HARMONEE HOUSE
For profit - Corporation
35 Beds
Independent
Data: November 2025
1 Immediate Jeopardy citation
Trust Grade
51/100
#481 of 1168 in TX
Last Inspection: September 2024
Within standard 12-15 month inspection cycle. Federal law requires annual inspections.
Overview
Harmonee House in Amherst, Texas, has a Trust Grade of C, indicating it is average and falls in the middle of the pack among nursing facilities. It ranks #481 out of 1,168 in Texas, placing it in the top half, and #2 out of 3 in Lamb County, meaning only one local option is better. The facility is showing improvement, with the number of issues decreasing from nine in 2023 to six in 2024. While staffing is a strength with good RN coverage and zero turnover, the facility has received fines totaling $7,446, which is concerning as it is higher than 50% of Texas facilities. However, there are notable weaknesses. A critical finding revealed that the facility failed to maintain proper infection control measures, risking the health of residents, especially regarding COVID-19 precautions. Additionally, there were multiple concerns related to food safety, such as improperly labeled and stored food items, which could lead to food-borne illnesses. Families should weigh these strengths and weaknesses when considering Harmonee House for their loved ones.
- Trust Score
- C
- In Texas
- #481/1168
- Safety Record
- High Risk
- Inspections
- Getting Better
- Staff Stability ○ Average
- Turnover data not reported for this facility.
- Penalties ⚠ Watch
- $7,446 in fines. Higher than 88% of Texas facilities, suggesting repeated compliance issues.
- Skilled Nurses ○ Average
- Each resident gets 37 minutes of Registered Nurse (RN) attention daily — about average for Texas. RNs are the most trained staff who monitor for health changes.
- Violations ⚠ Watch
- 20 deficiencies on record. Higher than average. Multiple issues found across inspections.
51/100
Top 41%
Review needed
9 → 6 violations
★★★☆☆
3.0
Overall Rating
★★☆☆☆
2.0
Staff Levels
★★★★☆
4.0
Care Quality
★★★☆☆
3.0
Inspection Score
↔
Stable
2023: 9 issues
2024: 6 issues
The Good
-
4-Star Quality Measures · Strong clinical quality outcomes
-
Full Sprinkler Coverage · Fire safety systems throughout facility
-
No fines on record
Facility shows strength in quality measures, fire safety.
The Bad
3-Star Overall Rating
Near Texas average (2.8)
Meets federal standards, typical of most facilities
Federal Fines: $7,446
Below median ($33,413)
Minor penalties assessed
The Ugly 20 deficiencies on record
1 life-threatening
Sept 2024
6 deficiencies
CONCERN
(D)
Potential for Harm - no one hurt, but risky conditions existed
Deficiency F0565
(Tag F0565)
Could have caused harm · This affected 1 resident
Based on interview and record review the facility failed to consider the views of a resident group and act promptly upon the grievances and recommendations of such groups concerning issues of resident...
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Based on interview and record review the facility failed to consider the views of a resident group and act promptly upon the grievances and recommendations of such groups concerning issues of resident care and life in the facility for 3 of 8 anonymous residents.
The facility failed to address a grievance put forth by the resident council regarding a resident who sang disruptively loud and spit on the floor and on other residents during meals.
This failure could lead to residents feeling unheard and unvalued in their place of residence.
Findings Included:
During a resident council meeting on 09/10/24 at 10:20 AM 3 of 8 attendees complained about a certain resident who sang at the top of her lungs during meals and spit loogies on the floor and occasionally on other residents during meals. The anonymous residents said the singing made it hard to hold conversations during mealtimes and the loogies made them lose their appetites. The residents stated that during lunch yesterday, when state was observing meal pass, the singing, spitting resident was not brought to the dining room to eat.
One of the anonymous residents said she filed a grievance with ADON regarding the singing, spitting resident. The anonymous resident said she was asked to write down her complaints and she did so. She said ADON told her there was nothing the facility could do because it was not fair to the singing, spitting resident to exclude her from the dining room. The anonymous resident then asked if she could take her meals in her room and was told she had to eat at least two meals a day in the dining room.
One of the other anonymous residents stated the singing, spitting resident spit a loogie on her forearm during a meal and ruined her appetite.
Another of the anonymous residents stated the singing, spitting resident spit on the residents she did not like.
All three anonymous residents stated they brought up their concerns last month at the resident council meeting and were told again that there was nothing the facility could do because it would infringe upon the singing, spitting resident's rights to exclude her from the dining room.
Record review of the past 6 months of grievances revealed no grievance about the singing, spitting resident.
Record review of the past 6 months of resident council minutes revealed no mention of the singing, spitting resident. The resident council meeting minutes from last month revealed all three anonymous residents were in attendance at the meeting on 08/27/24 and ADON was the staff in attendance.
During an interview on 09/11/24 at 09:44 AM LVN B stated when a resident told her they wanted to file a grievance she took it to the DON. She said if a resident filed a grievance and it was ignored, I'm sure they would kind of be upset about it. She stated she saw the singing, spitting resident being loud and disruptive in the dining room almost every day. LVN B stated she saw the singing, spitting resident spit on her chair, the floor, kind of anywhere. She stated she has not seen the singing, spitting resident spit on another resident. When asked what kind of interventions were tried when the singing, spitting resident was disruptive in the dining room and other residents complained she said nursing staff would try to redirect the singing, spitting resident or move her to another table.
During an interview on 09/11/24 at 09:56 AM CNA E stated if a resident wanted to file a grievance, she would alert her charge nurse. She stated if a resident filed a grievance, and it was ignored the resident would be negatively impacted because they have that right. She stated she has seen the singing, spitting resident yelling and singing in the dining room a lot. She said, At least they are church songs. She is very, very loud. CNA E stated she had not seen the singing, spitting resident spit on another resident but she had seen her spit on the floor. She stated, She just did it for breakfast.
During an interview on 09/11/24 at 10:03 AM ADM stated when a resident wants to file a grievance the facility will formalize it through written grievance process and follow up. She stated, We talk about it as a team and work to resolve issues promptly. She stated the facility does not have a particular staff who is the grievance officer but that all executive staff work together to resolve grievances. ADM stated to have a grievance ignored would have a negative impact on a resident. She said she had seen the singing, spitting resident being disruptively loud in the dining room. ADM stated she had seen the singing, spitting resident spit on the floor one time and had never see her spit on another resident.
During an interview on 09/11/24 at 10:33 AM ADON stated when a resident filed a grievance, she would put it in the grievance book and follow up on it and try to resolve it. She stated she did not remember the anonymous resident writing up a grievance regarding the singing, spitting resident and she did not remember the residents in resident council complaining about the singing, spitting resident during last month's meeting. She stated residents are not told they have to eat at least two meals in the dining room. She said they are encouraged to do so, but it is not a rule. When asked if she had witnessed the singing, spitting resident being disruptive in the dining room she stated, Um, at least daily! We give her coffee to redirect her. ADON said of the singing, spitting resident, She has a bad habit of spitting. Sometimes we move her to a table around the nurses' station and it calms her. She spits from frustration or overstimulation.
During an interview on 09/11/24 at 11:42 AM DON stated when a resident comes to her and tells her they do not like something or are unhappy she files a grievance on their behalf and assigns it to herself to ADON to investigate and resolve. DON said there was absolutely a negative outcome if a resident filed a grievance, and it was ignored. She continued, I mean, I don't get grievances from the ones that have dementia, so the ones that do have a grievance are cognitively aware and expect me to find a solution or at least be willing to come to an agreement. DON stated there is not rule that residents must eat in the dining room twice a day though she did say it was encouraged. She stated she has witnessed the singing, spitting resident being disruptive in the dining room. She said when she hears the singing, spitting resident being loud she gives her a cup of coffee. DON stated she had not seen the singing, spitting resident spit on another resident but added, I have seen her spit on the floor. I have known her all my life and it is her nature. When I see her do it, I hand her a paper towel ask her to spit in the paper towel.
Record review of facility policy titled Resident Rights and dated December 2020 revealed in part:
. Federal and state law guarantee certain basic rights to all residents of this facility. These rights include the resident's right to: . u. voice grievances to the facility . v. have the facility respond to his or her grievances .
Record review of facility policy titled Grievances/Complaints, Recording and Investigating and dated August 2024 revealed in part:
All grievances and complaints filed with the facility will be investigated and corrective actions will be taken to resolve grievance(s). 2. Upon receiving a grievance and complaint report the grievance officer will begin an investigation into the allegations. 7. The resident, or person acting on behalf of the resident, will be informed of the findings of the investigation, as well as any corrective actions recommended.
CONCERN
(D)
Potential for Harm - no one hurt, but risky conditions existed
Notification of Changes
(Tag F0580)
Could have caused harm · This affected 1 resident
**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, interview, and record review the facility failed to immediately inform the resident; consult with the resi...
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**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, interview, and record review the facility failed to immediately inform the resident; consult with the resident's physician; and notify consistent with his or her authority, the resident representative(s) when there is a significant change in the resident's physical, mental, or psychosocial status and notify the resident and the resident representative, if any, when there is a change in room for 1 (Resident #6) of 12 residents reviewed for notification of change of condition.
The facility failed to inform Resident #6's family of his positive COVID test and subsequent change of rooms to an isolation room.
This failure could place residents at risk of not having their change in condition communicated to their physician or representative.
Findings Included:
Record review of Resident #6's admission record dated 09/10/24 revealed an [AGE] year-old male admitted to the facility on [DATE] with diagnoses that included, but were not limited to, acute bronchitis (lining of tube that carries air to and from the lungs is inflamed causing cough with mucus, shortness of breath, and mild fever), dementia (a group of thinking and social symptoms that interferes with daily functioning), heart disease, and chronic obstructive pulmonary disease (inflammation of lung tissue due to non-infectious causes, which results in cough without mucus or phlegm, shortness of breath, and fatigue). Resident #6's family member A was listed as his responsible party and #1 emergency contact with two phone numbers and an address. His family member B was listed with one phone number and an address.
Record review of Resident #6's significant change MDS completed 05/11/24 revealed the following:
Section C indicated a BIMS score of 3 which indicated severely impaired cognition.
Section F indicated it was very important to Resident #6 to have his family involved in discussions about his care.
Record review of Resident #6's care plan initiated on 08/05/24 revealed entry dated 09/09/24 which indicated Resident #6 was positive for COVID and was moved into an isolation room.
Record review of Resident #6's progress notes from 09/09/24 revealed the following:
On 09/09/24 at 03:10 PM LVN A noted Resident still not feeling well this afternoon and continues with increased sleepiness and weakness. Also noted with nasal congestion. [Name of hospice nurse] with [Name of hospice] notified, and telephone order received to test resident for Covid. Resident tested for Covid using rapid test and results were positive. Resident placed on isolation precautions and [Name of hospice nurse] hospice notified. Awaiting any further orders at this time.
On 09/09/24 at 11:23 PM LVN H noted At approx. 2145 (09:45 PM) writer entered room just as resident slid out of bed onto his bottom. Called for assistance with call light. (Resident was) Oriented to self only. Unable to state why he was trying to get out of bed. Denies pain on assessment. Active ROM x 4 extremities, no deformities noted. Assisted to standing position and then back to bed. Incontinent care provided and settled back into bed. Fluids and call light are in reach. Called to notify [Name of Resident #6's family member A], [Name of Resident #6's family member B] answered and stated she would let [Resident #6's family member B] know.
Resident #6's progress notes from 09/09/24 to 09/10/24 revealed no documentation of notification of family regarding his positive COVID test and subsequent room change.
During an observation on 09/09/24 at 12:02 PM Resident #6 was lying on his back in bed under a blanket with his bed flat. He had his eyes closed and the lights in his shared room were off.
During an interview on 09/09/24 at 03:23 PM Resident #6's family member A was asked if the facility had notified her or Resident #6's positive COVID test. She replied the facility had called her in the past to let her know COVID was in the building but Resident #6 was okay. She indicated she had not received a call about his recent positive COVID test.
During an interview on 09/10/24 at 08:09 AM Resident #6's family member B answered family member A's phone and stated the family had not been notified of Resident #6's positive COVID test and subsequent room change. She stated on 09/09/24 the facility did call to notify the family of a fall Resident #6 had where he slid out of his bed but was not injured. She stated during that call the facility said nothing about a positive COVID test or room change. Resident #6's family member asked how long he would be on isolation and this surveyor encouraged her to call the facility for more information.
During an observation and interview on 09/10/24 at 09:28 AM Resident #6's new room has the door shut with signage on what PPE to wear before entering and to dispose of PPE inside the room. Resident #6 was seated on the edge of his bed in his isolation room. He stated he has started to feel better.
During an interview on 09/11/24 at 09:44 AM LVN B stated if a resident had a change of condition the doctor, DON, and family and hospice if they are on hospice should have been notified. She stated family should have been notified if a resident changed rooms. She stated it was the responsibility of the charge nurse to make said notifications and document them in the progress notes. When asked if there would be a negative outcome if a family was not informed of their resident testing positive for COVID she stated, I guess it depends. Especially if family comes often and resident wonders why not seeing them (family). She stated if a resident was positive for COVID, You always want to tell them (family of resident and resident) they are being isolated and the reason.
During an interview on 09/11/24 at 09:56 AM CNA E stated if a family was not notified of their resident's positive COVID test it would put others in danger from spread of COVID if the family came to visit their resident.
During an interview on 09/11/24 at 10:06 AM ADM stated the physician, family, DON/ADM should have been notified when a resident had a change of condition. She stated family should have been notified when a resident changed rooms. She stated nursing was responsible for making said notifications. She stated there was a negative outcome for residents if the family was not notified of positive COVID and a room change but she did not elaborate on what the negative outcome was.
During an observation and interview on 09/11/24 at 10:33 AM ADON stated immediate family should have been notified when a resident had a change of condition or change of room. She stated she thought LVN A notified the family of Resident #6 of his positive COVID test. ADON proceeded to look through Resident #6's progress notes in the EHR and said, But he (LVN A) didn't chart it. She stated there was no other place LVN A would have charted but in the progress notes. She stated charge nurses were responsible for notifying family members when a resident tested positive for COVID and/or had a change of room and they were to document the notification in the progress notes. She stated a possible negative outcome of not notifying family of positive COVID test and room change was the family would be shocked when they came to visit their family member.
During an interview on 09/11/24 at 11:42 AM DON stated charge nurses were responsible to notify physician and family when a resident had a change of condition or rooms. She stated the notification should be documented in the progress notes. When asked what a negative outcome of not notifying a family would be, DON stated, It depends, if the resident has dementia, they won't know one way or the other. It is situational to me. Some families don't participate in care, but still need to be notified.
During an interview on 09/11/24 at 12:05 PM LVN A stated he did call Resident #6's family member A to notify her of Resident #6's positive COVID test and resultant room change. He stated, She was having a hard time following what he was saying. He stated he did not know why he did not document the notification.
Record review of facility policy titled Change in a Resident's Condition or Status and dated July 2024 revealed in part:
Our facility shall promptly notify the resident, his or her Attending Physician, and representative (sponsor) of changes in the resident's medical/mental condition and/or status . 4. Unless otherwise instructed by the resident, a nurse will notify the resident's representative when: . b. There is a significant change in the resident's physical, mental, or psychosocial status; c. There is a need to change the resident's room assignment; .
CONCERN
(D)
Potential for Harm - no one hurt, but risky conditions existed
Deficiency F0657
(Tag F0657)
Could have caused harm · This affected 1 resident
**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, interview and record review the facility failed to ensure the care plan is prepared by an interdisciplinar...
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**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, interview and record review the facility failed to ensure the care plan is prepared by an interdisciplinary team, that includes to the extent practicable, the participation of the resident and the resident's representative(s) and if the participation of the resident or their resident representative is determined not practicable for the development of the resident care plan include an explanation in the resident's medical record for 1 (Resident #6) of 12 residents reviewed for care plan timing and revision.
The facility failed to invite Resident #6's family members to his care plan meeting.
This failure could lead to a lack of cohesiveness in resident care and/or residents not receiving necessary care.
Findings Included:
Record review of Resident #6's admission record dated 09/10/24 revealed an [AGE] year-old male admitted to the facility on [DATE] with diagnoses that included, but were not limited to, acute bronchitis (lining of tube that carries air to and from the lungs is inflamed causing cough with mucus, shortness of breath, and mild fever), type 2 diabetes (insufficient production of insulin, causing high blood sugar), dementia (a group of thinking and social symptoms that interferes with daily functioning), depression (a mood disorder that causes a persistent feeling of sadness and loss of interest), heart disease, cerebral aneurysm nonruptured (bulge or ballooning of blood vessel in the brain), and chronic obstructive pulmonary disease (inflammation of lung tissue due to non-infectious causes, which results in cough without mucus or phlegm, shortness of breath, and fatigue). Resident #6's family member A was listed as his responsible party and #1 emergency contact with two phone numbers and an address. His family member B was listed with one phone number and an address.
Record review of Resident #6's significant change MDS completed 05/11/24 revealed the following:
Section B indicated Resident #6 had unclear speech and was sometimes understood, but he usually understood others.
Section C indicated Resident #6 had a BIMS score of 3 which indicated severely impaired cognition.
Section F indicated it was very important to Resident #6 to have his family involved in discussions about his care.
Record review of Resident #6's care plan initiated on 08/05/24 revealed he would not be discharged to the community due to advanced dementia. The care plan indicated Resident #6 had impaired cognitive function, impaired thought processes, and difficulty making decisions due to long and short-term memory loss as well as difficulty communicating.
During an interview on 09/09/24 at 03:31 PM Resident #6's family member A stated she had not been invited to participate in a care plan for Resident #6 during his time in the facility. She said, They send me a letter when there is a party or something like Easter or Father's Day.
During an interview on 09/10/24 at 03:38 PM ADM stated DON was responsible for inviting family members to care planning meetings. She said DON sent a letter to the family and if she did not hear back from the family she would call them to determine if they wanted to attend the meeting or not.
During an interview on 09/11/24 at 09:24 AM DON stated she did not think she had any proof of inviting Resident #6's family to the care plan meeting. She stated it was in August and Resident #6's family member A came to talk with her. DON stated she was not sure of the day, just that it was in August.
During an interview on 09/11/24 at 09:26 AM DON stated Resident #6's family member A has been diagnosed with dementia and is close to being admitted to the facility so would probably not remember speaking with her (DON) about Resident #6's care plan. She stated she thought she wrote on the care plan itself that Resident #6's family member was a part of the meeting, but she would check to be sure.
During an interview on 09/11/24 at 09:44 AM LVN B was asked for a negative outcome for residents if family members were not invited to the care plan. She did not answer the question but she said, They (family members) should be invited, I know they are always invited.
During an interview on 09/11/24 at 09:56 AM CNA E stated a family's invitation to resident care plans was important to keep the family involved in what is going on. She stated, These residents here change regularly. There are a lot of memory issues and they (family) need to be up to date on what is going on.
During an interview on 09/11/24 at 10:06 AM ADM stated a possible negative outcome of family members of residents not being invited to care plans was, They would not be involved in care (of residents) and they are a vital part of care (of residents).
During an interview on 09/11/24 at 10:33 AM ADON stated DON is responsible for inviting residents' family members to care plan meetings. She said a possible negative outcome of family members not being invited to care plans meetings was the family would not be up to date on their (residents) care.
During an observation and interview on 09/11/24 at 11:42 AM DON stated she could not prove she invited Resident #6's family to his care plan. She stated, I am gonna say I dropped the ball. I did have a visit with her (Resident #6's family member A) in August . but I can't prove that I did. She held up an invitation letter to a care plan for another resident and stated she could not find the copy of the one she mailed to Resident #6's family member. She said when she invited family members to care plans, she mailed the letter and kept a copy for herself, but she could not find a copy of one for Resident #6's care plan in August. She said a possible negative outcome of a family not being invited to be part of the care plan meeting was, I mean it just helps them feel more involved in their loved one's care and they need to know what is going on with their loved one, any decline, any medication change.
Record review of facility policy titled Care Planning-Interdisciplinary Team and dated September 2013 revealed in part:
Our facility's care planning/interdisciplinary team is responsible for the development of an individualized comprehensive care plan for each resident. 3. The resident, the resident's family and/or the resident's legal representative/guardian or surrogate are encouraged to participate in the development of and revisions to the resident's care plan. 4. Every effort will be made to schedule care plan meetings at the best time of the day for the resident and family.
Record review of facility policy titled Resident Rights and dated December 2020 revealed in part:
. 1. Federal and state laws guarantee certain basic rights to all residents of this facility. These rights include the resident's right to: . p. be informed of, and participate in, his or her care planning and treatment; .
CONCERN
(D)
Potential for Harm - no one hurt, but risky conditions existed
Deficiency F0761
(Tag F0761)
Could have caused harm · This affected 1 resident
**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, interview, and record review; it was determined the facility failed to ensure medications were stored and ...
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**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, interview, and record review; it was determined the facility failed to ensure medications were stored and labeled in accordance with currently accepted professional principles on 1 of 1 medication carts, in that:.
3 medications were left loose in the medication cart and 2 residents' insulin vials and box packaging were not marked correctly with date of opening.
1 insulin medication vial in the medication cart drawer one was marked with an open date of 7-16-24 and the box packaging was dated 8-1-24. Insulin was still in use after 55 days from documented vial opening date.
1 insulin medication vial in the medication cart drawer one was open without an opening date marked on the vial or box packaging.
The facility's failure to ensure medications were labeled in accordance with currently accepted professional principles could place residents at risk for exposure to medication that is expired or ineffective; resulting in exacerbation of the disease being treated, exposure to contaminated products capable of causing infection, and other adverse reactions.
Findings include:
During observation on 09-09-24 at 11:32AM the medication cart was observed with Facility LVN A. In drawer one there was an open multidose vial of Novolog Insulin. Vial was dated 7-16-24 and box packaging dated 8-1-24was still in use 55 days after having been opened. LVN A verified the date written on the vial was 7-16-24 and the date on the box packaging was 8-1-24. LVN A was asked how many days from open date is insulin discarded. He stated,30 days from the opening date.
During observation on 09-09-24 at 11:36 AM to the medication cart drawer one an open vial of Lantus Insulin was observed without an open date on the vial or the box packaging. LVN A was asked when is the opening date to be documented on the insulin vial. He stated, When it is opened. LVN A verified there was no date documented on the insulin vial or box packaging.
During observation on 09-09-24 at 11:40AM medication cart second drawer had 3 loose medications. LVN A was able to identify the 3 loose medications. LVN A identified the medications. LVN A was asked what could be potential negative outcomes from residents not receiving these medications. He stated, Missing the Bethanechol could cause bladder discomfort, the Lasix could cause edema and the Eliquis could cause blood clots.
Interview with Administrator on 09-10-24 at 2:15PM she was asked for a policy on Medication Cart Monitoring and Medication Administration. She started the night shift nurse usually cleans, monitors, and stocks the medication cart. She did not know about the policies but would find them if she could she stated.
Interview 09-11-24 at 10:19AM with the DON when asked about who is responsible for monitoring the medication cart she stated, The Charge Nurse is responsible to clean it once a week. Usually, the night nurse and the Chare Nurse have that responsibility. The medication cart is everybody's responsibility. She stated, The policy for the medication Insulin is to be dated on the vial when it is opened and discarded after 30 days. When asked about the loose pills in the medication cart the DON stated, I feel we are doing much better with the prepackaged medications. We are finding less loose pills than we use to. When asked about the possible negative outcome of administering outdated medications to residents she stated, That's why we have expiration dates on medications so we will know. Negative outcomes for a resident could be uncontrolled blood glucose, hyperglycemia, or hypoglycemia.
Interview on 09-11-24 at 10:35AM with the ADON. She stated there is no policy for Medication Cart Monitoring. She stated, Usually the night nurse manages the medication cart cleaning and stocking. If we have an agency nurse over the weekend I go through the cart on Mondays. Asked about policy on medication insulin opening and discarding she stated, Insulin is to be dated on the day of opening of it. It is discarded 30 days from that opening date.
Record review of facility policy revealed the following:
Policy Title: Storage of Medications
Date issued: MED-PASS, Inc. [DATE]
5. Discontinued, outdated, or deteriorated drugs or biologicals are returned to the dispensing pharmacy or destroyed
12. Only persons authorized to prepare and administer medications have access to locked medications.
On 09-10-24 at 2:15PM asked Administrator for Medication Administration Policy. Did not receive prior to facility exit.
CONCERN
(E)
Potential for Harm - no one hurt, but risky conditions existed
Deficiency F0679
(Tag F0679)
Could have caused harm · This affected multiple residents
**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observations, interviews, and record reviews the facility failed to provide, based on the comprehensive assessment and ...
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**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observations, interviews, and record reviews the facility failed to provide, based on the comprehensive assessment and care plan and the preferences of each resident, an ongoing program to support residents in their choice of activities, both facility-sponsored group and individual activities and independent activities, designed to meet the interests of and support the physical, mental, and psychosocial well-being of each resident, encouraging both independence and interaction in the community for 5 of 8 anonymous residents observed for 3 of 3 (September 9, 10, and 11 of 2024) days and reviewed for quality of life.
The facility failed to ensure scheduled activities were taking place.
The facility failed to ensure activities met resident's needs/desires.
These failures could place residents at risk of boredom and/or a decline in their quality of life.
Findings Included:
Record review of facility activities calendar dated September 2024 revealed at least 5 activities scheduled each weekday and two activities scheduled each Saturday and Sunday for the month. In total there were 125 activities listed. Of those 65 were passive TV-based to include watching Wheel of Fortune (21 times), The Price is Right (19 times), Movie Madness (4 times), a chair-based exercise program called Sit and Fit (8 times), football games (9 times) and something listed as Days to Remember (4 times). Of the remaining 60 activities 32 were independent or required minimal social interaction to include Bird Watching (5 times), Independent Activities (4 times), One-on-One Visits (4 times), Music We Remember (5 times), Beauty Shop (2 times), Coffee & Chat (9 times), and Coloring (3 times). Of the remaining 28 activities 10 were led by volunteers from outside the facility to include Church (5 times), Bible & Bingo (4 times) and Pep Rally (1 time). The remaining 18 activities included Manicures and Chit Chat (4 times), Dominoes (4 times), Resident Council (1 time), Ice Cream Social (3 times), Monthly Birthday Party (1 time), National Donut Day (1 time), and Bingo (4 times). The calendar revealed the following times and activities scheduled for the three days of observation:
09/09/24: 9:00 Coffee & Chat; 10:00 Bird Watching; 11:00 Price is Right; 2:00 Music We Remember; 6:30 Wheel of Fortune
09/10/24: 9:00 Manicures and Chit Chat; 10:00 Sit & Fit; 11:00 Resident Council; 2:00 Movie Madness; 6:30 Wheel of Fortune
09/11/24: 9:00 Dominoes; 10:00 Bible and Bingo; 11:00 Price is Right; 2:00 Days to Remember; 630: Wheel of Fortune
During an interview on 09/09/24 at 11:25 AM DON stated ADON is also the AD, one of the infection preventionists, and the MDS nurse.
During an observation on 09/09/24 at 11:50 AM The Price is Right was playing on the TV in the dining room as residents were sitting at various tables talking with one another and waiting on lunch service. Few residents were seated facing the TV and those that were facing the TV were not looking at the TV.
During an interview on 09/09/24 at 04:14 PM an anonymous resident stated the only activity provided was Bingo on Wednesdays and he enjoyed attending.
During an interview on 09/10/24 at 10:20 AM 5 of 8 anonymous residents stated the facility only had activities on Wednesday. They stated the activity was bingo and bible study. When asked what types of activities they would like they stated, movie nights and crafts or something. The residents also mentioned that some residents could not use their hands or really understand games and might like to have music played for them.
During an observation on 09/10/24 at 02:42 PM revealed no one in the sitting area in the lobby and the TV was off.
During an observation on 09/10/24 at 02:43 PM two residents were noted to be watching a TV commercial at the end of the hall in the common area and one resident was noted to be watching TV in the dining room. No staff were present in either locale.
During an interview on 09/10/24 at 02:44 PM LVN A stated Movie Madness as listed on the activities calendar across from the nurses' station to be taking place today beginning at 02:00 PM usually takes place at the end of the hall or in the lobby area. He stated the TV hanging in the dining room had not been hanging there very long and he had not seen Movie Madness take place in the dining room.
During an observation and interview on 09/10/24 at 02:48 PM two anonymous residents were in a resident room watching TV. On the wall was a copy of the activities calendar. The residents stated the activities on the calendar do not happen. They stated the only reason Bingo and Bible Study took place was because a volunteer from a nearby town came in and hosted the activity. They stated they did not know ADON was AD until today's resident council meeting.
During an observation on 09/11/24 at 09:31 AM three residents were seated at three different tables in the dining room. There were no dominoes visible.
During an observation on 09/11/24 at 09:31 AM two residents were seated in the common area at the end of the hall. One on the couch and one in a w/c. They were not facing one another, and no dominoes were visible.
During an observation on 09/11/24 at 09:32 AM the two tables in the lobby area had no residents seated around them and no dominoes were visible.
During an observation on 09/11/24 at 09:33 AM the activity room was empty but cheerful and full of colorful paintings, puzzles, etc. No dominoes were visible.
During an interview on 09/11/24 at 09:38 AM HSK F stated she had worked for the facility for 2-3 months and had not observed residents involved in activities 4-5 times a day on weekdays.
During an interview on 09/11/24 at 09:38 AM HSK G stated she had worked for the facility for 1 month and had not observed activities taking place 4-5 times a day on weekdays.
During an observation and interview on 09/11/24 at 09:44 AM LVN B stated she had noticed residents involved in activities 4-5 times each weekday. When asked for an example she replied, Bingo and bible on Wednesdays for a little bit, sometimes watch TV, coffee time. She stated the CNAs lead activities but added, We have a helper that comes on Wednesdays. When asked if the residents played dominoes this morning she said, They are about to start right now, they are going to do bible and play bingo right now. When asked how residents know when an activity is taking place, she gestured to the board across from the nurses' station and said, Usually it is posed on that board right there and of course we remind them like today is Wednesday Bingo day. When asked where the activity Bird Watching took place she gestured to the window in the dining room from which you could see several bird feeders. When asked if staff are part of the bird watching activity she stated, Usually they (residents) will just sit there and watch them (birds). LVN B stated there was not a negative outcome for residents if the activities calendar was not followed.
During an interview on 09/11/24 at 09:56 AM CNA E stated she had worked for the facility for 7 months and she had observed residents involved in activities. When asked what kind of activities she stated, In summer they went outside a lot, had watermelon and ice cream on the patio. She stated the residents were going to play bingo today because a former resident's family member still comes and leads bingo. CNA E stated she had never helped organize or lead activities. She stated the residents do not have enough activity involvement. She said, I think if they had more there would be less .I'm not saying there's a lot of falls, but we have to redirect a lot of people (residents) because they wander a lot.
During an interview on 09/11/24 at 10:06 AM ADM stated she sees the resident involved in activities 5-6 times each weekday. She said, Our activities are a little less structured here and have a difficult time getting resident involvement. Dominoes was a thing for awhile and then it became this huge fight. When asked who usually led the activities she stated CNAs, ADON, and volunteers. She stated the facility is looking for a full time AD. When asked if there was a negative to outcome for residents if the activities calendar was not followed, ADM said, Yes, just that they anticipate something that didn't occur.
During an interview on 09/11/24 at 10:33 AM ADON stated the CNAs lead the activities on the weekdays. She stated her family member was a day CNA and was in charge of activities, but the family member transitioned to nights at the beginning of September. ADON stated her family member did not have AD certification. She stated Movie Madness on the activities calendar was when the CNAs basically set up a movie in the dining room and a movie in the other TV area at the end of the hall. She said sometimes a third movie would be playing in the lobby area. She stated it was called madness because movies were playing everywhere. She stated Movie Madness activity was held on 09/10/24 in the dining room and in the common area at the end of the hall. When asked who hosted Manicures and Chit Chat yesterday, ADON said she did not know. When asked who hosted Sit and Fit yesterday, she stated, I thought they turned on the TV yesterday morning but, honestly, I did not follow up yesterday. She stated residents are aware of activities because we go through and ask verbally if they want to attend. When asked what types of activities are done for residents who are bedbound or unable to participate in bingo, ADON stated, Usually our bedbound have hospice visitors coming in. The hospice marketer comes in and chaplains come in. She stated of the residents in the facility, We have maybe 5 who are totally with it. Sometimes we just play music and dance in the hallways. ADON stated weekend activities are led by CNAs and local churches. When asked what Independent Activities meant she said the residents could put puzzles together, read, or have family visits. ADON stated residents were allowed to be in the Activities Room when there was a craft. When asked what Days to Remember on the activities calendar was ADON said, Like today, we played a 9/11 video this morning at breakfast and will print out things for them to color. She said Music We Remember on the activities calendar involved staff playing music from the 50s and 60s on YouTube or the [NAME] at the nurses' station. When asked if it felt doable for her to be ADON, AD and MDS nurse, she stated, Spread thin most days because then I help with housekeeping too. ADON stated she felt the residents had enough activities to meet their needs. She could not think of a negative outcome of not following the activities calendar.
During an interview on 09/11/24 at 11:42 AM DON stated she had not seen residents involved in activities 5-6 times a day as noted on the activities calendar. She stated activities were led by CNAs. When asked if she thought residents had enough activities to meet their needs she stated, No, I don't think they do. One thing is they don't eat as well, don't get enough exercise to burn calories so don't get hungry. They don't receive the socialization that I feel like they probably need. When asked if there was a negative outcome for residents if the activities calendar was not followed, DON stated, Yeah, I mean they expect those things to take place.
Record review of resident council minutes dated 06/06/24 revealed ADON's family member was staff person in attendance and the note regarding activities was, Wish we could do more activities with you instead of you being on the floor as a CNA.
Record review of facility policy titled Activity Programs - Staffing and dated June 2018 revealed in part:
Our activity programs are staffed with personnel who have appropriate training and experience to meet the needs and interests of each resident. 2. The activity director/coordinator's responsibilities include: . c. monitoring and evaluating the residents' responses to activities and revising the approaches as appropriate; and d. developing, implementing, supervising and evaluating the activity programs at least quarterly. 5. Sufficient activity personnel are on duty to meet the needs of the residents and the functions of the activity programs.
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 observation, interview, and record review, the facility failed to store, prepare, distribute, and serve food in accordance with the professional standards for food service safety for 1 of 1 k...
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Based on observation, interview, and record review, the facility failed to store, prepare, distribute, and serve food in accordance with the professional standards for food service safety for 1 of 1 kitchen reviewed for kitchen sanitation.
1.
The facility failed to ensure freezer items were properly stored, labeled, and dated.
2.
The facility failed to ensure pantry foods were properly stored, labeled, and dated.
3.
The facility failed to ensure refrigerated foods were properly stored, labeled, and dated.
These failures could place residents who ate food served by the kitchen at risk of food-borne illness.
Findings included:
Observation of the refrigerator on 09/09/24 at 11:12 AM revealed the following:
1.
(1) bottle of ketchup, no date.
2.
(2) trays of cups, filled with various liquids, covered by a tray, no labels, or dates.
Observation of walk-in pantry on 09/09/24 at 11:15 AM revealed the following:
1.
(1) box of potatoes, open to the air, no label or date.
2.
(1) package of hot dog buns, 2 buns left, no label or date.
3.
(5) individual applesauce cups, no dates.
4.
(1) loaf of bread, no date.
Observation of walk-in freezer on 09/09/24 at 11:20 AM revealed the following:
1.
(6) Styrofoam cups with lids, filled with what appeared to be fruit, no labels, or dates.
2.
(2) bags of frozen veggies, no label or date.
3.
(1) box of what appeared to be breaded meat, no label or date.
In an interview on 09/10/24 at 10:35 AM, [NAME] C stated that all the cooks are responsible for labeling and dating food. He stated that if they put food out that was expired or bad, then someone could get sick.
In an interview on 09/10/24 at 10:39 AM, DM stated that it was everyone's responsibility in the kitchen to label and date food as it comes in and they must label and date leftovers. DM stated that she trains her staff by doing in services on labeling and dating foods as well as making sure leftovers are labeled. She stated that a negative outcome for not doing this could be that they could serve expired food to residents, and it could make them sick.
In an interview on 09/10/24 at 10:45 AM, [NAME] D stated that it was everyone's responsibility to check that food was labeled and dated properly. She stated that a possible negative outcome of food not being labeled and dated was they could serve spoiled food and it could make the resident's sick.
Record Review of facility policy dated October 2017 titled Food Receiving and Storage revealed in part:
.7. Dry foods that are stored in bins will be removed from original packaging, labeled and dated .
.8. All foods stored in the refrigerator or freezer will be covered, labeled and dated.
Aug 2023
8 deficiencies
CONCERN
(D)
Potential for Harm - no one hurt, but risky conditions existed
Deficiency F0578
(Tag F0578)
Could have caused harm · This affected 1 resident
**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, interview, and record review, the facility failed to ensure all residents had the right to formulate an ad...
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**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, interview, and record review, the facility failed to ensure all residents had the right to formulate an advance directive for 1 (Resident #2) of 12 residents reviewed for DNR orders.
Resident #2 had an Out-of-Hospital DNR order that was not completed as the physician did not date it.
This failure could place residents with DNR orders at risk for receiving, or not receiving, life-saving measures that align with their medical preferences.
Findings included:
Record review of Resident #2's face sheet, dated 08/06/2023 revealed an [AGE] year-old female admitted to the facility on [DATE] with diagnoses that included major depressive disorder(a mental disorder characterized by persistent low mood, low self-esteem, and loss of interest or pleasure in normally enjoyable activities), unspecified Dementia (loss of cognitive functioning-thinking, remembering and reasoning), and Pulmonary hypertension (high blood pressure that affects the arteries in the lungs and the right side of the heart). Resident #2's face sheet revealed an advance directive of DNR.
Record review of Resident #2's quarterly MDS assessment, dated 05/17/23, revealed a BIMS score of 6 out of 15 which indicated severe cognitive impairment.
Record review of Resident #2's care plan dated 07/26/2023 revealed, in part: Resident has an active DNR signed by resident and physician and placed in chart.
Record review of Resident #2's physician's orders revealed an active order for DNR dated of 05/28/21.
Record review of Resident #2 Out-of-Hospital DNR revealed the DNR document was not dated by the signing physician.
In an interview on 08/07/23 at 04:11 PM with LVN A, LVN A looked at the DNR document for Resident #2 and said it was a valid DNR. LVN A could not identify the missing date on the DNR document. LVN A said a possible negative outcome for having an incomplete DNR was The DNR would not be honored.
In an interview on 08/07/23 at 04:13 PM, DON looked at the DNR document for Resident #2. DON could not identify the missing date on the DNR document. DON pointed to the physician's order on the following page of the resident's chart and stated that the orders proved that the physician ordered it. DON stated only the DNR goes out with the resident. DON stated that the possible negative outcome for an incomplete DNR would be that it may not be honored.
Record review of a portion of the facility's policy dated April 2017, Do Not Resuscitate Order revealed the following:
.A Do Not Resuscitate (DNR) order form must be completed and signed by the Attending Physician .
Record review of the back of the previously mentioned Out-Of-Hospital Do-Not-Resuscitate document, which was titled, INSTRUCTIONS FOR ISSUING AN OUT-OF HOSPITAL DNR ORDER revealed the following:
.The original or a copy of a fully and properly completed Out-of-Hospital DNR order is sufficient evidence and will be honored by responding health care professionals .
CONCERN
(D)
Potential for Harm - no one hurt, but risky conditions existed
Assessment Accuracy
(Tag F0641)
Could have caused harm · This affected 1 resident
**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, interview, and record review the facility failed to ensure the assessment accurately reflected the residen...
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**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, interview, and record review the facility failed to ensure the assessment accurately reflected the resident's status for 1 (Resident #12) of 12 residents reviewed for accuracy of assessments.
Resident #12 received oxygen therapy but her MDS did not have oxygen therapy checked as a service received.
This failure could place residents at risk of receiving inappropriate care due to inaccurate assessments.
Findings Included:
Record review of Resident #12's face sheet, dated 08/06/23, revealed a [AGE] year-old female admitted to the facility on [DATE] with diagnoses that included, but were not limited to, pulmonary embolism (blood clot that blocks blood flow in a lung artery), high blood pressure, and shortness of breath.
Record review of Resident #12's Quarterly MDS, with a completion date of 06/16/23, revealed a BIMS of 12, which indicated moderately impaired cognition. Section G of the MDS noted Resident #12 needed limited assistance from one staff member across all ADLs except eating and personal hygiene where she was independent with a need for set up help only. Section O of the MDS indicated the resident had not received oxygen therapy in the 14 days prior to completion of the MDS.
Record review of Resident #12's care plan with a most recent start date of 07/14/23 revealed no mention of oxygen therapy.
Record review of Resident #12's Physician Orders, dated August 2023 revealed a PRN order for oxygen @ 2-3 lpm to keep sats (saturation) above 90% via n/c (nasal cannula). The order had a start date of 03/22/23.
Record review of oxygen saturation for Resident #12 from June 2023's Daily Vital and BM Record revealed Resident #12 received oxygen on 06/11/23, 06/14/23, and 06/15/23.
During an observation and interview on 08/07/23 at 12:00 PM Resident #12 was sitting in her recliner with her legs elevated and under a blanket. She was receiving O2 via nasal cannula at 4 lpm. She stated she has been on oxygen for about a year. Resident #12 said, I don't leave it off for long. I do better on it.
During an interview on 08/08/23 at 11:29 AM ADON stated she does the MDS Assessments for the facility. She said she followed the RAI as the policy for the assessments. She stated the look back period for an MDS assessment ends the day before completion of the MDS. When asked why June's Daily Vital and BM Records revealed Resident #12 was receiving oxygen therapy in the days prior to completion of her MDS but she was not coded on the MDS as receiving oxygen therapy, ADON said she was not sure. She said, If she is the one I am thinking about, I think Hospice just brought in the O2, and then back dated their order so when I did that MDS I didn't have any documentation of an order.
During an interview on 08/08/23 at 02:24 PM ADM stated a possible negative outcome of an MDS not reflecting the actual status of a resident was, Besides the fact that we don't get paid for giving extra care the care plan would be incorrect.
During an interview on 08/08/23 at 02:35 PM DON stated there was absolutely a possible negative outcome of an MDS not reflecting the actual status of a resident. She stated, For one thing, it's gonna affect the level of that resident and we might not be receiving as much as we could be to care for that resident, or we might be receiving too much which would be fraud. DON said she did not know why Resident #12's MDS did not reflect her oxygen therapy.
Record review of Section O of the MDS revealed the following instructions:
Check all of the following treatments, procedures, and programs that were performed during the last 14 days . Respiratory Treatments C. Oxygen therapy .
CONCERN
(D)
Potential for Harm - no one hurt, but risky conditions existed
Comprehensive Care Plan
(Tag F0656)
Could have caused harm · This affected 1 resident
**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on interview and record review the facility failed to develop and implement a comprehensive person-centered care plan that...
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**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on interview and record review the facility failed to develop and implement a comprehensive person-centered care plan that described the services that are to be furnished to attain or maintain the resident's highest practicable physical, mental, and psychosocial well-being for 1 (Resident #12) of 12 residents reviewed for care plan accuracy.
Resident #12 had an order for and was receiving oxygen therapy and it was not mentioned in her care plan.
Resident #12 had an order for and was receiving hospice care and it was not mentioned in her care plan.
These failures could place residents at risk of not receiving the care or treatment needed.
Findings Included:
Record review of Resident #12's face sheet, dated 08/06/23, revealed a [AGE] year-old female admitted to the facility on [DATE] with diagnoses that included, but were not limited to, pulmonary embolism (blood clot that blocks blood flow in a lung artery), high blood pressure, and shortness of breath.
Record review of Resident #12's Quarterly MDS, with a completion date of 06/16/23, revealed a BIMS of 12, which indicated moderately impaired cognition. Section G of the MDS noted Resident #12 needed limited assistance from one staff member across all ADLs except eating and personal hygiene where she was independent with a need for set up help only. Section O of the MDS indicated the resident had not received oxygen therapy in the 14 days prior to completion of the MDS. Section O further indicated Resident #12 was receiving hospice services.
Record review of oxygen saturation for Resident #12 from June 2023's Daily Vital and BM Record revealed Resident #12 received oxygen on 06/11/23, 06/14/23, and 06/15/23.
Record review of Resident #12's care plan with a most recent start date of 07/14/23 revealed no mention of oxygen therapy or hospice care.
Record review of Resident #12's Physician Orders, dated August 2023 revealed a PRN order for oxygen @ 2-3 lpm to keep sats (saturation) above 90% via n/c (nasal cannula). The order had a start date of 03/22/23. Resident #12's Physician Orders further revealed an order for admission to hospice care with a start date of 03/06/23.
During an interview on 08/08/23 at 09:25 AM LVN A said he was not sure who was responsible for care plans, but he thought it was DON and ADON. He said the only part he played in care planning was to give his feedback. When asked for a possible negative outcome of a care plan that did not accurately reflect a resident's hospice care status he said, Someone could send them to the hospital instead of calling hospice first. He said an inaccurate care plan kind of affects [a resident's] overall care.
During an interview on 08/08/23 at 09:25 AM DON stated ADON and a PRN nurse work on the facility's care plans. When asked who is responsible for the care plans, she said, Responsibility-wise I would say ultimately myself. I mean I try to review them [care plans] when the MDS's come due. I add to them [care plans]. When asked for a possible negative outcome of a care plan not accurately reflecting a resident receiving hospice care, DON said, It will change their level of care. It will limit the care provided to the facility rather than take into account the extra pair of eyes and hands that are here with hospice. It might affect medications because Hospice is responsible for medications related to diagnoses and also pain management and agitation management. She said she did not know why Resident #12's care plan did not mention hospice care or oxygen therapy and she would correct that this morning.
During an interview on 08/08/23 at 09:37 AM ADON stated DON was responsible for care plans. ADON said she updated care plans when she did the MDS. She said a possible negative outcome of a resident's care plan not reflecting the resident was on hospice was, Staff not being aware that they [residents] are receiving hospice care. She said a resident on hospice could be transferred out [for emergency care] rather than having hospice called. She stated she did not know why Resident #12's care plan did not reflect her hospice care.
Record review of a facility policy dated July 2017 and titled Hospice Program revealed the following:
. 13. Coordinated care plans for residents receiving hospice services will include the most recent hospice plan of care as well as the care and services provided by our facility (including the responsible provider and discipline assigned to specific tasks) in order to maintain the resident's highest practicable physical, mental, and psychosocial well-being. 15. The coordinated care plan shall be revised and updated as necessary to reflect the resident's current status .
Record review of a facility policy dated September 2013 and titled Care Planning - Interdisciplinary Team revealed the following:
Our facility's Care Planning/Interdisciplinary Team is responsible for the development of an individualized comprehensive care plan for each resident. 2. The care plan is based on the resident's comprehensive assessment .
Record review of a facility policy dated December 2016 and titled Care Plans, Comprehensive Person-Centered revealed the following:
. 8. The comprehensive, person-centered care plan will: . b. Describe the services that are to be furnished to attain or maintain the resident's highest practicable physical, mental, and psychosocial well-being. 13. Assessments of residents are ongoing and care plans are revised as information about the residents and the residents' conditions change. 14. The Interdisciplinary Team must review and update the care plan; . d. At least quarterly, in conjunction with the required quarterly MDS assessment.
CONCERN
(D)
Potential for Harm - no one hurt, but risky conditions existed
Respiratory Care
(Tag F0695)
Could have caused harm · This affected 1 resident
**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, interview, and record review the facility failed to ensure that a resident who needs respiratory care is p...
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**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, interview, and record review the facility failed to ensure that a resident who needs respiratory care is provided such care consistent with professional standards of practice, the person-centered care plan, and residents' goals and preferences for 2 (Resident #9 and Resident #12) of 12 residents reviewed for respiratory care.
1. Resident #9 had a physician's order for continuous oxygen via nasal cannula at 3 lpm and was receiving oxygen at higher concentrations.
2. Resident #12 had a physician's order for PRN oxygen via nasal cannula at 2-3 lpm and was receiving oxygen at higher concentrations.
These failures could place residents who receive oxygen at an increased risk for receiving oxygen at the wrong rate which could lead to hypercapnia (too much carbon dioxide in the blood), pulmonary oxygen toxicity (damage to the lung lining tissues and air sacs), hypoxemia (low levels of oxygen in the blood, decreasing the oxygen supply to vital organs), and shortness of breath.
Findings Included:
1. Record review of Resident #9's face sheet dated 08/06/23 revealed a [AGE] year-old male admitted to the facility on [DATE] with diagnoses that included, but were not limited to, high blood pressure, acute kidney failure (sudden episode of kidney failure that happens in hours or days), and acute respiratory failure with hypoxia (quick onset of a condition resulting from lower-than-normal levels of oxygen in the tissues of the body).
Record review of Resident #9's Quarterly MDS completed on 05/23/23 revealed a BIMS of 13 which indicated intact cognition. Section J of the MDS revealed Resident #9 had trouble with shortness of breath or trouble breathing with exertion (e.g., walking, bathing, transferring) and when lying flat. Section O of the MDS revealed Resident #9 received oxygen therapy while a resident.
Record review of Resident #9's care plan with a start date of 07/16/23 revealed a category entitled Active Disease. In this category was an intervention of administer O2 as indicated .
Record review of Resident #9's Physician Orders, dated August 2023, revealed an order for continuous oxygen @ 3 lpm via NC [nasal cannula]. The start date of this order was 06/28/23.
Record review of facility Daily Vital and BM Record for July revealed Resident #9 receiving O2 at 5 lpm on 07/10/23 and 4 lpm on 0720/23 and 07/22/23.
During an observation on 08/06/23 at 10:11 AM Resident #9 was sitting in his recliner asleep with a blanket across his lap. He was receiving O2 via nasal cannula at 3.5 lpm.
During an observation on 08/06/23 at 11:56 AM Resident #9 was sitting in his w/c watching TV and receiving O2 via nasal cannula at 3.5 lpm.
During an observation on 08/07/23 at 09:07 AM Resident #9 was sitting in his w/c receiving O2 via nasal cannula at 3.75 lpm.
During an observation on 08/08/23 at 09:13 AM Resident #9 was sitting in his recliner watching TV and receiving O2 via nasal cannula at 3.75 lpm.
2. Record review of Resident #12's face sheet, dated 08/06/23, revealed a [AGE] year-old female admitted to the facility on [DATE] with diagnoses that included, but were not limited to, pulmonary embolism (blood clot that blocks blood flow in a lung artery), high blood pressure, and shortness of breath.
Record review of Resident #12's Quarterly MDS, with a completion date of 06/16/23, revealed a BIMS of 12, which indicated moderately impaired cognition. Section J of the MDS revealed Resident #12 had trouble with shortness of breath or trouble breathing with exertion (e.g., walking, bathing, transferring). Section O of the MDS indicated the resident had not received oxygen therapy in the 14 days prior to completion of the MDS.
Record review of Resident #12's care plan with a most recent start date of 07/14/23 revealed no mention of oxygen therapy.
Record review of Resident #12's Physician Orders, dated August 2023 revealed a PRN order for oxygen @ 2-3 lpm to keep sats (saturation) above 90% via n/c (nasal cannula). The order had a start date of 03/22/23.
Record of facility Daily Vital and BM Record for July revealed Resident #12 received oxygen at 4 lpm on 07/27/23.
During an observation on 08/06/23 at 10:03 AM Resident #12 was lying in bed on her back asleep receiving O2 via nasal cannula at 4 lpm.
During an observation on 08/06/23 at 12:29 PM Resident #12 was lying in bed on her left side asleep receiving O2 via nasal cannula at 4 lpm.
During an observation on 08/06/23 at 12:37 PM Resident #12 was lying in bed on her left side asleep receiving O2 via nasal cannula at 4 lpm.
During an observation on 08/06/23 at 12:43 PM Resident #12 was lying in bed on her left side asleep receiving O2 via nasal cannula at 4 lpm.
During an observation on 08/06/23 at 1:09 PM Resident #12 was lying in bed on her back asleep receiving O2 via nasal cannula at 4 lpm.
During an observation on 08/07/23 at 09:10 AM Resident #12 was sleeping in her recliner under a blanket receiving O2 via nasal cannula at 4 lpm.
During an observation and interview on 08/07/23 at 12:00 PM Resident #12 was sitting in her recliner watching TV and receiving O2 via nasal cannula at 4 lpm. She stated she had been receiving oxygen therapy for about a year. Resident #12 said, I don't leave it off for long; I do better with it.
During an observation on 08/07/23 at 03:01 PM Resident #12 was asleep in her recliner receiving O2 via nasal cannula at 4 lpm.
During an observation on 08/08/23 at 08:51 AM Resident #12 was sitting in her recliner asleep and slumped to her left. Her O2 concentrator was set to 4 lpm and her nasal cannula was sitting in her lap.
During an interview on 08/08/23 at 09:17 AM LVN A said the nurses were responsible for setting the lpm on O2 concentrators. He said he looked at physician orders to determine what lpm to set the concentrator to. When asked what a possible negative outcome of a resident receiving O2 at higher lpm than ordered LVN A replied, It can damage the lungs. LVN A said he did not know why Resident #9 and Resident #12 were receiving O2 at higher concentrations than those ordered
During an observation and interview on 08/08/23 at 09:21 AM CNA C said the nurses are responsible for setting the lpm on O2 concentrators. She said the only part she plays in O2 administration was, I just usually put the hose on. Here CNA C mimed putting nasal cannulas in her own nostrils.
During an interview on 08/08/23 at 09:25 AM DON stated the nurses were responsible for setting the concentration levels of O2 for residents receiving O2 therapy. She said the nurses would refer to the physician orders to find out what lpm to set the O2 to. She said the physician orders were in the computer and in the paper charts. When asked for a possible negative outcome of a resident taking O2 at higher concentrations than ordered, DON said, The body becomes dependent and it is not a good thing, then they can't go back down [in concentration level]. When asked why Resident #12 was receiving O2 at higher concentration than ordered she said she did not know. She said Resident #9 occasionally changes his.
During an interview on 08/08/23 at 09:37 AM ADON said the nurses were responsible for setting concentration levels on O2 concentrators. She said they would refer to physician orders or the treatment book to find the correct lpm. ADON stated a possible negative outcome of receiving O2 at higher concentrations than ordered was the resident could get too much O2. ADON said she did not know why Resident #12 was receiving O2 at higher lpm than ordered. She stated Resident #9 usually messes with his [O2] constantly.
Record review of facility policy dated October of 2010 and titled; Oxygen Administration revealed the following:
. The purpose of this procedure is to provide guidelines for safe oxygen administration. 1. Verify that there is a physician's order for this procedure. Review the physician's orders or facility protocol for oxygen administration. 8. Turn on the oxygen. Unless otherwise ordered, start the flow of oxygen at the rate of 2 to 3 liters per minute. 10. Adjust the oxygen delivery device so that it is comfortable for the resident and the proper flow of oxygen is being administered.
Record review of facility policy dated July 2016 and titled; Medication and Treatment Orders revealed the following:
. 1. Medications shall be administered only upon the written order of a person duly licensed and authorized to prescribe medications in this state.
CONCERN
(D)
Potential for Harm - no one hurt, but risky conditions existed
Deficiency F0761
(Tag F0761)
Could have caused harm · This affected 1 resident
Based on observation, interview, and record review, the facility failed to ensure drugs and biologicals were stored and labeled in accordance with currently accepted professional principles for 1 of 1...
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Based on observation, interview, and record review, the facility failed to ensure drugs and biologicals were stored and labeled in accordance with currently accepted professional principles for 1 of 1 medication rooms.
Multiple loose pills and expired medication was found in the medication room.
The medication refrigerator was not kept at a temperature between 36 to 46 degrees.
The facility's failure could place all residents receiving medication that have lost integrity to not receive their therapeutic dose.
Findings included:
Observation on 08/06/23 at 10:24am revealed the medication refrigerator was unlocked by the LVN, and the lock box was unlocked within the refrigerator. The temperature on the thermometer read 22 degrees.
Observation and interview on 08/06/23 at 10:28am revealed multiple pills lose in the bottom medication basket The LVN stated that they must have come out of the packaging, I think those are discontinued.
Observed on medication label that medication had a use by date of 08/02/2022
Record review of the temperature log revealed that the temperature has been under 36 degrees for 08/01/23-08/05/23 with no temperature check performed on 08/06/2023.
Observation of medication packaging on 08/07/23 at 9:20 AM revealed that medication in the medication room refrigerator needed to be kept between 36 to 46 degrees. This includes Levemir Flex pen, Lorazepam oral solution, and Lorazepam suppositories and all vaccines. The temperature was at 41 degrees.
Interview on 08/07/23 at 10:51 AM with DON. Interview revealed that medications should be kept at a temperature of 36-46 degrees. DON stated that she ordered new medications for all residents with medications in the medication refrigerator, as well as the vaccines. DON stated medications that were expired were destroyed every 90 days.
Record review of policy named Storage of Medications, dated, April 2007 states the following:
Policy Statement
The facility shall store all drugs and biologicals in a safe, secure, and orderly manner.
Policy Interpretation and Implementation
1.
Drugs and biologicals shall be stored in the packaging, containers or other dispensing systems in which they are received. Only the issuing pharmacy is authorized to transfer medications between containers.
4.
The facility shall not use discontinued, outdated, or deteriorated drugs or biologicals. All such drugs shall be returned to the dispensing pharmacy or destroyed.
9. Medications requiring refrigeration must be stored in a refrigerator located in the drug room at the nurses' station or other secured location. Medication must be stored separately from food and must be labeled accordingly.
Record review of policy named Discarding and Destroying Medications, dated October 2014 states the following:
Policy Statement
Medications will be disposed of in accordance with federal, state and local regulations governing management of non-hazardous pharmaceuticals, hazardous waste and controlled substances.
1.
All unused controlled substances shall be retained in a securely locked area with restricted access until disposed of.
2.
Non-controlled and Schedule V (non-hazardous) controlled substances will be disposed of in accordance with state regulations and federal guidelines regarding disposition of non-hazardous medications.
CONCERN
(D)
Potential for Harm - no one hurt, but risky conditions existed
Medical Records
(Tag F0842)
Could have caused harm · This affected 1 resident
Based on interview and record review, the facility failed to maintain complete, accurate, readily accessible, and systemically organized records for 1 (Resident #6) of 12 residents reviewed for medica...
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Based on interview and record review, the facility failed to maintain complete, accurate, readily accessible, and systemically organized records for 1 (Resident #6) of 12 residents reviewed for medical records.
The facility failed to accurately document Resident #6's information in the correct resident's chart.
This failure could place all residents at risk of not receiving appropriate care through inadequate documentation, possibly resulting in the deterioration in condition, exacerbation of disease process, and increased risk of harm or injury.
Finding included:
Record Review of Resident #8's paper chart revealed that Resident #6's records have been placed into Resident #8's chart.
Interview on 08/07/23 at 10:44 AM with LVN A stated that the orders will come in on the fax in the business office. Business office manager will deliver them to the LVN who enters the information into the computer system and then places them in the paper chart. LVN A stated that the negative outcome would be that the situation would be very confusing and raise a lot of questions.
Interview on 08/07/23 at 10:53 AM with DON states that the faxes are delivered to either DON or ADON and the orders are placed in the computer system and then placed in the paper chart. DON stated that there wound not be a negative outcome due to the orders being placed in the correct chart on the computer system, but would be frustrating when looking for the paper copy of the order. DON stated that there is no policy for documentation.
CONCERN
(D)
Potential for Harm - no one hurt, but risky conditions existed
Infection Control
(Tag F0880)
Could have caused harm · This affected 1 resident
Based on observation, interview, and record review, the facility failed to establish and maintain an infection prevention and control program designed to provide a safe, sanitary, and comfortable envi...
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Based on observation, interview, and record review, the facility failed to establish and maintain an infection prevention and control program designed to provide a safe, sanitary, and comfortable environment and to help prevent the development and transmission of communicable diseases and infections for 1 of 3 residents (Resident #1) reviewed for infection control.
The facility failed to ensure that facility staff perform hand hygiene appropriately during incontinent care.
This failure could place the residents at an increased risk for potentially exposing them to viral infections, secondary infections, tissue breakdown, communicable diseases and feelings of isolation related to poor hygiene.
Findings included:
Observation on 08/07/23 at 11:17 AM revealed incontinent care of Resident #1. CNA C and NA D started incontinent care by letting Resident #1 know that it was time for a brief change. CNA C sanitized hands before donning the first set of gloves, but there was no observation of NA D performing hand hygiene. CNA C started to remove blankets from Resident #1 and started to remove the front of Resident #1's brief. CNA C then reached for a clean sheet to cover Resident #1 with the same gloves that she removed the front of Resident #1's brief with. CNA C handed NA D the sheet to cover Resident #1. CNA C took peri-wipes that had been set up previously to the start of peri-care. CNA C took a wipe and cleaned the thighs, reached for more clean wipes and cleaned the pubic area of Resident #1. CNA C removed gloves at this time and obtained clean gloves without performing hand hygiene. CNA C proceeded to perform Catheter care on Resident #1. Once Catheter care was performed, dirty gloves were removed, and clean gloves were obtained without hand hygiene being performed.
Interview on 08/07/23 at 11:29 AM with CNA C. CNA C was asked why hand hygiene wasn't performed after the removal of dirty gloves and the placement of clean gloves. CNA C stated I just missed it. CNA C was asked what a negative outcome would be for not performing hand hygiene at that time. CNA C stated contamination.
Interview on 08/07/23 at 11:33 AM with NA D. NA D was asked if hand hygiene was performed before the beginning of incontinent care for Resident #1. NA D stated that she had performed hand hygiene before entering the room.
Record review of facility provided policy named Handwashing/Hand Hygiene, dated August 2015 states the following:
Policy Statement
This facility considers hand hygiene the primary means to prevent the spread of infections.
Policy Interpretation and Implementation
1.
All personnel shall be trained and regularly in-serviced on the importance of hand hygiene in preventing the transmission of healthcare-associated infections.
2.
All personnel shall follow the handwashing/hand hygiene procedures to help prevent the spread of infections to other personnel, residents, and visitors.
3.
Hand hygiene products and supplies (sinks, soap, towels, alcohol-based hand rub, etc.) shall be readily accessible and convenient for staff use to encourage compliance with hand hygiene policies.
7. Use an alcohol-based hand rub containing at least 62% alcohol; or, alternatively, soap (antimicrobial or non-antimicrobial) and water for the following situations:
.b. Before and after direct contact with residents;
.h. Before moving from a contaminated body site to a clean body site during resident care;
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 observation, interview, and record review, the facility failed to store, prepare, distribute, and serve food in accordance with professional standards for food service safety in 1 of 1 kitche...
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Based on observation, interview, and record review, the facility failed to store, prepare, distribute, and serve food in accordance with professional standards for food service safety in 1 of 1 kitchen reviewed for kitchen sanitation.
1.
The facility failed to ensure refrigerated and freezer items were properly stored, labeled, and dated.
2.
The facility failed to ensure dented cans were not in circulation.
3.
The facility failed to ensure pantry foods were properly stored, labeled and dated.
These failures placed residents who ate food served by the kitchen at risk of cross contamination and food-borne illness.
Findings included:
In an observation of the walk-in pantry on 08/06/2023 at 09:45 AM the following was observed:
1-14.05 oz can of cut green beans dated 4/13 dented and stored with cans in circulation.
2-48 oz cans of Chicken of the Sea Tuna dated 4/13 dented and stored with cans in circulation.
1 open bag of brown gravy in its original packaging open to air with no seal-in a plastic clear
container with a blue lid; the blue lid was not sealed.
In an observation of the refrigerator on 08/06/2023 at 10:00 AM the following was observed:
1 gallon container 3/4 filled with orange liquid with no label or date.
1 gallon container 1/4 filled with purple liquid with no label or date.
1 gallon container 1/4 filled with yellow liquid with no label or date.
1 gallon container 1/2 filled with brown liquid with no label or date.
1 gallon container 1/8 filled with brown liquid with no label or date.
In an observation of the freezer on 08/06/2023 at 10:15 AM the following was observed:
7-1lb blocks of margarine with no date.
1 open clear package with no label or date with what appeared to have yeast rolls in the
package.
1 Ziplock bag with no label or date with what appeared to have corn in the package.
1 large clear package with no label or date with what appeared to have french-fries in the
package.
1 large clear package with no label or date with what appeared to have hushpuppies in the
package.
In an observation and interview on 08/06/2023 at 2:30 PM with DS, DS showed the surveyor a pantry away from the dry storage pantry with a sign on the cans DO NOT USE. DS stated that she recently started working at the facility. DS stated the negative outcome of having expired food or unlabeled food could cause a resident to get sick. DS stated that she has not given an in-service concerning expired/unlabeled foods to her employees but will work on it.
In an interview on 08/07/2023 at 8:34 AM with [NAME] B, [NAME] B stated that if she sees any items not labeled or expired, she throws them away. [NAME] B stated that a possible negative outcome for having unlabeled foods would be a resident getting sick.
In an interview on 08/07/2023 at 12:12 PM with DS, DS gave the surveyor policies concerning food storage and dented cans, DS stated that she saw the three cans in the dry pantry and said She was sorry that she missed them.
In an interview on 08/08/2023 at 9:33 AM with DS, DS stated that dented cans could cause botulism and is dangerous for the residents.
Record Review of policy and procedure dated 08/07/2023 titled Dented Cans
All cans will be evaluated for damage upon receipt from the supplier. Cans found to be dented will be
removed from circulation and placed in a designated area with the label Dented Cans-Do not use
until the cans can be returned to the supplier for credit.
Record Review of policy dated October 2017 titled Food Receiving and Storage
Dry foods that are stored in bins will be removed from original packaging, labeled and dated (use
by date).
All foods stored in the refrigerator or freezer will be covered, labeled, and dated (use by date).
Beverages must be dated when opened and discarded after twenty-four hours.
May 2023
1 deficiency
1 IJ (1 affecting multiple)
CRITICAL
(K)
📢 Someone Reported This
A family member, employee, or ombudsman was alarmed enough to file a formal complaint
Immediate Jeopardy (IJ) - the most serious Medicare violation
Infection Control
(Tag F0880)
Someone could have died · This affected multiple residents
**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observations, interviews, and record review, the facility failed to establish and maintain an infection prevention and ...
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**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observations, interviews, and record review, the facility failed to establish and maintain an infection prevention and control program designed to provide a safe, sanitary, and comfortable environment and to help prevent the development and transmission of communicable diseases and infections for 12 of 21 residents reviewed for infection control.
1. The facility failed to implement and maintain contact precautions and ensure staff utilized Personal Protective Equipment (PPE) appropriately to prevent cross contamination between residents' positive with COVID-19 and residents who were not positive for the virus.
2. The facility failed to ensure residents, especially those residents who were roommates of positive residents, were practicing social distancing to help prevent the spread of COVID-19 to residents who were negative for COVID-19.
An Immediate Jeopardy (IJ) was identified on 5/04/23 at 1:45 PM and the IJ template was provided to the facility Administrator on 5/04/23 at 3:18 PM. While the immediate jeopardy was lifted on 5/5/23 at 3:34 PM, the facility remained out of compliance at a scope no actual harm with potential for more than minimal harm: and a scope of pattern, due to the facility's need to evaluate the effectiveness of their plan of correction to prevent further concerns.
These failures placed residents and staff at risk of contracting COVID-19 and increased infections which could decrease their psycho-social well-being and quality of life.
Findings included:
Record Review of the facility provided resident roster, identified 8 residents (Resident #1, Resident #2, Resident #3, Resident #4, Resident #5, Resident #6, Resident #7, Resident #8) currently positive and quarantined for COVID, 3 residents (Resident #9, Resident #10, Resident #11) who were exposed to positive roommates, moved to different rooms and not in isolation.
Record Review of the facility provided Nurses Daily Cheat Sheet revealed the following COVID positive resdients and date of positive test for:
Resident #1, COVID positive on 5/3/23
Resident #2, COVID positive on 5/3/23
Resident #3, COVID positive on 5/3/23
Resident #4, COVID positive on 4/30/23
Resident #5, COVID positive on 4/27/23
Resident #6, COVID positive on 5/3/23
Resident #7, COVID positive on 5/3/23
Resident #8, COVID positive on 4/30/23
Record Review of an undated face sheet for Resident #1 revealed: admitted to the facility on [DATE] with the following diagnosis: Dementia, Type 2 diabetes, Osteoarthritis, Unspecified psychosis, Delirium
Record Review of an undated face sheet for Resident #2 revealed: admitted to the facility on [DATE] with the following diagnosis of malignant neoplasm of bronchus and lung, Hypertensive heart disease, Type 2 diabetes, Hyperlipidemia
Record Review of an undated face sheet for Resident #3 revealed: admitted to the facility on [DATE] with the following diagnosis: major depressive disorder, upspecified dementia, acute pain
Record Review of an undated face sheet for Resident #4 revealed: admitted to the facility on [DATE] with the following diagnosis autoimmune thyroiditis, Hyperlipidemia, Depression, Hypertensive heart disease, Rheumatoid arthritis, Heart failure, Atrial fibrillation, Hypothyroidism, Major depressive disorder.
Record Review of an undated face sheet for Resident #5 revealed: admitted to the facility on [DATE] with the following diagnosis Hyperlipidemia, Gastro-esophageal reflux; Acquired absence of right leg; Type 2 diabetes; Hypertensive heart disease; Chronic atrial fibrillation
Record Review of an undated face sheet for Resident #6 revealed: admitted to the facility on [DATE] with the following diagnosis: essential hypertension; Restlessness and agitation; Cellulitis of lower left limb; Depression; anxiety; Psoriasis; Psychotic disorder
Record Review of Resident #7's face sheet was unavailable for review.
Record Review of an undated face sheet for Resident #8's revealed: admitted to the facility on [DATE] with the following diagnosis Hyperlipidemia; Atrial fibrillation; Chronic obstructive pulmonary disease; Type 2 diabetes; Hypertension; Nontraumatic intracerebral hemorrhage in brain stem.
Above currently positive and quarantined for COVID
3 residents who were exposed to positive roommates, moved to different rooms and not in isolation.
(Resident #9, Resident #10, Resident #11)
Record Review of an undated face sheet for Resident #9 revealed: admitted to the facility on [DATE] (exposed to Resident #3) with the following diagnoses: chronic pain, primary hypertension, atrial fibrillation, Hyperlipidemia, Constipation, Cough
Record Review of an undated face sheet for Resident #10 revealed: admitted to the facility on [DATE] (exposed to Resident #4) with the following diagnoses: Hypertensive heart disease with heart failure; Anxiety disorder; Chronic kidney disease; Dependence on supplemental oxygen; Hypothyroidism; Acute and Chronic respiratory failure with hypoxia.
Record Review of an undated face sheet for Resident #11 revealed: admitted to the facility on [DATE] (exposed to Resident #5) with the following diagnoses: Nonrheumatic aortic stenosis; Hypertensive, Unspecified Dementia; Hyperlipidemia, Major depressive disorder; Generalized edema, Restlessness and agitation.
Record Review of an undated face sheet for Resident #12 revealed: admitted to the facility on [DATE] with the following diagnoses: Multiple sclerosis; chronic pain; seizures; Dysphagia; Gastro-esophageal reflux disease.
During an observation on 5/4/23 at 9:10 a.m. upon arrival to facility, posting on door dated 01/04/23 stated, Effective immediately. Due to the weekly update of COVID19 cases, the transmission levels are high, and face masks must be worn until further notice. Thank you for understanding and your commitment in helping to keep our residents safe.
During an observation on 5/4/23 at 9:11 a.m., upon entrance into the facility, sign in clipboard on entrance table and empty facemask box.
During an interview on 5/4/23 at 9:15 a.m. with the ADON, stated that there were 8 residents who are positive for COVID in the building and staff are required to wear surgical masks unless they enter a positive resident room and then they are required to wear an N-95 mask. The ADON stated she was not aware that there were no masks available at the entrance table. The ADON stated that there is a posting on the facility door notifying of the county transmission rate but that it is from January 2023 and has not been updated. The ADON stated she did not know who was responsible for changing the door positing but believed it was the Administrator because the Administrator is the Infection Control Preventionist. The ADON stated visitors are not notified of the COVID outbreak when they enter the building and there is nothing posted to inform them.
During an observation on 5/4/23 at approximately 10:00 a.m., of the 8 positive resident rooms, only 1 out of 8 positive resident rooms (Resident #5) had contact precautions and PPE usage notifications on the door.
During an observation on 5/4/23 at approximately 10 a.m., of the 8 positive resident rooms, only 1 out of 8 rooms (Resident #8) had hand sanitizer on the PPE cart for staff to disinfect their hands before or after contact with the positive resident.
During an observation on 5/4/23 at 10:10 a.m., Resident #9 (exposed roommate of Resident #3) was observed in wheelchair in living room with Resident #12 (non-exposed).
During an observation on 5/4/23 at 10:15 a.m. Resident #10 (exposed roommate or Resident #4) was in sitting in hallway.
During an Interview and observation on 5/4/23 at 11:10 a.m. with an LVN A, she stated she had no idea if there was COVID in the facility until she arrived to her shift and entered the nurse station. LVN A stated that after entrance into the facility she would have to walk past residents in the common areas before entering the nurse station. LVN A stated that only resident representatives were notified of COVID in the facility and any other visitors or family that would enter the facility would not be informed that there was COVID. LVN A stated that only when she would see a visitor without a mask, would she then inform them that there is COVID. LVN A stated that there was only one mask at the front entrance when she arrived this morning and PPE is locked up near the business office and staff have no access to it. LVN A stated that when the HHSC Investigator arrived in the resident halls, there were no postings notifying staff or visitors that there were positive COVID residents in the rooms except for Resident #8's room. LVN A stated that there were no face shields available that morning, and not all PPE carts were stocked.
During an observation on 5/4/23 at 11:37 a.m. of the facility's dining room, revealed exposed roommates of positive residents, Resident #9, Resident #10, and Resident #11 were sitting with unexposed residents waiting on lunch service.
During an interview on 5/4/23 at 11:45 a.m. with CNA B; stated that Residents #9, #10, #11, who had positive COVID roommates were able to freely walk around the facility and eat with residents in the dining hall. The CNA B stated there were no extra precautions for infection control with the residents who were exposed but tested negative for COVID. CNA B stated that they were not properly washing or disinfecting their hands, there were no postings on positive resident doors until after the Investigator arrived and visitors would not know there was COVID in a room prior to this morning because there were no postings on the door and no PPE carts outside of each positive resident's room. CNA B stated that Resident #9 is completely dependent on staff for all care areas, and someone would have put her in the living room area. CNA B stated that Resident #12 is also completely dependent on staff for all care areas, and someone would have put her in the living room area. CNA B stated that Resident #9 was exposed to COVID to by her roommate Resident #3. CNA B stated that Resident #12 has her own room and has not been exposed to COVID. CNA B stated that because Resident #12 was put in the living room area with Resident #9, Resident #12 has now been exposed to a resident who had a positive roommate. CNA B stated that they are not keeping exposed residents in isolation or away from other residents. CNA B stated that when she arrived to work that day there were only 2 surgical masks left in the box at the facility's entrance. CNA B stated she does not know if there is COVID in the building until she walks through the building to the nurses station. CNA B stated that PPE supplies are locked up in a room and staff who care for residents do not have access to that room. CNA B stated she is not sure who the Infection Preventionist is at the facility. CNA B stated that if she were an agency staff member or a visitor she would not know if there was COVID in the building nor would she know what rooms COVID had because the rooms were not marked until after the investigator walked through. CNA B stated that we are not containing COVID, we are spreading it because most rooms did not have any signs or PPE carts outside of the rooms.
During an interview with the ADM on 5/4/23 at 12:33 p.m.; stated that she was in charge of infection control but was unaware that 3 residents tested positive on 5/3/23 for COVID. The ADM stated she was not sure who tested the residents, and she should have been notified. The ADM stated that she was not aware that postings were not on positive resident doors and that it is policy for there to be postings. The ADM stated that staff are to wear full PPE including N-95 masks, gowns, gloves, and face shields/goggles when entering a COVID room. The ADM stated she was unaware that staff did not have access to the PPE supply and that they did not have face shields. The ADM stated they allowed exposed residents to roam the building. The ADM stated everyone in the building is exposed to COVID and it is a small facility. The ADM stated that she cannot guarantee that positive residents will not leave their rooms and roam the building. The ADM stated that that everyone is exposed to COVID, and they are not doing droplet precautions on exposed residents. The ADM stated she thought it was the ADONs job to put postings on the door. The ADM stated she did not know that staff were not notified of COVID positive staff/residents until they went back to the unit and had the shift change meeting.
During an observation on 5/5/23 at approximately 12:36 p.m. of CNA D, exiting Resident #5's room with wearing an N-95 mask that was modified to fit like a surgical mask and walked down the hall towards the dining room area.
During an interview and observation on 5/5/23 at 12:39 p.m. with CNA C; observed in Resident 11's room wearing an N-95 mask that was modified to fit like a surgical mask. CNA C stated she cut the N-95 mask loops and tied them to fit behind her ears instead of behind her head. CNA C stated that no one told her she could modify her mask. CNA C stated she had to wear a N-95 mask due to COVID in the building and modified it so it was more comfortable to wear. CNA C stated that she watched the in-service CDC videos on how to wear PPE and hand washing.
During an interview and observation on 5/5/23 at 12:42 p.m. with CNA D; observed in the hallway towards Resident #11's room. CNA D was observed with a modified N-95 mask cut to fit like a surgical mask. CNA D stated that the N-95 mask was too tight and she cut the straps and tied them to loop behind her ears. CNA D stated that she was not trained to cut the N-95 mask and was not instructed to cut the N-95 mask to fit comfortably. CNA D stated that she had been in COVID positive resident rooms with a modified N-95 mask on. CNA D stated that she received CDC training on how to properly wear PPE and to wash her hands. CNA D was observed delivering a meal tray to Resident #11 and did not disinfect her hands after exiting Resident #11's room. CNA D was observed walking back to the dining room, did not disinfect her hands, and picked up another resident tray.
During an interview and observation on 5/5/23 at 12:46 p.m. with the facility cook; observed wearing a modified N-95 mask that was cut and tied to fit like a surgical mask behind her ears. The [NAME] stated that she modified the mask because it was too tight and stated that the N-95 mask is designed to fit tight and looped around her head because it probably protects us from COVID. The [NAME] stated she was provided CDC training on how to properly wear PPE and proper hand washing. The [NAME] stated that after she watched the video, she should have changed her N-95 mask to a non-modified one.
During an interview and observation on 5/5/23 at 12:49 p.m. with the Housekeeper in the resident hall cleaning; observed wearing a N-95 mask that was modified to fit like a surgical mask. The Housekeeper stated that she cut the mask loops and tied them to fit behind her ears because it is too tight and gives her headaches. The Housekeeper stated she had not been trained on how to properly wear the N-95 mask.
During an observation on 5/5/23 at 12:55 p.m. of the Housekeeper, observed wearing modified N-95 mask.
During an interview on 5/5/23 at 1:04 p.m.; with the ADM; The ADM stated she did not know that staff had modified their N-95 masks to fit like a surgical mask. The ADM stated she will address with the staff. The ADM was advised that the IJ will not be lifted until the facility had addressed the issues and corrections.
During an interview on 5/5/23 at 1:15 p.m. with the ADON; stated that staff are not permitted to modify their N-95 masks. The ADON stated that there is no excuse for staff to modify their masks and by doing so, it is not providing them protection from COVID and could expose residents to COVID. The ADON stated that COVID had been around for 3 years, and staff should know how to properly wear N-95 masks and have been in-serviced and trained on it.
Record Review of facility policies for infection control:
Review of the facility policy, Equipment and Supplies used during Isolation dated: 2001 Med Pass, revised September 2017; revealed:
-The Infection Preventionist oversees the availability and inventory of prevention and control supplies.
Review of the facility policy, Isolation-Categories of Transmission-Based Precautions, dated 2001 Med-Pass, revised October 2018; revealed: :
-Appropriate notification is placed on the room entrance door and on the front of the chart so personnel and visitors are aware of the need for and type of precaution.
When a resident is placed on transmission-based precautions, appropriate notification is placed ont eh room entrance door and on the front of the chart so that personnel and visitors are aware of the need for and the type of precaution:
-Signage informs staff of the type of CDC precautions, instructions for PPE use and/or instructions to see nurse before entering.
-Facility makes every effort to use the least restrictive approach to managing individuals with potentially communicable infections. Transmission based precautions are used only when the spread of infection cannot be reasonably prevented by the less restrictive measures.
Droplet Precautions:
May be implemented for an individual documented or suspected to be infected with microorganisms transmitted by droplets that can be generated by the individual coughing, sneezing, talking.
-Residents on droplet precautions will be placed in a private room if available. Masks will be worn when entering the room. Gloves, gown and goggles should be worn if there is risk of spraying respiratory secretions.
Resident transport: A mask will be placed on the resident during transport from his/her rooms. The resident will be encouraged to follow respiratory hygiene/cough etiquette to minimize dispersal of droplets.
Review of the facility policy, Isolation-Notices of Transmission-Based Precautions, dated 2001 Med-Pass, revised October 2018:
-Notices will be used to alert personnel and visitors of transmission-based precautions:
-When transmission-based precautions are implemented the Infection Preventionist (or designee) determine the appropriate notification to be placed on the room entrance door and chart so that personnel and visitors are aware for the need for and type of precaution.
Airborne Precautions, Contact Precautions, Droplet Precautions: Place a notice on doorway instructing visitors to report to the nurses station before entering the room. Place a sign indicating (Aiborne, Contact or Droplet) precautions on the door to the resident room and resident chart.
Review of the facility policy, Equipment and Supplies Used During Isolation, dated: 2001 Med Pass, revised October 2018, revealed:
Appropriate infection prevention and control equipment and supplies are obtained, stored and used in accordance with current guidelines and manufacturer instructions:
The Infection Preventionist (or designee) oversees the availability and inventory of infection prevention and control supplies.
Review of the facility provided policy, Interim Infection Prevention and Control Recommendations for Healthcare Personnel during the Coronavirus Disease 2019 Pandemic, updated 9/27/2022;
-Patient Placement: Place a patient with suspected or confirmed SARS-CoV-2 infection in a single-person room; door should be kept closed (if safe to do so). Limit transport and movement of the patient outside of the room to medically essential purposes.
On 5/4/23 at 3:18 p.m., The Administrator was notified that an Immediate Jeopardy had been identified, IJ template provided, and a Plan of Removal was requested.
The Facility's Plan of Removal (as followed) was accepted 5/5//23 at 1:59 p.m.
What potential deficiency is being addressed by this Action Plan?
F880 Infection Prevention and Control: It is alleged that the facility failed to implement and maintain an infection prevention and control program to provide a safe environment and help prevent the development and transmission of infectious diseases.
Need for Immediate Action
The IJ documentation provided by HHSC on May 4, 2023, states the relaxed mindset in contact precautions including wearing and supplying PPE, notifying visitors of facility positivity rate, not posting contact isolation and droplet precautions on resident rooms, and not providing hand sanitizer could potentially bring in infection to any already vulnerable population. This could possibly spread to other staff and residents within the facility, which ultimately could affect the health and well-being of all residents.
Document the facility's actions taken to remove the immediacy in an IJ situation.
Following notification by the surveyor of the lack of signage notifying staff and visitors of the existence of Covid in the building, the administrator put a sign on the door of the building, by the sign-in station and two signs on the facility doors which read: There is currently a CoVid-19 outbreak in the building. Masks required.
Masks were placed at the sign-in desk for visitors to use. PPE and hand sanitizer was restocked in all isolation carts. Signs were placed on the doors of the isolated residents stating Droplet Precautions required. The residents who were exposed to the positive residents were placed on Contact Precautions. Exposed residents on Contact Precautions will be kept in their rooms away from other residents until cleared of the possibility of having Covid. In the future, all exposed residents will be moved to another room away from positive and negative residents until they have been cleared of the possibility of having Covid. All residents were tested on [DATE], and then two residents were tested again based on Doctor's orders on May 4, 2023. These two residents tested positive. The two new positives on May 4, 2023, were the only ones the Administrator was unaware of at the time of the entrance of the surveyor. Both the new positives were reported to NHSN per regulations. As of May 5, 2023, no new positive residents have been identified. Only 1 resident has any symptoms, which is a runny nose.
All staff who are not on vacation or out with Covid were in-serviced on Hand Hygiene and Correct PPE Usage using videos from CDC (Clean Hands: Combat CoVid-19 and Use Personal Protection Equipment (PPE) Correctly for CoVid-19). Staff who are PRN, currently on vacation or out with Covid will be required to complete the training prior to coming into the facility to work. Staff were also in-serviced on who the Infection Preventionist is.
Which residents were affected by this situation?
All residents have the potential to be affected by the alleged deficient Infection Prevention standards.
Who else is potentially affected?
All residents, staff and visitors have the potential to be affected by this deficient practice.
[facility] states the situation described above has been mitigated and is in substantial compliance as of May 5, 2023.
Monitoring of the Plan of Removal included:
During an observation of the facility entrance door on 5/5/23 at 12:00 p.m., notice of COVID posted on entrance door and mandate to wear masks.
During an observation of the entrance table inside the facility door on 5/5/23 at 12:00 p.m.; N-95 masks were on the entrance table next to hand sanitizer and a sign in sheet for staff and visitors to report any COVID symptoms.
During an interview on 5/5/23 at 12:10 p.m. with the ADM, stated that all resident rooms had postings notifying staff and visitors that PPE is required, and PPE carts have been placed and filled by resident rooms. The ADM stated that all residents who are positive or had been exposed are on quarantine. The ADM stated that the facility has trained the majority of the facility staff and will continue to train staff as they arrive for their shifts. The ADM stated that staff had been trained on N-95 masks, Droplet precautions, Contact Precautions, Infection Preventionist, PPE/Donning/Doffing, and watched a CDC video on COVID-19 and the ADON is verifying staff are watching the video and also verbally is instructing staff.
During an observation on 5/5/23 at approximately 12:40 p.m. revealed Residents #1, #2, #3, #4, #5, #6, #7, #8, #9, #10, #11 room doors had notices of contact precautions, PPE required and full PPE carts outside doors.
During an interview and observation on 5/5/23 at 3:15 p.m. with LVN A, CNA C, CNA D at the nurses station, all staff were observed wearing N-95 masks correctly. CNA C stated she was trained to wear her N-95 properly and to not modify the mask. CNA C stated that all staff are trying to redirect residents who have been exposed to COVID to stay in their rooms. CNA D stated that if she saw an exposed resident out of their room, she redirects them to their room. CNA D stated that there is plenty of PPE in the facility and all positive or isolated resident rooms have postings on the doors and full PPE carts outside the door. LVN A stated that all staff must wear N-95s in the facility and must wear full PPE in all positive resident rooms and exposed resident rooms.
During an observation on 5/5/23 at 3:30 p.m. in the facility's library, the ADON was in-servicing kitchen and housekeeping staff on proper handwashing, PPE, and isolation procedures.
Record Review of the facility provided in-service sign in sheets provided on 5/5/23 revealed staff were trained on N-95 masks, Droplet precautions, Contact Precautions, Infection Preventionist, PPE/Donning/Doffing, and watched CDC COVID-19 Prevention Messages for Frontline Long Term Care Staff-Use Personal Protective Equipment(PPE) correctly for COVID-19 (https://www.youtube.com/watch?v=YYTATw9yav4)
An Immediate Jeopardy (IJ) was identified on 5/04/23 at 1:45 PM and the IJ template was provided to the facility Administrator on 5/04/23 at 3:18 PM. While the immediate jeopardy was lifted on 5/5/23 at 3:34 PM the facility remained out of compliance at a scope potential for more than minimal harm: and a scope of pattern, due to the facility's need to evaluate the effectiveness of their plan of correction to prevent further concerns.
Jul 2022
5 deficiencies
CONCERN
(D)
Potential for Harm - no one hurt, but risky conditions existed
PASARR Coordination
(Tag F0644)
Could have caused harm · This affected 1 resident
**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, interview and record review, the facility failed facility coordinate assessments with the pre-admission sc...
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**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, interview and record review, the facility failed facility coordinate assessments with the pre-admission screening and resident review (PASARR) program to the maximum extent practicable to avoid duplicative testing and effort for two of 13 residents (Resident #20 and Resident #27) reviewed for PASARR.
The facility failed to refer Resident #20 and Resident #27 for PASARR Level II assessments after their PASARR listed them as having evidence or an indicator of Mental Illness.
This failure could place residents with a positive PASARR evaluation at risk for decreased quality of life, an increased and unnecessary risk of poor self-esteem and poor self-worth.
Findings include:
Record review of Resident #20's face sheet, dated 02/14/22, revealed an [AGE] year-old female admitted to the facility on [DATE] with diagnoses that included hypertension. The face sheet also contained a second sheet, dated 06/01/22, with additional current diagnoses of psychotic disorder with hallucinations due to known physiological conditin (a mental health problem that causes people to perceive or interpret things differently from those around them that might involve hallucinations or delusions).
Record review of Resident #20's Quarterly MDS, dated [DATE], revealed a BIMS score of two out of 15 which indicated the resident was severely cognitively impaired. Section E of the MDS titled, Behavior revealed, in part, .Psychosis: Hallucinations .Checked .Psychosis: Delusions .Checked. Section F titled, Functional Status revealed Resident #20 required extensive one-person assistance with bed mobility, transferring, toilet use and personal hygiene. She required supervision with set-up help only with eating. Section I titled, Active Diagnoses revealed diagnoses of depression (other than bipolar) and psychotic disorder (other than schizophrenia).
Record review of Resident #20's care plan, dated 06/08/22, revealed in part, [Resident #20] is at a high risk for falls related to .Psychotic disorder with hallucinations [sic], Psychotropic drug usage .
Record review of Resident #20's PASARR Level 1, dated 02/11/22, revealed, in part, Is there evidence or an indicator this is an individual that has a Mental Illness? No . Is there evidence or an indicator this is an individual that has an Intellectual Disability? No . Is there evidence or an indicator this is an individual that has a Developmental Disability (Related Condition) other than an Intellectual Disability (e.g., Autism, Cerebral Palsy, Spina Bifida)? No.
Record review of Resident #20's physician's orders, dated July 2022, revealed, in part, .order date 4/20/22 .Psychotic disorder w hallucin due to known physiol con [sic] .
Record review of document in Resident #20's chart titled, Consent for Antipsychotic or Neuroleptic Medication Treatment, dated 04/20/22, revealed, in part, .Residents Name [Resident #20] .I believe the individual has the following psychiatric condition and/or maladaptive behavior: hallucinations .The need for, and benefits of, the proposed treatment with antipsychotic or neuroleptic medications(s) is indicated: Amelioration of psychosis .
Record review of Resident #20's electronic chart with ADON revealed, in part, Resident Basic Information .Psychotic disorder with hallucinations due to [sic] .Onset 2/28/22.
During an observation and interview on 07/11/22 at 3:00 PM, Resident #20 was sitting in a wheelchair with a chair alarm attached to her and a head protector pad wrapped around her head. Resident #20 would mumble indecipherable words with decipherable words spoken intermittently. During the conversation, the only decipherable terms were husband and die here and retirement.
During an interview and record review on 07/13/22 at 2:30 PM with ADON, she confirmed that she was responsible for submitting PASARR information. She stated Resident #20 was admitted on [DATE] and when asked when Resident #20 was diagnosed with a psychotic disorder, ADON found on her computer, on the electronic health record, the diagnosis dated 02/28/22. ADON stated she knew PASARR qualifying diagnoses included mental health diagnoses, mental retardation or Down Syndrome, but otherwise she did not know what additional PASARR qualifying diagnoses were. She stated she did not know psychotic disorder was a PASARR qualifying diagnosis. She stated that when residents were admitted to the facility, they usually had very little information on them since most of the time they were being admitted from home. She stated Resident #20 had not visited a doctor in six years prior to her admission to the facility and herself and her family were very poor historians. ADON stated she did not know that a PASARR Level 1 had to be resubmitted if a resident was diagnosed with a qualifying diagnosis after their initial admission PASARR. She stated that the PASARR responsibility got thrown on her when the new Business Office Manager started a few years ago; the previous Business Office Manager was responsible for PASARR information before. ADON stated she did not receive PASARR training. She stated a potential negative consequence for PASARR information not being addressed correctly could be a resident could have been a danger to themselves or others.
Record review of Resident #27's face sheet, dated 06/01/22, revealed an [AGE] year-old male admitted to the facility on [DATE] with diagnoses that included unspecified dementia, Alzheimer's disease with late onset, personality change due to known physiological condition. The face sheet also contained a second sheet, dated 06/01/22, with additional current diagnoses of psychotic disorder with delusions due to known physiological condition (a mental health problem that causes people to perceive or interpret things differently from those around them that might involve hallucinations or delusions).
Record review of Resident #27's Quarterly MDS, dated [DATE], revealed a BIMS score could not be conducted. Section E of the MDS titled, Behavior revealed, in part, .Psychosis: Hallucinations .Checked .Psychosis: Delusions .Checked. Section G titled, Functional Status revealed Resident #20 required full staff performance with bed mobility, locomotion, dressing, eating, transferring, toilet use and personal hygiene. Section I titled, Active Diagnoses revealed diagnoses of anxiety, depression (other than bipolar), schizophrenia, post-traumatic stress disorder (PTSD), and psychotic disorder (other than schizophrenia).
Record review of Resident #27's care plan, dated 05/29/2021, revealed in part, [Resident #27] has varying mental function with inattention and disorganized thinking related to relocation. Interventions include observe for changes in mental status, encourage verbalization, approach resident warmly and positively, encourage resident to participate in activities. Resident 27's care plan also revealed in part, [Resident 27] has impaired communication associated with decline in cognitive status, delirium/disorganized thinking. Interventions include ask resident questions that require one- or two- word answers, face resident when speaking to resident, remove as much background noise as possible when speaking with resident.
Record review of Resident #27's PASARR Level 1, dated 05/ 31/2021, revealed, in part, Is there evidence or an indicator this is an individual that has a Mental Illness? No . Is there evidence or an indicator this is an individual that has an Intellectual Disability? No . Is there evidence or an indicator this is an individual that has a Developmental Disability (Related Condition) other than an Intellectual Disability (e.g., Autism, Cerebral Palsy, Spina Bifida)? No.
Record review of Resident #27's PASARR Level 1, dated 05/5/2022, revealed, in part, Is there evidence or an indicator this is an individual that has a Mental Illness? No . Is there evidence or an indicator this is an individual that has an Intellectual Disability? No . Is there evidence or an indicator this is an individual that has a Developmental Disability (Related Condition) other than an Intellectual Disability (e.g., Autism, Cerebral Palsy, Spina Bifida)? No.
Record review of document in Resident #27's chart titled, [physician name] [facility name] Diagnostic Evaluation, dated 07/01/2021, revealed, in part,
DSM Diagnostic Impression:
AXIS 1:
1.
F06.2 Psychotic disorder with delusions due to known physiological condition
2.
F02.81 Dementia in other diseases classified elsewhere with behavioral disturbance
3.
F41.9 Anxiety disorder, unspecified
During an interview with DON on 7/12/2022 at 2:22 PM, she stated Resident #27 was admitted [DATE]. DON stated the initial diagnosis of psychotic disorder with delusions due to known physiological condition was dated on 07/01/2022. She stated that there was no other PASARR done at the time of the new qualifying diagnosis. DON stated she did not know why it was not done. She stated the ADON would be the one who knows about the PASARR information because she handles PASARR information.
During an interview with ADON on 7/13/2022 at 03:32 PM, she stated she did not have a PASARR policy. ADON stated she is the one who has been submitting PASARR information for the past few years after the previous Business Office Manager left the facility. ADON stated she did not receive training for PASARR. She stated she did not know that a PASARR Level 1 needed to be resubmitted if a resident was diagnosed with a qualifying diagnosis after their initial admission PASARR. ADON stated a potential negative consequence for PASARR would be that the resident could be missing out on services according to their diagnosis.
CONCERN
(D)
Potential for Harm - no one hurt, but risky conditions existed
Comprehensive Care Plan
(Tag F0656)
Could have caused harm · This affected 1 resident
**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on interview and record review, the facility failed to develop and implement a comprehensive person-centered care plan con...
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**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on interview and record review, the facility failed to develop and implement a comprehensive person-centered care plan consistent with resident rights, that include measurable objectives and time frames to meet resident's mental and psychosocial needs for one of 13 residents (Resident #9) reviewed for accurate care plans.
The facility failed to develop a comprehensive person-centered care plan to address Resident #9's Type 2 Diabetes mellitus with hyperglycemia.
This failure could place the resident at risk for not having their person-centered needs met.
Findings included:
Record review of Resident #9's face sheet revealed a [AGE] year-old female resident re-admitted to the facility on [DATE] with a diagnosis to include Type 2 Diabetes mellitus with hyperglycemia.
Record review of Resident #9's Quarterly MDS, dated [DATE], revealed a BIMS score could not be completed resident is rarely/never understood and had a functionality of requiring one-person assistance with most activities. Section C titled, Cognitive Patterns revealed the staff assessment of short and long-term memory problem and did not have memory/ability recall. The cognitive skills for daily decision making was checked for moderately impaired-decisions poor, cues/supervision required. Section G titled, Functional Status revealed Resident #9 required extensive support and with one person assist with ADL's. Section I of the MDS titled Active diagnoses revealed a diagnosis of diabetes mellitus.
Record review of Residents #9's facility provided care plans dated 08/12/2020; 04/06/2021; and 12/08/2021 revealed no care plans to address Diabetes mellitus.
During an interview on 07/13/2022 at 07:53 PM the DON verified the facility did not complete a care plan to include Diabetes mellitus in any of the care plans completed for Resident #9. The DON confirmed that there was not a care plan completed after the 04/05/2022 MDS quarterly review. DON reported that she was currently updating a new care plan. DON revealed the DON was responsible for updating the care plans. DON confirmed that Resident #9 did have a diagnosis of Diabetes. When asked if Diabetes mellitus was in the any of the care plans for Resident #9, DON stated It should be in here. No reason should not be that she knows of. When asked when the diagnoses of Diabetes was made DON stated at admission. When asked what would happen if the care plan did not include something, DON stated the resident possibly would not receive the care needed and staff may not know to monitor the condition.
During an interview on 07/13/2022 at 08:10 PM the ADON stated that the DON is the person to update all Resident care plans. She stated the information is in the MDS when it is completed to include all information in the care plans. She stated that care plans are updated when a significant change is made or after the MDS is updated.
Record review of facility provided policy titled, Care Area Assessments with a revision date of 11-2019 revealed the following:
Policy Statement
-Care area assessments (CAAs) are used to help analyze data obtained from the MDS and to develop individualized care plans.
CONCERN
(D)
Potential for Harm - no one hurt, but risky conditions existed
Deficiency F0657
(Tag F0657)
Could have caused harm · This affected 1 resident
**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, interview and record review, the facility failed to review and revise the comprehensive care plan after ea...
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**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, interview and record review, the facility failed to review and revise the comprehensive care plan after each assessment, including both the comprehensive and quarterly review assessments for one of 13 residents (Resident #9) reviewed for care plan timing.
- The facility failed to update the comprehensive person-centered care plans to address resident's needs after MDS assessments for Resident #9.
This failure could place residents at risk for delayed treatment, care, and services that could result in not attaining or maintaining their highest practicable physical, mental, and psychosocial well-being.
Findings include:
Record review of Resident #9's face sheet revealed a [AGE] year-old female resident admitted to the facility on [DATE] with diagnoses to include diabetes mellitus with hyperglycemia.
Record review of Resident #9's quarterly MDS completed on 04/05/2022 revealed an active diagnoses of Diabetes mellitus checked in section I2900.
Record review of Resident #9's facility provided care plan revealed it was last updated 12/21/2021. There were no other care plans completed at the time of review. The care plan did not reveal any diagnoses or treatment plans for Resident #9's diagnosis of diabetes.
During an interview on 07/13/2022 at 7:53 PM with the DON, DON stated she was responsible for updating the care plans. DON stated care plans should have been updated/revised quarterly and when significant changes occurred. She verified the last care plan that had been completed for Resident #9 was dated 12/21/2021 and she was currently working on the new care plan. DON was asked how soon after an MDS was completed should a new care plan have been completed and the DON stated 10 days. DON confirmed the dates of MDS and Care Plans for Resident #9 had not been updated/revised within the timeframe. DON stated she was not employed at the facility when the care plan was not completed after the quarterly MDS assessment dated [DATE].
Record review of facility provided policy titled. Care Planning- Interdisciplinary Team revised September 2013, revealed the following:
Policy Interpretation and Implementation
1.
A comprehensive care plan for each resident is developed within seven days of completion of the resident assessment (MDS).
14. The Interdisciplinary Team must review and update the care plan:
a. When there has been a significant change in the resident's condition;
d. At least quarterly, in conjunction with the required quarterly MDS assessment.
CONCERN
(D)
Potential for Harm - no one hurt, but risky conditions existed
Deficiency F0761
(Tag F0761)
Could have caused harm · This affected 1 resident
**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, interview and record review, the facility failed to ensure drugs and biologicals used in the facility were...
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**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, interview and record review, the facility failed to ensure drugs and biologicals used in the facility were labeled in accordance with currently accepted professional principles, and included the appropriate accessory and cautionary instructions, and the expiration date when applicable for one of one medication cart reviewed for medication labeling.
The only medication cart in the facility contained an insulin pen that did not contain a resident identifying label or open or discard date.
This failure could place residents at risk for receiving the wrong insulin or receiving insulin that has expired.
Finding include:
Record review of Resident #9's face sheet, dated [DATE], revealed a [AGE] year-old female admitted to the facility on [DATE] with diagnoses that included, but were not limited to, type II diabetes mellitus with hyperglycemia (high blood sugar).
Record review of Resident #9's quarterly MDS, dated [DATE], revealed a BIMS was not able to be conducted due to the resident rarely or never being understood. The staff assessment for mental status revealed Resident #9 had a long-term and short-term memory problem, could not recall any information during the assessment and had moderately impaired cognitive skills for daily decision making. Section G titled, Functional Status revealed she required extensive one-person assistance with bed mobility and transferring, total one-person dependence with toilet use and personal hygiene. Section I titled Active Diagnoses revealed a diagnosis of diabetes mellitus.
Record review of Resident #9's care plan, dated [DATE], revealed, in part, [Resident #9] is at risk for Hyper/Hypoglycemia (high or low blood sugar) R/T diagnosis of Diabetes Type 2.
Record review of Resident #9's physicians orders, dated [DATE], revealed, in part, .Order Date [DATE] Type 2 diabetes mellitus with hyperglycemia .Levemir flex pen (insulin) 28 Units SQ QPM Dx Diabetes .Levemir flex pen 28u SQ QD at 0630 (6:30 AM).
Record review of Resident #9's treatment record, revealed Levemir initialed by staff as being administered every day for [DATE], up to [DATE].
During an observation and interview on [DATE] at 8:45 AM, a Levemir flex pen 100 units/mL was observed in the only medication cart with no open date or resident identifying information. The Levemir flex pen contained a manufacturer expiration date of [DATE] only. LVN B stated this belonged to Resident #9, she was the only resident taking that type of insulin, and LVN B said she used the last of the previous Levemir flex pen on that cart the previous Sunday morning ([DATE]) so she knew the night nurse opened that particular pen Sunday night ([DATE]). LVN B stated staff were supposed to label the flex pen with the date it was opened, and she also thought they should have asked the pharmacy for a label containing the resident's name. LVN B stated if it was her who put the flex pen in the medication cart, she would have labeled it with an open date, but she knew when it was opened. When asked how staff would know who the flex pen belonged to since there was not any resident identifying information on it, she stated Resident #9 was the only resident taking that medication. When asked what if they had an agency staff member who was working who was not familiar with the residents, how would they know when it was opened and LVN B stated they might not know when the Levemir flex pen was opened. LVN B stated she did think staff would know who it belonged to because Resident #9 was the only resident on a Levemir flex pen. LVN B stated not labeling or dating insulin pens could have resulted in giving a resident the wrong medication.
During an interview on [DATE] at 11:20 AM, DON stated all resident medications should have had a label on it containing the resident's name and the medication administration instructions. She stated insulin pens needed to be labeled with an open date, they were only good for 28 days after they were taken out of the refrigerator and opened. DON stated she would have expected her staff to discard an unlabeled insulin pen found in the medication cart and reorder a new one. She stated not having appropriately labeled medication could have resulted in staff giving a resident the wrong medication or administering a medication past its expiration date.
Record review of a facility provided policy titled Administering Medications, dated 2012, revealed, in part, .7. The individual administering the medication must check the label THREE (3) times to verify the right resident, right medication, right dosage, right time and right method (route) of administration before giving the medication .9. The expiration/beyond use date on the medication label must be checked prior to administering. When opening a multi-dose container, the date opened shall be recorded on the container .14. Insulin pens will be clearly labeled with the resident's name or other identifying information. Prior to administering insulin with an insulin pen, the Nurse will verify that the correct pen is used for that resident .
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 observation, interview, and record review, the facility failed to store, prepare, and serve food under sanitary conditions in 1 of 1 kitchen when they failed to:
A. Ensure foods were stored u...
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Based on observation, interview, and record review, the facility failed to store, prepare, and serve food under sanitary conditions in 1 of 1 kitchen when they failed to:
A. Ensure foods were stored under sanitary conditions.
B. Ensure expired food was discarded.
These failures could place residents who ate food served by the kitchen at risk for food-borne illnesses.
Findings include:
In an observation on 07/11/2022 at 11:18 AM the following issues in the dry storage were observed:
1.
1 unopened Enriched Wheat Sandwich Bread, Best by date 6/21/2022
2.
3 unopened packs of 12 Hot Dog Bun Enriched, Best by date 7/7/2022
3.
1 opened pack of 12 Hot Dog Bun Enriched containing 9 hot dog buns not labeled, Best by dated 7/7/2022
In an observation on 07/11/2022 at 11:22 AM the following issues in the freezer were observed:
1.
1 box Cubed Beef Steak Fritters- Box is opened, bag is open to air.
2.
1 Box Boneless Pork Chop Fritter Box opened, bag is unsealed
3.
5 eggos- not dated, not in box
4.
1 half full container of Rainbow Sherbet- not dated with discard date, no open date
In an observation on 07/12/2022 at 08:23 AM the following issues in the dry storage were observed:
1.
1 unopened Enriched Wheat Sandwich Bread, Best by date 6/21/2022
2.
3 unopened packs of 12 Hot Dog Bun Enriched, Best by date 7/7/2022
3.
1 opened pack of 12 Hot Dog Bun Enriched containing 9 hot dog buns not labeled, best by date 7/7/2022
In an observation on 07/12/2022 at 08:26 AM the following issues in the freezer were observed:
1.
1 Box Boneless Pork Chop Fritter Box opened, bag is unsealed
2.
5 eggos- not dated, not in box
3.
1 half full container of Rainbow Sherbet- not dated with discard date, no open date
In an observation on 07/12/2022 at 02:04 PM the following issues in the dry storage were observed:
1.
1 unopened Enriched Wheat Sandwich Bread, Best by date 6/21/2022
2.
3 unopened packs of 12 Hot Dog Bun Enriched, Best by date 7/7/2022
3.
1 opened pack of 12 Hot Dog Bun Enriched containing 9 hot dog buns not labeled, Best by date 7/7/2022
In an observation on 07/12/2022 at 02:06 PM the following issues in the freezer were observed:
1.
1 half full container of Rainbow Sherbet- not dated with discard date, no open date
During an interview with Dietary Manager on 7/12/2022 at 2:12 PM, she stated the 12 Hot Dog Bun best by date was 7/7/2022. She stated the Enriched Wheat Sandwich Bread best by date is 6/21/2022. The DM also stated today's date is 7/12/2022. The DM stated she just recently bought the Enriched Wheat Sandwich Bread two days ago and didn't realize it was past the best by date. The Dietary Manager removed the Enriched Wheat Sandwich Bread as well as the 4 packs of hot dog Buns and stated they needed to be discarded. The DM stated she did not see that they were past their best by date. When asked why it needed to be discarded, she stated The bread could have mold or bacteria. It could cause foodborne illness to residents. When this surveyor asked the DM why previously opened containers are required to have dates, she stated No one would know the date it needed to be discarded if it's not dated. She stated the food could hold bacteria and mold and cause foodborne illness in residents who consume it. DM stated all items needed to be sealed and dated to prevent foodborne illness in residents who consume it.
Review of the facility Nutritional Services policy titled Food Receiving and Storage, revised
December 2008, documents When food is delivered to the facility it will be inspected for safe transport and quality before being accepted . All foods stored in the refrigerator or freezer will be covered, labeled and dated (use by date)
Understanding Severity Codes (click to expand)
Life-Threatening (Immediate Jeopardy)
J - Isolated
K - Pattern
L - Widespread
Actual Harm
G - Isolated
H - Pattern
I - Widespread
Potential for Harm
D - Isolated
E - Pattern
F - Widespread
No Harm (Minor)
A - Isolated
B - Pattern
C - Widespread
Questions to Ask on Your Visit
- "What changes have you made since the serious inspection findings?"
- "Can I speak with families of current residents?"
- "What's your RN coverage like on weekends and overnight?"
Our Honest Assessment
Strengths
- • Licensed and certified facility. Meets minimum state requirements.
Concerns
- • Multiple safety concerns identified: 1 life-threatening violation(s). Review inspection reports carefully.
- • 20 deficiencies on record, including 1 critical (life-threatening) violation. These warrant careful review before choosing this facility.
- • Grade C (51/100). Below average facility with significant concerns.
Bottom line: Mixed indicators with Trust Score of 51/100. Visit in person and ask pointed questions.
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About This Facility
What is Harmonee House's CMS Rating?
CMS assigns HARMONEE HOUSE an overall rating of 3 out of 5 stars, which is considered average nationally. Within Texas, this rating places the facility higher than 99% of the state's 100 nursing homes. This mid-range rating indicates the facility meets federal standards but may have areas for improvement.
How is Harmonee House Staffed?
CMS rates HARMONEE HOUSE's staffing level at 2 out of 5 stars, which is below average compared to other nursing homes.
What Have Inspectors Found at Harmonee House?
State health inspectors documented 20 deficiencies at HARMONEE HOUSE during 2022 to 2024. These included: 1 Immediate Jeopardy (the most serious level, indicating potential for serious harm or death) and 19 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 Harmonee House?
HARMONEE HOUSE is owned by a for-profit company. For-profit facilities operate as businesses with obligations to shareholders or private owners. The facility operates independently rather than as part of a larger chain. With 35 certified beds and approximately 19 residents (about 54% occupancy), it is a smaller facility located in AMHERST, Texas.
How Does Harmonee House Compare to Other Texas Nursing Homes?
Compared to the 100 nursing homes in Texas, HARMONEE HOUSE's overall rating (3 stars) is above the state average of 2.8 and health inspection rating (3 stars) is at the national benchmark.
What Should Families Ask When Visiting Harmonee House?
Based on this facility's data, families visiting should ask: "What changes have been made since the serious inspection findings, and how are you preventing similar issues?" "Can you walk me through typical staffing levels on day, evening, and night shifts?" "Can I visit during a mealtime to observe dining assistance and food quality?" "How do you handle medical emergencies, and what is your hospital transfer rate?" These questions are particularly relevant given the facility's Immediate Jeopardy citations and the below-average staffing rating.
Is Harmonee House Safe?
Based on CMS inspection data, HARMONEE HOUSE has documented safety concerns. Inspectors have issued 1 Immediate Jeopardy citation (the most serious violation level indicating risk of serious injury or death). The facility has a 3-star overall rating and ranks #1 of 100 nursing homes in Texas. Families considering this facility should ask detailed questions about what corrective actions have been taken since these incidents.
Do Nurses at Harmonee House Stick Around?
HARMONEE HOUSE has not reported staff turnover data to CMS. Staff turnover matters because consistent caregivers learn residents' individual needs, medications, and preferences. When staff frequently change, this institutional knowledge is lost. Families should ask the facility directly about their staff retention rates and average employee tenure.
Was Harmonee House Ever Fined?
HARMONEE HOUSE has been fined $7,446 across 1 penalty action. This is below the Texas average of $33,153. While any fine indicates a compliance issue, fines under $50,000 are relatively common and typically reflect isolated problems that were subsequently corrected. Families should ask what specific issues led to these fines and confirm they've been resolved.
Is Harmonee House on Any Federal Watch List?
HARMONEE HOUSE is not on any federal watch list. The most significant is the Special Focus Facility (SFF) program, which identifies the bottom 1% of nursing homes nationally based on persistent, serious quality problems. Not being on this list means the facility has avoided the pattern of deficiencies that triggers enhanced federal oversight. This is a positive indicator, though families should still review the facility's inspection history directly.