CARRIAGE INN OF STEUBENVILLE
For profit - Corporation
120 Beds
Independent
Data: November 2025
Trust Grade
55/100
#433 of 913 in OH
Photo by Carriage Inn of Steubenville
Photo by Samson King
Photo by Samson King
1 / 5 photos
Last Inspection: March 2024
Within standard 12-15 month inspection cycle. Federal law requires annual inspections.
Overview
Carriage Inn of Steubenville has a Trust Grade of C, which means it is average and sits in the middle of the pack compared to other facilities. It ranks #433 out of 913 in Ohio, placing it in the top half of nursing homes in the state, and #2 out of 6 in Jefferson County, indicating that only one local option is better. Unfortunately, the facility is worsening, with issues increasing from 5 in 2022 to 11 in 2024. Staffing is a relative strength, earning a 3/5 star rating with a turnover rate of 37%, which is lower than the state average, suggesting that staff tend to stay longer and build relationships with residents. On the downside, there have been concerning incidents, including a resident who suffered a hip fracture after attempting to toilet themselves without proper assistance and a failure to ensure staff were adequately vetted for abuse or neglect histories, which poses a potential risk to all residents.
- Trust Score
- C
- In Ohio
- #433/913
- Safety Record
- Moderate
- Inspections
- Getting Worse
- Staff Stability ○ Average
- 37% turnover. Near Ohio's 48% average. Typical for the industry.
- Penalties ✓ Good
- No fines on record. Clean compliance history, better than most Ohio facilities.
- Skilled Nurses ✓ Good
- Each resident gets 52 minutes of Registered Nurse (RN) attention daily — more than average for Ohio. RNs are trained to catch health problems early.
- Violations ⚠ Watch
- 43 deficiencies on record. Higher than average. Multiple issues found across inspections.
55/100
Top 47%
Needs review
5 → 11 violations
★★★☆☆
3.0
Overall Rating
★★★☆☆
3.0
Staff Levels
★★★☆☆
3.0
Care Quality
★★★☆☆
3.0
Inspection Score
↔
Stable
2022: 5 issues
2024: 11 issues
The Good
-
Full Sprinkler Coverage · Fire safety systems throughout facility
-
No fines on record
-
Staff turnover below average (37%)
11 points below Ohio average of 48%
Facility shows strength in fire safety.
The Bad
3-Star Overall Rating
Near Ohio average (3.2)
Meets federal standards, typical of most facilities
Staff Turnover: 37%
Near Ohio avg (46%)
Typical for the industry
The Ugly 43 deficiencies on record
1 actual harm
Dec 2024
5 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
**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, medical record review, and interview, the facility failed to notify hospice of a resident refusal of respi...
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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 notify hospice of a resident refusal of respiratory treatments. This affected one (#83) of three residents sampled. The census was 84.
Findings include:
Medical record review revealed Resident #83 was admitted to the facility on [DATE] with diagnosis including Parkinson's disease.
Review of the significant change Minimum Data Set 3.0 assessment dated [DATE] revealed Resident #83 was severely impaired for daily decision-making, was receiving hospice services and had two or more falls resulting in no injuries and two or more falls resulting in injuries.
Review of the electronic Physician Orders dated 07/11/24 revealed Continuous Positive Airway Pressure (CPAP) machine (a treatment for sleep apnea that involves wearing a mask while you sleep that delivers mild air pressure to keep breathing airways open during sleep) to be worn at bedtime and continue home settings.
Review of the hospice Physician Plan of Care dated 10/16/24 revealed physician orders including to start oxygen via nasal cannula two liters to five liters per minute continuously.
On 12/17/24 at 9:32 A.M., observation revealed Resident #83 was lying in bed. An oxygen concentrator was observed beneath the window with nasal cannula (oxygen tubing that delivers oxygen through your nose) laying on the floor. The oxygen tubing was dated 11/09/24. A CPAP machine was observed sitting on the window sill.
On 12/18/24 at 9:03 A.M., interview with Certified Nursing Assistant #206 stated Resident #83 uses oxygen when he gets short of breath but would need to speak to the nurse about that.
On 12/18/24 at 9:22 A.M., interview with Licensed Practical Nurse (LPN) #208 verified there were no current physician orders in the computer for Resident #83's oxygen to be administered and the resident does not wear the oxygen continuously. LPN #208 also verified the CPAP order did not have the ordered settings and had been refused all but one day between 11/01/24 and 12/18/24 without notifying hospice or the physician.
This deficiency was an incidental finding discovered during the complaint investigation.
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
Accident Prevention
(Tag F0689)
Could have caused harm · This affected 1 resident
**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 fall interventions were ...
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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 fall interventions were implemented. This affected one (#83) of three residents sampled. The census was 84.
Findings include:
Medical record review revealed Resident #83 was admitted on [DATE] with diagnosis including Parkinson's disease.
Review of the significant change Minimum Data Set 3.0 assessment dated [DATE] revealed Resident #83 was severely impaired for daily decision-making, was receiving hospice services and had two or more falls resulting in no injuries and two or more falls resulting in injuries.
Review of the care plan: Potential for Falls: Resident is at risk for falls and fall related injury related to impaired vision, medication use, requires assist with transfers, and history of falls revised 10/30/24 revealed interventions including to keep call light within reach, assist with wearing proper footwear, assist with wearing glasses and encourage him to wear non-skid gripper socks when not wearing shoes.
Review of Resident #83's Progress Notes on 12/16/24 at 12:06 P.M. revealed Licensed Practical Nurse (LPN) #204 witnessed Resident #83 leaning to his left and appeared to be trying to get to his shoes. The resident fell to the floor and no injuries were observed. The physician and family were notified of the fall and staff were notified the resident was to be in a geri-chair at all times. On 12/17/24 at 12:16 P.M. Resident #83's fall intervention was changed from a geri-chair to keeping a grabber (reach extender that increases the range of a person's reach and grasp when grabbing objects) within reach. The resident was already utilizing a geri-chair for comfort as ordered by hospice services.
Review of the Fall Risk Evaluation dated 12/16/24 revealed Resident #83 was at high risk for falls. Review of the Learning Circle In-Service dated 12/16/24 revealed a new intervention for Resident #83 was to be in a geri-chair when up. Further review of the Inservice revealed no evidence Certified Nursing Assistant (CNA) #206 was educated of the resident's fall or signed the Inservice sheet as acknowledgment of the new intervention.
Review of Resident #83's fall care plan revealed no evidence the fall care plan was revised after his fall on 12/16/24 with the new intervention to have a grabber within reach or for the resident to be in a geri-chair when out of bed.
On 12/17/24 at 9:32 A.M., observation revealed Resident #83 was lying in bed wearing only an incontinence product with a sheet draped across his lower abdomen. The resident was not wearing gripper socks, no gripper socks were observed in the bed, his touch pad call light was not within reach and was positioned at the end of the bed, resting against the foot board.
On 12/18/24 at 9:02 A.M., observation revealed Resident #83 was lying in bed, was not wearing gripper socks or his glasses and his touchpad call light was positioned between the mattress and the footboard. Interview with Housekeeping #207 at the time of the observation verified the call light was not within reach of the resident.
On 12/18/24 at 9:03 A.M., interview with Certified Nursing Assistant (CNA) #206 revealed she was caring for Resident #83 and he was a high fall risk. CNA #206 verified Resident #83's touchpad call light was not within reach and stated his fall interventions included for the call light to be within reach, wearing his glasses, in a low bed with a floor mat and the bed against the wall. CNA #206 stated the resident was to be up in his specialized tilt-n-space wheelchair when out of bed. CNA #206 stated she was not aware of any recent falls or other interventions she should be checking.
On 12/18/24 at 9:11 A.M., interview with LPN #208 stated Resident #83 had a fall from his chair on 12/16/24 and the new intervention was for a grabber to be in reach to assist the resident in picking up items off the floor. LPN #208 stated after a resident fall, the nursing staff completes an investigation and starts education on the new interventions implemented to try to prevent the resident from falling again.
On 12/18/24 at 9:13 A.M., observation of Resident #83's room with LPN #208 revealed there was no grabber (extended reacher) in his room for use and the resident glasses were not on. LPN #208 verified without his glasses, Resident #83 would not be able to see the posted reminder on the wall that stated Please hit call light for assistance getting up!
On 12/18/24 at 10:00 A.M., interview with the Director of Nursing (DON) verified there was no grabber or reach extender available for use currently in the facility. The DON stated the grabbers were on order, had not been delivered yet and Resident #83 has not had one to use yet. The DON verified no other intervention had been implemented to prevent further falls since the 12/16/24 fall.
Review of the policy: Falls and Fall Risk, Managing reviewed 12/18/24 revealed staff was to identify interventions related to the resident's specific risks and causes to try to prevent the resident from falling and to try to minimize complications from falling. Fall risk factors included footwear that was unsafe or absent. Staff was to implement a resident-centered fall prevention plan to reduce the specific risk factors of falls for each resident at risk or with a history of falls.
This deficiency represents non-compliance investigated under Complaint Number OH00159914.
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
Respiratory Care
(Tag F0695)
Could have caused harm · This affected 1 resident
**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, medical record review, policy review and interview, the facility failed to provide appropriate care for ox...
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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 provide appropriate care for oxygen and respiratory equipment. This affected one (#83) of three residents sampled. The census was 84.
Findings include:
Medical record review revealed Resident #83 was admitted on [DATE] with diagnoses including Parkinson's disease, generalized anxiety disorder, pneumonia and acute respiratory failure with hypoxia.
Review of the electronic Physician Orders dated 07/11/24 revealed Continuous Positive Airway Pressure (CPAP) machine (a treatment for sleep apnea that involves wearing a mask while you sleep that delivers mild air pressure to keep breathing airways open during sleep) to be worn at bedtime and continue home settings.
Review of the hospice Physician Plan of Care dated 10/16/24 revealed physician orders including to start oxygen via nasal cannula two liters to five liters per minute continuously.
Review of the significant change Minimum Data Set 3.0 assessment dated [DATE] revealed Resident #83 was severely impaired for daily decision-making and was receiving hospice services.
On 12/17/24 at 9:32 A.M., observation revealed Resident #83 was lying in bed. An oxygen concentrator was observed beneath the window with nasal cannula (oxygen tubing that delivers oxygen through your nose) laying on the floor. The oxygen tubing was dated 11/09/24. A CPAP machine was observed sitting on the window sill and the face mask was observed to have speckled black spots on the cushion of the face mask as it was resting on the window sill. The face mask was not covered or resting on a barrier.
On 12/18/24 at 9:02 A.M., observation revealed Resident #83's oxygen tubing was laying on the floor and CPAP mask was laying on the window sill without a barrier.
On 12/18/24 at 9:03 A.M., interview with Certified Nursing Assistant #206 stated Resident #83 uses oxygen when he gets short of breath but would need to speak to the nurse about that.
On 12/18/24 at 9:13 A.M., interview with Licensed Practical Nurse (LPN) #208 verified Resident #83's oxygen and CPAP equipment should be kept in a bag and changed when used. LPN #208 verified the oxygen tubing was dated 11/09/24 and should be changed weekly by the nursing staff. At 9:22 A.M., LPN #208 stated there were no current physician orders in the computer for Resident #83's oxygen and the CPAP order did not have the ordered settings just to continue home settings but she did not know what those were. LPN #208 stated she would have to contact the physician for clarification.
Review of the policy: Oxygen Administration revised 12/18/24 revealed oxygen was to be administered to residents who need it, consistent with professional standards of practice, the comprehensive person-centered care plans and the resident's goals and preferences. Oxygen was to be administered under orders of a physician and cleaning and care of equipment shall be in accordance with facility policies.
This deficiency was an incidental finding discovered during the complaint investigation.
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
Unnecessary Medications
(Tag F0759)
Could have caused harm · This affected 1 resident
**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, medical record review, policy review and interview, the facility failed to administer medications as order...
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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 administer medications as ordered. This affected two (#50 and #58) of four residents observed for medication administration during 29 opportunities for error resulting in a 13.7% medication error rate. The census was 84.
Findings include:
1. Medical record review revealed Resident #50 was admitted on [DATE] with diagnoses including hypertension, congestive heart failure, coronary artery disease and anxiety.
Review of the electronic Physician Orders dated December 2024 revealed to administer medications including a chewable aspirin (ASA) 81 milligrams (mg), Isosorbide Dinitrate 30 mg once a day with physician parameters to hold if her systolic blood pressure (SBP) was less than 100, and Lopressor 25 mg with physician parameters to hold if her SBP was less than 100.
On 12/17/24 between 9:39 A.M. and 9:48 A.M., observation of Resident #50's medication administration revealed Registered Nurse (RN) #209 assessed Resident #50's blood pressure and stated it was 108/72 millimeters of mercury (mmHg). RN #209 went back to the medication cart and dispensed medication into a medication cup including ASA enteric coated (EC) 81 milligrams. During the medication administration, RN #209 stated she was not going to administer Isosorbide or Lopressor due to the resident's blood pressure reading of 108/72 mmHg. RN #209 verified the two medications were not administered despite the resident's blood pressure exceeding the parameters to withhold the medications.
2. Medical record review revealed Resident #58 was admitted on [DATE] with diagnoses including cerebral infarction.
Review of the electronic Physician Orders dated December 2024 revealed to administer medications including ASA 81 mg.
On 12/17/24 at 9:50 A.M., observation revealed RN #209 administered ASA EC 81 mg to Resident #58.
On 12/17/24 between 9:50 A.M. and 9:55 A.M., interview with Registered Nurse #209 verified ASA EC 81 mg was administered to Resident #58 and not an ASA 81 mg as ordered.
Review of the policy: Administering Medications revised April 2019 revealed medications were to be administered as prescribed.
This deficiency represents non-compliance investigated under Complaint Number OH00159914.
CONCERN
(D)
📢 Someone Reported This
A family member, employee, or ombudsman was alarmed enough to file a formal complaint
Potential for Harm - no one hurt, but risky conditions existed
Medical Records
(Tag F0842)
Could have caused harm · This affected 1 resident
**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on medical record review and interview, the facility failed to maintain a complete medical record. This affected one (Resi...
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**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on medical record review and interview, the facility failed to maintain a complete medical record. This affected one (Resident #85) of three residents sampled. The census was 84.
Findings include:
Closed medical record review revealed Resident #85 was admitted on [DATE] and discharged on 10/31/24.
Review of the closed record revealed a handwritten Physician's Progress Notes dated 10/25/24 by Nurse Practitioner #210 and Physician's Progress note dated 10/31/24 by Physician #201. The progress note sheet was not labeled with a resident name, identification number or room number. There was no identifying information on the Physician's Progress Note sheet to indicate who the note was for.
On 12/18/24 at 2:30 P.M., interview with the Director of Nursing (DON) verified the Physician Progress Note was in the closed record for Resident #85; however, with no resident information he could not verify what resident it was for without the physician and nurse practitioner to verify. The DON verified the medical record was not complete.
This deficiency is an incidental finding discovered during the complaint investigation.
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 F0602
(Tag F0602)
Could have caused harm · This affected multiple residents
THE FOLLOWING DEFICIENCY REPRESENTS AN INCIDENT OF PAST NONCOMPLIANCE THAT WAS SUBSEQUENTLY CORRECTED PRIOR TO THIS SURVEY.
Based on medical record review, review of a facility self-reported incident ...
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THE FOLLOWING DEFICIENCY REPRESENTS AN INCIDENT OF PAST NONCOMPLIANCE THAT WAS SUBSEQUENTLY CORRECTED PRIOR TO THIS SURVEY.
Based on medical record review, review of a facility self-reported incident (SRI), review of the facility investigation, facility policy review, and interview, the facility failed to ensure residents were free from misappropriation of medications. This affected 13 (Resident #1, #3, #4, #8, #12, #15, #16, #17, #18, #19, #20, #21, and #22) of 13 residents reviewed for misappropriation. The facility census was 99.
Findings include:
Review of the Self-Reported Incident (SRI) Tracking Number 251396, dated 08/31/24, revealed on 08/31/24, a concern was reported related to missing medications from Licensed Practical Nurse (LPN) #400's medication cart. On 08/31/24 at approximately 1:00 P.M. the Administrator was watching video cameras and noticed suspicious activity by LPN #400 while she was administering medications. LPN #400 was observed going through the narcotics drawer but not having the medication administration record (MAR) pulled up or documenting on the narcotic count sheets. LPN #400 was immediately suspended pending investigation. An immediate investigation was initiated. During a medication audit on 08/31/24 at 4:30 P.M., completed by the Director of Nursing (DON) and the Assistant Director of Nursing (ADON), it was determined that medications in the cart were unaccounted for, and several routine medications were found in the top drawer of the medication cart. These medications were identified by their imprint code on the medication and compared with resident medication profiles to establish who the medications belonged to. Routine medications in Paxits (a secure bag containing medications scheduled at a specific time of the day with clearly labeled medication information printed on the bag) were found discarded in the trash. Controlled substances were unaccounted for and not documented on MARS or on narcotic count sheets.
1. Review of the medical record for the Resident #1 revealed an admission date of 09/24/23. Diagnoses included dementia, psychotic disorder with hallucinations, adult failure to thrive, acute respiratory failure, and myasthenia gravis.
Review of the quarterly Minimum Data Set (MDS) assessment, dated 07/24/24, revealed the resident had severe cognitive impairment.
Review of the facility's SRI investigation revealed Resident #1 was not administered risperidone 0.5 milligrams (mg) on 08/31/24 at 12:00 P.M. or buspirone 15 mg on 08/31/24 at 2:00 P.M. as ordered by the physician.
2. Review of the medical record for the Resident #3 revealed an admission date of 06/07/23. Diagnoses included dementia, muscle wasting and atrophy, depression, anxiety disorder, and irritability and anger.
Review of the quarterly Minimum Data Set (MDS) assessment, dated 08/08/24, revealed the resident had severe cognitive impairment.
Review of the facility's SRI investigation revealed Resident #3 was not administered Prednisone 10 mg and sertraline 25 mg on 08/31/24 at 9:00 A.M. as ordered by the physician. Further review of Resident #3's Controlled Drug Receipt/Record/Disposition Form for oxycodone 5 mg indicated there should have been 47 pills remaining, however, there were only 46 pills remaining without documentation of administration of the oxycodone.
3. Review of the medical record for the Resident #4 revealed an admission date of 04/02/24. Diagnoses included metabolic encephalopathy, diabetes mellitus, chronic kidney disease, cerebral vascular disease, and repeated falls.
Review of the quarterly Minimum Data Set (MDS) assessment, dated 07/09/24, revealed the resident had moderate cognitive impairment.
Review of the facility's SRI investigation revealed Resident #4 was not administered metoclopramide 5 mg on 08/31/24 at 11:00 A.M. and gabapentin 400 mg on 08/31/24 at 2:00 P.M. as ordered by the physician.
4. Review of the medical record for the Resident #8 revealed an admission date of 12/21/21. Diagnoses included Alzheimer's disease, dementia, muscle wasting and atrophy, anxiety disorder, dysphagia, and repeated falls.
Review of the quarterly Minimum Data Set (MDS) assessment, dated 08/08/24, revealed the resident had severe cognitive impairment.
Review of the facility's SRI investigation revealed Resident #8 was not administered Depakote Sprinkle 125 mg, two tablets, on 08/31/24 at 9:00 A.M. as ordered by the physician.
5. Review of the medical record for the Resident #12 revealed an admission date of 08/02/13. Diagnoses included Alzheimer's disease, dementia, muscle wasting and atrophy, anxiety disorder, dysphagia, and repeated falls.
Review of the quarterly Minimum Data Set (MDS) assessment, dated 07/04/24, revealed the resident had moderate cognitive impairment.
Review of the facility's SRI investigation revealed Resident #12's Controlled Drug Receipt/Record/Disposition Form for oxycodone 10 mg indicated there should have been 11 pills remaining, however, there were only nine pills remaining and without documentation of administration. During interview on 08/31/24 with Resident #12, she stated she had not requested pain medication on that day.
6. Review of the medical record for the Resident #15 revealed an admission date of 08/12/22. Diagnoses included Alzheimer's disease, adult failure to thrive, anxiety disorder, dysphagia, and unsteadiness on feet.
Review of the annual Minimum Data Set (MDS) assessment, dated 06/08/24, revealed the resident had severe cognitive impairment.
Review of the facility's SRI investigation revealed Resident #15's Controlled Drug Receipt/Record/Disposition Form for lorazepam 0.5 mg indicated there should have been 53 pills remaining, however, there were only 52 pills remaining and without documentation of administration.
7. Review of the medical record for the Resident #16 revealed an admission date of 05/03/21. Diagnoses included dementia, depression, catatonic disorder, anxiety disorder, morbid obesity, and weakness.
Review of the quarterly Minimum Data Set (MDS) assessment, dated 07/30/24, revealed the resident had severe cognitive impairment.
Review of the facility's SRI investigation revealed Resident #16's Controlled Drug Receipt/Record/Disposition Form for lorazepam 0.5 mg indicated there should have been 55 pills remaining, however, there were only 52 pills remaining and without documentation of administration. Further review of Resident #16's Controlled Drug Receipt/Record/Disposition Form for Oxycodone 5 mg indicated there should have been 51 pills remaining, however, there were only 48 pills remaining without documentation of administration.
8. Review of the medical record for the Resident #17 revealed an admission date of 01/15/24. Diagnoses included metabolic encephalopathy, anemia, heart failure, neuropathy, chronic kidney disease, and osteoarthritis.
Review of the quarterly Minimum Data Set (MDS) assessment, dated 08/20/24, revealed the resident had intact cognition.
Review of the facility's SRI investigation revealed Resident #17 was not administered Gabapentin 800 mg on 08/31/24 at 2:00 P.M. as ordered by the physician. Further review revealed Resident #17's Controlled Drug Receipt/Record/Disposition Form for oxycodone 10 mg indicated there should have been 28 pills remaining, however, there were only 26 pills remaining without documentation of administration.
9. Review of the medical record for the Resident #18 revealed an admission date of 03/31/21. Diagnoses included hemiplegia and hemiparesis, aphasia, chronic obstructive pulmonary disease, anxiety disorder, and alcohol abuse.
Review of the quarterly Minimum Data Set (MDS) assessment, dated 08/01/24, revealed the resident had severe cognitive impairment.
Review of the facility's SRI investigation revealed Resident #18 was not administered Baclofen 20 mg on 08/31/24 at 2:00 P.M. as ordered by the physician. Further review revealed Resident #18's Controlled Drug Receipt/Record/Disposition Form for oxycodone 5 mg indicated there should have been 20 pills remaining, however, there were only 19 pills remaining without documentation of administration.
10. Review of the medical record for the Resident #19 revealed an admission date of 01/15/24. Diagnoses included metabolic encephalopathy, anemia, heart failure, neuropathy, chronic kidney disease, and osteoarthritis.
Review of the quarterly Minimum Data Set (MDS) assessment, dated 08/18/24, revealed the resident had moderate cognitive impairment.
Review of the facility's SRI investigation revealed Resident #19 was not administered Hydralazine 50 mg on 08/31/24 at 2:00 P.M. as ordered by the physician.
11. Review of the medical record for the Resident #20 revealed an admission date of 07/21/22. Diagnoses included dementia, depression, anxiety disorder, dysphagia, and muscle weakness.
Review of the quarterly Minimum Data Set (MDS) assessment, dated 08/09/24, revealed the resident had severe cognitive impairment.
Review of the facility's SRI investigation revealed Resident #20's Controlled Drug Receipt/Record/Disposition Form for tramadol 50 mg indicated there should have been 38 pills remaining, however, there were only 37 pills remaining and without documentation of administration.
12. Review of the medical record for the Resident #21 revealed an admission date of 05/28/19. Diagnoses included schizophrenia, anxiety disorder, anemia, and obesity.
Review of the quarterly Minimum Data Set (MDS) assessment, dated 08/23/24, revealed the resident had severe cognitive impairment.
Review of the facility's SRI investigation revealed Resident #21's Controlled Drug Receipt/Record/Disposition Form for lorazepam 0.5 mg indicated there should have been 24 pills remaining, however, there were only 22 pills remaining and without documentation of administration.
13. Review of the medical record for the Resident #22 revealed an admission date of 02/19/24. Diagnoses included malignant neoplasm if rectosigmoid junction and lung, anxiety disorder, muscle wasting and atrophy, and anemia.
Review of the quarterly Minimum Data Set (MDS) assessment, dated 08/22/24, revealed the resident had intact cognition.
Review of the facility's SRI investigation revealed Resident #22's Controlled Drug Receipt/Record/Disposition Form for lorazepam 0.5 mg indicated there should have been 42 pills remaining, however, there were only 41 pills remaining and without documentation of administration. Further review of Resident #22's Controlled Drug Receipt/Record/Disposition Form for oxycodone 10 mg indicated there should have been 32 pills remaining, however, there were only 30 pills remaining without documentation of administration. Further review of Resident #22's Controlled Drug Receipt/Record/Disposition Form for hydromorphone 2 mg indicated there should have been 4 pills remaining, however, there were only 3 pills remaining without documentation of administration.
Review of the facility investigation, initiated on 08/31/24, revealed LPN #400 was suspended immediately pending further investigation. LPN #400 denied misappropriating medications and resigned from employment at the facility via text messages sent to the DON. The allegation of misappropriation of medication was substantiated due to routine medications found in the trash without documentation of medication refusals (Controlled substances were also unaccounted for per SRI Tracking Number 251396). The facility could not prove without a reasonable doubt that LPN #400 had committed drug diversion.
During interview on 09/19/24 at 9:39 A.M., the DON confirmed the LPN #400 did not properly administer medications and a medication cart audit revealed numerous routine pills, still in medication packets, had been thrown in the trash during LPN #400's shift, loose pills were found in the medication cart, and narcotic count sheets revealed discrepancies with unaccounted for medications.
During interview on 09/19/24 at 12:39 P.M. the Administrator stated during observation of the facility's camera she noticed suspicious activity by LPN #400 during the medication administration pass. The medication cart was audited by the DON and ADON and numerous discrepancies were noted, and medications documented as having been administered were thrown in the trash. The Administrator stated LPN #400 was immediately suspended and ultimately resigned via a text message that was sent to the DON. The Administrator further stated the local police department was notified, and an investigation was initiated, incident number 24-009327.
Review of the facility policy titled, Abuse, Neglect, and Exploitation, dated 06/30/23, revealed misappropriation of resident property means the deliberate misplacement, exploitation, or wrongful, temporary or permanent, use of a resident's belongings or money without the resident's consent.
As a result of the incident, the facility took the following actions to correct the deficient practice on 08/31/24:
•
On 08/31/24, the Administrator immediately notified the Director of Nursing (DON) and Assistant Director of Nursing (ADON) of the potential misappropriation of resident medications. An SRI was filed through the Ohio Department of Health and an investigation completed. LPN #400 was immediately suspended. The investigation provided information that led the facility to believe that LPN #400 misappropriated resident medications by throwing them in the trash.
•
On 08/31/24, the DON and ADON conducted medication cart audit for LPN #400's medication cart and found medications discarded in the trash and in top drawer of cart or not properly documented.
•
On 08/31/24, the DON and ADON conducted physical assessments and interviews for all potentially affected residents with no negative findings.
•
On 08/31/24, the DON and ADON reviewed medical records for discrepancies or missing medications and completed facility wide medication cart audits with no additional significant findings.
•
On 08/31/24, all staff were educated on Abuse, Neglect, Misappropriation by the Administrator.
•
Beginning on 08/31/24, all nursing staff had received training by the DON and/or ADON, before their shift on Medication Management, Administering Medications, Controlled Substance Administration and Accountability, and the Six Medication Rights.
•
On 09/03/24, the Interdisciplinary Team (IDT) completed an Ad hoc Quality Assurance (QA) to discuss the incident and corrective action plan.
•
DON or designee to complete random shift to shift narcotic count, random medication cart and medication administration audits daily for seven days, then weekly for three weeks, and then monthly for three months and as needed. All findings will be reviewed by the IDT weekly then reported to QAPI weekly and as needed.
This deficiency represents non-compliance investigated under Complaint Number OH00157695
Mar 2024
5 deficiencies
CONCERN
(D)
Potential for Harm - no one hurt, but risky conditions existed
Deficiency F0578
(Tag F0578)
Could have caused harm · This affected 1 resident
**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on record review, staff interview and policy review, the facility failed to ensure accurate advanced directive information...
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**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on record review, staff interview and policy review, the facility failed to ensure accurate advanced directive information was present throughout the medical record. This affected three residents (#6, #28 and #32) of four residents reviewed for advanced directives. The facility census was 102.
Findings Include:
1. Review of medical record revealed Resident #28 was admitted to the facility on [DATE]. Medical diagnoses included chronic obstructive pulmonary disease, unspecified asthma, respiratory failure, transient cerebral ischemic attack, abdominal aortic aneurysm, and heart failure.
Review of Resident #28's quarterly Minimum Data Set (MDS) 3.0 assessment dated [DATE] revealed Resident #28 was cognitively intact.
Review of Resident #28's physician order, dated 08/15/23 identified Resident #28 was a Do Not Resuscitate Comfort Care (DNR-CC).
Review of Resident #28's plan of care, dated 12/23/22 revealed Resident and Responsible Party had elected a DNR-CC code status.
Review of Resident #28's paper medical record revealed a State of Ohio Do Not Resuscitate Comfort Care Arrest (DNR-CCA) signed and dated by Resident #28 and Physician on 08/16/23.
Interview on 03/11/24 at 10:07 A.M. with Registered Nurse (RN) #228 confirmed Resident #28's electronic medical record identified Resident #28 was a DNR-CC and her paper record revealed she was a DNR-CCA.
Further review of Resident #28's physician orders revealed Resident #28's code status order was updated on 03/11/24 at 11:24 A.M. to reflect Resident #28 was a DNR-CCA.
2. Review of medical record revealed Resident #32 was admitted to the facility on [DATE]. Medical diagnoses included chronic obstructive pulmonary disease, Type two diabetes mellitus, acute systolic chronic heart failure, chronic kidney disease, and hypertension.
Review of Resident #32's state operational MDS 3.0 assessment dated [DATE] revealed Resident #32 was cognitively impaired.
Review of Resident #32's physician order, dated 11/23/21 identified Resident #32 was a Do Not Resuscitate Comfort Care Arrest (DNR-CCA).
Review of Resident #32's plan of care, dated 11/23/21 revealed Resident and Responsible Party had elected a DNR-CCA code status.
Review of Resident #32's paper medical record revealed a Do Not Resuscitate Comfort Care (DNR-CC) signed and dated by Resident #32's Physician on 05/02/23.
Interview on 03/11/24 at 11:05 A.M. with Registered Nurse (RN) #338 confirmed Resident #32's electronic medical record identified Resident #32 was a DNR-CCA and her paper record revealed she was a DNR-CC.
Further review of Resident #32's physician orders revealed Resident #32's code status order was updated on 03/11/24 at 11:43 A.M. to reflect Resident #32 was a DNR-CC.
Review of facility policy titled Advance Directives dated 11/16 revealed the do not resuscitate (DNR) code status order will be supported by a signed physician's order even in the presence of an advanced directive, living will or power of attorney.
3. A review of Resident #6's medical record revealed she was admitted to the facility on [DATE]. Her diagnoses included adult onset diabetes mellitus, chronic obstructive pulmonary disease, chronic kidney disease, heart failure, and dementia.
A review of Resident #6's advanced directives in the hard chart of her medical records revealed she was a Do Not Resuscitate Comfort Care (DNR CC). The form was signed by the physician on 05/18/22. The DNR CC form indicated, after the State of Ohio DNR Protocol had been activated for a specific DNR CC patient, the protocol specified that emergency medical services and other health care workers were to do the following: They would suction the airway, administer oxygen, position for comfort, splint or immobilize, control bleeding, provide pain medication, provide emotional support, and contact other appropriate health care providers, such as hospice, home health, attending physician's, certified nurse practitioners, and clinical nurse specialists. They would not administer chest compressions, insert artificial airways, administer resuscitative drugs, defibrillate or cardiovert, provide respiratory assistance other than what was listed above, initiate resuscitative IV (intravenous), or initiate cardiac monitoring. The DNR CC was effective as soon as an authorized healthcare provider signed the form. A DNRCC-Arrest would not become effective until the patient/ resident experienced cardiac or respiratory arrest. Up until the time the patient/ resident experienced cardiac or respiratory arrest, they would receive all medical care necessary to treat any illness or injury, including intubation. They would be treated as any other medical patient. Should the patient/ resident experience cardiac or respiratory arrest during treatment, at that time the DNR protocol would be initiated and all resuscitative measures would stop.
A review of Resident #6's physician's orders in the electronic medical record (EMR) revealed the resident had an order in place identifying her code status as being a DNRCC- Arrest. The order had been in place since 05/17/22. It was not until 03/12/24 (after the facility had been made aware of a discrepancy in another resident's code status) that the resident's code status order was changed to a DNR CC. The prior order for a DNRCC-Arrest was discontinued at that time to ensure the advanced directive in the hard chart of the resident's medical record matched the physician's order in the EMR.
On 03/12/24 at 3:55 P.M., an interview with LPN #327 confirmed Resident #6's code status was not consistent between what was specified in her advanced directive in the hard chart of her medical record and what was specified under her physician's orders in the EMR. She confirmed the order had been changed in the EMR on 03/12/24 changing her code status from a DNRCC-Arrest to a DNR CC, after an issue with another resident's code status was identified and brought to their attention.
CONCERN
(D)
Potential for Harm - no one hurt, but risky conditions existed
Quality of Care
(Tag F0684)
Could have caused harm · This affected 1 resident
**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on record review, observation, review of an owner's manual/ technical specifications for a bed used for a resident, reside...
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**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on record review, observation, review of an owner's manual/ technical specifications for a bed used for a resident, resident interview and staff interview, the facility failed to ensure a resident had an appropriate sized bed/ mattress to allow for proper positioning to accommodate his height and failed to identify and timely treat another resident who displayed signs of intense itching. This affected one (#65) of two residents reviewed for positioning and one (#198) of one resident reviewed for non-pressure skin conditions.
Findings include:
1. A review of Resident #65's medical record revealed he was admitted to the facility on [DATE]. His diagnoses included morbid obesity, a stage IV pressure ulcer to the right heel (full thickness skin and tissue loss with exposed or directly palpable fascia, muscle, tendon, ligament, cartilage, or bone in the ulcer), and multiple contractures of the bilateral knees/ left hip/ left ankle.
A review of Resident #65's quarterly Minimum Data Set (MDS) assessment dated [DATE] revealed the resident did not have any communication issues and was cognitively intact. His height was recorded as being 80 inches (6'8) tall.
A review of Resident #65's active care plans revealed he had a care plan in place for an alteration in mobility. The interventions included the need to assist the resident with bed mobility as needed.
A review of Resident #65's physician's orders revealed he was to be on a pressure reduction mattress with a foot extender. That order had been in place since 09/26/23. They were also to encourage or assist the resident to elevate his heels while in bed. There were no physician's orders regarding any specialty bed being used such as a bariatric bed (larger bed for obese residents) or a bed/ mattress that accommodated his large size.
On 03/11/24 at 9:25 A.M., an observation of Resident #65 noted him to be lying in bed in a supine position with the head of his bed elevated. The foot board to the bed had been removed and the mattress extended about four to five inches past the end of the bed frame. His head extended past the top of the mattress by about six to eight inches. His feet were slightly hanging over the end of the bed. There was a gray colored rectangular shaped cushion placed between the top edge of the mattress and the head board that was lower than the level of the mattress and did not fully fill the gap between the mattress and the headboard. There were two pillows that had been placed under the resident's head with one pillow over top of the gray cushion and the other pillow more directly under the resident's head. It did not provide good head/ neck support. The resident reported he needed a longer bed and was six foot eight inches tall.
On 03/12/24 at 10:02 A.M., ongoing observations of Resident #65 noted him to remain in bed in a supine position with the head of the bed up. Maintenance Director #297 was asked to obtain measurements of the resident's bed frame and his mattress. The bed frame was noted to measure 88 inches and the mattress was measured to only be 80 inches long. He reported the bed the resident was in was a bariatric bed. He confirmed he had taken the foot board off the bed due to the resident's height. He acknowledged the mattress did not extend the full length of the bed frame and when the head of bed was raised the resident's heels were at the end of the bed and his head exceeded the end of the top of the mattress by about six to eight inches. He stated there were longer mattresses available to accommodate the length of the bed frame if the bed frame had been extended as the resident's was.
On 03/12/24 at 10:05 A.M., further interview with Resident #65 revealed he had been in the facility for about six months now. He had been in and out of the hospital a couple of times, but had been in the same bed since he first arrived. He confirmed the mattress was not long enough to accommodate his size as he was 6'8 tall. He reported he had mentioned the bed was not big enough for him at different times in the past, but he was not provided a new bed or mattress that was accommodating to his size. He also felt it was obvious by looking at him that his mattress was not the proper size for him as they had to take off the footboard. He also stated his head often extended further than the top of the mattress did and they had to use the gray pad at the head of his bed to fill in the gap between the end of the mattress and the head board on his bed. He stated a king size bed was the only bed he comfortably fit in and when he used a queen size bed in the past he would have to lie diagonally so he would fit. He felt some of the discomfort he experienced could have been related to his positioning but could not be sure that was the cause. He was in a longer bed the few times he was hospitalized and reported that bed was really comfortable.
The facility was asked to provide the owner's manual/ technical specifications for the bed Resident #65 currently had. A review of the bed specifications for the P903 bed revealed the overall length of the bed without the wall bumper could be adjusted from 87, 91 and 95 inches. The length of the mattress deck was 82.6 inches. Mattress lengths available included 80 inches, 84 inches, and 88 inches.
After the facility was asked to provide the bed specifications on 03/11/24, they provided a purchase requisition and a purchase order request the morning of 03/12/24 showing they had contacted a medical supply company about getting a new bed/ mattress for Resident #65. The purchase requisition was dated 03/11/24 and the purchase order was dated 03/12/24. There were three items on the purchase requisition and order for the amount of $1,588.00. The items had item numbers and there was a brief description of the items that included repairs and maintenance, supplies, and minor medical equipment. It did not specifically identify what items were ordered.
An acknowledgement letter from the medical supply company for an order date of 03/11/24 revealed they would be providing the facility with an Infinity Bariatric Expandable Hi-Low Full Electric Low Bed that was 88 inches long and had a width that expanded from 36 inches to 42 inches to 48 inches with a 650 pound capacity. A head and foot board would be provided for an expandable bed. They were also going to send a 42 inch x 84 inch multi-layered pressure reduction mattress w/ firm perimeter and fire barrier with a 600 pound capacity. The order also included a 42 (width) x 6 (depth) x 4 (length) mattress extender. Total order amount came to $1,703.13 not counting freight charges.
On 03/12/24 at 1:20 P.M., an interview with the facility's Administrator revealed they had contacted the medical supply company and had purchased a new bed frame and a longer mattress for Resident #65. They were just awaiting notification of a delivery date. She acknowledged the resident had been in the facility since 06/12/23 (about nine months now) and had been in the same bed that was not of proper size to accommodate his height.
2. A review of Resident #198's medical record revealed he was admitted to the facility on [DATE]. His diagnoses included adult inset diabetes mellitus, anxiety, and peripheral vascular disease. He did not have any skin related diagnoses such as psoriasis, eczema, or dermatitis.
A review of Resident #198's MDS assessment dated [DATE] revealed the resident did not have any communication issues and was cognitively intact. He was not noted to have displayed any behaviors or reject care during the seven days of the assessment period. His comprehensive care plans were still being developed.
A review of Resident #198's physician's orders revealed the resident did not have any orders to receive any medications by mouth or topically for itching. He was not ordered any oral anti-histamines nor did he had any cortisone creams that could be applied for itching skin.
A weekly skin only evaluation dated 03/12/24 revealed Resident #198's skin was assessed and he was only indicated to have had a pressure ulcer to his left heel. He was not indicated to have any rashes or any other skin issue at the time the assessment was completed.
A review of Resident #198's progress notes revealed there were not any progress notes that identified the resident as having any skin problems such as rashes or complaints of itching. Progress notes were reviewed from the date of his admission on [DATE] to 03/13/24.
On 03/10/24 at 4:07 P.M., an observation of Resident #198 noted him to be in his room in bed. He was noted to be scratching his arms. An interview with the resident at the time of the observation revealed his skin had been itching, but he did not receive anything for it. He stated he had been complaining but no one seemed to care.
On 03/12/24 at 4:20 P.M., ongoing observations of Resident #198 during a treatment observation for his pressure ulcer noted him to continue to be scratching. He had multiple red scabbed areas on his right shin that he had scratched open and was also noted scratching his neck area during the treatment. LPN #327 noted him scratching and had asked the resident about his itching. He informed her that he had been itching for some time and did not know if it was medication related or caused by something else. He informed her that he had told multiple people about it, but nothing had been done to address his itching. She did inform the resident that she would contact the doctor to see if they could get something ordered to help with his itching.
On 03/13/24 at 11:29 A.M., an interview with State Tested Nursing Assistant (STNA) #325 revealed she was the aide taking care of Resident #198 that day. She denied the resident complained much to her about anything. She denied she had seen the resident scratching and had not noted any rashes on him. She further denied he reported anything to her about him itching.
On 03/13/24 at 11:31 A.M., an interview with LPN #262 revealed she had just left Resident #198's room after checking his blood glucose level. She was familiar with the resident and was the nurse that did his admission assessment when he was admitted to the facility on [DATE]. She denied she was aware of the resident having any complaints of itching and denied she had seen him scratching when she was in his room checking his blood sugar. She was informed the resident had been observed to be scratching since observations were initiated on the resident beginning 03/10/24. She was asked to go back into the resident's room and check his skin to see if he had any rashes present. She entered the resident's room and immediately noted the resident was scratching his right shoulder. She asked the resident if she could check the resident's skin and he complied. The nurse noted the resident had pinpoint scratch marks (scabbed areas) to his bilateral shoulders, down both his arms, and down the front of his right leg. The nurse asked the resident if he was aware of any allergies he had to medications or food. He denied that he did. She reported he was not like that when she assessed him upon admission. She recalled the resident had that issue when he was in the facility the first time and thought they had Atarax and a Hydrocortisone cream they were using on him. She stated she would contact the physician and get something ordered to help with the resident's itching.
CONCERN
(E)
Potential for Harm - no one hurt, but risky conditions existed
Deficiency F0761
(Tag F0761)
Could have caused harm · This affected multiple residents
Based on observation, interview, record review, and review of the facility policy the facility failed to ensure Resident's #8, #43, and #197's insulin pens had a date they were first opened and used r...
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Based on observation, interview, record review, and review of the facility policy the facility failed to ensure Resident's #8, #43, and #197's insulin pens had a date they were first opened and used recorded on the pen. This affected three residents (Resident's #8, #43 and #197) who received insulin and resided on the second floor nursing unit.
Findings include:
1. Review of Resident #8's medical record revealed an admission date of 05/15/23 and diagnoses included chronic obstructive pulmonary disease, type two diabetes mellitus without complications and anxiety disorder.
Review of Resident #8's physician orders dated 11/16/23 revealed Novolin 70/30 FlexPen subcutaneous suspension pen-injector (70-30) 100 units per milliliter (ml) (insulin NPH isophane and regular (human), inject 50 units subcutaneously one time a day for diabetes.
2. Review of Resident #43's medical record revealed an admission date of 05/10/23 and diagnoses included diabetes mellitus without complications, Parkinson's disease and dysphagia.
Review of Resident #43's physician orders 07/06/23 revealed Levemir FlexPen subcutaneous solution pen-injector 100 units per ml (insulin detemir), inject 20 units subcutaneous two times a day related to type two diabetes mellitus without complications.
3. Review of Resident #197's medical record revealed an admission date of 10/16/23 and diagnoses included type two diabetes mellitus without complications, morbid obesity due to excess calories, congestive heart failure.
Review of Resident #197's physician orders dated 02/28/24 revealed Lantus SoloStar 100 units per ml solution pen-injector, inject 70 units subcutaneously at bedtime related to type two diabetes mellitus without complications.
Observation on 03/11/24 at 10:39 A.M. of Licensed Practical Nurse (LPN) #262 revealed she opened the top drawer of her medication cart, and checked the insulin pens of residents residing on the second floor nursing unit for dates when the insulin pens were first opened and used. Further observation revealed LPN #262 checked Resident #43's Levemir FlexPen 100 units per ml and noted there was no date the FlexPen was first opened and used written on it. Further review revealed LPN #262 checked the date on Resident #197's Lantus SoloStar 100 units per ml pen-injector and noted there was no date Resident #197's Lantus pen-injector was first opened and used written on it. Observation revealed LPN #262 checked the date on Resident #8's Novolin 70/30 insulin pen 100 units per ml and confirmed there was no date it was first opened and used written on it.
Interview on 03/11/24 at 10:39 A.M. of the Director of Nursing (DON) confirmed Resident #8, #43 and #197's insulin pens did not have the date they were first opened and used written on the pens. The DON stated the insulin pens needed to be discarded and she would have the pharmacy send Resident's #8, #43 and #197 replacement insulin pens. The DON indicated Resident's #8, #43 and #197 would not be charged for the insulin pens, and the facility would pay to replace them.
Review of the facility policy titled Administering Medications revised 04/2019 included medications were administered in a safe and timely manner, and as prescribed. The expiration or beyond use date on the medication label was checked prior to administering. When opening a multi-dose container, the date opened was recorded on the container. Insulin pens containing multiple doses of insulin were for single-resident use only.
CONCERN
(E)
Potential for Harm - no one hurt, but risky conditions existed
Antibiotic Stewardship
(Tag F0881)
Could have caused harm · This affected multiple residents
**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on medical record review, interview, and policy review the facility failed to ensure residents met criteria for antibiotic...
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**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on medical record review, interview, and policy review the facility failed to ensure residents met criteria for antibiotic treatment. This affected four residents (#29, #30, #78, and #82) of five reviewed for infections.
Findings include:
1. Record review revealed Resident #82 was admitted to the facility on [DATE] with diagnoses including pulmonary fibrosis, heart disease, and history of urinary tract infection (UTI).
Review of Resident #82's nursing note dated 03/04/24 revealed the resident had complaints of dysuria. New order from physician for Macrobid 100 milligram (mg) twice daily for five days and Pyridium 100 mg three times a day for four days.
Review of Resident #82's infection screening evaluation note dated 03/04/24 revealed the resident did not have an indwelling catheter and was afebrile. She had acute dysuria, and no other symptoms were noted.
Review of Resident #82's infection note dated 03/05/24 revealed the resident had possible UTI. No diagnostic test was performed, and the resident was ordered antibiotic therapy of Macrobid 100 milligrams (mg) for five days.
Review of Resident #82's antibiotic time out note dated 03/08/24 revealed on 03/04/24 the resident had complaints of dysuria and the hospice doctor placed the resident on antibiotics without obtaining urine. The resident had no complaints at this time. Per secure conversation with hospice doctor the resident needs to finish antibiotic as ordered due to history of recurrent UTI's.
Interview on 03/13/24 at 9:37 A.M., with Licensed Practical Nurse (LPN) #286 confirmed the resident did not meet criteria for antibiotic treatment nor was urine collected to ensure an antibiotic was warranted and appropriate. The facility had identified concerns with facility staff not completing the proper paperwork, however hospice was not provided education on antibiotic stewardship program.
2. Record review revealed Resident #30 was originally admitted to the facility on [DATE] and re-admitted on [DATE] with diagnoses including stage III kidney disease, benign prostatic hyperplasia with lower urinary tract symptoms, neuromuscular dysfunction of bladder, acute cystitis without hematuria, and heart disease.
Review of Resident #30's physician telehealth note dated 03/10/24 revealed the resident had complaints of bladder distention and uncomfortable pressure. Requested a straight cath for comfort. The straight cath was obtained and 450 cc plus a full sample cup of urine was obtained. The urine was malodorous, muddy yellowish green with a lot of mucus and sediment. The resident sees a urologist regularly. The resident had vomited once at the beginning of the shift and had watery liquid stools twice this shift. The abdomen was soft per staff and didn't look distended. The assessment and plan included diagnoses of acute cystitis, diarrhea, nausea and vomiting, and history of recurrent UTI's. Plan to order Zyvox 600 mg for seven days and contact precautions until urine culture results. Check stool for C-diff and as needed Zofran 4mg four times a day.
Review of Resident #30's health status note dated 03/10/24 revealed telehealth was contacted due to the resident having complaints of bladder distention and pressure. The resident also had nausea, vomiting, and diarrhea. New order for stat urinalysis for culture and sensitivity and stool sample for suspected c-diff, Zofran 4 mg every six hours and Zyvox 600 mg twice daily for five days for suspected UTI. The urine sample was taken to the lab for testing.
Review of Resident #30's infection screening evaluation dated 03/10/24 revealed the resident was afebrile and had acute dysuria, costovertebral angle pain or tenderness, diarrhea, nausea, and vomiting.
Review of Resident #30's infection note dated 03/11/24 revealed the resident urine was still pending. The resident was on Zyvox 600 mg twice a day for five days with no adverse reaction noted. The resident had no voiced complaints of pain or nausea and was afebrile.
Interview on 03/13/24 at 9:48 A.M., with LPN #286 revealed the resident did not meet criteria for antibiotics, however the telehealth doctor started the resident on antibiotics with justification. The culture was still pending. The facility has not educated the telehealth doctors on the antibiotic stewardship program.
3. Record review revealed Resident #78 was originally admitted to the facility on [DATE] with diagnoses including type II diabetes, long term use of antibiotics, history of UTI's, benign prostatic hyperplasia without lower urinary tract symptoms, and neuromuscular dysfunction of the bladder, and suprapubic catheter for neurogenic bladder.
Review of Resident #78's infection screening evaluation note dated 12/09/23 revealed the resident had supra-pubic tenderness and no other symptoms noted.
Review of Resident #78's infection note dated 12/11/23 revealed the resident was ordered Cefdinir 300 mg twice a day until 12/12/23 for UTI.
Review of Resident #78's antibiotic time out note dated 12/12/23 revealed the resident has returned from the emergency room with orders for antibiotics for three days for a UTI. The resident was not having any symptoms or signs of infection at this time. The resident supra-pubic catheter was draining clear yellow urine at this time. The antibiotic was completed today and doesn't require any further treatment.
Review of Resident #78's medical record revealed no evidence of a urine culture.
Review of Resident #78's infection screening evaluation dated 01/25/24 revealed the resident had an indwelling catheter and no symptoms.
Review of Resident #78 infection note dated 01/27/24 revealed the resident was ordered Augmentin 500/125 mg twice daily for five days for UTI from the hospital.
Review of Resident #78's antibiotic time out note dated 01/29/24 revealed the resident was re-admitted to the facility on [DATE] with intravenous antibiotics, however the order was changed to Augmentin by mouth on 01/26/24. The resident urine was dark colored. The physician was notified and wanted the antibiotic continued due to recurrent UTI's and hospitalization related to UTI.
Review of Resident #78's medical record revealed no evidence of a urine culture.
Review of Resident #78's infection screening evaluation dated 03/06/24 revealed the resident had visible hematuria.
Review of Resident #78's orders dated 03/07/24 revealed Bactrim DS 800-160 mg once a day prophylactic.
Review of Resident #78 infection note dated 03/08/24 revealed the resident had possible UTI and was ordered Bactrim DS 800-160 mg twice daily for seven days. The urinalysis was pending.
Review of Resident #78's urinalysis results dated 03/07/24 revealed the resident had plus four leukocytes and many bacteria. A culture was indicated.
Review of Resident #78's urine culture results dated 03/09/24 revealed the organism was proteus mirabilis and resistant to Bactrim. There was a handwritten note to discontinue the Bactrim and start Keflex 500 mg every six hours for seven days.
Review of Resident #78's orders dated 03/10/24 revealed Keflex 500 mg by mouth every six hours for UTI for seven days.
Interview on 03/13/24 at 9:56 A.M. and 10:03 A.M., with LPN #286 confirmed the Resident was treated for an UTI on 12/09/23 and 01/25/24, however the urine culture was never obtained to ensure the resident received appropriate treatment for a UTI. The LPN confirmed on 03/05/24 the doctor was visiting and noted gross hematuria in the resident foley bag and ordered a urinalysis and started the resident on antibiotics prior to receiving the urine culture. Once the urine culture came back the antibiotic had to be changed due to the Bactrim being resistant against the organism. The LPN confirmed the resident did not meet criteria for antibiotic treatment on 12/09/23 and 01/25/24 and the resident was started on antibiotics on 03/06/24 before the culture returned. The physician should have waited for the culture to return. The physician has not been educated on the antibiotic stewardship program.
4. Record review revealed Resident #29 was admitted to the facility on [DATE] with diagnoses including dementia, history of UTI, and spinal stenosis.
A. Review of Resident #29's health status note dated 02/16/24 revealed the resident returned form the emergency room with order for Keflex 500 mg twice daily for five days for UTI.
Review of Resident #29's infection screening evaluation dated 02/17/24 revealed the resident had delirium, new onset confusion, and new onset functional decline. The resident did not meet criteria for antibiotic treatment.
Review of Resident #29's antibiotic time out form dated 02/21/24 revealed the resident had gone to the emergency room on [DATE] due to being lethargic and functional decline and was diagnosed with UTI. The resident had two more days left on treatment and had no signs or symptoms of infection noted. The physician wanted antibiotic continued as ordered from the emergency room and if any signs and symptoms after completion of antibiotic to notify physician.
Review of Resident #29's medical record revealed no evidence of a urine culture.
Interview on 03/13/24 at 9:52 A.M., with LPN #286 revealed the resident did not meet criteria for antibiotic treatment, however the doctor wanted the antibiotic continued due to the resident had altered mental status.
Review of Resident #29's health status note dated 03/02/24 revealed a family member came to the nurse's station requesting to have the resident temperature taken due to the resident was flushed. The resident temperature was 102.2 otherwise good. The doctor was notified, and new orders were received for laboratory testing and chest x-ray on Monday and to start Rocephin 1 gram (gm) IM for seven days.
Review of Resident #29's Medication Administration Record (MAR) dated 03/2024 revealed the resident received Ceftriaxone Sodium Powder one gram IM for infection from 03/03/24 to 03/05/24. The order was originally 7 days.
Review of the infection screen note dated 03/02/24 revealed the resident one single temperature greater than 102. The resident had no other noted symptoms.
Review of Resident #29's health status note dated 03/05/24 revealed the resident had no signs or symptoms of infection and her labs were within normal limits and the chest x-ray was negative. The resident had only one temperature and all other temperatures were within normal limits. New orders to discontinue the Rocephin.
Interview on 03/13/24 at 7:20 A.M. and 9:52 A.M., with LPN #286 confirmed the resident did not meet criteria for antibiotic treatment.
Review of the facility policy and procedure titled Antibiotic Stewardship Program (dated 05/30/23) revealed it was the facility policy to implement and Antibiotic Stewardship Program as part of the facility overall infection prevention and control program. The Loeb Minimum Criteria may be used to determine whether to treat an infection with antibiotics. Clinical justification for the use of an antibiotic beyond the initial duration ordered such as a review of laboratory reports/cultures in order to determine if the antibiotic remains indicated or of adjustments to therapy should be made. Education regarding the program would be provided at least annually to facility staff, prescribing practitioner, residents, and families.
CONCERN
(F)
Potential for Harm - no one hurt, but risky conditions existed
Infection Control
(Tag F0880)
Could have caused harm · This affected most or all residents
2. Review of medical record for Resident #78 revealed an admission date of 01/06/24. Medical diagnoses included neuromuscular dysfunction of bladder, spinal stenosis, benign prostatic hyperplasia, and...
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2. Review of medical record for Resident #78 revealed an admission date of 01/06/24. Medical diagnoses included neuromuscular dysfunction of bladder, spinal stenosis, benign prostatic hyperplasia, and personal history of urinary tract infections.
Review of Medicare Five Day Minimum Data Set (MDS) 3.0 dated 02/14/24 revealed Resident #78 had moderate cognitive impairment, utilized an indwelling urinary catheter and was frequently incontinent of bowel.
Review of Resident #78's care plan dated 01/09/23 revealed Resident #78 utilized urinary catheter related to neurogenic bladder.
Review of physician orders for Resident #78 revealed an order dated 05/28/23 to cleanse supra pubic site with wound cleanser and apply antifungal cream and absorbent dressing daily.
Observation of catheter care on 03/11/24 at 3:52 P.M. for Resident #78 revealed Registered Nurse (RN) #338 gathered supplies, knocked on door, entered resident's room, and had shut resident's door for privacy. RN #338 placed supplies on prepared bedside table. RN #338 washed hands and donned gloves removed soiled dressing around supra pubic catheter site, cleansed site with gauze pads soaked in wound cleanser, dried with clean dry gauze pads and with soiled gloves applied new split gauze dressing over supra pubic catheter site. RN #338 was not observed to doff gloves perform hand hygiene and don new gloves after removing soiled dressing and prior to applying new dressing.
Interview on 03/11/24 at 4:00 P.M. with RN #338 confirmed gloves were not changed, and hand hygiene was not completed prior to applying clean dressing after soiled dressing was removed from Resident #78's supra pubic catheter site.
Review of facility policy titled Personal Protective Equipment dated 07/10/23 revealed gloves were to be changed and hand hygiene was to be completed between clean and dirty tasks.
Based on medical record review, interview, observation, and policy review the facility failed to trend and identify infections/organism. The facility also failed to use proper hand hygiene and glove use during suprapubic catheter care. This had the potential to affect all 102 residents residing in the building for infections and one resident (#78) of one observed for catheter care.
Findings include:
1. Review of the infection control logs, and facility floor plans dated 10/2023 to 03/2024 revealed no evidence the facility was trending and identifying all infections/organism. The facility was utilizing floor plans to trend the infection.
The October 2023 floor plan revealed the facility was trending genito- urinary (GU), gastro-intestinal (GI), skin, respiratory, eye, and others.
Review of the October 2023 infection control log revealed there was two sepsis, one otitis media, one tonsillitis, three conjunctivitis, two clostridium difficile (C-diff), one methicillin resistant staphylococcus aureus (MRSA) one Vancomycin Resistant Enterococcus (VRE), four pneumonia, two cellulitis, two wound infection, one skin infection, and 10 Urinary Tract Infections (UTI) however the UTIs did not include the organisms.
B. The November 2023 floor plan revealed the facility was trending GU, GI, skin, respiratory, eye, influenza A, and others.
Review of the November 2023 infection control log revealed there was one osteomyelitis, two C-diff, two MRSA, one Extended Spectrum Beta Lactamase (ESBL), one enterovirus gastrointestinal, one otitis media, and six unknown infections. There were 22 influenza A, two bronchitis, eight pneumonia, and one upper respiratory infection tract infection. There were three cellulitis, three skin infections, one cystitis, and eight UTI, however there was no evidence of the type of organisms.
C. The December 2023 floor plan revealed the facility was trending skin, UTI, LRI, URI, GI, eye, and others.
Review of the December 2023 infection control log revealed there was one C-diff, one enterovirus gastrointestinal, four MRSA, seven unknown, 29 COVID, seven pneumonia, one bronchitis, two influenza A, three cellulitis, one skin infection, one cystitis, and 29 UTI, however no indication of the organism.
D. The January 2024 floor plan revealed the facility was trending GI, GU, eye, respiratory, skin, and other.
Review of the January 2024 infection control log revealed one osteomyelitis, one strep throat, one periodontitis, one c-diff, three MRSA, one herpes zoster, one unknown infection, seven pneumonia, two bronchitis, five COVID, one skin infection, one cellulitis, and one wound infection.
E. The February 2024 floor plan revealed the facility was trending GI, GU, eye, respiratory, skin, and other.
Review of February 2024 infection control log revealed one bacteremia, three osteomyelitis, two periodontitis, one strep throat, three conjunctivitis, one herpes zoster, two bronchitis, five bronchitis, four COVID, three skin infections, and 10 UTI's, however no indication of the organism.
The March 2024 floor plan revealed the facility was trending skin, UTI, LRI, URI, GI, eye, and others.
Review of March 2024 electronic infection control log revealed there was one bacteremia, one strep throat, one conjunctivitis, two unknown, one bronchitis, one cellulitis, one UTI.
Review of March 2024 paper infection control log revealed on 400 hall there was one MRSA, one prophylactic for UTI, one unknown fever. The 200-hall had two UTI's, however no indication of the organism, one osteo, and one respiratory. The 300-hall had five UTI's without evidence of organisms, one dental prophylactic, one bacteremia, one strep throat, and one conjunctivitis.
The electronic logs only included room number, date of infection onset, infection, signs and symptoms, status, pharmacy order, and comments. There was no indication if the infection was community or hospital acquired.
Review of the facility policy titled Infection Prevention and Control Program (dated 05/12/23) revealed a system of surveillance would be utilized for prevention, identified, reporting, investigation, and controlling infections and communicable disease for all residents, staff, volunteers, visitors, and other individual providing services under a contractual arrangement based upon a facility assessment and accepted national standards. The policy didn't include directive or guidance on completing the infection control log or trending infection.
Interview on 03/13/24 at 9:30 A.M., with Licensed Practical Nurse (LPN) #286 confirmed she was trending infection by using a floor plan of the facility. The facility currently has three floors. The floor plan only includes the site of infection and not the infection/organism. The LPN confirmed if you looked at the floor plan there was no indication on which resident had MRSA since MRSA could be in several different body sites. The LPN confirmed the printed log did not indicate which logs were community or facility acquired nor did the UTI include the type of organism. The facility was looking into other alternatives to log infections due to there were identified issues.
May 2022
5 deficiencies
CONCERN
(D)
Potential for Harm - no one hurt, but risky conditions existed
PASARR Coordination
(Tag F0644)
Could have caused harm · This affected 1 resident
**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** 2. Review of Resident #45's medical record revealed an initial admission date of 07/27/21 and a readmission date of 03/29/22 (th...
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**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** 2. Review of Resident #45's medical record revealed an initial admission date of 07/27/21 and a readmission date of 03/29/22 (the resident had left the faciity on [DATE] for one day). Resident #45 had diagnoses (dated 05/07/21) including anxiety disorder, major depressive disorder, essential hypertension, weakness and unspecified heart failure. On 03/18/22 a new diagnosis of psychotic disorder with hallucinations and Parkinson's disease was added.
Resident #45's PASARR, dated 07/27/21 revealed the question of does the individual have a diagnosis(es) of any of the mental disorders listed below with the boxes beside mood disorder and panic or other severe anxiety disorder marked on the form. A PASARR, dated 03/29/22 revealed the questions of does the individual have a diagnosis(es) of any of the mental disorders listed below with the box beside no marked on the form.
Resident #45's care plan, dated 03/29/22 revealed the resident was at risk for drug related complications related to psychotropic medication use of antidepressant and anti-anxiety medications.
Resident #45's physician's orders revealed an order, dated 03/29/22 for the resident was to have psychiatric evaluations as indicated. The resident also had medication orders, dated 03/29/22 for Fluoxetine HCL 50 mg (milligram) by mouth one time a day for depression and anxiety, Nuplazid 34 mg by mouth one time a day for Parkinson's disease psychosis. On 05/15/22 an order was obtained for Ativan 0.5 mg by mouth every eight hours as needed for anxiety and agitation.
Review of Resident #45's Minimum Data Set (MDS) 3.0 assessment, dated 04/05/22 revealed the resident had moderate cognitive impairment and was not currently considered by the State Level II Preadmission Screening/Resident Review Identification Screen (PASARR) to have serious mental and/or intellectual disability or related condition. The MDS revealed the resident was receiving an anti-depressant medication.
On 05/16/22 at 2:19 P.M. interview with Resident #45 revealed he did not receive any type of psychiatric services.
On 05/17/22 at 8:53 A.M. interview with Admissions #536 revealed she had completed the 03/29/22 PASARR which did not reflect the resident having any mental health diagnoses or mental health medications marked. She reported she does not usually do the PASARR's. Admissions #536 revealed the liaison who usually does them wasn't in the facility so she did it. She reported since Resident #45 had only left for one day she did it to get it in the system. She verified she didn't know how to complete a PASARR and verified it was not accurate.
On 05/17/22 at 10:59 A.M. interview with SS #502 revealed on 03/18/22 a new diagnosis of psychotic disorder with hallucinations was noted and a new PASARR should have been completed. SS #502 revealed she was not aware of the diagnosis change on 03/18/22 but indicated she does have access to the electronic health record (EHR) were diagnoses were listed.
Based on record review, facility policy and procedure review and interview the facility failed to ensure Preadmission Screening and Resident Reviews (PASARR's) were completed accurately on admission and/or failed to ensure a new PASARR was completed following a change in diagnoses. This affected three residents (#12, #45, and #56) of five residents reviewed for PASARR.
Findings include:
1. Record review revealed Resident #56 was admitted to the facility on [DATE] with diagnoses including anxiety and dementia with behavioral disturbance.
Review of Resident #56's PASARR, dated 08/01/13 only included the determination that indicated the resident had no serious mental illness or a developmental disability.
On 10/25/13 the resident was diagnosed with major depression disorder single episode and on 01/29/16 the diagnosis was changed to recurrent major depression disorder. On 07/08/18 psychosis not due to a substance or known psychological condition was added. The resident had an acute hospital stay and was readmitted to the facility on [DATE].
Review of Resident #56's Minimum Date Set (MDS) 3.0 assessment, dated 10/19/21 revealed the resident did not have conditions related to serious mental illness. The resident was admitted on [DATE] and was re-admitted on [DATE] after an acute hospital stay. The resident's cognition was intact and the assessment revealed the resident was totally dependent on staff for transfers, locomotion, toilet use, bathing and personal hygiene.
On 05/17/22 at 11:00 A.M. interview with Social Service (SS) #502 revealed she was not sure who was responsible for completing the PASARR section of the MDS to ensure the PASARR was accurate and correct. The SS reported Resident #56's PASARR had not been updated since her admission in 2013 and should have been updated with each new mental illness diagnoses added after original admission. SS #502 confirmed there was no evidence a new PASARR was completed on 10/25/13 when major depression disorder single episode was added and changed to recurrent major depression disorder on 01/29/16 or on 07/08/18 when psychosis not due to a substance or known psychological condition was added to ensure the resident did not require Level II review for services.
Review of the facility policy and procedure titled PASARR, dated 04/2017 revealed to ensure that individuals with serious mental illness or an intellectual developmental disability who were seeking care in the nursing facility would receive appropriate care in the facility to address these conditions.
A resident review was required for any nursing facility resident with a serious mental illness or intellectual developmental disability who was admitted to the facility under hospital exemption but required more than 30 days of services and had experienced a significant change of condition.
3. Review of Resident #12's medical record revealed an admission date of 11/04/19 with diagnoses including Parkinson's disease, generalized anxiety disorder (05/30/18), schizophrenia (12/20/16), major depressive disorder (12/20/16), and developmental disorder of scholastic skills (12/20/16).
Review of a PASARR identification screen revealed the screening did not capture the diagnosis of schizophrenia or developmental disorder (condition that resulted in impairment of general intellectual functioning or adaptive behavior). The screening form indicated Resident #12's physician ordered skilled nursing services. The review results dated 11/04/19 indicated there were no indications of serious mental illness nor a developmental disorder and no referrals were made to the Department of Developmental Disorders for an evaluation to determine if Resident #12 would benefit from specialized services.
An annual Minimum Data Set (MDS) 3.0 assessment, dated 11/11/21 indicated Resident #12 was not considered by the State Level II PASARR process to have serious mental illness and/or intellectual disability or related condition. Resident #12 had clear speech, was able to understand others and make herself understood. Resident #12 was assessed as cognitively intact. Resident #12 transferred, ambulated, dressed, ate, used the toilet, and performed personal hygiene with supervision.
Review of the facility policy titled, The Healthcare Electronic Notification System Pre-admission Screening and Resident Review (PASARR) Level II revealed based on information provided in the PASARR, a determination was made as to whether the individual could be admitted to the nursing facility or whether further review was required. The system automatically forwarded any documents with indications of intellectual developmental disability to the Ohio Departments of Mental Health (ASCEND) and Addiction Services (OMHAS)and/or the Ohio Department of Developmental Disabilities ([NAME]) for additional Level II review. Nursing facilities were required to complete the PASARR accurately and submit it to the OMHAS and/or the [NAME] if indications of serious mental illness and/or developmental disabilities were present. OMHAS and [NAME] would take the appropriate action to perform the Level II review and would provide the submitter with documentation of the Level II determination.
On 05/17/22 at 10:58 A.M. interview with SS #502 verified the resident's screening was inaccurate. SS #502 verified if the screening was accurate it would have resulted in a Level II evaluation. There was no system in place to review PASARR for accuracy or changes.
CONCERN
(D)
Potential for Harm - no one hurt, but risky conditions existed
Deficiency F0661
(Tag F0661)
Could have caused harm · This affected 1 resident
**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on closed record review, facility policy and procedure review and interview the facility failed to ensure the discharge su...
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**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on closed record review, facility policy and procedure review and interview the facility failed to ensure the discharge summary completed for Resident #85 included a recapitulation of the resident's stay. This affected one resident (#85) of one resident reviewed for discharge.
Findings include:
Closed record review revealed Resident #85 was admitted to the facility on [DATE] and discharged to another skilled nursing facility on 03/11/22. The resident's diagnoses included severe protein malnutrition, osteomyelitis of vertebra, symbolic dysfunctions, dysphagia, weakness and need for assistance with personal care, pressure ulcer of sacral region, history of pulmonary embolism, encephalopathy, hyperlipidemia, gastrostomy, discitis and type II diabetes.
A discharge note, dated 03/11/22 revealed follow up instruction education was provided to the transferring facility. The resident was made aware of transfer and signed discharge paper and verbalized understanding.
Review of Resident #85's electronic medical record (EMR) revealed a recapitulation of resident's stay was not completed nor was a summary of the resident's status. A recapitulation of the resident's stay described the resident's course of treatment while residing in the facility. The recapitulation was to include but was not limited to: diagnoses, course of illness, treatment, and/or therapy, and pertinent lab, radiology, and consultation results, including any pending lab results. Items required to be in the final summary of the resident's status included: identification and demographic information, customary routine, cognitive patterns, communication, vision, mood and behavior patterns, psychosocial well-being, physical functioning and structural problems, continence disease diagnoses and health conditions, dental and nutritional status, skin condition, activity pursuit, medications, special treatments and procedures, discharge planning (as evidenced by most recent discharge care plan), documentation of summary information regarding the additional assessment performed on the care areas triggered by the completion of the MDS and documentation of participation in assessment. This refers to documentation of who participated in the assessment process. The assessment process must include direct observation and communication with the resident, as well as communication with licensed and non-licensed direct care/direct access staff members on all shifts.
Review of Resident #85's paper medical record revealed Resident #85 signed a discharge instruction of care sheet that included the name and address to the facility the resident was being transferred to, current treatment orders to the sacrum, right and left heel and feeding tube site. There was a notation to See attached medication review, however there was no evidence of an attachment or the resident's current physical status. There was no evidence of the resident's complete status at the time of discharge.
On 05/18/22 at 10:55 A.M. interview with Registered Nurse (RN) #701 revealed a recapitulation of stay was not completed for Resident #85. The facility had only completed the paper discharge instruction for care form and the facility did not keep a copy of the mediation review to ensure all medication were reconciled from admission.
Review of the facility policy and procedure titled Discharge Process, dated 07/2019 revealed the final discharge summary would be completed and a signed copy of the discharge and discharge medication list should be filed in the resident's chart.
CONCERN
(D)
Potential for Harm - no one hurt, but risky conditions existed
Medication Errors
(Tag F0758)
Could have caused harm · This affected 1 resident
**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** 2. Record review revealed Resident #48 was admitted to the facility on [DATE] with diagnoses including anxiety disorder, mental ...
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**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** 2. Record review revealed Resident #48 was admitted to the facility on [DATE] with diagnoses including anxiety disorder, mental disorder due to known physiological condition, intracranial injury, convulsion, hydrocephalus, major depressive disorder, conduct disorder, adult personality and behavior disorder and dementia with behavioral disturbance.
Review of a controlled substance sheet, dated 03/24/22 revealed the Ativan/Benadryl (AB) Gel 0.5-12.5 mg/ml was originally ordered on 03/23/22. The order was to apply one ml topically twice daily and to discard on 04/22/22 or sooner. The pharmacy sent 30 one ml syringes.
Review of Resident #48's current orders and medication administration records, dated 05/2022 revealed the resident was ordered Ativan/Benadryl (AB) gel 0.5 milligrams (mg)/12.5 mg one application topically twice daily as needed for anxiety. There was no indication where to apply the topically medication, the amount of the application, or a stop date.
Further review revealed on 05/12/22 16 syringes were destroyed.
Review of pharmacy communication note, dated 05/18/22 revealed the AB gel should be applied topically to the inner wrist.
Review of a pharmacy non-sterile compounding worksheet, dated 03/22/22 and faxed to the facility on [DATE] revealed Resident #48 was ordered AB Gel 0.5-12.5 mg/ml to be applied topically twice daily. There was no indication were to apply the topically gel. The medication expired within 30 days after compounding.
On 05/18/22 at 11:28 A.M. and 2:40 P.M. interview with Registered Nurse (RN) #700 revealed the order for the AB gel should have been discontinued on 05/12/22 when the medication was destroyed, however the order was not written. The current order did not include were to apply the topically gel, but the pharmacy indicated on 05/18/22 it should have been applied on the resident's inner wrist. RN #700 confirmed the medication expired within 30 days after being compound on 03/23/22, however was not destroyed until 05/12/22. The resident's last dose received was 04/02/22. The facility in-house psych physician had written the original prescription to be given scheduled twice a day, however the in-house physician changed the order to as needed on 03/30/22 but did not indicate a stop date. The RN revealed staff reported the in-house physician gave a verbal order on 05/12/22 to discontinue the medication due to non-use, however there was no documentation of the verbal order nor was the medication discontinued. The medication was still listed as a current medication order.
Review of the facility policy and procedure titled Use of Psychotropic Medication, dated 04/01/22 revealed as needed orders for all psychiatric drugs shall be used only when the medication was necessary to treat diagnosed specific conditions that were documented in the clinical record and for a limited duration (i.e. 14 days). If the attending physician or prescribing physician believed it was appropriate for the as needed order to be extended beyond the 14 days, he or she shall document their rational in the resident's medical record and indicate the duration for the as needed order.
Based on medical record review, facility policy and procedure review and interview the facility failed to ensure psychotropic medications were only administered when there were indications for use, failed to ensure non-pharmacological interventions were attempted prior to the administration of psychotropic medication ordered on an as necessary basis and/or failed to ensure orders for psychotropic medications were accurate and complete providing clear directions for use. This affected two residents (#8 and #48) of five residents reviewed for unnecessary medication use.
Findings include:
1. Review of Resident #8's medical record revealed diagnoses including anxiety disorder and dementia with behavioral disturbance.
Resident #8 had a physician's order for Ativan (anti-anxiety medication) 0.5 milligrams (mg) every four hours as necessary. Resident #8 also had an order for narcotic pain medication (Oxycodone HCL) 5 mg every four hours as needed for moderate to severe pain. Orders revealed staff were to monitor behaviors including screaming/yelling/calling out, picking at her skin, verbal and physical aggression, resisting care, non-compliance with treatment/medication regimen, anxiety and tearfulness.
Review of the March 2022 Medication Administration Record (MAR) revealed no record of anxiety on the behavior tracking. Eleven doses of Ativan were administered without documentation of the rationale or attempts to provide non-pharmacological interventions prior to administration. Six of the 11 Ativan doses were administered concurrently or within two minutes of the administration with the Oxycodone HCL.
Review of the April 2022 MAR revealed no documented behaviors for the resident. The MAR indicated 21 doses of Ativan were administered without documentation of the rationale or attempts to provide non-pharmacological interventions prior to administration. Seventeen of the 21 doses of Ativan were administered with Oxycodone. Of the 17 doses, 16 of them were administered between 7:30 P.M. and 9:00 P.M. The order for Ativan was revised for use for anxiety or insomnia on 04/28/22.
Review of the May 2022 MAR revealed no behaviors documented for the resident between 05/01/22 and 05/19/22. Fifteen doses of Ativan were administered without documentation of anxiety/insomnia or non-pharmacological interventions attempted prior to the Ativan administration.
On 05/19/22 at 9:35 A.M. the concerns related to the use of Ativan ordered on an as necessary basis without documentation of indications for use or attempts at non-pharmacological interventions were addressed with the Director of Nursing (DON). The DON reported she definitely knew Resident #8 had periods of anxiety but could not state why the episodes were not documented in the behavior tracking or why attempts of non-pharmacological interventions were not documented or provided.
On 05/19/22 at 10:18 A.M. Psych Nurse Practitioner (NP) #702 was interviewed regarding the frequency of the Ativan ordered on an as necessary basis without documentation of the need/indication for its use or without evidence of non-pharmacological interventions being attempted. NP #702 stated with each psychiatric visit, the psychiatric provider documented non-pharmacological interventions to attempt to address behaviors. NP #702 stated staff had not reported increased anxiety at night for the resident. NP #702 stated without more comprehensive documentation, it was difficult to determine if there were underlying factors causing increased anxiety at night which resulted in use of Ativan.
Review of the facility policy titled, Use of Psychotropic Medication, implemented 04/01/22 revealed the indications for initiating, withdrawing, or withholding medications, as well as the use of non-pharmacological approaches would be determined by assessing the resident's underlying condition, current signs, symptoms, expressions and preferences and goals for treatment and identification of underlying causes (when possible). Residents who received psychotropic drugs should also receive non-pharmacological interventions to facilitate reduction or discontinuation of the psychotropic drugs. Psychotropic medication ordered on an as necessary basis should be used only when the medication was necessary to treat a diagnosed specific condition that was documented in the clinical record and for a limited duration. Use of psychotropic medications for enduring conditions required the symptoms and therapeutic goals be clearly and specifically identified and documented. An evaluation should be documented to determine the resident's expressions or indications of distress were not due to a medical condition or problems that could be expected to improve or resolve as the underlying condition was treated or the offending medications were discontinued, not due to environmental stressors alone that could be addressed to improve the symptoms or maintain safety, not due to psychological stressors, anxiety or fear stemming from misunderstanding related to his or her cognitive impairment that could be expected to improve or resolve as the situation was addressed and persistent and negatively affect his or her quality of life.
CONCERN
(D)
Potential for Harm - no one hurt, but risky conditions existed
Dental Services
(Tag F0791)
Could have caused harm · This affected 1 resident
**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, record review, facility policy and procedure review and interview the facility failed to ensure Resident #...
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**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, record review, facility policy and procedure review and interview the facility failed to ensure Resident #2 was provided timely dental services to meet her needs. This affected one resident (#2) of three residents reviewed for dental care.
Findings include:
Review of Resident #2's medical record revealed the resident was admitted to the facility on [DATE] with diagnoses including cerebral palsy, type two diabetes, essential hypertension, hyperlipidemia and adult failure to thrive.
Review of Resident #2's physician's orders revealed an order, dated 08/20/18 for dental consult as needed. The resident had an order, dated 08/23/18 for the use of a mechanical (Hoyer) lift for transfers.
Review of Resident #2's care plans revealed the following:
A plan of care (initiated 08/24/18) revealed a focus on alteration in mobility related to her using a wheelchair. The goal was for Resident #2 to participate with mobility by staff assisting her with transfers as needed, by providing a wheel chair as needed, and by using a Hoyer lift for all transfers per order.
A plan of care (initiated 08/10/21) revealed a focus on dental care related to the resident had her own teeth without complaints of pain or discomfort at that time. She did have a filling that fell out and the dentist appointment was canceled due to COVID-19 restrictions and limitations.
A plan of care (initiated 10/25/21) revealed Resident #2 had gone to the dentist but she was unable to get treatment due to not being able to transfer. At this time she was having pain when eating cold foods due to having two broken teeth on the left bottom side of her mouth. The goals of the care plan were Resident #2 would have have dental consult for assessment and treatment of oral health problems as needed and she would be free of infection, pain or bleeding in the oral cavity. The interventions included encouraging Resident #2 to keep appointment for dental consult by explaining the need and importance and provide assistance as needed to prepare Resident #2 for the appointment.
A health status note, dated 02/14/20 at 4:30 P.M. revealed the resident complained of her mouth hurting. Her primary physician examined her and found red and inflamed gums on the left lower side of her mouth. She was started on Clindamycin (an antibiotic fort tooth infections) at that time. An infection progress note, dated 02/15/20 revealed the resident had an ongoing dental infection and the staff at the facility were to schedule a dental consult per Resident #2's primary physician directive. The facility reached out to the dentist who came onsite to schedule an emergency visit.
A health status note, dated 03/04/20 revealed an appointment had been set up with an offsite dental provider for 03/11/20. A health status note, dated 03/10/20 revealed the appointment scheduled for 03/11/20 had been canceled and a new appointment with a different offsite dental provider had been made for 03/26/20.
The next progress note regarding dental, dated 06/01/20 revealed appointment scheduled for 06/01/20 was canceled and rescheduled for 06/09/20.
The next progress note regarding dental, dated 08/30/21 revealed an appointment was set for an offsite dentist for 09/15/21.
Review of Resident #2's appointment return progress note, dated 09/15/21 revealed the dentist she had seen wanted her to see an oral surgery center for teeth extraction. Her appointment return progress note, dated 10/11/21 at 1:58 P.M. revealed the dentist at the oral surgery center refused to see her since she couldn't transfer. Review of Resident #2's progress notes revealed these were the only two appointment return progress notes in her record.
Review of the Minimum Data Set (MDS) 3.0 assessments, dated 08/05/21, 10/20/21 and 05/02/22 all revealed the resident was cognitively intact, had mouth or facial pain, discomfort or difficulty with chewing, was totally dependent and needed two+ persons to physically assist for transfer.
On 05/17/22 at 1:33 P.M. Resident #2 was observed to with some of her teeth darkened in color.
On 05/16/22 at 10:49 A.M. interview with Resident #2 revealed she had sensitive teeth and needed to have have two teeth pulled. The resident reported the facility couldn't find a dentist to help her. She revealed she needed assistance with transfers from her wheelchair to the dental chair. Resident #2 denied pain but reported the cold sensitivity was a problem and prevented her from eating things she liked, example of ice cream.
On 05/19/22 at 12:56 PM interview with the Director of Nursing (DON) revealed the facility had attempted to get Resident #2 into other dentists, but they were having problems finding a dentist who accepted Medicaid.
On 05/19/22 at 3:06 P.M. interview with Registered Nurse #700 revealed there was no written evidence of the facility calling other dentists since October 2021 to find a dentist who would take Resident #2's payment source.
Review of facility policy titled Dental Services, dated 04/01/22 revealed it was the policy of the facility to assist residents in obtaining routine (to he extent covered under the state plan) and emergency dental care. The policy also revealed referrals to dental providers shall be made as appropriate and all actions and information regarding dental services, including any delays related to obtaining dental services, would be documented in the resident's medical record.
CONCERN
(E)
Potential for Harm - no one hurt, but risky conditions existed
Food Safety
(Tag F0812)
Could have caused harm · This affected multiple residents
Based on observation, interview and facility policy review the facility failed to monitor refrigerator temperatures on one of three resident units and failed to ensure refrigerators were maintained in...
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Based on observation, interview and facility policy review the facility failed to monitor refrigerator temperatures on one of three resident units and failed to ensure refrigerators were maintained in a clean manner to prevent contamination and/or food borne illness. This had the potential to affect 19 residents (#33, #41, #49, #59, #76, #81, #82, #83, #84, #85, #86, #87, #88, #89, #90, #91, #233, #234 and #235) who resided on the Transitional Care unit (TCU) of 85 residents residing in the facility.
Findings include:
On 05/16/22 at 5:50 P.M. interview with Licensed Practical Nurse (LPN) #514 revealed if food was provided for residents on the Transitional Care unit (TCU) and the resident did not have their own refrigerator, the food was placed in the refrigerator in the Occupational Therapy (OT) room.
On 05/16/22 at 5:50 P.M. observation of the refrigerator in the OT room revealed the thermometer in the refrigerator read 73 degrees Fahrenheit. Among the items stored in the refrigerator were two containers of cream cheese with no name noted. There were red and brown sticky substances on the top left shelf of the refrigerator door and discolored dry red areas on the bottom refrigerator shelf and in the bottom two drawers. A posting on the refrigerator indicated refrigerator temperature logs could be located on the housekeeping cart.
On 05/16/22 at 5:52 P.M. LPN #514 verified the thermometer in the refrigerator read 73 degrees Fahrenheit and the refrigerator did not feel cold. LPN #514 verified the refrigerator was not clean, stating it was housekeeping's responsibility (to clean it).
Review of the facility Food Safety Requirements policy, dated 04/01/22 revealed foods that required refrigeration should be refrigerated immediately upon receipt. Practices to maintain safe refrigerated storage included monitoring food temperatures and functioning of the refrigeration equipment daily.
On 05/16/22 at 6:10 P.M. interview with Registered Nurse (RN) #700 revealed there had been no food borne illnesses in the facility. RN #700 revealed she had access to the temperature logs for the refrigerators. At 6:35 P.M. RN #700 revealed the temperature logs would have to be provided the following day.
On 05/17/22 at 10:19 A.M. RN #701 provided nursing and resident refrigerator temperature logs for the TCU which had recordings for refrigerator temperatures in the nursing station and rooms 401-410. RN #701 revealed they were the only logs available and they could find no temperatures recorded since February 2022. RN #701 verified there was no evidence of the refrigerator in the OT room being monitored. RN #701 revealed the refrigerator had not been functioning correctly and it was not supposed to be used. At 10:50 A.M. RN #701 revealed she was not sure who the cream cheese belonged to that was in the refrigerator.
Review of the facility Use and Storage of Food Brought in by Family or Visitors policy, implemented 04/01/22 revealed all food items taken to facility were required to be labeled and dated.
Infection control logs did not reveal outbreak related to food borne illnesses from September 2021 to May 2022, the time period reviewed.
The facility identified Resident #33, #41, #49, #59, #76, #81, #82, #83, #84, #85, #86, #87, #88, #89, #90, #91, #233, #234 and #235 who resided on TCU.
Aug 2019
27 deficiencies
1 Harm
SERIOUS
(G)
Actual Harm - a resident was hurt due to facility failures
Accident Prevention
(Tag F0689)
A resident was harmed · This affected 1 resident
**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on medical record review, policy review, observation and interview, the facility failed to ensure fall interventions were ...
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**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on medical record review, policy review, observation and interview, the facility failed to ensure fall interventions were in place for four residents (Resident #73, #38, #92 and #153) and failed to complete fall investigations for three (Resident #73, #38, and #153) of five residents reviewed for falls.
Actual Harm occurred on 05/15/19 when Resident #73, who was determined to be at a high risk for falls, attempted to transfer himself, resulting in an acute, closed head injury, hematoma to the back of his head, and skin tears requiring emergency care and on 05/12/19 and when Resident #153, who was confused and determined to be at risk for falls, attempted to toilet himself resulting in a hip fracture requiring surgical intervention. There was no evidence planned interventions were in place prior to the fall.
Findings include:
1. Medical record review revealed Resident #73 was admitted to the facility on [DATE] with diagnoses including Alzheimer's disease, muscle wasting and atrophy, and difficulty walking.
Review of a nursing progress note, dated 02/17/19, revealed the resident was found lying on the floor of his room. A skin tear was noted to his left elbow, and he stated that he bumped his head. A new intervention for visual reminders, to ask for assistance when getting out of bed was initiated. A fall investigation was not completed by the facility.
Review of the Minimum Data Set (MDS) 3.0 assessment, dated 05/07/19, revealed the resident required extensive, one-person assistance for mobility, transfers, and dressing.
Review of a nursing progress note, dated 05/15/19, revealed the resident was found in his room, lying on his back on the floor, with his head near the foot of the bed. The resident stated that he was trying to get up and didn't make it to the chair. The resident received skin tears to the right and left forearms, and a hematoma to the back of his head. Review of a nursing progress note, dated 05/15/19, revealed the resident was sent to the emergency room and diagnosed with an acute closed head injury related to the fall. A fall investigation was not completed by the facility.
Review of Resident #73's physician order, dated 05/15/19, revealed an order for non-skid socks, to be worn at all times. Review of the Plan of Care, dated 05/15/19, revealed a fall intervention for non-skid socks to be worn at all times.
Review of a nursing progress note, dated 05/22/19, revealed the resident was found sitting on the floor, leaning against his bed. The resident was wearing plain, cotton socks with no shoes. Bruising was noted to the resident's neck. The physician ordered an x-ray of the right shoulder and clavicle due to the resident complaining of pain in that area and cervical x-rays of the spine. Review of the cervical spine x-ray findings, dated 05/22/19 revealed no acute findings. A fall investigation was not completed by the facility. There were no fall investigations following the falls on 02/17/19, 05/15/19 and 05/22/19.
During interview on 07/11/19 at 11:40 A.M., the Director of Nursing (DON) reviewed the progress notes and confirmed the fall intervention for non-skid socks was not in place at the time of the fall on 05/22/19. The DON further confirmed there was no fall investigation following the falls on 02/17/19, 05/15/19 and 05/22/19, resulting in no investigation to attempt to determine the root cause of the falls, if planned interventions were in place at the time of the falls, if appropriate interventions were in place after the fall, and there was no monitoring to ensure planned interventions were put into place. The DON stated that fall investigations were not completed for every fall, prior to three weeks ago, when she assumed the role of DON.
Review of the facility's policy titled, Managing Falls and Fall Risk, revised May 2019, revealed if falling recurs despite initial interventions, staff will implement additional or different interventions, or indicate why the current approach remains relevant.
2. Resident #153 was admitted to the facility on [DATE] with diagnoses which included abnormal gait and mobility and muscle weakness. The resident was mobile in a wheelchair.
Review of the baseline care plan dated 05/08/19 revealed the goal was for the resident to be free from fall related injury, provide side rails, assist the resident with mobility as needed, ensure proper footwear, assist with toileting needs and incontinence care on routine rounds and as needed, keep bed in the lowest position, ensure call light was within reach, keep fluids and frequently used items within easy reach, observe medication use for side effects that may increase fall risk, and provide verbal reminders to not transfer or ambulate without assistance. There was no evidence the resident and/or family participated in the plan.
Review of the 05/08/19 nurse's note revealed the resident was only oriented to person and place.
Review of the fall risk assessment dated [DATE] revealed the resident was at risk for falls.
Review of the 05/09/19 nurse's note revealed the resident was oriented to person and place with confusion.
Review of the five-day MDS 3.0 assessment dated [DATE] revealed the resident's cognition was not assessed but he required extensive assistance of two or more staff for bed mobility, transfers and toileting. The resident did not walk. The resident was not steady, only able to stabilize with staff assistance for surface to surface transfers.
Review of the nurse note dated 05/12/19 at 12:00 P.M., revealed the staff was notified by a visitor the resident had fallen. Upon entering the resident's room the resident was found laying on the floor outside of the bedroom door in the common area on his left side with his back facing the door. The resident had on slipper socks. The resident stated he was going to the bathroom and complained of left hip pain. The resident presented with severe pain and decreased range of motion to the left leg. The resident was sent to the hospital.
Review of the hospital x-ray dated 05/12/19 revealed the resident had a left femoral neck fracture with impaction. Further review of the hospital consultation note dated 05/12/19 revealed the resident would be scheduled for surgery to perform a left bipolar hemiarthroplasty. The resident was discharged back to the facility after recovering from the surgery on 05/16/19.
Review of the interdisciplinary team meeting (IDT) note dated 05/13/19 revealed the intervention was going to be to move the residents room for easier access to the restroom and closer to the nurse. The resident would also be placed on every two hour toileting. Further review of the medical record revealed there were no further documentation related to the fall, interventions, causes or evidence interventions were in place prior to the fall. There was no investigation completed for the fall.
Review of the census indicated prior to the fall the resident was in room [ROOM NUMBER] and after the fall, when the resident returned from the hospital on [DATE] the resident was placed in room [ROOM NUMBER] which did not follow the above intervention.
Review of the fall risk care plan initiated 05/17/19 revealed on 05/12/19 the resident was to be toileted every two hours per order. Further review revealed there were no further interventions initiated until 05/17/19 which included to assist the resident with mobility as needed, assist the resident with wearing proper footwear, assist with toileting needs and incontinence care on routine rounds and as needed, include the resident and/or family in the treatment plan, keep call light in reach, keep fluids and frequently used items within easy reach, observe medications use for side effects that may increase fall risk, remind resident and assist with use of mobility devices as needed and therapy screens as needed.
Review of the fall risk assessment dated [DATE] revealed the resident was at risk for falls.
Review of the nurse's note dated 06/20/19 at 2:30 A.M., revealed the resident was found on the floor in the bathroom. Further review of the IDT note revealed the resident was educated on safety awareness when transferring. No interventions were put into place nor was it determined if prior interventions were in place at the time of the fall. There was no investigation completed for the fall nor any additional information available in the medical record. There was no order for or evidence the resident was toileted every two hours as planned.
On 07/08/19 at 4:04 P.M., the resident was observed being pushed back to his room in his wheelchair by staff, he had socks on his feet.
On 07/08/19 at 5:35 P.M., the resident was observed in bed which was not in the lowest position and he was bare foot.
On 07/08/19 at 5:36 P.M., attempted interview with the resident revealed he had no recollection of either of the above falls.
On 07/09/19 at 9:11 A.M., the resident was observed in his recliner in the room without a call button available if he needed assistance.
On 07/09/19 at 2:50 P.M., the resident was observed in bed which was not in the lowest position and the resident was bare foot.
On 07/11/19 at 11:20 A.M., interview with the Director of Nursing (DON) verified the fall investigations were to be completed in the computer system but none were completed for the 05/12/19 or 06/20/19 falls. The DON verified there was no investigation to attempt to determine the root cause of the falls, if planned interventions were in place at the time of the fall, if appropriate interventions were in place after the fall and no monitoring to ensure planned interventions were put into place.
On 07/11/19 at 11:35 A.M., interview with the MDS and care plan Licensed Practical Nurse (LPN) #56 revealed the admitting nurse completed the baseline care plan and it was not discussed as a team and then she completed the subsequent care plans based on the data from the MDS. She verified the two hour toileting was initiated prior to the development of the 05/17/19 falls care plan because it was a fall intervention.
3. Medical record review revealed Resident #92 was admitted to the facility on [DATE] with diagnoses including dementia, muscle weakness, and difficulty walking. Review of the MDS 3.0 assessment, dated 06/30/19, revealed the resident required limited, one-person assistance for mobility and transfers and supervision, one-person assistance for dressing.
Review of a Fall Incident Audit Report, dated 09/05/18, revealed Resident #92 was found lying face-down on the floor, beside her bed on 08/27/18. A hematoma and abrasion were noted to the right, upper arm, and a skin tear was noted to the right and left forearms. No further injuries were observed. The resident stated she was reaching to get a drink of water when she lost her balance and fell on the floor. A new intervention to ask for assistance when getting out of bed was initiated.
Review of a Fall Incident Audit Report, dated 07/10/19, revealed a fall occurred on 07/07/19 when the resident was overheard yelling help and found in her room, lying face down on the floor in front of her wheelchair. The resident stated that she was trying to wheel to the bathroom when her foot got stuck. The resident was observed wearing slide sandals with slick soles. The resident received an abrasion and two superficial lacerations to the forehead. The new intervention initiated was for the resident to wear non-skid socks, when not wearing non-skid shoes. An x-ray was ordered of the left ankle on 07/08/19, which revealed no fracture or dislocation.
Review of Resident #92's Plan of Care, dated 08/28/18, revealed a new fall intervention to assist the resident with ensuring she was wearing proper footwear.
During interview on 07/11/19 at 11:40 A.M., the Director of Nursing (DON) reviewed Resident #92's progress notes and confirmed the fall intervention for appropriate, non-skid footwear was not in place at the time of the fall on 07/07/19.
Review of the facility's policy titled, Managing Falls and Fall Risk, revised May 2019, revealed if falling recurs despite initial interventions, staff will implement additional or different interventions, or indicate why the current approach remains relevant.
4. Resident #38 was admitted to the facility on [DATE] with diagnoses including cerebral vascular accident with right sided hemiparesis, muscle wasting and weakness.
Review of the 02/05/19 MDS 3.0 assessment revealed the resident was not able to be interviewed. The resident required assistance from staff with activities of daily living (ADL) including bed mobility, transfers and toileting. The resident was unsteady without the assistance of staff.
Review of the nurse's note dated 04/14/2019 at 1:45 A.M. indicated the resident was heard shouting out from her room, Help. The resident was found sitting upward on floor. The resident had missed her wheelchair to use the bathroom and was sitting on the floor. The resident was educated to use her call light for assistance when she wanted to use the restroom. Further review of the IDT note dated 04/15/19 revealed a dycem, a sticky pad used to reduce sliding potential, was placed in the seat of the wheelchair. There was no further documentation of the fall in the medical record. It was unclear were the resident was prior to the fall and there was no evidence the call light was within reach or what if any other fall interventions were in place.
Review of the fall risk assessment dated [DATE] indicated the resident did not have any falls in the last 90 days.
Review of the nurse's note dated 06/18/2019 at 1:45 A.M., revealed the resident was observed on the floor on her back on the left side of the bed. No injuries were noted. Review of a nurse's note dated 06/20/19, revealed the resident was trying to get to her chair and indicated the resident was currently in skilled therapy for function decline in ADL. The IDT note indicated to ensure the bed was locked and in the lowest position.
On 07/08/19 at 11:20 A.M., interview with the resident revealed she had fallen and had gotten hurt but she was not able to describe her injuries.
On 07/08/19 at 4:20 P.M., 5:47 P.M. and 6:35 P.M., the resident was observed in her wheelchair with socks on that were not non-skid.
On 07/09/19 at 9:19 A.M., 10:46 A.M., 12:30 P.M. and 1:15 P.M., the resident was observed in her wheelchair with socks on that were not non-skid.
On 07/09/19 at 1:16 P.M., interview with LPN #16 verified the resident did not have on non-skid socks.
On 07/09/19 at 3:20 P.M., the resident was observed in her wheelchair with socks on that were not non-skid.
7/10/19 at 11:12 A.M. and 12:58 P.M., the resident was observed in her wheelchair with socks on that were not non-skid.
On 07/11/19 at 11:20 A.M., interview with the DON verified the fall investigations were available and located in the computer system but none were completed for the 04/14/19, 06/18/19 or 06/20/19 falls. The DON verified there was no investigation to attempt to determine the root cause of the falls, if planned interventions were in place at the time of the fall, if appropriate interventions were in place after the fall and no monitoring to ensure planned interventions were put into place.
CONCERN
(D)
Potential for Harm - no one hurt, but risky conditions existed
Resident Rights
(Tag F0550)
Could have caused harm · This affected 1 resident
**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on medical record review, observation and interview, the facility failed to ensure resident's clothing was inconspicuously...
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**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on medical record review, observation and interview, the facility failed to ensure resident's clothing was inconspicuously labeled. This affected one (Resident #43) of 13 residents reviewed on 300 Hall.
Findings included:
Record review revealed Resident #43 was admitted to the facility on [DATE] with diagnoses including muscle wasting and atrophy to bilateral lower legs, lack of coordination, dementia, schizoaffective disorder, psychosis, Alzheimer's, major depression, abnormal poster, and metabolic encephalopathy.
Review of Resident #43's quarterly Minimum Data Set (MDS) dated [DATE] indicated the resident had severe cognitive impairment and was totally dependent on staff for dressing.
Observation of Resident #43 on 07/08/19 at 11:53 A.M. and 07/10/19 at 7:43 A.M. revealed the resident's socks were visibly labeled on the top of her sock with her name and room number. On 07/10/19 at 7:43 A.M., the resident was sitting in a specialized chair in the dining room with other residents.
Interview on 07/10/19 at 7:44 A.M., with State Tested Nurse Aide (STNA) #37 verified Resident #43's socks were visibly labeled with her name and room number. The STNA reported laundry labeled the residents clothing with iron on labels.
Interview on 07/10/19 at 9:58 A.M. with the Administrator revealed the facility did not have a policy on labeling resident clothing.
CONCERN
(D)
Potential for Harm - no one hurt, but risky conditions existed
Transfer Notice
(Tag F0623)
Could have caused harm · This affected 1 resident
**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on record review, interview and policy review, the facility failed to ensure residents and/or resident representatives wer...
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**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on record review, interview and policy review, the facility failed to ensure residents and/or resident representatives were notified, in writing, of a transfer to the hospital. This affected one resident (Resident #103) of one resident reviewed for hospitalization.
Findings include:
Record review revealed Resident #103 was admitted to the facility on [DATE] with diagnoses including pneumonia, heart disease, metabolic encephalopathy, anemia, sepsis, rheumatoid arthritis, chronic pain, acute and chronic respiratory failure, and dysphagia. The resident was discharged to the hospital on [DATE].
Review of Resident #103's discharge Minimum Data Set (MDS) dated [DATE] revealed the resident was discharged to an acute care hospital on [DATE].
Review of Resident #103's nurse progress notes dated 04/25/19 revealed the resident was directly admitted to the hospital with re-occurring pneumonia. The progress notes did not indicate the resident or family was notified of the transfer in writing.
Interview on 07/10/19 at 2:57 P.M., with the Administrator verified there was no evidence written notification was provided to Resident #103 or her family after her transfer to the hospital on [DATE].
Interview on 07/11/19 at 8:39 A.M., with the Administrator, reported the facility did not have a policy that included notifying the resident/resident representative in writing upon transfer to the hospital.
CONCERN
(D)
Potential for Harm - no one hurt, but risky conditions existed
Deficiency F0645
(Tag F0645)
Could have caused harm · This affected 1 resident
**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on interview and record review, the facility failed to ensure Resident #13's Pre-admission Screening and Resident Review (...
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**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on interview and record review, the facility failed to ensure Resident #13's Pre-admission Screening and Resident Review (PASRR) extension was completed. This affected one of one resident in the facility with a limited PASRR approval for skilled therapy.
Findings include:
Resident #13 was admitted to the facility on [DATE] with diagnoses which included Developmental Delay with a recent fracture requiring short term rehabilitation.
Review of the care plan initiated [DATE] revealed to follow the PASRR recommendations.
Review of the admission Minimum Data Set (MDS) 3.0 dated [DATE] revealed the resident was cognitively intact, no level II PASRR was needed and active discharge planning was occurring.
Review of the PASRR determination revealed the resident was approved for 60 days for skilled services. This determination expired on [DATE], and if an extension would be requested it must be done by [DATE]. Further review of the medical record revealed there was no evidence of a request for an extension yet the resident remained in the facility.
On [DATE] at 12:30 P.M., interview with the resident revealed she was still not able to walk up steps, and the group home where she lived prior had steps. Her goal was to go back to the group home. No one had discussed her PASRR with her.
On [DATE] at 9:10 A.M., interview with Social Service Designee (SSD) #16 revealed she had been in the position for about one month and was not aware of the residents 60 day PASRR that expired on [DATE].
CONCERN
(D)
Potential for Harm - no one hurt, but risky conditions existed
Comprehensive Care Plan
(Tag F0656)
Could have caused harm · This affected 1 resident
**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on record review, observation and staff interview, the facility failed to ensure a resident's comprehensive care plans inc...
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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's comprehensive care plans included a care plan that identified him as having bilateral lower extremity contractures and reflected his non-compliance with restorative nursing for passive range of motion. This affected one (Resident #54) of 29 residents reviewed for comprehensive care plans.
Findings include:
A review of Resident #54's medical record revealed he was admitted to the facility on [DATE]. His diagnoses included muscle wasting and atrophy, muscle weakness, difficulty in walking and contractures of an unspecified joint.
A review of Resident #54's range of motion (ROM) assessment dated [DATE] revealed the resident was noted to have moderate limitations in range of motion in his hips, ankles, feet and toes when passive range of motion (PROM) was provided. The resident had severe limitations in ROM of his bilateral knees when PROM was provided.
A review of Resident #54's Minimum Data Set (MDS) assessment, an assessment tool used by the facility to identify a resident's level of care for reimbursement purposes, dated 05/26/19 revealed the resident did not have any communication issues. His cognition was intact with no impairment noted. He was not identified on the MDS as having displayed any behaviors nor was he known to reject care. He required extensive assistance of two staff for bed mobility and was totally dependent on two staff for transfers. Ambulation did not occur. He was indicated on the MDS as having a functional limitation in his range of motion on both sides of his lower extremities.
A review of Resident #54's active care plans revealed he did not have a care plan in place to address his contractures to his bilateral lower extremities. None of the existing care plans addressed him having contractures or included interventions that addressed them.
On 07/09/19 at 8:19 A.M., an observation of Resident #54 noted him to have contractures of his bilateral lower extremities. He had his legs bent at the knees with his legs drawn up to where his heels were near his upper posterior legs. None of the observations made of the resident in bed or in his specialty chair noted him to have his legs extended out away in a normal anatomical position.
On 07/11/19 at 3:57 P.M., an interview with Registered Nurse (RN) #45 confirmed Resident #54 had contractures of his bilateral lower extremities. She reported she was the facility's restorative nurse, and the resident had refused to participate in a restorative nursing program for passive range of motion. She also confirmed the resident's active care plans did not address his contractures nor did they indicate he was non-compliant with the restorative nursing program for passive range of motion that had been recommended by therapy.
CONCERN
(D)
Potential for Harm - no one hurt, but risky conditions existed
ADL Care
(Tag F0677)
Could have caused harm · This affected 1 resident
**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on record review, observation and interview, the facility failed to ensure Resident #45, a dependent resident, received as...
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**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on record review, observation and interview, the facility failed to ensure Resident #45, a dependent resident, received assistance with showers as indicated on the Plan of Care. This affected one (Resident #45) of five residents reviewed for activities of daily living (ADL).
Findings include:
Medical record review revealed Resident #45 was admitted to the facility on [DATE] with diagnoses including muscle wasting and atrophy, adult failure to thrive, and diabetes mellitus.
Review of the Minimum Data Set (MDS) 3.0 assessment, dated 05/16/19, revealed a Brief Interview for Mental Status (BIM) score of 15, which indicated Resident #45 was cognitively intact. The MDS further revealed Resident #45 was totally dependent and required physical assistance of one person during bathing. Review of the Care Plan, initiated on 11/28/18, revealed the resident will have ADL needs met with staff assistance.
During observations, between 07/08/19 and 07/10/19, the resident was wearing a blue hospital gown, which was not tied securely and was hanging loosely, exposing his chest. Resident #45's hair was uncombed and disheveled.
During interview on 07/10/19 at 8:59 A.M., Resident #45 revealed that he never received a shower, and he only received a bed bath. He revealed that he would like to have a shower and would like to be out more often.
Review of Resident #45's Shower Task Log revealed the resident did not receive a shower on 06/29/19, 07/03/19, and 07/06/19. Review of Resident #45's nursing progress notes and Shower Task Log did not reveal that he refused a shower.
During interview on 07/10/19 at 9:10 A.M., State-Tested Nursing Assistant (STNA) #121 confirmed the resident had not received a shower since 06/28/19, as indicated on the Shower Task Log. During interview on 07/10/19 at 10:15 A.M., the Director of Nursing (DON) confirmed Resident #45's Shower Task Log indicated a shower schedule of Wednesdays and Saturdays, and that the resident did not receive a shower, per the plan of care, on 06/29/19, 07/03/19, and 07/06/19.
CONCERN
(D)
Potential for Harm - no one hurt, but risky conditions existed
Deficiency F0679
(Tag F0679)
Could have caused harm · This affected 1 resident
**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, interview and record review, the facility failed to ensure one to one activities were provided as planned ...
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**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, interview and record review, the facility failed to ensure one to one activities were provided as planned for Resident's #11 and #22. This affected two of four residents reviewed for activities.
Findings include:
1. Resident #11 was admitted to the facility on [DATE] with diagnoses which included dementia and Parkinson's disease.
Review of the quarterly Minimum Data Set (MDS) 3.0 assessment dated [DATE] revealed the resident was not interviewable.
Review of the 03/07/19 progress note revealed the resident had a change in condition and needed one to one activities at this time for socialization because the resident spend the majority of his time in his room. The residents likes included music and entertainment.
Review of the residents current activities care plan initiated 03/12/19 revealed the resident would receive one to one visits two to three times a week for socialization. Interventions included to provide favorite activities such as television (TV), music, spiritual support and invite to sit in the lounge with other residents.
Review of the May 2019 calendar revealed one to one visits were scheduled on 05/01/19, 05/06/19, 05/11/19, 05/19/19, 05/21/19, 05/24/19 and 05/28/19. Further review of the participation record revealed the resident received one to one visits on 05/01/19, 05/06/19, 05/11/19, 05/19/19, 05/21/19, 05/24/19 and 05/28/19 of reading.
Review of the June 2019 calendar revealed one to one visits were scheduled on 06/01/19, 06/03/19, 06/09/19, 06/10/19, 06/11/19, 06/18/19, 06/22/19 and 06/27/19. Further review of the participation record revealed the resident received one to one visits on 06/01/19 of reading and TV, 06/03/19 and 06/09/19 of reading, 06/10/19 and 06/11/19 of reading and TV, 06/18/19 and 06/22/19 of reading, and 06/27/19 of reading and TV.
Review of the July 2019 calendar revealed one to one visits were scheduled on 07/01/19, 07/07/19 and 07/13/19. Further review of the participation record revealed the resident receive one to one visits on 07/01/19 of reading and TV and 07/07/19 of reading.
On 07/08/19 at 11:22 A.M., 12:42 P.M., 3:10 P.M., 4:25 P.M., 5:56 P.M. and 6:30 P.M., the resident was observed sleeping or not engaged in any activities.
On 07/09/19 at 9:20 A.M., 2:10 P.M. and 3:16 P.M., the resident was observed sleeping or not engaged in any activities.
On 07/10/19 at 10:12 A.M., 1:00 P.M. and 4:59 P.M., the resident was observed sleeping or not engaged in any activities.
On 07/11/19 at 8:40 A.M., 10:19 A.M. and 11:16 A.M., the resident was observed sleeping or not engaged in any activities.
On 07/11/19 at 10:35 A.M., interview with Activities Assistant (AA) #5 stated she provided one on one activities to residents on the days they were listed on the monthly calendars. She verified the one on one activities consisted of reading or watching TV with the resident despite other activities that could be done. She stated the visits were to be completed two to three times a week for about 20 minutes but were not always scheduled for two to three times a week and therefore not completed two to three times a week.
On 07/11/19 at 3:00 P.M., interview with Activities Director (AD) # 15 verified the resident did not receive one to one activities as planned nor were the one to one's provided individualized to the resident.
2. Resident #22 was admitted to the facility on [DATE] with diagnoses which included dementia.
Review of the activity initial review dated 10/10/18 revealed the residents interests included crossword puzzles, music, religious services, visits and bingo.
Review of the quarterly MDS 3.0 dated 04/18/19 revealed the resident was severely cognitively impaired.
Review of the 04/18/19 activities progress note revealed the resident had continued to decline and no longer did self directed activities. The resident would be placed on one to one activities two to three times a week for socialization.
Review of the residents current activities care plan initiated 04/19/19 revealed the resident would receive one to one visits two to three times a week. Interventions included to escort the resident off unit for programs of interest and provide items needed for self directed activities. The care plan was not updated to include individualized one to one activities according to the residents interests.
Review of the May 2019 calendar revealed one to one visits were scheduled on 05/01/19, 05/06/19, 05/11/19, 05/19/19, 05/21/19, 05/24/19 and 05/28/19. Further review of the participation record revealed the resident received one to one visits on 05/01/19 of reading, on 05/06/19 and 05/19/19 of reading and TV, and on 05/21/19 and 05/24/19 of reading.
Review of the June 2019 calendar revealed one to one visits were scheduled on 06/01/19, 06/03/19, 06/09/19, 06/10/19, 06/11/19, 06/18/19, 06/22/19 and 06/27/19. Further review of the participation record revealed the resident received one to one visits on 06/01/19, 06/09/19, 06/10/19, 06/11/19 of reading and TV, 06/18/19 and 06/22/19 of reading, and 06/27/19 of reading and TV.
Review of the July 2019 calendar revealed one to one visits were scheduled on 07/01/19, 07/07/19 and 07/13/19. Further review of the participation record revealed the resident receive one to one visits on 07/01/19 and 07/07/19 or reading.
Review of the 07/09/19 group activity participation log indicated the resident attended bingo at 2:15 P.M. despite the resident not getting out of bed and being observed in bed at 2:18 P.M.
On 07/08/19 at 9:00 A.M., 2:50 P.M., 4:15 P.m., 5:46 P.M. and 6:37 P.M., the resident was observed in bed sleeping without the TV on and no activities.
On 07/09/19 at 9:19 A.M., 10:48 A.M., 1:16 P.M., 2:18 P.M., and 3:00 P.M., the resident was observed in bed without the TV on and no activities.
On 07/10/19 at 10:21 A.M., 11:13 A.M., and 5:32 P.m., the resident was observed in bed without the TV on and no activities.
On 07/11/19 at 8:45 A.M., 10:20 A.M. and 11:17 A.M., the resident was observed in bed without the TV on and no activities.
On 07/11/19 at 10:35 A.M., interview with AA #5 stated she provided one on one activities to residents on the days they were listed on the monthly calendars. She verified the resident liked checkers, reading the paper and religious activities. She stated the visits were to be completed two to three times a week for about 20 minutes but were not always scheduled for two to three times a week and consisted of reading or watching TV with the resident.
On 07/11/19 at 3:00 P.M., interview with AD # 15 verified the resident did not receive one to one activities as planned. AD #15 verified the resident had not been out of bed in months and verified the group activity of bingo on 07/09/19 at 2:15 P.M., participation log indicated the resident attended was inaccurate.
On 07/11/19 at 3:45 P.M., interview with AD #15 verified the residents one to one activities were reading and watching TV and they were no individualized to the residents likes.
CONCERN
(D)
Potential for Harm - no one hurt, but risky conditions existed
Quality of Care
(Tag F0684)
Could have caused harm · This affected 1 resident
**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on record review, observation and interview, the facility failed to ensure Resident #17 was properly positioned in her whe...
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**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on record review, observation and interview, the facility failed to ensure Resident #17 was properly positioned in her wheelchair and failed to ensure Resident #22's compression stockings were worn per physician's order. This affected one (Resident #17) of two residents reviewed for positioning and one (Resident #22) of one resident reviewed for compression stockings.
Findings include:
1. Medical record review revealed Resident #17 was admitted to the facility on [DATE] with diagnoses including dementia, abnormal posture, and muscle weakness. Review of the Minimum Data Set (MDS) 3.0 assessment, dated 04/10/19, revealed Resident #17 was totally dependent and required the assistance of two persons for transfers and mobility and had a limitation in range of motion of both lower extremities.
During observation on 07/09/19 at 9:02 A.M., the resident was sitting in her reclining wheelchair with both feet unsupported and dangling behind the footrests.
During observation on 07/10/19 at 10:04 A.M., the resident was sitting in her wheelchair with both feet unsupported and dangling behind the footrests. The left footrest was placed in a vertical position.
During interview on 07/10/19 at 10:10 A.M., State-Tested Nursing Assistant (STNA) #92 verified Resident #17's feet were unsupported, dangling and not properly positioned on the footrests of the wheelchair.
During interview on 07/10/19 at 10:15 A.M., Licensed Practical Nurse (LPN) #21 verified Resident #17's feet were dangling and not properly supported on the footrests of the wheelchair.
2. Resident #22 was admitted to the facility on [DATE] with diagnoses which included chronic embolism and deep vein thrombosis of left lower extremity and dementia.
Review of the physician's order dated 10/17/18 revealed for the resident was to wear compression stocking in the A.M. and remove them in the P.M. Further review of the skin integrity care plan initiated 10/11/18 revealed it was updated on 04/30/19 to have the resident wear compression stockings in the A.M. and remove them in the P.M.
Review of the quarterly MDS 3.0 assessment dated [DATE] revealed the resident was severely confused and required extensive assistance of one person for dressing.
On 07/08/19 at 2:50 P.M. and 5:46 P.M., the resident was observed without her compression stockings on.
On 07/08/19 at 6:36 P.M., the resident was observed without her compression stockings on.
On 07/08/19 at 6:37 P.M., interview with STNA #7 verified the resident did not have on her compression stockings as ordered.
On 07/09/19 at 9:19 A.M., 10:48 A.M., 1:16 P.M., 2:18 P.M. and 2:59 P.M., the resident was observed without her compression stockings on.
On 07/09/19 at 3:00 P.M., interview with STNA #35 verified the resident did not have on her compression stockings as ordered. She stated there was no documentation to say what each resident needed for the aides to use as a guide. Information was passed on by verbal report or asking the nurse.
On 07/10/19 at 10:50 A.M., interview with the Assistant Director of Nursing (ADON) #45 indicated the aides had a device list they could review. After obtaining the device list, which she verified had not been updated since 06/15/19, it revealed there was no indication the resident was to wear compression stockings.
This is an example of continued noncompliance from the survey completed on 06/25/19.
CONCERN
(D)
Potential for Harm - no one hurt, but risky conditions existed
Deficiency F0685
(Tag F0685)
Could have caused harm · This affected 1 resident
**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on record review, interview and observation, the facility failed to adequately assess resident's hearing loss and provide ...
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**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on record review, interview and observation, the facility failed to adequately assess resident's hearing loss and provide timely audiology services to assess hearing loss and repair of hearing aids to ensure the resident-maintained hearing abilities. This affected one (Resident #46) of one resident reviewed for hearing.
Findings included:
Record review revealed Resident #46 was admitted to the facility on [DATE] and re-admitted [DATE] with diagnoses including communication deficit and diabetes.
Review of Resident #46's 360 Care audiology visit dated 04/03/19 revealed the resident was seen by a nurse practitioner and reported chronic hearing loss and tinnitus (ringing or buzzing noise) in both ears. The resident reported her hearing aids were not working well or have been broken for almost four years. The left hearing aid was broken, and the right hearing aid didn't fit properly in her ear. The resident would like audiology to consult to get new hearing aids. An audiology referral recommendation was made on 12/03/18. An audiology referral recommendation was being made as the resident would benefit from a hearing test by an audiologist in the next one to six months for hearing loss based upon additional information from the facility, resident, and doctor. The resident needed a new pair of hearing aids.
Review of Resident #46's communication deficit plan of care revealed the resident reported chronic hearing loss and chronic tinnitus. The resident's goal included the resident would retain/improve conversation. The resident's intervention included to arrange for a hearing consult as needed, and arrange for follow-up as ordered. There was no evidence the resident had hearing aids.
Review of Resident #46's quarterly Minimum Data Set (MDS) 3.0 assessment dated [DATE] indicated the resident had adequate hearing and no hearing devices.
Review of the MDS Resident Assessment Instrument (RAI) manual revealed to interview the resident and ask about hearing function in different situations, review the medical record, and prior to beginning the hearing assessment, ask the resident if he or she had own hearing aids or other hearing appliance and, if so, whether they were at the nursing home.
Interview on 07/09/19 at 8:37 A.M., with Resident #46 revealed she had hearing aids that were in disrepair. She reported her hearing had changed due to her diabetes. She had been waiting four months to have a hearing test done so she could get new hearing aids.
Interview on 07/10/19 at 10:41 A.M., the Administrator verified the resident had not seen the audiologist for hearing testing at this time. The audiologist would not be back until 08/07/19.
Interview and observation on 07/10/19 at 1:02 P.M., of Resident #46 with Registered Nurse (RN) #84 revealed the resident had two hearing aids in a box in her dresser. One hearing aid was broken. The resident reported she had stepped on it. She has had the hearing aids for five to six years and had brought them to the facility upon admission. She reported she would like to hear again and would like new hearing aids. She reported she had voiced concerns to staff, however she still had not seen the audiologist for her hearing test. The television was playing at normal volume during observation. The resident reported the voices on the television were muffled. RN #84 reported she was not aware the resident had hearing aids.
Interview on 07/10/19 at 1:34 P.M., RN #84 (MDS nurse) verified she was not aware the resident had hearing aids, nor did she ask the resident during the last MDS assessment. She confirmed the RAI manual indicated to interview the resident and ask about hearing function in different situations, review the medical record, and prior to beginning the hearing assessment, ask the resident if he or she had own hearing aids or other hearing appliance and, if so, whether they were at the nursing home. RN #84 confirmed the current plan of care did not indicate the resident had hearing aids. She indicated she coded the MDS indicating the resident had adequate hearing based on her observation that the resident was able to hear her when speaking at normal tone and her television was at a normal volume.
CONCERN
(D)
Potential for Harm - no one hurt, but risky conditions existed
Pressure Ulcer Prevention
(Tag F0686)
Could have caused harm · This affected 1 resident
**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, interview and record review, the facility failed to ensure Resident #38, who was at risk for developing pr...
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**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, interview and record review, the facility failed to ensure Resident #38, who was at risk for developing pressure ulcers, had interventions in place to prevent the development of pressure ulcers. This affected one of one resident reviewed for pressure ulcers.
Findings include:
Resident #38 was admitted to the facility on [DATE] with diagnoses which included cerebral vascular accident with right sided hemiparesis, muscle wasting, weakness and edema. The resident did not sleep in her bed but preferred to sleep in her wheelchair.
Review of the impaired skin integrity care plan, initiated 10/17/18, revealed interventions included to encourage the resident to elevate her legs and include the resident and/or responsible party in the treatment plan.
Review of the current physician's order initiated 04/07/19 revealed to encourage and assist the resident with elevating her heels while in bed, and assist with repositioning in bed at least every two hours and as needed.
Review of the most recent Braden assessment, an assessment to determine the risk for developing pressure ulcers, dated 04/30/19 and completed by the wound Licensed Practical Nurse (LPN) #106, revealed the resident scored a 16 which indicated the resident was at risk for developing pressure ulcers.
Review of the 05/13/19 Minimum Data Set (MDS) 3.0 assessment revealed the resident was not able to be interviewed. The resident required assistance from staff with activities of daily living (ADL) including dressing. The resident did not have any pressure ulcers.
Review of the physician's order dated 05/01/19 revealed to apply Unna boot to the right lower extremity, a compression dressing made by wrapping layers of gauze around your leg and foot up to the base of the toes. It is often used to protect an ulcer or open wound. The Unna boot was covered with Co-Ban which was used to secure and protect the Unna boot. It also helped immobilize injuries and provide compression. The dressing was changed weekly on Wednesdays (Wednesdays in May 2019 were 05/01/19, 05/08/19, 05/15/19, 05/22/19 and 05/29/19).
Review of the weekly skin rounds assessments dated 05/04/19 (Saturday), 05/12/19 (Sunday) and 05/25/19 (Saturday) revealed bony prominence's were assessed which included the right and left heel, and they were intact despite the heels not able to be observed due to the above dressing which could not be removed. The only pressure relieving device in place was a pressure relieving mattress. (Staff indicated the resident did not sleep in bed).
Review of the May 2019 Treatment Administrator Record (TAR) revealed the documentation was not consistent to accurately reflect when the Unna boot was changed. Also the TAR indicated the resident legs were elevated daily while in bed despite the resident not sleeping in bed. Further review of the May 2019 Medication Administrator Record (MAR) revealed the resident was monitored for behaviors including resisting care and being non-complaint with treatment and there were no behaviors noted for the month.
Review of the weekly skin rounds assessments for June 2019 revealed the only assessment completed was on 06/01/19 which indicated the right heel was intact. This assessment was completed on Saturday.
Review of the physician's order dated 06/06/19 revealed to cleanse the right heel with wound cleanser, apply opritcell, an alginate based gel fiber product (best used on wounds that have a large amount of exudate or fluid based inflammation) and used to provide an optimal moist wound healing environment and was indicated for use on partial and full thickness wounds. Then apply a foam dressing and change with the weekly (Wednesday) Unna boot dressing.
Review of the 06/06/19 wound observation evaluation indicated the resident was admitted with a right heel stasis ulcer with a small amount of serosanguineous drainage measuring 2.0 centimeters (cm) in length by 1.0 cm in width by 0.3 cm in depth with pink peri-wound tissue and well-defined shape and edges which was found during the weekly removal of the Unna boot. No new pressure relieving interventions were initiated for the heels. Further review of the 06/19/19 wound observation evaluation indicated the wound was unchanged yet slough tissue was present in the center and the width grew to 2.0 cm's. Further review of the 06/26/19 wound observation evaluation indicated the wound was unchanged yet 40 percent of necrosis and/or slough comprised the wound bed and the width measured 3.0 cm's.
Review of the June 2019 TAR revealed the documentation was not consistent to accurately reflect when the Unna boot and dressing to the right heel were changed. Also the TAR indicated the residents legs were elevated daily while in bed. Further review of the June 2019 MAR revealed the resident only had behaviors on two days for the month 06/14/19 and 06/23/19.
Review of the revised skin integrity care plan, dated 07/01/19 revealed the resident had a venous stasis pressure ulcer to the right heel. There were no added interventions for the development of the wounds.
Review of the 07/03/19 wound observation evaluation indicated the wound was unchanged yet the length measured 3.0 cm's. The wound was moist with yellow slough and slightly macerated. No interventions were put into place.
Review of the July 2019 TAR revealed the residents legs were elevated daily while in bed. Further review of the July 2019 MAR revealed the resident resisted care one time on 07/02/19.
On 07/08/19 at 9:10 A.M. and 11:19 A.M., the resident was observed in her wheelchair with Unna boots and socks, and her feet were on the floor.
On 07/08/19 at 11:20 A.M., interview with the resident revealed when asked about any sores or open areas she pointed to her legs but was not able to give any additional information.
On 07/08/19 at 4:20 P.M., 5:47 P.M. and 6:35 P.M., the resident was observed in her wheelchair with Unna boots and socks and her feet on the floor.
On 07/09/19 at 9:19 A.M., 10:46 A.M., 12:30 P.M. and 1:15 P.M., the resident was observed in her wheelchair with Unna boots and socks and her feet on the floor.
On 07/09/19 at 1:16 P.M., interview with Licensed Practical nurse (LPN) #19 revealed the resident did not sleep in bed. The family bought her a recliner so she could elevated her legs, but she did not like that either and preferred to sleep in her wheelchair. LPN #19 verified the resident had not worn any protective boots on her feet but usually just wore socks.
On 07/09/19 at 3:20 P.M., the resident was observed in her wheelchair with Unna boots and socks and her feet on the floor.
On 07/10/19 at 11:12 A.M. and 12:58 P.M., the resident was observed in her wheelchair with Unna boots and socks and her feet on the floor.
On 07/10/19 at 5:00 P.M., interview with the wound nurse, LPN #106, revealed the right heel wound currently measured 3.5 cm by 2.0 cm by 0.2 cm with 90 percent granulation and slough. LPN #106 verified she coded the heel as a stasis ulcer but could have been developed from the Unna boot. She verified there were no appropriate interventions in place prior to the development of the wound to the heel nor were any additional interventions implemented after development of the wound except for the treatment of the wound.
On 07/10/19 at 5:15 P.M., observation of the wound with LPN #106 and the wound physician #300 revealed a large area over the bony prominence of the right heel with pink tissue around the wound, but the wound was covered with a white area and had depth to it with drainage. During the observation the resident was very anxious and moving around while laying in bed repeatedly saying hurry I have to get up I have things to do.
On 07/10/19 at 5:25 P.M., interview with wound physician #300 verified the right heel was on the bony prominence of the right heel and was in fact a pressure ulcer and not a stasis ulcer. The physician indicated the wound had not gotten better and was going to change the treatment but decided to wait another week. The physician was aware the resident did not sleep in bed nor did she like to elevate her legs, and she liked to stay in her wheelchair.
On 07/11/19 at 5:40 P.M., interview with LPN #106 verified the TAR was inconsistent and could not accurately reflect when the weekly dressing changes of the Unna boot were completed, verified there were no interventions prior to or after the development of the heel pressure ulcer to alleviate pressure off the heels, verified the resident did not sleep in bed despite the TAR indicating she did daily and verified she coded the pressure ulcer as a stasis ulcer and inadvertently coded the wound as developed on admission when the wound was actually acquired while the resident was in the facility. She verified the right heel wound was originally found as a blister but had a depth of 0.3 cm and was not able to provide any addition descriptions of the wound when found on 06/06/19. LPN #106 verified the size of the wound had gotten bigger and there had been no improvement in the wound since found on 06/06/19.
CONCERN
(D)
Potential for Harm - no one hurt, but risky conditions existed
Incontinence Care
(Tag F0690)
Could have caused harm · This affected 1 resident
**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on record review, observation and interview, the facility failed to ensure Resident #45's urinal was located at his bedsid...
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**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on record review, observation and interview, the facility failed to ensure Resident #45's urinal was located at his bedside, as indicated on the Plan of Care. This affected one (Resident #45) of one resident reviewed for bowel and bladder incontinence.
Findings include:
Medical record review revealed Resident #45 was admitted to the facility on [DATE] with diagnoses including muscle wasting and atrophy, adult failure to thrive, and diabetes mellitus.
Review of the Minimum Data Set (MDS) 3.0 assessment, dated 05/16/19, revealed a Brief Interview for Mental Status (BIMS) score of 15, which indicated Resident #45 was cognitively intact. The MDS further revealed Resident #45 required extensive, physical assistance by two-persons during toileting and was frequently incontinent of urine and bowel. Review of the Care Plan, initiated on 11/28/18, revealed the resident will have activities of daily living (ADL) needs met with staff assistance, and the resident preferred to leave his urinal nearby, located on his bedside table and/or side rail.
During observation on 07/08/19 at 11:51 A.M., there was no urinal located in the resident's room. During interview on 07/08/19 at 11:52 A.M., the resident revealed that he did not know the location of his urinal.
During observation on 07/08/19 at 2:52 P.M., the urinal was not located in the resident's room. State-Tested Nursing Assistant (STNA) #110 entered the room and checked Resident #45's incontinence brief for wetness. STNA #110 revealed the resident sometimes uses his urinal and is checked for incontinence every two hours. During interview on 07/08/19 at 2:53 P.M., STNA #110 verified there was no urinal in the room, and she would go and get a urinal for the resident.
CONCERN
(D)
Potential for Harm - no one hurt, but risky conditions existed
Deficiency F0692
(Tag F0692)
Could have caused harm · This affected 1 resident
**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, interview and record review, the facility failed to ensure Resident #11, who sustained significant weight ...
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**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, interview and record review, the facility failed to ensure Resident #11, who sustained significant weight loss, had a comprehensive interdisciplinary plan of care in place including nutritional assessments to monitor the residents weights and provide adequate interventions in an attempt to decrease the weight loss and ensure the resident maintained optimal intake. This affected one of two residents reviewed for nutrition.
Findings include:
Resident #11 was admitted to the facility on [DATE] with diagnoses which included dementia and Parkinson's disease.
Review of the nutrition care plan initiated on 11/22/17 revealed the resident would be free of unavoidable weight fluctuations. The intervention was to encourage the resident to eat, observe the ability for the resident to feed himself, and provide assistance with meals as needed. The care plan was not revised until 02/26/19.
Review of the quarterly Minimum Data Set (MDS) 3.0 assessment dated [DATE] revealed the resident was not interviewable.
Review of the physician's order dated 11/15/17 revealed the resident had been on 40 milligrams of Lasix, a diuretic, which was continued until 02/16/19 when the resident went to the hospital.
Review of the December 2018 meal intake record revealed intake was sparatic with zero to 75 percent intakes and 22 meals not documented, with many intakes less than 50 percent.
Review of the Occupational Therapy (OT) evaluation dated 12/19/18 revealed the resident was having increased difficulty feeding himself. Upon assessment he required maximum assistance to complete self-feed with the use of built-up utensils. The resident presented with decreased coordination that impacted his feeding performance.
Review of the January 2019 meal intake record revealed the resident consumed less than 50 percent of at least half of the meals for the month.
Review of the 01/07/19 weights revealed the resident was 236 pounds which was stable for the resident.
Review of the physician's progress note dated 01/07/19 revealed there was no indication the physician was made aware of the residents decline in being able to feed himself.
Review of the 01/10/19 quarterly nutrition assessment revealed no changes in weight. The resident was on Lasix which could contribute to weight fluctuation and no edema was noted. There were no current interventions. The resident was confused and was consuming an average of 60 percent of his meals. Staff were to encourage meals were greater than 50 percent each day. There was no mention of the residents decreased ability to feed himself requiring skilled therapy.
Review of the OT Discharge summary dated [DATE] revealed the staff were educated the resident required cues during meals to maintain his attention for eating. The staff were to have the resident out of bed for all meals. The resident was referred to the restorative dining program.
Review of the restorative program note dated 01/24/19 revealed the resident was referred to restorative dining for all meals after completing skilled therapy. Further review of the restorative grids for January 2019 revealed the resident did not participate in any of the dinner meals.
Review of the February 2019 meal intake record revealed the resident refused or took in minimal amounts of food with 11 meals not documented until 02/12/19 when the resident went to the hospital.
Review of the restorative grids for February 2019 revealed the resident did not participate in any of the dinner meals, and there were 11 meals without any documentation prior to 02/12/19 when the resident was sent to the hospital.
Review of the 02/04/19 weight revealed the residents current weight was 199 pounds, which was a 37 pound weight loss in one month. Further review of the re-weight on 02/04/19 revealed the weight was 197 pounds or a 39 pound weight loss in one month.
Review of the nutrition progress note dated 02/04/19 revealed the resident lost 37 pounds in one month and was a significant weight loss for one, three and six months. The note stated the resident continued on Lasix which could cause weight fluctuation, and the resident had bilateral lower extremity edema. The note indicated the physician did not feel the weight loss occurred in the last 30 days and gradual weight loss was desired. The resident had edema to the bilateral lower extremities at this time. The resident was being fed at meals by staff when he stayed in bed. There were no interventions put into place.
Review of the psychiatrist order dated 02/08/19 revealed to initiate Remeron (an antidepressant also used for behavioral disturbances and an appetite stimulant) at night for behavioral disturbances. Further review of the note revealed staff reported the resident was mean and had an increase in combativeness at times but he was more so verbally aggressive towards them.
Review of the nutrition progress note dated 02/12/19 revealed the residents weight on 02/11/19 was 193 pounds which was a six pound weight loss in seven days. There were no interventions put into place by the Registered Dietetic Technician (DTR) #118.
Review of the hospital discharge note dated 02/16/19 revealed the resident had diagnoses included acute encephalopathy, urinary tract infection requiring antibiotics and atrioventricular block. The resident failed a swallowing study and was ordered nothing by mouth.
On 07/10/19 at 12:50 P.M., interview with DTR #118 verified she was the one who completed the progress notes. DTR #118 verified the nutritional care plan had not been updated to indicate the resident was having difficulty feeding himself requiring skilled therapy starting in December 2018, to indicated the resident was in restorative therapy in January 2019 nor addressing the recent significant weight loss. DTR #118 verified the notes indicated to ensure the resident ate at least 50 percent of his meals and when he did not she did not address the concern.
On 07/08/19 at 5:46 P.M., the resident was observed reclined in a Broda chair receiving his nutrition through a feeding tube.
On 07/10/19 at 1:35 P.M., interview with the Administrator reviewed and verified the above concerns.
On 07/10/19 at 2:35 P.M., interview with Occupational Therapist (OT) #108 revealed therapy was asked to pick up the resident in December 2018 because he was having a decline in feeding himself and not eating as much. OT #108 verified upon discharge from skilled therapy the resident was referred to restorative dining in January 2019 because he needed cueing and at times fed meals.
CONCERN
(D)
Potential for Harm - no one hurt, but risky conditions existed
Deficiency F0697
(Tag F0697)
Could have caused harm · This affected 1 resident
**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on record review, interview and policy review, the facility failed to timely administer Resident #18's narcotic pain medic...
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**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on record review, interview and policy review, the facility failed to timely administer Resident #18's narcotic pain medication. This affected one (Resident #18) of four residents reviewed for pain management.
Findings include:
Review of the medical record revealed Resident #18 was admitted to the facility on [DATE] with diagnoses including low back pain, displaced fracture of the neck, and muscle weakness. Review of the Minimum Data Set (MDS) 3.0 assessment, dated [DATE], revealed a Brief Interview for Mental Status (BIMS) score of 15, which indicated Resident #18 was cognitively intact. The MDS further revealed the resident had frequent pain and the administration of opioid pain medication.
Review of the Care Plan, dated [DATE], revealed the intervention to administer pain medication as ordered, observe for effectiveness and/or side effects, and to update the physician, as needed, regarding effectiveness or need for order change.
During interview on [DATE] at 11:50 A.M., Resident #18 revealed that she did not receive her 9:00 A.M. dose of Percocet, and her current pain level was a seven, on a one to ten pain level scale. The resident further revealed the facility ran out of her pain medication and the nurse was trying to contact her physician for a pain medication prescription.
Review of a physician order, dated [DATE], revealed an order for Percocet 5-325 milligrams (mg), an opioid pain medication, one tablet by mouth every 12 hours as needed for pain. Review of Resident #18's Medication Administration Record (MAR), dated [DATE], revealed the last dose of Percocet 5-325 mg was given on [DATE] at 9:00 P.M.
During interview on [DATE] at 11:55 A.M., Licensed Practical Nurse (LPN) #60 verified that Percocet 5-325 mg was not administered on [DATE] at 9:00 A.M. because the facility had been unable to reach the pain medicine physician for a new prescription. During interview on [DATE] at 5:10 P.M., the Director of Nursing (DON) confirmed the Percocet prescription was not available timely and the nursing staff should have obtained a prescription five days before the prescription expired. The DON further revealed that she would educate the staff to timely obtain medication prescriptions at least five days prior to the expiration date.
Review of the facility's policy titled Administering Medications, dated [DATE], revealed medications must be administered in accordance with the orders, including any required time frame.
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
**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on medical record review and interview, the facility failed to ensure pharmacy recommendations were addressed by the physi...
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**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on medical record review and interview, the facility failed to ensure pharmacy recommendations were addressed by the physician. This affected two (Resident #4 and #36) of five reviewed for unnecessary medications.
Findings included:
1. Record review revealed Resident #4 was admitted to the facility on [DATE] with diagnoses including need for assistance with personal care, pseudobulbar affect, major depression, pain, symbolic dysfunction, peripheral vascular disease, psychosis, heart disease, anxiety, dementia, anemia, and osteoarthritis. The resident was receiving Seroquel 25 milligrams (mg), an antipsychotic medication, daily for psychosis and Celexa 10 mg, an antidepressant medication, daily for depression.
Review of Resident #4's monthly pharmacy medication regimen review flow sheet revealed the pharmacist made recommendation to the prescriber on 01/14/19, 02/07/19, and 04/08/19. Further review revealed on 03/08/19 the pharmacist reviewed the residents record, however did not indicate if there were irregularities or recommendations.
Review of Resident #4's pharmacy recommendations revealed no evidence the pharmacy recommendations were addressed for 01/14/19, 02/07/19, 03/08/19, or 04/08/19.
Interview on 07/11/19 at 1:44 P.M. with Registered Nurse (RN) #45 verified there was no documented evidence the pharmacy recommendations were addressed by the physician on 01/14/19, 02/07/19, or 04/08/19. She found the blank recommendation for 01/14/19 that requested a stop date for Cephalexin, an antibiotic medication, which there was no order; however, it was completed on 01/19/19. The 02/07/19 recommendation requested diagnoses on the two Seroquel orders, and she was not able to find the recommendation for 03/08/19 or 04/08/19.
2. Record review revealed Resident #36 was admitted to the facility on [DATE] with diagnoses including cerebrovascular disease, chronic kidney disease, urinary incontinence, hypertension, anxiety, dementia, major depressive disorder, dysphagia, and psychosis.
Review of Resident #36's monthly pharmacy medication regimen review flow sheet revealed the pharmacist made recommendations to the prescriber on 07/31/18, 11/19/18, and 02/18/19.
Review of Resident #36's pharmacy recommendations revealed no evidence of pharmacy recommendations were addressed for 07/31/18, 11/19/18, and 02/18/19.
Interview on 07/11/19 at 1:44 P.M., with RN #45 verified she was unable to locate the pharmacy recommendations for 07/31/18, 11/19/18, and 02/18/19. She was able to find blank copies of the pharmacy recommendation for 11/19/18 and 02/18/19. The 11/19/18 recommendation was to change Metoprolol (beta-blocker) 100 mg daily to 50 mg twice daily and 02/18/19 was for gradual dose reductions for Lexapro (antidepressant) and Risperdal (antipsychotic). She was not able to find the recommendation for 07/31/18. She confirmed there was no evidence the pharmacy recommendations mentioned above had been addressed by the physician.
CONCERN
(D)
Potential for Harm - no one hurt, but risky conditions existed
Deficiency F0757
(Tag F0757)
Could have caused harm · This affected 1 resident
**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on record review, policy review and staff interview, the facility failed to ensure orders for narcotic pain medications us...
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**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on record review, policy review and staff interview, the facility failed to ensure orders for narcotic pain medications used on an as needed basis included parameters in which the medication should be used. This affected two (Resident #3 and #77) of six residents reviewed for unnecessary medications.
Findings include:
1. A review of Resident #3's medical record revealed she was admitted to the facility on [DATE]. Her diagnoses included leukemia and chronic blood clots of the deep veins of her right lower extremity.
A review of Resident #3's active physician's orders included orders for her to receive Acetaminophen 650 milligrams (mg) by mouth (po) every four hours as needed (prn) for moderate pain. She also had an order to receive Oxycodone (a narcotic analgesic) 5 mg po every four hours prn for pain. The order for Oxycodone did not include parameters that directed the nurses on when to administer the medication.
A review of Resident #3's medication administration record (MAR) for July 2019 revealed the resident received Oxycodone on a prn basis daily. She received between two and five doses each day for pain. The nurse administering the Oxycodone recorded the resident's pain level when the prn pain medication was given. The MAR indicated the nurse administered the Oxycodone to the resident on 07/04/19 at 8:00 A.M. for a pain level of one on a one to ten scale. She received two doses of Oxycodone on 07/04/19 at 1:00 P.M. and again on 07/09/19 at 4:07 P.M. for only a pain level of three on a one to ten scale. She received a dose of the Oxycodone 5 mg on a prn basis on 07/07/19 at 9:56 A.M. for a pain level of four on a one to ten scale. The remaining doses were used when the resident's pain was rated a five or higher on a one to ten scale. Findings were verified by Licensed Practical Nurse (LPN) #21.
A review of the facility's policy on administering pain medications, revised October 2010, revealed residents were not at risk for addiction to narcotic analgesics if used as prescribed for moderate to severe pain.
On 07/10/19 at 2:59 P.M., an interview with LPN #21 revealed Resident #3 verbalized when she had pain. He denied she was able to report the level of her pain using a one to ten scale, but they used a pain scale for residents with cognitive impairment. He reported the resident had a standard Tylenol order to be given on an a prn basis but she also had an order for Oxycodone prn. He reported he would consider mild pain to be a pain level of four or less. He would consider a pain level of five or more to be moderate to severe pain depending on how high the number was. He confirmed the order for the prn Oxycodone did not include any parameters that directed the nurse as to when to administer the prn Oxycodone. He reported the Oxycodone should not be used unless the resident was having moderate to severe pain. He denied he would use the prn Oxycodone for any pain level less than five. He reported the resident tended to sleep a lot during the day, and it could be related to her receiving the Oxycodone on an as needed basis when it was not really necessary. He had not known the resident to have any pain above a four on a one to ten scale when she was lying in bed.
2. Resident #77 admitted to the facility on [DATE] with diagnoses which included femur fracture and osteoarthritis.
Review of the physicians order dated 05/18/19 revealed to give two tablets of 325 milligrams (mg) of Acetaminophen (Tylenol), an analgesic, every four hours as needed for pain.
Review of the physicians order dated 05/20/19 revealed to give one tablet of 5-325 mg of Hydrocodone-Acetaminophen (Vicodin), a narcotic pain medication, every eight hours as needed for moderate to severe pain.
Review of the potential for pain care plan initiated 05/20/19 revealed the residents pain would be controlled. Interventions included assess the resident for location, onset, origin, intensity of and precipitating factors of pain utilizing a scale from zero to ten (mild, moderate and severe). Attempt to increase comfort through non-pharmacological interventions and include the resident in the treatment plan.
Review of the May 2019 Medication Administrator Record (MAR) revealed Tylenol was given on 05/19/19 twice for a pain score of five and seven which was effective. Vicodin was given on 05/20/19, 05/21/19, 05/22/19, 05/24/19 and 05/25/19 without assessing the residents pain level and no Tylenol was attempted prior. Also, for the doses of Vicodin given on 05/20/19, 05/21/19 and 05/25/19 there was no evidence of attempting non-pharmalogical interventions prior to the administration of the Vicodin.
Review of the MDS 3.0 dated 05/25/19 revealed the resident had mild cognitive impairment, was on scheduled and as needed pain medications and had occasional pain of intensity of a three from a scale of zero to ten. No pain assessment was completed.
Review of the June 2019 MAR revealed no Tylenol was given for pain. Vicodin was given on 06/05/19 (twice), 06/06/19, 06/10/19, 06/11/19 (twice), 06/12/19 (twice), 06/13/19, 06/14/19, 06/15/19, 06/18/19, 06/19/19, 06/20/19 (twice), 06/21/19 (twice), 06/24/19, 06/25/19, 06/26/19 (twice), 06/27/19 twice and 06/29/19. The range of the pain scale was between three and eight. Also for doses of Vicodin given on 06/05/19, 0606/19, 06/11/19, 06/12/19, 06/13/19, 06/14/19, 06/15/19, 06/20/19, 06/25/19, 06/26/19 and 06/27/19 there was no evidence of attempting non-pharmalogical interventions prior to the administration of the Vicodin.
Review of the July 2019 MAR revealed Tylenol was given on 07/03/19, 07/04/19, 07/05/19 and 07/09/19 with pain scores between three and eight. Vicodin was given on 07/01/19, 07/02/19, 07/03/19, 06/06/19, 07/06/19, 07/08/19, 07/09/19 and 07/10/19 with a pain scale between four and six. Also there was no evidence of attempting non-pharmalogical interventions prior to administration of the Vicodin.
On 07/09/19 at 5:45 P.M., interview with LPN #51 with review of the orders and the MAR's for July 2019 revealed first non-pharmalogical interventions should be attempted prior to giving any as needed medications. If that does not work, Tylenol should be attempted and then if the Tylenol was ineffective the Vicodin should be given. LPN #51 verified there was no evidence non-pharmalogical interventions were attempted prior to giving the as needed pain medications and verified there were no parameters for giving the Tylenol and Vicodin where given for the same pain levels, and they should not be interchangeable.
On 07/09/19 at 5:57 P.M., interview with the resident revealed she was very hard of hearing but was interviewable. The resident stated she was always in pain but did not like to take anything unless she had to and only wanted to take Tylenol, not any narcotics. She stated she was given one Tylenol pill for mild pain and two Tylenol pills for worse pain. The resident denied knowing she took any narcotics. She stated she would not want a narcotic because the more you take it the more you need it. Questioned the resident again about the use of narcotics and she repeated the same thing. When asked if the nurses asked her to rate her pain on a scale of zero to 10 she did not understand what that meant and stated they give her one to two Tylenol pills depending on how bad her pain was at the time.
On 07/10/19 at 1:30 P.M., interview with the Assistant Director of Nursing (ADON), with the Administrator present, revealed the concerns with no consistency of when the nurses were giving the Tylenol versus the Vicodin and no evidence of non-pharmalogical interventions prior to giving the as needed medications on many of the days the medications were given. The ADON verified Tylenol should be given for a pain from one to four and Vicodin for pain five to ten. She verified the May 2019 MAR did not use the pain scale prior to giving the medications. The ADON was informed the resident was not aware she was taking Vicodin and indicated she did not want to take the medication but only wanted to take Tylenol.
Review of the pain assessment and recognition policy, revised March 2018, revealed the staff should use a consistent approach and a standardized pain assessment instrument appropriate to the resident's cognitive level. Goals of pain treatment should be established and appropriate non-pharmalogical interventions such as local heat or ice, repositioning, massage and conversation about the pain. Medication interventions should be ordered and provided based on the resident's individual needs. An analgesic regimen should be utilized first as the lowest risk medications before using more problematic or higher risk approaches. Reduction in opioid analgesics are especially important in light of their limited efficacy in the treatment of chronic pain and their many diverse significant side effects.
CONCERN
(D)
Potential for Harm - no one hurt, but risky conditions existed
Unnecessary Medications
(Tag F0759)
Could have caused harm · This affected 1 resident
**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, record review, review of manufacturer's package insert and staff interview, the facility failed to ensure ...
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**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, record review, review of manufacturer's package insert and staff interview, the facility failed to ensure their medication error rate was less than 5%. There were three errors out of 27 opportunities for a medication error rate of 11%. This affected one (Resident #41) of two residents reviewed for medication administration.
Findings include:
A review of Resident #41's medical record revealed he was admitted to the facility on [DATE]. His diagnoses included chronic atrial fibrillation (an abnormal heart rhythm characterized by rapid and irregular beating of the atria), chronic obstructive pulmonary disease (COPD), and acute angle closure glaucoma of the left eye.
A review of Resident #41's active physician's orders revealed the resident was to receive Cardizem (a calcium channel blocker used in the treatment of atrial fibrillation) 60 milligrams (mg) by mouth (po) twice daily. He also had an order to receive Brimonidine Tartrate (medication used in the treatment of glaucoma) solution 2% with directions to give one drop in the left eye twice a day. His orders also included the use of Trelegy Ellipta aerosol powder (a combination inhaler of three different medications for the treatment of COPD) 100 micrograms (mcg)- 62.5 mcg-25 mcg one puff once a day.
On 07/10/19 at 7:58 A.M., an observation of a medication administration for Resident #41 noted Licensed Practical Nurse (LPN) #21 to administer the resident his morning medications. The nurse administered Brimonidine Tartrate solution 0.2% into the resident's right eye giving him two drops. After he gave the medicated eye drop in the resident's right eye, the resident pointed to his left eye and informed the nurse he should have given it in that eye. The nurse reassured the resident he gave it in the correct eye, but the resident insisted the nurse should have given it in his left eye. He stated it was always the left eye the nurses gave it in. The nurse acknowledged his mistake and told the resident he was correct, and it should have been given in his left eye. He then handed the resident his pills for him to take that included Cardizem 120 milligrams (mg) among his other pills. The nurse pulled the medications from a pre-packaged plastic bag that was sealed with all the medications that were due at that time. The front of the package listed all the medications the resident was to receive at that particular time of day. The pills were individually packaged inside that larger package with just the name of the medication and a dosage. He ended the medication administration pass by giving the resident his Trelegy Ellipta aerosol powder 100 micrograms (mcg)-62.5 mcg- 25 mcg inhaler to take. He handed the resident the inhaler after he primed it without providing any instruction to the resident. The resident inhaled the contents with one long inhalation. He handed the inhaler back to the nurse without rinsing his mouth with water. The nurse did not instruct him on the need to rinse and spit after using the inhaler.
A reconciliation of Resident #41's medications that were observed to be given for the morning medication pass was completed to check against the active physician's orders for errors. The active physician's orders showed an order change that reduced the resident's Cardizem from 120 mg once daily to 60 mg twice a day. The active physician's orders confirmed the resident's Brimonidine Tartrate solution 2% was to be given in the left eye (instead of the right eye in which the nurse gave it in) and he was only to get one drop instead of two that the nurse was observed to give. Findings were verified by LPN #21. He stated he would have to contact the resident's physician and notify her of the medication errors he committed while giving the resident his morning medications.
A review of Resident #41's medication administration record (MAR) for July 2019 revealed the resident was to receive Cardizem 60 mg po twice daily, Trelegy Ellipta 100 mcg- 62.5 mcg- 25 mcg one inhalation once daily and Brimonidine Tartrate solution 2% with directions to instill one drop in the left eye twice a day. The nurse initialed the medications were given as ordered. The MAR did include instructions to have the resident rinse his mouth after each use.
A review of the manufacturer's package insert for the Trelegy Ellipta revealed the instructions for use included the need to rinse the mouth after use. The directions were specific to rinse the mouth with water after the use of the inhaler and to spit, do not swallow the water. LPN #21 acknowledged he did not advise Resident #41 to rinse his mouth out with water and to spit after the use of the inhaler.
On 07/10/19 at 8:25 A.M., an interview with LPN #21 revealed he acknowledged his three medication errors he committed with the morning medication pass to Resident #41. He stated he was really nervous and was not used to someone watching him give medications when he erroneously administered two drops of Brimonidine Tartrate into the resident's wrong eye. He confirmed the orders was to give one drop in the left eye and not two drops in the right eye as he administered to the resident. He stated the error with the Cardizem was due to the packaging the medication came in. It still included Cardizem 120 mg capsules with the direction to give 120 mg once daily as previously ordered. He stated night shift should pull out the old package when the new prepackaged medication came in from the pharmacy with the new dosage ordered. He stated it was ultimately his responsibility to ensure he gave the correct medication, and he should have known by looking at the MAR the dosage was reduced to 60 mg twice daily. He knew the resident should have rinsed his mouth with water and spit the water out without swallowing but acknowledged he did not provide the resident the instructions to do so or hand him a cup of water to rinse and spit after the inhaler was given. He confirmed he informed the physician of the errors and stated the physician instructed them to hold the resident's evening dose of Cardizem since he administered the daily dose at one time instead of two divided doses. They were to monitor him for bradycardia (low pulse rate of less than 60 beats per minute).
CONCERN
(D)
Potential for Harm - no one hurt, but risky conditions existed
Deficiency F0760
(Tag F0760)
Could have caused harm · This affected 1 resident
**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on record review, observation, staff and physician interview, the facility failed to ensure a resident did not experience ...
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**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on record review, observation, staff and physician interview, the facility failed to ensure a resident did not experience a significant medication error during a medication administration observation. This affected one (Resident #41) of two residents reviewed for medication administration.
Findings include:
A review of Resident #41's medical record revealed he was admitted to the facility on [DATE]. His diagnoses included chronic atrial fibrillation (an abnormal heart rhythm characterized by a rapid and irregular beating of the atria).
A review of Resident #41's active physician's orders revealed he was to receive Cardizem (a calcium channel blocker used in the treatment of atrial fibrillation) 60 milligrams (mg) by mouth (po) twice a day. The resident had been on Cardizem 120 mg po every day, but an order was given to change the dose to 60 mg by mouth twice a day on 07/08/19 after the resident was transferred to the hospital for bradycardia (low heart rate of less than 60 beats per minute).
On 07/10/19 at 7:58 A.M., a medication administration observation for Resident #41 noted Licensed Practical Nurse (LPN) #21 to administer the resident his morning medications. Among the medications given, LPN #21 gave the resident Cardizem 120 mg po. The medications were pulled from a prepackaged pack that contained all the medications that were due for a particular day at a particular time. The prepackaged pack from the facility's contracted pharmacy that was pulled from the medication cart for Resident #41's morning medication pass for 07/10/19 included a Cardizem 120 mg capsule. The nurse administered the medication to the resident and signed off on the medication administration record (MAR) that the medication had been given.
A review of Resident #41's MAR for July 2019 revealed the MAR showed the resident was to receive Cardizem 60 mg po twice a day. The times for the Cardizem to be given were 9:00 A.M. and 9:00 P.M. LPN #21 initialed that he gave the resident Cardizem 60 mg by mouth as ordered despite giving the resident Cardizem 120 mg by mouth that was included in the pre-packaged pack sent from the pharmacy. Findings were confirmed with LPN #21.
On 07/10/19 at 8:25 A.M., an interview with LPN #21 revealed he did commit a significant medication error with Resident #41 when he gave the resident double the dose of Cardizem that he should have. He stated he pulled the Cardizem from the pre-packaged pack sent from the pharmacy that still had a Cardizem 120 mg capsule in it. He was not aware the resident's Cardizem dose had recently been changed from 120 mg once a day to 60 mg twice a day due to him having bradycardia thought to be caused by receiving the Cardizem at 120 mg in a one time dose. He reported it was normally the night shift nurse's responsibility to remove the pre-packaged packs that contained the old medications when a change in dosage occurred and the new packages arrived, but it was ultimately his responsibility to make sure he administered the proper dose. He acknowledged he should have noted the Cardizem was changed to 60 mg in two divided dosages instead of 120 mg in one dose by looking at the MAR. He indicated he would have to contact the physician to notify her of his medication error.
On 07/10/19 at 8:40 A.M., a follow up interview with LPN #21 revealed he had contacted the physician and notified her of his medication error pertaining to giving the resident twice the dose of his Cardizem. He stated the resident received 60 mg of Cardizem the evening of 07/09/19 and he gave 120 mg the morning of 07/10/19. The physician instructed them to hold the evening dose of Cardizem 60 mg that was scheduled for 07/10/19 at 9:00 P.M. The physician reported she would evaluate the resident when she visited the facility that day.
A review of a physician progress note for 07/10/19 revealed the physician had seen Resident #41 for a medication error. The physician indicated she had been in the facility when LPN #21 notified her of giving Resident #41 the wrong dose of Cardizem as he gave the resident 120 mg when 60 mg was ordered. The physician stated in her note she had recently changed the resident's dose over the weekend for bradycardia. The resident was asymptomatic when examined by the physician. She encouraged him to increase his fluid intake that day in an effort to flush out the medication. Poison control had been contacted by the facility's nursing administration staff at the direction of the physician and they were directed to just monitor the resident without any further recommendations. The resident's cardiologist was also notified of the medication error. An appointment with the cardiologist was made for August 2019 to follow up after the recent change in his Cardizem dosage. The physician requested an electrocardiogram (EKG) which showed sinus bradycardia of 56 nonspecific changes were noted. She ordered vital signs every hour until 6:00 P.M. that evening and then every shift that night thereafter. She directed them to hold the Cardizem 60 mg that evening and then for a heart rate less than 55 beats per minute.
A review of Resident #41's orders after his physician visit revealed the facility's nursing staff were also to notify the physician if the resident had any dizziness, lightheadedness or if his heart rate was less than 50 beats per minute. They could resume the Cardizem 60 mg po twice a day beginning 07/11/19.
On 07/10/19 at 9:50 A.M., an interview with Physician #500 revealed she assessed Resident #41 after it was reported to her that there was a medication error that pertained to his Cardizem. She reported the resident was currently stable and he was asymptomatic. His heart rate was regular at 60 beats per minute. She stated that was their concern now (referring to his heart rate). She reported they had obtained an EKG that was normal. She confirmed her orders were to obtain vital signs every hour until 6:00 P.M. that evening and then to obtain vital signs every shift through the remainder of the night. They planned to hold his evening dose of Cardizem. She indicated they had contacted the resident's cardiologist about the medication error and had also contacted him the day prior to about his heart rate being in the high 30's over the weekend. She reported the resident had been sent to the hospital for an evaluation the prior weekend for bradycardia. It was then, they decided to divide his daily dose of Cardizem into two divided doses giving him 60 mg twice a day instead of 120 mg once a day. She confirmed he had a follow up with the cardiologist scheduled for some time the first week or two of August. She reported they were considering the use of intravenous (IV) fluids if he became symptomatic but he was drinking well on his own. The cardiologist did not recommend IV fluids to be given due to him having a history of congestive heart failure. She wanted the nursing staff to monitor the resident for dizziness, lightheadedness and a heart rate less than 55 beats per minute.
CONCERN
(D)
Potential for Harm - no one hurt, but risky conditions existed
Deficiency F0919
(Tag F0919)
Could have caused harm · This affected 1 resident
**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on medical record review, observation and staff interview, the facility failed to the ensure call light was in reach for R...
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**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on medical record review, observation and staff interview, the facility failed to the ensure call light was in reach for Resident #45. This affected one of one resident observed for call lights.
Findings included:
Record review revealed Resident #45 was admitted to the facility on [DATE] with diagnoses including repeated falls, muscle wasting and atrophy, hydrocephalus, adult failure to thrive, rhabdomyolysis, diabetes, hypertension, weakness, and polyneuropathy.
Review of Resident #45's Minimum Data Set (MDS) 3.0 assessment, dated 05/16/19, revealed the resident required extensive assistance with bed mobility and was totally dependent for transfers.
Observation on 07/08/19 at 2:45 P.M. and 07/09/19 at 1:16 P.M., revealed Resident #45's call light was noted on the floor and not within the residents reach.
Interview on 07/09/19 at 1:16 P.M., with Licensed Practical Nurse (LPN) #19 confirmed the resident's call light was lying on the floor and not within the resident's reach. The LPN confirmed the resident was able to use his call light when it was within reach.
CONCERN
(E)
Potential for Harm - no one hurt, but risky conditions existed
Safe Environment
(Tag F0584)
Could have caused harm · This affected multiple residents
Based on observation and interview, the facility failed to ensure resident's rooms were maintained in a clean, sanitary, and safe condition. This affected five (Residents #3, #16, #20, #34, and #62) o...
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Based on observation and interview, the facility failed to ensure resident's rooms were maintained in a clean, sanitary, and safe condition. This affected five (Residents #3, #16, #20, #34, and #62) of 43 residents residing on 300 halls.
Findings included:
1. Observation of Resident #62's room on 07/08/19 at 3:57 P.M. and 07/10/19 at 1:59 P.M., revealed the resident's entry door was cracked. The findings were verified with the Maintenance Director (MD) on 07/10/19 at 1:59 P.M.
2. Observation of Resident #34's room on 07/08/19 at 4:20 P.M. and 07/10/19 at 2:05 P.M., revealed the metal baseboard heating shield that ran along the bottom of wall was bent outward exposing the heating coils. The wall next to both beds had dried water lines running down the wall. The findings were confirmed with the MD on 07/10/19 at 2:05 P.M.
3. Observation of Resident #16's room on 07/08/19 at 3:45 P.M. and 07/10/19 at 2:02 P.M., revealed the bathroom wall had a large four foot by four foot square area under the sink that was missing tile, and the plywood was exposed. The findings were confirmed with the MD on 07/10/19 at 2:02 P.M.
4. Observation of Resident #20's room on 07/08/19 at 3:18 P.M. and 07/10/19 at 1:58 P.M., revealed there was dry tube feeding drippings on the resident's night stand, floor beside the resident's bed, and on the wall. The baseboard heating shield that ran along the bottom of the wall was not attached to the metal base exposing the heating coils. The findings were confirmed with the MD on 07/10/19 at 1:58 P.M.
5. Observation of Resident #3's room on 07/08/19 at 4:06 P.M. and 07/10/19 at 2:18 P.M., revealed the resident's bedside tables in her room were chipped, and the one by the window had a dried white substance on it. The privacy curtain was stained with a red/brown substance. There was a patched area on the wall by the clock that had not been sanded or painted. The findings were confirmed with the MD on 07/10/19 at 2:18 P.M.
CONCERN
(F)
Potential for Harm - no one hurt, but risky conditions existed
Employment Screening
(Tag F0606)
Could have caused harm · This affected most or all residents
Based on review of personnel files, new hire list, staff interview and review of the facility abuse policy, the facility failed to ensure all staff were checked against the Nurse Aide Registry prior t...
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Based on review of personnel files, new hire list, staff interview and review of the facility abuse policy, the facility failed to ensure all staff were checked against the Nurse Aide Registry prior to employment to ensure the employee did not have a finding entered into the State Nurse Aide Registry concerning abuse, neglect, exploitation, mistreatment of residents or misappropriation of property. This had the potential to affect all residents residing in the facility.
Findings include:
Review of the new hire list dated 06/01/18 to 07/03/19 and personnel files revealed Housekeeper #8, Dietary Aide (DA) #13, DA #18, DA #25, DA #23, Hospitality Aide (HA) #29, DA #28, Director #32, [NAME] #41, HA #48, HA #50, Nurse Aide Training (NAT) #44, Laundry #66, HA #67, [NAME] #68, Maintenance Assistant (MA) #81, DA #89, DA #91, Maintenance Director (MD) #93, HA #94, HA #97, HA #104, HA #105, and NAT #110 had not been checked against the Nurse Aide Registry (NAR) prior to hire.
Interview on 07/09/19 at 11:53 A.M., with Human Resource Director (HRD) #102 verified she had no documented evidence the above non-licensed staff were checked against the NAR to ensure the employee did not have a finding entered into the State Nurse Aide Registry concerning abuse, neglect, exploitation, mistreatment of residents or misappropriation of property.
Review of the facility Abuse, Neglect, Misappropriation, and Exploitation policy originated dated 11/2016 revealed the facility would undertake background checks of all employees and to retain on file applicable record of current employees regarding such checks. The facility would do the following prior to hiring a new employee:
1a. Check with the Ohio NAR and any other nurse assistant registries that the facility had reason to believe contain information on an individual, prior to using the individual as a nursing assistant.
b. Check with all applicable licensing and certification authorities to ensure that employees hold the requisite license and/or certification status to perform their job function and do not have a disciplinary action in effect against his or her professional license by state licensure agency because of a finding of abuse, neglect, exploitation or misappropriation of resident property;
c. Conduct a criminal background check
d. Verify that the applicant was not excluded from any Federally-funded health care programs.
2. All potential employees certify as part of the employment application process that they had not been convicted of an offense or otherwise have been found guilty of an offense that would preclude employment in a nursing facility.
3. It is the ongoing obligation of all employees to alert the facility of any convictions or findings that would disqualify them form continued employment with the facility under Ohio or Federal law, or the facilities policy.
CONCERN
(F)
Potential for Harm - no one hurt, but risky conditions existed
Abuse Prevention Policies
(Tag F0607)
Could have caused harm · This affected most or all residents
Based on review of personnel files, new hire list, staff interview and review of the facility abuse policy, the facility failed to ensure all staff were checked against the Nurse Aide Registry prior t...
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Based on review of personnel files, new hire list, staff interview and review of the facility abuse policy, the facility failed to ensure all staff were checked against the Nurse Aide Registry prior to employment to ensure the employee did not have a finding entered into the State Nurse Aide Registry concerning abuse, neglect, exploitation, mistreatment of residents or misappropriation of property. This had the potential to affect all residents residing in the facility.
Findings include:
Review of the new hire list dated 06/01/18 to 07/03/19 and personnel files revealed Housekeeper #8, Dietary Aide (DA) #13, DA #18, DA #25, DA #23, Hospitality Aide (HA) #29, DA #28, Director #32, [NAME] #41, HA #48, HA #50, Nurse Aide Training (NAT) #44, Laundry #66, HA #67, [NAME] #68, Maintenance Assistant (MA) #81, DA #89, DA #91, Maintenance Director (MD) #93, HA #94, HA #97, HA #104, HA #105, and NAT #110 had not been checked against the Nurse Aide Registry (NAR) prior to hire.
Interview on 07/09/19 at 11:53 A.M., with Human Resource Director (HRD) #102 verified she had no documented evidence the above non-licensed staff were checked against the NAR to ensure the employee did not have a finding entered into the State Nurse Aide Registry concerning abuse, neglect, exploitation, mistreatment of residents or misappropriation of property.
Review of the facility Abuse, Neglect, Misappropriation, and Exploitation policy originated dated 11/2016 revealed the facility would undertake background checks of all employees and to retain on file applicable record of current employees regarding such checks. The facility would do the following prior to hiring a new employee:
1a. Check with the Ohio NAR and any other nurse assistant registries that the facility had reason to believe contain information on an individual, prior to using the individual as a nursing assistant.
b. Check with all applicable licensing and certification authorities to ensure that employees hold the requisite license and/or certification status to perform their job function and do not have a disciplinary action in effect against his or her professional license by state licensure agency because of a finding of abuse, neglect, exploitation or misappropriation of resident property;
c. Conduct a criminal background check
d. Verify that the applicant was not excluded from any Federally-funded health care programs.
2. All potential employees certify as part of the employment application process that they had not been convicted of an offense or otherwise have been found guilty of an offense that would preclude employment in a nursing facility.
3. It is the ongoing obligation of all employees to alert the facility of any convictions or findings that would disqualify them form continued employment with the facility under Ohio or Federal law, or the facilities policy.
CONCERN
(F)
Potential for Harm - no one hurt, but risky conditions existed
Deficiency F0800
(Tag F0800)
Could have caused harm · This affected most or all residents
Based on observation and interview, the facility failed to ensure all items met the minimum temperatures required at the start of tray line. This had the potential to affect the 99 residents who recei...
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Based on observation and interview, the facility failed to ensure all items met the minimum temperatures required at the start of tray line. This had the potential to affect the 99 residents who received meals from the facility. The facility identified one resident (Resident #11) who did not receive meals from the facility. The facility census was 100.
Findings include:
On 07/09/19 tray line observations from 4:30 P.M. until 5:06 P.M., revealed no temperature was obtained for the hot dogs, grilled cheese, pre-poured soups or pre-poured milk prior to or at any time during the observation. The hamburger temperature was 150 degrees Fahrenheit. (F). This was verified by [NAME] #89 at the time of the observations.
On 07/09/19 at 4:42 P.M., interview with [NAME] #89 verified she was done taking all the temperatures and was ready to begin serving the dinner meal. [NAME] #89 indicated all meats should be a minimum of 165 degrees F and she verified the hamburger was only 150 degrees F, and she did not attempt to increase the temperature. She also verified she did not take the temperature of the hot dog, grilled cheese, pre-poured soups or pre-poured milk.
On 07/10/19 at 4:00 P.M., interview with the Administrator verified the above findings.
CONCERN
(F)
Potential for Harm - no one hurt, but risky conditions existed
Deficiency F0804
(Tag F0804)
Could have caused harm · This affected most or all residents
Based on observation, interview and record review, the facility failed to ensure foods were at a palatable temperature and the puree foods were prepared according to the recipe to ensure optimal palat...
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Based on observation, interview and record review, the facility failed to ensure foods were at a palatable temperature and the puree foods were prepared according to the recipe to ensure optimal palatability. The facility identified one resident (Resident #11) who did not receive meals from the facility. The facility census was 100.
Findings include:
On 07/08/19 at 10:16 A.M., [NAME] #91 was observed preparing the pureed chicken patties. She put 13 patties and two cups of water into the Robot Coupe. Pureed them together, removed the chicken from the Robot Coupe and placed in the steamer to keep warm.
On 07/08/19 at 10:24 A.M., interview with [NAME] #91 verified she did not follow a recipe and just added water to the chicken patties to puree them. She was not able to find the recipe for the puree patties when asked.
On 07/09/19 at 4:36 P.M., [NAME] #89 took the tray line temperatures which included the turkey salad and macaroni salad which were both 40 degrees Fahrenheit (F) and the mixed vegetables which were 160 degrees F. At 4:42 P.M., the started plating the main entree for the 16 residents on the skilled unit. The main entree was cold turkey salad sandwich, cold macaroni salad, soup and milk. She plated the cold items on a heated pellet with a heated plate. The plates were then covered with an insulated lid and placed in the cart for delivery. At 4:46 P.M., the surveyor verified with [NAME] #89 she was placing items that were to remain cold on heated pellets and plates, she verified this and continued with the process. At 5:06 P.M., the skilled unit cart including the test tray left the kitchen. All 16 trays were passed by 5:10 P.M.
On 07/09/19 at 5:11 P.M., the test tray was tasted by the surveyor and the temperatures were taken by Dietary Manager (DM) #32 utilizing the facility thermometer with the following results: the milk tasted warm and was 48 degrees F, the mixed vegetables were luke warm and were 90 degrees F, the macaroni salad was warm and was 59 degrees F, the vegetable soup was luke warm and was 89 degrees F. This was verified by DM #32 at the time of the findings.
On 07/09/19 at 5:38 P.M., interview with DM #32 verified the milk was prepoured and was not placed in ice on tray line and the soup was prepoured and in insulated bowls and covered with lids but no heating element was used to keep them hot.
Review of the food committee meeting minutes dated 06/12/19 revealed the residents expressed concerns the cold colds including potato salad were served on hot plates.
Review of the puree chicken patty recipe revealed to add chicken broth to the chicken patties.
On 07/10/19 at 4:00 P.M., interview with the Administrator verified the above findings.
CONCERN
(F)
Potential for Harm - no one hurt, but risky conditions existed
Food Safety
(Tag F0812)
Could have caused harm · This affected most or all residents
Based on observation, interview and record review, the facility failed to ensure proper sanitation during the operation of the dish machine, during tray line, and for the ice machine. This had the pot...
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Based on observation, interview and record review, the facility failed to ensure proper sanitation during the operation of the dish machine, during tray line, and for the ice machine. This had the potential to affect the 99 residents who received meals from the facility. The facility identified one resident (Resident #11) who did not receive meals from the facility. The facility census was 100.
Findings include:
On 07/08/19 during the initial tour of the kitchen between 10:00 A.M. and 10:30 A.M., revealed there was a Dietary Aide (DA) #123 and [NAME] #89 operating the dish machine. They were half way done with the breakfast dishes. Interview with [NAME] #89 verified she did not know if the dish machine was a high temperature or chemical and did not test nor did she know how to test to ensure the dish machine was properly operating. Interview with DA #123 verified she did not check the dish machine for proper operation but stated it was a chemical DM. Neither the cook nor the DA were able to locate the dish machine log.
On 07/08/19 at 10:15 A.M., this was verified by Dietary Manager (DM) #32, who also was not able to locate the dish machine log.
On 07/08/19 at 10:25 A.M., observation of the ice machine revealed a thick black buildup of a slimy substance the distance across the entire lip of the inside of the machine were the ice was dispensed. This was verified by DM #32 at the time of the observation.
On 07/09/19 during tray line observation between 4:30 P.M. and 5:06 P.M., revealed flies and gnats were flying around and landing on the various food items on tray line including the buns, turkey salad, macaroni salad and hot dogs. This was verified by [NAME] #89 and Dietary Aid (DA) #123, who indicated it had been an ongoing problem. At 4:36 P.M., [NAME] #89 began taking the food temperatures. [NAME] #89 took the temperature of the pureed macaroni salad, turkey salad, macaroni salad and did not clean or sanitize the thermometer before or after each temperature was taken. [NAME] #89 then grabbed another thermometer and took the temperature of the mixed vegetables and then the pureed soup without cleaning or sanitizing between temperatures taken. Now each of the two thermometers had a build up of food on them. [NAME] #89 asked DA #123 to rinse off the thermometers. DA #123 with her gloved hands went to the dish machine and used the hose to rinse off the thermometers and returned holding the thermometers by the stems with her same gloved hands. [NAME] #89 then used one of the thermometers to take the temperature of the hamburgers. After this [NAME] #89 verified the above concerns and requested Dietary Manager (DM) #32 get her a different thermometer. DM #32 returned with a new thermometer that had never been used by the staff. [NAME] #89 placed the thermometer in the cream of mushroom soup. After this [NAME] #89 verified she did not clean the thermometer prior to use because it came from the packet and had never been used. The above was verified by DM #32.
On 07/09/19 at 5:07 P.M., interview with DM #32 verified the DA monthly cleaning schedule did not include cleaning of the ice machine, and she was not able to say the last time the ice machine was cleaned and verified the ice machine serviced the entire facility.
On 07/10/19 at 4:00 P.M., interview with the Administrator verified the above findings.
Review of the DA monthly cleaning schedule revealed it did not including cleaning of the ice machine.
Review of the cleaning instructions for the ice machine and equipment, not dated, revealed the ice machine should be cleaned and sanitized on a regular basis following the manufacturer's instructions.
Review of the dish machine temperature log, not dated, revealed the temperatures were monitored to ensure proper sanitizing of dishes. The log would be posted near the dish machine.
Review of the American Dish Service owners manual, dated 05/08, revealed to monitor chemicals to ensure proper sanitation between 50 and 100 parts per million.
CONCERN
(F)
Potential for Harm - no one hurt, but risky conditions existed
Infection Control
(Tag F0880)
Could have caused harm · This affected most or all residents
Based on review of the infection control log, observation, interview and policy review, the facility failed to ensure Legionella monitoring, a comprehensive infection control program was implemented, ...
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Based on review of the infection control log, observation, interview and policy review, the facility failed to ensure Legionella monitoring, a comprehensive infection control program was implemented, and ensure proper washing/handling of isolation laundry. This had the potential to affect all 100 residents residing in the facility.
Findings include:
1. Review of the infection control log dated 06/19 to 07/19 revealed no evidence of infection control log for 06/19 for the skilled unit, second floor and the third floor, only tract infections for the first three days (06/01/19 to 06/03/19). There was no evidence of an infection control log for 07/19.
Interview on 07/10/19 at 2:47 P.M., with the Director of Nursing (DON) revealed she was not able to locate the complete infection control log for 06/19 except for one page for the third floor started for the first three days of June. There was no infection control log for 07/19.
2. The surveyor requested evidence of Legionella program and monitoring per the facility policy during the survey progress, however the facility was not able to provide documentation.
Review of Legionella Water Management Program policy, dated 07/17, revealed the facility was committed to the prevention, detection, and control of water-borne contaminants, including Legionella. The water management program would be overseen by the water management team. The program would identify areas in the water system where Legionella bacteria could grow and spread. The water management program would include a team, description and diagram of the water system in the facility, identifying areas of growth, specific measures used to control the introduction or spread of Legionella (water temperatures, disinfectants), control limits/parameters, system to monitor the control limits and the effectiveness of control measure, a plan when the control limits were not met or not effective, and documentation of the program.
Interview on 07/10/19 at 1:28 P.M., with Administrator reported she was not able to locate the monitoring for the Legionella program. The previous Maintenance Director (MD) had resigned, and the facility was not able to find any of his documentation, including diagram of the water system and monitoring.
3. Interview and observation of the laundry room with Housekeeper #111 on 07/11/19 at 9:21 A.M., revealed all laundry was delivered to the laundry room through a laundry shoot. The laundry was observed to be in clear trash bag liners. The bags were not identified as isolation (MRSA and C-diff). The housekeeper reported isolation laundry used to come to the laundry room in red bags and was washed separately from the other laundry, however recently he was told red bags were no longer required. He confirmed there was no way to identify if the current laundry bags were isolation since the change. Currently all laundry, including isolation, would be sorted and put in the in the proper bin and then washed all together. There was a bin noted for bed lines, gowns, etc. All linens/gowns were washed in bleach, however personal laundry items would not be washed in bleach. The nursing staff try to encourage residents in isolation to wear gowns, so they can be bleached. Observation of the washing machine hot water temperatures revealed the water was 143 degrees Fahrenheit (F). The MD reported the highest hot water temperature he reached was 156.
Interview on 07/11/19 at 1:19 P.M., with the Administrator revealed the facility did not have a policy or procedure for washing isolation laundry.
This is an example of continued noncompliance from the survey completed on 06/25/19.
CONCERN
(F)
Potential for Harm - no one hurt, but risky conditions existed
Antibiotic Stewardship
(Tag F0881)
Could have caused harm · This affected most or all residents
**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on review of the infection control log, interview and policy review, the facility failed to implement a comprehensive anti...
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**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on review of the infection control log, interview and policy review, the facility failed to implement a comprehensive antibiotic stewardship program. This had the potential to affect all 100 residents residing in the facility.
Findings included:
Review of the infection control log dated 01/01/19 to 07/01/19 revealed no evidence an antibiotic stewardship program was implemented.
Interview on 07/01/19 at 2:47 P.M., with the Director of Nursing (DON) verified the facility had not implemented an antibiotic stewardship program at this time. The facility plans to implement the [NAME] criteria this month.
Review of antibiotic stewardship policy and procedure dated 11/17 revealed the facility would adapt an antibiotic stewardship program to monitor the use of antibiotics with each resident. The facility would educate and train staff and practitioners about the facility antibiotic stewardship program, including appropriate prescribing, monitoring, and surveillance of antibiotic use and outcomes.
CONCERN
(F)
Potential for Harm - no one hurt, but risky conditions existed
Deficiency F0925
(Tag F0925)
Could have caused harm · This affected most or all residents
Based on observation, interview and record review, the facility failed to ensure an effective pest control program was in place. This had the potential to affect the 100 residents residing in the faci...
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Based on observation, interview and record review, the facility failed to ensure an effective pest control program was in place. This had the potential to affect the 100 residents residing in the facility.
Findings include:
Review of the monthly pest control treatments dated 04/29/19, 05/21/19, 06/05/19 and 07/08/19 revealed there was no evidence the technician was notified of the fly and gnat activity in the kitchen in order to eradicate them.
On 07/08/19, during the initial tour of the kitchen between 10:00 A.M. and 10:30 A.M., revealed there were several flies and gnats flying around the kitchen. This was verified by Dietary Manager (DM) #32 at the time of the observations, who indicated she had worked at the facility for four months, and there had always been flies and gnats in the kitchen and other areas of the facility.
On 07/09/19 during the tray line observation between 4:30 P.M. and 5:06 P.M., revealed many gnats and several flies were observed flying around the kitchen and landing on foods, including the turkey salad, macaroni salad, buns and hot dogs. This was verified by [NAME] #89 and Dietary Aide (DA) #123, at the time they were observed swatting at the bugs during tray line operation.
On 07/10/19 at 11:20 A.M., interview with Dietary Manager (DM) #32 verified the pest control company comes monthly, and she had not requested any additional services despite the ongoing concerns with flies and gnats. She revealed she just read the policy which indicated she could call for additional visits when concerns were identified.
On 07/10/19 at 3:35 P.M., during the state ran resident council meeting with Resident's #41, #46, #55, #63, #71, #78, #79 and #92 revealed they had concerns with flies and had informed the facility but nothing had been done to eradicate the flies.
On 07/11/19 at 11:10 A.M., on the second floor Resident #11, who was not able to move arms, had a fly land on his head a couple times.
On 07/10/19 at 4:00 P.M., interview with the Administrator was informed of the above concerns.
Review of the pest control policy, not dated, revealed if pests were seen in the kitchen appropriate action should be taken to eliminate the situation. Preventative treatment programs would be in place but additional visits would be completed as concerns arise.
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
- "Can I speak with families of current residents?"
- "What's your RN coverage like on weekends and overnight?"
Our Honest Assessment
Strengths
- • No fines on record. Clean compliance history, better than most Ohio facilities.
- • 37% turnover. Below Ohio's 48% average. Good staff retention means consistent care.
Concerns
- • 43 deficiencies on record, including 1 serious (caused harm) violation. Ask about corrective actions taken.
- • Grade C (55/100). Below average facility with significant concerns.
Bottom line: Mixed indicators with Trust Score of 55/100. Visit in person and ask pointed questions.
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About This Facility
What is Carriage Inn Of Steubenville's CMS Rating?
CMS assigns CARRIAGE INN OF STEUBENVILLE an overall rating of 3 out of 5 stars, which is considered average nationally. Within Ohio, this rating places the facility higher than 0% of the state's 100 nursing homes. This mid-range rating indicates the facility meets federal standards but may have areas for improvement.
How is Carriage Inn Of Steubenville Staffed?
CMS rates CARRIAGE INN OF STEUBENVILLE's staffing level at 3 out of 5 stars, which is average compared to other nursing homes. Staff turnover is 37%, compared to the Ohio average of 46%. This relatively stable workforce can support continuity of care.
What Have Inspectors Found at Carriage Inn Of Steubenville?
State health inspectors documented 43 deficiencies at CARRIAGE INN OF STEUBENVILLE during 2019 to 2024. These included: 1 that caused actual resident harm and 42 with potential for harm. Deficiencies causing actual harm indicate documented cases where residents experienced negative health consequences.
Who Owns and Operates Carriage Inn Of Steubenville?
CARRIAGE INN OF STEUBENVILLE is owned by a for-profit company. For-profit facilities operate as businesses with obligations to shareholders or private owners. The facility operates independently rather than as part of a larger chain. With 120 certified beds and approximately 88 residents (about 73% occupancy), it is a mid-sized facility located in STEUBENVILLE, Ohio.
How Does Carriage Inn Of Steubenville Compare to Other Ohio Nursing Homes?
Compared to the 100 nursing homes in Ohio, CARRIAGE INN OF STEUBENVILLE's overall rating (3 stars) is below the state average of 3.2, staff turnover (37%) is near the state average of 46%, and health inspection rating (3 stars) is at the national benchmark.
What Should Families Ask When Visiting Carriage Inn Of Steubenville?
Based on this facility's data, families visiting should ask: "Can I visit during a mealtime to observe dining assistance and food quality?" "How do you handle medical emergencies, and what is your hospital transfer rate?" "Can I speak with family members of current residents about their experience?"
Is Carriage Inn Of Steubenville Safe?
Based on CMS inspection data, CARRIAGE INN OF STEUBENVILLE has a clean safety record: no substantiated abuse findings (meaning no confirmed cases of resident harm), no Immediate Jeopardy citations (the most serious violation level indicating risk of serious injury or death), and is not on the Special Focus Facility watch list (a federal program monitoring the lowest-performing 1% of nursing homes). The facility has a 3-star overall rating and ranks #100 of 100 nursing homes in Ohio. While no facility is perfect, families should still ask about staff-to-resident ratios and recent inspection results during their visit.
Do Nurses at Carriage Inn Of Steubenville Stick Around?
CARRIAGE INN OF STEUBENVILLE has a staff turnover rate of 37%, 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 Carriage Inn Of Steubenville Ever Fined?
CARRIAGE INN OF STEUBENVILLE has no federal fines on record. CMS issues fines when nursing homes fail to meet care standards or don't correct problems found during inspections. The absence of fines suggests the facility has either maintained compliance or corrected any issues before penalties were assessed. This is a positive indicator, though families should still review recent inspection reports for the full picture.
Is Carriage Inn Of Steubenville on Any Federal Watch List?
CARRIAGE INN OF STEUBENVILLE is not on any federal watch list. The most significant is the Special Focus Facility (SFF) program, which identifies the bottom 1% of nursing homes nationally based on persistent, serious quality problems. Not being on this list means the facility has avoided the pattern of deficiencies that triggers enhanced federal oversight. This is a positive indicator, though families should still review the facility's inspection history directly.