ARBORS AT WOODSFIELD
For profit - Corporation
95 Beds
ARBORS AT OHIO
Data: November 2025
Trust Grade
55/100
#398 of 913 in OH
Photo by Arbors at Woodsfield
Photo by Arbors at Woodsfield
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Last Inspection: April 2024
Within standard 12-15 month inspection cycle. Federal law requires annual inspections.
Overview
The Arbors at Woodsfield has a Trust Grade of C, indicating it is average compared to other nursing homes. It ranks #398 out of 913 facilities in Ohio, which places it in the top half of the state, and it is the best option in Monroe County, as it ranks #1 of 2. The facility is improving, with issues decreasing from 21 in 2022 to 12 in 2024. Staffing is a strength, rated at 4 out of 5 stars, with a turnover rate of 43%, which is better than the state average. There have been no fines, which is a positive sign. However, there have been some concerning incidents. A serious issue was identified where the facility failed to address significant weight loss in a resident, leading to actual harm. Additionally, there were concerns about food safety, as expired items were found in storage, which could impact residents' health. Lastly, the facility did not verify staff against the nurse aide registry prior to hiring, raising potential safety concerns. Overall, while there are strengths in staffing and no fines, families should be aware of the serious and concerning issues noted in inspections.
- Trust Score
- C
- In Ohio
- #398/913
- Safety Record
- Moderate
- Inspections
- Getting Better
- Staff Stability ○ Average
- 43% 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 53 minutes of Registered Nurse (RN) attention daily — more than average for Ohio. RNs are trained to catch health problems early.
- Violations ⚠ Watch
- 44 deficiencies on record. Higher than average. Multiple issues found across inspections.
55/100
Top 43%
Needs review
21 → 12 violations
★★★☆☆
3.0
Overall Rating
★★★★☆
4.0
Staff Levels
★★★★★
5.0
Care Quality
★★☆☆☆
2.0
Inspection Score
↔
Stable
2022: 21 issues
2024: 12 issues
The Good
-
4-Star Staffing Rating · Above-average nurse staffing levels
-
5-Star Quality Measures · Strong clinical quality outcomes
-
Full Sprinkler Coverage · Fire safety systems throughout facility
-
No fines on record
-
Staff turnover below average (43%)
5 points below Ohio average of 48%
Facility shows strength in staffing levels, quality measures, fire safety.
The Bad
3-Star Overall Rating
Near Ohio average (3.2)
Meets federal standards, typical of most facilities
Staff Turnover: 43%
Near Ohio avg (46%)
Typical for the industry
Chain: ARBORS AT OHIO
Part of a multi-facility chain
Ask about local staffing decisions and management
The Ugly 44 deficiencies on record
1 actual harm
Apr 2024
12 deficiencies
CONCERN
(D)
Potential for Harm - no one hurt, but risky conditions existed
Deficiency F0657
(Tag F0657)
Could have caused harm · This affected 1 resident
**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on record review and interviews, facility failed to conduct care conferences with residents in conjunction with minimum da...
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**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on record review and interviews, facility failed to conduct care conferences with residents in conjunction with minimum data set (MDS) assessments. This affected two residents (#24 and #49) of three residents reviewed for care planning. The facility census was 55.
Findings included:
1. Record review revealed Resident #24 was admitted to the facility on [DATE] with diagnoses including chronic obstructive pulmonary disease, atrial fibrillation, and cognitive communication deficit. Review of a quarterly MDS revealed Resident #24 had mildly impaired cognition.
Record review revealed Resident #24 had a discharge planning meeting with the social worker on 05/24/23, a care conference on 06/02/23, 09/20/23, 11/27/23, and a letter inviting them to a care conference on 01/24/24 but no record of the care conference being completed.
Interview on 04/08/24 at 4:08 P.M. with Resident #24 revealed they had not had a care conference or been able to make decisions regarding treatment.
Interview on 04/11/24 at 9:50 A.M. with Social Services Director (SSD) #126 revealed the admission care conference should be under an assessment called Discharge Planning Evaluation. SSD #126 confirmed the initial care conference was opened on 05/05/23 but completed on 05/09/23 and the interdisciplinary team was not included in the care conference.
2. Record review revealed Resident #49 was admitted to the facility on [DATE] with diagnoses including rhabdomyolysis, neoplasm of unspecified behavior of bladder, chronic obstructive pulmonary disease, and atrial fibrillation. Review of a quarterly MDS revealed Resident #49's cognition remained intact.
Record review revealed Resident #49 had a care conference on 07/28/23. Review of letters provided by SSD #126 revealed Resident #49 was invited to care conferences for 10/10/23 and 02/26/24 but no evidence was provided to show care conference were completed.
Interview on 04/08/24 at 10:14 A.M. with Resident #49 revealed he was not invited to participate in care conferences.
Interview on 04/10/24 with SSD #126 revealed care conferences are done upon admission, annually, quarterly, and with significant changes. SSD #126 stated she worked with the MDS nurse on scheduling care conferences who keeps a calendar of when residents are due for quarterly and annual assessments, then would send letters to invite resident and family members to care conferences. SSD #126 stated upon admission, the timing of the admission care conference depended on the availability of family members but the facility would still meet with the resident within the first 48 hours to start discharge planning. SSD #126 stated residents only get copies of care plans if they wanted them. SSD #126 stated Resident #49 should have had a care conference in February 2024 but was not able to find documentation and should have had one in October 2023 as well.
Review of a policy titled Comprehensive Care Plans (dated 06/30/22) revealed every effort should be made to schedule a care plan meeting at the best time of the day for the resident and family, and when a resident has no family, the ombudsman may be invited to attend the care plan meeting if desired by the resident.
CONCERN
(D)
Potential for Harm - no one hurt, but risky conditions existed
Deficiency F0676
(Tag F0676)
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 recommendations for restorative ambulation programs ...
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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 recommendations for restorative ambulation programs were implemented to maintain a resident's ambulatory status. This affected one resident (#37) of three residents reviewed for activities of daily living.
Findings include:
During an interview on 04/09/24 at 9:03 A.M., Resident #37 stated she used to ambulate with therapy. However, she had not received assistance with walking for weeks and felt she was getting weaker.
Review of Resident #37's medical record revealed diagnoses including degenerative disease of the nervous system, peripheral vascular disease, malignant neoplasm of the right breast, type two diabetes mellitus with neuropathy, osteoporosis, macular degeneration, abnormalities of gait and mobility, difficulty walking and generalized muscle weakness.
A Physical Therapy (PT) evaluation dated 11/02/23 indicated Resident #37 was referred to PT due to new onset of falls/fall risk, decrease in functional mobility, functional limitation with ambulation, reduced static balance, reduced dynamic balance, decrease in strength, increased need for assistance from others and reduced activity of daily living (ADL) participation. The PT evaluation Indicated Resident #37 had recently suffered a fall when ambulating to the bathroom with no injuries reported. Resident #37 reported her knee buckled on her while ambulating. At baseline, Resident #37 ambulated 50 feet using a rolling walker and minimal assist. A PT Discharge summary dated [DATE] indicated Resident #37 met a goal to safely ambulate 100 feet using the most appropriate assistive device and contact guard assistance (CGA). The summary indicated Resident #37 progressed well demonstrating improvements in functional strength and mobility. A restorative ambulation program was established for ambulation 100 feet with upright walker and CGA. Prognosis to maintain her current level of function was excellent with consistent staff support.
A Therapy to Restorative Nursing Communication - Resident Status Update form dated 01/05/24 indicated plans for a restorative ambulation program for Resident #37 to ambulate 100 feet with stand by assist and use of an upright walker.
A PT evaluation dated 02/06/24 indicated Resident #37 was referred for evaluation and treatment following a fall. The prior level of function when discharged from therapy was ambulating 100 feet with CGA. During the evaluation Resident #37 was able to walk 50 feet with CGA. The evaluation indicated Resident #37 felt unsteady when standing and when walking and was worried about falling. A PT Discharge summary dated [DATE] indicated Resident #37 met a goal of walking 100 feet with CGA on 02/22/24. The summary indicated Resident #37 progressed well demonstrating improvements in functional strength and mobility. A restorative ambulation program was established for ambulating 100 feet with CGA.
A therapy quarterly screen dated 04/08/24 indicated Resident #37 was requesting therapy services to improve strength and balance to improve functional mobility and reduce fall risk. PT was recommended.
During an interview on 04/09/24 at 3:00 P.M., Registered Nurse (RN) #132 (restorative nurse) stated she had not received a referral for restorative nursing program for Resident #37 since September 2023. When Resident #37 was placed on therapy caseload for ambulation the restorative ambulation programs were discontinued.
During an interview on 04/10/24 at 11:50 A.M., Physical Therapy Assistant (PTA)/rehab manager #400 provided a copy of the restorative referral for an ambulation program dated 01/05/24. PTA #400 stated it was an oversight of therapy not to complete a new referral to restorative nursing when PT ended 03/06/24 but assumed the program recommended 01/05/24 would resume.
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 medical record review, observation, and interview, the facility failed to provide oral care for a resident who is depen...
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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 provide oral care for a resident who is dependent on staff for personal care. This affected one resident (#46) of two residents reviewed for activities of daily living (ADL). The facility census was 55.
Findings included:
Record review revealed Resident #46 was admitted to the facility on [DATE] with diagnoses including Alzheimer's disease, type II diabetes, panic disorder, post traumatic stress disorder, and fibromyalgia.
Review of a quarterly minimum data set (MDS) completed on 01/17/24 revealed Resident #46 was dependent on staff for completing all activities of daily living.
Review of a care plan dated 10/23/23 revealed Resident #46 had an ADL self-care performance deficit related to Alzheimer's disease, dementia, and a history of falls. Goals included residents ADL needs would be met through the next review with interventions including two person assist for personal hygiene, encouraging participation in daily care and providing positive reinforcement for activities attempted and/or partially achieved, and providing cues and assist as needed to accomplish daily tasks. A dental care plan revealed Resident #46 had potential for dental problems related to age with a goal of having good oral hygiene habits through the next review and intervention including providing medication and/or treatment as ordered.
Interview on 04/08/24 at 4:45 P.M. with Resident #46's representative revealed at times, Resident #46 has bad breath and he did not believe her teeth were brushed.
Observation on 04/09/24 at 12:46 P.M. revealed Resident #46 was resting in bed. When asked if her teeth had been brushed, Resident #46 shook her head no. When asked to see her teeth, Resident #46 smiled and revealed her teeth had a layer of plaque and grime.
Observation on 04/09/25 at 3:13 P.M. revealed Resident #46 was seated in the hallway in her wheelchair. When asked if her teeth had been brushed, Resident #46 shook her head no and showed her teeth which continued to have a layer of plaque and grime.
Interview on 04/11/24 at 12:57 P.M. with State Tested Nursing Assistant (STNA) #134 revealed oral care should be completed on residents who can't brush their own teeth in the morning, evenings, and as needed. Oral care should be completed daily on residents who are dependent upon staff. STNA #134 stated Resident #46 was dependent upon staff for oral care and hygiene.
Interview on 04/11/24 at 1:16 P.M. with STNA #134 confirmed Resident #46's teeth had plaque and build up on them and confirmed Resident #46 shook her head no when asked if oral care had been completed and nodded her head yes when asked if she wanted oral care to be completed. STNA #134 stated even though Resident #46 does not speak often, she is able to accurately answer questions by shaking or nodding her head.
A policy for oral care was requested on 04/11/24 at 2:52 P.M. from Administrator but was not received.
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, record review and interview, the facility failed to ensure interventions to prevent pressure ulcers were i...
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**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, record review and interview, the facility failed to ensure interventions to prevent pressure ulcers were in place per orders. This affected one resident (#39) of two residents reviewed for pressure ulcers. The facility census was 55.
Findings included:
Record review revealed Resident #39 admitted to the facility on [DATE] with diagnoses including heart failure, type II diabetes, chronic obstructive pulmonary disease, atrial fibrillation, and dementia.
Review of orders revealed Resident #39 had orders in place for an alternating air mattress (01/08/24) and zero gravity boots to bilateral feet while in bed (starting on 02/01/23 and discontinued on 04/08/24).
Review of care plan dated 12/31/23 revealed Resident #39 is at risk for impaired skin integrity related to confined to a bed all or most of the time, dementia, diabetes, incontinent of bladder, incontinent of bowel, needs assistance with activities of daily living, palliative care, peripheral vascular disease diagnosis, and skin break down to coccyx. Interventions included skin prep to bilateral heels, turn and reposition as tolerated and preventative treatments as ordered.
Review of a quarterly minimum data set completed on 01/25/24 revealed Resident #39 required maximum assistance for bed mobility and had pressure reducing devices in bed.
Observation on 04/08/24 at 10:34 A.M. revealed Resident #39 was resting in bed with an alternating air mattress in place and zero gravity boots were noted to be on her dresser.
Observation on 04/08/24 at 4:14 P.M. revealed Resident #39 was in bed and her zero gravity boots were on her dresser.
Interview on 04/08/24 at 4:15 P.M. with Registered Nurse (RN) #110 verified Resident #39 should have her zero gravity boots on while resting in bed.
Review of a policy titled Pressure Ulcer/Skin Breakdown - Clinical Protocol (dated 03/20/24) revealed based on the comprehensive assessment of a resident, a resident receives care consistent with professional standards of practice to percent pressure ulcers and does not develop pressure ulcers unless the individual's clinical condition demonstrates they were unavoidable. The plan of care for prevention and/or treatment of pressure ulcers will be developed based on the assessments to include but not limited to support surfaces, turning schedule/off-loading, moisture management, incontinence management, nutritional management, pain management, disease effects of perfusion and/or healing, medications that may effect perfusion and/or healing. The physician will authorize pertinent orders related to wound treatments including pressure reduction surfaces.
CONCERN
(D)
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 record review, observation, and staff interview, the facility failed to implement fall prevention interventions for a r...
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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 implement fall prevention interventions for a resident with a history of falls. This affected one resident (#27) of three residents reviewed for accidents.
Findings include:
Review of Resident #27's medical record revealed she was admitted to the facility on [DATE]. Her diagnoses included a stroke with hemiplegia (paralysis) and hemiparesis (weakness) affecting her left non-dominant side, unspecified convulsions, Alzheimer's disease, vascular dementia, severe intellectual disabilities, muscle weakness, unsteadiness on her feet, and difficulty walking.
Review of Resident #27's quarterly Minimum Data Set (MDS) assessment dated [DATE] revealed the resident's cognition was severely impaired. She had a functional limitation in her range of motion on one side of her upper and lower extremity. She had one fall since the prior assessment that was without injury.
Review of Resident #27's plan of care revealed she had a care plan in place for being at risk for falls. The interventions included the need for her to be in a low bed when not providing care. That intervention had been revised on 10/12/23. Her physician's orders also included the need for a low bed when not providing care with that order originating on 02/03/23.
Review of Resident #27's progress notes revealed her last fall occurred on 01/06/24 at 5:54 A.M. She was found lying on the floor on the mat that was next to her bed. Her bed was indicated to be in its lowest position with no injuries occurring as a result of that fall.
On 04/08/24 at 1:40 P.M., an observation of Resident #27 noted her to be lying in bed. Her bed was not noted to be in its lowest position and staff were not in the room providing care.
On 04/10/24 at 2:26 P.M., further observation of Resident #27 noted her again in bed with the bed not in it's lowest position. Staff were not in the room providing any care to the resident at the time the observation was made.
On 04/10/24 at 2:45 P.M., an observation was made of Resident #27 still in bed with her bed not in its lowest position. The bed frame was off the floor about 12 inches and the resident was on a deep perimeter pressure reduction mattress on top of that. Findings were confirmed with Licensed Practical Nurse (LPN) #107.
On 04/10/24 at 2:47 P.M., an interview with LPN #107 confirmed Resident #27's bed should be maintained in its lowest position when not receiving care as per her physician's orders and care plan. She lowered the resident's bed by about six inches so it was closer to the floor. She said she was not able to lower it further due to the bed being able to be moved when it was in its lowest position and the caster wheels were in contact with the floor.
CONCERN
(D)
Potential for Harm - no one hurt, but risky conditions existed
Deficiency F0805
(Tag F0805)
Could have caused harm · This affected 1 resident
Based on observation and interview, the facility failed to prepare pureed foods to meet the needs of residents requiring a pureed diet. This affected two residents (#5 and #19) of two residents who re...
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Based on observation and interview, the facility failed to prepare pureed foods to meet the needs of residents requiring a pureed diet. This affected two residents (#5 and #19) of two residents who received a pureed diet. The facility census was 55.
Findings included:
Observation on 04/10/24 at 9:15 A.M. revealed [NAME] #420 washed her hands prior to beginning pureed foods. The first pureed food item to be prepared was a vegetable salad with Italian dressing. [NAME] #420 began by adding 12 ounces of vegetables with dressing already mixed in to the Robocoup machine. [NAME] #420 ran the machine for approximately 30 seconds, then paused to scrape the sides of the machine before continuing to blend again. She repeated this process 10 times. [NAME] #420 stated the food was not getting to the appropriate pureed texture and asked Dietary Manager (DM) #430 what to do; DM #430 stated she did not know what to do. [NAME] #420 stopped pureeing the mixture at 9:27 A.M. to taste, but said it was not ready to serve yet. She started to puree the mixture again for approximately 30 seconds, then stopped to scrape the sides before continuing to puree. [NAME] #420 stated the food was ready to serve. When tasted, chunks were still visible on tongue which was confirmed by [NAME] #420 and DM #430 at 9:32 A.M. [NAME] #420 began to puree the mixture again after adding one more serving of vegetables. After approximately 30 seconds, she paused to scrape the sides with a spatula before pureeing again. She repeated this process five times. At 9:40 A.M., [NAME] #420 stated the mixture was ready to serve. When tasted, the texture was still gritty with pieces getting stuck on tongue and back of mouth. [NAME] #420 stated she did not know what else to do to make the texture appropriate for those receiving a pureed diet. [NAME] #420 then added one tablespoon of Italian dressing to the mixture, pureed for approximately 30 seconds, paused to scrape the sides and added another tablespoon of Italian dressing and repeated this process three more times. [NAME] #420 used the back of her gloved left hand to wipe her nose, did not remove gloves or wash hands. At 9:49 A.M., she paused to taste the texture again which still had chunks of vegetables. DM #430 called Regional Dietary Manager (RDM) #160 who stated to continue running the machine. At 9:53 A.M., [NAME] #420 started the machine again. After approximately one minute of pureeing, [NAME] #420 stopped so she and DM #430 could taste the mixture, which was still gritty in consistency, and discarded their used spoons on the prep table. DM #430 picked up the spoons to throw them in the trash and [NAME] #420 placed her gloved right hand on the prep table where the spoons had previously been. At approximately 10:00 A.M. [NAME] #420 discarded the mixture and stated she would cook a different vegetable to puree.
Interview on 04/10/24 at 10 A.M. with DM #430 confirmed above findings.
Observation on 04/10/24 at 10:28 A.M. revealed [NAME] #420 added 12 ounces of broccoli to the Robocoupe machine and began to puree. She paused to scrape the sides, added one tablespoon of Italian dressing, then started pureeing again. This process was repeated three times. RDM #160 was present at this time and instructed [NAME] #420 to add more liquid to the mixture; [NAME] #420 added a tablespoon of Italian dressing to the mixture. After approximately 30 seconds, mixture was tasted and still not a smooth consistency. [NAME] #420 added another tablespoon of Italian dressing and scraped sides, then continued pureeing. This process was repeated twice. At 10:40 A.M., RDM #160 took over the pureeing process and added two tablespoons of milk and one tablespoon of thickener to the mixture. At 10:49 A.M., the pureeing process was completed for the broccoli and ready to serve at the appropriate texture.
Interview on 04/10/24 at 11:56 A.M. with RDM #160 confirmed all findings.
The facility identified Residents #5 and #19 were to receive pureed diets.
CONCERN
(D)
Potential for Harm - no one hurt, but risky conditions existed
Deficiency F0806
(Tag F0806)
Could have caused harm · This affected 1 resident
Based on observations, record review, review of a food preference form, and interview, the facility failed to ensure a resident received food according to assessed food preferences/dislikes. This affe...
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Based on observations, record review, review of a food preference form, and interview, the facility failed to ensure a resident received food according to assessed food preferences/dislikes. This affected one resident (#58) of 24 residents reviewed for food/nutrition.
Findings include:
During an interview on 04/08/24 at 11:50 A.M., Resident #58 reported she did not like the facility's scrambled eggs so the facility generally prepared and served her fried eggs.
Review of Resident #58's medical record revealed diagnoses including morbid obesity, anxiety disorder and depressive disorder.
A care plan initiated 03/22/24 indicated Resident #58 was at risk for altered nutritional status related to a baseline care plan indicating obesity and medication diagnoses that included hyperlipidemia, depression, vitamin D deficiency, heart failure, and stage three chronic kidney disease. Interventions included providing meals/fluids based on resident food preferences and updating/honoring resident's food preferences on the tray ticket.
On 04/09/24 at 8:19 A.M., Resident #58 was observed in bed with her breakfast tray in front of her. Items served included scrambled eggs. Resident #58 stated she addressed it with one of the girls and was told because her meal ticket indicated scrambled eggs there was nothing she could do to provide an alternate.
On 04/09/24 at 8:27 A.M., interview with Dietary District Manager #160 verified Resident #58's food preference list indicated she disliked scrambled eggs. Upon request, Dietary District Manager #160 stated he would prepare fried eggs for Resident #58.
CONCERN
(D)
Potential for Harm - no one hurt, but risky conditions existed
Antibiotic Stewardship
(Tag F0881)
Could have caused harm · This affected 1 resident
**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on record review, review of facility infection reports, review of inservice records, staff interview, and policy review, t...
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**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on record review, review of facility infection reports, review of inservice records, staff interview, and policy review, the facility failed to ensure antibiotics were not used unless criteria was met for the treatment of urinary tract infections. This affected one resident (#11) of five residents reviewed for unnecessary medications.
Findings include:
Review of Resident #11's medical record revealed she was admitted to the facility on [DATE]. Her diagnoses included neurogenic disorder withe Lewy bodies, Parkinson's disease, psychotic disorder with delusions, anxiety disorder and chronic kidney disease.
Review of Resident #11's quarterly Minimum Data Set (MDS) assessment dated [DATE] revealed she had clear speech and was usually able to make herself understood. Her cognition was moderately impaired.
Review of Resident #11's progress notes revealed the resident was straight catheterized on 03/07/24 at 5:05 A.M. for a urinalysis. Preliminary urine results were received on 03/07/24 at 10:33 P.M. and showed the resident's urine to be straw yellow in color and its appearance was turbid. There was a large amount of leukocytes and blood in the urine, but nitrites were negative. Protein was present, white blood cells were too numerous to count and had many bacteria. The physician was notified of the results and instructed the nurse to await the urine culture results.
Further review of Resident #11's progress notes revealed a nurse's note dated 03/08/24 at 2:38 P.M. revealed the resident had complaints of burning on urination. The physician was notified and gave an order for Pyridium (an analgesic that could relieve symptoms caused by urinary tract infections and other urinary problems) 200 milligrams (mg) by mouth x six doses. He also ordered Macrobid (an antibiotic used in the treatment of urinary tract infections) 100 mg by mouth twice a day for seven days (14 doses).
Further review of Resident #11's progress notes revealed a nurse's note dated 03/09/24 at 12:49 P.M. that indicated the resident's urine culture and sensitivity report was received and reported to the physician. A nurse's note dated 03/10/24 at 11:07 A.M. revealed the physician gave an order to discontinue the resident's Macrobid due to the urine culture and sensitivity report that had been received. The culture and sensitivity report only showed flora.
Review of Resident #11's physician's orders revealed resident was started on Macrobid 100 mg by mouth two times a day for 14 administrations until finished. The order had been given on 03/08/24 and was discontinued on 03/10/24.
Review of Resident #11's urine culture report for final results resulted on 03/08/24 at 8:52 P.M. revealed the urine culture showed 50,000 CFU/ml of mixed commensal flora. The results were faxed to the physician on 03/09/24, as was hand written on the bottom of the culture report, and informed the physician the resident was currently on Macrobid. A note was added on culture report to stop the Macrobid on 03/10/24.
Review of Resident #11's infection report dated 03/08/24 revealed the resident had a symptom onset date of 03/06/24. Symptoms include increased frequency/ urgency and urine having a cloudy appearance. The infection report indicated a urine specimen was collected on 03/07/24. The initial urine showed positive leukocytes, white blood cells, red blood cells, bacteria, protein, and blood. The infection report indicated the culture and sensitivity report was pending and Macrobid 100 mg was ordered to be given by mouth x 14 doses. The report showed the Macrobid was discontinued due to the culture results.
Review of Resident #11's medication administration record for March 2024 revealed the resident started receiving the Macrobid with an evening dose on 03/08/24. It was discontinued after the morning dose on 03/10/24. Findings were reviewed with the Director of Nursing (DON) on 04/10/24 at 11:50 A.M.
On 04/10/24 at 12:05 P.M., an interview with the DON confirmed Resident #11 received an antibiotic for the treatment of a urinary tract infection that did not meet criteria for treatment. She suspected the physician started the resident on the Macrobid before the final culture results were received based on the resident's complaints of dysuria (burning with urination). She acknowledged the resident had been started on Pyridium to help with the burning with urination before the antibiotic had been started. She further acknowledged increasing fluids with the resident may have provided additional relief of her dysuria until the final culture results were available to see if she had a urinary tract infection that needed treatment. She confirmed the final culture results came back showing mixed commensal flora at 50,000 CFU/ml that did not meet criteria for treatment. She stated she had been having problems getting the resident's physician (also the facility's medical director) to abide by the antibiotic stewardship program and had educated him in the past. She stated the physician did not usually provide a rationale to them when wanting to treat a resident for an infection that did not meet criteria. He was more likely to start an antibiotic if a resident displayed symptoms of an infection or the family wanted the resident started on an antibiotic even before the final culture results were received. She acknowledged the resident received four doses of an antibiotic for symptoms of an infection that did not meet the criteria for treatment before it had been stopped.
A review of the facility's policy on Antibiotic Stewardship Program (revised 12/13/23) revealed it was the policy of the facility to implement an antibiotic stewardship program as part of the facility's overall infection prevention and control program. The purpose of the program was to optimize the treatment of infections while reducing the adverse events associated with antibiotic use. The infection preventionist coordinated all antibiotic stewardship activities, maintained documentation, and served as a resource for all clinical staff. The medical director served as the primary medical point of contact for the program and served as a Liaison between the facility and other medical staff members. The antibiotic use protocols included the facility using the McGeer criteria to define infections.
CONCERN
(E)
Potential for Harm - no one hurt, but risky conditions existed
Resident Rights
(Tag F0550)
Could have caused harm · This affected multiple residents
Based on observation and interview, the facility failed to ensure all residents received a dignified dining experience when residents seated at a table were not served their meals at the same time. Th...
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Based on observation and interview, the facility failed to ensure all residents received a dignified dining experience when residents seated at a table were not served their meals at the same time. This affected four residents (#2, #8, #47, and #161) of 20 residents observed in the dining room. The facility census was 55.
Findings included:
Observation on 04/08/24 at 11:09 A.M. revealed Residents #2, #8, #47, and #161 were seated at a table together. Throughout the dining process, the following was observed:
-11:09 A.M. Resident #8 received her meal, staff then began to serve other tables.
-11:19 A.M. Resident #47 received a bowl of soup.
-11:22 A.M. Resident #2 received her tray.
-11:26 A.M. Resident #161 received her tray.
Interview on 04/08/24 at 11:30 A.M. with Registered Nurse (RN) #135 revealed each table should be served at a time. RN #135 confirmed the above findings.
Interview on 04/11/24 at 5:23 P.M. with Resident #47 revealed a lot of times, the residents at lunch tables are not served at the same time. Resident #47 stated it is frustrating and upsetting to be seated at a table with other residents who are eating when she doesn't have her tray because she gets hungry or feels bad when she is served before others.
Review of a policy titled Promoting/Maintaining Resident Dignity (dated 10/26/23) revealed it is the policy of the facility to protect and promote resident rights and dignity. All staff members involved in providing care to residents to promote and maintain resident dignity and respect resident rights.
CONCERN
(E)
Potential for Harm - no one hurt, but risky conditions existed
Deficiency F0655
(Tag F0655)
Could have caused harm · This affected multiple residents
**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** 3. Record review revealed Resident #20 was admitted to the facility on [DATE] with diagnoses including rhabdomyolysis, type II d...
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**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** 3. Record review revealed Resident #20 was admitted to the facility on [DATE] with diagnoses including rhabdomyolysis, type II diabetes, acute kidney failure, and major depressive disorder. Review of MDS completed on 01/24/24 revealed Resident #20 had moderately impaired cognition.
Record review revealed no evidence a baseline care plan was completed within 48 hours of admission or that a copy was given to Resident #20.
Interview on 04/10/24 at 2:29 P.M. with Social Services Director (SSD) #126 revealed care conferences should be completed upon admission, annually, quarterly, and for significant changes. SSD #126 stated after a resident admits, the timing of the care conference depends on family availability but most of the time she meets with the resident to give baseline care plans if they want to have a copy. SSD #126 stated care conferences could be located in the assessment tab in PointClickCare.
Request for baseline care plan was made to Administrator on 04/11/24 at 11:53 A.M. with no response.
4. Record review revealed Resident #24 was admitted to the facility on [DATE] with diagnoses including chronic obstructive pulmonary disease, atrial fibrillation, hydronephrosis, and cognitive communication deficit. Review of a quarterly MDS completed on 02/06/24 revealed Resident #24 had mildly impaired cognition.
Record review revealed no evidence a baseline care plan was completed or given to Resident #24 within 48 hours of admission.
Interview on 04/10/24 at 2:29 P.M. with Social Services Director (SSD) #126 revealed care conferences should be completed upon admission, annually, quarterly, and for significant changes. SSD #126 stated after a resident admits, the timing of the care conference depends on family availability but most of the time she meets with the resident to give baseline care plans if they want to have a copy. SSD #126 stated care conferences could be located in the assessment tab in PointClickCare.
Request for baseline care plan was made to Administrator on 04/11/24 at 11:53 A.M. with no response.
5. Record review revealed Resident #46 was admitted to the facility on [DATE] with diagnoses including Alzheimer's disease, type II diabetes, panic disorder, and post traumatic stress disorder. Review of quarterly MDS completed on 01/17/24 revealed Resident #46 had moderately impaired cognition.
Record review revealed no evidence a baseline care plan was completed or given to Resident #46 within 48 hours of admission.
Interview on 04/10/24 at 2:29 P.M. with Social Services Director (SSD) #126 revealed care conferences should be completed upon admission, annually, quarterly, and for significant changes. SSD #126 stated after a resident admits, the timing of the care conference depends on family availability but most of the time she meets with the resident to give baseline care plans if they want to have a copy. SSD #126 stated care conferences could be located in the assessment tab in PointClickCare.
Request for baseline care plan was made to Administrator on 04/11/24 at 11:53 A.M. with no response.
Review of a policy titled Baseline Care Plan (dated 12/28/23) revealed a baseline care plan should be developed within 48 hours of a resident's admission, should include the minimum healthcare information necessary to properly care for a resident including but not limited to initial goals based on admission orders, physician orders, dietary orders, therapy services, social services, and Pre-admission Screening recommendations if applicable. The baseline care plan should be used until staff conducts the comprehensive assessment and develop an interdisciplinary comprehensive care plan. The facility should provide the resident and their representative with a summary of the care plan that includes but is not limited to the initial goals of the resident, a summary of the resident's medications and dietary instructions, any services and treatments to be administered by the facility and personnel acting on behalf of the facility, and any updated information based on the details of the comprehensive care plan as necessary.
Based on medical record review and interview, the facility failed to ensure baseline care plans were developed and/or summaries of the baseline care plan were provided to the residents and their representatives. This affected five residents (#20, #24, #46, #58 and #263) of 23 residents whose care plans were reviewed.
Findings include:
1. Review of Resident #58's medical record revealed diagnoses including left artificial shoulder joint, osteoarthritis of the left shoulder, morbid obesity, stage three chronic kidney disease, Stage two (shallow) pressure ulcer of the left heel, hypertension, generalized muscle weakness, difficulty walking, anxiety disorder, depressive disorder, vitamin D deficiency, hyperlipidemia, osteoarthritis of bilateral knees and of the right hip.
Review of Resident #58's nursing admission assessment dated [DATE] revealed as needs or risks were identified the facility identified interventions to be implemented. There was no evidence the facility discussed the baseline care plan or provided a summary of it to Resident #58 and/or a representative.
An admission Minimum Data Set (MDS) assessment dated [DATE] indicated Resident #58 was able to understand others. Resident #58 was assessed as cognitively intact with a Brief Interview of Mental Status (BIMS) score of 14 (out of 15 possible points).
During an interview on 04/10/24 at 4:09 P.M., Social Service Director/Designee (SSD) #126 provided a discharge planning evaluation dated 03/11/24 which she stated was a care plan meeting. The discharge planning evaluation addressed information such as the reason for admission, type of stay, expectations for the stay, discharge plan, a review of types of equipment Resident #58 had available to her upon discharge, and environmental barriers to discharge. The form indicated topics discussed also included activities, activities of daily living/rehab, and mood/behavior. The form contained an area to specify who was provided a copy of the care plan and it indicated it was na (not applicable). SSD #126 verified Resident #58 was not provided with a written summary of the baseline care plan.
2. Review of Resident #263's medical record revealed diagnoses including congestive heart failure (CHF), type two diabetes mellitus, hypertensive heart disease, pressure ulcer of the left heel, hyperlipidemia, depression, peripheral vascular disease, and generalized muscle weakness.
Review of nursing admission evaluation dated 03/28/24 revealed interventions were initiated for identified areas of concerns/risks. There was no documentation of Resident #263 receiving a summary of the baseline care plan.
On 04/10/24 at 4:09 P.M., SSD #126 provided a Discharge Planning Evaluation dated 03/29/24 which had an area to summarize the discussion of the care plan conference which indicated there was none. The form also indicated a copy of the care plan was not provided to anybody. SSD #126 verified a written summary of the baseline care plan was not provided to Resident #263.
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 F0804
(Tag F0804)
Could have caused harm · This affected multiple residents
**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** 5. Record review revealed Resident #49 was admitted to the facility on [DATE] with diagnoses including rhabdomyolysis, neoplasm ...
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**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** 5. Record review revealed Resident #49 was admitted to the facility on [DATE] with diagnoses including rhabdomyolysis, neoplasm of unspecified behavior of bladder, chronic obstructive pulmonary disease, atrial fibrillation, and type II diabetes.
Review of orders revealed Resident #49 received a regular diet with regular textures and thin liquids.
Review of a quarterly MDS completed on 02/26/24 revealed Resident #49 required set up help for eating and had no weight concerns.
Review of a care plan completed 02/21/24 revealed Resident #49 was at risk for altered nutritional status related to weight loss, advanced age, and medical diagnoses. The goal was for Resident #49 to receive and tolerate diet as ordered and consume adequately to maintain weight with no further weight loss, maintain hydration, and aid in the maintenance of skin integrity through the next review. Interventions included encouraging Resident #49 to attend dining room for meals, provide meals and fluids based on residents food preferences and as ordered, let the resident know where food is located on the tray, and observe percentage of intakes for changes in eating habits.
Interview on 04/08/24 at 10:10 A.M. with Resident #49 revealed he thought the food at the facility tasted terrible and was not very warm.
Observation on 04/10/24 at 12:11 P.M. revealed State Tested Nurse Aide (STNA) #122 walked out of a resident's room after delivering a tray and stated, that pizza is hard as a rock and I can't cut it. STNA #122 retrieved a grilled cheese sandwich for the resident as a substitute.
Test tray was completed on 04/10/24 at 12:25 P.M. and revealed the pizza was burnt and black on the bottom, was hard to bite into, and did not maintain an appetizing taste.
Interview on 04/10/24 at 2:25 P.M. with Resident #49 revealed the pizza for lunch was not good, the bottom was black and burnt, it was hard to chew and made his teeth hurt to eat.
This deficiency represents non-compliance investigated under Complaint Number OH00151791.
Based on observation, medical record review, review of menus, and interview, the facility failed to ensure food was palatable. This affected four residents (#37, #49, #58 and #263) of six residents reviewed for food concerns and one additional resident (Resident #36).
Findings include:
1. Review of Resident #58's medical record revealed diagnoses including heart failure and stage three chronic kidney disease. An admission Minimum Data Set (MDS) assessment dated [DATE] indicated Resident #58 was cognitively intact and able to make herself understood.
On 04/08/24 at 11:54 A.M., Resident #58's lunch was served. Potatoes were dark brown on all sides except two potatoes which had one lighter brown side. Resident #58 tapped her fork on the potatoes and it made a sound as if scraping burned toast. Resident #58 reported the potatoes were hard. As Resident #58 attempted to get one of the potatoes on a fork it and another potato left the plate and landed on the over the bed table. Resident #58 reported the green beans were not seasoned (no evidence of seasoning was noted with observation) according to the meal ticket.
Review of the menu for 04/08/24 for lunch revealed menu items included marinated chicken thigh, seasoned green beans, potato wedges, dinner roll/bread, and chocolate cake with peanut butter frosting.
On 04/08/24 at 12:00 P.M., [NAME] #405 stated there were no potatoes or green beans left over to taste. [NAME] #405 stated she thought the potatoes looked dark but denied they felt hard on the tray line.
On 04/08/24 at 12:29 P.M. State Tested Nursing Assistant (STNA) #122 was observed picking up trays and stated nobody was really eating the potatoes and stated the potatoes appeared burnt.
2. Review of Resident #36's medical record revealed diagnoses including orthostatic hypotension and history of malignant neoplasm of the kidney. A quarterly MDS dated [DATE] indicated Resident #36 was cognitively intact.
On 04/08/24 at 12:21 P.M., Resident #36 reported the potatoes were as hard as rocks and she could not eat them.
3. Review of Resident #37's medical record revealed diagnoses of malignant neoplasm of the right breast and type two diabetes mellitus. A quarterly MDS dated [DATE] revealed Resident #37 was cognitively intact and was usually able to make herself understood.
During an interview on 04/09/24 at 8:51 A.M., Resident #37 stated sometimes food was over and under cooked. Resident #37 stated the potatoes served for lunch on 04/08/24 were hard.
4. Review of Resident #263's medical record revealed diagnoses including type two diabetes mellitus and stage three pressure ulcer (significant wound that has penetrated through the top two layers of the skin and reached the fatty tissue beneath) of the left heel. An admission MDS dated [DATE] indicated Resident #263 was cognitively intact.
On 04/09/24 at 8:34 A.M., Resident #263 stated he received something on his lunch tray on 04/08/24 which he assumed was supposed to be potatoes that was listed on the meal ticket but they were too hard to eat.
CONCERN
(F)
📢 Someone Reported This
A family member, employee, or ombudsman was alarmed enough to file a formal complaint
Potential for Harm - no one hurt, but risky conditions existed
Food Safety
(Tag F0812)
Could have caused harm · This affected most or all residents
Based on observations, interviews, and policy review, the facility failed to store and prepare foods in a sanitary manner. This had the potential to affect all 55 residents residing in the facility.
F...
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Based on observations, interviews, and policy review, the facility failed to store and prepare foods in a sanitary manner. This had the potential to affect all 55 residents residing in the facility.
Findings included:
Observations on 04/08/24 between 9:15 A.M. and 9:18 A.M. revealed an eight-quart container of rice crispies in the dry storage room with a use by date of 03/27/24, two dozen hard-boiled eggs in the walk-in refrigerator with an expiration date of 03/10/24, half a white onion with a use by date of 04/04/24, a whole onion with a use by date of 04/06/24, a half a gallon of parmesan cheese with an expiration date of 03/27/24, and a bag of shredded cheddar cheese with an expiration date of 03/27/24.
Interview on 04/08/24 at 9:20 A.M. with Dietary Manager (DM) #430 confirmed the above findings.
Additional observations of the kitchen on 04/08/24 at 9:26 A.M. revealed food splashes on the prep area walls, food debris and crumbs on the shelving for dishes and pans as well as on the floor below the beverage area, and sticky grime throughout the stainless-steel shelving in the kitchen. DM #430 confirmed findings at the time observations were made.
Observation on 04/10/24 at 9:36 A.M. revealed shelving containing spices in the kitchen had a layer of dust, crumbs, and grime; the table with the steamer had a layer of sticky grime on top, the oven and stove had thick layers of grime and debris, two large white containers with flour and sugar had dark brown, sticky grime covering them, the shelf with the microwave had rust, and a container of baking soda was noted with a use by date of 01/10/24.
Interview on 04/10/24 at 10 A.M. with DM #430 confirmed above findings.
Observation on 04/10/24 at 10:26 A.M. revealed a white carafe on the clean dishes shelf that had dried, brown crust on it and two clear containers with food debris.
Interview on 04/10/24 at 10:26 A.M. with Dietary Aide (DA) #410 confirmed findings, removed the white carafe and rinsed it in water before placing it back on the clean dishes shelf.
Review of a policy titled Food Receiving and Storage (dated 01/01/22) revealed foods shall be received and stored in a manner that complied with safe food handling practices as outline in the FDA Food Code. Food Services or other staff will maintain clean food storage areas at all times, dry foods that are stored in bins and refrigerated foods stored in the refrigerator will be labeled and dated with an opened on and use by date.
Review of a policy titled Food Preparation and Service (dated 01/01/22) revealed food service employees shall prepare and serve food in a manner that complies with safe food handling practices. Food preparation staff will adhere to proper hygiene and sanitary practices to prevent the spread of foodborne illness.
This deficiency represents non-compliance investigated under Complaint Number OH00151791.
May 2022
21 deficiencies
1 Harm
SERIOUS
(G)
Actual Harm - a resident was hurt due to facility failures
Deficiency F0692
(Tag F0692)
A resident was harmed · This affected 1 resident
**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, record review, review of medical nutrition therapy recommendations, facility policy and procedure review a...
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**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, record review, review of medical nutrition therapy recommendations, facility policy and procedure review and interview the facility failed to timely address significant weight loss and/or communicate weight loss recommendations to appropriate staff.
Actual Harm occurred on 05/25/22 when Resident #41 was assessed to have a 11.2 pound/11.07% severe weight loss in less than thirty days following her admission on [DATE]. During this time period, the facility failed to implement timely comprehensive, individualized and effective interventions to prevent the weight loss, promote weight gain, communicate dietary recommendations to the physician and ensure an ordered dietary supplement was being consumed by the resident.
This affected three residents (#20, #32 and #41) of six residents reviewed for nutrition/weight loss. The facility identified four residents with significant weight loss.
Findings include:
1. Review of Resident #41's medical record revealed the resident was admitted on [DATE] with diagnoses of unspecified fracture of the sacrum, chronic obstructive pulmonary disease, unspecified dementia without behavioral disturbances, history of falling, essential hypertension, generalized muscle weakness and anxiety. Record review revealed the resident's admission weight on 04/27/22 was 101.2 pounds.
Review of Resident #41's physician's orders revealed on 04/27/22 she was ordered a regular diet with regular texture and regular fluids of thin consistency. On 04/28/02 the resident was ordered weekly weights for four weeks then monthly.
Review of Resident #41's care plan, dated 04/29/22 revealed the resident had a potential for decline in nutritional status related to sub-optimal intake of food/fluids. The goal was for the resident to maintain adequate nutritional status as evidenced by maintaining weight in the range of 100-105 pounds, having no signs or symptoms of malnutrition and consuming at least 50% of at least three meals daily. Interventions were to provide and serve diet as ordered, weigh per facility protocol and report significant weight changes to the registered dietitian, encourage fluid intake and provide a multivitamin and calcium supplement daily.
Review of the Minimum Data Set (MDS) 3.0 assessment, dated 05/02/22 revealed the resident was moderately cognitively intact and had poor appetite. The assessment revealed the resident was independent with her eating ability, needed setup help only with meals and was not prescribed a weight-loss regimen.
On 05/04/22 the resident weighed 95.0 pounds and on 05/05/22 the resident's weight was 96 pounds which reflected a 5.2 pound weight loss from admission [DATE] to 05/05/22).
Review of Resident #41's 05/06/22 nutrition and hydration note revealed recommendations to get resident up in wheelchair for meals, allow resident to smoke per facility rules, encourage fluid intake and start Med Plus 2.0 (120 milliliters (ml)) supplement two times per day.
Review of a Medical Nutritional Therapy Recommendation form for Resident #41, dated 05/06/22 revealed it included only the recommendation for Med Plus 2.0 (120 ml) two times per day. The recommendations for the resident to be up in wheelchair, encouraging fluid intake and smoking were not included on the form. In addition, there was no evidence the recommendation for the resident to be up in the wheelchair for meals was added to the resident's plan of care.
On 05/06/22 a physician order was obtained for Med Plus 2.0 (a dietary supplement) 120 milliliters (ml) two times a day for calorie support.
Review of the medication administration record revealed the Med Plus 2.0 supplement was scheduled to be administered at 8:00 A.M. and 8:00 P.M. Staff were to include the percentage of supplement consumed. From 05/06/22 at 8:00 P.M. through 05/13/22 at 8:00 P.M. the resident was only consuming 50 percent (%) of the ordered supplement. There was no evidence the facility re-evaluated the appropriateness of the supplement or effectiveness of this intervention to promote weight gain, prevent additional weight loss during this time period.
On 05/14/22 and 05/15/22 the resident consumed only 25% of the 8:00 P.M. Med Plus. On 05/16/22 the resident weighed 92.8 pounds which reflected an additional 3.2 pound weight loss from 05/05/22. There was no evidence the resident was reassessed or evidence of any new dietary interventions being considered/initiated at that time.
On 05/16/22 and 05/17/22 the resident did not consume any of the 8:00 A.M. Med Plus supplement. Between 05/18/22 and 05/25/22 the resident consumed between 10% and 60% of the ordered supplement. On 05/25/22 the resident weighed 90 pounds which reflected an additional 2.8 pound weight loss from 05/16/22.
From an admission [DATE]) weight of 101.2 pounds to a current weight on 05/25/22 of 90 pounds the resident sustained an 11.2 pound/11.07% severe weight loss in less than one month.
Review of Resident #41's percentage of meals eaten between 04/29/22 and 05/28/22 revealed she had refused 35 meals and her percentage of meal intake ranged from five percent to 100 percent with the average for 52 meals being 21.7 percent.
On 05/24/22 at 12:09 P.M. Resident #41 was observed lying in bed with head of bed (HOB) elevated and her meal tray on her over bed table. The meal consisted of ham, spinach, mashed sweet potatoes, cottage cheese, chocolate ice cream, fresh fruit in pieces and coffee. At 12:25 P.M. Resident #41 remained in bed with the HOB elevated and minimal of meal eaten. A staff member was observed to ask the resident if she would like tray left for additional time to eat and the resident responded, no.
On 05/24/22 at 6:00 P.M. Resident #41 was observed lying in bed with the HOB elevated. The resident had ice cream on the meal tray and had eaten some pudding and cookies. The resident had consumed a minimal amount of the total meal.
On 05/25/22 at 7:21 A.M. interview with the Director of Nursing (DON) revealed when the dietitian made a recommendation, it was provided to the nursing department and if a physician's order was needed, then the resident's physician was contacted to obtain the order. The DON failed to provide evidence the resident's decreased meal intakes, supplement intakes and continued weight loss were timely reported to the physician/dietitian for re-evaluation or for changes to nutritional interventions to prevent additional weight loss/promote weight gain for the resident.
On 05/25/22 at 7:48 A.M. Resident #41 was observed sitting in bed eating breakfast with the HOB elevated. Interview with the resident at the time of the observation revealed she was aware she was losing weight and it was a concern for her family. She reported she doesn't have pain from her previous sacrum fracture and could sit in a chair.
On 05/25/22 at 11:40 A.M. interview with Dietitian #206 revealed in general, her recommendations were placed on a Medical Nutritional Therapy Recommendation form and provided to the the DON, dietary manager and nurses working the hall to implement or to be used by nursing to contact the physician for orders, if physician orders were required.
On 05/25/22 at 11:56 A.M. interview with State Tested Nursing Assistant (STNA) #137 revealed she was not aware of any recommendation to get Resident #41 up in her wheelchair for meals. STNA #137 revealed she does not ask Resident #41 on a regular basis to sit in a chair for meals. She verified she is also not aware of any recommendations related to smoking for the resident.
On 05/25/22 at 12:30 P.M. interview with the DON revealed all recommendations from the dietitian were to be put on the Medical Nutritional Therapy Recommendations. The DON revealed if a physician order was needed, then the physician would be contacted for same. If a physician order wasn't needed, then the recommendations would be care planned and would result on the Medication Administration Record or Treatment Administration Record to guide nursing staff for care.
On 05/25/22 at 12:23 P.M. interview with Dietitian #206 verified the electronic health record (EHR) progress note dated 05/06/22, which she wrote, had four recommendations but only one recommendation was included on the Medical Nutritional Therapy Recommendations dated for the same day for Resident #41. Dietitian #206 revealed she doesn't put all the recommendations on the Medical Nutritional Therapy Recommendations form, only the ones that required a physician's order. Dietitian #206 revealed she expected the nursing staff to read her progress notes to be aware of all of the recommendations.
On 05/25/22 at 2:26 P.M. a nutrition/hydration note revealed the resident had a significant weight loss since admission to the facility related to sub-optimal caloric intake. The note revealed poor performance at meals continues; not taking Med Plus supplement very well. At this time the dietitian recommended adding the frozen nutritional supplement, magic cup at all meals for calorie support.
On 05/26/22 at 7:45 A.M. Resident #41 was observed sitting in bed eating breakfast with the HOB elevated
Review of the facility policy titled Nutritional Management, dated 01/01/21 revealed the facility provided care and services to each resident to ensure the resident maintained acceptable parameters of nutritional status in the context of his or her overall condition. It revealed that acceptable parameters of nutritional status referred to factors that reflect that an individual's nutritional status was adequate, relative to his/her overall condition and prognosis, such as weight, food/fluid intake and pertinent laboratory values. The policy added that a systemic approach was used to optimize each resident's nutritional status by developing and consistently implementing pertinent approaches. In addition, it revealed interventions would be individualized to address the specific needs of the resident. Example included environmental interventions. An example of an environmental intervention would be having the resident sit in a chair during meals.
Review of the facility policy titled Comprehensive Care Plans, dated 01/01/21 revealed the comprehensive care plan would be prepared by an Interdisciplinary Team, that included a member of the food and nutrition services staff.
Review of the Resident Food Preferences Policy, implemented 01/01/21 revealed nutritional assessments would include an evaluation of individual food preferences. Upon the resident's admission, (the) Dietary Manager or designee would identify a resident's food preferences. When possible, this would be done by direct interview with the resident as soon as possible after admission. The resident's clinical record (orders, care plan, or other appropriate locations) would document the resident's likes and dislikes and special dietary instructions or limitations such as altered food consistency and caloric restrictions. The dietary manager or designee would visit residents periodically to determine if revisions were needed regarding food preferences. The nursing staff would inform the kitchen about resident requests. The Food Services Department would offer food substitutes for individuals who do not want to eat the primary meal.
Review of the Weight Monitoring Policy and Procedure, dated 01/01/21 revealed based on the resident's comprehensive assessment, the facility would ensure that all residents maintained acceptable parameters of nutritional status, such as usual body weight or desirable body weight range and electrolyte imbalance, unless the resident's clinical condition demonstrates this was not possible or resident preferences indicated otherwise. Weight could be a useful indicator of nutritional status. Interventions would be identified, implemented, monitored and modified (as appropriate), consistent with the resident's assessed needs, choices, preferences, goals and current professional standards to maintain acceptable parameters of nutritional status.
A weight monitoring schedule will be developed upon admission for all residents:
a. weights should be recorded at the time obtained.
b. newly admitted residents- monitor weight weekly for four weeks
c. Residents with weight loss- monitor weight weekly
d. If clinically indicated- monitor weight daily
e. All others- monitor weight monthly
Further review of the policy revealed weight analysis, the newly recorded resident weight should be compared to the previous recorded weight. A significant change in weight is defined as:
a. 5% change in weight in one month (30 days)
b. 7.5% change in weight in three months (90 days)
c. 10% change in weight in six months (180 days)
The physician should be informed of a significant change in weight and may order nutritional interventions. The interdisciplinary plan of care communicates care instructions to the staff.
2. Review of Resident #20's medical record revealed an admission date of 03/03/22 with diagnoses including unspecified injury of the head, metabolic encephalopathy, dementia without behavioral disturbance and rhabdomyolosis.
Review of the nutrition data collection/evaluation V2, dated 03/11/22 revealed the resident was on a pureed diet but the resident and family wanted her on a regular diet despite the risks and the resident's food preferences had been updated. The resident was admitted to the facility with a speech therapy recommendation from the hospital for a pureed diet. The resident would not eat the pureed texture, likely contributing to her weight loss. The resident and family requested a regular diet despite education on concerns for safety. The resident's diet was upgraded per physician's orders and the facility speech therapist was notified for consult. Poor oral intakes continued at this time, 33% meal intake since admission. The resident was dependent of staff for eating. The dietician recommended adding Med Pass 2.0 120 milliliters three times a day to provide an additional 720 calories and 30 grams of protein to meet the resident's estimated nutritional needs for weight maintenance. Staff should continue to encourage good oral intakes as tolerated by the resident. The dietician would continue to monitor and follow up as needed.
Review of the resident has the potential for nutritional deficits related to advanced age, weight loss and poor oral intake care plan initiated 03/11/22 revealed interventions including administer medications as ordered, monitor/document for side effects and effectiveness, monitor/document/report to nurse/physician as needed for any signs and symptoms of dysphagia (pocketing, choking, coughing, drooling, holding food in your mouth, several attempts at swallowing),
monitor/record/report to physician as needed signs and symptoms of malnutrition (emaciation, muscle wasting, significant weight loss (3 pounds in a week; greater than five pounds in a month; greater than 7.5% in 3 months or greater then 10% in six months) and provide and serve diet as ordered, provide and serve supplements as ordered. The care plan revealed the registered dietician was to evaluate and make diet change recommendations as needed and weigh per orders.
Review of the nutrition note, dated 03/24/22 revealed the resident weighed 173.8 pounds and had experienced a significant weight loss since admission to the facility. The resident refused to comply with the recommended food texture (pureed) and requested regular textures. The resident was refusing Med Plus 2.0 at times. The resident had continued weight loss despite addition of Med Plus supplement. Poor appetite continues. The resident was fed by staff. Recommendations: add house shake supplement with all meals and consider the start of Remeron (anti-depressant that can be used for weight gain) or Marinol (man-made form of cannabis used to treat loss of appetite that causes weight loss).
Review of the nutrition note, dated 03/30/22 revealed the resident continued to remain with a significant weight loss. An appetite stimulant was recommended on 03/24/22 and not yet ordered. Please consider an appetite stimulant and house shake supplement to continue. Discontinue the Med Pass 2.0 supplement die to the resident not taking.
The resident's physician declined an appetite stimulant.
Review of the physician's orders revealed to obtain a monthly weight between the first and the tenth of each month and a regular diet with thin liquids dated 04/01/22. A sippy cup and divided plate with meals was ordered beginning on 04/29/22.
Review of the resident's weights revealed the following:
03/05/22 194.8 pounds
03/08/22 188.6 pounds
03/15/22 173.8 pounds
03/29/22 162 pounds
04/02/22 166 pounds
05/06/22 153 pounds
05/09/22 160.9 pounds
05/10/22 159 pounds
No further weights were available.
Review of the quarterly MDS 3.0 assessment, dated 03/31/22 revealed the resident had a Brief Interview for Mental Status (BIMS) score of 14 indicating she was cognitively intact. The assessment revealed the resident required total dependence on two staff for bed mobility, transfers, toilet use and personal hygiene. The resident required extensive assistance of one staff member for eating. Lastly, the resident had experienced a weight loss of greater than 5% or more in the last month.
Review of the nutrition note, dated 05/06/22 revealed the resident weighed 153.2 pounds with significant weight loss noted. The resident had poor appetite and poor performance with meals even though assisted by family members. The resident was refusing to consume Med Plus 2.0, house shake supplement and nutritional juice supplement. Weight loss related to composition changes (muscle atrophy) and sub-optimal caloric intake. The resident was refusing the nutritional supplements on formulary at the facility. Numerous complaints about meals. Recommendations: discontinue shake supplements with meals and have the dietary manager see the resident for food preferences.
The medical record contained no evidence the resident's preferences were assessed/addressed.
Review of the resident's meal ticket revealed no evidence of meal preferences.
On 05/25/22 at 8:01 A.M. the resident was observed lying in bed with her meal tray covered. The resident was waiting for her family to assist her with her meal. The resident denied anyone asking about her food preferences and stated this would dramatically change how much food she consumed. The resident stated she liked soup but it was not an available option and she could not remember the last time she was provided soup by the facility.
On 05/25/22 at 8:12 A.M. interview with Dietary Manager #164 revealed soup was not on the menu replacement/always available items and she currently was not able to order soups. The DM revealed she was unsure if residents requested soups for meals but if I have it, I give it to them The DM denied having small cans of soup available. The DM revealed soups were not currently available to purchase per the budget. Lastly, the DM verified she was unaware Resident #20 had a preference for soup as she was unaware the dietician recommended the dietary manager discuss food preferences with the resident. The DM verified the resident's preferences had not been assessed, even upon her admission to the facility.
On 05/25/22 at 8:15 A.M. observation of the dry food storage revealed the facility had one 50 ounce can of chicken noddle soup and four 50 ounce cans of tomato soup. The facility also had nine 50 ounce cans of cream of mushroom soup used for cooking.
On 05/25/22 at 11:32 A.M. interview with Dietician #206 verified the resident had experienced an 18.2% weight loss since admission, less than three months ago indicating a significant weight loss. The dietician verified the resident should have been a weekly weight given her weight loss and the dietary manager was to have discussed food preferences with the resident as she had recommended on 05/06/22. The dietician revealed she writes her recommendations on the medical nutritional therapy recommendations log and that was provided to both floor nurses and the dietary manager. The dietician verified the recommendation for the dietary manager to discuss food preferences with the resident was not on the recommendation log, however staff should be reading her progress notes to ensure all recommendations were addressed.
3. Review of Resident #32's medical record revealed a 05/26/19 admission and a 12/03/20 readmission. Resident #32 had diagnoses including cerebral infarction, anemia, hypothyroidism and diverticulosis.
Review of the 05/14/21 potential for decline in nutritional status related to advanced age, significant weight loss and mechanically altered diet included a goal for the resident to maintain adequate nutritional status as evidenced by maintaining weight with no significant changes, no signs or symptoms of malnutrition and consuming at least 75 percent of at least three meals daily through review date. A 05/14/21 intervention included to weigh per facility policy, monitor, record, report to physician as needed signs and symptoms of malnutrition (emaciation, muscle wasting, significant weight loss of greater than five percent in one month, 7.5 percent in three months or greater than 10 percent in six months).
Record review revealed a significant weight loss trend starting 08/04/21 when the resident had a 6.9 pound weight loss of 5.2 percent in 30 days due to decreased calorie intake. The trend continued with the 10/07/21 assessment which included a 8.1 percent weight loss of 10.7 pounds in three months. The weight loss was monitored until the 12/10/21 quarterly nutritional assessment when the resident had a 7.6 percent weight loss of 9.6 pounds in 90 days and 12.1 percent weight loss in 180 days with a 16.2 pound weight loss. The resident had no change in appetite, but meal intake had decreased since lower gum soreness started. The plan was for the resident to have meats chopped and gravy provided to allow for less mastication (not using lower denture), also going to provide ice cream at lunch and dinner meals for caloric support.
Review of a physician's order revealed an order, dated 12/10/21 to add ice cream to lunch and dinner tray for weight loss trend. On 01/04/22 an order was obtained for a regular diet, regular texture, regular fluid, thin consistency, no straws/shred lettuce diet; change to chopped meats with gravy and add ice cream (magic cup) to lunch and dinner tray.
A 01/10/22 nutrition note included continued weight loss of seven pounds in 30 days for 5.9 percent, 8.9 percent/10.8 pounds in 90 days and 16.2 percent/21.5 pounds in 180 days. The note revealed no change in appetite, but meal intake has decreased to 50 percent since lower gum soreness started. CEA and CA-125 tests to rule out underlying condition that may be cause of weight loss was ordered and was within normal limits.
On 01/21/22 an order was received for the supplement, Med Pass 2.0 120 milliliters (ml) three times a day for weight loss.
The resident had a 4.2 pound weight gain between 01/04/22 and 02/02/22 then a seven pound 6.07 percent significant weight loss between 02/02/22 and 03/01/22.
The resident had a dental clean and check of dentures 03/10/22.
A 03/11/22 annual nutritional evaluation revealed the resident was triggering for a significant weight loss of 6.2 percent in 30 days, 8.2 percent in 90 days and 15.2 percent in 90 days. There were no recommendations made at that time.
A dietician recommendation, dated 03/30/22 to consider an appetite stimulant for continued weight loss. The physician was notified, however no new orders were received at that time.
On 04/02/22 the resident's weight was 103.6 pounds which reflected a 3.8 pound weight loss/3.54 percent between March and April of 2022. There was a 10.23 percent/11.8 pound weight loss in 60 days from 02/02/21 through 04/02/22.
There was no evidence of any additional nutritional interventions following the significant weight loss of 11.8 pounds in two months. There was no evidence the facility obtained weekly weights per policy with the trending weight loss starting in August of 2021.
Review of the 04/06/22 annual Minimum Data Set (MDS) 3.0 assessment revealed the resident was independent for daily decision making, independent with set up for eating and significant weight loss of greater than 5 percent in 30 days or greater than 10 percent in six months.
Review of a 05/06/22 nutrition note revealed the resident had a significant 10.2 percent/11.8 pound unintended weight loss in 90 days and a 15.1 percent/18.4 pound weight loss in 180 days. Caloric intake had declined in past several months related to ill-fitting denture and the resident had a sore in mouth (now resolved). The resident had uncontrolled movement resulting in increased energy expenditure. Facility physician would not order appetite stimulant. The note reflected to consider obtaining a neurological consult for uncontrolled movements. The Med Pass 2.0 supplement for weight loss was discontinued 05/06/22 due to the resident refusal.
On 05/23/22 at 10:42 A.M. interview with Resident #32 revealed the resident didn't know know why she is losing weight but indicated she didn't want to (lose weight). The resident did include she liked the ice cream and (magic cup) supplement.
On 05/25/22 at 11:59 A.M. interview with Dietician #206 revealed it was the facility policy if there was a resident with a significant weight loss to obtain weekly weights. Dietician #206 revealed she expected nursing staff to initiated the weekly weekly and indicated she didn't write an order for them. The dietician verified she had not provided increased nutritional support with the significant weight loss of 115.4 to 103.6 from 02/02/22 to 04/06/22. The dietician revealed she did not know what else to offer the resident. The resident would eat magic cups but she was not a fan of someone living on magic cup. She did not want to put more magic cup or ice cream on the tray because she wanted the resident to eat the regular meal. She did not consider having nursing offer an additional magic cup if the resident did not eat a specified percentage of her meal. She had not considered fortified foods.
Review of the Weight Monitoring Policy and Procedure, dated 01/01/21 revealed based on the resident's comprehensive assessment, the facility would ensure all residents maintain acceptable parameters of nutritional status, such as usual body weight or desirable body weight range and electrolyte imbalance, unless the resident's clinical condition demonstrates this was not possible or resident preferences indicated otherwise. Weight could be a useful indicator of nutritional status. Interventions would be identified, implemented, monitored and modified (as appropriate), consistent with the resident's assessed needs, choices, preferences, goals and current professional standards to maintain acceptable parameters of nutritional status.
A weight monitoring schedule will be developed upon admission for all residents:
a. weights should be recorded at the time obtained.
b. newly admitted residents- monitor weight weekly for four weeks
c. Residents with weight loss- monitor weight weekly
d. If clinically indicated- monitor weight daily
e. All others- monitor weight monthly
Further review of the policy revealed weight analysis: the newly recorded resident weight should be compared to the previous recorded weight. A significant change in weight is defined as:
a. 5% change in weight in one month (30 days)
b. 7.5% change in weight in three months (90 days)
c. 10% change in weight in six months (180 days)
The physician should be informed of a significant change in weight and may order nutritional interventions. The interdisciplinary plan of care communicated care instructions to the staff.
CONCERN
(D)
Potential for Harm - no one hurt, but risky conditions existed
Notification of Changes
(Tag F0580)
Could have caused harm · This affected 1 resident
Based on record review, facility policy and procedure review and interview the facility failed to ensure Resident #20's physician was notified timely following weight loss and the resident's family re...
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Based on record review, facility policy and procedure review and interview the facility failed to ensure Resident #20's physician was notified timely following weight loss and the resident's family request for an appetite stimulant. This affected one resident (#20) of six residents reviewed for nutrition.
Findings include:
Review of Resident #20's medical record revealed an admission date of 03/03/22 with diagnoses including unspecified injury of the head, metabolic encephalopathy, dementia without behavioral disturbance and rhabdomyolosis
Review of the physician's orders revealed an order to obtain a monthly weight between the first and the tenth of each month. The resident also had an order (dated 04/01/22) for a regular diet with thin liquids. On 04/29/22 a new order for a sippy cup and divided plate with meals was ordered.
Review of the resident's weights revealed the following:
03/05/22 194.8 pounds
03/08/22 188.6 pounds
03/15/22 173.8 pounds
03/29/22 162 pounds
04/02/22 166 pounds
05/06/22 153 pounds
05/09/22 160.9 pounds and
05/10/22 159 pounds
No further weights were available.
Review of the quarterly Minimum Data Set (MDS) 3.0 assessment, dated 03/31/22 revealed the resident had a Brief Interview for Mental Status (BIMS) score of 14 indicating she was cognitively intact and required total dependence of two staff for bed mobility, transfers, toilet use and personal hygiene. The resident required extensive assistance of one staff member for eating. Lastly, the resident had experienced a weight loss of greater than 5% or more in the last month
Review of the nursing progress notes revealed no evidence the resident's physician was notified of her weight loss from admission to 05/10/22.
Further review of the nursing progress notes, dated 04/16/22 at 5:11 A.M. revealed the resident's daughter would like an appetite stimulant for the resident due to weight loss. The note indicated, will address the next time we speak to the physician. The resident was aware and agreeable.
On 05/26/22 at 12:15 P.M. interview with the Director of Nursing verified the medical record did not contain documentation the resident's physician was notified of her continuous weight loss or the resident's daughter's request for an appetite stimulant. The DON verified her expectation would be for notification related to the resident's weight loss and the resident/family member's request for an appetite stimulant.
Review of the Weight Monitoring Policy and Procedure, dated 01/01/21 revealed the physician should be informed of a significant change in weight.
CONCERN
(D)
Potential for Harm - no one hurt, but risky conditions existed
Deficiency F0625
(Tag F0625)
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 Resident #50 was...
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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 Resident #50 was provided a notice of the facility bed hold policy and ability to return to the facility upon admission and prior to a hospital transfer. This affected one resident (#50) of one resident reviewed for hospitalization.
Findings include:
Review of Resident #50's closed medical record revealed an admission date of 03/11/22 with diagnoses including COVID-19, malignant neoplasm of the uterus, malignant neoplasm of the brain, and malignant neoplasm of the lung.
Review of the five day Minimum Data Set (MDS) 3.0 assessment, dated 03/15/22 revealed the resident was cognitively intact and required extensive assistance from two staff with bed mobility and extensive assistance of one staff member with dressing, toilet use and personal hygiene. A discharge, return not anticipated MDS 3.0 assessment was completed on 03/29/22.
Further review of the closed medical record revealed no evidence the facility bed hold policy was provided to the resident or family upon admission on [DATE], during the resident's stay or transfer to the hospital. The closed medical record contained no documentation of the resident and/or family stating they did not plan to return to the facility after hospitalization.
Review of a nursing progress note, dated 03/15/22 at 2:05 P.M. revealed the resident called her mother and said she had vomited once and was weak. The resident's mother called the resident's oncologist and the oncologist recommended to send the resident to the emergency room to be evaluated. The family and resident were aware and agreed.
On 05/25/22 at 8:30 A.M. interview with the Director of Nursing (DON) verified the resident was not provided information/bed hold letter upon transfer to the hospital and stated this was due to the resident's payer status. The DON then verified the resident should have received notification of the bed hold policy prior to transfer.
On 05/28/22 at 11:08 A.M. interview with the Administrator verified the facility bed hold information/policy was not provided to Resident #50 upon admission to the facility due to her COVID-19 status and had not been provided to the resident prior to her hospital transfer.
Review of the undated Notice of Bedhold Policy revealed a bed hold means the center shall not allow another resident to occupy your bed while you are temporarily away from the center (either due to hospitalization or therapeutic leave) and shall return to that bed when you return to the center.
CONCERN
(D)
Potential for Harm - no one hurt, but risky conditions existed
PASARR Coordination
(Tag F0644)
Could have caused harm · This affected 1 resident
Based on medical record review, facility policy and procedure review and interview the facility failed to complete a new Preadmission Screening and Resident Review (PASARR) screening for residents wit...
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Based on medical record review, facility policy and procedure review and interview the facility failed to complete a new Preadmission Screening and Resident Review (PASARR) screening for residents with newly added mental health diagnoses. This affected two residents (#44 and #17) of two residents reviewed for PASARR reviews.
Finding include:
1. Review of the medical record for Resident #44 revealed an admission date of 01/12/18.
Review of Resident #44's most recent PASARR, dated 01/11/2018 revealed Resident #44 did not have any diagnoses of dementia, anxiety or delusions.
Resident #44 had diagnoses added including dementia with Lewy bodies (dated 01/19/21), psychotic disorder with delusions due to known physiological conditions (dated 03/17/22), anxiety (dated 01/11/22) and major depressive disorder.
Review of the plan of care, dated 01/15/2018 and revised 10/02/2019 revealed Resident #44 was at risk of exhibiting behaviors such as crying related to depression. Interventions included to administer medication as ordered and to monitor for behaviors.
Review of the plan of care, dated 04/24/18 and revised 12/19/19 revealed Resident #44 had impaired cognitive function and dementia. Interventions included to administer medications as ordered, communicate with resident and family and cue reorient as needed.
Review of the plan of care, dated 09/27/18 and revised 01/12/22 revealed Resident #44 had anxiety. Interventions include to administer medication as ordered, monitor and document and attempt non pharmacological interventions.
Review of the plan of care, dated 01/07/2020 revealed Resident #44 experienced an altered thought process related to hallucinations. Interventions include approach with caution when symptomatic, if refuses return later, identify stressors causing behaviors, avoid whispering or laughing observe for changes in symptoms.
Review of Resident #44's quarterly Minimum Data Set (MDS) 3.0 assessment, dated 04/29/22 revealed a Brief Interview for Mental Status (BIMS) score of 13 indicating intact cognition for daily decision making abilities. Resident #44 was noted to experience hallucinations. The assessment revealed the resident required extensive assistance from two staff members for bed mobility and extensive assistance from one staff member for transfers, mobility, dressing, toilet use and personal hygiene. The MDS assessment revealed the resident had diagnoses of non-Alzheimer's dementia, Parkinson's disease, anxiety disorder, depression and psychotic disorder other than schizophrenia. Resident #44 was noted to receive antipsychotic and antidepressant medication seven days a week.
Review of the physician's orders for Resident #44 for May 2022 revealed the following orders:
Mirtazapine 15 milligram (mg) tablet one tablet at night time for depression
Monitor for nocturnal hallucinations for the use of antipsychotic medication
Nuplazid 34 mg capsule one capsule daily for anxiety
On 05/24/22 at 3:02 P.M. interview with Admissions/Marketing #111 revealed a new PASARR needed to be completed when a resident experienced a newly added mental illness diagnosis. Admissions/Marketing #111 verified a new PASARR should have been completed for Resident #44 when she was newly diagnosed with anxiety, dementia and delusions.
2. Review of Resident #17's medical record revealed an admission date of 11/06/09 with a diagnosis including major depression.
Review of the PASARR, dated 11/06/09 revealed the resident had no indication of serious mental illness nor developmental disabilities.
Further review of the medical record revealed new diagnoses of schizophrenia and psychosis not due to a substance or known psychological condition were added on 07/01/15
Review of the physician's orders revealed the resident had received the antipsychotic medication, Risperdal daily since 2017.
Review of the annual MDS 3.0 assessment, dated 03/01/22 revealed the resident was cognitively intact and not currently considered by the State Level II PASARR process to have serious mental illness and/or intellectual disability. Further review of the MDS revealed the resident had active diagnoses including psychotic disorder and schizophrenia. The resident received antipsychotic medication for seven days during the assessment period
On 05/24/22 3:57 P.M. interview with Social Service Director #130 verified completion of the annual MDS and PASARR review should have identified the resident required a new screening for Level II services.
Review of the Pre-admission Screen and Resident Review Policy, implemented 01/01/21 revealed an individual was considered to have a serious mental illness if the individual met the following requirements on diagnosis, level of impairment and duration of illness. A schizophrenic, mood, paranoid, panic or other severe anxiety disorder, somatoform disorder, personality disorder, other psychotic disorder, or another mental disorder that may lead to chronic disability. The facility was responsible for notifying the State agency which govern PASARR of a resident's condition change.
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
Based on record review, facility policy and procedure review and interview the facility failed to develop comprehensive and individual care plans for Resident #44 related to psychoactive medication, R...
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Based on record review, facility policy and procedure review and interview the facility failed to develop comprehensive and individual care plans for Resident #44 related to psychoactive medication, Resident #12 related to restorative nursing services and Resident #6 related to activities. This affected three residents (#6, #12 and #44) of 25 residents whose care plans were reviewed.
Findings include:
1. Review of the medical record for Resident #44 revealed an admission date of 01/12/18. Resident #44 had diagnoses including dementia with Lewy bodies (dated 01/19/21), psychotic disorder with delusions due to known physiological conditions (dated 03/17/22), anxiety (dated 01/11/22) and major depressive disorder.
Review of the plan of care, initiated on 01/12/18 and most recently revised on 01/12/22 revealed the resident had no care plan related to the use of an antipsychotic medication.
Review of Resident #44's quarterly Minimum Data Set (MDS) 3.0 assessment, dated 04/29/22 revealed a Brief Interview for Mental Status (BIMS) score of 13 indicating intact cognition for daily decision making abilities. Resident #44 was noted to experience hallucinations. The assessment revealed Resident #44 required extensive assistance from two staff members for bed mobility and extensive assistance from one staff member for transfers, mobility, dressing, toilet use and personal hygiene. The MDS assessment noted Resident #44 had diagnoses of non-Alzheimer's dementia, Parkinson's disease, anxiety disorder, depression, and psychotic disorder other than schizophrenia and received antipsychotic and antidepressant medication seven days a week.
Review of the physician's orders for Resident #44 for May 2022 revealed an order for Nuplazid 34 milligrams one capsule daily for anxiety (an atypical antipsychotic approved for treatment of Parkinson's disease psychosis).
On 05/26/22 12:48 P.M. interview with the Director of Nursing revealed the Minimum Data Set (MDS) nurse had deleted the care plan for the use of antipsychotic medication and she was not sure if the MDS nurse realized Resident #44 was still prescribed this class of medication or what may have happened.
2. Review of the medical record for Resident #12 revealed an initial admission date of 06/11/21 and a readmission date of 02/15/22. Resident #12 had diagnoses including cerebral infarction due to occlusion or stenosis of right middle cerebral artery, hemiplegia and hemiparesis following cerebral infarction affect left non-dominant side, facial weakness and difficulty walking.
Review of Resident #12's Minimum Data Set (MDS) 3.0 assessment, dated 02/22/22 revealed a Brief Interview for Mental Status (BIMS) score of 15 indicating intact cognition for daily decision making abilities. The assessment revealed Resident #12 required extensive assistance from one staff member for bed mobility, transfers, mobility, dressing, toilet use and personal hygiene. The assessment also noted Resident #12 had impairments to one upper and one lower extremity and required the use of a walker or wheelchair for mobility.
Review of Resident #12's plan of care, initiated on 02/15/22 and most recently revised on 03/23/22 revealed no plan of care to reflect a restorative nursing program for Resident #12.
Review of Resident #12's task of daily living that was to be completed revealed the resident was to receive active range of motion (AROM) and passive range of motion (PROM) with the assistance of one staff member twice a day or once a shift.
On 05/26/22 at 12:19 P.M. interview with the Director of Nursing confirmed Resident #12 did not have a plan of care to reflect her restorative program.
Review of the the facility policy titled Restorative Nursing Program, dated 01/01/22 revealed restorative documentation requirements included to incorporated into the plan of care which was part of the clinical record.
3. Review of Resident #6's medical record revealed a 04/22/04 admission with diagnoses including Alzheimer's disease, dementia, osteoarthritis and glaucoma.
Review of the 02/09/22 quarterly MDS 3.0 assessment revealed the resident was severely impaired for daily decision making and required extensive assistance to total dependence from staff for activities of daily living care. The resident was noted to be non-ambulatory and had upper extremity impairment to both sides.
Review of the resident's medical record revealed no current activity plan of care was in place for the resident.
On 05/24/22 at 4:45 P.M. interview with Social Services/Activity Director #130 verified the resident did not have an activity plan of care.
On 05/25/22 at 5:53 P.M. interview with the Director of Nursing verified the facility did not have a current activity plan of care for the resident. The DON revealed a previous activity plan of care had been resolved and discontinued for some unknown reason.
CONCERN
(D)
Potential for Harm - no one hurt, but risky conditions existed
Deficiency F0657
(Tag F0657)
Could have caused harm · This affected 1 resident
**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on record review, facility policy and procedure review and interview the facility failed to ensure comprehensive and indiv...
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**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on record review, facility policy and procedure review and interview the facility failed to ensure comprehensive and individualized care plans were revised for Resident #19 related to advance directives and Resident #43 related to medication administration. This affected two residents (#19 and #43) of 25 residents reviewed for care planning.
Findings include:
1. Review of Resident #19's medical record revealed the resident was admitted to the facility on [DATE] with diagnoses including essential hypertension, unspecified mononeuropathy of the right and left lower limb, hypothyroidism, unspecified asthma, age-related osteoporosis without current pathological fracture, and glaucoma. On 09/20/19 the diagnosis of repeated falls was added, on 12/12/20 the diagnosis of generalized muscle weakness was added, on 02/01/22 the diagnoses of difficulty walking, not elsewhere classified was added, and on 03/26/22 encounter for palliative care was added.
Record review revealed Resident 19 had advance directive paperwork, dated 03/26/22 indicating she was a DNR-CCA. This meant the resident did not want resuscitation procedures if her heart stopped beating and/or she stopped breathing.
Review of Resident #19's physician's orders revealed an advance directive order, dated 03/29/22 for a Do Not Resuscitate - Comfort Care Arrest (DNR-CCA)
Review of Resident #19's current care plan, dated 04/11/22 revealed she had a living will and durable power of attorney. It also revealed Resident #19 wished to be a full code status. This meant the resident wanted to have all resuscitation procedures provided to keep her alive if her heart stopped beating and/or she stopped breathing.
Review of Resident #19's significant change Minimum Data Set (MDS) 3.0 assessment, dated 04/05/22 revealed the resident was cognitively impaired and receiving Hospice care.
On 05/26/22 at 04:12 P.M. interview with the Director of Nursing verified Resident #19's physician's order revealed she was a DNR-CCA but her care plan had not been updated and reflected the resident's advance directives were for a full code status.
2. Review of Resident #43's medical record revealed the resident was admitted to the facility on [DATE] with diagnoses of cellulitis of the right lower limb, type two diabetes mellitus, chronic systolic heart failure and surgical aftercare following surgery of the skin and subcutaneous tissue.
Review of Resident #43's quarterly MDS 3.0 assessment, dated 04/15/22 revealed the resident was cognitively intact and had received six days of anticoagulation therapy.
Review of Resident #43's current orders did not reveal any anticoagulation therapy. Review of his previous physician's orders revealed he was ordered Enoxaparin Sodium Solution (an anticoagulation medication used to prevent clots after surgery) until 04/29/2022. Review of Resident #43's Medication Administration Records (MARs) dated March 2022 and April 2022 revealed he received Enoxaparin Sodium Solution from 03/30/22 to 04/29/22.
Review of Resident #43's current care plan, dated 03/30/22 and revised on 04/12/22 revealed he was receiving anticoagulant
therapy due to being post operative (recently having surgery). This care was continued into May 2022.
On 05/26/22 at 4:14 P.M. an interview with the facility DON verified Resident #43 was care planned for anticoagulation therapy and he was not receiving anticoagulant therapy at this time. Therefore, the care plan was not updated/correct for Resident 43's care needs.
Review of the facility policy titled Comprehensive Care Plans, dated 01/01/21 revealed the comprehensive care plan would be reviewed and revised by the interdisciplinary team after each comprehensive and quarterly MDS assessment.
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 a comprehensive ...
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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 a comprehensive discharge summary was completed for Resident #49 as required. This affected one resident (#49) of two residents reviewed for transfer/discharge.
Findings include:
Review of Resident #49's closed medical record revealed the resident was admitted on [DATE] with diagnoses including diabetes with neuropathy, pressure ulcers to the left buttock, right buttock and sacrum, a deep tissue injury to the right heel, congestive heart failure and colostomy due to cancer.
Review of the admission Minimum Data Set (MDS) 3.0 assessment, dated 04/14/22 revealed the resident was cognitively intact and required extensive assistance of two staff for bed mobility and total dependence of two staff members with transfers. The resident also required extensive assistance of one staff member with personal hygiene and total dependence of one staff member with toilet use. The resident had three Stage II pressure ulcers and one unstageable (deep tissue injury) pressure ulcer on admission.
Review of the physician's orders revealed the resident had an order for a controlled carbohydrate diet with large entree portions at meals, the supplement Prostat twice a day for wound healing, zinc oxide topically to thighs and scrotum, hydrogel and collagen mixture two times a day to the pressure ulcers to right buttock and sacrum (the pressure ulcer to the left buttock resolved on 04/20/22) and physical and occupational therapy services.
Further review of the physician's orders, dated 04/25/22 revealed an order to discharge to home on current medications and home health for nursing services, physical and occupational therapy.
Review of the Discharge to Home/Community/Assisted Living- Recapitulation of Stay Document, dated 04/25/22 revealed the resident received a controlled carbohydrate, regular diet with thin liquids and no dietary discharge summary was provided. Review of the Activity Discharge Summary revealed activity as tolerated and no activities discharge summary was provided. Review of the Social Services Discharge Summary revealed the resident's physician's name and office number and resident is discharging from this facility to home with his wife and home health services. No additional information was provided. No nursing discharge summary was provided and under other discharge information (respiratory, physical therapy, occupational therapy as necessary) revealed no documentation despite the resident receiving physical and occupational therapy services during his stay. The recapitulation did not contain a concise summary of the resident's stay and treatment course while in the facility.
On 05/25/22 at 4:20 P.M. interview with the Director of Nursing verified the recapitulation of the resident's stay was not a concise summary of the resident stay and course of treatment while in the facility.
Review of the Discharge Summary and Plan of Care Policy, dated 01/01/21 revealed it was the policy of the facility to ensure that a discharge planning process was in place which addressed the resident's discharge goals and needs, including caregiver support and referrals to local state agencies. Upon discharge of a resident (other than in emergency to the hospital or death) a discharge summary would be provided. The discharge summary should include an overview of the resident's stay that included but was not limited to: diagnoses, course of illness/treatment or therapy and pertinent lab, radiology and consultation results. A final summary of the resident's status at the time of discharge that was available to release to authorized persons and agencies, with the consent of the resident or resident's representative.
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 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 #15, who required staff assistance for activities of daily living care received adequate and timely assistance with nail care to maintain proper hygiene. This affected one resident (#15) of two residents reviewed for activities of daily living.
Findings include:
Review of Resident #15's medical record revealed the resident was admitted to the facility on [DATE] with diagnoses including osteomyelitis of vertebra, sacral and sacrococcygeal region, pressure ulcer of sacral region Stage IV (full-thickness skin and tissue loss with exposed fascia, muscle, tendon, ligament, cartilage, or bone in the ulcer), type 2 diabetes, atrial fibrillation, dementia, Alzheimer's, abnormal posture, heart failure and dysphagia.
A 03/07/22 activity of daily living plan of care revealed an intervention (dated 03/15/22) to check nail length and trim and clean on bath day and as necessary.
Review of the 03/08/22 admission Minimum Data Set (MDS) 3.0 assessment revealed the resident was severely impaired for daily decision, required extensive assist of two staff for bed mobility and transfers, was totally dependent of two staff for dressing, required extensive assist of one staff for eating, was totally dependent on two staff for toilet use and for personal hygiene and was totally dependent on one staff for bathing. The resident was admitted with one Stage 1 (superficial reddening of the skin (or red, blue or purple hues in darkly pigmented skin that when pressed does not turn white (non-blanchable erythema)) pressure ulcer and one Stage IV pressure ulcer.
The residents' shower days were Monday and Thursday during the midnight shift.
On Monday 05/23/22 at 10:35 A.M. all 10 digits of the resident's fingernails were observed to be long with dark debris under the nail beds.
On 05/24/22 at 11:52 A.M. observation revealed the resident's nails remained long with dark debris under the nail beds.
On 05/24/22 at 11:55 A.M. interview with State Tested Nursing Assistant (STNA) #131 revealed nail care was to be completed with baths and showers.
On 05/24/22 at 12:10 P.M. interview with Registered Nurse (RN) #144 verified the resident's fingernails were long bilaterally with dark debris under the nail beds. RN #144 verified the resident was unable to provide her own nail care.
Review of the facility 01/01/21 Nail Care policy revealed routine cleaning and inspection of nails would be provided during activity of daily living care on an ongoing basis.
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
Based on observation, record review and interview the facility failed to assess and timely notify the physician of an identified skin alteration for Resident #17. This affected one resident (#17) of o...
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Based on observation, record review and interview the facility failed to assess and timely notify the physician of an identified skin alteration for Resident #17. This affected one resident (#17) of one resident reviewed for non-pressure skin alterations.
Findings include:
Review of Resident #17's medical record revealed an admission date of 11/06/09 with a diagnosis including major depression.
Review of the physician's orders revealed an order (dated 09/10/19) for showers every Tuesday and Friday during the 7:00 A.M. to 3:00 P.M. shift and as needed and Nystatin cream twice a day for itching under the resident's breasts.
Review of annual Minimum Data Set (MDS) 3.0 assessment, dated 03/01/22 revealed the resident was cognitively intact, independent for activities of daily living and required supervision and set up help for bathing.
Review of the weekly skin assessments revealed the last skin assessment completed was dated 05/20/22 and no skin alterations were noted.
On 05/23/22 at 1:16 P.M. interview with Resident #17 revealed she had an area on her upper back that itched and the staff had applied hydrocortisone once but it didn't help and there was no other treatment provided.
Review of the bathtime skin anatomy diagram, dated 05/24/22 revealed the resident had a red area to the back of her neck. This area was documented on the form by State Tested Nursing Assistant (STNA) #137. The resident had received a shower and had her hair washed. The form was signed by Registered Nurse (RN) #144.
Further review of the physician's orders, progress notes, treatment records and skin assessments revealed no documentation related to the area as of 05/26/22 at 9:00 A.M.
On 05/26/22 at 9:00 A.M. the Director of Nursing (DON) and surveyor entered the resident's room and the resident consented to observation of her neck and upper back. The DON applied gloves and pulled the neck of the resident's shirt down, exposing a soft ball sized, raised, callous like area the DON described as firm to the to the lower right of the resident's neck. The resident complained of discomfort when the DON palpated the area.
On 05/26/22 at 9:02 A.M. the DON approached Licensed Practical Nurse (LPN) #106 and inquired about the area to the resident's right neck and the LPN stated the nurses had been applying hydrocortisone to the area. The DON instructed the LPN to notify the physician as the area may need a different treatment ordered.
On 05/26/22 at 11:21 A.M. interview with RN #144 verified she signed Resident #17's bathtime skin anatomy diagram dated 05/24/22. Further interview revealed her signature on the form verified she was aware of the area. The RN stated she applied lotion to the area and attempted to reach the physician for treatment orders but the physician never responded. The RN verified she did not document attempts to reach the physician regarding the resident's area and she was unaware of a hydrocortisone order to treat the resident's skin alteration to the back of the neck. The RN verified an order was required for treatments.
On 05/26/22 at 11:45 A.M. interview with the Director of Nursing verified the medical record did not contain documentation of the area to the back of the resident's neck, attempts to reach the physician, evidence of an order for hydrocortisone or evidence an appropriate treatment was being completed. The DON verified treatments required a physician's order and newly identified skin alterations should either have a skin assessment completed or an entry in the progress notes regarding the area. The DON verified RN #144 made a late entry note this date regarding the resident's area to her neck.
On 05/26/22 at 4:08 P.M. interview with STNA #137 revealed she showered Resident #17 on 05/24/22 and noted the area to the resident's neck. The STNA revealed she was usually the staff member who showered Resident #17 and stated that was the first time she noticed the area to the resident's neck. STNA #137 revealed skin sheets were completed with every shower to notify the nurse of any skin issues.
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
Based on observation, record review, manufacturer guidelines review, facility policy and procedure review and interview the facility failed to ensure pressure ulcer interventions were provided in acco...
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Based on observation, record review, manufacturer guidelines review, facility policy and procedure review and interview the facility failed to ensure pressure ulcer interventions were provided in accordance with manufacturer guidelines and to meet the needs of Resident #15. This affected one resident (#15) of two residents reviewed for pressure ulcers. The facility identified three residents who had pressure ulcers.
Findings include:
Review of Resident #15's medical record revealed a 03/02/22 admission with diagnoses including osteomyelitis of vertebra, sacral and sacrococcygeal region, pressure ulcer of sacral region Stage IV (full-thickness skin and tissue loss with exposed fascia, muscle, tendon, ligament, cartilage, or bone in the ulcer), type 2 diabetes, atrial fibrillation, dementia, Alzheimer's disease, abnormal posture, heart failure and dysphagia.
Record review revealed Resident #15 was admitted to the facility with a Stage IV pressure ulcer to the sacrum measuring 8.52 centimeter (cm) in length by 6.56 cm width with 0.7 cm depth and 0.7 cm tunneling at 3:00.
A plan of care was developed, dated 03/07/22 related to the Stage IV pressure ulcer plan to the sacrum and also a Stage I (non-blanchable erythema of intact skin) pressure ulcer to the heel.
Review of the 03/08/22 admission Minimum Data Set (MDS) 3.0 assessment revealed the resident was severely impaired for daily decision, required extensive assist of two staff for bed mobility and transfers, was totally dependent on two staff for dressing, required extensive assist from one staff for eating, was totally dependent on two staff for toilet use and for personal hygiene and totally dependent on one staff for bathing. The MDS assessment noted the resident was admitted with one Stage I pressure ulcer and one Stage IV pressure ulcer.
Review of the current physician's orders revealed the resident had an order for a special mattress to the bed and padded sides to bed frame to decrease risk of injury.
Record review revealed on 05/10/22 the resident weighed 120 pounds.
On 05/23/22 at 10:35 A.M. Resident #15 was observed in bed on her back with the head of the bed elevated approximately 20 degrees. The bed had a MedaCure low air loss mattress with a pump hanging on the footboard. The control at the foot of the bed was set on 365 pounds, firm.
On 05/24/22 at 11:52 A.M. observation revealed the MedaCure mattress remained set at 365 pounds, firm.
Review of the MedaCure Comfort Zone Lateral Rotating Mattress manufacturer guidelines revealed the mattress was designed for bed sore and wound care therapy and prevention, which may occur during an extended hospital stay and nursing home/long term care environment. The guidelines revealed for a weight of 110-145 pounds the pressure should be 33-36 millimeter of mercury (mmHg), soft.
The resident's bed was set between 350-400 pounds with 54-57 mmHg, firm.
Review of the Pressure Ulcer Skin Breakdown Clinical Protocol policy, implemented 01/01/21 revealed based on the comprehensive assessment of a resident the resident received care consistent with professional standards as a practice to prevent pressure ulcers, does not develop pressure ulcers unless the individuals clinical condition demonstrates they were unavoidable and a resident with pressure ulcers received necessary treatment and services consistent with professional standards of practice to promote healing, prevent infection and prevent new ulcers from developing.
On 05/24/22 at 12:10 P.M. interview with Registered Nurse #144 verified the weight on the air mattress was set at about 365 pounds, firm and the resident weighed 120 pounds which was a soft setting. The RN verified the bed setting was not consistent with the resident weight to provide optimal intervention.
CONCERN
(D)
Potential for Harm - no one hurt, but risky conditions existed
Deficiency F0688
(Tag F0688)
Could have caused harm · This affected 1 resident
Based on record review, facility policy and procedure review and interview the facility failed to provide a restorative program as scheduled for Resident #12. This affected one resident (#12) of four ...
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Based on record review, facility policy and procedure review and interview the facility failed to provide a restorative program as scheduled for Resident #12. This affected one resident (#12) of four residents reviewed for restorative programs.
Findings include:
Review of the medical record for Resident #12 revealed an initial admission date of 06/11/21 and a re-admission date of 02/15/22. Resident #12 had diagnoses including cerebral infarction due to occlusion or stenosis of right middle cerebral artery, hemiplegia and hemiparesis following cerebral infarction affect left non-dominant side, facial weakness and difficulty walking.
Review of Resident #12's admission Minimum Data Set (MDS) 3.0 assessment, dated 02/22/22 revealed a Brief Interview for Mental Status (BIMS) score of 15 indicating an intact cognition for daily decision making abilities. Resident #12 was assessed to require extensive assistance from one staff member for bed mobility, transfers, mobility, dressing, toilet use and personal hygiene. The MDS assessment revealed Resident #12 had impairments to one upper and one lower extremity and required the use of a walker or wheelchair for mobility.
Review of Resident #12's TASK documentation for daily living revealed the resident was to receive active range of motion (AROM) and passive range of motion (PROM) with the assistance of one staff member twice a day or once a shift.
Review of Resident #12's restorative TASK documentation for March 2022 revealed Resident #12 received restorative ambulation services and AROM four days.
Review of Resident #12's restorative TASK documentation for April 2022 revealed Resident #12 received restorative ambulation and AROM 18 of 30 days and PROM seven days.
Review of Resident #12's restorative TASK documentation for May 2022 (through 05/25/22) revealed Resident #12 receive restorative ambulation 13 days, restorative AROM 12 days and restorative PROM 13 days.
On 05/26/22 at 11:00 A.M. interview with Restorative Aide #149 revealed her official title and job duty was to be the restorative aide where she assisted residents with range of motion and ambulation programs. However, Restorative Aide #149 revealed most of the time she was not able to complete these job duties/programs for residents due to being pulled to work as an aide on the floor and providing care to all residents on a specific unit. When this occurred, it was each individual aides responsibility to complete the restorative programming for the residents. During the interview, Restorative Aide #149 confirmed Resident #12's restorative programs were not being completed as scheduled.
On 05/26/22 at 12:19 P.M. interview with the Director of Nursing (DON) confirmed Resident #12 was supposed to receive restorative therapy every shift and when asked if this was occurring as ordered, the DON indicated it was not due to the restorative aide being pulled to work the floor.
On 05/26/22 at 2:00 P.M. interview with Minimum Data Set (MDS) Nurse #133 confirmed the facility's restorative program had not been completed as she would like it to be due to the restorative aide(s) being pulled to work the floor.
Review of the the facility policy titled Restorative Nursing Program, dated 01/01/22 revealed the goals of restorative nursing included improving and/or maintaining independence in activities of daily living and mobility. A restorative nursing program, when appropriate was based on a the comprehensive assessment and resident.
CONCERN
(D)
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, 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 #5, who had a history of falls in the facility had fall interventions in place as planned and education to prevent additional falls. This affected one resident (#5) of four residents reviewed for accidents.
Findings include:
Review of Resident #5's record revealed the resident was admitted to the facility on [DATE] with diagnoses of degenerative disease of the nervous system, ataxia, type two diabetes mellitus, essential hypertension, hyperlipidemia, generalized muscle weakness and repeated falls.
Review of Resident #5's care plan, dated 02/06/22 revealed a goal for the resident to be free of falls. Interventions included to apply grip liner to the recliner and wheelchair and educate resident to leave lift chair in the seated position when not in use.
Review of the admission Minimum Data Set (MDS) 3.0 assessment, dated 02/18/22 revealed the resident was cognitively intact and had no falls prior to admission. The MDS assessment revealed Resident #19 was not steady and only able to move from a seated to standing position and walk with staff assistance for stabilization. The MDS also revealed the resident used mobility devices (walker and a wheelchair) and was receiving occupational and physical therapy to help increase independence with mobility.
Review of Resident #5's progress note, dated 02/19/22 revealed resident had an unwitnessed fall from the chair and her lift chair appeared to have pushed her forward too much. A progress note, dated 03/20/22 revealed the resident slid from her recliner.
Review of Resident #5's physician's orders revealed an order, dated 03/22/22 for a grip liner (sticky pad to prevent sliding out of the chair) to her wheelchair and recliner.
On 05/24/22 at 2:57 P.M. Resident #5's lift chair was observed to be elevated without her being in it. There was also no grip liner noted on any seating surface. On 05/24/22 at 5:15 P.M. Resident #5's lift chair was observed to be elevated without her being in it.
On 05/25/22 at 8:12 A.M. Resident #5 was observed sitting in her lift recliner without a grip liner in the chair. A grip liner was noted to be in the resident's motorized scooter which she was not using at the time.
On 05/26/22 at 7:27 A.M. observation of Resident #5 with the Administrator revealed Resident #5 was sitting in her lift recliner without a grip liner in the chair. A grip liner was noted to be in the resident's motorized scooter which she was not using at the time.
On 05/24/22 at 5:15 P.M. an interview with Registered Nurse (RN) #122 verified Resident #5's lift chair was elevated and not in use. She also verified there was no grip liner in the recliner chair, the wheelchair or the scooter chair which the resident was sitting in.
On 05/24/22 at 5:29 P.M. an interview with Resident #5 revealed she took the sticky stuff off her chair last weak. She also reported she didn't remember anyone telling her not to leave her lift chair elevated when she wasn't sitting in it.
On 05/24/22 at 5:30 P.M. an interview with the Administrator verified that even if Resident #5 had thrown her grip liner away last week, staff should have replaced it due to the resident's fall risk/potential.
On 05/25/22 at 8:12 A.M. an interview with Resident #5 revealed most of her falls had been due to her sliding out of her chair. She reported no one educated her on the purpose of the grip liner in her chairs. She reported now that she knew what the grip liners were for, she would not throw them away. She reported no one asked her where her grip liner was until the State surveyor inquired about it on 05/24/22.
On 05/26/22 at 7:31 A.M. observation and interview with the Administrator verified Resident #5 did not have grip liner on her recliner chair which she was sitting in at that time.
Review of facility policy titled Falls - Clinical Protocol, dated 10/30/2020 revealed interventions should be developed and implemented per the assessed needs.
CONCERN
(D)
Potential for Harm - no one hurt, but risky conditions existed
Deficiency F0808
(Tag F0808)
Could have caused harm · This affected 1 resident
Based on observation, record review, meal ticket review and interview the facility failed to ensure Resident #32 received a dysphagia diet as ordered. This affected one resident (#32) of ten residents...
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Based on observation, record review, meal ticket review and interview the facility failed to ensure Resident #32 received a dysphagia diet as ordered. This affected one resident (#32) of ten residents reviewed for dining.
Findings include:
Review of Resident #32's medical record revealed a 05/26/19 admission and a 12/03/20 readmission with diagnoses including cerebral infarction, anemia, hypothyroidism and diverticulosis.
Review of the 05/14/21 potential for decline in nutritional status related to advanced age, significant weight loss and mechanically altered diet plan of care revealed a goal for the resident to maintain adequate nutritional status as evidenced by maintaining weight with no significant changes, no signs or symptoms of malnutrition and consuming at least 75 percent of at least three meals daily through review date. A 05/14/21 intervention included to weigh per facility policy, monitor, record, report to physician as needed signs and symptoms of malnutrition (emaciation, muscle wasting, significant weight loss of greater than five percent in one month, 7.5 percent in three months or greater than 10 percent in six months).
A physician's order, dated 01/04/22 revealed an order for regular diet, regular texture, regular fluid, thin consistency, no straws/shred lettuce diet. The diet order also included to change to chopped meats with gravy and add ice cream (magic cup) to lunch and dinner tray.
A 01/10/22 nutrition note revealed the resident had continued weight loss of seven pounds in 30 days for 5.9 percent, 8.9 percent/10.8 pounds in 90 days and 16.2 percent/21.5 pounds in 180 days. No change in appetite, but meal intake has decreased to 50 percent since lower gum soreness started. The note revealed diet texture was changed.
On 05/23/22 at 12:04 P.M. observation of the lunch meal revealed the resident was feeding herself. The meal tray contained pureed turkey, carrots, noodles, pureed dinner roll, marble cake with white icing, lemonade, coffee, orange juice, orange frozen nutritional treat and chocolate ice cream.
Review of the diet slip revealed the resident was on a regular dysphagia mechanical diet. The diet slip indicated the cake was to be pureed. However, observation revealed the resident was served a whole piece of cake that was not pureed.
On 05/23/22 at 12:10 P.M. interview with Licensed Practical Nurse (LPN) #106 verified the cake was not pureed as the diet slip indicated. LPN #106 took the cake to the kitchen. She returned at 12:15 P.M. with pureed cake. LPN #106 verified the resident was served the wrong texture cake.
CONCERN
(D)
Potential for Harm - no one hurt, but risky conditions existed
Deficiency F0887
(Tag F0887)
Could have caused harm · This affected 1 resident
Based on record review, facility policy and procedure review and interview the facility failed to ensure residents received timely COVID-19 vaccination after receiving consent for administration. This...
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Based on record review, facility policy and procedure review and interview the facility failed to ensure residents received timely COVID-19 vaccination after receiving consent for administration. This affected one resident (#248) of one resident reviewed for transmission based precautions.
Findings include:
Review of Resident #248's medical record revealed an admission date of 05/14/22 with diagnoses including Parkinson's Disease, diabetes and neoplasm of the breast.
Review of the physician's orders, dated 05/14/22 revealed the resident was placed in transmission based precautions (TBP) for ten days (related to COVID-19) and if no symptoms, the facility may discontinue the precautions. The resident also had an order for a point of care test (COVID-19 rapid test) five days after admission.
Review of the Vaccination Administration Record Informed Consent for Vaccination in Long Term Care Facility revealed I want to receive the following vaccination: COVID-19 Vaccination. The form was signed by the resident on 05/14/22.
Review of the Immunization Documentation revealed no evidence the resident had received a COVID-19 vaccine as of 05/24/22.
Review of the COVID-19 Weekly Vaccine order revealed the facility was to contact the pharmacy weekly for availability. Orders must be completed by Monday at 6:00 P.M. for Thursday delivery. Any orders received after cut off would be fulfilled with (the) following week's order. One full dose of the Moderna Vaccine was ordered on Tuesday, 05/24/22 by the Director of Nursing (DON).
On 05/24/22 at 9:56 A.M. interview with the Director of Nursing (DON) revealed the resident had not received her vaccination for COVID-19 despite her consent for vaccination on 05/14/22. The DON revealed she had been off on vacation since 05/06/22 and had just returned on 05/23/22 and no other staff knew how to order the vaccine through the pharmacy. The DON stated she would train an additional nurse to ensure vaccines were ordered and administered timely. The DON verified the resident's COVID-19 was ordered on Tuesday, 05/24/22 after surveyor intervention.
Review of the facility COVID-19 vaccination policy, dated 05/21/21 revealed maximizing the COVID-19 vaccination rates in the facility would help reduce the risk residents and staff have of contracting and spreading COVID-19. The purpose of the policy and procedure was to outline the facility approaches to encourage both staff and residents to receive the COVID-19 vaccine.
CONCERN
(E)
Potential for Harm - no one hurt, but risky conditions existed
Deficiency F0565
(Tag F0565)
Could have caused harm · This affected multiple residents
Based on record review, facility policy and procedure review and interview the facility failed to ensure residents had a monthly resident council meeting and failed to ensure adequate and timely respo...
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Based on record review, facility policy and procedure review and interview the facility failed to ensure residents had a monthly resident council meeting and failed to ensure adequate and timely responses to residents' concerns. This affected 13 residents (#1, #4, #5, #9, #14, #21, #23, #31, #32, #37, #44, #45 and #155) of 50 residents residing in the facility who had voiced concerns through resident council.
Findings include:
Review of facility resident council minutes for the past twelve months revealed there was no meeting conducted in April 2022.
Review of facility resident council minutes, dated 08/09/21 revealed Residents #1, #4, #14, #21, #23, #32, #44 and #155 were informed that activities had started in that evening the month of August 2021.
Review of facility resident council minutes, dated 01/21/22 revealed Residents #4, #9, #14, #44 and #155 were informed soup being added to the menu was discussed with the kitchen manager and administrator but there was no funding for soup.
Review of facility resident council minutes, dated 03/13/22 revealed Residents #1, #4, #5, #9, #21, #23, #31, #32, #37 and #45 were informed the dietary manager was looking into different food items for the men.
On 05/26/22 at 11:31 A.M. an interview with the Administrator verified there was no resident council meeting in April 2022 due to not having an activities director. He also verified he did not offer the residents' a meeting opportunity the month of April 2022 with a different staff member. He reported he kept in touch with the president of resident council but a formal meeting was not offered.
On 05/26/22 at 12:00 P.M. an interview with Resident #4, #5, #9, and #23 revealed they had previously requested more activities and soups to be added to the menu. All four residents revealed they have not received any response as to why they don't have more activities or soup. The residents denied any recall of being told there was no funding for soup.
On 05/26/22 at 5:31 P.M. interview with the Administrator revealed the responses regarding resident concerns presented during resident council were discussed verbally during the next resident council meeting. The Administrator revealed there were no written responses provided to the residents of the facility.
Review of the facility policy titled Resident Council, dated 08/07/20 revealed the facility supported resident desires to be involved and have input into the operation of the facility. It also revealed council meetings were to be scheduled monthly or more frequently if requested by residents or the Administrator.
CONCERN
(E)
Potential for Harm - no one hurt, but risky conditions existed
Deficiency F0568
(Tag F0568)
Could have caused harm · This affected multiple residents
Based on review of resident personal fund account records, facility policy and procedure review and interview the facility failed to ensure quarterly bank statements were provided to residents/respons...
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Based on review of resident personal fund account records, facility policy and procedure review and interview the facility failed to ensure quarterly bank statements were provided to residents/responsible parties and available for review. This affected 30 resident (#1, #2, #3, #4, #5, #6, #7, #8, #9, #16, #18, #19, #20, #21, #23, #24, #26, #27, #28, #29, #30, #34, #35, #36, #37, #38, #43, #44, #47 and #155) of 30 residents who had personal fund accounts maintained by the facility. The facility census was 50.
Findings include:
On 05/23/22 at 3:56 P.M. interview with Resident #1 revealed a concern she did not receive a quarterly statement related to her personal fund account.
On 05/26/22 at 4:48 P.M. review of the resident personal account fund records with Business Office Manager #126 and Accounts Payable #152 revealed they had no written evidence of providing quarterly statements to all residents and/or the resident's responsible party for whom they managed personal fund accounts for. The staff members indicated they did receive quarterly resident trust fund (RTF) statements mailed to them from National Data Care RFMS banking and do not have electronic copies. They indicated they do send the statements to the responsible party or hand deliver them to each resident BOM #126 indicated if a resident was their own responsible party they would give the resident their quarterly statement in an envelop. If they had a financial responsible party then they would mail the responsible party the statement. If a resident had no responsible party and poor cognition they would file the quarterly statement and did not give it to anyone. The facility does not have the resident sign they received the statement, nor do they have responsible parties acknowledge they received the statement. They do not send them certified. The staff members indicated they do not make a copy of the quarterly statements to keep with the the residents' funds account records.
Review of Resident #1's fund records revealed a statement was in her file. Review of Resident's #19 records revealed no quarterly statement was in her file. Resident #6 and Resident #7 had statements in their fund file.
Review of the facility Resident Trust Funds Policies and Procedures, implemented 01/01/21 revealed the Resident Trust Funds (RTF) designee would mail quarterly RTF statements and retain a copy either hardcopy or electronically.
On 05/26/22 at 4:46 P.M. interview with Business Office Manager #126 and Accounts Payable #152 revealed Resident #6 and Resident #7 do not receive their statement nor does a responsible party, so they were kept in their file. Resident #19's daughter gets her statement so she did not have a statement in her file because they do not make copies. Resident #1 had her first quarter statement in her file. She was her own responsible party and should have received hers in an envelope. Since it was in her file there was no evidence she received it. Business Office Manager #126 and Accounts Payable #152 again verified they do not maintain copies of the quarterly statements.
During the interview, Business Office Manager #126 and Accounts Payable #152 revealed there were 30 residents, #1, #2, #3, #4, #5, #6, #7, #8, #9, #16, #18, #19, #20, #21, #23, #24, #26, #27, #28, #29, #30, #34, #35, #36, #37, #38, #43, #44, #47 and #155 for whom the facility managed personal funds for.
CONCERN
(E)
Potential for Harm - no one hurt, but risky conditions existed
Deficiency F0679
(Tag F0679)
Could have caused harm · This affected multiple residents
**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** 5. Review of the medical record for Resident #10 revealed an admission date of 05/10/17 with diagnoses including Alzheimer's dis...
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**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** 5. Review of the medical record for Resident #10 revealed an admission date of 05/10/17 with diagnoses including Alzheimer's disease, dementia with behavioral disturbances and encounter for palliative care.
Review of Resident #10's activity evaluation, dated 11/18/21 revealed Resident #10 enjoyed movies/television music talk radio, activities in own room, liked one on one and self-recreate and napped during the day. Resident #10 had minimal difficulty/poor hearing, unclear speech and impaired poor vision. The evaluation revealed Resident #10 was pleasant and cooperative and liked to watch television.
Review of Resident #10's MDS 3.0 assessment, dated 01/01/22 revealed a Brief Interview for Mental Status (BIMS) score of 06 indicating severely impaired cognition for daily decision making abilities. Resident #10 was noted to enjoy listening to music and religious services. The assessment revealed Resident #10 required total dependence from one staff member for locomotion on and off the unit.
Review of the undated plan of care revealed Resident #10 had little or no activity involvement related to decreased activity level. Resident #10 needed encouragement and assistance to activities. Resident #10 preferred church activities, music entertainment and bingo and indicated the resident could be loud and disruptive during activities. Interventions included to provide activity calendar, remind the resident the resident may leave activities at any time and was not required to stay for the entire activity and respect resident preferences for activities. The care plan revealed the resident needed assistance escort to activity functions.
Review of Resident #10's activity log from 04/27/22 through 05/26/22 revealed Resident #10 was provided watching a television as an activity 11 of the last 30 days. Continued review revealed Resident #10 was noted with 19 of 30 days with other documented under the activity section.
On 05/26/22 at 4:00 P.M. interview with the DON revealed the facility was currently without a full time qualified activity director and activities were not being provided on a routine basis. When asked what the other activity was for Resident #10, the DON revealed she was not sure.
Based on observation, record review, facility policy and procedure review and interview the facility failed to develop and implement a comprehensive and individualized activity program to meet the total care needs and/or preferences of all residents. This affected four residents (#6, #7, #10 and #15) of four residents reviewed for activities and four additional residents (#4, #5, #9 and #23) present at a resident group meeting during the survey who voiced concerns related to activities. The facility census was 50.
Findings include:
1. On 05/26/22 at 12:00 P.M. a group meeting interview with Resident #4, #5, #9, and #23 revealed they had previously requested more activities. All four residents revealed they have not received any response as to why they don't have more activities. During the meeting, the residents present reported there were not enough activities and they felt the facility needed to have more activities on the weekends. The residents indicated there were no activities on the weekends.
On 05/26/22 at 5:31 P.M. interview with the Administrator revealed the responses regarding resident concerns presented during resident council were discussed verbally during the next resident council meeting. The Administrator revealed there were no written responses provided to the residents of the facility.
Review of the monthly activity calendars revealed the weekends repeated the same activities on Saturday and Sunday.
On Saturdays the calendar listed daily chronicle at 2:30 P.M. worksheets, arts, coloring in the activity room and at 5:00 P.M. social hour.
On Sundays the calendar listed daily chronicle at 2:30 P.M. bible study in activity room and 5:00 P.M. cards and social in activity room.
Monday through Friday activities repeated the same activities each Monday, Tuesday, Wednesday, Thursday and Friday of the week. Each day indicated daily chronicles. Monday, Wednesday and Friday at 1:00 P.M. there was bingo. Every Tuesday and Thursday revealed game/arts and craft. Monday, Wednesday and Fridays at 5:00 P.M. the calendar listed social time and cards. On Tuesday and Thursday at 5:00 P.M. was movie.
On 05/26/22 at 5:53 P.M. interview with the Director of Nursing (DON) verified the facility did not have formal activities on the weekends since the part time activity aide went on leave. The facility revealed the former activity assistant, Assistant #205 last worked 02/16/22. The DON revealed staff had been offering some activities through the week.
Review of the facility Activities policy, revised 02/06/22 included it was the policy of the facility to provide an ongoing program to support residents in their choice of activities based on their comprehensive assessment, care plan, and preferences of each resident. Facility sponsored group and individual activities and independent activities would be designed to meet the interests of and support the physical, mental and psychosocial well being of each resident, as well as encourage both independence and interaction within the community. Special consideration would be made for developing meaningful activities for residents with dementia and/or special needs.
2. Review of Resident #6's medical record revealed the resident was admitted to the facility on [DATE] with diagnoses including Alzheimer's disease, dementia, osteoarthritis and glaucoma.
The most current annual activity evaluation was dated 10/30/20. The evaluation revealed the resident enjoyed family/friend visits, parties/social events, religious activities, movies and television and music/talk radio.
The 10/08/21 annual Minimum Data Set (MDS) 3.0 assessment revealed under Section F Preferences that it was not very important for the resident to have books, newspapers or magazines, to listen to music, to be around animals and pets, to keep up with the news, to do you things with groups of people, to do to her favorite activities or to go outside in the fresh air when weather was good. The MDS revealed it also wasn't important at all to participate in religious services or practices. The assessment revealed a family member or significant other was the respondent to the questions.
Review of the 02/09/22 quarterly MDS 3.0 assessment revealed the resident was severely impaired for daily decision making, required extensive assistance to total dependence from staff for all activities of daily living, was non-ambulatory and had upper extremity impairment on both sides.
Review of a 05/10/22 quarterly activity progress note revealed the resident's cognition and communication remained unchanged. The resident enjoyed structured activities and activities of own choosing, chooses activities to do and was at ease interacting with others. She had unclear speech, usually understands, had short term memory impairment and short attention. Her daughter visited once a year. The assessment documented the activity care plan remained appropriate.
However, record review revealed the resident had no activity plan of care.
On 05/23/22 at 11:46 A.M. Resident #6 was observed in bed with no activities occurring. On 05/23/22 at 3:46 P.M. the resident was in bed with the television on. On 05/24/22 at 12:31 P.M. the resident was in her room out of bed in a wheelchair with a Hoyer lift pad under her. The television was on. On 05/24/22 at 03:30 P.M. the resident was in her room sitting in a wheelchair.
Review of the activity attendance documentation in the facility electronic TASK section revealed the resident did not attend any planned activities in the last 30 days. The daily activities documented in the last 30 days included television and other. There were no refusals of activities documented.
The resident was not interviewable.
On 05/23/22 at 11:48 A.M. interview with State Tested Nursing Assistant (STNA) #108 revealed other on the TASK record could mean the resident was pushed to the nurse's station but stated she was unsure. The STNA revealed Resident #6 spent most of her time in bed or in her room in a wheelchair.
On 05/24/22 at 1:07 P.M. interview with Facility Support Advocate #146 revealed she assists with activities in the facility but does not keep track of who attended any particular activity.
On 05/24/22 at 4:23 P.M. interview with Social Services/Activities #130 revealed the facility had no paper documentation for activities as all activities were documented in the electronic documentation TASK section for each resident. During the interview, Social Services/Activities (#130) verified there were no activities for Resident #6 other than television and other and she did not know what other meant. There was no plan of care related to activities for Resident #6 and no evidence staff provided any type of one on one activities as the resident was typically in her room. Social Services/Activities #130 verified there was no documentation of activities of choice or an activity plan of care for Resident #6.
3. Review of Resident #7's medical record revealed an admission dated of 02/09/17 with diagnoses including cerebral infarction, chronic obstructive pulmonary disease, unspecified psychosis, Alzheimer early onset, delusional disorders, major depressive disorder, vascular dementia and congenital hypothyroidism.
Review of the 02/10/17 actively plan of care revealed the resident had little or no activity involvement related to decreased activity level. Interventions included to provide an activity calendar, provide items as needed for self-directed activities, remind the resident the resident may leave activities at any time and was not required to stay for the entire activity, respect the resident's preferences for activities and monitor for changes in mood, cognition or medical status that may impact activity involvement.
The resident had a 09/19/18 plan of care for exhibiting behaviors, having little or no interest or pleasure in doing activities related to resident's emotional discomfort or strain. An intervention included to provide a program of activities that was of interest and accommodates resident's status.
The 02/05/22 activities evaluation revealed the resident finds strength in faith and religion. She enjoyed family and friends visits, movies and television. She enjoyed activities in her own room and one on one in the evenings. The assessment indicated the resident preferred to be in her room in bed, liked to sleep a lot and declined all offered activities.
Review of the 02/09/22 annual MDS 3.0 assessment revealed the resident was severely impaired for daily decision making, had no behaviors present and had little interest or pleasure in doing things 12 or 14 days of the review. She was feeling tired and had little energy 12-14 days of the review. The assessment revealed the resident had trouble concentrating on things such as reading or watching television 12 or 14 days of the review. The assessment revealed it was not very important for her to have books, newspaper, magazines, or to listen to music, or to have animals around, or to keep up with the news, or to do things with groups of people. But reflected it was very important for her to do her favorite activities. The assessment revealed it was not important for her to go outside or to participate in religious activities. The assessment revealed the resident required extensive assist of two staff for bed mobility and was not transferred out of bed during the assessment period.
Review of the 05/10/22 quarterly activities progress note revealed the resident's cognition and communication was unchanged and she chooses activities to do. The resident was noted to have clear speech and usually understands. She had short term memory impairment and a short attention span. She enjoys activities of her choosing and was pleasant, happy and content. The note revealed the resident was independent in her wheelchair, would not initiate her own activity and her preferred setting for activities were in the day/activity room.
Review of the electronic TASK activity documentation for activities revealed no planned activities in the last 30 days had occurred. Daily documented activities were television and other. There were no refusals documented.
There was no evidence the resident was provided one on one activities or activities in her room.
On 05/23/22 at 10:39 A.M. and 3:47 P.M. and 05/24/22 at 12:31 P.M. and 3:31 P.M. revealed Resident #7 was in her room in bed. The resident's television was noted to be on.
On 05/24/22 at 12:59 P.M. interview with Resident #7 revealed she preferred to stay in bed because her back hurt.
On 05/24/22 at 4:23 P.M. interview with Social Services/Activities #130 revealed the STNA staff documented in the TASK section to reflect activity participation for Resident #7. Social Services/Activities #130 verified there was no evidence of any planned activities for the resident.
On 05/24/22 at 5:09 P.M. interview with STNA #108 revealed Resident #7 watched television and would sometimes come out in the hall for a half hour to an hour then wanted to get back to bed. The STNA revealed the facility had not had any formal activities for a while and indicated she talked to the resident about cats because she knew she had them.
4. Review of Resident #15's medical record revealed a 03/02/22 admission with diagnoses including osteomyelitis of vertebra, sacral and sacrococcygeal region, pressure ulcer of sacral region Stage IV (full-thickness skin and tissue loss with exposed fascia, muscle, tendon, ligament, cartilage, or bone in the ulcer), type 2 diabetes, atrial fibrillation, dementia, Alzheimer's, abnormal posture, heart failure and dysphagia.
Review of the resident's 03/04/22 activity evaluation revealed the location of the resident activities would be in her own room. The resident liked movies, television, music, talk radio, visits with family and friends as well as arts and crafts. She preferred one on one activities.
Review of the 03/08/22 admission MDS 3.0 assessment revealed the resident was severely impaired for daily decision, required extensive assist of two staff for bed mobility and transfers, was totally dependent on two staff for dressing, required extensive assist from one staff for eating, was totally dependent on two staff for toilet use and for personal hygiene and was totally dependent on one staff for bathing. Review of the preference section, Section F revealed the resident wanted to have family and close friends involved in decisions for care, to be around animals such as pets, to get fresh air when the weather was good and participate in religious services or practices.
The resident activity plan of care, initiated 03/14/22 revealed the resident had little or no activity involvement. Interventions would be pet visits and provide an activity calendar. There was nothing included in the plan of care indicating the resident was going to receive one on one visits as indicated on the 03/04/22 evaluation.
Review of the electronic TASK revealed daily routine activities included the resident had visits with family and friends, watched television and other. There was no indication what other meant. There were no planned activities documented for the resident in the last 30 days.
On 05/23/22 at 10:35 A.M., 2:54 P.M. and 5:03 P.M., on 05/24/22 at 11:52 A.M., 2:37 P.M. and 5:12 P.M. and on 05/25/22 at 11:48 A.M. and 3:47 P.M. Resident #15 was observed in bed with no activities occurring.
On 05/24/22 at 4:27 P.M. interview with Social Service/Activities #130 revealed she had not met the resident as of this date.
On 05/24/22 at 05:12 P.M. interview with STNA #113 revealed she had never assisted the resident up out of bed. The STNA revealed the resident liked her stuffed animals and kept them next to her chest and loved ice cream.
On 05/24/22 at 5:22 P.M. interview with Social Service/Activities #130 verified there was no evidence of one on one visits or pet visits for the resident.
On 05/24/22 at 5:57 P.M. during an interview with the DON, the concern related activities for Resident #15 was discussed. The DON verbalized she figured there would be an issue with activities and stated she did not know of activities being provided to the resident.
CONCERN
(E)
Potential for Harm - no one hurt, but risky conditions existed
Deficiency F0680
(Tag F0680)
Could have caused harm · This affected multiple residents
**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on record review and interview the facility failed to employ a qualified activity professional as required. This affected ...
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**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on record review and interview the facility failed to employ a qualified activity professional as required. This affected four residents (#10, #15, #7 and #6) of four residents reviewed for activities and four additional residents (#4, #5, #9 and #23) present at a resident group meeting who voiced concerns regarding activities. The facility census was 50.
Findings include:
1. Record review revealed the facility former Activity Director (AD), AD #204 who was qualified to function as facility activity director last date worked in the facility on 09/02/21.
Activity Director (AD) #203 was hired 09/08/21 and worked until 04/19/22. However, AD #203 was not certified or eligible as a therapeutic recreation specialist or as an activities professional by a recognized accrediting body. AD #203 did not have two years of experience in a social or recreational program within the last five year nor was she a qualified occupational therapist or occupational therapy assistant. AD #203 had not completed a training course approved by the State.
Activity Director (AD) #130 was hired on 05/09/22 but did not meet the qualifications for a qualified professional, qualified therapeutic recreation specialist or an activities professional.
Activity Assistant (AA) #205 went on leave 02/16/22 through 05/08/22 when she resigned. AA #205 was also not a qualified activity professional.
On 05/25/22 at 5:53 P.M. interview with the Director of Nursing verified the facility had not had a qualified activities professional since 09/02/21.
2. On 05/26/22 at 12:00 P.M. a group meeting interview with Resident #4, #5, #9, and #23 revealed they had previously requested more activities. All four residents revealed they have not received any response as to why they don't have more activities. During the meeting, the residents present reported there were not enough activities and they felt the facility needed to have more activities on the weekends. The residents indicated there were no activities on the weekends.
On 05/26/22 at 5:31 P.M. interview with the Administrator revealed the responses regarding resident concerns presented during resident council were discussed verbally during the next resident council meeting. The Administrator revealed there were no written responses provided to the residents of the facility.
Review of the monthly activity calendars revealed the weekends repeated the same activities on Saturday and Sunday.
On Saturdays the calendar listed daily chronicle at 2:30 P.M. worksheets, arts, coloring in the activity room and at 5:00 P.M. social hour.
On Sundays the calendar listed daily chronicle at 2:30 P.M. bible study in activity room and 5:00 P.M. cards and social in activity room.
Monday through Friday activities repeated the same activities each Monday, Tuesday, Wednesday, Thursday and Friday of the week. Each day indicated daily chronicles. Monday, Wednesday and Friday at 1:00 P.M. there was bingo. Every Tuesday and Thursday revealed game/arts and craft. Monday, Wednesday and Fridays at 5:00 P.M. the calendar listed social time and cards. On Tuesday and Thursday at 5:00 P.M. was movie.
On 05/26/22 at 5:53 P.M. interview with the Director of Nursing (DON) verified the facility did not have formal activities on the weekends since the part time activity aide went on leave. The facility revealed the former activity assistant, Assistant #205 last worked 02/16/22. The DON revealed staff had been offering some activities through the week.
Review of the facility Activities policy, revised 02/06/22 included it was the policy of the facility to provide an ongoing program to support residents in their choice of activities based on their comprehensive assessment, care plan, and preferences of each resident. Facility sponsored group and individual activities and independent activities would be designed to meet the interests of and support the physical, mental and psychosocial well being of each resident, as well as encourage both independence and interaction within the community. Special consideration would be made for developing meaningful activities for residents with dementia and/or special needs.
3. Review of Resident #6's medical record revealed the resident was admitted to the facility on [DATE] with diagnoses including Alzheimer's disease, dementia, osteoarthritis and glaucoma.
On 05/23/22 at 11:46 A.M. Resident #6 was observed in bed with no activities occurring. On 05/23/22 at 3:46 P.M. the resident was in bed with the television on. On 05/24/22 at 12:31 P.M. the resident was in her room out of bed in a wheelchair with a Hoyer lift pad under her. The television was on. On 05/24/22 at 03:30 P.M. the resident was in her room sitting in a wheelchair.
Review of the activity attendance documentation in the facility electronic TASK section revealed the resident did not attend any planned activities in the last 30 days. The daily activities documented in the last 30 days included television and other. There were no refusals of activities documented.
The resident was not interviewable.
On 05/23/22 at 11:48 A.M. interview with State Tested Nursing Assistant (STNA) #108 revealed other on the TASK record could mean the resident was pushed to the nurse's station but stated she was unsure. The STNA revealed Resident #6 spent most of her time in bed or in her room in a wheelchair.
On 05/24/22 at 1:07 P.M. interview with Facility Support Advocate #146 revealed she assists with activities in the facility but does not keep track of who attended any particular activity.
On 05/24/22 at 4:23 P.M. interview with Social Services/Activities #130 revealed the facility had no paper documentation for activities as all activities were documented in the electronic documentation TASK section for each resident. During the interview, Social Services/Activities (#130) verified there were no activities for Resident #6 other than television and other and she did not know what other meant. There was no plan of care related to activities for Resident #6 and no evidence staff provided any type of one on one activities as the resident was typically in her room. Social Services/Activities #130 verified there was no documentation of activities of choice or an activity plan of care for Resident #6.
4. Review of Resident #7's medical record revealed an admission dated of 02/09/17 with diagnoses including cerebral infarction, chronic obstructive pulmonary disease, unspecified psychosis, Alzheimer early onset, delusional disorders, major depressive disorder, vascular dementia and congenital hypothyroidism.
Review of the electronic TASK activity documentation for activities revealed no planned activities in the last 30 days had occurred. Daily documented activities were television and other. There were no refusals documented.
There was no evidence the resident was provided one on one activities or activities in her room.
On 05/23/22 at 10:39 A.M. and 3:47 P.M. and 05/24/22 at 12:31 P.M. and 3:31 P.M. revealed Resident #7 was in her room in bed. The resident's television was noted to be on.
On 05/24/22 at 12:59 P.M. interview with Resident #7 revealed she preferred to stay in bed because her back hurt.
On 05/24/22 at 4:23 P.M. interview with Social Services/Activities #130 revealed the STNA staff documented in the TASK section to reflect activity participation for Resident #7. Social Services/Activities #130 verified there was no evidence of any planned activities for the resident.
On 05/24/22 at 5:09 P.M. interview with STNA #108 revealed Resident #7 watched television and would sometimes come out in the hall for a half hour to an hour then wanted to get back to bed. The STNA revealed the facility had not had any formal activities for a while and indicated she talked to the resident about cats because she knew she had them.
5. Review of Resident #15's medical record revealed a 03/02/22 admission with diagnoses including osteomyelitis of vertebra, sacral and sacrococcygeal region, pressure ulcer of sacral region Stage IV (full-thickness skin and tissue loss with exposed fascia, muscle, tendon, ligament, cartilage, or bone in the ulcer), type 2 diabetes, atrial fibrillation, dementia, Alzheimer's, abnormal posture, heart failure and dysphagia.
Review of the electronic TASK revealed daily routine activities included the resident had visits with family and friends, watched television and other. There was no indication what other meant. There were no planned activities documented for the resident in the last 30 days.
On 05/23/22 at 10:35 A.M., 2:54 P.M. and 5:03 P.M., on 05/24/22 at 11:52 A.M., 2:37 P.M. and 5:12 P.M. and on 05/25/22 at 11:48 A.M. and 3:47 P.M. Resident #15 was observed in bed with no activities occurring.
On 05/24/22 at 4:27 P.M. interview with Social Service/Activities #130 revealed she had not met the resident as of this date.
On 05/24/22 at 05:12 P.M. interview with STNA #113 revealed she had never assisted the resident up out of bed. The STNA revealed the resident liked her stuffed animals and kept them next to her chest and loved ice cream.
On 05/24/22 at 5:22 P.M. interview with Social Service/Activities #130 verified there was no evidence of one on one visits or pet visits for the resident.
On 05/24/22 at 5:57 P.M. during an interview with the DON, the concern related activities for Resident #15 was discussed. The DON verbalized she figured there would be an issue with activities and stated she did not know of activities being provided to the resident.
6. Review of the medical record for Resident #10 revealed an admission date of 05/10/17 with diagnoses including Alzheimer's disease, dementia with behavioral disturbances and encounter for palliative care.
Review of Resident #10's activity log from 04/27/22 through 05/26/22 revealed Resident #10 was provided watching a television as an activity 11 of the last 30 days. Continued review revealed Resident #10 was noted with 19 of 30 days with other documented under the activity section.
On 05/26/22 at 4:00 P.M. interview with the DON revealed the facility was currently without a full time qualified activity director and activities were not being provided on a routine basis. When asked what the other activity was for Resident #10, the DON revealed she was not sure.
CONCERN
(E)
Potential for Harm - no one hurt, but risky conditions existed
Deficiency F0805
(Tag F0805)
Could have caused harm · This affected multiple residents
Based on observation, review of the facility menu, review of the National Dysphagia Diet Level documentation, completion of a test tray and interview the facility failed to ensure pureed diets were pr...
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Based on observation, review of the facility menu, review of the National Dysphagia Diet Level documentation, completion of a test tray and interview the facility failed to ensure pureed diets were prepared at the appropriate consistency. This affected four residents (#8, #15, #26 and #39) of four residents identified to receive pureed diets.
Findings include:
Review of the Week-At-A-Glance menu for the dinner on 05/24/22 revealed the menu consisted of BBQ chicken thigh, capri vegetable blend, baked beans, cornbread and a blondie for dessert.
On 05/24/22 at 4:02 P.M. observation of meal preparation revealed [NAME] #166 had already pureed the capri vegetables (zucchini, squash and carrots) and placed them in the steam table for service. [NAME] #166 was observed to place chicken thighs in the robo coupe (industrial blender) and pureed the chicken for the dinner meal. Once complete, [NAME] #166 placed the pureed chicken thighs into a metal pan and placed them in the steam table. [NAME] #166 verified the food was ready for service. Interview with [NAME] #166 at the time of the observation revealed [NAME] #166 stated the pureed consistency was smooth.
However, on 05/24/22 at 4:19 P.M. observation of the pureed capri vegetables revealed small chunks of vegetable was noted in the puree. A test tray of the vegetables was requested from Dietary Manager (DM) #164 and upon taste, small chunks of the vegetables were noted and the puree was not uniform and smooth. This was verified with DM #164 as she tasted the vegetables as well and stated they needed returned for additional puree in the robo coupe. The DM verified puree was to be smooth and a uniform consistency.
The facility identified four residents, Resident #8, #15, #26 and #39 who received pureed diets.
Review of the facility undated document titled National Dysphagia Diet Levels revealed a dysphagia puree diet provided cohesive food that was easy to swallow.
CONCERN
(E)
Potential for Harm - no one hurt, but risky conditions existed
Food Safety
(Tag F0812)
Could have caused harm · This affected multiple residents
Based on observation and interview the facility failed to ensure food was prepared in a sanitary manner to prevent contamination. This affected four residents (#8, #15, #26 and #39) of four residents ...
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Based on observation and interview the facility failed to ensure food was prepared in a sanitary manner to prevent contamination. This affected four residents (#8, #15, #26 and #39) of four residents identified to receive pureed diets.
Findings include:
On 05/24/22 at 4:33 P.M. [NAME] #166 was observed to prepare puree rice for four residents, Resident #8, #15, #26 and #39 while wearing disposable gloves. Chicken broth was observed to be the liquid for puree and was in a plastic container near the robo coup. A metal tablespoon was observed submerged in the chicken broth. [NAME] #166 obtained a 1/3 cup plastic measuring cup with a handle and dipped the measuring cup into the broth and poured the chicken broth into the robo coupe with the rice. The cook returned the measuring cup to the container of broth and released the handle, causing the measuring cup to slide into the broth and become submerged along with the tablespoon. The cook continued to use the measuring cup by reaching into the broth, with her gloved hand to grab the handle until the rice was pureed to consistency.
On 05/24/22 at 4:35 P.M. interview with [NAME] #166 verified the tablespoon had slipped into the broth as well as the measuring cup. The cook verified she continued to use the broth despite the utensils being submerged in the broth and indicated it was hot and she didn't want to burn her hand.
On 05/24/22 at 5:15 P.M. interview with Dietary Manager #164 verified the broth was considered contaminated and the cook should have started with new broth when the spoon and measuring cup slid into the broth.
The facility did not have a policy related to food preparation or contamination.
CONCERN
(E)
Potential for Harm - no one hurt, but risky conditions existed
Infection Control
(Tag F0880)
Could have caused harm · This affected multiple residents
Based on observation, record review, facility policy and procedure review and interview the facility failed to maintain adequate infection control practices, including the proper use of personal prote...
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Based on observation, record review, facility policy and procedure review and interview the facility failed to maintain adequate infection control practices, including the proper use of personal protective equipment (PPE) to prevent the spread of infection including COVID-19. This affected one resident (#248) who was in transmission based/droplet precautions and had the potential to affect 22 residents (#2, #3, #9, #11, #14, #15, #17, #19, #20, #21, #22, #25, #26, #27, #28, #29, #30, #35, #39, #41, #44, and #151) who resided on A Hall. The facility census was 50.
Findings include:
Review of Resident #248's medical record revealed an admission date of 05/14/22 with diagnoses including Parkinson's Disease, diabetes, contact with and (suspected) exposure to COVID-19 and neoplasm of the breast.
Review of the physician's orders revealed an order, dated 05/14/22 for a point of care (POC) COVID-19 test to be obtained five days after admission The resident also had an order for transmission based precautions for ten days and if no symptoms (of COVID-19), may discontinue (precautions) after the ten days.
On 05/23/22 at 11:24 A.M. observation during the lunch meal tray pass revealed Resident #248's door was closed. There was an isolation cart/bin at door. Signs were observed on and around the door indicating, Stop See Nurse before Entering, Use of personal protective equipment (PPE) when Caring for Patients with Confirmed or Suspected COVID-19, donning (applying) and doffing (removing) PPE step by step precautions, and Droplet/Contact/Airborne Transmission Based Precautions (TBP) what you should be wearing before entering room, N-95 mask, gown, gloves and shield.
On 05/23/22 at 11:28 A.M. State Tested Nursing Assistant (STNA) #141 was observed to apply a gown, face shield, N95 mask and gloves. She knocked on the resident's door, entered and then closed the door. At 11:35 A.M. STNA #141 opened the door. She had removed her gown and her gloves were off prior to exiting the room. STNA #141 continued to wear her face shield and N95 mask. The STNA sanitized her hands, applied gloves, put a barrier on the isolation bin, removed her face shield, sprayed it with peroxide multipurpose surface cleaner and let it dry on the barrier paper towel. She then removed her gloves, used hand sanitizer and applied new gloves. She removed her N95 mask she was wearing and put it in the lidded trash can next to the isolation bin. She then got a surgical mask and applied it prior to removing the gloves she had on when she removed the N95 mask that she had on in the isolation room. STNA #141 then removed her gloves and used hand sanitizer.
Review of the posted doffing instructions included to remove and discard respirator, perform hand hygiene after removing the respirator. (Step seven included to perform hand hygiene after removing the respirator/facemask).
On 05/23/22 at 11:40 A.M. interview with STNA #141 verified she removed the soiled N95 mask worn in the isolation room and placed a surgical mask on her face prior to removing the soiled gloves and performing hand hygiene thus possibly contaminating the surgical mask she applied for continued use/wear.
Resident #2, #3, #9, #11, #14, #15, #17, #19, #20, #21, #22, #25, #26, #27, #28, #29, #30, #35, #39, #41, #44 and #151 resided on the A Hall and were on STNA #141's assignment.
Review of the facility transmission based precautions policy, revised 05/11/21 revealed droplet precautions were a part of transmission based precautions. The intent of droplet precautions was to prevent transmission of pathogens through close respiratory or mucous membrane contact with respiratory towards secretions, example respiratory droplets that are generated by a resident who was coughing sneezing or talking. Healthcare personnel would wear a mask for close contact with infectious resident.
Dec 2019
11 deficiencies
CONCERN
(D)
Potential for Harm - no one hurt, but risky conditions existed
Deficiency F0582
(Tag F0582)
Could have caused harm · This affected 1 resident
Based on record review and interview the facility failed to ensure a resident remaining in the facility received completed liability notices once Medicare Part A services were discontinued. This affec...
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Based on record review and interview the facility failed to ensure a resident remaining in the facility received completed liability notices once Medicare Part A services were discontinued. This affected one resident (Resident #3) of three residents reviewed for liability notices. The facility's census was 60.
Findings include:
1. Review of Resident #3's medical record revealed an admission date of 03/01/1987 with diagnoses including muscle wasting and atrophy, cerebral palsy, and muscle weakness.
Review of the Notice of Medicare Non-coverage (NOMNC) revealed the resident's skilled services would end on 08/22/19 without an indication of what skilled services she received or why they were ending. Review of the Skilled Nursing Facility Advanced Beneficiary Notice of Non-coverage (SNFABN) provided by the facility revealed an unfinished form missing required information which included, the care being provide, the reason that Medicare may not pay, and the estimated cost of skilled services.
Interview on 12/03/19 10:41 AM with Social Service Director #54 confirmed the facility failed to indicate what skilled services Resident #3 was provided. She was also confirmed that facility also failed to provide a completed SNFABN to the resident or her representative.
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
2. Review of Resident #59's medical record revealed an admission date of 11/06/19 and diagnoses of cerebral infarction, hydrocephalus, and chronic migraines.
Review of Resident #59's November physici...
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2. Review of Resident #59's medical record revealed an admission date of 11/06/19 and diagnoses of cerebral infarction, hydrocephalus, and chronic migraines.
Review of Resident #59's November physician orders revealed three medications ordered for pain including, ibuprofen, Gabapentin, and Norco.
Review of Resident #59's care plan dated 11/18/19 revealed that the resident is at risk for chronic pain, and the only intervention listed was to monitor, record, and report to the nurse any signs or symptoms of non-verbal pain.
Review of the facility pain clinical protocol dated 03/22/2011 states that staff will provide elements of a comforting environment and appropriate physical and complimentary interventions.
Review of Resident #59's nursing admission evaluation dated 11/6/19 revealed the resident had frequent pain and the pain impacted her day to day activities and mood.
Interview on 12/02/19 at 3:41 P.M. with Resident #59 revealed she has constant pain and takes pain medication.
Observation on 12/04/19 at 3:15 P.M. revealed Resident #59 lying in bed with her light off and the door shut.
Interview with Resident #59 on 12/04/19 at 3:15 P.M. revealed that she currently had pain and she keeps the lights off due to frequent headaches. She revealed she usually gets a headache daily. She further revealed that she keeps her door shut due to noise making her headaches worse.
Interview on 12/04/19 at 3:39 P.M. the Director of Nursing (DON) verified that Resident #59 did not have a proper care plan and the only intervention for pain was to monitor, record, report to nurse any signs or symptoms of non-verbal pain.
Based on observation, record review and interview the facility failed to ensure comprehensive, resident centered care plans related to pain and anticoagulant therapy. This affected two residents (Resident #41 and #59) of 22 residents reviewed for care plans. The census was 60.
Findings include:
1. Review of Resident #41's medical record revealed an admission date of 08/21/19 with diagnoses including dementia without behavioral disturbance, hypertension and atrial fibrillation.
Review of the physician orders revealed coumadin (anticoagulant medication) daily.
Review of the care plan for resident will be free from discomfort or adverse reactions related to anticoagulant use through the next review date initiated 08/21/19 revealed one intervention of to administer medications as ordered.
On 12/05/19 at 9:50 A.M. interview with the Director of Nursing (DON) verified the plan of care had only one intervention and was not comprehensive or resident specific.
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
Based on medical record review, policy review and staff interview, the facility failed to ensure physician's orders were followed for a resident who hadn't had a bowel movement for greater than three ...
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Based on medical record review, policy review and staff interview, the facility failed to ensure physician's orders were followed for a resident who hadn't had a bowel movement for greater than three days. This affected one (Resident #5) of five residents reviewed for medication use. The facility's census was 60.
Findings include:
Review of Resident #5's medical record revealed an admission date of 02/10/17 with diagnoses that included chronic pain and constipation.
Further review of the medical record revealed the use of Tylenol with Codeine #4 (narcotic pain medication) 300 milligrams (mg)/ 60 mg twice daily and once daily as needed. Additional ordered medications included the use of Miralax (laxative) 17 grams every day, Colace (stool softener) 100 mg twice daily and Milk of Magnesia 30 milliliters (ml) every day as needed with additional orders to give if no bowel movement in three days.
Review of Resident #5's care plan revealed a care plan in place for constipation with an intervention of administering Milk of Magnesia if no bowel movement in three days.
State Tested Nurse Aide (STNA) toileting records for bowel movements were reviewed from 11/01/19 to 12/04/19. No evidence of bowel movements were noted on 11/05/19 to 11/10/19 (six days), 11/15/19 to 11/17/19 (three days), 11/25/19 to 11/29/19 (five days) and 12/01/19 to 12/04/19 (four days).
Review of the medication administration record (MAR) for the months of November and December 2019 revealed no evidence of Milk of Magnesia administered after three days of no bowel movements as ordered by the physician and according to the resident's care plan.
Review of the facility policy for Urinary and Bowel Incontinence and Care- Clinical Protocol dated 03/23/11 indicated: Documentation of bowel movements and intervention per doctor order if no bowel movement in three days or as described by the physician.
Interview with the Director of Nursing on 12/05/19 at 8:20 A.M. verified the physician's orders were not followed when Resident #5 did not have a bowel movement over three days on 11/05/19 to 11/10/19, 11/15/19 to 11/17/19, 11/25/19 to 11/29/19 and 12/01/19 to 12/04/19.
CONCERN
(D)
Potential for Harm - no one hurt, but risky conditions existed
Deficiency F0688
(Tag F0688)
Could have caused harm · This affected 1 resident
**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on record review, policy review, and staff interview, the facility failed to ensure a resident received the appropriate re...
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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 a resident received the appropriate restorative nursing program for range of motion as recommended by occupational therapy. This affected one (Resident #3) of one residents reviewed for range of motion.
Findings include:
A review of Resident #3's medical record revealed she was admitted to the facility on [DATE]. Her diagnoses included cerebral palsy, an unspecified intellectual disability, contracture of the left wrist, pain in the joints of an unspecified hand, muscle weakness and muscle wasting and atrophy.
A review of Resident #3's annual Minimum Data Set (MDS) assessment, an assessment tool used by the facility to identify a resident's level of care for reimbursement purposes, dated 11/12/19 revealed the resident had clear speech. She was usually able to make herself understood and sometimes was able to understand others. Her cognition was severely impaired. She was not indicated to have had any behaviors nor was she known to reject care. She was indicated to have had a functional limitation in range of motion (ROM) of her bilateral upper extremities. She was not marked on the MDS as having received any ROM or splinting services during the MDS reference period.
A review of Resident #3's active care plans revealed she did not have a care plan in place that was specific to a contracture to her left wrist. She did have a care plan for osteoarthritis that included the intervention to provide daily range of motion exercises both active (resident performed herself without any hands on assist by the staff) and passive (staff provided hands on assist to help the resident perform ROM exercises) as tolerated.
A review of Resident #3's occupational therapy (OT) evaluation and plan of treatment for a certification period between 03/16/19 and 04/12/19 revealed the resident had cerebral palsy, a contracture of the left wrist and pain in joints of unspecified hand. Her long term goal was for the resident and caregivers to demonstrate correct technique and follow through for restorative ROM and splinting programs. The upper extremity (UE) ROM assessment indicated her left UE ROM was impaired with decreased left wrist flexion, postured with wrist cocked up, digit four (ring finger) crossed over digit three (middle finger) and tucked in between digits two (index finger) and digit three. The resident could open her hand on command with some difficulty. She tended to use her right hand to open her left hand. The resident had some discomfort with passive ROM (PROM) and had a lack in wrist flexion.
A review of Resident #3's OT discharge summary for the date of service between 03/16/19 and 04/12/19 revealed they wanted the resident to continue with restorative ROM after being discharged from therapy. Her prognosis for maintaining her current level of function was good with consistent staff follow through. They recommended restorative ROM and a referral was made.
A review of Resident #3's therapy recommendation for a restorative program revealed the therapist referred the resident to a restorative nursing program for PROM to be completed to the left hand. The resident was to receive two to three sets of 10 repetitions for digit (finger) extensions and wrist extension to a neutral position as the resident allowed/ tolerated to decrease the risk of a contracture/ deformity.
A review of Resident #3's electronic health record revealed there was no documented evidence of the resident receiving restorative nursing for PROM to the left hand as recommended by the occupational therapist after the referral had been made on 04/12/19. There was a restorative program monthly documentation assessment dated [DATE] that indicated the resident was receiving restorative nursing for active range of motion (AROM) but not PROM that had been recommended by the occupational therapist. A section regarding her participation indicated her start date and end date was 07/12/19. It asked how many times the resident participated in the program and it was marked 0. She was not indicated to be unavailable nor was she marked as having refused to participate in the program. The assessment indicated she was not meeting her goals as she did not participate and the plan was to discharge her from the restorative program at that time. Findings were verified by the Director of Nursing (DON).
On 12/04/19 at 10:19 A.M., an interview with the DON revealed she was not able to find any evidence of PROM services having been provided to Resident #3 as recommended by occupational therapy. She acknowledged the restorative program monthly documentation assessment specified the resident was receiving AROM and not PROM that had been recommended. She confirmed the resident had been discharged from the restorative nursing program due to not participating when she was not physically capable of performing AROM. She had no documented evidence to show PROM had ever been attempted to provided to the resident since 04/12/19.
A review of the facility's policy on Restorative Nursing Program revised March 2019 revealed the type of programs offered included PROM, AROM and splint or brace assistance. Anyone could make a referral to the restorative nursing program to include therapy. Areas that could indicate a referral to rehabilitation was warranted included the end of therapy to continue goal achievement or maintenance to prevent a decline. The restorative nursing program was to be led by the DON or designee (restorative nurse, unit manager).
CONCERN
(D)
Potential for Harm - no one hurt, but risky conditions existed
Incontinence Care
(Tag F0690)
Could have caused harm · This affected 1 resident
Based on observation, record review, and interview the facility failed to follow a physician order regarding the insertion of an indwelling urinary catheter for Resident #263. This affected one reside...
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Based on observation, record review, and interview the facility failed to follow a physician order regarding the insertion of an indwelling urinary catheter for Resident #263. This affected one resident reviewed for indwelling urinary catheter. The facility census was 60.
Findings include:
Review of Resident #263's medical record revealed an admission date of 9/18/19 with diagnoses including urinary tract infection, cerebral infarction, and difficulty walking.
Review of September, 2019 physician orders revealed orders from 09/19/19 to remove Resident #263's urinary catheter and obtain post void residual, and if greater than 200 cc to reinsert the catheter. It was further revealed that the resident had an order for an antibiotic Keflex 500 milligrams every 12 hours related to urinary tract infection that would be completed on 09/25/19.
Review of Resident #263 nursing notes dated 9/19/19 revealed a post void residual of 25 milliliters of pale yellow urine returned. Review of 9/20/19 nursing note revealed an entry stating,Poor urine output. Cathed for 200 milliliters clear amber urine. Catheter left indwelling.
Further review of September, 2019 physician orders did not reveal an order to recheck Resident #263 for post void residual or to reinsert the indwelling catheter.
Observation on 12/02/19 at 2:31 P.M. revealed Resident #263 resting in bed with an indwelling urinary catheter in place.
Interview on 12/03/19 at 3:55 P.M. with the Director of Nursing verified the facility did not obtain an order to reinsert Resident #263's indwelling urinary catheter. She further revealed she believes there was a misunderstanding between two nurses and the physicians order resulting in the unnecessary reinsertion on the indwelling urinary catheter for Resident #263.
CONCERN
(D)
Potential for Harm - no one hurt, but risky conditions existed
Deficiency F0757
(Tag F0757)
Could have caused harm · This affected 1 resident
Based on observation, record review, nurse drug reference review and interview the facility failed to ensure an apical pulse was monitored prior to the administration of Digoxin. This affected one res...
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Based on observation, record review, nurse drug reference review and interview the facility failed to ensure an apical pulse was monitored prior to the administration of Digoxin. This affected one resident (Resident #1) of five residents observed for medication administration. The census was 60.
Findings Include:
Review of Resident #1's medical record revealed an admission date of 11/21/19 with diagnoses including atrial fibrillation, anxiety, depression
Review of the physician orders revealed Digoxin (used to treat heart failure or atrial fibrillation) 125 micrograms (mcg) daily; verify pulse is 60-110 beats per minute.
Review of the Long Term Care Nursing Drug Handbook published 2018 by Lexicomp revealed to monitor an apical pulse before administering any dose.
On 12/03/19 at 7:59 A.M. Registered Nurse (RN) #60 was observed to prepare medication for Resident #1, including Digoxin. At 8:04 A.M. RN #60 was observed to check a radial pulse on Resident #1 prior to administration of the resident's Digoxin. The resident's radial pulse was 74 beats per minute.
On 12/03/19 at 8:05 A.M. interview with RN #60 verified an apical pulse should have been obtained prior to administration of Resident #1's Digoxin.
CONCERN
(E)
Potential for Harm - no one hurt, but risky conditions existed
Deficiency F0804
(Tag F0804)
Could have caused harm · This affected multiple residents
Based on record review, observation, test tray, policy review and interview the facility failed to ensure food was served at appropriate holding temperatures. This had the potential to affect 14 resid...
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Based on record review, observation, test tray, policy review and interview the facility failed to ensure food was served at appropriate holding temperatures. This had the potential to affect 14 residents (Resident #8, #9, #12, #13, #14, #18, #19, #33, #37, #40, #53, #55, #56, and #60) of 21 residents residing on A hall and who eat in their rooms.
Findings include:
On 12/02/19 at 10:53 A.M. interview with Resident #53 revealed the food is usually cold and it's cold no matter if she eats in her room or the dining room.
On 12/02/19 at 3:26 P.M. interview with Resident #18 revealed the food was cold when she would eat in her room
On 12/03/19 at 11:12 P.M. Dietary [NAME] #105 was observed to obtain food temperatures prior to the lunch meal service. The brussel sprouts were 158 degrees Fahrenheit, sliced turkey 188.6 degrees and stuffing 160.7 degrees. Kitchen staff were observed to plate meals for the dining room and then for the residents eating in their room for A-hall. At 12:06 P.M., once all resident trays were placed on the A-hall cart, the surveyor requested a test tray be placed on the A-hall cart. At 12:08 P.M., the tray was placed on the food cart and the cart left the kitchen. At 12:09 P.M. the food cart reached A-hall. At 12:10 P.M. the facility staff began to pass trays on A-hall. At 12:27 P.M., all trays were passed to the 13 residents on A-hall and the test tray was taken to the admissions office approximately 10 feet from the food cart. Dietary Manager (DM) #200 obtained the following food temperatures: sliced turkey 118.2 degrees, brussel sprouts 115.3 degrees and stuffing 133 degrees. The surveyor began the process of a test tray and found the brussel sprouts and turkey to not be hot when served.
On 12/03/19 at 12:33 P.M. interview with DM #200 verified the trays should have been passed more timely and the test tray sat on the food cart for 18 minutes before it was served. Further interview verified the test tray food was served below service temperatures of 135 degrees.
Review of facility dining records revealed Resident #8, #9, #12, #13, #14, #18, #19, #33, #37, #40, #53, #55, #56, and #60 reside on A hall and eat in their rooms.
Review of Meal Distribution Policy dated 05/14 and revised 09/17 revealed all food items will be transported promptly for appropriate temperature maintenance.
Review of the Food: Preparation Policy dated 05/14 and revised 09/17 revealed the dining services coordinator/cook will be responsible for food preparation techniques which minimize the amount of time that food items are exposed to temperatures greater than 41 degrees or less than 135 degrees foods will be held at appropriate temperatures, greater than 135 degrees Fahrenheit for hot holding.
CONCERN
(E)
Potential for Harm - no one hurt, but risky conditions existed
Deficiency F0805
(Tag F0805)
Could have caused harm · This affected multiple residents
**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, taste test, recipe review and interview the facility failed to ensure pureed food items were prepared at t...
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**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, taste test, recipe review and interview the facility failed to ensure pureed food items were prepared at the appropriate texture and thickened liquids were served at the appropriate consistency. This had the potential to affect all seven residents receiving a pureed diet (Resident #7, #11, #17, #38, #49, #54 and #263) and one resident (Resident #60) of four residents receiving nectar thickened liquids. The census was 60.
Findings include:
1. On 12/04/19 at 10:00 A.M. Dietary [NAME] #105 prepared to puree eight servings of turkey for the seven residents (Resident #7, #11, #17, #38, #49, #54 and #263) receiving a puree diet. The cook stated she followed a recipe and would prepare the puree until a smooth, pudding-like consistency was achieved. The cook placed sliced turkey into the robo coup and began the puree process, adding liquid to thin the mixture. At 10:05 A.M. [NAME] #105 began to pour the puree turkey into a metal pan to be reheated for the lunch meal. [NAME] #105 verified the turkey was ready for the lunch meal service. This surveyor was provided a one half spoonful of the puree turkey. The puree turkey was thready and had lumps. Dietary Manager (DM) #200 and Surveyor #42015 also tasted the puree turkey. Surveyor #42015 verified the turkey was thready and had lumps. DM #200 stated the turkey would be reheated and pureed again before lunch service.
On 12/04/19 at 10:30 A.M. this surveyor tasted the warmed puree turkey. The texture was smooth without turkey threads or lumps.
On 12/04/19 at 12:00 P.M. interview with DM #200 verified the turkey had reached a smooth consistency for the lunch meal on 12/04/19 after being pureed additional time to meet the appropriate texture.
Review of the un-dated puree roast turkey recipe revealed the turkey would be blended until smooth.
2. Review of Resident #60's medical record revealed an admission date of 10/01/12 with diagnoses including sepsis, chronic respiratory failure, diabetes, congestive heart failure and dementia without behavioral disturbance.
Review of the physician orders revealed a full liquid, nourishing, nectar thickened diet dated 07/19/19.
Review of the quarterly minimum data set (MDS) dated [DATE] revealed the resident had severe cognitive impairment for daily decision making and required extensive assistance of one staff member with eating. The resident had experienced weight loss but was not on a prescribed weight loss regimen.
On 12/05/19 at 8:30 A.M. State Tested Nursing Assistant (STNA) #21 removed Resident #60's tray from the food cart. STNA #60 stated the resident took a few drinks from her thickened shake sent out from the kitchen and refused to eat the pureed fruit that was on her meal tray. STNA #60 stated this was the first time she had assisted Resident #60 with her meal but the resident did not eat or drink well. The surveyor observed the shake while poured from the drinking cup back into the cup the shake was sent in from the kitchen. The shake had lumps and was not a smooth, nectar thickened consistency.
On 12/05/19 at 10:30 A.M. interview with STNA #50 revealed the resident's thickened shake on her meal tray was not always sent at the appropriate consistency and she would sometimes thin the shake using the milk on the resident's tray.
On 12/05/19 at 2:00 P.M. interview with STNA #21 verified the shake sent from the kitchen for breakfast was not a smooth nectar consistency and contained lumps.
On 12/05/19 at 4:00 P.M. interview with the Director of Nursing (DON) verified the STNA's were not to thin thickened liquids sent from the kitchen and should return the shakes if they arrived to the unit too thick or too thin. The DON stated thickened liquids were used for residents at risk for aspiration and the consistency should not be altered by the staff on the floor.
On 12/05/19 at 5:00 P.M. interview with DM #200 revealed the facility used a gel thickener and the food items do not thicken further the longer they sit. The DM stated the kitchen staff had been inserviced recently regarding the use of the thickeners and the floor staff should not be thinning thickened liquids and the shake should be brought to the kitchen.
This deficiency substantiates Complaint Number OH00108428.
CONCERN
(E)
Potential for Harm - no one hurt, but risky conditions existed
Infection Control
(Tag F0880)
Could have caused harm · This affected multiple residents
Based on observation, record review, policy review and interview the facility to ensure infection control policy and procedures were implemented during meal service and medication administration. This...
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Based on observation, record review, policy review and interview the facility to ensure infection control policy and procedures were implemented during meal service and medication administration. This affected two residents (Resident #15 and #42) of 16 residents observed in the dining room for the lunch meal and two residents (Resident #1 and #54) of five residents observed for medication administration. The census was 60.
Findings include:
On 12/02/19 observation of the dining room revealed the following:
At 11:36 A.M. State Tested Nursing Assistant (STNA) #32 was observed to wipe under her nose with her right hand. The STNA did not use hand sanitizer or wash her hands. At 11:38 A.M. the STNA touched the back of Resident #42 as the resident went to her seat in the dining room. STNA #32 was then observed to go to the doorway of the kitchen and returned to Resident #42's table with two cups with handles and built up utensils for Resident #42. Still not have used hand sanitizer or washed her hands, at 11:42 A.M. STNA #32 was observed to touch the right arm of Resident #15 and then STNA #2 touched the hair on the right side of her head, using her right hand and did not wash her hands or use hand sanitizer. Continuing at 11:41 A.M. STNA #32 was observed to push the food service cart through the dining room and serve food items to Resident #42. At 11:56 A.M. STNA #32 was observed to use hand sanitizer.
On 12/02/19 at 12:08 P M. interview with STNA #32 verified she did not use hand sanitizer or wash her hands as observed. Further interview revealed she should use hand sanitizer between each resident and after touching her hair or face.
2. On 12/03/19 at 8:04 A.M. Registered Nurse (RN) #60 was observed to prepare medications for Resident #1 While popping Lisinopril (blood pressure medication) from the medication card, the pill was observed to miss the plastic medication cup under the card and fell to the top of the medication cart. RN #60 was observed to use a tongue depressor and scoop the Lisinopril into the medication cup and continue with medication preparation. At 8:05 A.M. RN #60 administered Resident #1's medications.
On 12/03/19 at 8:05 A.M. interview with RN #60 verified the top surface of the medication cart was considered dirty and a new Lisinopril should have been obtained from the medication card for administration and not scooped from the cart with a tongue depressor.
3. On 12/04/19 at 8:15 A.M. RN #58 was observed to prepare medications for Resident #54. RN #58 was observed to punch Cardizem ER 120 milligrams (mg) from the medication card directly into her ungloved hand and then from her ungloved hand into the plastic medication cup on top of the medication cart. The RN then continued to prepare the remainder of the resident's medications from the card into the plastic medication card. RN #58 entered the resident's room and asked the resident if she wanted the potassium crushed due to the size of the pill. RN #58 returned to the medication cart with the plastic medication cup. At 8:16 A.M. RN #58 was observed to removed the potassium from the medication cup with her ungloved hand and placed the pill in a plastic pouch and crushed the medication. RN #58 then returned to the resident's room to administer her medications.
On 12/04/19 at 8:18 A.M. interview with RN #58 verified she handled medications with her bare hands and should not touch medications with her bare hands.
Review of the Handwashing/Hand Hygiene Policy revised 02/18 revealed all personnel shall follow the handwashing/hand hygiene procedures to help prevent the spread of infections to other personnel, residents and visitors. Employees must wash their hands for 20 seconds using antimicrobial or non-antimicrobial soap and water under the following conditions: before and after direct contact with residents. In most situations. the preferred method of hand hygiene is with soap and water. If hands are not visibly soiled, use of an alcohol based hand rub containing 60-95% ethanol or isopropanol for the following situations: before and after direct contact with residents, before preparing or handling medications, after contact with a resident's intact skin.
Review of the Administering Medication Policy revised 05/18 revealed staff shall follow established facility infection control procedures when these apply to the administration of medication.
This deficiency substantiates Complaint Number OH00108428.
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 employee file review, policy review and interview the facility failed to ensure their abuse policy and procedure contained screening procedures for all staff to be checked against the nurse a...
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Based on employee file review, policy review and interview the facility failed to ensure their abuse policy and procedure contained screening procedures for all staff to be checked against the nurse aide registry (NAR) for potential abuse prior to beginning employment with the facility. The facility failed to ensure all licensed and un-licensed staff were checked against the NAR prior to employment. This had the potential to affect all 60 residents residing in the facility.
Findings include:
Review of employee files revealed the following:
1. Activity Aide #16 was hired on 10/04/19 and was not checked against the NAR prior to employment
2. Administrator #14 was hired on 11/04/19 and was not checked against the NAR prior to employment.
3. Maintenance Director #7 was hired on 01/11/19 and was not checked against the NAR prior to employment.
4. Licensed Practical Nurse (LPN) #74 was hired on 08/22/19 and was not checked against the NAR prior to employment.
5. LPN # 66 was hired on 03/08/19 and was not checked against the NAR prior to employment.
6. Registered Nurse (RN) #62 was hired on 01/03/19 and was not checked against the NAR prior to employment.
7. RN #60 was hired on 06/26/19 and was not checked against the NAR prior to employment.
8. RN #57 was hired on 08/26/19 and was not checked against the NAR prior to employment.
9. Physical Therapy Assistant (PTA) # 90, a contracted employee, began employment in the facility on 07/29/19 and was not checked against the NAR prior to employment.
10. Speech Therapist (ST) #91, a contracted employee, began employment in the facility on 06/01/19 and was not checked against the NAR prior to employment.
On 12/02/19 at 4:30 P.M. interview with Payroll Coordinator (PC) #9 verified only new housekeeping, laundry and state tested nursing assistants had been checked against the NAR. PC #9 verified the above listed staff had not been checked prior to employment.
On 12/03/19 at 5:15 P.M. interview with Administrator #101 verified the facility policy did not indicate all staff would be checked against the NAR prior to employment.
Review of the Abuse Prevention Program policy revised 02/22/18 revealed the facility conducts employee background checks per state and federal regulations, and will not knowingly employ or otherwise engage any individual who has been convicted of abusing, neglecting, mistreating individuals, misappropriation or anyone with a disciplinary action in effect against a professional license by a state or licensing body including the nurse aide registry. The facility abuse prevention/intervention education program includes, but is not limited to, the following: conducting background checks to avoid hiring persons or admitting new residents who have been found guilty (by a court of law) of abusing, neglecting, or mistreating individuals or those who have had a finding of such action entered into the state nurse aide registry or state sex offender registry.
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
Based on record reviews, interviews, and policy review the facility failed to implement a comprehensive antibiotic stewardship program to monitor and prevent unnecessary/inappropriate use of antibioti...
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Based on record reviews, interviews, and policy review the facility failed to implement a comprehensive antibiotic stewardship program to monitor and prevent unnecessary/inappropriate use of antibiotics. This affected four (Resident #4, Resident #15, Resident #43 and Resident #46) of 60 residents residing at the facility.
Findings included:
Review of the facility's monthly infection surveillance report revealed that Resident #4, Resident #15, Resident #43 and Resident #46 were all being treated for urinary tract infections. Each resident received a culture and sensitivity.
Review of each resident's infection report revealed the facility failed to complete the sensitivity to antibiotic section of the infection identification process portion of the infection report.
Interview on 12/05/19 at 4:00 P.M. with the Director of Nursing confirmed that the facility's antibiotic stewardship program was incomplete and the facility did not identify whether the bacteria from each resident's culture was sensitive to the antibiotic that the physician had prescribed.
Review of the Infection Control Program-Antibiotic Stewardship policy dated 11/28/17 revealed that antibiotic stewardship program will include appropriate prescribing, appropriate administration, and management practices to reduce inappropriate use to ensure that residents receive the right indication, right dose and right duration.
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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.
- • 43% turnover. Below Ohio's 48% average. Good staff retention means consistent care.
Concerns
- • 44 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 Arbors At Woodsfield's CMS Rating?
CMS assigns ARBORS AT WOODSFIELD 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 Arbors At Woodsfield Staffed?
CMS rates ARBORS AT WOODSFIELD's staffing level at 4 out of 5 stars, which is above average compared to other nursing homes. Staff turnover is 43%, compared to the Ohio average of 46%. This relatively stable workforce can support continuity of care.
What Have Inspectors Found at Arbors At Woodsfield?
State health inspectors documented 44 deficiencies at ARBORS AT WOODSFIELD during 2019 to 2024. These included: 1 that caused actual resident harm and 43 with potential for harm. Deficiencies causing actual harm indicate documented cases where residents experienced negative health consequences.
Who Owns and Operates Arbors At Woodsfield?
ARBORS AT WOODSFIELD is owned by a for-profit company. For-profit facilities operate as businesses with obligations to shareholders or private owners. The facility is operated by ARBORS AT OHIO, a chain that manages multiple nursing homes. With 95 certified beds and approximately 49 residents (about 52% occupancy), it is a smaller facility located in WOODSFIELD, Ohio.
How Does Arbors At Woodsfield Compare to Other Ohio Nursing Homes?
Compared to the 100 nursing homes in Ohio, ARBORS AT WOODSFIELD's overall rating (3 stars) is below the state average of 3.2, staff turnover (43%) is near the state average of 46%, and health inspection rating (2 stars) is below the national benchmark.
What Should Families Ask When Visiting Arbors At Woodsfield?
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 Arbors At Woodsfield Safe?
Based on CMS inspection data, ARBORS AT WOODSFIELD 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 Arbors At Woodsfield Stick Around?
ARBORS AT WOODSFIELD has a staff turnover rate of 43%, 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 Arbors At Woodsfield Ever Fined?
ARBORS AT WOODSFIELD 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 Arbors At Woodsfield on Any Federal Watch List?
ARBORS AT WOODSFIELD 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.