MARYVILLE
Non profit - Corporation
165 Beds
Independent
Data: November 2025
2 Immediate Jeopardy citations
Trust Grade
0/100
#62 of 127 in OR
Last Inspection: April 2025
Within standard 12-15 month inspection cycle. Federal law requires annual inspections.
Overview
Maryville nursing home in Beaverton, Oregon has received a Trust Grade of F, indicating significant concerns about the facility's care quality. It ranks #62 out of 127 facilities in Oregon, placing it in the top half, but it is only #7 out of 9 in Washington County, meaning there are better options nearby. Unfortunately, the trend is worsening, with reported issues increasing from 1 in 2024 to 3 in 2025. Staffing is a strong point, rated 5 out of 5 stars with a turnover rate of 44%, which is below the state average; however, the facility has concerning fines totaling $214,136, higher than 87% of Oregon facilities. Specific incidents raise alarms: one resident was allowed to elope, exposing them to unsafe conditions, while another fell during a shower due to inadequate assistance and suffered a fractured leg. Additionally, critical issues were noted with incomplete health assessments, putting residents at risk for unmanaged medication and other health concerns. Overall, while staffing shows promise, serious deficiencies and alarming incidents raise significant red flags for families considering this facility for their loved ones.
- Trust Score
- F
- In Oregon
- #62/127
- Safety Record
- High Risk
- Inspections
- Getting Worse
- Staff Stability ○ Average
- 44% turnover. Near Oregon's 48% average. Typical for the industry.
- Penalties ✓ Good
- $214,136 in fines. Lower than most Oregon facilities. Relatively clean record.
- Skilled Nurses ✓ Good
- Each resident gets 53 minutes of Registered Nurse (RN) attention daily — more than average for Oregon. RNs are trained to catch health problems early.
- Violations ⚠ Watch
- 36 deficiencies on record. Higher than average. Multiple issues found across inspections.
0/100
Top 48%
Review needed
1 → 3 violations
★★★☆☆
3.0
Overall Rating
★★★★★
5.0
Staff Levels
★★★★☆
4.0
Care Quality
★★☆☆☆
2.0
Inspection Score
↔
Stable
2024: 1 issues
2025: 3 issues
The Good
-
5-Star Staffing Rating · Excellent nurse staffing levels
-
4-Star Quality Measures · Strong clinical quality outcomes
-
Full Sprinkler Coverage · Fire safety systems throughout facility
-
No fines on record
-
Staff turnover below average (44%)
4 points below Oregon average of 48%
Facility shows strength in staffing levels, quality measures, fire safety.
The Bad
3-Star Overall Rating
Near Oregon average (3.0)
Meets federal standards, typical of most facilities
Staff Turnover: 44%
Near Oregon avg (46%)
Typical for the industry
Federal Fines: $214,136
Well above median ($33,413)
Significant penalties indicating serious issues
The Ugly 36 deficiencies on record
2 life-threatening 5 actual harm
Apr 2025
2 deficiencies
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, interview, and record review it was determined the facility failed to ensure dependent residents received ...
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**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, interview, and record review it was determined the facility failed to ensure dependent residents received required assistance with ADLs for 1 of 3 sampled residents (#36) reviewed for ADLs. This placed residents at risk for lack of personal hygiene. Findings include:
Resident 36 was admitted to the facility in 8/2024 with diagnoses including cerebral atherosclerosis (hardening of arteries in the brain) and dementia.
Resident 36's Significant Change MDS dated [DATE] indicated the resident was dependent on staff for personal hygiene and grooming.
Resident 36 was observed on 4/8/25 at 10:24 AM, and on 4/9/25 at 8:24 AM with a significant amount of chin hair visible.
On 4/8/25 at 10:24 AM, Resident 36 stated she/he did not want to have facial hair and would like for staff to take care of it for her/him. Resident 36 stated she/he relied on staff to shave unwanted facial hair.
On 4/9/25 at 2:13 PM, Staff 6 (CNA) stated she obtained information to care for Resident 36 from the [NAME] (bedside care plan) and acknowledged Resident 36 had long chin hairs.
On 4/9/25 at 2:18 PM, Staff 2 (DNS) observed and acknowledged Resident 36's facial hair and stated the resident was in need of a shave.
CONCERN
(F)
Potential for Harm - no one hurt, but risky conditions existed
Infection Control
(Tag F0880)
Could have caused harm · This affected most or all residents
**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** 1. Based on observation, interview and record review it was determined the facility failed to ensure proper hand hygiene was com...
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**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** 1. Based on observation, interview and record review it was determined the facility failed to ensure proper hand hygiene was completed during meals for 1 of 6 halls reviewed for dining. This placed residents at risk for cross contamination. Findings include:
The 8/2019 Handwashing/Hand Hygiene Policy indicated hand hygiene was the primary means to prevent the spread of infections. The policy indicated:
7. Use of an alcohol-based hand rub containing at least 62% alcohol; or alternatively, soap (antimicrobial or non-antimicrobial) and water for the following situations:
a. before and after direct contact with residents;
l. after contact with objects in the immediate vicinity of the resident;
o. before and after eating or handling food;
p. before and after assisting a resident with meals;
On 4/7/25 during the lunch meal in the west hall and dining room the following observations were made:
-12:05 PM Staff 10 (NA) removed three dirty breakfast trays from a two-tier serving cart and loaded the cart with three lunch trays. Staff 10 did not sanitize the cart prior to loading the cart with the lunch trays.
- 12:07 PM Staff 10 delivered lunch trays to three residents in the dining room, donned clothing protectors and set-up each tray for the three residents. Staff 10 did not sanitize her hands between each resident or after leaving the dining room.
-12:10 PM Staff 10 loaded the two-tier cart with three lunch trays and delivered the lunch tray to room [ROOM NUMBER] and exited the room without sanitizing her hands. Staff 10 delivered a lunch tray to room [ROOM NUMBER].1, assisted the resident with repositioning, adjusted the head of the bed and moved the bedside table. Staff 10 delivered a lunch tray to room [ROOM NUMBER].2, assisted the resident with repositioning in the bed, cleared and adjusted the bedside table.
On 4/7/25 at 12:14 PM Staff 10 acknowledged she did not sanitize her hands in between delivering the lunch trays and touching each resident in the dining room and in the rooms. Staff 10 stated she should have sanitized the cart after removing the dirty breakfast trays and before using it for the lunch trays.
On 4/7/25 at 12:20 PM Staff 2 (DNS) stated she expected all staff to complete hand hygiene after they passed out each resident tray and went in and out of resident rooms. Staff 2 stated she expected staff to sanitize the meal cart before each use.
2. Based on interview and record review it was determined the facility failed to develop and implement a water management program and conduct a risk analysis assessment for potential areas of growth and spread of water-borne pathogens and illness. This placed all residents at risk for exposure to water-borne pathogens. Findings include:
The Centers for Medicare and Medicaid Services Center for Clinical Standards and Quality/Safety and Oversight Group letter 17-30, revised on 7/6/18, on Requirement to Reduce Legionella Risk in Healthcare Facility Water Systems to Prevent Cases and Outbreaks of Legionnaires' Disease stated, Facilities must develop and adhere to policies and procedures that inhibit microbial growth in building water systems that reduce the risk of growth and spread of Legionella and other opportunistic pathogens in water.
A review of the facility's 9/2022 Legionella Water Management Policy revealed the following:
-The water management program is reviewed annually by the facility water management team.
-The purposes of the water management program are to identify areas in the water system where Legionella bacteria can grow and spread, and to reduce the risk of Legionnaire's disease.
-The water management program includes a detailed description and diagram of the water system in the facility and areas identified in the water system that could encourage the growth and spread of Legionella or other water-borne bacteria.
A review of the 2/2025 Facility Assessment revealed no evidence a risk assessment was completed to prevent the growth and spread of water-borne pathogens in the facility's main water system.
On 4/11/25 at 10:05 AM Staff 1 (Administrator) stated the facility did not have a water management program and did not have a prevention plan or system in place for the prevention of the spread of water-borne pathogens, such as Legionella, in the facility's main water system.
Jan 2025
1 deficiency
CONCERN
(D)
📢 Someone Reported This
A family member, employee, or ombudsman was alarmed enough to file a formal complaint
Potential for Harm - no one hurt, but risky conditions existed
Accident Prevention
(Tag F0689)
Could have caused harm · This affected 1 resident
Based on observation, interview and record review, it was determined the facility failed to follow care plan interventions related to aspiration risks for 1 of 3 sampled residents (#3) reviewed for ac...
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Based on observation, interview and record review, it was determined the facility failed to follow care plan interventions related to aspiration risks for 1 of 3 sampled residents (#3) reviewed for accidents.
Resident 3 admitted to the facility in 2024 with diagnoses including traumatic subdural hemorrhage (severe head injury) and dysphagia (difficulty with swallowing).
Resident 3's 9/3/24 Care Plan indicated the resident required one on one eating assistance due to dysphagia. The care plan stated staff were not to deliver until staff was ready to assist the resident.
The 9/2024 admission MDS identified Resident 3 was cognitively intact.
A 9/4/24 choking/aspiration investigation revealed Staff 5 (CNA) delivered Resident 3's lunch tray to the resident and informed Resident 3 that she would return to assist Resident 3 after delivering the last lunch tray. Resident 3 was noted to have begun eating without assistance and began to choke due to placing too much food in her/his mouth. Staff 4 (OT) was in the room at the time assisting Resident 3's roommate. Staff 4 was alerted by the resident's roommate that something was wrong with Resident 3. Staff 4 noted Resident 3 was choking and began to turn reddish purple. Staff 4 performed the Heimlich maneuver and was able to dislodge Resident 3's food from her/his throat.
The facility's choking and aspiration investigation concluded Staff 5 did not follow Resident 3's care plan and residents who required one on one eating assistance were not to be left alone with a meal tray until staff were ready to immediately assist residents with eating.
Observations conducted from 12/31/24 to 1/3/25 from, 9:30 AM to 3:40 PM, identified no additional issues or risks related to choking or aspiration for residents.
On 12/31/24 at 10:00 AM, Staff 5 (CNA) could not be reached for interview.
On 12/31/24 at 11:10 AM, Staff 4 confirmed Staff 5 had left Resident 3 with her/his meal tray before leaving the room and had conducted the Heimlich maneuver due to Resident 3 choking after she/he began to self-feed herself/himself.
On 12/31/24 at 11:49 AM, Staff 6 (RNCM) indicated that staff were not to leave trays for residents who required meal assistance due to the risk of choking and aspiration occurring.
On 1/3/25 at 11:52 AM, Staff 1 (Administrator) and Staff 2 (DNS) acknowledged Resident 3 choked as a result of Staff 5 not following the resident's care plan by leaving the resident's tray alone in her/his room.
Mar 2024
1 deficiency
1 Harm
SERIOUS
(G)
📢 Someone Reported This
A family member, employee, or ombudsman was alarmed enough to file a formal complaint
Actual Harm - a resident was hurt due to facility failures
Accident Prevention
(Tag F0689)
A resident was harmed · This affected 1 resident
**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on interview and record review it was determined the facility failed to ensure the plan of care was followed to provide ca...
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**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on interview and record review it was determined the facility failed to ensure the plan of care was followed to provide care-planned assistance to prevent a fall for 1 of 3 sampled residents (#3) reviewed for falls. This resulted in Resident 3's hospitalization with leg fracture and surgical repair. Findings include:
Resident 3 admitted to the facility in 2023 with diagnoses including a history of falls.
The 11/16/23 Care Plan indicated Resident 3 was at risk for falls related to impaired mobility. Interventions included providing a safe environment, including personal items within reach. The Care Plan also indicated Resident 3 required one-person assistance with bathing.
The 11/23/23 admission MDS indicated Resident 3 was cognitively intact.
A 12/30/23 fall investigation indicated Staff 3 (CNA) called Staff 4 (LPN) and Staff 5 (LPN) into Resident 3's room as the resident suffered a fall while in the shower. Upon entering the room, the resident was found lying on her/his right side. Resident 3 initially did not want to go to the hospital for evaluation. Resident 3 waited until family arrived and after speaking with staff, the resident agreed to go to the hospital. Resident 3 was found to have a right leg fracture requiring surgical repair. Witness statements indicated the following:
- Resident 3 stated she/he was in the shower and was not able to recall what she/he was doing. Resident 3 thought she/he may have reached for water or the shampoo and then fell on her/his side.
- Staff 3 stated she was providing Resident 3 with a shower in the resident's room. Staff 3 stated she transferred the resident to the shower chair and gave the resident a washcloth and shampoo. Staff 3 stated Resident 3 asked her to give her/him some time to wash her/his hair. Staff 3 stated she left the door open and closed the shower curtain halfway but was able to still see the resident. Staff 3 stated she went to make the resident's bed. Staff 3 stated Resident 3 fell out of the shower chair and onto the floor. Staff 3 stated she quicky called for the nurse. Staff 3 stated she read the [NAME] (CNA Care Plan) and Resident 3 was to receive one-person assistance with bathing. Staff 3 stated she did not physically assist the resident with bathing before she left to make the resident's bed. Staff 3 stated she, honestly didn't think anything would happen. I'm sorry.
- Staff 4 stated Staff 3 called her and Staff 4 into Resident 3's room. Resident 3 was found laying on her/his right side with the shower chair tipped over. Resident 3 denied pain to the right thigh and indicated pain only when putting her/his leg down. Resident 3 was assisted to a wheelchair.
- Staff 5 stated she assisted Staff 4 after Resident 3 fell. Staff 5 stated the resident was found wet on the floor inside the shower on her/his right side. Staff 5 stated Resident 3 indicated she/he may have been reaching for the shampoo or trying to get to the water, but could not recall for sure. The resident indicated she/he slipped and fell on her/his right side. Resident 3 was unable to extend her/his right leg completely out and an ice pack was applied to the right thigh. The resident was assisted to the wheelchair.
The fall investigation concluded Staff 3 read Resident 3's Care Plan prior to the shower and if Staff 3 remained with Resident 3, and completed the shower, the fall could have been avoided. The Care Plan Indicated Resident 3 required one-person assistance with bathing and Staff 3 was not physically close to the resident at the time of the incident.
On 3/15/24 at 9:58 AM Staff 5 (LPN) stated Resident 3 fell while in the shower. Staff 5 stated she recalled the resident was reaching for something when she/he fell. Staff 5 stated Resident 3 was able to move after the fall but was later sent out to the hospital. Staff 5 stated she believed Staff 3 was in the room with the resident but was unable to recall if Staff 3 was standing next to the resident or in the room doing other things when the fall occurred.
On 3/15/24 at 2:43 PM Staff 4 (LPN) stated she assisted Resident 3 after the fall. Staff 4 stated Staff 3 came out of the room and indicated Resident 3 fell. Staff 4 stated she and Staff 5 went to assist and found the shower chair was tipped over and the resident was on her/his right side. Staff 4 stated Resident 3 did not complain of any pain and was able to transfer to the wheelchair. Staff 4 stated Resident 3 did not want to go to the hospital at first, but later complained of increased pain and was sent out. Staff 4 stated Staff 3 indicated she was making Resident 3's bed while the resident was in the shower.
On 3/18/24 at 9:24 AM Staff 3 stated Resident 3's shower was connected to her/his room. Staff 3 stated she provided Resident 3 a shower on 12/30/23. Staff 3 stated she set up Resident 3 for the shower and the resident indicated she/he needed a minute to wash her/his hair. Staff 3 stated Resident 3 wanted to wash her/his own hair. Staff 3 stated she could see the resident in the shower from where she was standing at the bed. Staff 3 stated she didn't believe she was leaving the resident alone in the bathroom. Staff 3 stated she was next to the bed when she heard Resident 3 fall. Staff 3 stated the resident did not call out for help, and she was not sure how the resident fell as the resident was previously sitting on the shower chair. Staff 3 stated at the time of the incident, Resident 3's Care Plan indicated she/he required one-person assistance with bathing. Staff 3 stated she read Resident 3's Care Plan prior to the fall.
On 3/15/24 at 11:53 AM Staff 6 (RNCM) stated Staff 3 was providing a shower to Resident 3 at the time of the fall on 12/30/23. Staff 6 stated Resident 3 required one-person assistance with bathing at the time. Staff 6 stated Resident 3 asked for privacy and Staff 3 stepped out of the shower and went to make the resident's bed while keeping an eye on the resident. Staff 6 stated she believed the resident reached out for something and fell. Staff 6 stated Staff 3 was supposed to be within reach of Resident 3 during the shower. Staff 6 stated Staff 3 was able to see the resident in the shower, but was not close enough reach the resident to prevent the fall. Staff 6 stated Staff 3 was aware that Resident 3 required one-person assistance with bathing and acknowledged Staff 3 did not provide assistance per the resident's Care Plan, which resulted in a fall with a leg fracture.
On 3/18/24 at 12:39 PM Staff 17 (DNS) acknowledged Resident 3 suffered a fall with fracture due to Staff 3 not providing assistance per the resident's Care Plan for bathing. Staff 17 stated she asked Staff 3 to not return to the facility after the incident.
On 3/20/24 at 6:59 PM the facility provided additional information to indicate education and an inservice was provided to nursing staff related to the identifed incident. The deficient practice was determined to be past non-compliance, corrected on 1/3/24.
Dec 2023
9 deficiencies
1 IJ
CRITICAL
(J)
📢 Someone Reported This
A family member, employee, or ombudsman was alarmed enough to file a formal complaint
Immediate Jeopardy (IJ) - the most serious Medicare violation
Accident Prevention
(Tag F0689)
Someone could have died · This affected 1 resident
**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, interview and record review it was determined the facility failed to assess elopement risk and provide sup...
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**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, interview and record review it was determined the facility failed to assess elopement risk and provide supervision to prevent a severely cognitively impaired resident from eloping for 1 of 3 sampled residents (#272) reviewed for elopement. This failure resulted in an immediate jeopardy situation when Resident 272 eloped from the facility, was exposed to cold and rainy weather conditions, was without supervision at night in a high-traffic area, and was at risk for wandering into additional unsafe areas and getting lost. This placed the resident at risk for hypothermia, accidents, and a lack of access to support services. Findings include:
Resident 272 admitted on [DATE] with diagnoses including dementia with self-neglect.
A 11/15/23 Hospitalist History and Physical (H&P) indicated Resident 272 was hospitalized after she/he was found wandering in the streets and trying to get into various homes. Resident 272 was diagnosed with dementia in 2022 and had slowly worsening cognition for some time. Resident 272 had a SLUMS (cognitive assessment) score of 10, indicating severe cognitive impairment. The H&P indicated Resident 272 needed placement in a Memory Care Unit (MCU) (secure locked unit attached to a skilled nursing facility). The document indicated Resident 272 was unable to care of her/himself and had poor insight into her/his disability.
On 11/30/23 a provider progress note indicated Resident 272 was at high risk for elopement.
A review of Resident 272's clinical record revealed no evidence of careplanned interventions put in place to prevent elopement subsequent to the provider's indication that Resident 272 was at high risk for elopement.
A 12/3/23 facility investigation revealed the following:
- On 12/3/23 at approximately 2:00 AM staff determined Resident 272 was not in her/his room. Facility staff began searching the facility as well as notifying local authorities.
- Staff last made visual contact with Resident 272 at approximately 1:00 AM.
- Resident 272 was located on the street at approximately 3:30 AM (two and a half hours after the resident was last seen by facility staff), a half mile from the facility, outside a local convenience store. The resident indicated she/he did not know why she/he was on the street and indicated she/he was, Going to the jail.
- Facility staff determined Resident 272 eloped from her/his room via the window after opening the window and removing the screen.
- Facility staff reported earlier in the day Resident 272 asked staff, How to get out, and expressed that he was not supposed to be in the facility.
- On 12/5/23 Staff 23 (RN) stated she was aware an elopement assessment was required upon admission, but it was not completed, and stated, I don't think I [passed] it to the next shift to assist. It's my fault.
- On 12/5/23 Staff 57 (LPN) indicated she was aware of the resident's history of wandering prior to the 12/3/23 elopement and watched the resident closely. Staff 57 stated she previously asked Staff 58 (LPN Resident Care Manager) if Resident 272 needed a wanderguard (device used to prevent elopement) and was told, We could always assess it.
- On 12/5/23 Staff 59 (CNA) indicated Resident 272 was agitated in the evenings starting around 8:00 PM, paced the hallways, and asked how to get out of the unit.
- On 12/5/23 Staff 13 (LPN) indicated Resident 272 was agitated upon admit to the facility, barricaded her/his room with furniture, and wanted to leave. The evening prior to the resident's elopement, Resident 272 was agitated, and verbalized she/he wanted to leave.
- 1:1 supervision was put in place when the resident returned to the facility after her/his elopement, and window alarms were installed on 12/4/23.
- On 12/6/23 Resident 272 was moved to a new room with a window that faced a courtyard instead of the street.
Observations during the survey revealed the facility was located on the corner of two four-lane highways with a row of resident rooms facing the street. At the time of the elopement, Resident 272's room had a window with a view of the street.
Local weather records from 12/3/23 at 3:53 AM indicate a temperature of 47 degrees F with light rain.
Review of Resident 272's clinical record revealed no evidence of a completed elopement assessment until after the resident returned to the facility on [DATE].
Review of Resident 272's care plan, initiated on 11/28/23, revealed no information regarding elopement risk or exit-seeking behaviors, and no associated careplanned interventions to prevent elopement were initiated until the resident returned to the facility on [DATE].
On 12/14/23 at 4:32 PM Staff 49 (Activities Aide) stated Resident 272 exhibited exit-seeking behaviors. Staff 49 stated regularly around 4:00 PM Resident 272's behavior was to ask to leave the facility and stated staff couldn't hold her/him here. Staff 49 stated she witnessed Resident 272 go into other residents' rooms and open a window; she/he tried to exit from the doors and paced the halls. Staff 49 stated there was no redirecting her/him when she/he was like that.
On 12/14/23 at 4:40 PM Staff 50 (CNA) stated she was not familiar with Resident 272, but staff expressed concern regarding the position of her/his room [it faced a main road] because of Resident 272's history.
On 12/14/23 at 4:43 PM Staff 51 (CNA) stated Resident 272 was confused about why she/he was in the MCU. Staff 51 stated the resident thought she/he was in jail. Staff 51 stated she cared for the resident the day prior to the incident and the resident wanted to call the police because of feeling trapped in the facility.
On 12/14/23 at 4:45 PM Staff 52 (CNA) stated he helped Resident 272 a few days prior to the incident, and the resident thought she/he was in jail and talked about being trapped.
On 12/14/23 at 10:09 AM Staff 53 (CNA) stated Resident 272 was far more active in the evenings. Staff 53 stated Resident 272 did not cause any problems in the morning, but she knew that was not the case on evening or night shift. Staff 53 stated she only knew if residents were an elopement risk if they had a wander guard on or if the resident asked her about getting out.
On 12/14/23 at 10:49 AM Staff 55 (CNA) stated she did not know Resident 272 was an elopement risk. Staff 55 stated staff were told was Resident 272 was found by police breaking into houses. Staff 55 stated he was told Resident 272 was going to be very active.
On 12/14/23 at 11:11 AM Staff 56 (LPN) stated when Resident 272 was admitted she was given report that Resident 272 was confused and paranoid, and Resident 272 stated she/he didn't need to be here for too long and didn't want to be there.
On 12/14/23 at 4:30 PM Staff 57 (LPN) stated Resident 272 walked the entire unit every evening shift before the elopement. Staff 57 stated she spoke to staff on night shift to figure out Resident 272's care needs and night shift staff didn't have any information either. Staff 57 stated she tried to redirect her/him and educate her/him about the risks [of elopement], but Resident 272 didn't care. Staff 57 stated an elopement assessment was supposed to be done on the first day. If the nurse didn't finish the assessments on the shift the resident admitted , then the next shift was supposed to continue working on it and finish the assessment.
On 12/14/23 at 4:59 PM Staff 23 (RN) stated staff were not aware Resident 272 was an elopement risk when the resident admitted . Staff 23 stated she was not aware of a process to complete an elopement assessment upon admission.
On 12/14/23 at 5:30 PM the facility was notified that the failure to assess Resident 272's elopement risk, combined with the failure to put interventions in place to prevent elopement of a severely cognitively impaired resident, and Resident 272's subsequent elopement which placed the resident at risk for hypothermia subsequent to exposure to cold and wet weather, and additionally placed the resident at risk for accidents, and a lack of access to support services, constituted an Immediate Jeopardy (IJ) situation. An immediacy removal plan was requested.
On 12/14/23 at 8:17 PM The facility submitted an acceptable immediacy removal plan which would abate the IJ situation.
The immediacy removal plan included the following:
1. a. Resident 272 had an elopement risk assessment and elopement care plan initiated on 12/3/23. One on one monitoring and 15-minute checks were initiated immediately on return to secure unit. Her/his room and the adjacent room window alarms were installed on 12/4/23. A room change occurred when a room was available that did not have street access via window on 12/6/23. Physician adjusted residents' medication for behavior management and resident was placed on alert for medication changes and behavior monitoring. Resident will remain on every 15-minute checks until 12/26/23 when resident will be re-evaluated for medication effectiveness, continued elopement risk, determine if 15 minute checks are to continue or check time adjusted and elopement risk assessment re-evaluation will be completed.
b. The facility will audit every 15 minutes visual checks every shift by Charge Nurse and continue to monitor visual checks ongoing per determined schedule based on elopement assessment. Elopement assessment will be re-evaluated every two weeks times 90 days, then quarterly or more often as needed.
2. Resident 85, Residents 101, and Resident 105 will have their elopement risk assessment re-evaluated and updated as applicable and care plan interventions for elopement risk will be updated as applicable by 12/15/23.
3. On admission to the facility secured memory care unit, an elopement risk assessment will be completed on the day of admission to determine risk and safety needs and an elopement care plan will be initiated on the day of admission.
4. The elopement admission criteria policy and procedure will be updated to reflect elopement assessment process change by 12/15/23.
5. All staff assigned to memory care unit and facility IDT will be in serviced on updated policy and procedure regarding elopement assessment, risk and care plan interventions for safety by 12/15/23 end of day and ongoing.
6. The administrator, DNS, Quality Assurance nurse will audit all new admissions to memory care unit for elopement assessment and care plan completion.
7. Environmental Service Department will monitor window alarm devices placement daily.
The immediacy was removed on 12/15/23 based on onsite verification of the removal plan.
SERIOUS
(G)
📢 Someone Reported This
A family member, employee, or ombudsman was alarmed enough to file a formal complaint
Actual Harm - a resident was hurt due to facility failures
Quality of Care
(Tag F0684)
A resident was harmed · This affected 1 resident
2. Resident 322 was admitted in 11/2023 with diagnoses including right leg fracture and stroke.
Physician's orders dated 11/25/23 directed facility staff to place one lidocaine patch externally every...
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2. Resident 322 was admitted in 11/2023 with diagnoses including right leg fracture and stroke.
Physician's orders dated 11/25/23 directed facility staff to place one lidocaine patch externally every 12 hours and to remove for 12 hours.
Review of the 11/2023 and 12/2023 MAR revealed Resident 322 refused her/his lidocaine patch on the following days:
-11/25/23, 11/26/23 and 11/27/23.
-12/4/23, 12/5/23, 12/6/23, 12/7/23, 12/8/23, 12/9/23, 12/10/23 and 12/11/23.
There was no documented evidence the resident's physician was notified of Resident 322's refusals.
On 12/13/23 at 7:57 PM Staff 44 (LPN) stated the resident struggled with chronic pain but was not aware Resident 322 had an order for a lidocaine patch.
On 12/14/23 at 6:57 PM Staff 36 (CMA) stated she was aware Resident 322 refused her/his lidocaine patch and documented as a refusal but did not notify the physician.
On 12/18/23 at 10:30 AM Staff 2 (DNS) and Staff 29 (LPN-Resident Care Manager) confirmed, based on information on Resident 322's MARs, staff should have contacted the physician regarding her/his refusals.
Based on interview and record review it was determined the facility failed to prevent the development of moisture associated skin damage (MASD) and follow physician orders for 2 of 3 sampled residents (#s 322 and 372) reviewed for skin conditions and pain management. This failure resulted in Resident 372 developing MASD and placed residents at risk for increased pain. Findings include:
1. Resident 372 was admitted to the facility in 2018 with diagnoses including heart failure. On 3/1/23 a diagnosis of dementia with agitation was added.
Resident 372's 4/21/23 physician order indicated to apply barrier cream and cover with a foam dressing to the coccyx area two times a day for skin care protection.
The 8/2023 TAR indicated Resident 372 received dressing changes twice daily from 8/13/23 through 8/17/23.
The 8/18/23 Skin Incident Report indicated on 8/17/23 during a preventative dressing treatment it was noted Resident 372 had a partial-thickness skin loss that measured 4.78 cm in length x 3.2 cm wide moisture associated dermatitis to the coccyx. Resident 372 did not know how she/he got the skin injury.
The 8/17/23 progress note by Staff 3 (LPN) indicated Resident 372 had an order to apply barrier cream and cover with foam dressing to the coccyx area BID for skin protection. The last time the dressing was changed was by Staff 3 on 8/13/23. On 8/13/23 her/his skin was not effected and the dressing was for ulcer prevention. On 8/17/23 when Staff 3 came to work Resident 372 had a bed bath completed by Staff 4 (CNA). Staff 4 reported the dressing had a date of 8/13/23 that was signed by Staff 3. The skin check was completed and pressure was noted on the coccyx area and her/his skin came off. The area measured 4.8 cm x 3.2 cm. The skin was cleaned, barrier cream and dressing were applied.
On 12/13/23 at 2:31 PM Staff 3 stated on 8/17/23 Staff 4 reported Resident 372's current dressing on the coccyx was dated 8/13/23 and signed by Staff 3. Staff 3 stated he observed the dressing with Staff 4 and it was very wet. Staff 3 stated when he applied the dressing on 8/13/23 the skin was intact and when he removed the wet dressing on 8/17/23 the resident had a Stage 2 (partial thickness skin loss) pressure ulcer.
On 12/13/23 at 2:47 PM Staff 4 stated on 8/17/23 she observed Resident 372's dressing to the coccyx dated 8/13/23 and signed by Staff 3. Staff 4 stated she reported the observation to Staff 3.
On 12/15/23 at 12:23 PM Staff 5 (RNCM) acknowledged Resident 372 did not receive BID dressing changes as ordered from 8/14/23 through 8/17/23. Staff 5 further acknowledged Resident 372 did not have skin issues prior to the removal of the dressing on 8/17/23. Staff 5 acknowledged the skin assessment indicated it measured 3.11 cm x 2.03 cm on 8/18/23 and stated her/his open skin area was a combination of moisture related issues and a pressure ulcer.
CONCERN
(D)
📢 Someone Reported This
A family member, employee, or ombudsman was alarmed enough to file a formal complaint
Potential for Harm - no one hurt, but risky conditions existed
Resident Rights
(Tag F0550)
Could have caused harm · This affected 1 resident
Based on observation, interview and record review it was determined the facility failed to ensure a resident was treated in a dignified manner for 1 of 1 sampled resident (#324) reviewed for activitie...
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Based on observation, interview and record review it was determined the facility failed to ensure a resident was treated in a dignified manner for 1 of 1 sampled resident (#324) reviewed for activities. This placed residents at risk for being treated in a dishonorable manner. Findings include:
Resident 324 was admitted to the facility in 11/2023 with diagnoses including stroke and dysphagia (difficulty swallowing).
A 11/28/23 care plan revealed Resident 324 required one staff person assistance with personal hygiene, dressing and needed one to one assistance with eating.
On 12/13/23 at 8:30 AM Resident 324 was observed in bed asleep and two CNAs moved the resident up in bed and adjusted her/his pillows, the resident's eyes remained closed, and staff did not speak to the resident. Staff 32 (CNA) turned on the overhead light and said, it's time to wake up. Staff 32 used the bed control to raise the head of the bed to approximately 90 degrees (in an upright position) and Resident 324's head slumped towards her/his left shoulder. Staff 32 placed a clothing protector on the resident's chest but did not speak to the resident and her/his eyes remained closed and Staff 32 left the room. At 8:34 AM Staff 32 came back to the room with a washcloth in her hand, wet the washcloth and wiped the resident's face without speaking to the resident. Resident 324 lifted both of her/his arms up in the air in attempt to stop Staff 32, who said it's time to wake up. Resident 324 kept her/his eyes closed and Staff 32 stopped wiping the resident's face. Staff 32 proceeded to the right side of the resident's bed next to the bedside table that had Resident 324's breakfast. Staff 32 stood by the bed, took a spoon and scooped some thick liquid out of a cup and tried to feed the resident. Resident 324 did not open her/his mouth or eyes. Staff 32 removed the clothing protector from the resident and left the room.
On 12/13/23 at 8:40 AM Staff 32 stated Resident 324 was difficult to wake up in the mornings. Staff 32 admitted she should have talked more to the resident in attempt to wake her/him before raising the head of the bed in an upright position. Staff 32 stated the resident required one staff to help her/him with eating because she/he was a feeder. Staff 32 indicated she should have talked to the resident prior to washing her/his face and before placing the clothing protector on Resident 324.
On 12/13/23 at 9:28 AM Staff 31 (Speech Language Pathologist) stated she worked with Resident 324 regularly due to her/his dysphagia. Staff 31 indicated the resident was hard to wake up in the mornings and staff should talk to her/him and not rush the resident when providing assistance.
On 12/18/23 at 11:06 AM Staff 2 (DNS) and Staff 29 (LPN-Resident Care Manager) stated staff were expected to wake up Resident 324 gently and not rush her/his care. Staff 2 stated she expected staff to talk to Resident 324 the whole time or try to stimulate her/him by rubbing the resident's shoulder or feet and tell the resident what care they were going to give. Staff 2 stated staff were expected to ask permission before putting a clothing protector on for meals and to sit down when feeding any residents that needed help with eating.
CONCERN
(D)
📢 Someone Reported This
A family member, employee, or ombudsman was alarmed enough to file a formal complaint
Potential for Harm - no one hurt, but risky conditions existed
Notification of Changes
(Tag F0580)
Could have caused harm · This affected 1 resident
Based on interview and record review it was determined the facility failed to notify a resident's responsible party of a change in condition for 1 of 1 sampled resident (#372) reviewed for change of c...
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Based on interview and record review it was determined the facility failed to notify a resident's responsible party of a change in condition for 1 of 1 sampled resident (#372) reviewed for change of condition. This placed residents at risk for having uninformed responsible parties. Findings include:
Resident 372 was admitted to the facility in 2018 with diagnoses including heart failure. On 3/1/23 a diagnosis of dementia with agitation was added.
Resident 372's clinical record indicated Witness 2 (Family Member) was her/his responsible party, POA (Power of Attorney) for care, and Emergency Contact #1.
On 12/11/23 at 9:55 AM Witness 2 stated Resident 372 passed away in 8/2023 and when she went to the facility the day after to collect the resident's belongings, Staff 5 (RNCM) told her the resident had pressure ulcers. Witness 2 stated it was the first time she was notified of Resident 372's skin issues.
The 8/18/23 Skin Investigation by Staff 3 (LPN) indicated on 8/17/23 Resident 372 had a partial thickness skin loss which measured 4.78 cm x 3.2 cm to the coccyx. The investigation indicated it was moisture associated dermatitis. The investigation further indicated Witness 2 was not notified of the skin issue until 8/21/23 at 12:49 PM (four days after the skin issue was discovered).
On 12/13/23 at 2:31 PM Staff 3 stated he identified Resident 372's skin issue on 8/17/23 and acknowledged Witness 2 was not notified.
On 12/15/23 at 1:03 PM Staff 2 (DNS) acknowledged Witness 2 was not notified of Resident 372's skin issue until 8/21/23 and the expectation was for staff to inform the responsible party within 24 hours.
CONCERN
(D)
📢 Someone Reported This
A family member, employee, or ombudsman was alarmed enough to file a formal complaint
Potential for Harm - no one hurt, but risky conditions existed
Deficiency F0582
(Tag F0582)
Could have caused harm · This affected 1 resident
**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on interview and record review it was determined the facility failed to provide written notification to 2 of 3 sampled res...
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**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on interview and record review it was determined the facility failed to provide written notification to 2 of 3 sampled residents (#s 373 and 374) reviewed for Notice of Medicare of Non-Coverage (NOMNC). This placed residents at risk for unknown financial liabilities. Findings include:
1. Resident 373 was admitted to the facility on [DATE] and discharged from the facility on 6/27/23.
The 6/27/23 Discharge MDS indicated Resident 373 had a planned discharge with a Medicare covered stay at the facility.
A review of the resident's medical record revealed no indication a NOMNC was provided.
On 12/14/23 at 10:17 AM Staff 16 (Assistant Administrator) acknowledged a NOMNC was not provided to Resident 373.
2. Resident 374 was admitted to the facility on [DATE] and discharged from the facility on 7/14/23.
The 7/14/23 Discharge MDS indicated Resident 374 had a planned discharge with a Medicare covered stay at the facility.
A review of the resident's medical record revealed no indication a NOMNC was provided.
On 12/14/23 at 10:17 AM Staff 16 (Assistant Administrator) acknowledged a NOMNC was not provided to Resident 374.
CONCERN
(D)
📢 Someone Reported This
A family member, employee, or ombudsman was alarmed enough to file a formal complaint
Potential for Harm - no one hurt, but risky conditions existed
Incontinence Care
(Tag F0690)
Could have caused harm · This affected 1 resident
Based on interview and record review it was determined the facility failed to provide adequate bowel and bladder care for 2 of 3 sampled residents (#s 48 and 118) reviewed for bowel and bladder. This ...
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Based on interview and record review it was determined the facility failed to provide adequate bowel and bladder care for 2 of 3 sampled residents (#s 48 and 118) reviewed for bowel and bladder. This placed residents at risk for skin breakdown. Findings include:
1. Resident 48 was admitted to the facility in 11/2023 with diagnoses including left leg/hip fracture and right foot drop (difficulty lifting the front part of the foot).
A 11/2/23 care plan revealed Resident 48 required one staff person assistance with toileting and personal hygiene needs.
A review of a FRI dated 11/6/23 revealed Resident 48 was placed on a bedpan by Staff 41 (CNA). The resident was left on the bedpan for 30 minutes before Staff 43 (CNA) entered the room and removed the bedpan from under Resident 48. The resident was assessed by Staff 42 (RN) directly after the incident and was noted to have an indentation from the bedpan, she/he was not painful, not upset, or angry. Staff 2 (DNS) interviewed all parties involved and concluded Staff 41 did not abuse Resident 48 but could not rule out neglect.
On 12/12/23 at 11:46 AM Resident 48 indicated she/he was left on a bedpan for about 30 minutes. Resident 48 stated she/he was a little uncomfortable but did not have skin breakdown from the incident. Resident 48 indicated it was a one time occurrence and was dealt with appropriately.
On 12/13/23 at 12:28 PM Staff 43 indicated she arrived for her shift on 11/6/23 and was informed by Staff 42 that Resident 48 needed to be taken off a bedpan because she/he had been on the bedpan for roughly 40 minutes. Staff 43 stated when she entered the resident's room the resident did not appear upset but asked for the bedpan to be removed. Staff 43 indicated she removed the bedpan and could see marks on her/his buttocks from the bedpan.
On 12/13/23 at 6:41 PM Staff 42 stated he worked on 11/6/23 when Resident 48 was placed on a bedpan and Staff 41 forgot to remove the bedpan prior to leaving his shift. Staff 42 stated Resident 48 used her/his call light and Staff 43 removed the bedpan from underneath the resident. Staff 42 indicated the resident was assessed, was not angry or painful but indicated she/he was left on the bedpan too long.
On 12/18/23 at 9:27 AM Staff 41 (CNA) stated he cared for Resident 48 on 11/6/23 and acknowledged he placed the resident on the bedpan and forgot to remove the bedpan before he left his shift. Staff 41 indicated he was educated and in-serviced regarding the incident and that it was not a purposeful act and apologized to Resident 48.
On 12/18/23 at 11:14 AM Staff 2 (DNS) confirmed and acknowledged the incident occurred regarding Resident 48 on 11/6/23.
2. Resident 118 was admitted to the facility in 11/2023 with diagnoses including right arm fracture and a history of a hip fracture.
A 11/16/23 care plan revealed Resident 118 required two staff person assistance with toileting and required one staff person for personal hygiene needs.
A review of Resident 118's Urinary Incontinence and Indwelling Catheter CAA, dated 11/28/23 revealed the resident was frequently incontinent of bladder. Staff were to anticipate her/his needs, offer toileting frequently throughout the shift and provide incontinence care as needed.
On 12/12/23 at 10:48 AM and 12/13/23 at 1:02 PM Resident 118 and Witness 6 (Family Member) stated on two different occasions, staff neglected her/his call light and left her/him in a soaked brief and saturated bed for an extended period. Resident 118 indicated on one occasion staff failed to change her/him after dinner and she/he was not provided assistance until evening shift.
On 12/13/23 at 12:28 PM Staff 43 (CNA) stated Resident 118 required assistance with incontinence care because of bladder incontinence and she/he was a heavy wetter. Staff 43 indicated the resident was upset about sitting in a wet brief and bed several times. Staff 43 stated she provided incontinence care, changed the resident's bedding, and reported her concerns to the charge nurse.
On 12/13/23 at 6:51 PM Staff 42 (RN) stated Resident 118 had bladder incontinence and had sat in wet brief and bed.
On 10/18/23 at 10:52 AM Staff 2 (DNS) and Staff 40 (RNCM) denied knowing that Resident 118 received inadequate incontinence care and sat in a wet brief and bed. Staff 2 stated staff were expected to round every two hours and check on residents' dryness before the end of their shift.
CONCERN
(D)
📢 Someone Reported This
A family member, employee, or ombudsman was alarmed enough to file a formal complaint
Potential for Harm - no one hurt, but risky conditions existed
Respiratory Care
(Tag F0695)
Could have caused harm · This affected 1 resident
Based on observation, interview and record review it was determined the facility failed to follow physician orders for oxygen therapy and to ensure respiratory equipment was maintained for 1 of 1 samp...
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Based on observation, interview and record review it was determined the facility failed to follow physician orders for oxygen therapy and to ensure respiratory equipment was maintained for 1 of 1 sampled resident (#89) reviewed for respiratory care. This placed residents at risk for adverse respiratory complications and outcomes. Findings include:
Resident 89 was admitted to the facility in 6/2022 with diagnosis including COPD (chronic obstructive pulmonary disease).
a. Resident 89's Physician Order Summary Report as of 12/13/23 revealed the resident was to wear oxygen at one to three liters to keep her/his oxygen saturation between 88 to 92 percent. Staff were directed to document the saturation levels three times a day.
Resident 89's oxygen saturation levels from 11/12/23 through 12/12/23 indicated the resident wore oxygen at night and while oxygen was in use the resident's oxygen saturation levels ranged from 93 to 96 percent. The amount of oxygen the resident used at night was not documented.
On 12/13/23 at 1:21 PM Staff 22 (RN) stated the resident wore oxygen at night for COPD with parameters to keep the resident's oxygen saturation levels between 88 to 92 percent. Staff 22 stated they kept Resident 89's oxygen on all night per the resident's preference even when her/his oxygen saturation level exceeded 92 percent. Staff 22 verified Resident 89's oxygen saturation levels were above 92 percent when she/he was administered oxygen.
On 12/18/23 at 11:40 AM Staff 2 (DNS) confirmed Resident 89's oxygen saturation levels were at levels that exceeded the physician ordered parameter for oxygen administration. Staff 2 stated her expectation was for staff to follow the physician's orders.
b. Observations on 12/11/23 and 12/13/23 revealed Resident 89's oxygen tubing did not indicate when it was last changed.
Resident 89's 12/2023 Physician Orders and 12/2023 TAR revealed no order for oxygen tubing changes.
On 12/13/23 at 1:21 PM Staff 22 stated Resident 89's oxygen tubing was to be changed weekly, and labeled with a date and initials of staff to indicate when they were last changed. Staff 22 confirmed Resident 89's oxygen tubing was not labeled and there was no physician order for oxygen tubing changes.
On 12/18/23 at 11:40 AM Staff 2 stated her expectation was for residents receiving oxygen therapy to have a physician's order for oxygen tubing changes to be completed weekly.
CONCERN
(D)
📢 Someone Reported This
A family member, employee, or ombudsman was alarmed enough to file a formal complaint
Potential for Harm - no one hurt, but risky conditions existed
Unnecessary Medications
(Tag F0759)
Could have caused harm · This affected 1 resident
Based on observation, interview and record review it was determined the facility failed to ensure a medication error rate of less than five percent for 2 of 7 sampled residents (#s 17 and 57) reviewed...
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Based on observation, interview and record review it was determined the facility failed to ensure a medication error rate of less than five percent for 2 of 7 sampled residents (#s 17 and 57) reviewed for medication administration. The facility's medication error rate was 10.71%. This placed residents at risk for adverse medication consequences. Findings include:
1. Resident 17 was admitted to the facility in 12/2017 with diagnoses including diabetes.
Resident 17's 12/14/23 physician's orders included Humalog insulin 8 units to be administered to the resident subcutaneously (under the skin) two times a day.
The Humalog manufacturer instructions indicated a priming dose of two units prior to each dose with the Humalog insulin pen was required to remove air and ensure an accurate dose.
On 12/13/23 at 8:09 AM Staff 8 (LPN) was observed to dial 8 units on the Humalog insulin pen without first performing the two unit priming dose.
On 12/13/23 at 8:09 AM the surveyor stopped Staff 8 and asked about the priming dose. Staff 8 stated she did not routinely use a priming dose.
On 12/13/23 at 8:32 AM Staff 5 (RNCM) stated a priming dose for the Humalog insulin pen was completed when the pen was first accessed and not with every dose.
On 12/18/23 at 11:26 AM Staff 2 (DNS) stated she expected each dose of an insulin pen to be primed first with 2 units and medications were administered according to manufacturer instructions.
2. Resident 57 was admitted to the facility in 8/2018 with diagnoses including gastroenteritis and colitis (inflammation of the stomach and colon).
Resident 57's Physician Order Summary Report as of 12/12/23 indicated the following scheduled medication orders:
- polyethylene glycol (laxative) daily. Hold for loose stools.
- senna-docusate sodium (laxative) twice daily. Hold for loose stools.
Resident 57's bowel movement (BM) records indicated on 12/12/23 the resident had two soft/loose BMs and one large diarrhea BM.
On 12/13/23 at 9:00 AM Staff 8 (LPN) was observed to administer Resident 57 the scheduled polyethylene glycol and senna-docusate sodium medications.
On 12/13/23 at 11:39 AM Staff 8 stated her process was to check resident's bowel records prior to the administration of scheduled bowel medications. Staff 8 stated she was not aware of Resident 57's loose stools and acknowledged the resident's bowel medications should have been held for loose stools as the physician ordered.
On 12/18/23 at 11:26 AM Staff 2 (DNS) confirmed Resident 57 had loose/diarrhea stools on 12/12/23 and the resident's scheduled bowel medications were not held as the physician ordered. Staff 2 stated she expected medications to be administered as ordered.
CONCERN
(D)
📢 Someone Reported This
A family member, employee, or ombudsman was alarmed enough to file a formal complaint
Potential for Harm - no one hurt, but risky conditions existed
Deficiency F0761
(Tag F0761)
Could have caused harm · This affected 1 resident
**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, interview, and record review it was determined the facility failed to ensure 2 of 9 medication carts were ...
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**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, interview, and record review it was determined the facility failed to ensure 2 of 9 medication carts were properly secured during random observation. This placed residents at risk for reduced efficacy of medication and unauthorized access to medications. Findings include:
1. On 12/12/23 observations were made from 9:56 AM to 10:12 AM of a medication cart left unlocked and unattended near rooms [ROOM NUMBERS].
On 12/12/23 at 10:12 AM Staff 24 (CMA) acknowledged the cart was unlocked and was to be locked at all times when not in use.
On 12/18/23 at 9:09 AM Staff 2 (DNS) stated she expected the medication carts to be locked when the CMA and nurse were not at the cart.
2. On 12/13/23 observations were made from 12:47 PM to 1:02 PM of a medication cart left unlocked and unattended near the Center Hall dining room.
On 12/13/23 at 1:02 PM Staff 6 (RN) acknowledged the cart was unattended and unlocked.
On 12/18/23 at 9:09 AM Staff 2 (DNS) stated she expected the medication carts to be locked when the CMA and nurse were not at the cart.
Aug 2023
6 deficiencies
1 Harm
SERIOUS
(G)
📢 Someone Reported This
A family member, employee, or ombudsman was alarmed enough to file a formal complaint
Actual Harm - a resident was hurt due to facility failures
Accident Prevention
(Tag F0689)
A resident was harmed · This affected 1 resident
**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on interview and record review it was determined the facility failed to follow resident care plans related to transfers fo...
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**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on interview and record review it was determined the facility failed to follow resident care plans related to transfers for 3 of 7 sampled residents (#s 1, 2 and 24) reviewed for safety and transfers. Resident 1 fell and sustained a femur fracture. Findings include:
Resident 1 was admitted to the facility in 2022 with diagnoses including hypertension, lymphedema, and reduced mobility.
The admission MDS dated [DATE] indicated Resident 1 required two-person extensive physical assistance for transfers.
Resident 1's Care Plan dated 8/30/22 identified Resident 1 to be at risk for falls due to decreased mobility and weakness. Interventions on the care plan included two person mechanical lift assistance for transfers.
A Facility Investigation Report dated 6/15/22 at 3:10 PM indicated Resident 1 fell to the floor from the commode and sustained an oblique fracture of the right distal femur. According to the investigation, Staff 18 (CNA) assisted Resident 1 from the commode back to bed when Resident 1 slid from the commode to floor. This caused Resident 1's right leg to point inwards while her/his left leg remained straight. Staff 18 grabbed Resident 1 by the upper body and called for help. Staff 19 (CNA) assisted Staff 18 to lower Resident 1 to the floor. The investigation revealed Resident 1 sustained a right distal femur fracture as a result of the fall. Staff 18 indicated she did not follow Resident 1's care plan that required 2-person extensive assistance for transfers.
On 8/8/23 at 10:30 AM the surveyor attempted to contact Staff 18 but was unable to reach her.
On 8/8/23 at 1:08 PM Staff 19 stated Staff 18 called for help during the 6/15/22 incident and witnessed Resident 1 with both legs twisted while she/he began to slide to the floor. Staff 19 confirmed Resident 1 was a two-person transfer and Resident 1 sustained an injury as a result of the fall.
On 8/8/23 at 1:37 PM Staff 20 (RN) stated Staff 18 reported the incident. Staff 20 further stated Resident 1 complained of pain and an x-ray was conducted at the facility which confirmed Resident 1 sustained a fracture and was transferred to the hospital. Staff 20 confirmed Staff 18 did not follow the care plan.
On 8/16/23 at 12:34 PM Staff 1 (Administrator), Staff 9 (Regional RN) and Staff 2 (Quality Assurance RN) acknowledged Staff 18 did not follow Resident 1's Care Plan which resulted in a right femur fracture.
2. Resident 2 was admitted to the facility in 2018 with diagnoses including stroke and paralysis.
The admission MDS dated [DATE] indicated Resident 2 required two-person extensive physical assistance for transfers.
Resident 2's Care Plan dated 7/10/23, revised on 4/17/23 identified Resident 2 to be at high risk for falls related to paralysis.
According to Nursing Notes dated 6/21/22 at 7:59 AM and 10:30 AM, Staff 3 (LPN) indicated Resident 2 experienced pain near her/his left breast. The note revealed Staff 19 strapped Resident 2 too tightly then transferred her/him into a shower chair which caused significant pain and resulted in a 15 cm x 14 cm bruise near the left breast. Resident 2 was identified as a two-person assistance for transfers.
A Facility Investigation Report dated 6/25/22 revealed Staff 19 confirmed the strap used to transfer Resident 2 was tightened too tightly. Staff 19 further indicated when he attempted to transfer Resident 2 the strap became unsecured which caused Resident 2 significant pain. Staff 19 removed the strap and reported the incident. The facility revealed Resident 2 sustained a significant bruise on her/his left breast.
On 8/7/23 at 11:47 AM Resident 2 stated she/he was being transferred using a sit to stand device. Resident 2 indicated Staff 19 strapped her/him too tightly which caused significant discomfort. Resident 2 stated she/he had to communicate several times to the CNA to stop the transfer due to the pain before the CNA stopped. Resident 2 stated once the strap was removed a large bruise had formed near her/his left breast. Resident 2 confirmed to the surveyor that she/he required two-person assistance for transfers.
On 8/7/23 at 2:43 PM Staff 19 (CNA) confirmed he did not follow the care plan when transferring Resident 2 which led to the bruise.
On 8/16/23 at 12:34 PM Staff 1 (Administrator), Staff 2 (Quality Assurance RN) and Staff 9 (Regional RN) confirmed the findings above and no additional information was provided.
3. Resident 24 was admitted to the facility in 2023 with diagnosis including atrial fibrillation and heart failure.
The admission MDS dated [DATE] indicated Resident 24 required two-person extensive physical assistance for transfers.
Resident 24's Care Plan dated 4/5/23 indicated Resident 24 was a two-person transfer and required non-skid footwear and use of a transfer pole for all transfers. Resident 24 was identified as a fall risk due to gait, balance, vision, and hearing problems.
A Facility Investigation Report dated 5/10/23 at 11:40 AM indicated Staff 4 (LPN) was alerted by Staff 21 (PT Assistant/PTA) that Resident 24 reported significant pain in her/his great right toe during physical therapy. Resident 24 indicated her/his foot slipped and hit a wall during a shower performed by Staff 22 (CNA). An x-ray was ordered which revealed Resident 24 sustained a fracture in her/his great right toe. Staff 22 (CNA) reported that despite knowing Resident 24 was a two-person transfer with a transfer pole and required non-skid socks, he did not believe it to be necessary. The Facility Investigation revealed Staff 22 failed to follow Resident 24's Care Plan related to transfers.
On 8/11/23 at 11:22 AM Staff 22 confirmed he did not follow Resident 24's care plan, Staff 22 indicated he believed Resident 24 was not injured after she/he hit her/his foot based on his assessment and therefore did not report the incident to the Charge Nurse. Staff 22 confirmed Resident 24 sustained a fracture on the right great toe as a result of the incident.
On 8/11/23 at 11:28 AM Staff 4 stated the incident was reported to her the day after by the PTA. Staff 4 stated she requested an order for an x-ray to be conducted on Resident 24's right big toe. Staff 4 confirmed a fracture of Resident 24's right big toe was sustained as a result of Staff 22 not following Resident 24's care plan.
On 8/11/23 at 11:45 AM Staff 21 confirmed she was alerted by Resident 24 regarding the residents reported toe pain. Staff 21 confirmed Resident 24 sustained a fracture.
On 8/16/23 at 12:34 PM Staff 1 (Administrator), Staff 2 (Quality Assurance RN) and Staff 9 (Regional RN) confirmed the above findings and no additional information was provided.
CONCERN
(D)
📢 Someone Reported This
A family member, employee, or ombudsman was alarmed enough to file a formal complaint
Potential for Harm - no one hurt, but risky conditions existed
Free from Abuse/Neglect
(Tag F0600)
Could have caused harm · This affected 1 resident
2. Resident 18 was admitted to the facility in 2016 with diagnoses including dementia, hypertension, and hyperlipidemia.
Resident 18's 7/20/23 admission MDS included Resident 18 had a BIMS score of 2...
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2. Resident 18 was admitted to the facility in 2016 with diagnoses including dementia, hypertension, and hyperlipidemia.
Resident 18's 7/20/23 admission MDS included Resident 18 had a BIMS score of 2 out of 15 indicating significant cognitive impairment.
Resident 18's Care Plan dated 11/27/19, and revised on 10/24/22, revealed Resident 18 had a history of behaviors related to verbal and physical altercations related to verbal abuse.
A Facility Incident Report dated 10/19/22 revealed Staff 24 (CNA) stated to Resident 19 you think you are special; you are not better than everyone else. The facility conducted interviews with Staff 24 and identified Staff 24 admitted to the altercation.
On 8/8/23 at 11:50 AM Staff 24 could not be reached for comment.
On 8/8/23 at 12:02 PM Staff 3 (LPN) confirmed the incident of verbal abuse as well as the words that were spoken from Staff 24 on the day of incident.
On 8/16/23 at 12:34 PM Staff 1 (Administrator), Staff 2 (Quality Assurance RN) and Staff 9 (Regional RN) the verbal abuse findings were confirmed with all parties and no additional information was provided.
Based on interview and record review it was determined the facility failed to ensure residents were free from abuse for 2 of 11 sampled residents (#s 18 and 25) reviewed for abuse. This placed residents at risk for verbal and physical abuse and psychosocial harm. Findings include:
1. Resident 3 admitted to the facility in 2020 with diagnoses including dementia.
Resident 25 admitted to the facility in 2020 with diagnoses including dementia and stroke.
Resident 3's 6/6/23 Progress Note indicated Resident 3 had a physical altercation with Resident 25. Resident 3 scratched Resident 25's face when Resident 25 accidentally bumped Resident 3's wheelchair. Resident 25 sustained a skin tear to the forehead which measured 0.4 cm x 0.3 cm.
The 6/6/23 Facility Investigation revealed Resident 3 scratched Resident 25 on the forehead when Resident 25 accidentally bumped her/his wheelchair into Resident 3's wheelchair, which resulted in a 0.4 cm x 0.3 cm skin tear.
On 8/9/23 at 12:20 PM Staff 2 (Quality Assurance RN) and Staff 3 (LPN Resident Care Manager) confirmed Resident 2 physically abused Resident 25 on 6/6/23 when Resident 3 scratched Resident 25's forehead.
CONCERN
(D)
📢 Someone Reported This
A family member, employee, or ombudsman was alarmed enough to file a formal complaint
Potential for Harm - no one hurt, but risky conditions existed
ADL Care
(Tag F0677)
Could have caused harm · This affected 1 resident
Based on interview and record review it was determined the facility failed to provide timely ADL assistance for 1 of 4 sampled resident (#13) reviewed for ADL Assistance. This placed residents at risk...
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Based on interview and record review it was determined the facility failed to provide timely ADL assistance for 1 of 4 sampled resident (#13) reviewed for ADL Assistance. This placed residents at risk for untimely and unmet care needs. Findings include:
Resident 13 was admitted to the facility in 2022 with diagnosis including Gullain-Barre Syndrome (a condition that causes rapid muscle weakness).
Resident 13's Care Plan dated 8/3/22 identified Resident 13 required assistance with toileting.
A Facility Investigation Report dated 9/27/22 stated Resident 13 reported she/he was left on the commode for nearly an hour by Staff 23 (CNA). Resident 13 indicated no staff came to assist her/him off the commode until they were notified by family. The investigation revealed Staff 23 witnessed Resident 13's call light activation but continued to complete his daily duties as he assumed other staff were going to answer the call light.
On 8/11/23 at 3:10 PM Staff 23 confirmed he walked past the resident's activated call light, but did not respond and assist Resident 13.
On 8/16/23 at 12:34 PM Staff 1 (Administrator), Staff 2 (Quality Assurance RN) and Staff 9 (Regional RN) confirmed Resident 13 did not receive timely ADL assistance. No additional information was provided.
CONCERN
(D)
📢 Someone Reported This
A family member, employee, or ombudsman was alarmed enough to file a formal complaint
Potential for Harm - no one hurt, but risky conditions existed
Quality of Care
(Tag F0684)
Could have caused harm · This affected 1 resident
**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY**
Based on interview and record review it was determined the facility failed to respond timely to a change of condition for 1 of ...
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**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY**
Based on interview and record review it was determined the facility failed to respond timely to a change of condition for 1 of 3 sampled residents (#26) reviewed for change of condition. This placed residents at risk for a delay in treatment. Findings include:
1. Resident 26 admitted to the facility on [DATE] with diagnoses including left femur fracture with left artificial joint.
The 6/16/23 Pain Care Plan instructed staff to monitor, record and report to the nurse any signs or symptoms of non-verbal pain or complaints of pain.
The 6/26/23 at 10:50 AM Progress Note revealed Resident 26 had increased pain to the left hip, was unable to work with therapy and the left leg appeared to be turned in. The physician was notified.
The 6/26/23 Physician Encounter note revealed the resident had significant pain and a deformity was noted upon exam. An urgent x-ray was ordered and a left leg dislocation was suspected.
The 6/26/23 Facility Investigation revealed Staff 5 (CNA) noted the resident had pain both times incontinent care was performed during the night shift, but did not report the pain to the nurse. Staff 6 (CNA) assisted the resident to transfer to the commode on day shift, had to utilize the sit-to-stand machine and noted the resident had pain. Staff 6 did not report the deviation from Resident 26's baseline related to transferring or the complaints of pain to the nurse. Staff 4 (LPN) observed the resident in her/his wheelchair sitting awkwardly. Staff 4 assisted Resident 26 back to bed and noted the resident was weak, in pain and not helping much to stand. The nurse provided the resident with a narcotic pain medication and ice, but did not assess the resident for the change of condition. Staff 10 (PT Assistant) assessed the resident and notified Staff 4 (at 10:00 am) the left leg was turned inward. Staff 4 then notified the physician.
The 6/27/23 Physician Encounter Note revealed Resident 26 was transferred to the Emergency Department on 6/26/23 due to worsening pain in the left leg with notable internal rotation. Resident 26 was diagnosed with a prosthetic dislocation, she/he underwent a closed reduction in the Emergency department and was transferred back to the facility the same day.
Staff 5 and Staff 6 were unavailable for interview.
On 8/14/23 at 11:14 AM Staff 4 verified she assisted Resident 26 back to bed, noted she/he was painful and weak and confirmed Staff 10 was the staff member who assessed Resident 26's change of condition.
On 8/14/23 at 11:30 AM Staff 8 (RNCM) confirmed both Staff 5 and Staff 6 did not report Resident 26's pain or change of condition to the nurse and Staff 4 did not assess Resident 26's change of condition.
CONCERN
(D)
📢 Someone Reported This
A family member, employee, or ombudsman was alarmed enough to file a formal complaint
Potential for Harm - no one hurt, but risky conditions existed
Infection Control
(Tag F0880)
Could have caused harm · This affected 1 resident
Based on interview and record review it was determined the facility follow proper infection control techniques during bowel care for 1 of 1 sampled resident (#18) reviewed for bowel care. This placed ...
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Based on interview and record review it was determined the facility follow proper infection control techniques during bowel care for 1 of 1 sampled resident (#18) reviewed for bowel care. This placed residents at risk for cross contamination. Findings include:
Resident 18 was admitted to the facility in 2016 with diagnoses including dementia, hypertension, and hyperlipidemia.
Resident 18's 7/20/23 admission MDS identified Resident 18 with a BIMS score of 2 out of 15 which indicated significant cognitive impairment and frequent bowel and bladder incontinence.
A Facility Incident Report dated 10/19/22 revealed Staff 24 (CNA) performed improper infection control related to the use of gloves and handling of Resident 18's bowel care. Staff 24 stated she did not wear gloves when providing bowel care or when performing peri care. Staff 24 further stated she used the same wipes used to the clean the toilet on Resident 19's skin.
On 8/8/23 at 11:50 AM Staff 24 could not be reached for comment.
On 8/8/23 at 12:02 PM Staff 3 (LPN) confirmed Staff 24 performed improper infection control procedures and practices related to cleaning and hygiene. Staff 3 indicated Staff 24 used the same wipes to clean Resident 18's toilet on Resident 18's skin and confirmed Staff 24 handled Resident 18's bowel movement without gloves.
On 8/16/23 at 12:34 PM Staff 1 (Administrator), Staff 2 (Quality Assurance RN) and Staff 9 (Regional RN) confirmed the above findings and no additional information was provided.
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 F0725
(Tag F0725)
Could have caused harm · This affected multiple residents
**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, interview, and record review it was determined the facility failed to ensure sufficient staffing to meet r...
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**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, interview, and record review it was determined the facility failed to ensure sufficient staffing to meet resident care needs for 1 of 1 facility reviewed for sufficient and competent staffing. This placed residents at risk for delayed and unmet care needs. Findings include:
Resident 15 admitted to the facility in 8/2022 with diagnoses including congestive heart failure and chronic kidney disease.
Resident 15's most recent Quarterly MDS dated [DATE] revealed a BIMS score of 15, indicating no cognitive impairment. Resident 15 was assessed to be an extensive assist with bed mobility, transfers and toileting, was continent of bowel and bladder and used a bedpan.
The facility submitted a report to the state agency on 10/3/22 which revealed Resident 15 told a staff member she/he was left on the bedpan for one and a half hours on 9/30/22. She/he stated the call light was activated around 6:00 PM and she/he waited a long time for a CNA to respond. The facility's investigation concluded the agency CNA who initially assisted Resident 15 on the bedpan left for her meal break and assumed the other CNA would assist the resident off the bedpan. The other CNA was unable to assist the resident and she/he was not assisted for approximately two hours. Resident 15 reported discomfort on her/his back and coccyx while on the bedpan but sustained no injuries.
Resident 15 was not interviewed due to discharging from the facility.
Resident 19 admitted to the facility in 4/2022 with diagnoses including stroke and heart disease.
Resident 19's Quarterly MDS dated [DATE] revealed a BIMS score of 12, indicating moderate cognitive impairment. Resident 19 was assessed to be an extensive assist with bed mobility, transfers and toileting. She/he was incontinent of bowel and bladder and wore incontinent briefs.
On 8/16/23 at 1:22 PM, Witness 1 (Family Member) stated she frequently visited Resident 19 from 4/2022 through 11/2022, recalled the resident had on a wet or soiled brief, and it took staff half an hour to an hour to respond. Witness 1 stated she had to find staff due to nobody answering the call light and upon responding staff told her they were short-staffed. Witness 1 recalled a few occasions when Staff 15 (CNA) was the only CNA on the hall and could not reposition or provide cares to Resident 19 alone.
On 8/8/23 at 10:49 AM and 8/14/23 at 2:20 PM, Staff 13 (CNA) stated last fall and winter was really bad related to staffing levels and day shift was the least staffed. She/he recalled CNA's had up to 12 residents assigned to them on a shift, there were long call light response wait times, delayed care for residents, and it was chaotic. Staff 13 stated the current resident assignent for CNA's was six to seven residents but there were times when showers were not given due to time constraints.
On 8/14/23 at 12:12 PM Staff 15 recalled the facility was short-staffed 11/2022 and 12/2022 and the resident assignments were higher than usual. Staff 15 recalled she/he finished resident cares but was unsure if other staff were able to finish the care timely.
On 8/14/23 at 2:41 PM, Staff 14 (CNA) stated the facility was short-staffed in the fall of 2022 and cares were provided late which included taking vital signs, bringing water and snacks to residents and completing incontinence care timely. Staff 14 recalled she/he was assigned up to 11 residents and the average ratio for evening shift was nine residents per CNA.
Review of the Direct Care Staff Daily Reports from 9/1/22 through 9/30/22, 10/1/22 through 10/31/22, 11/1/22 through 11/30/22 and 12/1/22 through 12/31/22 revealed the facility did not meet state staffing requirements for CNAs for 16 out of 30 days in 9/2022, 14 out of 31 days in 10/2022, 21 out of 30 days in 11/2022 and 19 out of 31 days in 12/2022. The majority of the staffing shortages were for day shift.
On 8/14/23 at 2:21 PM, Staff 11 (Staffing Coordinator) confirmed the facility was short staffed from 9/2022 through 12/2022 and it was challenging to find staff willing to work day shifts.
Apr 2023
7 deficiencies
2 Harm
SERIOUS
(G)
📢 Someone Reported This
A family member, employee, or ombudsman was alarmed enough to file a formal complaint
Actual Harm - a resident was hurt due to facility failures
Deficiency F0687
(Tag F0687)
A resident was harmed · This affected 1 resident
Based on interview and record review it was determined the facility failed to provide adequate foot care for 1 of 3 sampled residents (#6) reviewed for diabetic foot care. This caused Resident 6 to de...
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Based on interview and record review it was determined the facility failed to provide adequate foot care for 1 of 3 sampled residents (#6) reviewed for diabetic foot care. This caused Resident 6 to develop a full thickness diabetic foot ulcer. This placed other residents at risk for increased foot problems. Findings include:
Resident 6 was admitted to the facility in 2017 with diagnoses including diabetes with neurological complication.
Review of Resident 6's clinical record revealed the following:
A care plan intervention initiated 7/2017 revealed Resident 6 was to always wear her/his custom diabetic shoes when up and or mobilizing.
According to the resident's record she/he was provided new diabetic shoes on an annual basis from 2019 through 2021.
On 5/2/22 secure communication with the physician noted the top of all the toes on Resident 6's left foot were pink, possibly from the resident's shoes.
Resident 6's clinical record indicated she/he was not reassessed, the care plan was not updated to address potential issues with the shoes not fitting, and monitoring of the resident's toes was not initiated. There was no documentation in Resident 6's clinical record indicating her/his toes were being monitored daily by a licensed nurse.
According to the resident's record, in June of 2022 the resident did not receive new diabetic shoes due to a physician refusing to sign the authorization request.
Progress notes dated 10/1/22 indicated Resident 6 had a full thickness wound to the top of her/his left great toe.
A United Wound Healing (UWH) progress note dated 10/20/22 indicated not to use the diabetic shoes due to the shoes causing increased irritation to the left foot.
A UWH progress note dated 10/25/22 indicated despite wound nurse recommendations, Resident 6 still wore her/his old diabetic shoe over the full thickness ulcer on her/his left great toe. Additionally, a blister to the same toe as the full thickness ulcer was noted to have formed since 10/20/22.
On 3/29/23 at 3:37 PM Staff 9 (CNA) stated in the last six months Resident 6 stated she/he did not like her/his shoes, they made her/his feet hurt. Staff 9 also stated there were times when Resident 6 had non-skid socks and her/his shoes on and that caused a lot of pain to the resident as well. There was no documented evidence in Resident 6's clinical record this information was reported, and no changes were made to the resident's care as a result.
On 4/5/23 at 12:13 PM Staff 7 (Care Manager) stated Resident 6's foot wound could have been caused by her/his old diabetic shoes not fitting properly.
On 4/7/23 at 3:38 PM Witness 3 (Wound RN) indicated Resident 6 had a claw toe which raised the knuckle up; it put her/him at risk because the toe rubbed on any type of surface not designed to take that into consideration. She advised the facility to stop use of the resident's old shoe, however it was noted still on the left foot five days after she advised the shoe to no longer be used. Witness 3 indicated given the information available, Resident 6's shoes were the cause of irritation that led to the diabetic foot ulcer.
SERIOUS
(G)
📢 Someone Reported This
A family member, employee, or ombudsman was alarmed enough to file a formal complaint
Actual Harm - a resident was hurt due to facility failures
Deficiency F0692
(Tag F0692)
A resident was harmed · This affected 1 resident
Based on interview and record review it was determined the facility failed to ensure a resident received sufficient fluid intake for 1 of 3 sampled residents (#6) reviewed for hydration. This failure ...
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Based on interview and record review it was determined the facility failed to ensure a resident received sufficient fluid intake for 1 of 3 sampled residents (#6) reviewed for hydration. This failure resulted in Resident 6 being hospitalized due to dehydration. This placed residents at risk for dehydration. Findings include:
Resident 6 was admitted to the facility in 2022 with diagnoses including Alzheimer's disease and difficulty swallowing.
A 3/28/19 aspiration care plan indicated Resident 6 had a diet order of General/Puree/honey thick liquids; no straws, liquids via 2 handled cup. Resident 6 was to be close 1:1 supervision with full 1:1 cueing and 1:1 assistance as indicated for eating and drinking. The care plan provided no info on how resident 6 was to get drinks between meals, or how the resident was being monitored specifically for dehydration.
A 6/29/21 and 4/19/22 medical nutritional therapy assessment indicated Resident 6 required an estimated 1700 milliliters of fluids per day.
A review of Resident 6's meal and fluid intake record for 4/2022 revealed the following intakes:
4/1 - 940 mL
4/2 - 833 mL
4/3 - 640 mL
4/4 - 1000 mL
4/5 - 980 mL
4/6 - 400 mL
4/7 - 680 mL
4/8 - 720 mL
4/9 - 640 mL
4/10 - 720 mL
4/11 - 870 mL
4/12 - 710 mL
4/13 - 240 mL
4/14 - RNA
4/15 - RNA
4/16 - ---
4/17 - 240 mL
4/18 - 1030 mL
4/19 - 660 mL
4/20 - 820 mL
4/21 - 360 mL
4/22 - 720 mL
4/23 - 1000 mL
4/24 - 400 mL
A progress note dated 4/24/22 indicated resident 6 was sent out to the emergency room for evaluation due to low blood pressure and increased respirations.
A progress note dated 4/27/22 indicated Resident 6 was re-admitted from the hospital with diagnoses including dehydration and lethargy.
Hospital Records dated 4/27/22 indicated Resident 6 was treated in the hospital for free water deficit and received three liters of fluids.
On 4/7/23 at 10:58 AM Staff 11 (RN) indicated new interventions were put in place to monitor Resident 6's fluid status after returning from the hospital due to dehydration.
CONCERN
(D)
📢 Someone Reported This
A family member, employee, or ombudsman was alarmed enough to file a formal complaint
Potential for Harm - no one hurt, but risky conditions existed
Free from Abuse/Neglect
(Tag F0600)
Could have caused harm · This affected 1 resident
Based on observation, interview, and record review it was determined the facility failed to ensure residents were free from abuse for 1 of 3 sampled residents (#3) reviewed for abuse. This placed resi...
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Based on observation, interview, and record review it was determined the facility failed to ensure residents were free from abuse for 1 of 3 sampled residents (#3) reviewed for abuse. This placed residents at risk for abuse. Findings include:
Resident 3 was admitted to the facility in 2021 with diagnoses including Alzheimer's disease.
A 2/4/23 Progress Note (PN) revealed Resident 3 and Resident 2 were observed in an altercation in the common area, Resident 3's left arm was in the grip of Resident 2's hand. There was a small bruise and a skin tear noted to Resident 3's arm from the altercation.
A 2/4/23 Incident report indicated staff were aware Resident 2 and 3 should not be near each other due to known behaviors. The incident report further indicated staff were in proximity to Residents 2 and 3 however were not paying close attention to the residents.
On 3/29/23 Staff 3 (LN), Staff 4 (CNA), and Staff 5 (CNA) confirmed Resident 3 and Resident 2 were to be kept apart due to their behaviors.
On 4/5/23 at 12:13 PM Staff 7 (Care Manager) confirmed the altercation occurred between Resident 3 and Resident 2.
CONCERN
(D)
📢 Someone Reported This
A family member, employee, or ombudsman was alarmed enough to file a formal complaint
Potential for Harm - no one hurt, but risky conditions existed
Investigate Abuse
(Tag F0610)
Could have caused harm · This affected 1 resident
Based on interview and record review it was determined the facility failed to complete a thorough investigation for 1 of 3 sampled residents (#6) reviewed for abuse. This placed residents at risk for ...
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Based on interview and record review it was determined the facility failed to complete a thorough investigation for 1 of 3 sampled residents (#6) reviewed for abuse. This placed residents at risk for inaccurate investigations. Findings include:
Resident 6 was admitted to the facility in 2022 with diagnoses including Alzheimer's disease.
Resident 6 had incident reports and summaries on the following dates:
A 12/1/22 incident report Indicated Resident 6 had two new bruises. The facility suspected resident behaviors to be the cause. The resident stated, I got beat up by someone. There were no staff interviews conducted. A suspicion of a cause was identified but no actual precipitating event was found.
A 1/6/23 incident report indicated Resident 6 had a new bruise to the right lateral upper thigh. Resident 6 was unable to give a description of the cause. There were no staff interviews conducted. A suspicion of a cause was identified but no actual precipitating event was found, and no new interventions initiated.
A second 1/11/23 incident report indicated Resident 6 had a new bruise to the left lower outer leg. Resident 6 was unable to give a description of the cause. There were no staff interviews conducted. A suspicion of a cause was identified but no actual precipitating event was found.
A 1/19/23 incident report indicated Resident 6 had a new skin tear to her/his left arm. Resident 6 was unable to give a description of the cause. There were no staff interviews conducted. A potential cause was identified but no new interventions were put in place.
A 1/28/23 incident report indicated Resident 6 had a new bruise to the left upper chest measuring 4 cm by 3.4 cm. Resident 6 was unable to give a description of the cause. There were no staff interviews conducted. A suspicion of a cause was identified but no actual precipitating event was found.
A 2/2/23 incident report indicated Resident 6 had a new bruise to the anterior left upper arm. Resident 6 was unable to give a description of the cause. There were no staff interviews conducted. A suspicion of a cause was identified but no actual precipitating event was found.
A 2/7/23 incident report indicated Resident 6 had a new bruise to the right upper chest area measuring 3 cm by 5 cm, and a bruise to the back of her/his left thigh. Resident 6 was unable to give a description of the cause. There were no staff interviews conducted. A suspicion of a cause was identified but no actual precipitating event was found, and no new interventions implemented.
On 4/5/23 at 12:13 PM Staff 7 (LN Care manager) confirmed these investigations were not thorough.
CONCERN
(D)
📢 Someone Reported This
A family member, employee, or ombudsman was alarmed enough to file a formal complaint
Potential for Harm - no one hurt, but risky conditions existed
Deficiency F0772
(Tag F0772)
Could have caused harm · This affected 1 resident
Based on interview and record review it was determined the facility failed to process physician laboratory orders timely for 1 of 3 sampled residents (#8) reviewed for laboratory services. This placed...
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Based on interview and record review it was determined the facility failed to process physician laboratory orders timely for 1 of 3 sampled residents (#8) reviewed for laboratory services. This placed residents at risk for untreated conditions. Findings include:
Resident 8 admitted to the facility in 2020 with diagnoses including chronic kidney disease.
A physician order dated 12/10/20 indicated staff were to obtain a UA with C & S (culture and sensitivity) for Resident 8.
A physician progress note dated 12/14/20 indicated a C & S was not received.
A physician progress note dated 12/16/20 indicated the physician ordered a second UA and C & S due to the results of the first C & S not being completed.
Laboratory services results indicated the second UA was completed with no bacteria seen on 12/20/20. This was 10 days after the original order was given.
A stat physician order dated 6/1/21 indicated the physician ordered a UA with C & S for Resident 8.
Laboratory services results indicated an Automated UA was completed on 6/1/21, a C & S was not completed despite the facility sending the order correctly.
A 6/7/21 physician progress note indicated the C & S result never returned despite facility request. The progress note further indicated a second UA and C & S was ordered.
On 4/5/23 at 12:51 PM Staff 1 (Administrator) acknowledged the laboratory was not able to complete orders correctly. Staff 1 further stated the facility identified failures of that laboratory services company in early 2022. Staff 1 interviewed other laboratory services and switched companies in June of 2022.
During survey, residents had laboratory services available to them. Lab requests were made, and results returned timely.
On 5/15/22, the Past Noncompliance was corrected when the facility completed an investigation into new laboratory services and signed a new contract. The Plan of Correction included: 1. QA discussion of intermittent problems, 2. Conversations with old lab representatives, 3. Contact with other facilities for other possible laboratory options. 4. Negotiations and contract signing on 5/12/22 with new laboratory.
CONCERN
(D)
📢 Someone Reported This
A family member, employee, or ombudsman was alarmed enough to file a formal complaint
Potential for Harm - no one hurt, but risky conditions existed
Deficiency F0849
(Tag F0849)
Could have caused harm · This affected 1 resident
Based on interview and record review it was determined the facility failed to ensure hospice residents were routinely evaluated by physicians for PRN psychotropic use for 1 of 3 sampled residents (#4)...
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Based on interview and record review it was determined the facility failed to ensure hospice residents were routinely evaluated by physicians for PRN psychotropic use for 1 of 3 sampled residents (#4) reviewed for psychotropic medications. This placed residents at risk for receiving unnecessary psychotropic medications. Findings include:
Resident 4 was readmitted to the facility in 2023 for palliative care and ankle and foot infection.
A faxed physician order dated 1/12/23 indicated Resident 5 was prescribed Haloperidol (Antipsychotic) as needed. There was no stop date indicated on the physician order.
A faxed physician order dated 2/23/23 indicated Resident 5 was prescribed Quetiapine (Antipsychotic) one tab three times a day as needed. Thirty tabs in the initial order with three refills authorized which resulted in a 30 days' supply. There was no stop date indicated on the physician order.
The 1/2023 through 2/2023 MAR indicated Resident 4 had orders for Haldol (antipsychotic) every four hours PRN for agitation or hallucinations. Order start date of 1/18/23 and a discontinue date of 2/23/23.
There were no provider notes indicating Resident 4 was re-evaluated in person for the use of PRN Haldol for more than two weeks.
The 2/2023 through 3/2023 MAR indicated Resident 4 had orders for Seroquel (Antipsychotic) every eight hours PRN for dangerous agitation or aggressive behaviors. Order start date of 2/23/23 and a discontinue date of 3/18/23. The Seroquel order description was changed by the facility multiple times however the dosage order remained the same.
There were no provider notes indicating Resident 4 was re-evaluated in person for the use of PRN Seroquel.
On 3/26/23 at 12:56 PM Staff 4 (Resident Care Manager) stated Resident 21 readmitted to the facility on hospice services. Staff 4 stated there was no evidence the hospice provider re-evaluated the PRN Haldol. Staff 4 added the provider gave an extension past the 14 days of the order.
On 3/27/23 at 8:38 AM Staff 2 (DNS) was asked about PRN antipsychotic medications and stated the facility asked hospice to reassess and reorder the medication. Staff 2 added the facility needed to follow up with hospice.
On 4/4/23 at 1:17 PM Staff 10 (RN) confirmed when hospice sent orders, they never put a stop date on the orders. Staff 10 further stated she could not recall ever seeing a hospice provider in the facility and knew hospice did not like being told a face-to-face visit was required or a medication stop date.
CONCERN
(D)
📢 Someone Reported This
A family member, employee, or ombudsman was alarmed enough to file a formal complaint
Potential for Harm - no one hurt, but risky conditions existed
Antibiotic Stewardship
(Tag F0881)
Could have caused harm · This affected 1 resident
Based on interview and record review it was determined the facility failed to implement their Antibiotic Stewardship program to ensure antibiotics were used in accordance with current FDA (Food and dr...
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Based on interview and record review it was determined the facility failed to implement their Antibiotic Stewardship program to ensure antibiotics were used in accordance with current FDA (Food and drug administration) and CDC guidance for 2 of 3 sampled residents (#s 5 and 8) reviewed for infections. This placed residents at risk for proliferation of drug resistant organisms. Findings Include:
1. Resident 8 admitted to the facility in 2020 with diagnoses including chronic kidney disease.
A. A physician progress note dated 12/10/20 indicated Resident 8 had increased weakness, fatigue, and poor appetite over the last 1-2 days. There were no reports of localized signs, symptoms, or fever. Resident 8's vitals were normal.
A physician order dated 12/10/20 indicated staff were to obtain a UA with C & S (culture and sensitivity-determines appropriate antibiotic for the identified infection) for Resident 8.
A physician order dated 12/10/20 indicated staff were to initiate treatment for urine infection with Cephalexin (antibiotic) for five days. Antibiotics were started without the C & S.
A physician progress note dated 12/16/20 indicated the physician ordered a second UA and culture and sensitivity due to the results of the first not being completed
A physician order dated 12/16/20 indicated Resident 8 was to be administered Ceftriaxone (antibiotic) for five days.
Laboratory service results indicated the second UA was completed with no bacteria seen on 12/20/20.
A review of Resident 8's clinical record indicated antibiotics were administered without indication for use.
On 4/6/23 at 11:15 AM Staff 2 (DNS) confirmed the antibiotics were started early and the facility should have spoken with the physician regarding antibiotic stewardship (waiting for C & S) prior to starting the antibiotic.
B. A physician progress note dated 6/1/21 indicated resident 8 was noted to have increased lethargy and reduced intake for the last two days. No other symptoms noted.
A stat physician order dated 6/1/21 indicated a UA with culture and sensitivity (C & S) for Resident 8.
A physician order dated 6/2/21 indicated Resident 8 was to be administered Cephalexin (antibiotic) for five days.
A 6/7/21 physician progress note indicated the culture and sensitivity result never returned despite facility request.
On 4/6/23 at 11:15 AM Staff 2 (DNS) confirmed the antibiotics were started early and the facility should have spoken with the physician regarding antibiotic stewardship (waiting for C & S) prior to starting the antibiotic.
2. Resident 5 admitted to the facility in 2021 with diagnoses including urinary incontinence.
A progress note dated 1/9/23 indicated Resident 5 was shivering and walked around the unit. Resident 5's blood pressure was slightly elevated; all other vitals were within normal range. The progress notes also indicated the resident had a low-grade fever the night before.
On 1/9/23 secure communication between the facility and Resident 5's physician revealed the physician ordered a UA with C & S (culture and sensitivity). Once the facility notified the physician the urine was collected for analysis the physician ordered Cipro (antibiotic) to be started immediately for a UTI.
Resident 5's record indicated the C & S was reported to the facility on 1/12/23, three days after the antibiotic was started.
On 4/6/23 at 11:15 AM Staff 2 (DNS) confirmed Resident 5's physician started antibiotics prior to the receipt of the C & S.
Jan 2023
7 deficiencies
1 IJ (1 affecting multiple)
CRITICAL
(K)
📢 Someone Reported This
A family member, employee, or ombudsman was alarmed enough to file a formal complaint
Immediate Jeopardy (IJ) - the most serious Medicare violation
Comprehensive Assessments
(Tag F0636)
Someone could have died · This affected multiple residents
Based on interview and record review it was determined the facility failed to complete admission and annual MDSes, for 4 of 9 sampled residents (#s 1, 2, 3 and 9) reviewed for MDS. There were an addit...
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Based on interview and record review it was determined the facility failed to complete admission and annual MDSes, for 4 of 9 sampled residents (#s 1, 2, 3 and 9) reviewed for MDS. There were an additional 26 non-sampled residents with incomplete admission or annual MDSes. This failure was determined to be an immediate jeopardy situation because it put residents at risk for unmanaged medications, side effects from medications, skin conditions, and unknown needs that were never identified or addressed, which could have led to permanent injury, severe infection, and unknown potential harm due to the lack of comprehensive assessment. Findings include:
1. Resident 1 admitted in 2022 with diagnoses including dementia, depression, and neurocognitive disorder with Lewy body dementia (uncontrolled body movements and hallucinations).
Review of Resident 1's record indicated the following was missing:
- 11/7/2022 admission MDS was incomplete.
- Comprehensive care plan was incomplete.
- Monitoring of symptoms and side effects for clonazepam (antianxiety medications).
- Monitoring of symptoms and side effects for Olanzapine (antipsychotic medications).
- Monitoring of symptoms and side effects for Paroxetine (antidepressant medications).
Failure to assess for the appropriate use of these medications and failure to monitor for symptoms and side effects of these medications can lead to seizures, internal bleeding, difficulty breathing, uncontrolled body movements, loss of self-control, swelling, and thoughts of suicide.
The incomplete admission assessment also resulted in a failure to assess the resident's functional capacity and needs, and an appropriate plan of care for, but not limited to, the following:
-Infections, psychotropic medications, behavioral health, permanent side effects from medications, vision and dental needs, trauma informed care, appropriate activity and socialization, cultural and religious needs as well as other unassessed needs.
This failure put Resident 1 at risk for unmonitored medications, behavioral health issues, psychotropic medication reactions, and any number of unknown treatable conditions due to a lack of assessment. This deficiency was likely to result in permanent injury, severe infection, mental anguish, and/or exposed other residents in the facility to potential behaviors.
On 1/18/23 at 11:14 Staff 4 (RN) stated she believed all MDSes she was responsible for were completed and was unaware Resident 1's MDS was not completed.
On 1/24/23 at 7:00 PM - Staff 3 (RN Consultant) confirmed the comprehensive care plans and monitoring of medications were not in place due to the admission MDS not being completed.
2. Resident 3 admitted in 2022 with diagnoses including Parkinson's disease, depression, and osteoporosis.
Review of Resident 3's record indicated the following was missing:
- 8/29/22 admission MDS.
- Comprehensive care plan.
- Assessment of and monitoring for symptoms and side effects for Paroxetine (antidepressant medications).
- Assessment of and monitoring for symptoms and side effects for Carbidopa-Levodopa (Parkinson's medications).
- A care plan for antipsychotic medications.
Failure to monitor for symptoms and side effects of these medications can lead to internal bleeding, swelling of face, throat, thoughts of death, uncontrolled movement, seizures, and difficulty breathing.
The incomplete admission assessment also resulted in failure to assess the resident's functional capacity and needs, and lack of an appropriate provide a plan of care for, but not limited to, the following:
- Infections, psychotropic medications, behavioral health, permanent side effects from medications, pain, vision and dental needs, trauma informed care, cultural and religious needs, weight and fluid management and other unassessed needs.
These failures put Resident 3 at risk for unmanaged medications and side effects, unmonitored behaviors, potential vision impairment, dental pain, and any number of unknown treatable conditions due to a lack of assessment. This deficiency was likely to result in permanent injury, severe infection, mental anguish, and/or potentially exposed other residents in the facility to behaviors.
On 1/25/22 at 12:42 Staff 5 (RN) confirmed the monitoring, care plans, and MDS were missing or incomplete.
3. Resident 2 admitted in 2022 with diagnoses including mental and behavioral disorders, chronic obstructive pulmonary disorder, presence of cardiac pacemaker, and heart failure.
Review of Resident 2's record indicated the following was missing:
- 10/17/22 admission MDS was incomplete.
- Comprehensive care plan was incomplete.
The incomplete admission assessment resulted in a failure to assess the resident's functional capacity and needs, and lack of an appropriate plan of care for, but not limited to, the following:
-Infections, behavioral health, pain, vision and dental needs, trauma informed care, appropriate activity and socialization, respiratory problems, cultural and religious needs as well as other unassessed needs.
This failure put Resident 2 at risk for behavioral health issues, vision issues, dental problems, pain, medication reactions, breathing issues, and any number of unknown treatable conditions due to a lack of assessment. This deficiency was likely to result in permanent injury, severe infection, mental anguish, and could have exposed other residents in the facility to behaviors.
On 1/24/23 at 7:00 PM Staff 3 (RN Consultant) confirmed the comprehensive care plans were not in place due to the admission MDS not being completed.
4. Resident 9 admitted in 2022 with diagnoses including gout, skin cancer, kidney disease, and atrial flutter.
Review of Resident 9's record indicated the following was missing:
- 9/3/22 admission MDS
- Comprehensive care plan.
The incomplete admission assessment resulted in a failure to assess the resident's functional capacity and needs, and lack of an appropriate plan of care for, but not limited to, the following:
- Psychotropic medications, behavioral health, permanent side effects from medications, safety, pain, vision and dental needs, trauma informed care, appropriate activity and socialization, cultural and religious needs, end of life care, other unassessed needs.
This failure put Resident 9 at risk for unmanaged medications, unmanaged pain, incomplete knowledge of skin issues, potential heart problems, bleeding risk, and any number of unknown treatable conditions due to a lack of assessment. This failure was likely to result in permanent injury, significant physical pain, mental anguish, inadequate end of life services and potentially an early death.
On 1/26/23 Staff 6 (RN) confirmed the admission MDS and care plans were missing or incomplete.
5. The 1/13/23 MDS [NAME] report (computer generated list of residents with missing MDS information) was compared to current medical records on 1/19/23 which revealed an additional 19 missing admission MDSes, as well as seven Annual MDSes.
On 1/24/23 at 7:00 PM staff 3 (RN consultant) confirmed the comprehensive care plans were not in place due to the admission MDS not being completed.
On 1/24/23 at 6:20 PM the facility was notified of the Immediate Jeopardy (IJ) situation and an immediacy removal plan was requested.
On 1/24/23 at 7:53 PM the facility submitted an acceptable immediacy removal plan which would abate the IJ situation.
The immediacy removal plan included the following:
- The facility will complete any admission and/ or Annual assessments that are incomplete for Residents 1 and 3 and update the care plan and other appropriate monitoring and documentation as applicable by 1/27/2023
- The facility has audited all current in-house residents for MDS completion as of 1/24/23. Any current admission and annual missing assessments will be completed by 1/27/23 which includes care planning and other appropriate monitoring and documentation as applicable.
- The facility will immediately begin reviewing all new admissions for timely completion of MDSes including care planning and other appropriate documentation as applicable within the 24-hour report process 1/25/2023
- The medical records coordinator will monitor all admission and annual assessment due dates and report all due dates to the interdisciplinary team members and daily stand up and report immediately to the director of nursing services and administrator any admission and Annual MDSe that are out of compliance. The director of nurses will meet with the interdisciplinary team for an action plan of timely completion.
- The facility has a skilled MDS Coordinator who will be utilized to assist with other facility units to maintain timely admission and annual MDS assessments. The facility will continue to retain outside MDS completion support as needed with a contracted RCM (Resident Care Manager) and Nurse Consultant.
- The Quality Assurance nurse, administrator and director of nursing services will review weekly for ongoing compliance.
On 1/30/23 at 1:45 PM record review was completed which verified the immediacy removal plan was fully implemented on 1/26/23.
CONCERN
(D)
📢 Someone Reported This
A family member, employee, or ombudsman was alarmed enough to file a formal complaint
Potential for Harm - no one hurt, but risky conditions existed
Administration
(Tag F0835)
Could have caused harm · This affected 1 resident
Based on the immediate jeopardy in the area of resident assessment it was determined the facility was not administered by the management team in an effective and efficient manner. Residents (#s 1, 2, ...
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Based on the immediate jeopardy in the area of resident assessment it was determined the facility was not administered by the management team in an effective and efficient manner. Residents (#s 1, 2, 3 and 9) as well as others, had missing admission MDSs and were placed at risk for unassessed care needs and significant physical and mental injury. Findings include:
1. Resident 1 admitted in 2022 with diagnoses including dementia.
Review of Resident 1's record indicated the 11/7/22 admission MDS, comprehensive care plan, and monitoring of psychotropic medications were missing or incomplete.
On 1/18/23 at 11:14 Staff 4 (RCM) stated she believed all MDSs she was responsible for were completed and was unaware Resident 1's MDS was not done.
On 1/26/23 at 4:09 PM Staff 1 (Administrator) confirmed being aware incomplete MDSs were an issue since 12/2021 and had attempted to address the problem since that time.
2. Resident 2 admitted in 2022 with diagnoses including mental and behavioral disorders.
Review of Resident 2's record indicated the 10/17/22 admission MDS and comprehensive care plan were missing or incomplete.
On 1/24/23 at 7:00 PM Staff 3 (RN consultant) confirmed the comprehensive care plans were not in place due to the admission MDS not being completed.
On 1/26/23 at 4:09 PM Staff 1 (Administrator) confirmed being aware incomplete MDSs were an issue since 12/2021 and had attempted to address the problem since that time.
3. Resident 3 admitted in 2022 with diagnoses including Parkinson's disease.
Review of Resident 3's record indicated the 8/29/22 admission MDS, comprehensive care plans, and monitoring of psychotropic medications were missing or incomplete.
On 1/25/22 at 12:42 Staff 5 (RN) confirmed the monitoring, care plans, and MDS were missing or incomplete.
On 1/26/23 at 4:09 PM Staff 1 (Administrator) confirmed being aware incomplete MDSs were an issue since 12/2021 and had attempted to address the problem since that time.
4. Resident 9 admitted in 2022 with diagnoses including gout.
Review of Resident 9's record indicated the 9/3/22 admission MDS and comprehensive care plan were missing or incomplete.
On 1/24/23 at 7:00 PM Staff 5 (RN) confirmed the comprehensive care plans were not in place due to the admission MDS not being completed.
On 1/26/23 at 4:09 PM Staff 1 (Administrator) confirmed being aware incomplete MDSs were an issue since 12/2021 and had attempted to address the problem since that time.
5. As of 1/19/23 there were an additional 105 missing or incomplete Resident Assessments including Admission, Annual, Quarterly, Discharge, Entry, and Significant Change of Condition.
On 1/26/23 at 4:09 PM Staff 1 (Administrator) confirmed being aware incomplete MDSs were an issue since 12/2021 and had attempted to address the problem since that time.
Refer to F-636
CONCERN
(D)
📢 Someone Reported This
A family member, employee, or ombudsman was alarmed enough to file a formal complaint
Potential for Harm - no one hurt, but risky conditions existed
QAPI Program
(Tag F0867)
Could have caused harm · This affected 1 resident
Based on interview and record review it was determined the facility's QAA committee failed to correct deficiencies in the areas of MDS completion. This placed residents at risk for injury and adverse ...
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Based on interview and record review it was determined the facility's QAA committee failed to correct deficiencies in the areas of MDS completion. This placed residents at risk for injury and adverse consequences. Findings include:
The facility failed to complete Admission, Annual, Discharge and Quarterly MDS assessments in the required timeframe for 9 of 9 sampled residents reviewed for MDS.
On 1/18/23 at 11:51 AM Staff 8 (Quality Assurance/Infection Prevention), Staff 6 (RN) and Staff 9 (RN) confirmed Staff 1 (Administrator), Staff 2 (DNS), and Staff 3 (RN consultant) were aware of the late MDSs in 2021 and timely MDS completion was still a problem as of 1/18/23.
On 1/26/23 at 4:09 PM Staff 1 (Administrator) confirmed being aware incomplete MDSs were an issue since 12/2021 and had attempted to address the problem since that time.
Refer to F636, F638, and F842.
CONCERN
(D)
📢 Someone Reported This
A family member, employee, or ombudsman was alarmed enough to file a formal complaint
Potential for Harm - no one hurt, but risky conditions existed
Deficiency F0868
(Tag F0868)
Could have caused harm · This affected 1 resident
Based on interview and record review it was determined the facility failed to meet at least quarterly and ensure an adequate number of staff attended for 2 of 2 QAA (Quality Assessment and Assurance) ...
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Based on interview and record review it was determined the facility failed to meet at least quarterly and ensure an adequate number of staff attended for 2 of 2 QAA (Quality Assessment and Assurance) meetings reviewed for QAA. This placed residents at risk for lack of direct care staff insight and timely response to facility concerns brought to QAA. Findings Include:
The facility records revealed QAPI (Quality Assurance Performance Improvement) meetings were conducted on 5/2022 and 10/2022, and one was scheduled for 2/2023. The 5/2022 meeting was held with Staff 1 (Administrator), Staff 2 (DNS), and Staff 3 (RN consultant) and was missing the medical director and two additional staff from the facility.
On 1/18/23 at 11:51 AM Staff 8 (Quality Assurance/Infection Prevention) confirmed QAPI has not met for a significant period. Staff 8 could not recall specifically when the last meeting was.
On 1/27/23 at 4:19 PM staff 8 (QA/IP) confirmed the facility had held QAPI meetings in 5/2022 and 10/2022 as well as one scheduled for 2/2023. Staff 8 indicated the 5/2022 QAPI meeting was held by Staff 1 (Administrator), Staff 2 (DNS), and Staff 3 (RN consultant).
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 F0638
(Tag F0638)
Could have caused harm · This affected multiple residents
Based on interview and record review it was determined the facility failed to complete Quarterly MDS assessments in the required timeframe for 4 of 9 sampled residents (#s 3, 4, 5 and 6) reviewed for ...
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Based on interview and record review it was determined the facility failed to complete Quarterly MDS assessments in the required timeframe for 4 of 9 sampled residents (#s 3, 4, 5 and 6) reviewed for MDS. This placed residents at risk for unassessed care needs. Findings include:
The RAI Manual Chapter 2 instructed to complete a quarterly MDS assessment within 92 days of the previous assessment and within 14 days of the ARD (assessment reference date).
1. Resident 3 admitted to the facility in 2022 with diagnoses including depression.
The 11/29/22 Quarterly MDS was completed on 1/25/23; 149 days from the previous assessment.
On 1/25/23 at 12:42 PM staff 5 (RN) verified the 11/29/22 Quarterly MDS was not completed on time.
2. Resident 4 was admitted to the facility in 2021 with diagnoses including major depressive disorder.
The 12/19/22 Quarterly MDS was completed on 1/19/23; 123 days from the previous assessment.
On 1/25/23 at 12:27 PM staff 7 (RN) confirmed the 12/19/22 Quarterly MDS was not completed on time.
3. Resident 5 admitted to the facility in 2020 with diagnoses including Alzheimer's.
The 9/26/22 Quarterly MDS was completed on 1/24/23; 212 days from the previous assessment.
On 1/25/23 at 12:27 PM staff 7 (RCM) confirmed the 12/19/22 Quarterly MDS was not completed on time.
4. Resident 6 admitted to the facility in 2021 with diagnoses including Alzheimer's disease.
The 11/16/22 Quarterly MDS was completed on 1/25/23; 162 days from the previous assessment.
On 1/25/23 at 12:27 PM staff 7 (RCM) confirmed the 12/19/22 Quarterly MDS was not completed on time.
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
Quality of Care
(Tag F0684)
Could have caused harm · This affected multiple residents
Based on interview and record review it was determined the facility failed to consistently assess, monitor, and accurately document skin related conditions for 4 of 9 sampled resident (#s 5, 6, 8 and ...
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Based on interview and record review it was determined the facility failed to consistently assess, monitor, and accurately document skin related conditions for 4 of 9 sampled resident (#s 5, 6, 8 and 9) reviewed for MDS. This placed residents at risk for discomfort and worsening of wounds. Findings include:
1. Resident 5 admitted in 2020 with diagnoses including dementia.
Resident 5 had an order for skin checks to be completed in a wound assessment every Sunday, this order started on 9/18/22.
Skin and Wound - Total Body Skin Assessments were completed on:
9/25/22, 10/2/22, 10/5/22, 11/27/22, 1/8/23, 1/15/23.
Wound and Skin Assessments were completed on:
3/23/22, 3/26/22, 3/30/22, 4/6/22, 4/23/22, 5/4/22, 5/11/22, 6/18/22, 6/22/22, 7/20/22, 7/30/22, 8/3/22, 9/21/22, 12/21/22, 12/28/22.
Record review revealed there were no weekly skin assessments between 10/6/22 through 11/26/22 and between 11/28/22 through 12/20/22.
On 1/25/23 at 12:27 PM Staff 7 (RN) confirmed staff should be completing assessments weekly and there was no other place the documentation would have been.
2. Resident 6 admitted in 2021 with diagnoses including dementia.
Resident 6 had an order for skin checks to be completed in a skin and wound assessment weekly, this order started on 9/12/21.
PCC Skin & Wound - Total Body Skin Assessments were completed on:
7/3/22, 7/10/22, 7/24/22, 8/7/22
Skin & Wound Evaluation were completed on:
10/31/22, 11/10/22, 11/23/22, 11/30/22, 1/27/22, 2/7/22, 2/10/22, 2/17/22, 2/23/22, 3/1/22, 3/2/22
Wound and Skin Assessment were completed on:
11/7/21, 11/14/21, 11/28/21, 12/5/21, 12/12/21, 12/26/21, 1/9/22, 2/13/22, 2/27/22, 3/6/22, 3/13/22, 3/20/22, 5/29/22, 6/5/22, 8/4/22
Record review revealed there were no weekly skin assessments between 1/10/22 through 1/26/22, between 3/21/22 through 5/28/22, and 6/6/22 through 8/3/22.
On 1/25/23 at 12:27 PM Staff 7 (RN) confirmed staff should be completing assessments weekly and there was no other place the documentation would have been.
3. Resident 8 admitted in 2022 with diagnoses including diabetes.
Resident 8 had an order for weekly skin audit on shower days and to document in the skin & wound assessment form, this order started 8/10/22.
Skin & Wound evaluations were completed on:
8/29/22, 9/12/22, 9/19/22, 9/27/22, 10/4/22, 10/17/22, 11/9/22, 11/16/22, 11/22/22, 12/6/22 and 1/17/23.
Wound and Skin Assessments were complete on:
8/30/22, 9/6/22, 9/13/22, 9/20/22, 9/27/22, 10/4/22, 1/26/23.
Record review revealed there were no weekly skin assessments between 8/10/22 through 8/29/22, 10/17/22 through 11/9/22 and 1/4/23 through 1/17/23.
On 1/25/22 at 12:42 PM Staff 5 (RN) confirmed skin assessments were supposed to be completed weekly.
4. Resident 9 admitted on 2022 with diagnoses including skin cancer.
Resident 9 had the following orders:
A. BUTTOCKS: cleanse with house wound cleanser, dry thoroughly, and apply bordered foam dressing in the morning for skin care, this order started on 8/28/2022.
B. Licensed Nurse to do Weekly Skin Audit on Shower Day in the morning every Tuesday, document in skin and wound assessment weekly, this order started on 8/30/2022.
C. Umbilicus and peri naval area. Cleanse with wound cleanser and pat dry. Apply ointment cover with foam dressing two times a day for discharge D/C when it resolved. This order started on 8/31/2022.
D. Clean with wound cleanser, pat dry, skin perp the peri wound. Apply calcium alginate with silver in between the macerated areas between toes on both feet. Cleanse and change daily. Soak the right foot to get the gauze off and for future dressings to avoid disrupting healing tissue in the morning D/C when it resolved. This order started 8/31/2022.
Three incomplete wound evaluations all dated 8/29/22 indicated the resident had right and left buttock wounds only.
A 9/9/22 Wound and Skin Assessment indicated Resident 9 had:
- Redness to coccyx without measurements or staging.
- Right foot, 3rd, 4th, and 5th toe wounds without measurements or staging.
- Umbilicus redness without measurements or staging.
- Scrotum redness without measurements or staging.
On 1/26/23 at 11:25 AM Staff 6 (RN) confirmed the 9/9/22 assessment was the only one that included all the skin conditions. Staff 6 confirmed the skin conditions were treated, but not well documented.
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
Medical Records
(Tag F0842)
Could have caused harm · This affected multiple residents
Based on interview and record review it was determined the facility failed to ensure residents' medical records were complete and accurate for 3 of 9 sampled residents (#s 2, 7 and 8) reviewed for MDS...
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Based on interview and record review it was determined the facility failed to ensure residents' medical records were complete and accurate for 3 of 9 sampled residents (#s 2, 7 and 8) reviewed for MDS. This placed residents at risk for inaccurate medical records. Findings include:
1. Resident 2 admitted to the facility in 2022 with diagnoses including heart failure.
Resident 2 discharged on 10/21/22. Resident 2's 10/21/22 Discharge MDS was not completed as of 1/27/23.
On 1/26/23 at 11:25 AM staff 6 (RCM) verified the 10/21/22 Discharge MDS was not completed.
2. Resident 7 was admitted to the facility in 2022 with diagnoses including Alzheimer's.
Resident 7 discharged on 4/10/22. Resident 7's 4/4/22 Discharge MDS was not completed as of 1/27/23.
On 1/25/23 at 12:42 PM staff 5 (RN) verified the 10/21/22 Discharge MDS was not completed.
3. Resident 8 admitted to the facility in 2022 with diagnoses including diabetes.
Resident 8 discharged on 12/26/22. Resident 8's 12/26/22 Discharge MDS was not completed until 1/26/22.
On 1/25/23 at 12:42 PM staff 5 (RN) verified the 10/21/22 Discharge MDS was not completed.
Jan 2019
3 deficiencies
CONCERN
(D)
Potential for Harm - no one hurt, but risky conditions existed
Deficiency F0578
(Tag F0578)
Could have caused harm · This affected 1 resident
**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on interview and record review it was determined the facility failed to ensure residents received written information rega...
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**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on interview and record review it was determined the facility failed to ensure residents received written information regarding their right to execute an advance directive and to obtain existing copies of advance directives for residents when available for 3 of 6 sampled residents (#s 9, 81 and 106) reviewed for advance directives. This placed residents at risk for not having their health care decisions honored. Findings include:
1. Resident 9 was admitted to the facility in 2015 with diagnoses including a neurological disorder. The resident's most recent annual assessment dated [DATE] indicated she/he was cognitively intact.
Resident 9's clinical record contained a POLST (Physician's Order for Life Sustaining Treatment) dated 5/5/15 with orders to attempt resuscitation. The record revealed no evidence of an advance directive.
On 1/9/19 at 12:48 PM Resident 9 stated no one spoke to her/him about an advance directive but she/he would like to formulate an advance directive.
On 1/10/19 at 3:00 PM Staff 1 (RNCM) acknowledged there was no system in place to provide residents who resided in the facility an opportunity to formulate an advance directive.
2. Resident 81 admitted to the facility in 11/2018 with diagnoses including dementia.
On 1/9/19 at 12:15 PM Witness 3 (Family Member) stated Resident 81 had an advance directive in place. Witness 3 was not sure if the facility had a copy of the advance directive.
On 1/9/19 at 12:32 PM Staff 8 (Medical Records) stated the facility did not have a copy of the resident's advance directive.
On 1/9/19 at 1:28 PM Staff 3 (Social Services) stated the resident's family was supposed to bring in a copy of the advance directive. Staff 3 stated information about advance directives was documented in care conference notes. Staff 3 was unable to provide any notes regarding an advance directive for Resident 81. Staff 3 stated resident care managers were responsible for following up with families regarding advance directives.
On 1/10/19 at 12:27 PM Staff 1 (RNCM) stated she did not ask residents about advance directives and she thought social services took care of it.
3. Resident 106 admitted to the facility in 2015 with diagnoses including dementia.
No evidence was found in the resident's clinical record to indicate the resident or resident's family was given information on completing an advance directive.
On 1/9/19 at 12:16 PM Staff 2 (RNCM) stated she was not sure if the resident or resident's family was provided information on completing an advance directive.
CONCERN
(D)
Potential for Harm - no one hurt, but risky conditions existed
Deficiency F0657
(Tag F0657)
Could have caused harm · This affected 1 resident
Based on interview and record review it was determined the facility failed to review and revise a resident's care plan related to weight loss and catheter use for 2 of 5 sampled residents (#s 54 and 8...
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Based on interview and record review it was determined the facility failed to review and revise a resident's care plan related to weight loss and catheter use for 2 of 5 sampled residents (#s 54 and 81) reviewed for nutrition and catheters. This placed residents at risk for unmet needs. Findings include:
1. Resident 54 readmitted to the facility in 11/2018 with diagnoses including enlarged prostate and urinary retention.
The 11/8/18 admission MDS and Urinary Incontinence CAA indicated Resident 54 did not have a catheter and was sometimes had urinary incontinence.
A 11/20/18 progress note indicated Resident 54 returned to the facility with a catheter in place after an appointment with a urologist.
A 12/11/18 progress note indicated the resident's use of the catheter was discontinued.
A review of Resident 54's clinical record revealed no evidence the care plan was updated regarding the presence of a catheter between 11/20/18 and 12/11/18.
On 1/11/19 at 11:35 AM Staff 1 (RNCM) acknowledged Resident 54's care plan was not updated regarding the presence of a catheter.
2. Resident 81 admitted to the facility in 11/2018 with diagnoses including celiac disease and gastrointestinal hemorrhage.
A 11/28/18 Nutrition Assessment indicated the resident currently weighed 105 pounds and was underweight. The assessment indicated a goal for the resident to gain 1-2 pounds per week.
Resident 81's weight records revealed the following weights:
- 11/27/18:
104.9 lbs
- 12/4/18:
100.4 lbs
- 12/11/18:
97.8 lbs
- 12/18/18:
97.6 lbs
- 12/24/18:
94.0 lbs
- 12/31/18:
91.0 lbs
- 1/7/19:
92.0 lbs
On 1/10/19 the resident's current care plan for nutrition was reviewed. The care plan indicated Resident 81 was at risk for suboptimal intake. The care plan did not include any indication the resident experienced weight decline, nor any indication of interventions in place to prevent further weight decline.
On 1/10/19 at 12:27 PM Staff 1 (RNCM) acknowledged Resident 81's care plan was not updated regarding the resident's weight decline.
Refer to F692.
CONCERN
(D)
Potential for Harm - no one hurt, but risky conditions existed
Deficiency F0692
(Tag F0692)
Could have caused harm · This affected 1 resident
Based on observation, interview and record review it was determined the facility failed to ensure residents maintained adequate nutritional status for 1 of 4 sampled residents (#81) reviewed for nutri...
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Based on observation, interview and record review it was determined the facility failed to ensure residents maintained adequate nutritional status for 1 of 4 sampled residents (#81) reviewed for nutrition. This placed residents at risk for unplanned weight loss. Findings include:
Resident 81 admitted to the facility in 11/2018 with diagnoses including celiac disease and gastrointestinal hemorrhage.
A 11/28/18 Nutrition Assessment indicated the resident currently weighed 105 pounds and was underweight. The assessment indicated a goal for the resident to gain 1-2 pounds per week.
A 12/14/18 dietary order indicated Resident 81 was on a general (non-calorie enhanced), gluten-restricted diet.
On 1/8/19, 1/9/19 and 1/10/19 Resident 81 was observed to eat independently. Resident 81 received a general (non-calorie enhanced), gluten-restricted meal. Resident 81 was observed to direct her/his own meal choices and preferences.
The 11/2018, 12/2018 and 1/2019 TARs indicated Resident 81 received a high-calorie nutritional supplement twice per day.
Resident 81's weight records revealed the following weights:
- 11/27/18:
104.9 lbs
- 12/4/18:
100.4 lbs
- 12/11/18:
97.8 lbs
- 12/18/18:
97.6 lbs
- 12/24/18:
94.0 lbs
- 12/31/18:
91.0 lbs
- 1/7/19:
92.0 lbs
A 12/17/18 Nutrition Assessment noted the resident's significant weight loss and attributed the weight loss to the resident's decreased meal intake while on a mechanically soft diet. The assessment indicated the resident's diet was upgraded to a regular texture and the goal was for the resident to regain the lost weight.
No evidence was found to indicate a subsequent assessment of the resident's nutritional needs was completed after 12/17/18 even though the resident's weights continued to decline.
On 1/10/19 the resident's current care plan for nutrition was reviewed. The care plan indicated Resident 81 was at risk for suboptimal intake. The care plan indicated staff were to monitor, record and report any signs or symptoms of malnutrition including significant weight loss, defined as three pounds in one week or greater than five percent in one month. The care plan indicated Resident 81 would be evaluated by a dietitian as needed. The care plan did not include any indication the resident experienced weight decline, nor any indication of interventions in place to prevent further weight decline.
A review of the resident's progress notes between 12/18/18 and 1/7/19 revealed the resident experienced acute medical conditions including: nose bleeds, loose stools, vomiting, bloody stools, bloody urine and a UTI.
On 1/10/19 at 12:17 PM Resident 81 stated she/he always received the correct meal and always received enough to eat.
On 1/10/19 at 12:27 PM Staff 1 (RNCM) acknowledged Resident 81's severe weight loss of 12.3% in 42 days. Staff 1 stated Resident 81 had acute medical needs recently and staff were focused on treating the acute conditions. Staff 1 acknowledged Resident 81's nutritional needs were not reassessed subsequent to the resident's continued weight loss. Staff 1 stated typically the treatment team, including the dietitian, met to discuss what interventions might be implemented, such as calorie-enhanced meals, in order to prevent further weight decline.
Understanding Severity Codes (click to expand)
Life-Threatening (Immediate Jeopardy)
J - Isolated
K - Pattern
L - Widespread
Actual Harm
G - Isolated
H - Pattern
I - Widespread
Potential for Harm
D - Isolated
E - Pattern
F - Widespread
No Harm (Minor)
A - Isolated
B - Pattern
C - Widespread
Questions to Ask on Your Visit
- "What changes have you made since the serious inspection findings?"
- "Can I speak with families of current residents?"
- "What's your RN coverage like on weekends and overnight?"
Our Honest Assessment
Strengths
- • 44% turnover. Below Oregon's 48% average. Good staff retention means consistent care.
Concerns
- • Multiple safety concerns identified: 2 life-threatening violation(s), 5 harm violation(s), $214,136 in fines. Review inspection reports carefully.
- • 36 deficiencies on record, including 2 critical (life-threatening) violations. These warrant careful review before choosing this facility.
- • $214,136 in fines. Extremely high, among the most fined facilities in Oregon. Major compliance failures.
- • Grade F (0/100). Below average facility with significant concerns.
Bottom line: Trust Score of 0/100 indicates significant concerns. Thoroughly evaluate alternatives.
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About This Facility
What is Maryville's CMS Rating?
CMS assigns MARYVILLE an overall rating of 3 out of 5 stars, which is considered average nationally. Within Oregon, 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 Maryville Staffed?
CMS rates MARYVILLE's staffing level at 5 out of 5 stars, which is much above average compared to other nursing homes. Staff turnover is 44%, compared to the Oregon average of 46%. This relatively stable workforce can support continuity of care.
What Have Inspectors Found at Maryville?
State health inspectors documented 36 deficiencies at MARYVILLE during 2019 to 2025. These included: 2 Immediate Jeopardy (the most serious level, indicating potential for serious harm or death), 5 that caused actual resident harm, and 29 with potential for harm. Immediate Jeopardy findings are rare and represent the most serious regulatory concerns. They require immediate corrective action.
Who Owns and Operates Maryville?
MARYVILLE is owned by a non-profit organization. Non-profit facilities reinvest revenue into operations rather than distributing to shareholders. The facility operates independently rather than as part of a larger chain. With 165 certified beds and approximately 135 residents (about 82% occupancy), it is a mid-sized facility located in BEAVERTON, Oregon.
How Does Maryville Compare to Other Oregon Nursing Homes?
Compared to the 100 nursing homes in Oregon, MARYVILLE's overall rating (3 stars) matches the state average, staff turnover (44%) is near the state average of 46%, and health inspection rating (2 stars) is below the national benchmark.
What Should Families Ask When Visiting Maryville?
Based on this facility's data, families visiting should ask: "What changes have been made since the serious inspection findings, and how are you preventing similar issues?" "Can I visit during a mealtime to observe dining assistance and food quality?" "How do you handle medical emergencies, and what is your hospital transfer rate?" "Can I speak with family members of current residents about their experience?" These questions are particularly relevant given the facility's Immediate Jeopardy citations.
Is Maryville Safe?
Based on CMS inspection data, MARYVILLE has documented safety concerns. Inspectors have issued 2 Immediate Jeopardy citations (the most serious violation level indicating risk of serious injury or death). The facility has a 3-star overall rating and ranks #1 of 100 nursing homes in Oregon. Families considering this facility should ask detailed questions about what corrective actions have been taken since these incidents.
Do Nurses at Maryville Stick Around?
MARYVILLE has a staff turnover rate of 44%, which is about average for Oregon 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 Maryville Ever Fined?
MARYVILLE has been fined $214,136 across 4 penalty actions. This is 6.1x the Oregon average of $35,220. Fines at this level are uncommon and typically indicate a pattern of serious deficiencies, repeated violations, or failure to correct problems promptly. CMS reserves penalties of this magnitude for facilities that pose significant, documented risk to resident health or safety. Families should request specific documentation of what issues led to these fines and what systemic changes have been implemented.
Is Maryville on Any Federal Watch List?
MARYVILLE 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.