MAPLEWOOD HEALTH CARE CENTER
For profit - Corporation
160 Beds
AHAVA HEALTHCARE
Data: November 2025
1 Immediate Jeopardy citation
Trust Grade
0/100
#267 of 298 in TN
Photo by Maplewood Health Care Center
Photo by Maplewood Health Care Center
Photo by Maplewood Health Care Center
1 / 5 photos
Last Inspection: January 2025
Within standard 12-15 month inspection cycle. Federal law requires annual inspections.
Overview
Maplewood Health Care Center has received a Trust Grade of F, indicating significant concerns about the quality of care provided. Ranked #267 out of 298 facilities in Tennessee, this places them in the bottom half of nursing homes in the state and #5 out of 6 in Madison County, meaning there are very few better local options. The facility's conditions are worsening, with issues increasing from 10 in 2022 to 15 in 2025. Although staffing received an average rating of 3 out of 5 stars, the turnover rate is concerning at 62%, higher than the state average, which may impact consistency of care. Families should be aware that the facility has incurred fines totaling $144,120, which is above the average for Tennessee, indicating ongoing compliance problems. Specific incidents include a critical failure to provide adequate nursing staff, which led to a resident requiring emergency hospitalization after their condition changed without proper assessment. Additionally, another resident did not receive essential morning medications, resulting in dangerously high blood glucose levels. There was also a serious oversight in fall prevention, as one resident fell and fractured a hip due to a lack of proper assistance. While there are some strengths, such as average RN coverage, the overall picture presents several serious weaknesses that families should consider carefully.
- Trust Score
- F
- In Tennessee
- #267/298
- Safety Record
- High Risk
- Inspections
- Getting Worse
- Staff Stability ⚠ Watch
- 62% turnover. Above average. Higher turnover means staff may not know residents' routines.
- Penalties ○ Average
- $144,120 in fines. Higher than 63% of Tennessee facilities. Some compliance issues.
- Skilled Nurses ✓ Good
- Each resident gets 42 minutes of Registered Nurse (RN) attention daily — more than average for Tennessee. RNs are trained to catch health problems early.
- Violations ⚠ Watch
- 32 deficiencies on record. Higher than average. Multiple issues found across inspections.
0/100
Bottom 11%
Review needed
10 → 15 violations
★☆☆☆☆
1.0
Overall Rating
★★★☆☆
3.0
Staff Levels
★★☆☆☆
2.0
Care Quality
★☆☆☆☆
1.0
Inspection Score
↔
Stable
2022: 10 issues
2025: 15 issues
The Good
-
Full Sprinkler Coverage · Fire safety systems throughout facility
-
No fines on record
Facility shows strength in fire safety.
The Bad
1-Star Overall Rating
Below Tennessee average (2.8)
Significant quality concerns identified by CMS
Staff Turnover: 62%
16pts above Tennessee avg (46%)
Frequent staff changes - ask about care continuity
Federal Fines: $144,120
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
Staff turnover is elevated (62%)
14 points above Tennessee average of 48%
The Ugly 32 deficiencies on record
1 life-threatening 4 actual harm
Mar 2025
1 deficiency
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
Free from Abuse/Neglect
(Tag F0600)
Someone could have died · This affected 1 resident
**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on policy review, facility daily staffing review, medical record review, hospital record review, and interview, the facili...
Read full inspector narrative →
**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on policy review, facility daily staffing review, medical record review, hospital record review, and interview, the facility failed to ensure residents were free of neglect as evidenced by the facility's failure to provide sufficient licensed nursing staff to perform assessments and administer morning medications as ordered for 6 of 6 (Resident #1,#2, #3, #4, #5, and #6) sampled residents reviewed. The facility's failure resulted in Immediate Jeopardy (IJ) when Resident #1 experienced a change of condition, and a nurse was not available on the 100 Hall to assess Resident #1. Resident #1's spouse called 911. Resident #1 was evaluated in the Emergency Department (ED) and admitted to the hospital. Resident #2 did not receive the morning blood glucose check, scheduled Insulin or Metformin, as ordered by the physician on 2/23/2025, and at 7:46 PM, Resident #2's blood glucose level reached 402 milligrams per deciliter (mg/dl).
Immediate Jeopardy (IJ) is a situation in which a 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.
A partial-extended survey was conducted 2/28/2025 through 3/3/2025.
The Administrator and the Director of Nursing (DON) were notified of the Immediate Jeopardy (IJ) for F-600 on 2/24/2025 at 6:30 PM, in the Administrator's office.
The facility was cited Immediate Jeopardy at F-600 at a scope and severity of J which is substandard quality of care.
An acceptable Removal Plan, which removed the immediacy of the Jeopardy for F600 was received on 2/28/2025, and the Removal Plan was validated onsite by the surveyor on 3/3/2025 through policy review, medical record review, observation, review of education records, and staff interviews.
The IJ began on 2/23/2025 through 2/26/2025 for F-600, the IJ was removed on 2/27/2025.
The facility's noncompliance at F-600 continues at a scope and severity of D for monitoring of the effectiveness of the corrective actions.
The facility is required to submit a Plan of Correction.
The findings include:
1. 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 by developing and implementing policies and procedures to prohibit and prevent .neglect .Neglect means failure of the facility, its employees, or service providers to provide goods and services to a resident that are necessary to avoid physical harm, pain, mental anguish, or emotional distress .
Review of the facility's undated policy titled, Medication Administration, revealed .Medications are administered by licensed nurses .as ordered by the physician .
Review of the facility's undated policy titled, Blood Glucose Monitoring, revealed .The facility will perform blood glucose monitoring as per physician's orders .
2. Review of the medical record revealed Resident #1 was admitted to the facility on [DATE], with diagnoses of Type 1 Diabetes, Heart Failure, and Acquired absence of left leg. Resident #1 was admitted to the facility from an acute care hospital after a left leg amputation.
Review of the physician's orders dated 2/22/2025, included Apixaban (anticoagulation medication used to thin the blood to prevent blood clots and stroke) 2 milligrams (mg) by mouth 2 times a day.
Review of the Order Summary Report for February 2025, revealed .2/22/2025 .Apixaban .5mg by mouth two times a day for blood .
Review of the Medication Administration Record (MAR) dated 2/23/2025, revealed Resident #1 did not receive the 8:00 AM Apixaban medication as scheduled.
Review of the progress notes dated 2/23/2025, revealed there was no documentation Resident #1 was transferred to the hospital by Emergency Medical Services (EMS).
Review of the hospital medical record dated 2/23/2025, revealed .2/23/2025 at 14:23 [2:23 PM] .[Resident #1] presented to the Emergency Department [ED]. Patient was brought here from [Named Nursing Home] .he was not getting his medications .there was no nurse available to give them to him .review of systems .positive for fatigue .weakness .Blood Pressure 115/49 Review of the hospital lab results dated 2/23/2025 revealed blood glucose [blood sugar] level 276 mg/dl .2/23/2025 at 1841 [6:41 PM] CM [Case Management] Director received a message asking if an APS [Adult Protective Services] or Ombudsman referral needed to be made on the patient due to neglect at [Named Nursing Home] due to patient not receiving his morning meds [medications] and they didn't have a nurse .CM Director called [Named Nursing Home] Administrator to find out what was going on .[Named Administrator] stated they had a nurse call in .Final [ED] Diagnosis: Generalized Weakness, Coronary Artery Disease, Chronic Kidney Disease, and Type 2 Diabetes .
During an interview on 2/24/2025 at 11:05 AM, the Administrator confirmed Resident #1 was transferred to the hospital on 2/23/2025 at approximately 1:30 PM, Resident #1 did not receive his morning medications and there was not a nurse on the 100 Hall to assess Resident #1 for a change in condition prior to being transferred to the hospital.
3. Review of the medical record revealed Resident #2 was admitted to the facility on [DATE], with diagnoses of Type 2 Diabetes, Dementia, and Polyneuropathy.
Review of the physician's orders dated 2/21/2025, revealed Glargine (long-acting insulin used to lower blood glucose level in diabetic patients) 25 units subcutaneously (beneath the skin) 2 times a day and Metformin 500 mg 2 times a day.
Review of the MAR dated 2/23/2025, revealed .Glargine 25 units subcutaneously two times a day for Diabetes .0800 [8:00 AM] .Metformin .500mg .by mouth two times a day [at] 0800 [8:00 AM] and 1600 [4:00 PM] .
Review of the Medication Audit Report dated 2/23/2025, revealed Metformin 500 mg was scheduled to be administered at 8:00 AM. The Metformin was administered at 2:44 PM. Novolin R (Regular-short acting) sliding scale Insulin was scheduled to be administered at 11:00 AM. The Novolin R insulin was administered at 2:47 PM.
There was no documentation Resident #2 received a blood glucose check, and the scheduled Glargine insulin or Metformin on 2/23/205 at 8:00 AM as ordered by the physician.
Review of the Blood Sugar Summary for Resident #2 revealed the following:
On 2/23/2025 at 8:00 AM, there was no blood sugar documented.
On 2/23/2025 at 11:00 AM, there was no blood sugar documented.
On 2/23/2025 at 2:47 PM, Resident #2's blood sugar was 313 mg/dl and 8 units of Novolin R insulin was administered.
On 2/23/2025 at 5:32 PM, Resident #2's blood sugar was 332mg/dl and 8 units of Novolin R insulin was administered.
On 2/23/2025 at 7:46 PM, Resident #2 blood sugar was 402 mg/dl.
During interview on 2/24/2025 at 3:32 PM, the DON confirmed Resident #2 did not receive morning blood glucose checks, insulin or Metformin as scheduled on 2/23/2025. The DON confirmed Resident #2 experienced elevated blood glucose levels in the afternoon, and it continued to rise to 402 mg/dl. The DON confirmed elevated blood glucose levels could lead to serious complications for diabetic residents.
4. Review of the medical record revealed Resident #3 was admitted to the facility on [DATE], with diagnoses of Abscess of buttock, Methicillin Resistant Staphylococcus Aureus Infection, Type 2 Diabetes, and Seizure disorder.
Review of the admission physician orders for Resident #3 revealed the following dated orders:
1/28/2025 Keppra (seizure medication) 500mg 1 tablet two times a day for seizures.
1/29/2025 Insulin Lispro (fast acting insulin to treat diabetes) sliding scale for blood glucose:
201-250 = administer 2 units sc.
251-300= administer 4 units sc.
301- 350= administer 8 units sc.
401-500= administer 10 units sc.
2/22/2025 Clindamycin (antibiotic) 300 mg three times a day by mouth for infection control.
2/22/2025 Mupirocin external ointment 2% (treatment/prevention of skin infections) apply two times a day for infection control.
Review of the Medication Administration Audit Report dated 2/23/2025 revealed Resident #3 did not receive the following medications as scheduled:
Keppra 500 mg scheduled for 8:00 AM was not administered until 3:33 PM.
Clindamycin scheduled for 8:00 AM, 12:00 PM, and 8:00 PM, was not administered until 4:05 PM.
Mupirocin ointment scheduled for 8:00 AM was not administered until 2:01 PM.
Insulin Lispro sliding scale scheduled for 11:00 AM was not administered until 2:00 PM.
5. Review of the medical record revealed Resident #4 was admitted to the facility on [DATE], with diagnoses of Type 2 Diabetes, Chronic Kidney Disease, Chronic Heart Failure, and Atrial Fibrillation (irregular heart rhythm).
Review of the physician orders for Resident #4 revealed the following dated orders:
1/30/2025 Amiodarone HCL (medication used to treat life-threatening heart rhythm problem) 200mg by mouth one time a day.
1/30/2025 Insulin Lispro sliding scale insulin sc before meals and at bedtime.
1/29/2025 Midodrine 10 mg by mouth three times a day for blood pressure.
Review of the Medication Administration Audit Report dated 2/23/2025 revealed Resident #4 did not receive the following medications as scheduled:
Amiodarone 200 mg scheduled for 8:00 AM, was not administered until 2:55 PM.
Insulin Lispro sliding scheduled for 11:30 AM was not administered.
Midodrine 10 mg scheduled for 8:00 AM and 12:00 PM, the documentation revealed both scheduled doses were administered at 3:58 PM.
6. Review of the medical record revealed Resident #5 was admitted to the facility on [DATE], and re-admitted [DATE], with diagnoses of Infection following a procedure, open wound right foot subsequent encounter, Type 2 Diabetes, Hypertensive Heart disease with Heart Failure.
Review of the physician orders for Resident #5 revealed the following dated orders:
2/22/2025 Insulin Lispro sliding scale administer sc before meals and at bedtime.
Review of the Medication Administration Audit Report dated 2/23/2025 revealed:
The Insulin Lispro sliding scale insulin scheduled before lunch at 11:30 AM was not administered until 2:00 PM.
7. Review of the medical record revealed Resident #6 was admitted to the facility on [DATE], with diagnoses of Aftercare following surgical amputation, Type 2 Diabetes, and Chronic Kidney Disease.
Review of the physician orders for Resident #6 revealed the following dated orders:
2/23/2025 Glipizide (diabetes medication) 2.5 mg extended release by mouth one time a day.
2/18/2025 Metoprolol Tartrate (medication used to treat high blood pressure) 50 mg by mouth two times a day.
Review of the Medication Administration Audit Report dated 2/23/2025 revealed:
The Glipizide 2.5mg extended release scheduled for 8:00 AM was not administered until 2:19 PM.
The Metoprolol Tartrate 50 mg scheduled for 8:00 AM was not administered until 2:34 PM.
8. Review of the daily staffing schedule dated Sunday, 2/23/2025, revealed Licensed Practical Nurse (LPN) A did not report to work for the 7:00 AM - 7:00 PM shift as scheduled on the 100 hall. LPN C was assigned to work the 300 Hall from 7:00 AM- 7:00 PM and the 100 Hall from 7:30 AM- 2:00 PM. LPN B reported to work at 1:50 PM to work on the 100 Hall. LPN C was unable to provide care for the residents on the 100 Hall due to the workload on the 300 Hall.
9. During an interview on 2/24/2025 at 8:25 AM, the Administrator stated, .the 7:00 AM nurse assigned to the 100 Hall [LPN A] did not show up for work . The Administrator stated LPN C was assigned to the 300 hall and the 100 hall was added to (LPN C)'s assignment when (LPN A) didn't show up for work. (LPN C) had a hospice resident on the 300 hall that was transitioning (a term used for a hospice patient in the process of dying) so (LPN C) was busy caring for the hospice resident. The Administrator confirmed on 2/23/2025 there were 25 residents on the 100 hall and 24 residents on the 300 hall and the residents on 100 hall did not receive scheduled morning medications as ordered.
During an interview on 2/24/2025 at 9:23 AM, EMS Paramedic E stated, . I received the 911 call around 1:30 PM to go out to [Named facility]. [Named Resident #1]'s wife stated he had not received any meds today because there was not a nurse working on the 100 Hall. EMS Paramedic E stated, .[Resident #1]'s spouse was concerned because the resident was sweating and seemed sick .[Resident #1]'s spouse couldn't find a nurse on the hall to assess [Resident #1]. The resident's spouse called 911. When we got there [at the facility] there wasn't a nurse [on the 100 hall] to get report from . EMS Paramedic E stated Resident #1 was transported by EMS to the Emergency Department and admitted to the hospital.
During an interview on 2/24/2025 at 9:55 AM, LPN B stated she was on-call for the facility on 2/23/2025. LPN B was asked to explain what being on-call meant. LPN B stated, The on-call nurse is responsible for coming to work if a scheduled nurse can't work. LPN B was asked what time she was contacted by the facility to report to work to replace the 100 hall nurse (LPN A). LPN B stated, .I got a phone call around 12:30 [PM] from the Staffing Coordinator. I was grocery shopping at the time, so I went home, changed clothes and came to work. LPN B was asked what time she arrived to work on the 100 hall. LPN B stated, .I got here [at the facility] around 1:45 PM .[Named LPN C] and [Named LPN F] were just beginning to check vital signs and start passing meds on the 100 hall .
LPN B arrived 6.75 hours after the day shift began, to replace LPN A, and was assigned to the 100 hall.
During an interview on 2/24/2025 at 10:08 AM, LPN C stated, I came in [to work] at 7:00 AM, I was told by [Named LPN D] there wasn't a nurse on the 100 hall, the nurse [LPN A] scheduled to work didn't show up, but that [Named LPN B] would be coming in soon. So I took the med [medication] cart keys (to the 100 hall med cart) and went back to my hall [300 hall]. I had a resident [on the 300 hall] that was transitioning [dying] so I was busy with that resident. Around 11:30 AM, I sent a text message to the DON [Director of Nursing] and told her the nurse scheduled to work on the 100 hall didn't show up today and the DON told me we needed to tag team the 100 hall to give medications to the residents. LPN C was asked what time he went to the 100 hall to administer medications. LPN C stated, It was around 1:30 PM. [Named LPN F] helped me, we started checking vital signs and giving medicines to the residents on the 100 hall .
LPN C and LPN F began administering medications and checking vital signs on the 100 hall at 1:30 PM (6.5 hours after the 7:00 AM- 7:00 PM shift began).
During an interview on 2/24/2025 at 10:30 AM, LPN D stated she worked the night shift (7:00 PM-7:00 AM) on 2/22/2025 on the 200 Hall. LPN D stated, .The nurse [LPN A] scheduled to work [2/23/2025 on the 7:00 AM- 7:00 PM shift] the 100 hall, didn't show up for work. I tried to call [named Staffing Coordinator]. I text the DON around 7:20 AM and told her the day [100 hall] nurse did not show up. I never spoke with [LPN B], the nurse on-call .
During an interview on 2/24/2025 at 10:47 AM, the DON was asked if she was told the 100 hall nurse did not show up to work on 2/23/2025 for the 7:00 AM shift. The DON confirmed (LPN D) contacted her on 2/23/2025 around 7:20 AM and reported the 100 hall nurse [LPN A] had not reported to work. The DON was asked what was done to replace the 100 hall nurse. The DON stated, .I told [named LPN D] to reach out to the [named Staffing Coordinator]. The DON confirmed she did not follow up with the staffing coordinator or the on-call nurse (LPN B) to ensure the 100 hall had nursing coverage.
During an interview on 2/24/2025 at 10: 49 AM, the Staffing Coordinator stated [named Registered Nurse F] called me at 12:34 PM, and said the day nurse [100 hall] didn't show up, I reached out to [named LPN B] to come in. [LPN B] said she was at the grocery store and would come in. The Staffing Coordinator was asked if anyone tried to reach her at shift change. The staffing coordinator stated, No, the first time I was called was at 12:34 PM, and I called [LPN B] right away .
During an interview on 2/25/2025 at 4:18 PM, Resident #1's spouse stated, .On Sunday [2/23/2025] around 11:30 [AM] I went to see him [Resident #1], he was really sweaty and didn't look good. I thought he might have a fever or a low blood sugar. I asked the girl [unknown name] at the nurse's station if the nurse could check on him. The girl sitting at the desk said, 'He don't [doesn't] have a nurse.' I said, 'What do you mean he doesn't have a nurse.' I just called the ambulance .[Resident #1] is still in the hospital today [2/25/2025] .
An acceptable Removal Plan, which removed the immediacy of the Jeopardy for F600 was received on 2/28/2025, and the Removal Plan was validated onsite by the surveyor on 3/3/2025 through policy review, medical record review, observation, review of education records, and staff interviews.
The 300 hall Charge Nurse verified the 100 hall medication count and keys at 7:28 AM on 2/23/2025 from the 7:00 PM - 7:00 AM 100 hall charge nurse after being informed that assigned nurse would be arriving soon. This 300 Hall Charge Nurse then returned to 300 hall to continue medication administration on hall 300.
From approximately 8:15 AM to 10:15 AM on 2/23/2025, the treatment nurse was noted providing treatments on the 100 hall for various residents, to include Resident #2.
Following completion of care for other unforeseen acute resident conditions and 300 hall medication administration, the 300 hall Charge Nurse alerted the Director of Nursing that the scheduled nurse that was believed to be arriving late for the 100 hall, had not arrived. The Registered Nurse charge nurse from hall 200 attempted to notify the staffing coordinator/scheduler at approximately 12:12 PM on 2/23/2025.
The 300 Hall Charge Nurse began medication administration for the 100 hall until the Nurse Manager on call arrived at 1:49 PM on 2/23/2025.
On 2/23/2025 at approximately 12:40 PM, the Nursing Home Administrator was made aware that the scheduled 100 hall 7:00 AM -7:00 PM shift charge nurse had not arrived to scheduled shift. The Director of Nursing notified the Regional Director of Clinical Services at approximately 1:40 PM.
At approximately 2:00 PM and 3:40 PM on 2/23/2025, a governing body meeting was held with attendance including the Director of Nursing, Administrator, Regional Director of Clinical Services (RDCS), Chief Operating Officer, and [NAME] President (VP) of Clinical Services to discuss findings, root cause, plan of correction, education, and development and implementation of a Performance and Improvement Plan. The Root Cause was determined to be the Charge Nurse failure to report to duty, gap in employee communication, and unforeseen patient acuity that coincided with the 300 Hall nurse's medication pass leading to the delay.
Education was provided on 2/23/2025 to the RDCS, Administrator, and Director of Nursing by the VP of Clinical Services and the Chief Operating Officer regarding On-Call Procedures, which included but were not limited to the specific details of rotating the Administrator, Director of Nursing, or Assistant Director of Nursing as designated, verifying the facility following each 7:00 AM to 7:00 PM shift change to ensure adequate and appropriate staff to administer resident medications and to monitor/assess residents needs and conditions, Communication, Procedure for delayed/missed medication, Assessments and Notifications, Reinstructed regarding Abuse Prohibition and Neglect, Staffing Procedures and adjustments which included but were not limited to specific details of shift relief has not arrived by their scheduled shift time, the off going nurse will promptly contact the Nurse Manager on call. The Nurse Manager on call will coordinate charge nurse coverage with the staffing scheduler. The off going nurse will remain at the facility to complete medication administration and to ensure resident care is continued until the Nurse Manager on call or oncoming nurse has arrived to relieve the off going charge nurse, and procedure of notifying the physician following assessing all potentially affected residents for further direction of action related to delayed or missed medication administration, and ongoing monitoring plan to prevent recurrence.
On 2/23/2025 at 2:47 PM, Resident #2's blood glucose level was assessed at 313 mg/dl by the 300 Hall Charge Nurse with 8 units of Novolin R per sliding scale administered per physician order; at 5:32 PM, Resident #2's blood glucose level was assessed by the on call Nurse Manager at 332 mg/dl with 8 units of Novolin R administered per sliding scale
Resident #2 noted with physician order stating metFORMIN HCL [hydrochloride] ER [extended release] Oral Tablet Extended Release 24 Hour 500 MG (Metformin HCL) Give 500 mg by mouth two times a day for DM. On 2/23/2025, the 300 hall Charge Nurse administered the Metformin 500 mg dose to Resident #2 at 2:44 PM. Metformin 500 mg was also administered to Resident #2 by on call Nurse Manager for next scheduled dose following Physician notification of delayed and missed morning medication administrations at 5:28 PM. The Charge Nurse administered 25 units of Insulin Glargine as ordered at 7:46 PM on 2/23/2025 with a blood glucose of 402 mg/dl.
All 100 hall residents, to include Resident #2, were evaluated for delayed medications by the Director of Nursing and Licensed Practical Nurse. All applicable Residents blood glucose levels, to include Resident #2, were assessed per accucheck on 2/23/2025 upon arrival of Director of Nursing to facility between 2:00 PM and 3:00 PM with physician notification completed.
The Medical Director was notified by the DON on 2/23/2025, for notification of all delayed medications and missed accuchecks and insulin administration with current blood glucose levels obtained. The Physician was notified of all medications showing missed administration with verbal agreement provided to administer all medications at this time; notified of all missed accuchecks and insulin administrations with current blood glucose levels with no further orders. The Medical Director was included in adhoc [for this situation] Quality Assurance and Performance Improvement (QAPI) meeting on 2/23/25 with attendance including Administrator, Director of Nursing, and Regional Director of Clinical Services for discussion of notification of resident assessment findings, to include Resident #2, reviewed and approved Performance Plan developed.
2/23/2025 All on duty Licensed Nurses were educated by the Director of Nursing and Regional Director of Clinical Services regarding On-call procedures, communication, timely medication administration, reinstructed regarding abuse prohibition and neglect, and staffing procedures which details included but not limited to the facility procedure/protocol of notifying the Nurse Manager on call if a clinical staff member does not report to their scheduled shift in order for coverage to be coordinated. All off duty, to include PRN (as needed) or Agency, licensed nurses will receive this education prior to the beginning of their next shift.
The Director of Nursing and Regional Director of Clinical Services completed a Medication Administration audit for all residents on 2/23/2025.
On 2/24/2025 at 7:15 pm, a Governing Body meeting was held with the Administrator, Director of Nursing, Regional Director of Clinical Services, and VP of Clinical Services to discuss the notification of immediate jeopardy. Reviewed all findings from 2/23/2025 and developed Performance Improvement with agreement to continue with action and plan developed.
Adhoc QAPI meeting held on 2/26/2025 with the Medical Director to share Removal and in agreement with Plan of Correction and Monitoring in place effective 2/23/2025.
The Director of Nursing and/or Assistant Director of Nursing will audit medication administration competition. Monitoring will occur twice daily x (times) 7 days, then twice daily during business days x 3 weeks, then weekly thereafter during morning clinical meeting. If substantial compliance is not met, re-education will be initiated, and audits will be reinitiated.
The Director of Nursing will report the findings to the monthly QAPI Committee meeting.
Removal plan was discussed and approved by Medical Director 2/25/25, 2/26/25, and 2/28/25.
The Administrator will ensure the removal plan is completed.
Jan 2025
14 deficiencies
2 Harm
SERIOUS
(G)
Actual Harm - a resident was hurt due to facility failures
Pressure Ulcer Prevention
(Tag F0686)
A resident was harmed · This affected 1 resident
**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 p...
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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 prevent the development of a pressure ulcer/injury and failed to provide treatments for 2 of 4 (Residents #72, and #85) sampled residents reviewed for pressure ulcers/injuries. Resident #72, who was at risk of developing pressure ulcers/injuries due to contractures [a permanent tightening of muscles, tendons, ligaments, skin, or other tissues that limits movement of a joint or body part] of the extremities and was dependent on staff for preventative interventions, developed a pressure ulcer/injury to the palm of her left hand from having long fingernails embedded into the skin, resulting in actual Harm to Resident #72.
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 .grooming .personal .hygiene .The facility will maintain individual objectives of the care plan and periodic review and evaluation .
Review of the facility's undated policy titled, Pressure Injury Prevention and Management, revealed .This facility is committed to the prevention of avoidable pressure injuries .facility shall establish and utilize a systemic approach for pressure injury prevention .Licensed nurses will conduct a full body skin assessment .weekly .Nursing assistants will inspect skin during bath and report any concerns .Interventions will be based on specific factors identified in the risk .skin assessment .moisture management, impaired mobility .
2. Review of the medical record revealed Resident #72 was admitted to the facility on [DATE], with diagnoses including Hemiplegia, Left Knee Contracture, and Right Knee Contracture.
Review of the annual Minimum Data Set (MDS) assessment dated [DATE], revealed a Brief Interview for Mental Status (BIMS) score of 15 which indicated Resident #72 was cognitively intact. Resident #72 required substantial assistance with most Activities of Daily Living (ADLs) and was dependent for bathing and dressing. The resident had upper and lower extremity impairment on 1 side.
Review of the Weekly Skin Check, for Resident #72 dated 12/12/2024, revealed .no new or abnormal skin issues this weekly assessment .
Review of the quarterly MDS assessment dated [DATE], revealed a BIMS score of 14 which indicated Resident #72 was cognitively intact. Resident #72 required substantial assistance with most ADLs and was dependent for bathing and dressing. The resident had upper and lower extremity impairment on 1 side.
Review of the Nurses Note for Resident #72 dated 12/18/2024, revealed .Summoned to resident's room per staff, noted a trauma wound to plam [palm] of left hand r/t [related to] contratcure [contracture] and fingernails digging into skin. Daughter persent [present] at bedside et [and] is aware. [Named physician] is aware with new orders to cleanse left hand with dwc [dermal wound cleanser]/ns [normal saline], pat dry, silde [slide] silver alginate between fingers and palm of hand. Change Qd [every day] et PRN [as needed] .
Review of the Physician's Order for Resident #72 dated 12/18/2024, revealed .Cleanse left hand with dwc/ns, pat dry, place silver alginate between fingers and palm of hand. Every day shift AND every 1 hours as needed .
Review of the .Follow Up Question Report ., for Resident #72 dated 12/1/2024-12/31/2024, revealed no issues during skin observations for 12/7/2024-12/19/2024.
Review of the .Weekly Wound Progress ., for Resident #72 dated 12/19/2024, revealed .Left hand [palm] .trauma .2.0 [centimeters (cm) length] 1.35 [width] 0.1 [depth] .
Review of the Weekly Skin Check, for Resident #72 dated 12/20/2024, revealed .no new skin issues noted at this time .
Review of the care plan for Resident #72 dated 9/29/2023, with a revision date of 12/20/2024, revealed .Trauma from nails to palm of left hand, Nails trimmed . There were no interventions implemented to prevent further pressure injury to the resident's left palm.
Review of the Nurses Note for Resident #72 dated 12/20/2024, revealed .Wound Trauma- Cleanse left hand with dwc/ns, pat dry, place silver alginate between fingers and palm of hand. every day shift, pt [patient] refused to have dressing changed, asked to wait till [until] saturday [Saturday] 12/21 [12/21/2024].
Review of the Treatment Administration Record (TAR) dated December 2024, revealed the facility failed to document the treatment for the pressure injury to the left palm on December 21, 2024.
Review of the .Weekly Wound Progress ., dated 12/23/2024, revealed .Left hand (palm) .1.5 [length] 1.2 [width] 0.1 [depth] .
Review of the .Weekly Skin Check, dated 12/28/2024, revealed .no new skin issues noted .
Review of the .Weekly Wound Progress ., dated 12/30/2024, revealed .Left hand (palm) .1.08 [length] 0.7 [width] 0.1 [depth] .
Review of the .Weekly Skin Check, dated 1/4/2025, revealed .no new skin issues noted .
Review of the TAR dated January 2025, revealed the facility failed to document the treatment for the pressure injury on January 4, 2025.
During an interview on 1/13/2025 at 11:10 AM, the Treatment Nurse confirmed the wound to Resident #72's hand was a preventable pressure ulcer/injury and should have been noticed during the Certified Nursing Assistants (CNA) skin assessments.
During an observation and interview on 1/13/2025 at 11:30 AM, the Treatment Nurse was asked if this surveyor could see the area of the pressure injury to Resident #72's hand. The Treatment Nurse tried to open the resident's left hand and was able to open the resident's hand enough to see that the wound had healed. Further observations revealed Resident #72's nails were long and needed to be trimmed. The Treatment Nurse stated she was going to trim the resident's nails when the daughter arrived. The Treatment Nurse stated that the resident usually keeps a washcloth in her hand to prevent any further pressure injuries since she refused anything else to be in her hand to prevent pressure injuries. Observations revealed Resident #72 did not have a washcloth in her left hand as a measure to prevent further pressure injuries to the palm of her contracted left hand.
During an interview on 1/13/2025 at 12:53 PM, the Director of Nursing (DON) confirmed that trimming nails and nail care should be done during residents' personal care and Resident #72's hand was a preventable pressure ulcer/injury. The DON confirmed the weekly skin assessment should have had documentation of skin issues prior to when the trauma to the palm of the hand occurred.
3. Review of the medical record revealed Resident #85 was admitted to the facility on [DATE], with diagnosis of Metabolic Encephalopathy, Sepsis, Pressure Ulcer Sacral Area Stage 4, Osteomyelitis, Atrial Fibrillation, Acute Kidney Failure, Anxiety, Paraplegia, and Bladder Neck Obstruction.
Review of the quarterly MDS dated [DATE], revealed Resident #85 had a BIMS score of 6, indicating Resident #85 had severe cognitive impairment. The resident was dependent on staff for all ADL's. Resident #85 had a Stage 4 pressure ulcer.
Review of the Physician Orders dated 10/24/2024, revealed Wound Pressure-Cleanse sacrum with .ns .collagen powder, dakins [cleaning solution] soaked gauze and secure with cover dressing.
Review of the November 2024 TAR revealed the following missed treatments for a Stage 4 sacral pressure ulcer: 11/4/2024, 11/5/2024, and 11/26/2024.
Review of the December 2024 TAR revealed the following missed treatments for a Stage 4 sacral pressure ulcer: 12/8/2024, 12/21/2024 and 12/22/2024.
Review of the January 2025 TAR revealed the following missed treatments for a Stage 4 sacral pressure ulcer: 1/4/2025 and 1/5/2025.
During an interview on 1/14/2025 at 3:00 PM, the Interim DON was shown the TARS with the missing treatments. The Interim DON was asked should there be missing treatments related to pressure ulcer care. The Interim DON stated, No.
4. During an interview on 1/13/2025 at 12:53 PM, the Interim DON was asked if staff should be missing treatments. The Interim DON stated, No, if they are missed, a reason should be documented.
SERIOUS
(G)
Actual Harm - a resident was hurt due to facility failures
Accident Prevention
(Tag F0689)
A resident was harmed · This affected 1 resident
**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on policy review, medical record review, facility investigation review, and interview, the facility failed to implement fa...
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**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on policy review, medical record review, facility investigation review, and interview, the facility failed to implement fall interventions for 1 of 4 (Resident #56) sampled residents reviewed for falls. The facility failed to follow the fall prevention intervention of 2 person bed mobility assistance, when on 11/17/2024, Resident #56 fell out of the bed and sustained a fractured hip, resulting in Actual HARM to Resident #56.
The findings include:
1. Review of the facility's undated 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 .The nurse will indicate the resident's fall risk . and initiate interventions on the resident's baseline care plan .with the resident's level of risk .
Review of the facility's undated policy titled, Comprehensive Care Plan Policy, revealed .Qualified staff responsible for carrying out interventions specified in the care plan will be notified of their roles and responsibilities for carrying out the interventions .
2. Review of the medical record revealed Resident #56 was admitted to the facility on [DATE], with diagnoses including Left Hemiplegia, Parkinsons, Dementia, Fracture of Left Femur, Diabetes, Depression, Anxiety, Testicular Hypofunction, and Impulse Disorder.
Review of the Fall Risk Assessment for Resident #56 dated 12/28/2023, revealed .High Risk for Falling .
Review of the Nurse Progress Note for Resident #56 dated 12/28/2023 at 12:34 PM, revealed .Resident was laying on his stomach on the floor next to [the] bed .Laceration noted on right forearm .bruise forming on right knee. Blood noted in nostrils .Two staff members are to be used while providing care .
Review of the Nurse Progress Note for Resident #56 dated 12/28/2023 at 7:15 PM, revealed .Vital Signs .Blood Pressure: 165/96; Heart Rate: 96 .also observed prominent swelling to the left knee, redness / bruising to the nasal region, and abrasions located throughout various [regions] of the body that were sustained from the fall .resident voiced excruciating pain .MD [Medical Director] .order to send the resident out to the .ER [emergency room] for evaluation .
Review of the Facility Investigation Incident Report for Resident #56 dated 12/28/2023, revealed .Resident was laying on his stomach on the floor .Immediate Action Taken .Two staff members are to be used while providing care .
Review of the care plan for Resident #56 dated 12/29/2023, revealed .two persons assist with bed mobility .
Multiple attempts were made to contact the Nurse and CNA that were present for the fall on 12/28/2023, with no success.
Review of the quarterly Minimum Data Set (MDS) dated [DATE], revealed a Brief Interview for Mental Status (BIMS) score of 15, which indicated Resident #56 was cognitively intact and required moderate assist with ADLs (Activities of Daily Living).
Review of the annual MDS dated [DATE], revealed a BIMS score of 15, which indicated Resident #56 had no cognitive impairment, required extensive assist with ADLs, and 2 person assist with turns and repositions.
Review of the Care Plan dated 11/17/2024, revealed Resident #56 required 2 person assist with bed mobility.
Review of the Facility Investigation Incident Report for Resident #56 dated 11/17/2024 at 9:00 PM, revealed .resident found in floor laying on back between the bed and the window on left side .while CNA was administering ADL/incontinent care, cna [CNA] was rolling resident over from the right side of bed to clean and he [Resident #56] had grabbed to night stand draw [drawer] .continues to fall into floor .Immediate Action Taken .head to toe assessment .neuro checks started .EMS [Emergency Medical Services] contacted for transfer to ER .
Review of the Nurse Progress Note for Resident #56 dated 11/17/2024 at 10:43 PM, revealed .EMS here to transport to ER .Resident refusing to go to ER .
Review of the Fall Risk Assessment for Resident #56 dated 11/17/2024, revealed .Moderate Risk for Falling .
Review of the Nurse Progress Note for Resident #56 dated 11/18/2024 at 6:45 AM, revealed .Resident complaining of L [Left] hip pain and being unable to lift LLE [Left Lower Extremity] MD contacted and ordered resident be transferred to ED [Emergency Department] for evaluation and imaging .
Review of the Hospital Record for Resident #56 dated 11/18/2024, revealed .male brought in .after having fallen on his left hip when being turned in the bed .complains of left .thigh pain .CT [Computed Tomography] Scan [medical imaging used to obtain detailed internal images of the body] imaging showed minimally displaced/impacted .femoral neck [specific type of hip fracture] fracture .
Review of the Nurse Progress Note for Resident #56 dated 11/18/2024 at 9:12 PM, revealed .Resident admitted to [the] hospital due to fractured left hip . Resident #56 was admitted to the hospital on [DATE] - 11/20/2024.
Review of the Nurse Progress Note for Resident #56 dated 11/20/2024 at 5:17 PM, revealed .admission Summary .Resident arrived to fscility [facility] via [by way of] EMS per stretcher x [times] 2 attendants. admitted S/p [status post-a shorthand notation to indicate a specific event or procedure for a past medical event] hospitalization for fx [fracture] to hip from fall .
Review of the Physician's Order for Resident #56 dated 11/20/2024, revealed .non weight bearing to LLE every shift for Left hip fx .Ensure surgical site clean dray [dry] and intact .
Review of the significant change MDS assessment dated [DATE], revealed a BIMS score of 15, which indicated Resident #56 was cognitively intact. Resident #56 was dependent on staff for bed mobility and experienced a fall with a major injury requiring surgery.
During an interview on 1/14/2025 at 2:48 PM, Registered Nurse (RN) C stated .I was in another room and the CNA [CNA D] came out and hollered for help .I went in and said let me get help .got staff and used the hoyer [mechanical lift] to get him back on the bed .he [Resident #56] said she [CNA D] rolled me out of the bed .she was changing him. She said he grabbed the side table and kept on rolling .I called EMS, and when they got there he refused to go .They [EMS] asked him appropriate questions and they said he was okay .when I came back the next morning he was gone .I turned in CNA [D] witness statement [a document that records facts and details] to DON [Director of Nursing] CNA [D] was [the] only one in the room .He's supposed to be 2 person assist .
During an interview on 1/14/2025 at 3:16 PM, CNA D stated .When I rolled him [Resident #56] over he was holding onto the nightstand .started falling out of the bed .I didn't find out until after that he [Resident #56] was a 2 person assist .I had just started working on that side .
CONCERN
(D)
Potential for Harm - no one hurt, but risky conditions existed
Resident Rights
(Tag F0550)
Could have caused harm · This affected 1 resident
Based on policy review, observation, and interview the facility failed to provide a private space that prevented interference for the resident group meeting for 1 of 1 (Resident Council) sampled group...
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Based on policy review, observation, and interview the facility failed to provide a private space that prevented interference for the resident group meeting for 1 of 1 (Resident Council) sampled group reviewed.
The findings include:
1. Review of the facility's policy titled, Resident Council Procedural Guide, dated 11/28/2017, revealed .facility supports the rights of residents to organize and participate in resident groups .The resident has a right to organize and participate in resident groups in the facility .The facility must provide a resident .private space .they must be provided privacy for meetings .
2. Observation in the Dining Room on 1/9/2025 at 10:20 AM, during the Resident Council Meeting, revealed the Maintenance Director came into the Dining Room, walked in front of the residents in the group meeting, and exited down the facility hallway.
Observation in the Dining Room on 1/9/2025 at 10:28 AM, during the Resident Council Meeting, revealed the Maintenance Assistant came into the Dining Room, walked in front of the residents in the group meeting, and exited down the facility hallway.
3. During an interview on 1/9/2025 at 10:54 AM, the Activity Director was asked if a private place should be provided for uninterrupted resident council meetings. The Activity Director stated, Yes.
During an interview on 1/9/2025 at 11:25 AM, the Director of Nursing (DON) was asked if a private place should be provided for uninterrupted resident council meetings. The DON stated, Yes.
CONCERN
(D)
Potential for Harm - no one hurt, but risky conditions existed
Deficiency F0565
(Tag F0565)
Could have caused harm · This affected 1 resident
Based on policy review, observation, and interview the facility failed to provide a private space that prevented interference for the resident group meeting for 1 of 1 (Resident Council) sampled group...
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Based on policy review, observation, and interview the facility failed to provide a private space that prevented interference for the resident group meeting for 1 of 1 (Resident Council) sampled group reviewed.
The findings include:
1. Review of the facility's policy titled, Resident Council Procedural Guide, dated 11/28/2017, revealed .facility supports the rights of residents to organize and participate in resident groups .The resident has a right to organize and participate in resident groups in the facility .The facility must provide a resident .private space .they must be provided privacy for meetings .
2. Observation in the Dining Room on 1/9/2025 at 10:20 AM, during the Resident Council Meeting, revealed the Maintenance Director came into the Dining Room, walked in front of the residents in the group meeting, and exited down the facility hallway.
Observation in the Dining Room on 1/9/2025 at 10:28 AM, during the Resident Council Meeting, revealed the Maintenance Assistant came into the Dining Room, walked in front of the residents in the group meeting, and exited down the facility hallway.
3. During an interview on 1/9/2025 at 10:54 AM, the Activity Director was asked if a private place should be provided for uninterrupted resident council meetings. The Activity Director stated, Yes.
During an interview on 1/9/2025 at 11:25 AM, the Director of Nursing (DON) was asked if a private place should be provided for uninterrupted resident council meetings. The DON stated, Yes.
CONCERN
(D)
Potential for Harm - no one hurt, but risky conditions existed
Notification of Changes
(Tag F0580)
Could have caused harm · This affected 1 resident
**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on policy review, medical record review and interview, the facility failed to notify the resident's legal representative o...
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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 notify the resident's legal representative of a transfer of the resident from the facility for 1 of 1 (Resident #81) sampled resident reviewed for notification of change.
The findings include:
1. Review of the undated facility policy titled, Notification of Changes, revealed .The facility must inform .or notify the resident's family member or legal representative when there is a change requiring such notification .Circumstances requiring notification include .A transfer or discharge of the resident from the facility .
Review of the undated facility policy titled, Transfer and Discharge (including AMA), revealed .Emergency Transfers/ Discharges- initiated by the facility for medical reasons .Notify resident and/or resident representatives .
2. Review of the medical record revealed Resident #81 was admitted to the facility on [DATE], with diagnoses including Dysphagia, Dementia, Alzheimer's Disease, and Gastro-Esophageal Reflux.
Review of quarterly Minimum Data Set (MDS) assessment dated [DATE], revealed a Brief Interview for Mental Status (BIMS) score of 00, indicating Resident #81 had severely impaired cognition.
Review of Progress Note dated 12/31/2024 at 6:22 PM, Revealed .Resident [#81] had two episodes of vomiting coffee ground emesis, on call md [Medical Doctor] made aware with order to send resident to [Named Hospital] ED [Emergency Department] for eval. [evaluation] RP [Responsible Party] aware of transfer. Resident transferred to [Named Hospital] .
This progress note was written after Resident #81 had been sent out to the hospital, the hospital notified the daughter, and then daughter called the facility to confirm the resident had been sent out.
During a phone interview on 1/6/2025 at 3:05 PM, Resident #81's RP stated .They did not call New Years Eve when they sent her out. The hospital notified me she was there .I called [the facility] and asked them what was going on .
During an interview on 1/14/2025 at 4:18 PM, the Interim Director of Nursing (DON) was asked, What would you consider a reasonable amount of time to notify the RP if a resident is transferred to the hospital? The Interim DON stated, Within an hour. We may not call immediately if it's an emergency, but as soon as we get them out of the building they should call.
The facility failed to notify the resident's RP of the transfer from the facility to the hospital.
CONCERN
(D)
Potential for Harm - no one hurt, but risky conditions existed
Safe Environment
(Tag F0584)
Could have caused harm · This affected 1 resident
Based on policy review, observation, and interview, the facility failed to provide effective housekeeping to maintain a sanitary environment for 4 of 86 resident rooms (Residents #3, #28, #34, #61, #8...
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Based on policy review, observation, and interview, the facility failed to provide effective housekeeping to maintain a sanitary environment for 4 of 86 resident rooms (Residents #3, #28, #34, #61, #82, #84, and #94)
The findings include:
1. Review of the undated facility policy Resident Rights, revealed .The resident has a right to a safe, clean, comfortable and homelike environment .
Review of the facility's CLEANING SCHEDULE, dated 10/11/2023, revealed .Monday .Wednesday .Friday .Sunday .Clean commode top to base of commode .Wednesday .Friday .clean .IV poles .Monday .Clean walls, light, everything on the wall, wash window and window seal .Daily dust mop and mop room .
Review of the facility's Deep Cleaning List, revealed .Dust and polish all furniture .Dry mop and wet mop entire floor-move all furniture .clean windows, screens, ledges, blinds .Dust high areas .curtain -window and cubicle .Clean Feeding Tube Poles .Clean and disinfect toilet bowl .
2. Multiple observations in Resident #3's room on 1/6/2025 at 9:50 AM, 1/7/2024 at 8:18 AM, and on 1/8/2025 at 8:27 AM, revealed dirty baseboards by the air conditioner and the window blinds had yellowish-brown splatter marks. The commode had a dirty grayish black ring around the water line and a dark brown smear above the water line on the left side.
3. Multiple observations in Resident #82 and Resident #94's shared bathroom on 1/6/2025 at 10:23 AM and on 1/8/2025 at 8:13 AM, revealed a strong odor of urine and the floor was sticky with visible footprints. The floor entering the room was sticky and revealed footprints and wheelchair marks. Dirt and crumbs were observed on the floor. Dark streaks and splatter were observed on the wall beneath the sink. The floor between Resident #94's bed and the wall had several grayish spots and splatters.
4. Multiple observations in Resident #34 and #61's room on 1/6/2025 at 10:32 AM and on 1/09/25 at 9:04 AM, revealed the window valance by the bed had large spots of thick gray dusty build up showing in the folds of the material.
5. Multiple observations in Resident #28 and 84's room on 1/6/2025 at 10:32 AM, 1/07/25 at 8:31 AM, and on 1/8/2025 at 8:19 AM, the base of the enteral feeding tube pole had a yellowish tan hardened substance on and around the base of the pole, and crumbs and dirt on the floor between the two beds.
During an interview on 1/09/25 at 9:04 AM, the Administrator confirmed toilets should be cleaned, resident rooms and bathrooms should be clean without odors, the resident's floors should be clean, and the curtains should not be showing a thick layer of dust.
During an interview on 1/13/2025 at 10:55 AM, the Head of Housekeeping confirmed the resident rooms should be kept clean and odor free.
CONCERN
(D)
Potential for Harm - no one hurt, but risky conditions existed
Report Alleged Abuse
(Tag F0609)
Could have caused harm · This affected 1 resident
**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on policy review, medical record review, and interview, the facility failed to report an allegation of staff to resident a...
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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 report an allegation of staff to resident abuse for (Resident #76 and #307) and an injury of unknown origin (Resident #81) for 3 of 10 sampled residents reviewed for Abuse.
The finding include:
1. Review of the facility's undated policy titled, Abuse, Neglect, and Exploitation revealed, .Abuse .includes verbal abuse, sexual abuse, physical abuse, and mental abuse .verbal abuse .includes disparaging and derogatory terms to residents .physical .hitting, slapping .includes controlling behavior through corporal punishment .designate an Abuse Coordinator in the facility who is responsible for reporting allegations or suspected abuse . to the state survey agency and other officials in accordance with state law .Possible indicators of abuse include .Resident, staff, or family report of abuse .physical marks such as bruises .physical injury of a resident, of a unknown source .Reporting of all alleged violations to the Administrator, state agency, adult protective services and to all other required agencies .Immediately, but no later than 2 hours after the allegation is made .Not later than 24 hours if the events that cause the allegation do not involve abuse and do not result in serious bodily injury .
2. Review of the medical record revealed Resident #76 was admitted to the facility on [DATE] with diagnoses including Multiple Sclerosis, Paraplegia, Seizures, Bipolar 2 Disorder, and Anxiety.
Review of the quarterly Minimum Data Set (MDS) assessment dated [DATE], revealed Resident #76 had a Brief Interview for Mental Status (BIMS) score of 15, which indicated Resident #76 was cognitively intact.
During an interview on 1/6/2025 at 4:09 PM, Resident #76 reported to the surveyor an allegation of verbal abuse. Resident #76 stated a [named employee] called him a derogatory name. The Surveyor finished the interview and reported the allegation of verbal abuse to the Administrator in his office.
The allegation of verbal abuse was not reported to the state agency until 1/15/2025 (9 days after the allegation was made).
During an interview on 1/15/2025 at 2:20 PM, the Administrator was asked the types of abuse do you report to the state agency. The Administrator stated, Any type of abuse, physical, verbal, sexual, misappropriation . The Administrator confirmed he did not report to the state agency, Resident #76's allegation of verbal abuse. The Administrator was asked should you have reported this allegation of verbal abuse. The Administrator stated, Yes.
3. Review of the medical record revealed Resident #81 was admitted to the facility on [DATE] with diagnoses including Fracture of Part of Neck of Right Femur, Dementia, Alzheimer's Disease, Muscle Weakness, History of Falling, and Unsteadiness on Feet.
Review of the quarterly MDS dated [DATE], revealed a BIMS score of 00, which indicated Resident #81 was severely cognitively impaired.
Review of Resident #81's Progress Note dated 12/25/2024 at 5:10 AM, revealed .resident noted with discoloration to left forehead no s[signs]/[or]sx [symptoms] of pain noted will continue to monitor.
Review of (Named Company) Weekly Skin Checks revealed .12/26/2024 .Any bruising or redness .no .1/2/2025 .Any bruising or redness .no, No new skin issues .
Review of the (Named Hospital) report dated 12/31/2024, revealed .77 yr [year] female brought in from [Named facility] nursing home after 2 reported episodes of coffee ground emesis. Pt [patient] is . nonverbal .Yellow bruise noted to forehead .
During a phone interview on 1/6/2025 at 2:40 PM, Resident #81's daughter stated .She was sent out about a week ago and they did not call me, the hospital did. When I got to hospital, she had a bruise on her forehead .
During an observation on 1/8/2025 at 8:11 AM, Resident #81 was sitting in a wheelchair in the dining room with a yellow fading bruise to the left center of her forehead.
During an interview on 1/8/2025 at 4:04 PM, LPN E was asked, Do you know when or where the yellow bruise on the resident's forehead came from? LPN E stated, She had a previous fall sometime in the beginning of December.
During an interview on 1/8/2025 at 4:08 PM, Resident #81's daughter was asked when she noticed the bruise on her forehead. She replied, It wasn't there when I went out of town the Saturday before Christmas [December 21, 2024.] I saw it on 1/1/2025 when I saw her in the hospital when she was sent out. Resident's daughter was asked if she asked anyone from the facility where the bruise came from. Resident #81's daughter stated, They [facility staff] said that the bruise was from a previous fall from December twenty-something .
During an interview on 1/13/2025 at 10:31 AM, LPN F was asked to describe Resident #81's bruise. LPN F stated, It was on the left side of her forehead .I saw a purplish area to her left forehead. The LPN F was asked if she did an investigation or completed an incident report. The LPN F replied, I put a pillow for positioning, no I didn't know what happened, so I didn't know what to put on a report .
During an interview on 1/14/2025 at 2:23 PM, the Administrator stated, .We are acknowledging Resident #81 had a fall .we are still investigating .I have reported to the state as injury of unknown origin, there is no suspicion of abuse .the bruise should have been documented and investigated .
During an interview on 1/14/2025 at 4:15 PM, the DON confirmed LPN F should have documented and reported an occurrence of Resident #81's bruise to the forehead, and the facility should have investigated the bruise .
3. Review of the medical record revealed Resident #307 was admitted to the facility on [DATE] and readmitted on [DATE] with diagnoses including Paraplegia, Chronic Obstructive Pulmonary Disease, Urinary Retention, and Depression.
Review of the quarterly MDS dated [DATE] revealed a BIMS score of 13 which indicated Resident #307 was cognitively intact without physical behaviors directed towards others.
Review of the quarterly MDS dated [DATE] revealed a BIMS score of 15 which indicated Resident #307 was cognitively intact without physical behaviors directed towards others.
During an interview on 1/6/2025 at 11:10 AM Resident #307 stated .the nurse on hall 5 .tried to take my phone away from me and I swung and she grabbed my hand and held it down .I was cussing her and she said something about my mama and I said something about her and then I spit at her and she grabbed a towel and put it over my face and almost smothered me and I said I was calling the police .I called 911 again and the police officer came, and I told them I wanted to press charges. Then the ambulance got here, and they took me to the hospital. [Named Social worker] came and talked to me about it when I got back on Friday [1/3/2025] .
The Administrator was notified of the allegation of abuse on 1/6/2025.
During an interview on 1/13/2025 at 9:26 AM the Assistant Director of Nursing (ADON) A stated it was bought up to the Social Worker during the 48-hour care plan meeting.
During an interview on 1/13/2025 at 9:31 AM the Administrator stated .it was discovered in care plan meeting on 1/3/2025 .the way it was reported it was not an allegation .it was a complaint .it was reported as a complaint, not as an allegation .different types of grabbing .if [Resident #307] felt he was abused he would voice it and he did not voice it in that manner from what I understand. If he felt abused or was voiced as abuse he would tell me. He did not tell me that. Based on what he said and how it was reported to me it was not abuse . The surveyor asked, When I reported this to you last week did you talk to [Resident #307] The Administrator stated, I can't remember if I talked to him about this or not .He did not say the word abuse. He voiced it as a complaint, not abuse .This is not abuse so it wasn't reported .
During an interview on 1/13/2025 at 10:02 AM the Social Service Director (SSD) was asked what Resident #307 told her. The SSD stated, .she [LPN F] held my arm down and put a rag over my face .he said he felt safe in the building .the way I perceived it, if he didn't feel safe, he would not have wanted to go back to the room .He is the first one that would tell if something was wrong. If he was genuinely upset, he would have said that and not have us prompt the question .I would not perceive that as abuse .
During an interview on 1/15/2025 at 2:25 PM, the Administrator stated I still feel it's not abuse .so it doesn't need to be reported .
The allegation of staff to resident abuse was not reported to the state agency until 1/15/2025.
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, medical record review, and interview, the facility failed to thoroughly investigate alleged allegations ...
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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 thoroughly investigate alleged allegations of abuse that included an injury of unknown origin (Resident #81) and staff to resident abuse (Resident #307) for 2 of 11 sampled residents reviewed for abuse.
The findings include:
1. Review of the facility's undated policy titled, Abuse, Neglect and Exploitation, revealed . An immediate investigation is warranted .B. Written procedures for investigation include .Identifying staff responsible for the investigation . Investigating different types of alleged violations .Identifying and interviewing all involved persons, including the alleged victim .others who might have knowledge of the allegations .Focusing the investigation on determining if abuse . and/or mistreatment has occurred, the extent, and cause .Providing complete and thorough documentation of the investigation .
Review of the facility's undated policy titled, .Incidents and Accidents, revealed It is the policy of this facility for staff .to report, investigate, and review any accidents or incidents .The following incidents require an incident report .Falls .Unobserved injuries .The supervisor or other designee will be notified of the incident .The nurse will contact the resident's practitioner .In the event of an unwitnessed fall or blow to the head, the nurse will initiate neurological checks .The resident's family or representative will be notified of the incident .The nurse will enter the incident information into the appropriate form/system within 24 hours of occurrence .Meeting regulatory requirements .Documentation should include .nature of the incident .initial findings .date, time .notifications .The nurse will examine any first aid to any visitor or employee involved in an incident .If an incident was witnessed by other people, the supervisor or designee will obtain written documentation of the event by those that witnessed it and submit that documentation to the Director of Nursing and/or Administrator .
2. Review of the medical record revealed Resident #81 was admitted to the facility on [DATE], with diagnoses including Fracture of Part of Neck of Right Femur, Dementia, Alzheimer's Disease, Muscle Weakness, History of Falling, and Unsteadiness on Feet.
Review of the quarterly MDS dated [DATE], revealed a BIMS score of 00, which indicated Resident #81 was severely cognitively impaired.
Review of Resident #81's Progress Note dated 12/25/2024 at 5:10 AM, revealed .resident noted with discoloration to left forehead no s [signs]/[or] sx [symptoms] of pain noted will continue to monitor.
Review of (Named Company) Weekly Skin Checks revealed .12/26/2024 .Any bruising or redness .no .1/2/2025 .Any bruising or redness .no, No new skin issues .
Review of the (Named Hospital) report dated 12/31/2024, revealed .77 yr [year] female brought in from [Named facility] nursing home after 2 reported episodes of coffee ground emesis. Pt [patient] is . nonverbal .Yellow bruise noted to forehead .
During a phone interview on 1/6/2025 at 2:40 PM, Resident #81's Daughter stated .She was sent out about a week ago and they did not call me, the hospital did. When I got to hospital, she had a bruise on her forehead .
During an observation on 1/8/2025 at 8:11 AM, Resident #81 was sitting in a wheelchair in the dining room with a yellow fading bruise to the left center of her forehead.
During an interview on 1/8/2025 at 4:04 PM, LPN E was asked, Do you know when or where the yellow bruise on the resident's forehead came from? LPN E stated, She had a previous fall sometime in the beginning of December.
During an interview on 1/8/2025 at 4:08 PM, the Resident #81's daughter was asked, when she noticed the bruise on her forehead. She replied, It wasn't there when I went out of town the Saturday before Christmas. I saw it on 1/1/2025 when I saw her in the hospital when she was sent out. Resident's daughter was asked if she asked anyone from the facility where the bruise came from. Resident #81's daughter stated, [Facility staff] said that the bruise was from a previous fall from December twenty-something .
During an interview on 1/13/2025 at 10:31 AM, LPN F was asked to describe Resident #81's bruise. LPN F stated, It was on the left side of her forehead .I saw a purplish area to her left forehead. The LPN F was asked if she did an investigation or complete an incident report. The LPN F replied, I put a pillow for positioning, no I didn't know what happened, so I didn't know what to put on a report .
During an interview on 1/14/2025 at 4:15 PM, the Interim DON confirmed LPN F should have documented and reported an occurrence of Resident #81's bruise to the forehead, and the facility should have reported and investigated the bruise immediately .
During an interview on 1/14/2025 at 2:23 PM, the Administrator stated, .We are acknowledging Resident #81 had a fall .we are still investigating .I have reported to the state as injury of unknown origin, there is no suspicion of abuse .the bruise should have been documented and investigated . All three individuals are suspended pending investigation .
3. Review of the medical record revealed Resident #307 was admitted to the facility on [DATE], and readmitted on [DATE], with diagnoses including Paraplegia, Chronic Obstructive Pulmonary Disease, Urinary Retention, and Depression.
Review of the quarterly MDS dated [DATE], revealed a BIMS score of 13, which indicated Resident #307 was cognitively intact without physical behaviors directed towards others.
Review of the quarterly MDS dated [DATE], revealed a BIMS score of 15, which indicated Resident # 307 was cognitively intact without physical behaviors directed towards others.
Review of the progress notes dated 12/27/2024, revealed .Behavior Note . Resident called 911 complaining of pain from suprapubic cath [catheter] upon arriving to room this writer asked resident what was going on, he preceded to say, the ambulance was on the way this writer asked resident again what was going on and why did he call them? Resident began to get loud and .this writer stated to him that that is not the correct way to speak to someone trying to help him resident then attempted to run me over with his chair as he told me to get .out of his room.
During an interview on 1/6/2025 at 11:10 AM Resident #307 stated .the nurse on hall 5 .tried to take my phone away from me and I swung and she grabbed my hand and held it down .I was cussing her and she said something about my mama and I said something about her and then I spit at her and she grabbed a towel and put it over my face an almost smothered me and I said I was calling the police .I called 911 again and the police officer came, and I told them I wanted to press charges. Then the ambulance got here, and they took me to the hospital. [Named Social worker] came and talked to me about it when I got back on Friday [1/3/2025] .
The Administrator was notified of the allegation of abuse on 1/6/2025.
During an interview on 1/13/2025 at 9:26 AM, the Assistant Director of Nursing (ADON) A stated it was brought up to the Social Worker during the 48-hour care plan meeting.
During an interview on 1/13/2025 at 9:31 AM, the Administrator stated .it was discovered in care plan meeting on 1/3/2025 .the way it was reported it was not an allegation .it was a complaint .it was reported as a complaint, not as an allegation .different types of grabbing .if he [Resident #307] felt he was abused he would voice it and he did not voice it in that manner from what I understand. If he felt abused or was voiced as abuse he would tell me. He did not tell me that. Based on what he said and how it was reported to me it was not abuse . The surveyor asked, When I reported this to you last week did you talk to him The Administrator stated, I can't remember if I talked to him about this or not .He did not say the word abuse. He voiced it as a complaint, not abuse .This is not abuse so it wasn't reported .
During an interview on 1/13/2025 at 10:02 AM the Social Service Director (SSD) was asked what Resident #307 told her. The SW stated, .she [LPN F] held my arm down and put a rag over my face .he said he felt safe in the building .the way I perceived it, if he didn't feel safe, he would not have wanted to go back to the room .He is the first one that would tell if something was wrong. If he was genuinely upset, he would have said that and not have us prompt the question .I would not perceive that as abuse .
During an interview on 1/15/2025 at 2:25 PM, the Administrator stated I still feel it's not abuse .
Review of the undated Summary provided revealed .nurse tried to grab his arm and place a rag on his face .
CONCERN
(D)
Potential for Harm - no one hurt, but risky conditions existed
Comprehensive Care Plan
(Tag F0656)
Could have caused harm · This affected 1 resident
**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on policy review, medical record review, and interview, the facility failed to develop a care plan for 1 of 32 (Resident #...
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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 develop a care plan for 1 of 32 (Resident #72) residents reviewed for care plans.
The findings include:
1. Review of the facility's undated policy titled, Pressure Ulcer Prevention and Management, revealed This facility is committed to the prevention of avoidable pressure injuries .Nursing assistants will inspect skin during bath and will report any concerns to the resident's nurse timely .Interventions will be based on specific factors .skin assessment .moisture management, impaired mobility .Interventions will be documented in the care plan and communicated to all relevant staff .
2. Review of the medical record revealed Resident #72 was admitted to the facility on [DATE], with diagnoses including Hemiplegia, Epilepsy, Left Knee Contracture, and Right Knee Contracture.
Review of the annual Minimum Data Set (MDS) assessment dated [DATE] revealed a Brief Interview for Mental Status (BIMS) score of 15 which indicated Resident #72 was cognitively intact. Resident was at risk for pressure injuries and had upper and lower extremity impairment on 1 side, and substantial assistance to totally dependent with ADLs.
Review of the quarterly MDS assessment dated [DATE] revealed a BIMS score of 14 which indicated Resident #72 was cognitively intact. Resident was at risk for pressure injuries and had upper and lower extremity impairment on 1 side, and substantial assistance to totally dependent with ADLs.
Review of the care plan with a revision date of 12/20/2024 revealed .trauma from nails to palm of left hand, nails trimmed . There were no interventions in place.
During an interview on 1/13/2025 at 12:53 PM, the Minimum Data Set (MDS) Coordinator confirmed there should be an intervention on the care plan for trauma from nails to the palm of the left hand.
The facility failed to develop a care plan for Resident #72 to include interventions for wound care to palm of the left hand.
CONCERN
(D)
Potential for Harm - no one hurt, but risky conditions existed
Deficiency F0657
(Tag F0657)
Could have caused harm · This affected 1 resident
**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on policy review, medical record review, and interview, the facility failed to conduct a quarterly care plan conference me...
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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 a quarterly care plan conference meetings with resident/family representative for 1 of 32 (Resident #68) sampled residents reviewed for care plan meetings.
The findings include:
1. Review of the undated facility 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 .The care planning process will include an assessment of the resident's personal and cultural preferences in developing goals of care .The comprehensive care plan will be prepared by an interdisciplinary team, that includes .Family members, surrogate, or others desired by the resident .The comprehensive care plan will be reviewed and revised by the interdisciplinary team after each comprehensive and quarterly Minimum Data Set [MDS] assessment .
2. Review of the medical record revealed Resident #68 was admitted to the facility on [DATE], with diagnoses including Lack of Coordination, Severe Protein Calorie Malnutrition, Diabetes, Heart Disease, Anxiety and Depression.
Review of the quarterly Minimum Data Set (MDS) dated [DATE] revealed Resident #68 is rarely/never understood and is dependent on staff for Activity of Daily Living.
3. The facility was unable to provide documentation that a quarterly Care Conference was conducted with the Resident or Responsible Party regarding the quarterly 1/15/2024 comprehensive assessment.
4. During an interview on 1/13/2025 at 9:21 AM, the Social Service Director confirmed the family representative was not invited to the care plan meeting for the comprehensive MDS for January.
During an interview on 1/13/2025 at 10:50 AM, the Regional Director of Clinical Services confirmed a care plan conference meeting with family should be quarterly with the MDS assessment completion.
CONCERN
(D)
📢 Someone Reported This
A family member, employee, or ombudsman was alarmed enough to file a formal complaint
Potential for Harm - no one hurt, but risky conditions existed
Pharmacy Services
(Tag F0755)
Could have caused harm · This affected 1 resident
Based on facility policy review, observation, and interview the facility failed to ensure that medication records were in order and an account of the controlled medications were maintained and reconci...
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Based on facility policy review, observation, and interview the facility failed to ensure that medication records were in order and an account of the controlled medications were maintained and reconciled for 1 of 5 Registered Nurse (RN) J observed for Medication Administration.
The findings include:
1. Review of the facility's undated policy titled Medication Administration, revealed .Observe resident consumption of medication .if medication is a controlled substance, sign narcotic book .
2. Observation at the 300 hall Medication (Med) Cart beginning on 1/13/2025 at 1:31 PM revealed the following:
a. LPN J was asked to review Resident #1's narcotic reconciliation. Review of the Controlled Drug Record for Resident #1 revealed .GABAPENTIN (used to treat seizures and nerve pain) .300 MG (Milligram) CAPSULE .Amount Remaining 10 .
Review of Resident #1's narcotic card revealed a count of 8 capsules remaining. LPN J was asked about the difference in the number and stated, .I gave him a dose at 8 and another at noon .That's how busy I have been .There are 8 in the package, not 10 .
b. LPN J was asked to review Resident #20's narcotic reconciliation. Review of the Controlled Drug Record for Resident #20 revealed .ALPRAZOLAM (used to treat anxiety) 1 MG TABS .Amount Remaining .18 .
Review of Resident #20's narcotic card revealed a count of 16 tablets remaining. LPN J was asked about the difference in the number and stated, .I gave her a dose at 8 and another at noon .I signed them off in the computer but haven't signed them off in the book yet .
c. LPN J was asked to review Resident #48's narcotic reconciliation. Review of the Controlled Drug Record for Resident #48 revealed .HYDROcodone/ACET (Acetaminophen used to control pain) 5-325MG TAB .Amount Remaining .11 .
Review of Resident #48's's narcotic card revealed a count of 10 tablets remaining. LPN J was asked about the difference in the number and stated, .I gave her a dose at 8 .I haven't written it in the book yet .
During an interview on 1/13/25 at 2:25 PM, the Interim Director of Nursing (DON) confirmed that narcotics should be signed out in the Narcotics Book after they are administered.
CONCERN
(D)
Potential for Harm - no one hurt, but risky conditions existed
Deficiency F0761
(Tag F0761)
Could have caused harm · This affected 1 resident
Based on policy review, observation, and interview, the facility failed to ensure medications were properly stored and labeled when expired medications were observed in 1 of 1 (Med Storage Room) medic...
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Based on policy review, observation, and interview, the facility failed to ensure medications were properly stored and labeled when expired medications were observed in 1 of 1 (Med Storage Room) medication storage areas, and when an over-the-counter medication was observed in a shared bathroom.
The findings include:
1. Review of the facility's undated policy titled Medication Storage revealed .All drugs and biologicals will be stored in locked compartments .The pharmacy and all medication rooms are routinely inspected .for discontinued, outdated .medications .
2. Observation in the Medication Room on 1/15/2025 at 1:51 PM, revealed 8 expired Humalog Solution 100 UNIT/ML Pens with the use by date of 12/19/24.
During an interview on 1/15/2025 at 2:28 PM, the Assistant Director of Nursing A confirmed that there should be no expired medications in the med room.
3. Observation in the shared bathroom for Resident # 36 and #79 on 1/6/2025 at 9:43 AM, and 5:31 PM, revealed a 7.1-ounce pump can of over-the-counter medication for muscle cramps.
During an interview on 1/14/2025 at 3:07 PM, the Interim Director of Nursing (DON) was asked should there be over the counter medication in the bathroom. The Interim DON stated, No.
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 practices to prevent th...
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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 practices to prevent the potential spread of infections for 1 of 1 (Licensed Practical Nurse (LPN) E) staff members that failed to use hand hygiene during ostomy care.
The findings include:
1. The facility's undated policy titled, Hand Hygiene, revealed .All staff will perform hand hygiene procedures to prevent the spread of infection to other personnel, residents, and visitors .Before and after handling clean or soiled dressings .
2. Review of the medical record revealed Resident #6 was admitted to the facility on [DATE], with diagnoses including Dementia, Quadriplegia, Diabetes, and Heart Failure.
Review of the quarterly Minimum Data Set (MDS) dated [DATE], revealed Resident #6's Brief Interview for Mental Status (BIMS) of 9, indicating severe cognitive impairment, and functional limitation for range of motion (ROM) to lower extremity with impairment on one side. Resident #6 requires total assistance for all activities of daily living (ADL's), and Ileostomy was coded during this review.
Review of Resident #6's physician orders dated 6/11/2024, revealed .Change ostomy bag every 3 days and as needed one time a day, every 3 day(s) for ostomy care .
Observation in resident's room on 1/13/2025 at 11:09 AM, revealed Resident #6 lying in the bed wearing a hospital gown. LPN E entered Resident #6's room to perform ostomy care. LPN E washed his hands, donned a pair of gloves, removed the partially filled ostomy bag, cleaned around the stoma with a wet wipe, measured the stoma site, picked up a pair of scissors and cut around the ostomy bag and then placed the bag over the stoma. LPN E then placed on the dirty supplies in a plastic bag and tied the bag up. LPN E removed his gloves, washed his hands, then placed the plastic bag in trash barrel in the hallway.
During an interview on 1/14/2025 at 3:00 PM, LPN E confirmed he should have changed gloves, washed his hands and donned on a new pair of gloves after he had cleaned the stoma area and then applied the new pouch.
During an interview on 1/14/25 at 01:35 PM, the Assistant Director of Nursing (ADON) stated, .after removal pouch wash hands after cleaning stoma, measure and then apply ostomy bag, wash hands and confirmed turn the water off with a new paper towel.
During an interview on 1/15/2025 at 2:47 PM, The Director of Nursing confirmed the Licensed Nurse should change gloves, wash hands and don a new pair of gloves after cleansing the ostomy stoma, to apply the new pouch.
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
Food Safety
(Tag F0812)
Could have caused harm · This affected multiple residents
Based on policy review, observation, kitchen sanitation logs, and interview, the facility failed to ensure food was stored, handled, prepared, and served under sanitary conditions. The kitchen floor w...
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Based on policy review, observation, kitchen sanitation logs, and interview, the facility failed to ensure food was stored, handled, prepared, and served under sanitary conditions. The kitchen floor was dirty, the cook ware had sticky black carbon build-up, the convection oven had dried food particles inside with thick black sticky substance buildup. The meal and miscellaneous carts were dirty with dry food particles inside the carts. The facility failed to complete the food temperature log, freezer log, and cooler log. The facility failed to check the dish washer temperatures and sanitizing solution level three times a day. The facility had a census of 103 with 101 of those residents receiving a tray from the kitchen.
The findings include:
1. Review of the facility undated policy titled, Sanitation Inspection, revealed .It is the policy of this facility to conduct inspections to ensure food service areas are clean, sanitary and in compliance with .state and federal regulations. All food service areas shall be kept clean, sanitary, free from litter .Daily: Food service staff shall inspect refrigerators/coolers, freezer, storage area temperatures, and dishwasher temperatures daily .the dietary manager shall inspect all food services areas weekly to ensure .
Review of the facility undated policy titled, Monitoring of Cooler and Freezer Temperatures, revealed .It is the policy of this facility to maintain temperatures of coolers and freezers at the appropriate temperature to promote food safety .Logs for recording temperatures for each refrigerator or freezer will be posted in a visible location outside the freezer or refrigerator unit .Temperatures will be checked and logged at least twice per day by designated personnel .
Review of the facility undated policy titled, Record of Food Temperatures, revealed .It is the policy of this facility to record food temperatures daily to ensure food is at the proper serving temperature(s) before trays are assembled .Food temperatures will be checked on all items prepared in the dietary department .Measure and record the temperatures for each food product and milk at all meals. Record temperature on the temperature log .
Review of the facility undated policy titled, Food Safety Requirements, revealed .It is the policy of this facility to ensure dishes and utensils are cleaned under sanitary conditions through adequate dishwasher temperatures .For low temperature dishwasher .the wash temperature shall be 120 .F [Fahrenheit] .The 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 .at least once per shift .Water temperatures shall be measured and recorded prior to each meal and/or after the dishwasher has been emptied or re-filled for cleaning purposes .
2. Observation in the kitchen on 1/7/2024 at 1:16 PM, revealed the following.
The Kitchen floor was dirty with dried food crumbs, and pieces of paper on the kitchen floor.
The dish washer temperatures and test the sanitizing solution level of the low temperature dishwasher had not been completed.
3. Observation in the kitchen on 1/8/2024 at 11:16 AM, revealed the following.
The Kitchen floor was dirty with dried food crumbs, and pieces of paper on the kitchen floor.
The convection oven had dried food particles and had a thick black sticky substance buildup inside.
One meal cart was dirty with dry food particles on the bottom of the cart.
One metal cart that the plates lids were stored on, was dirty.
One miscellaneous silver cart that contained peanut butter, jelly, bread, and hotdog buns was dirty and contained food particles.
The freezer log, cooler log and the dish washer temperatures and test the sanitizing solution logs had not been completed.
4. Observation in the kitchen on 1/9/2024 at 7:44 AM, revealed the following.
The Kitchen floor was dirty with dried food crumbs and had a plastic lid lying on the kitchen floor.
The convection oven had dried food particles and a thick black sticky substance buildup inside.
One meal cart was dirty with dry food particles on the bottom of the cart.
One miscellaneous silver cart that contained peanut butter, jelly, bread, and hotdog buns was dirty and contained food particles.
5. Review of the Time/Temperature Food Preparation Log . dated November 2024 failed to reflect the completion of the food temperature checks for all three meals on 11/2/2024, 11/3/2024, 11/4/2024, 11/5/2024, 11/6/2024, 11/7/2024, 11/8/2024, 11/9/2024, 11/10/2024, 11/11/2024, 11/12/2024, 11/13/2024, 11/15/2024, 11/16/2024, 11/17/2024, 11/18/2024, 11/19/2024, 11/20/2024, 11/21/2024, 11/22/2024, 11/23/2024, 11/24/2024, 11/25/2024, 11/26/2024, 11/27/2024, 11/28/2024, 11/29/2024, and 11/30/2024.
Review of the Time/Temperature Food Preparation Log . dated December 2024 failed to reflect the completion of the food temperature checks for all three meals on 12/1/2024, 12/2/2024, 12/3/2024, 12/4/2024, 12/5/2024, 12/6/2024, 12/7/2024, 12/8/2024, 12/9/2024, 12/10/2024, 12/11/2024, 12/12/2024, 12/13/2024, 12/14/2024, 12/15/2024, 12/16/2024, 12/19/2024, 12/20/2024, 12/21/2024, 12/22/2024, 12/23/2024, 12/24/2024, 12/25/2024, 12/26/2024, 12/27/2024, 12/28/2024, 12/29/2024, 12/30/2024 and 12/31/2024.
Review of the Time/Temperature Food Preparation Log . dated January 2025 failed to reflect the completion of the food temperature checks for all three meals on 1/1/2025, 1/2/2025, 1/3/2025, 1/4/2025, 1/5/2025, 1/6/2025, and 1/7/2025.
6. Review of the TEMP [Temperature] LOG - FREEZER . Temperature logs dated November 2024, revealed the freezer temperature should be checked twice a day in the AM and PM, and initialed. Review of the freezer temperature logs failed to reflect the completion of the AM and PM checks on 11/1/2024, 11/2/2024, 11/3/2024, 11/4/2024, 11/5/2024, 11/6/2024, 11/7/2024, 11/8/2024, 11/9/2024, 11/10/2024, 11/11/2024, 11/13/2024, 11/14/2024, 11/15/2024, 11/16/2024, 11/17/2024, 11/18/2024, 11/19/2024, 11/20/2024, 11/21/2024, 11/22/2024, 11/23/2024, 11/24/2024, 11/25/2024, 11/26/2024, 11/27/2024, 11/28/2024, 11/29/2024, and 11/30/2024.
Review of the TEMP [Temperature] LOG - FREEZER . Temperature logs dated December 2024, revealed freezer temperature was to be checked twice a day in the AM and PM, and initialed. Review of the freezer temperature logs failed to reflect the completion of the AM and PM checks on 12/3/2024, 12/4/2024, 12/9/2024, 12/10/2024, 12/15/2024, 12/16/2024, 12/21/2024, 12/22/2024, 12/28/2024, 12/29/2024, 12/30/2024, and 12/31/2024.
7. Review of the reach in TEMP [Temperature] LOG - COOLER . Temperature logs dated November 2024, revealed the cooler temperature was to be checked twice a day in the AM and PM, and initialed. Review of the reach in cooler temperature logs failed to reflect the completion of the AM and PM checks on 11/1/2024, 11/2/2024, 11/3/2024, 11/11/2024, 11/12/2024, 11/15/2024, 11/16/2024, 11/17/2024, 11/18/2024, 11/21/2024, 11/22/2024, 11/23/2024, 11/24/2024, 11/27/2024, 11/28/2024, 11/29/2024, and 11/30/2024.
Review of the reach in TEMP [Temperature] LOG - COOLER . Temperature logs dated December 2024, revealed the cooler temperature was to be checked twice a day in the AM and PM and initialed. Review of the reach in cooler temperature logs failed to reflect the completion of the AM and PM checks on 12/3/2024, 12/4/2024, 12/7/2024, 12/8/2024, 12/9/2024, 12/10/2024, 12/11/2024, 12/12/2024, 12/13/2024, 12/14/2024, 12/15/2024, 12/16/2024, 12/17/2024, 12/18/2024, 12/21/2024, 12/22/2024, 12/23/2024, 12/25/2024, 12/26/2024, 12/27/2024, 12/28/2024, 12/29/2024, 12/30/2024, and 12/31/2024.
Review of the reach in TEMP [Temperature] LOG - COOLER . Temperature logs dated January 2025, revealed the cooler temperature was to be checked twice a day in the AM and PM and initialed. Review of the reach in cooler temperature logs failed to reflect the completion of the AM and PM checks on 1/1/2025, and 1/2/2025.
8. Review of the DISH MACHINE LOG . sanitation logs dated November 2024, revealed dish machine temperature checks and sanitizer testing with a chemical strip was to be tested at breakfast, lunch, and supper, and initialed as being completed. Review of the sanitation logs failed to reflect the completion of all the breakfast, lunch and supper dish machine temperature checks, sanitizer checks, with initials on 11/1/2024, 11/2/2024, 11/3/2024, 11/4/2024, 11/5/2024, 11/6/2024, 11/7/2024, 11/8/2024, 11/9/2024, 11/10/2024, 11/11/2024, 11/12/2024, 11/13/2024, 11/14/2024, 11/15/2024, 11/16/2024, 11/17/2024, 11/18/2024, 11/19/2024, 11/20/2024, 11/21/2024, 11/22/2024, 11/23/2024, 11/24/2024, 11/25/2024, 11/26/2024, 11/27/2024, 11/28/2024, 11/29/2024, and 11/30/2024.
Review of the DISH MACHINE LOG . sanitation logs dated December 2024, revealed dish machine temperature checks and sanitizer testing with a chemical strip was to be tested at breakfast, lunch, and supper and initialed as being completed. Review of the sanitation logs failed to reflect the completion of all the breakfast, lunch and supper dish machine temperature checks, sanitizer checks, with initials on 12/1/2024, 12/2/2024, 12/3/2024, 12/4/2024, 12/5/2024, 12/6/2024, 12/7/2024, 12/8/2024, 12/9/2024, 12/11/2024, 12/12/2024, 12/13/2024, 12/14/2024, 12/15/2024, 12/16/2024, 12/17/2024, 12/18/2024, 12/19/2024, 12/20/2024, 12/21/2024, 12/22/2024, 12/23/2024, 12/24/2024, 12/25/2024, 12/26/2024, 12/27/2024, 12/28/2024, 12/29/2024, 12/30/2024, and 12/31/2024.
During a telephone interview on 1/14/2025 at 8:17 AM, Registered Dietician (RD) confirmed the kitchen should be cleaned, meal temperatures should be checked on the line before it's served and documented, and the dishware temperatures with sanitizer should be checked and documented.
During an interview 1/14/2025 at 2:03 PM, the Certified Dietary Manager (CDM) confirmed the kitchen and the equipment should be clean and stated, .it was dirty I can't lie about it . I have never run a dirty kitchen .that's going to change .one of the best things happened the other day .sprinkler popped .when they [kitchen staff] seen the dirt come off the floor .said that's what is in our floor, it's dirty .I didn't hold them accountable for what they did in 24 [referring to 2024] .then you guys come .I've told them for the whole year .I showed them what was supposed to be done .I know I haven't done my job due diligent .moving forward it's going to be by the book .bent the rule not putting my foot down . The CDM confirmed the staff should document the meal temperatures with every meal, check the dish washer temperatures and the sanitizer three times a day, check the temperatures and document the freezer and cooler temperatures twice a day and stated, .I tell them it's not me it's what the state looks for .the whole nine yard and I have preached that to them for the whole year .and it takes you to come in to validate .25 [referring to 2025] is a different year .they aren't going to like me .I told my staff we are going to get a tag of some sort .I was expecting it because I know what I gave you wasn't sufficient .
During an interview on 1/14/2025 at 4:01 PM, the Administrator confirmed the kitchen should be clean, the staff should document the meal temperatures with every meal, check the dish washer temperatures and the sanitizer three times a day, check the temperatures and document the freezer and cooler temperatures twice a day.
Aug 2022
10 deficiencies
2 Harm
SERIOUS
(G)
Actual Harm - a resident was hurt due to facility failures
Notification of Changes
(Tag F0580)
A resident was harmed · This affected 1 resident
**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on review of the National Pressure Ulcer Advisory Panel (NPUAP) Prevention and Treatment of Pressure Ulcers: Quick Referen...
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**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on review of the National Pressure Ulcer Advisory Panel (NPUAP) Prevention and Treatment of Pressure Ulcers: Quick Reference Guide, policy review, medical record review, observation, and interview, the facility failed to ensure the Responsible Party was notified of a newly identified pressure ulcer, failed to ensure the Wound Care Nurse was notified of skin condition changes, and failed to ensure the Physician was notified and orders were obtained for a newly identified pressure ulcer for 1 of 5 sampled residents (Resident #42) reviewed with in-house acquired pressure ulcers. The facility's failure to notify the Wound Care Nurse of skin condition changes/redness and to notify the Physician and obtain orders for a newly identified pressure ulcer resulted in actual Harm when skin condition changes deteriorated and progressed to an Unstageable pressure ulcer.
The findings include:
Review of the National Pressure Ulcer Advisory Panel (NPUAP) Prevention and Treatment of Pressure Ulcers: Quick Reference Guide, dated 2019, revealed Stage III [3]: Full thickness skin loss Full thickness loss. Subcutaneous fat may be visible but bone, tendon, or muscle are not exposed. Slough [dead tissue] may be present .May include undermining and tunneling .Category/Stage IV [4] : Full thickness tissue loss Full thickness tissue loss with exposed bone, tendon, or muscle. Slough or eschar [a thick crust of dead tissue] may be present .Unstageable: Depth unknown Full thickness tissue loss in which the base of the ulcer is covered by a slough (yellow, tan, gray, green, or brown) and or eschar (tan, brown, or black) in the wound bed .
Review of the facility's policy titled, .Skin Integrity Management System, dated 2/24/2021, revealed .If a new pressure injury is noted .Notification of Physician and Responsible Party will be documented in the Progress Notes .Contact Physician for treatment recommendation approval .
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 this 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 .
Review of the medical record, revealed Resident #42 was admitted to the facility on [DATE] with diagnoses of Osteoporosis, Dementia, Sick Sinus Syndrome, and Peripheral Vascular Disease.
Review of a Nurse Practitioner Note dated 6/17/2022, revealed .no skin wound .
Review of the annual Minimum Data Set (MDS) assessment dated [DATE], revealed Resident #42 had severely impaired cognition, was totally dependent on staff for Activities of Daily Living (ADLs), was always incontinent of bladder and bowel, was at risk for pressure ulcers, had no unhealed pressure ulcers, and had a pressure relieving device for the bed.
Review of a quarterly Braden Scale dated 6/30/2022, revealed Resident #42 was at moderate risk for developing pressure ulcers.
Review of a Nurses' Progress Note dated 7/9/2022 at 5:55 PM, written by Agency Licensed Practical Nurse (LPN) #7, revealed .while completing rounds, CNA [Certified Nursing Assistant] discovered wound to right buttock. CNA noticed that bed air mattress was turned off. Notified wound care nurse .
Review of a Nurses' Progress Note dated 7/9/2022 at 7:00 PM, written by Agency LPN #7, revealed .Wound is 4 cm [centimeters] in length and 4.5 cm in width . There was no documentation of a description of the wound or a stage of the wound.
Review of the Weekly Wound Progress notes revealed no documentation that the Physician or the Responsible Party (RP) were notified about the new pressure wound on 7/9/2022.
Review of a Nurses' Progress Note dated 7/11/2022, written by Wound Care Nurse #2, revealed, .Notified by ADON [Assistant Director of Nursing] of residents wound to R [Right] buttocks .MD [Medical Doctor] made aware with new orders to cleanse R buttocks with dwc [wound cleanser], apply santyl, calcium alg [alginate] [absorbs wound drainage and provides a moist environment for wound healing], and secure with protective dressing daily and PRN (as needed) .Tx [Treatment] completed per MD orders. [Named Responsible Party] contacted and voiced understanding and stated she would tell Responsible Party . The Physician and RP were not notified until 7/11/2022.
Review of a Weekly Wound Progress Note written by Wound Care Nurse #2, dated 7/11/2022, revealed, .Site .R buttocks .Type .Pressure .Length .4.0 [centimeters] .Width .4.5 [centimeters] .Depth 0.1 [centimeters] .Stage .Unstageable .Necrotic tissue present .Acquired in Facility .MD notified .RP notified . The MD (for treatment orders) and the RP were not notified until 2 days after the wound was discovered.
Review of a Physicians' Order dated 7/11/2022, revealed .Wound Pressure .cleanse R buttock wound with dwc .apply santyl, calcium alg, and secure with protective dressing .every day shift . Review of the medical record revealed there was no other order for the Right buttock wound prior to 7/11/2022.
Review of a Late Entry Nurses' Progress Note, written by Wound Care Nurse #1, revealed the note was written on 7/15/2022 with an effective date of 7/9/2022 and documented, .Received report of incident that resident obtained wound to sacral region. Treatment started of Calcium Alginate with santyl [ointment that removes dead tissue from wounds] and dry protective dressing daily .
Review of a Weekly Wound Progress Note dated 8/17/2022, revealed .Site .R buttocks .Type .Pressure .Length .2.8 [centimeters] .Width .4.2 [centimeters] .Depth 0.5 [centimeters] .Stage .IV [4] .Granulation tissue present .Slough tissue present .Necrotic tissue present .
Observation in the resident's room on 8/17/2022 at 1:00 PM, revealed Wound Care Nurse #2 removed the dressing to Resident #42's right buttock to reveal a Stage 4 Pressure Ulcer approximately 3 centimeters long and 4 centimeters wide with a depth of 0.5 centimeter.
During a telephone interview on 8/19/2022 at 11:48 AM, LPN #5 confirmed she had taken care of Resident #42 on 7/7/2022, and she had no skin breakdown. She stated, .I would have shown it [skin breakdown] to the nurse .when I came back on the 8th [7/8/2022] she was already gone to the Covid Unit .
During an interview on 8/19/2022 at 12:01 PM, LPN #1 confirmed she had moved Resident #42 to the Covid Unit on 7/8/2022, and she had no skin breakdown.
During an interview on 8/19/2022 at 2:26 PM, CNA #1 confirmed she worked the 7:00 PM to 7:00 AM shift on 7/8/2022. She confirmed she could not remember the name of the CNA that relieved her, but after report they made rounds together. She stated, I went in .she [Resident #42] was slumped down in the bed .the air mattress motor was turned off. She was sunk in .the mattress had deflated down. I put my hand on the end of the bed to feel the mattress, and I felt the hard metal under the mattress where there was no air it was hard .I flipped it back on. I stayed and watched the mattress fully inflate .we turned her over and looked at her right side .where she was laying and the whole hip and leg was real red all the way down from laying so long. We positioned her and put a pillow between her legs, and it was time for shift to end, and I left . There was no documentation of the redness or that a nurse was notified of the redness in the medical record.
During a telephone interview on 8/19/2022 at 6:02 PM, Agency LPN #7 confirmed she assessed the wound and stated, It looked black, it felt like dead tissue, mushy, no drainage .
During an interview on 8/19/2022 at 6:18 PM, the Administrator confirmed Wound Care Nurse #1 had left before her shift was supposed to end on 8/19/2022 and was scheduled to work from 7:00 AM to 7:00 PM. Wound Care Nurse #1 was not available for interview in person or by telephone.
During a telephone interview on 8/19/2022 at 6:20 PM, Wound Care Nurse #2 stated, .That Monday [7/11/2022], I came in, I was notified by the ADON [Assistant Director of Nursing] of [Named Resident #42]'s wound. I got the order for wound care. She was asked if there was an order for the wound care on 7/9/2022. She stated, I don't see one in there. I would have gotten the order from [Named MD]. I usually get the order from them .
During an interview on 8/19/2022 at 6:51 PM, the Director of Nursing (DON) was asked when the treatment order was obtained for Resident #42's wound that was identified on 7/9/2022. She stated, Monday, 7/11/2022. She was asked when the order should have been obtained. She stated, Immediately .I did not find out until Monday [7/11/2022], we read it in the morning report in the notes .we saw [Named Agency LPN #7]'s notes, we started investigating. She was asked when she should have been notified about the wound. She stated, Immediately .
During an interview on 8/19/2022 at 7:38 PM, ADON #2 confirmed the treatment for Resident #42's right buttock wound was not ordered and the Physician was not notified of the wound until 7/11/2022.
The facility's failure to notify the nurse of skin condition changes and to notify the Physician and obtain orders for a newly identified pressure ulcer resulted in actual Harm when skin condition changes deteriorated and progressed to an Unstageable pressure ulcer.
SERIOUS
(G)
Actual Harm - a resident was hurt due to facility failures
Pressure Ulcer Prevention
(Tag F0686)
A resident was harmed · This affected 1 resident
**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on review of the National Pressure Ulcer Advisory Panel (NPUAP) Prevention and Treatment of Pressure Ulcers: Quick Referen...
Read full inspector narrative →
**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on review of the National Pressure Ulcer Advisory Panel (NPUAP) Prevention and Treatment of Pressure Ulcers: Quick Reference Guide, policy review, medical record review, observation, and interview, the facility failed to ensure changes in a resident's skin condition were identified, assessed, reported, a physician's order for treatment was obtained and treatments were provided before the skin condition changes deteriorated to an Unstageable Pressure Ulcer and failed to ensure a pressure ulcer was accurately assessed and identified before it became an unstageable pressure ulcer for 2 of 5 sampled residents (Resident #42 and #99) reviewed with in-house acquired pressure ulcers. The facility's failure to identify, assess, report, and provide treatment before newly identified skin changes and pressure ulcers deteriorated and progressed to Unstageable pressure ulcers resulted in actual Harm for Resident #42 and Resident #99.
The findings include:
Review of the National Pressure Ulcer Advisory Panel (NPUAP) Prevention and Treatment of Pressure Ulcers: Quick Reference Guide, dated 2019, revealed .Conduct a comprehensive skin and tissue assessment for all individuals at risk of pressure injuries: As soon as possible after admission/transfer to the healthcare service .As a part of every risk assessment .Periodically as indicated by the individual's degree of pressure injury risk Stage III [3]: Full thickness skin loss Full thickness loss. Subcutaneous fat may be visible but bone, tendon, or muscle are not exposed. Slough [dead tissue] may be present .May include undermining and tunneling .Category/Stage IV [4] : Full thickness tissue loss Full thickness tissue loss with exposed bone, tendon, or muscle. Slough or eschar [a thick crust of dead tissue] may be present .Unstageable: Depth unknown Full thickness tissue loss in which the base of the ulcer is covered by a slough (yellow, tan, gray, green, or brown) and or eschar (tan, brown, or black) in the wound bed .
Review of the facility's policy titled, .Skin Integrity Management System, dated 2/24/2021, revealed .Treatment for an identified area is documented on the Treatment Administration Record (TAR) .If a new pressure injury is noted, a Weekly Wound Progress .will be started. Notification of Physician and Responsible Party will be documented in the Progress Notes .Contact Physician for treatment recommendation approval .
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 this 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 .Treatment decisions will be based on .Characteristics of the wound .Pressure injury stage .Size .including shape, depth, and presence of tunneling and/or undermining .volume and characteristics of exudate .presence of pain .Presence of infection or need to address bacterial bioburden .condition of the tissue in the wound bed .condition of periwound skin .
Review of the medical record, revealed Resident #42 was admitted to the facility on [DATE] with diagnoses of Osteoporosis, Dementia, Sick Sinus Syndrome, and Peripheral Vascular Disease.
Review of a Nurse Practitioner Note dated 6/17/2022, revealed .no skin wound .
Review of the annual Minimum Data Set (MDS) assessment dated [DATE], revealed Resident #42 had severely impaired cognition, was totally dependent on staff for Activities of Daily Living (ADLs), was always incontinent of bladder and bowel, was at risk for pressure ulcers, had no unhealed pressure ulcers, and had a pressure relieving device for the bed.
Review of a quarterly Braden Scale dated 6/30/2022, revealed Resident #42 was at moderate risk for developing pressure ulcers.
Review of a Nurses' Progress Note dated 7/9/2022 at 5:55 PM, written by Agency Licensed Practical Nurse (LPN) #7, revealed .while completing rounds, CNA [Certified Nursing Assistant] discovered wound to right buttock. CNA noticed that bed air mattress was turned off. Notified wound care nurse .
Review of a Nurses' Progress Note dated 7/9/2022 at 7:00 PM, written by Agency LPN #7, revealed .Wound is 4 cm [centimeters] in length and 4.5 cm in width .
Review of a Late Entry Nurses' Progress Note, written by Wound Care Nurse #1, revealed the note was written on 7/15/2022 with an effective date of 7/9/2022 and documented, .Received report of incident that resident obtained wound to sacral region. Treatment started of Calcium Alginate with santyl [ointment that removes dead tissue from wounds] and dry protective dressing daily [the Physician was not notified of the wound and treatment was not started until 7/11/2022] .
Review of the Weekly Wound Progress Notes revealed no documented assessment of Resident #42's sacral wound on 7/9/2022 by Wound Care Nurse #1. There was no documentation that the Physician or the Responsible Party (RP) were notified about the new pressure wound on 7/9/2022.
Review of a Physicians' Order dated 7/11/2022, revealed .Wound Pressure .cleanse R [right] buttock wound with dwc .apply santyl, calcium alg, and secure with protective dressing .every day shift . Review of the medical record revealed there was no other order for the Right buttock wound prior to 7/11/2022.
Review of a Nurses' Progress Note dated 7/11/2022, written by Wound Care Nurse #2, revealed, .Notified by ADON [Assistant Director of Nursing] of residents wound to R buttocks .MD [Medical Doctor] made aware with new orders to cleanse R buttocks with dwc [wound cleanser], apply santyl, calcium alg [alginate] [absorbs wound drainage and provides a moist environment for wound healing], and secure with protective dressing daily and PRN (as needed) .Tx [Treatment] completed per MD orders. [Named Responsible Party] contacted and voiced understanding and stated she would tell Responsible Party .
Review of a Weekly Wound Progress Note written by Wound Care Nurse #2, dated 7/11/2022, revealed, .Site .R buttocks .Type .Pressure .Length .4.0 [centimeters] .Width .4.5 [centimeters] .Depth 0.1 [centimeters] .Stage .Unstageable .Necrotic tissue present .Acquired in Facility .MD notified .RP notified . The Physician and RP were not notified until 7/11/2022. This was 2 days after the wound was discovered.
Review of the 7/2022 Treatment Administration Record (TAR), revealed treatments were not documented as administered on 7/16/2022, 7/17/2022, or 7/22/2022.
Review of a Weekly Wound Progress Note dated 8/17/2022, revealed .Site .R buttocks .Type .Pressure .Length .2.8 [centimeters] .Width .4.2 [centimeters] .Depth 0.5 [centimeters] .Stage .IV [4] .Granulation tissue present .Slough tissue present .Necrotic tissue present .
Observation in the resident's room on 8/17/2022 at 1:00 PM, revealed Wound Care Nurse #2 removed the dressing to Resident #42's right buttock to reveal a Stage 4 Pressure Ulcer approximately 3 centimeters long and 4 centimeters wide with a depth of 0.5 centimeter.
During a telephone interview on 8/19/2022 at 11:48 AM, LPN #5 confirmed she had provided care for Resident #42 on 7/7/2022, and she had no skin breakdown. She stated, .I would have shown it [skin breakdown] to the nurse .when I came back on the 8th [7/8/2022] she was already gone to the COVID Unit .
During an interview on 8/19/2022 at 12:01 PM, LPN #1 confirmed she had moved Resident #42 to the COVID Unit on 7/8/2022, and she had no skin breakdown.
During an interview on 8/19/2022 at 2:26 PM, CNA #1 confirmed she worked the 7:00 PM to 7:00 AM shift on 7/8/2022. She confirmed she was doing 1 on 1 with a wandering resident in the COVID Unit. She stated, .the way his room was, you could sit in the doorway and watch him. I had to focus on him and was told to do one on one. I could not help with the patients. When [Named Agency LPN #8] was working 7-11 [7:00 PM to 11:00 PM] she was passing meds [medications] and checking the patients, she never stopped. At 11 [11:00 PM] [Named Agency LPN #9] came and we found out she was a nurse .so [Named Agency LPN #8] said you take one half of the hall and I'll take the other half, so [Named Agency LPN #9] ended up on the right side with [Named Resident #42]. I was able to watch from where I was sitting and could see the hallway. CNA #1 was asked if Agency LPN #9 checked on her patients through the night. She stated, She wasn't doing like she was supposed to . She stated Agency LPN #9 spent most of the night sitting in the room where the nurses chart and was not checking on her patients like she nurses were trained to do. She confirmed she could not remember the name of the CNA that relieved her, but after report they made rounds together. She stated, I went in .she [Resident #42] was slumped down in the bed .the air mattress motor was turned off. She was sunk in .the mattress had deflated down. I put my hand on the end of the bed to feel the mattress, and I felt the hard metal under the mattress where there was no air it was hard .I flipped it back on. I stayed and watched the mattress fully inflate .we turned her over and looked at her right side .where she was laying and the whole hip and leg was real red all the way down from laying so long. We positioned her and put a pillow between her legs, and it was time for shift to end, and I left . There was no documentation of the redness or that a nurse was notified of the redness in the medical record.
During a telephone interview on 8/19/2022 at 3:52 PM, CNA #2 confirmed she worked in the COVID Unit on the day shift on 7/8/2022 when Resident #42 came to the unit. She confirmed she checked on the resident and changed her. She confirmed she had no breakdown, and the mattress was inflated and working. She stated, I'm certain.
During a telephone interview on 8/19/2022 at 3:52 PM, Agency LPN #8 confirmed she had worked on the COVID Unit on 7/8/2022 on the 7:00 PM to 7:00 AM shift. She confirmed there were more than 20 patients on the unit that night, and she was the only staff member to provide care for all the residents. She confirmed there was a CNA, but she was doing 1 on 1 with another resident who was a wanderer, so she couldn't help her. She stated it was very difficult to administer medications, check and change residents, and don and doff personal protective equipment while providing care for over 20 residents. She stated, .another nurse came later in the shift .I took the left side, she took the right side . She was asked if the air mattress was on and inflated when she checked her. She stated, .I'm sure it was. I took her vital signs. I leaned on the bed . She stated, .I learned she had the wound the next day .I think they said her air mattress was off all night long .
During a telephone interview on 8/19/2022 at 5:04 PM, Agency LPN #7 confirmed she worked 7/9/2022 on the 7:00 AM to 7:00 PM shift in the COVID Unit. She stated, .CNA came to me later in the afternoon, don't remember what time, and told me she found a wound on [Named Resident #42]. She told me they had found the bed turned off .don't know when .
During a telephone interview on 8/19/2022 at 6:02 PM, Agency LPN #7 confirmed she assessed the wound and stated, It looked black, it felt like dead tissue, mushy, no drainage .I called [Named Wound Care Nurse #1]. She brought some stuff back .but didn't tell me what to do .she called me on the phone, she told me what to do, put that cream on it and covered it . She confirmed Wound Care Nurse #1 never entered the Covid unit to assess the wound on Resident #42.
During an interview on 8/19/2022 at 6:18 PM, the Administrator confirmed Wound Care Nurse #1 had left before her shift was scheduled to end on 8/19/2022. He confirmed they had been trying to reach her to find out what was going on, but she would not answer her phone. He confirmed she was scheduled to work from 7:00 AM to 7:00 PM. Wound Care Nurse #1 was not available for interview in person or by telephone.
During a telephone interview on 8/19/2022 at 6:20 PM, Wound Care Nurse #2 stated, .That Monday [7/11/2022], I came in, I was notified by the ADON [Assistant Director of Nursing] of [Named Resident #42]'s wound. I got the order for wound care. She was asked if there was an order for the wound care on 7/9/2022. She stated, I don't see one in there. I would have gotten the order from [Named MD]. I usually get the order from them. Every wound is different based on how it looks. She [Wound Care Nurse #1] should have come, assessed it, gotten an order, and dressed it .I don't see a wound assessment on that day . She confirmed Wound Care Nurse #1 should have started an investigation that day.
During an interview on 8/19/2022 at 6:51 PM, the Director of Nursing (DON) was asked when the treatment order was obtained for Resident #42's wound that was identified on 7/9/2022. She stated, Monday, 7/11/2022. She was asked when the order should have been obtained. She stated, Immediately. She was asked if Wound Care Nurse #1 should have assessed the wound. She stated, Yes, 100 percent. I did not find out until Monday, we read it in the morning report in the notes .we saw [Named Agency LPN #7]'s notes, we started investigating. She was asked if she knew the nurse on the COVID Unit was by herself providing care for 21 patients for 4 hours on the night shift of 7/8/2022. She stated, No, if I had known that I would have been up here. She was asked when she should have been notified about the wound. She stated, Immediately .would have started the investigation. She stated, .We didn't get to the root cause of how or who turned off the bed.
During an interview on 8/19/2022 at 7:38 PM, ADON #2 confirmed the treatment for Resident #42's right buttock wound was not ordered until 7/11/2022, and treatments were not documented as administered on 7/16/2022, 7/17/2022, and 7/22/2022.
Review of the medical record, revealed Resident #99 was admitted on [DATE] with diagnoses of Diabetes, Acute Respiratory Failure, End stage Renal Disease, Hypertension, and Dependence on Renal Dialysis.
Review of the quarterly MDS assessment dated [DATE], revealed Resident #99 was cognitively intact.
Review of Physician's Orders dated 8/1/2022, revealed .Wound pressure .cleanse right out [outer] knee wound with dwc/ns [wound cleanser/normal saline], apply santyl, silver alg [alginate], and secure with protective dressing every 1 hour as need [needed] AND every day shift .
Review of Skin/Wound Note dated 7/25/2022, revealed .Resident readmitted to [Named Facility] from [Named Hospital] Scratch marks observed to bil [bilateral] legs and upper arms, resident is dialysis patient . There was no documentation of a wound to the right outer ankle.
Review of Weekly Wound Progress Note date 8/1/2022, revealed .right out [outer] knee .Pressure .Length 2.8 .Width 2.6 .Depth 0.2 .Stage III [3] .Observed new wound this am [morning] to residents [resident's] right outer knee .tend [tends] to lay her right knee on its outer side .[Named Wound Care Company] to evaluate on Wednesday .
Review of Physician's Orders dated 8/1/2022, revealed .Wound pressure .cleanse right out [outer] knee wound with dwc/ns [wound cleanser/normal saline], apply santyl, silver alg [alginate], and secure with protective dressing every 1 hour as need [needed] AND every day shift .
Review of a (Named Wound Care Company) Note dated 8/3/2022, revealed the new wound to the right knee was not identified during the Wound Care Physician's visit.
Review of a (Named Wound Care Company) Note dated 8/10/2022, revealed .UNSTAGEABLE (DUE TO NECROSIS) OF THE RIGHT, LATERAL KNEE FULL THICKNESS .Remove Necrotic Tissue and Established Margins of Viable Tissue .
During an interview on 8/19/2022 at 2:40 PM, Wound Care Nurse #1 stated it [the pressure ulcer to the right lateral knee] looked like a large bunion on the side of her leg . The Wound Care Nurse was asked if she had completed a skin assessment and documented her findings. The Wound Care Nurse stated, .No I did not document anything .
Observation in the resident's room on 8/19/2022 at 3:10 PM, with the Wound Care Nurse #1, revealed an open area approximately a half dollar size to the left lateral side of the leg just below the knee with a small amount of slough in the wound bed. There was no dressing covering the wound.
During an interview on 8/19/2022 at 3:29 PM, Wound Care Nurse #2 confirmed the wound was identified on 8/1/2022 as a Stage 3 pressure ulcer. Wound Care Nurse #2 confirmed during a skin assessment on 8/1/2022, she staged the wound as a stage 3 that was open with granulation tissue and slough in the wound bed. Wound Care Nurse #2 confirmed the wound was not assessed by the Wound Care Physician until 8/10/2022 and he identified the wound as unstageable on that day.
During an interview on 8/19/2022 at 3:50 PM, the Wound Care Physician confirmed he did not see the wound on 8/3/2022. The Wound Care Physician confirmed when he saw the wound he could not tell the depth and staged it as an unstageable. The Wound Care Physician confirmed it was ideal to identify a wound at a stage 1 or stage 2 and stated, .you should see some indication early that something is going on .
During an interview on 8/19/2022 at 6:57 PM, the Regional Nurse Consultant confirmed a wound should be identified as early as possible at a stage 1 or 2.
The facility's failure to identify, assess, report, and provide treatment before newly identified skin changes and pressure ulcers deteriorated and progressed to Unstageable pressure ulcers resulted in actual Harm for Resident #42 and Resident #99.
CONCERN
(D)
Potential for Harm - no one hurt, but risky conditions existed
Deficiency F0657
(Tag F0657)
Could have caused harm · This affected 1 resident
**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on policy review, medical record review, observation, and interview, the facility failed to conduct Care Plan meetings and...
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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 conduct Care Plan meetings and include the Interdisciplinary Team (IDT) for 5 of 29 sampled residents (Resident #16, #32, #35, #94 and #99) reviewed for care planning.
The findings include:
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, consistent with 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, that includes, but is not limited to .attending physician .registered nurse with responsibility for the resident .member of the food and nutrition services staff .resident and the resident's representative .Other appropriate staff or professionals in disciplines .The RAI [Resident Assessment Instrument] coordinator .Activities Director/Staff .Social Services Director/Social Worker .Licensed therapist .
Review of the medical record, revealed Resident #16 was admitted to the facility on [DATE] with diagnoses of Multiple Sclerosis, Ileostomy, Chronic Kidney Disease, and Heart Failure.
Review of Resident #16's MDS assessment schedule revealed Resident #16 should have had a Care Plan meeting on 9/10/2021, 12/8/2021, 3/8/2022 and 6/6/2022.
Review of the medical record revealed there were no quarterly Care Plan meetings held for Resident #16 on 9/10/2021, 12/8/2021, and 3/8/2022.
Review of the quarterly Minimum Data Set (MDS) assessment dated [DATE], revealed Resident #16 was cognitively intact.
Review of the sign in sheet dated 6/13/2022, revealed the Licensed Practical Nurse, Social Worker, Dietary Manager, and the resident's spouse attended the Care Plan meeting on 6/13/2022. The facility failed to include the entire IDT team.
Review of the medical record, revealed Resident #32 was admitted to the facility on [DATE] with diagnoses of Heart Failure, Atrial Fibrillation, Restless Leg Syndrome, and Anxiety Disorder.
Review of the MDS schedule revealed Resident #32 should have had a Care Plan meeting on 9/21/2021, 12/16/2021, 3/16/2022, and 6/22/2022.
Review of the Progress Notes dated 9/21/2021 revealed a Care plan meeting was held with the Social Worker, the MDS Coordinator, and the son. The facility was unable to provide a sign in sheet for the meeting held on 9/21/2021. The facility failed to include the entire IDT team.
Review of the sign in sheet dated 4/14/2022, revealed the Social Worker, MDS Coordinator, and Resident #32 attended the meeting on 4/14/2022. The facility failed to include the entire IDT team.
Review of the annual MDS assessment dated [DATE], revealed Resident #32 was cognitively intact.
Review of the medical record revealed there were no quarterly Care Plan meetings held on 12/16/2021, 3/16/2022, and 6/22/2022.
Review of the medical record, revealed Resident #35 was admitted to the facility on [DATE] with diagnoses of Paraplegia, Anxiety Disorder, Peripheral Vascular Disease, and Chronic Obstructive Pulmonary Disease.
Review of the MDS schedule revealed Resident #35 should have had a Care Plan meeting on 11/26/2021, 2/21/2022, 3/15/2022 with a significant change, and 6/23/2022.
Review of the Progress Notes dated 11/23/2021, revealed the facility had a Care Plan meeting. The facility failed to provide a sign in sheet for the scheduled meeting on 11/23/2021.
Review of the medical record, revealed there were no quarterly Care Plan meetings held on 2/21/2022 and 3/15/2022.
Review of the sign in sheet for 6/10/2022, revealed the Registered Nurse, Dietary Manager, Social Worker, and the sister attended the meeting. The facility failed to include Resident #35 in the meeting.
Review of the quarterly MDS assessment dated [DATE], revealed Resident #35 was cognitively intact.
During an interview on 8/18/2022 at 9:50 AM, the Social Worker #1 was asked if a cognitively intact resident should be included in the Care Plan meeting? She stated, Yes.
Review of medical record, revealed Resident #94 was admitted to the facility on [DATE] with diagnoses of Hypertension, Dementia, Atrial Fibrillation, and Depression.
Review of the sign in sheets dated 11/23/2021, revealed the Licensed Practical Nurse, Social Worker, Director of Therapy and Resident #94 attended the Care Plan meeting. The facility failed to include the entire IDT team.
Review of the sign in sheets dated 2/15/2022, revealed the MDS Coordinator, 2 Social Workers, and the granddaughter attended the Care Plan meeting. The facility failed to include the entire IDT team.
Review of the sign in sheets dated 7/12/2022, revealed the Dietary Manager, Nurse Manager, Social Worker, granddaughter, and Resident #94 attended the Care Plan meeting. The facility failed to include the entire IDT team.
Review of the quarterly MDS assessment dated [DATE], revealed Resident #94 was cognitively intact.
Review of the medical record, revealed Resident #99 was admitted on [DATE] with a diagnoses of Diabetes, Acute Respiratory Failure, End stage Renal Disease, Hypertension, and Dependence on Renal Dialysis.
Review of the Progress Note dated 11/17/2021 revealed there was a Care Plan Meeting held with the IDT and Resident #99. There was no sign in sheet for the meeting held on 11/17/2021.
Review of the sign in sheet dated 4/22/2022, revealed the Dietary Manager, Social Worker, the MDS Coordinator, and the daughter attended the meeting held on 4/22/2022. The facility failed to include the entire IDT team.
Review of the quarterly MDS assessment dated [DATE], revealed Resident #99 was cognitively intact.
Review of the sign in sheet dated 7/26/2022, revealed the Therapist, Social Worker, Dietary Manager, MDS Coordinator, and the Responsible Party (RP) attended the meeting held on 7/26/2022. There was no documentation Resident #99 was invited to attend the meeting.
During an interview on 8/17/2022 at 3:14 PM, Social Worker #1 confirmed the IDT team consisted of someone from nursing, therapy, activity, dietary, and social services. The Social Worker confirmed the meetings should be held quarterly after completion of the MDS. The Social Worker confirmed Resident #32 should have had the Care Plan meetings quarterly. The Social Worker confirmed the facility was unable to provide a sign in sheet for each Care Plan meeting.
During an interview 8/17/2022 at 3:23 PM, Social Worker #1 confirmed Resident #99 had a Care Plan meeting on 11/17/2021, 4/22/2022, and 7/26/2022. Social Worker #1 confirmed she was unable to provide a sign in sheet for 11/17/2021 with the entire IDT team and the resident. The Social Worker #1 confirmed on 4/22/2022, the sign in sheet contained the Dietary Manager, Social Worker, MDS Coordinator, and the daughter. Nursing, Therapy, and the resident were not involved in the meeting. Social Worker #1 confirmed on 7/26/2022, the sign in sheet contained the Physical Therapy Assistant, Social Worker, Dietary Manager, MDS Coordinator, and the daughter. Nursing and the resident were not present.
During an interview on 8/19/2022 at 7:14 PM, the Regional Nurse Consultant confirmed there should be a sign in roster with all the IDT members present at each Care Plan meeting. The Regional Nurse Consultant confirmed the Care Plan meetings should be held quarterly.
CONCERN
(D)
Potential for Harm - no one hurt, but risky conditions existed
Deficiency F0679
(Tag F0679)
Could have caused harm · This affected 1 resident
**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on policy review, medical record review, and interview, the facility failed to provide an ongoing program of activities de...
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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 provide an ongoing program of activities designed to meet the interests, physical, mental, and psychosocial well-being for 1 of 1 sampled resident (Resident #99) reviewed for activities.
The findings include:
Review of the facility's undated policy titled, .Activities, revealed .It is the policy of this facility to provide an ongoing program to support residents in their choice of activities based on their comprehensive assessment, care plan, and preferences. Facility-sponsored group, individual, and independent activities will be designed to meet the interests of each resident, as well as support their physical, mental, and psychosocial well-being. Activities will encourage both independence and interaction within the community .Activities may be conducted in different ways .One-to-One Programs .
Review of the medical record, revealed Resident #99 was admitted to the facility on [DATE] and readmitted on [DATE] with diagnoses of Diabetes, Acute Respiratory Failure, End stage Renal Disease, Hypertension, and Dependence on Renal Dialysis.
Review of the Care Plan dated 12/3/2018, revealed .Resident will be encouraged to attend activities .Resident will be encouraged to engage in self-directed activities .Assist resident if needed to get to activity .invite to socials, special events, current events, music, spiritual groups .Remind resident before activities start .
Review of the quarterly Minimum Data Set (MDS) assessment dated [DATE], revealed Resident #99 was cognitively intact.
Review of the medical record, revealed there was no documentation Resident #99 had been provided or offered activities.
During an interview on 8/17/2022 at 11:05 AM, the Activity Director confirmed there was no documentation Resident #99 had been provided in-room activities. The Activity Director was asked if he should have provided in-room activities for residents who were bed bound. The Activity Director stated, .that is the best way to reach everyone in the facility .
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, observation, and interview, the facility failed to ensure the environment was fre...
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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 the environment was free of accident hazards when 1 of 3 sampled residents (Resident #35) reviewed for accident hazards was observed smoking without wearing a smoking apron.
The findings include:
Review of the facility's undated policy titled, .Resident Smoking, revealed, .This facility provides a safe and healthy environment for residents .including safety as related to smoking .Residents who smoke will be further assessed, using the Smoking Assessment, to determine whether or not supervision is required for smoking, or if resident is safe to smoke at all .All safe smoking measures will be documented on each resident's care plan and communicated to all staff .who will be responsible for supervising residents while smoking. Supervision will be provided as indicated on each resident's care plan .
Review of the medical record, revealed Resident #35 was admitted to the facility on [DATE] with diagnoses of Paraplegia, Chronic Obstructive Pulmonary Disease, Anxiety, and Peripheral Vascular Disease.
Review of the Care Plan revised on 5/30/2021, revealed .The resident is a smoker .will not suffer injury from unsafe smoking practices .The resident requires SUPERVISION while smoking .
Review of the quarterly Minimum Data Set (MDS) dated [DATE], revealed Resident #35 had intact cognition.
Review of the Smoking Assessments dated 12/28/2021 and 6/14/2022 revealed Resident #35 smoked, required supervision, and needed a smoking apron.
Observation on the Smoking Patio on 8/15/2022 at 2:30 PM, on 8/16/2022 at 2:40 PM, and on 8/17/2022 at 9:40 AM, revealed Resident #35 seated in his electric wheelchair, smoking a cigarette without wearing a smoking apron.
During an interview on 8/19/2022 at 8:18 PM, the Administrator was asked if a resident who was assessed to wear a smoking apron should have the apron on at all times when they are smoking. He stated, Yes .
CONCERN
(D)
Potential for Harm - no one hurt, but risky conditions existed
Respiratory Care
(Tag F0695)
Could have caused harm · This affected 1 resident
**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on policy review, medical record review, observation, and interview, the facility failed to obtain and follow Physician Or...
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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 obtain and follow Physician Orders for oxygen for 2 of 4 sampled residents (Resident #65 and #66) reviewed for respiratory care.
The findings include:
Review of the facility's undated policy titled, .Provider Orders, revealed .This facility shall use uniform guidelines for the ordering of medications .Medication should be administered only upon the signed order of a person lawfully authorized to prescribe .Each medication order should be documented with the date, time, and signature of the person receiving the order .The order should be recorded on the physician order sheet, and the Medication Administration Record (MAR) .
Review of the facility's undated policy titled, .Oxygen Administration, revealed, .Oxygen is administered under orders of a physician .
Review of the medical record, revealed Resident #65 was admitted to the facility on [DATE] with diagnoses of Chronic Kidney Disease, Heart Failure, Chronic Obstructive Pulmonary Disease, Aphasia, Dysphagia, Cerebral Infarction, Hemiplegia, and Hemiparesis.
Review of quarterly Minimum Data Set (MDS) assessment dated [DATE], revealed Resident #65 had moderately impaired cognition, experienced shortness of breath or trouble breathing when lying flat, and received Oxygen.
Review of a Physicians' Order dated 6/6/2022, revealed, .Oxygen at 2L [Liters] BNC [Binasal Cannula] prn [as needed] to keep sat [Oxygen saturation] greater than 90% [percent] every day and night shift .
Observation in the resident's room on 8/15/2022 at 9:15 AM, 2:29 PM, and 4:05 PM, on 8/16/2022 at 8:35 AM and 9:54 AM, on 8/17/2022 at 11:08 AM and 3:12 PM, and on 8/18/2022 at 8:28 AM, revealed Resident #65 was receiving oxygen through a binasal cannula, and the rate on the oxygen concentrator was set at 3 Liters per minute.
During an interview on 8/19/2022 at 8:43 AM, in the resident's room, Licensed Practical Nurse (LPN) #1 looked at Resident #65's Oxygen concentrator and confirmed the rate was 3 Liters per minute.
During an interview on 8/19/2022 at 7:12 PM, the Regional Nurse Consultant was asked if the nursing staff should follow the provider's order when administering oxygen to a resident. She stated, Yes.
Review of the medical record, revealed Resident #66 was admitted to the facility on [DATE] with diagnoses of Heart Failure, Chronic Obstructive Pulmonary Disease, Diabetes, Chronic Kidney Disease, Alzheimer's Disease, Dementia, and Dysphagia.
Review of the significant change MDS dated [DATE], revealed Resident #66 had severe cognitive impairment, experienced shortness of breath or trouble breathing when lying flat, and received Oxygen.
Review of the Physician Orders revealed there was no order for oxygen administration.
Observation in the resident's room on 8/15/2022 at 8:57 AM, on 8/16/2022 at 8:46 AM, 9:55 AM, and 5:12 PM, on 8/17/2022 at 8:09 AM, 11:02 AM, 1:03 PM, and 3:30 PM, and on 8/19/2022 at 8:31 AM, revealed Resident #66 was receiving oxygen through a binasal cannula, and the rate on the oxygen concentrator was set at 2.5 Liters per minute.
During an interview on 8/19/2022 at 8:47 AM, in the resident's room, LPN #1 confirmed Resident #66 was receiving oxygen at 2.5 Liters per minute.
During an interview on 8/19/2022 at 7:12 PM, the Regional Nurse Consultant was asked if there should be an order for administering oxygen to a resident. She stated, Yes.
CONCERN
(D)
Potential for Harm - no one hurt, but risky conditions existed
Deficiency F0725
(Tag F0725)
Could have caused harm · This affected 1 resident
**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on medical record review and interview, the facility failed to ensure sufficient staffing for 1 of 5 sampled residents (Re...
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**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on medical record review and interview, the facility failed to ensure sufficient staffing for 1 of 5 sampled residents (Resident #42) reviewed for Pressure Ulcers.
The findings include:
Review of the medical record, revealed Resident #42 was admitted to the facility on [DATE] with diagnoses of Osteoporosis, Dementia, Sick Sinus Syndrome, and Peripheral Vascular Disease.
Review of a Nurse Practitioner Note dated 6/17/2022, revealed .no skin wound .
Review of the annual Minimum Data Set (MDS) assessment dated [DATE], revealed Resident #42 had severely impaired cognition, was totally dependent on staff for Activities of Daily Living (ADLs), was always incontinent of bladder and bowel, was at risk for pressure ulcers, had no unhealed pressure ulcers, and had a pressure relieving device for the bed.
Review of a quarterly Braden Scale dated 6/30/2022, revealed Resident #42 was at moderate risk for developing pressure ulcers.
Review of a Nurses' Progress Note dated 7/9/2022 at 5:55 PM, written by Agency Licensed Practical Nurse (LPN) #7, revealed .while completing rounds, CNA [Certified Nursing Assistant] discovered wound to right buttock. CNA noticed that bed air mattress was turned off. Notified wound care nurse .
Review of a Nurses' Progress Note dated 7/9/2022 at 7:00 PM, written by Agency LPN #7, revealed .Wound is 4 cm [centimeters] in length and 4.5 cm in width .
Review of a Late Entry Nurses' Progress Note, written by Wound Care Nurse #1, revealed the note was written on 7/15/2022 with an effective date of 7/9/2022 and documented, .Received report of incident that resident obtained wound to sacral region .
Review of a Physicians' Order dated 7/11/2022, revealed .Wound Pressure .cleanse R [right] buttock wound with dwc [wound cleanser] .apply santyl, calcium alg [alginate], and secure with protective dressing .every day shift .
During a telephone interview on 8/19/2022 at 11:48 AM, LPN #5 confirmed she had provided care for Resident #42 on 7/7/2022, and she had no skin breakdown. She stated, .I would have shown it [skin breakdown] to the nurse .when I came back on the 8th [7/8/2022] she was already gone to the COVID Unit .
During an interview on 8/19/2022 at 12:01 PM, LPN #1 confirmed she had moved Resident #42 to the COVID Unit on 7/8/2022, and she had no skin breakdown.
During an interview on 8/19/2022 at 2:26 PM, CNA #1 confirmed she worked the 7:00 PM to 7:00 AM shift on 7/8/2022. She confirmed she was doing 1 on 1 with a wandering resident in the COVID Unit. She stated, .the way his room was, you could sit in the doorway and watch him. I had to focus on him and was told to do one on one. I could not help with the patients. When [Named Agency LPN #8] was working 7-11 [7:00 PM to 11:00 PM] she was passing meds [medications] and checking the patients, she never stopped. At 11 [11:00 PM] [Named Agency LPN #9] came and we found out she was a nurse .so [Named Agency LPN #8] said you take one half of the hall and I'll take the other half, so [Named Agency LPN #9] ended up on the right side with [Named Resident #42]. I was able to watch from where I was sitting and could see the hallway. CNA #1 was asked if Agency LPN #9 checked on her patients through the night. She stated, She wasn't doing like she was supposed to . She stated Agency LPN #9 spent most of the night sitting in the room where the nurses chart and was not checking on her patients like she nurses were trained to do. She confirmed she could not remember the name of the CNA that relieved her, but after report they made rounds together. She stated, I went in .she [Resident #42] was slumped down in the bed .the air mattress motor was turned off. She was sunk in .the mattress had deflated down. I put my hand on the end of the bed to feel the mattress, and I felt the hard metal under the mattress where there was no air it was hard .I flipped it back on. I stayed and watched the mattress fully inflate .we turned her over and looked at her right side .where she was laying and the whole hip and leg was real red all the way down from laying so long. We positioned her and put a pillow between her legs, and it was time for shift to end, and I left .
During a telephone interview on 8/19/2022 at 3:52 PM, Agency LPN #8 confirmed she had worked on the COVID Unit on 7/8/2022 on the 7:00 PM to 7:00 AM shift. She confirmed there were more than 20 patients on the unit that night, and she was the only staff member to provide care for all the residents. She confirmed there was a CNA, but she was doing 1 on 1 with another resident who was a wanderer, so she couldn't help her. She stated it was very difficult to administer medications, check and change residents, and don and doff personal protective equipment while providing care for over 20 residents. She stated, .another nurse came later in the shift .I took the left side, she took the right side .
During a telephone interview on 8/19/2022 at 5:04 PM, Agency LPN #7 confirmed she worked 7/9/2022 on the 7:00 AM to 7:00 PM shift in the COVID Unit. She stated, .CNA came to me later in the afternoon, don't remember what time, and told me she found a wound on [Named Resident #42]. She told me they had found the bed turned off .don't know when .
During an interview on 8/19/2022 at 6:51 PM, the Director of Nursing (DON) was asked if she knew the nurse on the COVID Unit was by herself providing care for 21 patients for 4 hours on the night shift of 7/8/2022. She stated, No, if I had known that I would have been up here.
CONCERN
(E)
Potential for Harm - no one hurt, but risky conditions existed
Resident Rights
(Tag F0550)
Could have caused harm · This affected multiple residents
**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on policy review, observation, and interview, the facility failed to maintain or enhance residents' dignity and respect wh...
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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 maintain or enhance residents' dignity and respect when staff failed to provide privacy for 3 of 7 sampled residents (Resident #54, #57 and #91) reviewed during medication administration and when an indwelling urinary catheter was uncovered and visible to hallway traffic for 1 of 2 sampled residents (Resident #99) reviewed for urinary catheters.
The findings include:
Review of the facility's undated policy titled, .Medication Administration, revealed .Provide privacy .
Review of the facility's undated policy titled, .Resident Rights, revealed .The resident has a right to be treated with respect and dignity .
Observation in the resident's room on 8/15/2022 at 11:37 AM, revealed Licensed Practical Nurse (LPN) #1 exposed Resident #91's abdomen during insulin administration, the door to the room was open and the privacy curtain was not pulled. LPN #1 did not provide privacy for Resident #91 during insulin administration. The resident's abdomen would be visible to anyone walking in the hallway.
Observation in the resident's room on 8/16/2022 at 4:05 PM, revealed LPN #1 did not pull the privacy curtain for Resident #54 and administered a medication patch to Resident #54's chest, exposing the right upper chest. LPN #1 did not provide privacy for Resident #54 during administration of a medicated patch. The resident's chest would be visible to anyone walking in the hallway.
Observation in the resident's room on 8/17/2022 at 8:40 AM, revealed LPN #2 did not pull the privacy curtain and exposed Resident #57's lower back when applying a medication patch.
The resident's lower back would be visible to anyone walking in the hallway.
During an interview on 8/19/2022 at 7:12 PM, the Regional Nurse Consultant was asked if a nurse should provide privacy when exposing a resident's body to administer an injection or to apply a medication patch. The Regional Nurse Consultant stated, Yes.
Review of the medical record, revealed Resident #99 was admitted to the facility on [DATE] and readmitted on [DATE] with diagnoses of Diabetes, Acute Respiratory Failure, End Stage Renal Disease, Hypertension, and Dependence on Renal Dialysis.
Review of the Physicians Orders dated 7/22/2022, revealed .catheter .
Observation in the resident's room on 8/15/2022 at 9:48 AM, revealed Resident #99 had an indwelling urinary catheter bag that was on the left side of the bed, uncovered, facing the door and visible from the hallway with approximately 20 milliliters of amber urine in the catheter bag.
Observation in the resident's room on 8/16/2022 at 9:43 AM at 2:06 PM, revealed Resident #99's indwelling urinary catheter bag was on the left side of the bed, uncovered, facing the door and visible from the hallway with urine visible in the bag.
During an interview on 8/19/2022 at 7:14 PM, the Regional Nurse Consultant confirmed the indwelling catheter bag should be covered.
CONCERN
(E)
Potential for Harm - no one hurt, but risky conditions existed
Deficiency F0761
(Tag F0761)
Could have caused harm · This affected multiple residents
**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 medications were proper...
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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 medications were properly stored and secured when medications were found unattended and unsecured in 2 of 84 resident rooms (Resident #2 and #28's room), when 1 of 7 medication carts (100 Hall Extended Medication Cart) was left unlocked and unattended, when opened, unlabeled and expired medications were found in 4 of 7 medication carts (100 Extended Hall Medication Cart, 200 Hall Medication Cart, 300 Hall Medication Cart, and 400 Hall Medication Cart), and when a medication was hanging out of the medication cart and was unsecured on 1 of 7 medication carts (100 Extended Hall Medication Cart).
The findings include:
Review of the facility's undated policy titled, .Medication Storage, revealed, .It is the policy of this facility to ensure all medications housed on our premises will be stored in the pharmacy and/or medication rooms according to the manufacturer's recommendations and sufficient to ensure proper sanitation, temperature, light, ventilation, moisture control, segregation, and security .All drugs and biologicals will be stored in locked compartments .medication carts, cabinets, drawers, refrigerators, medication rooms .under proper temperature controls .Only authorized personnel will have access to the keys to locked compartments .During a medication pass, medications must be under the direct observation of the person administering medications or locked in the medication storage area/cart .The pharmacy and all medication rooms are routinely inspected by the consultant pharmacist for discontinued, outdated, defective, or deteriorated medications with worn, illegible, or missing labels .
Review of the medical record, revealed Resident #2 was admitted to the facility on [DATE] with diagnoses of Cerebral Infarction, Hemiplegia, Hemiparesis, End Stage Renal Disease, and Dialysis Dependence.
Review of the quarterly Minimum Data Set (MDS) dated [DATE], revealed Resident #2 was cognitively intact.
Observation in the resident's room on 8/15/2022 at 9:12 AM, revealed Resident #2 had a medication cup containing 6 pills on the over bed table unattended.
Review of the medical record, revealed Resident #28 was admitted to the facility on [DATE] with diagnoses of Diabetes, Heart Disease, Cognitive Communication Deficit, and Rheumatoid Arthritis.
Review of the admission MDS dated [DATE], revealed Resident #28 had moderately impaired cognition.
Observation in the resident's room on 8/15/2022 at 9:41 AM, revealed Resident #28 had a medication cup containing 10 pills on the over bed table unattended.
During an interview on 8/15/2022 at 9:39 AM, Agency Licensed Practical Nurse (LPN) #1 confirmed she should not leave medication at the bedside.
Observation in the 100 Extended Hall on 8/15/2022 at 2:14 PM, revealed the 100 Hall Extended Medication Cart was open, unlocked, and unattended.
Observation in the 100 Extended Hall on 8/15/22 at 2:15 PM, with Agency LPN #1, revealed the following was inside the 100 Extended Hall Medication Cart:
a. One vial of lidocaine, opened and undated
b. One Lantus flex pen with an open date of 5/23/2022, and an expiration date of 6/23/2022
During an interview on 8/15/2022 at 2:15 PM, Agency Licensed Practical Nurse (LPN) #1 stated, .no, it [medication cart] should not be unlocked .I had to go down the hall to check on another resident . Agency LPN #1 confirmed there should not be expired medication, opened, and undated medication in the medication cart.
Observation at the 400 Hall Medication Cart on 8/16/2022 at 4:34 PM, revealed a bottle of Vitamin E with an expiration date of 6/2022, a bottle of Calcium 600 milligrams (mg) plus Vitamin D 5 mg with an expiration date of 6/2022, and a bottle of Aspirin 81 mg with no legible expiration date.
During an interview on 8/16/2022 at 4:34 PM, LPN #3 confirmed there should not be expired medications or medications with no legible expiration date inside the medication cart.
Observation at the 100 Extended Hall Medication Cart on 8/16/2022 at 5:37 PM, revealed a tablet in a plastic sleeve, labeled as Pravastatin 20 mg hanging out of the medication cart, and the medication cart was unattended. Resident #101 was in a wheelchair, propelling himself in proximity to the medication cart.
During an interview on 8/16/2022 at 5:40 PM, the Registered Nurse (RN) Supervisor confirmed the pill should not be hanging out of the drawer and stated, it must have got [gotten] hung .
Observation at the 200 Hall Medication Cart on 8/17/2022 at 4:57 PM, revealed the following:
a. four unlabeled 30 milliliter (ml) medication cups containing multiple, unidentified tablets in the 2nd drawer of the medication cart
b. five unlabeled 30 ml medication cups containing multiple, unidentified tablets in the 4th drawer of the medication cart
c. an unlabeled 30 ml medication cup filled with unidentified white tablets in the left top drawer of the medication cart
During an interview on 8/17/2022 at 5:00 PM, Agency LPN #10 was asked if it she should have opened, unlabeled, undated medication cups filled with unknown tablets inside the medication cart. She stated, No. Agency LPN #10 was asked about the cup of white tablets. She stated, .looks like all the same pills, but those aren't mine .don't know where these came from .
Observation at the 300 Hall Medication Cart on 8/17/2022 at 5:05 PM, revealed an opened vial of Humulin R (Regular) insulin with no opened date.
During an interview on 8/17/2022 at 5:07 PM, Agency LPN #11 confirmed all opened medications should be labeled with an open date and the unlabeled insulin should be discarded.
During an interview on 8/17/2022 at 5:30 PM, the Director of Nursing (DON) was asked if nursing staff should have numerous unlabeled 30 ml medication cups filled with multiple various tablets inside the medication cart. The DON stated, No.
During an interview on 8/17/2022 at 5:40 PM, at the 200 Hall Medication Cart, LPN #10 was asked where the cup of white tablets were. LPN #10 stated, I threw them in the trash. The DON was asked if medications should be thrown in the regular trash bin. The DON stated, No.
During an interview on 8/19/2022 at 7:15 PM, the Regional Nurse Consultant was asked if there should be opened, expired, and unlabeled medications inside the medication carts. She stated, No. The Regional Nurse Consultant was asked if nursing staff should have numerous unlabeled 30 ml medication cups filled with multiple various tablets inside the medication cart. The Regional Nurse Consultant stated, No.
CONCERN
(F)
Potential for Harm - no one hurt, but risky conditions existed
Infection Control
(Tag F0880)
Could have caused harm · This affected most or all residents
Based on the Centers for Disease Control and Prevention (CDC) guidelines, policy review, review of Employee Screening logs, employee time sheets, observation, and interview, the facility failed to ens...
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Based on the Centers for Disease Control and Prevention (CDC) guidelines, policy review, review of Employee Screening logs, employee time sheets, observation, and interview, the facility failed to ensure practices to maintain the spread of infection were maintained when 11 of 144 staff members (Agency Licensed Practical Nurse (LPN) #2, #3, #4, #5 and #6, Certified Nursing Assistant (CNA) #1, #3, and #4, Agency CNA #1, #2, and #3) failed to complete screening for the prevention and detection of COVID-19 prior to working on 3 of 3 days (8/12/2022, 8/13/2022, and 8/14/2022) reviewed, when 2 of 5 nurses (Agency LPN #1 and LPN #2) failed to discard a lancet in the sharps container and failed to clean the inhaler mouth piece after use, and when 1 of 1 CNA (Restorative CNA #1) failed to clean the reusable equipment (resident lift) after use. This had the potential to affect the 111 residents residing in the facility.
The findings include:
Review of the CDC document titled, Interim Infection Prevention and Control Recommendations for Healthcare Personnel During the Coronavirus Disease 2019 (COVID-19) Pandemic, updated 2/2/2022, revealed .Recommended routine infection prevention and control (IPC) practices during the COVID-19 pandemic .Establish a process to identify anyone entering the facility, regardless of their vaccination status .options could include (but are not limited to) : individual screening on arrival at the facility .
Review of the facility's policy titled, Sign-In Kiosks, dated 2/1/2022, revealed .In an ongoing response to the current coronavirus (COVID-19) pandemic, this community has implemented the use of the Sign-in Kiosks to perform symptom screenings of staff .upon entry into the building .staff sign-in kiosk to record the body temperature of all those entering the facility and ask COVID-19 related screening questions before any person is permitted to enter the community .
Review of the facility's undated policy titled, Medication Administration, revealed Medications are administered .in a manner to prevent contamination or infection .Metered dose inhalers .follow manufacturer's product information for administration instructions .
Review of the facility's undated policy titled, Administration of Injections, revealed .Dispose of sharps in puncture-resistant containers .
Review of the facility's undated policy titled, Cleaning and Disinfection of Resident-Care Equipment, revealed .Resident-care equipment can be source of indirect transmission of pathogens. Reusable resident-care equipment will be cleaned and disinfected in accordance with current CDC recommendations in order to break the chain of infection .Each user is responsible for routine cleaning and disinfection of multi-resident items after each use, particularly before use for another resident .
Random observation on 8/15/2022 at 10:15 AM, revealed a sign posted at the front entrance requiring all staff and visitors to sign in at the Kiosk.
Review of the Employee Screening logs and employee time sheets revealed the following employees worked on the following days and failed to screen for signs and symptoms of COVID-19:
a. 8/12/2022- Agency LPN #3 and #6, CNA #1 and #3.
b. 8/13/2022- Agency LPN #5, and #6, CNA #4, and Agency CNA #3.
c. 8/14/2022- Agency LPN #2 and #4, CNA #3, Agency CNA #1 and #2.
During an interview on 8/19/2022 at 5:06 PM, Assistant Director of Nursing (ADON) #1 reviewed the employee schedules, screening logs, and time sheets for 8/12/2022, 8/13/2022 and 8/14/2022, and confirmed all staff should screen in before entering the patient care area and confirmed these 11 staff members did not screen.
During an interview on 8/19/2022 at 7:07 PM, the Administrator and Regional Nurse Consultant confirmed all staff should screen for COVID-19 prior to working.
Observation in the resident's room on 8/15/2022 at 11:38 AM, revealed Agency LPN #1 entered Resident #91's room, donned her gloves, checked the resident's blood glucose, put the lancet and strip in her gloves, and placed the gloves into the trash can in the resident's room.
During an interview on 8/15/2022 at 11:40 AM, Agency LPN #1 confirmed she placed the lancet in her gloves and then put them in the trash can.
During an interview on 8/19/2022 at 7:12 PM, the Regional Nurse Consultant confirmed that, after using a lancet for glucose check, the lancet should go into a sharps container and should not be rolled up in the gloves and placed in the trash bin.
Observation in the resident's room on 8/17/2022 at 8:52 AM, LPN #2 entered Resident #71's room, administered the inhaler medication to the resident, and failed to clean the mouth piece after the administration of the inhaler medication. LPN #2 then placed the uncleaned inhaler medication into the medication cart.
During an interview on 8/19/2022 at 7:14 PM, the Regional Nurse Consultant confirmed nursing staff should clean the mouth piece of an inhaler after each use.
Observation in the resident's room on 8/17/2022 at 12:57 PM, revealed Restorative CNA #1 weighed Resident #7 using the lift. She then exited the room with the lift and placed the lift outside in the hallway next to Resident #64's room. Restorative CNA #1 failed to clean the lift after use.
Observation in the resident's room on 8/17/2022 at 1:24 PM, revealed Restorative CNA #1 entered Resident #64's room with the lift without cleaning it. She exited Resident #64's room and placed the lift at the nursing station and failed to clean the lift after use.
During an interview on 8/17/2022 at 1:24 PM, Restorative CNA #1 confirmed that she did not clean the equipment after each resident use. She stated the equipment is cleaned at the end of the shift.
During an interview on 8/19/2022 at 7:14 PM, the Regional Nurse Consultant confirmed the reusable equipment should be cleaned after each use.
Oct 2019
7 deficiencies
CONCERN
(D)
Potential for Harm - no one hurt, but risky conditions existed
Safe Environment
(Tag F0584)
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 the environment was clean, comfortable, and sa...
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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 the environment was clean, comfortable, and sanitary when overbed tables were not clean, a nasal cannula storage bag was not clean and was undated, suction machines were uncovered, a used lancet and a contaminated alcohol pad were observed on the floor, and a fan was covered with dust in 6 of 85 (room [ROOM NUMBER], #200, #401, #209, #130 and #114) resident rooms.
The findings include:
1. Review of the facility's .Clean Schedule revealed over bed tables should be cleaned every day, Monday through Sunday.
The facility's .Equipment Cleaning, Disinfecting and Maintenance policy dated 9/2017 documented, .All nursing staff are accountable with Environmental Service Department for ensuring and monitoring proper and routing [routine] cleaning/disinfecting of equipment for resident use .The following equipment is cleaned/disinfected after each resident use and when visibly soiled .O2 [Oxygen] concentrators .between residents and daily while in use .
The facility's Waste Disposal policy dated 9/11/90 and revised 1/30/07, documented, .Sharps and needles which are considered to be contaminated will be placed directly in an approved 'sharps container' immediately after use .
2. Observations in room [ROOM NUMBER] on 10/14/19 at 7:45 AM, 11:01 AM, and 12:32 PM, and on 10/15/19 at 7:30 AM, and 4:00 PM, revealed 2 overbed tables with dried black and brown stains, dirt, and debris covering the bottom of the tables.
Interview with the Housekeeping Supervisor on 10/17/19 at 11:22 PM, in room [ROOM NUMBER], the Housekeeping Supervisor confirmed the overbed tables were not clean.
Observations in room [ROOM NUMBER]B on 10/14/19 at 8:08 AM and 10:36 AM, and on 10/15/19 at 7:35 AM and 12:40 PM, revealed a nasal cannula storage bag dated 4/16/18 with a brown substance smeared on the outside.
Interview with the Director of Nursing (DON) on 10/16/19 at 8:20 AM, in room [ROOM NUMBER]B, the DON confirmed the nasal cannula storage bag was dated 4/16/18 and was dirty.
Observations in room [ROOM NUMBER]B on 10/14/19 at 9:09 AM and 2:10 PM, on 10/15/19 at 8:30 AM, and 4:30 PM, and on 10/16/19 at 10:10 AM, revealed an uncovered suction canister with sputum present sitting on the bedside table.
Observations in room [ROOM NUMBER]B on 10/14/19 at 9:24 AM, revealed a used lancet and an alcohol pad with a brownish red substance on the floor.
Interview with Licensed Practical Nurse (LPN) #3 on 10/14/19 at 9:28 AM, in room [ROOM NUMBER]B, LPN #3 confirmed the lancet should have been disposed of in a sharps box.
Observations in room [ROOM NUMBER] on 10/14/19 at 1:29 PM and 3:29 PM, and on 10/15/19 at 7:52 PM and 4:15 PM, revealed two overbed tables with black and brown substances and old food debris covering them.
Interview with the Housekeeping Supervisor on 10/17/19 at 11:23 PM, in room [ROOM NUMBER], the Housekeeping Supervisor confirmed the overbed tables were not clean.
Observations in room [ROOM NUMBER]B on 10/15/19 at 12:40 PM and 4:38 PM, revealed a fan with a thick layer of dust on the blades and outside casing.
Interview with the Housekeeping Supervisor on 10/16/19 at 7:45 AM, in room [ROOM NUMBER]B, the Housekeeping Supervisor confirmed the fan was dirty.
Observations in room [ROOM NUMBER] on 10/15/19 at 2:34 PM and 4:36 PM, and on 10/16/19 at 8:17 AM, revealed an uncovered suction canister with secretions visible on the bedside table.
Interview with the DON on 10/17/19 at 11:12 AM, in the DON office, the DON was asked should the suction canisters be uncovered and visible in resident rooms. The DON stated, No.
CONCERN
(D)
Potential for Harm - no one hurt, but risky conditions existed
ADL Care
(Tag F0677)
Could have caused harm · This affected 1 resident
**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on policy review, medical record review, observation, and interview, the facility failed to provide assistance with daily ...
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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 assistance with daily oral hygiene for 1 of 2 (Resident #47) sampled residents reviewed for activities of daily living.
The findings include:
The facility's .Oral Care policy dated 10/17 documented, .Our facility will provide oral care with adl [activities of daily living] care and as needed to maintain the oral cavity .
Medical record review revealed Resident #47 was admitted to the facility on [DATE] with diagnoses of Guillain-Barre Syndrome, Congestive Heart Failure, Dementia, Diabetes, and Aortic Valve Disease.
Review of the admission Minimum Data Set (MDS) dated [DATE] revealed Resident #47 was cognitively intact and required extensive assistance from staff for personal hygiene.
Observations in Resident #47's room on 10/15/19 at 9:07 AM and 4:08 PM, and on 10/16/19 at 7:48 AM and 4:05 PM, revealed Resident #47's teeth were covered with a brownish, yellow substance with food particles between her teeth.
Interview with Resident #47 on 10/15/19 at 8:48 AM, in Resident #47's room, Resident #47 stated she was not receiving assistance to brush her teeth.
Interview with Certified Nursing Assistant (CNA) #1 on 10/16/19 at 9:05 AM, in Resident #47's room, CNA #1 was asked how often Resident #47 received assistance to brush her teeth. CNA #1 stated, Every other day.
Interview with the Director of Nursing (DON) on 10/16/19 at 2:55 PM, in the Activity Room, the DON was asked how often residents should receive oral care, such as assistance with brushing their teeth. The DON stated, Every morning with their ADL care.
CONCERN
(D)
Potential for Harm - no one hurt, but risky conditions existed
Quality of Care
(Tag F0684)
Could have caused harm · This affected 1 resident
**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on medical record review and interview, the facility failed to ensure medications were administered as ordered for 1 of 29...
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**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on medical record review and interview, the facility failed to ensure medications were administered as ordered for 1 of 29 (Resident #25) sampled residents reviewed.
The findings include:
Medical record review revealed Resident #25 was admitted to the facility on [DATE] with diagnoses of Bladder Neck Obstruction, Congestive Heart Failure, Benign Prostatic Hyperplasia, Hypertension, Hyperlipidemia, and Atrial Fibrillation.
Review of the Physician's Orders dated 8/5/19 revealed the following:
a. Flomax Capsule 0.4 Milligrams, give 1 capsule by mouth at bedtime for Benign Prostatic Hyperplasia.
b. Potassium Chloride, Extended Release, 20 Milliequivalents, give 2 tablets by mouth three times a day for supplement.
c. Pravastatin 20 Milligrams, give 1 tablet by mouth at bedtime for Cholesterol.
d. Spironolactone 25 Milligrams, give 1 tablet by mouth two times a day for Congestive Heart Failure.
Review of the October, 2019 Medication Administration Record for Resident #25 revealed he did not receive the medications as ordered on 10/14/19.
Interview with Resident #25 on 10/16/19 8:05 AM, in his room, Resident #25 stated, I didn't receive my medicine last night .she crushed them. I don't like my meds crushed. I want to see what they are giving me.
Phone interview with Licensed Practical Nurse (LPN) #4 on 10/16/19 at 1:08 PM, LPN #4 stated, I crushed up the meds, went in the room and then I think, that's not supposed to be crushed. He said, 'I'm not taking that.' LPN #4 was asked if she should have administered Resident #47's medications as they were ordered. LPN #4 stated, Yes.
CONCERN
(D)
Potential for Harm - no one hurt, but risky conditions existed
Respiratory Care
(Tag F0695)
Could have caused harm · This affected 1 resident
**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on policy review, medical record review, observation, and interview, the facility failed to follow the physician orders fo...
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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 follow the physician orders for oxygen and failed to ensure oxygen tubing was dated for 2 of 6 (Resident #100 and #112) sampled residents reviewed for respiratory services.
The findings include:
1. The facility's Oxygen Administration Policy dated 12/1/07 documented, .Resident will be provided oxygen through either a tank or concentrator at the rate specified by the MD [Medical Doctor] .Oxygen tubing .will be changed weekly and prn .
2. Medical record review revealed Resident #100 was admitted to the facility on [DATE] with diagnoses of Hypertensive Urgency, Guillain-Barre Syndrome, Chronic Obstructive Pulmonary Disease, Cerebral Infarction, Sleep Apnea, and Shortness of Breath.
The Physician's Orders dated 7/3/19 documented, Oxygen at 2 liters per nasal cannula as needed for SOB [shortness of breath] .
Observations in Residents #100's room on 10/14/19 at 8:08 AM, 10:36 AM, and 2:59 PM, and on 10/15/19 at 7:53 AM, 12:40 PM and 4:38 PM, revealed Resident #100 was receiving oxygen per nasal cannula at a flow rate of 3 liters/minute.
Interview with the Director of Nursing (DON) on 10/16/19 at 8:18 AM, outside Resident #100's room, the DON was asked if the physician orders were being followed for an oxygen rate of 2 liters. The DON stated, No.
3. Medical record review revealed Resident #112 was admitted to the facility on [DATE] with diagnoses of Traumatic Subdural Hemorrhage, Tracheostomy Status, Gastrostomy Status, Acute Respiratory Failure, Atrial Fibrillation, Dysphagia, Diabetes, and Cerebral Infarction.
The Physican's Orders dated 4/8/19 documented, .O2 [oxygen] AT 28% [percent] (2 LPM [liters per minute]) VIA [by] TRACH [Tracheostomy] .
Observations in Resident #112's room on 10/15/19 at 2:34 PM and 4:36 PM, and on 10/16/19 at 8:17 AM, revealed the oxygen tubing was not labeled or dated.
Interview with the Assistant Director of Nursing (ADON) on 10/16/19 at 8:30 AM, in Resident #112's room, the ADON confirmed the oxygen tubing was not labeled or dated.
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 not stored past their expirat...
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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 not stored past their expiration date in 1 of 9 (Main Medication Room) medication storage areas.
The findings include:
The facility's MEDICATION: ordering, receiving, labeling, storage, drug regiment review reporting/documenting .and destruction of controlled substances policy revised [DATE] documented, .Medications are stored, labeled, handled, and accounted for in a safe manner complying with federal/state laws and standards of professional practice .
Observations in the Main Medication Room on [DATE] at 1:50 PM, revealed 2 bags of 0.45% (percent) Sodium Chloride (Intravenous Solution) with an expiration date of [DATE].
Interview with the Assistant Director of Nursing (ADON) on [DATE] at 1:53 PM, in the Main Medication Room, the ADON confirmed the 2 bags of 0.45% Sodium Chloride were expired.
CONCERN
(E)
Potential for Harm - no one hurt, but risky conditions existed
Tube Feeding
(Tag F0693)
Could have caused harm · This affected multiple residents
**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on medical review, observation, and interview, the facility failed to ensure enteral feeding water flush rates were accura...
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**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on medical review, observation, and interview, the facility failed to ensure enteral feeding water flush rates were accurate for 2 of 4 (Resident #12 and #112 ) sampled residents reviewed for enteral feedings.
The findings include:
1. Medical record review revealed Resident #12 was admitted to the facility on [DATE] with diagnoses of Cerebral Infarction, Hemiplegia and Hemiparesis, Diabetes, Aphasia, Dysphagia, Convulsions and Obesity.
The Physician's Orders dated 7/9/19 documented, .Enteral Feed Order every shift for enteral feeding GLUCERNA 1.2 Per PEG [Percutaneous Endoscopic Gastrostomy tube] @ [at] 70 cc [cubic centimeters]/HR [hour] CONTINUOUS X [times] 24 HOURS WITH 25 ML [milliliters]/HOUR H2O [water] FLUSH PER PUMP .
Observations in Resident #12's room on 10/15/19 at 3:00 PM and 4:25 PM, and on 10/16/19 at 8:02 AM and 11:05 AM, revealed the water flush was infusing at 35 cc/hr.
Interview with Licensed Practical Nurse (LPN) #2 on 10/16/19 at 11:07 AM, in Resident #12's room, LPN #2 confirmed the water flush was infusing at 35 cc/hr and confirmed the water flush was infusing at the incorrect rate.
Interview with the ADON on 10/16/19 at 11:10 AM, in the DON Office, the ADON was asked if a resident has an order for a water flush at 25 ml/hr, should the water be infusing at 35cc/hr. The ADON shook her head (indicating No).
2. Medical record review revealed Resident #112 was admitted to the facility on [DATE] with diagnoses of Traumatic Subdural Hemorrhage, Tracheostomy Status, Gastrostomy Status, Acute Respiratory Failure, Atrial Fibrillation, Hypertension, Dysphagia, Depressive Disorder, Anxiety Disorder, Diabetes, and Cerebral Infarction.
The Physician's Orders dated 9/18/19 documented, .Enteral Feed Order .Jevity 1.5 @ 50 cc/hr continuous per pump with 40 cc/hr H2O flush via [by] PEG .
Observations in Resident #112's room on 10/15/19 at 2:34 PM and 4:36 PM, and on 10/16/19 at 8:17 AM, revealed the water flush was infusing at 45 cc/hr.
Interview with the Director of Nursing (DON) and Assistant Director of Nursing (ADON) on 10/17/19 at 4:15 PM, in the DON Office, the DON was asked if a water flush was ordered at 40cc/hr, should the flush be infusing at 45 cc/hr. The DON stated No.
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 policy review, observation, and interview, the facility failed to ensure practices to prevent the potential spread of infection were maintained when 1 of 3 (Licensed Practical Nurse (LPN) #2)...
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Based on policy review, observation, and interview, the facility failed to ensure practices to prevent the potential spread of infection were maintained when 1 of 3 (Licensed Practical Nurse (LPN) #2) nurses contaminated a reusable medication basket and failed to maintain sterility of an insulin syringe needle during medication administration and when 1 of 1 (LPN #1) nurses failed to perform proper hand hygiene during tracheostomy care.
The findings include:
1. Observations in Resident #66's room on 10/15/19 beginning at 7:40 AM, revealed LPN #2 took a plastic basket from the medication cart containing insulin and placed it on Resident #66's over the bed table without a barrier. LPN #2 then drew up 6 units of Humulin R insulin and allowed the needle to touch the side of a plastic cup sitting on the overbed table LPN #2 then used the contaminated needle to inject the Humulin R insulin into Resident #66's right upper arm. LPN #2 returned the plastic basket to the medication cart without cleaning the plastic basket.
Interview with the [NAME] President of Clinical Services on 10/17/19 at 9:50 AM, in the Director of Nursing (DON) Office, the [NAME] President of Clinical Services was asked if a resident should receive an injection with a needle that had touched the side of a plastic cup. The [NAME] President of Clinical Services stated, No. The [NAME] President of Clinical Services was asked if a plastic basket placed on an overbed table without a barrier should be placed back into the medication cart without cleaning the plastic basket. The [NAME] President of Clinical Services stated, No.
2. The Hand-Hygiene Technique policy dated 8/2017 documented, .To prevent and to control the spread of infectious disease .Appropriate .handwashing .Before or after direct contact with residents .After contact with resident's skin .
Observations of tracheostomy care in Resident #5's room on 10/16/19 at 10:10 AM, revealed Licensed Practical Nurse (LPN) #1 washed her hands, touched the overbed table, touched Resident #5's left hand and then touched the left side rail of the bed. LPN #1 did not perform hand hygiene before she donned gloves to perform tracheostomy care.
Interview with LPN #1 on 10/16/19 at 10:25 AM, in Resident #5's room, LPN #1 was asked should hand hygiene be performed prior to applying gloves during tracheostomy care. LPN #1 stated, .yes I should have .
Understanding Severity Codes (click to expand)
Life-Threatening (Immediate Jeopardy)
J - Isolated
K - Pattern
L - Widespread
Actual Harm
G - Isolated
H - Pattern
I - Widespread
Potential for Harm
D - Isolated
E - Pattern
F - Widespread
No Harm (Minor)
A - Isolated
B - Pattern
C - Widespread
Questions to Ask on Your Visit
- "What changes have you made since the serious inspection findings?"
- "What safeguards are in place to prevent abuse and neglect?"
- "Why is there high staff turnover? How do you retain staff?"
- "Can I speak with families of current residents?"
- "What's your RN coverage like on weekends and overnight?"
Our Honest Assessment
Strengths
- • Licensed and certified facility. Meets minimum state requirements.
Concerns
- • Multiple safety concerns identified: Federal abuse finding, 1 life-threatening violation(s), 4 harm violation(s), $144,120 in fines, Payment denial on record. Review inspection reports carefully.
- • 32 deficiencies on record, including 1 critical (life-threatening) violation. These warrant careful review before choosing this facility.
- • $144,120 in fines. Extremely high, among the most fined facilities in Tennessee. Major compliance failures.
- • Grade F (0/100). Below average facility with significant concerns.
Bottom line: This facility has a substantiated abuse finding. Extreme caution advised. Explore alternatives.
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About This Facility
What is Maplewood Health's CMS Rating?
CMS assigns MAPLEWOOD HEALTH CARE CENTER an overall rating of 1 out of 5 stars, which is considered much 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 Maplewood Health Staffed?
CMS rates MAPLEWOOD HEALTH CARE CENTER's staffing level at 3 out of 5 stars, which is average compared to other nursing homes. Staff turnover is 62%, which is 16 percentage points above the Tennessee average of 46%. High turnover can affect care consistency as new staff learn residents' individual needs.
What Have Inspectors Found at Maplewood Health?
State health inspectors documented 32 deficiencies at MAPLEWOOD HEALTH CARE CENTER during 2019 to 2025. These included: 1 Immediate Jeopardy (the most serious level, indicating potential for serious harm or death), 4 that caused actual resident harm, and 27 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 Maplewood Health?
MAPLEWOOD 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 160 certified beds and approximately 109 residents (about 68% occupancy), it is a mid-sized facility located in JACKSON, Tennessee.
How Does Maplewood Health Compare to Other Tennessee Nursing Homes?
Compared to the 100 nursing homes in Tennessee, MAPLEWOOD HEALTH CARE CENTER's overall rating (1 stars) is below the state average of 2.8, staff turnover (62%) is significantly higher than the state average of 46%, and health inspection rating (1 stars) is much below the national benchmark.
What Should Families Ask When Visiting Maplewood 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?" "What safeguards and monitoring systems are in place to protect residents from abuse or neglect?" "How do you ensure continuity of care given staff turnover, and what is your staff retention strategy?" "Can I visit during a mealtime to observe dining assistance and food quality?" These questions are particularly relevant given the facility's Immediate Jeopardy citations, the substantiated abuse finding on record, and the facility's high staff turnover rate.
Is Maplewood Health Safe?
Based on CMS inspection data, MAPLEWOOD HEALTH CARE CENTER has documented safety concerns. The facility has 1 substantiated abuse finding (meaning confirmed case of resident harm by staff or other residents). Inspectors have issued 1 Immediate Jeopardy citation (the most serious violation level indicating risk of serious injury or death). The facility has a 1-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 Maplewood Health Stick Around?
Staff turnover at MAPLEWOOD HEALTH CARE CENTER is high. At 62%, the facility is 16 percentage points above the Tennessee average of 46%. High turnover means new staff may not know residents' individual needs, medications, or preferences. It can also be disorienting for residents, especially those with dementia who rely on familiar faces. Families should ask: What is causing the turnover? What retention programs are in place? How do you ensure care continuity during staff transitions?
Was Maplewood Health Ever Fined?
MAPLEWOOD HEALTH CARE CENTER has been fined $144,120 across 1 penalty action. This is 4.2x the Tennessee average of $34,520. 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 Maplewood Health on Any Federal Watch List?
MAPLEWOOD 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.