoses. Review of the resident's immunization consent form dated 09/11/23 revealed the resident refused consents and signed the consent with the resident's initials. On 01/22/25 at 8:50 A.M. interview with the Business Office Manager (BOM) #132 revealed the resident was within the $200 limit and a spend down letter was not sent due to having no person in place for financial power of attorney (POA) or guardianship. She revealed the county did not have guardians at this time so they have not started trying to get the resident a guardian. On 01/22/25 at 9:36 A.M. interview with the Secretary #320 revealed the county was very limited on guardians, however a local attorney was providing guardianship. She said in the event there is not available guardians in the county then the facility would have to look outside of the facility. On 01/22/25 at 9:45 A.M. interview with Secretary #330 revealed the local law office was accepting skilled nursing facility residents for guardianship. On 01/22/25 at 10:15 A.M. interview with the Administrator revealed he was unaware of the local attorney providing guardianship. The Administrator revealed the required documents would be sent to the law office to begin the guardianship process.

CONCERN (D)

Potential for Harm - no one hurt, but risky conditions existed

Deficiency F0569 (Tag F0569)

Could have caused harm · This affected 1 resident

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Based on review of resident financial records and staff interview, the facility failed to notify a resident that received Medicaid benefits when the amount in the resident's account reached $200 less than the SSI resource limit for one person, and that, if the amount in the account, reaches the SSI resource limit for one person, the resident may lose eligibility for Medicaid or SSI. This affected one of six residents whose financial records were reviewed (#19). The facility handled the funds for 52 residents. The facility census was 85. Findings Include: Review of the financial records for Resident #19 revealed the facility managed her funds. Review of the resident's quarterly resident fund statement revealed the balance in the resident's account had been greater than $1800.00 since 10/01/24. On 10/01/24 the balance was $1881.99. The current balance in the account was $1950.97. On 01/22/25 at 8:50 A.M. interview with the Business Office Manager (BOM) #132 confirmed the Resident #19 received Medicaid benefits and that the resident's balance was within the $200 of the resource limit. BOM #132 verified there had been no attempts to obtain a guardian to manage her funds.

CONCERN (D)

Potential for Harm - no one hurt, but risky conditions existed

Deficiency F0578 (Tag F0578)

Could have caused harm · This affected 1 resident

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**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on medical record review, review of the code status binder, interview, and policy review the facility failed to ensure resident code status was consistent and accurate. This affected three residents (#54, #85, and #191) of three reviewed for advance directives. Findings included: 1. Medical record review revealed Resident #54 was admitted to the facility on [DATE] with diagnoses including malignant neoplasm of liver, type two diabetes, urinary tract infection, anemia, paroxysmal atrial fibrillation, congestive heart failure, cardiomegaly, hyperlipidemia, anxiety, history of acute kidney, ileus, acute pulmonary edema, conjunctival hemorrhage, severe sepsis with septic shock, sepsis, encephalopathy, bacteriuria, liver disease, diarrhea, infectious gastroenteritis and colitis, muscle weakness, difficulty walking, need for assistance with personal care. Review of Resident #54's census tab revealed the resident was admitted [DATE] and was discharged on [DATE] and no anticipated to return (short-term general hospital stay), however was re-admitted [DATE]. Review of Resident #54 current orders dated 01/2025 revealed the resident code status was Do-Not-Resuscitate Comfort Care-Arrest (DNRCC-A) originally dated [DATE]. Review of Resident #54 current plan of care revealed there was a social aspect plan of care dated [DATE] that indicated the resident/resident representative had chosen the following advanced directives DNRCC-A. The interventions included to have advance directives reviewed quarterly and as needed. Review of Resident #54 progress note dated [DATE] revealed the resident was admitted [DATE] for five-day respite with possibility of long-term care. The code status reviewed with resident; code status is DNRCC-A. Review of the code status binder on [DATE] revealed no evidence of a signed code directive. Review of Resident #54's medical record revealed no evidence of a signed code directive. Interview on [DATE] at 2:00 P.M., with Registered Nurse (RN) #212 revealed the resident was discharged on [DATE] and was re-admitted originally for a respite stay on [DATE]. The RN confirmed the order entered in the computer was DNRCC-A. The nurse confirmed the electronic medical record, nor the code status binder had a copy of a signed DNRCC-A. The nurse reported she would have to call hospice to confirm the code status. Interview on [DATE] at 2:08 P.M., with Resident #54 revealed she doesn't want CPR. Interview on [DATE] at 2:22 P.M., with RN #212 revealed she called hospice, and hospice had sent over a signed code status directive and the resident was not a DNRCC-A but a DNRCC. The RN reported she was going to change the order to DNRCC and place a copy of the signed code status form in the electronic medical record and code status binder. 2. Medical record review revealed Resident #191 was admitted to the facility on [DATE] with diagnoses including chronic obstructive pulmonary disease, acute respiratory failure with hypoxia, sepsis, tracheostomy, gastrostomy, hypertension, atrial fibrillation, acute kidney failure, protein-calorie malnutrition, anxiety, hyperlipidemia, and tobacco use. Review of Resident #191's hospital discharge note dated [DATE] revealed the resident's code status as DNRCC-A Further review of Resident #191's face sheet and orders revealed no evidence of orders for the resident's code status. Review of Resident #191 social aspect care plan dated [DATE] revealed the resident/resident representative had chosen the following advanced directives. There was no evidence of the resident code status/advance directive. Review of the code status binder on [DATE] revealed no evidence of the resident's code status. Interview on [DATE] at 2:05 P.M., with RN #212 confirmed the resident did not have an order for her code status, however someone had entered full code on the face sheet. RN #212 reported she doesn't know when the code status was updated on the face sheet. The RN reported she would add an order for the resident code status. Interview on [DATE] at 2:10 P.M., with Resident #191 revealed she wanted to be a full code. Review of the facility policy titled Advance Directives (dated 12/2016) revealed upon admission, the resident would be provided a written information concerning the right to refuse or accept medical or surgical treatment and to formulate an advance directive if he or she chooses to do so. The social service director of designee would inquire of the resident, his/her family members and/or legal representative, about the existence of any written advance directive. The plan of care for each resident will be consistent with his or her documented treatment preferences and/or advance directive. The interdisciplinary team will review annually with the resident advance directives to ensure that such directives are still the wishes of the resident. The DON or designee would notify the attending physician of advance directives so that appropriate orders can be documented in the resident's medical record and plan of care. The attending physician would not be required to orders for which he or she had an ethical or conscientious. 3. Record review revealed Resident #85 was admitted to the facility on [DATE] with diagnoses including vascular dementia with agitation, post traumatic stress disorder, and idiopathic gout. Review of hospital paperwork dated [DATE] revealed Resident #85 had a full code status in place. Review of an order dated [DATE] revealed Resident #85 had a do not resuscitate and do not intubate order in place (DNR/DNI). Review of a progress note dated [DATE] at 1:43 P.M. by Social Service Designee (SSD) #190 revealed Resident #85 admitted to the facility on [DATE] and the code status was reviewed which was a full code. Interview on [DATE] at 4:20 P.M. with Director of Nursing (DON) confirmed there was in order in place for Resident #85 to have a DNR/DNI in place but there was no signed paperwork in place. Additionally, DON stated upon admission to the facility, Resident #85's family was called to clarify code status and chose for him to be a full code status however the order was never updated. If Resident #85 were to have coded, due to the DNR order in place, Resident #85 would not have been resuscitated.

CONCERN (D)

Potential for Harm - no one hurt, but risky conditions existed

Notification of Changes (Tag F0580)

Could have caused harm · This affected 1 resident

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CONCERN (D)

Potential for Harm - no one hurt, but risky conditions existed

Report Alleged Abuse (Tag F0609)

Could have caused harm · This affected 1 resident

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**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on staff interviews, policy review, and record review, the facility failed to report an allegation of sexual abuse. This affected one resident (#27) of seven residents reviewed on the memory care unit. The facility census was 85. Findings include: Record review revealed Resident #27 was admitted to the facility on [DATE] with diagnoses including dementia, hypertension, angina pectoris, attention and concentration deficit following cerebral infarction, and personal history of a traumatic brain injury. Record review revealed Resident #27 had a court appointed legal guardian of person and estate as of 05/14/24 related to being deemed an incompetent adult in the probate court. Resident #27 resided on the facility secured memory care unit. Review of a care plan dated 07/22/24 revealed Resident #27 may demonstrate inappropriate behaviors including agitation. The care plan was not specific to what the inappropriate behaviors were and did not include evidence of sexually inappropriate behaviors for the resident. In addition, there was no evidence in the medical record or plan of care that the resident was sexually active with other residents in the facility. Review of Resident #27's Minimum Data Set (MDS) assessment dated [DATE] revealed the cognitive assessment was incomplete. The assessment revealed Resident #27 refused care one to three days of the seven-day assessment reference period. Review of a psychiatric consult note documented in Resident #21's medical record, dated 11/21/24 at 1:40 P.M. revealed Resident #21 was caught on 11/16/24 having sexual relations with a gentleman (identified to be Resident #27) on the unit. The note indicated staff were being diligent at trying to keep them apart. Record review revealed no documentation of this incident was included in Resident #27's medical record. Following the incident, there was no evidence Resident #27 was assessed for injury, assessed related to his ability to consent to a sexual relationship with another resident/Resident #21 or evidence the resident's legal guardian was notified. Review of a nursing note dated 11/21/24 at 1:27 P.M. by RN #188 revealed Resident #27 was found with Resident #21 in his room with her shirt pulled slightly up and the female resident was redirected out of Resident #27's room. There was no evidence that the medical provider or legal guardian were notified of the incident. Review of a handwritten, unsigned note dated 11/21/24 revealed Resident #27's guardian was alerted of a relationship with a resident, and noted the resident does not like to be told to stay out of the female resident's room. Staff were educated to assist with socializing in the common area. Record review revealed there was no evidence Resident #27 was assessed related to his ability to consent to a sexual relationship with another resident/Resident #21 at this time. Record review revealed Resident #21 admitted to the facility on [DATE] with diagnoses including anoxic brain damage, unspecified dementia, opioid use with opioid-induced psychotic disorder, bipolar disorder, major depression, chronic viral Hepatitis C, [NAME] (an eating disorder in which a person eats things not usually considered food), and acute Hepatitis C without hepatic coma. Record review revealed Resident #21 had a court appointed legal guardian of person and estate as of 05/02/22 related to being deemed an incompetent adult in probate court. Resident #21 resided on the facility secured memory care unit. Review of a care plan dated 04/15/24 revealed Resident #21 demonstrated inappropriate behaviors including making false accusations about peers and staff. There was no evidence of a care plan related to sexually inappropriate behaviors or that the resident was sexually active with other residents in the facility. Review of a MDS assessment completed on 11/15/24 revealed Resident #21 had severe cognitive impairment. The MDS revealed the resident had no behaviors. Review of a nursing note dated 11/21/24 at 1:17 P.M. by RN #188 revealed Resident #21 was found in Resident #27's room with her shirt up. Resident #21 was redirected out of the male resident's room. There was no evidence Resident #21's physician or legal guardian were notified of the incident. In addition, there was no evidence the facility implemented additional interventions to prevent continued sexual behaviors from occurring. Review of a psychiatric consult note documented in Resident #21's medical record, dated 11/21/24 at 1:40 P.M. revealed Resident #21 was caught on 11/16/24 having sexual relations with a gentleman (identified to be Resident #27) on the unit. The note indicated staff were being diligent at trying to keep them apart. The note indicated Resident #21 was not on birth control and a pregnancy test was ordered. Review of orders revealed Resident #21 had an order entered by LPN #165 dated 11/21/24 for a pregnancy test to be completed on 12/02/24. Review of a handwritten, unsigned note dated 11/21/24 revealed Resident #21's guardian was notified of sexual behaviors and stated, that's how she is. The note indicated Resident #21 was spoken to about appropriate and inappropriate behaviors. However, there was no evidence the facility implemented additional interventions to prevent continued sexual behaviors at this time. Review of the medical record revealed a progress note dated 12/22/24 at 10:46 A.M. by RN #212 that included Resident #21 wanders ad lib and is very friendly with male resident (Resident #27). Review of an addendum to a psychiatric consult note dated 12/26/24 at 1:37 P.M. revealed after speaking with staff, a pattern of Resident #21's behavior was that she tended to be more sexual with any new male resident. A recommendation for Tagamet 400 milligrams (mg) twice daily was provided in addition to a recommendation Resident #21 be placed on birth control if appropriate clinically. Record review revealed no evidence the facility implemented any additional non-pharmacological interventions and/or supervision to timely identify and/or prevent continued sexual behaviors by Resident #21 at this time. Review of orders revealed Resident #21 received an order dated 12/26/24 for Tagamet 200 mg two tablets twice daily by mouth. Review of the Ohio Department of Health Enhanced Information Dissemination and Collection revealed no evidence the facility reported the allegation of sexual abuse between Residents #21 and #27. Interview on 01/14/25 at 2:36 P.M. with RN #188 revealed there had been an incident where Resident #21 was in a room with a male resident (Resident #27) and pulled her shirt up, but the resident stated she only showed the male resident her belly button. Resident #21 was then started on Tagamet to lessen behaviors and sex drive, which the RN stated she believed were working. The RN also indicated staff were to ensure Resident #21 and Resident #27 were not alone in the same room together. Interview on 01/15/25 at 8:26 A.M. with certified nursing assistant (CNA) #153 revealed she believed Resident #21 and Resident #27 were boyfriend and girlfriend and stated they had been caught a few times together behind closed doors. She stated the residents were caught lying in bed together, but one time it was more than that, although the CNA stated she was not working at the time of this incident. The CNA revealed staff were to make sure the residents were not alone behind closed doors. Interview on 01/15/25 at 8:50 A.M. with CNA #202 revealed she had seen Resident #21 holding hands with and kissing Resident #27 more on the evening shift. The CNA stated she tried to redirect and separate the residents when this occurred. Interview on 01/15/25 at 8:55 A.M. with LPN #165 revealed she had observed Resident #21 holding hands with Resident #27 but denied knowledge of any type of sexually inappropriate behaviors being reported to her. An additional interview on 01/15/25 at 9:02 A.M. with LPN #165 revealed (in November 2024) Resident #21 told Psychiatrist #305 that she needed a pregnancy test, and Psychiatrist #305 ordered the test. LPN #165 stated she just entered the test in the computer but did not inquire why it was necessary. Interview on 01/15/25 at 9:03 A.M. with Psychiatrist #305 revealed he was informed by staff (unable to state which staff) Resident #21 had sexual relations with a male resident on the unit. He stated Resident #21 still menstruated, so after being made aware of the sexual activity, a pregnancy test was ordered (the test was negative). Psychiatrist #305 revealed if the resident continued to have sex, she should be started on birth control. During the interview, Psychiatrist #305 revealed he confirmed with Resident #21 she had sex with another resident, and stated the resident was quite proud. However, there was no evidence the psychiatrist discussed with staff the other resident involved in the sexual activity to ensure the resident was able to and had consented to the sexual activity. Interview on 01/15/25 at 10:16 A.M. with Licensed Social Worker (LSW) #313 revealed she worked with Psychiatrist #305 for any consults in the facility. She stated she was contacted (unable to recall by which facility staff member) because Resident #21 had allegedly been having sex with a male resident (Resident #27). The LSW revealed since the resident still had menses, there was a possibility of her becoming pregnant, so Psychiatrist #305 ordered a pregnancy test, then eventually started her on Tagamet. However, there was no evidence the LSW discussed with staff the other resident involved in the sexual activity to ensure the resident was able to and had consented to the sexual activity. Interview on 01/15/25 at 10:35 A.M. with Resident #21 revealed she had a boyfriend and identified him as Resident #27. Resident #21 stated they had already had sex (including penetration) without protection, and they got in trouble because she could still get pregnant. Resident #21 stated she sees Resident #27 every day. During the interview Resident #21 stated all the staff know about her sex life. Resident #21 stated I have tried to hide myself, but I'm not hideable due to having a loud voice and Resident #27 is able to find her. Interview on 01/15/25 at 10:39 A.M. with RN #188 revealed she had heard CNA #300 allegedly witnessed Resident #21 and Resident #27 having sex. During the interview, Resident #21 approached RN #188 and stated she needed condoms so she could have safe sex. Interview on 01/15/25 at 11:42 A.M. with SSD #190 revealed she had spoken with Resident #21 about her interactions with Resident #27 as she felt Resident #21 was able to remember a little more than Resident #27 could. SSD #190 revealed she cautioned Resident #21 about the relationship because of the age difference between the two residents and the resident's memory impairment. During the interview, she confirmed Resident #21 had a diagnosis of Hepatitis C and having unprotected sex with another person would not be safe. Interview on 01/15/25 at 1:12 P.M. with CNA #300 revealed (on 11/16/24) she was about to provide incontinence care to another resident, but there were no gloves in the room, so she went to Resident #27's room because she recalled seeing gloves in there. She stated upon entering the room, she observed Resident #21 lying with her back on the bed with her buttocks towards the edge and her legs spread while Resident #27 was standing in front of her penetrating her. Both residents were completely naked. She stated she was new to the facility and did not know what to do, and she noticed the residents became nervous with her presence as well. She stated she closed the door and walked to the nurse's station to ask what to do. She was informed by CNA #203 the residents needed to be separated, and a statement needed to be written. CNA #300 stated CNA#203 took her statement. Interview on 01/15/25 at 3:09 P.M. with the director of nursing (DON) revealed she was aware Resident #21 and Resident #27 would hold hands, and she was aware there was human contact where some upper body contact was attempted or did happen. However, she stated she was not aware of any invasive contact (eluding to sexual intercourse). The DON verified Resident #27, due to cognitive impairment would not be able to consent to sexual activity. The DON revealed she was unaware of pregnancy testing for Resident #21 until 01/13/25. The DON revealed she was aware Tagamet had been ordered for Resident #21 to decrease her libido and deter potential attempts at sex. The DON indicated it was her expectation if two residents were observed having sex that the staff would call her and the Administrator, not leave until they were interviewed, and an investigation and self-reported incident (SRI) would be completed immediately. During the interview, the DON indicated she was unaware of this incident involving Resident #27 in 11/2024 until interview with the State agency surveyor. Interview on 01/16/25 at 8:16 A.M. with RN #188 revealed she could not recall working at the time Resident #21 and Resident #27 were observed having sex, despite being on the schedule to work on this date (11/16/24). During the interview, the RN was unable to recall information from this time period. During the interview, RN #188 revealed she was also unaware Resident #21 had Hepatitis C and the potential for spreading it during sex. Interview on 01/16/25 at 8:18 A.M. with CNA #203 revealed she was working at the facility (on 11/16/24) when CNA #300 informed her Resident #21 and Resident #27 were in Resident #27's room having sex and she was unsure what to do. CNA #203 stated she told CNA #300 the resident's needed separated, so she went to split them up, but they had already separated themselves and were getting their clothes back on. Both residents were naked at that time. CNA #203 stated she told RN #188 about the incident, but she was passing medications, so she told CNA #300 to write a witness statement and place it on the medication cart. Interview on 01/16/25 at 8:34 A.M. with the DON revealed no one inquired why the pregnancy test was ordered for Resident #21 in November 2024. The DON verified the lack of written documentation of the sexual intercourse incident in the resident's medical records at the time of the incident, lack of responsible party/guardian notification and physician notification. The DON verified the incident was not reported to the State agency and/or investigated as an incident of sexual abuse. The DON also verified the lack of comprehensive assessments and care plans related to the ability to consent to sexual activity for Resident #27. During the interview, the DON denied knowledge of CNA #300 writing a statement following the observed incident on 11/16/24. Review of a policy titled Abuse, Neglect, Exploitation and Misappropriation of Resident Property (dated 2016) revealed all allegations of abuse must be reported immediately to the administrator, who reports to the State Agency immediately bot not later than two hours after the allegation is made.

CONCERN (D)

Potential for Harm - no one hurt, but risky conditions existed

Investigate Abuse (Tag F0610)

Could have caused harm · This affected 1 resident

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**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on staff interviews, policy review, and record review, the facility failed to thoroughly investigate an allegation of sexual abuse. This affected one resident (#27) of seven residents reviewed on the memory care unit. The facility census was 85. Findings include: Record review revealed Resident #27 was admitted to the facility on [DATE] with diagnoses including dementia, hypertension, angina pectoris, attention and concentration deficit following cerebral infarction, and personal history of a traumatic brain injury. Record review revealed Resident #27 had a court appointed legal guardian of person and estate as of 05/14/24 related to being deemed an incompetent adult in the probate court. Resident #27 resided on the facility secured memory care unit. Review of a care plan dated 07/22/24 revealed Resident #27 may demonstrate inappropriate behaviors including agitation. The care plan was not specific to what the inappropriate behaviors were and did not include evidence of sexually inappropriate behaviors for the resident. In addition, there was no evidence in the medical record or plan of care that the resident was sexually active with other residents in the facility. Review of Resident #27's Minimum Data Set (MDS) assessment dated [DATE] revealed the cognitive assessment was incomplete. The assessment revealed Resident #27 refused care one to three days of the seven-day assessment reference period. Review of a psychiatric consult note documented in Resident #21's medical record, dated 11/21/24 at 1:40 P.M. revealed Resident #21 was caught on 11/16/24 having sexual relations with a gentleman (identified to be Resident #27) on the unit. The note indicated staff were being diligent at trying to keep them apart. Record review revealed no documentation of this incident was included in Resident #27's medical record. Following the incident, there was no evidence Resident #27 was assessed for injury, assessed related to his ability to consent to a sexual relationship with another resident/resident #21 or evidence the resident's legal guardian was notified. Review of a nursing note dated 11/21/24 at 1:27 P.M. by Registered Nurse (RN) #188 revealed Resident #27 was found with Resident #21 in his room with her shirt pulled slightly up and the female resident was redirected out of Resident #27's room. There was no evidence that the medical provider or legal guardian were notified of the incident. Review of a handwritten, unsigned note dated 11/21/24 revealed Resident #27's guardian was alerted of a relationship with a resident, and noted the resident does not like to be told to stay out of the female resident's room. Staff were educated to assist with socializing in the common area. Record review revealed there was no evidence Resident #27 was assessed related to his ability to consent to a sexual relationship with another resident/Resident #21 at this time. Record review revealed Resident #21 was admitted to the facility on [DATE] with diagnoses including anoxic brain damage, unspecified dementia, opioid use with opioid-induced psychotic disorder, bipolar disorder, major depression, chronic viral Hepatitis C, [NAME] (an eating disorder in which a person eats things not usually considered food), and acute Hepatitis C without hepatic coma. Record review revealed Resident #21 had a court appointed legal guardian of person and estate as of 05/02/22 related to being deemed an incompetent adult in probate court. Resident #21 resided on the facility secured memory care unit. Review of a care plan dated 04/15/24 revealed Resident #21 demonstrated inappropriate behaviors including making false accusations about peers and staff. There was no evidence of a care plan related to sexually inappropriate behaviors or that the resident was sexually active with other residents in the facility. Review of a MDS assessment completed on 11/15/24 revealed Resident #21 had severe cognitive impairment. The MDS revealed the resident had no behaviors. Review of a nursing note dated 11/21/24 at 1:17 P.M. by RN #188 revealed Resident #21 was found in Resident #27's room with her shirt up. Resident #21 was redirected out of the male resident's room. There was no evidence Resident #21's physician or legal guardian were notified of the incident. In addition, there was no evidence the facility implemented additional interventions to prevent continued sexual behaviors from occurring. Review of a psychiatric consult note documented in Resident #21's medical record, dated 11/21/24 at 1:40 P.M. revealed Resident #21 was caught on 11/16/24 having sexual relations with a gentleman (identified to be Resident #27) on the unit. The note indicated staff were being diligent at trying to keep them apart. The note indicated Resident #21 was not on birth control and a pregnancy test was ordered. Review of orders revealed Resident #21 had an order entered by Licensed Practical Nurse (LPN) #165 dated 11/21/24 for a pregnancy test to be completed on 12/02/24. Review of a handwritten, unsigned note dated 11/21/24 revealed Resident #21's guardian was notified of sexual behaviors and stated, that's how she is. The note indicated Resident #21 was spoken to about appropriate and inappropriate behaviors. However, there was no evidence the facility implemented additional interventions to prevent continued sexual behaviors at this time. Review of the medical record revealed a progress note dated 12/22/24 at 10:46 A.M. by RN #212 that included Resident #21 wanders ad lib and is very friendly with male resident (Resident #27). Review of an addendum to a psychiatric consult note dated 12/26/24 at 1:37 P.M. revealed after speaking with staff, a pattern of Resident #21's behavior was that she tended to be more sexual with any new male resident. A recommendation for Tagamet 400 milligrams (mg) twice daily was provided in addition to a recommendation Resident #21 be placed on birth control if appropriate clinically. Record review revealed no evidence the facility implemented any additional non-pharmacological interventions and/or supervision to timely identify and/or prevent continued sexual behaviors by Resident #21 at this time. Review of orders revealed Resident #21 received an order dated 12/26/24 for Tagamet 200 mg two tablets twice daily by mouth. Review of the Enhanced Information Dissemination and Collection revealed no evidence the facility reported the allegation of sexual abuse between Residents #21 and #27. There was no documented evidence an investigation was initiated or completed in regard to the allegation of sexual abuse to Resident #27. Interview on 01/15/25 at 3:09 P.M. with the DON revealed she was aware Resident #21 and Resident #27 would hold hands, and she was aware there was human contact where some upper body contact was attempted or did happen. However, she stated she was not aware of any invasive contact (eluding to sexual intercourse). The DON verified Resident #27, due to cognitive impairment would not be able to consent to sexual activity. The DON revealed she was unaware of pregnancy testing for Resident #21 until 01/13/25. The DON revealed she was aware Tagamet had been ordered for Resident #21 to decrease her libido and deter potential attempts at sex. The DON indicated it was her expectation if two residents were observed having sex that the staff would call her and the Administrator, not leave until they were interviewed, and an investigation and self-reported incident (SRI) would be completed immediately. During the interview, the DON indicated she was unaware of this incident involving Resident #27 in 11/2024 until interview with the State agency surveyor. Interview on 01/16/25 at 8:34 A.M. with the DON verified the incident was not reported to the State agency and/or investigated as an incident of sexual abuse. Review of a policy titled Abuse, Neglect, Exploitation and Misappropriation of Resident Property (dated 2016) revealed all allegations of abuse must be reported immediately to the administrator, who reports to the State Agency immediately bot not later than two hours after the allegation is made. Once the administrator and State Agency are notified, an investigation of the allegation violation will be conducted. The investigation must be completed within five working days unless there are special circumstances causing the investigation to last longer. The resident, accused and all witnesses including those who witnessed/heard the incident, came in close contact with the resident the day of the incident, and employees who worked closely with the accused/alleged victim and perpetrator the day of the incident. Statements should be obtained, medical reports and statements should be obtained if applicable, the resident records should be reviewed, and evidence of the investigation should be documented.

CONCERN (D)

Potential for Harm - no one hurt, but risky conditions existed

Transfer Notice (Tag F0623)

Could have caused harm · This affected 1 resident

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**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on record review, review of email correspondence to the local Ombudsman, and staff interview, the facility failed to ensure the local Ombudsman was notified of a resident's transfer to the hospital as required. This affected one resident (#88) of one residents reviewed for hospitalization. Findings include: Review of Resident #88's closed medical record revealed the resident was admitted to the facility on [DATE]. His diagnoses included nodular sclerosis Hodgkin lymphoma, metabolic encephalopathy, end stage renal disease, dependence on hemodialysis, myoclonus (sudden, involuntary muscle jerking/ spasms), hypertension, and adult onset diabetes mellitus. Review of Resident #88's progress notes revealed a nurse's note dated 10/29/24 at 8:10 P.M. that indicated the resident was sent to the emergency room for an evaluation at the request of his family. The progress note did not specify what change in condition the resident had that prompted the family to want him sent to the emergency room, but transportation had been set up with the local emergency medical service (EMS). He left the faciity on [DATE] at 8:13 P.M. Review of Resident #88's electronic medical record (EMR) noted a Notice of Transfer or Discharge observation dated 10/30/24 that was completed Social Service Director (SSD) #190 at 8:28 A.M. SSD #190 indicated the resident had been transferred to the hospital as it was necessary to meet the resident's welfare and the resident's needs could not be met in the facility. The observation detail report included the mailing address for the Long- Term Care Ombudsman and a phone number. It did not include a place to indicate whether the Ombudsman's office had been notified of the transfer, or not. Review of an email correspondence from SSD #190 to the Ombudsman's office revealed an email was sent with a subject line of the facility's October 2024 discharges. Attached to that email was a discharge summary report that was for the time period of 10/01/24 through 10/31/24. Thirteen (13) residents were indicated to have been discharged from the facility with 12 of them being a discharge to home. One pertained to a resident's discharge to an acute care hospital. None of the 13 residents were Resident #88's transfer to the hospital on [DATE]. Findings were reviewed with SSD #190. On 01/22/24 at 1:45 P.M., an interview with SSD #190 revealed she was the employee that was responsible for notifying the Ombudsman of any discharges or transfers from the facility. She confirmed Resident #88's transfer to the hospital was not included on the discharge summary report for 10/01/24 through 10/31/24 she used to notify the Ombudsman of all transfers and discharges that month. She could not explain why Resident #88's transfer was not on that report since it fell between 10/01/24 and 10/31/24. She reported another resident's name had been included who was also sent to the hospital at the request of resident or their family member. She denied she had any other documented evidence of the Ombudsman being notified of the resident's transfer to the hospital, since it was not on that list.

CONCERN (D)

Potential for Harm - no one hurt, but risky conditions existed

Comprehensive Assessments (Tag F0636)

Could have caused harm · This affected 1 resident

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**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, record review and staff interview, the facility failed to ensure the Minimum Data Set (MDS) assessment was accurate for two residents (#30, #38) in the area of dental and dialysis. This affected two residents (#30, #38) of 20 sampled residents. The facility census was 85. Findings Include: 1. Review of the medical record for Resident #30 revealed an initial admission date of 08/30/23 with the latest readmission of 12/10/24 with the diagnoses including but not limited to partial traumatic amputation of left foot, osteomyelitis, sepsis, diabetes mellitus with neuropathy, hypertension, hyperlipidemia, osteoarthritis, gastro-esophageal reflux disease, constipation, edema, nausea and vomiting and anemia. Review of the resident's plan of care revealed no care plan addressing the resident's dialysis or potential for infection related to the central line. Review of the resident's quarterly Minimum Data Set (MDS) assessment dated [DATE] revealed the resident's cognition was not assessed. The assessment indicated the resident had not received dialysis services. Review of the resident's monthly physician orders for January 2025 revealed no physician orders for offsite hemodialysis. On 01/15/25 at 3:52 P.M., interview with the Director of Nursing (DON) verified the MDS was not coded correctly to reflect the resident's hemodialysis. 2. Review of the medical record for Resident #38 revealed an initial admission date of 02/02/23 with the latest readmission of 06/02/23 with the diagnoses including but not limited to metabolic encephalopathy, sepsis, acidosis, epilepsy, solitary pulmonary nodule right upper lobe, dementia with behavioral disturbances, esophageal thickening, diabetes mellitus, hypertension, anxiety disorder, mood disorder, insomnia, dental caries and added on 09/20/24 schizophrenia. Review of the resident's admission observation and data collection dated 02/02/23 revealed the resident had her own natural teeth. The assessment indicated the resident's teeth had no cavities or broken teeth. Review of the plan of care dated 02/16/23 revealed the resident had potential for mouth pain related to problems developing with natural teeth. Interventions included assess condition of oral cavity, teeth, tongue and lips as needed, assess location of pain, quality and characteristic of pain, duration, intensity and severity of pain, aggravating and alleviating factors as needed, check dentures for a proper/comfortable fit, dental evaluation and intervention as needed, encourage fluids to keep oral cavity moist, medications as ordered, observe and report difficulties, observe and report difficulties chewing/swallowing, observe for need for change diet consistency to increase ease of eating, obtain a dietary consult as needed, follow recommendations as required and offer and provide mouth care as needed. Review of the resident's quarterly observation and data collection dated 11/01/24 revealed the resident's natural teeth had no cavities or were not broken. The assessment indicated the resident had no ulcers, lesions, halitosis, dry membranes or bleeding gums. Review of the resident's comprehensive Minimum Data Set (MDS) assessment dated [DATE] revealed the resident had no cognitive deficit. The assessment indicated the resident had no obvious or likely cavity or broken natural teeth. On 01/13/25 at 9:19 A.M., observation of the resident revealed she had multiple black broken teeth with obvious caries. On 01/14/25 at 12:14 P.M., interview with the DON verified the oral assessments and MDS failed to reflect the resident's black broken teeth with obvious caries.

CONCERN (D)

Potential for Harm - no one hurt, but risky conditions existed

Deficiency F0637 (Tag F0637)

Could have caused harm · This affected 1 resident

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**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on record review and staff interview the facility failed to complete a significant change minimum data set ( MDS) for one resident (#40) within 14 days of the resident being admitted to hospice services. This affected one resident (#40) of 20 residents reviewed for assessments. The facility census was 85. Findings Include: Record review revealed Resident #40 was admitted to the facility on [DATE] with diagnoses including abdominal aortic aneurysm without rupture, malignant neoplasm of prostate, and unspecified dementia. Review of a social services note dated 12/16/24 at 3:28 P.M. revealed Resident #40's family requested a referral be sent to hospice. Review of orders revealed Resident #40 admitted to hospice services on 12/17/24 for a diagnosis of senile degeneration of the brain. Review of minimum data set (MDS) assessments revealed a significant change assessment for Resident #40 was not completed within 14 days of the resident's admission to hospice. Interview on 01/15/24 at 10:27 A.M. with MDS Nurse #139 revealed if a resident has a significant change in status, including an admission to hospice services, a significant change MDS should be completed within 14 days. MDS Nurse #139 confirmed Resident #40 did not have a significant change MDS completed upon admission to hospice.

CONCERN (D)

Potential for Harm - no one hurt, but risky conditions existed

PASARR Coordination (Tag F0644)

Could have caused harm · This affected 1 resident

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**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on record review, staff interview and facility policy review, the facility failed to ensure a significant change Pre-admission Screening and Resident Review (PASARR) was completed when a mental health diagnosis was newly added. This affected one resident (#38) of four residents reviewed for PASARR. The facility census was 85. Findings Include: Review of the medical record for Resident #38 revealed an initial admission date of 02/02/23 with the latest readmission of 06/02/23 with the diagnoses including but not limited to metabolic encephalopathy, sepsis, acidosis, epilepsy, solitary pulmonary nodule right upper lobe, dementia with behavioral disturbances, esophageal thickening, diabetes mellitus, hypertension, anxiety disorder, mood disorder, insomnia, dental caries and added on 09/20/24 schizophrenia. Review of the plan of care dated 11/22/24 revealed the resident suffers from schizophrenia and is at risk for change in ability, thinking, perception, behavior and personality. Interventions included assist to identify effective coping mechanisms, maintain a calm environment and approach with the resident, monitor the resident's behavior endangers self or other, intervene if necessary, obtain a psych consult/psychosocial therapy as needed, provide outlets for expression of hostility and anger, restrict access to potentially harmful items, set limits and expectations for behavior with resident, use physical/chemical restraints as last resort, administer psychotropic medications per physician orders and monitor for side effects, encourage resident to openly express feelings and reinforce appropriate expressions of these feelings, establish and maintain consistency in resident's routine when possible, let resident make own decisions as long as the decisions are not a danger to self or others, limit overstimulation of resident, notify physician of changes in resident's mood/behavior, restate resident's conversations to validate it, a gradual dose reduction (GDR) will be attempted to separate quarters with at least one month between attempts per the physician recommendation, gradual does reduction must be attempted annually thereafter unless medically contraindicated, monitor for changes in resident's functional status, monitor for effectiveness of medication, notify physician if medication is ineffective, monitor for any drug related side effects, order for as needed medications will have designated purpose for use, administration of as needed medications will be documented in the medical record and indicate prior interventions to include non-pharmacological interventions, perform an AIMS assessment on admission and quarterly to monitor for the occurrence of tardive dyskinesia. Review of the resident's comprehensive Minimum Data Set (MDS) assessment dated [DATE] revealed the resident had no cognitive deficit. The assessment indicated dementia, anxiety and schizophrenia was a current diagnoses. On 01/14/25 at 1:35 P.M., interview with the Director of Social Services (DSS) #190 verified when the diagnoses of schizophrenia was added on 09/20/24 a significant change PASARR was not completed. Review of the facility policy titled, PASRR, (last revised 01/20) revealed all new admission and readmissions are screened for mental health disorders (MHD) and intellectual disabilities (ID) or related disorders per the Medicaid Pre-admission Screening and Resident Review process.

CONCERN (D)

Potential for Harm - no one hurt, but risky conditions existed

Deficiency F0645 (Tag F0645)

Could have caused harm · This affected 1 resident

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**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on record review and interview, the facility failed to ensure a pre-admission screening and resident review (PASARR) assessment was correct upon resident admission to the facility. This affected one resident (#85) of four residents reviewed for PASARRs. The facility census was 85. Findings include: Record review revealed Resident #85 was admitted to the facility on [DATE] with diagnoses including vascular dementia with agitation, post-traumatic stress disorder (PTSD), and idiopathic gout. Review of a PASARR completed on 11/21/24 revealed no evidence of PTSD being listed as a serious mental illness. Interview on 01/14/25 at 1:46 P.M. with Social Services Director (SSD) #190 confirmed PTSD was not listed on Resident #85's PASARR.

CONCERN (D)

Potential for Harm - no one hurt, but risky conditions existed

Deficiency F0646 (Tag F0646)

Could have caused harm · This affected 1 resident

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**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on record review and interview, the facility failed to ensure a significant change Pre-admission Screening and Resident Review (PASARR) contained correct developmental disability diagnoses. This affected one resident (#23) of four residents reviewed for PASARR assessments. The facility census was 85. Findings include: Record review revealed Resident #23 was admitted to the facility on [DATE] with diagnoses including schizoaffective disorder, altered mental status, schizophrenia, and moderate intellectual disabilities. Review of a significant change PASARR completed on 08/05/24 revealed no evidence Resident #23 had a diagnosis of moderate intellectual disabilities. Interview on 01/14/25 at 1:46 P.M. with Social Services Director (SSD) #190 confirmed moderate intellectual disabilities was not listed on Resident #23's PASARR.

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

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**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, record review, interview and facility policy review, the facility failed to develop a comprehensive plan of care for three residents (#30, #31, #38). This affected three residents (#30, #31, #38) of 20 sampled residents. The facility census was 85. Findings Include: 1. Review of the medical record for Resident #30 revealed an initial admission date of 08/30/23 with the latest readmission of 12/10/24 with the diagnoses including but not limited to partial traumatic amputation of left foot, osteomyelitis, sepsis, diabetes mellitus with neuropathy, hypertension, hyperlipidemia, osteoarthritis, gastro-esophageal reflux disease, constipation, edema, nausea and vomiting and anemia. Review of the resident's plan of care revealed no care plan addressing the resident's dialysis or potential for infection related to the central line. Review of the resident's quarterly Minimum Data Set (MDS) assessment dated [DATE] revealed the resident's cognition was not assessed. The assessment indicated the resident had not received dialysis services. Review of the resident's monthly physician orders for January 2025 revealed no physician orders for offsite hemodialysis. On 01/15/25 at 3:52 P.M., interview with the Director of Nursing (DON) verified the lack of a comprehensive assessment addressing the resident's hemodialysis and potential for infection related to the port used for hemodialysis. 2. Review of the medical record for Resident #38 revealed an initial admission date of 02/02/23 with the latest readmission of 06/02/23 with the diagnoses including but not limited to metabolic encephalopathy, sepsis, acidosis, epilepsy, solitary pulmonary nodule right upper lobe, dementia with behavioral disturbances, esophageal thickening, diabetes mellitus, hypertension, anxiety disorder, mood disorder, insomnia, dental caries and added on 09/20/24 schizophrenia. Review of the resident's admission observation and data collection dated 02/02/23 revealed the resident had her own natural teeth. The assessment indicated the resident's teeth had no cavities or broken teeth. Review of the plan of care dated 02/16/23 revealed the resident had potential for mouth pain related to problems developing with natural teeth. Interventions included assess condition of oral cavity, teeth, tongue and lips as needed, assess location of pain, quality and characteristic of pain, duration, intensity and severity of pain, aggravating and alleviating factors as needed, check dentures for a proper/comfortable fit, dental evaluation and intervention as needed, encourage fluids to keep oral cavity moist, medications as ordered, observe and report difficulties, observe and report difficulties chewing/swallowing, observe for need for change diet consistency to increase ease of eating, obtain a dietary consult as needed, follow recommendations as required and offer and provide mouth care as needed. Review of the resident's quarterly observation and data collection dated 11/01/24 revealed the resident's natural teeth had no cavities or were not broken. The assessment indicated the resident had no ulcers, lesions, halitosis, dry membranes or bleeding gums. Review of the resident's comprehensive Minimum Data Set (MDS) assessment dated [DATE] revealed the resident had no cognitive deficit. The assessment indicated the resident had no obvious or likely cavity or broken natural teeth. On 01/13/25 at 9:19 A.M., observation of the resident revealed she had multiple black broken teeth with obvious caries. On 01/14/25 at 12:14 P.M., interview with the DON verified resident's dental care plan failed to address the resident's black broken teeth with obvious caries. Review of the facility policy titled, Comprehensive Person Centered Care Plans, (dated 12/16) revealed a comprehensive person center care plan that includes measurable objectives and timetables to meet the resident's physical, psychosocial and functional needs is developed and implemented for each resident. 3. Medical record review revealed Resident #31 was admitted to the facility on [DATE] with diagnoses including diffuse traumatic brain injury, hemiplegia, deformity of the head, and convulsions. Review of Resident #31's current orders dated 12/18/24 revealed the resident was to always wear a safety helmet when out of bed. Review of Resident #31's plan of care revealed no evidence of a plan of care for a safety helmet. Interview on 01/21/25 at 8:26 A.M., with Registered Nurse (RN) #139 confirmed the resident was ordered to wear a safety helmet when out of bed, however there was no plan of care for the safety helmet.

CONCERN (D)

Potential for Harm - no one hurt, but risky conditions existed

Deficiency F0657 (Tag F0657)

Could have caused harm · This affected 1 resident

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**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** 3. Review of Resident #1's medical record revealed she was admitted to the facility on [DATE]. Her diagnoses included paraplegia, neurogenic bowel, colostomy status, neuromuscular dysfunction of the bladder, Stage IV pressure ulcer (full-thickness skin and tissue loss with exposed fascia, muscle, tendon, ligament, cartilage, or bone in the ulcer) on her buttock, chronic pain syndrome, chronic peripheral venous insufficiency, chronic obstructive pulmonary disease (COPD), major depressive disorder, attention deficit and hyperactive disorder (ADHD), bipolar disorder, anxiety disorder, and muscle weakness. Review of Resident #1's annual Minimum Data Set (MDS) assessment completed on 01/01/25 revealed the resident did not have any communication issues and was cognitively intact. She was known to have verbal behaviors directed at others, but was not known to reject care. She had a functional limitation in her range of motion for her bilateral lower extremities. She was dependent on staff for bed mobility and transfers and a motorized wheelchair was indicated to be the mobility device she used. Her prior MDS assessment was a quarterly MDS assessment completed on 10/01/24. Review of Resident #1's care conference reports revealed the resident's last recorded care conference meeting had been held on 08/29/24. There was no documented evidence of a care conference meeting being held on or around 10/01/24, when the resident's last quarterly MDS assessment was completed or on or around 01/01/25, when the resident's annual MDS assessment was completed. On 01/13/25 at 10:58 A.M., an interview with Resident #1 revealed she could only recall having had one care conference meeting in the time she had been at the facility. She denied she had been invited to attend any recent care conference meetings, despite her having a quarterly MDS assessment completed on 10/01/24 and an annual MDS assessment completed on 01/01/25. She reported she would have liked to have one and would have attended if offered. On 01/15/25 at 4:57 P.M., an interview with SSD #190 revealed any care conference meetings held for Resident #1 would have been documented under the observation tab of the electronic medical record (EMR). She reported the resident was about due for another care conference meeting. She verified the last documented care conference meeting they had for the resident was on 08/29/24. She denied they had completed a care conference meeting for the resident since and despite a quarterly MDS assessment being completed on 10/01/24 and an annual MDS assessment being completed on 01/01/25. She acknowledged the resident was past due for a care conference meeting since she had not had one in the last 90 days (quarterly). She tried to complete them a week after their quarterly or annual MDS assessment was done, but were getting behind on them. She was still trying to play catch up on them since she took over that position in July 2024. They were trying to get them (care conference meetings) all done in one day each week, but they had so many to do she was not able to keep up. Her IDT was wanting them scheduled all on the same day, but she felt she was going to have to schedule them twice a week to be able to get them all done. It was hard to get her IDT together for the meetings for more than just once a week. A review of the facility's policy on Care Conferences (revised 01/2020) revealed the facility's care planning/ IDT was responsible for the development of an individualized comprehensive care plan for each resident. A comprehensive care plan for each resident was developed within seven days of completion of the resident assessment (MDS). Care conferences would be scheduled to include the resident, resident representative, and IDT as soon as possible after admission, routinely, and with a change in condition. Based on record review, policy review, and interview, the facility failed to ensure comprehensive care plans were up to date. This affected two residents (#21 and #71) of three residents reviewed for care planning. The facility also failed to complete quarterly care conferences. This affected one resident (#1) of three residents reviewed for care planning. The facility census was 85. Findings include: 1. Record review revealed Resident #21 was admitted to the facility on [DATE] with diagnoses including anoxic brain damage, unspecified dementia, and bipolar disorder. Review of a minimum data set (MDS) completed on 11/15/24 revealed Resident #21 exhibited no behaviors. Review of a care plan last revised on 11/18/24 revealed Resident #21 did not have a care plan for sexually inappropriate behaviors in place. Review of a nursing note dated 11/21/24 at 1:17 P.M. by Registered Nurse (RN) #188 revealed Resident #21 was found in a male resident's room with her shirt up. Resident was redirected out of the male resident's room. Interview on 01/14/25 at 10:28 A.M. with Social Services Director (SSD) #190 revealed behaviors should be listed in the care plan with interventions. SSD #190 stated the MDS nurse is responsible for completing care plans. Interview on 01/15/25 at 10:26 A.M. with MDS Nurse #139 revealed the behavior care plans should be completed by the social worker. Interview on 01/16/25 at 8:34 P.M. with Director of Nursing (DON) confirmed Resident #21's care plan was not updated to include sexually inappropriate behaviors. 2. Record review revealed Resident #71 was admitted to the facility on [DATE] with diagnoses including atrial fibrillation, dementia, and hypertension. Review of an MDS completed on 09/30/24 revealed Resident #71 had behaviors including delusions and wandering daily. Review of a nursing note dated 10/31/24 at 7:58 P.M. by RN #188 revealed Resident #71 had his hands wrapped around a Certified Nursing Assistant (CNA)'s neck, and the CNA was red and sweating. Resident #71 was redirected and was sent to the emergency department for evaluation. Review of a nursing note dated 10/31/24 at 8:44 P.M. by RN #162 revealed Resident #71 returned to the facility with no new orders. Review of a care plan last reviewed on 11/13/24 revealed no care plan to address Resident #71's aggressive behaviors. Interview on 01/14/25 at 10:28 A.M. with Social Services Director (SSD) #190 revealed behaviors should be listed in the care plan with interventions. SSD #190 stated the MDS nurse is responsible for completing care plans. Interview on 01/15/25 at 10:26 A.M. with MDS Nurse #139 revealed the behavior care plans should be completed by the social worker. MDS Nurse #139 confirmed there was not a behavior care plan in Resident #71's record.

CONCERN (D)

Potential for Harm - no one hurt, but risky conditions existed

Deficiency F0661 (Tag F0661)

Could have caused harm · This affected 1 resident

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**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on record review, interview, and facility policy review, the facility failed to complete a discharge summary that included a recapitulation of the resident's stay. This affected one resident (#87) of one resident reviewed for discharge. The facility census was 85. Findings Include: Review of the closed medical record for Resident #87 revealed an initial admission date of 10/11/24 with the diagnoses including but not limited to traumatic subdural hemorrhage, rhabdomyolysis, diabetes mellitus, hyperlipidemia, hypertension, benign prostatic hyperplasia, obesity, diverticulosis, osteoarthritis, incisional hernia, dysphagia, generalized muscle weakness and disorders of kidney and ureter, renal mass. The resident was discharged to his own home on [DATE]. Review of the baseline care plan dated 10/11/24 revealed the baseline care plan will identify my care needs, risk, strengths and goals for the first 48 hours. Interventions included the resident will be receiving skilled care and his discharge planning, goals, community referrals, transportation, health knowledge deficits and follow-up will be discussed and planned with the resident and as needed with selected representatives. Review of the resident's five day MDS assessment dated [DATE] revealed the resident's cognition was not assessed. The assessment indicated the resident required partial/moderate assistance with ADL's. The assessment indicated the resident's goal was to discharge to the community. Review of the progress note dated 10/16/24 at 11:25 A.M. revealed the resident voiced wishes to be discharged on this day. The resident's wife was at bedside and in agreement. The resident denied any need for medical equipment or home health services. The resident was encouraged to continue with therapy in house as ordered but denied the need for therapy. The Certified Nurse Practitioner (CNP) was updated on the resident's wishes and a new order was received to discharged the resident home per his request. The discharge instructions were reviewed with the resident and his wife with no questions. The resident was encouraged to follow up with the surgeon and his primary care physician as soon as possible. The resident was encouraged to go to the emergency department (ED) if any complications should occur. The resident was discharged to home at this times and appeared to be in stable condition. Review of the discharge instructions dated 10/16/24 revealed the physician orders and a list of the resident's medications have been provided for discharge, see attached and discharge medications and physician's orders have been reviewed with the resident and/or responsible party, understanding of the medications and administration had been verbalized and confirmed. The discharge instructions provided no recapitulation of the resident's stay. Review of the medical record revealed no documented evidence of a completed discharge summary that included a recapitulation of the resident's stay. On 01/15/25 at 3:18 P.M., interview with Social Service Director (SSD) #190 verified the resident had no discharge summary that included a recapitulation of the resident's stay. Review of the facility policy titled, Discharge Summary and Plan, (dated 2021 and last revised 12/16) revealed when a resident's discharge is anticipated, a discharge summary and post-discharge plan will be developed to assist the resident to adjust to his/her new living environment. The discharge summary will include a recapitulation of the resident's stay at this facility and a final summary of the resident's status at the time of the discharge in accordance with established regulations governing release of resident information and as permitted by the resident. The discharge summary shall include a description of the resident's current diagnoses, medical history, course of illness, treatment and/or therapy since entering the facility, current laboratory, radiology, consultation and diagnostic test results, physical and mental functional status, ability to perform activities of daily living, sensory and physical impairments, nutritional status and requirements, special treatments or procedures, discharge potential, dental condition, activity potential, rehabilitation potential, cognitive status and medication therapy. A copy of the following will be provided to the resident and receiving facility and a [NAME] will be filed in the resident's medical record, an evaluation of the resident's discharge needs, the post discharge plan and the discharge summary.

CONCERN (D)

Potential for Harm - no one hurt, but risky conditions existed

ADL Care (Tag F0677)

Could have caused harm · This affected 1 resident

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**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on record review, observation, and staff interview, the facility failed to ensure a resident who was dependent on staff for personal care received the assistance needed with nail care. This affected one resident (#57) of two residents reviewed for activities of daily living (ADL's). The facility census was 85. Findings Include: Review of the medical record for Resident #57 revealed an initial admission date of 12/28/22 with the diagnoses including but not limited to Alzheimer's disease, dementia, chronic kidney disease, hypertension, vitamin D deficiency and dysphagia. Review of the plan of care dated 01/06/23 revealed the resident required staff assistance to complete activities of daily living (ADL) tasks completely and safely. Interventions included allow resident sufficient time to complete all or parts of task, do not rush resident, encourage resident to do as much as safely possible for self, observe the deterioration in ADL abilities and report if occurs, provide adequate resident periods between activities and therapy evaluation and treat as needed and ordered. Review of the resident's comprehensive Minimum Data Set (MDS) dated [DATE] revealed the resident had a severe cognitive deficit. On 01/13/25 at 11:02 A.M., observation of Resident #57 revealed his nails were long and jagged with brown substance under the nail. On 01/14/25 at 10:43 A.M., observation of the resident revealed his nails remained long, jagged with a brown substance under the nail. On 01/14/25 at 1:59 P.M., interview with Certified Nursing Assistant (CNA) #158 verified the resident's nails were long, jagged with a brown substance under nail.

CONCERN (D)

Potential for Harm - no one hurt, but risky conditions existed

Incontinence Care (Tag F0690)

Could have caused harm · This affected 1 resident

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**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** 2. Review of Resident #1's medical record revealed she was admitted to the facility on [DATE]. Her diagnoses included paraplegia, Stage IV pressure ulcer (full-thickness skin and tissue loss with exposed fascia, muscle, tendon, ligament, cartilage, or bone in the ulcer) of the buttocks, neuromuscular dysfunction of the bladder, supra-pubic catheter status, and muscle weakness. Review of Resident #1's annual Minimum Data Set (MDS) assessment dated [DATE] revealed the resident did not have any communication issues and was cognitively intact. She was known to display verbal behaviors directed at others, but was not known to reject care during the seven days of the assessment period. She had a functional limitation in her range of motion of her bilateral lower extremities. She was dependent on staff for bed mobility and transfers. She required supervision or touching assistance for toileting hygiene. She was coded as having the use of an indwelling urinary catheter. Review of Resident #1's active care plans revealed the resident had a care plan in place for the use of an indwelling urinary catheter related to a neurogenic bladder. The care plan was initiated on 02/09/23. The goal was for the resident to be free of any signs of complication such as a urinary tract infection. The interventions included the need to provide assistance with catheter care per the physician's orders. Review of Resident #1's physician's orders revealed the resident had an order in place to provide supra-pubic catheter care every shift (twice a day). The order had been in place since 03/10/23. On 01/13/25 at 11:02 A.M., an interview with Resident #1 revealed she was not receiving routine supra-pubic catheter care. She denied the staff were completing catheter care every shift (twice a day) as ordered. On 01/14/25 at 2:20 P.M., an interview with State Tested Nursing Assistant (STNA) #199 revealed the aides were responsible for doing catheter care and it was done at least once a day. She was not aware Resident #1's physician's orders was for it to be done every shift (twice a day). She could not say if the resident's catheter care was being done on day shift or the afternoon shift when she thought it was only to be done once a day. She indicated all she knew was that it (catheter care) would be done at some point before the resident went to bed for the night. She recalled she had performed catheter care for the resident in the past and the resident was compliant with her catheter care. On 01/14/25 at 2:30 P.M., an interview with RN #162 revealed Resident #1 had the use of a supra-pubic catheter. She claimed catheter care was being performed by the resident and was not completed by the staff, unless it was needed. On 01/14/24 at 3:00 P.M., a follow up interview with Resident #1 revealed she was not performing her own catheter care, as was indicated by RN #162. She asked how she could be performing her own catheter care if the staff were not sitting her up with any supplies to do so. She indicated on occasion she would ask for supplies to do it when she noted a spot of blood on her bed sheets or if she noted her catheter site to appear irritated. On 01/14/25 at 3:30 P.M., a follow up interview with RN #162 was conducted to inform her Resident #1 denied she was doing her own catheter care as the nurse believed. She was also informed the aide interviewed believed catheter care was only needed to be completed once a day instead of every shift (twice a day) as ordered. Review of the facility's policy on Urinary Catheter Care (revised September 2014) revealed the purpose of the procedure was to prevent catheter associated urinary tract infections. They were to review the resident's plan of care for any special needs of the resident. The policy was vague and was not specific as to how often catheter care was to be provided. Based on record review, interviews and facility policy review, the facility failed to treat one resident (#11) for a urinary tract infection (UTI) in a timely manner. Additionally, the facility also failed to provide one resident (#1) with routine indwelling urinary catheter care. This affected two residents (#11, #1) of three residents reviewed for catheter or UTI. The facility census was 85. Findings Include: 1. Review of the medical record for Resident #11 revealed an initial admission date of 05/07/21 with the latest readmission of 07/05/22 with the diagnoses including but not limited to osteoarthritis, major depressive disorder, mood disorder, constipation, Major depressive disorder, irritable bowel syndrome, hypertension, dysphagia, acute failure to thrive, insomnia, anxiety and palliative care. Review of Resident #11's progress notes dated 10/01/24 at 10:53 A.M. revealed the resident believed she had a urine infection. The hospice nurse visited and was aware. The entry indicated a urine was sent on 09/30/24 and results were pending. Review of the urinalysis and culture and sensitive (UA/C&S) results dated 10/03/24 from the urine collected on 09/30/24 revealed the resident had greater than 100,000 of the two bacteria aerococcus urinae and enterococcus faecalis and the bacteria was sensitive to the antibiotic Macrobid (a medication used to treat an infection). Review of the progress note dated 10/05/24 at 3:24 P.M. revealed the nurse called the facility contracted lab for the urine results completed on 09/30/24. Review of the progress note dated 10/06/24 at 3:34 P.M. revealed the nurse again phone the facility contracted lab for the 09/30/24 urine results. The entry documented the facility was awaiting results. Review of the progress note dated 10/06/24 at 5:02 P.M. revealed the facility received the culture and sensitivity (C&S) results. The hospice nurse practitioner was notified and a new order was received for Macrobid 100 milligrams (mg) by mouth twice daily for seven days. The entry indicated the resident's hospice services wound deliver the medication to the facility on [DATE]. Review of the resident's progress note dated 10/07/24 at 1:21 P.M. revealed the resident's hospice service had not delivered the resident's medication to the facility. The nurse pulled the first dose of the medication from the facility's Omnicell (emergency drug system). Review of the resident's October 2024 Medication Administration Record (MAR) revealed the first dose of Macrobid 100 mg was not administered until 10/07/24. Review of the resident's quarterly Minimum Data Set (MDS) assessment dated [DATE] revealed the resident had a moderate cognitive deficit. The assessment indicated the resident was always incontinent of both bowel and bladder. The assessment indicated the resident had not been treated for an infection in the past 30 days. On 01/22/25 at 12:50 P.M., interview with the Director of Nursing (DON) verified the UA/C&S results were available on 10/03/24 and the treatment for the resident's UTI was not started until 10/07/24.

CONCERN (D)

Potential for Harm - no one hurt, but risky conditions existed

Deficiency F0692 (Tag F0692)

Could have caused harm · This affected 1 resident

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**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on record review, Registered Dietician (RD) recommendation review, interview and facility policy review, the facility failed to implement dietary recommendations and obtain physician ordered daily weights for one resident (#30). This affected one resident (#30) of two residents reviewed for nutrition. The facility census was 85. Findings Include: Review of the medical record for Resident #30 revealed an initial admission date of 08/30/23 with the latest readmission of 12/10/24 with the diagnoses including but not limited to partial traumatic amputation of left foot, osteomyelitis, sepsis, diabetes mellitus with neuropathy, hypertension, hyperlipidemia, osteoarthritis, gastro-esophageal reflux disease, constipation, edema, nausea and vomiting and anemia. Review of the plan of care dated 09/05/23 revealed the resident required increased caloric, protein, and/or nutrient needs, protein intake encourage, food related diet noncompliance with therapeutic diet restriction, end stage renal disease (ESRD), weight loss desired, diet noncompliance increased protein needs albumin within normal limits and target weight fluctuations. Interventions included communicate with dialysis as needed, nutrition education, dietitian to re-evaluate as indicated, encourage fluids, labs as ordered by physician, obtain weights as ordered an as needed, provide diet as ordered, provide supplements and vitamins and/or minerals as ordered. Review of the resident's quarterly Minimum Data Set (MDS) assessment dated [DATE] revealed the resident's cognition was not assessed. The assessment indicated the resident had a known weight loss and was on a physician prescribed weight loss regimen and received a therapeutic diet. Review of the resident's monthly physician orders for January 2025 identified and order dated 10/29/24 for daily weight. Review of the resident's daily weights from 10/29/24 revealed the resident's daily weight was not obtained on 11/18/24, 12/14/24, 12/20/24, 12/23/24, 12/28/24, 12/30/24, 01/02/25, 01/03/25 and 01/16/24. Review of the resident's nutritional observation dated 12/14/24 revealed the RD recommended to add a renal diet and double protein portion to the resident's diet. Review of the diet recommendation dated 12/15/24 revealed the RD recommended to add renal diet and double protein portions for all meals to the resident's diet. Review of the medical record revealed no evidence the RD recommendations were implemented. On 01/15/25 at 3:52 P.M., interview with the Director of Nursing (DON) verified the resident's daily weights were not obtained as physician ordered. On 01/21/25 at 11:49 A.M., interview with RD #350 revealed she spoke with dialysis on 01/20/25 and no longer recommended adding the renal diet. RD #350 verified the double protein portion for all meals was recommended. RD #350 verified the recommendation had not been implemented. Review of the facility policy titled, Weight Policy, (dated 11/18) revealed it was the policy of the facility to attain/maintain a resident's weight within the recommended range as appropriate in relation to their medical and physical status. Weights will be obtained in a timely and accurate manner, documented and responded to appropriately. The resident will be weighted every week for three weeks for the following three weeks then monthly unless otherwise by the physician/Nurse Practitioner (NP) or dietician.

CONCERN (D)

Potential for Harm - no one hurt, but risky conditions existed

Respiratory Care (Tag F0695)

Could have caused harm · This affected 1 resident

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**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** 3. Review of the medical record for Resident #57 revealed an initial admission date of 12/28/22 with the diagnoses including but not limited to Alzheimer's disease, dementia, chronic kidney disease, hypertension, vitamin D deficiency and dysphagia. Review of the resident's plan of care revealed no care plan addressing the resident's oxygen use. Review of the resident's comprehensive Minimum Data Set (MDS) dated [DATE] revealed the resident had a severe cognitive deficit. The assessment indicated the resident had not utilized oxygen therapy. Review of the resident's monthly physician orders identified no orders for oxygen use. Review of the resident's progress note dated 01/13/25 at 4:44 P.M. revealed the resident had reported new onset of wheezing and shortness of breath. The Nurse Practitioner (NP) was notified while in house on rounds. New orders received for chest x-ray and start DuoNebs four times daily for five days. Further review of the resident's progress notes revealed no documented evidence of when and why the resident was started on oxygen therapy on the night shift on 01/13/25. On 01/13/25 at 10:55 A.M., observation of Resident #57 revealed he was sitting in his chair with oxygen on via nasal cannula at three liters. Further observation revealed the oxygen had no humidification. On 01/13/25 at 12:05 P.M., observation of Certified Nursing Assistant (CNA) #183 revealed the CNA assisted the resident into his bedside chair. The resident's oxygen tubing was noted to be laying on the floor. The CNA picked the tubing up and placed in the crease of the resident's chair. On 01/13/25 at 2:16 P.M., observation of the resident revealed he had oxygen on via nasal cannula at three liters. Further observation revealed the nasal cannula was the same nasal cannula as laying on the floor. On 01/13/25 at 2:23 P.M., interview with Licensed Practical Nurse (LPN) #211 verified the resident had the same oxygen tubing dated 01/12/25 that was on the floor. The LPN also verified the resident had no physician orders for the oxygen. She stated the night shift nurse reported the resident's oxygen saturation had dropped so she put him on oxygen. Review of the facility policy titled, Oxygen Administration, (last revised 10/10) revealed the purpose of the procedure was to provide guidelines for safe oxygen administration. Preparation included verify that there is a physician's order for this procedure. Review the physician's orders or facility protocol for oxygen administration. Check the humidifying jar to be sure they are in good working order and are securely fastened. Be sure there is water in the humidifying jar and that the water level is high enough that the water bubbles as oxygen flows through. After completing the oxygen setup or adjustment, the following should be recorded in the resident's medical record, the date and time the procedure was preformed, the name and title of the individual who performed the procedure, the rate of oxygen flow, route and rationale, the frequency and duration of the treatment, the reason for as needed administration, all assessment data obtained before, during and after the procedure, how the resident tolerated the procedure, if the resident refused the procedure and the signature and title of the person recording the data. Based on medical record review, review of hospital records, observation, interview, and policy review the facility failed to ensure residents had oxygen orders, respiratory medications were administered as ordered, respiratory supplies were stored properly, and emergency tracheostomy supplies were readily available. This affected three residents (#57, #67, #191) of three residents reviewed for respiratory care and medication observation. Findings included: 1. Record review revealed Resident #191 was admitted to the facility on [DATE] with diagnoses including chronic obstructive pulmonary disease, acute respiratory failure with hypoxia, sepsis, tracheostomy, gastrostomy, hypertension, atrial fibrillation, acute kidney failure, protein-calorie malnutrition, anxiety, hyperlipidemia, and tobacco use. A. Review of Resident #191's current order revealed no evidence of oxygen orders. Observation on 01/13/25 at 10:24 A.M., revealed there was a used tracheostomy mask lying on the resident's bedside table she was using, and her nebulizer was in a chair and her mouthpiece was lying directly on the chair seat without any barrier or bag. There were no emergency trach supplies (cannula, ambu bag, tracheostomy kit, etc.) readily available. The resident reported she had an ambu bag the hospital gave her that was under a pile of clothing that she had piled in the corner of the room near her chair. The resident trach mask was attached to an oxygen concentrator. Interview on 01/13/25 at 10:35 A.M., with Licensed Practical Nurse (LPN) #177 and Registered Nurse (RN) #162 confirmed the resident's emergency tracheostomy supplies and ambu bag should have been in a bag near the head of the resident's bed in case of an emergency. The staff were not sure of the size of cannula the resident currently had in-place. The staff searched the resident room and found size 6.5 and 7.0 cannulas box in the resident's closet. The nurses reported they were not sure what the facility's policy was on tracheostomy care. The staff members confirmed the resident's nebulizer mouthpiece was lying on the chair without a barrier and the used tracheostomy mask should have been discarded after used. B. Observation on 01/15/25 at 10:16 A.M. revealed Resident #191's nebulizer mouthpiece was lying directly on the chair without a bag or barrier. The resident reported she was never provided with a bag to place the mouthpiece in. The resident was receiving oxygen via trach. Interview on 01/15/25 at 10:16 A.M., with RN #212 confirmed the nebulizer mouthpiece was lying directly on the chair without a barrier or in a bag. The RN reported the resident must have thrown the bag away. An interview on 01/15/25 at 1:52 P.M., with the Director of Nursing (DON) revealed the facility doesn't have a policy for nebulizer storage/care and was told to give the surveyor the cleaning and disinfection of resident-care items and equipment, which did not include nebulizers storage/care. Interview on 01/16/25 at 9:20 A.M. with the Resident#191 verified she was receiving oxygen via trach. Interview on 01/16/25 at 10:56 A.M., with Nurse Practitioner (NP) 315 confirmed the resident did not have oxygen orders and she had just added them to the resident's orders. Interview on 01/16/25 at 11:06 A.M., with LPN #177 confirmed the resident was on oxygen via trach and the resident did not have orders or oxygen. Review of the facility policy titled Tracheostomy Care (dated 04/2021) revealed a replacement tracheostomy tube must always be available at the bedside. A suction machine, supply of suction catheters, exam and sterile gloves, and flush solution, must always be available at the beside. Review of the policy titled Cleaning and Disinfection of Resident-Care items and Equipment (dated 2001) revealed no procedures for storing nebulizers or caring for nebulizer equipment. C. Review of Resident #191's discharge hospital orders dated 01/06/25 and the Physician History and Physical dated 01/08/25 revealed the resident was ordered DuoNeb (Albuterol and Atrovent) inhalation treatments via nebulizer four times daily and Albuterol inhalation treatments as needed for six hours for wheezing and shortness of breath. Review of Resident #191's Medication Administration Records (MAR) and orders dated 01/2025 revealed no evidence the DuoNeb was ordered or administered. Further review revealed the albuterol was ordered four times daily. The interview on 01/16/25 at 9:20 A.M., with Resident #191 revealed staff were administering the inhalation treatments (nebulizer) treatments mostly orally and no using the tracheostomy. Interview on 01/16/25 at 10:56 A.M., with Nurse Practitioner (NP) 315 confirmed staff did not enter the correct orders on admission. The residents should have been receiving the DuoNeb four times a day and the Albuterol only as needed via trach and not by mouth. Interview on 01/16/25 at 11:06 A.M., with LPN #177 verified she had spoken to NP #315 to reconcile admission orders and the current orders. The LPN confirmed the DuoNeb was never ordered, and the Albuterol should have been as needed and not scheduled four times a day. LPN #177 confirmed staff should have been administering the inhalation/nebulizer treatment via trach mask and not by mouth. 2. Medical record review revealed Resident #67 was admitted to the facility on [DATE] with diagnoses including chronic obstructive pulmonary disease with (acute) exacerbation, acute and chronic respiratory failure with hypoxia, toxic effect of tobacco cigarettes, intentional self-harm, sequela, respiratory conditions due to other specified external agents, dependence on supplemental oxygen, chronic kidney disease. Review of Resident #67's current orders dated 01/2025 revealed Norvasc (calcium channel blocker) 5 milligrams (MG) administer two tablets once daily and Breztri (bronchodilator) Aerosphere 160-9-4.8 micrograms (mcg) aerosol two puffs twice daily and to rinse mouth with water after using. Review of Medscape revealed Breztri was an orally inhaled corticosteroid that could cause oropharyngeal candidiasis (yeast infection), and patients were advised to rinse mouth out with water and without swallowing after use. Observation on 01/15/25 at 7:51 A.M., of Resident #67's medication administration with Registered Nurse (RN) #110 revealed RN #110 only administered one 5 mg tablet of Norvasc (order was for two tablets) and did not have Resident #67 rinse with water after the administration of Breztri per order. Findings were confirmed with RN #110 after observation. Review of the facility's policy titled Medication Administration-General Guidelines (dated 11/2018) revealed medication are administered as prescribed in accordance with good nursing principles and practices and only by person legally authorized to do so. The person administering medication adheres to good hand hygiene. Follow the five rights (right resident, right drug, right dose, right route, and right time) are applied for each medication being administered. The medication administration record (MAR) is always employed during medication administration. Medication are administered in accordance with written orders of the prescriber. 2. Medical record review revealed Resident #67 was admitted to the facility on [DATE] with diagnoses including chronic obstructive pulmonary disease with (acute) exacerbation, acute and chronic respiratory failure with hypoxia, toxic effect of tobacco cigarettes, intentional self-harm, sequela, respiratory conditions due to other specified external agents, dependence on supplemental oxygen, chronic kidney disease. Review of Resident #67's current orders dated 01/2025 revealed Norvasc (calcium channel blocker) 5 milligrams (MG) administer two tablets once daily and Breztri (bronchodilator) Aerosphere 160-9-4.8 micrograms (mcg) aerosol two puffs twice daily and to rinse mouth with water after using. Review of Medscape revealed Breztri was an orally inhaled corticosteroid that could cause oropharyngeal candidiasis (yeast infection), and patients were advised to rinse mouth out with water and without swallowing after use. Observation on 01/15/25 at 7:51 A.M., of Resident #67's medication administration with Registered Nurse (RN) #110 revealed RN #110 only administered one 5 mg tablet of Norvasc (order was for two tablets) and did not have Resident #67 rinse with water after the administration of Breztri per order. Findings were confirmed with RN #110 after observation. Review of the facility's policy titled Medication Administration-General Guidelines (dated 11/2018) revealed medication are administered as prescribed in accordance with good nursing principles and practices and only by person legally authorized to do so. The person administering medication adheres to good hand hygiene. Follow the five rights (right resident, right drug, right dose, right route, and right time) are applied for each medication being administered. The medication administration record (MAR) is always employed during medication administration. Medication are administered in accordance with written orders of the prescriber.

CONCERN (D)

Potential for Harm - no one hurt, but risky conditions existed

Deficiency F0698 (Tag F0698)

Could have caused harm · This affected 1 resident

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**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on medical record review, observation, interviews and facility policy review, the facility failed to ensure a resident who required dialysis services received ordered care. This affected one resident (#30) of one resident reviewed for dialysis. The facility census was 85. Findings include Review of the medical record for Resident #30 revealed an initial admission date of 08/30/23 with the latest readmission of 12/10/24 with the diagnoses including but not limited to partial traumatic amputation of left foot, osteomyelitis, sepsis, diabetes mellitus with neuropathy, hypertension, hyperlipidemia, osteoarthritis, gastro-esophageal reflux disease, constipation, edema, nausea and vomiting and anemia. Review of the resident's plan of care revealed no care plan addressing the resident's dialysis or potential for infection related to the central line. Review of the resident's quarterly Minimum Data Set (MDS) assessment dated [DATE] revealed the resident's cognition was not assessed. The assessment indicated the resident had a known weight loss and was on a physician prescribed weight loss regimen and received a therapeutic diet. The assessment indicated the resident had not received dialysis services. Review of the resident's monthly physician orders for January 2025 revealed no physician orders for the name, location and phone number of the offsite dialysis, days of the week dialysis would occur and chair time. Review of the medical record revealed no evidence of dialysis communications forms, labs or communication between the dietician and the dialysis center. On 01/14/25 at 9:40 A.M., interview with the resident revealed she receives dialysis every Tuesday, Thursday and Saturday. She revealed she leaves for dialysis at 10:00 A.M. and does not take a communication form to dialysis with her for the dialysis center. She then revealed when she brings papers back from dialysis she tries to give them to the nurse, however they tell her the papers are for her. On 01/14/25 at 2:07 P.M., interview with Registered Nurse (RN) #162 confirmed the facility does not send a dialysis communication form with the resident. On 01/15/25 at 3:52 P.M., interview with the Director of Nursing (DON) verified a dialysis communication form was to be sent with the resident with each dialysis day. She revealed she was unaware the staff nurses was not providing the form. On 01/16/25 at 9:33 A.M., interview with Dialysis Registered Dietician (DRD) #355 revealed the facility does not communicate with the dialysis center. She stated the facility was unreliable so the resident is weighed prior to being placed on dialysis and after dialysis. She revealed she was unsure who the facility RD was and had not communicated with her. She revealed she faxes treatment sheets weekly and laboratory results monthly. Review of the facility policy titled, Dialysis Care, (last reviewed 06/22) revealed it was the policy of this facility to ensure resident that receive dialysis treatment are safe, well assessed and that the facility collaborates care with the dialysis center. Dialysis requires a physician's order that is specific to the individual resident's needs. The order should include which dialysis center, dialysis schedule of days/times ad the phone number of the dialysis center. The facility shall use a form to communicate between the dialysis center with each visit. The nurse will complete and assessment of the resident prior to leaving facility and upon return to facility for each dialysis visit. Upon return from dialysis the nurse will review the communication form sent to dialysis center. The care plan for the resident who receives dialysis care should include but not limited to name of dialysis center, treatment days/times and phone number, if/when a meal is needed to be sent with resident to dialysis, method of transportation to/from dialysis care, emergency contact name and phone number for dialysis center, emergency contact name and phone number for resident, port/shunt/fistula site location, bruit and thrill of the fistula to be assessed every shift, directions related to care of the port/shunt/fistula site, observe port/shunt/fistula site for signs/symptoms of infection every shift, observe port/shunt/fistula site for signs/symptoms of bleeding every shift, observation of mental status, activity to be tolerated, encourage use of arm with port/shunt/fistula, dietary recommendations, fluid restrictions recommendations, weekly weights as ordered and observation for shortness of breath and increase of congestion.

CONCERN (D)

Potential for Harm - no one hurt, but risky conditions existed

Deficiency F0699 (Tag F0699)

Could have caused harm · This affected 1 resident

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**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on record review, staff interview and facility policy review, the facility failed to assess, implement and monitor one resident (#38) with known post traumatic stress disorder (PTSD) for triggers and preferences to eliminate or mitigate triggers that may cause re-traumatization of the resident. This affected one resident (#38) of five residents reviewed for behavioral-emotional needs. The facility census was 85. Findings Include: Review of the medical record for Resident #38 revealed an initial admission date of 02/02/23 with the latest readmission of 06/02/23 with the diagnoses including but not limited to metabolic encephalopathy, sepsis, acidosis, epilepsy, solitary pulmonary nodule right upper lobe, dementia with behavioral disturbances, esophageal thickening, diabetes mellitus, hypertension, anxiety disorder, mood disorder, insomnia, dental caries and added on 09/20/24 schizophrenia. Review of the plan of care dated 02/02/23 revealed the resident presents with diagnoses of post traumatic stress disorder (PTSD). Interventions included assist the resident to identify and avoid triggers from the traumatic experience which may include arguing and raised voice, encourage family support system as appropriate, medications as orders, observe for changes in behaviors and altered mood and refer to physician as needed, provide supportive counseling contracts as needed and psych services referral as needed. Review of the resident's comprehensive Minimum Data Set (MDS) assessment dated [DATE] revealed the resident had no cognitive deficit. The assessment indicated dementia, anxiety and schizophrenia was a current diagnoses, however PTSD was not coded as a current diagnoses. Review of the medical record revealed no evidence a trauma assessment was completed to identify the resident's cause of PTSD, triggers and preferences to eliminate or mitigate triggers that may cause re-traumatization of the resident. On 01/14/25 at 1:35 P.M., interview with Social Service Director (SSD) #190 verified a trauma assessment was completed to identify the resident's cause of PTSD, triggers and preferences to eliminate or mitigate triggers that may cause re-traumatization of the resident. Review of the facility policy titled, Trauma Informed Care, (dated 03/19) revealed the purpose of the policy was to guide the staff in appropriate and compassionate care specific to individuals who have experienced trauma. Nursing staff are trained on screening tools, trauma assessments and how to identify triggers associated with re-traumatization.

CONCERN (D)

Potential for Harm - no one hurt, but risky conditions existed

Deficiency F0742 (Tag F0742)

Could have caused harm · This affected 1 resident

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**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on medical record review and interviews, the facility failed to ensure a resident received referrals for psychiatric services and failed to ensure a resident had interventions in place to address aggressive behaviors. This affected one resident (#71) of one reviewed for choices and one resident (#85) two reviewed for dementia care. Findings included: 1. Medical record review revealed Resident #85 was admitted to the facility on [DATE] with diagnoses including dementia, post-traumatic stress disorder, insomnia, generalized anxiety, and wandering. Review of Resident #85's current orders dated 01/2025 revealed the resident was ordered clonazepam 0.25 milligrams (mg) 0.25 mg in the morning 0.5 mg in the evening and every eight hours needed for agitation and anxiety. The resident was also ordered Zyprexa (antipsychotic) 2.5 mg in the morning and 5 mg at 4:00 P.M. There was no indication for use. Review of Resident #85's hospital notes dated 11/22/4 indicated the resident was on Zyprexa for anxiety and agitation. Review of Resident #85's history and physical dated 11/27/24 revealed the resident was on Zyprexa for chronic stress disorder and psych (services) was to follow. Review of Resident #85's physician note dated 12/25/24 revealed the resident to follow up with psych (services). Review of Resident #85's medical record revealed no evidence the resident had been seen or referred to psych services. Interview on 01/22/25 at 2:37 P.M. and 3:08 P.M., with Licensed Practical Nurse (LPN) #177 confirmed the physician had indicated the resident was to be followed by psych services for the chronic stress disorder, however the referral was never made. The LPN #177 called psych services and they would see the resident tomorrow. 2. Record review revealed Resident #71 was admitted to the facility on [DATE] with diagnoses including atrial fibrillation, dementia, anxiety disorder, and mild cognitive impairment. Review of an MDS assessment completed on 09/30/24 revealed Resident #71 had severe cognitive impairment and behaviors including delusions and wandering daily. Review of a nursing note dated 10/31/24 at 7:58 P.M. by RN #188 revealed Resident #71 had his hands wrapped around a Certified Nursing Assistant (CNA)'s neck, and the CNA was red and sweating. Resident #71 was redirected and was sent to the emergency department for evaluation. Review of a nursing note dated 10/31/24 at 8:44 P.M. by RN #162 revealed Resident #71 returned to the facility with no new orders. Review of a social services note dated 11/01/24 at 11:31 A.M. by Social Services Director (SSD) #190 revealed she left a message with the facility's consulting psychiatrist to discuss the incident and best next steps for Resident #71. Review of a nursing note dated 11/08/24 at 5:49 A.M. by Licensed Practical Nurse (LPN) #177 revealed Resident #71 was restless throughout the night, urinated on the floor, was verbally aggressive, and difficult to redirect. Review of a care plan last reviewed on 11/13/24 revealed no care plan to address Resident #71's aggressive behaviors. Interview on 01/14/25 at 10:28 A.M. with SSD #190 revealed Resident #71 had abnormally aggressive behaviors after having a surgery, but he has gotten better. SSD #190 stated she was aware of the incident where Resident #71 grabbed an STNA by the neck and after the incident, she allowed nursing staff to apply their own interventions and nursing staff complete the care plan. SSD #190 stated nursing staff reported Resident #71 is only aggressive to staff and not residents. Review of the medical record revealed no evidence Resident #71 was seen by psychiatric services to address the increase in behaviors. An additional interview with SSD #190 on 01/14/25 at 3:07 P.M. confirmed Resident #71 had not been seen by the psychiatrist yet after the outburst of aggression in October. SSD #190 stated a follow up evaluation will be completed during the psychiatrist's next visit on 01/16/25. Interview on 01/15/25 at 8:37 A.M. with CNA #153 revealed she had seen Resident #71 have aggressive behaviors and at one point, Resident #71 got out the doors of the facility and when she went to redirect, Resident #71 pinned her against the fence and was yelling in her face. CNA #153 stated over the last couple days, Resident #71 had been more aggressive and she had seen him be irritated with other residents. Interview on 01/15/25 at 8:44 A.M. with CNA #202 revealed she has seen Resident #71 have behaviors including threatening to hit, choke, or throw things at people, usually staff. Interview on 01/22/25 at 1:37 P.M. with SSD #190 confirmed despite requesting the psychiatrist follow up with Resident #71, she did not request he be seen again until the survey took place and brought the lack of follow up to her attention.

CONCERN (D)

Potential for Harm - no one hurt, but risky conditions existed

Drug Regimen Review (Tag F0756)

Could have caused harm · This affected 1 resident

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**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** 2. Review of the medical record for Resident #19 revealed an initial admission date of secondary Parkinsonism, diabetes mellitus, aphasia, hyperlipidemia, bipolar disorder, depressive episodes, schizoaffective disorder, bipolar type, anxiety disorder, schizophreniform and dementia. Review of the resident's quarterly Minimum Data Set (MDS) assessment dated [DATE] revealed the resident had a severe cognitive deficit. Review of the mood and behavior revealed the resident displayed no behaviors. The assessment indicated dementia, anxiety disorder, depression, bipolar disorder and schizophrenia were active diagnoses. The resident received antipsychotic, antianxiety, antidepressant and hypoglycemic medications. Review of the pharmacy recommendation dated 04/08/24 revealed the pharmacist recommended the following labs, basic metabolic panel (BMP), hemoglobin A1c (Hgb A1c), liver function test (LFT) and complete blood count (CBC) every six months. The physician addressed the recommendation on 04/15/24 and agreed with the recommendation. Review of the resident's monthly physician orders revealed no orders for the laboratory tests BMP, HgbA1c, LFT and CBC every six months. On 01/15/25 at 11:58 A.M., interview with the Director of Nursing (DON) verified the pharmacy recommendation with the ordered laboratory tests were not implemented. Review of the facility policy titled, Lab Results, (not dated) revealed the physician will identify and order diagnostic and lab testing based on the resident's diagnostic and monitoring needs. The staff will process test requisitions and arrange for tests. The laboratory, diagnostic, radiology provider or other testing source will report test results to the facility. Based on record review, staff interview, and policy review, the facility failed to ensure pharmacy recommendations that were the result of monthly medication regimen reviews were responded to timely or at all by the physician. This affected two residents (#1 and #19) of five residents reviewed for unnecessary medications. Findings include: 1. Review of Resident #1's medical record revealed she was admitted to the facility on [DATE]. Her diagnoses included bipolar disorder, attention deficit/ hyperactive disorder, major depressive disorder, anxiety disorder, and insomnia. Review of the facility's pharmacy reports for monthly medication regimen reviews revealed Resident #1's medications were reviewed monthly over the past 12 months by the contracted pharmacist to note any irregularities in the resident's medications that needed to be addressed by the physician. The pharmacy provided two separate reports showing those residents who had been seen for a monthly medication regimen review and those seen that did not have any irregularities noted during that monthly review. Out of the 12 monthly medication regimen reviews that had been completed for the resident, pharmacy recommendations made on 03/07/24, 05/07/24, 08/07/24, 09/04/24, and 10/07/24, as a result of those reviews. Review of Resident #1's pharmacy recommendation dated 03/07/24 revealed the pharmacist recommended the physician evaluate the resident for the continued use of Aripiprazole (an anti-psychotic) 2 milligrams (mg) that was being used daily. The resident had been on Aripiprazole 2 mg daily since 12/27/23. There was no documented evidence of the physician responding to that recommendation timely, as the facility was unable to provide a copy of the pharmacy recommendation with the physician's response, and the resident continued to receive that medication at the same ordered dose until 08/30/24. Review of Resident #1's pharmacy recommendation dated 05/07/24 revealed the pharmacist recommended the physician evaluate the resident for the continued use of Bupropion ER 450 mg daily. The resident had been on Bupropion ER 450 mg daily since 12/19/23. There was no documented evidence of the physician responding to that recommendation, as the facility was unable to provide a copy of the pharmacy recommendation with the physician's response, and the resident continued to receive that medication at the same ordered dose since 12/19/23. Review of Resident #1's pharmacy recommendation dated 08/07/24 revealed the pharmacist recommended the physician evaluate the resident for the use of Belsomra 10 mg every night at bedtime. The resident was started on that medication on 07/25/24 and, according to the manufacturer, it should not be used more than seven to 10 days. There was no documented evidence of the physician responding to that recommendation timely, as the facility was unable to provide a copy of the pharmacy recommendation with the physician's response, and the resident continued to receive that medication at the same ordered dose until 10/03/24 (when the medication was discontinued). Review of Resident #1's pharmacy recommendation dated 09/04/24 revealed the pharmacist recommended the physician evaluate the resident for the continued use of Fluoxetine 40 mg daily. The resident had been on Fluoxetine 40 mg daily since 04/25/24. There was no documented evidence of the physician responding to that recommendation, as the facility was unable to provide a copy of the pharmacy recommendation with the physician's response, and the resident continued to receive that medication at the same ordered dose since 04/25/24. Review of Resident #1's pharmacy recommendation dated 10/07/24 revealed the pharmacist recommended the physician evaluate the resident for the use of Rozerem. The resident was started on that medication on 10/03/24 and, according to the manufacturer, that medication should not be used for more than seven to 10 days. There was no documented evidence of the physician responding to that recommendation timely, as the facility was unable to provide a copy of the pharmacy recommendation with the physician's response, and the resident continued to receive that medication at the same ordered dose of 8 mg every night at bedtime from 10/03/24 until 11/21/24, when the medication was discontinued. Review of the facility's policy on Medication Regimen Reviews (revised May 2019) revealed the consulting pharmacist would review the medication regimen of each resident at least monthly. The goal of the medication regimen review (MRR) was to promote positive outcomes while minimizing adverse consequences and potential risks associated with medications. Within 24 hours of the MRR, the consulting pharmacist provided a written report to the attending physicians for each resident identified as having a non-life threatening medication irregularity. The attending physician was to document in the medical record that the irregularity had been reviewed and what (if any) action was taken to address it. If the physician did not provide a timely or adequate response, or the consulting pharmacist identified that no action had been taken, he/ she was to contact the medical director or (if the medical director was the physician of record) the Administrator. Copies of the medication regimen review reports, including the physician's responses, were to be maintained as part of the permanent medical record.

CONCERN (D)

Potential for Harm - no one hurt, but risky conditions existed

Deficiency F0757 (Tag F0757)

Could have caused harm · This affected 1 resident

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**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** 3. Review of Resident #74's medical record revealed the resident was admitted to the facility on [DATE]. Her diagnoses included adult onset diabetes mellitus. Review of Resident #74's physician's orders revealed the resident had an order for Basaglar (Insulin Glargine) KwikPen (long acting insulin) 100 units/ milliliter (ml) 35 units subcutaneously (SQ) twice a day (BID), Insulin Aspart (rapid acting insulin) 100 units/ ml 14 units SQ before meals (ac), Insulin Aspart 100 units/ ml before meals as per sliding scale. The sliding scale was for the resident to receive additional Insulin Aspart before meals based on the resident's blood glucose level. He was to receive two additional units if his blood sugar was 151 milligrams (mg)/ deciliter (dl) to 200 mg/dl, four additional units if his blood sugar was 201-250 mg/dl, six additional units if his blood sugar was between 251- 300 mg/dl, eight additional units if his blood sugar was between 301-350 mg/ dl, and 10 additional units if his blood sugar was between 351- 400 mg/ dl. The order also included parameters in which to notify the physician. They were directed to notify the physician if the resident's blood sugar was less than 60 mg/ dl or above 400 mg/ dl. Review of Resident #74's medication administration records (MAR's) for January 2025 revealed there were two separate occasions in which the resident's blood sugars were found to be outside the parameters that required physician notification. The resident's blood sugar was recorded as being low at 57 mg/ dl (normal ranges 80- 130 mg/dl) on 01/17/25 between the hours of 4:00 A.M. and 6:00 A.M. and was then high at 473 mg/ dl on 01/18/25 between the hours of 10:00 A.M. and 12:00 P.M. without documented evidence on the MAR of the physician being notified as ordered. In addition, on 01/17/25 between the hours of 4:00 P.M. and 6:00 P.M., the resident's blood sugar was recorded as being 487 mg/ dl. The physician was notified of that elevated blood sugar and gave instructions to the nurse to administer the highest amount of Insulin Aspart the resident could receive based on his current sliding scale orders. The MAR did not provide any evidence of the resident being given any additional Insulin Aspart allowable by his sliding scale as was ordered by the physician when the resident's blood sugar was 487 mg/ dl. The nurse was further instructed to recheck the resident's blood sugar in two hours and to provide additional insulin coverage based on the sliding scale, if needed. The resident's blood sugar was rechecked on 01/18/25 at 7:30 P.M. and found to remain high at 394 mg/ dl. There was no documented evidence of any additional insulin coverage being given to the resident when his blood sugar remained high, as was ordered by the physician. Review of Resident #74's progress notes revealed there was no documented evidence to show the physician was notified of the resident's low blood sugar of 57 mg/ dl on 01/17/25 between the hours of 4:00 A.M. and 6:00 A.M. as was set forth in the parameters given as part of the resident's sliding scale insulin coverage. There was also no documented evidence to show the physician was notified of the resident's elevated blood sugar of 473 mg/ dl on 01/18/25, when checked between 10:00 A.M. and 12:00 P.M., as was indicated in the parameters set forth in the physician's orders. The progress notes also did not provide any documented evidence of the nurse administering any additional insulin coverage to the resident based on his sliding scale when the resident's blood sugar was initially high on 01/17/25 between 4:00 P.M. and 6:00 P.M. or when rechecked on 01/17/25 at 7:30 P.M. as ordered by the physician. Findings were verified by the Director of Nursing (DON). On 01/21/25 at 4:30 P.M., an interview with the DON confirmed Resident #74 had parameters in place to notify the physician, if the resident's blood sugar was less than 60 or greater than 400 mg/ dl. She acknowledged the MAR and the progress notes did not provide any evidence the physician was notified when the resident's blood sugar was found to be low at 57 mg/ dl on 01/17/25 between 4:00 A.M. and 6:00 A.M. or when it was high at 473 mg/ dl on 01/18/25 between 10:00 A.M. and 12:00 P.M. She further acknowledged there was no documented evidence of the resident being given the highest dose of Insulin Aspart, as allowed per his sliding scale, when his blood sugar was 487 mg/ dl on 01/17/25 between 4:00 P.M. and 6:00 P.M. as was instructed to do so by the physician according to the progress notes on 01/17/25 at 4:45 P.M. She also confirmed that on 01/17/25 at 7:30 P.M., when the resident's blood sugar was rechecked and found to remain high at 394 mg/ dl, there was no evidence of any additional insulin being given, as per the resident's sliding scale, and as was directed to do so by the physician. Based on medical record review, interview, and policy review the facility failed to ensure residents were free from unnecessary medications when pain medication failed to have parameters and failed to ensure sliding scale insulin was followed per orders. This affected three residents (#74, #85, and #191) of six reviewed for unnecessary medication review. The facility census was 85. Findings included: 1. Medical record review revealed Resident #85 was admitted to the facility on [DATE] with diagnoses including dementia, post-traumatic stress disorder, gout, insomnia, generalized anxiety, hypertension, hyperlipemia, and wandering. A. Review of Resident #85's orders and medication administration record dated 12/22/24 to 01/21/25 revealed the resident was ordered lidocaine patch 5% apply one patch on in the morning and remove at night. Do not wear it for more than 12 hours in a 24-hour period. The resident refused to apply the patch 11 times and refused to have the patch removed 10 times. Interview on 01/22/25 at 2:37 P.M. and 3:08 P.M., with Licensed Practical Nurse (LPN) 177 confirmed resident had refused his Lidocaine Patch applied 11 times and removed 10 times and there was no evidence the provider was notified of the refusals. The LPN reported she contacted the Nurse Practitioner (NP) after reviewing with the surveyor and the NP gave new orders to discontinue the Lidocaine patch. B. Review of Resident #85's progress note dated 01/01/25 revealed the nurse was notified the resident's right eye was red in color. The nurse called the on call provider and received new orders for polymyxin (antibiotic) one drop every four hours for seven days. Review of Resident #85's orders dated 01/2025 revealed polymyxin one drop four times daily was ordered on 01/01/25 to start on 01/02/25. There was no evidence of which eye to administer the eye drop. Review of Resident #85's medication administration record (MAR) dated 01/2025 revealed polymyxin one drop four times a day. There was no evidence of which eye to administer the medication. The residents did not receive any doses on 01/02/24 of the polymyxin and the medication was discontinued on 01/08/25 (six days). Interview on 01/22/25 at 3:43 P.M., with the Director of Nursing (DON) confirmed the resident was ordered polymyxin for seven days, however only received six days due the medication was not available for all four doses on 01/02/25. 2. Medical record review revealed Resident #191 was admitted to the facility on [DATE] with diagnoses including chronic obstructive pulmonary disease, acute respiratory failure with hypoxia, sepsis, tracheostomy, gastrostomy, hypertension, atrial fibrillation, acute kidney failure, protein-calorie malnutrition, anxiety, hyperlipidemia, and tobacco use. Review of Resident #191's hospital discharge orders dated 01/06/25 revealed to administer oxycodone 2.5 to 5 milligrams (mg) give 2.5 milligrams for pain 5-7 and 5 mg for pain 8-10 every six hours as needed. Review of Resident #191's history and physical data dated 01/08/25 revealed to administer oxycodone 2.5 to 5 milligrams (mg) give 2.5 milligrams for pain 5-7 and 5 mg for pain 8-10 every six hours as needed. Review of Resident #191's orders and medication administration record (MAR) dated 01/06/25 to 01/15/25 revealed oxycodone 5 mg give 0.5 to one tablet every six hours as needed. There was no evidence of parameters when to administer 0.5 or one tablet. The resident had received eight doses from 01/11/25 to 01/15/25 without evidence if 0.5 or one tablet was administered or rate of pain. Interview on 01/16/25 at 10:56 A.M., with the Nurse Practitioner (NP) 315 revealed the unit manager had shared the surveyor's concerns today with her. The NP reported the facility had contacted her upon admission and they were to follow the hospital discharge orders administer oxycodone 2.5 to 5 milligrams (mg) give 2.5 milligrams for pain 5-7 and 5 mg for pain 8-10 every six hours as needed. The NP changed the order today to administer one tablet every six hours as needed for pain. Interview on 01/16/25 at 11:06 A.M., with Licensed Practical Nurse (LPN)/Unit Manger #177 confirmed the order was entered incorrectly and order didn't indicate when to administer 0.5 or one tablet was administered and staff were not documenting the resident pain rating prior to or after administering the oxycodone.

CONCERN (D)

Potential for Harm - no one hurt, but risky conditions existed

Medication Errors (Tag F0758)

Could have caused harm · This affected 1 resident

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**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** 3. Review of the medical record for Resident #19 revealed an initial admission date of secondary Parkinsonism, diabetes mellitus, aphasia, hyperlipidemia, bipolar disorder, depressive episodes, schizoaffective disorder, bipolar type, anxiety disorder, schizophreniform and dementia. Review of the plan of care dated 08/07/24 revealed the resident was at risk for adverse consequences related to receiving antianxiety medication for anxiety. Interventions included administer medication per physician orders, attempt gradual does reduction (GDR) in two separate quarters (with at least one month between the attempts) during the first year the resident receives an anxiolytic medication, then yearly, unless clinically contraindicated, attempt non-pharmacological interventions prior to administering as needed anxiolytic, observe for drug use effectiveness and adverse consequences, notify physician of adverse effects, pharmacy consultant as needed and provide the lowest effective dose possible. Review of the psych consult dated 10/29/24 revealed the medication Buspar 7.5 milligrams (mg) twice daily was to be discontinued due to no longer needed and the amount of serotonergic agents the resident was on. Review of the resident's quarterly Minimum Data Set (MDS) assessment dated [DATE] revealed the resident had a severe cognitive deficit. Review of the mood and behavior revealed the resident displayed no behaviors. The assessment indicated dementia, anxiety disorder, depression, bipolar disorder and schizophrenia were active diagnoses. The resident received antipsychotic, antianxiety, antidepressant and hypoglycemic medications. Review of the monthly physician orders for January 2025 identified an order for Buspar 7.5 mg by mouth twice daily. Review of the resident's October, November and December 2024 and January 2025 Medication Administration Records (MAR) revealed the resident was administered Buspar 7.5 mg by mouth twice daily. On 01/15/25 at 9:25 A.M., interview with the Director of Nursing (DON) verified the Buspar 7.5 mg was not discontinued on 10/29/24 as indicated by the psychiatrist. Based on medical record review, review of hospital records, interviews, and policy review the facility failed to ensure psychotropic drugs were administered as ordered, properly assessed, and had appropriate diagnoses. This affected three residents (#19, #85, and #191) of six reviewed of unnecessary medication review. Findings included: 1. Medical record review revealed Resident #85 was admitted to the facility on [DATE] with diagnoses including dementia, post-traumatic stress disorder, insomnia, generalized anxiety, and wandering. Review of Resident #85's current orders dated 01/2025 revealed the resident was ordered clonazepam 0.25 milligrams (mg) 0.25 mg in the morning 0.5 mg in the evening and every eight hours as needed for agitation and anxiety. There was no evidence of a stop date for the as needed clonazepam order. The resident also ordered Zyprexa (antipsychotic) 2.5 mg in the morning and 5 mg at 4:00 P.M. There was no indication for use. Review of Resident #85's hospital notes dated 11/22/24 indicated the resident was on Zyprexa for anxiety and agitation. Review of Resident #85's history and physical dated 11/27/24 revealed the resident was on Zyprexa for chronic stress disorder and psych (services) was to follow. Review of Resident #85's physician note dated 12/25/24 revealed the resident to follow up with psych (services). Review of Resident #85's medical record revealed no evidence the resident had been seen or referred to psych services. Review of Resident #85's assessment/observation revealed no evidence the resident had an abnormal involuntary movement scale (AIMS) test performed (test to measure the severity of orofacial and extremity movement in adults taking antipsychotic medications). Interview on 01/22/25 at 2:37 P.M. and 3:08 P.M., with Licensed Practical Nurse (LPN) #177 confirmed the physician had indicated the resident was to be followed by psych services for the chronic stress disorder, however the referral was never made. LPN #177 also confirmed the resident did not have an appropriate diagnosis for the use of Zyprexa and the as needed clonazepam order did not have a stop date. She had reached out the Nurse Practitioner and she wanted the resident seen by psych services for an appropriate diagnosis, however she ordered the clonazepam to be stopped in 14 days. Interview on 01/22/25 at 4:47 P.M., with LPN #165 confirmed Resident #85 did not have an AIMS test performed. 2. Medical record review revealed Resident #191 was admitted to the facility on [DATE] with diagnoses including chronic obstructive pulmonary disease, acute respiratory failure with hypoxia, sepsis, tracheostomy, gastrostomy, hypertension, atrial fibrillation, acute kidney failure, protein-calorie malnutrition, anxiety, hyperlipidemia, and tobacco use. Review of Resident #191's hospital discharge orders dated 01/06/25 revealed Xanax 0.25 milligrams (mg) three times daily as needed for anxiety and panic disorder. Review of Resident #191's orders dated 01/06/25 revealed Xanax 0.25 mg three times daily. Review of Resident #191's history and physical dated 01/08/25 revealed Xanax 0.25 milligrams (mg) three times daily as needed for anxiety and panic disorder. Review of Resident #191's progress note dated 01/11/2025 revealed the resident requested this nurse come into her room and discuss her medication. The resident states that she no longer wishes to receive Xanax unless it is extremely necessary, states she does not like the way it makes her feel. The writer informed the resident that she was free to refuse any medication and this nurse would not administer it unless she has requested. Review of Resident #191's Medication Administration Record (MAR) dated 01/06/25 to 01/15/25 revealed Xanax 0.25 mg three times daily. The Xanax was not administered on 01/07/25 and two doses on 01/08/25 due to it not being available. The resident refused two doses on 01/11/25, 01/12/25, one dose on 01/13/24 and 01/14/25, and two doses on 01/15/25. An interview on 01/16/25 at 10:56 A.M., with the Nurse Practitioner #315 revealed the unit manager had shared the surveyors concerns today with her. The NP reported the facility had contacted her upon admission and they were to follow the hospital discharge orders for the Xanax 0.25 mg to be as needed not scheduled three times daily. Interview on 01/16/25 at 11:06 A.M., with Licensed Practical Nurse (LPN)/Unit Manger #177 confirmed the Xanax order was entered into the medical record incorrectly. The Xanax was ordered as needed three times a day and staff had entered it was scheduled three times a day. The facility will complete a medication error form for Xanax. Review of the facility's policy titled Antipsychotic Medication Use (dated 12/2016) revealed antipsychotic medication may be considered for a resident with dementia but only after medical, physical, functional, psychological, emotional psychiatric, social, and environmental causes of behavioral symptoms have been identified and addressed. Antipsychotic medication would be prescribed at the lowest possible dose for the shortest period of time. Residents would only receive antipsychotic medications when necessary to treat specific conditions for which they are indicated and effective. New admission would be evaluated for appropriateness and indication for use. As needed orders will not be renewed beyond 14 days unless the healthcare practitioner has evaluated the resident for the appropriateness of that medication.

CONCERN (D)

Potential for Harm - no one hurt, but risky conditions existed

Laboratory Services (Tag F0770)

Could have caused harm · This affected 1 resident

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**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on medical record review, staff interview and facility policy review, the facility failed to ensure physician ordered laboratory tests were obtained as ordered. This affected two residents (#19, #38) of five residents reviewed for unnecessary medications. The facility census was 85. Findings Include: 1. Review of the medical record for Resident #19 revealed an initial admission date of secondary Parkinsonism, diabetes mellitus, aphasia, hyperlipidemia, bipolar disorder, depressive episodes, schizoaffective disorder, bipolar type, anxiety disorder, schizophreniform and dementia. Review of the resident's quarterly Minimum Data Set (MDS) assessment dated [DATE] revealed the resident had a severe cognitive deficit. Review of the resident's monthly physician orders identified an order dated 06/08/19 for the laboratory tests complete blood count (CBC), thyroid stimulating hormone (TSH), hemoglobin A1c (HgbA1c), vitamin D level, vitamin B 12 level and lipid panel annually in July. Review of the medical record revealed no evidence the physician ordered CBC, TSH, HgbA1c, vitamin D level, vitamin B 12 leve and lipid panel was obtained annually in July 2024. Review of the medical record revealed no documented evidence the resident refused the laboratory tests in July 2024. On 01/16/25 at 10:39 A.M., interview with the Director of Nursing (DON) revealed the resident refuses labs. The DON revealed she called the facility contracted lab for the test results, however the laboratory tests had not been drawn. Review of the facility policy titled, Lab Results, (not dated) revealed the physician will identify and order diagnostic and lab testing based on the resident's diagnostic and monitoring needs. The staff will process test requisitions and arrange for tests. The laboratory, diagnostic, radiology provider or other testing source will report test results to the facility. 2. Review of the medical record for Resident #38 revealed an initial admission date of 02/02/23 with the latest readmission of 06/02/23 with the diagnoses including but not limited to metabolic encephalopathy, sepsis, acidosis, epilepsy, solitary pulmonary nodule right upper lobe, dementia with behavioral disturbances, esophageal thickening, diabetes mellitus, hypertension, anxiety disorder, mood disorder, insomnia, dental caries and added on 09/20/24 schizophrenia. Review of the resident's comprehensive Minimum Data Set (MDS) assessment dated [DATE] revealed the resident had no cognitive deficit. Review of the resident's monthly physician orders for January 2025 identified an order dated 05/30/24 hemoglobin A1c (HgbA1c) every six months. Review of the medical record revealed no evidence the HgbA1c were drawn ever six months as physician ordered. On 01/14/25 at 12:14 PM interview with the Director of Nursing (DON) confirmed the physician ordered HgbA1c every six months was not drawn as physician ordered. Review of the facility policy titled, Lab Results, (not dated) revealed the physician will identify and order diagnostic and lab testing based on the resident's diagnostic and monitoring needs. The staff will process test requisitions and arrange for tests. The laboratory, diagnostic, radiology provider or other testing source will report test results to the facility.

CONCERN (D)

Potential for Harm - no one hurt, but risky conditions existed

Dental Services (Tag F0791)

Could have caused harm · This affected 1 resident

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**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, record review, interviews and facility policy review, the facility failed to ensure one resident (#38) received routine dental care. This affected one resident (#38) of one resident reviewed for dental services. The facility census was 85. Findings Include: Review of the medical record for Resident #38 revealed an initial admission date of 02/02/23 with the latest readmission of 06/02/23 with the diagnoses including but not limited to metabolic encephalopathy, sepsis, acidosis, epilepsy, solitary pulmonary nodule right upper lobe, dementia with behavioral disturbances, esophageal thickening, diabetes mellitus, hypertension, anxiety disorder, mood disorder, insomnia, dental caries and added on 09/20/24 schizophrenia. Review of the resident's admission observation and data collection dated 02/02/23 revealed the resident had her own natural teeth. The assessment indicated the resident's teeth had no cavities or broken teeth. Review of the plan of care dated 02/16/23 revealed the resident had potential for mouth pain related to problems developing with natural teeth. Interventions included assess condition of oral cavity, teeth, tongue and lips as needed, assess location of pain, quality and characteristic of pain, duration, intensity and severity of pain, aggravating and alleviating factors as needed, check dentures for a proper/comfortable fit, dental evaluation and intervention as needed, encourage fluids to keep oral cavity moist, medications as ordered, observe and report difficulties, observe and report difficulties chewing/swallowing, observe for need for change diet consistency to increase ease of eating, obtain a dietary consult as needed, follow recommendations as required and offer and provide mouth care as needed. Review of the resident's quarterly observation and data collection dated 11/01/24 revealed the resident's natural teeth had no cavities or were not broken. The assessment indicated the resident had no ulcers, lesions, halitosis, dry membranes or bleeding gums. Review of the resident's comprehensive Minimum Data Set (MDS) assessment dated [DATE] revealed the resident had no cognitive deficit. The assessment indicated the resident had no obvious or likely cavity or broken natural teeth. not coded as a current diagnoses. Review of the resident's monthly physician orders for January 2025 identified and order dated 02/02/23 may see as needed audiologist, dentist, podiatrist, psychologies and optometrist. Review of the resident's medical record revealed the resident had not been seen by a dentist since 08/17/23. On 01/13/25 at 9:19 A.M., observation of the resident revealed she had multiple black broken teeth with obvious caries. On 01/14/25 at 12:14 P.M., interview with the Director of Nursing (DON) verified the resident had not seen a dentist since 08/17/23. Review of the facility policy titled, Dental Services, (dated 12/16) revealed routine and emergency dental services are available to meet the resident's oral health services in accordance with the resident's assessment and plan of care. Routine and 24-hour emergency care dental services are provided to residents through a contract agreement with a licensed dentist that comes ot the facility monthly, referral to the resident's personal dentist, referral to community dentist or referral to other health care organizations that provide dental care. Social services representatives will assist residents with appointments, transportation, arrangements, and for reimbursement of dental services under the state plan, if eligible.

CONCERN (D)

Potential for Harm - no one hurt, but risky conditions existed

Medical Records (Tag F0842)

Could have caused harm · This affected 1 resident

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**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, medical record review, and interview, the facility failed to ensure a complete and accurate record. This affected three residents (#57, #11, #85) of 20 sampled residents. The census was 85. Findings Include: 1. Review of the medical record for Resident #57 revealed an initial admission date of 12/28/22 with the diagnoses including but not limited to Alzheimer's disease, dementia, chronic kidney disease, hypertension, vitamin D deficiency and dysphagia. Review of the resident's plan of care revealed no care plan addressing the resident's oxygen use. Review of the resident's comprehensive Minimum Data Set (MDS) dated [DATE] revealed the resident had a severe cognitive deficit. The assessment indicated the resident had not utilized oxygen therapy. Review of the resident's monthly physician orders identified no orders for oxygen use. Review of the resident's progress note dated 01/13/25 at 4:44 P.M. revealed the resident had reported new onset of wheezing and shortness of breath. The Nurse Practitioner (NP) was notified while in house on rounds. New orders received for chest x-ray and start DuoNebs four times daily for five days. Further review of the resident's progress notes revealed no documented evidence of when and why the resident was started on oxygen therapy on the night shift on 01/13/25. On 01/13/25 at 2:23 P.M., interview with Licensed Practical Nurse (LPN) #211 verified the resident had no physician orders for the oxygen or why the oxygen was initiated. 2. Review of the closed medical record for Resident #11 revealed an initial admission date of 07/05/21 with the latest readmission of 05/07/22 with the admitting diagnoses including but not limited to osteoarthritis, major depressive disorder, mood disorder, constipation, irritable bowel syndrome, hypertension, malignant neoplasm of female genital organ, dysphagia, tract infection, insomnia, unspecified, palliative care, and anxiety disorder. Review of the resident's discontinued physician orders revealed an order dated 10/22/24 for Cipro 500 milligrams (mg) by mouth twice daily until 10/29/24 for a urinary tract infection. Review of the medical record revealed no laboratory results or documentation related to the order for the Cipro 500 mg. Review of the resident's quarterly Minimum Data Set (MDS) assessment dated [DATE] revealed the resident had a moderate cognitive deficit. The assessment indicated the resident was always incontinent of both bowel and bladder. The assessment indicated the resident had not been treated for an infection in the past 30 days. On 01/22/25 at 12:50 P.M., interview with the Director of Nursing (DON) confirmed the lack laboratory results or documentation related to the use of the medication Cipro 500 mg. 3. Medical record review revealed Resident #85 was admitted to the facility on [DATE] with diagnoses including dementia, post-traumatic stress disorder, insomnia, generalized anxiety, and wandering. Review of Resident #85's orders dated 01/02/25 revealed orders for basic metabolic profile, completed blood count, sed rate, uric acid, and c-reactive protein. Review of Resident #85's medical record revealed no evidence of the basic metabolic profile, completed blood count, sed rate, uric acid, and a c-reactive protein was completed. Interview on 01/22/25 with Licensed Practical Nurse (LPN) 177 revealed the basic metabolic profile, completed blood count, sed rate, uric acid, and a c-reactive protein was completed, however it was never scanned into the resident's medical record. LPN #177 reported she could not print off the resident results, but she had it pulled up in the laboratory portal to provide evidence the testing was completed to the surveyor.

CONCERN (D)

Potential for Harm - no one hurt, but risky conditions existed

Antibiotic Stewardship (Tag F0881)

Could have caused harm · This affected 1 resident

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**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on record review, interview and facility policy review, the facility failed to ensure an appropriate reason for the use of an antibiotic for one resident (#11). This affected one resident (#11) of three residents reviewed for antibiotic use. The facility census was 85. Findings Include: Review of the closed medical record for Resident #11 revealed an initial admission date of 07/05/21 with the latest readmission of 05/07/22 with the admitting diagnoses including but not limited to osteoarthritis, major depressive disorder, mood disorder, constipation, irritable bowel syndrome, hypertension, malignant neoplasm of female genital organ, dysphagia, tract infection, insomnia, unspecified, palliative care, and anxiety disorder. Review of the resident's discontinued physician orders revealed an order dated 10/22/24 for Cipro 500 milligrams (mg) by mouth twice daily until 10/29/24 for a urinary tract infection. Review of the medical record revealed no laboratory results or documentation related to the order for the Cipro 500 mg. Review of the resident's quarterly Minimum Data Set (MDS) assessment dated [DATE] revealed the resident had a moderate cognitive deficit. The assessment indicated the resident was always incontinent of both bowel and bladder. The assessment indicated the resident had not been treated for an infection in the past 30 days. On 01/22/25 at 12:50 P.M., interview with the Director of Nursing (DON) confirmed the lack supporting laboratory results or documentation related to the use of the medication Cipro 500 mg. Review of the facility policy titled, Antibiotic Stewardship, (not dated) revealed it was the policy of the facility to maintain an antibiotic stewardship program with the mission of promoting the appropriate use of antibiotics to treat infection and reduce possible adverse events associated with antibiotic use. Providers will utilize the MGreers criteria when considering initiation of antibiotics. When an infection is suspected review with physician the criteria was met for use of antibiotics.

CONCERN (D)

Potential for Harm - no one hurt, but risky conditions existed

Deficiency F0883 (Tag F0883)

Could have caused harm · This affected 1 resident

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Based on record review, interview and facility policy review, the facility failed to ensure two residents (#30, #40) received vaccinations as requested. This affected two residents (#30, #40) of five residents reviewed for immunizations. Findings Include: 1. Review of the medical record for Resident #40 revealed an initial admission date of 10/08/24 with the diagnoses including but not limited to dementia, urinary tract infection (UTI), chronic obstructive pulmonary disease, convulsions, Rheumatoid arthritis, malignant neoplasm of prostate, benign neoplasm of prostate, diabetes mellitus and hyperlipidemia. Review of the resident's admission immunization consent packet dated 10/08/24 revealed the resident consented to have the influenza vaccine, pneumonia vaccine and COVID-19 vaccine. Review of the resident's November 2024 Medication Administration Record (MAR) revealed the resident received the influenza vaccination on 11/06/24. Review of the resident's medical record revealed no documented evidence the resident received the requested pneumonia vaccination as requested. On 01/22/25 at 2:20 P.M., interview with the Director of Nursing (DON) verified the resident had in fact requested the pneumonia vaccinations also and was not provided as requested. 2. Review of the medical record for Resident #30 revealed an initial admission date of 08/30/23 with the latest readmission of 12/10/24 with the diagnoses including but not limited to partial traumatic amputation of left foot, osteomyelitis, sepsis, diabetes mellitus with neuropathy, hypertension, hyperlipidemia, osteoarthritis, gastro-esophageal reflux disease, constipation, edema, nausea and vomiting and anemia. Review of the medical record revealed no immunization consent packet for the immunization consent for the 2024-2025 season. Review of the medical record revealed a family member was her financial POA and not her healthcare POA. On 01/22/25 at 2:20 P.M., interview with the DON she was trying to get contact the resident's power of attorney (POA). The DON verified the resident was her own person and the resident had not received the flu and pneumonia vaccinations as requested. Review of the facility policy titled, Pneumococcal Vaccine, (not dated) revealed all residents will be offered Pneumococcal vaccines to aid in preventing pneumonia/Pneumococcal infections. Review of the facility policy titled, Influenza Vaccine, (not dated) revealed all residents and employees who have no medical contraindications to the vaccine will be offered the influenza vaccine annually to encourage and promote the benefits associated with vaccinations against influenza.

CONCERN (D)

Potential for Harm - no one hurt, but risky conditions existed

Deficiency F0887 (Tag F0887)

Could have caused harm · This affected 1 resident

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Based on record review and interview, the facility failed to ensure two residents (#30, #40) received vaccinations as requested. This affected two residents (#30, #40) of five residents reviewed for immunizations. Findings Include: 1. Review of the medical record for Resident #40 revealed an initial admission date of 10/08/24 with the diagnoses including but not limited to dementia, urinary tract infection (UTI), chronic obstructive pulmonary disease, convulsions, Rheumatoid arthritis, malignant neoplasm of prostate, benign neoplasm of prostate, diabetes mellitus and hyperlipidemia. Review of the resident's admission immunization consent packet dated 10/08/24 revealed the resident consented to have the COVID-19 vaccine. Review of the resident's medical record revealed no documented evidence the resident received the requested COVID-19 vaccination as requested. On 01/22/25 at 2:20 P.M., interview with the Director of Nursing (DON) verified the resident had in fact requested the COVID-19 vaccination and was not provided as requested. 2. Review of the medical record for Resident #30 revealed an initial admission date of 08/30/23 with the latest readmission of 12/10/24 with the diagnoses including but not limited to partial traumatic amputation of left foot, osteomyelitis, sepsis, diabetes mellitus with neuropathy, hypertension, hyperlipidemia, osteoarthritis, gastro-esophageal reflux disease, constipation, edema, nausea and vomiting and anemia. Review of the medical record revealed no immunization consent packet for the immunization consent for the 2024-2025 season. Review of the medical record revealed a family member was her financial POA and not her healthcare POA. On 01/22/25 at 2:20 P.M., interview with the DON she was trying to get contact the resident's power of attorney (POA). The DON verified the resident was her own person and the resident had not received the COVID-19 vaccination as requested.

CONCERN (E)

Potential for Harm - no one hurt, but risky conditions existed

Pharmacy Services (Tag F0755)

Could have caused harm · This affected multiple residents

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**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** 4. Review of Resident #1's medical record revealed the resident was admitted to the facility on [DATE]. Her diagnoses included paraplegia, neurogenic bowel, colostomy status, neuromuscular dysfunction of the bladder, supra-pubic catheter status, stage IV pressure ulcer on her buttock, chronic pain syndrome, chronic obstructive pulmonary disease (COPD), major depressive disorder, attention deficit/ hyperactive disorder, bipolar disorder, anxiety disorder, nicotine dependence, neuralgia, and neuritis. Review of Resident #1's physician's orders revealed she had an order in place to receive Dayvigo 5 milligrams (mg) by mouth every night at bedtime for insomnia. The order had been in place since 11/22/24. Review of Resident #1's medication administration records (MAR's) for December 2024 and January 2025 revealed the resident was not receiving Dayvigo 5 mg by mouth every night at bedtime as was ordered for insomnia. The MAR for December 2024 showed the Dayvigo was not administered on 12/07/24, 12/15/24, 12/16/24, or on 12/17/24 due to the medication being unavailable. The MAR's for January 2025 revealed the resident was not given Dayvigo on 01/01/25 and then again between 01/06/25 through 01/12/25. The reason specified on the MAR as to why the Dayvigo was not given as ordered was again due to the medication being unavailable. Review of pharmacy delivery manifests revealed the facility's contracted pharmacy was sending Dayvigo for Resident #1's use in the quantity of three tablets with each delivery. Three tablets of Dayvigo was indicated to have been delivered on 11/22/24, 11/27/24, 12/01/24, 12/11/24, 12/25/24, and again on 12/31/24. Five tablets of Dayvigo was delivered on 12/18/24. The doses provided as indicated on the delivery manifest did not allow the resident to receive the Dayvigo on a nightly basis as ordered for insomnia. On 01/16/25 at 10:20 A.M., an interview with LPN #125 revealed the facility was having issues with receiving medications from their contracted pharmacy when needed. She stated it was just not for Resident #1, but for other residents too. She indicated refills could be ordered ahead of time using the computer, but there were times they would be told it was too soon to order a refill. She acknowledged there were four days in December and nine days in January 2025 in which Resident #1's MAR's indicated the resident had not received her Dayvigo as ordered due to the medication not being available for administration. She was not sure if there was some insurance issue going on and the medication needed pre-authorization. She acknowledged Dayvigo was a scheduled medication the resident had ordered and had been receiving since 11/22/24. She agreed it should be made available to them by the pharmacy for administration to the resident since it was a scheduled medication. She reported she would contact the pharmacy to get clarification as to why there had been issues having the medication on hand to administer. On 01/16/25 at 12:25 P.M., a follow up interview with LPN #125 revealed she had spoken to the pharmacist regarding Resident #1's Dayvigo. She was told the resident's insurance was not covering the medication. She was not able to state if or when the pharmacist had been in contact with the facility to let them know what the issue was with delivering the Dayvigo so it was available for administration as ordered. She had reached out to the psychiatrist and they were going to restart the resident on Belsomra for her insomnia that had been used in the past. Based on medical record review, review of facility contracts, interviews, and policy review the facility failed to ensure medications were available for administration as ordered. This affected four residents (#1, #31, #85, and #191) of seven residents reviewed for medication review. Findings included: 1. Medical record review revealed Resident #31 was admitted to the facility on [DATE] at 5:05 P.M., with diagnoses including diffuse traumatic brain injury with loss of consciousness, hemiplegia, depression, gastro-esophageal reflux, insomnia, chronic kidney disease, deformity of the head, atrial fibrillation, chronic pain, and iron deficiency anemia. Review of Resident #31's current orders dated 01/2025 revealed meropenem two grams intravenous every eight hours (6:00 A.M., 2:00 P.M., and 10:00 P.M.) and vancomycin 750 mg intravenous every 12 hours (goal trough range 15-20 mcg/ml) at 8:00 A.M. and 8:00 P.M. Review of Resident #31's Medication Administration Record (MAR) dated 12/16/24 to 01/15/25 revealed the resident didn't receive meropenem (antibiotic) on 12/18/24 10:00 P.M., 12/19/24 at 6:00 A.M.,12/29/24 at 2:00 P.M. due to the medication was not available. Further review revealed the resident was not administered Vancomycin on 12/18/24 8:00 P.M., 12/19/24 at 8:00 A.M., 12/23/24 at 8:00 A.M., 12/29/24 at 8:00 P.M., 12/30/24 at 8:00 A.M. and 8:00 P.M. and 12/31/24 at 8:00 A.M., due to the medication was not available. The physician was not notified until 12/31/24 the medication was not available. Interview on 01/21/24 at 12:56 P.M. and 1:38 P.M., with Licensed Practical Nurse (LPN) #177 confirmed Resident #31 did not receive meropenem on 12/18/24 10:00 P.M., 12/19/24 at 6:00 A.M.,12/29/24 at 2:00 P.M. and vancomycin on 12/18/24 8:00 P.M., 12/19/24 at 8:00 A.M., 12/23/24 at 8:00 A.M., 12/29/24 at 8:00 P.M., 12/30/24 at 8:00 A.M. and 8:00 P.M. and 12/31/24 at 8:00 A.M., due to the medications were not available to administer. LPN #177 confirmed the facility has had issues getting medication timely from the pharmacy. The pharmacy was four hours away from the facility and was not local. 2. Medical record review revealed Resident #85 was admitted to the facility on [DATE] with diagnoses including dementia, post-traumatic stress disorder, gout, insomnia, generalized anxiety, hypertension, hyperlipemia, and wandering. Review of Resident #85's MAR and orders dated 12/16/24 to 01/15/25 revealed on 01/07/25 the resident was not administered Vitamin C (supplement) two tablets once daily and Calcium 500 (supplement) milligrams (mg) due to the medications were not available. The resident did not receive carvedilol (beta-blocker) 25 mg A.M. and P.M. dose on 01/01/25, the P.M. dose on 01/02/25 and 01/03/25, 01/06/25, 01/07/25, 01/08/25, and 01/10/25 due to the medication was not available. On 01/01/25 the resident was not administered the 0.25 mg and the 0.5 mg dose of clonazepam (antianxiety) due to not being available. On 01/02/25 the resident did not receive four doses of polymyxin (antibiotic) due to the medication was not available. On 01/20/25 the pravastatin (cholesterol medication) was not administered due to it was not available. Interview on 01/22/25 at 2:37 P.M., with LPN #177 confirmed Resident #85 did not receive the above medications because they were not available from the pharmacy to administer. 3. Medical record review revealed Resident #191 was admitted to the facility on [DATE] at 7:00 P.M. with diagnoses including chronic obstructive pulmonary disease, acute respiratory failure with hypoxia, sepsis, tracheostomy, gastrostomy, hypertension, atrial fibrillation, acute kidney failure, protein-calorie malnutrition, anxiety, hyperlipidemia, and tobacco use. Review of Resident #191's MAR and orders dated 01/06/25 to 01/15/25 revealed the resident did not receive amiodarone (antiarrhythmic), budesonide (steroid), prempro (estrogen), Xarelto (anticoagulant), Flonase nasal spray, Lipitor (cholesterol), and Zoloft (depression) on 01/07/25 or 01/08/25, due to the medications were not available. The resident did not receive Prevacid (proton pump inhibitor) on 01/07/25, 01/08/25, 01/11/25, 01/13/25, 01/14/25, due to the medication was not available. The midodrine (alpha 1 agonists) was not administered three doses on 01/07/25, and two doses on 01/08/25 due to the medication was not available. Interview on 01/16/25 at 9:20 A.M., with Resident #191 confirmed she did not receive most of her medication for two or three days after she was admitted . Interview on 01/16/25 at 11:06 A.M., with LPN #177 confirmed Resident #191 was admitted on [DATE] and did not receive the above medication due to they were not available from the pharmacy. The LPN reported it has been an issue with pharmacy not delivering medication timely. The facility has an emergency stock of medication, however most of Resident #191's medications were not available in the emergency stock nor did staff remove the two (Lipitor and Xarelto) that were available to administer. Review of the pharmacy agreement (dated 10/01/22) revealed the pharmacy shall deliver medications and provide services to the facility seven days a week, three-hundred sixty-five days a year, with modified schedules for national holidays based on a daily delivery schedule mutually determined by the facility and pharmacy. Emergency delivery of medications shall be done by the Pharmacy during normal business hours, except for circumstances beyond reasonable control, and emergency services shall be available after hours through an answering service with a pharmacist on-call. The Pharmacy shall establish an emergency system for backup and/or interim order dispensing. Any emergency drug supply provided under Section shall be property of the Pharmacy as prescribed by applicable laws. During the course of the survey, the surveyor requested information regarding the pharmacy emergency system from the Administrator, however no information was received.

CONCERN (E)

Potential for Harm - no one hurt, but risky conditions existed

Deficiency F0761 (Tag F0761)

Could have caused harm · This affected multiple residents

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4. On 01/22/25 at 9:35 A.M., an observation of the 300 hall medication administration cart revealed there were two insulin flexpens found in the top drawer of the medication cart that were not dated when first used. There was a Lantus (slow acting insulin) flexpen that belonged to Resident #9 that was stored in a plastic bag. The plastic bag had a label that identified what the medication was and who it belonged to. There was not a date written on the plastic bag or the flexpen itself that showed when the Lantus flexpen was first used. A second insulin flexpen was also found in the top drawer of the medication administration cart for Resident #54. The flexpen was Insulin Lispro 100 units/ ml Kwikpen and had a label that indicated it was pulled out of the facility's Omnicell medication dispensing system. The resident's name was written on the bag, but there was no date that indicated when the flexpen was first used. Due to the insulin flexpens not being dated when first put in use, it could not be known when the insulin flexpens should be disposed of. Findings were verified by RN #162. On 01/22/25 at 9:37 A.M., an interview with RN #162 confirmed the two insulin flexpens found in the top drawer of the 300 hall medication administration cart did not include a date to show when it was first used. She acknowledged a date should have been added on the plastic bag the insulin flexpens were being stored in or on the flexpens themselves so the nurses would know what their expiration dates were. She knew the flexpens were only good for a certain number of days, after they had been removed from the refrigerator and put in use. On 01/22/25 at 9:40 A.M., an interview with the Director of Nursing (DON) revealed she and the unit manager had just went through the medication administration carts last evening to check and ensure all items were properly labeled and dated. She acknowledged two flexpens were found in the 300 hall medication administration cart that had not been dated when first used. She confirmed insulin flexpens should be dated when first used, so they knew when to discard them. Review of the facility's Insulin Reference Guide (updated February 2024) revealed Lantus (Insulin Glargine) should be refrigerated until it's expiration date or could be stored at room temperature for up to 28 days. In-use storage indicated it should be stored at room temperature for up to 28 days. They were not to refrigerate it, after being put in use. Insulin Lispro was also only to be stored at room temperature for up to 28 days. Based on medical record review, observation, interview and policy review the facility failed to ensure medications were properly stored, medication carts were locked when unsupervised, and insulin medications were dated when opened. This had the potential to affect all 22 of 22 residents on 200 hall, all 14 of 14 residents on 300 hall, and all 22 of 22 residents on 400 hall. Findings included: 1. Observation of medication administration on 01/15/25 at 7:51 A.M., with Registered Nurse (RN) #110 revealed the RN left the medication cart unlocked with the keys in the lock and walked into Resident #67's room to administer medications. The medication cart was not in RN #110's view. Interview on 01/15/24 at 8:33 A.M., with RN #110 confirmed he left the 400-medication unlocked and left the keys in the lock and the medication cart was not in his view. 2. Observation on 01/16/25 at 10:16 A.M. of the 400 hall medication cart revealed the medication cart was left unlocked and unattended. No staff were observed on the 400 hall. The surveyor waited a few minutes and then walked down to 300 hall to get the nurse (RN #110). Interview on 01/16/25 at 10:19 A.M. RN #110 confirmed he was responsible for 300 and 400 medication carts today and he had left the 400-medication cart unlocked and unattended. 3. Observation on 01/22/25 at 1:45 P.M., the 400 hall cart was left unlocked and unattended. Interview on 01/22/25 at 1:48 P.M. RN #162 confirmed she left the medication cart unlocked and unattended. Review of the facility's policy titled Medication Administration-General Guidelines (dated 11/2018) revealed medication are administered as prescribed in accordance with good nursing principles and practices and only by person legally authorized to do so. During administration of medications, the medication cart was kept closed and locked when out of sight of the facility medication administration personnel.

CONCERN (E)

Potential for Harm - no one hurt, but risky conditions existed

Infection Control (Tag F0880)

Could have caused harm · This affected multiple residents

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**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** 6. Review of Resident #1's medical record revealed she was admitted to the facility on [DATE]. Her diagnoses included paraplegia, neurogenic bowel, colostomy status, neuromuscular dysfunction of the bladder, supra-pubic catheter status, peripheral vascular disease, chronic pain syndrome, muscle weakness, and a stage IV pressure ulcer (full-thickness skin and tissue loss with exposed fascia, muscle, tendon, ligament, cartilage, or bone in the ulcer) on her buttocks. Review of Resident #1's physician's orders revealed the resident had an order in place to cleanse her wounds with normal saline, pat dry, lightly pack her wounds with 1/4 inch Iodoform packing gauze, cover with Mepilex border dressing or equivalent, may use ABD pad and tape to cover. The order had been in place since 11/08/24. Review of Resident #1's active care plans revealed she had a care plan in place for having pressure ulcers on her buttocks. The care plan originated on 02/24/23. The goal was for the resident's pressure ulcers to heal without complications. Interventions included providing treatment as per the physician's orders. On 01/14/25 at 3:10 P.M., a treatment observation was made of the treatment to Resident #1's pressure ulcers. The treatment was provided by RN #162 and she was assisted by LPN #165. The resident was not noted to be in enhanced barrier precautions despite being known to have chronic wounds and medically invasive devices, which included a colostomy and a supra-pubic catheter. The nurses did not don a gown while preparing to do her treatments. Treatments were observed for the resident's stage IV pressure ulcers to her left buttocks and her right hip. LPN #162 performed the treatments to both the resident's pressure ulcers at the same time and did not treat each wound separately to prevent any potential cross-contamination between the two wounds. She was observed to don disposable gloves, after washing her hands, and removed the old dressings covering the pressure ulcer to the right hip followed by the left buttocks. The old dressing over the right hip ulcer had a moderate amount of serosanguineous drainage on it. The old dressing covering the left buttock ulcer had a small amount of serosanguineous drainage. Both dressings were disposed of in a plastic bag sitting at the foot of the bed. The nurse removed her disposable gloves and donned new disposable gloves without performing any hand hygiene between glove changes. She cleansed the right hip wound first using a 4x4 gauze that she moistened with wound cleanser. She wiped around the wound and then the center of the wound, without using separate areas of the moistened gauze. She was not noted to pat the wound to the right hip with a dry 4x4 gauze, after it was cleansed. She then proceeded to clean the wound on the left buttock in the same fashion she did the right hip wound. She did not change gloves or perform any hand hygiene between cleansing the two wounds. After cleansing the left buttock wound, she removed her disposable gloves and donned new gloves, again without performing hand hygiene. She did not bring in a pair of scissors with her to use during the treatment. The resident informed the nurse that she had a pair of surgical scissors she got when out to the wound clinic and gave them to the nurse to use. The resident's scissors were stored in a fanny pack pouch. The nurse was not observed to disinfect the scissors before she was noted to use them to cut off the amount of Iodoform packing gauze she needed to pack the right hip wound. A cotton tip applicator was then used to pack the wound on the right hip. The right hip had a circular red area around the opening of the ulcer that was larger than the size of a golf ball. The nurse then obtained another piece of the Iodoform packing gauze from it's bottle cutting a piece off using the same scissors she had that had not been properly disinfected. She did not dispose of her gloves, perform hand hygiene, and don new gloves before she proceeded to pack the resident's left buttock pressure ulcer. The left buttock wound was packed using less Iodoform packing gauze than what was used to pack the right hip pressure ulcer. She laid an ABD pad on the resident's right hip area above the wound opening with the surface of the ABD pad that was going to be placed over the right hip wound in direct contact with the resident's skin. While the ABD pad was resting on the resident's skin above the right hip area, she applied tape along the four edges of the ABD pad. After securing the tape, she then placed the same side of the ABD pad that had been in contact with the resident's skin over the right hip wound before securing it in place by pressing down on the taped edges. She was then observed to use the scissors that had not been properly disinfected to cut a second ABD pad in half. The half of the ABD pad she intended to use was laid on top of a paper towel that she had previously placed on the bedside table to use as a barrier. She did not lay the ABD pad on the inside of the dressing package that it came in. The surface side that was going to be applied over the resident's left buttock pressure ulcer was laid directly on the paper towel. She then placed tape around the border of the ABD pad that had been cut in half. She placed the side of the ABD pad that had been in direct contact with the paper towel directly over the resident's wound on her left buttock. She then secured the dressing by pressing over the taped edges of the ABD pad. She dated the dressings and gathered her supplies putting all used supplies in her plastic bag. The nurse left the resident's room taking her used treatment supplies that were put in a plastic bag to the nurses's station without performing any hand hygiene. On 01/14/25 at 3:30 P.M., an interview with RN #162 confirmed she completed the treatments to Resident #1's two pressure ulcers at the same time instead of doing each treatment separately. She acknowledged by doing them at the same time she increased the risk of cross-contamination if one of the two wounds would have been infected. She further acknowledged that she did not perform proper glove changes and hand hygiene at appropriate times during the course of the treatments, as she should have. She was informed changing disposable gloves did not negate the need to perform hand hygiene between glove changes. She confirmed she did not bring in a pair of scissors to use during the dressing changes and used a pair that the resident had in her fanny pack. She denied she disinfected the scissors before she used them to cut the Iodoform packing gauze or the ABD pad, which could have contaminated the dressing supplies that she placed in and over the resident's wounds. She also confirmed she had placed the sides of the ABD pads that she used to cover the resident's open wounds on surfaces that were not clean, while placing the tape around the ABD pads' edges. She agreed it would have been easier to cut the tape to the lengths she needed prior to getting the ABD pads out of their packaging so she could have placed the ABD pads directly over the wounds with clean surfaces and then tape the edges of the ABD pads to the resident's skin. She acknowledged the practice she followed did not follow proper infection control practices, as it was possible the resident had bacterial organisms on her skin and she was more likely to introduce bacterial organisms into the wounds causing infections by doing what she did. She then confirmed she had removed her gloves and gathered the trash bag containing the used supplies and left the resident's room without performing any hand hygiene. Review of the facility's policy on Dry/ Clean Dressings (revised September 2013) revealed the purpose of the procedure was to provide guidelines for the application of dry, clean dressings. Steps in the procedure included the need to remove gloves after removing the old dressing and discard both the gloves and the dressing into a plastic or biohazard bag. The nurse was then directed to wash and dry their hands thoroughly. The nurse was then directed to remove her disposable gloves and discard into a designated container and to wash and dry hands thoroughly upon leaving the resident's room. Based on observation, record review, interviews and facility policy review, the facility failed to maintain appropriate infection control practices to prevent the potential spread of infection in the area of tracheostomy care, dressing change, medication administration and enhanced barrier precautions (EBP). This affected ten residents (Residents #1, #9, #22, #30, #31, #54, #61, #74, #191, #240) of 85 residents who require enhanced barrier precautions and four residents (#1, #10, #67, and #191) of 20 residents reviewed for infection control practices. Additionally, the facility failed to ensure the infection control log was accurate and tracked bacteria from nosocomial infections and infection control polices were reviewed annually. This had the potential to affect all 85 residents residing in the facility. Findings Included: 1. Observation on 01/13/25 during the initial tour of the facility revealed no evidence of the facility implementing EBP for those residents observed having tracheostomy, enteral tubes, indwelling urinary catheter and dialysis port. Review of the facility provided list revealed Resident #1, #9, #22, #30, #31, #54, #61, #74, #191, #240 required EBP and was not implemented. On 01/15/25 at 11:30 A.M., interview with the Director of Nursing (DON) confirmed the lack of EBP being implemented for those residents with wounds and/or an indwelling medical device. Review of the facility policy titled, Enhanced Barrier Precautions, (dated 04/01/24) revealed it was the policy of the facility to implement enhanced barrier precautions (EBP) for the prevention of transmission of multi-drug-resistant organisms (MDRO). EBP refer to an infection control intervention designed yo reduced transmission of MDRO that employs targeted gown and gloves use during high contact resident care activities. A physician's order will be obtained for EBP for residents with any of the following , wounds (pressure ulcers, diabetic foot ulcers, unhealed surgical wounds and chronic venous stasis ulcer) and indwelling medical device (central lines, urinary catheters, feeding tubes, tracheostomy/ventilator tubes), even if the resident is not known to be infection or colonized with a MDRO. Implementation of EBP include make gowns and gloves available immediately near or outside of the resident's room. The Infection Preventionist will incorporate monitoring and assessment of adherence to determine the need for additional training and education. High contact resident care activities included, dressing, bathing, transferring, providing hygiene, changing linens, changing briefs or assisting with toileting, device care or use and wound care. EBP should be used for for the duration of the affected resident's stay in the facility or until the resolution of the wound or discontinuation of the indwelling medical device that placed them at higher risk. 2. Review of the August, September, October, November and December 2024 infection control log revealed the facility was not tracking all bacteria, including nosocomial bacteria. On 01/22/25 at 12:50 P.M. interview with the Director of Nursing (DON) verified the lack of infection control monitoring, infection control log not being correct. 3. Review of the facility policy titled, Infection Control and Prevention Policy and Guidelines, (last revised 08/19) revealed no documented evidence the policy is reviewed annually. On 01/22/25 at 3:21 P.M., interview with the DON verified the infection control policy is not reviewed yearly and policies are being sent to her by the facility's consultant. 4. Observation of medication administration pass on 01/15/25 from 7:35 A.M. to 7:51 A.M., with Registered Nurse (RN) 110 removed a Potassium (supplement) 20 milliequivalent (meq) tablet from a blister packet into his ungloved hand and then broke it in half and placed the two halves into a medication cup. Next, RN #110 moved another blister packet from the mediation cart of Bumetanide (diuretic) 2 milligrams (mg) and popped one pill into his ungloved and un-sanitized hand and placed it in the medication cup with Potassium. The RN took the medication cup to room [ROOM NUMBER] (Resident #10) and gave the medication to the resident to take. The resident consumed the medication the nurse had touched with his bare and un-sanitized hands. RN #110 returned to the medication cart and performed hand hygiene with hand sanitizer and then took his keys out of his pocket to open the medication cart to administer the next residents' medications. RN #110 removed 10 pills from blister packets/pill bottles using the same technic by popping the pills into his bare un-sanitized/ungloved hands or pouring into his hands and then placed the pills into a medication cup. The RN took the pills to room [ROOM NUMBER] and administered the medication to Resident #67. Resident #67 had consumed the medications. Interview on 01/15/25 at 8:33 A.M., with RN #110 verified he pops medication from the blister packages/bottles into his bare hands first and then place the pills into the medication cups instead of popping/pouring them directly into the medication cup preventing contamination. The RN also confirmed he broke the Potassium pill with his bare hands and then placed it into the medication cup instead of using gloves. Review of the facility's policy titled Medication Administration-General Guidelines (dated 11/2018) revealed medication are administered as prescribed in accordance with good nursing principles and practices and only by legally authorized person to do so. The person administering medication adheres to good hand hygiene. If breaking a tablet performs appropriate hand hygiene prior to handling tablets and examination gloves must be worn to prevent touching the tablet during the process. 5. Record review revealed Resident #191 was admitted to the facility on [DATE] with diagnoses including chronic obstructive pulmonary disease, acute respiratory failure with hypoxia, sepsis, tracheostomy, gastrostomy, hypertension, atrial fibrillation, acute kidney failure, protein-calorie malnutrition, anxiety, hyperlipidemia, and tobacco use. A. Observation on 01/13/25 at 10:24 A.M., and 01/15/25 at 10:16 A.M. of Resident #191's room, revealed no evidence the resident was in enhanced barrier precautions (EBP). Review of Resident #191's current orders dated 01/2025 revealed no evidence of orders for EBP. Interview on 01/15/25 at 10:30 A.M., with Licensed Practical Nurse (LPN) 177 and Registered Nurse (RN) #212 reported they have never heard of enhanced barrier precautions (EBP) and were not aware residents that had a foley catheter, chronic wound, or indwelling mech device required to follow EBP. The LPN and RN confirmed the resident was not on any type of precautions and had a tracheostomy and gastrostomy tube. B. Observation of Resident #191's tracheostomy care on 01/15/25 at 10:16 AM with RN #212 performing the procedure and LPN #177 assisting revealed neither staff had applied a gown or mask. RN #212 had set up a sterile field to perform tracheostomy care. During the procedure the RN cleaned the cannula with a brush and then placed the contained brush back in the middle of the sterile field. The pipe cleaners, four by fours, and split drain sponge were still on the sterile field. After the RN cleaned the cannula, she placed the clean cannula into the stoma and did not change her gloves and wash her hands. The RN wore the same gloves throughout the entire procedure. Interview on 01/15/25 at 10:30 A.M., with LPN #177 and RN #212 confirmed they did not wear a gown or mask during tracheostomy care. RN #212 confirmed she had placed the contaminated brush on the sterile field instead of throwing the brush in the trash that was next to her, and she didn't wash her hands after cleaning the cannula and replacing the cannula back into the stoma per the facility's policy to prevent the spread of infections. Review of the facility's policy titled Enhanced Barrier Precaution (dated 04/01/24) revealed the facility responsibility to implement enhanced barrier precautions for the prevention of transmission of multi-drug-resistant organisms. EBP refers to an infection control intervention designed to reduce transmission of multi-drug-resistant organism that employs targeted gown, and gloves used during high contact resident care activities. All staff received training on EBP upon hire and at least annually and are expected to comply with all designated precautions. An order for EBP would be obtained for residents with an of the following: wound, and/or indwelling, medical devices (tracheostomy) even if the resident was not known to be infected or colonized with a MDRO. EBP include make gowns and gloves available immediately near or outside of the resident's room. Faced protection may also be needed if performing activity with risk of splash or spray example tracheostomy care. High-contact resident care activity dressing, bathing, transferring, providing hygiene, changing linens, changing briefs, or assisting with toileting, devices care use, tracheostomy and wound care. Review of the facility policy titled Tracheostomy Care (dated 04/2021) revealed when providing cannula care a sterile field must be maintained. Soak the cannula in hydrogen peroxide/saline solution mixture, clean with a brush, rinse with saline and dry with pipe cleaners. Remove and discard gloves into appropriate receptacles. Wash hands and put on fresh gloves and replace the cannula carefully and lock in place.

CONCERN (F)

Potential for Harm - no one hurt, but risky conditions existed

Deficiency F0730 (Tag F0730)

Could have caused harm · This affected most or all residents

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Based on employee record review and staff interview, the facility failed to ensure Certified Nursing Assistants (CNA) performance reviews were completed as required at least every 12 months. This had the potential to affect all 85 residents residing in the facility. The facility census was 85. Findings Include: 1. Review of the employee file for CNA #106 revealed a hire date of 06/10/22. Further review of the employee file revealed no annual performance review for 2024. On 01/22/25 at 5:45 P.M., interview with Human Resource (HR) #187 and the Director of Nursing (DON) verified the employee performance review was not completed as required. 2. Review of the employee file for CNA #182 revealed no evidence of annual training for the memory care unit and 12 hours of annual in-services. Interview on 01/22/25 at 5:42 P.M. with the DON confirmed she was not able to provide evidence of CNA #182's annual training for the memory care unit or 12 hours of annual in-services.

CONCERN (F)

Potential for Harm - no one hurt, but risky conditions existed

Room Equipment (Tag F0908)

Could have caused harm · This affected most or all residents

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Based on observation and interview the facility failed to ensure the oven was in safe operational condition and failed to ensure the facility had adequate supply of plates and cups. This had the potential to affect all 85 residents residing in the facility. Findings included: 1. Observation of 400 hall lunch dining on 01/13/25 12:03 P.M., revealed disposable plates were used for the grilled cheese and desserts. Interview on 01/13/25 at 12:03 A.M. with Certified Nurse's Aide (CNA) #183 confirmed some lunch items were served on disposable plates. The CNA was unsure why the kitchen was using them unless the dishwasher was down. Interview on 01/14/25 at 10:27 A.M., with [NAME] #144 and the Dietary Manger (DM) #128 confirmed the facility had to use disposable plates yesterday for lunch due to the kitchen was short about 80 small plates. The DM reported he had put several requests in for more small plates but was denied. 2. Observation of lunch tray line on 01/14/25 at 11:15 A.M., revealed the mashed potatoes temperature measured 109 degrees Fahrenheit (F) when removed from the oven. [NAME] #144 placed the mashed potatoes back in the oven. At 11:22 A.M. [NAME] #144 removed the mashed potatoes to check the temperature and the potatoes remained at 109 degrees Fahrenheit. The [NAME] reported the oven was newer however there has been issues with the pilot light not staying lit. The [NAME] reported she must frequently remove the front panel and relight the pilot light with a lighter. The [NAME] reported you never know when the pilot light is going to go out. There was no warning. Last week she was cooking bacon, and the bacon was not getting done and she kept adding time and after 10 minutes she realized the pilot light had went out. The facility has not called anyone to come and look at the oven. Interview on 01/14/25 at 11:22 A.M., with the DM #128 confirmed he was aware of the issues with the pilot light; however, the facility had switched contract company, and he didn't have a number to contact the new contractor. 3. Observation on 01/14/25 at 12:11 P.M., of 500 lunch dining revealed the staff ran out plastic cups for drinks. Certified Nursing Assistants (CNA) #160 and #169 confirmed they had to stop serving lunch trays while another staff member went to find cups. The CNA's reported they frequently run out of plastic cups and coffee cups during dining. Interview on 01/14/25 at 12:46 P.M. with [NAME] #144 and Dietary Assistants #121 and #181 confirmed the kitchen was short on coffee cups and plastic drinking cups. The Dietary Aides reported they can usually get coffee cups back out quickly; however, the plastic cups have been an issue, and they have been replacing them with disposable cups. Interview on 01/14/25 at 12:40 P.M., with DM #128 revealed he had just ordered plates and had the maintenance director reach out to the contracting company to service the oven. He would have to order cups and he would do that now.

CONCERN (F)

Potential for Harm - no one hurt, but risky conditions existed

Deficiency F0947 (Tag F0947)

Could have caused harm · This affected most or all residents

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Based on employee record review and staff interview, the facility failed to ensure Certified Nursing Assistants (CNA) were provided 12 hours of continuing education per year. This had the potential to affect all 85 residents residing in the facility. Findings Include: 1. Review of the employee file for CNA #106 revealed a hire date of 06/10/22. Further review of the employee file revealed no evidence of 12 hours of continuing education per year. 2. Review of the employee file for CNA #119 revealed a hire date of 08/28/19. Further review of the employee file revealed no evidence of 12 hours of continuing education per year. 3. Review of the employee file for CNA #208 revealed a hire date of 02/08/21. Further review of the employee file revealed no evidence of 12 hours of continuing education per year. On 01/22/25 at 5:45 P.M., interview with Human Resource (HR) #187 and the Director of Nursing (DON) verified the employees had not completed the 12 hours of continuing education per year.

Nov 2024 4 deficiencies

CONCERN (D) 📢 Someone Reported This

A family member, employee, or ombudsman was alarmed enough to file a formal complaint

Potential for Harm - no one hurt, but risky conditions existed

Quality of Care (Tag F0684)

Could have caused harm · This affected 1 resident

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**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on record review, resident interview, staff interview, and policy interview, the facility failed to ensure a resident received appropriate wound care to a surgical site and to a non-pressure ulcer on his right foot. They also failed to ensure wounds were assessed upon admission and weekly thereafter to monitor for healing. This affected one (#56) of three residents reviewed for wounds/ dressing changes. Findings include: Review of Resident #56's medical record revealed he was admitted to the facility on [DATE]. His diagnoses included status post transmetatarsal amputation of the right foot on 11/06/24, osteomyelitis of the right foot and ankle, partial traumatic amputation of two or more right lesser toes, diabetes mellitus, peripheral vascular disease, and a chronic, non-pressure ulcer of the right heel. Review of Resident #56's hospital records revealed they included a Discharge summary dated [DATE]. The discharge summary from the hospital revealed the resident's care was being handed off to a primary care physician (PCP) and the PCP was to address the following: resident status post partial amputation of the right foot. The resident was discharged on oral antibiotics and he was to follow up with podiatry after discharge. Discharge medications were listed to include Augmentin 500-125 milligrams (mg) one tablet by mouth every 12 hours for seven days. The discharge summary also included the need for a future appointment on 11/14/24, with the podiatrist that did his surgery and performed the transmetatarsal amputation of the right foot. There was not any treatment orders included with the discharge summary for the resident's surgical site or the chronic, non-pressure ulcer on his right heel. Further review of Resident #56's hospital records revealed 85 pages had been scanned and uploaded into the resident's electronic medical record (EMR) under documents and included an Emergency Department (ED) to Hospital admission report dated 11/01/24. The ED to Hospital admission report included updates on the resident's medications and treatment orders. The report indicated a treatment order was received on 11/06/24 at 5:28 P.M. by the podiatrist that specified wound care the resident was to receive to the surgical site and non-pressure ulcer on his right heel. They were directed to cleanse the wounds with normal saline, apply medi-honey and cover with 2x2 gauze with the right heel then on the right do the same, but just add a small portion of Dermagran cut to fit with that to keep the area moist and cover with 2x2 gauze to the right heel keeping the forefront dressing intact. The treatment ordered was to start on 11/07/24. Review of Resident #56's admission orders provided by the Director of Nursing (DON) revealed she provided four of five pages that she said was the resident's admission orders in place at the time of his admission. Page 1 of 5 was not provided. What was provided was a list of the resident's medications, problem list, allergies and intolerances, vital signs, advanced directives, insurance information, immunizations, procedures, results of blood sugars obtained between 11/09/24 through 11/20/24, goals, and social history. They were not orders present upon his admission. There were no treatment orders for wound care of the resident's surgical wound or the non-pressure ulcer to the right heel. Review of Resident #56's care plans revealed he had care plans in place for having an ulcer related to diabetes on his right heel. The care plan was initiated on 11/11/24. Interventions included to treat the ulcer per the physician's orders. That approach started on 11/11/24. He also had a care plan for a surgical incision to his right foot. That care plan originated on 11/11/24. Interventions included treatment to surgical site as ordered by the physician. That approach started on 11/11/24. Review of Resident #56's physician's orders revealed treatment orders were not put in place for wound care to the resident's right foot (surgical site and right heel ulcer) until 11/10/24 (two days after his admission). The initial treatment put in place was to cleanse with normal saline, apply Xeroform to distal incision line and medi-honey to heel wound, cover with a dry clean dressing and kerlix, apply light compression with ace wrap as the resident allowed changing daily and prn. A subsequent order was received on 11/14/24 for the right foot incision to be cleansed with wound wash, dry, paint with Betadine along the incision line, cover with 4x4 and ABD, wrapping with kerlix once daily. Review of Resident #56's treatment administration record (TAR) for November 2024 revealed there was no documented evidence of any treatments being provided to the resident's surgical incision on his right foot or to the chronic ulcer on his right heel until 11/10/24. The first treatment performed on 11/10/24 during the 7:00 A.M. to 7:00 P.M. shift was completed by Registered Nurse (RN) #100. Review of Resident #56's nurses' progress notes revealed a nurse's progress note dated 11/09/24 at 1:04 P.M. by RN #100 that indicated she provided incision care to the resident per orders. The nurse's note did not mention any treatment being performed to the resident's chronic, non-pressure ulcer to the right heel. Further review of Resident #56's nurses' progress notes revealed the resident was out of the facility for a physician's appointment. Wound care was indicated to have been provided at the physician's appointment. Review of a physician visit report dated 11/14/24, for Resident #56's visit to the podiatrist that performed his surgery, revealed the resident presented that day for a follow up from his surgery. The resident voiced frustration with the process at the nursing home facility as the resident indicated they had only changed his dressing once. The podiatrist indicated he was going to write orders for once a day dressing changes because not only did he have the transmetatarsal incision, he also had a heel ulcer. Sutures were found to be in place and mild edema was present when the podiatrist examined the resident's right foot. The plan was to continue with the post-op course. Instructions provided for the nursing home was for daily dressing changes to be performed by removing the dressing, painting the incision line with Betadine, then cover with a 4x4 and ABD. As for the posterior right heel, he wanted to add honey to a 4x4, then ABD and wrap with kerlix over the entire dressing. Duricef (antibiotic) 500 mg by mouth was ordered twice a day for seven days. Further review of Resident #56's EMR revealed it was absent for any evidence of wound assessments being completed for the surgical incision of the right foot, after his toes had been removed, and to the right heel, where he was known to have a chronic, non-pressure ulcer. The admission observation assessment indicated wounds were present upon admission but referred to a wound event report. The events under the EMR revealed their had not been any wound events created for the resident, after his admission to the facility on [DATE]. The wound management tab under the EMR was also absent for any evidence of a wound assessment having been completed for any areas the resident was known to have since his admission into the facility. On 11/18/24 at 10:45 A.M., an interview with Resident #56 revealed he did not have any concerns with his wound care, since this past Thursday. He stated, prior to that, wound care was not being provided to his surgical site or the ulcer on his right heel for the first few days he was there. He denied he got his dressing to his right foot changed when he first came and it was supposed to be done daily. He indicated it was not until he went out for his follow up appointment with the podiatrist that did his surgery that he was sent back with a note from the podiatrist instructing the staff that they needed to change his dressing daily. He credited his daughter with ensuring the treatment was getting done, after his follow up appointment, as she had stayed on top of the nurses to ensure it was being done. On 11/20/24 at 2:45 P.M., an interview with RN #100 revealed she was not present when Resident #56 was admitted to the facility on [DATE] (Friday). She did work the Saturday and Sunday, after his admission. She confirmed she did perform incision care to the resident's right foot on Saturday 11/09/24, as she indicated in her progress note. She reported the resident asked to have his dressing changed so she cleaned it with normal saline and put a dry clean dressing (DCD) on it. She claimed that she cleaned the right heel too and covered that with a dressing as well. She acknowledged the resident did not have any treatment orders in place at the time of his admission and the treatment that she performed was not consistent with the treatment the podiatrist ordered on 11/06/24, after the resident's surgical amputation and debridement of his right heel. She denied she had contacted a physician for wound care orders, when the resident requested to have his dressing changed on 11/09/24. She stated she knew the nurse practitioner was going to be assessing his wound on Monday (11/11/24) and would likely give treatment orders then. She claimed to have performed the same treatment to the resident's wounds on Sunday (11/10/24), as well. On 11/20/24 at 3:05 P.M., an interview with the director of nursing (DON) revealed she did not have any documented evidence to support Resident #56's surgical wound on his right foot and the chronic, non-pressure ulcer to the right heel had been assessed upon his admission or with subsequent weekly wound assessments. She stated any wound assessments that had been done would have been documented on a wound event or under wound management in the EMR. If an assessment would have been done, it should have shown up under one of the two areas of the EMR. She acknowledged the resident did not have any treatment orders in place to care for his surgical incision or heel ulcer until 11/10/24 (two days after his admission). She further acknowledged the treatment that was indicated to have been provided to the resident on 11/09/24 was not the treatment that the podiatrist ordered for the resident following his surgery on 11/06/24. Review of the facility's policy on wound care revealed it was the policy of the facility to provide therapeutic treatment to heal wounds. Treatments implemented by a nurse required a physician's order. Wounds would be evaluated when they were observed and weekly until resolved. This deficiency represents non-compliance investigated under Master Complaint Number OH00159789

CONCERN (D) 📢 Someone Reported This

A family member, employee, or ombudsman was alarmed enough to file a formal complaint

Potential for Harm - no one hurt, but risky conditions existed

Incontinence Care (Tag F0690)

Could have caused harm · This affected 1 resident

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**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on record review, review of an Omnicell (medication dispensing system) Inventory list, and staff interview, the facility failed to ensure a resident identified as having a urinary tract infection received antibiotic therapy timely, after it was ordered. This affected one (#91) of three residents reviewed for urinary tract infections. Findings include: Review of Resident #91's medical record revealed the resident was admitted to the facility on [DATE]. She remained in the facility until her discharge from the facility to home on [DATE]. Her diagnoses included a malignant neoplasm of the anus, hemiplegia and hemiparesis following a stroke affecting her right dominant side, aphasia, and dysphagia. Review of Resident #91's nurses' progress notes revealed a nurse's note dated 10/13/24 at 9:46 A.M. that indicated the resident's indwelling urinary catheter was noted to be leaking. The nurse attempted to irrigate the indwelling urinary catheter without any results. The indwelling urinary catheter was changed with return of cloudy yellow urine noted. Further review of Resident #91's nurses' progress notes revealed a nurse's note dated 10/17/24 at 1:04 P.M. that indicated the hospice nurse visited the facility and an urinalysis culture and sensitivity result was received. The resident's nurse practitioner was notified and a new order was received for the resident to receive Bactrim DS 800/ 160 milligrams (mg) twice a day (BID) x 10 days. Review of Resident #91's urine culture result for a urinalysis collected on 10/15/24 revealed the final results on 10/17/24 showed the resident had greater than 100,000 CFU/ml of Proteus Mirabilis. The organism was sensitive to Trimethoprim/ Sulfa (Bactrim DS). Review of Resident #91's physician's orders revealed the resident had two different orders for Bactrim DS for the treatment of a UTI. The first order written was on 10/17/24 and was for the resident to receive Bactrim DS (Sulfamethoxazole-Trimethoprim) 800-160 mg one tablet by mouth (po) BID. The order was to continue through 10/28/24. That order was discontinued on 10/21/24. A second order was written on 10/21/24 and was for the resident to receive Bactrim DS 800-160 mg one tablet po BID. That order was to continue through 10/31/24. Review of Resident #91's medication administration record (MAR's) for October 2024 revealed the resident was not documented as having received the Bactrim DS, that was ordered on 10/17/24, until 10/21/24. The MAR indicated the start date was to be on 10/18/24, after the order had been given. The nurses that were to administer the Bactrim DS (beginning on 10/18/24) documented five doses were not administered to the resident. The reason stated as to why the antibiotic had not been given was that they were awaiting delivery and that the medication was unavailable. Review of the facility's Omnicell Inventory list for the Omnicell medication dispensing system they had to supply stock/ emergency medications revealed the facility's Omnicell contained SMZ-TMP (Bactrim DS) 800-160 mg tablets, as was ordered for the Resident #91 to receive beginning on 10/18/24. Ten (10) tablets of the medication was indicated to be available for use if pulled from the medication dispensing system. On 11/19/24 at 9:50 A.M., an interview with the Director of Nursing (DON) was conducted to determine why Resident #91 was not given Bactrim DS timely beginning on 10/18/24, after it was ordered on 10/17/24 for the treatment of a UTI. She acknowledged the MAR for October 2024 did not show the resident began receiving the antibiotic until 10/21/24 and the reason the antibiotic had not been given was due to them awaiting delivery and it not being available for administration. The DON stated she believed the facility's Omnicell did contain Bactrim DS as one of the medications that was available for use from that medication dispensing system. She verified the Omnicell Inventory list did show Bactrim DS 800-160 mg was one of many medications available in the system for use. She further verified the inventory list indicated there was 10 tablets maintained in the Omnicell dispensing system. She reported she would see if she could obtain a report to show what the inventory count was for Bactrim DS at the time the staff nurses were documenting they were not administering it due to it's unavailability. She returned with a Transaction by Item/ Procedure report for a date range between 10/17/24 through 11/19/24 that showed 23 tablets of SMZ-TMP 800-160 Double Strength (DS) tablets were on hand on 10/18/24, when the antibiotic was supposed to be given. A dose of Bactrim DS had not been pulled from the Omnicell until 11/03/24, showing the antibiotic was readily available. On 11/19/24 at 10:15 A.M., an interview with RN #150 confirmed she was one of the nurses that signed Resident #91's October 2024 MAR to reflect a dose of her Bactrim DS was not given due to it's unavailability. She signed off the MAR on 10/21/24 for the morning dose to reflect the antibiotic was not given due to it not being available. She was asked if she attempted to pull it out of the Omnicell, since it was listed on the inventory list as one of the medications available in that system. She stated she did not recognize the medication was available as it was listed on the Omnicell Inventory sheet as SMZ-TMP and she did not recognize it as being the same as Bactrim DS. This deficiency represents non-compliance investigated under Complaint Number OH00159481.

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

Tube Feeding (Tag F0693)

Could have caused harm · This affected 1 resident

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**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on record review, resident representative interview, staff interview, and policy review, the facility failed to ensure appropriate care and treatment was provided to a resident that had a gastrostomy tube. This affected one ( #91) of one residents reviewed for gastrostomy tubes. Findings include: Review of Resident #91's medical record revealed she was admitted to the facility on [DATE]. She remained in the facility until she was discharged home on [DATE]. Her diagnoses included hemiplegia (paralysis) and hemiparesis (weakness) following a stroke, dysphagia (difficulty swallowing), aphasia (difficulty with speech), and gastrostomy status (placement of a tube into the stomach from the abdominal wall for the administration of nutritional supplements). Review of Resident #91's physician's orders revealed she had an order in place to receive Jevity 1.5 cal. 240 milliliters (ml) per feeding tube three times a day as needed (prn), if she did not eat her meals by mouth. The physician's orders did not include any treatment orders for the resident's gastrostomy tube site until 07/26/24, when an order was received to perform tube site care twice a day. There were no physician's orders pertaining to gastrostomy site care from the resident's admission date 07/16/24 through 07/25/24 (10 days after admission). Review of Resident #91's care plans revealed she had a care plan in place for requiring tube feedings related to a stroke that placed her at risk for complications. The goal was for her to not exhibit signs of complications from feeding tube or enteral feeding solution through the next review date. The interventions did not include the need to perform any care/ treatment to the resident's gastrostomy tube site. Review of Resident #91's treatment administration record (TAR's) for July 2024 revealed there was no documented evidence to show any treatments were provided to the resident's gastrostomy site until 07/26/24. The TAR did not show any treatments being completed to that site between 07/16/24 and 07/25/24. As of 07/26/24, the facility's nurses started to document tube site care was being completed twice a day by initialing the TAR to show it had been completed. Further review of Resident #91's TAR's revealed it was not until the September 2024 TAR that the nurses began documenting they were cleaning the resident's gastrostomy site with soap and water before patting it dry and covering with a split gauze once daily. That treatment was initiated beginning on 09/12/24. On 11/19/24 at 2:02 P.M., an interview with Resident #91's representative revealed he did have concerns with the resident's dressing not being changed, as it should have been. He stated there was a time when he came in and it looked like the dressing to her gastrostomy tube site had not been changed for several days. He stated it was dirty and it had a drainage line that encircled the gastrostomy tube. On 11/19/24 at 3:48 P.M., an interview with the facility's Director of Nursing (DON) revealed she could not find any documented evidence to show they were providing any type of treatment to Resident #91's gastrostomy tube site, prior to 07/26/24. She acknowledged it was not until 09/12/24 that the physician's orders included directions to wash the area with soap and water and apply a split gauze dressing daily. Prior to that and between 07/26/24 through 09/11/24, they were only documenting tube site care being provided twice a day. She agreed tube site care was not descriptive as to what care was provided and she would have hoped the nurses were washing the site with soap and water. She indicated, when the resident came into the facility under the care and services of hospice, they did not have a treatment ordered for her gastrostomy tube site. She confirmed, if no order was in place, the nurse that admitted the resident should have called hospice or the physician for treatment orders. This deficiency represents non-compliance investigated under Complaint Number OH00159481.

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

Pharmacy Services (Tag F0755)

Could have caused harm · This affected 1 resident

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**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on record review, review of controlled drug use records, staff interview, and policy review, the facility failed to ensure controlled medications administered to a resident, as indicated on the medication administration records, were also properly documented on controlled drug use record sheets for reconciliation purposes. This affected one (#91) of three residents reviewed for controlled medication use. Findings include: Review of Resident #91's medical record revealed she was admitted to the facility on [DATE]. She remained in the facility until her discharge from the facility to home on [DATE]. Her diagnoses included a malignant neoplasm of the anus, hemiplegia and hemiparesis following a stroke affecting her right dominant side, aphasia (difficulty with speech), and gastrostomy status. Review of Resident #91's physician's orders revealed the resident had the use of Morphine Sulfate (controlled narcotic pain medication) concentrate 20 milligrams (mg)/ milliliter (ml) 0.5 ml (10 mg) orally every hour as needed. The order originated on 07/16/24 and she had been under the care and services of hospice since her admission. Review of Resident #91's medication administration records (MAR's) for September and October 2024 revealed the resident was given multiple doses of her Morphine Sulfate on an as needed basis. The September 2024 MAR revealed three doses of Morphine Sulfate had been given to the resident on 09/21/24 at 11:29 A.M., 09/24/24 at 6:38 P.M., and 09/27/24 at 1:50 P.M. The October 2024 MAR revealed one dose of Morphine Sulfate had been given on 10/13/24 at 6:43 P.M. Review of Resident #91's Controlled Drug Use Record for Morphine Sulfate 20 mg/ ml revealed 29 ml of Morphine Sulfate was received on 07/16/24. Twenty-seven (27) doses were documented as having been administered to the resident between 07/26/24 and 11/06/24. The doses administered to the resident on 09/21/24 at 11:29 A.M., 09/24/24 at 6:38 P.M., 09/27/24 at 1:50 P.M., and 10/13/24 at 6:43 P.M. (as indicated on the MAR's for those two months) were not recorded on the Controlled Drug Use Record as having been given. Findings were verified by the Director of Nursing (DON). On 11/20/24 at 11:00 A.M., an interview with the facility's DON revealed she had investigated reports of Resident #91 having had six ml of her Morphine Sulfate missing from her bottle. She stated she was able to account for all the liquid Morphine, when reviewing the resident's MAR's and the Controlled Drug Use Record for her Morphine Sulfate. She confirmed she determined not all doses that were signed off on the MAR's for September and October 2024 were found on the Controlled Drug Use Record. She confirmed the four doses indicated above had not been recorded on the Controlled Drug Use Record. She also stated there was a second sheet of the Controlled Drug Use Record that could not be found that had additional doses of the Morphine Sulfate that had been given to the resident between 11/07/24 and 11/13/24, before the resident's discharge. She was not sure what happened to that sheet as it should have been turned into her at the time of the resident's discharge from the facility. She reported she received the bottle that had the remaining balance of the Morphine Sulfate but no one knew what happened to the sheet. She acknowledged all doses of the controlled medication should have been recorded on the MAR and the Controlled Drug Use Record for reconciliation purposes. Review of the facility's policy on Controlled Substances (revised April 2019) revealed it was the policy of the facility to comply with all laws, regulations, and other requirements related to handling, storage, disposal, and documentation of controlled medications. Controlled medications were to be reconciled upon receipt, administration, disposition, and at the end of each shift. Upon administration, the nurse administering the medication was responsible for recording the name of the resident receiving the medication, name, strength and dose of the medication, time of administration, method of administration, quantity of the medication remaining, and the signature of the nurse administering the medication. This deficiency represents incidental findings of non-compliance investigated under Master Complaint Number OH00159789.

Sept 2024 1 deficiency

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 F0761 (Tag F0761)

Could have caused harm · This affected multiple residents

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**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, staff interview, and policy review, the facility failed to ensure medications were properly dated when first accessed/ used. This involved three of four medication administration carts and affected a total of eight residents (#30, #32, #50, #54, #55, #63, #75, and #77). The facility's census was 87. Findings include: 1 a.) On 09/23/24 at 10:09 A.M., an observation of the 400 hall medication administration cart with Licensed Practical Nurse (LPN) #35 revealed there were three multi-use vials of Lantus (slow acting insulin) 100 units/ milliliter (ml) 10 ml vials in the top drawer of the medication administration cart for Resident #32. The vials were stored in one bag and all three vials had been opened. The label on the bag the insulin vials were stored in provided directions under a high alert. The directions indicated the insulin should be refrigerated and, once opened, it should be discarded after 28 days. There was a place on the label to indicate the date when the vial had been opened. A date was not added on the label and none of the three multi-use vials had a date written on them to show when they had been opened/ accessed. Findings were verified by LPN #35 at the time of the observation. There was also three vials of Lantus 100 units/ ml 10 ml vials in a bag for Resident #77. All three of the vials had been opened and none of the three were dated when first accessed. The label on the bag the insulin vials were being stored in included a high alert that indicated once opened it was to be discarded after 28 days. The label included a place to write the date the vial was opened, but was intended to hold only one vial. There was the numbers 7-16 written on the label, but it was not clear if that was a date one of the vials had been opened or not. If it was a date one of the vials were opened, it would have exceeded the 28 days in which it should have been discarded. Findings were verified by LPN #35 at the time of the observation. Further review of the 400 hall medication administration cart revealed there was a small box in the top of the medication cart that contained Latanoprost 0.005% ophthalmic (eye) solution for Resident #75. The plastic bottle inside the box that held the eye drops had been opened. There was no date on the bottle or the box to indicate when the medication bottle was opened. The label on the box the eye drops came in provided direction on the storage of the medication. The label revealed the opened bottle could be stored at room temperature and was to be discarded after six weeks. Without a date, it was not clear as to when the ophthalmic eye drops should be discarded. Findings were verified by LPN #35 at the time of the observation. On 09/23/24 at 10:15 A.M., an interview with LPN #35 revealed all multi- use vials and other medications that were multi-use should be dated when first accessed/ opened. She confirmed you would not know when to discard the medication, after it had been opened, in accordance with the instructions included on the medication labels. 1 b.) On 09/23/24 at 10:35 A.M., an observation of the 300 hall medication administration cart with Registered Nurse (RN) #500 present revealed there were three bottles of liquid medicine found in the medication administration cart that was not dated when opened. One bottle was a stock bottle of Maalox 12 fluid ounce (355 ml) that was in the bottom drawer of the medication cart and had been opened. There was no date on the outside of the bottle to indicate when it had been opened. There was also a bottle of Lactulose solution 10 Grams (Gms)/ 15 ml for Resident #55 that had been opened and not dated. A third bottle of [NAME]/ PSE/ DM syrup 2/30/10 for Resident #30 that was found in one of the lower pull out drawers that had been opened. It was not dated after it had been opened. Findings were verified by RN #50 at the time of the observation. On 09/23/24 at 10:39 A.M., an interview with RN #500 revealed bottles containing liquid medication should be dated when first opened. She was not able to determine when the three bottles found in the medication administration cart had been opened. 1 c.) On 09/23/24 at 10:55 A.M., an observation of the medication administration cart for the 200 hall with RN #100 present revealed there was a Lantus 100 unit/ ml flexpen that was found in the top drawer of the medication cart that belonged to Resident #63. The flexpen had been used, but was not dated to reflect when it was first used. The label on the bag the flexpen was stored in included a high alert that indicated once opened it could be stored at room temperature for 26 days. There was a place on the label for them to indicate the date it was opened but no date was added. Findings were confirmed with RN #100 at the time of the observation. She confirmed flexpens should be dated when first used, so the nurses knew when to discard them by. There was a Novolog 100 unit/ ml flexpen for Resident #54 found in the top drawer of the 200 hall medication cart that was being used. There was no date written on the flexpen or on the label on the bag the flexpen was stored in that indicated when it had first been used. The label included a high alert that directed the nurses the flexpen could be stored at room temperature for up to 28 days. There was also two Tresiba (insulin) 100 units/ ml flexpens for Resident #50 that were found in the top drawer of the medication cart. One of the flexpens was dated 09/12/24 to show when it was first used. The other flexpen was not dated and could not be determined if it had been used or not. The label on the bag it came in had a high alert that instructed the staff to refrigerate and once opened it could be stored at room temperature for up to 65 days. RN #100 confirmed Resident #50 should not have two Tresiba flexpens stored in the medication cart at the same time. She stated the flexpen that was not in use should have been stored in the refrigerator, as the label indicated, until it was put in use. She further acknowledged all multi-use flexpens should be dated when first used, so the nursing staff would know the date the flexpens should be discarded by. She confirmed none of the insulin flexpens mentioned above had a date on the flexpen or on the bag they came in to show when they were first used. Review of the facility's policy on Storage of Medications (revised 04/2007) revealed the facility should store all drugs and biologicals in a safe, secure, and orderly manner. Drugs and biologicals should be stored in the packaging, containers or other dispensing systems in which they were received. Only the issuing pharmacy was authorized to transfer medications between containers. The facility should not use discontinued, outdated, or deteriorated drugs or biologicals. This deficiency represents non-compliance investigated under Complaint Number OH00157490.

Sept 2024 2 deficiencies

CONCERN (D) 📢 Someone Reported This

A family member, employee, or ombudsman was alarmed enough to file a formal complaint

Potential for Harm - no one hurt, but risky conditions existed

Report Alleged Abuse (Tag F0609)

Could have caused harm · This affected 1 resident

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**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on record review, policy review, and interview, the facility failed to investigate an allegation of misappropriation within the required five days. This affected one resident (#20) of one resident reviewed for misappropriation. The facility census was 95. Findings include: Record review revealed Resident #20 was admitted to the facility on [DATE] with diagnoses including end stage renal disease, type II diabetes, and chronic kidney disease. Review of care plan dated 08/29/24 revealed Resident #20 did not have behaviors or a history of confusion. Review of a self-reported incident (SRI) initiated on 07/26/24 revealed Resident #20 reported his wallet was missing on 07/25/24. The room was searched, common areas searched, and an investigation was begun. Further review of the SRI revealed it was not completed until 08/07/24 which was outside of the required five-day period. Interview on 09/05/24 at 9:34 A.M. with the Administrator revealed the SRI was initiated and submitted on 07/26/24. The Administrator stated a thorough investigation was completed within the five days, but the facility did not upload the final investigation until 08/07/24. Review of a policy titled Abuse, Neglect, Exploitation and Misappropriation of Resident Property (dated 2016) revealed the investigation must be completed within five working days unless there are special circumstances causing the investigation to continue beyond five working days. This deficiency represents incidental findings of non-compliance investigated under Master Complaint Number OH00157064.

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

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Based on record review, observations and interviews, the facility failed to follow infection control protocols. This affected 18 residents (#1, #2, #3, #4, #5, #6, #7, #8, #9, #10, #11, #12, #13, #14, #15, #16, #17, and #18) of 26 residents residing on the memory care unit. The facility census was 95. Findings included: Review of the incident log revealed the facility had 33 residents with COVID-19. Review of current census revealed 19 residents still remained COVID positive with 18 of those residents residing on the memory care unit. During the initial tour on 09/03/24 between 7:46 A.M. and 7:58 A.M., revealed one room was identified on the memory care unit to have droplet precautions in place. Interview on 09/03/24 at 10:31 A.M. with Licensed Practical Nurse (LPN) #176 revealed the memory care unit has quite a few COVID positive residents. Residents who wander are encouraged to stay in their room, but they do not because they are confused so they are then encouraged to wear a mask and they are also noncompliant with that. LPN #176 stated the staff just try to keep the residents separated from each other as much as possible. LPN #176 stated when interacting with residents who have COVID, droplet precautions are in place which include gown, gloves, an N-95 mask, and a face shield. A KN-94 mask is acceptable if staff are not in a room with a COVID positive resident. During the interview, LPN #176 was observed to be wearing a KN-95 mask in common areas where several residents identified as having COVID were located. She was not wearing eye protection, gloves, or a gown. Interview on 09/03/24 at 11:15 A.M. with Director of Nursing (DON) revealed she did not have an infection control log, map, or trend tracking worksheet. The DON stated her previous Assistant DON was the infection preventionist and quit without notice over the weekend and took all the infection control information with her. The DON stated she would continue to attempt to reach previous Assistant DON but she declined to provide contact information because she was more worried about what ADON would say than about the current concerns with the survey. The DON stated she would be able to put a new infection control log together before the end of the survey. Observations were made continuously of the memory care unit on 09/03/24 from 12:25 P.M. to 12:40 P.M. Twelve (12) residents were in the common area of the facility for meals. Some residents were observed coughing or sneezing. Staff were noted to only be wearing masks but no additional personal protective equipment (PPE). There was still only one resident room door with the droplet precautions on the door indicating COVID positive residents. Staff were observed throughout this timeframe assisting residents back to their rooms in close proximity. Interview on 09/03/24 at 12:57 P.M. with State Tested Nursing Assistant (STNA) #190 revealed it was her first time working the memory care unit so she was unable to identify the residents who did or did not have COVID. During interview, STNA #190 was noted to only be utilizing one strap of her N-95 mask. Interview and observation on 09/03/24 at 3:12 P.M. with the DON on the memory care unit confirmed 18 residents were positive for COVID. Confirmed sign postings were visible on one resident door and one was found on a cart outside of another door. The DON confirmed staff should be wearing N-95 masks in high risk areas and none of the staff on memory care should be wearing a KN-95 mask. The DON confirmed staff should be wearing additional PPE given the population they work with are noncompliant with isolation and wearing masks. Review of a facility policy titled COVID-19 Prevention and Management (dated 09/27/22) revealed N-95 respirators are mandated to be worn while in droplet isolation or quarantine rooms. Disciplinary actions could be taken if staff are observed not wearing a mask, wearing a mask inappropriately, not wearing eye protection on a residential unit, not wearing all required PPE while entering an isolation room. The resident's door should be kept closed at all times, contact and droplet precautions should be maintained, if a resident must leave their room they must wear a face mask, perform hand hygiene, limit their movement in the facility and utilize social distancing. The policy did not identify how to proceed in the case of a memory care unit. This deficiency represents non-compliance investigated under Master Complaint Number OH00157064 and Complaint Number OH00157037. This deficiency is evidence of continued non-compliance from the survey dated 08/06/24.

Aug 2024 4 deficiencies

CONCERN (F) 📢 Someone Reported This

A family member, employee, or ombudsman was alarmed enough to file a formal complaint

Potential for Harm - no one hurt, but risky conditions existed

Food Safety (Tag F0812)

Could have caused harm · This affected most or all residents

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Based on observation, policy review, and staff interview, the facility failed to ensure food was properly stored in the dry food storage area to prevent spoilage/ possible contamination from insects and/ or rodents. This had the potential to affect all residents in the facility who received food from the kitchen. The facility's census was 95. Findings include: Observations of the food storage area in the facility's basement on 08/05/24 at 11:25 A.M. revealed the facility was utilizing the basement for the storage of refrigerated and frozen food items, as well as dry food. The basement was noted to have one large room that contained a box freezer, walk in refrigerators, walk in freezers, and some storage of dry food goods on shelves along the wall. The back end of the basement was noted to have a series of three rooms. One of the three rooms was a small room on the right that was being used for the storage of dry food. It was located next to the center room in the back that had some medical supplies and other random items stored in that room. There was a strong sewer odor present in the basement that was more prevalent the further back you went. The sewer odor was strongest in the central back room where sewage was noted to have leaked from a sewer pipe and was puddled on the floor. Not all of the floor was under the sewage that had been leaking out. The brownish black liquid from the sewer line was coming from the right wall towards the middle of the floor. There were a large amount of gnats or fruit flies flying around that central back room. Some of the gnats or fruit flies were observed in the dry storage room landing on boxes and other packaged food that was stored in that room. A box of Premium Parboil [NAME] was noted on one of the shelves in the dry food storage room. The box was opened and contained a blue plastic bag inside of it. The blue plastic bag that contained the grains of rice was noted to be left open and was not properly sealed to protect it from possible contamination. Findings were reviewed with Maintenance Director #100. On 08/05/24 at 11:30 A.M., an interview was conducted with Maintenance Director #100, who revealed the sewer line had been leaking for the past month and a half or so ago. He stated they had a company come and try to patch it, but it did not take care of the issue. It started to leak three to four days, after the patch was done. They had to periodically go in and clean up the floor that had the sewage leaking onto it from the drain pipe. He acknowledged the foul odor that was in the basement to include around the dry food storage area, as well as the gnats or fruit flies that were flying around the room where the leaking sewer line was and in the dry food storage room. He confirmed the box of rice in the dry food storage room was not properly sealed, after being opened, and the contents were exposed to possible insect/ rodent contamination. He removed the box from the dry food storage area and disposed of it by placing outside the basement door that led to the outside. Review of the facility's policy on Food Receiving and Storage (undated) revealed foods shall be received and stored in a manner that complied with safe food handling practices. Food services or other designated staff, would maintain a clean food storage area at all times. This deficiency represents incidental findings of non-compliance investigated under Complaint Number OH00155914.

CONCERN (F) 📢 Someone Reported This

A family member, employee, or ombudsman was alarmed enough to file a formal complaint

Potential for Harm - no one hurt, but risky conditions existed

Infection Control (Tag F0880)

Could have caused harm · This affected most or all residents

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**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, review of quotes for equipment replacement, review of a facility issued check, review of the administrator's notes, review of daily temperature log sheets, review of correspondence with the facility's chemical supplier, and staff interview, the facility failed to ensure the hot water tank that supplied the washing machines were properly maintained in a working order to provide adequate hot water to the washers or utilize appropriate bleach or bleach alternative products to properly disinfect/ sanitize linens and residents' personal clothing. This affected all residents that resided in the facility. The facility's census was 95. Findings include: Observations of the facility's laundry room on 08/05/24 at 11:15 A.M. revealed they had two washing machines that were used to process the facility and residents' laundry. The hot water tank that provided the washing machines with hot water was leaking and was currently not in use according to Maintenance Director #100 (who accompanied the surveyor during tour of the building). The leaking of water was noted to be coming out from under the hot water tank. Maintenance Director #100 indicated the bottom of the hot water tank was rusted out and would have to be replaced. He had shut the hot water tank down so it would not burn up, due to it leaking water and not being able to maintain the appropriate amount of water within the tank. He had ran a line of cold water to the washing machines so they could still be used, but did not have any hot water running to them. He stated bleach should be used when washing all items that they were laundering. The washing machines not having hot water had been an issue for about a month or so. It (hot water tank) started dripping, but then started leaking more. He claimed they were in the process of getting that hot water tank replaced. It was a special order and had been ordered with them expecting it any day now. On 08/05/24 at 1:45 P.M., an interview with Laundry Aide #115 revealed she worked in the facility's laundry room two days a week and had worked in the facility for the past 11 years. She confirmed they did not have any hot water being supplied to the washing machines in the facility's laundry room. She reported the problem with the lack of hot water in the laundry room had been going on a a few months now. She reported they had chemicals that they used in the washing machines and pointed out where they were and what they were. There were five gallon buckets of different cleaning products to include N-Surf P Laundry Detergent, N-[NAME] Laundry Brightener (bleach), Boost Plus (for stain lifting) and a fabric softener product. She indicated the only water they had going to the washing machines at that time was cold water. She was asked about the facility's process for running linens and residents' personal clothing through the washing machines. She stated she followed the Laundry Wash Formula Menu that was posted on the wall that told them what setting to enter for the type of items they were washing. She denied bleach would be used when washing the residents' personal clothing that was colored. She denied they had any bleach alternative such as an oxygen activated bleach or color safe bleach for the residents' colored personal clothing. She was not sure how they were ensuring the clothing items washed without bleach were getting properly sanitized when not using any hot water. On 08/05/24 at 1:54 P.M., further interview with Maintenance Director #100 (who was also the facility's laundry/ housekeeping supervisor) revealed the problem with the hot water tank started the first week or so of July 2024. Within a week or so of it leaking, he shut it down and was running straight cold water to the washing machines. He indicated they were supposed to be adding bleach to the washing machine with each items being laundered. The bottom of the hot water tank had rusted and needed to be replaced. They obtained a quote to get it replaced, but they had the air conditioning unit go down around the same time and that took precedent over getting the hot water tank replaced. When informed the laundry aide that was interviewed indicated bleach was not being used in the wash cycles when laundering the residents' colored personal clothes, he stated it should have been. He did not think the settings put as much bleach in as when doing linens and other whites but thought there was some bleach being added. He later acknowledged the setting being entered when laundering the residents' colored personal clothing did not have bleach going into it, as was reported by the laundry aide. Review of a quote from a local plumbing contractor dated 07/02/24 revealed the facility received an estimate for replacing the hot water heater that supplied hot water to the facility's laundry room. The total amount of the replacement was $18,200.00. Review of a check (Check #2411) from the facility to the local plumbing company revealed they had issued a check to the plumbing company for the amount of $18,200.00. The date on the check was 07/05/24. Review of the facility's administrator's notes documented on a personal note pad revealed on 07/01/24 he had spoke with a person at 11:30 A.M. regarding washer temperatures. It was recommended by the person he spoke to add additional chemicals (bleach- double as usual) to clean clothes. It was clarified by the administrator that the person mentioned in his notes regarding the recommendation for the use of double the bleach was a life safety code specialist that did a lot through the Ohio Healthcare Association. Review of a correspondence from the facility's chemical company's Director of Operations to the facility revealed he sent the letter accompanying another letter below written by [NAME] Industries Inc. (company of the washing machine products used by the facility) in 2023 regarding disinfection of textiles in the laundering process, giving information on the disinfection taking place in the washers, even when washing in cold water. The letter further indicated consistent with CDC guidelines during laundering, the pH levels were increasing and decreasing regardless of water temperature; the ambient temperatures were elevated during the drying process; there were multiple bath exchanges or changes of water during the wash; and the appropriate levels of chlorine bleach and sour were in use. Further information from the manufacturer of the laundry products the facility used revealed more information was provided by the company to their customers to address concerns about Clostridium Difficile, Covid-19, and other pathogens that were prevalent in institutional facilities. It further went on to say, the disinfection of textiles was accomplished in the laundering process by virtue of a combination of factors as previously stated above. In addition, it included the need to use appropriate levels of Chlorine bleach or color safe Hydrogen Peroxide, and a neutralizing sour (acid). If the above steps were employed to disinfect contaminated linens in all healthcare operations and were consistent with CDC recommendations, a kill level of 99.9% or better could be obtained when processing linens. Review of the facility's daily temperature log sheets for July 2024 revealed the logs included a temperature of the laundry room water temperature. The log was noted to consistently have the temperature of 146 degrees Fahrenheit (F.) recorded as being the temperature obtained, even during the time the laundry room's hot water tank was shut down and only cold water was being provided to the washing machines. On 08/05/24 at 4:12 P.M., a follow up interview was completed with Maintenance Director #100. He confirmed the water temperatures recorded on their logs for the laundry water temperature was not accurate. He stated he had left that log blank, when the facility's hot water tank that supplied the laundry room was down, and was told he had to put in a temperature that was not actually obtained. He further stated they had just received the check for the hot water tank replacement that day and the plumbing company came over and picked it up that morning. He indicated the hot water tank had been ordered (as of 08/05/24) and not previously as he indicated earlier. It was expected that the replacement hot water tank would be installed this coming Friday. This deficiency represents non-compliance investigated under Complaint Number OH00155914.

CONCERN (F) 📢 Someone Reported This

A family member, employee, or ombudsman was alarmed enough to file a formal complaint

Potential for Harm - no one hurt, but risky conditions existed

Room Equipment (Tag F0908)

Could have caused harm · This affected most or all residents

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**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, review of quotes for equipment replacement, review of a facility issued check, and staff interview, the facility failed to ensure the hot water tank that supplied the washing machines were properly maintained in a working order to provide adequate hot water to the facility's washing machines to be able to properly disinfect/ sanitize linens and the residents' personal clothing. This affected all residents that resided in the facility. The facility's census was 95. Findings include: Observations of the facility's laundry room on 08/05/24 at 11:15 A.M. revealed they had two washing machines that were used to process the facility and residents' laundry. The hot water tank that provided the washing machines with hot water was leaking and was currently not in use, according to Maintenance Director #100 (who accompanied the surveyor during tour of the building). The leaking of water was noted to be coming out from under the hot water tank. Maintenance Director #100 indicated the bottom of the hot water tank was rusted out and would have to be replaced. He had shut the hot water tank down, so it would not burn up due to it leaking water and not being able to maintain the appropriate amount of water within the tank. He had ran a line of cold water to the washing machines so they could still be used, but did not have any hot water running to them. The washing machines not having hot water had been an issue for about a month or so. He claimed they were in the process of getting that hot water tank replaced. It was a special order and had been ordered with them expecting it any day now. On 08/05/24 at 1:45 P.M., an interview with Laundry Aide #115 revealed she worked in the facility's laundry room two days a week and had worked in the facility for the past 11 years. She confirmed they did not have any hot water being supplied to the washing machines in the facility's laundry room and the problem had been going on for a few months now. She reported they had chemicals that they used in the washing machines and pointed out where they were and what they were. There were five gallon buckets of different laundry products to include N-Surf P Laundry Detergent, N-[NAME] Laundry Brightener (bleach), Boost Plus (for stain lifting) and a fabric softener product. She indicated the only water they had going to the washing machines at that time was cold water. She was asked about the facility's process for running linens and residents' personal clothing through the washing machines. She stated she followed the Laundry Wash Formula Menu that was posted on the wall that told them what setting to enter for the type of items they were washing. She denied bleach would be used when washing the residents' personal clothing that were colored. She denied they had any bleach alternative such as an oxygen activated bleach or color safe bleach for the residents' colored personal clothing. She was not sure how they were ensuring the clothing items washed without bleach were getting properly sanitized when not using any hot water. On 08/05/24 at 1:54 P.M., an interview with Maintenance Director #100 (who was also the facility's laundry/ housekeeping supervisor) revealed the problem with the hot water tank started the first week or so of July 2024. Within a week or so of it leaking, he shut it down and was running straight cold water to the washing machines. He indicated they were supposed to be adding bleach to the washing machine with each of the items being laundered. The bottom of the hot water tank had rusted and needed to be replaced. They obtained a quote to get it replaced, but they had the air conditioning unit go down around the same time and that took precedent over getting the hot water tank replaced. When informed the laundry aide that was interviewed indicated bleach was not being used in the wash cycles when laundering the residents' colored personal clothes, he stated it should have been. He did not think the settings put as much bleach in as when doing linens and other whites but thought there was some bleach being added. He later acknowledged the setting being entered when laundering the residents' colored personal clothing did not have bleach going into it, as was reported by the laundry aide. Review of a quote from a local plumbing contractor dated 07/02/24 revealed the facility received an estimate for replacing the hot water heater that supplied hot water to the facility's laundry room. The total amount of the replacement was $18,200.00. Review of a check (Check #2411) from the facility to the local plumbing company revealed they had issued a check to the plumbing company for the amount of $18,200.00. The date on the check was 07/05/24. On 08/05/24 at 4:12 P.M., a follow up interview was completed with Maintenance Director #100. He stated the facility was given the check for the hot water tank replacement that day and the plumbing company came over and picked it up earlier that morning. He indicated the hot water tank had been ordered (as of 08/05/24) and not when he had previously indicated. It was expected that the replacement hot water tank would be installed this coming Friday. This deficiency represents non-compliance investigated under Complaint Number OH00155914.

CONCERN (F) 📢 Someone Reported This

A family member, employee, or ombudsman was alarmed enough to file a formal complaint

Potential for Harm - no one hurt, but risky conditions existed

Safe Environment (Tag F0921)

Could have caused harm · This affected most or all residents

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Based on observation, review of work invoices, review of quotes for plumbing work that needed to be done, and staff interview, the facility failed to ensure the basement area utilized for food storage was maintained in a clean/ sanitary manner as a leaking sewer pipe was not timely repaired. This had the potential to affect all residents residing in the facility. The facility census was 95. Findings include: On 08/05/24 at 11:25 A.M., an observation of the facility's basement revealed they were utilizing the basement for the storage of refrigerated and frozen food items, as well as dry food goods. The basement was noted to have one large room that contained a box freezer and some storage of dry food goods on shelves along the wall. Further back was a walk in refrigerator and a walk in freezer. Towards the back of the basement there were three rooms. A small storage room at the back left corner, a larger storage room in the back center, and a dry food storage area in the back right corner. There was a strong sewage odor present in the basement that was more prevalent the further back you went in the basement. The sewage odor was strongest in the central back room where sewage was noted to have leaked from a sewer pipe and was puddled up on the floor. Not all of the floor was under the sewage that had been leaking out. The brownish-black liquid from the sewer pipe was coming from the right side wall towards and the puddle extended to the middle of the floor. There were a lot of gnats or fruit flies flying around that central back room. Some of the gnats or fruit flies were observed in the dry food storage room as well and were noted to have landed on boxes and other packaged food being stored in that room. The facility's Administrator accompanied the surveyor and Maintenance Director #100 down to the basement during the tour. He was not forth coming of any problems they had in the basement pertaining to a leaking sewer pipe. It was not until the surveyor entered that area in an effort to identify the source of the smell that it was known they had a leaking sewer pipe. On 08/05/24 at 11:30 A.M., an interview was conducted with Maintenance Director #100. He initially indicated the sewer pipe had been leaking for the past month and a half or so. He later reported the problems with the leaking sewer pipe had been an ongoing issue for the past three months. He stated they had a local plumbing company come and patch it, but the repairs did not work. It started to leak three to four days, after the patch was done. They had to periodically go in and clean the sewage off the floor that had continuously leaked from the sewer pipe. He acknowledged there was a strong, foul odor in the basement where they were storing food and where employees were around. There were a lot of gnats or fruit flies that were flying around the room where the leaking sewer pipe was and they were also in other areas of the basement that was being used to store food. Invoices and work orders were requested for review for the repairs to the sewer line that had been attempted and any quotes for future repairs they intended to make. Review of a invoice from a local plumbing company dated 07/09/24 revealed they came to the facility in response to a sewer line leaking. The balance due was $262.99. A description of the work done included Clemet and plumbing labor. Review of a quote obtained from Mr. Rooter Plumbing dated 07/25/24 revealed the facility received a quote from the plumbing company for the amount of $3,500.00. The description of the work needed was for any type of underground dig job, bursts, or liners. On 08/05/24 at 1:54 P.M., a follow up interview with Maintenance Director #100 revealed he had taken pictures of the leaking sewer pipe and had sent it to the Administrator and the facility's owner. Quotes were obtained from a local plumbing company as well as from a chain plumbing company from a nearby area. He indicated the bids were an open ended bid as they were not sure what all they would get into when they had to dig up the concrete of the basement floor that the sewer pipe ran into. The leak was approximately six inches from the floor and they would have to have a certain length of good pipe to tie into at the T piece. The quote from the national chain plumber had been obtained weeks ago and the quote from the local privately owned plumbing company was within a week after they attempted to patch the leak unsuccessfully. He denied any approvals had been made for the quotes to get the work done until that day (08/05/24). He stated they have the national chain plumbing company scheduled to come this coming 08/08/24 at 9:00 A.M. He did not feel the repair to the leaking sewer pipe was timely. He indicated they had to wait to get an approval for any work to be done and that sometimes did not always happen that fast. They have had a lot that had been in disrepair the past few months that they had been working on such as the HVAC units but had not got to taking care of the leaking sewer drain yet. This deficiency represents non-compliance investigated under Complaint Number OH00155914.

Apr 2024 1 deficiency

CONCERN (D) 📢 Someone Reported This

A family member, employee, or ombudsman was alarmed enough to file a formal complaint

Potential for Harm - no one hurt, but risky conditions existed

Laboratory Services (Tag F0770)

Could have caused harm · This affected 1 resident

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**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on medical record review and staff interview the facility failed to ensure residents received laboratory testing as ordered by the physician. This affected one (Resident #34) of three residents reviewed for laboratory services. The facility census was 91. Findings include: Review of the medical record for Resident #34 revealed an admission date of 02/22/24 with diagnoses including osteomyelitis to left foot, aftercare of surgical removal of two toes on left foot, type two diabetes mellitus, and vascular dementia. Review of the admission Minimum Data Set (MDS) assessment for Resident #34 dated 02/29/24 revealed the resident had intact cognition and required minimal assistance of one person for activities of daily living. Review of the hospital discharge instructions for Resident #34 dated 02/22/24 revealed the hospital physician wrote an order for the resident to have the following laboratory blood tests drawn once per week: complete blood count, sedimentation rate, C-reactive protein, creatinine kinase. Review of the medical record for Resident #34 revealed the facility did not initiate the order for the laboratory blood tests upon resident's admission on [DATE]. The order was implemented on 03/14/24 and there were no results of labs drawn until 03/14/24. Interview on 04/08/24 at 2:45 P.M. with the Director of Nursing (DON) confirmed the facility did not implement the orders for weekly laboratory blood draws for Resident #34 upon resident's admission on [DATE]. The facility did not implement the order for weekly labs until 03/14/24. The facility did not provide a laboratory policy as requested. This deficiency represents noncompliance investigated under Complaint Number OH00152280.

Dec 2023 32 deficiencies 3 Harm

SERIOUS (G)

Actual Harm - a resident was hurt due to facility failures

Quality of Care (Tag F0684)

A resident was harmed · This affected 1 resident

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**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** 2. Record review revealed Resident #29 admitted to the facility on [DATE] with diagnoses including dementia, atherosclerotic heart disease without angina, atrial fibrillation, psychosis not due to a substance or known condition, hyperlipidemia, ischemic cardiomyopathy, congestive heart failure, anxiety disorder, other depression episodes, mood (affective) disorder, and insomnia. Review of a nursing note from 06/12/23 at 7:05 P.M. by Nurse #235 revealed a hospice aide had notified her Resident #29 was on the floor in the common area. Resident #29 complained of right wrist pain but had no visible injuries, all assessments were within normal limits, vital signs and neuro checks were within normal limits. Review of the medication administration record (MAR) from 06/12/23 revealed Resident #29 did not receive any medication related to her complaint of pain. Review of a nursing note from 06/13/23 at 2:01 P.M. by Registered Nurse (RN) #197 revealed Resident #29 was noted to have bruising to right wrist with slight swelling, but range of motion was intact and there were no complaints of pain. RN #197 did not notify the physician or resident representative of the change in condition. Review of a nursing note from 06/14/23 at 3:59 P.M. by Nurse #235 revealed Resident #29 was noted to have a deformity to her nose with light bruising under her eyes, right wrist noted with edema, redness, and bruising status post fall on 06/12/23. Nurse #235 notified the physician and received a new order to send Resident #29 to the emergency department for evaluation; family was also made aware. Review of nursing note from 06/14/23 at 8:43 P.M. by Licensed Practical Nurse (LPN) #194 revealed Resident #29 would be returning from the emergency department with a diagnosis of right fifth digit metacarpal nondisplaced fracture and was refusing to keep her splint on. Interview on 12/06/23 at 8:52 A.M. with DON revealed an x-ray was not completed at the time Resident #29 fell and complained of pain and the physician was not notified of worsening bruising and swelling until 06/14/23 which demonstrated a delay in care and treatment for the resident. The DON verified the resident had sustained a fracture as a result of the fall. Review of the facility policy titled Change in Condition and physician notification policy dated 09/2020 revealed the facilities policy was to promptly identify, respond to, and report changes in the resident condition to the resident's physician. When a change of condition was discovered, the nurse would evaluate the resident and notify the resident's physician with pertinent information and document the findings timely. Based on observation, record review, interview and facility policy review, the facility failed to ensure timely and necessary care and services were provided to meet the total care needs of all residents. Actual Harm occurred on 09/24/23 at 10:00 P.M. when the facility failed to timely treat and seek medical intervention for Resident #44 following a fall with left hip fracture. On 09/24/23 at 10:30 P.M. Resident #44 was assessed to have an elevated blood pressure of 216/68, followed by multiple other elevated blood pressures. On 09/25/23 at 2:28 A.M. the resident exhibited groin pain and on 09/25/23 at 1:04 P.M. the resident exhibited pain not controlled by Tylenol. The facility did not notify the physician of the pain until 09/25/23 at 6:12 P.M. when an order was given for left hip and femur x-rays and Percocet (a narcotic analgesic) was ordered for pain. The x-rays were not obtained until 09/26/23 and the facility was subsequently informed Resident #44 had a hip fracture on 09/26/23 at 2:00 P.M. The resident arrived at the emergency department on 09/26/23 at 5:03 P.M., 43 hours after the fall occurred, where she rated her pain a 10 on a scale of zero to 10 and presented with signs of deformity in her left hip. Resident #44 had surgical repair of her hip on 09/27/23. Actual harm occurred on 06/12/23 when the facility failed to timely treat and seek medical intervention for Resident #29 following a fall with subsequent nondisplaced fracture of the 5th metacarpal. At the time of the fall, Resident #29 complained of wrist pain, did not receive any pain medications, and no new orders were given for evaluation. On 06/13/23, Resident #29 exhibited worsening injury to her wrist when it began to swell and bruise. The physician and Resident #29's family were not made aware and no further assessment was completed. On 06/14/23 Resident #29 continued to have bruising to her wrist along with edema, and new onset of bruising to her face. Resident #29 was then sent to the hospital for evaluation and treatment where she was diagnosed with nondisplaced fracture of 5th metacarpal. This affected three residents (#29, #44, and #188) of seven residents reviewed for quality of care and treatment. The facility census was 85. Findings included: 1. Review of Resident #44's medical record revealed she was admitted on [DATE] with diagnoses including generalized muscle weakness, unsteadiness on feet, difficulty in walking, chronic obstructive pulmonary disease (COPD), type two diabetes, and hypertensive heart disease. Review of Resident #44's significant change Minimum Data Set (MDS) 3.0 assessment, dated 10/17/23, revealed she was mildly cognitively impaired. Further review revealed she was dependent for sit to stand, chair/bed to chair transfer, toilet transfer, tub/shower transfer, and walking 10 feet. Additionally, the MDS revealed she had not had any falls since the prior assessment. Review of Resident #44's most recent documented vital signs prior to her fall, dated 09/19/23 at 1:48 P.M., revealed her blood pressure was 138/80, her pulse was 78, and her respirations were 20. Review of Resident #44's progress note, dated 09/24/23 at 10:00 P.M. revealed the State Tested Nursing Assistant (STNA) approached the nurse and reported Resident #44 was on the floor. Resident #44 was lying on the floor with her head under the foot of the bed and her legs extended towards the center of the room. There was juice spilled on the floor and her. Resident #44 denied pain other than from hitting her head on the bed. She reported the head pain was when she actively hit it and the pain had gone away. There were no injuries noted from the fall. Resident #44 reported she was trying to switch from lying at the foot of the bed to the head of the bed. Resident #44 reported, I was not walking. I just slipped. Vital signs were within normal limits per her baseline except for an elevated blood pressure. Resident #44's blood pressure was 170/70, her pulse was 68, and her respirations were 16. Neurological assessments were initiated at 10:00 P.M. and normal. The situation with the vital signs were reported to the nurse practitioner and to hospice. Both entities directed to continue to monitor the resident's blood pressure due to the elevated blood pressure could be situational and from being irritated. Review of Resident #44's documented vital signs, dated 09/24/23 at 10:30 P.M., revealed her blood pressure was 216/68 (hypertensive), her pulse was 64, and her respirations were 17. Review of Resident #44's documented vital signs, dated 09/24/23 at 10:45 P.M., revealed her blood pressure was 191/77 (hypertensive), her pulse was 68, and her respirations were 18. Review of Resident #44's fall event documentation, dated 09/24/23 at 11:14 P.M., revealed she had fallen in her room and had pain to the back of her head which she rated a one on a scale of zero to ten. Resident #44's pupils were 3 mm round and brisk to light, her speech was clear, and she was alert and oriented to person and place. There was no change noted in mental status. There was no injury noted, she had range of motion to all four extremities without pain or limitations, there was no rotation/deformity/shortening noted to her lower extremities. Her upper and lower left and right extremities were strong. Review of Resident #44's documented vital signs, dated 09/24/23 at 11:45 P.M., revealed her blood pressure was 145/93 (hypertensive), her pulse was 63, and her respirations were 18. Review of Resident #44's documented vital signs, dated 09/25/23 at 12:15 A.M., revealed her blood pressure was 163/66 (hypertensive), her pulse was 71, and her respirations were 16. Review of Resident #44's progress note, dated 09/25/23 at 12:32 A.M., revealed she voiced complaints of shoulder pain to the STNA. Resident #44 had told the STNA not to tell the nurse. Resident #44 was found lying on her left side when she fell. Resident #44 stated she had always had issues with the shoulder, but falling had just made it sore. Range of motion (ROM) of the shoulder was normal at the time of the fall. Resident #44 now showed pain when moving the shoulder but was still able to more it. Review of Resident #44's documented vital signs, dated 09/25/23 at 12:45 A.M., revealed her blood pressure was 178/68 (hypertensive), her pulse was 71, and her respirations were 16. Review of Resident #44's documented vital signs, dated 09/25/23 at 1:45 A.M., revealed her blood pressure was 178/68 (hypertensive), her pulse was 64, and her respirations were 16. Review of Resident #44's progress note, dated 09/25/23 at 2:28 A.M., revealed she continued to voice complaints about her shoulder and was now voicing complaints about groin pain. Resident #44 would grab her inner thigh when speaking of the pain. The note indicated there were no signs of hip fracture at the time as leg lengths were even. Resident #44 denied pain in the hip area when the nurse touched it. As needed Tylenol was given per physician order. Review of Resident #44's Medication Administration Record (MAR), dated 09/23, revealed on 09/25/23 at 2:28 A.M. she received Tylenol 650 milligram (mg) (no pain level document) and it was effective for her pain. Review of Resident #44's documented vital signs, dated 09/25/23 at 2:45 A.M., revealed her blood pressure was 160/63 (hypertensive), her pulse was 73, and her respirations were 16. Review of Resident #44's documented vital signs, dated 09/25/23 at 3:45 A.M., revealed her blood pressure was 154/65 (hypertensive), her pulse was 65, and her respirations were 16. Review of Resident #44's interdisciplinary department note, dated 09/25/23 at 9:15 A.M., revealed she had slipped off the edge of the bed while attempting to switch to the other end of the bed. No injury was noted. New interventions of bed in the lowest position so feed can reach the floor due to the resident being short in stature. The facility would monitor the new intervention for effectiveness and notify medical doctor if not effective. Review of Resident #44's MAR, dated 09/2023, revealed on 09/25/23 at 1:04 P.M. she received Tylenol 650 mg (no pain level documented) and it was not effective for pain. Review of Resident #44's Certified Nurse Practitioner (CNP) progress note, dated 09/25/23 at 6:08 P.M., revealed the nurses called and stated Resident #44 had rolled out of bed and hit her head. Resident #44's blood pressure was initially 170/70, then 128/70, then 216/68, then 191/77 and then 145/70. Hospice was aware of the fall. Resident #44's neurological assessments were within normal limits. Resident #44 was denying any pain, and her assessments were within normal limits. There was no pain in hips or rotation upon the nursing assessment. Review of Resident #44's CNP progress note, dated 09/25/23 at 6:12 P.M. revealed the nurses called and stated Resident #44 was now complaining of left hip/leg pain after rolling out of bed. There was no external rotation noted but the pain was new for her. The medical provider's plan of care included: left hip and femur x-ray, Percocet 5/325 mg by mouth every six hours as needed for pain, and if fracture is indicated on the x-rays, please send her to the emergency department as soon as possible. Review of Resident #44's MAR, dated 09/23, revealed no Percocet was administered for pain. Review of Resident #44's progress note, dated 09/25/23 at 9:30 P.M., revealed the portable x-ray provider telephoned and stated they would come on 09/26/23 to complete the x-ray and would call the facility when they were 20 to 30 minutes away. Review of Resident #44's progress note, dated 09/26/23 at 12:22 A.M., revealed she continued to voice complaints of pain in her left hip/leg and x-ray was ordered for this date. Review of Resident #44's physician order, dated 09/25/23, revealed an order for a left upper hip and left femur x-ray. Review of Resident #44's radiology results, dated 09/26/23 at 10:41 CDT, revealed an acute fracture of the femoral neck. Review of Resident #44's progress note, dated 09/26/23 at 2:00 P.M., revealed x-ray results received from portable x-ray provider and the medical director in the facility and aware of the results. Orders were received to send Resident #44 to the emergency department for treatment. The next of kin was contacted along with the hospice provider. Emergency Medical Services (EMS) was notified of need for transport. Review of Resident #44's emergency department report, dated 09/26/23 at 5:03 P.M., revealed she presented to the emergency department from a nursing home with a femur fracture due to a fall two days ago. Her blood pressure was 173/81, her pulse was 79, and her respirations were 28. Resident #44 rated her pain a 10 on a scale of zero to 10 and described it as intermittent, sharp, and nonradiating (stayed in one location). She reported she did not have pain when she was not moving the leg but had significant pain with movement. Resident #44's left leg was shortened and rotated (signs of a hip fracture) and deformity was noted. She was not able to perform range of motion. Review of Resident #44's hospital Discharge summary, dated [DATE], revealed she had a left hip hemiarthroplasty (surgical procedure that involves replacing half of the hip joint) surgery on 09/27/23 to correct her left femoral neck fracture. Telephone interview on 12/11/23 at 10:20 A.M. with CNP #225 revealed she was not informed Resident #44 developed pain in her shoulder on 09/25/23 at 12:32 A.M., developed groin pain on 09/25/23 at 2:28 A.M., or had the many elevated blood pressures. CNP #225 revealed she would have sent Resident #44 out to the emergency department (ED) for assessment and care if Resident #44's hospice company had approved. CNP #225 also revealed when she provided the telephone order for the left hip and femur x-ray it was to be completed stat. CNP #225 revealed she was not informed the portable x-ray was not available until 09/26/23 or she would have sent Resident #44 out the evening of 09/25/23 to the ED for assessment and care if Resident #44's hospice company had approved. Telephone interview on 12/11/23 at 1:35 P.M. with Hospice Nurse #223 revealed based on hospice documentation, they received a phone call on 09/24/23 at 10:45 P.M. that Resident #44 had fallen, but there were no injuries. She reported the next documentation was on 09/26/23 when the facility received x-ray results of a fractured hip and Resident #44 was sent to the local emergency department for care. Hospice Nurse #223 verified there was no documentation to support hospice was notified between the 09/24/23 10:45 P.M. note and the 09/26/23 fracture confirmed by radiology note. Hospice Nurse #223 verified there was no documentation of shoulder pain, groin pain, or elevated blood pressures. Hospice Nurse #223 verified hospice would not have stopped transport to local emergency department for care and services. Interview on 12/11/23 at 2:52 P.M. with the Director of Nursing (DON) verified Resident #44 did have a delay in care and services on 09/24/23 at 10:00 P.M. when she fell out of bed and presented with a blood pressure at 10:30 P.M. of 216/68 and continued to have elevated blood pressures, then continued to develop new symptoms of injury and pain not controlled by the medication ordered. She verified there was an additional delay in care and services when the portable radiology company could not complete the x-rays until 09/26/23. The DON verbalized there was a need for training with their staff regarding residents not experiencing a delay in care and services. Review of the facility policy titled Change in Condition and physician notification policy dated 09/2020 revealed the facilities policy was to promptly identify, respond to, and report changes in the resident condition to the resident's physician. When a change of condition was discovered, the nurse would evaluate the resident and notify the resident's physician with pertinent information and document the findings timely. 3. Record review revealed Resident #188 was admitted to the facility on [DATE] with diagnoses including unspecified cirrhosis of liver, ascites, unspecified protein-calorie malnutrition, essential (primary) hypertension, hypertensive heart disease without heart failure, acute kidney failure, unspecified, solitary pulmonary nodule, hypo-osmolality and hyponatremia, thrombocytopenia, unspecified. Review of Resident #188's hospital note dated 10/31/23 revealed the resident had bilateral lower extremity swelling. Review of Resident #188's current orders and medication administration records dated 11/06/23 to 12/06/23 revealed the resident was receiving Lasix (diuretic) 20 mg once daily between 7:00 A.M. to 11:00 A.M. and Spironolactone (diuretic) 20 mg once daily between 7:00 A.M. to 11:00 A.M. The resident an as needed order for Oxycodone 5 mg one every six hours for pain and which she had received 12 doses. There was no evidence non-pharmacological intervention were attempted or pain was assessed prior to administration of the Oxycodone. Review of Resident #188 base line plan of care dated 11/06/23 revealed the resident had a venous/stasis ulcer. Interventions include notifying physician of any adverse finding with skin integrity and to inspect the skin when repositioning, toileting, assisting with ADL's and notifying the nurse of any adverse findings. The resident had no pain. The resident was receiving analgesics/opioids and diuretics and to administer medication as order and notify the physician if any side effects. There was no evidence the resident had edema. Review of Resident #188's skin integrity plan of care related to decreased mobility and ascites dated 11/27/23 revealed weekly skin assessment, pressure reduction cushion to chair, and moisture barrier protectant to perineal area as needed. Review of Residents #188's care plan for high-risk medication dated 11/27/23 revealed the resident received diuretic medication related to hypertension. The intervention included to observe for cardiovascular system and fluid status to determine the effectiveness of diuretic therapy (e.g., edema, jugular vein distention, mental confusion, shortness of breath, abnormal breath sounds, abnormal heart sounds). Review of Resident #188's care plan for pain dated 11/27/23 revealed the resident had pain related to cirrhosis of the liver and decreased bed mobility. The intervention included administering medication as ordered and notifying the physician if any side effects observed or lack of effectiveness and notifying the physician of increased pain. Observe for and record for verbal and non-verbal signs of pain. Attempt non-pharmacological interventions. Observation on 12/04/23 at 3:06 P.M., of Resident #188 revealed the resident was sitting in a recliner with her feet on the floor and no compression stockings were noted. The resident had severe swelling in her bilateral lower extremities (BLE) and verbalized complaints of pain. The resident reported her current pain management program was not effective due to staff does not administer pain medication timely upon request or not at all upon request. The resident reported her pain was so bad at night it was affecting her sleep. Review of Resident #188's skilled charting notes dated 12/03/23 12/04/23, and 12/05/23 revealed the resident had no lower extremity edema. Further review of Resident #188's medical record dated 11/06/23 to 12/05/23 revealed there was only one documentation regarding lower extremity edema on 12/01/23 that indicated the resident had bilateral lower extremity edema. Observation on 12/06/23 at 7:36 A.M., with Assistant Director of Nursing (ADON) #150 and the Director of Nursing (DON) revealed the resident was sitting in the recliner and her legs were not elevated nor did she have compression stocking in-place. The resident's socks were so tight around the top of her legs that it left indentation around her legs when they were pushed down by staff. The ADON continued to remove the resident's socks and the resident had severe pitting edema in bilateral lower legs. The left leg had blister like areas forming on the lower leg. The ADON had assessed the edema by pushing down on the tops of the residents' feet and the front of the legs. The area did not return to normal, and the indentation stayed where the nurse had pushed down. The ADON reported she would classify the edema as four plus pitting edema. The resident reported again to the staff the pain was so bad at night in her legs and feet that she couldn't sleep. She confirmed she had requested pain medication and sometimes she doesn't get it all or she must wait a long time to get it. The resident reported she has a high tolerance for pain but the pain at night was rated a 10 out of 10. The DON reported she would have the physician assess the resident today. Interview on 12/06/23 10:00 A.M., with the DON confirmed staff had been charting no edema except the one progress note on 12/01/23 that indicated the resident continued to have edema and there was no documented evidence the physician was notified of the edema or pain. The DON confirmed there was no documented evidence the pain was assessed prior to administration of the Oxycodone or non-pharmacological attempted prior. The DON reported the nursing staff were new to the facility and were new graduates with not much nursing experience. The facility did not have a policy regarding edema, however staff should utilize the change of condition policy. Review of Resident #188's progress note dated 12/06/28 at 5:28 P.M. revealed the resident continued with increased edema to BLE. The left lower extremity (LLE) was noted with redness and increased warmth. The in-house physician visited and wrote new orders for an antibiotic, Keflex 250 milligrams (mg) twice daily for seven days, laboratory testing including a complete blood count (CBC) and comprehensive metabolic profile (CMP) in one week and to schedule Oxycodone 5 mg every night as the resident stated the pain was at night and requested pain medication to be given every night. Review of the facility policy titled Change in Condition and physician notification policy dated 09/2020 revealed the facilities policy was to promptly identify, respond to, and report changes in the resident condition to the resident's physician. When a change of condition was discovered, the nurse would evaluate the resident and notify the resident's physician with pertinent information and document the findings timely. Review of the facility policy titled Skin Care dated 08/2019 revealed to notify the wound nurse, physician, dietician, and resident representative upon observation of a skin change in condition or new skin area. Review of the facility policy titled Wound Care dated 12/2020 revealed wounds would be evaluated when they are observed and weekly until resolved. Wounds would be monitored for location, size (length, width, depth), undermining, tunneling, exudate, necrotic tissue, and the presence or absence of granulation tissue or epithelialization. Only pressure ulcers would be staged.

SERIOUS (G)

Actual Harm - a resident was hurt due to facility failures

Pressure Ulcer Prevention (Tag F0686)

A resident was harmed · This affected 1 resident

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**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, record review and interview the facility failed to provide comprehensive and individualized interventions to Resident #188 to prevent the deterioration of a pressure ulcer. The facility also failed to ensure pressure ulcer assessments were comprehensive and completed weekly. Actual Harm occurred on 12/06/23 when Resident #188, who was admitted with a Stage II (partial-thickness skin loss with exposed dermis) pressure ulcer to the buttocks was identified to have deterioration to the ulcer which was now assessed to be unstageable (obscured full-thickness skin and tissue loss) related to the lack of comprehensive and individuated interventions being in place and lack of ongoing monitoring and timely identification of the wound deterioration. This affected one resident (#188) of one resident reviewed for pressure ulcers. Findings include: Record review revealed Resident #188 was admitted to the facility on [DATE] with diagnoses including unspecified cirrhosis of liver, ascites, unspecified protein-calorie malnutrition, essential (primary) hypertension, hypertensive heart disease without heart failure, acute kidney failure, unspecified, solitary pulmonary nodule, hypo-osmolality and hyponatremia, thrombocytopenia, unspecified. There was no evidence the resident had diagnoses of pressure ulcers on the diagnoses list. Review of Resident #188' Braden score dated 11/06/23 revealed the resident was at risk for the development of pressure ulcers. Review of Resident #188's admission skin event note for pressure dated 11/06/23 revealed the resident had area on the right buttocks that measured 0.5 centimeters (cm) in length by 0.5 cm width. The assessment did not included a documented depth or stage of the pressure ulcer. Review of Resident #188 base line plan of care dated 11/06/23 revealed the resident had a venous/stasis ulcer. The baseline care plan did not reflect pressure ulcers or pressure ulcer risk. Interventions include notifying physician of any adverse finding with skin integrity and to inspect the skin when repositioning, toileting, assisting with activities of daily living (ADL) care and notifying the nurse of any adverse findings. Review of Resident #188's admission Minimum Data Set (MDS) dated [DATE] revealed the resident had a Stage II (partial-thickness skin loss with exposed dermis) pressure ulcer present on admission. Review of Resident #188's plan of care revealed no evidence the facility developed a comprehensive and individualized plan of care related to pressure ulcers. Review of Resident #188's wound management note revealed on 11/10/23 the resident had a pressure ulcer on right buttocks, however no staging of the pressure ulcer was completed. The first wound management note (on 11/10/23 at 2:16 P.M.) reflected the wound measured 1.4 cm in length by 1.9 cm width with 0.1 cm depth and no exudate, granulation tissue present and an order to apply zinc topically. The next wound management note was dated 11/17/23 which reflected the wound measured 0.9 cm by 1.4 cm by 0.1 cm with granulation tissue and was improving. The last wound management note dated 11/21/23 reflected the wound measured 0.9 cm by 0.9 cm by 0.1 cm and had granulation tissue and no exudate. There were no more measurements in the electronic medical record (EMR) after 11/21/23. Review of Resident #188's wound consult notes dated 11/10/23 to 12/01/23 revealed the resident had a Stage II pressure ulcer on her buttocks since admission to the facility. The area measured 1.4 cm by 1.9 cm by 0.1 cm. The wound base was shallow and composed of 100% clean tissue, no drainage, and peri wound area appeared normal. The note indicated to apply Desitin or equivalent to area every shift and as needed. On 11/17/23 the area measured 0.9 cm by 1.4 cm by 0.1 cm assessment of wound bed; continue with Desitin. On 11/21/23 the area was 0.9 cm by 0.9 cm by 0.1 cm; continue treatment and assessment no change. On 12/01/23 the area measured 0.7 cm by 0.9 cm by 0.1 cm; same assessment and treatment. Review of Resident #188's skin integrity related to decreased mobility and ascites plan of care, dated 11/27/23 revealed weekly skin assessment, pressure reduction cushion to chair, and moisture barrier protectant to perineal area as needed. Observation on 12/04/23 at 3:06 P.M. and 12/05/23 at 8:05 A.M., revealed no evidence the resident had a pressure relieving cushion under her while she was noted sitting in her recliner. Observation on 12/06/23 at 7:36 A.M., with Assistant Director of Nursing (ADON) #150 and the Director of Nursing (DON) revealed Resident #188 was sitting in a recliner with her feet on the floor. The staff members stood the resident up and there was no pressure relieving cushion under the resident. The resident had an open area on her buttocks the size of a pea. The area had yellow stingy tissue in the wound bed and the depth appeared to measure 0.3 cm. ADON #150 reported she was the facility wound nurse; however, had not taken any formal classes and she was not aware the wound had declined nor was there any documentation indicating the wound had declined. Interview on 12/06/23 at 8:37 A.M., 10:20 A.M., and 10:44 A.M., with ADON #150 and the DON revealed they had gone back and measured the resident's pressure ulcer. The area measured 0.7 cm by 0.9 cm by 0.3 cm, which was a decline from 12/01/23. The DON confirmed the resident did not have a comprehensive plan of care for the pressure ulcer nor did the resident have a pressure relieving cushion on the chair during the observation at 7:36 A.M. The ADON reported she updated the wound consultant on the measurements, and she indicated to continue to use the zinc and foam dressing. The ADON confirmed she did not update the wound consultant on the changes of the wound bed (yellow slough). The DON reported she would have the medical director look at the wound today as well due to zinc probably not being an appropriate treatment due to the wound being now unstageable. The ADON and DON confirmed the pressure ulcers assessments were not comprehensive to include the staging of the wound. There was no evidence a weekly pressure ulcer assessment was completed by the facility or wound consultant from 11/21/23 to 12/01/23. The facility staff had not documented an assessment since 11/21/23 in the medical record. The ADON reported she had just received the wound consultation notes from the consultant; however, she had not had time to enter the facility notes yet. The ADON reported she usually rounded with the wound consultant and they observed the wounds together. She doesn't enter her notes at that time and would wait until she received the wound consultants' notes. The DON reported the wound measured 0.7 cm by 0.9 cm by 0.3 cm with edges epibole thick and rounded. The wound bed was 85% pale pink granulation and 15% white/yellow slough, however the computer system only allowed staff to enter one option for the wound bed so for example she would have to enter the slough or granulation she couldn't enter both. Review of Resident #188's physician wound consult note dated 12/06/23 revealed the resident was a seen by a digital visit. The wound note indicated the resident's pressure area measured 0.7 cm by 0.9 cm by an undetermined depth (UTD). The wound base was composed of 50% granulation and the wound was unstageable. The wound would likely benefit from debridement when the physician group visited in a couple days. The plan was to protect with Alginate (dressing) until that time. The wound had a moderate amount of serous drainage and a decline in the wound status was noted. The note included, due to the resident's unavailability the electronic data was evaluated and then discussed with the nurse caring for the resident. The resident was in mild transient pain during the wound assessment, which was resolved post assessment. The treatment/dressing was chosen to help promote autolytic debridement of the wound. Interview on 12/06/23 at 2:10 P.M., with the DON reported she had sent an encrypted photo to the wound consult doctor whom oversees the nurse practitioner who comes to the facility and he reviewed the photo and he felt the wound bed was 50% granulation and 50% slough and staged the pressure ulcer as unstageable. Review of the facility undated Pressure Injury Staging Guide revealed a Stage II pressure ulcer was partial-thickness skin loss with exposed dermis. Unstageable pressure ulcers were defined as obscured full-thickness skin and tissue loss. The facility reported they didn't have a policy and procedure related to pressure ulcers.

SERIOUS (G)

Actual Harm - a resident was hurt due to facility failures

Deficiency F0744 (Tag F0744)

A resident was harmed · This affected 1 resident

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**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on record review and interview, the facility failed to develop and implement an effective and comprehensive plan to address the dementia/behavioral health care needs of Resident #47 to prevent a resident to resident altercation resulting in harm to Resident #29. Actual harm occurred on 11/23/23 when Resident #47 physically pushed Resident #29 after Resident #29 tried to take a paper away from Resident #47. As a result of the altercation, Resident #29 fell to the ground, hitting her head on a wheelchair, leaving a laceration which required three staples. This affected two residents (#47 and #29) of six residents reviewed for abuse. The facility census was 85. Findings included: Record review revealed Resident #29 admitted to the facility on [DATE] with diagnoses including dementia, atherosclerotic heart disease without angina, atrial fibrillation, psychosis not due to a substance or known condition, hyperlipidemia, ischemic cardiomyopathy, congestive heart failure, anxiety disorder, other depression episodes, mood (affective) disorder, and insomnia. Review of nursing note from 11/23/23 at 2:30 P.M. by Registered Nurse (RN) #137 revealed Resident #29 had tried to take a paper away from Resident #47, when Resident #47 shoved Resident #29 backwards. Resident #29 hit her head and back on a wheelchair and had a one inch laceration at the bottom of the back of her head. Staff had to hold pressure to the laceration until the ambulance arrived. Family was notified of the incident. Review of nursing note from 11/24/23 at 6:26 A.M. by Licensed Practical Nurse (LPN) #133 revealed Resident #29 was returning to the facility from the emergency department with three staples in the back of her head. Review of nursing notes for Resident #47 revealed there was not a note made to document the incident. Review of a Behavior Event assessment completed on 11/23/23 at 6:59 P.M. by RN #137 revealed immediate actions by the facility included redirecting Resident #47 and relocating to a quiet location. Review of Resident #47's care plan revealed no interventions in place regarding Resident #47's aggressive behaviors toward other residents. Interview on 12/11/23 at 2:44 P.M. with LPN #133 revealed Resident #47 does have some behaviors that are very territorial regarding his belongings. Interview on 12/07/23 ar 4:30 P.M. with Resident Care Associate (RCA) #163 revealed Resident #47 can be aggressive when he is writing and coloring on his papers. RCA #163 stated he has seen Resident #47 push someone and reminded him he cannot push other residents which usually calmed him down. RCA #163 stated the intervention in place to protect other residents from Resident #47 when he was agitated was to keep an eye on him. Interview on 12/11/23 at 2:44 P.M. with LPN #133 revealed Resident #47 does have some behaviors that are very territorial regarding his belongings. Interview on 12/11/23 at 5:01 P.M. with Director of Nursing (DON) revealed the intervention in place to prevent Resident #47 from having aggressive behaviors towards other residents was redirection due to a lack of the resident's cognition. Interview on 12/12/23 at 11:05 A.M. with the Director of Nursing (DON) revealed the location of 15-minute checks for Resident #47 following incident on 11/23/23 could not be located. Interview on 12/12/23 at 1:56 P.M. with State Tested Nursing Assistant (STNA) #132 revealed Resident #47 does get agitated at times, specifically when he was writing with his pen and paper and if he thought someone was stealing it, he would let them know. STNA #132 stated she was not aware of any interventions in place to prevent Resident #47 from becoming aggressive with other residents. Interview on 12/12/23 at 2:16 P.M. with STNA #148 revealed Resident #47 had behaviors regarding his pen and papers, and if he was told to move them from the table during meals, he would use the bathroom in the dining room chair. STNA #148 stated interventions in place to prevent Resident #47 from becoming aggressive with other residents included taking Resident #47 to his room to calm down.

CONCERN (D)

Potential for Harm - no one hurt, but risky conditions existed

Deficiency F0568 (Tag F0568)

Could have caused harm · This affected 1 resident

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**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on interview, resident funds documentation review, and facility policy review, the facility failed to ensure staff were not witnesses for Resident #32's and #62's account and failed to ensure money was dispersed timely upon the death of Resident #288. This affected three residents (#32, #62, and #288) of five residents reviewed for personal funds. The facility census was 85. Findings include: 1. Review of Resident #32's medical record revealed she was admitted to the facility on [DATE] with diagnoses including senile degeneration of the brain, nonexudative age-related macular degeneration, and mixed hyperlipidemia. Review of Resident #32's admission Minimum Data Set (MDS) 3.0 assessment, dated 08/10/23, revealed she was severely cognitively impaired. Review of Resident #32's Resident Fund Management Services Authorization and Agreement to Handle Resident Funds, dated 08/03/23, revealed the witness for the authorization was Business Office Manager (BOM) #179. Interview on 12/13/32 at 8:35 A.M. with BOM #179 revealed she had been the witness when Resident #32's representative authorized the facility to handle her personal funds on 08/03/23. She revealed she did not know she was not allowed to be the witness. 2. Review of Resident #62's medical record revealed he was admitted to the facility on [DATE] with diagnoses including hypertensive encephalopathy, hypertensive heart disease with heart failure, vascular dementia, and essential hypertension. He was discharged from the facility on 12/02/23. Review of Resident #62's admission MDS 3.0 assessment, dated 07/10/23, revealed he was severely cognitively impaired. Review of Resident #62's Resident Fund Management Services Authorization and Agreement to Handle Resident Funds, dated 06/29/23, revealed the witness for the authorization was BOM #179. Interview on 12/13/32 at 8:35 A.M. with BOM #179 revealed she had been the witness when Resident #62's representative authorized the facility to handle his personal funds on 06/29/23. She revealed she did not know she was not allowed to be the witness. 3. Review of Resident #288's medical record revealed she was admitted to the facility on [DATE] with diagnoses including acute respiratory disease, unspecified heart failure, gastro-esophageal reflux disease, and weakness. Further review revealed she was discharged on 03/02/23. Review of Resident #288's Resident Trust Fund Authorization, dated 02/17/21, revealed the facility managed her funds. Review of Resident #288's Resident Statement Landscape revealed her account was closed on 03/23/23 due to expiring on 03/02/23. However, the remaining funds in her account, $1,964.52, were not dispersed at they should have been. Interview on 12/13/23 at 8:36 A.M. with BOM #179 verified she did close the account but did not send the money back to the State of Ohio and she should have. She could not answer why the money was not sent back to the State of Ohio. She verified it was not acceptable to hold money which should have been returned to the State of Ohio for nine months after a resident has passed away. Review of the facility policy titled, Resident Personal Funds, undated, revealed upon discharge, eviction, or death of a resident with a personal funds deposited with the facility, the facility will convey within 30 days the resident's funds and a final account of those funds to the resident, or in the case of death, the individual or probate jurisdiction administering the resident's estate, in accordance with State law.

CONCERN (D)

Potential for Harm - no one hurt, but risky conditions existed

Deficiency F0578 (Tag F0578)

Could have caused harm · This affected 1 resident

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**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on medical record review, resident and staff interviews, and policy review the facility failed to ensure the resident's code status/advance directives were consistent in the medical record and failed to include the resident in the decision-making process related to his code status. This affected one resident (#34) of 24 residents reviewed for advanced directive. Findings include: Record review revealed Resident #34 was admitted to the facility on [DATE] with diagnoses including cerebral infarction, bipolar, anxiety, heart disease, atrial fibrillation, diabetes, seizures, knee pain, and depression. Review of Resident #34's current orders dated 12/2023 revealed on 07/05/22 the resident's code status was a do-not-resuscitate comfort care (DNRCC). The resident's original order dated 05/27/21 indicated the resident was a full code. Further review of Resident #34's medical record revealed no evidence of a signed advanced directive for DNRCC. Interview on 12/06/23 at 3:21 P.M., with the Administrator confirmed Resident #34's orders indicated the residents code status was DNRCC; however, there was no evidence an advance directive was signed. Interview on 12/07/23 at 8:11 A.M., with the Director of Nursing (DON) confirmed there was no signed consent form for the residents DNRCC advance directive that was ordered on 07/05/22; however, the facility had the physician sign a DNRCC advance directive yesterday (12/06/23). Interview on 12/07/23 at 11:09 A.M., with Resident #34, Social Service Designee (SSD) #178, and the DON revealed the resident reported he never felt so good in his life and had already survived several heart attacks and he wanted to be a full code. The resident verified no one had talked to him about changing his code status to an DNRCC yesterday. The DON confirmed the facility had the physician sign a DNRCC advance directive yesterday due to there being an order written on 07/05/22 for an DNRCC; however, the facility did not discuss with the resident his wishes on his code status. Review of the facility Advance Directives policy, dated 2016, revealed all advance directives shall be displayed prominently in the medical record. An advanced directive included Do-Not-Resuscitate.

CONCERN (D)

Potential for Harm - no one hurt, but risky conditions existed

Free from Abuse/Neglect (Tag F0600)

Could have caused harm · This affected 1 resident

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**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on record review, interview and facility policy review, the facility failed to provide adequate supervision and effective/necessary intervention for Resident #68 to prevent potential incidents of resident to resident sexual abuse toward Resident #77. This affected two residents (#68 and #77) of six residents reviewed for abuse. The facility census was 85. Findings included: Record review revealed Resident #68 admitted to the facility on [DATE] with diagnoses including metabolic encephalopathy, hypertension, hyperlipidemia, gout, vascular dementia, and insomnia. Review of nursing note dated 08/18/23 at 6:01 P.M. revealed Resident #68 was sitting in the dining room and began to make sexual statements during conversations with female residents. Staff did redirect Resident #68, but he circled back to sexual statements and was speaking of orgies with female residents. Staff were instructed to encourage Resident #68 to sit at tables with mostly male residents. Record review revealed Resident #77 admitted to the facility on [DATE] with diagnoses including Alzheimer's disease, dementia without behaviors, hypertensive heart disease without heart failure, hypertension, hyperlipidemia, polyarthritis, and vascular dementia. Review of care plan revealed no behaviors were documented. Review of a nursing note from 09/15/23 at 11:19 A.M. revealed Resident #68 was making inappropriate sexual comments to female peers while sitting in the common room, and was redirected to sit with men. Review of a provider note on 09/19/23 at 5:02 P.M. by Certified Nurse Practitioner (CNP) #225 revealed Resident #68 was evaluated after having inappropriate behaviors with female residents and getting into bed with a female resident without his pants on. Resident #68 had been speaking about sex a lot with another male residents. Review of a nursing note from 09/20/23 at 9:12 P.M. by Licensed Practical Nurse (LPN) #256 revealed another resident was found in Resident #77's bed, and residents were separated. At the time of the incident, the resident's representative was notified and declined to send Resident #77 to the hospital for further evaluation. Record review revealed the facility submitted a self-reported incident, tracking number 239417, involving an incident of sexual abuse occurring on 09/20/23 at 9:05 P.M. involving Resident #68 and Resident #77. A narrative summary of the incident and investigation revealed Resident #68 was found in Resident #77's room in her bed unclothed. Resident #77 was fully clothed and under her sheets. The residents were separated immediately and increased supervision was initiated. Notification to the physician and family occurred and head to toe assessments completed on both residents revealed no were issues noted. Resident #68 was seen by a psychiatrist on 09/21/23 with medication changes noted. The facility investigation revealed both residents remained at psychosocial baseline with no additional concerns at this time. The incident noted Resident #68 was disoriented and got into the wrong bed and was easily redirected. No sexual allegations were made throughout the investigation. Resident #77's family declined to send the resident to the hospital for further evaluation. As a result of the investigation, the facility unsubstantiated the incident of sexual abuse. Review of both Resident #68 and Resident #77's care plans revealed no comprehensive and individualized plan of care were developed following this incident related to sexual activity and/or inappropriate sexual behavior for either resident. A witness statement, dated 09/20/23 by Resident Care Assistant (RCA) #163 revealed RCA #163 had started rounds at approximately 8:30 P.M. when he noticed Resident #77 was not in her bed. RCA #163 walked into Resident #68's room and witnessed both residents in bed, with Resident #68's arm wrapped around Resident #77. Resident #68 was naked and Resident #77 was fully dressed. After being separated and taken to her room, Resident #77 was completely silent. By the time RCA #163 left the room, Resident #77 had laid down in her bed in the fetal position and was holding her stomach. RCA #163 did report this to the nurse and the resident was placed on 15-minute checks. Review of this witness statement revealed it differed from the content of the location where the residents were found in the above SRI and nursing note. The discrepancy was not explained during the investigation. Review of a provider note from 09/21/23 at 5:01 P.M. by CNP #225 revealed nursing staff notified her Resident #68 had been found in bed with a female resident naked. He had been noted to be more sexual lately with other residents. Psychiatric consult requested. Review of a provider note on 10/08/23 at 10:48 P.M. by CNP #225 revealed Resident #68 had been displaying increased behavioral issues with female residents, crawling into their beds at times naked, and believed they were his wife. Follow-up psychiatric notes for Resident #68 dated 10/19/23 revealed there had been some improvement with the sexual acting out behaviors. No frank aggression, no frank agitation, dementia does appear to be progressing. A note, dated 11/02/23 for Resident #68 revealed the resident's sexual acting out had been resolved. A note, dated 11/16/23 revealed no mention of behaviors; the resident was seen for determining (mental) capacity. Review of a provider note from 11/18/23 at 8:57 P.M. by CNP #225 revealed Resident #68 was seen and evaluated due to thinking he was going to marry a female resident. Resident #68 was having behaviors towards two female residents specifically, psych started the resident on the anti-depressant medication, Paxil in hopes to help behaviors and indicated the medication, Tagament might also be necessary. Review of nursing note from 12/03/23 at 9:21 P.M. revealed Resident #68 was in Resident #77's bed with her. Resident #68 had no shirt on and his pants were inside out, and the bedroom door was shut. During dinner, STNA staff had reported Resident #68 asked Resident #77 to go to his room with him but was redirected. Record review revealed no assessment or interventions were initiated following this incident on 12/03/23. Interview on 12/07/23 at 10:58 A.M. with STNA #132 revealed Resident #68 climbed into bed with women he thought were his wife, but was redirectable. Interview on 12/07/23 at 4:30 P.M. with RCA #163 revealed Resident #68 was usually able to be redirected from inappropriate behaviors. During the interview, RCA #163 recalled an incident (date not provided) when Resident #68 was completely nude in bed with Resident #77, but Resident #77 was clothed wearing Resident #68's shirt. RCA #163 also reported Resident #68 was once in a female residents bed sleeping and wearing a pull up, but the other resident was sitting in a chair watching him. RCA #163 reported an additional incident with Resident #68 and Resident #77 where both resident's were in Resident #77's bed but fully clothed. No additional investigations or documentation of additional incidents were provided by the facility to review as part of the annual survey process. Interview on 12/11/23 at 2:37 P.M. with STNA #198 revealed Resident #68 had behaviors with a female resident and you had to keep an eye on him, including an incident where Resident #68 was naked in bed with Resident #77 who was clothed. STNA #198 stated even on this date she received report to keep an eye on the residents. Interview on 12/11/23 at 2:44 P.M. with LPN #133 revealed Resident #68 was in a room with a female resident on the day of the interview and were separated rather quickly. Interview on 12/11/23 at 5:52 P.M. with Registered Nurse (RN) #202 confirmed Resident #68 and Resident #77 did not have care plan for sexually inappropriate behaviors in their care plans. Interview on 12/12/23 at 11:05 A.M. with Director of Nursing (DON) revealed staff were unable to locate documentation of 15 minute checks for Resident #68's incidents of being found in bed with Resident #77. Interview on 12/12/23 at 2:18 P.M. with STNA #148 revealed Resident #68 does have sexual behaviors towards two female residents, and when he goes in their rooms he always takes off all his clothes except for his underwear at times. STNA #148 stated this happens often and she stated she did not believe any of the residents had the ability to consent to this type of interaction. The STNA was not aware the residents' families had been notified of the continued interactions, since it was not a big deal the first time it happened. Review of witness statement received on 12/12/23 from LPN #158 revealed aides were walking down the hall and saw Resident #68 and #77 trying to get into the wrong bed together, they were both assisted to their own beds, and families were not notified because there was no change of condition regarding charting from 12/03/23. Interview on 12/13/23 at 12:19 P.M. with DON revealed she believed at times Resident #68 and Resident #77 could consent to intimate activities; however she stated she did not believe there was a way to assess when they were or were not. Attempts to reach Resident #77's family during the onsite investigation were unsuccessful. Review of the facility Abuse Policy defined sexual abuse as non-consensual sexual contact of any type with a resident. Incidents of resident to resident sexual abuse would be referred to the facility interdisciplinary team (IDT) for determination of appropriate interventions. Record review revealed no evidence the facility IDT team determined any appropriate interventions to prevent Resident #77 or other residents from being sexually abused by Resident #68.

CONCERN (D)

Potential for Harm - no one hurt, but risky conditions existed

Report Alleged Abuse (Tag F0609)

Could have caused harm · This affected 1 resident

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**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on record review, interview, and facility policy review the facility failed to report and/or investigate an injury of unknown origin for Resident #29. This affected one resident (#29) of one resident reviewed for reporting requirements. The facility census was 85. Findings include: Record review revealed Resident #29 admitted to the facility on [DATE] with diagnoses including dementia, atherosclerotic heart disease without angina, atrial fibrillation, psychosis not due to a substance or known condition, hyperlipidemia, ischemic cardiomyopathy, congestive heart failure, anxiety disorder, other depression episodes, mood (affective) disorder, and insomnia. Review of orders revealed Resident #29 had an order for a mat to the floor by the bed on 10/23/21. Review of nursing note from 01/12/23 at 3:36 A.M. by Licensed Practical Nurse (LPN) #194 revealed a nursing aide summoned her to Resident #29's room while resident was in bed to observe new discoloration to the right eye and redness under the left eye, with no complaints of pain. Review of nursing note from 01/12/23 at 6:13 A.M. by LPN #194 revealed when Resident #29 entered the dining room, bruising was noted to the inner corner of the right eye and redness across the bridge of the nose and under the left eye with slight swelling. Resident #29 denied pain. LPN #194 concluded the note by stating Resident #29 was frequently up at night in her room with lights off and in her closet. Review of an interdisciplinary team note on 01/13/23 at 8:26 A.M. by Registered Nurse (RN) #245 revealed bruising was consistent with accidentally bumping into an object. Interview on 12/06/23 at 8:52 A.M. with the Director of Nursing (DON) revealed she spoke with staff regarding Resident #29's bruising and thought maybe Resident #29 rolled over in her sleep and hit her face on the dresser by her bed. The DON confirmed no interviews were completed to investigate the bruising. Interview on 12/07/23 at 3:21 P.M. with the DON revealed she did not think facial bruising would be considered suspicious and the nurse had done a good investigation by stating Resident #29 had probably hit her face off something in her closet. The DON stated Resident #29 does not often exit her closet with bruising on her face, but she does rummage in her closet a lot, so it was plausible. Review of a policy titled Abuse, Neglect, Exploitation & Misappropriation of Resident Property revealed an injury of unknown source occurs when the source of the injury was not observed by any person, or the source of the injury could not be explained by the resident and the injury is suspicious because of the location, extent, or number of injuries observed. The policy further stated the facility will have procedures in place to identify events such as suspicious bruising of residents, the administrator should be notified immediately, and the facility will notify the state agency as soon as possible but no later than 24 hours from the time the incident was made known to staff. The investigation should be completed in five working days unless there are special circumstances, the resident and all witnesses should be interviewed including staff on duty when injury was discovered and prior shifts as well, and evidence of an investigation.

CONCERN (D)

Potential for Harm - no one hurt, but risky conditions existed

Deficiency F0645 (Tag F0645)

Could have caused harm · This affected 1 resident

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**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** 3. Record review revealed Resident #47 admitted to the facility on [DATE] with diagnoses including heart failure, schizoaffective disorder, schizophrenia, conduct disorder, dementia with behaviors, disorientation, obsessive compulsive disorder, intellectual disabilities, anxiety disorder, depressive disorder, hyperlipidemia, hypertension, altered mental status, and hypoxia. Record review revealed a hospital exemption was completed for Resident #47 prior to admission, but the facility did not complete a PASARR once it was determined Resident #47 would be staying in the facility longer than 30 days. Interview on 12/05/23 at 5:01 P.M. with SSD #178 confirmed a PASARR was never completed for Resident #47. Review of the undated facility policy titled, Resident Assessment - Coordination with PASARR Program revealed the facility coordinates assessments with the PASARR program under Medicaid to ensure that individuals with a mental disorder, intellectual disability, or a related condition receives care and services in the most integrated setting appropriate to their needs. Based on interview, resident record review, and facility policy review, the facility failed to ensure the Preadmission Screening and Resident Reviews (PASARRs) were completed accurately upon admission. This affected three residents (#4, #16, and #47) of nine residents reviewed for PASARR. The facility census was 85. Findings include: 1. Review of Resident #16's medical record revealed she was admitted to the facility on [DATE] with diagnoses including schizophrenia (entered 10/31/18), anxiety disorder (entered 10/31/18), and other specified depressive episodes (entered 06/20/19). Review of Resident #16's quarterly Minimum Data Set (MDS) 3.0 assessment, dated 09/05/23, revealed she was severely cognitively impaired, had active diagnoses of anxiety, depression, and schizophrenia, and had verbal and physical behavioral symptoms directed toward others one to three days of the seven day assessment reference period. Review of Resident #16's physician order, dated 06/26/23, identified she was to receive Haldol decanoate (a long acting antipsychotic medication) 50 milligram/milliliter (mg/ml) intramuscular one day a month on the 27th of the month; physician order, dated 03/31/23, identified Lorazepam Intensol concentrate (an antianxiety medication) two mg/ml amount of 0.5 ml oral every four hours as needed for anxiety, agitation and shortness of breath; and physician order, dated 12/05/23, identified she was to receive ADR Cream (Ativan, Diphenhydramine, and Reglan) topically 2 ml topically (discontinue oral schedule Ativan when cream is started) every two hours as needed for restless, anxiety, and aggressive behavior not to exceed 12 ml daily total. Review of Resident #16's most recent PASARR, dated 10/23/18, revealed under Section D: Indications of Serious Mental Illness, the box beside schizophrenia was marked with an X and the review results revealed she was not applicable for services. Interview on 12/05/23 at 8:35 A.M. with Social Services Director (SSD) #178 verified Resident #16's PASARR was not accurate upon admission. She verified anxiety disorder should have also been marked with an X. 2. A review of Resident #4's medical record revealed he was admitted to the facility on [DATE]. His diagnoses included unspecified dementia without behavioral disturbances and bipolar disorder. A review of Resident #4's PASARR Identification Screen dated 07/07/23 revealed the PASARR was completed for a Preadmission Screening (PAS) from the community. Section (E.) of the PASARR was to document all the diagnoses the resident had of any mental disorders that were listed below. The diagnoses listed below included mood disorder, but mood disorder was not marked despite the resident's diagnoses including bipolar disorder (which was a mood disorder). The PASARR result notice indicated the resident did not have any indications of a serious mental illness and/ or developmental disability based on the PASARR Identification Screen that was submitted. On 12/12/23 at 4:23 P.M., an interview with SSD #178 revealed she was the one who was responsible for PASARR's. She confirmed Resident #4's PASARR Identification Screen completed on 07/07/23 did not accurately reflect the resident's mental illness diagnoses as a mood disorder or any other mental illness diagnosis was marked on the identification screen. She acknowledged he had bipolar disorder, and the identification screen should have been marked to reflect he had a mood disorder, since bipolar disorder was a type of mood disorder. She stated she should have completed a significant change PASARR when noting the PASARR Identification Screen previously completed was not completed accurately to reflect his mental illness diagnoses.

CONCERN (D)

Potential for Harm - no one hurt, but risky conditions existed

Accident Prevention (Tag F0689)

Could have caused harm · This affected 1 resident

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**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on record review, observation, interview, and facility policy review the facility failed to ensure effective fall interventions were in place for Residents #29 and #44, and the facility failed to ensure 15-minute checks were completed for Resident #19 when he made statements of self-harm. This affected three (Residents #19, #29, and #44) of five residents reviewed for accidents and hazards. The facility census was 85. Findings include: 1. Record review revealed Resident #19 admitted to the facility on [DATE] with diagnoses including senile degeneration of the brain, pneumonia, hydronephrosis, dementia with agitation, atherosclerotic heart disease with angina, hypertension, cardiac arrhythmia, myocardial infarction, hyperlipidemia, depression, and anxiety. Review of a quarterly Minimum Data Set (MDS) assessment completed on 09/28/23 revealed Resident #19 had severely impaired cognition, mild depression, and hallucinations. Review of orders revealed Resident #19 was ordered lorazepam (anti-anxiety) 0.5 milligrams (mg) every hour as needed, Paxil (anti-depressant) 30 mg once a day, and Seroquel (antipsychotic) 25 mg at bedtime. Review of nursing note completed by Licensed Practical Nurse (LPN) #133 on 07/30/23 at 10:06 P.M. revealed Resident #19 stated he was going to kill himself and was looking for a gun. Resident #19 continued by stating he had nothing to live for. LPN #133 charted 15-minute checks would be initiated. Interview on 12/11/23 at 9:53 A.M. with Director of Nursing (DON) revealed there was no documented evidence of 15-minute checks on file. Interview on 12/11/23 at 10:21 A.M. with Social Services Director (SSD) #178 revealed if a resident makes suicidal statements, she does check in to make sure they are alright, then sends a referral to a psychiatrist. SSD #178 stated if the clinical team determines it is necessary, 15-minute checks are implemented, but there is no policy to follow in these situations. SSD #178 reported she was not made aware of Resident #19's thoughts of self-harm. Interview on 12/22/23 at 2:44 P.M. with LPN #133 revealed when Resident #19 had thoughts of self-harm it was usually after a visit from his wife. LPN #133 stated when a resident makes such statements, the facility will monitor the resident one-on-one or 15-minute checks will be started, inform the family, physician, and management. 2. Record review revealed Resident #29 admitted to the facility on [DATE] with diagnoses including dementia, atherosclerotic heart disease without angina, atrial fibrillation, psychosis not due to a substance or known condition, hyperlipidemia, ischemic cardiomyopathy, congestive heart failure, anxiety disorder, other depression episodes, mood (affective) disorder, and insomnia. Review of the physician's orders revealed Resident #29 had an order dated 10/23/21 for a mat to the floor by the bed. Review of the care plan last revised on 11/08/23 revealed the following interventions were in place for Resident #29 regarding falls: • Therapy to evaluate and treat on 05/09/23. • Staff to assist the resident with transfers as needed on 05/09/18. • Provide non-skid footwear on 05/09/23. • Keep personal items and frequently used items within reach on 05/09/18. • Keep call light within reach on 05/09/18. • Ensure the floor is free of liquids and foreign objects on 05/09/18. • Encourage the resident to assume standing position slowly on 05/09/18. • Encourage the resident to leave the door to the room open as she will allow on 04/29/19. • Please provide a clutter reduction activity monthly to be completed by Life Enrichment Assistant on 12/16/19. • Offer restroom every two to three hours while awake on 01/13/20. • Encourage the resident to leave the bathroom light on to improve visualization of room at night on 01/13/20. • Place footwear in the closet as pairs on 07/21/20. • Orthostatic blood pressure every shift for 72 hours on 07/21/20. • Staff to keep objects out of the walkway on 08/24/20. • Leave the light on above the sink at night as resident will allow on 08/26/20. • Staff to assist the resident with cleaning room as resident will allow on 09/13/20. • Staff to assist resident with dressing and undressing as resident will allow on 11/09/20. • Staff to clean up spills from the floor on 11/11/20. • Assist the resident with toileting upon arising on 03/29/21. • Encourage rest periods after meals on 08/03/21. • Staff to take the resident outside in daylight hours if weather is appropriate during periods of restlessness on 08/10/21. • Provide diversional activities during periods of restlessness on 08/10/21. • Staff to redirect the resident away from congested areas on 08/23/21. • Mat to the floor beside the bed and dresser on 10/26/21. • Encourage the resident to sit on the outer edge of the dining room on 05/09/22. • Check to ensure non-skid footwear is on resident's feet with rounds and care on 08/09/22. • Redirect the resident away from other resident's rooms on 10/25/22. • Offer rest periods after meals as resident will allow on 01/30/23. • Assist the resident with toileting upon rising, after meals, and at bedtime (HS) as the resident will allow on 03/21/23. • Non-skid strips to the floor by the bed on 06/26/23. • Encourage supervised activities after meals as the resident will allow on 08/14/23. • Assist the resident to her room after meals as she will allow on 08/31/23. • Bed in lowest position on 09/11/23. • Staff to assist the resident with picking up items from the floor on 10/24/23. • Mat to floor by bed on 10/27/23. Observations on 12/05/23 at 12:43 P.M., 12/06/23 at 4:37 P.M., and 12/07/23 at 10:46 A.M. revealed a floor mat to the right of Resident #29's bed and no non-skid strips. Interview on 12/07/23 at 10:58 A.M. with State Tested Nursing Assistant (STNA) #132 revealed fall interventions for Resident #29 included gripper socks, floor mat beside bed, and bed in low position. STNA #132 looked under the floor mat in Resident #29's room and there were no non-skid strips in place. Interview on 12/07/23 at 4:30 P.M. with Resident Care Associate (RCA) #163 revealed interventions in place for falls for Resident #29 included a floor mat and keeping an eye on her. RCA #163 did not think there were non-skid strips in Resident #29's room. Interview on 12/11/23 at 2:44 P.M. with LPN #133 revealed Resident #29 does not like to keep her gripper socks on. Interventions for falls for Resident #29 included gripper socks, staff to assist in picking items up off the floor, mat by her bed, and a low led. Interview on 12/11/23 at 5:01 P.M. with the Director of Nursing (DON) confirmed the fall interventions in place were contradictory and were not effective to prevent resident falls. Review of a policy titled Falls Policy revealed current interventions will be reviewed and new interventions implemented to reduce the risk of a fall. 3. Review of Resident #44's medical record revealed she was admitted on [DATE] with diagnoses including generalized muscle weakness, unsteadiness on feet, difficulty in walking, chronic obstructive pulmonary disease (COPD), type two diabetes, and hypertensive heart disease. Review of Resident #44's significant change MDS assessment, dated 10/17/23, revealed she was mildly cognitively impaired. Further review revealed she was dependent for sit-to-stand, chair/bed to chair transfer, toilet transfer, tub/shower transfer, and walking ten feet. Additionally, the MDS revealed she had not had any falls since the prior assessment. Review of Resident #44's plan of care, dated 11/04/23, revealed she was at risk for falling related to history of falls and weakness. Interventions included bed in lowest position (entered 09/25/23), non-skid strips to floor by bed (entered 04/19/23), and mat next to bed (entered 12/15/22). Review of Resident #44's physician order, dated 03/10/23, identified she was to a mat to the floor for safety; and physician orders, dated 04/18/23, identified Resident #44's bed was to be kept in the lowest position as the resident would allow and there were to be nonskid strips to the floor in front of the bed. Review of Resident #44's Treatment Administration Record (TAR), dated 12/01/23 to 12/05/23, revealed non-ski strip to floor, bed in low position, and mat to floor were documented as being in place. Observation on 12/04/23 at 7:24 A.M. of Resident #44 lying in bed. Her bed was not in the lowest position, there were no non-skid strips on the floor in front of her bed, and there was no mat in front of her bed. Observation on 12/05/23 at 9:53 A.M. of Resident #44 lying in bed. Her bed was not in the lowest position, there were no non-skid strips on the floor in front of her bed, and there was no mat in front of her bed. Observation on 12/05/23 at 12:44 P.M. of Resident #44 sitting in bed eating lunch, the bed was not in the lowest position, there was no mat on the floor, and no nonskid strips on the floor. Observation was made with Registered Nurse (RN) #137. She verified all three fall interventions were not in place and should have been. She also verified Resident #44's TAR had documentation that the three fall prevention interventions were in place. Review of the facility policy titled, Falls Policy, revised 10/18, revealed it was the policy of the facility to complete a resident fall risk and implantation of interventions to attempt to prevent or reduce falls/accidents and injuries related to falls.

CONCERN (D)

Potential for Harm - no one hurt, but risky conditions existed

Incontinence Care (Tag F0690)

Could have caused harm · This affected 1 resident

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**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, medical record review, policy review and interview, the facility failed to ensure a bowel protocol was followed for Resident #9, failed to ensure adequate and proper urinary catheter care was documented and orders were followed for a trial removal of a urinary catheter for Resident #186 and failed to ensure proper infection control measures were maintained during urinary catheter care to prevent Resident #13 from developing a urinary tract infection. This affected one resident (#9) of one resident reviewed for dialysis and two residents (#186 and #13) of two residents reviewed for urinary catheters. Findings included: 1. Record review revealed Resident #9 was admitted to the facility on [DATE] with diagnoses including end stage renal disease, dependent on renal dialysis, anemia, diabetes, severe protein-calorie malnutrition, dementia, mild with other behavioral disturbance, and hypertension. Review of Resident #9's quarterly Minimum Date Set (MDS) dated [DATE] revealed the resident was always continent of bowel. Review of the Resident #9's incontinence plan of care dated 01/04/23 revealed the resident experienced episodes of incontinence related to medication, decreased mobility, and end stage renal disease (ESRD). Review of Resident #9's bowel records dated 12/01/23 to 12/11/23 revealed no evidence the resident has had any bowel movements during this time period Review of Resident #9's orders and medication administration records (MAR) dated 12/2023 revealed the resident had an order for as needed Senna (stool softener) twice daily, however it was not administered. Interview on 12/11/23 at 12:43 P.M., with the Assistant Director of Nursing (ADON) #150 confirmed there was no documented evidence the resident had a bowel movement from 12/01/23 to 12/11/23. The ADON reported she would have staff implement the bowel protocol right away. Review of Resident #9's bowel records dated 12/11/23 to 12/13/23 revealed no evidence the resident had a bowel movement after staff confirmed on 12/11/23 the resident had not had a bowel movement since 11/30/23. Review of Resident #9's bowel observation note dated 12/11/23 revealed staff had opened an observation note due to the resident not having a bowel movement greater than 10 days, however the form was not completed. Review of Resident #9's orders and medication administration records (MAR) dated 12/2023 revealed the resident had an order for as needed Senna (stool softener) twice daily, however it was not administered. There was no evidence a bowel protocol was implemented or ordered. Interview on 12/13/23 at 8:04 A.M., with the Director of Nursing (DON) confirmed Resident #9 has not had a bowel movement since 11/30/23 even after it was brought to the staff attention on 12/11/23 the facility still never implemented any intervention. The DON confirmed the observation form was not completed on 12/11/23. There was no evidence the resident has had bowel movement for 13 days now. The DON reported the facility did not have a policy or procedure; however, they were orders for bowel protocol. Usually if a resident doesn't have a bowel movement after three days the facility should contact the provider and get orders for the bowel protocol or some type of intervention. 2. Record review revealed Resident #186 was admitted to the facility on [DATE] and re-admitted on [DATE] with diagnoses including acute urinary retention and metabolic encephalopathy. Review of Resident #186's hospital discharge order dated 11/24/23 revealed the resident failed a voiding trial on 11/24/23 and an indwelling urinary (Foley) catheter was replaced. Recommended voiding trial in one to two weeks. Observation on 12/04/23 at 4:37 P.M., revealed the resident had a urinary Foley catheter in place. Review of Resident #186's orders and medication/treatment administration records dated 11/24/23 to 12/12/23 revealed no evidence of trial removal of the urinary Foley catheter or documented evidence of Foley catheter care. Review of Resident #186's bladder plan of care dated 12/07/23 revealed the resident used a Foley catheter for diagnoses of urinary retention. There was no evidence the resident had a Foley catheter plan of care prior to 12/07/23. Interview on 12/12/23 at 2:04 P.M. and 3:21 P.M., with the DON confirmed there was no evidence the facility attempted to remove the Foley or documented evidence Foley catheter care was performed. The DON reported there was a set order for Foley care that should automatically show up for staff when they have a resident admitted with a urinary catheter, however there was none entered for Resident #186. The DON confirmed the resident was planning on discharging home next week so she would put in orders for the trial removal of the catheter today. Review of the facility undated policy and procedure titled Perineal Care revealed the following information should be recorded in the resident's medical record: The date and time catheter care were given, the name and title of the individual giving the catheter care, all assessment data obtained, any problems or complications, how the resident tolerated the procedure, and if the resident refused the reason why. 3. On 12/07/23 at 12:54 P.M. State Tested Nursing Assistant (STNA) #102 was observed providing urinary catheter care to Resident #13. The resident's urine was observed to be cloudy in the catheter tubing at the time of the observation. The STNA reported the resident was under hospice care and hospice supplied all the resident's catheter supplies and she was not sure who was responsible for changing the actual urinary catheter and tubing, but verified the tubing was cloudy. Resident #13 reported she thought the tubing was changed last week. During the observation, STNA #102 assisted the resident from her bed into the bathroom which contained only a toilet and laid the urinary catheter drainage bag directly on the floor. The urinary catheter drainage bag had a cover that covered the sides of the bag, but not the bottom of the bag. The STNA washed her hands and filled a water basin up in the sink with warm water and soap. She then applied gloves and pulled down the resident's pants and removed her (incontinence) brief. The STNA left the resident on the toilet and walked out to the sink and retrieved a towel and two wet wash clothes which one of the wet wash clothes she applied soap to it. The STNA started at the top of the urinary catheter tubing with the soap wet wash cloth and swiped down the catheter tubing and then changed position and repeated the procedure with the wet washcloth and towel. The STNA did not clean the resident's genitalia area. Next the STNA emptied the water from the basin in the sink and ran new water and soap to clean the resident's perineum area. She cleaned the perineum area and removed her gloves as she exited the bathroom. The STNA did not perform any type of hand hygiene and applied new gloves. The STNA went to the resident's closet and removed a brief and returned to the bathroom and placed a new brief on the resident. As the STNA was attempting to place the Foley bag thorough the resident's pant legs the drain tube came out of the holder and touched the floor. The STNA replaced the drain tube in the holder without cleaning it. The STNA exited the bathroom and removed her gloves and washed her hands. The STNA then assisted the resident to her recliner and placed the urinary drainage bag on the side of the recliner, however the bag was lying directly on the floor. The STNA applied new gloves and removed a measuring container from the bathroom. She placed a paper towel under the measuring container and removed drainage bag and held it above the container and removed the drain tube from the holder and opened the clamp. The measuring container was filled, however there was still a large amount of urine remaining in the drainage bag. She clamped the drain tube and placed it back into the holder without cleaning the drain tube. She emptied the measuring container of urine in the toilet and returned to the resident and repeated the same procedure. At no time was the drain tubing cleaned. The STNA rinsed the graduate container with water and placed it on a paper towel on the back of the toilet to dry. She removed her gloves and washed her hands. Interview on 12/07/23 at 3:11 P.M., with the Director of Nursing (DON) and STNA #102 revealed staff should clean the perineum area as part of catheter care, the drain tube should have been cleaned with alcohol wipes, and the drainage bag and drain tube should never touch the floor. Review of competency checklist for urinary catheter care and emptying a urinary drainage bad dated 06/11/19 revealed to wash hands, explained procedure, place clean supplies on beside stand or over bed table with easy reach, fill was basin 1/2 full of warm water. Put on gloves, provide privacy, place bed protector under the resident, was the residents genitalia and perineum thoroughly with soap and water, rinse, and towel dry. Pour the water down the toilet, and flush. Put on clean gloves, cover resident exposing only perineum. Use a washcloth with warm water and soap to cleanse the labia. Use one area of wash cloth for each downward stroke. Next, change the position of the washcloth and cleanse around the urethral meatus with a clean washcloth rinse with warm water using the above technique. Use a clean washcloth with warm water and soap to clean the catheter from insertion site to approximately 4 inches outward. Secure the catheter utilizing a leg band. Wash and dry hands. Position resident for comfort and ensure call light in reach. Clean bedside stand, put supplies away and wash and dry hands. To empty the urinary drainage bag, place a paper towel on the floor under drainage bag. Position measuring container under the drainage bed. Remove drain tube from holder. Open the drain clamp and let the urine flow into the measuring container. After the bag has emptied clamp the drain. Wipe the drain with an alcohol wipe and discard the wipe. Replace the drain back in the holder. Pour and flush urine down the toilet and rinse the measuring container and remove gloves, wash, and dry hands. Place call light in reach. Review of STNA #102's competency checklist for urinary catheter care and emptying a urinary drain bag revealed it was last completed on 11/16/22. Review of the facility policy titled Catheter Care, Urinary dated 2021 revealed to be sure the catheter tubing and drainage bag were kept off the floor.

CONCERN (D)

Potential for Harm - no one hurt, but risky conditions existed

Deficiency F0692 (Tag F0692)

Could have caused harm · This affected 1 resident

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**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** 2. Record review revealed Resident #68 admitted to the facility on [DATE] with diagnoses including metabolic encephalopathy, periapical abscess without sinus, alcohol abuse, hypertension, hyperlipidemia, other pancytopenia, gout, gastro-esophageal reflux disease, vascular dementia, and insomnia. Review of the nutrition note from 11/02/23 at 11:26 A.M. by RD #220 revealed Resident #68 had a moderate weight loss in 30 days and had a body mass index (BMI) of 21.9 which was slightly low for his age. RD #220 recommended Resident #68 receive fortified foods with meals to provide additional energy source to promote weight gain to reach ideal BMI of 22-29. Review of the care plan last revised on 11/07/23 revealed a dietary plan of care that stated it was recommended for Resident #68 to receive fortified foods with meals due to moderate weight loss over 30 days. Review of the physician's orders revealed Resident #68 received a new order on 11/03/23 for a Mighty Shake supplement three times a day with meals. Observation on 12/07/23 at 11:45 A.M. revealed Resident #68 did not have a supplement with his meal, and his meal ticket did not mention fortified foods. STNA #132 confirmed fortified foods were not listed on Resident #68's ticket at the time of the observation. [NAME] #155 was also present at this time and revealed there were no fortified foods sent out to the unit, and there were also no supplements in the refrigerator on the unit. Interview on 12/11/23 at 12:31 P.M. with RD #220 revealed she is a consultant at multiple buildings and gets them mixed up at times. This facility did not currently offer fortified foods, so her recommendation was made in error. RD #220 stated if the facility did offer fortified foods, that would have been her recommendation. The only supplement the facility was able to offer was Mighty Shakes. RD #220 revealed the facility did not call to inform her fortified foods were unavailable, so she was unable to revise her recommendation. Interview on 12/07/23 at 4:50 P.M. with RD #220 revealed she was unaware Resident #68 was not receiving fortified foods per her recommendation. RD #220 stated typically it is preferred for a resident to receive supplements via food first to promote quality of life and giving actual foods and typically if fortified foods don't work, the facility would then move on to supplement shakes, then an appetite stimulant. Based on medical record review, observation, and interviews the facility failed to ensure residents received nutritional supplements as ordered. This affected one resident (#9) of one resident reviewed for dialysis and one resident (#68) of two residents reviewed for nutrition. Findings include: 1. Record review revealed Resident #9 was admitted to the facility on [DATE] with diagnoses including end stage renal disease, anemia in chronic kidney disease, dependence on renal dialysis, type one diabetes mellitus with unspecified complications, unspecified sequelae of cerebral infarction, dysphagia following cerebral infarction, unspecified severe protein-calorie malnutrition, vitamin D deficiency, unspecified dementia, mild, with other behavioral disturbance, hypertension, atherosclerotic heart disease of native coronary artery without angina pectoris, and chronic bronchitis. Review of Resident #9's current orders dated 12/2023 revealed Ensure Clear twice daily and to start Mighty Shake at bedtime when available. Review of Resident #9's medication/treatment administration records dated 12/01/23 to 12/11/23 revealed on 12/05/24, 12/06/23, 12/10/23 staff charted none for the Mighty Shake; however, did not indicate what none meant. On 12/03/23 and 12/07/23 the resident refused the Mighty Shake, and the other days she took 1-100 percent. The Ensure Clear was to be administered twice daily from 7:00 A.M. to 11:00 A.M. and 7:00 P.M. to 11:00 P.M. The resident was not available for one dose on 12/01/23 and refused on 12/03/23 and 12/07/23, staff charted, none on both doses on 12/06/23 and 12/10/23 and one dose on 12/07/23. The other days and doses the residents' intakes varied from 1-100 percent. Interview on 12/11/23 at 12:38 P.M., with the facilities contracted Registered Dietitian (RD) #220 revealed the facility had no Ensure Clear available for months. The RD reported she had to change the order to Mighty Shakes a few months ago because it was the only supplement the facility was going to provide to residents. The resident was ordered Ensure Clear originally because she had poor intake and diarrhea with the previous supplement she was on. The RD reported she did not realize staff were still documenting the resident was receiving the Ensure Clear because she doesn't look at the administration records/orders. The RD reported she obtained her information from under the supplement tab, and it doesn't indicate the name of the supplement just the percent of intakes. The RD confirmed she had not communicated with the Dialysis Center RD since April 2023 and was not aware if there were any new recommendations or not. Interview on 12/11/23 at 3:21 P.M., with the Dialysis Center RD #221 confirmed communication with the facility regarding Resident #9's care had been difficult. The facilities dietitian had not returned calls, responded to emails, or been available when she had tried to call the facility. The floor staff sometimes don't understand, and it would be beneficial to talk to the dietitian. She had to call the other day and speak to the floor staff to verify what supplements the resident was taking, and she was told the resident was taking two Ensure Clears daily and one Mighty Shake at night. RD #221 reported the facilities RD (RD #220) had just called her to obtain the last three notes for the surveyor and reported she had not been able to open the emails because they were sent encrypted. Review of Resident #9's bowel records dated 10/01/23 to 12/13/23 revealed staff were not recording the consistency of the bowel movement (BM) except on 11/30/23 it indicated the resident had loose BM. Observation on 12/12/23 at 10:40 A.M. of the supplements in the main kitchen with the Dietary Manger (DM) #175 revealed there was no evidence of any type of nutritional supplement including Ensure Clear or Mighty Shakes in the kitchen. The DM reported he was new, and he could not recall the last time supplements were ordered. Additional observation on 12/12/23 from 10:48 A.M. to 11:01 A.M. of the 300-, 400-, and 500-unit refrigerators revealed no evidence of nutritional supplements in the refrigerators. Interviews on 12/12/23 from 10:48 A.M. to 11:01 A.M. with State Tested Nurse's Aide (STNA) #110 revealed the facility was out of supplements and had to go out into the community to get them. Someone had bought her one six pack of Boost for her unit. Resident Care Assistant (RCA) #176 reported she worked yesterday and didn't recall seeing any nutritional supplements and confirmed there were none on her unit at this time that she had seen. Licensed Practical Nurse (LPN) #133 reported the facility staff had gone and bought Ensure for her to use today on her unit. The LPN confirmed the facility has not had Ensure Clear for two or three months. Interview on 12/12/23 at 10:51 A.M., with the Director of Nursing (DON) and Assistant Director of Nursing (ADON) #150 revealed she was not aware until this morning the facility was out of the Mighty Shakes on the 300, 400, and 500 units. The facility had a staff member go to the local store to buy some supplements. The DON reported the facility has not had Ensure Clear for two months or so and she was not aware Resident #9 had an order for the Ensure Clear, and staff were signing off Resident #9 was receiving it when it was not even available.

CONCERN (D)

Potential for Harm - no one hurt, but risky conditions existed

Tube Feeding (Tag F0693)

Could have caused harm · This affected 1 resident

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**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, interview, resident record review, and facility policy review, the facility failed to ensure Resident #39's enteral tube placement was confirmed prior to administering medications. This affected one resident (#39) of one resident reviewed for tube feeding. The facility census was 85. Findings include: Review of Resident #39's medical record revealed she was admitted to the facility on [DATE] with diagnoses including cerebral infarction (stroke) due to unspecified occlusion, malignant neoplasm of female breast, asthma, and essential hypertension. Review of Resident #39's quarterly Minimum Data Set (MDS) assessment, dated 10/31/23, revealed she was cognitively intact and had a feeding tube. Review of Resident #39's physician order, dated 07/25/23, identified her enteral tube placement was to be checked by air bolus and aspirating stomach contents before medications and tube feed bolus delivery. Observation on 12/07/23 at 8:81 A.M. of Licensed Practical Nurse (LPN) #187 preparing the morning medications for Resident #39. LPN #187 entered Resident #39's room and administered her inhalers first. LPN #187 then inserted a 60 milliliter (ml) syringe into Resident #39's enteral tube and administered 60 ml of water, followed by her crushed medications. Once all the crushed medications were administered, LPN #187 administered another 60 ml of water. At no time, did LPN #187 assess placement of Resident #39's enteral tube. Interview on 12/07/23 at 9:36 A.M. with LPN #187 verified she did not check Resident #39's enteral tube placement by auscultation or aspiration prior to administering medications and should have. Interview on 12/07/23 at 3:12 P.M. with the Director of Nursing (DON) verified enteral tubes should be assessed for placement prior to medication administration. Review of the undated facility policy titled, Care and Treatment of Feeding Tubes revealed it was the policy of the facility to utilize feeding tubes in accordance with current clinical standards of practice, with interventions to prevent complications to the extent possible. Further review revealed in accordance with facility protocol, licensed nurses will monitor and check that the feeding tube is in the right location: tube placement will be verified before beginning a feeding and before administering medications.

CONCERN (D)

Potential for Harm - no one hurt, but risky conditions existed

Respiratory Care (Tag F0695)

Could have caused harm · This affected 1 resident

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**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** 3. Record review revealed Resident #13 admitted to the facility on [DATE] with diagnoses including multiple sclerosis, neuromuscular dysfunction of the bladder, anxiety disorder, major depressive disorder, hallucinations, and osteoarthritis. Review of the physician's orders revealed Resident #13 received an order for oxygen at two to four liters per nasal cannula continuous as needed for shortness of breath or cyanosis on 03/10/23, change oxygen tubing monthly on 01/07/20, clean external concentrator filter every two weeks on 01/07/20, assess/observe for signs and symptoms of shortness of breath while lying flat on 03/10/23, and head of bed elevated to alleviate/reduce shortness of breath while lying flat on 03/10/23. Observation on 12/05/23 at 10:05 A.M. revealed Resident #13's oxygen tubing was not labeled with a date, and there was a hole in the tubing. Observation on 12/05/23 at 12:03 P.M. revealed Resident #13's oxygen tubing was not labeled with a date, and there was a hole in the tubing. Interview on 12/05/23 at 12:07 P.M. with State Tested Nursing Assistant (STNA) #206 confirmed there was a hole in the oxygen tubing, and it was not dated. Observation on 12/06/23 at 4:55 P.M. revealed Resident #13's oxygen tubing had not been changed. Administrator confirmed. Based on observation, interview, resident record review, and facility policy review, the facility failed to ensure oxygen was administered per physician's order, oxygen tubing was changed per physician's order, and tubing and nebulizer equipment was maintained in a sanitary manner. This affected three residents (#13, #44, and #58) of three residents reviewed for respiratory care. The facility census was 85. Findings include: 1. Review of Resident #44's medical record revealed she was admitted to the facility on [DATE] with diagnoses including chronic obstructive pulmonary disease (COPD), chronic respiratory failure unspecified, unspecified asthma, and emphysema. Review of Resident #44's significant change Minimum Data Set (MDS) assessment, dated 10/17/23, revealed she was cognitively impaired and received oxygen therapy. Review of Resident #44's plan of care, dated 11/04/22, revealed she had a potential for shortness of breath while lying flat related to COPD and respiratory failure. One of the interventions revealed administer oxygen per physician's order and as needed. Review of Resident #44's physician's order, dated 03/10/23, identified she was to receive continuous oxygen via a nasal cannula at two liters/minute (l/min). Review of Resident #44's Treatment Administration Record (TAR), dated 12/01/23 to 12/05/23, revealed she had received her oxygen at two l/min. Observation on 12/04/23 at 10:54 A.M. of Resident #44 lying in bed receiving oxygen via a nasal cannula at three l/min and the tubing was dated 12/02/23. Resident #44's nebulizer mask and tubing were also sitting on her nightstand. It was not in a bag for protection from germs, and there was no date documented on the nebulizer tubing. Observation on 12/05/23 at 9:15 A.M. of Resident #44 lying in bed receiving oxygen via a nasal cannula at three l/min and the tubing was dated 12/02/23. Resident #44's nebulizer mask and tubing were also sitting on her nightstand. It was not in a bag for protection from germs, and there was no date documented on the nebulizer tubing. Interview on 12/05/23 at 12:09 P.M. with Resident #44 revealed she knew she had COPD but had never been informed her oxygen should stay at two l/min. Observation on 12/05/23 at 12:15 P.M. with Registered Nurse (RN) #137 of Resident #44 sitting in bed receiving oxygen via a nasal cannula at three l/min. RN #137 verified Resident #44's oxygen was running at three l/min. Observation at the same time of Resident #44's nebulizer mask and undated tubing lying on her nightstand. An interview at the time with RN #137 verified the nebulizer mask should be stored in a clean bag and the tubing should be dated. Interview on 12/05/23 at 12:18 P.M., after reviewing Resident #44's physician's orders, RN #137 verified the oxygen was not being administered as ordered at two l/min. She also verified that since Resident #44 had COPD, the higher dose of oxygen could depress her drive to breath. After reviewing Resident #44's TAR, RN #137 revealed the documentation that she was receiving oxygen at two l/min was not accurate since she was receiving oxygen at three l/min. 2. Review of Resident #58's medical record revealed he was admitted to the facility on [DATE] with diagnoses including COPD with (acute) exacerbation, acute and chronic respiratory failure, respiratory conditions due to other specified external agents, and unspecified chronic bronchitis. Review of Resident #58's quarterly MDS 3.0 assessment, dated 10/20/23, revealed he was mildly cognitively impaired and received oxygen therapy while a resident. Review of Resident #58's plan of care, dated 11/04/22, revealed he had a potential for shortness of breath while lying flat related to COPD and respiratory failure. One of the interventions revealed administer oxygen per physician's order and as needed. Review of Resident #58's physician's order, dated 05/10/23, identified he was to receive continuous oxygen via his nasal cannula at two l/min. Review of Resident #58's TAR, dated 12/01/23 to 12/05/23, revealed he had received his oxygen at two l/min, and his oxygen tubing had been changed on 12/01/23. Observation on 12/04/23 at 2:55 P.M. of Resident #58 lying in bed receiving oxygen via a nasal cannula at three l/min, and the tubing was dated 07/30/23. Resident #58's nebulizer and mouthpiece were sitting on his oxygen concentrator and not stored in a bag. The date on the nebulizer tubing was 11/10/23. Observation on 12/05/23 at 9:13 A.M. of Resident #58 lying in bed receiving oxygen via a nasal cannula at three l/min, and the tubing was dated 07/30/23. Resident #58's nebulizer and mouthpiece were sitting on his oxygen concentrator and not stored in a bag to protect it from germs. Observation on 12/05/23 at 12:20 P.M. with RN #137 of Resident #58 lying in bed receiving oxygen via a nasal cannula at 3.5 l/min. RN #137 verified Resident #58's oxygen was running at 3.5 l/min, and the date on the tubing was 07/30/23. She reported the oxygen tubing had been used for too long and should be changed monthly. Observation at the same time of Resident #58's nebulizer and mouthpiece lying on top of his oxygen concentrator. An interview at the time with RN #137 verified the nebulizer and mouthpiece should be stored in a clean bag. Interview on 12/05/23 at 12:24 P.M., after reviewing Resident #58's physician orders, RN #137 verified the oxygen was not being administered as ordered at two l/min. She also verified that since Resident #58 had COPD, the higher dose of oxygen could depress his drive to breath. After reviewing Resident #58's TAR, RN #137 revealed the documentation that he was receiving oxygen at two l/min was not accurate since he was receiving oxygen at 3.5 l/min and his oxygen tubing was not dated 12/01/23. Review of the facility policy titled, Oxygen Administration, revised 10/10, revealed the purpose of the procedure was to provide guidelines for safe oxygen administration. Further review revealed verify that there is a physician's order for this procedure. Review the physician's orders or facility protocol for oxygen administration. Additionally, the policy revealed adjust the oxygen delivery device so that it is comfortable for the resident and the proper flow of oxygen is being administered.

CONCERN (D)

Potential for Harm - no one hurt, but risky conditions existed

Deficiency F0697 (Tag F0697)

Could have caused harm · This affected 1 resident

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**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on record review, observation, interview, and facility policy review the facility failed to ensure residents had an effective pain management program. This affected two residents (#186 and #188) of three residents reviewed for pain. Findings include: 1. Record review revealed Resident #188 was admitted to the facility on [DATE] with diagnoses including unspecified cirrhosis of liver, ascites, unspecified protein-calorie malnutrition, essential (primary) hypertension, hypertensive heart disease without heart failure, acute kidney failure, unspecified, solitary pulmonary nodule, hypo-osmolality and hyponatremia, thrombocytopenia, unspecified. Review of Resident #188's current physician's orders and medication administration records (MAR) dated 11/06/23 to 12/06/23 revealed the resident was receiving Oxycodone (opioid pain medication) 5 milligrams (mg) once every six hours for pain as needed and she had received 12 doses. There was no evidence non-pharmacological interventions were attempted or pain was assessed prior to administration of the Oxycodone. Review of Resident #188 baseline plan of care dated 11/06/23 revealed the resident had no pain. The resident was receiving analgesics/opioids and diuretics and to administer the medication as ordered and notify the physician if there were any side effects. There was no evidence the resident had edema. Review of Resident #188's care plan for pain dated 11/27/23 revealed the resident had pain related to cirrhosis of the liver and decreased bed mobility. The intervention included administering medication as ordered and notifying the physician if any side effects observed or lack of effectiveness and notifying the physician of increased pain. Observe for and record for verbal and non-verbal signs of pain. Attempt non-pharmacological interventions. Observation on 12/04/23 at 3:06 P.M., of Resident #188 revealed the resident was sitting in a recliner with her feet on the floor and no compression stockings were noted. The resident had severe swelling in her bilateral lower extremities (BLE) and verbalized complaints of pain. The resident reported her current pain management program was not effective due to staff does not administer pain medication timely upon request or not at all upon request. The pain was so bad at night it was affecting her sleep. Review of Resident #188's skilled charting notes dated 11/06/23, 12/04/23, and 12/05/23 revealed the resident had no pain. Observation on 12/06/23 at 7:36 A.M., with Assistant Director of Nursing (ADON) #150 and the Director of Nursing (DON) revealed the resident was sitting in the recliner and her legs were not elevated nor did she have compression stocking in-place. The resident's socks were tight around the top of her legs that left indentation around her legs when they were pushed down by staff. The ADON continued to remove the resident's socks and the resident had severe pitting edema in bilateral lower legs. The left leg had blisters like areas forming on the lower leg. The ADON had assessed the edema by pushing down on the tops of the residents' feet and the front of the legs. The area did not return to normal, and the indentation stayed where the nurse had pushed down. The ADON reported she would classify the edema as four plus pitting edema. The resident reported again to the staff the pain was so bad at night in her legs and feet that she couldn't sleep. She confirmed she had requested pain medication and sometimes she doesn't get it all or she must wait a long time to get it. The resident reported she has a high tolerance for pain, but the pain at night was ten on a scale from zero to ten. The DON reported she would have the physician assess the resident today. Interview on 12/06/23 10:00 A.M., with the DON confirmed no documented evidence the physician was notified of the edema or pain. The DON confirmed there was no documented evidence that the pain was assessed prior to administration of the Oxycodone or non-pharmacological attempted prior. The DON reported the nursing staff were new to the facility and were new graduates with not much nursing experience. Review of Resident #188's progress note dated 12/06/28 at 5:28 P.M. revealed the resident continued with increased edema to BLE. The left lower extremity (LLE) was noted with redness and increased warmth. The in-house physician visited and wrote new orders for Keflex (antibiotic) 250 milligrams (mg) twice daily for seven days, complete blood count (CBC) and comprehensive metabolic profile (CMP) in one week and to schedule Oxycodone 5 mg every night as the resident stated the pain was at night and requested pain medication to be given every night. Review of the facility policy titled, Change in Condition and physician notification policy, dated 09/2020, revealed the facilities policy was to promptly identify, respond to, and report changes in the resident condition to the resident's physician. When a change of condition was discovered, the nurse would evaluate the resident and notify the resident's physician with pertinent information and document the findings timely. 2. Record review revealed Resident #186 revealed was admitted to the facility originally on 11/07/23 and was discharged on 11/19/23 and re-admitted on [DATE] with a diagnosis of fractured vertebra and surgical aftercare following surgery (fusion of spine), urinary retention, pneumonia, severe sepsis with septic shock, and pulmonary embolism. Review of Resident #186's current physician's orders dated 12/2023 revealed the resident had two orders for Percocet's 7.5-325 mg for pain. One order was to administer Percocet one every six hours as needed and one four times daily. Review of Resident #186's MAR dated 11/24/23 to 12/11/23 revealed no evidence the as needed Percocet had been administered. The scheduled Percocet was scheduled from 7:00 A.M. to 11:00 A.M., 12:30 P.M. to 3:30 P.M., 5:00 P.M. to 7:00 P.M. and 8:00 to 11:30 P.M. There were additional comments that indicated on 12/01/23 the medication was administered at 6:38 A.M., 12/02/23 at 6:05 A.M., 12/02/23 8:47 P.M. given at unknown time due to administered by another nurse, 12/03/23 administered at 6:04 A.M., per facilities expectations, 12/03/23 administered at 7:17 P.M., 12/04/23 administered at 6:09 A.M., 12/06/23 administered early at 5:35 A.M., per resident request, 12/07/23 administered at 3:56 P.M. administered early per resident request, 12/08/23 administered early at 6:23 A.M., per residents request, and 12/11/23 administered at 6:47 A.M. Review of Resident #186 Percocet narcotic control sheet dated 11/12/23 revealed the order was to take one Percocet by mouth four times daily for pain. Number #7 pill was not signed off by a staff member nor was the date amount used or wasted completed. One 11/27/23 the resident only received three doses (order for four times daily). On 12/02/23 the resident received six doses; however, there was nothing marked on the MAR that an as needed dose was administered). On 12/10/23 the resident received five does; however, there was nothing marked on the MAR that the as needed Percocet was administered. Several times of administration times were not legible or not documented. Further review revealed no evidence there was as needed a Percocet control sheet or card. Review of Resident #186's pain plan of care dated 12/07/23 revealed the resident was at risk for pain related to recent surgery to repair fracture, peripheral vascular disease, ankylosing, spondylitis, gastric reflux disease, and rheumatoid arthritis. The intervention included administering medication as ordered and to notify the physician of any side effects observed or lack of effectiveness. Interview on 12/12/23 at 12:26 P.M., with Resident #186 revealed his pain was not controlled. The resident described the pain as a dull pain in his back and legs. Interview on 12/12/23 at 2:00 P.M., with the DON reported she had spoken to the pharmacist and the as needed Percocet script had run out and was not rewritten. The DON confirmed there was no evidence on the MAR that the as needed Percocet was administered; however, there were two days the resident received more than four doses. The DON confirmed there was no evidence staff had signed out #7 on the control sheet. The DON confirmed the way the times were set up for the schedule times was not an effective way to manage pain since one staff could give the first dose as late 11:00 A.M. and the next dose could be given as early as 12:30 P.M. The DON also verified staff did not include times on the Narcotic control sheets indicating what time the medication was administered and there was no way of telling in the electronic medical record to ensure there was enough time between does. The facility did not have a policy on administering when the times are set up at 7:00-11:00 A.M., 12:30 to 3:30 P.M., etc. but the expectation would be for the medication to be given within those time frames and not before or after. The DON reported she was going to change the administration time to set times to ensure the medication was administered every eight hours. Review of the undated facility policy titled Pain Management revealed the facility must ensure that pain management was provided to residents who require such services.

CONCERN (D)

Potential for Harm - no one hurt, but risky conditions existed

Deficiency F0698 (Tag F0698)

Could have caused harm · This affected 1 resident

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**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on record review, interview, and facility policy review the facility failed to maintain communication with the dialysis center. This affected one resident (#9) of one resident reviewed for dialysis. Findings include: Record review revealed Resident #9 was admitted to the facility on [DATE] with diagnoses including end stage renal disease, anemia in chronic kidney disease, dependence on renal dialysis, type one diabetes mellitus with unspecified complications, unspecified sequelae of cerebral infarction, dysphagia following cerebral infarction, unspecified severe protein-calorie malnutrition, vitamin D deficiency, unspecified dementia, mild, with other behavioral disturbance, hypertension, atherosclerotic heart disease of native coronary artery without angina pectoris, and chronic bronchitis. Review of Resident #9's medical record dated 10/01/2023 to 12/11/23 revealed no evidence of notes from the dialysis center regarding care, diet, or treatments. Review of Resident #9's renal failure plan of care dated 01/04/23 revealed to coordinate care with the dialysis center. The resident scheduled days were Monday, Wednesday, and Friday. Interview on 12/11/23 at 12:38 P.M. with the facilities contracted Registered Dietitian (RD) #220 revealed she had not communicated in some time with the dialysis centers RD. The RD reported she doesn't receive dialysis communication information and she would have to call the dialysis center to get notes for the surveyor. Interview on 12/11/23 at 3:21 P.M., with the Dialysis Center RD #221 confirmed communication with the facility regarding Resident #9's care had been difficult. The facilities dietitian had not returned calls, responded to emails, or been available when she had tried to call the facility. The floor staff sometimes don't understand, and it would be beneficial to talk to the dietitian. She had to call the other day and speak to the floor staff to verify what supplements the resident was taking, and she was told the resident was taking two Ensure Clears daily and one Mighty Shake at night. RD #221 reported the facilities RD (RD #220) had just called her to obtain the last three notes for the surveyor and reported she had not been able to open the emails because they were sent encrypted. Interview on 12/11/23 at 3:46 P.M., with the Director of Nursing (DON) revealed she was not able to find documented evidence the dialysis center had sent notes back to the facility regarding the resident care and treatment. The facility completed an observation note and sent it with the resident on dialysis days; however, there was no evidence the dialysis center had sent any notes or records back. She had called the dialysis center, and they were faxing notes for the last three months as soon as possible. Review of the undated facility policy titled Dialysis Care revealed the facility would ensure residents that receive daily treatment are safe, well assessed, and that the facility collaborates care with the dialysis center. Registered dietitian to evaluate the resident's nutrition, hydration needs, and restrictions as it related to the resident's renal condition. The nurse will complete an assessment of the resident prior to leaving facility and upon return to the facility. Upon return from dialysis center, the nurse will review the communication form sent to dialysis, if the dialysis center fails/refuse to provide communication, document on the form.

CONCERN (D)

Potential for Harm - no one hurt, but risky conditions existed

Deficiency F0745 (Tag F0745)

Could have caused harm · This affected 1 resident

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**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on record review and interviews, the facility failed to provide medically related social services to ensure Resident #19 maintained the highest practicable psychosocial well-being. This affected one resident (#19) of one resident reviewed for medically necessary social services. This facility census was 85. Findings include: Record review revealed Resident #19 admitted to the facility on [DATE] with diagnoses including senile degeneration of the brain, pneumonia, hydronephrosis, dementia with agitation, atherosclerotic heart disease with angina, hypertension, cardiac arrhythmia, myocardial infarction, hyperlipidemia, depression, and anxiety. Review of the quarterly Minimum Data Set (MDS) assessment completed on 09/28/23 revealed Resident #19 had severely impaired cognition, mild depression, and hallucinations. Review of the physician's orders revealed Resident #19 was ordered lorazepam (antianxiety) 0.5 milligrams (mg) every hour as needed, Paxil (anti-depressant) 30 mg once a day, and Seroquel (antipsychotic) 25 mg at bedtime. Review of the nursing note completed by Licensed Practical Nurse (LPN) #133 on 07/30/23 at 10:06 P.M. revealed Resident #19 stated he was going to kill himself and was looking for a gun. Resident #19 continued by stating he had nothing to live for. Interview on 12/11/23 at 10:12 A.M. with Social Services Director (SSD) #178 revealed if a resident was having thoughts of self-harm or symptoms of depression, she would follow up with the resident to ensure they were at baseline and their well-being was taken care of. If a resident was having struggles with mental health, a referral was made to a psychiatrist immediately. SSD #178 reported there was not a policy or procedure in place for when residents make suicidal statements, but the facility ensures their safety and assesses whether the resident had access or means. SSD #178 reported she was not notified Resident #19 stated he wanted to harm himself. Interview on 12/11/23 at 2:44 P.M. with LPN #133 revealed when Resident #19 makes statements about self-harm, staff asks if he needs anything, try to engage him in activities, or take him to lay down for a nap. LPN #133 stated Resident #19 usually struggles with mental health after he has visits with his wife. LPN #133 reported the staff can call the social worker when they need her; however, they know the residents on the memory care unit more than the social worker, so they do not always notify her of incidents.

CONCERN (D)

Potential for Harm - no one hurt, but risky conditions existed

Pharmacy Services (Tag F0755)

Could have caused harm · This affected 1 resident

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**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on record review, interview, and facility policy review the facility failed to ensure antibiotic medication to treat an infection for Resident #186 was properly ordered/transcribed following a hospitalization to ensure the resident received all doses ordered of the medication. This affected one resident (#186) of five residents reviewed for medication review. Findings include: Review of the facility November 2023 infection control log revealed Resident #186 was admitted with pneumonia and sepsis that was confirmed by chest x-ray on 10/28/23. The log noted the resident received Rocephin (antibiotic) from 11/08/23 to 11/21/23; (however, the resident was noted to be hospitalized from [DATE] to 11/24/23). Record review revealed Resident #186 was originally admitted to the facility on [DATE] with diagnoses including acute respiratory failure with hypoxia, pneumonia due to other streptococci (bacteria), severe sepsis with septic shock, pulmonary embolism, pulmonary nodule, and chronic obstructive pulmonary disease (COPD). The resident was transferred to the hospital and then re-admitted on [DATE] with a diagnosis of pneumonia. Review of Resident #186's hospital re-admission orders dated 11/24/23 revealed to continue the antibiotic, Rocephin 2 grams (gm)/50 milliliters (ml) intravenously until 11/25/23 as prescribed. The resident had diagnoses including strep bovis bacteremia (had been ordered antibiotic treatment for four weeks by another local hospital), right pneumothorax, left-side necrotizing pneumonia versus malignancy, and had tested positive for COVID-19 on 11/22/23. Review of Resident #186's physician's orders for November 2023 revealed the Rocephin was discontinued on 11/21/23 (even though the resident was transferred to the hospital on [DATE]). There was no evidence the Rocephin order was re-written upon the resident's re-admission on [DATE]. Interview on 12/12/23 at 2:00 P.M., with the Director of Nursing (DON) confirmed the resident did not receive the Rocephin as ordered following re-admission on [DATE] as noted in the hospital re-admission orders paperwork. Review of the facility undated Antibiotic Stewardship policy revealed antibiotics were powerful tools for fighting and preventing infections. Every antibiotic prescribed must be documented in the medical record for every resident, regardless of prior prescriptions or documentation elsewhere.

CONCERN (D)

Potential for Harm - no one hurt, but risky conditions existed

Drug Regimen Review (Tag F0756)

Could have caused harm · This affected 1 resident

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**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** 3. Record review revealed Resident #19 admitted to the facility on [DATE] with diagnoses including senile degeneration of the brain, pneumonia, hydronephrosis, dementia with agitation, atherosclerotic heart disease with angina, hypertension, cardiac arrhythmia, myocardial infarction, hyperlipidemia, depression, and anxiety. Review of a quarterly Minimum Data Set (MDS) assessment completed on 09/28/23 revealed Resident #19 had severely impaired cognition, mild depression, and hallucinations. Review of orders revealed Resident #19 was ordered lorazepam (antianxiety) 0.5 milligrams (mg) every hour as needed, Paxil (anti-depressant) 30 mg once a day, and Seroquel (antipsychotic) 25 mg at bedtime. Review of a pharmacy recommendation from 03/06/23 revealed a recommendation was made to decrease the antipsychotic, risperidone. The physician did not review the recommendation until 06/22/23. Interview on 12/13/23 at 12:20 P.M. with the DON confirmed the physician's signature on the pharmacy recommendation from 03/06/23 was dated for what appeared to be 06/22/23. Based on record review, staff interview, and policy review, the facility failed to ensure pharmacy recommendations made as part of the residents' monthly medication regimen review were addressed by the physician and/or addressed timely. This affected three residents (#4, #19, and #25) of five residents reviewed for unnecessary medications. Findings include: 1. A review of Resident #4's medical record revealed he was admitted to the facility on [DATE]. His diagnoses included unspecified dementia and bipolar disorder. A review of Resident #4's physician's orders revealed he had orders to receive Zyprexa (an antipsychotic medication) 10 milligrams (mg) by mouth twice a day. He also had an order to receive Zyprexa 10 mg intramuscular (IM) every eight hours as needed for severe aggression and agitation. A review of Resident #4's monthly medication regimen reviews revealed the resident's medications were reviewed monthly by the consulting pharmacist since his admission to the facility. Recommendations were made based on those monthly reviews on 08/07/23 and 11/05/23. A review of Resident #4's pharmacy recommendation dated 08/07/23 revealed the consulting pharmacist informed the physician that according to new Centers for Medicare and Medicaid (CMS) guidelines regarding as needed (prn) antipsychotics, those prn medications could only be written for 14 days initially and could only be re-ordered if the prescriber visited the resident and extended the order. The pharmacist recommended the physician evaluate and consider discontinuing the Zyprexa 10 mg IM every eight hours prn if they felt it was appropriate. There was no documented evidence of the physician responding to that recommendation, and the resident continued to have an order for the Zyprexa to be given every eight hours prn for severe aggression and agitation. A review of Resident #4's pharmacy recommendation for 11/05/23 revealed the consulting pharmacist had recommended to the physician that he consider a gradual dose reduction attempt for the resident's use of Zyprexa 10 mg by mouth (po) twice daily (BID). There was no documented evidence of the physician responding to that recommendation, and the resident continued to receive Zyprexa 10 mg po BID. On 12/13/23 at 8:30 A.M., an interview with the Director of Nursing (DON) confirmed the pharmacy recommendations made on 08/07/23 and 11/05/23 were not addressed by the physician after the recommendations were made by the pharmacist as part of the resident's monthly medication regimen review. She acknowledged the resident had an order to receive Zyprexa 10 mg IM every eight hours prn for severe aggression and agitation greater than the 14 days it should have been initially ordered for without being evaluated by a physician for the continued use past the initial 14-day period. She stated she reached out to the psychiatrist as well and did not see where he had addressed the pharmacy recommendations either. She reported she did not see where the resident had any order changes pertaining to the scheduled and prn Zyprexa since they had been first ordered. A review of the facility's policy on Antipsychotic Medication Use, revised December 2016, revealed antipsychotic medications would be prescribed at the lowest possible dosage for the shortest period of time and were subject to gradual dose reduction and re-review. Residents who were admitted from the community or transferred from a hospital and who were already receiving antipsychotic medications would be evaluated for the appropriateness and indications for use. The interdisciplinary team would re-evaluate the use of antipsychotic medications at the time of admission and/ or within two weeks to consider whether the medication could be reduced, tapered, or discontinued. PRN orders for antipsychotic medications would not be renewed beyond 14 days unless the healthcare practitioner had evaluated the resident for the appropriateness of that medication. 2. A review of Resident #25's medical record revealed she was admitted to the facility on [DATE]. Her diagnoses included unspecified dementia, unspecified psychosis, restlessness and agitation, anxiety disorder, and depression. A review of Resident #25's physician's orders revealed the resident had an order to receive Seroquel (an antipsychotic medication) 50 mg po three times a day (TID). That order had been in place since 01/14/23. The resident also had an order to receive Depakote (a mood stabilizer) 250 mg BID. That order originated on 06/21/23. A review of Resident #25's pharmacy recommendation dated 03/06/23 revealed the consulting pharmacist recommended the physician to consider a GDR attempt for the use of Seroquel 50 mg po TID. The pharmacist's recommendation was from a monthly medication regimen review that had been completed on 03/06/23. The physician did not respond to the consulting pharmacist's recommendation for a GDR consideration for the use of Seroquel until 05/23/23 (over two months after the recommendation was made). Findings were verified by the DON. A review of Resident #25's pharmacy recommendation dated 07/17/23 revealed the consulting pharmacist recommended a GDR consideration for the use of Depakote as part of their monthly medication regimen review. There was no documented evidence supporting that recommendation had been addressed by the physician. On 12/13/23 at 8:30 A.M., an interview with the DON revealed she was not able to find any evidence of the physician responding to the pharmacy recommendation made on 07/17/23 pertaining to the Depakote. She had to contact the pharmacy to obtain a copy of that recommendation and did not see where the physician had acted upon the recommendation. She also acknowledged the pharmacy recommendation pertaining to a GDR consideration for the use of Seroquel made on 03/06/23 was not addressed timely by the physician as the physician did not act upon the recommendation until two and a half months after the recommendation was made. She reported they have had difficulty getting the physician to respond timely or at all to the pharmacist's recommendations when made.

CONCERN (D)

Potential for Harm - no one hurt, but risky conditions existed

Deficiency F0757 (Tag F0757)

Could have caused harm · This affected 1 resident

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**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, record review, facility policy review and interview the facility failed to ensure Resident #189's pulse (heart rate) was obtained prior to the administration of Digoxin, a cardiac glycoside medication, as ordered by the physician to ensure the medication was only administered when necessary. This affected one resident (#189) of three residents observed for medication administration. The facility census was 85. Findings included: Review of Resident #189's medical record revealed he was admitted to the facility on [DATE] with diagnoses including cerebral infarction (stroke) due to thrombosis, hypertensive heart disease with heart failure, acute systolic (congestive) heart failure, and cardiomyopathy. Review of Resident #189's five day Minimum Data Set (MDS) 3.0 assessment, dated 11/30/23, revealed he was mildly cognitively impaired. Review of Resident #189's physician's orders revealed an order, dated 11/28/23, for Digoxin (a cardiac glycoside that enhances the contractility of the heart, but lowers the heart rate) 125 microgram (mcg) (0.125 milligram (mg) orally with special instructions to not give if pulse (heart rate) was under 60. The order indicated the resident's pulse was to be taken apical, once a day. Review of Resident #189's vital signs revealed his most recent pulse was obtained on 12/06/23 at 6:11 A.M. and was 68 beats per minute. Review of Resident #189's Medication Administration Record (MAR), dated 12/2023, revealed his Digoxin had been administered on 12/01/23, 12/02/23, and 12/05/23 without his pulse being checked prior to administration. On 12/07/23 at 7:35 A.M. Registered Nurse (RN) #157 was observed preparing the morning medications for Resident #189. RN #157 prepared Resident #189's medications including his Digoxin. She entered Resident #189's room and administered his oral medications, including the Digoxin, without first obtaining the resident's heart rate. She then continued to administer his inhalers and an intravenous antibiotic. Interview on 12/07/23 at 7:42 A.M. with RN #157 verified she did not obtain Resident #189's heart rate prior to administering the Digoxin. She verified she knew she needed to check the heart rate prior to administering the medications and didn't know why she didn't today. She verified it was potentially dangerous to administer Digoxin when a person's pulse was below 60. RN #157 then obtained Resident #189's pulse and it was 63. Interview on 12/07/23 at 3:12 P.M. with the DON verified residents who were receiving Digoxin should have their pulse assessed prior to administration of the Digoxin medication. Review of the facility policy titled, Medication Administration - General Guidelines, revised 01/2018, revealed medications were administered as prescribed in accordance with good nursing practices and only by persons legally authorized to do so. Further review revealed medications were administered in accordance with written orders of the prescriber.

CONCERN (D)

Potential for Harm - no one hurt, but risky conditions existed

Medication Errors (Tag F0758)

Could have caused harm · This affected 1 resident

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**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on record review, review of a medication error report, staff interview, and policy review, the facility failed to ensure Abnormal Involuntary Movement Scale (AIMS) assessments were performed on a resident receiving antipsychotic medications to identify any side effects related to their use. They also failed to ensure a resident did not receive an extra dose of an anti-anxiety medication that was outside the orders given by the physician. This affected two residents (#4 and #28) of five residents reviewed for unnecessary medications. Findings include: 1. A review of Resident #4's medical record revealed he was admitted to the facility on [DATE]. His diagnoses included unspecified dementia and bipolar disorder. A review of Resident #4's physician's orders revealed he had an order to receive Zyprexa (an antipsychotic medication) 10 milligrams (mg) by mouth (po) twice a day (BID). The order had been in place since 07/31/23. Resident #4's electronic medical record (EMR) was absent for any evidence of an AIMS assessment having been completed since his admission to the facility on [DATE] despite him having received an antipsychotic medication on a scheduled basis. Findings were verified by the Director of Nursing (DON). On 12/12/23 at 2:50 P.M., an interview with the DON confirmed Resident #4 was receiving Zyprexa 10 mg BID as ordered. She acknowledged his EMR did not show evidence of an AIMS assessment being completed to test him for abnormal involuntary movements that can be associated with antipsychotic use. She initially thought their admission nursing assessment included an AIMS assessment, but she acknowledged that it did not. She then thought the quarterly nursing assessment would have included an AIMS assessment but acknowledged one had not been completed for the resident since his admission to the facility on [DATE]. She followed up with the surveyor a short time later and reported she had an AIMS assessment completed for the resident. A review of the facility's policy on Antipsychotic Medication Use, revised December 2016, revealed nursing staff shall monitor for and report any of the following side effects and adverse consequences of antipsychotic medications to the attending physician: neurological side effects that included akathisia, dystonia, extrapyramidal effects, akinesia, or tardive dyskinesia (repetitive involuntary movements such as grimacing and eye blinking often caused by long-term use of some psychotropic medications. 2. A review of Resident #28's medical record revealed she was admitted to the facility on [DATE]. Her diagnoses included unspecified dementia with anxiety and anxiety disorder. A review of Resident #28's physician's orders revealed the resident had an order to receive Xanax (an anti-anxiety medication) 0.25 mg po once a day in the evening between 7:00 P.M. and 11:00 P.M. The order originated on 10/24/23. A review of Resident #28's nurses' progress notes revealed a nurse's note dated 11/17/23 by Licensed Practical Nurse (LPN) #187 that indicated the resident was given a Xanax at 4:00 P.M. LPN #187 indicated the nurse on the previous shift gave it without signing off the electronic medication administration record (eMAR). LPN #187 indicated in the nurse's note that she gave the resident a Xanax at 8:00 P.M. as scheduled. A review of an event report for Resident #28's medication error occurring on 11/17/23 revealed the resident was given a dose of Xanax at 4:00 P.M. that the nurse did not document the medication as having been given on the eMAR resulting in the resident being given an extra dose when her scheduled dose of Xanax was given at 8:00 P.M. The medication error report incorrectly identified the medication as being Ativan when they were to indicate what the correct order was. LPN #187 who completed the event report inadvertently identified the medication as Ativan 0.5 mg at bedtime as being the medication involved. The progress notes that were pulled and made part of the event report (medication error report) correctly identified Xanax as being the medication involved in the medication error. A review of Resident #28's eMAR for November 2023 revealed LPN #187 signed off that she had given the resident her scheduled dose of Xanax 0.25 mg po as ordered every day in the evening. The eMAR indicated the window for administration was between 7:00 P.M. and 11:00 P.M. There was no dose of Xanax marked as having been given on 11/17/23 at 4:00 P.M. nor did the resident's physician's order allow for a dose to be administered at that time. The resident did not have an as needed (prn) order for Xanax as it was only ordered on a scheduled basis. A review of Resident #28's controlled drug use record for Xanax confirmed two doses of Xanax 0.25 mg were administered to the resident on 11/17/23. A dose was indicated to have been given to the resident on 11/17/23 at 4:00 P.M. by LPN #168. A second dose was documented as having been given on 11/17/23 at 8:00 P.M. by LPN #187. On 12/13/23 at 10:20 A.M., an interview with the DON confirmed Resident #28 received an extra dose of Xanax 0.25 mg on 11/17/23 as two doses were signed out as having been given to the resident in the afternoon/ evening of 11/17/23. She acknowledged the first dose that was signed out for 11/17/23 at 4:00 P.M. was outside the window of administration for the resident to receive her scheduled dose of Xanax that was ordered to be given between 7:00 P.M. and 11:00 P.M. She verified LPN #168 had signed out a dose on the controlled drug use record for 11/17/23 at 4:00 P.M. but did not sign the dose as having been given on the eMAR. As a result, LPN #187 administered the scheduled dose of Xanax 0.25 mg to the resident on 11/17/23 at 8:00 P.M. and signed it off on the eMAR. The resident received double the dose of Xanax on 11/17/23 at 0.5 mg had been given instead of the 0.25 mg that was ordered. She was asked why LPN #168 would have given the resident Xanax outside of the window for administration and replied it was likely that the resident was asking for it. She acknowledged there was not a prn order for the resident to receive Xanax and should not have been given outside the parameters set by the physician's orders.

CONCERN (D)

Potential for Harm - no one hurt, but risky conditions existed

Unnecessary Medications (Tag F0759)

Could have caused harm · This affected 1 resident

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**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, resident record review, policy review and interview the facility failed to maintain a medication error rate of less than five (5) percent (%). The medication error rate was calculated to be 7.69% and included three medication errors of 39 medication administration opportunities. The facility also failed to ensure inhalation medications were administered following manufacturer recommendations for proper use and to prevent compliacations. This affected three residents (#39, #66, and #189) of three residents observed for medication administration. The facility census was 85. Findings included: 1. Review of Resident #189's medical record revealed he was admitted to the facility on [DATE] with diagnoses including cerebral infarction (stroke) due to thrombosis, hypertensive heart disease with heart failure, acute systolic (congestive) heart failure, and cardiomyopathy. Review of Resident #189's five day Minimum Data Set (MDS) 3.0 assessment, dated 11/30/23, revealed he was mildly cognitively impaired. Review of Resident #189's physician order, dated 11/28/23, revealed he was to receive Digoxin (a cardiac glycoside that enhances the contractility of the heart, but lowers the heart rate) 125 microgram (mcg) (0.125 milligram (mg) orally with special instructions to not give if pulse (heart rate) was under 60. The order indicated to take pulse apical, once a day. Review of Resident #189's vital signs revealed his most recent pulse was obtained on 12/06/23 at 6:11 A.M. and was 68 per minute. On 12/07/23 at 7:35 A.M. Registered Nurse (RN) #157 was observed preparing the morning medications for Resident #189. RN #157 prepared Resident #189's medications including his Digoxin. She entered Resident #189's room and administered his oral medications, including the Digoxin, without obtaining a heart rate. She then continued to administer his inhalers and an intravenous antibiotic. Interview on 12/07/23 at 7:42 A.M. with RN #157 verified she did not obtain Resident #189's heart rate prior to administering the Digoxin. She verified she knew she needed to check the heart rate prior to administering the medications and didn't know why she didn't today. She verified it was potentially dangerous to administer Digoxin when a person's pulse was below 60. RN #157 then obtained Resident #189's pulse and it was 63. Interview on 12/07/23 at 3:12 P.M. with the Director of Nursing verified residents who were receiving Digoxin should have their pulse assessed prior to administration of the Digoxin. 2. Review of Resident #66's medical record revealed she was admitted to the facility on [DATE] with diagnoses including malignant neoplasm of unspecified part of the lung, chronic obstructive pulmonary disease, hypothyroidism, and shortness of breath. Review of Resident #66's admission MDS 3.0 assessment, dated 09/14/23, revealed she was cognitively intact. Review of Resident #66's physician's orders, dated 09/07/23, revealed she was to receive Symbicort (budesonide-formoterol - a corticosteroid inhaler) HFA aerosol inhaler 160-4.5 micrograms (mcg)/actuation, administer two puffs inhalation twice a day; and a physician order, dated 09/07/23, identified she was to receive Spiriva (tiotropium bromide) inhalation device 18 mcg, administer two puffs twice a day. Observation on 12/07/23 at 8:14 A.M. of Licensed Practical Nurse (LPN) #187 preparing the morning medications for Resident #66 revealed the LPN prepared Resident #66's medications and the Spiriva in the medication cart for Resident #66 was not the correct dosage. The Spiriva in the medication cart was 2.5 mcg and not 18 mcg as ordered. LPN #187 reported she would not administer the Spiriva. LPN #187 entered Resident #66's room and administered her Symbicort first. LPN #187 did not direct or offer Resident #66 to rinse her mouth and spit the water out. LPN #187 then administered Resident #66's oral medications. Interview on 12/07/23 at 9:35 A.M. with LPN #187 verified she did not administer the Spiriva as ordered and she did not have Resident #66 rinse her mouth and spit after the administration of the Symbicort inhaler. She verified residents should rinse and spit after administration of a corticosteroid inhaler. Interview on 12/07/23 at 11:02 A.M. with LPN #187 verified she had not contacted the pharmacy or the physician regarding the Spiriva not being available for administration. LPN #187 reported she marked it as not available on the Medication Administration Record (MAR), dated 12/23. Review of Resident #66's MAR, dated 12/23, revealed the Spiriva was documented as not available. Review of Resident #66's progress notes, reviewed on 12/07/23 at 11:12 A.M., revealed no documentation of the pharmacy or the physician being notified of the unavailability of the Spiriva. Interview on 12/07/23 at 3:12 P.M. with the DON verified if a resident's medication is not available, the pharmacy and physician should be notified. Review of the Symbicort medication insert, revised 12/2017, revealed after you finish taking Symbicort, rinse your mouth with water. Spit out the water. Do not swallow it. 3. Review of Resident #39's medical record revealed she was admitted to the facility on [DATE] with diagnoses including cerebral infarction (stroke) due to unspecified occlusion, malignant neoplasm of female breast, asthma, and essential hypertension. Review of Resident #39's quarterly MDS 3.0 assessment, dated 10/31/23, revealed she was cognitively intact and had a feeding tube while a resident. Review of Resident #39's physician order, dated 08/22/23, identified she was to receive Symbicort (budesonide-formoterol - a corticosteroid inhaler) HFA aerosol inhaler 160-4.5 (mcg)/actuation, administer two puffs inhalation with special instructions to rinse mouth with water after using and do not swallow, twice a day; and physician order, dated 08/22/23, identified she was to receive Omeprazole-sodium bicarbonate packet 20-1,680 milligrams (mg), administer on packed via gastric tube. Observation on 12/07/23 at 8:81 A.M. of LPN #187 preparing the morning medications for Resident #39. LPN #187 prepared Resident #39's medications and the Omeprazole-sodium bicarbonate packet was not available. LPN #187 verbalized she was not concerned about not having the Omeprazole sodium bicarbonate packet because Resident #39 was receiving Omeprazole 20 mg also. LPN #187 entered Resident #39's room and administered her inhalers first. LPN #187 did not direct or offer Resident #39 to rinse her mouth and spit the water out. LPN #187 then administered Resident #39's medications via her enteral tube. Interview on 12/07/23 at 9:36 A.M. with LPN #187 verified she did not administer the Omeprazole sodium bicarbonate packet as ordered and she did not have Resident #39 rinse her mouth and spit after the administration of the Symbicort inhaler. She verified residents should rinse and spit after administration of a corticosteroid inhaler. Interview on 12/07/23 at 11:03 A.M. with LPN #187 verified she had not contacted the pharmacy or the physician regarding the sodium bicarbonate packet not being available for administration. Review of Resident #39's MAR, dated 12/2023, revealed her Omeprazole-sodium bicarbonate packet 20-1,680 mg was marked a not available. Review of Resident #39's progress notes, reviewed on 12/07/23 at 11:10 A.M., revealed no documentation of the pharmacy or the physician being notified of the unavailability of the Omeprazole-sodium bicarbonate packet 20-1,680 mg. Interview on 12/07/23 at 3:12 P.M. with the DON verified if a resident's medication is not available, the pharmacy and physician should be notified. Review of the Symbicort medication insert, revised 12/2017, revealed after you finish taking Symbicort, rinse your mouth with water. Spit out the water. Do not swallow it. Review of the facility policy titled, Medication Administration - General Guidelines, revised 01/2018, revealed medications are administered as prescribed in accordance with good nursing practices and only by persons legally authorized to do so. Further review reveals medications are administered in accordance with written orders of the prescriber. Additionally, if a medication with a current, active order cannot be located in the mediation cart/drawer, other areas of the medication cart, medication room, and facility (e.g., other units) are searched, if possible. If the medication cannot be located after further investigation, the pharmacy is contacted, or medication may be removed from the emergency drug supply.

CONCERN (D)

Potential for Harm - no one hurt, but risky conditions existed

Dental Services (Tag F0791)

Could have caused harm · This affected 1 resident

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**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on record review and interview the facility failed to appropriately communicate dental concerns involving Resident #30. This affected one resident (#30) of four residents reviewed for dental services. The facility census was 85. Findings included: Review of Resident #30's medical record revealed she was admitted to the facility on [DATE] with diagnoses including major depressive disorder, single episode, adjustment disorder, suicide attempt, suicidal ideations, generalized anxiety disorder, unspecified atrial fibrillation, and essential hypertension. Review of Resident #30's quarterly Minimum Data Set (MDS) dated [DATE], revealed she was cognitively intact and did not have any broken or loosely fitting full or partial dentures, or mouth or facial pain. Review of Resident #30's physician orders, dated 07/06/23 revealed the resident may see a dentist as needed. Review of Resident #30's progress note, dated 11/09/23 and documented by Registered Dietitian (RD) #220, revealed Resident #30 reported some dental pain related to broken teeth, but stated it was not affecting her oral food intake and denied having any chewing or swallowing difficulties. Interview on 12/04/23 at 10:40 A.M. with Resident #30 revealed she had been waiting to see the dentist for six months. She reported she did not have any pain but did have a cracked tooth on the right upper side. Resident #30 reported she had discussed it with the nurse upon admission and later with the dietitian. Interview on 12/11/23 at 11:10 A.M. with Social Services Director (SSD) #178 revealed she was not aware of any dental concerns for Resident #30. Interview on 12/11/23 at 11:43 A.M. with RD #220 revealed she did not inform anyone of Resident #30's pain and should have. She reported she usually focuses more on swallowing and informs the speech therapist of difficulties swallowing. She verified she should also focused on pain and let the nurses know if a resident is complaining of dental pain.

CONCERN (E)

Potential for Harm - no one hurt, but risky conditions existed

PASARR Coordination (Tag F0644)

Could have caused harm · This affected multiple residents

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**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** 3. Record review revealed Resident #13 admitted to the facility on [DATE] with diagnoses including multiple sclerosis, neuromuscular dysfunction of the bladder, anxiety disorder, major depressive disorder, hallucinations, and osteoarthritis. Review of orders revealed Resident #13 had an order to add a diagnosis of schizophrenia on 03/30/23. Review of a quarterly MDS completed on 11/09/23 revealed Resident #13 had behaviors of hallucinations. Record review revealed Resident #13 did not receive a new PASARR to identify the new diagnosis of schizophrenia. Interview on 12/05/23 at 5:01 P.M. with SSD #178 confirmed a new PASARR had not been completed since Resident #13 received a diagnosis of schizophrenia and she had not been notified of the schizophrenia diagnosis. 4. Record review revealed Resident #63 admitted to the facility on [DATE] with diagnoses including major depressive disorder, dementia, anxiety disorder, post-traumatic stress disorder (PTSD), pseudobulbar affect, anemia, hypothyroidism, hyperlipidemia, and adult failure to thrive. Record review revealed Resident #63 had PASARR completed on 08/29/22 which did not have the diagnosis of PTSD listed. Interview on 12/05/23 at 5:01 P.M. SSD #178 confirmed Resident #63's PASARR should reflect the diagnosis of PTSD. SSD #178 stated she completes PASARRs when residents admit from the community, if they admit from another referral source she will print and keep a copy, and if a new diagnosis is added she should complete a significant change PASARR to reflect the change. SSD #178 stated the facility cancelled the behavior monitoring meeting so the process in tracking new diagnoses was disrupted. Review of the undated facility policy titled, Resident Assessment - Coordination with PASARR Program revealed the facility coordinates assessments with the PASARR program under Medicaid to ensure that individuals with a mental disorder, intellectual disability, or a related condition receives care and services in the most integrated setting appropriate to their needs. Based on interview, resident record review, and facility policy review, the facility failed to ensure Preadmission Screening and Resident Reviews (PASARRs) were updated appropriately. This affected four residents (#13, #16, #26, #63) of nine residents reviewed for PASARR. The facility census was 85. Findings include: 1. Review of Resident #16's medical record revealed she was admitted to the facility on [DATE] with diagnoses including schizophrenia (entered 10/31/18), anxiety disorder (entered 10/31/18), and other specified depressive episodes (entered 06/20/19). Review of Resident #16's quarterly Minimum Data Set (MDS) 3.0 assessment, dated 09/05/23, revealed she was severely cognitively impaired, had active diagnoses of anxiety, depression, and schizophrenia, and had verbal and physical behavioral symptoms directed toward others one to three days of the seven-day assessment reference period. Review of Resident #16's physician order, dated 06/26/23, identified she was to receive Haldol decanoate (a long acting antipsychotic medication) 50 milligram/milliliter (mg/ml) intramuscular one day a month on the 27th of the month; physician order, dated 03/31/23, identified Lorazepam Intensol concentrate (an antianxiety medication) two mg/ml amount of 0.5 ml oral every four hours as needed for anxiety, agitation and shortness of breath; and physician order, dated 12/05/23, identified she was to receive ADR Cream (Ativan, Diphenhydramine, and Reglan) topically 2 ml topically (discontinue oral schedule Ativan when cream is started) every two hours as needed for restless, anxiety, and aggressive behavior not to exceed 12 ml daily total. Review of Resident #16's most recent PASARR, dated 10/23/18, revealed under Section D: Indications of Serious Mental Illness, the box beside schizophrenia was marked with an X and the review results revealed she was not applicable for services. The box beside anxiety disorder had not been marked with an X. Review of Resident #16's PASARR, dated 12/05/23, revealed under Section E: Indications of Serious Mental Illness, subsection 1), the boxes beside schizophrenia, mood disorder, and panic or other severe anxiety disorder were marked with and X. Further review under Section E: indications of Serious Mental Illness, subsection 6), the boxes beside anti-psychotics, anti-depressants, anti-anxiety, and mood stabilizer were marked with an X. Interview on 12/05/23 at 8:35 A.M. with the Social Services Director (SSD) #178 verified Resident #16 did not have an up-to-date PASARR. She reported the most recent PASARR Resident #16 had was dated 10/23/18 and she completed a new one the A.M. of 12/05/23 after this surveyor asked for a copy of the most recent PASARR. Interview on 12/05/23 at 3:21 P.M. with SSD #178 verified Resident #16's PASARR, dated 12/05/23, was still not accurate because she was not on an antidepressant or mood stabilizer. She verified the PASARR needed to be accurate. 2. Review of Resident #26's medical record revealed she was admitted to the facility on [DATE] with diagnoses including opioid use, unspecified with opioid induced psychotic disorder (entered 02/01/23), bipolar disorder (entered 02/01/23), major depressive disorder, single episode, mild (entered 01/02/23), and generalized anxiety disorder (entered 07/24/23). Review of Resident #26's quarterly Minimum Data Set (MDS) 3.0 assessment, dated 08/30/23, revealed she was mildly cognitively impaired, had active psychiatric/mood disorders of anxiety, depression, and bipolar, and did not exhibit verbal or physical behaviors towards others. Review of Resident #26's physician order, dated 07/22/23, identified she was to receive Buspirone (an antianxiety medication) 5 mg twice a day for anxiety; and a physician order, dated 07/03/23, identified Trintellix (an antidepressant medication) 20 mg once a day. Review of Resident #26's most recent PASARR, dated 01/31/23, revealed under section E: Indications of Serious Mental Illness subsection 6), the boxes beside of anti-depressant and anti-anxiety were not marked with an X. Interview 12/05/23 at 3:01 P.M. with SSD #178 verified Resident #26's PASARR, dated 01/31/23 was the most recent, and was not up to date since she was taking antianxiety and antidepressant medications. She verified the current PASARR was not up-to-date and should be.

CONCERN (E)

Potential for Harm - no one hurt, but risky conditions existed

Comprehensive Care Plan (Tag F0656)

Could have caused harm · This affected multiple residents

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**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** 3. Record review revealed Resident #13 admitted to the facility on [DATE] with diagnoses including multiple sclerosis, neuromuscular dysfunction of the bladder, anxiety disorder, major depressive disorder, hallucinations, and osteoarthritis. Review of a quarterly MDS assessment completed on 11/09/23 revealed Resident #13 had behaviors of hallucinations. Review of orders revealed Resident #13 was ordered dated 02/22/23 for buspirone 15 mg (antianxiety medication) three times a day by mouth for anxiety, an order dated 04/27/23 for olanzapine 10 mg (an antipsychotic medication) by mouth for delusions and hallucinations, an order dated 03/29/23 for Zoloft 100 mg (antidepressant medication) by mouth, and an order to add a diagnosis of schizophrenia on 03/30/23. Review of the care plan last revised on 11/22/23 revealed no comprehensive care plan was initiated related to new diagnosis of schizophrenia. Interview on 12/13/23 at 12:04 P.M. with RN #202 confirmed there was not a comprehensive care plan in relation to schizophrenia for Resident #13. Review of a policy titled Care Plan, Person-Centered Comprehensive revealed care planning is ongoing and care plans should be revised as information about the residents and the residents' conditions change. 2. Review of Resident #30's medical record revealed she was admitted to the facility on [DATE] with diagnoses including major depressive disorder, single episode, adjustment disorder, suicide attempt, suicidal ideations, generalized anxiety disorder, unspecified atrial fibrillation, and essential hypertension. Review of Resident #30's quarterly Minimum Data Set (MDS) 3.0 assessment, dated 11/10/23, revealed she was cognitively intact and had active diagnoses of anxiety and depression. Review of Resident #30's comprehensive plan of care revealed no care plan for anxiety. Interview on 12/11/23 at 10:28 A.M. with Registered Nurse (RN) #202 verified there was no anxiety plan of care for Resident #30, and there should be. She reported she initiated an anxiety care plan for Resident #30 on 12/11/23. Review of the facility policy titled, Care Plans, Comprehensive Person-Centered, revised 12/18, revealed a comprehensive, person-centered care plan that includes measurable objectives and timetables to meet the resident's physical, psychosocial and functional needs is developed and implemented for each resident. Further review revealed the comprehensive, person-centered care plan will incorporate identified problem areas. 4. Record review revealed Resident #188 was admitted to the facility on [DATE] with diagnoses including unspecified cirrhosis of liver, ascites, unspecified protein-calorie malnutrition, essential (primary) hypertension, hypertensive heart disease without heart failure, acute kidney failure, unspecified, solitary pulmonary nodule, hypo-osmolality, and hyponatremia, thrombocytopenia, unspecified. There was no evidence the resident had diagnoses of pressure ulcers on the diagnoses list. Review of Resident #188's admission MDS assessment dated [DATE] revealed Resident #188 had a stage II pressure (partial-thickness skin loss with exposed dermis) on admission. Review of Resident #188' Braden score dated 11/06/23 revealed the resident was at risk for pressure ulcer development. Review of Resident #188's admission skin event note for pressure dated 11/06/23 revealed the resident had area on the right buttocks that measured 0.5 centimeters (cm) by 0.5 cm. There was no documented depth or stage of the pressure ulcer. Review of Resident #188's wound management note revealed on 11/10/23 the resident had a pressure ulcer on right buttocks; however, there was no staging of the pressure ulcer. The first wound management note was on 11/10/23 at 2:16 P.M., indicated the wound measured 1.4 cm by 1.9 cm by 0.1 cm no exudate, granulation tissue, and to apply Zinc topically. The next wound management note was for 11/17/23 that indicated the wound was 0.9 cm by 1.4 cm by 0.1 cm with granulation tissue and was improving. The last wound management note was 11/21/23 0.9 cm by 0.9 cm by 0.1 cm granulation tissue no exudate. There were no more measurements in the electronic medical record (EMR) after 11/21/23. Review of Resident #188's wound consult notes dated 11/10/23 to 12/01/23 revealed the resident had a stage II pressure ulcer on her buttocks since admission to the facility. The area measured 1.4 cm by 1.9 cm by 0.1 cm. The wound base was shallow and composed of 100 percent (%) clean tissue, no drainage, and peri wound area appeared normal. Apply [NAME] or equivalent to area every shift and as needed. On 11/17/23 the area measured 0.9 cm by 1.4 cm by 0.1 cm assessment of wound bed same continue with Desitin. On 11/21/23 the area was 0.9 cm by 0.9 cm by 0.1 cm, continue treatment and assessment, there was no change. On 12/01/23 the area measured 0.7 cm by 0.9 cm by 0.1 cm, same assessment and treatment. Review of the undated facilities pressure injury staging guide revealed a stage II pressure ulcer was partial-thickness skin loss with exposed dermis. Unstageable was obscured full-thickness skin and tissue loss. Review of Resident #188's plan of care revealed no evidence of a plan of care for pressure ulcers. Review of Resident #188's skin integrity related to decreased mobility and ascites dated 11/27/23 revealed weekly skin assessment, pressure reduction cushion to chair, and moisture barrier protectant to perineal area as needed. Review of Resident #188 base line plan of care dated 11/06/23 revealed the resident had a venous/stasis ulcer. Interventions include notifying physician of any adverse finding with skin integrity and to inspect the skin when repositioning, toileting, assisting with activities of daily living, and notify the nurse of any adverse findings. There was no documented evidence of a pressure ulcer base line plan of care. Observation on 12/06/23 at 7:36 A.M., with Assistant Director of Nursing (ADON) #150 and the DON of Resident #188 revealed the resident was sitting in a recliner with feet on the floor. The staff member stood the resident up and there was no pressure relieving cushion under the resident. The resident had an open area on her buttocks the size of a pea. The area had yellow stringy tissue in the wound bed and the depth appeared to measure 0.3 cm deep. Interview on 12/06/23 at 8:37 A.M., 10:20 A.M., and 10:44 A.M., with ADON #150 and the DON revealed they had gone back and measured the pressure ulcer. The area measured 0.7 cm by 0.9 cm by 0.3 cm, which was a decline from 12/01/23. The DON confirmed the resident did not have a comprehensive plan of care for the pressure ulcer, nor did the resident have a pressure relieving cushion on the chair. Based on observation, record review, staff interview, and facility policy review, the facility failed to ensure residents had comprehensive care plans in place to address pressure ulcers, schizophrenia, anxiety, and insomnia. This affected four resident's (#4, #13, #30, and #188) of 26 residents reviewed for care plans. Findings include: 1. A review of Resident #4's medical record revealed he was admitted to the facility on [DATE]. His diagnoses included insomnia. A review of Resident #4's physician's orders revealed he had an order to receive Melatonin (a supplemental sleep aid) 10 milligrams (mg) by mouth every night at bedtime. The order had been in place since 09/20/23. A review of Resident #4's active care plans revealed he did not have a care plan in place to address his diagnosis of insomnia or the use of Melatonin as a sleep aid. Findings were verified by the Director of Nursing (DON). On 12/12/23 at 2:50 P.M., an interview with the DON confirmed she was not able to find a care plan for the resident to address his diagnosis of insomnia and use of a sleep aid. She stated they initiated a care plan for insomnia, after it was brought to her attention. A review of the facility's policy on Comprehensive Assessments and the Care Delivery Process, revised December 2016, revealed comprehensive assessments would be conducted to assist in developing person-centered care plans. Comprehensive assessments, care planning and the care delivery process involved collecting and analyzing information, choosing, and initiating interventions, and then monitoring results and adjusting interventions.

CONCERN (E)

Potential for Harm - no one hurt, but risky conditions existed

Deficiency F0657 (Tag F0657)

Could have caused harm · This affected multiple residents

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**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on record review and interview the facility failed to ensure residents and representatives were invited to participate in care conferences and care plans were updated to reflect residents' current conditions. This affected four residents (#8, #29, #47, and #68) of five residents reviewed for care planning. The facility census was 85. Findings include: 1. Record review revealed Resident #29 admitted to the facility on [DATE] with diagnoses including dementia, contusion of the head, atherosclerotic heart disease without angina, atrial fibrillation, psychosis not due to a substance or known condition, hyperlipidemia, ischemic cardiomyopathy, encephalopathy, cognitive communication deficit, insomnia, and dysphagia. Review of the care conferences revealed Resident #29 had a care conference on 10/10/22 and did not have another care conference until 04/19/23. Interview on 12/05/23 at 5:01 P.M. with Social Services Director (SSD) #178 revealed care conference invitation cards were sent out monthly based on the Minimum Data Set (MDS) assessment calendar to ensure they are completed quarterly. Interview on 12/11/23 at 10:07 A.M. with SSD #178 confirmed Resident #29 did not have a care conference between 10/10/22 and 04/19/23, and they should be completed approximately every three months. 2. Record review revealed Resident #47 admitted to the facility on [DATE] with diagnoses including heart failure, schizoaffective disorder, schizophrenia, conduct disorder, dementia with behaviors, disorientation, obsessive compulsive disorder, intellectual disabilities, anxiety disorder, depressive disorder, hyperlipidemia, hypertension, altered mental status, and hypoxia. Review of a resident-to-resident Event assessment completed on 09/03/23 at 6:49 P.M. by Licensed Practical Nurse (LPN) #255 revealed Resident #47 made contact with another resident with an event description of resident pushed another resident. The assessment indicated Resident #47 was angry and anxious prior to incident, and the immediate intervention put in place included staff to allow privacy of his room as resident allows. Review of a nursing note on 09/03/23 at 6:50 P.M. by LPN #255 revealed resident made contact with another resident, staff intervened an redirection given. Review of a Behavior and Mood Event assessment completed on 11/23/23 at 6:59 P.M. by Registered Nurse (RN) #137 revealed Resident #47 shoved another resident because she was attempting to take his papers. Immediate interventions included redirection and relocated to a quiet location. Review of an interdisciplinary team note completed on 11/27/23 at 7:30 A.M. by the Director of Nursing (DON) revealed resident became slightly aggressive when another resident attempted to move personal belonging from dining room table. Both residents were redirected easily and continued to participate in normal routines. Review of the care plan last reviewed on 09/29/23 revealed Resident #47 had inappropriate behaviors including placing inappropriate objects in personal orifices. There were no mentions of resident-to-resident incidents or aggressive behaviors. Interview on 12/13/23 at 12:04 PM with RN #202 confirmed there was not a care plan or interventions in place for Resident #47 regarding aggressive behaviors toward other residents. 3. Record review revealed Resident #68 admitted to the facility on [DATE] with diagnoses including metabolic encephalopathy, hypertension, hyperlipidemia, gout, vascular dementia, and insomnia. Review of the nursing note on 09/20/23 at 9:12 A.M. by LPN #256 revealed Resident #68 was found in another resident's bed. Residents were separated, and one on one was provided. Review of the nursing note on 12/03/23 at 9:21 P.M. by LPN #158 revealed Resident #68 was found in a female resident's room in bed with her with no shirt on and his pants inside out. Review of the care plan revealed no interventions in place to address sexually inappropriate behaviors. Interview on 12/13/23 at 12:04 P.M. with RN #202 confirmed there was no care plan in place to address Resident #68's sexually inappropriate behaviors. 4. Review of Resident #8's medical record revealed she was admitted to the facility on [DATE] with diagnoses including chronic obstructive pulmonary disease (COPD), chronic diastolic (congestive) heart failure, type two diabetes mellitus without complications, anxiety disorder, and major depressive disorder. Review of Resident #8's quarterly MDS 3.0 assessment, dated 10/01/23, revealed she was cognitively intact. Interview on 12/04/23 at 11:23 A.M. with Resident #8 revealed she did not recall having care conferences every quarter. Review of Resident #8's medical record revealed she had care conferences, which are entered into the electronic medical record as Resident First Meetings, on 02/26/22, 06/03/22, 10/10/22, 01/02/23, 04/06/23, and 08/08/23. Interview on 12/11/23 at 2:37 P.M. with SSD #178 verified she was a month late regarding the conferences on 10/10/22, 08/08/23, and the one which was due 11/08/23 and not completed as of the interview. SSD #178 reported she liked to do the care conferences following the completion of the MDS, but she tended to have more care conferences than there were MDS evaluations.

CONCERN (E)

Potential for Harm - no one hurt, but risky conditions existed

Infection Control (Tag F0880)

Could have caused harm · This affected multiple residents

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3. On 12/04/23 STNA #109 was observed passing lunch meal trays. The following concerns were identified during the observation related to infection control: At 11:50 A.M., STNA #109 delivered a tray to Resident #195, helped set up the meal, exited the room and did not sanitize her hands. At 11:57 A.M., STNA #109 delivered a tray to Resident #2, set up the tray, exited the room and did not sanitize her hands. At 11:58 A.M., STNA #109 delivered a tray to another resident, exited the room, sanitized hands, then entered Resident #27's room to get the resident repositioned in bed, exited the room and did not sanitize her hands. At 12:03 P.M. STNA #109 grabbed another tray and delivered it to Resident #14 and then exited the room without sanitizing her hands. At 12:08 P.M., STNA #109 delivered a tray to Resident #193 and did not sanitize her hands. Interview 12/04/23 at 12:12 P.M. with STNA #109 confirmed above observations. Review of policy titled Food Preparation and Service revealed food and nutrition services staff, including nursing services personnel, should wash their hands before serving food to residents. Review of the facility undated policy titled, Guidelines for Handwashing/Hand Hygiene, revealed handwashing was the single most important factor in preventing transmission of infections. Hand hygiene was a general term that applied to either handwashing or the use of an antiseptic hand rub, also known as alcohol-based hand rub (ABHR). Further review revealed all health care workers shall utilize hand hygiene frequently and appropriately. Health care workers shall use hand hygiene at times such as: before/after preparing/serving meals, drinks, tube feedings, etc., and before/after having direct physical contact with residents. Based on observation, facility policy review and interview, the facility failed to develop and implement a comprehensive infection control program to prevent the spread of infection. The facility failed to ensure hand hygiene was performed when passing residents their meals in their rooms and failed to ensure a glucometer was cleaned and disinfected after use. This had the potential to affect eight residents (#2, #14, #16, #27, #52, #57, #193, and #195) observed during lunch service and three residents (#11, #44, and #57) who required blood glucose monitoring using the shared glucometer from the 500 front medication cart. The facility census was 85. Findings included: 1. Observation on 12//11/23 at 7:59 A.M. as Licensed Practical Nurse (LPN) #187 prepared to obtain a finger stick blood sugar (FSBS) from Resident #11 revealed LPN #187 obtained her supplies and cleaned the glucometer with Swovo Medical and Commercial Disinfecting Wipe for approximately 10 seconds. LPN #187 then completed hand hygiene, applied (donned) gloves and proceeded to Resident #11's room. LPN #187 used a tissue as a barrier around the glucometer as she held it. LPN #187 put a test strip in the glucometer, punctured Resident #11's finger after cleaning it with alcohol and placed a drop of blood on the test strip which was inserted into the glucometer. After obtaining a fasting blood sugar (FSBS) reading, LPN #187 completed hand hygiene and the lancet and test strip were disposed of in the sharp container. LPN #187 placed the glucometer on top of the medication cart and then in the top right drawer of the medication cart without cleaning/disinfecting the glucometer. An interview at the time of the observation with LPN #187 verified she did not clean or disinfect the glucometer after using it to obtain an FSBS on Resident #11. LPN #187 stated, I thought I only had to do it between residents. This surveyor explained that any germs in Resident #11's room or on her hands as LPN #187 was touching her and then the glucometer were now on the glucometer, on the top of the medication cart, and in the top right drawer of the medication cart. LPN #187 then obtained a Swovo Medical and Commercial Disinfecting Wipe and cleaned the glucometer. LPN #187 verified she did not realize the SWOVO Medical and Commercial Disinfecting Wipe needed to make contact with the glucometer for two minutes for COVID-19 virus killing to be effective. Interview on 12/11/23 at 8:11 A.M. with the Director of Nursing (DON) verified glucometers should be cleaned and disinfected after use on a resident and prior to being returned to the medication cart for infection control. Interview on 12/13/23 at 3:30 P.M. with the DON revealed the front 500 unit medication cart glucometer could have been used on two additional residents, Resident #44 and #57. At the time of the interview, she also indicated there were no residents on the unit with hepatitis or human immunodeficiency virus (HIV). Review of the SWOVO Medical and Commercial Disinfecting Wipe flier, provided by the facility, revealed under product details of a two minute killing time for COVID-19 and documentation the wipe killed 99.9% of bacteria in 15 seconds. Review of the facility policy titled, Obtaining a Fingerstick Glucose Level, revised 10/2011, revealed clean and disinfect reusable equipment between uses according to the manufacturer's instructions and current infection control standards of practice. 2. On 12/04/23 at 12:05 P.M. State Tested Nursing Assistant (STNA) #136 was observed delivering lunch meals to residents on the 500 unit. STNA #136 delivered a lunch meal to Resident #52. While in Resident #52's room, STNA #136 set up his meal, touched his over bed table, and physically assisted him from lying in the bed to sitting on the side of the bed to eat. STNA #136 then exited Resident #52's room and walked to the meal cart to retrieve the next tray for Resident #57. She did not perform hand hygiene prior to retrieving Resident #57's tray. After placing drinks and rolled silverware with napkin on the meal tray, STNA #136 delivered the meal to Resident #57, placed it on her over bed table, and then adjusted the over bed table for Resident #57. STNA #136 exited Resident #57's room and walked to the meal cart to retrieve the next tray for Resident #16. She did not perform hand hygiene prior to retrieving Resident #16's tray. After placing rolled silverware with napkin on the meal tray (no drink needed because Resident #16 was holding her drink), STNA #136 delivered the meal to Resident #16's room and placed it on the over bed table. Resident #16 was in the hallway in her wheelchair and STNA #136 assisted Resident #16 into her room by pushing her wheelchair. Resident #16 wanted her meal on her nightstand and STNA #136 placed it on her nightstand for her. STNA #136 then washed her hands in the restroom diagonal from the nurses' station on the unit. Interview on 12/04/23 at 12:12 P.M. with STNA #136 verified she did not perform hand hygiene between providing residents their meals and after touching items and residents in the rooms. She reported she thought she only had to perform hand hygiene after delivering and assisting three residents and not between each resident. Review of policy titled Food Preparation and Service revealed food and nutrition services staff, including nursing services personnel, should wash their hands before serving food to residents. Review of the facility undated policy titled, Guidelines for Handwashing/Hand Hygiene, revealed handwashing was the single most important factor in preventing transmission of infections. Hand hygiene was a general term that applied to either handwashing or the use of an antiseptic hand rub, also known as alcohol-based hand rub (ABHR). Further review revealed all health care workers shall utilize hand hygiene frequently and appropriately. Health care workers shall use hand hygiene at times such as: before/after preparing/serving meals, drinks, tube feedings, etc., and before/after having direct physical contact with residents.

CONCERN (E)

Potential for Harm - no one hurt, but risky conditions existed

Deficiency F0883 (Tag F0883)

Could have caused harm · This affected multiple residents

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**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on record review, review of invoice documents, facility policy review and interview, the facility failed to ensure immunizations were provided timely and as requested. This affected two residents (#9 and #34) and had the potential to affect 38 additional residents identified on a facility log to have consented to receiving a pneumococcal vaccine in September 2023 without evidence of administration. The facility census was 85. Findings included: 1. Record review revealed Resident #34 was admitted to the facility on [DATE] with diagnoses including respiratory disease, heart disease, hepatitis, and diabetes. Review of Resident #34's immunization consent form dated 09/11/23 revealed the resident consented to receive the pneumococcal, influenza (flu), and COVID vaccine. Review of Resident #34's immunization record revealed the resident had received a pneumococcal vaccine in 11/11/21 from an outside care setting. There was no evidence of the type of pneumococcal vaccine the resident had received at that time. Following the resident's consent (in September 2023), there was no evidence the resident received a pneumococcal, or COVID vaccine in 2023 as requested. The resident did not receive the influenza vaccine until 12/10/23 after the State agency annual survey had begun. 2. Record review revealed Resident #9 was admitted to the facility on [DATE] with diagnoses including end stage renal disease, anemia in chronic kidney disease, dependence on renal dialysis, type 1 diabetes mellitus with unspecified complications, unspecified sequelae of cerebral infarction, dysphagia following cerebral infarction, unspecified severe protein-calorie malnutrition, vitamin D deficiency, unspecified dementia, mild, with other behavioral disturbance, hypertension, atherosclerotic heart disease of native coronary artery without angina pectoris, and chronic bronchitis. Review of Resident #9's immunization consent form dated 09/11/23 revealed the resident consented to the pneumococcal, flu, and COVID vaccine. Review of Resident #9's immunization record revealed no evidence the resident had ever received a pneumococcal vaccine. There was no evidence the resident received a pneumococcal or COVID vaccine in the facility after providing consent in September 2023. The resident did not receive the influenza vaccine until 12/10/23 after the State agency annual survey had begun. Review of the facility invoices dated 09/12/23 revealed no evidence the facility had ordered pneumococcal or COVID-19 vaccines to ensure they were available and administered to residents as required/requested. Interview on 12/13/23 at 9:15 A.M. and 11:00 A.M., with the Director of Nursing (DON) confirmed Resident #34 and #9 had consented to all three vaccines. The flu vaccine was administered on 12/10/23; however, the DON indicated the COVID booster was on a national shortage and not available. During the interviews, the DON originally reported the pneumococcal vaccines were ordered in September 2023, but stated she had not received it nor had she followed up to see why it was not delivered. Upon further investigation the DON confirmed the pneumococcal vaccines were never actually ordered nor did the facility have any pneumococcal vaccines in stock to administer. The DON reported she called the pharmacy on this date (12/13/23) and they indicated they would deliver pneumococcal vaccines today and she would start administering the immunization today. During the interview, the DON revealed there were 38 additional residents, who had consented to receive a pneumococcal vaccine in September 2023 who had not received the vaccination as of this date. The DON reported she had not reached out to the local health department or any other entity to see if the facility could obtain COVID vaccines. Review of the facility undated policy titled COVID-19 Prevention and Management revealed each resident would be offered the COVID-19 vaccine unless medically contraindicated or the resident has already been immunized. Review of the facility undated policy titled Immunization Prevention and Control revealed all residents would be offered the pneumococcal vaccines to aid in preventing pneumonia/pneumococcal infections. The facility policy did appear to be consistent with the current recommendations from the Centers for Disease Control (CDC) related to pneumococcal vaccination recommendations.

CONCERN (F)

Potential for Harm - no one hurt, but risky conditions existed

Deficiency F0761 (Tag F0761)

Could have caused harm · This affected most or all residents

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**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, interview, and facility policy review, the facility failed to ensure medications were appropriately packaged, labeled, and secured. This affected three medication carts of three medication carts (Connections 300 Hall, Front 500 Hall and Back 500 Hall) observed and one medication room (Connections 300 Nurses' Station) of one medication room observed. The facility census was 85. Findings included: 1. Observation on 12/07/23 at 8:01 A. M. of the Connections 300 Hall medication cart revealed 18 whole or one-half pieces of medication loose in the second drawer of the medication cart. This was verified during the observation by Registered Nurse (RN) #157. She also verified it was not proper storage to have loose medication in the drawers of the medications cart. 2. Observation on 12/07/23 at 8:39 A.M. of the Front 500 Hall medication cart revealed 20 whole or one-half pieces of medication loose in the second drawer of the medication cart. There was also a multi-dose bottle of Lantus insulin (opened and 1/2 used) labeled for Resident #57 with no documented date of opening on the bottle, and a multi-dose bottle of Lantus insulin (opened and 1/2 used) and a multi-dose bottle of Insulin Lispro (opened and almost empty) labeled for Resident #11 with no documented dated of opening on the bottle. The loose medications and undated insulin bottles were verified during the observation by Licensed Practical Nurse (LPN) #187. She also verified it was not proper storage to have loose medication in the drawers of the medication cart or insulin bottles not properly dated when opened. LPN #187 also reported she thought insulin was good for 90 days once opened. Review of undated pharmaceutical guidance titled, Highlights of Prescribing Lantus provided by the facility revealed after Lantus insulin vials had been opened (in-use) they could be used for up to 28 days. Review of undated pharmaceutical guidance titled, Highlights of Prescribing Insulin Lispro provided by the facility revealed after Insulin Lispro vials had been opened (in-use) they could be used for up to 28 days. 3. Observation on 12/07/23 at 9:37 A.M. of the Back 500 Hall medication cart revealed 16 whole or one-half pieces of medication loose in the second drawer of the medication cart. This was verified during the observation by Licensed Practical Nurse (LPN) #187. She also verified it was not proper storage to have loose medication in the drawers of the medications cart. 4. Observation on 12/07/23 at 10:49 A.M. of the Connection 300 Nurses' Station medication refrigerator revealed two open and used multi-dose bottles of purified tuberculin for tuberculosis testing. Neither of the bottles had been dated when they were opened. RN #157 verified the tuberculin bottles had been used, had not been dated and should have been. She verified there was no way to know how long they had been open. Interview on 12/07/23 at 3:12 P.M. with the DON verified multi-dose bottles of insulin and tuberculin should be dated when opened and there shouldn't be loose medication in the medication carts. Review of undated pharmaceutical guidance titled, Tuberculin Purified Protein Derivative provided by the facility revealed vials in use more than 30 days should be discarded due to possible oxidation and degradation which may affect potency. Review of the facility policy titled, Storage of Medications, revised 04/2007, revealed the facility shall store all drugs and biologicals in a safe, secure, and orderly manner. Drugs and biologicals shall be stored in the packaging, container, or other dispensing systems in which they are received. Further review revealed the nursing staff shall be responsible for maintaining medication storage and preparation areas in a clean, safe, and sanitary manner. 5. Observation on 12/12/23 at 7:35 A.M. with the Administrator revealed as the Administrator and surveyor were walking down the 300 hall a medication cart was observed to be unlocked and unsupervised outside room [ROOM NUMBER]. Interview on 12/12/23 at 7:35 A.M. with the Administrator confirmed the cart was left unlocked and unsupervised. The Administrator locked the medication cart at time of finding. Review of the facility policy titled, Storage of Medications, revised 04/2007, revealed the facility shall store all drugs and biologicals in a safe, secure, and orderly manner. Drugs and biologicals shall be stored in the packaging, container, or other dispensing systems in which they are received. Further review revealed the nursing staff shall be responsible for maintaining medication storage and preparation areas in a clean, safe, and sanitary manner.

CONCERN (F)

Potential for Harm - no one hurt, but risky conditions existed

Food Safety (Tag F0812)

Could have caused harm · This affected most or all residents

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Based on observation, facility policy review and interview, facility failed to prepare foods in a sanitary manner and failed discard food items that were out of date/expired. This had the potential to affect 84 of 84 residents who received meal trays from the kitchen. The facility census was 85. Findings included: 1. On 12/04/23 from 8:39 A.M. to 9:12 A.M. observations made during the initial tour of the kitchen revealed the following concerns: A plastic container with cheddar cheese which expired on 12/03/23. A container of dried, crispy onions with a best by date of 10/27/23. A dented can of strawberry pie filling. Two bags of baby spinach with a use by date of 11/25/23. There was no operational thermometer in the walk-in refrigerator. Interview on 12/04/23 at 9:12 A.M. with Director of Food Services (DFS) confirmed the above findings/concerns at the time of the observations. 2. On 12/06/23 at 11:15 A.M. observation of tray line/meal preparation revealed of the lunch meal, which included corned beef hash and scrambled eggs revealed the following concerns: At 11:22 A.M., [NAME] #155 touched her left ear with her left hand and did not wash her hands before continuing to prepare food. At 11:29 A.M., Dining Services Assistant (DSA) #112 touched her mask, then proceeded to touch the microwave an other plates. At 11:31 A.M., DSA #171 touched her mask, then her cheek, her apron and then placed her hands on her hips. She did not wash her hands and proceeded to use tongs to grab bread for grilled cheese, then put gloves on to handle the grilled cheese to add butter before placing it on the grill. At 11:34 A.M. [NAME] #155 put on oven mitts, got additional food out of the oven, took off the oven mitts then proceeded to work without performing hand hygiene. At 11:37 A.M., DSA #171 touched her left, lower back then proceeded to place fries in the deep fryer. At 11:38 A.M. [NAME] #155 touched the refrigerator handle to retrieve mashed potatoes, put them in the microwave, the continued to prepare food. At 11:44 A.M. DSA #171 placed her hand on her left hip while cooking, then continued to place food on a plate without performing hand hygiene. At 11:47 A.M. [NAME] #155 unplugged a heated delivery cart, moved the cart forward towards the tray line, plugged in back in, then proceeded plating food to serve. At 11:53 A.M. DSA #171 tucked a strand of hair behind her ear, touched her mask, then began serving again. At 12:07 P.M. DSA #171 touched her mask then prepared a hamburger. Interview on 12/06/23 at 12:13 P.M. with [NAME] #155 confirmed all observations. Review of a policy titled Food Preparation and Service revealed staff should adhere to proper hygiene and sanitary practices to prevent the spread of food-borne illness.

MINOR (C)

Minor Issue - procedural, no safety impact

Transfer Notice (Tag F0623)

Minor procedural issue · This affected most or all residents

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**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on record review, interview and facility policy review, the facility failed to ensure Resident #84 who was being transferred to the local emergency department received a notice of transfer/discharge. This affected one resident (#84) of one resident reviewed for hospitalization and had the potential to affect all 85 residents residing in the facility. Findings included: Review of Resident #84's medical record revealed she was admitted to the facility on [DATE] with diagnoses including tubulo-interstitial nephritis, morbid (severe) obesity, type two diabetes, chronic obstructive pulmonary disease (COPD), essential hypertension, and hypertensive heart disease without heart failure. Review of Resident #84's quarterly [NAME] Data Set (MDS) 3.0 assessment, dated 10/06/23, revealed she was cognitively intact. Review of Resident #84's progress note, dated 10/31/23 and timed 9:02 P.M., revealed the ambulance and emergency personnel arrived and the resident left the building appearing in stable condition. She was alert and oriented times four (person, place, time, and situation). The family left separately with all of the resident's personal belongings with the resident's permission. The resident stated this was done in case she stayed at the hospital longer and her room was not able to be held in the facility. Interview on 12/12/23 at 1:00 P.M. with Registered Nurse (RN) #202 revealed notification of transfer/discharge were documented in observations in the electronic health record. Review of Resident #84's observations revealed no documentation to support she received a transfer/discharge notice. Interview on 12/12/23 at 2:01 P.M. with the Director of Nursing (DON) verified there was no documentation to support Resident #84 received a transfer/discharge notice prior to her transfer out to the emergency department on 10/31/23 and she should have. Review of the facility policy titled, Transfer and Discharge Documentation, revised 12/2016, revealed when a resident was transferred or discharged from the facility, the following information would be documented in the medication record: an appropriate notice was provided to the resident and/or legal representative.

MINOR (C)

Minor Issue - procedural, no safety impact

Deficiency F0625 (Tag F0625)

Minor procedural issue · This affected most or all residents

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**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on record review, interview and facility policy review, the facility failed to ensure a resident who was being transferred to the local emergency department received a notice of bed hold. This affected one resident (#84) of one resident reviewed for hospitalization and had the potential to affect all 85 residents residing in the facility. Findings included: Review of Resident #84's medical record revealed she was admitted to the facility on [DATE] with diagnoses including tubulo-interstitial nephritis, morbid (severe) obesity, type two diabetes, chronic obstructive pulmonary disease (COPD), essential hypertension, and hypertensive heart disease without heart failure. Review of Resident #84's quarterly [NAME] Data Set (MDS) 3.0 assessment, dated 10/06/23, revealed she was cognitively intact. Review of Resident #84's progress note, dated 10/31/23 and timed 9:02 P.M., revealed the ambulance and emergency personnel arrived and the resident left the building appearing in stable condition. She was alert and oriented times four (person, place, time, and situation). The family left separately with all of the resident's personal belongings with the resident's permission. The resident stated this was done in case she stayed at the hospital longer and her room was not able to be held in the facility. Interview on 12/12/23 at 1:00 P.M. with Registered Nurse (RN) #202 revealed notification of bed hold was documented in observations in the electronic health record. Review of Resident #84's observations revealed no documentation to support she received a bed hold notice. Interview on 12/12/23 at 2:01 P.M. with the Director of Nursing (DON) verified there was no documentation to support Resident #84 received a bed hold notice prior to her transfer out to the emergency department on 10/31/23 and she should have. Review of the facility policy titled, Bed Hold Policy, revised 1/2020, revealed before transferring a resident from the facility, the resident would be provided in writing information on the resident's rights and limitations regarding bed holds.

MINOR (C)

Minor Issue - procedural, no safety impact

Staffing Information (Tag F0732)

Minor procedural issue · This affected most or all residents

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Based on observation, interview, and facility policy review the facility failed to ensure the daily staffing data was posted daily and included the facility name per the regulation. This had the potential to affect all 85 residents residing in the facility. Findings include: Observation on 12/04/23 at 9:10 A.M. revealed the daily staffing data posting was noted on the wall in the hallway heading towards the 200 halls. The posting didn't include the facility name and the last posting was dated 11/30/23. Observation of daily staffing data posts dated 12/04/23, 12/05/23, 12/06/23, and 12/07/23 revealed no evidence the facility name was posted on the daily posting. Interview and observation on 12/04/23 at 9:12 A.M., with Receptionist #151 confirmed the daily staffing data posting was only posted in the hallway by the office and the last one posted was 11/30/23, and today was 12/04/23. Interview on 12/04/23 at 10:08 A.M. and 12/13/23 at 8:26 A.M., with the Director of Nursing (DON) confirmed the daily staffing data posting had not been updated since 11/30/23, and the name of the facility was not included on the daily posting. The DON confirmed the daily posting was only posted in one area on the hallway heading towards 200 halls. Review of the undated facility staffing policy revealed the facility would provide sufficient and competent staff to meet the care and services needs for all residents in accordance with their care plans and facility assessment. The direct care staffing would be posted daily in a prominent place and readily accessible to residents.

Apr 2022 11 deficiencies

CONCERN (D)

Potential for Harm - no one hurt, but risky conditions existed

Deficiency F0561 (Tag F0561)

Could have caused harm · This affected 1 resident

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Based on record review, staff interview and facility policy review the facility failed to ensure Resident #27's bathing preference for showers was honored. This affected one resident (#27) of one resident reviewed for choices. Findings Include: Review of Resident #27's medical record revealed an admission date of 06/08/21 with diagnoses including COVID-19, chronic obstructive pulmonary disease, protein calorie malnutrition, cardiomegaly, severe morbid obesity, obstructive and reflux uropathy, hydronephrosis, hypothyroidism, bipolar disorder, major depressive disorder, obstructive sleep apnea, hypertension, adult failure to thrive and generalized muscle weakness. Review of the life enrichment assessment, dated 06/09/21 it was somewhat important for the resident to choose the type of bathing she received. The assessment indicated she preferred showers. Review of the plan of care, dated 06/22/21 revealed the resident required staff assistance to complete activities of daily living (ADL) tasks completely and safely. Interventions included allow resident sufficient time to complete all or parts of task, do not rush resident, encourage resident to do as much as safely possible for self, observe for deterioration in ADL abilities and report if occurs, provide resident adequate rest periods between activities and therapy evaluation and treatment as needed and ordered. The care plan also indicated the resident preferred to wear facility gowns Review of the facility's shower schedule revealed the resident was scheduled for showers every Wednesday and Saturday on day shift. Review of the resident's shower documentation from 01/01/22 through 04/11/22 revealed the resident received only bed baths, however preferred showers. On 04/11/22 at 11:03 A.M. interview with Resident #27 revealed she preferred showers but the staff only assisted/provided her with bed baths. The resident did not provide any additional information as to why she was not provided showers. On 04/12/22 at 2:04 P.M. interview with State Tested Nursing Assistant (STNA) #102 revealed the resident received bed baths. On 04/12/22 at 3:58 P.M. interview with the Director of Nursing (DON) revealed the resident refused to get out of bed. She said staff do offer showers but the resident would refuse to get out of bed. The DON revealed refusals were documented in the nurse's notes and the STNA staff were able to document in a different system. However, no additional information was provided to support the resident had refused showers. Review of the facility policy titled, Resident Choice, dated 06/02/16 revealed the resident had the right to make choices regarding their care, daily routine, religious practices and activity participation.

CONCERN (D)

Potential for Harm - no one hurt, but risky conditions existed

Deficiency F0582 (Tag F0582)

Could have caused harm · This affected 1 resident

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**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on record review and staff interview the facility failed to ensure a beneficiary notice was provided to Resident #70 in a timely manner. This affected one resident (#70) of three residents reviewed for beneficiary notices. Findings Include: Resident #70 was admitted to the facility on [DATE] with diagnoses including encephalopathy, nontraumatic intracerebral hemorrhage, hypertensive emergency, atrial fibrillation, chronic kidney disease, cardiomegaly, benign prostatic hyperplasia, osteoarthritis, coagulation defect, age related physical debility, hypertension, hyperlipidemia and cerebral infarction. Review of the Minimum Data Set (MDS) 3.0 assessment, dated 02/13/22 revealed Resident #70 had intact cognition. Review of Resident #70's beneficiary notice, dated 03/01/22 revealed his last day of covered of rehabilitation and skilled nursing services was on 03/01/22. Resident #70 was presented the beneficiary notice and was told about his last day of covered services on 03/01/22, when he signed that form indicating he understood the financial and services change. On 04/12/22 at 9:40 A.M. interview with Director of Social Services #146 confirmed Resident #70 received the beneficiary notice on same day his skilled and rehabilitation services were to end. She confirmed he also signed the document on the last day of covered services, which was 03/01/22. The notice was not provided in advance of the termination of services as required.

CONCERN (D)

Potential for Harm - no one hurt, but risky conditions existed

Deficiency F0645 (Tag F0645)

Could have caused harm · This affected 1 resident

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**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on record review and staff interview the facility failed to ensure Resident #29's Preadmission Screening and Resident Review (PASARR) was accurate at the time of the resident's admission. This affected one resident (#29) of two residents reviewed for PASARR. Findings Include: Resident #29 was admitted to the facility on [DATE] with diagnoses including hypertensive heart and chronic kidney disease, type II diabetes mellitus, chronic kidney disease, congestive heart failure, psychosis (08/20/20), hyperlipidemia, peripheral vascular disease, Meniere's disease, anxiety disorder (03/10/21), dependence on supplemental oxygen, cardiomyopathy, dysphagia, difficulty walking, chronic obstructive pulmonary disease, hydrocephalus, other specified depressive episodes and old myocardial infarction. Review of the Minimum Data Set (MDS) 3.0 assessment, dated 01/28/22 revealed the resident was cognitively intact. Review of Resident #29's PASARR document, dated 08/10/20, revealed under section D, titled Indications of Serious Mental Illness, the PASARR document indicated the resident had no mental disorders. However, review of Resident #29's medical record face sheet and admission/discharge hospital records, dated 08/12/20 revealed the resident was admitted to the facility with the diagnoses of anxiety disorder and psychosis. Both of these diagnoses should have been listed on the PASARR document when it was completed. On 04/13/22 at 3:05 P.M. interview with Director of Social Services #146 revealed the facility would complete a PASARR document when a resident was admitted (and expected to stay longer than 30 days) or when there was a change in condition and it was needed. She stated she was reliant on the nursing staff to inform her when there was a change in a residents condition/diagnoses. She also confirmed she does not know how information would get to her if a diagnosis changed from nursing. She confirmed Resident #29's PASARR document was not accurate when Resident #29 first admitted to the facility and indicated the PASARR would be updated and resubmitted at this time.

CONCERN (D)

Potential for Harm - no one hurt, but risky conditions existed

ADL Care (Tag F0677)

Could have caused harm · This affected 1 resident

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Based on observation, record review, interview and facility policy review the facility failed to ensure Resident #27, Resident #31 and Resident #46, who required staff assistance for activity of daily living (ADL) care received adequate and timely assistance with showers, dressing and/or oral care to maintain proper grooming and hygiene. This affected three residents (#27, #31 and #46) of six residents reviewed for ADL care. Findings Include: 1. Review of Resident #27's medical record revealed an admission date of 06/08/21 with diagnoses including COVID-19, chronic obstructive pulmonary disease, protein calorie malnutrition, cardiomegaly, severe morbid obesity, obstructive and reflux uropathy, hydronephrosis, hypothyroidism, bipolar disorder, major depressive disorder, obstructive sleep apnea, hypertension, adult failure to thrive and generalized muscle weakness. Review of the life enrichment assessment, dated 06/09/21 revealed it was somewhat important for the resident to choose the type of bathing she received. The assessment indicated she preferred showers. Review of the plan of care, dated 06/22/21 revealed the resident required staff assistance to complete activities of daily living (ADL) tasks completely and safely. Interventions included allow resident sufficient time to complete all or parts of task, do not rush resident, encourage resident to do as much as safely possible for self, observe for deterioration in ADL abilities and report if occurs. provide resident adequate rest periods between activities, resident prefers to wear facility gowns and therapy evaluation and treat as needed and ordered. Review of the facility's shower schedule revealed the resident was scheduled for showers every Wednesday and Saturday on day shift. Review of the January 2022 shower documentation revealed the resident had eight scheduled opportunities for showers and only received two complete bed baths during the month. Review of the February 2022 shower documentation revealed the resident had eight scheduled opportunities for showers and only received two complete bed baths for the month. Review of the March 2022 shower documentation revealed the resident had nine scheduled opportunities for showers and only received one complete bed bath for the month. Review of the April 2022 shower documentation revealed the resident had three scheduled opportunities for showers to date and had not received any showers. On 04/11/22 at 11:03 A.M. interview with Resident #27 revealed she doesn't receive showers and just gets wiped off. On 04/12/22 at 3:58 P.M. interview with the Director of Nursing (DON) verified the resident had not received all of her scheduled bathing. 2. Review of Resident #31's medical record revealed an admission date of 06/27/20 with the admitting diagnoses of dementia with Lewy bodies, COVID-19, heart failure, anxiety disorder, major depressive disorder, psychosis, obstructive sleep apnea, gastro-esophageal reflux disease, osteoarthritis, restlessness and agitation, constipation and dysphagia. Review of the plan of care, dated 07/10/20 revealed the resident required assistance to complete ADL tasks completely and safely. Interventions included allow resident sufficient time to complete all or parts of task, encourage resident to do as much as safely possible for herself, observe for deterioration in ADL abilities and report if occurs, provide adequate resident periods between activities and therapy evaluation and treat as needed and as ordered. Review of the resident's quarterly Minimum Data Set (MDS) 3.0 assessment, dated 02/04/22 revealed the resident's cognition was not assessed. Review of the mood and behavior revealed the resident displayed no behaviors. The resident was dependent on two staff for dressing. The assessment indicated the resident had no skin issues. The assessment indicated the resident was receiving hospice services. Review of the monthly physician's orders for April 2022 revealed an order, dated 10/26/20 for staff to check resident for non-skid footwear with care and rounds and replace as needed. On 04/11/22 at 2:35 P.M., 04/12/22 at 4:10 P.M. and 04/13/22 at 8:52 A.M. Resident #31 was observed wearing shoes without any socks. On 04/13/22 at 1:45 PM interview with State Tested Nursing Assistant (STNA) #187 verified the resident did not have socks on with her shoes but had socks available for use. 3. Review of Resident #46's medical record revealed an initial admission date of 02/03/20 with the most recent admission date 12/03/20. Resident #46 had diagnoses including COVID-19, Alzheimer's disease, protein-calorie malnutrition, hyperlipidemia, anxiety disorder, major depressive disorder, gastro-esophageal reflux disease, osteoporosis, mood disorder and unspecified fall. Review of the plan of care, dated 02/14/20 revealed the resident had potential for mouth pain related to potential problems with natural teeth. Interventions included assess condition of oral cavity, teeth, tongue and lips as needed, assess location of pain, dental evaluation and intervention as needed, encourage fluids to keep oral cavity moist, medications as ordered, observe and report difficulties chewing/swallowing, observe for need for changing diet consistency and offer and provide mouth care as needed. Review of the dental consult, dated 11/04/21 revealed the resident was seen and found to have light calculus and heavy plaque. The dentist recommended assistance from staff for daily hygiene. Review of the quarterly observation and data collection document, dated 01/05/22 revealed the resident had halitosis and inflamed gums. The assessment documented the resident had her own teeth and allowed the staff to brush her teeth. Review of the profile card guide, dated 03/08/22 revealed the resident had her own teeth and were to be brushed twice daily. Review of the resident's comprehensive Minimum Data Set (MDS) 3.0 assessment, dated 03/23/22 revealed the resident had clear speech, understands others, makes herself understood and had a serve cognitive deficit. Review of the mood and behavior section of the MDS revealed the resident had not rejected care. The assessment revealed the resident required extensive assistance from two staff with transfers, bed mobility and personal hygiene, including brushing teeth. The MDS indicated the resident had no obvious or likely cavity or loose natural teeth. On 04/11/22 at 10:26 A.M., 04/12/22 at 9:23 A.M. and 04/13/22 at 8:55 A.M. Resident #46 was observed to have a thick white build up of debris on her teeth. On 04/13/22 at 11:38 A.M. interview with the Director of Nursing verified the resident had a build up of thick white debris on her teeth and required staff assistance for oral care as noted above. Review of the facility policy titled, Oral Care, dated 05/11/16 revealed oral care was to be performed with AM and PM care, as needed and per request of the resident.

CONCERN (D)

Potential for Harm - no one hurt, but risky conditions existed

Quality of Care (Tag F0684)

Could have caused harm · This affected 1 resident

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Based on observation, record review, interview and facility policy and procedure review the facility failed to ensure comprehensive and individualized collaboration of care with the Hospice provider for Resident #31 including changes to guardianship and advance directives and failed to ensure a skin tear and bruising was monitored and treated. This affected one resident (#31) of one resident reviewed for Hospice services and non-pressure related skin conditions. Findings Include: Review of Resident #31's medical record revealed an admission date of 06/27/20 with the admitting diagnoses of dementia with Lewy bodies, COVID-19, heart failure, anxiety disorder, major depressive disorder, psychosis, obstructive sleep apnea, gastro-esophageal reflux disease, osteoarthritis, restlessness and agitation, constipation and dysphagia. Review of the resident's quarterly Minimum Data Set (MDS) 3.0 assessment, dated 02/04/22 revealed the resident's cognition was not assessed. Review of the mood and behavior section revealed the resident displayed no behaviors. The assessment revealed the resident was dependent on two staff for dressing and indicated the resident had no skin issues. The assessment indicated the resident was receiving hospice services. a. Review of the skin tear/laceration skin event, dated 03/22/22 revealed while staff had been transferring the resident she flailed her arm striking it on the wheelchair causing a skin tear to her right forearm. The skin tear measured 1.0 centimeters (cm) in length by 0.5 cm width with superficial depth. The skin was brushed back over the site after cleansing with soap and water and an Allevyn patch was applied. On 04/11/22 at 2:34 P.M. observation of Resident #31's right forearm revealed a large reddish-purple bruise with a scabbed area to her right forearm. Further observation revealed no treatment in place to the scabbed area. Review of the resident's medical record failed to provide an acute plan of care addressing any bruise and skin tear to the resident's right forearm. Review of the monthly physician's orders for April 2022 failed to identify any ongoing treatment order or monitoring order for the bruise and skin tear to the right forearm. Review of the medical record failed to provide continued monitoring and treatment for bruise and skin tear to right forearm after 04/04/22. On 04/14/22 at 11:35 A.M. interview with Assistant Director of Nursing (ADON) #123 verified the resident had no treatment for the area and no monitoring of the areas of impairment to her arm. Review of the facility policy titled, Bruises, Rash, Lesion, Skin Tear, Laceration Assessment Guidelines, dated 05/10/16 revealed weekly follow-up assessment may be completed to ensure bruises/skin tears were in the process of healing. b. Review of the plan of care, dated 12/03/21 revealed the resident required care related to end stage dementia. Interventions included administer drugs as needed for palliation per physician order, administer pain medication as ordered and as needed, be available for resident/family for concerns, needs or wishes, communicate with hospice when changes are indicated to the plan, coordinate care with hospice provider, coordinate plan of care with hospice agency reflecting the hospice philosophy, identify the care and services, identify the care and services to be provided by the facility and the hospice agency and medication and medical supplies to be provided by hospice as needed for palliation and management of the terminal illness, related conditions, provide food and fluids for comfort, provide supportive counseling as needed and respect resident's spiritual and cultural needs. Review of the plan of care, dated 02/17/21 revealed the resident/resident representative had chosen advance directives. Interventions included advance directives reviewed quarterly and as needed, honor my durable power of attorney (POA), honor financial POA, honor medical POA, provide information and/or referrals to end of life resources and supports as needed and provide treating entities with updated notification of advance directives. Review of the April 2022 monthly physician's orders revealed an order (initiated 06/27/20) for a code status of Do Not Resuscitate- Comfort Care (DNRCC). On 04/13/22 at 3:38 P.M. interview with the Director of Nursing (DON) revealed she was unable to locate the resident's DNRCC form so she called the resident's Hospice service to obtain a copy. Upon communication with the Hospice provider on this date, the DON was notified the resident's daughter was now her legal guardian and had changed the resident's code status to a full code. The DON revealed this information had not been communicated to the facility previously. The DON revealed she then contacted the resident's daughter and was informed the resident's daughter had been her guardian since March 2022 and she did request her mother to be a full code. The DON verified the facility and the Hospice service failed to collaborate the resident's care regarding her code status. She said she contacted the resident's physician and notified him of the resident's daughter's request and he gave an order for the resident to be a full code following surveyor intervention.

CONCERN (D)

Potential for Harm - no one hurt, but risky conditions existed

Accident Prevention (Tag F0689)

Could have caused harm · This affected 1 resident

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Based on observation, record review, interview and facility policy and procedure review the facility failed to ensure interventions were in place to prevent falls for Resident #23. This affected one resident (#23) of six residents reviewed for accidents. Findings Include: Review of Resident #23's medical record revealed an admission date of 12/13/21 with diagnoses including vascular dementia without behavioral disturbances, psychosis and repeated falls. Review of the plan of care, initiated 12/24/21 revealed the resident was at risk for falls related to being unsteady at times, dementia and medications. Interventions included a Dycem (a non-slip, rubber-like plastic material used to stabilize surfaces) to the seat of the resident's wheelchair implemented on 04/06/22. Review of the quarterly Minimum Data Set (MDS) 3.0 assessment, dated 02/02/22 revealed the resident had impaired memory and required extensive assistance of one staff member with bed mobility, dressing, toilet use and personal hygiene. The resident required limited assistance of one staff member with transfers. The resident was always incontinent of bladder and frequently incontinent of bowel and had experienced falls since the last assessment period. Review of the quarterly Observation and Data Collection Form, dated 03/05/22 identified the resident as a fall risk. On 04/12/22 at 1:50 P.M. observation revealed the resident was using her feet to propel herself around the dining room on the secured unit. On 04/12/22 at 1:53 P.M. the resident stated Oh and was observed to slide out of her wheelchair onto the dining room floor. Activities Associate (AA) #154 went to check on the resident and summoned for assistance from Registered Nurse (RN) #102. No Dycem was observed on the resident's wheelchair seat. On 04/12/22 at 1:56 P.M. interview with RN #102 verified the ordered Dycem was not in the seat of the resident's wheelchair and the resident was notorious for removing the Dycem from her wheelchair seat. On 04/12/22 at 2:10 P.M. interview with RN #102 revealed a corner section of the resident's Dycem was found on a table in the dining room and the resident would sometimes tear the dycem in pieces. Review of the Fall Management Program Guidelines Policy and Procedure, implemented 05/31/17 and revised 05/22/18 revealed the facility strived to maintain a hazard free environment, mitigate fall risk factors and implement preventative measures.

CONCERN (D)

Potential for Harm - no one hurt, but risky conditions existed

Deficiency F0692 (Tag F0692)

Could have caused harm · This affected 1 resident

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**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** 3. Resident #11 was admitted to the facility on [DATE] with diagnoses included paranoid schizophrenia, hypothyroidism, hyperlipidemia, anxiety disorder, disorder of kidney and ureter, epilepsy, insomnia, hypertension, and unsteadiness on feet. Review of Resident #11's nutritional care plan, dated 01/27/22 revealed an intervention to obtain weights as ordered/needed. Review of the MDS 3.0 assessment, dated 01/28/22 revealed the resident exhibited severe cognitive impairment. Review of nutritional note, dated 03/07/22 revealed Dietitian #201 recommended weekly weights be taken for the next four weeks to verify the weight loss was stabilizing. Review of Resident #11's physician's orders revealed from 03/08/22 to 03/29/22 revealed weight were to be taken once a week for monitoring. This was not completed/documented in the medical record. Review nutritional notes, dated 03/22/22 and 03/29/22 revealed the weight from 03/15/22 was used as the weight of record and basis of Dietitian #201 analysis; there were no other weights documented in the medical record. Also, Dietitian #201 recommended weights continue to be monitored. Review of Resident #11's medical records revealed on 04/13/22 (during the annual survey process), the following weights were entered into the medical record: 01/21/22 (191 pounds), 02/02/22 (179.8 pounds), 02/14/22 (176.6 pounds), 03/06/22 (168.2 pounds), and 03/15/22 (165.6 pounds). Review of Resident #11's weights, after being entered to the electronic record on 04/13/22, revealed the following weights: 03/21/22 (167.4 pounds), 03/29/22 (160.6 pounds), 04/01/22 (160.6 pounds), 04/04/22 (159.9 pounds), 04/11/22 (156.3 pounds). There was no documentation to support a dietitian review of the significant weight loss from 03/21/22 to 04/11/22. Interview with Dietitian #201 on 04/14/22 at 12:12 P.M. and 12:59 P.M. confirmed she was basing her nutritional notes on 03/22/22 and 03/29/22 with the 03/15/22 weight. She confirmed she was not informed or notified of any other weights that should have been taken weekly after 03/15/22. She confirmed with the approximately 11 pound loss from 03/21/22 to 04/11/22, which was handwritten in the weight book but not shared with Dietitian #201, she would have wanted to be notified about this and would have looked at intakes and weights to determine if the resident's nutritional intakes were appropriate. She confirmed she was not sure anything would have changed with Resident #11's nutritional plan/orders, but she also confirmed she needed all the information to make that determination. Interview with Assistant Director of Nursing (ADON) #123 on 04/14/22 at 12:19 PM confirmed weights after 03/15/22 were not entered into the electronic medical records for Dietitian #201 to review until 04/13/22. She stated the typical procedure was for staff to take the weight and document it in the weight book, and then either her or a floor nurse would put them in the electronic medical record. She stated some of the nurses and managers have had to work the floor lately due to staffing issues, so she did not have time to enter them. She revealed the weights were to be put into the electronic medical records as soon as possible. Review of facility Clinical Services-Weight Monitoring policy, dated 12/21/20 revealed weight monitoring was essential to the well-being of the residents served and required a multidisciplinary approach. The facility was to perform a daily review of missing admission weights and provide a list to the floor staff to obtain. Routine review of missing weights would be performed to ensure daily, weekly, and monthly weights were being completed. Based on observation, record review, interview, meal ticket review and facility policy and procedure review the facility failed to ensure Resident #1 and Resident #36 were provided a diet as ordered during the dinner meal on 04/13/22 and failed to ensure weights were documented in the electronic health record and weight loss was reported timely to the dietician as necessary for Resident #11. This affected three residents (#1, #11 and #36) of five residents reviewed for nutrition. Findings include: 1. Review of Resident #1's medical record revealed an admission date of 12/15/21 with diagnoses including Parkinson's Disease, Alzheimer's Disease and chronic obstructive pulmonary disease. Review of the physician's orders revealed the resident had an order (initiated 12/15/21) for a regular, pureed diet with double portions and nectar thickened liquids at meals. Review of the plan of care revealed the resident was malnourished/nutritional risk related to diagnosis, inadequate nutrient/energy intakes and/or metabolic demands; body mass index less than 19, increased metabolic demands with chronic obstructive pulmonary disease warranting oral nutritional supplement for additional calories and protein; risk for sub-optimal oral intakes in the setting of Parkinson's Disease, Alzheimer's and swallowing impairment. The care plan revealed the resident had a mechanically altered diet, initiated 12/2021 with interventions including provide diet per orders. Review of the nutrition progress note, dated 03/23/22 revealed the resident's weight was 86-88 pounds. The resident received a pureed diet with nectar thickened liquids for ease of chewing and swallowing and double portions at meals. The note revealed the weight was within a stable range. Review of the quarterly Minimum Data Set (MDS) 3.0 assessment, dated 03/23/22 revealed the resident was severely impaired for daily decision making and required extensive assistance of one staff member with bed mobility, transfers and ambulation and eating. The resident required extensive assistance of two staff members with dressing, personal hygiene and toilet use. The resident was 60 inches tall and weighed 88 pounds with no weight loss over the last six months. On 04/13/22 at 5:30 P.M. State Tested Nursing Assistant (STNA) #158 was observed to serve Resident #1 a small dish of pureed ham sandwich, a small dish of pureed garden vegetable soup and a small dish of pureed fruit. The resident was also served a thickened juice beverage. Resident Care Associate (RCA) #169 sat with the resident in the dining room and fed the resident her meal. On 04/13/22 at 5:42 P.M. Licensed Practical Nurse (LPN) #107 removed the three small, empty bowls from the table with RCA #169 and Resident #1 while the RCA assisted the resident with her thickened juice. On 04/13/22 at 5:43 P.M. RCA #169 asked Resident #1 if she was done (the resident did not answer) and the RCA assisted Resident #1 from the table. On 04/13/22 at 5:44 P.M., interview with RCA #169 revealed she fed Resident #1 one small dish of pureed sandwich, a small dish of garden vegetable soup and a small dish of fruit for 100% of the meal provided. On 04/13/22 at 5:51 P.M. interview with Dining Services Assistant Director (DSAD) #120 revealed she was the cook for the supper meal and she sent two bowls of pureed ham sandwich and two bowls of soup for Resident #1 to equal her ordered double portions. DSAD #120 indicated the bowls were on the top shelf of the food cart. On 04/13/22 at 5:52 P.M. observation of the food cart revealed double portions of the soup and sandwich were sent to the unit for Resident #1 and interview with RCA #169 verified the resident was not provided her diet per order. RCA #169 verified the dietary department had sent the correct amount of food for the resident for the meal but it was not provided to her. 2. Review of Resident #36's medical record revealed an admission date of 06/23/18 with diagnoses including heart disease, Alzheimer's Disease, dementia without behavioral disturbance, psychosis, and cancer of the large intestine. Record review revealed the resident had a plan of care, initiated 07/06/18 related to at risk for malnutrition related to no natural teeth. Interventions included to increase calorie intake as needed. Review of the physician's orders revealed Hospice care was initiated 02/07/20. The resident had an order (initiated 01/08/21) for a regular, pureed diet with double portions of entree, nectar thickened liquids and may have pleasure foods. Review of the quarterly MDS 3.0 assessment, dated 02/10/22 revealed the resident was severely impaired for daily decision making and required extensive assistance of two staff members with activities of daily living. Review of the nutrition progress note, dated 02/22/22 revealed the resident's weight was stable at 95 pounds. The resident was a weight loss risk with end of life processes, Alzheimer's progression and hospice. The resident received a regular puree diet with double portion entree and nectar thickened liquids. On 04/13/22 at 5:15 P.M. Resident #36 was observed to be served her meal of a small dish of pureed garden vegetable soup and ham sandwich. The resident began to eat her meal without concerns. Review of the resident's meal ticket revealed a puree diet with double portion of the entree and nectar thickened liquids. On 04/13/22 at 5:51 P.M. interview with Dining Services Assistant Director (DSAD) #120 revealed she was the cook for the supper meal and an additional dish of soup was on the food cart for the resident's double entree diet order. DSAD #120 stated the bowl was on the top shelf of the food cart. On 04/13/22 at 5:52 P.M. observation of the food cart revealed double portions of the soup (the entree) was provided for Resident #36 from the kitchen. RCA #169 verified the dietary department had sent the correct amount of food for the resident for the meal but it was not provided to her.

CONCERN (D)

Potential for Harm - no one hurt, but risky conditions existed

Medication Errors (Tag F0758)

Could have caused harm · This affected 1 resident

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**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on record review and interview the facility failed to ensure psychotropic medications were only administered to residents with clinical justification and as needed psychotropic medications were evaluated for duration of use. This affected three residents (#32, #62 and #272) of six residents reviewed for unnecessary medication use. Findings include: 1. Review of Resident #36's medical record revealed an admission date of 06/23/18 with diagnoses including heart disease, Alzheimer's Disease, dementia without behavioral disturbance, psychosis, anxiety and cancer of the large intestine. Review of the physician's orders revealed an order (initiated 07/01/21) for the medication Ativan (antianxiety) 0.5 milligrams (mg) twice a day and Ativan 2 mg per milliliter (ml) give 0.5 mg every four hours as needed for restlessness and anxiety. The order for the as needed doses of Ativan did not have a duration indicated. On 04/14/22 at 11:52 A.M. interview with Regional Nurse #200 verified the order for as needed Ativan didn't have a duration (stop date). 2. Review of Resident #62's medical record revealed an admission date of 09/28/20 with diagnoses including unspecified dementia with behavioral disturbances, hallucinations and bipolar disorder. Review of the physician's orders revealed an order for the medication Ativan (antianxiety medication) 0.5 mg orally every six hours as needed for agitation written 08/16/21 and Ativan two mg per milliliter give 0.25 ml intramuscular every six hours as needed for agitation written 12/01/21. The orders for Ativan did not indicate a duration. Review of the progress note, dated 12/30/21 at 12:40 P.M. revealed the physician visited and completed a chart review. No changes were made at the present time and all current medication orders remained with no changes. On 04/14/22 at 11:52 A.M. interview with Registered Nurse (RN) #200 verified the resident's as needed Ativan order did not have a duration for use and the order must indicate a duration (stop/cut-off date). 3. Review of Resident #272's medical record revealed the resident was admitted on [DATE] with diagnoses including dementia without behavioral disturbance, anxiety, depression and insomnia. Review of the admission physician's medication orders revealed an order for Geodon (antipsychotic medication) used to treat schizophrenia and bipolar disorder 20 mg daily at bedtime. Review of the admission Minimum Data Set (MDS) 3.0 assessment, dated 04/01/22 revealed the resident had severe cognitive impairment and required limited assistance of one staff member with bed mobility, transfers and toilet use. The resident required extensive assistance of one staff member with dressing and was occasionally incontinent of bladder and always continent of bowel. The resident received an antipsychotic medications six days during the assessment period and the diagnoses included anxiety, depression (not including bipolar disorder) and non-Alzheimer's type dementia. Further review of the medical record revealed no clinical justification to support the use of Geodon and no evaluation of need upon admission to the facility. On 04/12/22 at 4:30 P.M. interview with the Director of Nursing verified the resident was receiving an antipsychotic medication without an approved diagnosis or clinical justification after arrival to the facility.

CONCERN (D)

Potential for Harm - no one hurt, but risky conditions existed

Deficiency F0807 (Tag F0807)

Could have caused harm · This affected 1 resident

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Based on observation, record review, staff interview and facility policy and procedure review the facility failed to ensure fluids were readily available for Resident #31 for independent fluid consumption. This affected one resident (#31) of two residents reviewed for hydration. Findings Include: Review of Resident #31's medical record revealed an admission date of 06/27/20 with the admitting diagnoses of dementia with Lewy bodies, COVID-19, heart failure, anxiety disorder, major depressive disorder, psychosis, obstructive sleep apnea, gastroesophageal reflux disease, osteoarthritis, restlessness and agitation, constipation and dysphagia. Review of the plan of care, dated 11/19/21 revealed the resident was on hospice with potential for unavoidable weight loss and nutritional decline and wanted to remain comfortable. Interventions included allow resident to eat and drink as able or as desired, offer alternate and substitute items if needed and weigh monthly or as ordered by physician. Review of the resident's quarterly Minimum Data Set (MDS) 3.0 assessment, dated 02/04/22 revealed the resident's cognition was not assessed. Review of the mood and behavior section of the assessment revealed the resident displayed no behaviors. The resident was dependent on two staff for dressing. The assessment indicated the resident had no skin issues. The assessment indicated the resident was receiving Hospice services. Review of the monthly physician's orders for April 2022 revealed an order dated 02/18/22 to encourage fluids as resident would allow, 02/21/22 for a regular pureed diet with thin liquids and 03/23/22 for Ensure clear one carton three times daily. On 04/11/22 at 2:33 P.M., observation of the resident revealed she was sitting at dining room table with box of miscellaneous items and puzzles. The resident was observed to place doll clothing from a plastic box into her mouth and began sucking on the clothing. The resident's mouth was noted to be dry. A request was made for something to drink for the resident. The resident was given two drinks of lemonade by the State Tested Nursing Assistant (STNA) #187 and the drink was then placed out of the resident's reach. The resident then began placing puzzle pieces into her mouth, sucking on them. The glass of lemonade was moved to within the resident's reach and she immediately drank the remainder of the lemonade. On 04/12/22 at 4:10 P.M. observation of the resident revealed she was sitting at a dining room table with various puzzles, doll clothing and pictures in front of her. She was observed placing the puzzle pieces in her mouth, biting and sucking on the puzzle pieces. On 04/13/22 at 1:45 P.M. observation of the resident revealed she was at the dining room table with a plastic flower pot with a glove and various puzzle pieces in it. She yelled out at an unidentified hospice aide walking by the dining room. The hospice aide spoke with the resident and noted she was placing the items in her mouth and asked if she wanted a drink or food. The resident was given fluids and drank a cup of water at that time. On 04/13/22 at 1:45 P.M. interview with State Tested Nursing Assistant (STNA) #187 revealed the resident does place activity items in her mouth and thought activities staff routinely cleaned the items. At the time of the interview, the STNA verified the resident's mouth was dry and the resident had no access to fluids to consume independently while in the dining area. On 04/14/22 at 10:20 A.M., interview with Life Enrichment Director (LED) #137 revealed she was unaware the resident placed the activity items in her mouth. She was notified of the resident seeking fluids and observation of the resident drinking the cup of lemonade. At the time of the interview, LED #137 asked the resident if she would like something to drink and she said she would love it. Review of the facility policy titled Hydration Management, dated 08/01/16 revealed for residents at risk for dehydration implement individualized interventions which promote sufficient fluid intake to maintain proper hydration. Risk factors may include but were not limited to dependence on staff for mobility and provision of fluid intake.

CONCERN (E)

Potential for Harm - no one hurt, but risky conditions existed

Deficiency F0569 (Tag F0569)

Could have caused harm · This affected multiple residents

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**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on record review, staff interview and facility policy and procedure review the facility failed to ensure resident financial accounts were maintained within the appropriate limits. This affected two residents (#25 and #43) of six residents whose financial records were reviewed. Findings Include: Review of current state Medicaid resident trust guidelines revealed each resident who utilized Medicaid may not keep more than $2000.00 in a trust account. Also, the same guidelines confirmed the COVID-19 stimulus checks (three total) did not count as monthly income; so it would not affect a resident's medical coverage. However, a resident who utilized Medicaid and received stimulus payment(s) had 12 months to spend that money from the time they received it to stay within the allowable limit. Review of federal COVID-19 stimulus documentation revealed three different economic impact payments made to eligible persons. The following were the dates and payment amounts for individuals: $1200 in April 2020, $600 in December 2020/January 2021 and $1400 in March 2021. With these guidelines, a resident who received all three stimulus payments would only be permitted to have the following amounts in their trust account: from April 2020 to December 2020/January 2021, $3200; from December 2020/January 2021 to March 2021, $3800; and from March 2021 to April 2021, $5200. Starting in April 2021 residents were only permitted to have $4000. Starting in December 2021/January 2022, residents were only permitted to have $3400. Then, in April 2022, residents would have to be back down to the permitted $2000. 1. Resident #25 was admitted to the facility on [DATE] with diagnoses including dementia, type II diabetes, morbid obesity, major depressive disorder, hyperlipidemia, personal history of traumatic brain injury, anxiety disorder, abnormalities of gait and mobility, and hypertension. Review of the Minimum Data Set (MDS) 3.0 assessment, dated 01/21/22 revealed the resident was severely cognitively impaired. Review of Resident #25's financial records revealed the resident received Medicaid. According to her bank statement, dated 04/01/21 to 06/30/21, she received a stimulus payment of $1400 on 04/07/21. She also received a total amount of $1800 with her two previous stimulus checks. The resident account total as of 12/31/21 was $5510.06 and on 03/31/22 was $5091.27. According to federal and state guidelines, the resident was permitted to have $3400 in her trust account starting January 2022. On 04/14/22 at 1:15 P.M. and 1:33 P.M. interview with Business Support Staff #202 and Director of Social Services #146 revealed they speak with residents and their families during care conferences if the resident's trust account was over the Medicaid limit. The stated they would also send quarterly letters to residents/representatives when they were over the limit. Both staff revealed if these meetings/discussions occurred, they would have record of them in the resident's medical records. However, there was no documented evidence of discussions with Resident #25 or the resident's representatives about spending down the money. During the interviews, both staff verified the resident was currently over the allowable Medicaid limit and a spend down was necessary. Review of facility Resident Trust Fund Management policy, dated August 2021 revealed the facility would maintain the management of resident trust fund accounts in each campus to ensure compliance with state and federal guidelines. The campus would notify residents in writing who received Medicaid benefits when the balance of the account was $200 less than the maximum amount allowed to be eligible for Medicaid. Review of the undated facility Medicaid Fund Surplus policy revealed the definition of a surplus of funds was when there was an amount of cash over the resource limit for an active Medicaid recipient. Having a surplus at the time of Medicaid application or recertification could cause eligibility to be denied. To ensure the funds were appropriately spent down below the resource limit, follow the below process: funds should be spent on the needs of the resident (clothes, toiletries, electronics, etc. or a pre-paid burial plan). 2. Resident #43 was admitted to the facility on [DATE] with diagnoses including dementia, Parkinsonism, specified depressive episodes, schizoaffective disorder, basil cell carcinoma, bipolar disorder, hyperlipidemia, anxiety disorder, and type II diabetes. Review of the MDS 3.0 assessment, dated 02/09/22 revealed the resident had severe cognitive impairment. Review of Resident #43's financial records revealed she received Medicaid. According to her bank statement, dated 04/01/21 to 06/30/21, she received a stimulus payment of $1400 on 04/07/21. She also received a total amount of $1800 with her two previous stimulus checks. The resident account total as of 12/31/21 was $4340.98 and on 03/31/22 it was $4401.96. According to federal and state guidelines, the resident was permitted to have $3400 in her trust account starting January 2022. On 04/14/22 at 1:15 P.M. and 1:33 P.M. interview with Business Support Staff #202 and Director of Social Services #146 revealed they speak with residents and their families during care conferences if the resident's trust account was over the Medicaid limit. The stated they would also send quarterly letters to residents/representatives when they were over the limit. Both staff revealed if these meetings/discussions occurred, they would have record of them in the resident's medical records. However, there was no documented evidence of discussions with Resident #43 or the resident's representatives about spending down the money. During the interviews, both staff verified the resident was currently over the allowable Medicaid limit and a spend down was necessary. Review of facility Resident Trust Fund Management policy, dated August 2021 revealed the facility would maintain the management of resident trust fund accounts in each campus to ensure compliance with state and federal guidelines. The campus would notify residents in writing who received Medicaid benefits when the balance of the account was $200 less than the maximum amount allowed to be eligible for Medicaid. Review of the undated facility Medicaid Fund Surplus policy revealed the definition of a surplus of funds was when there was an amount of cash over the resource limit for an active Medicaid recipient. Having a surplus at the time of Medicaid application or recertification could cause eligibility to be denied. To ensure the funds were appropriately spent down below the resource limit, follow the below process: funds should be spent on the needs of the resident (clothes, toiletries, electronics, etc. or a pre-paid burial plan).

CONCERN (E)

Potential for Harm - no one hurt, but risky conditions existed

Drug Regimen Review (Tag F0756)

Could have caused harm · This affected multiple residents

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**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on record review and staff interview the facility failed to ensure pharmacy recommendations were timely and appropriately addressed. This affected four residents (#29, #322, #36 and #62) of six residents reviewed for unnecessary medication use. Findings Include: 1. Resident #29 was admitted to the facility on [DATE] with diagnoses including hypertensive heart and chronic kidney disease, type II diabetes, chronic kidney disease, congestive heart failure, psychosis (08/20/20), hyperlipidemia, peripheral vascular disease, Meniere's disease, Anxiety disorder (03/10/21), dependence on supplemental oxygen, cardiomyopathy, dysphagia, difficulty walking, chronic obstructive pulmonary disease, hydrocephalus, other specified depressive episodes, and old myocardial infarction. Review of Resident #29's medical records revealed a pharmacy recommendation, dated 06/23/21 to review the following medications to consider the benefit/need of them: Haloperidol 0.5 milligrams (mg) twice daily, Ativan 0.5 mg three times daily, and Sertraline 100 mg twice daily. Review of an Event Report, dated 06/23/21 revealed the physician was notified of the pharmacy recommendations. It also indicated that the physician disagreed with the recommendation, but did not give specific details as to what was disagreed with, or justification for the disagreement. Review of Resident #29's progress note, dated 06/24/21 revealed the physician was updated with the pharmacy recommendation with no new orders at this time. Review of Resident #29's progress note, dated 07/01/21 revealed the physician reported to the facility that no reduction in Haloperidol, Ativan, or Sertraline were going to occur at that time. There was no justification given; only that there would be no reduction. Review of Resident #29's medical records revealed a pharmacy recommendation, dated 02/20/22 to review the use of as needed (PRN) Bisacodyl, as needed Milk of Magnesia and as needed Promethazine. The recommendation was to potentially discontinue the use of them because they had not been used. According to an Event Report, dated 02/20/22 the physician was notified of the pharmacy recommendation. The event report did not indicate whether the resident agreed or disagreed with the recommendation. Review of Resident #29's progress note, dated 02/28/22 revealed the facility documented per physician report he had reviewed Resident #29's medications with no new changes. There was no justification given for not giving any new orders or to the specific pharmacy recommendation. Interview with Regional Director #200 on 04/14/22 at 11:41 A.M. confirmed there was no justification and/or clarification for Resident #29's pharmacy recommendations as noted above. 2. Resident #322 was admitted to the facility on [DATE] with diagnoses including acute posthemorrhagic anemia, chronic respiratory failure, atrial fibrillation, old myocardial infarction, atherosclerotic heart disease, chronic kidney disease, congestive heart failure, chronic obstructive pulmonary disease, emphysema, type II diabetes, sleep apnea, hyperlipidemia, depression, anxiety disorder, polyp of colon, dizziness and giddiness, restlessness and agitation, and personal history of transient ischemic attack. Review of Resident #322's medical record revealed a pharmacy recommendation, dated 07/20/21 to review current order of Levemir 10 units and Toujeo 10 units for possible duplicate therapy. Review of an Event Report, dated 07/20/21 revealed the physician was notified of the pharmacy recommendation and agreed with the recommendation. Review of Resident #322's progress notes, dated 07/31/21 confirmed staff reported to the physician to review the use of both long acting insulin for possible duplicate therapy. Review of progress note, dated 08/03/21 revealed Levemir was discontinued on 07/29/21, which was prior to the entry on 07/31/21 in which the facility reported to the physician about the pharmacy recommendation. Also, there was no documented justification for the discontinuation of Levemir, and there was no clarification to the event report, dated 07/20/21, when the physician reported that he agreed with the recommendation. Review of Resident #322's medical record revealed a pharmacy recommendation, dated 11/08/21 to review her current order of DuoNeb as opposed to the hospital discharge records recommending the resident be placed on Albuterol. The recommendation stated, please clarify. According to the Event Report, dated 11/08/21, the physician was notified of the recommendation and agreed with all the recommendations. Review of Resident #322's progress note, dated 11/10/21 revealed staff recorded, physician in for house visit, reviews pharmacy recommendations and agrees. There was no clarification and/or justification to the actual pharmacy recommendation. Interview with Regional Director #200 on 04/14/22 at 11:41 A.M. confirmed there was no justification and/or clarification for Resident #322 related to the above pharmacy recommendations. 3. Review of Resident #36's medical record revealed an admission date of 06/23/18 with diagnoses including heart disease, Alzheimer's Disease, dementia without behavioral disturbance, psychosis, anxiety and cancer of the large intestine. Review of the physician's orders revealed an order (dated 07/01/21) for the medication Ativan (antianxiety) 0.5 milligrams (mg) twice a day and Ativan 2 mg per milliliter (ml) give 0.5 mg every four hours as needed for restlessness and anxiety. The order for the as needed doses of Ativan did not have a duration indicated. Review of the quarterly Minimum Data Set (MDS) 3.0 assessment, dated 02/10/22 revealed the resident was severely impaired for daily decision making and required extensive assistance of two staff members fir activities of daily living. Review of the pharmacy recommendation, dated 11/08/21 revealed the resident had protocol anxiolytic/hypnotic orders for as needed Ativan. Since hospice still focuses on the last six months of life please consider adding a stop date of six months. Orders started on 07/01/21 and needs a stop date. Review of the nursing progress note, dated 11/11/21 at 6:08 A.M. revealed the primary care physician extended the antianxiety medication for six months. Further review of the physician orders revealed the Ativan order was not written to extend the Ativan/antianxiety medication for six months. On 04/14/22 at 11:52 A.M. interview with Regional Nurse #200 verified the pharmacy recommendation was not addressed as recommended. 4. Review of Resident #62's medical record revealed an admission date of 09/28/20 with diagnoses including unspecified dementia with behavioral disturbances, hallucinations and major depressive disorder. Review of the physician's orders revealed an order for the medication Seroquel (antipsychotic medication) 25 mg twice a day for anxiety and agitation; Ativan (antianxiety medication) 0.5 mg orally every six hours as needed for agitation written on 08/16/21 and Ativan two mg per milliliter give 0.25 ml intramuscular every six hours as needed for agitation written on 12/01/21. The orders for Ativan did not indicate a duration. Review of the pharmacy recommendation, dated 12/13/21 revealed the resident received as needed Ativan that was due for evaluation. Please review/evaluate continued need/benefit and consider if appropriate to attempt a gradual dose reduction at this time. If maintaining the as needed Ativan orders, please add re-evaluation date. The recommendation also noted the resident had orders for Seroquel that was due for evaluation. Please review/evaluate continued need/benefit and consider if appropriate to a attempt a gradual dose reduction at this time. If maintaining the dose, please document the rationale for the record. Review of the progress note, dated 12/30/21 at 12:40 P.M. revealed the physician visited and completed a chart review. No changes were made at the present time and all current medication orders remained with no changes. On 04/14/22 at 11:52 A.M. interview with Regional Director #200 verified the pharmacy recommended was not addressed.

Understanding Severity Codes (click to expand)

Life-Threatening (Immediate Jeopardy)

J - Isolated K - Pattern L - Widespread

Actual Harm

G - Isolated H - Pattern I - Widespread

Potential for Harm

D - Isolated E - Pattern F - Widespread

No Harm (Minor)

A - Isolated B - Pattern C - Widespread

Questions to Ask on Your Visit

"What changes have you made since the serious inspection findings?"
"What safeguards are in place to prevent abuse and neglect?"
"Can I speak with families of current residents?"
"What's your RN coverage like on weekends and overnight?"

Our Honest Assessment

Strengths

• Licensed and certified facility. Meets minimum state requirements.

Concerns

• Multiple safety concerns identified: Federal abuse finding, 1 life-threatening violation(s), Special Focus Facility, 6 harm violation(s), $51,951 in fines, Payment denial on record. Review inspection reports carefully.
• 97 deficiencies on record, including 1 critical (life-threatening) violation. These warrant careful review before choosing this facility.
• $51,951 in fines. Extremely high, among the most fined facilities in Ohio. Major compliance failures.
• Grade F (0/100). Below average facility with significant concerns.

Bottom line: This facility has a substantiated abuse finding. Extreme caution advised. Explore alternatives.

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About This Facility

What is Highland Oaks's CMS Rating?

CMS assigns HIGHLAND OAKS HEALTH CENTER an overall rating of 1 out of 5 stars, which is considered much below average nationally. Within Ohio, 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 Highland Oaks Staffed?

CMS rates HIGHLAND OAKS HEALTH CENTER's staffing level at 4 out of 5 stars, which is above average compared to other nursing homes. Staff turnover is 48%, compared to the Ohio average of 46%.

What Have Inspectors Found at Highland Oaks?

State health inspectors documented 97 deficiencies at HIGHLAND OAKS HEALTH CENTER during 2022 to 2025. These included: 1 Immediate Jeopardy (the most serious level, indicating potential for serious harm or death), 6 that caused actual resident harm, 87 with potential for harm, and 3 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 Highland Oaks?

HIGHLAND OAKS HEALTH CENTER is owned by a for-profit company. For-profit facilities operate as businesses with obligations to shareholders or private owners. The facility is operated by TRILOGY HEALTH SERVICES, a chain that manages multiple nursing homes. With 99 certified beds and approximately 91 residents (about 92% occupancy), it is a smaller facility located in MCCONNELSVILLE, Ohio.

How Does Highland Oaks Compare to Other Ohio Nursing Homes?

Compared to the 100 nursing homes in Ohio, HIGHLAND OAKS HEALTH CENTER's overall rating (1 stars) is below the state average of 3.2, staff turnover (48%) is near the state average of 46%, and health inspection rating (1 stars) is much below the national benchmark.

What Should Families Ask When Visiting Highland Oaks?

Based on this facility's data, families visiting should ask: "What changes have been made since the serious inspection findings, and how are you preventing similar issues?" "What safeguards and monitoring systems are in place to protect residents from abuse or neglect?" "Can I visit during a mealtime to observe dining assistance and food quality?" "How do you handle medical emergencies, and what is your hospital transfer rate?" These questions are particularly relevant given the facility's Immediate Jeopardy citations and the substantiated abuse finding on record.

Is Highland Oaks Safe?

Based on CMS inspection data, HIGHLAND OAKS HEALTH CENTER has documented safety concerns. The facility has 1 substantiated abuse finding (meaning confirmed case of resident harm by staff or other residents). Inspectors have issued 1 Immediate Jeopardy citation (the most serious violation level indicating risk of serious injury or death). The facility is currently on the Special Focus Facility watch list (a federal program monitoring the lowest-performing 1% of nursing homes nationwide). The facility has a 1-star overall rating and ranks #100 of 100 nursing homes in Ohio. Families considering this facility should ask detailed questions about what corrective actions have been taken since these incidents.

Do Nurses at Highland Oaks Stick Around?

HIGHLAND OAKS HEALTH CENTER has a staff turnover rate of 48%, which is about average for Ohio 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 Highland Oaks Ever Fined?

HIGHLAND OAKS HEALTH CENTER has been fined $51,951 across 1 penalty action. This is above the Ohio average of $33,598. 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 Highland Oaks on Any Federal Watch List?

HIGHLAND OAKS HEALTH CENTER is currently an SFF Candidate, meaning CMS has identified it as potentially qualifying for the Special Focus Facility watch list. SFF Candidates have a history of serious deficiencies but haven't yet reached the threshold for full SFF designation. The facility is being monitored more closely — if problems continue, it may be added to the official watch list. Families should ask what the facility is doing to address the issues that led to this status.

Facility Details

Beds: 99
Avg. Residents: 91
Occupancy: 92.2%
Ownership: For profit - Limited Liability company
Chain: TRILOGY HEALTH SERVICES
Medicare: Yes
Medicaid: Yes
Sprinklers: Yes

Trust Score Breakdown

Base Score: 50
1-Star Rating: +0
1 Immediate Jeopardy citation: -12
6 Actual Harm citations: -30
97 Deficiencies: -10
Fines ($51,951): -10
Abuse Finding: -15
Special Focus Facility: -20
Final Score: 0/100

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Data: CMS Medicare Care Compare

Updated: November 2025

Facility ID: 365147