LYONSVIEW HEALTH AND REHABILITATION CENTER
For profit - Limited Liability company
222 Beds
CHAMPION CARE
Data: November 2025
5 Immediate Jeopardy citations
Trust Grade
0/100
#263 of 298 in TN
Last Inspection: April 2023
Over 2 years since last inspection. Current conditions may differ from available data.
Overview
Lyonview Health and Rehabilitation Center has received a Trust Grade of F, indicating poor quality and significant concerns about the facility. It ranks #263 out of 298 in Tennessee, placing it in the bottom half of nursing homes statewide, and #13 out of 13 in Knox County, meaning there are no better local options available. While the facility has shown improvement in addressing issues, dropping from 11 problems in 2023 to 2 in 2024, the overall situation remains concerning. Staffing is a significant weakness, with a low rating of 1 out of 5 stars and a high turnover rate of 62%, which is above the state average. The facility also faces serious issues, including a critical finding where food was not stored safely, and pests were present in the kitchen, raising serious health risks for residents.
- Trust Score
- F
- In Tennessee
- #263/298
- Safety Record
- High Risk
- Inspections
- Getting Better
- Staff Stability ⚠ Watch
- 62% turnover. Above average. Higher turnover means staff may not know residents' routines.
- Penalties ✓ Good
- $99,788 in fines. Lower than most Tennessee facilities. Relatively clean record.
- Skilled Nurses ⚠ Watch
- Each resident gets only 22 minutes of Registered Nurse (RN) attention daily — below average for Tennessee. Fewer RN minutes means fewer trained eyes watching for problems.
- Violations ⚠ Watch
- 18 deficiencies on record. Higher than average. Multiple issues found across inspections.
0/100
Bottom 12%
Review needed
11 → 2 violations
★☆☆☆☆
1.0
Overall Rating
★☆☆☆☆
1.0
Staff Levels
★☆☆☆☆
1.0
Care Quality
★☆☆☆☆
1.0
Inspection Score
↔
Stable
2023: 11 issues
2024: 2 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%
15pts above Tennessee avg (46%)
Frequent staff changes - ask about care continuity
Federal Fines: $99,788
Well above median ($33,413)
Moderate penalties - review what triggered them
Chain: CHAMPION CARE
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 18 deficiencies on record
5 life-threatening 3 actual harm
Jul 2024
2 deficiencies
1 IJ
CRITICAL
(J)
📢 Someone Reported This
A family member, employee, or ombudsman was alarmed enough to file a formal complaint
Immediate Jeopardy (IJ) - the most serious Medicare violation
Accident Prevention
(Tag F0689)
Someone could have died · This affected 1 resident
**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on facility policy review, medical record review, facility documentation review, and interviews, the facility failed to en...
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**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on facility policy review, medical record review, facility documentation review, and interviews, the facility failed to ensure 1 of 8 (Resident #1) sampled residents reviewed for accident hazards received adequate supervision to prevent elopement (a situation where a resident leaves the premises or safe area without necessary supervision). On 12/10/2023, at approximately 10:50 PM, the facility staff observed Resident #1, a vulnerable and cognitively impaired resident with a history of wandering behaviors, outside the building next to a fence. The facility's failure to provide adequate supervision to Resident #1 resulted in Immediate Jeopardy (IJ), (a situation in which the provider's noncompliance with one or more requirements of participation has caused or is likely to cause serious injury, harm, impairment, or death to a resident) for Resident #1 and placed 4 other residents identified as having the potential for elopement at risk for Immediate Jeopardy.
The Administrator, Director of Nursing (DON), and Assistant Director of Nursing (ADON) were notified of the Immediate Jeopardy on 7/24/2024 at 8:48 AM in the Administrator's office.
The facility was cited Immediate Jeopardy at F-689 at a scope and severity of J which constitutes Substandard Quality of Care.
The IJ began on 12/10/2023 and continued through 12/13/2023. The facility's corrective actions were completed on 12/13/2023.
An acceptable Removal Plan/Allegation of Compliance for the past noncompliance, which removed the immediacy, was provided by the facility on 7/24/2024 and was validated on site.
The IJ was cited as past noncompliance for F-689 and the facility is not required to submit a Plan of Correction.
The findings include:
Review of the undated facility policy titled, Elopement Response, revealed .Purpose: It is the intent of the facility to provide a safe and home-like environment for all residents and to provide adequate supervision .to prevent the possibility of elopement or unsafe wandering .Elopement: When a resident leaves the facility premises or a safe area without authorization .or supervision .Any staff member observing a resident attempting to leave the premises .shall attempt to re-direct the resident .
Review of the medical record revealed Resident #1 was admitted to the facility on [DATE] with diagnoses including Dementia, Anxiety Disorder, and Hypertension.
Review of an Elopement Risk assessment dated [DATE] and reviewed on 10/24/2023, revealed Resident #1 was a moderate risk for elopement on the assessment .cognitively impaired with poor decision making skills .resident ambulate independently, with or without assistive device .resident verbally expressed the desire to go home .[box checked for the following] Resident is not at risk for elopement/wandering at this time .Summary of Review .Resident ambulates throughout the facility looking for bank, dept [department] store .She knows her room number .No exit seeking toward doors observed .Date 10/24/23 .
Review of a care plan for Resident #1 dated 2/23/2023 showed .Elopement risk as evidenced by a history of wandering aimlessly, impaired safety awareness .
Review of a quarterly Minimum Data Set (MDS) assessment dated [DATE], revealed Resident #1 scored an 8 on the Brief Interview for Mental Status (BIMS) assessment which indicated moderate cognitive impairment, and no wandering behaviors were identified on the MDS.
Review of a witness statement dated 12/10/2023, revealed Certified Nursing Assistant (CNA) A stated .just .got to 400 hall nurse [Registered Nurse, (RN) D] was .going outside .[RN D] came right back in saying [Resident #1] was outside. [RN D] .2nd shift CNAs and I went outside .escorted her back inside, when I came in I went to her room. Door was shut, opened door to find her window wide open and no screen .Let others [nurses] see it [see the window open] then closed the window .3rd shift CNA and I keep close watch to [Resident #1], assisted with getting an UA [urinalysis, a test of urine for checking for presence of bacteria] and skin assessment then helped [Resident #1] to bed .
Review of a progress note for Resident #1 dated 12/11/2023 at 2:15 AM, revealed .At [10:50 PM] this nurse was informed that resident had climbed out of room window and was observed outside attempting to climb fence on facility property. Resident was assisted by staff inside facility. Resident observed AA/O [alert and oriented] to self .no c/o [complaints of] pain or discomfort. small abrasion .base of index finger. No other injuries observed at this time. When asked why resident climbed out window, resident stated 'I wanted to go home'. Resident stated 'I don't understand what I did wrong'. Nurse informed resident of risk for injury and staff responsibility for her care and safety. Resident observed at this time with sweater, shirt, pants, and tennis shoes on-appropriately dressed .Nurse [RN D] stated 'the resident was never left unattended, she opened the exterior door and yelled for the CNA's to assist her that a resident had gotten outside'. Staff assisted the resident back inside the facility via wheelchair and placed in hall next to resident's room. Nurse informed that the window was open. This Nurse [RN D] closed the window and had made .notification at [11:15 PM] to have maintenance come into facility to screw window shut .skin assessment obtained and documented .residents RP [responsible party] was notified .
Review of a witness statement dated 12/11/2023, revealed CNA B stated .20 mins[minutes] before th [the] incident [Resident #1] was at the nurses station talking to us she went back to her room with her door shut as usual .
Review of a witness statement dated 12/11/2023, revealed CNA C stated .was observing [Resident #1] come back in from outside I [CNA C] watched over [Resident #1] after she came to her room from being outside .my shift 11p [PM]- 7 AM .
Review of a witness statement dated 12/11/2023, revealed RN D stated .[RN D] stepped off the unit 400 hall side door for some air. Observed resident [Resident #1] .outside standing at fence attempting to climb fence I held door open and did not leave .while I called for CNAs to come that a resident was outside .[Resident #1] had on appropriate clothing and sneakers .[Resident #1] was assisted back inside and to her room where it was observed that her window was standing open .has no obvious injury except for small abrasion .Right index finger .
Review of the facility documentation for Resident #1 dated 12/11/2023, revealed .On 12/10/2023, Administrator was notified .that [Resident #1] was outside by the fence .nurse observed this and called .for help .Resident was escorted back into the building and checked. Increased monitoring was initiated .Resident was appropriately dressed in warm clothes. Resident room was checked for environmental safety and staff continues to monitor closely .Describe any changes in the resident's behavior .No changes .
Review of a progress note for Resident #1 dated 12/11/2024 at 7:49 PM, revealed .resident continues to voice wanting to leave the facility DON .notified instructed to provide 1 on 1 care. CNA sitting in room at bedside resident laying in bed no distress noted .
During a telephone interview on 7/23/2024 at 3:35 PM, CNA A stated the resident elopement happened as she showed up for her 11-7 shift on 12/10/2023, the nurse was going outside for fresh air and saw Resident #1 against the fence. Staff brought her in and found her door closed, window open and screen off laying outside the building. The CNA stated no one saw her leave the building through the window. The nurse who found her by the fence was RN D. The resident .was on 1 on 1 watch for 72 hours after that happened .
During an interview on 7/24/2024 at 8:48 AM, the Administrator stated, immediately following the incident, rounds were done with other residents to make sure no other residents were affected and the resident had increased supervision. The Administrator stated 1:1 [1 on 1] supervision was initiated on 12/11/2023 at 7:00 PM after Resident #1's comments about wanting to go home were heard by staff. The Administrator stated that before 12/10/2023, there were no stop screws on any windows except the back 400 hall (secure unit), and the screws were put on all windows after the incident. The Administrator confirmed that Resident #1 eloped from the facility.
During an interview on 7/24/2024 at 9:35 AM, CNA F stated she was working on 12/10/2023 and stated the nurse went to the outside door and stepped out and saw Resident #1 .holding on to the fence about to go over it . The CNA went outside and helped the resident inside with another staff member (RN D). The CNA stated she did not see the resident climb out the window as the resident's door was closed. The CNA stated she had never witnessed Resident #1 trying to get out a door or window, but the resident had asked to get out of doors before while wandering.
The facility's corrective actions for the removal plan were issued to the state surveyors on 7/24/2024. The corrective action plan included the following:
1. How the corrective action will be accomplished for those residents found to have been affected by the deficient practice.
The facility held a Quality Assurance Performance Improvement meeting on 12/11/2023 during which the attendees found it necessary to ensure building windows were all secure, review the Elopement Response policy with staff, review the Abuse policy with staff, and review elopement protocol with staff. The Administrator, Director of Rehab Therapy, Admissions, Human Resources Director, and Business Office Manager were included in the meeting.
2. How the facility completed the action plan and identified and protected other residents having the potential to be affected by the same deficient practice.
A head count was completed for all residents on 12/10/2023 by the DON and designees and elopement assessments completed on all residents on 12/12/2023, and the elopement assessments were ongoing and were used to update elopement books with current pictures of those residents to be kept at each nurses' station. Five residents were identified as elopement risk outside of the secured unit.
Physician's orders, care plans and TASK [CNA communication] were updated on 12/11/2023 by MDS staff and included assessments completed on 12/12/2023 by medical and psychiatric nurse practitioners for Resident #1.
All windows were checked and secured per regulations and completed on 12/11/2023 by the Maintenance Director and the Facility Manager. Ongoing door checks were initiated on 12/11/2023 by the Maintenance Director.
Education was completed with current staff on 12/11/2023 by the Administrator and DON and will be ongoing for new staff. Education included Abuse and Elopement procedures and management. Continuing education was provided via telephone to include staff not available to attend in person and was completed on 12/13/2023.
3. What measures were put into place or systemic changes made to ensure the deficient practice will not reoccur.
Elopement drills were completed on 12/11/2023 and will be ongoing.
Elopement education is ongoing through monthly staff meetings, orientation, and in-services for employees.
Ongoing window audits were initiated on 12/11/2023 by the Environmental Service Director to ensure secure windows for all residents.
Monitoring will be completed by a designated monitor who performs daily rounds to check for window security.
The Removal Plan was validated onsite by the surveyors on 7/24/2024 which included review of the facility documentation to show each step was completed and staff interviews to confirm the completed and ongoing actions. Interviews with 21 staff members confirmed staff had been educated on elopement and participated in elopement drills.
CONCERN
(D)
📢 Someone Reported This
A family member, employee, or ombudsman was alarmed enough to file a formal complaint
Potential for Harm - no one hurt, but risky conditions existed
Free from Abuse/Neglect
(Tag F0600)
Could have caused harm · This affected 1 resident
**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on facility policy review, medical record review, facility investigation documentation review, police report review, and i...
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**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on facility policy review, medical record review, facility investigation documentation review, police report review, and interview, the facility failed to protect the residents' right to be free from physical abuse for 3 residents (Resident #2, Resident #4, and Resident #6) of 21 residents reviewed for abuse.
The findings include:
Review of the facility policy titled, Abuse, Neglect, Misappropriation, Exploitation Policy, effective 8/2023, revealed .Purpose: To prohibit and prevent abuse, neglect, exploitation .and to ensure reporting of alleged violations .
Review of the medical record revealed Resident #2 was admitted to the facility on [DATE] with diagnoses including Hemiplegia, Type 2 Diabetes Mellitus, and Major Depressive Disorder.
Review of a quarterly Minimum Data Set (MDS) assessment dated [DATE], revealed Resident #2 scored a 15 on the Brief Interview for Mental Status (BIMS) which indicated the resident was cognitively intact. Continued review revealed no behaviors were observed during the assessment period.
Review of the comprehensive care plan for Resident #2 revised 9/28/2023, revealed .Resident tries to direct other residents without their approval .Resident to notify staff for assistance for other residents as needed instead of her trying to direct them .
Review of the medical record revealed Resident #3 was admitted to the facility on [DATE] with diagnosis including Alzheimer's Disease, Encounter for Palliative Care, and non-Hodgkin lymphoma. Continued review revealed the resident discharged to another facility on 11/9/2023.
Review of a quarterly MDS assessment dated [DATE], revealed Resident #3 scored a 99 on the BIMS which indicated the resident was unable to complete the interview. Continued review revealed no behaviors were observed during the assessment period.
Review of the comprehensive care plan for Resident #3 revised 9/28/2023, revealed .Provide doll to resident when agitated and redirect to room .Psy [psychiatric] services referral as needed .
Review of the facility investigation dated 9/28/2023, revealed .[Resident #2] .was assisting another resident .[Resident #3] from another resident room .[Resident #3] made contact with [Resident #2's] face Resident #2 stated .it was a tap .[Resident #2] wanted nothing to be done regarding incident .Reeducated [Resident #3] to get staff for redirection of other residents .
Review of a Police Report investigation dated 9/28/2023, revealed .on 9/28/2023 .officer .responded to Simple Assault .The complainant .is the director of the nursing home .stated that one resident had hit another resident .When went to speak with the suspect .was unable to get clear statement from her due to severely declined mental state .I then spoke with the victim .who stated she was trying to get .[suspect] back to correct room and .[suspect] hit her in the side of the face .stated it wasn't hard .she did not have any injuries from being hit .
Review of a Skin Assessment for Resident #2 completed on 9/28/2023 revealed no injuries or new areas observed.
Review of a Psychiatric Nurse Practitioner (NP) note for Resident #3 dated 9/29/2023, revealed .[Resident #3] is alert with confusion .co-managed by .hospice .[NP] asked to see [Resident #3] regarding altercation between another resident [Resident #2] .[Resident #3]does not have the mental capacity to answer questions about the the incident .does not appear to be in any distress .continues to be confused .no known triggers to behaviors or modifying factors .Recommendations .discontinue .[antipsychotic medication] .
Review of a Psychiatric NP Note for Resident #2 dated 9/29/2023, revealed .[Resident #2] is pleasant and smiling .asked to see [Resident #2] regarding an incident where she [Resident #2] was smacked by another resident [Resident #3] .[Resident #2] states she likes to help take care of the other residents and feels like she can be helpful with redirection .we discussed boundaries and letting the staff take care of other residents .Recommendations: continue current treatment plan and medications .
During an interview on 7/24/2024 at 12:51 PM, Licensed Practical Nurse (LPN) H stated she was standing there when incident happened on 9/28/2023, and she observed Resident #3 hit Resident #2 in the face. Continued interview revealed the LPN denied prior incidents between the two residents. Interview revealed the residents were immediately separated with neither resident having any injury.
During an interview on 7/24/2024 at 1:02 PM, Resident #2 stated she was redirecting Resident #3 and she [Resident #2] smacked her .it didn't hurt . Continued interview revealed the resident stated no further incidents happened between the two residents.
Review of the medical record revealed Resident #4 was admitted to the facility on [DATE] with diagnoses including Contractures, Hypertension, and Hypoglycemia. Continued review revealed the resident transferred to another facility she had resided at prior to admission on [DATE].
Review of an admission MDS assessment dated [DATE], revealed Resident #4 scored a 15 on the BIMS assessment which indicated resident was cognitively intact. Continued review revealed no behaviors were observed during the review.
Review of the comprehensive care plan for Resident #4 revised 12/28/2023, revealed .allow resident the opportunity to identify own self needs .encourage the resident to participate in conversation .refer to Psy [psychiatric] PRN [as needed] .
Review of the medical record revealed Resident #5 was admitted to the facility on [DATE] with diagnoses including Progressive Ophthalmoplegia, Type 2 Diabetes Mellitus, and Urinary Tract Infection.
Review of an admission MDS assessment dated [DATE], revealed Resident #5 scored a 99 on the BIMS assessment indicating the resident was unable to complete the interview. Continued review revealed no behaviors were observed during the review.
Review of the comprehensive care plan for Resident #5 revised 12/28/2023, revealed .resident to resident altercation .causative factors/ situations will be identified and avoided .redirect as needed .allow resident to express thoughts and feelings .send to ER [emergency room] for psychiatric evaluation .
Review of a Nursing Progress Note for Resident #5 dated 12/28/2023, revealed .[Resident #5]went into [Resident #4's] room and was squeezing and holding her leg and hitting roommate [Resident #4] .
Review of the facility investigation dated 12/28/2023, revealed .[Resident #4] was struck and grabbed by roommate [Resident #5] .roommate and resident separated immediately .[Resident #5] was sent to hospital .
Review of facility documentation dated 12/28/2023, revealed .Administrator notified police .two police officers came to building to interview residents [Resident #4 and Resident #5] they did not feel that they needed to do police report on this .
Review of a Skin Assessment for Resident #4 completed on 12/28/2023, revealed no changes or bruising noted.
Review of a Psychiatric NP Note for Resident #4 dated 12/28/2023, revealed .[Resident #4] lying in her bed .nursing observed another resident [Resident #5] pulling on her legs and tapping on her leg .[Resident #4] denies .injuries or areas in which resident touched her will continue to monitor for any latent effects of this incident. No injury noted, resident denies any pain or discomfort .
Review of a Psychiatric NP Note for Resident #5 dated 12/28/2023, revealed .[Resident #5] has a history of vascular dementia .she was observed pulling on another resident's leg [Resident #4] trying to pull resident toward her .she denies any pain or discomfort or recollection of the above mentioned incident with the other resident .Resident has had increased behaviors .has been evaluated by the psychiatric nurse practitioner .without significant improvement in her behaviors, will ask that she be sent for geropsychiatric evaluation .
During an interview on 7/24/2024 at 7:12 AM, the Social Services Director (SSD) stated she was aware of the resident-to-resident contact when Resident #5 struck and squeezed Resident #4. Continued interview revealed the SSD was not aware of any other incidents prior to Resident #4 discharge on [DATE] .
During an interview on 7/24/2024 at 9:15 AM, Resident #5 appeared frail and confused and unable to recall the incident [between Resident #4 and Resident #5] stating .everyone is treating her well .
Review of the medical record revealed Resident #6 was admitted to the facility on [DATE] with diagnoses including Major Depressive Disorder, Anxiety Disorder, and Acute Respiratory Failure.
Review of a quarterly MDS assessment dated [DATE], revealed Resident #6 scored a 15 on the BIMS assessment which indicated resident was cognitively intact. Continued review revealed no behaviors observed during the assessment period.
Review of the comprehensive care plan for Resident #6 revised 12/17/2023, revealed .resident to resident altercation .causative factors/situation will be identified .allow resident to express thought and feelings .refer to mental health for evaluation .
Review of the medical record revealed Resident #7 was admitted to the facility on [DATE] with diagnoses including Dementia and Behavioral Disturbances.
Review of the admission MDS assessment dated [DATE], revealed Resident #7 scored a 3 on the BIMS assessment indicating severe cognitive impairment. Continued review revealed no behaviors observed during the assessment period.
Review of the comprehensive care plan for Resident #7 revised 12/17/2023, revealed .resident to resident altercation .causative factor/ situations will be identified .redirect as needed .maintain calm environment .refer to mental health .
Review of the facility investigation dated 12/17/2023, revealed .heard .[Resident #6] saying, get her [Resident #7]out of my room .[Resident #7] was hitting [Resident #6] on the arm. Resident #7 was immediately escorted back to her room.
Review of facility documentation dated 12/17/2023, revealed .police were notified and came to building. They do not feel that an official police report needs to be made .there is no redness or bruising at all during full body assessment .
Review of a Skin Assessment for Resident #6 completed 12/17/2023, revealed no injuries or new areas found .
Review of a Psychiatric NP Note for Resident #6 dated 12/21/2023 revealed .[Resident #6] had an encounter with [Resident #7]. It was reported [Residnet #6] was hit by [Resident #7] .[Resident #6] feels safe and does not feel threatened when she sees the resident who was accused of hitting her .she said it was incredibly silly to bring a cop. She agreed to talk to the Police officer .as long as he had a sense of humor .she said it was not like she was punched or hurt .
Review of a Psychiatric NP Note for Resident #7 dated 12/18/2023 revealed .[Resident #7] wandered into another residents room and lightly tapped the other resident [Resident #6] on the arm .she has no recollection .she is pleasantly confused .she is easily redirected .ordered a urinalysis, CBC [complete blood count], CMP [comprehensive metabolic panel] to rule out any type of metabolic disturbances that could cause these behaviors .
During an interview on 7/24/2024 at 7:12 AM, the SSD stated Resident #6 and Resident #7 had no prior resident to resident altercations denied any lasting effects with either resident. Continued interview revealed the residents had no further altercations with Resident #7. Resident #7 had a planned discharge from the facility to home on 1/5/2024.
During an interview on 7/24/2024 at 9:22 AM, Resident #6 stated everyone is good to her and when questioned about the past incident. The resident stated, .that was nothing but a light hit and overreaction . Continued interview revealed the resident was immediately removed from her room with no further incidents.
During an interview on 7/24/2024 at 2:02 PM, the Administrator confirmed .if the facility investigation said it [physical contact] happened between the residents, when Resident #3 struck [Resident #2, when Resident #5 struck Resident #4, and when Resident #7 struck Resident #6] then it is true .
Apr 2023
11 deficiencies
4 IJ (4 facility-wide)
CRITICAL
(L)
Immediate Jeopardy (IJ) - the most serious Medicare violation
Food Safety
(Tag F0812)
Someone could have died · This affected most or all residents
⚠️ Facility-wide issue
**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on review of the Centers for Disease Control (CDC) and Prevention and U.S. Department of Housing and [NAME] Development He...
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**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on review of the Centers for Disease Control (CDC) and Prevention and U.S. Department of Housing and [NAME] Development Healthy Housing Reference Manual, job description review, facility documentation review, facility policy review, observation, and interview, the facility failed to ensure food was stored, prepared, and served under sanitary conditions. The facility failed to maintain effective pest control in the kitchen as evidenced by the presence of live and dead roaches in the kitchen and food preparation areas which had the potential to affect all 144 residents in the facility. Deficiencies were cited resulting in an Immediate Jeopardy (a situation in which the provider's noncompliance with one or more requirements of participation has caused, or is likely to cause, serious injury, harm, impairment, or death to a resident).
The Interim Administrator and Regional [NAME] President/Administrator (ADM#1) were notified of the Immediate Jeopardy for F812 and F925 on 4/4/2023 at 6:36 PM in the Administrator's office.
The Regional [NAME] President/Administrator (ADM#1) was notified of the Immediate Jeopardy for F835 on 4/11/2023 at 10:55 AM in the Administrator's office.
The Interim Administrator and Regional [NAME] President/Administrator (ADM#1) were notified of the Immediate Jeopardy for F837 on 4/12/2023 at 11:57 AM in the Administrator's office.
The facility was cited Immediate Jeopardy at F812 (L), F835 (L), F837 (L), and F925 (L).
The facility was cited F656 (G), F-684 (G), and F710 (G).
The Immediate Jeopardy began 4/3/2023 and was removed 4/13/2023.
An acceptable removal plan, which removed the immediacy of the jeopardy, was received 4/12/2023 at 5:37 PM, and the corrective actions were validated on-site by the surveyors on 4/13/2023.
The facility is required to submit a Plan of Correction.
The findings include:
Review of documentation titled, Centers for Disease Control and Prevention and U.S. Department of Housing and [NAME] Development. Healthy housing reference manual. Atlanta: US Department of Health and Human Services, dated 2006, showed .The existence of cockroaches, rats, and mice mean that they can also be vectors for significant problems that affect health and well-being. They are capable of transmitting diseases to humans .Disease Vectors and Pests .Integrated pest management (IPM) techniques are necessary to reduce the number of pests that threaten human health and property. This systems approach to the problem relies on more than one technique to reduce or eliminate pests. It can be visualized best as concentric rings of protection that reduce the need for the most risky and dangerous options of control and the potential for pests to evolve and develop. It typically involves using some or all of the following steps .monitoring, identifying, and determining the level of threat from pests .Daytime sightings may indicate potentially heavy infestations .German cockroach (Blattella germanica) . Four management strategies exist for controlling cockroaches. The first is prevention .The second strategy is sanitation. This denies cockroaches food, water, and shelter. These efforts include quickly cleaning food particles from shelving and floors; timely washing of dinnerware; and routine cleaning under refrigerators, stoves, furniture, and similar areas . The third
strategy is trapping . The fourth strategy is chemical control .Rodent-associated diseases affecting humans include plague, murine typhus, leptospirosis, rickettsialpox, and rat-bite fever. The three primary rodents of concern to the homeowner are the Norway rat (Rattus norvegicus), roof rat (Rattus rattus), and the house mouse (Mus musculus). The term commensal is applied to these rodents, meaning they live at people's expense .The first of four basic strategies for controlling rodents is to eliminate food sources. To accomplish this, it is imperative .to do a goodjob of solid waste management. This requires proper storing, collecting, and disposing of refuse .
Review of the facility's policy titled, Food-Related Garbage and Rubbish Disposal, revised 4/2006, showed .Food-related garbage and rubbish shall be disposed of in accordance with current state laws regulating such matters .All garbage and rubbish containing food wastes shall be kept in containers .All garbage and rubbish containers shall be provided with tight-fitting lids or covers and must be kept covered when stored or not in continuous use .Garbage and rubbish containing food wastes will be stored in a manner that is inaccessible to vermin .
Review of the facility's policy titled, Pest Control, revised 5/2008, showed .Our facility shall maintain an effective pest control program .This facility maintains an on-going pest control program to ensure that the building is kept free of insects and rodents .Pest control services are provided .
Review of the facility's policy, Sanitization, revised 12/2008, showed .The food service area shall be maintained in a clean and sanitary manner .All kitchens, kitchen areas and dining areas shall be kept clean, free from litter and rubbish and protected from rodents, roaches, flies and other insects .All utensils, counters, shelves and equipment shall be kept clean, maintained in good repair and shall be free from breaks, corrosions, open seams, cracks and chipped areas that my affect their use of proper cleaning .All equipment, food contact surfaces and utensils shall be washed to remove or completely loosen soils by using the manual or mechanical means necessary and sanitized using hot water and/or chemical sanitizing solutions .For fixed equipment or utensils that do not fit in the dishwashing machine, washing shall consist of the following steps .Equipment will be disassembled as necessary to allow access of the detergent/solution to all parts .Removable components will be scraped to remove food particle accumulation and washed according to manual or dishwashing procedures .Plasticware .that cannot be sanitized or are hazardous because of chips, cracks .shall be discarded. Damaged or broken equipment that cannot be repaired shall be discarded .Kitchen wastes that are not disposed of by mechanical means shall be kept in clean, leakproof, nonabsorbent, tightly closed containers .Kitchen .surfaces not in contact with food shall be cleaned on a regular schedule and frequently enough to prevent accumulation of grime .The Food Services Manager will be responsible for scheduling staff for regular cleaning of kitchen .Food service staff will be trained to maintain cleanliness throughout their work areas during all tasks, and to clean after each task .
Review of the facility's policy titled, Food Receiving and Storage, revised 11/29/2021, showed .Foods shall be received and stored in a manner that complies with safe food handling practices .Food services, or other designated staff, will maintain clean food storage areas at all times .Non-refrigerated foods, disposable dishware and napkins will be stored in a designated dry storage unit which is temperature and humidity controlled, free of insects and rodents and kept clean .Food in designated storage areas shall be kept of the floor .
Review of the facility's documentation titled, Agreement to Provide Dietitian Consulting Services Between [name of provider company] and [name of the facility], dated 3/22/2022, showed .Dietitian shall review Facility's food safety and sanitation procedures to assure quality food service .Dietitian shall provide written reports of work completed to the Facility Administrator as requested .
Review of a Director of Food Services job description, undated, and unsigned by the Dietary Manager, showed .The primary purpose of your job description is to assist .directing the overall operation of the Food Services Department in accordance with current federal, state, and local standards, guidelines and regulations governing our facility .to assure that quality nutritional services are provided on a daily basis and that the Food Services Department is maintained in a clean, safe, and sanitary manner .Inspect food storage rooms .Review and assist in developing a plan of correction for food services .deficiencies noted during survey inspections .Ensure that food services service work areas are maintained in a clean and sanitary manner. Ensure that food storage rooms, preparation areas .are maintained in a clean, safe, and sanitary manner .Make weekly inspections of all food services functions to assure that quality control measures are continually maintained .Education .Be a graduate of an accredited course in dietetic training approved by the American Dietetic Association .Must have training in cost control, food management, diet therapy .Specific Requirements .Must be registered as a Food Service Director in this state .Must be knowledgeable of food services practices and procedures as well as the laws, regulations and guidelines governing food services functions in nursing care facilities .Must maintain the care and use of supplies, equipment .and maintain the appearance of food services service areas; must perform regular inspections of food services service areas for sanitation order, safety and proper performance of assigned duties .
Review of an Administrator job description, undated, and unsigned, showed .The primary purpose of your job position is to direct the day-to-day functions of the facility in accordance with current federal, state, and local standards, guidelines, and regulations .to assure that the highest degree of quality care can be provided to our residents at all times .Safety and Sanitation .Ensure that the facility is maintained in a clean and safe manner for resident comfort and convenience by assuring that necessary equipment and supplies are maintained to perform such duties/services .assure that the facility is maintained in a clean, safe and sanitary manner .
Review of the facility's documentation, untitled and undated, of the Regional [NAME] President job responsibilities showed, .Regional Vice-President .work has purpose .improve the quality of life of .patients .will act in the role of a trusted advisor .to identify improvement opportunities .The Regional [NAME] President is responsible for overall programs .Direct day-to-day management oversight .which ensures the health, safety, and satisfaction of all residents .Ensuring the quality of care and service delivered is of the highest level .
During an observation and tour of the kitchen with the Dietary Manager (DM #1) on 4/3/2023 at 9:27 AM, the following was observed:
1.
No trash can at the handwash sink.
2.
The cover on eye wash sprayer was broken off and missing.
3.
In the walk-in refrigerator, there were orange juices, apple juices, and prune juices which the DM #1 stated was left over from the prior day (4/2/2023) but were incorrectly dated (4/3/2023). This incorrect dating was confirmed by DM #1.
4.
Macaroni and cheese stored unsealed with a torn cover in walk-in refrigerator.
5.
Cheese slices stored uncovered in the walk-in refrigerator and confirmed by
DM #1. DM #1 identified approximately 1 ½ pounds of uncovered cheese and discarded it.
6.
Four (4) cooler bags stored in walk-in refrigerator next to other food items, which was confirmed by DM #1. DM #1 stated the cooler bags had been used by the Activities staff to transport food to the residents, and were stored on the top shelf in the refrigerator next to other food items.
7.
The air vent over the food preparation area near wash sink was noted as rusted with peeling paint. DM #1 confirmed that the vent had been in this condition for a couple of months (exact time period unknown).
8.
Food residue noted on the clean glassware.
9.
A spoon and food debris was noted in the hand wash sink.
10.
A dirty used glove was noted lying on the food prep area.
11.
The florescent light fixtures were noted to have multiple dead insects.
12.
Broken thermometer noted in the ice cream storage cooler.
13.
An employee water bottle in the food preparation area.
14.
DM #1 confirmed a roach crawled up the wall behind the ice cream storage cooler.
15.
In the dry storage area, DM #1 confirmed a coffee cup contained a dried food substance.
16.
In the dry storage area, DM#1 confirmed 2 jackets stored near thickened water and plastic cups.
17.
DM #1 confirmed 7 of the 9 coolers were stored .dirty .
18.
In the dry storage area, there was a serving dish and plastic bowls stored on the floor and the floor was noted with a black substance. DM #1 confirmed the condition of the floor was .unacceptable .
19.
In dry storage area, 2 trays of wine glasses, 1 cardboard box of to-go boxes, on top shelf of shelving unit were not stored below the fire line.
20.
In dry storage area, large amount of dust was noted on the vent and the sprinkler head.
21.
In dry storage area, flour and corn meal bins were unsealed and open to air.
22.
A cell phone left on top of the food warmer.
23.
A jacket, eyeglasses, hammer, black backpack and a water bottle was observed in the food prep area.
24.
4 trays of Apple cobbler in serving bowls were left on a rack, uncovered and opened to air food prep area.
25.
Refrigerator had an undated peanut butter and jelly sandwich.
26.
2 coffee carafes had missing lids open to air.
27.
Observation showed a staff member pushed an uncovered bin loaded with multiple plastic bags of trash from the dining room through the kitchen prep area.
28.
Trash was uncovered and overflowing onto the ground near a rolling cart at the back door of the kitchen.
29.
DM #1 confirmed 3 spatulas with chips/broken pieces were noted in a clean utensil drawer. DM #1 further confirmed the broken pieces of spatula were consistent with mice or rat bites.
30.
The oven door and control dials were noted with dark dried food debris and dead roaches behind the control dials.
31.
54 expired milk cartons in milk cooler. (50 whole milk cartons with expiration date of 4/2/2023 and 4 fat free milk cartons with expiration dates of 3/27/2023).
During an observation and interview on 4/3/2023 at 9:27 AM, DM #1 was observed using a paper towel with an ungloved hand to kill roach crawling on the wall behind the milk cooler. Without performing hand hygiene, DM #1 proceeded to remove the thermometer from the reach in cooler and wipe the thermometer on his soiled shirt. DM #1 then replaced thermometer into reach in cooler. DM #1 was informed by the surveyor of the need to sanitize the thermometer after wiping it on his shirt.
During an observation and interview in the kitchen on 4/4/2023 at 9:30 AM, DM #1 and Registered Dietitian (RD #1) confirmed the following:
1.
Dish room had orange/rusty areas around the ceiling on the trim, dried debris around the floor base.
2.
RD #1 confirmed multiple live roaches were observed on the clean side of the dish table and in the dish room.
3.
Kitchen table under flat top grill, equipment electric boxes on the back of stove and smoker, faucet handles with thick dark, greasy, and crumbly debris.
4.
Behind the double oven on the floor was thick dark debris.
5.
Juice machine spouts were noted with dried debris
6.
3 compartment sink #1 had pipes with dust and dried debris.
7.
3 compartment sink #2 drain was full with black flaky debris in water.
8.
Dried food debris on the back of the steam table.
9.
DM #1 confirmed live roaches were noted inside one sleeve of the plate warmer and contained thick dark buildup in the bottom of the warmer and contained clean plates ready for use.
10.
Walk in cooler contained 2 bags of cereal unsealed, unlabeled, open to air, and partially used, 2-1-gallon jugs ½ full each of mayonnaise open and undated.
11.
Walk in freezer had 1 gallon bag ½ full of frozen diced chicken unlabeled and undated, a 2.5-pound bag of peppers/onions open, unlabeled, and undated.
12.
Observation of the chemical room showed paper, debris, and thick dark marks on the floor.
During an observation on the 100 hallway on 4/4/2023 at 1:57 PM, a live cockroach was noted crawling on the forehead of Surveyor #1. Surveyor #3 removed the cockroach from the surveyor's forehead, and killed and disposed the cockroach.
During an interview on 4/4/2023 at 3:10 PM, Pest Control Technician (PCT)#1 revealed .Previous vendor had rodent control program PCT #1 confirmed roach communes in .cracks where the caulking is missing . were noted in the kitchen and roaches were observed in the dish room, the wall behind the freezer and the center serving line.
During a facility kitchen tour on 4/5/2023 at 8:13 AM, DM #1, RD #1, and Regional [NAME] President/Administrator (ADM#1) confirmed the following:
1.
No hot water at the hand wash sink.
2.
The cover on eye wash sprayer was broken off and missing.
3.
Live and dead roaches observed in the kitchen.
4.
Debris and dead and live roaches noted in the plate warmer.
5.
Debris noted behind the equipment along the walls.
6.
Disheveled paper and boxes next to two (2) gallon jugs of bleach stored on the floor.
During an observation and interview, in the kitchen on 4/5/2023 at 8:28 AM, RD #1 confirmed the presence of live roaches in the plate warmer (picture taken).
During an observation and interview in the kitchen on 4/5/2023 at 8:41 AM, DM #1 confirmed quarter baking pans were observed nested wet. DM #1 stated .yeah, that pan's wet .
During an observation and tour of the kitchen on 4/5/2023 at 8:43 AM, a roach was observed crawling up the wall, in the kitchen, near an ice scoop. The ice scoop was uncovered, positioned in an open holder, attached to the wall.
During an observation and tour of the kitchen on 4/5/2023 at 8:45 AM, multiple live roaches were observed in the kitchen, behind the ice machine, milk cooler, reach in refrigerator, under the drink station table, and under the serving line.
During an interview in the kitchen on 4/5/2023 at 8:50 AM, RD #1 revealed she was not aware until 4/4/2023, of a pest control problem in the facility.
During an interview in the kitchen on 4/5/2023 at 8:50 AM, DM #1 revealed that he was not aware of the last time pest control came to service the facility.
During an interview on 4/5/2023 at 8:58 AM, the Maintenance Director (MA #1) stated, .We've always had an issue .[regarding pests .It's .ongoing .I have seen them .I have seen them since November [2022] .It needs to be taken care of immediately . MA #1 confirmed that the pest control had not been completed because of .lack of payment . by the facility. MA #1 stated .We've had a few Administrators .[Previous Administrator Name (ADM #2)] . had been advised of the pest control problem. MA #1 stated the interim administrator had been made aware of the pest control problem .in the last week or so . MA #1 revealed he had requested the replacement of the kitchen vents on 2/28/2023 and the Corporate office had not sent the replacement vents until after .you guys [surveyors] walk in the door . MA #1 revealed he checked the water temperatures .Yes, we check them, supposed to do it weekly .but it's about every two weeks . MA #1 further stated the hot water was off at the hand washing sink in the kitchen because it was 160 degrees and that the mixing valves probably needed to be maintenanced. MA #1 revealed he had seen roaches .in the past .randomly throughout the building . MA #1 revealed .They're [kitchen staff] supposed to dump that [garbage] daily .I guess [they wait to dump it] when there is a male .some of that stuff . heavy . MA #1 revealed the kitchen staff were responsible to clean trash area.
During an interview in the dining area outside the kitchen on 4/5/2023 at 9:25 AM, Regional [NAME] President/Administrator (ADM#1) stated .usually the Maintenance Director or Dietary Manager would make us aware if they've not had these things [pest control services] . Regional [NAME] President/ADM #1 confirmed she had been the Administrator of Record for the facility since 2/11/2023. ADM #1 confirmed a pest control issue had not been identified by the facility. ADM #1 confirmed that the Corporate Office was responsible for bills to be paid. Bills were .recorded here [at the facility] and sent to the Corporate Office for payment there .Checks are cut centrally . Interview revealed the Regional VP had fiscal responsibility.
During an interview on 4/6/2023 at 8:36 AM, Licensed Practical Nurse (LPN) #6 revealed she had .seen roaches in resident's rooms and on the hallway .I've seen them [roaches] the whole two years . on the 100, 200, and 300 hallways. LPN #6 revealed that pest sightings had been reported through a maintenance book.
During an interview and document review on 4/6/2023 at 8:43 AM, the Assistant Director of Nursing (ADON #1) provided copies of the maintenance book which revealed multiple reports of pest sightings in the facility since 2022.
During an interview on 4/6/2023 at 9:10 AM, Physical Therapist (PT #1) revealed he had .seen a couple of roaches .those little bitty mice .in lounge . PT #1 revealed the pests were reported to maintenance and .I told my boss .
During an interview on 4/6/2023 at 1:30 PM, with Resident #26 and Resident #28's sitters revealed there was a roach on the floor of Resident #28's room, adjacent to the sink area .about 2 weeks ago . During the interview Resident #26 revealed there was a .rodent .[mouse] . in her room several months ago.
During an observation and tour of the kitchen on 4/10/2023 at 3:31 PM, showed the following:
1.
A dark dried substance on the clean dish rack
2.
A 5 gallon bucket ½ full of powdered thickener, stored in the dry storage area, open to air
3.
Live roaches behind the ice machine on the wall and on the floor
4.
A live roach on the floor in front of the oven and climbing up the door frame to the dish room.
5.
A sleeve of disposable 8 ounce cups open to air on the prep table.
6.
The steamer contained a dark murky water with brown and white foam floating on top of the water and the water had a foul odor.
During an interview on 4/10/2023 at 3:51 PM, DM #1 confirmed there was a dark, dried substance on the clean dish rack, the bucket of thickener was left open to air, live roaches in the kitchen, the sleeve of the disposable cups had been left open to air, and the steamer contained dirty water. DM #1 stated the steamer had only been used at breakfast to maintain pureed food temperature until the food was served and the steamer had not been cleaned. DM #1 confirmed the kitchen had been closed for service from 4/3/2023 (the steamer was not to be used on 4/10/2023).
During an interview on 4/12/2023 at 9:12 AM, MA #1 revealed he observed on the pest control logs the presence of mice in the facility. MA #1 stated he placed sticky pads throughout the inside and outside of the facility and revealed the sticky pads had been checked every couple of days in with varied amounts of mice observed on pads.
During an observation in the Conference Room, on 4/12/2023 at 3:23 PM, Surveyor #2 found a live roach had crawled on her chest.
On 4/13/2023, Surveyors reviewed the education and sign in sheets which validated the corrective action plans onsite which was provided by the Regional [NAME] President/ADM #1 and Interim Administrator. Surveyors verified onsite the kitchen was closed for meal service from 4/3/2023 - 4/13/2023. Surveyors verified resident meals were obtained from an outside source from 4/3/2023 - 4/13/2023. Surveyors verified by review of cleaning logs that meal preparation and meal serving areas were being conducted three times daily in a sanitary manner. Surveyors observed dishes, utensils, pots, pans, meal prep items, surfaces, and equipment to ensure these were cleaned and sanitized three times daily after each meal. Surveyors verified the dishware was cleaned, sanitized, dried, and stored properly in airtight and waterproof containers. Surveyors interviewed dietary staff & cleaning logs to verify the kitchen was cleaned and sanitized at the end of each day. Surveyors interviewed the pest control technician and observed the kitchen to verify the treatment strategies were effective and the presence of dead and live pest were improving. Interview with the pest control
technician, Regional [NAME] President/Administrator (ADM#1), Interim Administrator, and Registered Dietician showed they are consulting with the pest control service provider for treatment strategies. Surveyors verified on 4/13/2023 the kitchen was cleaned by the dietary manager, dietary staff, and other members of the facility's team. Surveyors observed all unsealed boxes of meal preparation items had been discarded. Observations showed a clean oven, stove, and door frame to the washroom.
Noncompliance at F-812 continues at a scope and severity of F for monitoring of the effectiveness of the corrective actions.
The facility is required to submit a plan of correction.
CRITICAL
(L)
Immediate Jeopardy (IJ) - the most serious Medicare violation
Administration
(Tag F0835)
Someone could have died · This affected most or all residents
⚠️ Facility-wide issue
Based on review of the facility policy review, Administrator's job description, review of the facility's Medical Director Agreements, facility documentation review, and interview the facility's Admini...
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Based on review of the facility policy review, Administrator's job description, review of the facility's Medical Director Agreements, facility documentation review, and interview the facility's Administration failed to manage its resources and operating budget to maintain an effective pest control program after an invoice was not paid to the pest control company which resulted in an interruption in services from 11/30/2022 - 4/4/2023 and an outbreak of pest in the facility's kitchen. The facility's failure did not maintain the highest practicable physical, mental, and psychosocial wellbeing of the 144 residents residing in the facility.
The Regional [NAME] President of Operations failed to address facility concerns. Deficiencies were cited resulting in an Immediate Jeopardy (a situation in which the provider's noncompliance with one or more requirements of participation has caused, or is likely to cause, serious injury, harm, impairment, or death to a resident).
The Interim Administrator and Regional [NAME] President/Administrator (ADM #1) were notified of the Immediate Jeopardy for F812 and F925 on 4/4/2023 at 6:36 PM in the Administrator's office.
The Regional [NAME] President/Administrator (ADM #1) was notified of the Immediate Jeopardy for F835 on 4/11/2023 at 10:55 AM in the Administrator's office.
The Interim Administrator and Regional [NAME] President/Administrator (ADM #1) were notified of the Immediate Jeopardy for F837 on 4/12/2023 at 11:57 AM in the Administrator's office.
The facility was cited Immediate Jeopardy at F812 (L), F835 (L), F837 (L), and F925 (L).
The facility was cited F656 (G), F-684 (G), and F710 (G).
The Immediate Jeopardy began on 4/3/2023 and was removed on 4/13/2023.
An acceptable removal plan, which removed the immediacy of the jeopardy, was received 4/12/2023 at 5:37 PM, and the corrective actions were validated on-site by the surveyors on 4/13/2023.
The facility is required to submit a Plan of Correction.
The findings include:
Review of the facility's policy titled, Pest Control, revised 5/2008, showed .Our facility shall maintain an effective pest control program .This facility maintains an on-going pest control program to ensure that the building is kept free of insects and rodents .Pest control services are provided .
Review of the facility's Administrator job description, undated, and unsigned, showed .The primary purpose of your job position is to direct the day-to-day functions of the facility in accordance with current federal, state, and local standards, guidelines, and regulations that govern nursing facilities to assure that the highest degree of quality care can be provided to our residents at all times .Safety and Sanitation .Ensure that the building and grounds are maintained in good repair .Ensure that the facility is maintained in a clean and safe manner for resident comfort and convenience by assuring that necessary equipment and supplies are maintained to perform such duties/services .assure that the facility is maintained in a clean, safe and sanitary manner .Prepare an annual operating budget for approval by the governing board and allocate the resources to carry out programs and activities of the facility .
Review of the facility's documentation, untitled and undated, of the Regional [NAME] President job responsibilities showed, .Regional Vice-President .work has purpose .improve the quality of life of .patients .will act in the role of a trusted advisor .to identify improvement opportunities .The Regional [NAME] President is responsible for overall programs .Direct day-to-day management oversight .which ensures the health, safety, and satisfaction of all residents .Ensuring the quality of care and service delivered is of the highest level .
Review of an email on 11/4/2022 at 11:59 AM, titled request [previous pest control company name] payment from the facility Business Office Manager (BOM #1) to Regional [NAME] President of Operations/Administrator (ADM) #1 revealed .[name of previous pest control company] pest control called regarding balance of [$]3600.00 .They will not be back out to services [service] us without a payment first .Can we please get them paid .
Review of an email on 11/21/2022 at 11:16 AM, titled RE: request [previous pest control company name] payment from BOM # to Regional [NAME] President of Operations/Administrator (ADM) #1 revealed [name of previous pest control company] .called regarding payment again. They have stopped services and will be sending us to collections by the end of the month if they do not receive payment. They are looking for payment from July through October [2022] .Can we get them a payment of $3600.00 .
Review of an email on 3/31/2023 at 1:58 PM, titled [previous pest control company name] payment request from Business Office Manager (BOM #1) to Regional [NAME] President of Operations/Administrator (ADM) #1 revealed .Can we get payment as soon as possible? We owe them $1125.00. We really need the pest control service started back up before our annual survey .
During an observation and interview on 4/3/2023 at 9:27 AM, Dietary Manager (DM) #1 used a paper towel with an ungloved hand to kill roach crawling on the wall in the kitchen and did not sanitize hands.
During an observation and interview in the kitchen on 4/4/2023 at 9:30 AM, DM #1 and Registered Dietitian (RD) #1 confirmed live roaches were observed on the clean side of the dish table and in the dish room.
During an observation and interview in the kitchen on 4/4/2023 at 9:30 AM, DM #1 confirmed live roaches were noted inside one sleeve of the plate warmer used to serve hot food to residents in the facility.
During an interview on 4/4/2023 at 3:10 PM, Pest Control Technician (PCT)#1 revealed .Previous vendor had rodent control program PCT #1 confirmed roach communes in the .cracks where the caulking is missing . were noted in the kitchen and roaches were observed in the dish room, the wall behind the freezer and the center serving line, where there is a curling cord, and .some roaches were trying to run in that .
During an observation and interview, in the kitchen on 4/5/2023 at 8:28 AM, RD #1 confirmed the presence of live roaches in the plate warmer.
During an observation and tour of the kitchen on 4/5/2023 at 8:45 AM, multiple live roaches were observed in the kitchen, behind the ice machine, milk cooler, reach-in refrigerator, under the drink station table, and under the serving line.
During an interview in the kitchen on 4/5/2023 at 8:50 AM, DM #1 revealed he was not aware when pest control serviced the facility.
During an interview on 4/5/2023 at 8:58 AM, the Maintenance Director (MA #1) stated, .we've .had an issue .[regarding pests] .it's .ongoing .I have seen them .since November [2022] .It needs to be taken care of immediately . MA #1 confirmed the pest control had not been completed because of .lack of payment . by the facility.
During an interview on 4/5/2023 at 9:25 AM, the Regional [NAME] President of Operations/ADM #1 confirmed the corporate office was responsible for bills to be paid. Bills were .recorded here [at the facility] and sent to the corporate office for payment .The Regional [NAME] President of Operations/ADM#1 had fiscal responsibility .
During an interview and document review on 4/6/2023 at 8:43 AM, the Assistant Director of Nursing (ADON #1) provided copies of the maintenance book which revealed multiple reports of pest sightings in the facility since 2022.
During an interview on 4/11/2023 at 2:31 PM, Medical Director [MD#1], confirmed he was not made aware of pest control concerns in the facility by the Administrator.
During an interview on 4/12/2023 at 3:33 PM, the Regional [NAME] President of Operations/ADM#1 confirmed she had not consulted with another qualified clinician to address the administration concerns.
On 4/13/2023, Surveyors reviewed the education and sign in sheets which validated the corrective action plans onsite which was provided by the Regional [NAME] President/Administrator (ADM #1). Surveyors verified onsite the kitchen was closed for meal service from 4/3/2023 - 4/13/2023. Surveyors verified a new contract for pest control had been initiated on 4/5/2023. Interview with the pest control technician showed pest control was provided on 4/4/2023, 4/5/2023, 4/6/2023 and 4/10/2023. Further interview with the pest control technician showed pest control services will be continued through the month of April. Interviews with licensed nurses showed 100% of staff had been educated on food borne illnesses and had been completed by 4/12/2023. The surveyors verified the Business Office Manager (BOM) provided the correct email address to the pest control services and the pest control provider provided the BOM with the pest control invoice. Surveyors verified in service and education had been conducted by the Corporate Controller to the Interim Administrator, Regional [NAME] President/Administrator (ADM #1) and Business Office Manager (BOM) on 4/11/2023. The Surveyors verified payment for pest control service had been issued to the pest control service one month in advance for the month of April and May to be sure no disruption of service. Interview with the Interim Administrator, Regional [NAME] President/Administrator (ADM #1), and BOM showed they were aware of the accounts payable process and steps to ensure payments to pest control services. Surveyors verified audits had been conducted by the administrator to determine the quality assurance efforts were in place.
Noncompliance at F-835 continues at a scope and severity of F for monitoring of the effectiveness of the corrective actions.
The facility is required to submit a plan of correction.
CRITICAL
(L)
Immediate Jeopardy (IJ) - the most serious Medicare violation
Deficiency F0837
(Tag F0837)
Someone could have died · This affected most or all residents
⚠️ Facility-wide issue
Based on job description review, facility documentation, observations, and interviews the facility failed to produce evidence of an effective governing body (GB), failed to manage its financial resour...
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Based on job description review, facility documentation, observations, and interviews the facility failed to produce evidence of an effective governing body (GB), failed to manage its financial resources to ensure an effective pest control program was maintained for 144 residents in the facility. Deficiencies were cited resulting in an Immediate Jeopardy (a situation in which the provider's noncompliance with one or more requirements of participation has caused, or is likely to cause, serious injury, harm, impairment, or death to a resident).
The Interim Administrator and Regional [NAME] President/Administrator (ADM #1) were notified of the Immediate Jeopardy for F812 and F925 on 4/4/2023 at 6:36 PM in the Administrator's office.
The Regional [NAME] President/Administrator (ADM #1) was notified of the Immediate Jeopardy for F835 on 4/11/2023 at 10:55 AM in the Administrator's office.
The Interim Administrator and Regional [NAME] President/Administrator (ADM #1) were notified of the Immediate Jeopardy for F837 on 4/12/2023 at 11:57 AM in the Administrator's office.
The facility was cited Immediate Jeopardy at F812 (L), F835 (L), F837 (L), and F925 (L).
The facility was cited F656 (G), F-684 (G), and F710 (G) .
The Immediate Jeopardy began on 4/3/2023 and was removed on 4/13/2023.
An acceptable removal plan, which removed the immediacy of the jeopardy, was received 4/12/2023 at 5:37 PM, and the corrective actions were validated on-site by the surveyors on 4/13/2023.
The facility is required to submit a Plan of Correction.
Findings include:
Review of the facility's documentation, untitled and undated, of the Regional [NAME] President job responsibilities showed, .Regional Vice-President of Operations .work has purpose; the capacity to strengthen the financial stability .improve the quality of life of .patients .will act in the role of a trusted advisor .to identify improvement opportunities, share pertinent data and information, and be responsive to .needs .Lead Board Chair prep calls, content creation, Executive Director calls, and participate in Board Meetings .Follow up on .issues .The Regional [NAME] President is responsible for overall programs .in accordance with the policies, procedures and in compliance with state, local and federal guidelines. Direct day-to-day management oversight .which ensures the health, safety, and satisfaction of all residents, budgetary control .responsibilities include .Fiscal Management, Quality Assurance .Regulatory Compliance .Property and Plant Maintenance and Improvements .Conduct site visits on a regular and routine basis to assist Executive Directors and Department Supervisors with operating issues and to monitor the quality of all programs and departmental operations .Creating and adhering to the budget .Ensuring the quality of care and service delivered is of the highest level .
Review of an email on 11/4/2022 at 11:59 AM, titled request [previous pest control company name] payment from the facility Business Office Manager (BOM #1) to Regional [NAME] President of Operations/Administrator (ADM) #1 revealed .[name of previous pest control company] pest control called regarding balance of [$]3600.00 .They will not be back out to services [service] us without a payment first .Can we please get them paid .
Review of an email on 11/21/2022 at 11:16 AM, titled RE: request [previous pest control company name] payment from BOM # to Regional [NAME] President of Operations/Administrator (ADM) #1 revealed [name of previous pest control company] .called regarding payment again. They have stopped services and will be sending us to collections by the end of the month if they do not receive payment. They are looking for payment from July through October [2022] .Can we get them a payment of $3600.00 .
Review of the Medical Director Agreement signed by Medical Director [MD] #1 showed . Physician [reference to Medical Director/Physician] shall guide, approve, and help oversee the development, implementation, and monitoring/evaluation of Facility's resident care policies and procedures in the following areas: .admission policies and care practices that address the types of residents that may be admitted and retained based upon the ability of the Facility to provide the services and care to meet their needs .Mechanisms for communicating and resolving issues related to medical care . Physician shall be responsible for coordination of medical care in the Facility. Physician shall help the Facility obtain and maintain timely and appropriate medical care that supports the healthcare needs of the residents, is consistent with current standards of practice, and helps the Facility meet its regulatory requirements .
Review of the Medical Director Agreement signed by MD #2 on 11/23/2022, showed, .Scope of Services: Medical Director shall provide overall medical leadership for .operations including the nursing facility .Medical Director shall provide medical direction and guidance .including participation in the .QI (quality improvement) meetings .This agreement shall be for a term of one (1) year from the effective date above the signature line . Further review revealed there was no mention of Medical Director #2's responsibilities limited to the skilled residents.
Review of the Minutes of Board of Directors Meeting (Governing Body), dated 12/7/2022 revealed the meeting was held via video teleconference and the topics were fiscal in nature. The minutes did not reflect clinical or any other concerns other than revenue for the facility.
Review of an email on 3/31/2023 at 1:58 PM, titled [previous pest control company name] payment request from BOM #1 to Regional [NAME] President of Operations/Administrator (ADM) #1 revealed .Can we get payment as soon as possible? We owe them $1125.00. We really need the pest control service started back up before our annual survey .
During an interview on 4/11/2023 at 2:31 PM, MD #1 stated he had not been made aware of the members of the GB.
During an interview on 4/12/2023 at 3:13 PM, Registered Nurse (RN) #2 stated the governing body consist of the Administrator, Regional [NAME] President and Senior Director of Clinical Operations.
During an interview on 4/12/2023 at 3:33 PM, the Regional [NAME] President of Operations/ADM #1 confirmed she was a member of the GB and reported to the Chief Executive Officer (CEO) but was unable to readily identify all members of the governing body. She stated the governing body meets monthly to discuss Quality Indicators, staffing, financial operations, HR [Human Resources] updates, and business office updates. Regional [NAME] President of Operations/ADM #1 stated past due pest control bills or concerns with the facility acquiring two medical directors was not discussed in morning standup, QAPI or Governing Body meetings. Regional [NAME] President of Operations/ADM #1 was not sure if Governing Body was aware of past due pest control bills (this information is conflicting due to emails sent to Regional [NAME] President of Operations/ADM #1). Regional [NAME] President of Operations/ADM #1 stated the Chief Financial Officer, or designee is responsible for invoice and bill payment approval. She stated the GB had only discussed accounts receivable and further confirmed no other issues or concerns of the facility had been identified or discussed during their monthly meetings.
4/13/2023, Surveyors reviewed the education and sign in sheets which validated the corrective action plans onsite which was provided by the Regional [NAME] President/Administrator (ADM #1). Surveyors verified onsite the kitchen was closed for meal service from 4/3/2023-4/13/2023. Surveyors verified a new contract for pest control had been initiated on 4/5/2023. Interview with the he pest control technician showed pest control was provided on 4/4/2023, 4/5/2023, 4/6/2023 and 4/10/2023. Further interview with the pest control technician showed pest control services will be continued through the month of April. Interviews with licensed nurses showed 100% of staff had been educated on food borne illnesses and had been completed by 4/12/2023. The surveyors verified payment for pest control service had been issued to the pest control service one month in advance for the month of April and May to be sure no disruption of service. Surveyors verified in-service and education had been conducted by the Corporate Controller to the Interim Administrator, Regional [NAME] President/Administrator (ADM #1), and Business Office Manager (BOM). Interview with the Interim Administrator, Regional [NAME] President/Administrator (ADM #1), and BOM showed they were aware of the accounts payable process and steps to ensure payments to pest control services. Surveyors verified audits had been conducted by the administrator to determine the quality assurance efforts were in place.
Noncompliance at F-837 continues at a scope and severity of F for monitoring of the effectiveness of the corrective actions.
The facility is required to submit a plan of correction.
CRITICAL
(L)
Immediate Jeopardy (IJ) - the most serious Medicare violation
Deficiency F0925
(Tag F0925)
Someone could have died · This affected most or all residents
⚠️ Facility-wide issue
Based on facility policy review, electronic communication review, observation, and interview the facility failed to maintain an effective pest control program potentially affecting 144 residents. Defi...
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Based on facility policy review, electronic communication review, observation, and interview the facility failed to maintain an effective pest control program potentially affecting 144 residents. Deficiencies were cited resulting in an Immediate Jeopardy (a situation in which the provider's noncompliance with one or more requirements of participation has caused, or is likely to cause, serious injury, harm, impairment, or death to a resident).
The Interim Administrator and Regional [NAME] President/Administrator (ADM #1) were notified of the Immediate Jeopardy for F812 and F925 on 4/4/2023 at 6:36 PM in the Administrator's office.
The Regional [NAME] President/Administrator (ADM #1) was notified of the Immediate Jeopardy for F835 on 4/11/2023 at 10:55 AM in the Administrator's office.
The Interim Administrator and Regional [NAME] President/Administrator (ADM #1) were notified of the Immediate Jeopardy for F837 on 4/12/2023 at 11:57 AM in the Administrator's office.
The facility was cited Immediate Jeopardy at F812 (L), F835 (L), F837 (L), and F925 (L).
The facility was cited F656 (G), F-684 (G), and F710 (G).
The Immediate Jeopardy began on 4/3/2023 and was removed on 4/13/2023.
An acceptable removal plan, which removed the immediacy of the jeopardy, was received 4/12/2023 at 5:37 PM, and the corrective actions were validated on-site by the surveyors on 4/13/2023.
The facility is required to submit a Plan of Correction.
The findings include:
Review of the facility's policy titled, Pest Control, revised 5/2008, showed .Our facility shall maintain an effective pest control program .This facility maintains an on-going pest control program to ensure that the building is kept free of insects and rodents .Pest control services are provided .
Review of an email dated 11/4/2022 at 11:59 AM, titled request [previous pest control company name] payment from the facility Business Office Manager (BOM #1) revealed, .[name of previous pest control company] pest control called regarding balance of [$]3600.00 .They will not be back out to services [service] us without a payment first .Can we please get them paid .
Review of an email dated 11/21/2022 at 11:16 AM, titled RE: request [previous pest control company name] payment from BOM #1 revealed, [name of previous pest control company] .called regarding payment again. They have stopped services and will be sending us to collections by the end of the month if they do not receive payment. They are looking for payment from July through October [2022] .Can we get them a payment of $3600.00 .
Review of an email dated 3/31/2023 at 1:58 PM, titled [previous pest control company name] payment request from Business Office Manager (BOM #1) revealed, .Can we get payment as soon as possible? We owe them $1125.00. We really need the pest control service started back up before our annual survey .
During an observation, interview and tour of the kitchen with the Dietary Manager (DM #1) on 4/3/2023 at 9:27 AM, the following was observed:
1.
DM #1 confirmed florescent light fixtures showed multiple insects.
2.
DM #1 confirmed a roach crawled up the wall behind the ice cream storage cooler.
During an observation and interview on 4/3/2023 at 9:27 AM, DM#1 used a paper towel with a bare hand to kill a roach crawling on the wall behind the milk cooler.
During an observation and interview in the kitchen, on 4/4/2023 at 9:30 AM, DM #1 and Registered Dietitian (RD) revealed the following:
1.
RD #1 confirmed live roaches on the clean side of the dish table.
2.
DM #1 confirmed live roaches inside one sleeve of the plate warmer 2 empty sleeves with thick dark buildup in the bottom, two sleeves full of plates ready to be used.
During an observation on 4/4/2023 at 1:57 PM, on the 100 hallway revealed a live cockroach crawling on the forehead of Surveyor #1. Surveyor #3 removed and killed the cockroach.
During an interview on 4/4/2023 at 3:10 PM, Pest Control Technician (PCT) #1 revealed .Previous vendor had rodent control program PCT #1 further revealed he found some roach communes in the kitchen in .cracks where the caulking is missing . The roach locations were in the dish room, the wall behind the freezer and the center serving line, where there is a curling cord and some roaches were trying to run in that.
During an observation and interview in the kitchen, on 4/5/2023 at 8:28 AM, RD #1 confirmed the presence of live roaches in the plate warmer on clean plates (picture taken).
During an observation and tour of the kitchen on 4/5/2023 at 8:43 AM, a roach was observed crawling up the wall, in the kitchen, near an ice scoop. The ice scoop was uncovered, positioned in an open holder, attached to the wall.
During an observation and tour of the kitchen on 4/5/2023 at 8:45 AM, multiple live roaches were observed in the kitchen, behind the ice machine, milk cooler, reach in refrigerator, under the drink station table, and under the serving line.
During an interview in the kitchen on 4/5/2023 at 8:50 AM, DM #1 revealed that he was not aware of the last time pest control came to the facility.
During an interview in the dining area outside the kitchen on 4/5/2023 at 9:25 AM, Regional [NAME] President/Administrator of Record (ADM #1) revealed .usually the Maintenance Director or Dietary Manager would make us aware if they've not had these things [pest control services] . ADM #1 confirmed that the Corporate Office was responsible for bills to be paid. Bills were .recorded here [at the facility] and sent to the Corporate Office for payment there .Checks are cut centrally .
During an interview on 4/5/2023 at 8:58 AM, the Maintenance Director (MA #1) stated, .We've always had an issue .[regarding pests] . MA #1 stated regarding the roaches in the kitchen, .It's .ongoing .I have seen them .I have seen them since November [2022] .It needs to be taken care of immediately . MA #1 confirmed the pest control had not been completed because of .lack of payment . by the facility. MA #1 stated .We've had a few Administrators .[Previous Administrator Name (ADM #2)] . had been advised of the pest control problem. MA #1 stated the interim administrator had been made aware of the pest control problem. MA #1 revealed he had seen roaches .in the past .randomly throughout the building .
During an interview on 4/6/2023 at 8:36 AM, Licensed Practical Nurse (LPN) #6 revealed she had .seen roaches in resident's rooms and on the hallway .I've seen them [roaches] the whole two years . on the 100, 200, and 300 hallways. LPN #6 revealed that pest sightings had been reported through a maintenance book.
During an interview and document review on 4/6/2023 at 8:43 AM, the Assistant Director of Nursing (ADON #1) provided copies of the maintenance book which revealed multiple reports of pest sightings in the facility since 2022.
During an interview on 4/6/2023 at 9:10 AM, Physical Therapist (PT #1) revealed he had .seen a couple of roaches .those little bitty mice .in lounge . PT #1 revealed that the pests were reported to maintenance and .I told my boss .
During an interview on 4/6/2023 at 1:30 PM, with Resident #26 and Resident #28's sitters revealed there was a roach in the floor of Resident #28's room, adjacent to the sink area, .about 2 weeks ago . During the interview, Resident #26 revealed there was a .rodent [mouse] . in her room several months ago.
During an observation and tour of the kitchen on 4/10/2023 at 3:31 PM, showed live roaches behind the ice machine on the wall, the floor, front of the oven, and on the door frame.
During an interview on 4/12/2023 at 9:12 AM, MA #1 revealed he observed the pest control logs there was presence of mice in the facility and the logs were reviewed in the daily morning meeting. MA #1 placed sticky pads throughout the inside and outside of the facility and revealed that the sticky pads had been checked every couple of days in which varied amounts of mice have been observed.
During an observation in the Conference Room, on 4/12/2023 at 3:23 PM, Surveyor #2 found a roach crawling on her chest.
During an interview on 4/13/2023 at 10:05 AM, Registered Nurse #2 confirmed there was not an effective pest control program at the facility.
On 4/13/2023, Surveyors reviewed the education and sign in sheets which validated the corrective action plans onsite which was provided by the Regional [NAME] President/Administrator (ADM #1). Surveyors verified onsite the kitchen was closed for meal service from 4/3/2023-4/13/2023. Surveyors verified resident meals were obtained from an outside source from 4/3/2023-4/13/2023. Surveyors verified by review of cleaning logs that meal preparation and meal serving areas were being conducted three times daily in a sanitary manner. Surveyors observed dishes, utensils, pots, pans, meal prep items, surfaces, and equipment to ensure these were cleaned and sanitized three times daily after each meal. Surveyors verified the dishware was cleaned, sanitized, dried, and stored properly in airtight and waterproof containers. Surveyors interviewed dietary staff & cleaning logs to verify the kitchen was cleaned and sanitized at the end of each day. Surveyors interviewed the pest control technician and observed the kitchen to verify the treatment strategies were effective and the presence of dead and live pest were improving. Interview with the pest control technician, Regional [NAME] President/Administrator (ADM #1), Interim Administrator, and Registered Dietician showed they are consulting with the pest control service provider for treatment strategies. Surveyors verified on 4/13/2023 the kitchen was cleaned by the dietary manager, dietary staff, and other members of the facility's team. Surveyors observed all unsealed boxes of meal preparation items had been discarded. Observations showed a clean oven, stove, and door frame to the washroom.
Noncompliance at F-925 continues at a scope and severity of F for monitoring of the effectiveness of the corrective actions.
The facility is required to submit a plan of correction.
SERIOUS
(G)
📢 Someone Reported This
A family member, employee, or ombudsman was alarmed enough to file a formal complaint
Actual Harm - a resident was hurt due to facility failures
Comprehensive Care Plan
(Tag F0656)
A resident was harmed · This affected 1 resident
**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on the facility policy review, medical record review and interview, the facility failed to develop and implement care plan...
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**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on the facility policy review, medical record review and interview, the facility failed to develop and implement care plans for 2 Residents (Residents #583 and #102) of 36 residents reviewed for care plans. The facility failure to implement Resident #583's care plan resulted in the resident having a critical lab value, the resident was transferred to the hospital and diagnosed with a GI (Gastrointestinal Bleed), Anemia, and required a blood transfusion which resulted in Harm for Resident #583. The facility failed to develop and implement an individualized and person-centered care plan related to activities for 1 non-English speaking resident (Resident #102) of 2 non-English speaking residents reviewed.
The findings include:
Review of the facility's policy titled, Care Plans, Comprehensive Person-Centered, revised 12/2016, showed .A comprehensive, person-centered care plan that includes measurable objectives and timetables to meet the resident's physical, psychosocial and functional needs is developed and implemented for each resident .The care plan interventions are derived from a thorough analysis of the information gathered as part of the comprehensive assessment .The Interdisciplinary Team (IDT), in conjunction with the resident and his/her family or legal representative, develops and implements a comprehensive, person-centered care plan for each resident. The care planning process will .Facilitate resident and/or representative involvement .Include an assessment of the resident's strengths and needs; and Incorporate the resident's personal and cultural preferences in developing the goals of care .The comprehensive, person-centered care plan will .Describe the services that are to be furnished to attain or maintain the resident's highest practicable physical, mental, and psychosocial well-being .Incorporate identified problem areas; Reflect treatment goals, timetables and objectives in measurable outcomes; .Care plan interventions are chosen only after careful data gathering, proper sequencing of events, careful consideration of the relationship between the residents' problem areas and their causes, and relevant clinical decision making .
Review of the facility's policy titled, Activity Programs, revised 8/2006, showed Individualized and group activities are provided that .Reflect .choices and rights of the resident .Reflect the cultural and religious interests, hobbies, life experiences, and personal preferences of the residents .
Review of the medical record revealed Resident #583 was admitted to the facility on [DATE] with diagnoses including Acute Embolism and Thrombosis of Unspecified Deep Vein of Right Lower Extremity, Stage 3 Chronic Kidney Disease, and Venous Insufficiency.
Review of Resident #583's care plan dated 12/29/2022, revealed the resident was care planned for potential bleeding secondary to anticoagulant therapy related to reoccurring deep vein thrombosis. Interventions in place included administer anticoagulant medication as ordered, monitor labs as ordered, notify physician of abnormal labs and document, monitor daily during care for signs/symptoms of bleeding and to notify the physician of abnormal findings.
Review of the physician order dated 12/30/2022, revealed an order to check the resident's Prothrombin Time (PT a test that measures how quickly the blood clots) and International Normalized Ratio (INR a test that measures how long it takes blood to clot) every Monday.
Review of a lab dated 1/2/2023 revealed Resident #583 had a PT of 11.4 (normal range 9.6-12.2) and the resident's INR was 1.0 (normal range 0.80-3.50).
Review of a physician order dated 1/4/2023, revealed .Give xtra [extra] 1 mg [milligram] coumadin [warfarin][the generic name for a blood thinner medication used to prevent blood clots] daily for a total of 6 mg warfarin daily po [by mouth] .check PT/INR Monday [1/9/2023] .
Review of Resident #583's admission Minimum Data Set (MDS) assessment dated [DATE], revealed the resident had a Brief Interview for Mental Status (BIMS) score of 6 which indicated the resident had severe cognitive impairment. The resident had received an anticoagulant during her last 7 days or since admission/entry or reentry into the facility.
Review of a lab dated 1/9/2023, revealed Resident #583 had a Prothrombin time of 30.5 (high), and an INR of 2.81.
Review of Resident #583's Physician order dated 1/10/2023 revealed, .D/C [discontinue] warfarin 6 mg po daily start warfarin 5 mg on M [Monday] W[Wednesday] F [Friday], S [Saturday] S [Sunday] start warfarin 6 mg on T [Tuesday], T [Thursday] check PT INR Monday [1/16/2023] .
Review of a lab dated 1/16/2023, revealed the facility had performed a PT/INR lab draw on Resident #583 on 1/16/2023. Review showed there was a coagulation defect (blood specimen clotted). Review revealed the PT/INR lab was not redrawn after the coagulation defect.
Review of physician orders dated 1/10/2023-1/23/2023, showed the resident's PT/INR lab draw was not re-ordered. Review of orders revealed no documentation related to the missing results from the resident's PT/INR lab draw from 1/16/2023 or concerns related to the resident's PT/INR.
Review of the Medication Administration Records (MARS) dated 1/11/2023-1/22/2023, revealed Resident #583 continued to receive Warfarin 5 mg on Monday, Wednesday, Friday, Saturday, and Sunday. Resident #583 received Warfarin 6 mg on Tuesday and Thursday.
Review of a physician note dated 1/20/2023, electronically signed at 9:36 PM, revealed Resident #583's Physician (Medical Director #2) had assessed the resident on 1/20/2023. Review revealed, .Chief complaint .Reason for visit .Acute visit to SNF .Patient seen due to staff stopping me in hallway due to her SOB [shortness of breath][symptom of low Hgb] .She [Resident #583] has been [in] therapy and became dyspneic [short of breath] .upon checking her VS [vital signs] her T [temperature] was high at 100.1 .Due to her urinary frequency a ua [urine analysis (UA) test used to test a person's urine] was ordered .Her u/a from 1/20[1/20/2023] revealed .none bacteria were seen . Review revealed no documentation related to the missing results from the resident's PT/INR lab draw from 1/16/2023 or concerns related to the resident's PT/INR.
Review of a physician order dated 1/23/2023 revealed, . PT/INR in AM [morning] . Fax me INR from 1/16/23 [2023, approximately 13 days since resulted PT/INR lab levels reviewed by the Medical Director #2] .
Review of a lab dated 1/24/2023, revealed the resident had a Prothrombin time >90 (normal range 9.6-12.2) and an INR of >9 (normal range 0.80-3.50). Review revealed this was a critical lab and the resident's INR was elevated.
Review of the MAR dated 1/23/2023, revealed Resident # 583's Coumadin doses were held on 1/23/2023 and 1/24/2023.
Review of a physician order dated 1/24/2023 revealed, .INR [lab] on M [Monday], W [Wednesday], F [Friday] while on antibiotic .DX [diagnosis] Right lung PNA [Pneumonia] .
Review of a physician order dated 1/24/2023, revealed .1) Vitamin K [medication used to manage and treat bleeding] 1 po [by mouth] now (5mg) 2) PT/INR in AM [the physician ordered another lab draw to be performed the next day 1/25/2023 in the facility] 3) D/C Coumadin .Indication-DX [diagnose] critical INR/Blood work [last resulted PT/INR performed 1/09/2023] .
Review of the physician order dated 1/24/2023 revealed, .Send to [name of hospital emergency room] per son request .
Review of Resident #583's Hospital History and Physical, dated 1/24/2023, revealed .Nursing home sent the patient for shortness of breath and low H &H [hemoglobin and hematocrit/red blood cell count] .I [hospital physician] did call and speak with her son who reported that she had not felt well for 3 or 4 days .She is also profoundly supratherapeutic [an amount of drug/medication that was greater than the therapeutic concentration]on her INR .She has received Kcentra [a medication use for urgent reversal of acquired coagulation factor deficiency induced by Coumadin/Warfarin] .Tells [Resident #583] me that she just feels rough Review revealed the resident had Hemorrhagic disorder [spontaneous or near spontaneous bleeding caused by a defect in the clotting mechanisms] due to circulating anticoagulants[in her bloodstream] and had heme positive stool [blood in stool] and an INR greater than 12. The resident's Coumadin medication was held. The resident had Acute Blood Loss Anemia with blackish colored stool. She was diagnosed with COVID and Acute Respiratory Failure. Review revealed, .Patient [Resident #583] is quite ill in conjunction with her frailty her prognosis is poor .GI bleed .I suspect this is related to her having a supratherapeutic INR .Acute blood loss anemia .Patient is in the process of being transfused [blood transfusion] Hemorrhagic disorder secondary to extrinsic [administering of anticoagulant medication] anticoagulants therapy .
Review of Resident #583's Hospital discharge date d 1/27/2023 revealed . Discharge diagnoses .Hemorrhagic disorder .Acute blood loss anemia .COVID 19 .Acute respiratory Failure .Supratherapeutic INR .GI bleed . Review of discharge medication list showed the resident was not discharged from the hospital with an order for Coumadin/Warfarin.
Review of a nursing note dated 1/27/2023 at 4:43 PM, revealed the resident returned to the nursing home following her hospitalization.
During an interview on 4/11/2023 at 10:17 AM, Resident #583's Physician (Medical Director #2) stated the care plan informed the staff on how to care for residents in the facility. The Medical Director confirmed the resident had no PT/INR labs with results from 1/10/2023-1/23/2023 and the facility failed to monitor Resident #583's labs. Medical Director #2 revealed the resident's PT/INR lab was drawn on 1/24/2023 and was a critical lab value. Resident #583 required hospitalization, was diagnosed with a GI bleed, Anemia and required a blood transfusion, the resident had a supratherapeutic INR and required treatment with Kcentra [a medication use for urgent reversal of acquired coagulation factor deficiency induced by warfarin]. The Medical Director confirmed Resident #583's care plan was not followed and the resident's labs were not monitored by the facility the week of 1/16/2023. Medical Director #2 stated .The missed labs contributed to the resident being harmed .
During an interview on 4/11/2023 at 2:14 PM, Medical Director #1 confirmed the facility failed to follow the resident's care plan to monitor the residents PT/INR and caused harm for Resident #583.
During an interview on 4/11/2023 at 3:45 PM, Licensed Practical Nurse (LPN #8) revealed Resident #583's care plan was accurate. The LPN revealed the care plan was used as a guide for the CNAs, Nurses, and Physicians to implement interventions for resident care. The LPN confirmed Resident #583's care plan was not followed by staff and the resident's lab were not monitored by the facility.
Resident #102 was admitted to the facility on [DATE] with diagnoses including Dysphagia, Unspecified Dementia with Other Behavioral Disturbance, End Stage Renal Disease, Chronic Congestive Heart Failure, Acute Respiratory Failure, Diabetes Mellitus, Polyneuropathy and Depression.
Review of a quarterly Minimum Data Set (MDS) assessment dated [DATE], showed the resident scored a 12 on the Brief Interview for Mental Status (BIMS) assessment which indicated the resident had moderate cognitive impairment. The MDS showed the resident's activities of choosing clothes to wear, bedtime, being around animals/pets, keeping up with the news, doing things with groups of people, doing favorite activities, and going outside when there was good weather was somewhat important to the resident, and the activity of listening to music was very important.
Review of a comprehensive care plan dated 9/20/2022, revised on 9/29/2022, and 4/4/2023, revealed Resident #102 was at risk for cognitive deficit related to the diagnosis of Dementia and had a communication barrier related to .Vietnamese as .first language . with interventions including .Contact RP [responsible party] via phone to translate, if needed. The care plan showed to post an activity calendar in the resident's room, encourage the resident to do activities in his own way, and provide the resident with in room activities. The resident enjoyed watching television and listening to Vietnamese music .[Resident #102] will be offered 1:1 visits and be invited to OOR [out of room] activities .had decreased mobility . and required assistance of staff with activities of daily living (ADLs) . The care plan showed there was no specific person-centered activities related to the resident's language, religious and cultural preference.
During an observation on 4/3/2023 at 5:14 PM, Resident #102 was asleep in bed. Observation of the resident's room showed the television was playing on an English-speaking program and an activities calendar printed in English was posted on the resident's wall. Continued observation showed no activities of the Vietnamese language available in the resident's room.
During an observation and interview on 4/4/2023 at 3:48 PM, Resident #102 was awake, laying in bed. Attempts to interview Resident #102 were unsuccessful due to the resident's inability to communicate in English. Continued observation showed the television program on in the resident's room was in the English language.
During an interview on 4/6/2023 at 11:52 AM, the Activities Director revealed she was responsible for completing the activities portion of the care plan. The Activities Director confirmed Resident #102 had limited person-centered activities on the care plan and stated .I wish I could do 100% more . The Activities Director further stated Vietnamese television programs or videos had not been provided to the resident and the activities calendar had only been provided in the English language. The Activities Director confirmed the activity care plan did not meet the needs of Resident #102.
SERIOUS
(G)
📢 Someone Reported This
A family member, employee, or ombudsman was alarmed enough to file a formal complaint
Actual Harm - a resident was hurt due to facility failures
Quality of Care
(Tag F0684)
A resident was harmed · This affected 1 resident
**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on the facility policy review, medical record review, and interview, the facility failed to follow a physician's order to ...
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**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on the facility policy review, medical record review, and interview, the facility failed to follow a physician's order to obtain a weekly lab for medication monitoring for 1 resident (Resident 583) of 30 residents reviewed for quality of care. Resident #583's lab specimen clotted rendering the specimen unusable, and a new specimen was not obtained. The facility's failure to ensure Resident #583's lab was obtained per the physician order resulted in an elevated International Normalized Ratio (INR a test which measures how long it takes blood to clot) critical lab value which required the resident to be hospitalized , diagnosed with a GI (Gastrointestinal) bleed upon arrival to the hospital, and required a blood transfusion, which resulted in Harm for Resident #583.
The findings include:
Review of the facility's policy, Anticoagulation-Clinical Protocol, dated 9/2012, revealed .Assessment and Recognition .The physician will identify individuals who are currently anticoagulated .Assess for evidence of effects related to the subtherapeutic or greater than therapeutic drug level related to that particular drug .In addition, the nurses shall assess and document/report the following .Recent labs, including therapeutic dose monitoring .Treatment/Management The physician will prescribe anticoagulation therapy .appropriately .
Review of the facility's policy, Lab and Diagnostic Test Results-Clinical Protocol, dated 2012 revealed .Assessment and Recognition .the physician will identify and order diagnostic and lab testing based on diagnostic and monitoring needs .The staff will process test requisitions and arrange for tests .The laboratory, diagnostic .or other testing source will report test results to the facility .A nurse will review all results .The person who is to communicate results to a physician will review and be prepared to discuss the following .How test results might relate to the individual's current status, treatments, or medications .The nursing staff will then contact the physician .A physician will respond within an appropriate time frame, based on .the clinical significance of the information .Physician decisions .When responding to notification of test results, the physician and staff will discuss the implications of the test results for the resident, as well as subsequent actions .
Review revealed Resident #583 was admitted to the facility on [DATE] with diagnoses including Acute Embolism and Thrombosis of Unspecified Deep Vein of Right Lower Extremity, Stage 3 Chronic Kidney Disease, and Venous Insufficiency.
Review of Resident #583's admission Minimum Data Set (MDS) assessment dated [DATE], revealed the resident had a Brief Interview for Mental Status (BIMS) score of 6 which indicated the resident had severe cognitive impairment. Review revealed the resident had received an anticoagulant during her last 7 days or since admission/entry or reentry into the facility.
Review of Resident #583's care plan dated 12/29/2022, revealed the resident was care planned for potential for bleeding secondary to anticoagulant therapy related to reoccurring deep vein thrombosis. Interventions in place included administer anticoagulant medication as ordered, monitor labs as ordered, notify physician of abnormal labs and document, monitor daily during care for signs/symptoms of bleeding and to notify the physician of abnormal findings.
Review of a physician order dated 12/30/2022, revealed an order to check the resident's Prothrombin time (PT a test which measures how quickly the blood clots) and INR every Monday.
Review of a lab dated 1/2/2023 revealed Resident #583 had a PT of 11.4 (normal range 9.6-12.2) and the resident's INR was 1.0 (normal range 0.80-3.50).
Review of a physician order dated 1/4/2023, revealed .Give xtra [extra] 1mg [milligram] coumadin [Warfarin, the generic name for a blood thinner medication used to prevent blood clots] daily for a total of 6 mg warfarin daily po [by mouth] .check PT/INR Monday [1/9/2023] .
Review of a lab dated 1/9/2023 revealed Resident #583 had a PT of 30.5 (high), and an INR of 2.81.
Review of a physician order dated 1/10/2023 revealed, .D/C [discontinue] warfarin 6 mg po daily start warfarin 5 mg on M [Monday] W [Wednesday] F [Friday], S [Saturday] S [Sunday] start warfarin 6 mg on T [Tuesday], T [Thursday] check PT INR Monday [1/16/2023] .
Review of a lab dated 1/16/2023 revealed the facility had performed a PT/INR lab draw on Resident #583 on 1/16/2023. Review showed there was a coagulation defect (blood specimen clotted). Review revealed the PT/INR labs was not redrawn from 1/10/2023-1/23/2023 after the coagulation defect.
Review of a physician orders dated 1/10/2023-1/23/2023 showed the resident's PT/INR lab draw was not re-ordered. Review of orders revealed no documentation related to the missing results from the resident's PT/INR lab draw from 1/16/2023 or concerns related to the resident's PT/INR
Review of the Medication Administration Records (MARS) dated 1/11/2023-1/22/2023 revealed the resident continued to receive Warfarin 5 mg on Monday, Wednesday, Friday, Saturday, and Sunday. Resident #583 received Warfarin 6 mg on Tuesday and Thursday.
Review of a physician note dated 1/20/2023 at 9:36 PM, revealed Resident #583's Physician (Medical Director #2) had assessed the resident on 1/20/2023. Review revealed, .Chief complaint .Reason for visit .Acute visit to SNF .Patient seen due to staff stopping me in hallway due to her SOB [shortness of breath] . She [Resident #583] has been therapy [to therapy] and became dyspneic [short of breath] .upon checking her VS [vital signs] her T [temperature] was high at 100.1 .Due to her urinary frequency a ua [urine analysis (UA) test used to test a person's urine] was ordered .Her u/a from 1/20[1/20/2023] revealed .none[no] bacteria were seen . Review revealed Medical Director #2 had reviewed Resident #583's UA results on 1/20/2023. Review of Medical Director #2's note revealed the physician did not address the missing results from the resident's PT/INR lab draw from 1/16/2023 or concerns related to the resident's PT/INR.
Review of the MAR dated 1/2023 revealed the resident's scheduled doses of Warfarin had not been adjusted from 1/11/2023-1/22/2023 after PT/INR results were not obtained for review by the physician.
Review of a physician order dated 1/23/2023 revealed, . PT/INR in AM . Fax me INR from 1/16/23 [2023] [13 days after the 1/9/2023 PT/INR results] .
Review of Resident #583's MAR revealed the resident's 5 mg and 6 mg dose Warfarin was held on 1/23/2023 with no specified reason given.
Review of a nursing note dated 1/24/2023 at 3:18 PM revealed, .Resident was showing s/s [signs/symptoms] of SOB [shortness of breath] during therapy .Upon examination resident O2 [oxygen saturation level] was 71% . started resident on oxygen 2 L [liters] .O2 [oxygen saturation level] came up to 97% . [name of the resident's physician] stated she was stopping by and will exam resident herself upon arrival .When [name of physician] came she stated that she believed the resident was fine that she wasn't worried that anything was wrong with resident [Resident #583] .X-ray came back and showed resident had R [right] side PNA [Pneumonia], and labs came back and showed critical lab values .Son was notified and stated he wanted his mother sent out due to critical values .Awaiting ambulance services now .
Review of a lab dated 1/24/2023 revealed the resident had a Prothrombin time >90 (normal range 9.6-12.2) and an INR of >9 (normal range 0.80-3.50).
Review of a physician order dated 1/24/2023 revealed, .Vitamin K [medication used to manage and treat bleeding] 1 po [by mouth] now (5mg) .PT/INR in AM [1/25/2023] .D/C Coumadin .Indication-DX [diagnose] .critical INR/Blood work .
Review of the physician order dated 1/24/2023, revealed .Send to [name of hospital emergency room] per son request .
Review of Resident #583's nursing note dated 1/24/2023 at 3:52 PM, revealed the resident was sent to the emergency room at 3:45 PM by ambulance per the resident's son request.
Review of Resident #583's Hospital History and Physical, dated 1/24/2023, revealed .Nursing home sent the patient for shortness of breath and low H &H [hemoglobin and hematocrit/red blood cell count] .I [hospital physician] did call and speak with her son who reported that she had not felt well for 3 or 4 days .She is also profoundly supratherapeutic [an amount of drug medication that was greater than the therapeutic concentration] on her INR .She has received Kcentra [a medication used for urgent reversal of Coumadin effects) .Tells me that she [Resident #583] just feels rough. Review revealed, .Patient [Resident #583] is quite ill in conjunction with her frailty her prognosis is poor . GI bleed .I suspect this is related to her having a supratherapeutic INR .Acute blood loss anemia .Patient is in the process of being transfused [blood transfusion] Hemorrhagic [spontaneous or near spontaneous bleeding caused by a defect in clotting mechanisms] disorder secondary to .anticoagulants therapy . Review revealed the resident had Hemorrhagic disorder due to circulating anticoagulants and had heme positive stool [blood in stool] and an INR greater than 12. The resident's Coumadin medication was held in the hospital. The resident had an Acute Blood Loss Anemia with blackish colored stool. The resident was diagnosed with COVID-19 and Acute Respiratory Failure in the hospital.
Review of Resident #583's Hospital discharge date of 1/27/2023 revealed . Discharge diagnoses .Hemorrhagic disorder .Acute blood loss anemia .Acute respiratory Failure .Supratherapeutic INR .GI bleed .
Review of a physician note dated 1/27/2023 revealed, .96 y/o [year old] .female readmitting from [name of the hospital] after a 1/24/2023 admission due to hemorrhagic disorder d/t [due to] circulating anticoagulants, Acute blood loss anemia, COVID-19 .
During an interview on 4/4/2023 at 9:25 AM, Licensed Practical Nurse (LPN) #7 stated, .I called [name of the resident's Physician Medical Director #2] one morning [1/24/2023] patient [Resident #583] was not acting right .[name of Medical Director #2] she stated she was fine .When patient went to hospital, she tested positive for COVID and had a GI bleed .I called son [Resident #583's son] and told him she wasn't doing like self [1/24/2023] and told him her critical labs values .Patient was tired .She [Resident #583] had declined [in her physical health] . The LPN confirmed the resident's son requested the resident be sent to the hospital due to the resident's critical labs values.
During an interview on 4/4/2023 at 2:10 PM, LPN #5 confirmed the nurses were responsible for checking and ensuring each lab draw was performed as ordered by the physician. The LPN stated, No one questioned the missed lab [Resident #583's resulted PT/INR] for 2 weeks .
During an interview on 4/5/2023 at 2:54 PM, Medical Director #1 confirmed .I've been concern about quality of care . He stated Coumadin/Warfarin was a high-risk medication and residents on the medication could have adverse reactions. The Medical Director revealed only a few residents in the facility were on Coumadin/Warfarin due to the risks of adverse reactions and side effects of the medication. The Medical Director revealed residents in the facility on Coumadin/Warfarin were to have their PT/INR levels reviewed and monitored weekly. Medical Director #1 confirmed the facility failed to monitor, check, and review Resident #583's PT/INR for approximately 2 weeks. Medical Director #1 stated the resident had an INR of 9 (on 1/24/2023) which was a critical lab value. Medical Director #1 confirmed the facility failed to ensure Resident #583's PT/INR resulted lab was obtained [the week of 1/16/2023] [7 days after the resident's INR was resulted on 1/9/2023]. Medical Director #1 revealed PT/INR labs were to be reviewed weekly to ensure adjustments were made to the resident's Coumadin/Warfarin drug regimen based on their weekly PT/INR lab results. Medical Director #1 stated, .The patient [Resident #583] could have bleed out . Medical Director #1 confirmed Resident #583 had a high potential for harm when Resident #583's PT/INR lab value was not determined on 1/16/2023 to ensure the resident was receiving a therapeutic dose of Warfarin/ Coumadin. Medical Director #1 stated, .You can easily have GI bleed and bleed out if medication [Coumadin] given and no lab [performed] to monitor INR/PT every week .High risk of severe outcome .If she fell, she [Resident #583] could bleed out easily . Medical Director #1 confirmed Resident #583 was harmed.
During an interview on 4/6/2023 at 11:02 AM, the DON confirmed the process for obtaining resident labs were the following: The physician wrote an order for a lab to be performed. The nurse on duty responsible for the resident or the Unit Nurse Manger then placed the order for the lab in the computer. The night shift nurse then printed the lab requisition for the lab scheduled to be drawn the next morning/or on day shift. The resident's nurse then placed the lab requisition in the lab book located at the nurse's station. The outside lab personnel retrieve the lab book the day of the lab draw. The lab personnel review the requisition. The lab personnel perform the lab draw and collected the lab specimen. The lab personnel then signed their name on the form in the lab book next to the resident's name to confirm a lab draw had been performed. The DON confirmed Resident #583 continued to received Warfarin/ Coumadin at the same dosage without having a lab with current PT/INR levels from 1/9/2023-1/23/2023. The DON confirmed the facility was aware the lab was not resulted on 1/16/2023 and confirmed the facility failed to reorder and obtain a PT/INR on Resident #583 the week of 1/16/2023. The DON confirmed Resident #583's Warfarin/Coumadin medication was not readjusted after 1/10/2023-1/22/2023. The DON revealed the resident's nurse called the resident's son and informed him of the critical lab values and the resident's son initiated and requested the resident be sent to the hospital for treatment.
During an interview on 4/10/2023 at 7:50 AM, LPN #11 stated the nurses were responsible for printing resident lab results from the computer located at the nursing station. The LPN stated the resident's assigned nurse would then place the results of the lab in the resident's physician's lab book for review by the physician. The LPN stated if labs were ordered STAT or were not resulted the resident's physician would either be verbally informed in person of the results, telephoned, or faxed the results. The LPN stated the resident's Physician would then order the lab to be redrawn or discontinue the lab. The Nurse stated, . [Medical Director #2] wants it [lab results] called or faxed .If not resulted Nurse calls the doctor and get an order to redraw labs .
During an interview on 4/10/2023 at 2:44 PM, the DON stated, .The Unit Managers [Nurse Managers] ensure labs are done .and doctors are informed of the lab results daily . The DON confirmed Resident #583's PT/INR lab was drawn by an outside lab service on 1/16/2023. The DON stated the Unit Manger notified the Medical Director on 1/16/2023 the resident's PT/INR was not resulted. The DON stated she was present at the nursing station when the Unit Manager informed Medical Director #2 Resident #583's PT/INR labs were not resulted from 1/16/2023. The DON confirmed Medical Director #2 did not give the Unit Manger a verbal order to reorder the resident's PT/INR lab. The DON stated the Medical Director #2 had the resident's chart in her hand and was to write an order for the lab to be redrawn. The DON confirmed Coumadin/Warfarin was a high-risk medication. The DON confirmed the resident's INR was 9 on 1/24/2023. The DON stated, .If not monitored [PT/INR labs] blood [a resident's] can get too thin and they can bleed to death or require a blood transfusion . The DON confirmed Resident #583 had a change in her medical status and required hospitalization.
During an interview on 4/10/2023 at 3:14 PM, Nurse Practitioner (NP) #1 stated residents who are ordered and receiving Coumadin/Warfarin were to have their PT/INR labs drawn at least weekly and have their labs reviewed by the NP/Physician weekly to ensure residents receive appropriate therapeutic dosages of Coumadin. The NP #1 confirmed PT/INR levels are reviewed and drawn to ensure a resident does not bleed out. The NP #1 stated an adverse effect of Warfarin was a GI Bleed or any bleeding. The NP #1 stated, .That's a problem if someone gets Warfarin and has a GI bleed .
During an interview on 4/11/2023 at 10:17 AM, Medical Director #2 stated, .If labs not drawn they [nurse] call me tell me to reorder the lab .I don't recall if any staff asked me to reorder [Resident #583's labs [PT/INR when not resulted on 1/16/2023] .My expectation is for staff .to redraw the labs the next day . Medical Director #2 confirmed Resident #583 continued to receive the same dosage of Coumadin/Warfarin without a current PT/INR the week of 1/16/2023. Medical Director #2 confirmed the Resident #583's transfer to hospital was initiated by the resident's son on 1/24/2023. Medical Director #2 confirmed the resident had an INR of 9 on 1/24/2023 required hospitalization, was diagnosed with a GI bleed, Anemia, a supratherapeutic INR which required urgent treatment with Kcentra to reverse the effects of her Coumadin/Warfarin medication she received at the facility and required a blood transfusion. Medical Director #2 stated she was responsible for providing quality of care to the Resident #583.
During an interview on 4/11/2023 at 2:14 PM, Medical Director #1 stated .The resident [Resident #583} failed to receive appropriate quality of care and treatment at the facility to prevent harm .
During an interview on 4/11/2023 at 3:45 PM, LPN #8 stated, .She [Resident #583] continued to receive medications [Coumadin] that's a big No No .she did not receive proper care .
During an interview on 4/11/2023 at 4:00 PM, LPN #10 revealed the resident had to receive a higher level of care because of elevated INR. The LPN stated, If too high your blood too thin and you can bleed out [blood loss to such a degree the person bleeding dies] .and can require blood .It would be hard to stop bleeding . LPN #10 stated, .The patient [Resident #583] did not get quality care .
During an interview on 4/12/2023 at 11:00 AM, .Nurse Practitioner #2 confirmed the resident's lab values were not obtained and monitored weekly by the facility. The Nurse Practitioner stated, .Not keeping up with PT/INR can cause harm .The resident (Resident #583) didn't get good quality of care .That caused her harm .
During an interview on 4/12/2023 at 12:01 PM, the LPN #8 stated, .The Doctor was going to leave the patient in house [at the nursing home] the son was the one who wanted the resident sent to the hospital . The LPN revealed the resident's PT/INR was not drawn 1/17/2023-1/23/2023 and the resident's PT/INR was not monitored. The LPN stated, .I can say she [Resident #583] did not get good quality care .
During an interview on 4/13/2023 at 10:45 AM, Medical Director #1 revealed the professional standard was for all labs ordered to be collected, reviewed and followed up by the facility. Medical Director #1 confirmed STAT labs [laboratory tests and services that are needed immediately in order to manage medical emergencies] for Resident #583 should have been ordered when it was noted the Resident #583's PT/INR results were not available [1/9/2023-1/23/2023]. Medical Director #1 revealed if PT/INR labs are not resulted they should be re-ordered. The Medical Director confirmed the facility failed to provide quality of care to Resident #583 which resulted in harm to Resident #583.
SERIOUS
(G)
📢 Someone Reported This
A family member, employee, or ombudsman was alarmed enough to file a formal complaint
Actual Harm - a resident was hurt due to facility failures
Deficiency F0710
(Tag F0710)
A resident was harmed · This affected 1 resident
**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on the facility policy review, medical record review and interview, the facility failed to ensure 1 resident's (Resident #...
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**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on the facility policy review, medical record review and interview, the facility failed to ensure 1 resident's (Resident #583) medical care was supervised by a physician of 36 residents reviewed for physician services. The facility's failure to monitor Resident #583's medical status resulted in an elevated International Normalized Ratio (INR a test which measures how long it takes blood to clot) critical lab value which required the resident to be hospitalized , diagnosed with a GI (Gastrointestinal) bleed upon arrival to the hospital and required a blood transfusion, which resulted in Harm for Resident #583.
The findings include:
Review of the facility's policy, Anticoagulation-Clinical Protocol, dated 9/2012, revealed .Assessment and Recognition .The physician will identify individuals who are currently anticoagulated .Assess for evidence of effects related to the subtherapeutic or greater than therapeutic drug level related to that particular drug .In addition, the nurses shall assess and document/report the following .Current anticoagulant therapy .Recent labs, including therapeutic dose monitoring .Treatment/Management The physician will prescribe anticoagulation therapy .appropriately .
Review of the facility's policy, Physician Services, dated 4/2013, revealed .Policy Interpretation and Implementation .The resident's attending physician participates in the resident's assessment and care planning, monitoring changes in resident's medical status, providing consultation or treatment when called by the facility, and overseeing a relevant plan of care for the resident .The physician will perform pertinent, timely medical assessments: prescribe an appropriate medical regimen: provide adequate, timely information about the resident's condition and medical needs .
Resident #583 was admitted to the facility on [DATE] with diagnoses including Acute Embolism and Thrombosis of Unspecified Deep Vein of Right Lower Extremity, Stage 3 Chronic Kidney Disease, and Venous Insufficiency.
Review of Resident #583's care plan dated 12/29/2022 revealed the resident was care planned for potential for bleeding secondary to anticoagulant therapy related to reoccurring deep vein thrombosis. Interventions in place included administer anticoagulant medication as ordered, monitor labs as ordered, notify physician of abnormal labs and document, monitor daily during care for signs/symptoms of bleeding and to notify the physician of abnormal findings.
Review of a physician order dated 12/30/2022, revealed an order to check the resident's Prothrombin time (PT a test which measures how quickly the blood clots) and INR every Monday.
Review of Resident #583's admission Minimum Data Set (MDS) assessment dated [DATE], revealed the resident had a Brief Interview for Mental Status (BIMS) score of 6 which indicated the resident had severe cognitive impairment. Review revealed the resident had received an anticoagulant during her last 7 days or since admission/entry or reentry into the facility.
Review of a lab dated 1/9/2023 revealed Resident #583 had a PT of 30.5 (normal range 9.6-12.2)), and an INR of 2.81 (normal range 0.80-3.50).
Review of a physician order dated 1/10/2023 revealed, .D/C [discontinue] warfarin 6 mg po daily start warfarin 5 mg on M [Monday] W [Wednesday] F [Friday], S [Saturday] S [Sunday] start warfarin 6 mg on T [Tuesday], T [Thursday] check PT INR Monday [1/16/2023] .
Review of a lab dated 1/16/2023 revealed the facility had performed a PT/INR lab draw on Resident #583 on 1/16/2023. Review showed there was a coagulation defect (clotted blood specimen). Review revealed the PT/INR lab was not redrawn.
Review of physician orders dated 1/16/2023-1/23/2023, showed the resident's PT/INR lab draw was not re-ordered by the physician. Review of orders revealed no documentation related to the missing results from the resident's PT/INR lab draw from 1/16/2023 or concerns related to the resident's PT/INR
Review of lab results revealed a repeat PT/INR lab draw was not performed from 1/16/2023-1/23/2023.
Review of a physician note dated 1/20/2023 at 9:36 PM, revealed Resident #583's Physician (Medical Director #2) had assessed the resident on 1/20/2023. Review revealed, .Chief complaint .Reason for visit .Acute visit to SNF .Patient seen due to staff stopping me in hallway due to her SOB . She [Resident #583] has been therapy[to therapy] and became dyspneic(short of breath) .upon checking her VS [vital signs] her T[temperature] was high at 100.1 .Due to her urinary frequency a ua [urine analysis (UA) test used to test a person's urine] was ordered .Her u/a from 1/20[1/20/2023] revealed .none[no] bacteria were seen . Review revealed Medical Director #2 had reviewed Resident #583's UA results on 1/20/2023. Review of MD #2's note revealed no documentation related to the missing results from the resident's PT/INR lab draw from 1/16/2023 or concerns related to the resident's PT/INR.
Review of the MAR dated 1/2023 revealed the resident's scheduled doses of Warfarin had not been adjusted from 1/11/2023-1/22/2023, after PT/INR results were not obtained or reviewed by the physician.
Review of a physician order dated 1/23/2023, revealed .PT/INR in AM .Fax me INR from 1/16/23 [2023] [13 days after the 1/9/2023 PT/INR results] .
Review of a nursing note dated 1/24/2023 at 3:18 PM revealed, .Resident was showing s/s [signs/symptoms] of SOB [shortness of breath][ a symptom of a low hgb]during therapy .Upon examination resident O2 [oxygen saturation level] was 71% .started resident on oxygen 2 L[liters] .O2[oxygen saturation level] came up to 97% .[name of the resident's physician] stated she was stopping by and will exam resident herself upon arrival .When [name of physician] came she stated that she believed the resident was fine that she wasn't worried that anything was wrong with resident [Resident #583] .X-ray came back and showed resident had R [right] side PNA [Pneumonia], and labs came back and showed critical lab values .Son was notified and stated he wanted his mother sent out due to critical values .Awaiting ambulance services now .
Review of a lab dated 1/24/2023 revealed the resident had a PT >90 (normal range 9.6-12.2) and an INR of >9 (normal range 0.80-3.50).
Review of a physician order dated 1/24/2023 revealed, .Vitamin K [medication used to treat bleeding] 1 po [by mouth] now (5mg) .PT/INR in AM [1/25/2023] .D/C Coumadin .Indication-DX [diagnose] .critical INR/Blood work .
Review of the physician order dated 1/24/2023 revealed, .Send to [name of hospital emergency room] per son request .
Review of a nursing note dated 1/24/2023 at 3:52 PM, revealed the resident was sent to the emergency room at 3:45 PM, by ambulance per the resident's son request.
Review of Resident #583's Hospital History and Physical, dated 1/24/2023, revealed .Nursing home sent the patient for shortness of breath and low H &H [hemoglobin and hematocrit/ red blood cell measurements lab values] .I [hospital physician] did call and speak with her son who reported that she had not felt well for 3 or 4 days .She is also profoundly supratherapeutic [an amount of drug medication that was greater than the therapeutic concentration] on her INR .She has received Kcentra [a medication used for urgent reversal of adverse effects of Coumadin] .Tells me me that she [Resident #583] just feels rough. Review revealed .Patient [Resident #583] is quite ill in conjunction with her frailty her prognosis is poor . GI bleed .I suspect this is related to her having a supratherapeutic INR .Acute blood loss anemia .Patient is in the process of being transfused [blood transfusion] Hemorrhagic [spontaneous or near spontaneous bleeding caused by a defect in clotting mechanisms] disorder secondary to .anticoagulants therapy . Review revealed the resident had Hemorrhagic disorder due to circulating anticoagulants and had heme positive stool [blood in stool] and an INR greater than 12. The resident's Coumadin medication was held in the hospital. The resident had an Acute Blood Loss Anemia with blackish colored stool. The resident was diagnosed with COVID-19 and Acute Respiratory Failure in the hospital.
Review of Resident 583's Hospital Discharge report, dated of 1/27/2023, revealed .Discharge diagnoses .Hemorrhagic disorder .Acute blood loss anemia .Acute respiratory Failure .Supratherapeutic INR .GI bleed .
Review of a physician note dated 1/27/2023 revealed, .96 y/o [year old] .female readmitting from [name of the hospital] after a 1/24/2023 admission due to hemorrhagic disorder d/t [due to] circulating anticoagulants, Acute blood loss anemia, COVID-19 .
During an interview on 4/4/2023 at 9:25 AM, revealed, Licensed Practical Nurse (LPN) #7 stated, .I called [name of the resident's Physician Medical Director #2] on morning [1/24/2023] patient [Resident #583] was not acting right .[name of Medical Director #2] she stated she was fine .When patient went to hospital, she tested positive for COVID and had a GI bleed .I called son [Resident #583's son] and told him she wasn't doing like self [1/24/2023] and told him [Resident #583's son] her critical labs .Patient was tired .She [Resident #583] had declined [in her physical health] . The LPN confirmed the resident's son requested the resident be sent to the hospital due to her critical lab values.
During an interview on 4/5/2023 at 2:54 PM, Medical Director #1 confirmed Coumadin/Warfarin was a high-risk medication and residents on the medication could have adverse reactions. Medical Director #1 revealed only a few residents in the facility were on Coumadin/Warfarin due to the risks of adverse reactions and side effects of the medication. Medical Director #1 stated residents in the facility on Coumadin/Warfarin were to have their PT/INR levels reviewed and monitored by the physician weekly. Medical Director #1 confirmed the resident's Physician (Medical Director #2) failed to monitor, check, and review Resident #583's PT/INR for approximately 2 weeks. Medical Director #1 stated the resident had an INR of 9 (on 1/24/2023) which was a critical lab value. Medical Director #1 confirmed Medical Director #2 failed to ensure Resident #583's PT/INR lab was obtained [the week of 1/16/2023] and a PT/INR was not obtained until 1/23/2023 (14 days after the resident's lab was resulted on 1/9/2023). Medical Director #1 confirmed PT/INR labs were to be reviewed weekly by the physician to ensure adjustments were made to the resident's Coumadin/Warfarin drug regimen based on the resident's weekly PT/INR labs results. Medical Director #1 stated, .The patient [Resident #583] could have bleed out . Medical Director #1 confirmed Resident #583 had a high potential for harm when Resident #583's PT/INR lab was not redrawn on 1/16/2023 to ensure the resident was receiving a therapeutic dose of Warfarin/Coumadin. Medical Director #1 stated .You can easily have GI bleed and bleed out [blood loss to such a degree that the person bleeding dies] if medication [Coumadin] given and no lab [performed] to monitor PT/INR every week .High risk of severe outcome .If she fell, she [Resident #583] could bleed out easily .
During an interview on 4/6/2023 at 11:02 AM, the Director of Nursing (DON] confirmed Resident #583 continued to received Warfarin/ Coumadin at the same dosage without having a lab with current PT/INR levels from 1/9/2023-1/23/2023. The DON revealed Medical Director #2 (Resident #583's Physician) was notified of the lab not being resulted on 1/16/2023 by the nurse. The DON confirmed Medical Director #2 failed to reorder a PT/INR for Resident #583 the week of 1/16/2023. The DON revealed the resident's nurse called the resident's son and informed him of the critical lab values on 1/24/2023 and the resident's son requested the resident be sent to the hospital for treatment.
During an interview on 4/10/2023 at 2:44 PM, the DON confirmed Coumadin/Warfarin was a high-risk medication. The DON stated, .If not monitored [PT/INR labs] blood [a resident's] can get too thin and they can bleed to death or require a blood transfusion . The DON confirmed Resident #583 had a change in her medical status and required hospitalization.
During an interview on 4/10/2023 at 3:14 PM, Nurse Practitioner (NP) #1 confirmed Resident #583 continued to receive the same dosage of Coumadin without a current PT/INR level. The NP #1 confirmed PT/INR were to be monitored and checked by the physician weekly to ensure residents were receiving the appropriate dose of Coumadin/Warfarin medication to prevent adverse side effects such as bleeding and a GI bleed. The NP revealed the Coumadin/Warfarin protocol was for the Physician to hold Resident #583's Monday's dose (1/16/2023) of Coumadin until a PT/INR was obtained to determine if the resident's Coumadin was at a therapeutic level. The NP #1 stated, . PT/INR levels are reviewed and drawn to ensure a resident's does not bleed out, have blood in their stool .That's a problem if someone gets Warfarin and has a GI bleed . NP #1 confirmed Resident #583 failed to receive appropriate Physician services to prevent harm to the resident [Resident #583] which caused the resident to be hospitalized .
During an interview on 4/11/2023 at 10:17 AM, Resident #583's Physician (Medical Director #2) confirmed the resident had an INR of 9 on 1/24/2023 required hospitalization, was diagnosed with a GI Bleed, Anemia, required a blood transfusion, and had supratherapeutic INR which required urgent treatment with Kcentra to reverse the effects of her Coumadin/Warfarin medication she received at the facility. Medical Director #2 confirmed the resident's son had initiated the resident's transfer to the hospital for treatment after being made aware by the floor nurse of his mother's critical lab values. Medical Director #2 confirmed she was responsible for monitoring the resident's PT/INR and was responsible for regulating the resident's medication based on the resident's PT/INR results. Medical Director #2 confirmed the resident continued to receive the same dosage of Coumadin from 1/10/2023-1/23/2023 and the PT/INR's were not monitored by Medical Director #2. Medical Director #2 confirmed she was unaware the resident did not have a PT/INR from 1/16/2023-1/23/2023.
During an interview on 4/11/2023 at 2:14 PM, Medical Director #1 confirmed the resident's Medical Director #2 failed to monitor and review Resident #583 PT/INR from 1/16/2023- 1/23/2023. Medical Director #1 confirmed STAT labs [laboratory tests and services that are needed immediately in order to manage medical emergencies] for Resident #583 were to be ordered when[Medical Director #2 noted the resident's PT/INR results were not available. The Medical Director #1 revealed the resident's INR was 9 (1/24/2023) and Resident #583 was not medically stable. The Medical Director #1 stated the resident required a higher level of care then the facility could provide, and the resident should have been sent out immediately to the hospital for treatment when Resident #583's PT/INR results were critical (Medical Director #2 was treating the resident at the facility for elevated INR and wrote an order to have INR drawn on 1/25/2023 after a critical lab value was resulted). Medical Director #1 stated Medical Director #2 was lucky the resident did not fall, or she could have had a serious bleed. The Medical Director #1 confirmed the resident sustained a GI bleed, required a blood transfusion, and required Kcentra to reverse the effects of Coumadin she received at the facility. Medical Director #1 confirmed Resident #583 did not receive effective physician supervision to prevent harm to Resident #583.
During an interview on 4/12/2023 at 11:00 AM, NP #1 confirmed Resident #583 was harmed as a result of not having her PT/INR monitored weekly by the Medical Director #2.
During an interview on 4/13/2023 at 10:45 AM, Medical Director #1 stated, .The professional standard is the Physician must follow up and ensure all labs are done, reviewed and collected . Medical Director #1 confirmed stat labs for Resident #583 were to be ordered when the physician noted the resident's PT/INR results were not available. Medical Director #1 revealed if labs are not resulted physicians were to re-order PT/INR labs. The Medical Director #1 confirmed the facility failed to provide physician services to meet professional standards which caused Resident #583 harm.
CONCERN
(D)
📢 Someone Reported This
A family member, employee, or ombudsman was alarmed enough to file a formal complaint
Potential for Harm - no one hurt, but risky conditions existed
Free from Abuse/Neglect
(Tag F0600)
Could have caused harm · This affected 1 resident
**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY**
Surveyor: [NAME]-[NAME], [NAME]
Based on facility policy review, facility investigation review, medical record review, observat...
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**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY**
Surveyor: [NAME]-[NAME], [NAME]
Based on facility policy review, facility investigation review, medical record review, observation and interview, the facility failed to protect 2 Residents (#56 and #17) from physical abuse of 30 residents reviewed for abuse.
The findings include:
Review of the facility policy titled, Abuse Prevention/Reporting Policy and Procedure, dated 2018, showed .Residents must not be subjected to abuse by anyone, including, but not limited to employees, other residents .Abuse is defined as willful infliction of injury .
Resident #56 was admitted to the facility 10/1/2021, with diagnoses including Vascular Dementia without Behavioral Disturbance, Hypertension, Type II Diabetes Mellitus, Major Depressive Disorder and Chronic Kidney Disease.
Review of Resident #56's quarterly Minimum Data Set (MDS) assessment dated [DATE], showed the resident had severe cognitive impairment, a short and long term memory problem, and displayed inattention and disorganized thinking during the assessment. Resident #56 required extensive assistance of 1 staff member for bed mobility, transfer and activities of daily living. The resident required supervision of 1 staff for locomotion on the unit. The resident received anti-anxiety and anti-depressant medications for the past 7 day look back period.
Resident #332 was admitted to the facility on [DATE], with diagnoses including: COVID-19, Encephalopathy, Unspecified Intellectual Disabilities, Adjustment Disorder, Cognitive Communication Deficit and Chronic Obstructive Pulmonary Disease.
Review of Resident #332's comprehensive care plan dated 9/9/2022, showed .Bx [Hx-history] of physical aggression towards another resident. Resident became physically aggressive towards staff on 9/8/2022 and 2/12/2023. SW to follow up with resident x 3 days dt [due to] altercation .Resident has no awareness of personal space .Resident will not display any physical aggression thru [through] next review .
Review of Resident #332's quarterly MDS assessment dated [DATE], showed the resident had moderate cognitive impairment. The resident felt down, tired and bad about herself for 2-6 days, and no behaviors were documented. Resident required limited assistance of 1 staff member for bed mobility, transfer, and activities of daily living. The resident received anti-anxiety medication for the past 7 day look back period.
Review of facility documentation, untitled, and undated showed .Female resident [Resident #332] was sitting in the hallway outside of her room. Another female resident [Resident #56] approached her and attempted to touch some of the resident's [Resident #332] personal items .Staff reported that the resident [Resident #332] struck the other female resident [Resident #56] on the upper arm .the residents were separated .
Review of facility documentation, untitled, and undated, showed .On 2/12/2023 at approximately 2:45 PM, this writer was walking down the hallway .observed [Resident #332's name] raise hand and strike [Resident #56] on the right shoulder .Residents were separated .
During an interview on 4/5/2023 at 10:27 AM, Licensed Practical Nurse (LPN) #2 confirmed both residents were in the hallway, near the nurses station .[Resident #332's name] raised her hand and slapped [Resident #56's name] .I saw it .I couldn't get there fast enough . LPN #2 stated both residents were separated and assessed with no injury.
During an interview on 4/5/2023 at 2:20 PM, Social Worker (SW) #1 stated .[Resident #56 name] was a nurturing person, but did not have spatial boundaries, she would get in other people's space . SW #1 described the resident to resident altercation as .[Resident #56 name] was messing with her [Resident #332] stuff and got a little whack from that .
During an interview on 4/6/2023 at 9:17 AM, Registered Nurse (RN) #2 confirmed she was aware of the resident to resident altercation. RN #2 stated the facility substantiated the allegation of resident to resident abuse had occurred.
Resident #12 was admitted to the facility on [DATE], with diagnoses including Hypertension, Vascular Dementia without Behaviors, Type II Diabetes, Depression, and Anxiety Disorder.
Review of Resident #12's comprehensive care plan dated 12/1/2022, showed .resident will maintain stable mood and have improved behaviors in the next 90 days .Interventions approach in a calm manner .Offer activities of interest .Monitor behaviors .Administer medications as ordered .Monitor for side effects of medications .
Review of the facility's investigation documentation dated 3/16/2023, showed Certified Nursing Assistant (CNA) #1 stated .female resident [Resident#56] stopped in front of the male resident [Resident #12] and was adjusting her socks and shoes .CNA #1 observed the male resident strike the female resident on the face and knocked off her glasses Did not see the female resident make any contact to the male resident . CNA #1 stated .the 2 residents were separated, and she took the female resident back to her home unit. No injuries noted to either resident .
Review of a nurse progress note dated 3/16/2023 5:03 AM, .resident [Resident #56] was brought to the unit with broken glasses, and this nurse was told she was hit in the face by another resident [Resident #12] on another hall.
During an interview on 4/6/2023 at 8:45 AM, LPN #1 revealed resident (Resident #56) had come out of her room on to hallway. The altercation occurred when the resident was sitting in wheelchair, in the hallway taking her shoes off. The man (Resident #12) was sitting beside her, and he stated he thought she was going to touch his feet, he struck her in the face knocking her reading glasses off of her face. No injuries were observed to the residents upon assessment. Both residents were separated immediately.
During an interview on 4/6/2023 at 10:30 AM, the Regional [NAME] President/Administrator (ADM) #1 confirmed the altercation between Resident #12 and Resident #56 had occurred.
Resident #17 was admitted to the facility on [DATE] with diagnoses including Anxiety Disorder, Chronic Pain Syndrome, Major Depressive Disorder, Panic Disorder, Diabetes, Bipolar Disorder, Schizophrenia, and Dementia with Behavior Disturbance.
Review of Resident #17's admission MDS assessment dated [DATE], showed a BIMS score of 14 which indicated cognitively intact, verbal behavior symptoms and rejection of care exhibited 1 to 3 days, required supervision for bed mobility, transfer, dressing, personal hygiene, bathing and ambulation.
Resident #282 was admitted to the facility on [DATE], with diagnoses including Anxiety Disorder, Alzheimer's Disease, and Dementia without Behavior Disturbance.
Review of Resident #282's admission MDS assessment dated [DATE], showed a BIMS score of 1, which indicated had severe cognitive impairment, required limited assistance of 1 staff member for bed mobility, supervision, oversight to walk in room, extensive assistance of 1staff member for dressing, total dependence for toilet use and personal hygiene.
Review of Resident #282's nurse progress note dated 4/2/2023 3:19 PM, showed .noted to be wandering around facility without assistance, wandering to different resident rooms and noted to have increased anxiety noted. prn [as needed] [name of anti-anxiety medication] administered and noted to be effective .
Review of Resident #17's nurse progress note dated 4/3/2023, showed .RESIDENT STATED SHE WOKE UP AROUND 130P [1:30 pm] TO HER ROOMMATE [Resident #282] TOUCHING HER FACE. AND WHEN SHE OPENED HER EYES, HER ROOMMATE THROUGH THE PAPER BACK BOOK SHE HAD IN HAND AND HIT RESIDENT IN THE HEAD. RESIDENT STATED SHE WASN'T HURT. and thank GOD IT WAS A PAPER BACK BOOK.
Review of Resident #282's nurse progress note dated 4/3/2023 at 5:44 PM, showed .At 1:30 pm CNA reported that Resident's roommate reported that resident came into room and put her hand on her face the (roommates face) and made noise in an angry tone. Roommate states I must have went back to sleep for a second I woke up and she had her arm raised. She had a book in her hand and threw it at me
Review of a social worker progress note for Resident #17 dated 4/3/2023 at 7:18 PM, showed .Sw [Social Worker] spoke with resident regarding incident with another resident. Resident reports her being asleep and waking up to her roommate having her hand on her face. Then when resident opened her eyes, her roommate had a book in her hand and threw a paperback book at resident hitting her in the head .
During an observation and interview on 4/4/2023 at 3:17 PM, Resident #17 stated she liked her new room on the 200 hallway because she doesn't have a roommate. When asked if she recalled an issue with her previous roommate, she stated there was nothing between her and her roommate.
During an interview on 4/5/2023 at 2:00 PM, Housekeeper #2 stated she witnessed the incident between Resident #282 and Resident #17 in the resident's room. She stated Resident #282 stood up and pulled the resident's curtain back. She stated she heard Resident #17 say .What are you doing . Housekeeper #2 stated she saw Resident #282 poking Resident #17 in the head with her finger. She stated Resident #17 got out of bed and Resident #282 hit Resident #17 on the head with one of Resident #17's books. She stated she called for help and CNA #3 came in the resident's room. The residents were standing facing each other and the residents were separated. Resident #17 was moved to a different room on a different hallway. Resident #282 was escorted to the nurse's station for observation.
During an interview on 4/11/2023 at 4:10 PM, Regional [NAME] President/Administrator (ADM #1) stated she was involved in the investigation of the resident altercation between Resident # 282 and #17 which had occurred. She stated the facility did not consider altercation as abuse. The Interim Administrator stated the facility was aware Resident #282 struck Resident #17 with a book, but there was no psychological harm to the resident, so the facility .did not substantiate abuse .
CONCERN
(D)
Potential for Harm - no one hurt, but risky conditions existed
Deficiency F0676
(Tag F0676)
Could have caused harm · This affected 1 resident
**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on facility policy review, medical record review, observation, and interview, the facility failed to provide interpretatio...
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**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on facility policy review, medical record review, observation, and interview, the facility failed to provide interpretation services or an effective communication service for 1 non-English speaking resident (Resident #102) of 2 non-English speaking residents reviewed.
The findings include:
Review of the facility's policy titled, Translation and/or Interpretation, revised 5/2017, showed .This facility's language access program will ensure that individuals with limited English proficiency (LEP) shall have meaningful access to information and services provided by the facility .the types of language access services provided by this facility shall be determined by the following factors .The size .of the eligible LEP population served by the facility .The frequency with which the particular LEP population is in contact with the facility .The nature and/or importance of the information or service that needs to be conveyed .The point of contact regarding facility's language access program is the Director of Social Services .All LEP persons will be informed of their rights to obtain competent oral translation services free of charge .Non-vital: information includes .Dietary .menus .and activity services .Competent oral translation of vital information .and non-vital information shall be provided in a timely manner and at no cost to the resident through the following means A staff interpreter who is trained and competent in the skill of interpreting .Contracted interpreter service .Voluntary community interpreters who are trained and competent in the skill of interpreting .Telephone interpretation service .Interpretation devices, translation applications or on line services .Family members and friends may be relied upon to provide interpretation services for the resident .It is understood that providing meaningful access to services provided by this facility requires also that the LEP residents needs and questions are accurately communicated to the staff .
Resident #102 was admitted to the facility on [DATE] with diagnoses including Dysphagia, Unspecified Dementia with Other Behavioral Disturbance, End Stage Renal Disease, Chronic Congestive Heart Failure, Acute Respiratory Failure, Diabetes Mellitus, Polyneuropathy, and Depression.
Review of a quarterly Minimum Data Set (MDS) assessment dated [DATE], showed Resident #102 scored a 12 on the Brief Interview for Mental Status (BIMS) assessment which indicated the resident had moderate cognitive impairment. The MDS showed the resident required extensive 1 staff assistance for bed mobility, and was totally dependent on 1 staff for transfers, locomotion on and off the unit, toileting, and hygiene.
Review of a comprehensive care plan dated 9/20/2022, revised on 9/29/2022 and 4/4/2023, revealed Resident #102 was at risk for cognitive deficit related to the diagnosis of Dementia and had a communication barrier related to .Vietnamese as .first language . with interventions including .Contact RP [responsible party] via phone to translate, if needed .
Review of a Nurse Practitioner (NP) progress note dated 2/27/2023 showed Resident #102 was alert and oriented to self, place, time, and situation and followed commands.
Review of a physician's progress note dated 3/27/2023 showed Resident #102 was alert and oriented to self, place, time, and situation.
During an observation on 4/3/2023 at 5:14 PM, Resident #102 was asleep in bed. Observation of the resident's room showed a communication paper provided by the resident's family which included .Drink .Hunger .Hot .Cold .Pain .Sleepy .Up (out of bed) .Down (to bed) . Continued observation showed the resident's daughter's phone number was posted on the resident's bulletin board to aid with translation.
During an interview on 4/4/2023 at 3:41 PM, the Director of Nursing (DON) confirmed Resident #102 had limited English communication, the family had posted a paper with words the resident used to communicate his basic needs, and communication could also occur with Resident #102 using an application on a cellular (cell) telephone (phone).
During an observation in Resident #102's room and interview on 4/4/2023 at 3:48 PM, Licensed Practical Nurse (LPN) #9 stated she used the communication paper in the resident's room or called the resident's daughter to aid with translation. The LPN stated she was not aware of the facility having a translation service if the resident's daughter was unable to be reached.
During an observation and interview with LPN #9, in Resident #102's room, on 4/4/2023 at 3:48 PM, Resident #102 was awake, laying on his bed. Attempts to interview Resident #102 was unsuccessful due to the resident's inability to communicate in English. Continued observation showed the television program on in the resident's room was in English.
During an observation and interview, on 4/4/2023 at 4:08 PM, Resident Aide (RA) #1 stated there was a communication paper on the resident's board to help with basic needs, or at times the staff could call the Resident's daughter on the phone to help translate. RA #1 stated she could use Google App [Application] to help with translation, if needed. Observation of the Google App with RA #1 showed she was unable to demonstrate use of the application for translation.
During an observation and interview on 4/4/2023 at 4:18 PM, Certified Nursing Assistant (CNA) #2 stated she communicated with Resident #102 with a paper that hung on the resident's wall. The CNA stated she did not have conversations with the resident and used the paper or body language to help determine the resident's needs. The CNA stated she had Google translator if she had her cell phone to aid with communication. Observation with CNA #2 of the Google translator on the CNA's cell phone, showed she was unable to demonstrate use of the application for translation.
During an observation and interview on 4/5/2023 at 2:04 PM, Licensed Practical Nurse (LPN) #6 stated she used .Google Translate . on her phone to communicate with Resident #102. LPN #6 stated the facility did not have a translation service to aid in communication with the resident. LPN #6 stated she was not aware if the facility had any Vietnamese reading materials, activities, or items for the resident's use. Observation of the Google Translate application on the LPN's cell phone and on the resident's cell phone, with LPN #6, showed the LPN was unable to demonstrate use of the translation application on either phone.
During a telephone interview on 4/5/2023 at 5:40 PM, Resident #102's daughter confirmed Resident #102 expressed his basic needs through the paper she created in the resident's room. The resident's daughter stated the facility staff .call me all the time . and stated the facility had not provided an alternate means of translation services for the resident. Resident #102's daughter stated the resident loved Vietnamese music and the facility only provided the activity 2-3 days per week. The resident's daughter also stated she was not aware of any other activities in Vietnamese provided in to the resident.
During an interview on 4/6/2023, at 9:01 AM, the Social Services Director stated she had conducted assessments of the resident previously and had not used a translation service to conduct the assessments.
During an interview on 4/6/2023 at 9:25 AM, the Interim Administrator confirmed the facility did not have translator/translation agreement .I don't believe we have one .
During an observation and interview on 4/6/2023 at 11:52 AM, the Activities Director revealed communication between her, and Resident #102 usually occurred with a translation application on a cell phone. The Activities Director stated she had not provided Vietnamese language movies, books, or other activities for Resident #102. The Activity Director confirmed the activity calendar in Resident #102's room was in the English language and she had not thought to try to provide in the Vietnamese language. The Activities Director stated the daily scheduled activities had not been discussed in the Vietnamese language to the resident. Observation of a translation application on the Activity Director's cell phone, with the Activities Director, showed it took multiple attempts and more than 10 minutes to demonstrate how the translation service worked. The Activities Director stated she was not aware any further translation services available at the facility.
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 facility policy review, medical record review, observation, and interview, the facility failed to develop and implement...
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**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on facility policy review, medical record review, observation, and interview, the facility failed to develop and implement an individualized and activities program to meet the needs for 1 non-English speaking resident (Resident #102) of 2 non-English speaking residents reviewed for activities.
The findings include:
Review of the facility's policy titled, Activity Programs, revised 8/2006, showed Activity programs designed to meet the needs of each resident are available on a daily basis .Our activity programs are designed to encourage maximum individual participation and are geared to the individual resident's needs .Activities are scheduled 7 (seven) days a week and residents are given an opportunity to contribute to the planning, preparation, conducting, cleanup, and critique of the programs .Our activity programs consist of individual and small and large group activities that are designed to meet the needs and interests of each resident and include, as a minimum .Activities that stimulate the cardiovascular system and assist with range of motion, such as exercise, movement to music, wheelchair basketball/volleyball .are offered five to seven times per week .Intellectual activities that are mentally stimulating, such as current events, trivia, word games, book reviews, educational movies .are provided five to seven times per week .Spiritual programming is scheduled to meet the religious needs of the residents .Creative and expressive activities .are available on a regular basis to meet the needs of residents .Social activities are scheduled to increase self esteem, to stimulate interest and friendships, and to provide fun and enjoyment .Scheduled activities are posted on the resident bulletin board schedules are also provided individually to residents who cannot access the bulletin board .Individualized and group activities are provided that .Reflect the schedules, choices and rights of the residents .are offered at hours convenient to the residents, including evenings, holidays and weekends .Reflect the cultural and religious interests, hobbies, life experiences, and personal preferences of the residents .
Resident #102 was admitted to the facility on [DATE] with diagnoses including Dysphagia, Unspecified Dementia with Other Behavioral Disturbance, End Stage Renal Disease, Chronic Congestive Heart Failure, Acute Respiratory Failure, Diabetes Mellitus, Polyneuropathy, and Depression.
Review of a quarterly Minimum Data Set (MDS) assessment dated [DATE], showed the resident scored a 12 on the Brief Interview for Mental Status (BIMS) assessment which indicated the resident had moderate cognitive impairment. The MDS showed the resident's activities of choosing clothes to wear, bedtime, being around animals/pets, keeping up with the news, doing things with groups of people, doing favorite activities, and going outside when there was good weather was somewhat important to the resident, and the activity of listening to music was very important.
Review of a comprehensive care plan dated 9/20/2022, revised on 9/29/2022, and 4/4/2023, revealed Resident #102 was at risk for cognitive deficit related to the diagnosis of Dementia and had a communication barrier. The resident .was born in Vietnam with Vietnamese as his first language . The care plan showed to post an activity calendar in the resident's room, encourage the resident to do activities in his own way, and provide the resident with in room activities. The resident enjoyed watching television and listening to Vietnamese music .[Resident #102] will be offered 1:1 visits and be invited to OOR [out of room] activities .had decreased mobility . and required assistance of staff with activities of daily living (ADLs) The care plan showed there was no specific person-centered activities related to the resident's language, religious or cultural preference.
Review of the resident's individual daily activity record dated 1/1/2023-1/31/2023, showed Resident #102 participated in the radio/television activity (provided in the English language) all 31 days. The resident's individual daily activity record showed the resident participated in the activity of music/CDs (compact discs) for 10 of the 10 days offered.
Review of a nurse practitioner (NP) progress note dated 2/27/2023, showed Resident #102 was alert and oriented to self, place, time, and situation and followed commands.
Review of the resident's individual daily activity record dated 2/1/2023-2/28/2023, showed Resident #102 participated for 28 days when radio/television (provided in the English language) and the telephone/facetime activity was provided. The resident's individual daily activity record showed the resident participated in the activity of music/CDs 12 of the 12 offered days.
Review of a physician's progress note dated 3/27/2023, showed Resident #102 was alert and oriented to self, place, time, and situation.
Review of the resident's individual daily activity record dated 3/1/2023-3/31/2023, showed Resident #102 participated in 1 of the 1 offered dry for the coffee, food/snacks, and movie activity (provided in English language). The resident's individual daily activity record showed the resident participated in 31 of 31 days of the activity of radio/television (provided in the English language) and 31 of 31 days of the telephone/face time activity. The resident's individual daily activity record showed the resident participated in 9 of the 9 offered days of the activity of music/CDs and verbal discussions held by the activities staff were conducted on 9 of the 10 offered days. All other activities were blank.
During observations on 4/3/2023 at 5:14 PM, Resident #102 was lying in bed asleep. The television was playing on an English-speaking program and an activities calendar printed in English was posted on the resident's wall. Continued observation showed no activities of the Vietnamese language and culture were available in the resident's room.
During observations on on 4/5/2023 at 11:00 AM, Resident #102 was lying in bed asleep. The television was playing on an English-speaking program and an activities calendar printed in English was posted on the resident's wall. Continued observation showed no activities of the Vietnamese language and culture were available in the resident's room.
During a telephone interview on 4/5/2023 at 5:40 PM, Resident #102's daughter confirmed Resident #102 expressed his basic needs through the paper she created in the resident's room. The resident's daughter stated the facility staff .call me all the time . and stated the facility had not provided translation services for the resident. Resident #102's daughter stated the resident loved Vietnamese music and the facility only provided the activity 2-3 days per week. The resident's daughter also stated she was not aware of any other Vietnamese activities that were provided to the resident.
During observations on 4/6/2023 at 11:45 AM, Resident #102 was lying in bed asleep. The television was playing on an English-speaking program and an activities calendar printed in English was posted on the resident's wall. Continued observation showed no activities of the Vietnamese language and culture were available in the resident's room.
During an interview on 4/6/2023 at 11:52 AM, the Activities Director revealed communication with Resident #102 occurred with a translation application on her cell phone. The Activities Director stated the Vietnamese music activity had been provided to the resident .2 to 3 times a week .usually .like 20 minutes .[or by a tablet electronic device] for an hour . at times. The Activities Director stated the resident and the resident's family stated Resident #102 enjoyed music .whenever I've talked to him, he says he likes his music . The Activities Director confirmed Resident #102 had limited person-centered activities and stated .I wish I could do 100% more . The Activities Director further stated Vietnamese television programs or videos were not available and had not been provided to the resident, the activities calendar had only been provided in the English language, and other than the music provided 2-3 days per week, no other Vietnamese cultural or language activities had been provided. The Activities Director further stated, the facility had a pet therapy program and was not aware if Resident #102 had been offered or participated in the activity. The Activities Director confirmed the activity care plan did not meet the needs of Resident #102.
CONCERN
(F)
Potential for Harm - no one hurt, but risky conditions existed
Deficiency F0841
(Tag F0841)
Could have caused harm · This affected most or all residents
Based on facility policy review and interview the facility failed to ensure Medical Director duties were coordinated to clearly delineate responsibilities of the facility's Medical Directors. The faci...
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Based on facility policy review and interview the facility failed to ensure Medical Director duties were coordinated to clearly delineate responsibilities of the facility's Medical Directors. The facility's failure to implement and coordinate resident care created an environment which impaired the nursing staff to effectively provide patient care and services which had the potential to affect all 144 residents in the facility.
The findings include:
Review of the Medical Director Agreement signed by Medical Director #1 showed . Physician [reference to Medical Director/Physician] shall guide, approve, and help oversee the development, implementation, and monitoring/evaluation of Facility's resident care policies and procedures in the following areas: .admission policies and care practices that address the types of residents that may be admitted and retained based upon the ability of the Facility to provide the services and care to meet their needs .Mechanisms for communicating and resolving issues related to medical care . Physician shall be responsible for coordination of medical care in the Facility. Physician shall help the Facility obtain and maintain timely and appropriate medical care that supports the healthcare needs of the residents, is consistent with current standards of practice, and helps the Facility meet its regulatory requirements .
Review of the Medical Director Agreement signed by Medical Director #2 on 11/23/2022, showed .Scope of Services: Medical Director shall provide overall medical leadership for .operations including the nursing facility .Medical Director shall provide medical direction and guidance .including participation in the .QI (quality improvement) meetings .This agreement shall be for a term of one (1) year from the effective date above the signature line . Further review revealed there was no mention of Medical Director #2's responsibilities limited to the skilled residents.
During an interview on 4/11/2023 at 2:14 PM, Medical Dierector #1 (MD #1) stated .with 2 medical directors it causes conflict .definitely . it would impede the nursing home [resident care] .
During an interview on 4/11/2023 at 2:31 PM, MD#1 stated after his most recent contract was signed, then he was told by the facility MD #2 would reside over the skilled residents and he (MD#1) would be over the rest (remainder of the residents). MD #1 stated that he understood he was not to contact (MD#2) regarding residents and that his care for residents was separate from (MD#2). MD #1 stated he was to consider (MD#2) as an equal provider and that no one was over one another. MD #1 revealed his contract with the facility stated he should have control of resident care but stated he was not allowed to have total control. MD #1 stated he feels this lack of total control causes confusion with the nursing staff and unequivocally impedes nurses' abilities to streamline resident care. MD #1 stated .I can't do my job if I don't know what's going on . MD #1 stated the Regional [NAME] President of Operations/ADM #1 told him not to communicate with (MD#2) and stated there is not a system in place at this facility to address resident care issues or failures as the medical director. MD #1 confirmed he told the Chief Executive Officer (CEO) care concerns needed to be handled with MD #2 and the facility could not continue to operate with two medical directors. The CEO advised MD #1 he (CEO) would .look into things .however nothing has changed here .
During an interview on 4/12/2023 at 3:13 PM, Registered Nurse (RN) #2 stated staff have told her MD #2 was unapproachable and nurses were confused on which medical director to report resident health concerns to on a daily basis.
During an interview on 4/12/2023 at 3:33 PM, the Regional [NAME] President of Operations/ADM #1 stated she remembered getting an email from a clinical staff member regarding clinical care practices and negative interactions with MD #2 but, .cannot remember details . ADM #1 stated she could not address the clinical concerns and confirmed she had not consulted with any qualified clinical counterpart to MD#2 for assistance in addressing the issues presented. The Regional [NAME] President of Operations/ADM #1 stated she talked to MD #2 about interpersonal interactions with the nursing staff. The Regional [NAME] President of Operations/ADM #1 stated the MD #1 was told that he would be sharing medical director roles with MD#2. The Regional [NAME] President of Operations/ADM #1 confirmed MD #2 was to have control over skilled residents and the MD #1 who was appointed in 2018, would have control over the remaining residents. Regional [NAME] President of Operations/ADM #1 stated .if nurses have concerns with the medical provider, they can contact the [facility's] compliance line . Regional [NAME] President of Operations/ADM #1 verified she is part of the governing body. Regional [NAME] President of Operations/ADM #1 stated the governing body meets monthly to discuss Quality Indicators, staffing, financial operations, HR [Human Resources] updates, and business office updates. Regional [NAME] President of Operations/ADM #1 stated past due pest control bills or concerns with the facility acquiring two medical directors was not discussed in morning standup, QAPI or Governing Body meetings. Regional [NAME] President of Operations/ADM #1 was not sure if Governing Body was aware of past due pest control bills.
Jun 2021
1 deficiency
CONCERN
(D)
Potential for Harm - no one hurt, but risky conditions existed
Free from Abuse/Neglect
(Tag F0600)
Could have caused harm · This affected 1 resident
**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on facility policy review, medical record review, review of facility documentation, and interview, the facility failed to ...
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**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on facility policy review, medical record review, review of facility documentation, and interview, the facility failed to ensure 2 residents (#55 and #53) remained free from abuse of 14 residents reviewed for abuse.
The findings include:
Review of the facility's policy titled, Abuse Prevention/Reporting Policy and Procedure dated 8/15/2017 showed .Every resident has the right to be free from abuse, neglect, misappropriation .exploitation, corporal punishment, involuntary seclusion, and any physical or chemical restraint .Residents must not be subjected to abuse by anyone, including, but not limited to .other residents .
Medical record review showed Resident #55 was admitted to the facility on [DATE] with diagnoses including Chronic Obstructive Pulmonary Disease, Dementia, Adult Failure to Thrive, Anxiety Disorder, and Palliative Care.
Medical record review showed Resident #77 was admitted to the facility on [DATE] with diagnoses including Cognitive Communication Deficit and Dementia
Medical record review of Resident #77's care plan dated 3/11/2019 showed the resident was care planned for .behavior problem: Hx [history] of delusions, physical and verbal aggression toward staff . Continued review revealed interventions to observe and redirect inappropriate behaviors as needed.
Medical record review of a Significant Change Minimum Data Set (MDS) dated [DATE] for Resident #77 showed the resident scored a 5 on the Brief Interview for Mental Status (BIMS) indicating the resident was severely cognitively impaired. Continued review revealed the resident required supervision and set-up help for transfers and locomotion on the unit and was assessed as having behavior problems which interfered with participation in activities and behavior which intruded on the privacy of others.
Record review showed the Social Services yearly assessment dated [DATE] included, .[Resident #77] is a long term care resident .alert and pleasant during visit. Brief Interview of Mental Status score of 5 - Severe impairment .Cognitive decline reported and observed .more confused .times when she asked staff if she lives here and unable to find her room or the bathroom .Neurocognitive Impairment/Neurocognitive D/O [disorder] .dx [diagnosis] of Depression, Generalized Anxiety Disorder, Insomnia, and Pseudobulbar Affect secondary to Dementia .followed by Psych services .
Review of a facility Post-Incident Actions dated 3/25/2021 showed .CNA [Certified Nursing Assistant] informed nurse that [Resident #77] slapped another resident [Resident #55] in the face .
Review of the facility's Follow-up Report for Resident #55 dated 3/26/2021 - 3/30/2021, showed .Incident Type: Resident to Resident .No injuries noted . Review showed daily assessments done by the Memory Care nursing staff and the Director of Nursing (DON). On 3/26/2021 the assessment included .This resident has no recall. No skin issues .Will continue to observe .
Review of Resident #77's Quarterly MDS dated [DATE], showed she had a BIMS of 4 indicating the resident was severely cognitively impaired, required extensive assistance of one person for transfer and for locomotion with her wheelchair. Further review showed the resident was documented as having delusions and physical and verbal behavior symptoms directed towards others 1 to 3 days during the assessment period.
Review of Resident #77's nursing notes revealed on 5/24/2021 the resident was transferred to Memory Care (the secured unit) for exit seeking behavior and wandering.
Review of a nursing note dated 5/25/202, showed Resident #77, while seated in a wheelchair, approached Memory Care unit CNA #1 while the CNA was assisting another resident (Resident #55) back into her wheelchair. Resident #77, also in a wheelchair, proceeded to hit Resident #55 on the buttocks as Resident #55 sat down in her wheelchair. Resident #77 then slapped Resident #55 on the right side of her face. Further review of the nursing notes showed Resident #77 was transferred to the hospital for evaluation for gero-psych placement. Continued review of the nursing notes showed Resident #77 was re-admitted to the facility's Memory Care unit on 5/28/2021.
Medical record review showed Resident #53 was admitted to the facility's Memory Care unit on 5/14/2021 with diagnoses including Dementia with Psychosis, Cirrhosis, Parkinson's Disease, Depression, and Anxiety.
Review of the facility's documentation, dated 5/18/2021, showed on 5/17/2021 .resident to resident abuse .[Resident #77] became upset and smacked Resident #53. Investigation initiated .neither resident received any injury and both could not recall the incident .Resident #77 was admitted to a behavioral facility on 5/20/2021 for further evaluation and treatment .
Telephone interview on 6/30/2021 at 8:00 AM, with CNA #2, on 6/30/2021, at 8:00 AM, confirmed she was present when Resident #77, seated in the hall in her wheelchair, reached out and hit Resident #53 on the thigh 3 times as he walked around Resident #77. Continued interview confirmed the CNA immediately separated the residents and notified the nurse in charge.
During a telephone interview on 6/30/2021 at 9:00 AM, with Licensed Practical Nurse (LPN) #1, in charge of the Memory Care unit, on 6/30/2021 at 9:00 AM, confirmed her assessment of Resident #53, after the incident on 5/17/2021, showed no injury from the incident and no recall of the incident. The LPN stated .she [Resident #77] had been acting out for months .
During an interview on 6/30/2021 at 2:15 PM, with the Administrator, the Administrator confirmed the incidents with Resident #77 were resident to resident abuse.
Aug 2019
4 deficiencies
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 review of facility policy, medical record review, review of a facility investigation, and interview, the facility faile...
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**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on review of facility policy, medical record review, review of a facility investigation, and interview, the facility failed to ensure an alleged violation involving abuse was reported to the State Survey Agency within the required timeframe for 1 resident (#108) of 17 residents reviewed for abuse.
The findings include:
Review of the facility policy Abuse Prevention/Reporting Policy and Procedures, dated 2018, revealed .If the events that caused the allegation involve abuse and/or result in serious bodily injury, reporting must be within 2 hours of the allegation being made or no later than 24 hours if the events that cause the allegation do not involve abuse and do not result in serious bodily injury .
Medical record review revealed Resident #108 was admitted to the facility on [DATE] with diagnoses including Vascular Dementia Without Behavioral Disturbance and Anxiety Disorder.
Medical record review of the Certified Nursing Assistant Interdisciplinary Care Plan dated 1/15/19 revealed .Mood .short-tempered .Behavior Symptoms .physical behavioral symptoms directed at others .
Medical record review of a Quarterly Minimum Data Set, dated [DATE] revealed the resident was severely cognitively impaired.
Review of a facility investigation dated 8/13/19 revealed Resident #108 was observed slapping another resident on 8/10/19 at 7:10 PM, in the secure unit. Further review revealed the incident was reported to State Survey Agency on 8/12/19 at 11:44 AM (2 days later).
Interview with the Director of Nursing on 8/21/19 at 7:51 AM, in the Conference Room revealed she was notified of an allegation of abuse late at night on 8/10/19. Further interview confirmed the allegation of abuse was not reported to the State Survey Agency until 8/12/19 at 11:44 AM. Continued interview confirmed the facility failed to report the allegation of abuse within the required time frame.
CONCERN
(D)
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 expired medications were not available for resident use in 1 of 4 medication carts observed.
The findings inclu...
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Based on facility policy review, observation and interview the facility failed to ensure expired medications were not available for resident use in 1 of 4 medication carts observed.
The findings include:
Review of the facility policy, Storage of Medication, revised 4/2007, revealed
.Drugs and biologicals shall be stored in the packing, containers or other dispensing systems in which they are received. Only the issuing pharmacy is authorized to transfer medications between containers . Further review revealed .The facility shall not use discontinued, outdated, or deteriorated drugs or biologicals. All such drugs shall be returned to the dispensing pharmacy or destroyed .
Observation with Licensed Practical Nurse (LPN) Unit Manager #1 on 8/21/19 at 3:20 PM, at the 300 lower end medication cart, in the 300 hallway revealed the following expired items:
6 Ondansetron (nausea medication) 4 milligram (mg) tablets, individually packaged with the expiration date of 8/3/19 in zip-lock bag labeled Ondansetron 4mg with expiration label of 9/4/19. Further observation revealed 3 individually packaged Ondansetron 4mg tablets with the expiration date of 9/4/19 were combined in the labeled zip lock bag.
Interview with LPN Unit Manager #1 on 8/21/19 at 3:25 PM, at the 300 lower end medication cart, confirmed the expired 6 Ondansetron 4mg tablets were available for resident use.
Interview with the Director of Nursing (DON) on 8/21/19 at 4:05 PM, in the conference room, confirmed expired medications were available for resident use and the facility failed to discard of the expired medications per facility policy.
CONCERN
(F)
Potential for Harm - no one hurt, but risky conditions existed
Food Safety
(Tag F0812)
Could have caused harm · This affected most or all residents
Based on review of the facility policy, observation, and interview the facility failed to serve food at a palatable temperature, maintain a temperature log for 1 of 2 nourishment room freezers, ensure...
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Based on review of the facility policy, observation, and interview the facility failed to serve food at a palatable temperature, maintain a temperature log for 1 of 2 nourishment room freezers, ensure undated, unlabeled food and drink items were not available for resident use in 1 of 2 nourishment refrigerators potentially affecting 113 residents.
The findings include:
Review of the facility policy Refrigerators and Freezers, revised 12/2014 revealed .This facility will ensure safe refrigerator and freezer maintenance, temperatures, and sanitization .2. Monthly tracking sheets for all .freezers will be posted to record temperatures .4. Food Service Supervisors or designated employees will check and record .freezer temperatures daily .7. All food shall be appropriately dated .
Observation with the Dietary Manager (DM) on 8/19/19 at 12:00 PM, in the kitchen, revealed the DM calibrated the thermometer and obtained the food temperatures on the tray line. Further observation and interview revealed fish at 147 degrees Fahrenheit, rice at 165 degrees Fahrenheit, mechanical chicken at 155 degrees Fahrenheit, and pureed green beans at 145 degrees Fahrenheit.
Observation and interview with the DM on 8/20/19 at 7:47 AM, in the conference room, revealed the DM calibrated the thermometer and obtained the temperature of the food on the breakfast test tray sent on the meal cart to the 200 hall. Further observation and interview revealed gravy at 127 degrees Fahrenheit and scrambled eggs 125.8 degrees Fahrenheit. Continued interview confirmed the gravy and eggs were below the holding temperature of 140 degrees Farenheit.
Observation and interview with the DM on 8/21/19 at 12:40 PM, on the 100 hall, revealed the DM calibrated the thermometer and obtained the temperatures of the food on the lunch test tray sent on the meal cart to the 100 hall. Further observation and interview revealed a hamburger patty at 106 degrees Fahrenheit. Continued interview confirmed the hamburger patty was below the holding temperature of 140 degrees Farenheit.
Observation with the Assistant Housekeeping Supervisor and DM on 8/21/19 at 1:30 PM, in the 400 hall nourishment room, revealed a nourishment refrigerator for resident use containing the following items:
1.
One 5.5 ounce bag of barbeque chips, opened, undated, and unlabeled.
2.
One quart-sized plastic water bottle, ½ used, undated, and unlabeled.
3.
Two 16 ounce plastic water bottles, ½ used, undated, and unlabeled.
4.
Two plastic-wrapped peanut butter and jelly sandwiches, undated and unlabeled.
5.
One 16 ounce bottle of soda, ¾ used, undated, and unlabeled.
6.
One 7 ounce bowl of corn flakes cereal, undated.
7.
One 6 ounce glass bowl containing clear and brown liquid, undated and unlabeled.
8.
One Styrofoam to-go box inside a white plastic bag, undated and unlabeled.
9.
Three 6 ounce bowls of cereal, undated.
10.
One quart-sized plastic bag ¼ full of fruit, undated and unlabeled.
11.
One quart-sized plastic bottle containing a purple liquid, undated and unlabeled.
Observation with the DM on 8/21/19 at 2:00 PM, in the 400 hall nourishment room, revealed a nourishment freezer for resident use with no temperature log and containing the following items:
1.
One 32 ounce blue ½ used shaved ice drink, undated and unlabeled.
2.
One 12 ounce restaurant cup, undated.
Interview with the Assistant Housekeeping Supervisor, DM, and Unit Manager #1 on 8/21/19 at 2:05 PM, outside the 400 hall nourishment room, confirmed the items should have been both dated and labeled and needed to be thrown away. Further interview confirmed a thermometer was not kept in the 400 unit nourishment room freezer and a temperature log had not been maintained.
CONCERN
(F)
Potential for Harm - no one hurt, but risky conditions existed
Deficiency F0925
(Tag F0925)
Could have caused harm · This affected most or all residents
Based on review of facility policy, review of pest control documentation, observation, and interview the facility failed to maintain an effective pest control program in 1 of 1 kitchens, potentially a...
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Based on review of facility policy, review of pest control documentation, observation, and interview the facility failed to maintain an effective pest control program in 1 of 1 kitchens, potentially affecting 113 residents.
The findings include:
Review of facility policy, Pest Control, revised May 2008, revealed .Our facility shall maintain an effective pest control program .to ensure that the building is kept free of insects .
Observation with the Dietary Manager (DM) on 8/19/19 at 8:55 AM, in the kitchen, revealed 2 roaches crawling inside an out-of-order side-by-side refrigerator.
Interview with the DM on 8/19/19 at 8:55 AM, in the kitchen, confirmed .it was obviously a cockroach .
Observation with the DM on 8/19/19 at 9:00 AM, in the kitchen, revealed a roach crawling along the kitchen floor.
Interview with the DM on 8/19/19 at 9:00 AM, in the kitchen, confirmed .there's another cockroach .
Observation with the DM on 8/19/19 at 9:05 AM, in the kitchen, revealed a roach crawling along the kitchen floor.
Observation with the DM on 8/19/19 at 9:20 AM, in the dish room of the kitchen, revealed a dead roach underneath the dishwasher and a live roach crawling up the center section of the dishwasher line where clean dishes come out, crawling towards the sanitization compartment.
Interview with the DM on 8/19/19 at 9:20 AM, in the dish room of the kitchen, confirmed .yeah [I see it too] .
Observation with the DM on 8/19/19 at 9:30 AM, in the dish room of the kitchen, revealed a partially decomposed dead roach on top of the dishwasher.
Interview with the DM on 8/19/19 at 9:30 AM, in the dish room of the kitchen, confirmed .it looks like a dead roach .
Observation with the DM on 8/20/19 at 11:45 AM, in the dish room of the kitchen, revealed a dead roach underneath the dishwasher in the same place as observed on 8/19/19.
Interview with the DM on 8/20/19 at 11:45 AM, in the dish room of the kitchen, confirmed the observation.
Observation with the DM on 8/21/19 at 8:50 AM, in the dish room of the kitchen, revealed a dead roach underneath the dishwasher in the same place as observed on 8/19/19 at 9:20 AM and at 11:45 AM.
Interview with the DM on 8/21/19 at 8:50 AM, in the dish room of the kitchen, confirmed the observation.
Observation with the DM on 8/21/19 at 8:52 AM, revealed a dead roach on the floor in the corner of the dish room.
Interview with the DM on 8/21/19 at 8:52 AM, in the dish room of the kitchen, confirmed the observation.
Interview with the Registered Dietician on 8/21/19 at 9:15 AM, outside the kitchen confirmed the kitchen had a pest control problem and .needs more pest control .
Interview with the Maintenance Director on 8/21/19 at 8:13 AM, in the conference room, confirmed prior to the survey, the facility was unaware of the roach problem in the kitchen.
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, 5 life-threatening violation(s), Special Focus Facility, 3 harm violation(s), $99,788 in fines, Payment denial on record. Review inspection reports carefully.
- • 18 deficiencies on record, including 5 critical (life-threatening) violations. These warrant careful review before choosing this facility.
- • $99,788 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 Lyonsview Center's CMS Rating?
CMS assigns LYONSVIEW HEALTH AND REHABILITATION 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 Lyonsview Center Staffed?
CMS rates LYONSVIEW HEALTH AND REHABILITATION CENTER's staffing level at 1 out of 5 stars, which is much below average compared to other nursing homes. Staff turnover is 62%, which is 15 percentage points above the Tennessee average of 46%. High turnover can affect care consistency as new staff learn residents' individual needs. RN turnover specifically is 56%, which is notably high. RNs provide skilled clinical oversight, so turnover in this role can affect medical care quality.
What Have Inspectors Found at Lyonsview Center?
State health inspectors documented 18 deficiencies at LYONSVIEW HEALTH AND REHABILITATION CENTER during 2019 to 2024. These included: 5 Immediate Jeopardy (the most serious level, indicating potential for serious harm or death), 3 that caused actual resident harm, and 10 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 Lyonsview Center?
LYONSVIEW HEALTH AND REHABILITATION 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 CHAMPION CARE, a chain that manages multiple nursing homes. With 222 certified beds and approximately 160 residents (about 72% occupancy), it is a large facility located in KNOXVILLE, Tennessee.
How Does Lyonsview Center Compare to Other Tennessee Nursing Homes?
Compared to the 100 nursing homes in Tennessee, LYONSVIEW HEALTH AND REHABILITATION 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 Lyonsview Center?
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 you walk me through typical staffing levels on day, evening, and night shifts?" These questions are particularly relevant given the facility's Immediate Jeopardy citations, the substantiated abuse finding on record, the facility's high staff turnover rate, and the below-average staffing rating.
Is Lyonsview Center Safe?
Based on CMS inspection data, LYONSVIEW HEALTH AND REHABILITATION 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 5 Immediate Jeopardy citations (the most serious violation level indicating risk of serious injury or death). The facility is currently on the Special Focus Facility watch list (a federal program monitoring the lowest-performing 1% of nursing homes nationwide). 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 Lyonsview Center Stick Around?
Staff turnover at LYONSVIEW HEALTH AND REHABILITATION CENTER is high. At 62%, the facility is 15 percentage points above the Tennessee average of 46%. Registered Nurse turnover is particularly concerning at 56%. RNs handle complex medical decisions and coordinate care — frequent RN changes can directly impact care quality. 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 Lyonsview Center Ever Fined?
LYONSVIEW HEALTH AND REHABILITATION CENTER has been fined $99,788 across 2 penalty actions. This is above the Tennessee average of $34,077. Fines in this range indicate compliance issues significant enough for CMS to impose meaningful financial consequences. Common causes include delayed correction of deficiencies, repeat violations, or care failures affecting resident safety. Families should ask facility leadership what changes have been made since these penalties.
Is Lyonsview Center on Any Federal Watch List?
LYONSVIEW HEALTH AND REHABILITATION CENTER is currently an SFF Candidate, meaning CMS has identified it as potentially qualifying for the Special Focus Facility watch list. SFF Candidates have a history of serious deficiencies but haven't yet reached the threshold for full SFF designation. The facility is being monitored more closely — if problems continue, it may be added to the official watch list. Families should ask what the facility is doing to address the issues that led to this status.