LAURELWOOD HEALTH CARE CENTER
For profit - Corporation
64 Beds
AHAVA HEALTHCARE
Data: November 2025
1 Immediate Jeopardy citation
Trust Grade
23/100
#196 of 298 in TN
Photo by Laurelwood Health Care Center
Photo by Laurelwood Health Care Center
Photo by Laurelwood Health Care Center
1 / 5 photos
Last Inspection: January 2025
Within standard 12-15 month inspection cycle. Federal law requires annual inspections.
Overview
Laurelwood Health Care Center has received a Trust Grade of F, indicating significant concerns about the quality of care and services provided. Ranked #196 out of 298 facilities in Tennessee, they are in the bottom half of nursing homes in the state, and #4 out of 6 in Madison County means only two local options are worse. The facility is improving, having reduced issues from 9 to 7 over the past year, but it still faces serious challenges. Staffing is a relative strength, with a turnover rate of 47%, slightly better than the state average, but the RN coverage is concerning, being lower than 94% of facilities in Tennessee, which may impact the quality of care. Additionally, $126,516 in fines raises alarms about compliance, reflecting ongoing problems. Specific incidents include a failure to prevent falls for a resident, which resulted in delayed medical attention after a serious fall, and issues related to unsanitary food preparation and serving conditions, which could jeopardize residents' health. Overall, while there are some positive aspects like staffing stability, the facility has significant weaknesses that families should carefully consider.
- Trust Score
- F
- In Tennessee
- #196/298
- Safety Record
- High Risk
- Inspections
- Getting Better
- Staff Stability ⚠ Watch
- 47% turnover. Above average. Higher turnover means staff may not know residents' routines.
- Penalties ○ Average
- $126,516 in fines. Higher than 63% of Tennessee facilities. Some compliance issues.
- Skilled Nurses ⚠ Watch
- Each resident gets only 17 minutes of Registered Nurse (RN) attention daily — below average for Tennessee. Fewer RN minutes means fewer trained eyes watching for problems.
- Violations ⚠ Watch
- 21 deficiencies on record. Higher than average. Multiple issues found across inspections.
23/100
Bottom 35%
Review needed
9 → 7 violations
★★☆☆☆
2.0
Overall Rating
★★☆☆☆
2.0
Staff Levels
★★★☆☆
3.0
Care Quality
★★☆☆☆
2.0
Inspection Score
↔
Stable
2024: 9 issues
2025: 7 issues
The Good
-
Full Sprinkler Coverage · Fire safety systems throughout facility
-
No fines on record
Facility shows strength in fire safety.
The Bad
2-Star Overall Rating
Below Tennessee average (2.8)
Below average - review inspection findings carefully
Staff Turnover: 47%
Near Tennessee avg (46%)
Higher turnover may affect care consistency
Federal Fines: $126,516
Well above median ($33,413)
Significant penalties indicating serious issues
Chain: AHAVA HEALTHCARE
Part of a multi-facility chain
Ask about local staffing decisions and management
The Ugly 21 deficiencies on record
1 life-threatening
Jan 2025
7 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 policy review, record review, and interview the facility failed to provide information to the residents regarding their...
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**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on policy review, record review, and interview the facility failed to provide information to the residents regarding their right to refuse medical or surgical treatment or to formulate an advance directive for 6 of 24 (Resident #34, #40, #41, #42, #47 and #49) residents reviewed for Advance Directives.
The findings include:
1. Review of the facility's undated policy titled, Resident Rights, revealed The facility will inform the resident both orally and in writing .the resident understands .The right to request, refuse, and/or discontinue treatment .and to formulate an advance directive .
2. Review of the medical record revealed Resident #34 was admitted to the facility on [DATE], with diagnoses including Hemiplegia, Epilepsy, and Anxiety.
Review of the quarterly Minimum Data Set (MDS) assessment dated [DATE], revealed Resident #34 was rarely/never understood and cognitive skills for daily decision making were moderately impaired.
Review of the facility document Advanced Directive Acknowledgement, dated 3/30/2023, revealed the document was not filled out completely.
3. Review of the medical record revealed Resident #40 was admitted to the facility on [DATE], with diagnoses including Hemiplegia, Parkinson's Disease, Paranoid Schizophrenia, and Depression.
Review of the quarterly MDS assessment dated [DATE], revealed a BIMS score of 12 which indicated Resident #40 was moderately cognitively impaired.
Review of the facility document Advanced Directive Acknowledgement, dated 9/22/2023, revealed the document was not filled out completely.
4.Review of the medical record revealed Resident #41 was admitted to the facility on [DATE], with diagnoses including Anxiety, Depression, and Brief Psychotic Disorder.
Review of the quarterly MDS assessment dated [DATE], revealed a BIMS score of 10 which indicated Resident #41 was moderately cognitively impaired.
Review of facility document, Advance Directive Acknowledgement, dated 7/7/2023 revealed the document was not filled out completely.
5. Review of medical record revealed Resident #42 was admitted on [DATE], with diagnoses including Bipolar, Anxiety, and Idiopathic Progressive Neuropathy.
Review of the quarterly MDS assessment dated [DATE], revealed a BIMS score of 15, which indicated Resident #42 was cognitively intact.
Review of facility document, Advance Directive Acknowledgement, dated 5/11/2023, revealed the document was not filled out completely.
6. Review of the medical record revealed Resident #47 was admitted to the facility on [DATE], with diagnoses including Cerebral Palsy, Adult Failure to Thrive, Anxiety, and Seizures.
Review of the quarterly MDS dated [DATE], revealed Resident #47's cognitive skills for decision making were severely impaired.
Review of facility document, Advance Directive Acknowledgement, dated 5/20/2024, revealed the document was not filled out completely.
7. Review of the medical record revealed Resident #49 was admitted to the facility on [DATE], with diagnoses including Cerebral Infarction, Dementia, Chronic Liver Failure, and Schizophrenia.
Review of the quarterly MDS dated [DATE], revealed a BIMS score of 13, which indicated Resident #49 was cognitively intact.
Review of facility document, Advance Directive Acknowledgement, dated 2/26/2024 revealed the document was not filled out completely.
8. During an interview on 1/22/2025 at 10:58 AM, the Administrator and Regional Director of Clinical Services confirmed the Advance Directive should be filled out completely to show education was provided to the Resident or Responsible Party (RP).
CONCERN
(D)
Potential for Harm - no one hurt, but risky conditions existed
Pressure Ulcer Prevention
(Tag F0686)
Could have caused harm · This affected 1 resident
**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on policy review, medical record review, and interview, it was determined the facility failed to have physician orders and...
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**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on policy review, medical record review, and interview, it was determined the facility failed to have physician orders and failed to provide pressure ulcer/injury treatments for 1 of 4 (Resident #258) sampled residents reviewed for pressure ulcer/injuries.
The findings include:
1. Review of the facility's undated policy titled, Pressure Injury Prevention and Management, .This facility is committed to the prevention of avoidable pressure ulcers .and to provide treatment and services to heal the pressure ulcer/injury .and the development of additional pressure ulcers/injuries .Licensed nurses will conduct a full body skin assessment on all residents upon admission/readmission .Findings will be documented in the medical record .the attending physician will be notified of .the presence of a new pressure ulcer upon identification .
2. Review of the medical record review revealed Resident #258 was readmitted to the facility on [DATE], with diagnoses including Chronic Obstructive Pulmonary Disease, Absence of Left Leg Above the Knee, Absence of Right Toes, Gastrostomy, Alzheimer's Disease, and Peripheral Vascular Disease.
Review of the care plan dated 1/13/2025, revealed Resident #258 returned from the hospital to the facility with a left Leg above the knee amputation and a right toe amputation.
Review of a Progress Note dated 1/13/2025, revealed The writer conducted skin check on resident on 01/14/2025 .Resident has above the knee amputation on left leg. Right second toe amputation .resident has right gluteal would [wound] 3.5 [centimeters] x [by] 7.0 x 0.5. Coccyx wound 1.0 x 1.5 x 0.3 .
Review of the Physician's Order dated 1/17/2025, revealed, Clean pressure wound to superior sacrum with wound cleanser and pat dry .
Review of a Physician's Order dated 1/17/2025, revealed Clean pressure wound to inferior sacrum with wound cleanser and pat dry .
Review of the Treatment Administration Record (TAR) dated 1/1/2025-1/31/2025, revealed Resident #258's treatment to the inferior and superior sacrum was not documented as performed until 1/17/2025.
During an interview on 1/22/2025 at 11:11 AM, Licensed Practical Nurse (LPN) B confirmed Resident #258 was admitted to the facility on [DATE], LPN B stated she came in late that evening and assessed Resident #258 on 1/14/2025. LPN B was asked, Did you get a treatment started. LPN B confirmed she cleaned the area and put a dressing on it, LPN B confirmed a treatment for the sacrum was ordered on 1/16/2024 by the [Named treatment Company] doctor.
During an interview on 1/22/2025 at 2:45 PM, the Director of Nursing (DON) was asked when a doctor's order should be obtained for a treatment. The DON stated, Immediately. The DON was asked if she knew LPN B did not get an order for the sacrum. The DON confirmed that LPN B should have written an order for the sacrum the day of the assessment on 1/14/2025.
CONCERN
(D)
Potential for Harm - no one hurt, but risky conditions existed
Accident Prevention
(Tag F0689)
Could have caused harm · This affected 1 resident
**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on policy review, medical record review, and interview, the facility failed to take appropriate actions in accordance with...
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**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on policy review, medical record review, and interview, the facility failed to take appropriate actions in accordance with the facility's policy when a fall occurred for 1 of 3 (Resident #5) reviewed for falls.
The findings include:
1. Review of the facility's undated policy titled, Fall Prevention Program, revealed .When any resident experiences a fall, the facility will .Assess the resident .Complete a fall assessment .Complete an incident report .Notify physician and family .Review the resident's care plan and update as indicated .Document all assessments and actions .Obtain witness statements .
2. Review of the medical record review revealed Resident #5 was admitted to the facility on [DATE], with diagnoses including Diabetes, Disorganized Schizophrenia, Anxiety, Blindness, Obsessive Compulsive Disorder, and Major Depressive Disorder.
Review of the Care Plan dated 1/7/2025 revealed Resident #5 is at risk for falls.
Review of the quarterly Minimum Data Set (MDS) dated [DATE], revealed a Brief Interview for Mental Status (BIMS) score of 12, which indicated Resident #5 was moderately cognitively impaired. Resident #5 was assessed to have highly impaired vision.
Review of the Progress Notes dated 1/15/2024, 1/16/2024, 1/17/2024, 1/18/2024 and 1/21/2024, revealed Resident #5 had a witnessed fall on 1/14/2024.
During an interview on 1/23/2025 at 9:18 AM, the Director of Nursing (DON) was asked for the complete investigation related to the 1/14/2025 fall. The DON confirmed she was not able to provide any documentation related to this fall. The DON was unable to provide a resident assessment after the fall, an incident report, notification of the physician or family, any assessments related to the fall, and no witness statements. The DON was asked should you have completed a fall investigation. She stated, Yes .we did look at the cameras, Resident #5 was in the dining room, she bent over and slid out of her chair.
CONCERN
(D)
Potential for Harm - no one hurt, but risky conditions existed
Incontinence Care
(Tag F0690)
Could have caused harm · This affected 1 resident
**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on policy review, medical record review, observation, and interview, the facility failed to provide care and services for ...
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**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on policy review, medical record review, observation, and interview, the facility failed to provide care and services for an indwelling urinary catheter (a tube in the bladder that drains the urine) for 1 of 1 (Resident #258) sampled residents reviewed for indwelling catheters.
The findings include:
1. Review of the undated facility policy titled Catheter Care, revealed .It is the policy of this facility to ensure that residents with indwelling catheters receive appropriate catheter care and maintain their dignity and privacy when indwelling catheters are in use .Catheter care will be performed every shift and as needed by nursing personnel .Privacy bags will be available and catheter drainage bags will be covered at all times while in use .Empty drainage bags when bag is half- full or at least each shift .
2. Review of the medical record revealed Resident #258 was admitted to the facility on [DATE], with diagnoses including Chronic Obstructive Pulmonary Disease, Gastrostomy, Alzheimer's Disease and Peripheral Vascular Disease.
Review of the quarterly Minimum Data Set (MDS) assessment dated [DATE], revealed a Brief Interview for Mental Status (BIMS) score of 3, which indicated Resident #258 was severely cognitively impaired. Resident was always incontinent of bowel and bladder.
Observation in Resident's #258's room on 1/21/2025 at 10:42 AM, revealed the foley catheter was not in a dignity bag.
Observation in Resident #258's room on 1/21/2025 at 1:59 PM, 1/22/2025 at 2:02 PM, and 1/23/2025 at 4:17 PM, revealed a Foley catheter bag was wrapped in a pillowcase.
Review of the medical record on 1/21/2025, revealed no physician's orders for a foley catheter and no orders for catheter care.
Review of the Physician's orders dated 1/22/2025, revealed .catheter care daily and prn [as needed] with soap and water. every shift for Catheter care AND every 1 hours as needed for cath [catheter] care prn with soap and water .record output every shift for record output record output each shift .catheter .TYPE: Foley SIZE:_16 fr [French] BALLOON:__15___CC every shift for Foley catheter care Check placement and secure .Ensure catheter tubing is secured to resident's leg as tolerated, to prevent accidental dislodgement .
Review of Care Plan dated 1/22/2025 revealed .Resident has incontinence of bowel .1/22/25 - order for indwelling urinary catheter . Resident has indwelling urinary catheter 16 f [French]/15cc [cubic centimeter] r/t [related to] wound .
During an Interview on 1/22/2025 at 2:21 PM, the Director of Nursing (DON) was asked when Resident #258's catheter was placed. The DON stated that she came from the hospital with one and we left it in due to pressure ulcers to her buttocks. The DON confirmed that Resident #258 did not have an order for the foley catheter or the catheter care. The DON confirmed that there should be foley catheter orders and catheter care orders. The DON confirmed that catheters should be in dignity bags for privacy. The DON stated, .We have ordered some [privacy bags], I told them to put a pillowcase to cover it .
CONCERN
(D)
Potential for Harm - no one hurt, but risky conditions existed
Deficiency F0692
(Tag F0692)
Could have caused harm · This affected 1 resident
**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on policy review, medical record review, and interview, the facility failed to follow the facility's policy for monitoring...
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**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on policy review, medical record review, and interview, the facility failed to follow the facility's policy for monitoring weekly weights for 1 of 3 (Resident #1) sampled residents reviewed for nutritional status.
The findings include:
1. Review of the facility's policy titled, Weight System, dated 3/4/2022, revealed .If weight concerns are noted/weights are not stable, notify your RD [Registered Dietician] and continue the weekly weights until stable .
2. Review of medical record revealed Resident #1 was admitted on [DATE], with diagnoses including Hypertension, Diabetes, Hyponatremia, Overweight, and Abnormality of Albumin.
Review of the Physician Orders dated 3/12/2024, revealed .HOUSE SUPPLEMENT three times a day for give 6oz for increased calorie intake. end date 7/10/24 .
Review of the Care Plan dated 5/24/2024, revealed .resident at nutrition risk related to diagnosis of diabetes mellitus .gradual weight loss .house supplement as ordered, regular texture diet with thin liquids .set up assist with meals .hs [hour of sleep] snack . RD [Registered Dietitian] to eval [evaluate] with recommendations as needed .Weights per facility protocol .
Review of the Physician Orders dated 7/10/24, revealed .HOUSE SUPPLEMENT four times a day for give 6oz for increased calorie intake .
Review of the Physician Orders dated 7/11/2024, revealed . weekly weights r/t [related to] weight loss .
Review of the Weight Summary for Resident #1 dated 7/24/2024, revealed the resident weighed 180 lbs. On 1/17/2025, the resident weighed 169 pounds which is a -6.11 % Loss.
Review of the quarterly Minimum Data Set (MDS) assessment dated [DATE], revealed a Brief Interview for Mental Status (BIMS) score of 15 which indicated Resident #1 was cognitively intact with no symptoms of depression. Resident had no problems related to swallowing disorder, no broken or loosely fitting dentures and no difficulty with chewing.
Review of the facility Weight Summary for Resident #1 revealed the facility failed to get weekly weights for the weeks of 8/5/2024, 8/19/2024, 8/26/2024, 9/9/2024, 9/16/2024, and 9/23/2024.
Review of the Dietary Assessment dated 9/30/2024, revealed . resident on carbohydrate-controlled diet with thin liquids. Residents with most recent weight of 182 and ideal body weight of 172. Resident consumes 26-100% of all meals .
Review of the facility Weight Summary for Resident #1 revealed the facility failed to get a weekly weight for the week of 9/31/2024.
Review of the Weight Summary for Resident #1 dated 10/7/2024, revealed the resident weighed 183 lbs. On 1/17/2025, the resident weighed 169 pounds which is a -7.65 % Loss.
Review of the facility Weight Summary for Resident #1 revealed the facility failed to get weekly weights for the weeks of 10/14/2024, 10/21/2024, 10/28/2024, and 11/4/2024.
Review of the significant change MDS assessment dated [DATE], revealed a BIMS score of 15 which indicated Resident #1 was cognitively intact with no symptoms of depression. Resident is independent for eating. Resident has no problems related to swallowing disorder. Resident weighed 173 pounds. Weight loss of 5% or more in the last month or more in the last 6 months and is not on a prescribed weight-loss regimen.
Review of the facility Weight Summary for Resident #1 revealed the facility failed to get weekly weights for the weeks of 12/9/2024, 12/16/2024, and 12/23/2024.
Review of the Dietary Assessment dated 1/2/2025, revealed .resident on carbohydrate-controlled diet with thin liquids. Resident with most recent weight of 163 lbs. with and ideal body weight of 172. Resident consumes 26-100% of all meals .
Review of the Physician Orders dated 1/2/2025, revealed .Mirtazapine Tablet 15 MG Give 1 tablet by mouth at bedtime for Appetite .
Review of the Interdisciplinary Team Note dated 1/7/2025, revealed .Being monitored for weight loss. He was started on Remeron for appetite (1/2/25). Appetite varies .
During an interview on 1/22/2025 at 4:31 PM, the [NAME] President (VP) of Nutrition was asked if she was aware of Resident #1's significant weight loss that occurred in the last 3 months of 7.65%. She stated He was stable July through October then started going down about 10 pounds. He had been on House supplement then put on weekly weights. The VP of Nutrition was asked if she had documentation of his nutritional assessments. She replied, You can't see the orders. We put him on weekly weight his po [oral] intake was ok. The VP was asked if Resident #1 was still on weekly weights. VP of Nutrition replied, I don't think he is. Once he starts to get stable, we take him off the weekly weights. I know you look back 6 months, but I am more concerned about the last 60 days.
During an interview on 1/23/2025 at 2:50 PM, the Director of Nursing (DON) confirmed that any resident with an order for weekly weights should have weights assessed weekly and documented.
CONCERN
(D)
Potential for Harm - no one hurt, but risky conditions existed
Infection Control
(Tag F0880)
Could have caused harm · This affected 1 resident
**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on policy review, medical record review, observation, and interview, the facility failed to ensure infection control pract...
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**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on policy review, medical record review, observation, and interview, the facility failed to ensure infection control practices were followed during medication administration when 1 of 3 Licensed Practical Nurse (LPN) A nurses failed to follow Enhanced Barrier Precautions (EBP) when administering PEG (percutaneous endoscopic gastrostomy) tube medications and failed to perform appropriate hand hygiene.
The findings include:
1. Review of the undated facility policy titled, Enhanced Barrier Precautions, revealed .It is the policy of this facility to implement enhanced barrier precautions for the prevention of transmission of multidrug-resistant organisms .Enhanced barrier precautions (EBP) refers to an infection control intervention designed to reduce transmission of multidrug-resistant organisms that employs targeted gown and gloves use during high contact resident care activities .High-contact resident care activities include .Device care or use: .feeding tubes .
Review of the undated facility policy titled, Hand Hygiene, revealed .The use of gloves does not replace hand hygiene. If your task requires gloves, perform hand hygiene prior to donning gloves, and immediately after removing gloves .
2. Review of medical record revealed Resident #31 was admitted on [DATE], with diagnosis including Gastrostomy.
Review of the quarterly Minimum Data Set (MDS) assessment dated [DATE], revealed a Brief Interview for Mental Status (BIMS) score of 12, which indicated Resident #31 was moderately cognitively impaired.
Review of Physician's orders dated 4/17/2024 revealed .Enhanced barrier precautions r/t [related to] peg tube every shift .
Observation in Resident's room on 1/22/2024 at 11:00 AM, revealed LPN A removed gloves, did not perform hand hygiene, cleaned stethoscope, removed medication, put on gloves .opened capsules, removed gloves, did not perform hand hygiene, administered medications per peg and did not wear a gown.
During an interview on 1/22/2025 at 11:23 AM, LPN A was asked if Resident #31 was in Enhanced Barriers. She replied, No. LPN A was asked if there was a sign on the door that says enhanced barrier. She replied, Yes, but he is not sick. LPN A was asked if PPE [Personal Protective Equipment] should have been worn when providing care to a resident in Enhanced Precautions. LPN A stated, Yes. I never would have thought of that. LPN A confirmed that hand hygiene should have been performed after taking off dirty gloves and before putting on clean gloves.
During an interview on 1/23/2025 at 2:50 PM, the Director of Nursing (DON) was asked if nursing staff providing care to residents should know what EBP are. The DON replied, Yes, absolutely. The DON confirmed the nurse should have worn PPE when administering peg meds to a resident in EBP. The DON confirmed that staff should perform hand hygiene after removing gloves and before putting on clean gloves.
CONCERN
(E)
Potential for Harm - no one hurt, but risky conditions existed
Food Safety
(Tag F0812)
Could have caused harm · This affected multiple residents
Based on policy review, observation, and interview, the facility failed to ensure food was served under sanitary conditions when carbon covered cookware was used in the kitchen, the dishwasher thermom...
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Based on policy review, observation, and interview, the facility failed to ensure food was served under sanitary conditions when carbon covered cookware was used in the kitchen, the dishwasher thermometer failed to reach 120 degrees during the wash cycle, sanitation solution did not measure appropriately, when residents were served with unsanitary plates and silverware, when expired foods were found in the dry storage area and in the Emergency Food Supply. The facility had a census of 53, with 51 of those resident's receiving a lunch tray from the kitchen on 1/23/2025, and 49 receiving a breakfast tray on 1/24/2025.
The findings included:
1. Review of the facility's undated policy titled, Dishwasher Temperatures, revealed .It is the policy of this facility to ensure dishes and utensils are cleaned under sanitary conditions through adequate dishwasher temperatures .low temperature dishwashers .wash temperature shall be 120 degrees F [Fahrenheit] .sanitizing solution shall be 50ppm (parts per million) hypochlorite (chlorine) on dish surface in final rinse .Chemical solutions shall be maintained at the correct concentration .
2. Observation on 1/21/2025 at 8:09 AM, and on 1/22/2025 at 11:05 AM, revealed 2 large and 3 small pans, 1 small and 3 medium pots, 4 steam table pans, and 3 skillets with thick carbon build up.
Observation on 1/22/2025 at 11:10, revealed two containers of peanut butter with a best if used by date of September 20, 2024, and a can of tomato juice with an expiration date of November 28, 2024.
Observation and interview on 1/23/2025 at 11:10 AM, revealed while the low temperature dishwasher was washing and rinsing dishes, the temperature gauge on the machine read 40 degrees and did not move the whole cycle. The Dietary Manager (DM) was asked to check the sanitation with the dishwasher test strips. The DM confirmed that the dishwasher test strips were not measuring the correct amount of chemicals during the rinse. The DM also confirmed that the thermometer was not working correctly and used a cooking thermometer to check the temperature during a wash cycle. The temperature was 112.6 Fahrenheit.
Observation on 1/23/25 at 11:30 AM, revealed Dietary staff serving lunch on regular dishware that had been washed in the malfunctioning dishwasher.
Observation on 1/24/25 at 7:42 AM, revealed residents being served breakfast on regular dishware that had been washed in the malfunctioning dishwasher.
3. During an observation and interview on 1/24/2025 at 9:00 AM, the DM confirmed the facility would have to replace the broken temperature gauge, the repairman had just worked on the dishwasher machine and the machine was currently working properly. The DM used a kitchen thermometer to test the water during the wash cycle and it read 130 degrees. The dishwasher sanitation strip also tested correctly at this time. The DM was asked if the residents of the facility should have been served lunch on regular dining plates on 1/23/2024 and breakfast on 1/24/2025 knowing that the dishwasher temperature and the chemical sanitation was not what it should have been. The Dietary Manager confirmed he should have used disposable plates and utensils.
4. Observation and interview at the Emergency Food Supply Storage Area on 1/24/2025 at 9:32 AM, revealed the following:
a. Four containers of peanut butter with a best used by date of July 13, 2024, and two containers of peanut butter with a best if used by date of 2/16/2021.
b. Two cans of tomato juice with an expiration date of November 28, 2024.
c. Three cans of Cream of Chicken Soup with an expiration date of January 12, 2024.
d. One gallon of Apple Cider Vinegar with an expiration date of 1/10/2024.
e. One case containing 22 cans of evaporated milk with an expiration date of 3/24/2022.
The DM confirmed there should not be any expired food items in the Emergency Food Supply or in the kitchen and stated, .I will get rid of all of this right now . The DM was asked what should have been done for lunch on 1/23/2024 when the dishwasher was noted to not have the right temperature and the right sanitation. The DM stated, .I should have used the paper plates and utensils . The DM was asked what he should have done for breakfast on 1/24/2025 since the repairman had not been in yet to service the dishwasher. The DM stated, .disposable plates should have been used .
Mar 2024
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** AMENDED 6.10.24
Based on policy review, Occupational Safety and Health Administration (OSHA) review, medical record review, obse...
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**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** AMENDED 6.10.24
Based on policy review, Occupational Safety and Health Administration (OSHA) review, medical record review, observations, and interview, the facility failed to ensure the residents' environment was free of accidents and hazards when the facility failed to develop and implement care plan interventions to prevent falls for a resident with high risk of falls, supervise a cognitively impaired Resident, failed to monitor the Resident's condition post fall, and failed to provide care and services for 1 of 10 (Resident #42) sampled residents reviewed for falls. Resident #42 is a moderately cognitively impaired Resident who was ambulatory with a walker, fell on [DATE], and had complaints of right hip pain documented on 10/19/2023. The facility failed to obtain the Xray until 10/25/2023, and failed to assess the Resident when the Resident complained of post fall pain on 10/19/2023, 10/20/2023, and 10/24/2023. Resident #42 was transferred to the hospital's emergency department (ED) 12 days after the fall and admitted for a surgical repair of a fractured hip. The facility's failure to provide supervision of cognitively impaired resident and immediately assess the Resident with complaints of right hip pain following a fall which required surgical repair, resulted in Immediate Jeopardy for Resident #42.
Immediate Jeopardy (a situation in which the provider's noncompliance with one or more requirements of participation has caused, or is likely to cause, serious injury, harm, impairment, or death to a resident) was identified related to the facility's failure to monitor and assess Resident #42, who complained of right hip pain following a fall.
An extended survey was conducted from 3/25/2024 to 3/26/2024.
The Administrator was notified of the Immediate Jeopardy (IJ) for F-689 on 3/25/2024 at 5:29 PM, in the Employee Break Room related to Resident #42's fall.
The facility was cited Immediate Jeopardy at F-689, at a severity of J which is Substandard Quality of Care.
The Immediate Jeopardy began on 10/19/2023, and is ongoing.
The findings include:
1. Review of the facility policy Resident Rights dated 10/18/2022, revealed .The resident has a right to a safe .environment .
Review of the facility undated policy, Abuse, Neglect, and Exploitation revealed .Establishing a safe environment .
Review of the undated facility policy titled, Fall Prevention Program, revealed .Each resident will be assessed for the risks of falling and will receive care and services in accordance with the level of risk to minimize the likelihood of falls .When any resident experiences a fall, the facility will .Assess the resident .Complete a fall assessment .Complete an incident report .Notify physician and family .Review the resident's care plan and update as indicated .Document all assessments and actions .Obtain witness statements in the case of injury .
2. Review of the medical record revealed Resident #42 was admitted to the facility on [DATE], with diagnoses of Cerebral Infarction, Aortic Stenosis, Schizoaffective Disorder, Dementia, Dyskinesia, Depression, Seizures, Auditory Hallucinations .
Review of the facility's MORSE FALL SCALE for Resident #42 dated 8/16/2022, revealed Resident #42 was high risk for falls.
Review of the care plan with a revision date of 8/22/2022, revealed no documentation of interventions to prevent falls for Resident #42, who was identified as high risk for falls.
Review of the annual Minimum Data Set (MDS) dated [DATE], for Resident #42 revealed a Brief Interview for Mental Status (BIMS) score of 9 which indicated Resident #42 is moderately cognitively impaired, and required extensive assist for most Activities of Daily Living and required assistance of a walker with ambulation.
There was no documentation Resident #42's care plan was revised to reflect interventions to prevent falls.
Review of the facility's MORSE FALL SCALE for Resident #42 dated 10/14/2023, revealed Resident #42 was high risk for falls.
Review of the HIGH RISK EVENT - INVESTIGATION STATEMENT for Resident #42 dated 10/14/2023, revealed .Type of Incident: unwitnessed fall .Did you witness the incident .No .[staff] Walked in the room resident [Resident #42] was on the floor .
Review of the Incident Report dated 10/14/2023, for Resident #42 revealed .when [staff] walking in the room she [Resident #42] was calm laying on the floor on her right side in front of the tv [television] .Injury Type .Fracture .Right Trochanter (hip) [unknown why the staff documented a hip fracture here prior to the 10/25/23 Xray report] .Injuries Report Post Incident .No Injuries Observed Post Incident .Witnesses .No Witnesses found .
There was no documentation the care plan had been revised following Resident #42's fall on 10/14/2023 with interventions to prevent further falls.
Review of the October 2023 Medication Administration Record (MAR) for 10/14/2023 - 10/26/2023 revealed nursing documented Resident #42's pain level as 0 (on a scale of 1 - 10 with 10 being the most severe and 0 being no pain) for the day and night shifts.
Review of the Nursing Progress Notes dated 10/16/2023, revealed .Resident [Resident #42] had an unwitnessed fall [regarding the 10/14/2023 fall] .
Review of the Physical Therapy (PT) Evaluation and Plan of Treatment for Resident #42 dated 10/17/2023, revealed .Multiple medical conditions, Multiple medications .Desired change in Condition of Risk Area: to prevent falls .pt had unwitnessed fall on 10/14/2023, she was not using her walker, She was found on the floor on her R [Right] side, noted skin tear to R [Right] elbow .
Review of the Physical Therapy Treatment Encounter Note for Resident #42 dated 10/19/2023, revealed .pt [patient, Resident #42] c/o increased R [Right] hip pain .Pt [patient] attempted RLE [Right Lower Extremity] exercises but c/o [complained of] pain and demoed [demonstrated] decreased ROM [Range of Motion] .PTA [Physical therapy Assistant] notified NSG [nursing] on pt pain. NSG [Nursing] aware . There was no documentation of a nursing pain assessment for Resident #42's complaint of right hip pain that was reported by the therapist during the 10/19/2023 therapy session.
Review of the Intern Physician's Progress Notes dated 10/20/2023, for Resident #42 revealed .Nursing Home Visit .patient [Resident #42] report R hip pain since having a fall over the last weekend 5 days ago .R hip pain .on palpation of R hip .X-ray to be ordered to assess for acute fracture .Will consider adding pain medication . There was no documentation of a nursing pain assessment for Resident #42's complaint of right hip pain reported during the physician's visit on 10/20/2023.
Review of the Physician's Orders for October 2023 revealed there was no order documented on 10/20/2023 for Xray.
Review of the Physical Therapy Note dated 10/24/2023, for Resident #42 revealed .right hip pain .notified nursing of patient's [Resident #42] pain .
Review of the Nursing Progress Notes dated 10/24/2023, for Resident #42 revealed .therapy [PT] stated pt [Resident #42] c/o hip pain today .will cont'd [continued] to monitor as doctor stated we can get an x-ray .and notify doctor . There was no documentation the X-ray was obtained on 10/24/2023.
Review of the Nursing Progress Notes dated 10/26/2023 at 1:14 PM, revealed .[Resident #42] being monitored for hip pain. Xray completed and resulted 10/25/2023.
Review of the nursing progress notes revealed the physician was not notified of the STAT x-ray results from 10/25/2023 that revealed Resident #42 had a fractured hip.
Review of the Nursing Progress Notes dated 10/26/2023, revealed .Resident [Resident #42] being monitored for hip pain. Xray completed and resulted 10/25/2023 .Dr [named Medical Director] in facility for visit. Reviewed x-ray .hip is broken and externally rotated .MD [Medical Director] ordered resident be sent [to the hospital] .for evaluation and possible repair .
Review of the Physician's Progress Notes dated 10/26/2023 at 2:51 PM, for Resident #42, revealed .Hip Pain .injury mechanism was a fall .pain is present in the right hip .described as stabbing .pain is moderate .inability to bear weight .loss of motion .Hip joint externally rotated, Any movement causes significant pain .closed fracture of right hip with nonunion .
Review of the Hospital ED medical record revealed Resident #42 presented to the ED on 10/26/2023, 12 days after the Resident fell on [DATE].
Review of the ED Triage Assessment performed on 10/26/2023 4:46 PM, revealed Resident #42 presented to the ED via Emergency Medical Service (EMS) with complaints of .Fall with R [right] hip .Severe pain .
The ED Nursing assessment dated [DATE], revealed, .PAtient [Patient, Resident #42] presents from [Named Nursing Home] with c/o [complaints of] R hip pain from a fall days ago and an xray resulted 24 hours ago showing a possible fracture .Severe pain .Arm, right .Bruising .
Review of the Hospital ED Nurse Practitioner note dated 10/26/2023 at 4:50 PM, for Resident #42 revealed, .Right shoulder pain; Traumatic hematoma of right upper arm; Impacted fracture of right hip; Fall .Additional history: Patient [Resident #42] presents to emergency department with complaints of right hip pain right arm pain and head pain. Patient states she had a fall approximately 1 week ago at the nursing home that was unwitnessed .At this time she is complaining of right hip pain and a large hematoma to the right upper arm. She also states she has a headache .
Review of the Hospital X-ray report of the Resident #42's right hip dated 10/26/2023, revealed .Acute to subacute superiorly displaced and impacted right femoral neck fracture. No dislocation of the femoral head from the acetabulum [part of the hip bone]. Underlying moderate osteopenia. Moderate right and mild left hip DJD [Degenerative joint disease] with loss of joint space and subchondral sclerosis [bones thicken] .
Review of the Hospital History & Physical dated 10/26/2023, for Resident #42, revealed .Patient [Resident #42] is a [AGE] year-old female with a past medical history of dementia, CVA [Cerebral Vascular Accident also known as a stroke], osteoarthritis, schizoaffective disorder and seizures who presents from the nursing home due to a right femur fracture .patient is alert and oriented to name only, she does not answer questions appropriately .she has had right shoulder pain and right hip pain. Right hip x-ray shows acute to subacute superior displaced and impacted right femoral neck fracture. Orthopedic surgery consulted. Right CT [computerized tomography - a detailed scan to determine/identify internal problems] shoulder shows severe DJD as well as multiple pulmonary nodules. CT brain unremarkable. CT cervical spine unremarkable .
Review of the Radiology Consultation Report dated 10/26/2023, revealed Acute to subacute superiorly displaced and impacted right femoral neck fracture .Underlying moderate osteopenia. Moderate right and mild left hip DJD [degenerative joint disease] with loss of joint space and subchondral sclerosis .
Resident #42 had an Arthroplasty Partial Hip (replacement of the damaged and/or worn out bone) at the hospital on [DATE].
Review of the Hospital Progress Note dated 11/5/2023, revealed .[Resident #42] had been up walking on 11/3/2023 but then started shouting with pain when she sat in a chair. [Resident #42] was found have acute right hip dislocation Resident #42 required a second operation while in the hospital on [DATE] to repair the dislocated hip.
Review of the Hospital Discharge summary dated [DATE], for Resident #42 revealed, Patient [Resident #42] is a [AGE] year-old female with a past medical history of dementia, CVA [stroke], osteoarthritis, schizoaffective disorder and seizures who presents from the nursing home due to a right femur fracture. On my encounter, patient is alert and oriented to name only, she does not answer questions appropriately .She underwent right hip hemiarthroplasty [replacement of the damaged or worn out bone] on 10/27 [2023] .hemoglobin was down to 6.4 [normal 12 - 15] on 10/29 [2023] .transfused [blood to improve the hemoglobin levels] .required another unit of Packed red blood cells on 10/30 when her hemoglobin was 7.5 .[Resident #42] was noted to have some coughing after eating and a video swallow eval was obtained, with the recommendation of dysphagia chopped diet with nectar thick liquids She was found have acute right hip dislocation. This was reduced in the OR [operating room] on 11/04 [2023] .As she [Resident #42] was getting ready for discharge, started to have hip pain, repeat x-ray showed recurrent right hip dislocation. She went back to OR on 11/8 [2023]for irrigation, debridement, and evacuation of large right hip hematoma and revision of hemiarthroplasty to total hip arthroplasty .Patient [Resident #42] needs to follow up for his [her] primary care provider for imaging lung nodules .Need to discuss antiplatelet therapy .
Review of the medical record revealed Resident #42 was readmitted to the long term care facility on 11/14/2023, with diagnoses of Cerebral Infarction, Aortic Stenosis, Schizoaffective Disorder, Dementia, Dyskinesia, Depression, Seizures, Auditory Hallucinations and Fracture of Head and Neck of Right Femur.
Review of the significant change MDS dated [DATE], revealed Resident #42 scored a 7 on the BIMS indicating the Resident is severely cognitively impaired and sustained a fall in the last month.
Review of the care plan revised 11/17/2023, revealed the intervention for falls was to keep the call light in place. There was no documentation of other fall interventions to prevent further falls.
During an observation in Resident #42's room on 3/18/2024 at 9:49 AM, Resident #42 was sitting in the wheelchair with her socks on.
During an observation in Resident #42's room on 3/19/2024 at 8:08 AM, Resident #42 was in her wheelchair and her call light was on the floor behind the wheelchair.
During an observation in Resident #42's room on 3/25/2024 7:56 AM, Resident #42 was in the bed and the call light was laying over the chair next to the hospital bed out of reach for the resident.
During a telephone interview on 3/21/2024 at 4:05 PM, the Physical Therapy Director stated, We saw her [Resident #42] for a few days before she went to the hospital .I believe it was an unwitnessed fall .[Physical Therapy] reported her [Resident #42] pain to nursing a few times .
During an interview on 3/25/2024 at 1:49 PM, Certified Nursing Assistant (CNA) B was asked to explain what happened the day of Resident #42's fall on 10/14/2023. CNA B stated, .she [Resident #42] was reaching for her walker and fell on her butt, she didn't hit her head [the fall was unwitnessed] and I yelled out to the charge nurse .
During an interview on 3/25/2024 at 1:40 PM, the Intern Physician who documented on 10/20/23 that an Xray would be performed on Resident #42, was asked to explain the process for ordering x-rays since the Intern Physician didn't have access to the Electronic Medical record (EMR). The Intern Physician stated, .we communicate to the nurse, and she [the nurse] immediately puts in the order .
During an interview on 3/25/2024 at 3:17 PM, the DON was asked for the Intern Physician order and results for the x-ray that was ordered on 10/20/2023 for Resident #42. The DON was unable to find a 10/20/2023 physician order for an Xray in the EMR. The DON stated the nurse must not have ordered the Xray on 10/20/2023. The DON was pointed out that some of the facility documentation states that Resident #42 experienced a witnessed fall and other facility documentation states Resident #42 experienced an unwitnessed fall. The DON was asked to clarify if witnessed or unwitnessed fall for Resident #42. The DON stated Resident #42's fall cannot be determined as witnessed or unwitnessed unless further investigation was completed.
CONCERN
(D)
📢 Someone Reported This
A family member, employee, or ombudsman was alarmed enough to file a formal complaint
Potential for Harm - no one hurt, but risky conditions existed
Report Alleged Abuse
(Tag F0609)
Could have caused harm · This affected 1 resident
**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on policy review, job description review, medical record review, and interview, the facility failed to report injuries of ...
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**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on policy review, job description review, medical record review, and interview, the facility failed to report injuries of unknown source to the state agency, adult protective services, law enforcement, and Ombudsman for 1 of 13 (Resident #42) sampled residents reviewed for abuse.
The findings include:
1. Review of the facility's policy titled Resident Rights dated 9/21/2020, revealed .Consult with the Resident's physician .An accident involving the Resident which results in injury and has the potential for requiring physician intervention .
Review of the facility's undated policy titled, .Abuse, Neglect, and Exploitation, revealed .It is the policy of this facility to provide protections for the health, welfare and rights of each resident .Possible indicators of abuse include, but not limited to .physical marks such as bruises .on a resident's body .physical injury of a resident, of unknown source .The facility will make efforts to ensure all residents are protected from physical .harm during and after the investigation .Reporting of all alleged violations to the Administrator, state agency, adult protective services and to all other required agencies as is required .Immediately, but not later than 2 hours after the allegation is made, if the events that cause the allegation involve abuse or result in serious bodily injury .
2. Review of the Facility's Administrator Job Description dated 7/29/2021, revealed .Leads, guides and directs the operations of the healthcare facility in accordance with local, state, and federal regulations, standards and established policies and procedures to provide appropriate care and services to residents .Ensures residents incidents and concerns that rise to a reportable event such as alleged abuse, neglect .are reported to the correct entity within the stated regulatory requirement .reports any allegations of abuse, neglect .protects residents from abuse .
Review of the Facility's Director of Nursing Job Description dated 10/22/2021, revealed .Oversees resident incidents and concerns daily to identify any unusual occurrences and reports them promptly to the Administrator and/or state agency for appropriate action .Monitors for allegations of potential abuse or neglect .participates in the investigative process .Reports any allegations of abuse, neglect .Protect residents from abuse .
3. Review of the medical record revealed Resident #42 was admitted to the facility on [DATE], with diagnosis of Cerebral Infarction, Aortic Stenosis, Schizoaffective Disorder, Dementia, Dyskinesia, Depression, Seizures, and Auditory Hallucinations.
Review of the significant change Minimum Data Set (MDS) dated [DATE], revealed Resident #42 scored a 7 on the Brief Interview for Mental Status (BIMS), which indicated severely cognitively impairment.
Review of the significant change MDS dated [DATE], revealed Resident #42 scored a 7 on the BIMS, indicating the resident is severely cognitively impaired and needs extensive assist dressing, bathing, and toileting.
Review of a facility untitled document dated 3/16/2024, revealed CNA G provided a bed bath and documented that Resident #42's skin had no bruising.
Observations in Resident #42's room on 3/18/2024 at 9:49 AM, revealed Resident # 42 in the bed with their arms under the sheet and blanket. A dime size purple/bluish bruise was noted to the resident's lip and chest area.
Observations in Resident #42's room on 3/20/2024 at 1:12 PM, revealed the Resident sitting in the wheelchair with a short sleeve shirt on. A bruise that was yellow/greenish about the size of a tennis ball was observed and a dark purple bruise the size of a half dollar with a hematoma in the middle was observed to Resident #42's left arm.
During an interview on 3/20/2024 at 1:18 PM, Licensed Practical Nurse (LPN) L was asked if she knew how Resident #42 received the bruises on the lips, chest area and arm. LPN L confirmed she had not identified the bruises on Resident #42 prior to the surveyor observation.
Observation in the Resident's room on 3/20/2024 at 1:21 PM, the Director of Nurses (DON) was shown the bruised areas on Resident #42's lip and arm. The DON stated she had not made aware of the bruising to the Resident's lip and arm.
Review of the facility's Investigation Statement dated 3/20/2024, revealed LPN L's action was to assess Resident #42's skin. This was done after DON and LPN L were made aware of bruising by the surveyors.
Review of a facility Incident Report dated 3/20/2024 at 5:57 PM, and Investigation Statement dated 3/20/2024, revealed LPN L observed a small bruise to the left mid side of Resident #42's chin, purple in color and dime sized. LPN L did not address the bruise of unknown source to the Resident's left arm, lip and chest area on the Investigation Statement or Incident Report.
Review of the facility's Weekly Wound Progress Note dated 3/21/2024, revealed Resident #42 had a chest, chin and left arm bruise. The lip bruise was not identified.
During an interview on 3/21/2024 at 8:01 AM, CNA J was asked about the bruises on Resident #42. CNA J stated, I don't know anything about the bruises, I was already asked yesterday
During an interview on 3/21/2024 at 8:06 AM, CNA A was asked about the bruises on Resident #42. CNA A stated, I don't [provide] care for Resident #42 and haven't heard anything about what happened CNA A was asked what would she do if she found a bruise on a resident. CNA A stated, I would report it to [the] nurse.
During an interview on 3/21/2024 at 11:26 AM, the Treatment Nurse was asked if she had noticed bruising on Resident #42. The Treatment Nurse confirmed she noticed the bruise on Resident #42's lip on 3/20/2024 and that the bruise was new. The Treatment Nurse confirmed she did the Resident's skin assessment on 3/14/2024 and did not notice a bruise on the Resident's left arm. The Treatment Nurse confirmed there was no documentation related to Resident #42's bruises prior to 3/20/2024.
During an interview on 3/21/2024 at 11:47 AM, the DON confirmed she had not identified a bruise to Resident #42's left upper arm or lip. The DON stated that LPN L did a skin assessment on 3/20/2024 and the LPN should have noticed the bruising. The DON stated the bruise on Resident #42's chest area was from the Resident scratching her chest. The DON verified that there was no documentation of Resident #42 scratching her chest and causing bruising.
During an interview on 3/21/2024 at 6:06 PM, the Administrator confirmed a bruise of unknown source to Resident #42's left upper arm had not been reported to him. The Administrator stated he heard about the left lower lip bruise and would look into the bruising on Resident #42's arm.
Review of a facility Incident Reporting System (IRS) form dated 3/21/2024 at 8:17 PM, for Resident #42 revealed staff became aware of an incident on 3/20/2024 at 6:40 PM, per outside agency. The Administrator became aware of an incident on 3/21/2024 at 5:40 PM, per outside agency. The report verified the bruising was of unknown source.
Review of a facility Progress Note dated 3/21/2024, for Resident #42 revealed Late entry: 3/20/24 [2024] .assessment of patient [Resident #42] this shift a small bruise purple in color on left mid chin was observed . The note did not address the bruising to the Resident's arm, lip and chest area.
Review of a facility Investigation Reportable Folder dated 3/21/2024, revealed the Administrator was made aware on 3/21/2024 that Resident #42 had a yellow color bruise to the outside upper extremity of unknown source.
During an interview on 3/25/2024 at 3:17 PM, the DON confirmed a bruise of unknown source has to be investigated and reported to the Administrator. The DON was asked if she felt the investigation for the bruises for Resident #42 was conducted in a timely manner. The DON stated, .the arm was not done timely . The DON was asked when she had been made aware of the bruises on Resident #42. The DON stated, .It may have been when [named Surveyor #1] showed me . The DON confirmed a nurse should have noticed the bruising on Resident #42 and notified the DON. The DON was asked should LPN L performed a full skin assessment on Resident #42 3/20/2024. The DON stated, Yes.
During an interview on 3/26/2024 at 10:24 AM, the Administrator confirmed he did not start an investigation, or report the injuries of unknown source until he was made aware of the bruises on 3/21/2024. The Administrator confirmed it was possible that a staff member should have seen Resident #42's bruises during shower and bathing. The Administrator was asked when Surveyor #1 reported the bruises to staff, should he have been notified. The Administrator stated, Yes.
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
**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on policy review, job description review, medical record review, facility investigation, observation and interview, the fa...
Read full inspector narrative →
**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on policy review, job description review, medical record review, facility investigation, observation and interview, the facility failed to thoroughly investigate an unwitnessed fall with injury and bruises of unknown source in order to identify possible factors of abuse and/or neglect for 1 of 13 sampled residents (Resident #42) reviewed for abuse/neglect.
The findings include:
1. Review of the undated facility policy titled, Abuse, Neglect, and Exploitation, revealed .The facility will have written procedures to assist staff in identifying the different types of abuse .physical abuse .Possible indicators of abuse .include, but are not limited to: Physical mark's such as bruises .on a resident's body .Physical injury of a resident, of unknown source .Investigation of Alleged Abuse, Neglect and Exploitation .An immediate investigation is warranted when suspicion of abuse .occur .Written procedure for investigations include: Identifying staff responsible for the investigations .Investigating different types of alleged violations .Identifying and interviewing all involved persons, including the alleged victim .witnesses, and others who might have knowledge of the allegations .Focusing the investigation on determining if abuse .has occurred, the extent, and cause; and Providing complete and thorough documentation of the investigation .
Review of the undated facility policy titled, Fall Prevention Program, revealed .Each resident will be assessed for the risks of falling and will receive care and services in accordance with the level of risk to minimize the likelihood of falls .When any resident experiences a fall, the facility will .Assess the resident .Complete a fall assessment .Complete an incident report .Notify physician and family .Review the resident's care plan and update as indicated .Document all assessments and actions .Obtain witness statements in the case of injury .
2. Review of the facility's Administrator JOB DESCRIPTION, dated 7/29/2021, revealed .Lead, guides and directs the operations of the healthcare facility in accordance with local, state and federal regulations, standards and established facility policies and procedures to provide appropriate care and services to residents Ensures resident incidents and concerns that arise to a reportable event such as alleged abuse, neglect, mistreatment, misappropriation .are reported to the correct entity within the stated regulatory requirement .Reports any allegations of abuse, neglect .or mistreatment of residents to supervisor and/or administrator .Protects residents from abuse, and cooperates with all
investigations .
Review of the facility's Director of Nursing JOB DESCRIPTION, dated 10/22/2021, revealed .Plans, develops, organizes, implements, evaluates and directs the overall operations of the Nursing Services department, as well as its programs and activities, in accordance with current state and federal laws and regulations .Interprets and communicates policies and procedures to nursing staff, and monitors staff practices and implementation .Performs rounds to observe residents and ensure nursing needs are being met .Communicates directly with residents .and members of the interdisciplinary team to coordinate care and services and respond to and resolve complaints and concerns .Oversees resident incidents and concerns daily to identify any unusual occurrences and reports them promptly to the Administrator and/or state agency for appropriate action .Monitors for allegations of potential abuse or neglect, or misappropriation of resident property and participates in the investigative process .Reports any allegations of abuse, neglect .or mistreatment of residents to supervisor and/or administrator. Protects residents from abuse, and cooperates with all investigations .
3. Review of the medical record revealed Resident #42 was admitted to the facility on [DATE], with diagnoses of Cerebral Infarction, Aortic Stenosis, Schizoaffective Disorder, Dementia, and Dyskinesia.
Review of the annual Minimum Data Set (MDS) dated [DATE], for Resident #42 revealed a Brief Interview for Mental Status (BIMS) score of 9 which indicated Resident #42 was moderately cognitively impaired, required extensive assist for most Activities of Daily Living and required assistance of a walker with ambulation.
Review of the Nursing Progress Notes dated 10/14/2023 at 4:13 PM, revealed Resident [Resident #42] is noted walking without walker this shift and was found lying on the floor on her right side she is noted with a small skin tear to the right elbow .no new orders at this time .
Review of the Incident Report dated 10/14/2023 revealed .when [staff] walking in the room she [Resident #42] was calm laying on the floor on her right side in front of the tv .Injury Type Fracture .Right trochanter (hip) [unknown why the staff documented a hip fracture here prior to the 10/25/2023 Xray report] .no witnesses found .
Review of the Nursing Progress Notes dated 10/15/2023 at 3:02 AM, revealed .resident had unwitnessed fall on 10/14 with noted skin tear on right elbow .
Review of the Physician Progress Note dated 10/20/2023, revealed Nursing Home Visit .Right hip pain .DX [diagnosis] Hip Pain Reason for Visit .The patient reports right hip pain since having a fall over the last weekend 5 days ago .reports decreased movement .x-ray to be ordered to assess for acute fracture .will consider adding pain medication if needed .
Review of the Physician's orders revealed there were no orders for the x-ray ordered on 10/20/2023.
Review of the Nursing Progress Notes dated 10/24/2023 at 3:46 PM, revealed .therapy stated pt [Resident#42] c/o [complain of] hip pain today will cont'd [continued] to monitor as doctor stated we can get an x-ray if needed .
Review of the Physician's order dated 10/25/2023, revealed . X-ray of (R) [right] hip STAT [immediately] for Pain .
Review of the Nursing Progress Notes dated 10/26/2023 at 1:14 PM, revealed .[Resident #42] being monitored for hip pain. Xray completed and resulted 10/25/2023.
Review of the Nursing Progress Notes revealed the physician was not notified of the STAT x-ray results from 10/25/2023.
Review of the Physicians Progress Note dated 10/26/2023 at 2:51 PM, revealed .Closed fracture of right hip .Dx hip pain Reason for visit Hip Pain The incident occurred more than 1 week ago. The incident occurred at a nursing home. The injury mechanism was a fall. The pain is present in the right hip. The quality of the pain is described as stabbing. The pain is moderate. Associated symptoms include an inability to bear weight and a loss of motion. The symptoms are aggravated by weight bearing .Transfer to Emergency Department for further evaluation .
Resident #42 was transferred to the hospital on [DATE] and underwent surgical repair of the right fractured hip.
Review of the medical record revealed that Resident #42 was readmitted to the facility on [DATE] with diagnoses of Cerebral Infarction, Aortic Stenosis, Schizoaffective Disorder, Dementia, Dyskinesia and Fracture of Head and Neck of Right Femur.
There was no documentation the facility investigated the unwitnessed fall which occurred on 10/14/2023.
Observation in Resident #42's room on 3/18/2024 at 9:49 AM, revealed Resident # 42 in the bed with her arms under the sheet and blanket. A dime size purple/bluish bruise was noted to the resident's lip and chest area.
Observation in Resident #42's room on 3/20/2024 at 1:12 PM, revealed Resident #42 sitting in the wheelchair with a short sleeve shirt on and an old bruise that was yellow/green about the size of a tennis ball with a dark purple bruise the size of a half dollar with a hematoma in the middle was noted to Resident #42's left upper arm.
There was no documentation of a facility investigation to determine the cause of the bruises.
After the facility was questioned on 3/20/2024 regarding the bruises on Resident #42, the facility submitted an Investigation Statement dated 3/20/2024, for Resident #42 documenting the action plan was to assess Resident #42's skin.
The facility Incident Report dated 3/20/2024 at 5:57 PM, and the facility Investigation Statement dated 3/20/2024, revealed LPN L assessed Resident #42 and observed a small bruise to the left mid side of chin, purple in color and dime sized. LPN L did not address the bruise of unknown source to left arm and chest area on the Investigation Statement or Incident Report.
Review of an Incident Reporting System (IRS) form dated 3/21/2024 at 8:17 PM for Resident #42, revealed staff became aware of incident on 3/20/2024 at 6:40 PM, per outside agency. The Administrator became aware of incident on 3/21/2024 at 5:40 PM, per outside agency. The report verified the bruising was of unknown source.
During an interview on 3/20/2024 at 1:18 PM, Licensed Practical Nurse (LPN) L was asked if she knew how Resident #42 received the bruises on her lips, chest area and arm. LPN L confirmed she had not identified the bruises on Resident #42 prior to the surveyor observation.
During an interview on 3/21/2024 at 8:01 AM, CNA J was asked about the bruises on Resident #42. CNA J stated, I don't know anything about the bruises, I was already asked yesterday.
During an interview on 3/21/2024 at 8:06 AM, CNA A was asked about the bruises on Resident #42. CNA A stated, I don't [provide] care for Resident #42 and haven't heard anything about what happened CNA A was asked what she would do if she found a bruise. CNA A stated, I would report it to [the] nurse.
During an interview on 3/21/2024 at 11:26 AM, the Treatment Nurse was asked if she had noticed bruising on Resident #42. The Treatment Nurse confirmed she noticed the bruise on Resident #42's lip on 3/20/2024 and that the bruise was new.
During an interview on 3/21/2024 at 11:47 AM, the DON confirmed she had not identified a bruise to Resident #42's left upper arm or lip. The DON stated that LPN L did a skin assessment on 3/20/2024 and the LPN should have noticed the bruising. The DON stated the bruise on Resident #42's chest area was from the Resident scratching her chest. The DON verified that there was no documentation of Resident #42 scratching her chest and causing bruising.
During an interview on 3/21/2024 at 6:05 PM, The Administrator confirmed that interviews are a part of a complete investigation.
During an interview on 3/25/2024 at 3:17 PM, the DON confirmed a bruise of unknown source has to be investigated. The DON was asked if she felt the investigation for the bruises for Resident #42 was conducted in a timely manner. The DON stated, .the arm was not done timely . The DON was asked when she had been made aware of the bruises on Resident #42. The DON stated, .It may have been when [named Surveyor] showed me . The DON confirmed a nurse should have noticed the bruising on Resident #42 and notified the DON. The DON was asked should LPN L have performed a full skin assessment for Resident #42 on 3/20/2024. The DON stated, Yes. The DON was asked how many witness statements she gets when investigating a fall. The DON stated, .I will usually get 2 or 3 . The DON confirmed she did not get a witness statement from the nurse. The DON confirmed that it is not a complete investigation if the fall cannot be determined as witnessed or unwitnessed.
During an interview on 3/26/2024 at 10:24 AM, the Administrator confirmed he did not start an investigation, or report the injuries of unknown source until he was made aware of the bruises on 3/21/2024. The Administrator confirmed it was possible that a staff member should have seen Resident #42's bruises during shower and bathing. The Administrator was asked when the surveyors reported the bruises to staff, should he have been notified. The Administrator stated, Yes.
CONCERN
(D)
📢 Someone Reported This
A family member, employee, or ombudsman was alarmed enough to file a formal complaint
Potential for Harm - no one hurt, but risky conditions existed
Deficiency F0657
(Tag F0657)
Could have caused harm · This affected 1 resident
**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on policy review, medical record review, and interview, the facility failed to conduct Care Plan meetings for 1 of 14 (Res...
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**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on policy review, medical record review, and interview, the facility failed to conduct Care Plan meetings for 1 of 14 (Resident #356) sampled residents and failed to update the care plan for 1 of 14 (Resident #42) sampled residents reviewed for care planning.
The findings include:
1. Review of the facility's undated policy titled, Comprehensive Care Plans, revealed .It is the policy of this facility to develop and implement a comprehensive person-centered care plan for each resident rights, that includes measurable objectives and timeframes to meet a resident's medical, nursing, and mental and psychosocial needs that are identified in the resident's comprehensive assessment .The comprehensive care plan will be prepared by an interdisciplinary team [IDT], that includes, but is not limited to .A registered nurse .A nurse aide .A member of the food and nutrition services staff .The RAI [Resident Assessment Instrument] Coordinator .Activity Director .Licensed therapist .Social Services Director .Family members .The comprehensive care plan will be reviewed and revised by the interdisciplinary team after each comprehensive and quarterly MDS [Minimum Data Set] assessment .
2. Review of the closed medical record revealed Resident #356 was admitted on [DATE], with a readmission on [DATE], with diagnoses of Dementia, Major Depressive Disorder, Diabetes, Post Traumatic Stress Syndrome, and Hypertension.
Review of the quarterly Minimum Data Set (MDS) dated [DATE], revealed Resident #356 had a Brief Interview for Metal Status (BIMS) score of 3, which indicated he was severely cognitively impaired with wandering behaviors and required total staff dependence for activities of daily living (ADLs).
Review of the Monthly Calendar revealed Resident #365 was scheduled for a Care Plan meeting on 1/18/2023, and on 4/11/2023 at 10:00 AM.
During a telephone interview on 3/26/2024 at 1:31 PM, Family Member A was asked if the facility conducted a care plan meeting to discuss the care and services Resident #365 was getting. Family Member A stated, No .there wasn't any care plan meeting .the only person I talked to was the Social Worker .
During an interview on 3/26/2024 at 3:09 PM, the Social Service/Admissions was asked if she could provide documentation where Resident #365's care plan meeting was held on 1/18/2023 and 4/11/2023. The Social Service/Admissions confirmed she was unable to provide documentation the care plan meetings were held.
During an interview on 3/26/2024 at 3:11 PM, the Director of Nursing (DON) and the Assistant Director of Nursing (ADON) were asked how often the care plan meetings were held. The DON stated, .quarterly . The DON was asked to describe the process for scheduling the care plan meetings. The DON stated, .they are held quarterly .we notify the family .Social Worker sends out an invite or invite by phone or mail .
The DON was asked should Resident #365's Responsible Party have been invited to the Care Plan meeting scheduled in January and April of 2023. The DON stated, Yes.
The facility was unable to provide documentation of the IDT Care Plan meetings.
3. Review of the medical record revealed Resident #42 was admitted to the facility on [DATE], with diagnoses of Schizoaffective Disorder, Dementia, Depression, and Seizures.
Review of the facility's MORSE FALL SCALE, dated 8/16/2022, revealed Resident #42 was a high risk for falls.
Review of the care plan dated 8/22/2022, revealed there was no documentation of interventions to prevent falls for Resident #42, who was identified as high risk for falls.
Review of the annual MDS dated [DATE], for Resident #42 revealed a BIMS score of 9 which indicated Resident #42 was moderately cognitively impaired, required extensive assist for most ADLs and required assistance of a walker for ambulation.
There was no documentation the care plan had been revised to include fall interventions following Resident #42's fall on 10/14/2023.
During an interview on 3/25/2024 at 3:17 PM, the DON confirmed there were no revisions to the care plan to prevent further falls for Resident #42.
CONCERN
(D)
Potential for Harm - no one hurt, but risky conditions existed
Deficiency F0687
(Tag F0687)
Could have caused harm · This affected 1 resident
**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on policy review, medical record review, observation, and interview, the facility failed to provide podiatry care and serv...
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**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on policy review, medical record review, observation, and interview, the facility failed to provide podiatry care and services for 1 of 1 (Resident #46) sampled residents reviewed for podiatry services.
The findings include:
1. Review of the facility's undated policy titled, Activities of Daily Living (ADLs), revealed .A resident who is unable to carry out activities of daily living will receive the necessary services to maintain good nutrition, grooming, and personal and oral hygiene .
2. Review of the medical record revealed Resident #46 was admitted to the facility on [DATE], with diagnoses of Neuropathy, Bipolar, Osteoarthritis, Psoriasis, and Anxiety.
Review of the quarterly Minimum Data Set (MDS) dated [DATE], revealed Resident #46 had a Brief Interview for Mental Status (BIMS) score of 15, which indicated he was cognitively intact.
Review of the Care Plan dated 2/8/2024, revealed .Resident is at risk for skin breakdown . impaired bed mobility . There was no documentation interventions related to nail care was included.
Review of the (Named) Podiatry Services Progress Note dated 6/28/2023, revealed .Reason for visit: Thick/Myotic [Mycotic] Nails [a fungal infection that affects toenails or fingernails] .Painful on left great toe, left 2nd toe, left 3rd toe, right great toe right 2nd toe .Thickened .Crumbly .Plan to follow up in 2-3 months for at risk nail care .
Observation in the resident's room on 3/20/2024 at 1:21 PM, revealed Resident #46's toenails were brown, thick, and long.
Observation in the resident's room on 3/21/2024 at 4:03 PM, revealed Resident #46's toenails were extremely long, thick, and brown and it appeared as though one may have fallen off.
During an interview on 3/20/2024 at 3:14 PM, the Social Service/Admissions was asked when the last podiatry appointment was for Resident #46. The Social Service/Admissions confirmed it was in January. The Social Service/Admissions was asked to provide a copy of the visit note from podiatry. The Social Service/Admissions was unable to provide a visit note for January.
During an interview on 3/21/2024 at 9:42 AM, the Social Service/Admissions stated that (Named Podiatry Service) was unable to come in January due to the Business Office Manager (BOM) was unable to get the resident list to them in time. The Social Service/Admissions stated, .it will probably be May when podiatry comes back to the facility . The Social Service/Admissions confirmed that it had been almost a year since podiatry had been to the facility.
CONCERN
(D)
📢 Someone Reported This
A family member, employee, or ombudsman was alarmed enough to file a formal complaint
Potential for Harm - no one hurt, but risky conditions existed
Deficiency F0692
(Tag F0692)
Could have caused harm · This affected 1 resident
**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on policy review, medical record review, observation, and interview, the facility failed to provide care and services to m...
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**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on policy review, medical record review, observation, and interview, the facility failed to provide care and services to maintain adequate nutritional status via enteral feeding (nutrition provided via use of a gastric feeding tube) for 1 of 3 (Resident #11) sampled residents reviewed for enteral feeding.
The findings include:
1. Review of the facility's undated policy titled, Care and Treatment of Feeding Tubes, revealed .It is a policy of this facility to utilize feeding tubes in accordance with current clinical standards of practice, with interventions to prevent complication to the extent possible .Feeding tubes will be utilized according to physician orders, which typically include .the kind of feeding and its caloric value, volume, duration, mechanism of administration, and frequency of flush .The resident's plan of care will address the use of feeding tube, including strategies to prevent complications .The facility will utilize the Registered Dietician [RD] in estimating and calculating a resident's daily nutritional and hydration needs .
Review of the facility's undated policy titled, Weight System, revealed .Residents are weighed at admission, readmission, and per physician orders. Weekly weights are completed for an additional 3 weeks (or longer) if not stable on the following .Admit .Readmit .Significant weight change of 5% [percent] or more in 1 month or less, 7.5% in 3 months or 10% in 6 months .Physician's orders .Residents are to be weighed on admission and re-admission. These weights are to be completed within 24 hours of admission/readmission .Weight .is to be recorded in the EMR [electronic medical record] clinical record .Residents with a significant weight loss or gain .will be placed on weekly weights x [times] 4 week's or until weight is stable and no weight concerns are noted .If weight concerns are noted, weights are not stable, notify your RD and continue the weekly weights until stable .A designated person(s) will be assigned to obtain weights for accuracy and consistency .
Review of the facility's policy titled, Dietary .Consultant Dietitian Services, dated 11/22/2017, revealed .The Consultant Dietitian prepares a list of clinical recommendations at each visit and discusses these with the Dietary Manager [DM] and Director of Nursing [DON] .
Review of the facility's policy titled, NUTRITION MANAGEMENT, dated 10/18/2022, revealed .The facility provides care and services to each resident to ensure the resident maintains acceptable parameters of nutritional status in the context of his or her overall condition .Nursing staff shall obtain the resident's height and weight upon admission, and subsequently in accordance with facility policy .
2. Review of medical record revealed Resident #11 was admitted on [DATE], with a readmission on [DATE], with diagnoses of Acute Respiratory Failure, Dysphagia, Schizophrenia, Major Depression, and Gastroesophageal Reflux Disease.
Review of the Progress Note, dated 1/23/2024, revealed .resident is noted in her wheelchair pupils sluggish not responding to stimuli unable to safely administer medications .new order to send resident to the ER [emergency room] for treatment .
Review of Named Hospital Records revealed Resident #11 was admitted to the hospital on [DATE] with a discharge date of 2/3/2024. The Hospital record revealed .This is a 55 yo [year old] F [female] .who was admitted with acute encephalopathy .ESBL [extended spectrum beta-lactamases] [a type of enzyme or chemical produced by some bacteria] .She has been requiring tube feeds with possible indication for PEG tube .Back to her nursing facility once cleared .
Review of the Hospital Discharge Physician's Orders dated 2/2/2024 (dated the day before hospital discharge), revealed .NOTHING BY MOUTH diet Nothing by mouth texture, Nothing by mouth consistency .
Review of the Progress Note, dated 2/3/2024, revealed .Health Status Note .Resident returned via [by] stretcher x[times] 2 EMS [emergency medical service] transport .
Review of Physician's Orders dated 2/5/2024, revealed .Isosource 1.5 @ [at] 45mL/hr [milliliters/hour] with 45cc [centimeter] Q [every] 4 hours H2O [water] flush per Kangaroo pump continuously .
The facility failed to complete a readmission weight for Resident #11's readmission on [DATE], within 24 hours of return to the facility.
Record review revealed Resident #11's weight on 2/9/2024 was 104 pounds, 6 days after readmission from the hospital.
Review of the significant change Minimum Data Set (MDS) dated [DATE], revealed Resident #11 was unable to complete the Brief Interview for Metal Status (BIMS), which indicated she was severely cognitively impaired.
The facility failed to complete weekly weights for Resident #11 for the week of 2/11/2024 through 2/17/2024 and the week of 2/25/2024 through 3/2/2024.
Review of the significant change Minimum Data Set (MDS) dated [DATE], revealed Resident #11 was unable to complete the Brief Interview for Metal Status (BIMS), which indicated she was severely cognitively impaired.
Review of the Progress Note dated 3/13/2024, revealed .Nutrition/Dietary Note .Enteral feeding Isosource [high-protein, low fiber, whole protein formula] 1.5 [whole-protein formula with 18 % [percent] of calories from protein] .Has had wt [weight] loss. Significant x 90, 7.3% x 180 .Will recommend increasing rate of feeding to 50ml/hr continuous with 50ml flush every 4 hours for additional calories and protein .
Review of the email dated 3/13/2024, revealed a communication between the Registered Dietitian (RD) and the Assistant Director of Nursing (ADON) .[Named Resident #11] .Will recommend increasing rate of feeding to 50ml/hr [milliliter/hour] continuous with 50ml flush every 4 hours for additional calories and protein .
Review of the Physician's Orders dated 3/21/2024, revealed .Isosource [high-protein, low fiber, whole protein formula] 1.5 @ [at] 50mL/hr [millimeter/hour] with 60cc [cubic centimeter] Q [every] 4 hours H2O [water] flush per .
The facility failed to address the 3/13/2024 RD recommendation to increase the enteral feeding for Resident #11 until 3/21/2024, 8 days later.
Observation in the resident's room on 3/18/2024 at 10:12 AM, 3/18/2024 at 3:33 PM, 3/19/2024 at 8:09 AM, 3/19/2024 at 2:46 PM, 3/20/2024 at 8:43 AM, and on 3/20/2024 at 2:55 PM, revealed Resident #11's Isosource 1.5 infusing by pump at 45 ml/hr.
The facility failed to act upon the RD recommendations of Isosource 50 ml/hr.
Observation and interview in the resident's room on 3/22/2024 at 8:56 AM, with Certified Nursing Assistant (CNA) C and CNA K, revealed Resident #11 was fully dressed in a sweater, jogging pants, brief, socks, and an abdominal binder. Resident #11 weighed 105.7 pounds. CNA C and CNA K were asked if they felt Resident #11 looked thin. CNA C stated, Yes.
Observation and interview in the resident's room on 3/25/2024 at 11:16 PM, with CNA C and RN (Registered Nurse) N, after being checked and changed, Resident #11 was dressed in a light weight gown and brief. Resident #11's weight was 104 pounds.
During the observations of staff weighing resident #11 on 3/22/2024 and 3/25/2024 revealed the facility failed to consistently weigh Resident #11 with the same clothing.
During a telephone interview on 3/21/2024 at 2:52 PM, the RD was asked about Resident #11's nutritional status. The RD stated, .she just came back with a peg tube [allows nutrition, fluids, and medication to be delivered directly into the stomach] on 2/2/2024 .on 3/13/2024, I increased the feeding to 50 cc/hour continuously. The RD was asked to tell about the process of making recommendations for changes. The RD stated, .I send the recommendation to the .[Named ADON] the orders .she would put it in place . The RD was asked should the recommendation have been started. The RD stated, .Yes .it should have been started .I increased the rate to 50 cc/hr [centimeter/hour] she had a weight lost [prior to the hospitalization on 1/23/2024] .I looked at that and for additional proteins and calories .her ideal body weight is 120 pounds .I used her adjusted body weight to increase her calories to get her close where she needs to be . The RD confirmed that Resident #11 had a significant weight lost in January 2024 of a 7.9 % in 3 months.
During an interview on 3/21/1024 at 3:27 PM, the ADON was asked to tell about the process for when a recommendation is received from the RD. The ADON stated, .once she [RD] sends the email, I call the doctor and tell him the recommendation . The ADON confirmed that the RD sent an email on 3/13/2024 for the increase in Resident #11's enteral feeding.
During an interview on 3/22/2024 at 9:00 AM, the ADON was asked if the facility had a weight log that shows what the residents are weighed in (clothing) for consistent weights obtained. The ADON stated, .No .I don't have a log . The ADON was asked about the process for the resident's weights. The ADON stated, .at the first of the month I give [Named CNA C] a printed log with resident names and there is a spot to write in the resident weights .when she get all the weights she brings it back and I go over the weights and look at the weights .if it is 4 pounds greater or less from the previous weights .I send [Named RD] an email with the differences .then she will send recommendations .I log the weights in [Named EMR] .the new admissions are weighed on arrival .then weekly times 4 weeks .when the resident leaves and goes to the hospital .they come back and are weighed [weekly] times 4 as well .the residents should be checked and changed and weighed in their gown and brief only . The ADON confirmed that Resident #11 should have been weighed within 24 hours of admission and readmission and weekly if triggered for a significant weight loss.
During an interview on 3/25/2024 at 10:50 AM, CNA C was asked who helps weigh the residents. CNA C stated, .I grab who is on the hallway with the lift .or the aides who are assigned to the resident . CNA C was asked how she knows what clothes Resident #11 should have on when she weighs her. CNA C stated, .She has a variety of clothes .she has long sleeve .shirt and sweat pants . CNA C was asked if she ever weighed Resident #11 in her gown and brief before and if so how often. CNA C stated, Yes .it depends on what time a day it is . CNA C was asked if she had a log to document what the residents are weighed in. CNA C stated, No ma'am . CNA C was asked who monitors the weights to make sure they are accurate. CNA C stated, .I just give them [to Named ADON] .the weights .they [ADON] let me know who gets the weight and how often CNA C was asked when a resident goes out to the hospital how often they are weighed on readmission. CNA C stated, .Once a week. CNA C was asked why Resident #11 did not get weekly weights on readmission in February 2024 and in March 2024, and if she (CNA C) was out during the readmission. CNA C stated, .No .they just give me a list of residents who need to be weighed . CNA C was asked if she was aware Resident #11 was on weekly weights. CNA C stated, No.
During an interview on 3/26/2024 at 8:49 AM, CNA K was asked if she completed the resident's weights when CNA C is off. CNA K stated, Yes .I get someone off the floor to help me . CNA K was asked how she is made aware of what clothing the resident had on when CNA C weighed the residents. CNA K stated, I don't know .I have no idea . CNA K was asked when she weighs Resident #11 what she normally weighs her in. CNA K stated, .In a gown and make sure she is dry [clean brief] .
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
Safe Environment
(Tag F0584)
Could have caused harm · This affected multiple residents
Based on policy review, observation, and interview, the facility failed to provide effective housekeeping to maintain a sanitary environment for 8 of 35 resident's rooms (Resident #1, #2, #37, #43, #2...
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Based on policy review, observation, and interview, the facility failed to provide effective housekeeping to maintain a sanitary environment for 8 of 35 resident's rooms (Resident #1, #2, #37, #43, #22, #39, #46, and #50), 1 of 4 communal bathrooms (200 Hall), and 1 of 3 scales (Standing Life Scale) observed.
The findings include:
1. Review of the facility's undated policy titled, .Routine Cleaning and Disinfection, revealed .It is the policy of this facility to ensure the provision of routine cleaning and disinfection in order to provide a safe, sanitary environment .Consistent surface cleaning and disinfection .tray tables .resident chairs .sinks and faucets .
2. Observations in the resident's room on 3/18/2024 at 9:25 AM, and 3/19/2024 at 3:25 PM, revealed Resident #46's over the bed table was caked with dust and spots of what appeared to be dried liquids.
Observations in the resident's room on 3/18/2024 at 9:30 AM and 11:34 AM, and on 3/19/2024 at 8:30 AM, revealed Resident #41's over the bed table had a dried brown circle on the top, table base with thick caked on dust in between the crevices, and crumbs on the floor.
Observations in the resident's room on 3/18/2024 at 9:42 AM and 3/19/2024 at 8:06 AM, revealed Resident #2's wheelchair had hair wrapped around the axle of the wheel and dirty buildup of dried liquids and dirt on the frame of the chair.
Observations in the 200 Hall women's communal bathroom on 3/18/2024 at 9:43 AM and 11:06 AM, revealed a clogged sink with standing cloudy water in the sink, a dirty floor with hair and marks from dirty wheels of a wheelchair, and numerous unlabeled bath basins in the floor.
Observations in the 200 Hall women's communal bathroom on 3/18/2024 at 11:06 AM, revealed a paper towel on the floor, sink with standing water, hairbrush in windowsill with hair in it, plunger not wrapped up sitting in the shower area, unlabeled bath basins on the floor, and the door wouldn't shut properly.
Observations in Resident #1's room on 3/18/2024 at 11:17 AM, revealed the wheelchair's safety tag that was hanging down from the back had a 4-5 inch brown smear down it.
During an observation and interview on 3/18/2024 at 5:15 PM, the Director of Nursing (DON) confirmed the bathroom sink should be fixed and not have standing water in it and bath basins should not be in the floor or unlabeled.
Observation in the 200 Hall women's communal bathroom on 3/19/2024 at 7:59 AM, revealed the sink had an out of order sign on it. The facility failed to provide a place for proper hand hygiene after toileting.
Observations in the resident's room on 3/19/2024 at 8:02 AM, 3/20/2024 at 7:50 AM and 1:12 PM, revealed Resident #42's over the bed table had thick caked on dirt in the crevices of the base.
Observations on the patio on 3/19/2024 at 8:25 AM, revealed Resident #1's tag had a 4 to 5 inch brown smear on it.
Observation in the 200 Hall women's communal bathroom on 3/20/2024 at 1:10 PM, revealed a used washcloth in the sink, paper towels on sink, toilet paper on the floor by sink, dirty wheelchair tracks on the floor, and a used towel on the windowsill.
Observation on the 300 Hall by the dining room on 3/20/2024 at 1:22 PM, revealed Resident #1's wheelchair's safety tag hanging down from the back had a 4-5 inch brown smear down it.
During an observation and interview on 3/20/2024 at 1:22 PM, the DON was shown Resident #1's wheelchair. The DON confirmed that the brown smear stain should not be there.
During an observation and interview in Resident #2's room on 3/20/2024 at 1:22 PM, the DON was shown the wheelchair with hair wrapped around the axle of the wheel, dirty buildup of dried liquids, and dirty frame of the chair. The DON confirmed that the wheelchair should be clean.
Observations in the 200 Hall women's communal bathroom on 3/20/2024 at 4:00 PM, revealed the floor had wet paper towels and other white paper products on the floor. There were also multiple wet spots on the floor.
During an observation and interview on 3/20/2024 at 4:07 PM, the DON was asked should the bathrooms be kept clean and tidy. The DON stated, Yes.
Observations on the 100 Hall on 3/24/2024 at 4:36 PM, and 3/25/2024 at 5:20 PM, revealed the standing lift with a large number of crumbs and a black substance on the back of the lift.
During an observation and interview on the 100 Hall on 3/26/2024 at 10:24 AM, RN N was asked to identify the particles on the standing lift. RN N stated, .looks like food crumbs from where it was on the residents' clothes when they stood on the lift, and the black stains look dirty .
During an observation and interview on 3/20/2024 at 10:11 AM, the DON was taken to several rooms on the 200 hall. The DON was asked if she felt the over bed tables were dirty, she stated Yes .
During an interview on 3/20/2024 at 10:27 AM, Housekeeper O was asked what she cleans in the resident rooms. Housekeeper O stated, .I clean the top of the over bed table . When asked if she was supposed to clean the base of the tables, she replied, .no, I don't have the right stuff [cleaning products] to clean them with . When Housekeeper O was asked if she thought they were dirty, she stated Yes .
During an interview on 3/20/2024 at 10:35 AM, the Housekeeping Supervisor confirmed that there was no schedule to clean the over bed tables. The Housekeeping Supervisor stated, .the over bed tables are taken outside and pressure washed when it is warm out .
CONCERN
(E)
Potential for Harm - no one hurt, but risky conditions existed
Food Safety
(Tag F0812)
Could have caused harm · This affected multiple residents
Based on policy review, observation, and interview, the facility failed to ensure food was stored, prepared, and served under sanitary conditions as evidenced by the paper towel dispenser not working,...
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Based on policy review, observation, and interview, the facility failed to ensure food was stored, prepared, and served under sanitary conditions as evidenced by the paper towel dispenser not working, dirty trash cans, vent fans are coated with a thick grayish brown substance, large utensil holder dirty with package of crackers inside, greasy ice cream scoop, spice and condiment holder dirty with food crumbs, dirty kitchen floors, carbon build up on pots and pans, wet pans stacked on top of other pans, fryer baskets coated in yellow sticky substance; handles sticky, ice machine dirty, clean dishes on top of dirty trays, transport and bus (tiered utility cart) carts dirty, eye wash station with crumbs and dust, meat slicer greasy with reddish brown substance underneath, mixer and mixer table dirty, nutrition refrigerator dirty with spilled substance on rack, no thermometer, and supplements stuck to the rack. The facility had a census of 52 with 48 of those residents receiving a meal tray from the kitchen.
The findings include:
1.Review of the facility's policy titled, FOOD SERVICE SAFETY, dated 10/18/2022, revealed .all equipment used in the handling of food shall be cleaned and sanitized .follow facility procedures .cleaning .fixed cooking equipment .must wear hair restraints [hairnet] to prevent hair from contacting food .Food and beverages shall be distributed and served to residents in a manner that prevent contamination .include .washing hands properly before distributing trays .washing hands between contact with residents and after collecting soiled plates and food waste .use of gloves when touching and assisting with ready-to-eat foods .
2. Review of the undated Daily Cleaning Schedule, revealed .Mixer (each shift), Knife Rack (each shift), Carts and Tray Carts wipe and sanitize (daily), Condiment/Silverware Bins/Cart (daily), Ice Machine (each shift), Hand Sink-Soap/Paper Towels (daily), Kitchen Floors (daily), Garbage Cans & Lids Washed (daily) .
3. Observation on 3/18/2024 at 8:12 AM, 3/20/2024 at 11:24 AM, and 3/20/2023 at 1:30 PM revealed the kitchen door was propped open.
Observations on 3/18/2024 at 8:55 AM, 3/19/2024 at 4:00 PM, 3/20/2024 at 8:12 AM, and 3/21/2024 at 3:00 PM, revealed the paper towel dispenser was in disrepair.
Observation on 3/18/2024 at 8:55 AM, revealed the trash can next to the hand washing sink was covered with thick, sticky, stains, and dried liquid and the foot pedal would not open related to the lid was stuck to the bag in the can.
Observation on 3/18/2024 at 9:00 AM, revealed 2 vent fans in the walk-in refrigerator were coated with a thick grayish brown substance.
Observations on 3/18/2024 at 9:05 AM, 3/19/2024 at 4:02 PM, and 3/20/2024 8:19 AM, revealed an ice cream scoop that was greasy, clear plastic bins for large utensils had crumbs inside, 3 packages of graham crackers inside a bin, and a sticky reddish-brown substance on bottoms of bins.
Observations on 3/18/2024 at 9:05 AM, and 3/20/2024 at 8:19 AM, revealed 8 gray plastic containers holding spices and condiments were covered with dust and crumbs on the edges and on the inside.
Observations on 3/18/2024 at 9:10 AM, and 3/19/2024 at 4:05 PM, revealed the floor around and behind stove was dirty with dried greasy splatters.
Observation on 3/18/2024 at 9:12 AM, revealed 2 shallow pans, 1 medium size pan, and 4 large pans with dark thick carbon buildup.
Observation on 3/18/2024 at 9:12 AM, revealed the dish washer staff member stored a wet pan on top of another pan under the steam table.
Observation on 3/18/2024 at 9:13 AM, revealed one muffin pan with crumbs scattered inside of it in the clean pan area.
Observation on 3/18/2024 9:13 AM, revealed 2 fry baskets on the counter next to the meat slicer, coated with thick hard dried yellow sticky substance around the edges and handles.
Observation on 3/18/2024 at 9:15 AM, revealed 4 medium and 2 large metal pans stacked on the low shelf and were not completely dried.
Observation on 3/18/2024 at 9:16 AM, revealed the right side of the ice machine had brownish red splashes and the top of the door had small brown crumbs scattered along the edge.
Observation on 3/18/2024 at 9:17 AM, and 3/19/2024 at 4:01 PM, revealed a metal rack with clean dishes on top of 4 trays that had crumbs and dust on them.
Observations on 3/18/2024 at 9:22 AM, and 3/19/2024 at 4:11 PM, revealed 3 food bus carts with dried drip marks down the sides and around the back of the vents, 2 bus carts had sticky build up in edges and corners of each shelf area, sticky handles with crumbs, and buildup in the textured/grooved areas.
Observations on 3/19/2024 at 4:08 PM, and 3/20/2024 at 11:34 PM, revealed the eye wash station in dishwashing room had crumbs and dust in it.
Observations on 3/20/2024 at 8:19 AM, revealed the meat slicer was greasy, covered with fingerprints, and had a reddish-brown substance on the base under the blade.
Observation on 3/20/2024 at 8:19 AM, revealed the mixer table was covered with white/yellow, dried splatter marks. The body of the mixer was dusty and had a greasy looking film on it. The mixer shield had a brownish red sticky like substance under the metal guard.
Observation in the nutrition refrigerator on 3/20/2024 at 3:02 PM, revealed a yellow sticky dried spill substance on bottom rack with a box of supplements stuck to it, and there was no thermometer in the freezer. The freezer was filled with stacks of frozen randomly shaped liquid ice packs and hard plastic ice packs that kept falling out when the freezer door was opened.
During an interview on 3/20/2024 at 8:12 AM, the Dietary Manager (DM) was asked should the paper towel dispenser have been working for the last 3 days. The DM stated, .Yes ma'am, I need to get that fixed.
During an interview on 3/20/2024 at 8:13 AM, the DM was asked if he had noticed the trash can was sticky it wouldn't even open when the foot pedal was pressed. The DM stated, .it shouldn't be like that.
During an interview on 3/20/2024 at 8:14 AM, the DM was asked if the storage bins should have the crumbs and dirty buildup in them, and if the floors should be dirty. The DM stated, .No ma'am .
During an interview on 3/20/2024 at 8:15 AM, the DM confirmed the pans needed to be free of carbon buildup and they should not be stacked while wet.
During an interview on 3/20/2024 at 8:19 AM, the DM was asked if the mixer and the meat slicer should have been cleaned. The DM stated, Yes.
During an interview on 3/20/2024 at 8:27 AM, the DM was shown the ice machine with the splash-over from the sink on the side, and the metal cart with clean dishes on it that had crumbs on the trays under them. The DM confirmed they needed to be cleaned and the vent fans on the walk-in refrigerator should be clean.
During an interview on 3/20/2024 at 1:42 PM, the DM confirmed the kitchen doors should be closed and stated this could compromise a sanitary kitchen environment.
During an interview on 3/20/2024 at 1:42 PM, the DM was asked if the carts should have multiple drip marks down the sides of them and the bus carts have dirty buildup all over them. The DM stated, .no ma'am .
During an interview on 3/20/2024 at 3:04 PM, the DM was asked if the freezer in the nutrition refrigerator should have a thermometer. The DM stated, I didn't know I was supposed to be over the nutrition fridge .
CONCERN
(E)
Potential for Harm - no one hurt, but risky conditions existed
Infection Control
(Tag F0880)
Could have caused harm · This affected multiple residents
Based on CDC (Centers for Disease Control and Prevention) guidelines, observation, and interview, the facility failed to ensure proper infection control practices were followed when 2 of 3 (Licensed P...
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Based on CDC (Centers for Disease Control and Prevention) guidelines, observation, and interview, the facility failed to ensure proper infection control practices were followed when 2 of 3 (Licensed Practical Nurse (LPN L and M) nurses failed to clean reusable equipment before use on residents during medication administration.
The findings include:
1. Review of the CDC guidelines revealed, .CDC recommendations for disinfecting .stethoscopes include disinfecting between each patient . whereas semi critical stethoscopes [Semi-critical items which come into contact with the mucous membranes or with the skin that is not intact] should be disinfected before use on each patient .
Review of guidelines at Health.com, .Wipe the sensor with a cotton swab or pad dipped in rubbing alcohol or bleach. Or you can rinse the forehead thermometer with lukewarm soapy water .Let the forehead thermometer air dry .
2. Observation during medication administration on the 100 Hall on 3/19/2024 at 7:15 AM, revealed LPN M entered the Resident #14's room, used a temple thermometer on the resident, LPN M then exited the room and placed thermometer in her jacket pocket. LPN M failed to clean the thermometer after use on Resident #14.
Observation during medication administration on the 100 Hall on 3/20/2024 at 7:42 AM, revealed LPN M entered Resident #24's room, used a temporal thermometer on the resident, LPN M then exited the room and placed thermometer in her jacket pocket. LPN M failed to clean the thermometer after use on Resident #24.
Observation during medication administration on the 200 Hall on 3/20/2024 at 8:09 AM, revealed LPN N entered Resident #54's room, with the medications, donned clean pair of gloves, removed the stethoscope from around her neck, checked for PEG tube placement and checked residual, LPN N replaced the stethoscope back around her neck. LPN N failed to clean or disinfect the stethoscope after use.
During an interview on 3/22/2024 at 10:11 AM, the Director of Nursing (DON) confirmed that a stethoscope and temporal thermometer should be cleaned after checking PEG (Percutaneous endoscopic gastrostomy) tube (placed for nutrition) placement on a resident, and if a thermometer touches a resident's forehead it should be cleaned before using the next resident.
Jan 2022
5 deficiencies
CONCERN
(D)
Potential for Harm - no one hurt, but risky conditions existed
Deficiency F0582
(Tag F0582)
Could have caused harm · This affected 1 resident
**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on medical record review and interview, the facility failed to provide 3 of 3 residents (Resident #7, #31, and #99) with t...
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**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on medical record review and interview, the facility failed to provide 3 of 3 residents (Resident #7, #31, and #99) with the Advanced Beneficiary Notice (ABN), Center for Medicare and Medicaid Services (CMS)-10055 when therapy services were discontinued and the resident remained in the facility for long-term care services or was discharged from the facility. This failure left residents without information related to the cost of therapy services if they desired to continue the services in the facility and did not allow for them to have an informed choice.
Findings include:
Review of the medical record, revealed Resident #7 was admitted to the facility on [DATE] with diagnoses of Paranoid Schizophrenia, Anxiety, Extrapyramidal and Movement Disorder, and Dementia with Behaviors.
Resident #7 received physical therapy, occupational therapy, and speech language therapy. The Social Service Director (SSD) provided the Skilled Nursing Facility Advance Beneficiary Notice (SNFABN)(CMS-10055) form informing therapy services would end on 11/5/2021. The form was stamped .RECEIVED [DATE] .
Review of the ABN for Resident #7 revealed her skilled days ended on 11/5/2021 and the conservator stamped the form on 11/5/2021. The facility failed to provide a 3-day notice. Therefore, the resident and representative were not provided with the choice to continue the services, pay privately for the services, or to stop the services.
During an interview on 1/11/2022 at 2:14 PM, the Social Service Director confirmed she mailed the form for Resident #7 to her conservator and she stamped it the same date of 11/5/2021.
Review of the medical record, revealed Resident #31 was admitted to the facility on [DATE] with diagnoses of Dementia with Behaviors, Depression, Alcohol Dependence, Anxiety, Schizoaffective Disorder, and Dysphagia.
Resident #31 received physical therapy, occupational therapy, and speech language therapy. The SSD provided the (SNFABN)(CMS-10055) form informing therapy services would end on 10/8/2021. The form was signed by his son on 10/8/2021.
Review of the ABN for Resident #31 revealed his skilled days ended 10/8/2021 the son signed the form on 10/8/2021. The facility failed to provide a 3-day notice. Therefore, the resident and representative were not provided with the choice to continue the services, pay privately for the services, or to stop the services.
During an interview on 1/11/2022 at 2:17 PM, the Social Service Director stated, I mailed [Named Resident #31's] form and family signed on 10/8/2021. The Social Service Director was asked for the dated form she mailed to the family for their signature. She confirmed she discarded the form that was mailed.
Review of the medical record, revealed Resident #99 was admitted to the facility on [DATE] with diagnoses of Chronic Ischemic Heart Disease, Coronary Artery Disease, Diabetes, Anemia, Acute Pulmonary Edema, Chronic Kidney Disease, Dementia with Behaviors, Acute Kidney Disease, and Hypertension.
Resident #99 received physical therapy and occupational therapy. The SSD provided the Skilled Nursing Facility Advance Beneficiary Notice (SNFABN)(CMS-10055) form informing therapy services would end on 9/9/2021. The form had a handwritten notation .sent in mail 9-6 [2021] .
Review of the ABN for Resident #99 revealed her skilled days ended 9/9/2021. There was no date or signature of the resident or the authorized representative. The facility failed to provide the a 3-day notice. Therefore, the resident and representative were not provided with the choice to continue the services, pay privately for the services, or to stop the services.
During an interview on 1/11/2022 at 2:19 PM, the Social Service Director confirmed the timeframe for ABNs are that families should be notified 3 days prior to discharge. She confirmed the forms for Resident #7, Resident #31, and Resident #99 did not reflect a 3-day notice was provided.
CONCERN
(D)
Potential for Harm - no one hurt, but risky conditions existed
Pressure Ulcer Prevention
(Tag F0686)
Could have caused harm · This affected 1 resident
**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on policy review, medical record review, observation, and interview, the facility failed to provide care and services for ...
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**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on policy review, medical record review, observation, and interview, the facility failed to provide care and services for a pressure injury when facility staff failed to document antibiotic administration as ordered, pressure injury treatments as ordered, and failed to perform hand hygiene during wound care for 1 of 1 sampled resident (Resident #40) reviewed for pressure ulcers.
The findings include:
Review of the facility's undated policy titled, Wound Treatment Management, revealed .To promote wound healing of various types of wounds, it is the policy of the facility to provide evidence-based treatments in accordance with current standards of practice and physician orders .Wound treatments will be provided in accordance with physician orders .Treatments will be documented on the Treatment Administration Record .
Review of the facility's undated policy titled, Hand Hygiene, revealed .All staff will perform proper hand hygiene procedures to prevent the spread of infection .Hand hygiene is indicated and will be performed under the conditions listed in, but not limited to .the use of gloves does not replace hand hygiene .perform hand hygiene prior to donning gloves, and immediately after removing gloves .Before and after handling clean or soiled dressings .
Review of the medical record, revealed Resident #40 was admitted to the facility on [DATE] with diagnoses of Paraplegia, Cerebrovascular Disease, Delusional Disorders, Schizophrenia, Depression, Anxiety Disorder, Obstructive and Reflux Uropathy, Psychotic Disorder, and Pressure Ulcer of Sacral Region-Stage 4.
Review of a Physician's Order dated 10/15/2021, revealed to administer Daptomycin 300 milligrams (mg) and Ertapenem 1 gram (G) intravenously (IV) daily for infection until 11/13/2021.
Review of a Physician's Order dated 10/16/2021, revealed .Cleanse sacrum with Wound Cleanser, pay [pat] dry, apply santyl [medication to treat pressure injury], pack with calcium alginate [wound dressing to promote moist healing], cover with ABD [abdominal] pad, secure with tape daily and prn [as needed] .every day shift for stage 4 to sacrum .
Review of a Physician's Order dated 10/21/2021, revealed, .Cleanse sacrum with Dakin's [solution used to treat skin and tissue infections], pay [pat] dry, pack wound with 4x4's [gauze pads] dampened with Dakin's for wet to dry dressing, cover with ABD pad, and place bordered gauze over area twice daily .every day and night shift for stage 4 to sacrum .
Review of the Medication Administration Record (MAR) dated October 2021, revealed the IV Daptomycin and Ertapenem was not documented as administered on 10/19/2021, 10/23/2021, 10/24/2021, and 10/28/2021.
Review of the Treatment Administration Record (TAR) dated October 2021, revealed no treatments were documented for Resident #40's sacral pressure injury on 10/18/2021, 10/19/2021, the night shift on 10/22/2021, 10/23/2021, 10/28/2021, and 10/31/2021, and the day shift on 10/24/2021, 10/26/2021, 10/28/2021, 10/29/2021, and 10/30/2021.
Review of a Physician's Order dated 11/15/2021, revealed, .Cleanse sacrum with wound cleanser, pat dry, pack wound with 4x4's dampened with Dakin's for wet to dry dressing, cover with ABD pad, and place bordered gauze over area twice daily .every day and night shift for stage 4 to sacrum .
Review of a Physician's Order dated 11/24/2021, revealed to administer Daptomycin 300 mg IV every day shift and Ertapenem 1 G IV every 24 hours, with a start date of 11/26/2021.
Review of the MAR dated November 2021, revealed no documentation that IV Daptomycin was administered on 11/26/2021, 11/29/2021 and 11/30/2021 and no documentation that IV Ertapenem was administered on 11/26/2021 and 11/29/2021.
Review of the TAR dated November 2021, revealed no treatments were documented for Resident #40's pressure injury for the night shift on 11/2/2021, 11/6/2021, 11/14/2021, 11/17/2021, 11/18/2021, 11/19/2021, 11/27/2021, and 11/28/2021, and for the day shift on 11/4/2021, 11/7/2021, 11/10/2021, 11/11/2021, and 11/14/2021.
Review of a Physician's Order dated 12/9/2021, revealed, .Cleanse sacrum with wound cleanser, pat dry, pack wound with 4x4's dampened with Dakin's for wet to dry to dry dressing, cover with ABD pad, place large bordered gauze over area and secure with gauze tape twice daily .every day and night shift for stage 4 to sacrum .
Review of the MAR dated December 2021, revealed no documentation that IV Daptomycin was administered on 12/5/2021 and 12/19/2021.
Review of the TAR dated December 2021, revealed no treatments were documented for Resident #40's pressure injury for the night shift on 12/3/2021, 12/4/2021, 12/5/2021, 12/8/2021, 12/13/2021, 12/17/2021, 12/19/2021, 12/22/2021, and 12/31/2021.
Review of the TAR dated January 2022, revealed no treatments were documented for Resident #40's pressure injury on 1/1/2022 for the day or night shift, and on 1/3/2022 for the day shift.
Wound care observation in Resident #40's room on 1/12/2022 at 11:20 AM, revealed the Assistant Director of Nursing (ADON) performed hand hygiene, donned gloves, removed the dressing from the resident's stage 4 sacral pressure injury, cleaned the wound with wound cleanser, packed the wound bed with gauze soaked with Dakin's solution, removed her gloves, and disposed of them in a biohazard bag. The ADON did not remove her gloves, perform hand hygiene and don a new pair of gloves prior to cleaning and packing the wound. The ADON returned to the treatment cart outside of Resident #40's room to obtain more gloves. She performed hand hygiene and re-entered the resident's room, placed several pairs of gloves on a wax paper barrier, donned gloves, opened the ABD pad package, removed her gloves, disposed of the gloves in a biohazard bag, and donned a new pair of gloves. The ADON failed to perform hand hygiene prior to donning gloves, placed the ABD pad over the wound bed, taped the pad in place, removed her right glove, disposed of it in a biohazard bag, dated and signed the dressing, removed her left glove, disposed of it in the biohazard bag, and donned gloves. The ADON failed to perform hand hygiene prior to donning the new pair of gloves, tied the biohazard bag, removed her gloves, took the biohazard bag to the wound treatment cart, and placed the bag in the biohazard bin on the right side of the cart.
During an interview on 1/13/2021 at 7:48 AM, the Director of Nursing (DON) confirmed hand hygiene should be performed immediately after removing gloves and prior to donning a new pair of gloves.
During an interview on 1/13/2022 at 11:12 PM, the DON confirmed the MAR did not reflect the antibiotics were administered according to the physician's orders. The DON confirmed the antibiotics should have been administered and documented as ordered. The DON confirmed that wound care treatments should have been completed and documented as ordered.
CONCERN
(D)
Potential for Harm - no one hurt, but risky conditions existed
Accident Prevention
(Tag F0689)
Could have caused harm · This affected 1 resident
**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on policy review, medical record review, and interview, the facility failed to follow their policy and the Care Plan for 1...
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**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on policy review, medical record review, and interview, the facility failed to follow their policy and the Care Plan for 1 of 3 sampled residents (Resident #13) reviewed for falls.
The findings include:
Review of the Facility's undated policy titled, Care Plans - Comprehensive, revealed .Our facility's care planning/interdisciplinary team, in coordination with the resident, his/her family .develops and maintains a comprehensive care plan for each resident that identifies the highest level of functioning the resident may be expected to attain .
Review of the Facility's undated policy titled, Fall Prevention Program, revealed .each resident will be assessed for the risk of falling and will receive care and services in accordance with the level of risk to minimize the likelihood of falls .A fall is an event in which an individual unintentionally comes to rest on the ground, floor, or other level .The event may be witnessed, reported, or presumed when a resident is found on the floor or ground, and can occur anywhere .Each resident risk factors and environmental hazards will be evaluated when developing the resident's comprehensive care plan .Intervention will be monitored for effectiveness .When any resident experiences a fall, the facility will .Assess the resident .Complete a fall assessment .Complete an incident report .
Review of the Facility's undated policy titled, Falls Management, revealed .PROTOCOL: POST FALL .Assess the resident and implement appropriate measures .Nursing to complete per policy and procedure .Incident report .Resident Event Documentation .Pain Assessment .Adjust/add intervention on the Plan of Care .Present the resident at the morning interdisciplinary team meeting .
Review of the medical record, revealed Resident #13 was admitted on [DATE] with a diagnoses of Aphasia, Schizophrenia, Major Depression, Hypertension, Anxiety Disorder, Dysphagia, and Displaced Fracture of Distal Phalanx of Right Index Finger.
Review of the annual Minimum Data Set (MDS) assessment dated [DATE], revealed Resident #13 had a BIMS of 99, which indicated she was severely cognitively impaired, was totally dependent on staff for activities of daily living, required 2 staff for assistance with transfers, and had one fall with major injury.
Review of the Care Plan Dated 7/8/2021, revealed .Resident is at risk for falls .12/21/2021- Mat to Floor .3/14/21 [2021] TACO MATTRESS TO BED .Resident requires extensive assistance for 1 person/s [persons] for transfers .
Review of the Progress Notes dated 10/15/2021, revealed .Resident scooting in floor yelling/crying and grabbing staff .
Review of Progress Notes dated 10/24/2021, revealed .Resident had voluntary and intentional change of planes with body control no injury's [injuries] noted .
Review of the Incident Review Quality Assurance form dated 10/28/2021, revealed .Fall .(R)[right] hand bruise .Location of Occurrence .Hallway .Interventions/Correction Implemented .x-ray [Radiology] .[Named x-ray Company] .Sent to ER [emergency room] .
Review of Progress Notes dated 12/19/2021, revealed .Resident with intentional change of plane of body and put self in floor with bed in low position, scooting on buttocks going out of room .
Review of Progress Notes dated 12/21/2021, revealed .Resident found by CNA [Certified Nursing Assistant] in the floor crawling around (This resident frequently climbs out of bed to floor) Approximately quarter inch laceration noted to middle of forehead .Assisted to wheelchair .
Review of the Incident Review Quality Assurance form dated 12/21/2021, revealed .Resident's Activities at Time of Incident .Found in Floor Crawling near bed .Interventions/Corrections Implemented .floor mat .
Review of the Incident Review Quality Assurance form dated 1/12/2022, revealed .Found on Floor .Fall .Date of Occurrence 1/10/2022 .Location of Occurrence: Residents room .Results of Investigation .resident in floor inside room nurse made aware by CNA per investigation resident noted to be on mat of floor .bed in lowest position prior to breakfast .Interventions/Corrections Implemented .staff to offer resident up to wheelchair prior to breakfast .
Review of High Risk Event-Investigation Statement dated 1/12/2022, revealed .Type of incident .unwitnessed fall on 1/10/2022 .Person Making Statement .CNA #2 .resident was in the floor while passing trays .
Observation in the resident's room on 1/10/2022 at 6:17 AM, 1/10/2022 at 3:00 PM, and 1/11/2022 at 3:22 PM, revealed Resident #13 was resting in the bed, there were no fall mats at the bedside, and there was Taco mattress/concave mattress on the resident's bed.
During an interview on 1/12/2022 at 2:20 PM, the Director of Nursing (DON) confirmed that the Resident #13 should have a fall mat and concave mattress in place according to the Care Plan.
During an interview on 1/12/2022 at 3:24 PM, Licensed Practical Nurse (LPN) #4 confirmed that she did not report or complete an incident report for Resident #13's fall on 1/10/2022.
During an interview on 1/12/2022 at 4:16 PM, LPN #2 confirmed that she did not see a fall mat in place for Resident #13 until 1/13/2022. LPN #2 confirmed that Resident #13 did not have a concave mattress on her bed.
During an interview on 1/13/2022 at 11:55 AM, the MDS Coordinator stated, .we initiated the new Care Plans .the DON and ADON tell me the interventions .then I enter it into the Care Plan .we meet as a team .
CONCERN
(D)
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 policy review, observation, and interview, the facility failed to ensure medications were properly and securely stored ...
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**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on policy review, observation, and interview, the facility failed to ensure medications were properly and securely stored in 2 of 5 medication storage areas (100 Hall Medication Cart and Treatment Cart) when internal, external medications, and chemicals were stored together, medications were expired, and medications were left unattended in 2 resident rooms (Resident #5 and #147's room).
The findings include:
Review of the facility's policy titled, MEDICATION STORAGE IN THE FACILITY, dated [DATE], revealed .Orally administered medications are kept separate from externally used medications .Potentially harmful substances such as .household poisons, cleaning supplies, disinfectants are clearly identified and stored in a locked area separately from medications .outdated, contaminated, or deteriorated .are immediately removed from inventory, disposed of according to procedures for medication disposal .
Observation of the 100 Hall Medication Cart on [DATE] at 5:59 AM, revealed the following:
a. 2 buckets of Micro Kill wipes
b. 1 bucket of Clorox disinfecting wipes
c. 2 bottles of Febreze
d. 1 pack of 75 % alcohol wipes
e. 1 bottle of Valproic Acid
f. 1 bottle of Iron supplement
g. 1 bottle of Levetiracetam
During an interview on [DATE] at 5:59 AM, Licensed Practical Nurse (LPN) #1 confirmed that the external, internal medications, and chemicals should not be stored together.
Observation in the resident's room on [DATE] at 8:31 AM, revealed LPN #2 entered Resident #5's room, placed the Zinc Oxide on the over bed table, adjusted the bed, exited the room, and left the Zinc Oxide unattended.
During an interview on [DATE] at 8:50 AM, LPN #2 confirmed that she should not have left the medication at the resident's bedside unattended.
Observation in the resident's room on [DATE] at 11:44 AM, revealed Registered Nurse (RN) #1 started the intravenous (IV) antibiotic, exited Resident #147's room and left 2 normal saline and 2 heparin flush syringes lying on the IV pump unattended.
During an interview on [DATE] at 10:57 AM, RN #1 confirmed that she should not have left the normal saline and heparin syringes at the bedside.
Observation of the Treatment Cart on [DATE] at 12:11 PM, revealed 10 packs of Xeroform Petrolatum dressing with an expiration date of 6/2021.
During an interview on [DATE] at 12:11 PM, the Director of Nursing (DON) confirmed the Xeroform Petrolatum dressing was expired.
During an interview on [DATE] at 4:41 PM, the DON confirmed that staff should not leave medication at the bedside unattended. The DON confirmed that the medication carts should not have expired medication, and internal, external medications, and chemicals should not be stored together.
CONCERN
(D)
Potential for Harm - no one hurt, but risky conditions existed
Safe Environment
(Tag F0921)
Could have caused harm · This affected 1 resident
Based on policy review, observation, and interview, the facility failed to provide and maintain a safe and sanitary environment for 1 of 10 common areas (100 Hall Women's Bathroom/Shower Room) when de...
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Based on policy review, observation, and interview, the facility failed to provide and maintain a safe and sanitary environment for 1 of 10 common areas (100 Hall Women's Bathroom/Shower Room) when debris, a used adult brief, a dirty shower chair, and stool were on the floor of the bathroom/shower room.
The findings include:
Review of the facility's undated policy titled, Routine Cleaning and Disinfection, revealed .It is the policy of this facility to ensure the provision of routine cleaning and disinfection in order to provide a safe, sanitary environment and to prevent the development and transmission of infections to the extent possible .
Observation of the 100 Hall Women's Bathroom/Shower Room on 1/10/2022 at 6:00 AM, 7:35 AM, and 8:58 AM, revealed dirty floors with wadded up paper towels, toilet paper, opened bandage wrappers, and small plastic tubing caps scattered behind the door and on the floor. A large amount of stool was smeared on the toilet seat in the first bathroom stall with wadded up paper towels and toilet paper on the floor. The second bathroom stall had wadded up paper towels and toilet paper scattered on the floor with a large amount of toilet paper and paper towels in the toilet bowel with yellow liquid present. The shower area had wadded up paper towels and toilet paper scattered on the floor with a brown, yellowish and white stained shower chair that had a blackish/brown substance present on the seat, legs and arms. Formed stool was observed in multiple places on a large porous mat present on the shower stall floor. The hopper had a large amount of yellow liquid present with a yellowish-brown substance. There was a strong malodorous odor present.
Observation of the 100 Hall Women's Bathroom/Shower Room on 1/10/2022 at 10:50 AM and 2:43 PM, revealed the shower area had formed stool present in multiple places on the mat of the shower stall floor and a strong malodorous odor was present.
Observation of the 100 Hall Women's Bathroom/Shower Room on 1/11/2022 at 8:55 AM, 11:35 AM, 2:41 PM, and 4:58 PM, revealed the shower area had partially formed stool present in multiple places on the mat on the shower stall floor and a strong malodorous odor was present.
Observation of the 100 Hall Women's Bathroom/Shower Room on 1/12/2022 at 7:57 AM, 9:40 AM, and 10:03 AM, revealed the shower area had stool present in multiple places on the mat on the shower stall floor and a strong malodorous odor was present.
Observation of the 100 Hall Women's Bathroom/Shower Room on 1/13/2022 at 7:43 AM, 9:24 AM, 10:42 AM, 11:53 AM, 2:53 PM, and 3:00 PM, revealed a used, adult brief present on the floor next to the toilet in the first stall.
During an interview on 1/11/2022 at 11:42 AM, the Director of Environmental Services confirmed that the bathroom/shower rooms should not have stool present on the toilet seats and shower stall floor, the hopper bowel should not be stained with a yellowish-brown substance, and there should not be a strong malodorous odor present.
During an interview on 1/12/2022 at 7:59 AM, Director of Nursing (DON) confirmed that stool was present in multiple places on the mat on the shower stall floor of the 100 Hall Women's Bathroom/Shower Room and stool should not be present.
During an interview on 1/13/2022 at 10:03 AM, the DON confirmed that stool was present in multiple places on the mat on the shower stall floor of the 100 Hall Women's Bathroom/Shower and stool should not be present.
During an interview on 1/13/2022 at 3:00 PM, the DON confirmed there was a used adult brief present on the floor next to the toilet in the first stall of the 100 Hall Women's Bathroom/Shower Room and that a used brief should not be in there at all.
Understanding Severity Codes (click to expand)
Life-Threatening (Immediate Jeopardy)
J - Isolated
K - Pattern
L - Widespread
Actual Harm
G - Isolated
H - Pattern
I - Widespread
Potential for Harm
D - Isolated
E - Pattern
F - Widespread
No Harm (Minor)
A - Isolated
B - Pattern
C - Widespread
Questions to Ask on Your Visit
- "What changes have you made since the serious inspection findings?"
- "Can I speak with families of current residents?"
- "What's your RN coverage like on weekends and overnight?"
Our Honest Assessment
Strengths
- • Licensed and certified facility. Meets minimum state requirements.
Concerns
- • Multiple safety concerns identified: 1 life-threatening violation(s), $126,516 in fines, Payment denial on record. Review inspection reports carefully.
- • 21 deficiencies on record, including 1 critical (life-threatening) violation. These warrant careful review before choosing this facility.
- • $126,516 in fines. Extremely high, among the most fined facilities in Tennessee. Major compliance failures.
- • Grade F (23/100). Below average facility with significant concerns.
Bottom line: Trust Score of 23/100 indicates significant concerns. Thoroughly evaluate alternatives.
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About This Facility
What is Laurelwood Health's CMS Rating?
CMS assigns LAURELWOOD HEALTH CARE CENTER an overall rating of 2 out of 5 stars, which is considered below average nationally. Within Tennessee, this rating places the facility higher than 0% of the state's 100 nursing homes. A rating at this level reflects concerns identified through health inspections, staffing assessments, or quality measures that families should carefully consider.
How is Laurelwood Health Staffed?
CMS rates LAURELWOOD HEALTH CARE CENTER's staffing level at 2 out of 5 stars, which is below average compared to other nursing homes. Staff turnover is 47%, compared to the Tennessee average of 46%. RN turnover specifically is 62%, which is notably high. RNs provide skilled clinical oversight, so turnover in this role can affect medical care quality.
What Have Inspectors Found at Laurelwood Health?
State health inspectors documented 21 deficiencies at LAURELWOOD HEALTH CARE CENTER during 2022 to 2025. These included: 1 Immediate Jeopardy (the most serious level, indicating potential for serious harm or death) and 20 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 Laurelwood Health?
LAURELWOOD HEALTH CARE CENTER is owned by a for-profit company. For-profit facilities operate as businesses with obligations to shareholders or private owners. The facility is operated by AHAVA HEALTHCARE, a chain that manages multiple nursing homes. With 64 certified beds and approximately 50 residents (about 78% occupancy), it is a smaller facility located in JACKSON, Tennessee.
How Does Laurelwood Health Compare to Other Tennessee Nursing Homes?
Compared to the 100 nursing homes in Tennessee, LAURELWOOD HEALTH CARE CENTER's overall rating (2 stars) is below the state average of 2.8, staff turnover (47%) is near the state average of 46%, and health inspection rating (2 stars) is below the national benchmark.
What Should Families Ask When Visiting Laurelwood Health?
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 you walk me through typical staffing levels on day, evening, and night shifts?" "Can I visit during a mealtime to observe dining assistance and food quality?" "How do you handle medical emergencies, and what is your hospital transfer rate?" These questions are particularly relevant given the facility's Immediate Jeopardy citations and the below-average staffing rating.
Is Laurelwood Health Safe?
Based on CMS inspection data, LAURELWOOD HEALTH CARE CENTER has documented safety concerns. Inspectors have issued 1 Immediate Jeopardy citation (the most serious violation level indicating risk of serious injury or death). The facility has a 2-star overall rating and ranks #100 of 100 nursing homes in Tennessee. Families considering this facility should ask detailed questions about what corrective actions have been taken since these incidents.
Do Nurses at Laurelwood Health Stick Around?
LAURELWOOD HEALTH CARE CENTER has a staff turnover rate of 47%, which is about average for Tennessee 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 Laurelwood Health Ever Fined?
LAURELWOOD HEALTH CARE CENTER has been fined $126,516 across 1 penalty action. This is 3.7x the Tennessee average of $34,344. 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 Laurelwood Health on Any Federal Watch List?
LAURELWOOD HEALTH CARE CENTER 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.