ST JAMES HOUSE OF BAYTOWN
For profit - Corporation
105 Beds
Independent
Data: November 2025
1 Immediate Jeopardy citation
Trust Grade
56/100
#343 of 1168 in TX
Photo by Michael Corley
Photo by Michael Corley
Photo by Tony William
1 / 10 photos
Last Inspection: June 2024
Within standard 12-15 month inspection cycle. Federal law requires annual inspections.
Overview
St. James House of Baytown has a Trust Grade of C, which means it is average and sits in the middle of the pack among nursing homes. It ranks #343 out of 1,168 facilities in Texas, placing it in the top half, but only #30 out of 95 in Harris County, indicating there are better local options. The facility is improving, with issues decreasing from 2 in 2024 to 1 in 2025, but still has concerning staffing ratings, with only average staffing at 3 out of 5 stars and a turnover rate of 47%, which is slightly below the Texas average. They have been fined $14,901, which is relatively average, but it raises some concerns about compliance. Notably, there were critical incidents, such as a failure to notify a physician after a resident exhibited severe symptoms, leading to the resident's death, and serious issues regarding the timely administration of insulin for multiple residents. While the facility has good overall ratings and is improving, families should consider both its strengths and significant weaknesses when making a decision.
- Trust Score
- C
- In Texas
- #343/1168
- Safety Record
- High Risk
- Inspections
- Getting Better
- Staff Stability ⚠ Watch
- 47% turnover. Above average. Higher turnover means staff may not know residents' routines.
- Penalties ○ Average
- $14,901 in fines. Higher than 63% of Texas facilities. Some compliance issues.
- Skilled Nurses ⚠ Watch
- Each resident gets only 16 minutes of Registered Nurse (RN) attention daily — below average for Texas. Fewer RN minutes means fewer trained eyes watching for problems.
- Violations ⚠ Watch
- 17 deficiencies on record. Higher than average. Multiple issues found across inspections.
56/100
Top 29%
Review needed
2 → 1 violations
★★★★☆
4.0
Overall Rating
★★★☆☆
3.0
Staff Levels
★★★★☆
4.0
Care Quality
★★★★☆
4.0
Inspection Score
↔
Stable
2024: 2 issues
2025: 1 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
Staff Turnover: 47%
Near Texas avg (46%)
Higher turnover may affect care consistency
Federal Fines: $14,901
Below median ($33,413)
Minor penalties assessed
The Ugly 17 deficiencies on record
1 life-threatening 1 actual harm
Jan 2025
1 deficiency
1 IJ
CRITICAL
(J)
📢 Someone Reported This
A family member, employee, or ombudsman was alarmed enough to file a formal complaint
Immediate Jeopardy (IJ) - the most serious Medicare violation
Notification of Changes
(Tag F0580)
Someone could have died · This affected 1 resident
**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, interview and record review the facility failed to immediately inform the resident, consult with the resid...
Read full inspector narrative →
**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 when there was a significant change in the resident's physical, mental, or psychosocial status and a need to alter treatment significantly for 1 of 5 residents (CR#1) reviewed for physician notification.
The facility failed to contact the physician for over 5 hours when CR#1 had shortness of breath and was gurgling. After approximately 5 hours, CR #1 was sent to the hospital via emergency transport and was admitted with Pneumonia, Acute Kidney Failure, and Septic Shock and expired 2 days later.
An Immediate Jeopardy (IJ) situation was identified on [DATE]. While the IJ was removed on [DATE], the facility remained out of compliance at a scope of isolated with the potential for more than minimal harm, due to the facility's need to evaluate the effectiveness of corrective systems.
This failure could place residents at risk of delayed treatment that has the propensity to lead to death.
Findings include:
Record review of CR #1 face sheet revealed a [AGE] year-old who was admitted to the facility on [DATE]. CR #1 had diagnoses which included Vascular Dementia (Occurs when blood vessels in the brain are damaged, reducing blood flow and brain function), Cerebral Infarction (Stroke), Cognitive Communication Deficit, Dysphagia (swallowing difficulties), Functional Dyspepsia (A chronic condition that causes pain or discomfort in the upper abdomen, often near the ribs), Anemia (lack of blood), Anxiety disorder, Hypoglycemia (low blood sugar), Unspecified Atrial Fibrillation (a heart condition), Neuromuscular dysfunction ( A group of diseases that affect the nerves and muscles that control movement in the body), Constipation and Type 2 diabetes.
Record review of CR#1's Quarterly MDS, dated [DATE], revealed a BIMS score of 99, which indicated the resident was unable to complete the interview.
Record review of CR#1's baseline care plan, dated [DATE] and revised on [DATE], revealed allowing residents to make decision regarding treatment, care and provide opportunities for resident to make choices.
Communication: Resident has a communication problem related to minimal difficulty heating, history of stroke. Goal included: The resident will maintain current level of communication function through the review date. Interventions included: Anticipate and meet needs. Communication: Allow adequate time to respond, repeat as necessary, do not rush, request clarification from the ensure understanding, face when speaking, make eye contact, turn off TV/radio to reduce environmental noise, Ask yes/no questions if appropriate, use simple, brief, consistent words/cues, use alternative communication tools as needed. Discuss with resident/ family concerns or feelings regarding communication difficulty. Encourage resident to continue stating thoughts even if resident is having difficulty. Focus on a word or phrase that makes sense, or responds to the feeling resident is trying to express. Ensure/provide a safe environment: Call light in reach, Adequate low glare light, Bed in lowest position and wheels locked, Avoid isolation. Monitor for/record confounding problems: decline in cognitive status, mood, decline in ADL, deterioration in respiratory status, oral motor function, hearing impairment (ear discharge and cerumen (wax) accumulation, poor fitting/missing dental appliances etc.
Record review of NP note, completed on [DATE] at 10:18 PM, revealed LVN A reported change of condition; CR#1 had difficulty breathing and crackles in breathing sound. Order-Stat Chest X Ray, Duonebs Q4 prn X 5 days ordered.
Record review of progress note, completed on [DATE], *late entry*, revealed resident noted with rattles and 96 % 02 sats. V/S 138/78- BP, 97.6 Temp, 70, 26. On Call Physician notified change in condition. NP with orders for STAT Chest X Ray and Duonebs (a sterile inhalation solution containing a combination of albuterol and ipratropium). every 4 hours PRN X 5 Days. Duonebs administered. Resident rattles present O2 Sats at 89%. Resident noted responsive to tactile stimuli with cold clammy skin and hands. 911 called at 1105 to transfer resident to hospital. RP notified of change in condition and transfer to ER. Resident left facility at 1120PM.
In an interview on [DATE] with LVN A at 2:08 PM, she stated she got a report from LVN D that she needed to go check on CR #1. She stated when she assessed CR #1, his breathing was not good. She described the resident as, just not being the same person. She stated she took his vital signs and contacted the on-call NP. She stated she received orders to do Stat Chest X ray and to put him in Duonebs. She stated she completed Duonebs for about 5 minutes and it appeared it was not helping and the resident was not getting better so she called 911 and they came immediately, and CR #1 was transported to the hospital. She stated the resident was still responsive when 911 arrived. She stated she contacted the RP of the change in condition and CR #1's transfer to the hospital. She stated the nurse that was assigned to CR#1 prior to her was LVN E. She stated she last worked with CR #1 2 days prior and she did not see any difficult changes with the resident when she worked with him.
In an interview on [DATE] with CNA B at 3:07 PM, she stated she checked on CR #1 around 3:00 pm on [DATE] and he was complaining of pain. She stated she informed LVN E and LVN E informed she could not give the resident any medication because the nurse on the prior shift had already given him medication. She stated she checked on CR #1 between 4 and 4:30 PM and she noticed he sounded a little congested, as if he could have been coming down with a cold, she stated it sounded like something was in his chest (mucus) but his breathing did not sound gurgly but she could hear it (the mucus) whenever he yelled. She stated the resident did not really eat his dinner, it is unknown if it was common for the resident. She stated between 8:00 PM-8:30 PM, she provided incontinent care and the resident sounded gurgly, as if he had mucus in his throat or possibly needed to cough. (Initially CNA B stated she informed LVN E but in a later interview she stated she left the resident's room to wash her hands and when she returned, LVN E was already in the room checking on CR #1). She stated she left the room to wash her hands and when she returned LVN E was in the room checking on the resident, trying to get him to cough (telling the resident to try to cough it up). She stated she was unsure of what occurred after because she only peeked in to check on the resident and she did not remain in the room.
In an interview on [DATE] with CNA C at 10:09 AM, she stated she worked with CR #1 on Christmas Day. She stated she worked the night shift. She stated she checked on the resident at the start of her shift and the resident was in bed. She stated CR #1 was not complaining of pain, but he was making noises(random noises). She stated CR #1 was not responding to questions. She stated she informed LVN A there was a concern with CR #1 and LVN A provided a breathing medicine and she called 911.
In an interview on [DATE] with the MD at 10:19 AM, he stated he last saw CR #1 on Christmas eve and he assessed the resident due to being constipated. He stated he did not notice issues with breathing or congestion when CR #1 was assessed. He stated when there was a change in condition, the facility staff should call him or the call center. He stated they had a 24-hour call center. He stated whenever there was a change of condition, they were expected to call as quickly as they could, got vitals and pertinent information so the provider could make a judgement of the situation. The MD stated no one from the facility contacted him at the time of the change in condition. He stated the facility contacted the call center with CR#1's change in condition and the call that was placed the night of [DATE]. He stated that his expectation is that the facility either reaches out to him for a change in condition or if it is after hours, they are to reach out to the on call center.
In an interview on [DATE] with the DON at 10:35AM, she stated she was not at the facility when the incident occurred. She stated the gurgling was not a common thing for CR #1. She stated the gurgling, and the shortness of breath would be considered a change in condition. If the resident would have had these symptoms earlier, the staff are expected to assess, call the physician, order labs and send out if needed. She stated once the patient is stable, they would notify the family. She stated whenever a resident had a change in condition, the staff would complete a S Bar (Communication tool used to share information about a resident's condition, used when a resident had a change in condition) for the resident and provide vitals to the physician.
In an interview on [DATE] with LVN D at 12:30 PM, she stated she works the 2:00pm-10:00pm. She stated she worked on Christmas day and she worked station 3. She stated she did see CR #1 on Christmas day. She stated she happen to see CR #1 when she was walking down his hall. She stated the resident did not look right and she gave him a washcloth. When asked to elaborate on what that meant; she stated the resident looked like he was sweating a little. She stated she seen the resident around 9:30pm/10:00pm. She stated the resident sounded a little congested when she seen him. She stated CR #1 did not sound gurgly when she seen him. She stated the resident did not complain of pain when she seen him. She stated she informed the CNA B of the residents condition. She stated she does not know if the nurse assigned to the resident was notified. She stated the night nurse (LVN A) that she should go check on the resident because she did not know what was going on with him. She stated she went back into the room with LVN A to assist with the nebulizer machine but she left shortly after.
In an interview on [DATE] with LVN E at 2:02 PM, she stated she noticed after dinner (exact time unknown) CR #1 appeared to be a little congested, but his breathing was not labored, she stated it sounded more like wheezing than congestion. She stated one of the previous aides (name unknown) informed her CR #1 had been sick. She stated she assessed the resident for pain and he was provided pain medication. She stated they repositioned CR #1, and it helped his congestion. She stated she checked CR #1's O2 stats and he was fine. She stated she did not observe anything imminent. She stated towards the end of her shift, she checked on the resident again and she tried to get him to cough. She stated the resident coughed up a little mucus and it helped. She stated LVN A came in for night shift around 10:00 PM and contacted the NP and got an order for the nebulizer and x ray and they sent the resident out. She stated the xray was not completed because the resident was sent out instead. She stated she did not contact the MD sooner because she did not think anything was imminent. She stated the resident appeared to be congested as if he was coming down with a cold.
Record review of CR#1's hospital medical records, dated [DATE], revealed CR#1's admitting diagnosis was pneumonia and septic shock with low blood pressure and low blood sugar. CR #1 expired at [DATE].
Record review of the facility's, undated, policy Change in a Resident's Condition or Status, revealed 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 . 1. The Nurse Supervisor/Change Nurse will notify the resident's Attending Physician or On-Call Physician when there has been . c. A significant change in the resident's physical/emotional/mental condition .g. A need to transfer the resident to a hospital/treatment center .i. Instructions to notify the physician of changes in the resident's condition.
This was determined to be an Immediate Jeopardy (IJ) on [DATE] at 4:34PM. The Administrator and DON were notified. The Administrator was provide with the IJ template on [DATE] at 4:38 PM.
FACILITY'S PLAN OF REMOVAL DATED [DATE].
Introduction:
On [DATE], at 4:35PM, an Immediate Jeopardy was identified due to failed to contact physician for over 5 hours when CR#1 had a change in condition in that he had shortness of breath and was gurgling.
All current residents could be at risk of having a change of condition and have the potential to be impacted by this deficient practice.
As a result of the IJ the facility has implemented the following.
1. Administrator, DON and ADON were in-serviced by Chief Nursing Officer as well as regional nurse: Healthcare regarding resident changes in condition, follow-up, staff reporting of incidents and changes in condition and notifying the medical director and or designated on call provider Admin, DON and ADON in-serviced on the need for increased staff education and monitoring including new hires and agency staff. All verbalized understanding. In service completed on [DATE].
2. Facility reviewed policies and procedures prior to in-services. No changes were made to policies, as a result of the initial review.
3. Administrator, DON and ADON completed the following:
a. The facility DON and ADON on [DATE] at 5:00 PM implemented the following:
All on duty nursing staff were in-serviced on the following by DON and ADON.
i. MD notification of change in condition, including change in mental status/alertness
ii. Notification of DON/ Administrator of any change in condition.
iii. Resident follow-up monitoring
iv. Monitoring residents for change in condition.
b. Signs/Symptoms of Resident change of condition to include but not limited to:
i. mental status,
ii. Changes in breathing
iii. unarousable while sleeping,
iv. changes to pupils
v. inability to/or refusing to eat, drink or take medications.
vi. Documentation
4. Facility also conducted additional in-services on:
c. Abuse, neglect and exploitation.
d. Documentation
5. Completion date [DATE] at 7am.
6. All other nurses will be in-serviced prior to starting their next scheduled shift. The DON, ADON or designee will in-service the nursing staff.
7. Additionally, DON/ADON may provide in-service training to charge nurses by phone prior to the start of their next shift.
8. Administrator, DON and or Designee will review all residents who have had a change in condition. An audit will be conducted on all residents with a change in condition to ensure compliance with the policy. Nurse's found to have not followed policy
will be subjected to further training and/or disciplinary action up to and including termination of employment. This review has been added to the morning meeting packet and will be reviewed daily.
9. A reference binder has been set up for nursing staff to quickly access the policy on changes of condition. New Hires, Agency Staff and existing staff will be oriented to the location of the information and will be in-serviced by DON, ADON or Designee. The binder
will be maintained at the Station 1 nurses station. This binder was placed at station 1 on [DATE].
10. Staffing Coordinator was in-serviced by Corporate Administrator and DON. Staffing Coordinator was directed to make contact with all agency employees prior to their shift and provide direction on completing the required in-services and sign offs. A quick reference binder was developed and implemented for agency staff on [DATE].
11. An Audit was conducted on [DATE]-[DATE] for residents having a change in condition, residents who were identified as having a change of condition in the past 30 days were reviewed.
a. The facility Identified 43 residents with change of condition during the review period.
b. Facility reviewed all 43 changes of condition; timely notification of medical director and/or designee was identified in 42 of 43 instances.
12. Agency LVN (LVN E) involved in CR#1s care was in-serviced on [DATE] by the DON. Agency nurse was added to the do not return to facility list on [DATE].
13. CR #1 Passed away in the hospital on [DATE]
14. Administrator, DON/ADON will monitor this plan of removal and correction daily during morning meeting for the next 30 days.
15. The facility completed an ad-hoc QAPI, regarding the incident resulting in the IJ. QAPI Committee will add residents with change of condition to the agenda and will review data for 8 weeks. Additionally, any change of conditions will be reviewed in morning meeting.
Monitoring of the POR included the following:
Observation of nurses station 1, revealed the DON set up a reference binder for nurses to review when signing in for work. The reference binder included the change in condition policy.
Observation of quick reference binder created for agency staff; the binder included an agency staff orientation training acknowledgement check off list and policies for Abuse, Resident Care, Effective Communication, Mechanical Lift, HIPAA/Privacy/Confidentiality, Notification of Change, Incidents/Accidents, Resident Rights, Med Pass/MISC (Nurses only), PPE and Handwashing.
Interviews on [DATE] between 8:00AM and 4:00 PM with 17 staff across three shifts to include 6AM-2PM, 2PM-10PM & 10PM-6AM (RN's, LVN's, CNA's, ADON, DON, Staffing Coordinator, and Administrator) indicated they had been in-serviced on Urgency, Changes in Conditions , taking vitals and how to identify change in condition and who to immediately report changes to (the nurse, DON, ADON or MD) and the importance of documentation in the system immediately (to ensure the resident is getting proper care). During the interviews each staff member was asked to provide an example of what they felt was urgency and what they would do. All CNA's interviewed indicated they would immediately contact the RN or LVN if the vitals were too low, or the resident had a change in condition. They also indicated if necessary and they were unable to contact the RN/LVN they would contact the ADON or DON and then complete the appropriate documentation afterwards. The RN and LVN indicated the same. They also indicated it was imperative for them not to wait to document, but to document all occurrences.
The DON will closely monitor changes in conditions with patients by completing an audit daily and reviewing all new physician orders from 30 days prior to present and foregoing.
Record review of the Plan of Removal revealed each medical staff member (RN's, LVN's, CNA's, ADON, DON, Staffing Coordinator, and Administrator) were in-serviced, between [DATE] and [DATE] on Urgency in the notifications when resident vitals were abnormal, any changes in resident conditions, heart rate are out of the normal parameters or any changes in breathing an immediate notification to nursing and physician is required and documentation of date and time of the occurrence.
Record review of audit completed by DON revealed all residents were audits for change in conditions (skin, falls, incidents with injury, antibiotics, hospitalization, change on 24-hour report, wounds, MD notifications) within the last 30 days. All residents were in stable condition. There was no concerns.
Record review of the facility in-service documentation dated [DATE], revealed All Staff were in-serviced for Abuse and Neglect Policy, Change of Condition Policy, Documentation Policy, Change of condition-when to report to MD/NP/PA.
An Immediate Jeopardy (IJ) situation was identified on [DATE]. While the IJ was removed on [DATE], the facility remained out of compliance at a scope of isolated with the potential for more than minimal harm, due to the facility's need to evaluate the effectiveness of corrective systems.
Oct 2024
1 deficiency
CONCERN
(E)
📢 Someone Reported This
A family member, employee, or ombudsman was alarmed enough to file a formal complaint
Potential for Harm - no one hurt, but risky conditions existed
Respiratory Care
(Tag F0695)
Could have caused harm · This affected multiple residents
**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, interview, and record review, the facility failed to ensure that residents who needed respiratory care wer...
Read full inspector narrative →
**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, interview, and record review, the facility failed to ensure that residents who needed respiratory care were provided such care, consistent with professional standards of practice, the comprehensive person-centered care plan and the residents' goals and preferences for 2 of 3 residents (Residents #1 and #2) reviewed for respiratory care.
1.
The facility failed to ensure the filter in Resident #1's oxygen concentrator was not dirty.
2.
The facility failed to ensure Resident #1's portable oxygen cylinder was not empty while in use.
3.
The facility failed to ensure Resident #2's oxygen cannula positioned in her nose for 2 hours.
These failures could place residents who required respiratory treatments at risk of receiving inadequate respiratory treatments and could result in a decline in health.
Findings Included:
Resident #1
Record review of Resident #1's face sheet dated 10/9/2024 revealed she was a [AGE] year-old female who was admitted to the facility originally on 12/12/2018 and most recently was admitted on [DATE]. Her diagnoses included, shortness of breath (difficulty breathing), Chronic obstructive pulmonary disease (common lung disease causing restricted airflow and breathing problems) and heart failure.
Record review of Resident #1's admission MDS dated [DATE] revealed a BIMS (test used to measure cognitive decline) of 99, which indicated the resident was not able to complete the interview. Further review revealed Active Diagnoses - Debility, Cardiorespiratory conditions, Heart Failure, Hypertension (high blood pressure), Pulmonary - Asthma, Chronic Obstructive Pulmonary Disease . Section O - Respiratory treatments revealed Resident #1 had oxygen therapy.
Record review of Resident #1's care plan dated 8/16/2024 revealed the following:
Required Oxygen at 2-4 L per n/c daily continuous to maintain o2 sats greater than 95
Goal - Will maintain oxygen saturation levels
Intervention - Administer oxygen as ordered
Record review of Resident #1's Order Summary dated 10/9/2024 revealed the following in part:
Oxygen at 2-4 liters PE Nasal cannula daily continuous to maintain 02 sat > [sic] 95% every shift for shortness of breath related to shortness of breath (start date 9/3/2024). Levalbuterol HCI (hydrochloric acid) solution nebulizer .63 mg/3ml. 1 vial inhale orally every 8 hours as needed for COPD (start date 9/3/2024)
Record review of Resident #1's admission MDS dated [DATE] revealed a BIMS of 99, which indicated the resident was not able to complete the interview. Further review revealed Active
Diagnoses - Debility, Cardiorespiratory conditions, Heart Failure, Hypertension (high blood pressure), Pulmonary - Asthma, Chronic Obstructive Pulmonary Disease.
Record review of Resident #1's nurses notes dated 10/9/2026 at 11:46 a.m., written by LVN A revealed the following:
Changed O2 tank this AM [morning] Attempted to get O2 reading O2 machiene [sic] not reading attempted to warm ands [sic] and gave breathing treatment no distress noted. O2 reading 92% no distress noted at this time.
Resident #2
Record Review of Resident #2's face sheet dated 10/9/2024 for revealed she was a [AGE] year-old, female who was admitted to the facility on [DATE]. Her diagnoses included Dementia (memory loss), shortness of breath (difficulty breathing), Chronic obstructive pulmonary disease (common lung disease causing restricted airflow and breathing problems), cerebral infarction (disrupted blood flow to the brain), and hypertension (high blood pressure).
Record review of the physician's orders dated 10/7/2024 revealed Resident #2 had orders for the following:
Oxygen at 2-4 liters per nasal cannula daily continuous to maintain o2 sats > 95% (order date 11/1/2022)
to receive 02 at 2L/m via NC Continuously every shift. Additional order dated 6/4/24 revealed Oxygen at 2-4 LPM via nasal cannula continuously. Monitor 02 sat. every shift.
Record review Resident #2's Quarterly MDS assessment dated [DATE] revealed a BIMS score 14 indicating the resident was cognitively intact. Review of Section O: Special treatment revealed the resident was coded as receiving respiratory treatments - continuous oxygen therapy.
Record Review of Resident #2's care plan dated 8/29/2022 revealed the following:
Required Oxygen: Continuous
Start date 8/29/2022 - Status - Active
Care plan Goal - Will maintain oxygen saturation levels.
Intervention - Administer oxygen as ordered.
Record review of the physician's orders dated 10/7/2024 revealed Resident #2 had orders for the following:
Oxygen at 2-4 liters per nasal cannula daily continuous to maintain o2 sats > 95% (order date 11/1/2022) to receive 02 at 2L/m via NC Continuously every shift. Additional order dated 6/4/24 revealed Oxygen at 2-4 LPM via nasal cannula continuously. Monitor 02 sat. every shift.
Observation on 10/9/2024 at 9:01 a.m. - 9:18 a.m. revealed Resident #1 was in her wheelchair, in a common area, with a portable O2 tank and cannula in her nose. The O2 gauge indicator was in the refill zone and the needle was on zero.
An interview on 10/9/2024 at 9:02 a.m. was attempted. Resident #1 made a continuous moaning sound when asked if she had any shortness of breath . Resident #1 was not able to answer how she felt.
Interview on 10/9/2024 at 9:03 a.m. CNA A said Resident #1 had been sitting in the common area for approximately 10-15 minutes. She said she had not checked Resident #1's oxygen gauge and the nurse was responsible.
Interview on 10/9/2024 at 9:18 a.m. LVN A said she sat Resident #1 in the common area at approximately 8:45 a.m. She said the O2 gauge was close to the refill. She said she was completing other tasks for about 30 minutes. She said the gauge was in the refill zone, but it did not mean the resident was out of oxygen. She said she was not sure how long the gauge had been in the refill zone and the indicator was pointed to zero. She said the oxygen should be changed before it was empty. She said she was not able to determine if there was oxygen left in the tank and if the resident was receiving oxygen.
Observation and interview on 10/9/2024 at 9:21 a.m. revealed LVN A attempted to measure Resident #1's oxygen saturations. LVN A rubbed Resident #1's hands with her hands for a minute. LVN A said Resident #1's hands were too cold for the pulse oximeter to get a reading. LVN A said she would give Resident #1 a breathing treatment because she was not sure if her 02 saturations were below her normal range.
Observation and interview on 10/09/2024 at 9:25 a.m. with LVN A, in Resident #1's room, revealed the oxygen concentrator filter had a layer of light gray hairy substance. LVN A took Resident #1 into the room to give her a breathing treatment. LVN A said the nurses did not change the filters and she thought it was maintenance's responsibility. She said she was never told to clean the filters.
Observation and interview on 10/09/2024 at 9:34 a.m., revealed Resident #2 was asleep in bed. Resident #2's concentrator was on and the tubing/cannula was on the floor next to the concentrator at the head of the bed.
Interview on 10/9/2024 at 10:15 a.m. Maint. said he was not told to clean the oxygen concentrator filters. He said a previous DON cleaned the filters.
Observation and interview on 10/09/2024 at 11:37 a.m., revealed Resident #2 was asleep in bed. Resident #2's concentrator and tubing/cannula was in the same position as the earlier observation revealed. Resident #2 was aroused when her name was called. Resident #2 touched on her chest and nose as she tried to find her oxygen. She said she did not know where the oxygen was and had not taken it off. She said she normally had it on. She said she could not remember if the nurse or aide came into her room.
Interview and observation on 10/9/2024 at 11:39 a.m. CNA B said she was not aware the tubing for Resident #2's was on the floor. She said she had been in the resident's room but could not remember what time. She said she normally rounded every two hours. She said she was in another resident's room changing the sheets for the past several minutes. She said Resident #2 was supposed to have the oxygen on but was not sure if it was continuous or as needed. She said she had not placed the oxygen on Resident #2 at anytime during her shift .
Interview on 10/9/2024 at 11:56 a.m. LVN B said she last checked on Resident #2 at 8:30 a.m. She said she was not aware Resident #2's oxygen cannula was not on. She said Resident #2 had a behavior of taking the oxygen off. LVN B said she normally made round to check on resident every two hours. She said Resident #2 could experience shortness of breath or low o2 saturations if she went without oxygen.
Interview on 10/9/2024 at 12:35 p.m. the ADON said when a resident's portable oxygen tank was in the red refill zone, then the tank should be changed to a full tank. She said she expected the nurses to monitor the portable tank to ensure it was not empty. She said if the oxygen tank was empty, Resident #1 would not have received the therapeutic effect of the oxygen need to prevent shortness of breath. The ADON said she changed out Resident #2's cannula and ensured it was in place after it was found on the floor. The ADON said Resident #2 was care planned for taking the oxygen off . She said she was not able to explain why the cannula was in the same position on the floor for approximately two hours.
Interview on 10/9/2024 at 1:49 p.m. the DON said nurse should check the portable oxygen tanks every shift. She said the nurses worked 6:30 a.m. - 2:30 p.m. The DON said possibly the tank was used yesterday (10/8/24) and it was not a full tank. She said normally the portable tanks were used for approximately 3 hours continuously before they are depleted. She said, If the gauge indicator is in the red (refill) section, the tank is empty. She said residents on continuous oxygen are at risk for lower oxygen saturations, confusion, and shortness of breath if they did not receive oxygen as ordered. The DON said she was not sure which staff changed out the concentrator filters and not instructed staff to do so . She said she was not sure how often the oxygen concentrator filters needed to be changed. She said the layer of gray matter that was on Resident #1's concentrator filter indicated the filter needed to be cleaned. She said the layer of gray matter could prevent the flow which could affect the resident. The DON said Resident #2 was on continuous o2 and the CNAs and nurses were responsible for ensuring Resident #2 had her oxygen on. She said Resident #2 could suffer from respiratory problems without the supplemental oxygen.
Interview on 10/9/2024 at 2:08 p.m. the NP said he was notified approximately at 12:00 p.m. today about Resident #1's low o2 saturations (92%). He said because Resident #1 had COPD, any o2 saturations over 85% were good. He said the oxygen tank should have oxygen and not read zero. He said he was not sure if there was a risk to the resident, but there may not be efficient delivery flow of the oxygen if any was left in the tank.
Interview on 10/9/2024 at 2:43 p.m. with the ADMIN, said he expected nurses to follow doctor's orders for oxygen administration. He said the DON and ADON were responsible for ensuring the oxygen tanks had adequate oxygen and were not empty. He said he monitored resident care by making rounds. The ADMIN said maintenance was responsible for checking the oxygen concentrator filters. He said he did not implement the process and it was prior to his hiring. He said he had not instructed maintenance to clean the oxygen concentrator filters. He said he was not aware of the risk and nursing would be better to ask what the risk was.
Record review of facility policy Oxygen Administration not dated, reflected the following:
Oxygen Administration
Purpose - 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 .
3. Assemble the equipment and supplies as needed
General Guidelines
1. Oxygen therapy is administered by way of an oxygen mask, nasal cannula .
b. The nasal cannula is a tub that is placed approximately one-half inch into the resident nose. It is held in place by an elastic band placed around the resident head .
Steps in Procedure
10. Check the mask, tank, humidifying jar, etc., to be sure they are in good working order .
11. Observe the resident upon setup and periodically thereafter to be sure oxygen is being tolerated .
Record review of online source (https://my.clevelandclinic.org/health/treatments/25181-oxygen-tank) Respiratory When is an Oxygen Tank Empty? dated 8/4/2023 reflected the following:
An oxygen tank is considered empty when the pressure gauge reads near zero, indicating that the volume of oxygen inside has been nearly or completely used up.
However, it's vital never to let the tank reach absolute zero, especially in medical settings, to ensure patient safety and to maintain tank integrity.
Record review of manufacture manual for the oxygen concentrator (model A-1025DS - copyright dated 2023) revealed the following:
. Recommended cleaning interval- Air Filter - 7 days - cleaning method - mild dish soap and warm water.
Jun 2024
1 deficiency
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 observation, interview, and record review, the facility failed to ensure residents received treatment and care in accor...
Read full inspector narrative →
**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, interview, and record review, the facility failed to ensure residents received treatment and care in accordance with professional standards of practice, the comprehensive person-centered care plan, and the residents' choices for 1 (Resident #20) of 6 residents reviewed for quality of care in that:
The facility failed to ensure Resident #20 received a weekly skin assessment by a licensed nurse between 12/27/22 - 6/26/24 in accordance with the facility policy and care plan.
This failure could place residents at risk of unidentified skin breakdown.
The findings include:
Record review of Resident #20's face sheet dated 6/27/24 revealed a [AGE] year-old female who admitted on [DATE]. Her diagnoses included dementia, muscle wasting, heart failure, mild protein-calorie malnutrition, hypertension (high blood pressure), and major depressive disorders.
Record review of Resident #20's quarterly MDS assessment dated [DATE] revealed the resident was unable to complete the brief interview for mental status. Staff assessed her mental status as severely impaired. She required assistance from staff with ADL care. She was at risk of developing pressure ulcers.
Record review of Resident #20's care plan dated 6/27/24 revealed she would remain free from tissue injury through preventative nursing measures. Interventions included a weekly body audit by LN.
Record review of Resident #20's quarterly Braden Risk Assessment (used to predict pressure sore risk) dated 6/18/24 by the ADON revealed she was at mild risk of developing pressure sores.
Record review of Resident #20's Skin Inspection revealed the last documented inspection was conducted on 12/27/2022 by the previous wound care nurse. There was no documentation of a weekly body audit conducted by a nurse in the resident's clinical record since 12/2022.
Record review of Resident #20's Skin Concern Roster dated 12/1/23 - 6/27/24 revealed she had no new skin concerns. The skin concern roster was completed by CNAs during baths and incontinent care.
Record review of the facility's computer-generated skin Assessment Schedule for Thursday 6/27/24 - Wednesday 7/3/24 revealed Resident #20 was not listed on it.
In an observation and attempted interview on 6/25/24 at 11:28 a.m., Resident #20 was lying on a couch in the common area, groomed, and not in distress. She did not respond to this Surveyor's greeting.
Interview on 6/27/24 at 11:00 a.m., the ADON said the wound care nurse normally conducted the weekly skin assessments, but she stopped working at the facility one month ago. She said she and the charge nurses currently did the skin assessments and used a computer-generated list to know which residents to assess on the assigned day. She said she was unsure how Resident #20 fell off the list. She said CNAs conducted a daily skin check during showers and would report any issues to the nurse. She said nurses were trained to do the detailed head to toe skin assessment to ensure no skin deviations for the residents. She said she did monitor to ensure nurses completed the weekly skin assessments but because Resident #20 was not on the list, she was unable to verify that it was done in the system. She said she never had any concerns with Resident #20's skin.
Interview on 6/27/24 at 12:02 p.m., the DON said there was a glitch in the computer system. He said all other residents were on the skin assessment list. He said the purpose of the weekly skin assessment, conducted by the nurse, was to check the whole body and ensure the skin was intact and nothing was missed. He said nurses did skin assessments according to facility's protocol. He said daily skin checks were done by CNAs who would report any skin changes.
Interview on 6/27/24 at 1:46 p.m., the Regional Administrator said he would submit a ticket through the IT department to see when Residents #20 fell off the weekly skin assessment schedule generated by the system. He said he expected skin assessments to be done as planned and according to schedule. He said the purpose of the weekly skin assessment, conducted by the nurse, was to check for skin tears, injuries, and for the health and care of the resident. He said CNAs were trained to report anything seen to the nurse for a more thorough inspection.
Interview on 6/27/24 at 2:40 p.m., the DON said he did not realize there was a glitch in the system. He said the ADON was responsible for reviewing the weekly skin audits and would refer any concerns to him. He said no concerns were identified. He said if nurse skin assessments were not done the residents could end up with unknown skin issues.
Record review of the facility's undated Skin Program, Pressure Ulcers & Other Wounds policy read in part, .Prevention, Treatment, & Documentation . Risk Assessment & Routine Care for All Residents . 4. Nursing assistants will check all residents' skin during each episode of care, bathing, etc. Reddened areas will be reported to the licensed nurse . 6. Body Audits for impaired skin integrity will be performed weekly by a licensed nurse and findings will be documented in the medical record .
May 2023
2 deficiencies
CONCERN
(E)
📢 Someone Reported This
A family member, employee, or ombudsman was alarmed enough to file a formal complaint
Potential for Harm - no one hurt, but risky conditions existed
Food Safety
(Tag F0812)
Could have caused harm · This affected multiple residents
Based on 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...
Read full inspector narrative →
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 food procurement in that:
-Food items were found in the kitchen with expired and beyond the use by date.
These failures could affect residents who ate food from the facility kitchen and place them at risk of food borne illness and disease.
Findings include:
Observation of the facility's kitchen and interview on 05/09/23 between 8:30 am and 8:45 am with the Dietary [NAME] A revealed the following:
-A plastic container of Pimiento Cheese with a used by date 04/27/23 in the walk-in refrigerator.
-A plastic container of sliced deli ham with a used by date 05/06/23 in the walk-in refrigerator.
-A plastic container of American Sliced Cheese with a used by date 04/10/23 in the walk-in refrigerator.
Interview with the Dietary [NAME] A on 05/09/23 at 8:35 AM, she said that the container of food items with expired used by date should have been used or discarded prior to the used by date.
Interview with the Dietary Food Service Manager on 05/10/23 at 9:00 AM she said that the dietary staff Should have used or discarded the food prior to the used by date.
Record review of facility's Policy on Food Storage dated 06/17/2021
Read in part . Leftover food is stored in covered containers or wrapped carefully and securely. Each item is clearly labeled and dated before being refrigerated. Leftover food is used within 2-3 days or discarded .
.
MINOR
(C)
📢 Someone Reported This
A family member, employee, or ombudsman was alarmed enough to file a formal complaint
Minor Issue - procedural, no safety impact
Garbage Disposal
(Tag F0814)
Minor procedural issue · This affected most or all residents
Based on observation, interview and record review, the facility must dispose of garbage and refuse properly for 1 of 1 dumpster reviewed for garbage disposal.
-The facility failed to ensure the dumpst...
Read full inspector narrative →
Based on observation, interview and record review, the facility must dispose of garbage and refuse properly for 1 of 1 dumpster reviewed for garbage disposal.
-The facility failed to ensure the dumpster lids and doors were secured.
This failure could place residents at risk of infection from improperly disposed garbage.
Findings include:
Observation on 05-09-23 at 8:45 am, with Dietary [NAME] A revealed the facility's dumpster area, which was in the lot behind the dietary department had a commercial -size dumpster and the lid and door were open.
Interview on 5-09-23, with Dietary [NAME] A she said that they were in-serviced that the Dumpster lids must be closed at all times when not in use.
Interview on 5-10-23 at 10:00 am, with the Food Service Manager she said that the dumpster lids always must be closed to keep vermin, pests, and insects out of the dumpster and from entering the facility.
Policy and Procedure for Food -Related Garbage and Rubbish Disposal read in part . 7. Outside dumpsters provided by garbage pick up services well be kept closed and free of surrounding litter .
.
Mar 2023
1 deficiency
CONCERN
(D)
📢 Someone Reported This
A family member, employee, or ombudsman was alarmed enough to file a formal complaint
Potential for Harm - no one hurt, but risky conditions existed
Medical Records
(Tag F0842)
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 maintain clinical records on each resident that were complete and a...
Read full inspector narrative →
**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on interview and record review, the facility failed to maintain clinical records on each resident that were complete and accurately documented, in accordance with accepted professional standards and practices, for 1 of 7 residents (CR #1) whose records were reviewed for accuracy and completeness in that:
The facility failed to accurately document CR#1's regular diet on his dietary meal service admission order.
This failure could place residents at risk of having inaccurate records and errors in care by staff.
Findings include:
Record review of CR#1's Face Sheet dated 2/25/23 revealed he was a [AGE] year old male who admitted to the facility on [DATE] and readmitted on [DATE] with the following diagnoses, Essential Hypertension (abnormally high blood pressure that is not the result of a secondary medical condition), atrial fibrillation (an irregular, often very rapid heart rhythm that can lead to blood clots in the heart), pain, constipation (difficulty in emptying bowels, usually associated with hardened feces), gastro-esophageal reflux disease (condition that occurs when stomach acid repeatedly flows back into the tube connecting the mouth and stomach (the esophagus) without esophagitis (inflammation that damages the esophagus/tube that connects the mouth and the stomach), and chronic obstructive pulmonary disease (a group of lung diseases that block airflow and make it difficult to breath, causing lung damage that cannot be reversed).
Record review of CR#1's admission MDS dated [DATE] revealed his BIMS was scored a 99 indicating the resident was unable to complete the interview for cognitive status. His SAMS was coded for Cognitive Skills for Daily Decision Making as being Moderately impaired. CR #1 was coded as requiring Limited assistance of one staff for his bed mobility, transfer, dressing, bathing, and locomotion on the unit. He required extensive assistance of one staff for toileting and personal hygiene. He was coded as requiring supervision, set-up assistance with eating. He was coded in section K, Swallowing/Nutritional Status, K0100. Swallowing Disorder .C. Coughing or choking during meals or when swallowing medications. C. Mechanically altered diet-require change in texture or food or liquids (e.g., pureed food, thickened liquids).
Record review of discharge orders from Hospital A dated as signed on 6/1/22 revealed the following order: DIET Heart Healthy Dysphagia (sic) 5 moist/minced.
Record review of undated Facility A nursing intake form read as follows, Diet Texture: dysphagia .Liquid: Thin liquid.
Record review of CR#1's Physician/Prescriber .order sheet dated 6/1/22 revealed the following order: Admit to Facility A under the care of Physician A . Diet: regular with thin liquids. Telephone Order.
Record review of CR #1's Comprehensive Risk assessment dated [DATE] read in part: Current Diet/Consistency/Tube Feeding order/Average Meal Intake: Pureed diet. and had been signed as completed by DM A.
Interview with DM A on 3/8/23 at 9:44 am who said that she was the new Dietary Manager in June of 2022 and had just started. The DM said she could not recall who trained her. The DM said she could not recall if she worked the day CR #1 was served his lunch on 6/3/22, or if he had been served the appropriate or ordered diet, but she said that she had CR #1 listed as a pureed diet, so that would have been the diet CR #1 would have been served. She could not remember where she got the information regarding CR #1's diet.
In an interview with the DON on 3/8/23 at 3:58pm who said that although he was the DON at the time of CR #1's admission to the facility, he did not remember what diet he was on or what diet CR #1 had been served during his stay. He said that the IDT met in or around 2/27/23 with Physician A and determined that the diet order for CR #1 was a transcription error. The DON said that the original physician order was for a regular diet and the DM A somehow documented a pureed diet in error.
Telephone interview with Physician A on 3/8/23 at 4:18pm who said that he was the Physician for CR #1 and was asked recently by the facility to review CR #1's chart. He said he did not recall what CR #1's diet was without looking at it first, but whatever diet he wrote would have been the diet for CR#1. He said that the IDT at the facility met, and they all determined that there was a transcription error. He said that as far as he remembered, a DM could not write orders and believed the transcription error was with her.
In a follow up interview with the DON on 3/8/23 at 4:22pm he said that the admitting nurse at that time, would have been the one responsible for CR #1's admission orders. He said that he and or the ADON should have checked the orders and did not know why or how they did not check CR #1's orders. He said he could not be 100% sure of what diet CR #1 was served but believed CR #1 had received the correct diet throughout his facility stay.
Record review of undated facility policy and procedure titled admission Orders read in part: 1. The written orders should include at a minimum a. Dietary .3. The orders should provide information to maintain or improve the resident's functional abilities until staff can conduct a comprehensive assessment and develop an interdisciplinary care plan. The policy and procedure did not contain any information on the accuracy or transcription of orders.
Record review of undated facility policy and procedure titled Orders-Verbal /Telephone revealed the policy did not contain any information on the accuracy or transcription of orders.
Mar 2022
11 deficiencies
1 Harm
SERIOUS
(H)
Actual Harm - a resident was hurt due to facility failures
Deficiency F0760
(Tag F0760)
A resident was harmed · This affected multiple residents
**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on interview and record review, the facility failed to ensure that residents receive treatment and care in accordance with...
Read full inspector narrative →
**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on interview and record review, the facility failed to ensure that residents receive treatment and care in accordance with professional standards of practice for 7 of 7 residents (Resident #4, Resident 17, Resident #55, Resident #59, Resident #64, Resident #91, Resident #345) reviewed for quality of care.
- The facility failed to set orders and to ensure that pre-prandial insulin, (insulin that should be administered within 5-20 minutes before meals) was administered at 6 AM, 2 hours before the breakfast meal for Resident #4 and Resident #64.
- The facility failed to administer sliding scale insulin timely before meals as ordered by the physician for Resident #4, Resident #17, Resident #59, Resident #91, and Resident #345 by administering it before 6 AM, 2 hours before the breakfast meal.
- The facility failed to administer Insulin as ordered by the physician to Resident #55 when her BG was greater than 200.
- The facility failed to manage Resident #4, Resident #55, Resident #65 and Resident #91's pre-prandial insulin resulting in increase in HbA1c, a lab value that represents a 3 month average of blood glucose.
These failures could place residents receiving insulin at risk for hypoglycemic episodes, increased HbA1c hospitalization, and/or death.
Resident #4
Record review of Resident #4's face sheet dated 03/16/22 revealed, a [AGE] year-old male who admitted to the facility on [DATE] with diagnoses which included: stage 2 CKD, type 2 diabetes with diabetic nephropathy(deterioration of kidney function).
Record review of Resident #4's MDS dated [DATE] revealed, severely impaired cognition as indicated by a BIMS score of 5 out of 15, extensive assistance with most ADLs, and frequently incontinent of both bladder and bowel.
Record review of Resident #4's Care Plan started 03/11/21 revealed, Area- diabetes type 2 uncontrolled blood sugars, Goal- A1c will by below 6, Intervention- Administer oral hypoglycemic agents as ordered. There was no mention of the resident receiving insulin.
Record review of Resident #4's A1c Lab results revealed:
-04/21/21 was 8.7%,
-08/17/21 was 8.4%, and
-02/15/22 was 9.9%.
Interview on 03/17/22 at 1:05 PM, Resident #4 said the nurses checked his blood sugar in the morning at 5:00 AM and gave him his insulin. He said his blood sugar went up to 600mg/dl before he came to the facility and he does not feel different, but it has been up to 500mg/dl when he was in the facility.
Record review of Resident #4's Physician Order dated 01/20/22 revealed, Type 2 diabetes mellitus with diabetic nephropathy, accucheck (finger stick blood glucose reading) QAM with Novolog Flexpen s/s, with administration time code of 5:30 AM. 0-200 = none, 201-250= 2 units, 251-300= 4 units, 301-350= 6 units, 351-400= 8 units, 401-450= 10 units, 451-499= 10 units and call MD.
Record review of Resident #4's January 2022 MAR for Novolog revealed:
05:30 AM -01/21/22 BG-225, 2 units RLQ, 01/25/22 BG-335 6 units LUQ, 01/26/22 BG-450, 10 units LUARM. 01/27/22 BG-356, 8 units RUARM. 01/29/22 BG 353- 8 units LLQ. 01/30/21 BG-221, 2 units RLQ.
Record review of Resident #4's February 2022 MAR for Novolog revealed:
5:30 AM -02/02/22 BG-256, 4 RUQ. 02/06/22 BG 202, 2 units left thigh. 02/08/09 BG 240- 2 units right thigh. 02/09/22 BG-209, 2 units RLQ. 02/11/22 BG-397, 8 units LUQ. 02/15 BG-274, 4 units RUARM. 02/16/22 BG-301, 6 units LLQ. 02/18/22 BG-214, 2 units RLQ. 02/22 BG-279, 4 units LUQ.
Record review of Resident #4's March 2022 MAR for Novolog revealed,
5:30 AM -03/01/22 BG 202- 2 units RUQ. 03/02/22 BG-213, units unknown LLQ. 03/03/22 BG-320, 6 units LUARM. 03/4/22 BG-300, 4 units LUQ. 03/07/22 BG-361, 8 units LLQ. 03/08/22 BG-270, 4 units. 03/11/22 BG-324, 6 units RLQ, 03/11/22 BG-203, 2 units left mid-thigh, 03/12/22 BG-336, 6 units RUARM. 03/15/22 BG-391, 8 units LUQ. 03/16/22 BG-302, unknown units LLQ.
Record review of Resident #4's Physician Order dated 01/20/22 revealed, Humalog 100 unit/mL Kwikpen give 5 units SQ daily in AM Hold for BS <80 with administration time codes of 6 AM.
Record review of Resident #4's January MAR for Humalog Kwikpen revealed:
Resident received 5 units at 6 AM on 01/03/22, 01/07/22, 01/08/22, 01/15/22 and 01/18/22, 01/21/22, 01/25/22, 01/26/22, 01/27/22, 01/29,22, 01/30/22, 01/31/22.
Record review of Resident #4's February MAR for Humalog revealed:
Resident received 5 units at 6 AM on 02/02/22 to 02/11/22, 02/13/22, 02/15/22 to 02/19/22, 02/22/22 to 02/24/22, 02/26/22 and 02/27/22.
Record review of Resident #4's February MAR for Humalog revealed:
Resident received 5 units at 6 AM on 03/02/22, 03/04/22, 03/06/22, 03/7/22, 03/11/22, 03/12/22, 03/15/22, 03/16/22.
Resident #17
Record review of Resident # 17's face sheet dated 03/16/22 revealed, an [AGE] year-old female admitted to the facility on [DATE] with diagnoses which included: type 2 diabetes without complications.
Record review of Resident #17's Quarterly MDS dated [DATE] revealed, severely impaired cognition as indicated by a BIMS score of 5 out of 15, supervision with most ADLs, occasionally incontinent of bladder and always continent of bowel.
Record review of Resident #17's Care Plan with start date of 11/5/2019 revealed, Area- Diabetes Mellitus, Goal- will have blood glucose within normal range, Intervention- Administer insulin as ordered.
Record review of Resident #17's A1c Labs revealed:
-10/12/20 was 8.7%,
12/18/20 was 8.4%,
01/11/21 was 8.6%,
05/12/21 was 5.9%,
07/21/21 was 7.7%,
10/19/21 was 7.7%, and
01/18/22 was 7.5%.
Record review of Resident #17's Physician Orders dated 08/16/21 revealed, Type 2 diabetes mellitus without complication accucheck twice daily with Humalog 100 units/mL vial per s/s with administration time codes of 6AM and 4PM. 0-250 = 0 units, 251-400=3 units, >400= call MD for orders.
Record review of Resident #17's January 2022 MAR revealed:
6 AM- Resident did not receive any insulin at 6 AM for the month of January because her blood glucose reading was less than 250.
4 PM- 01/02/22 BG-256, 3 units LLQ. 01/03/22 BG-342, 3 units RUARM. 01/09/22 BG-254, 3 units RUARM. 01/11/22 BG-280, 3 units LUARM. 01/18/22 BG-266, 3 units LUARM. 01/19/22 BG-251, 3 units RUARM. 01/21/22 BG-262, 3 units RUARM. 01/22/22 BG-251, 3 RUARM. 01/24/22 BG-311, 3 units RUARM. 01/25/22 BG-268, 3 units LUARM. 01/26/22 BG-252, 3 units RUARM, 01/31/22 BG-318, 3 units LLQ.
Record review of Resident #17's February 2022 MAR revealed:
6 AM- Resident did not receive any insulin at 6 AM for the month of January because her blood glucose reading was less than 250.
4 PM- 02/01/22 BG-275, 3 units RUARM. 02/11/22 BG-332, 3 units RUARM.
Record review of Resident #17's March 2022 MAR revealed:
6 AM- Resident did not receive any insulin at 6 AM for the month of January because her blood glucose reading was less than 250.
4 PM- 03/04/22 BG-261, 3 units LLQ.
Resident #55
Record review of Resident #55's face sheet dated 03/16/22 revealed, a [AGE] year-old female who admitted to the facility on [DATE] with diagnoses which included: cellulitis of the left lower limb, type 2 diabetes without complications.
Record review of Resident #55's Quarterly MDS dated [DATE] revealed, intact cognition as indicated by a BIMS score of 15 out of 15, extensive assistance with most ADLs, occasionally incontinent of bladder and always continent of bowel.
Record review of Resident #55's Care Plan with start date 11/22/21 revealed, Area- Diabetes Mellitus, Goal- A1c will be below 6 through next review, Intervention- administer oral hypoglycemic agents as ordered. There was no mention of the resident receiving insulin.
Record review of Resident #55's A1c Labs revealed:
08/24/20 was 5.9%,
11/23/20 was 6%,
02/21/21 was 8.7%,
05/24/21 was 8.3%,
08/16/21 was 7.4%, and
02/21/22 was 9.5%.
In an interview on 03/17/22 at 01:07 PM, Resident #55 said she did not receive any insulin.
Record review of Resident #55's Physician Orders dated 12/02/19 revealed, type 2 diabetes mellitus without complications accucheck everyday with PRN Novolog SQ per sliding scale. 0-200 = 0 units, 201-250= 2 units, 251-300= 4 units, 301-350= 6 units, 351-400= 8 units, 401-450= 10 units, 451-499= 10 units and call MD
Record review of Resident #55's January 2022 MAR revealed, on 01/31/22 the resident had a BG of 233 but she did not receive 2 units of Insulin as ordered.
Record review of Resident #55's February 2022 MAR revealed, on 02/07/22 BG of 204, 02/14/22 BG of 252, 02/21/22 BG of 220, 02/28/22 BG of 249. Resident #55 did not receive any insulin per her sliding scale as ordered by her physician
Record review of Resident #55's March 2022 MAR revealed, on 03/07 BG of 250, 03/14/22 BG of 245. Resident #55 did not receive any insulin per her sliding scale as ordered by her physician.
Resident #59
Record review of Resident #59's face sheet dated 03/16/22 revealed, an [AGE] year-old male who admitted to the facility on [DATE] with diagnoses which included: polyneuropathy, type 2 diabetes with unspecified complications and hyperglycemia.
Record review of Resident #59's Quarterly MDS dated [DATE] revealed, moderately impaired cognition, extensive assistance with most ADLs and frequently incontinent of both bladder and bowel.
Record review of Resident #59's Care Plan started 02/05/20 revealed, area- type 2 diabetes uncontrolled blood sugars, goal- A1c will be below 6% and have no complications through next review. Intervention- Administer oral hypoglycemic agents as ordered. There was no mention of the resident receiving insulin.
Record review of Resident #59's HgbA1c Labs revealed:
07/16/21 was 7.9%,
10/01/21 was 7.9%, and
01/07/22 was 7.9%.
Record review of Resident #59's Physician Order dated 01/21/20 revealed, Type 2 diabetes with unspecified complications, Accucheck BID before meals with Humalog 100 unit/ml vial per s/s with time codes for administration at 6 AM and 4 PM.0-60 0 units 60-200 = 0 units, 201-250= 2 units, 251-300= 4 units, 301-350= 6 units, 351-400= 8 units, 401-450= 10 units, 451-499= 10 units and call MD
Record review of Resident #59's March 2022 MAR revealed,
4 PM 03/01/21 BG-229, 2 units RUARM. 03/06/21 BG-272, 4 units LUARM. 03/08/21 BG-217, 2 units LLQ. 03/14/22 BG-260, 4 units LLQ.
Resident #64
Record review of Resident #64's face sheet dated 03/16/22 revealed, [AGE] year-old-female who admitted to the facility on [DATE] with diagnoses which included type 2 diabetes with other diabetic neurological complications.
Record review of Resident #64's MDS dated [DATE] revealed, moderately impaired cognition as indicated by a BIMS score of 12 out of 15, limited assistance with most ADLs and frequently incontinent of both bladder and bowel.
Record review of Resident #64's Care Plan started 10/12/21 revealed, area- diabetes, goal- A1c will be below 6%, intervention- administer oral hypoglycemic agents as ordered. There was no mention of the resident receiving insulin.
Record review of Resident #64's HgbA1c Labs revealed:
- 04/15/21 was 6.6%,
- 08/02/21 was 10.3%, and
- 02/07/22 was 11%.
Record review of Resident #64's Physician Orders dated 02/06/22 revealed, Novolog 100 units/mL. Give 12 units SQ BID. Hold for BS less than 80 with administration time codes of 6 AM and 6 PM.
Record review of Resident #64's progress notes revealed, the resident had diabetic ulcers on both heels that were acquired in the facility.
Record review of Resident #64's wound assessment report, dated 03/15/2022, stated, made aware of new skin concerns by staff . noted diabetic ulcer to right heel. Blood blistered site measures 2.0 cm by 3.5 cm, skin remains intact at this time . Noted diabetic ulcer to left heel. Area maroon in color. Site measures 3.0 cm by 2.5 cm, skin intact .
Record review of Resident #64's March 2022 MAR revealed, resident received 10 units at 6 AM from 03/01/22 to 03/16/22 and 10 units at 4 PM from 03/01/22 to 03/15/22.
Resident #91
Record review of Resident #91's face sheet dated 03/16/22 revealed, an [AGE] year-old female who admitted to the facility on [DATE] with diagnoses which included: cellulitis of the upper limb, hypertension, progressive neuropathy (damage to one or more nerves that result in numbness, tingling, muscle weakness pain in the affected area) and type 2 diabetes with other circulatory complications.
Record review of Resident #91's MDS dated [DATE] revealed, severely impaired cognition, extensive assistance with most ADLs and always incontinent of both bladder and bowel.
Record review of Resident #91's Care Plan started 05/05/21 revealed, area- diabetes with diabetic polyneuropathy, goal- A1c will be below 6, intervention-administered oral hypoglycemic agents as ordered. There was no mention of the resident receiving insulin.
Record review of Resident #91's HgbA1c labs revealed:
- 04/26/21 was 4.9% and
- 02/08/22 was 7.1%.
Record review of Resident #91's Physician Orders dated 02/04/22 revealed, Type 2 diabetes with diabetic polyneuropathy, Accucheck BID AC with Novolog 100 unit/ml vial per s/s with time codes for administration at 6 AM and 4 PM. 60-200 = 0 units, 201-250= 2 units, 251-300= 4 units, 301-350= 6 units, 351-400= 8 units, 401-450= 10 units, 451-499= 10 units and call MD.
Record review of Resident #91's March 2022 MAR revealed:
6AM 03/01/22 BG-221, 2 units right lower, 03/02/22 BG-266, 4 units LLQ, 03/03/22 BG- 215, 2 units RLQ, 03/04/22 BG-301, 6 units RLQ. 03/05/22 BG-266, 4 units RLQ, 03/06/22 BG-274, 4 units RLQ, 03/07/22 BG-362, 8 units RLQ, 03/08/22 BG-355, 8 units LLQ, 03/09/22 BG-318, 6 units RUARM, 03/10/22 BG- 319, 6 units LLQ, 03/11/22 BG-391, 8 units RLQ, 03/12/22 BG-350, 6 units RLQ. 03/13/22 BG-424, 10 units LUQ,
03/14/22 BG-286, 4 units LUQ. 03/15/22 BG-342- left thigh, 03/16/22 BG, 396 right thigh.
4PM- 03/01/22 BG-250, 2 right upper arm, 03/02/22 BG-203, 2 units LLQ, 03/03/22 BG- 305, 6 units LLQ, 03/04/22 BG-241, 2 units LLQ. 03/05/22 BG-316, 6 units LLQ, 03/06/22 BG-417, 10 units LLQ, 03/07/22 BG-321, 6 units RUARM, 03/08/22 BG-323, 84 units LUARM, 03/09/22 BG-324, 6 units RUARM, 03/10/22 BG- 319, 6 units LLQ, 03/11/22 BG-309, 6 units LLQ, 03/13/22 BG-308, 6 units RLQ,
03/14/22 BG-364, 8 units RUQ.
Resident #345
Record review of Resident #345's face sheet dated 03/16/22 revealed, a [AGE] year-old female who admitted to the facility on [DATE] with diagnoses which included: type 2 diabetes, hypertension and vascular dementia without behavioral disturbance.
Record review of Resident #345's admission MDS dated [DATE] revealed, severely impaired cognition as indicated by a BIMS score of 7 out of 15, limited assistance for all ADLs and always continent of bladder and occasionally incontinent of bowel.
Record review of Resident #345's Care Plan started 03/02/22 revealed, Area- diabetes Mellitus (type 2): uncontrolled blood sugar levels, goal- A1c ( a % that represents a 3 month average of blood sugars) will be below 6%, interventions- administer oral hypoglycemic agents as ordered. There was no mention of the resident receiving insulin.
Record review of Resident #345's HgbA1c Lab revealed:
- 03/16/22 was 8.8%.
Record review of Resident #345's Physicians Orders dated 03/06/22 revealed, Accucheck BID AC with Humalog 100 unit/mL vial per s/s with Time Codes of administration at 6 AM and 4 PM. 0-200 = 0 units, 201-250= 2 units, 251-300= 4 units, 301-350= 6 units, 351-400= 8 units, 401-450= 10 units, 451-499= 10 units and call MD.
Record review of Resident #345's March 2022 MAR revealed:
6AM: 03/12/22 BG-215, 2 units Left thigh, 03/16/22 BG-209 2 units right upper quadrant.
4 PM: 03/07/22 BG-221 2 units, left upper arm. 03/08/22 BG-272, 4 units right lower quadrant. 03/09/22 BG-222, 2 units left upper arm. 03/10/22 BG-382, 8 units right upper quadrant. 03/12/22 BG-249 2 units, left lower quadrant. 03/13/22 BG-259, 4 units left lower quadrant. 03/14/22 288, 4 units left lower quadrant.
An observation at 03/16/22 at 07:25 AM revealed, LVN D shadowing LVN N at the nursing cart. LVN N said that there were no sliding scale insulins to administer that morning because they were already completed by the night shift prior to the beginning of her shift at 6 AM. She said that this was the time morning insulin was always administered.
An observation at 03/16/22 at 08:20 AM revealed, meal tray carts arriving on the 600 hall.
In an interview on 03/16/22 at 07:30 AM, the ADON said that all morning insulin's including sliding scale and pre-prandial insulin were completed by the night shift and that insulin administration was not in relation to meals but was scheduled for 6AM and 4 PM. She said breakfast was normally around 8 am and that residents had snacks available to them between 6 am and 8 am. The ADON said that when administered insulin earlier than meals the expectation was for them to monitor the residents for signs and symptoms of hypoglycemia.
In an interview on 03/16/22 at 07:44 AM, LVN R said that she had no insulin to administer that morning because it was completed by the night shift prior to her arrival at 6 am. She said that this was the time morning insulin were always administered.
In an interview on 03/16/22 at 08:25 AM, LVN D said that sliding scale insulin should be administered when you know the resident's tray is arriving and she would not administer them 2 hours before meals because it could place the resident at risk for hypoglycemia. She said the facility had night shift nurses complete morning insulin administration before the morning shift started at 6 AM.
In an interview on 03/16/22 at 11:22 AM, the Physician said that the facility night shift nurses had been administering pre-prandial insulin because it was easier to get it done. He said while there was a risk of hypoglycemia if pre-prandial insulin was administered without a meal the facility used low sliding scale doses to avoid hypoglycemia, so they have had no problems. The Physician said that pre-prandial insulin should be administered closer to meals and not at 2 hours before a meal but would not give a narrower timeframe. He said for LTC patients his goal was for an A1C <8 % which is an average glucose around 183.
In an interview on 03/16/22 at 02:00 PM, the DON said that pre-prandial insulin (Humalog and Novolog) are dosed per sliding scale in anticipation of increased blood glucose levels when a resident eats and that at most they should be administered close to a meal but no longer than 1 hour before. He said the risk of uncontrolled/ill managed blood sugars was hypoglycemia, impaired wound healing, and any condition which a consequence of uncontrolled blood sugars.
In an interview on 03/18/2022 at 12:50 PM, the DON said Novolog insulin peaks within 1 hour and continues to work within 2-4 hours, and if a resident had not eaten within that first hour, the resident would need to be watched for hypoglycemic effects such as nausea and vomiting and change in mental status. He said there was the need to balance the effect of the insulin with the timing of meals to keep blood glucose levels stable. He said each resident with diabetes is clinically different, some are stable, some are regular, for some insulin would need to be held if not eating, and some need to be monitored for symptoms. The DON said some people can become chronically hyperglycemic with the insulin. He said the goal was to keep resident blood glucose levels as normalized as possible to track trends and know when to adjust their diabetes management regimen and medication. The DON said those with diabetes generally have a risk for wounds and decreased healing abilities.
Record review of the Package Insert for Novolog revealed: Dosage and Administration- Subcutaneous injection: Inject subcutaneously within 5-10 minutes before a meal into the abdominal area, thigh, buttocks or upper arm.
Record review of the Package Insert for Humalog revealed, Dosage and Administration- Subcutaneous injection: Administer HUMALOG U-100 or U-200 by subcutaneous injection into the abdominal wall, upper arm or buttocks within 15 minutes before a meal or immediately after a meal.
Record review of the facility posted Meal Times revealed:
Hall Carts -Breakfast 07:15 AM, Lunch 11:15 AM, Dinner 05:15 PM
Dining Room- Breakfast closed, Lunch 11:30 AM, Dinner 05:30 PM
Not times for snacks were documented on the document.
Record review of the facility policy titled Medications- Administering with no revision date revealed, 3- medications must be administered in accordance with the orders including any required time frame. 4- Medications must be administered within one(1) hour of their prescribed time, unless otherwise specified (for example, before and after meal orders).
Record review of American Diabetes Association Standards of Medical Care in Diabetes-2021 revised 01/2021 revealed:
6- Glycemic Targets. Table 6.1-Estimated average glucose
A1C (%) to mg/dL
5% ~ 97 (76-120)
6% ~ 126 (100-152)
7% ~ 154 (123-185)
8% ~ 183 (147-217)
9% ~ 212 (170-249)
10% ~ 240 (193-282)
11% ~ 269 (217-314)
12% ~ 298 (240-347)
12-Older Adults. Table 12.1
Patient Characteristic- Complex, Reasonable A1C goal <8.0% = Fasting or pre-prandial glucose goal of 90-150 mg/dL, bedtime glucose goal 100-180mg/dL.
CONCERN
(D)
Potential for Harm - no one hurt, but risky conditions existed
Deficiency F0554
(Tag F0554)
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 provisions of self-administering medication...
Read full inspector narrative →
**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, interview, and record review the facility failed to ensure the provisions of self-administering medication were consistent with professional standards of practice for 2 of 18 residents sampled.
-The facility failed to have physician's orders, a care plan and health record that documented Resident #14 and Resident #16 were clinically appropriate for self-administering of medication(s).
This failure could affect residents with medication needs to receive the level of quality of care necessary to maintain their quality of health.
Findings included:
Resident #14
Record Review of Resident #14 Face Sheet on 03/16/22 at 02:59 PM revealed resident has nausea with vomiting, unspecified, ulcerative (chronic) proctitis, pneumonitis due to inhalation of food and vomit, other recurrent depressive disorders and altered mental status.
Record Review of Resident #14 Care plan dated 02/02/22. Resident has difficulty with decision making dementia and mild cognitive impairment.
Record Review of Resident #14 Physician Order dated 03/09/22 Amlodipine Besylate 10 mg tablets give 1 tab by mouth daily. Hold if SPS is <110 or Pulse <60. Physician Order dated 02/14/22 Metoprolol Tartrate 25mg give 1 tab 2 times daily. Hold for SBP <110, DBP 0 and HR <60. Physician Order dated 11/04/21 Arour Thyroid 15mg tablet give 1 tab by mouth daily. Physician Order dated 09/01/21 Colace 100mg capsule give 1 capsule by mouth 2 times daily. Physician Order dated 11/22/21 Zyrtec 10mg tablet by mouth daily. Physician Order dated 07/21/21 Pepcid 20 mg by mouth 2 times daily.
Record Review of Resident #14 CMA EMAR dated 03/15/22 at 08:00 A.M. Aspirin 81mg Chewable tablet, 10:00 A.M. Metoprolol Tartrate 25mg, Multiple Vitamin w-mineral, Probiotic, Pepcid 20mg tablet, and Amlodipine Besylate 10mg tablet and Colace 100mg capsule.
Resident #16
Record Review of Resident #16 Face Sheet on 03/16/22 at 03:19 P.M. revealed resident is diagnosed with major depressive disorder, recurrent severe without psycho features and anxiety unspecified lack of coordination.
Record Review of Resident #16 Care plan dated 02/02/22. Resident has difficulty with decision making resident is diagnosed with mild cognitive impairment.
Record Review of Resident #16 Physician Order dated 1/24/22 Tums tablet given 2 times a day as needed for indigestion (Gastro-esophageal reflux disease without esophagitis)
Record Review of Resident #16 CMA EMAR dated 03/15/22 revealed that the resident received a 08:00 A.M. dose of Tums tablet chewable give 2 tabs PO TID. DX: Indigestion administered by LVN H.
Record Review of 03/15/22 Staffing Assignment revealed that CMA B, LVN B, and CNA R worked the day shift 6:00 A.M. to 02:00 P.M. on the 100 hall and LVN H worked the day shift 6:00 A.M. to 02:00 P.M on the 200 Hall. Each staff member initialed behind their name acknowledging they were on shift.
Observation on 03/15/22 at 09:41 AM of 3 pills in a clear pill cup sitting on resident's bedside table. Resident #14 picked up pill cup, stirred the pills in the cup with her finger and placed back down on the bedside table.
Observation on 03/15/22 at 10:37 AM of 2 stacked tums one pink and one yellow sitting on Resident #16 nightstand.
Interview on 03/15/22 at 09:41 AM with Resident #14, who said on 3/14/22 sometime in the late evening, exact time unknown and she woke with an upset stomach and vomited. When the nurse whose name and description she could not provide, came around to pass out medication, her stomach was still feeling upset. The nurse left her medication so she could take her meds once her stomach settled. She was taking small bites of food: a cookie and a banana in between taking each pill as her stomach settled. She could not recall what medication she was taking or what the medication was prescribed for. She said that the nurse has not left medication for her to take without being present before.
In an interview on 03/15/22 at 10:37 AM with Resident #16 who said she has acid reflux quite often. The tums on her nightstand was left by the nurse whose name and description she could not remember. She said that she felt good now, but that can change at any moment and she has the tums at beside in case her heartburn rises up. The nursing staff leave tums for her on the nightstand all the time to keep her from suffering until staff can bring her some when her acid reflux flares. She said LVN H was passing out meds.
Interview on 03/15/22 at 10:59 AM with CNA R who said she does not administer medication, the nurses administering medication. She believes it ws LVN B and/or CMA B on shift today.
Interview on 03/15/22 at 12:29 PM with Resident #14 who said that she took meds and was able to get them down okay. She said she takes her thyroid pill at 5 PM. She said she likes staff to leave meds so she can divide the meds out between food since she has a lot of pills to take. She said she does not know what all the pills are for, but believes the long capsule is for stomach. She avoids asking staff what meds she was taking because she will forget anyway, and she does not want to drive them up the wall asking the nurses every day.
Interview on 03/16/22 at 01:32 PM with the DON who said the medication administration process requires a physician's order to prescribe the medication. Prior to qualified staff passing medication, staff must follow hand hygienic/infection control parodical. Staff must ensure that the physician order matches the resident receiving medication and it is the correct medication and correct dose. Staff must determine if there is any special parameters needed such as: must be taking with water, juice, with food, and follow any crush, swallow, or chew orders. Then check policy to see if the resident requires the medication to be sprinkled into say apple sauce and spoon feed. Confirm with the resident that the medication is the right medications and once taken, the staff must sign off that the medication was administered. The facility has no residents with self-medication administration orders. A resident with a stomachache at the time of med pass and wishes not to take meds due to earlier vomiting should be held. Med Aides should loop back around and check back with the resident and attempt to administer later as long as the medication is giving within that medications time parameter. No medication should be left for the resident to take on their own and med Aides cannot leave medication with residents. The risk of leaving medication with residents are other residents, family members: children visiting could take the medication. The medication could be taken outside the time parameters, residents could forget to take medication thinking they had and had not and staff will not be able to accurately chart resident's medication intake.
Interview on 03/17/22 at 09:39 AM with Resident #16, she no longer had the Tums as she took them. She tries to keep Tums for when she has heartburn or indigestion. Sometimes the facility runs out and then she does not get them when she really needs them. She said LVN H was passing out meds today.
Interview on 03/18/22 at 02:59 PM with the Administration who said Resident #14 and Resident #16 do not have self-administrating medication orders.
Interview on 03/22/22 at 4:02 PM with CMA B, she said she has worked for the Infacility for 7 years as a medication aide. Her shift is 6 AM to 2 PM. CMA B confirmed that she worked 3/15/22 from 6:00 A.M. to 02:00 P.M. on the 100 hall and confirmed that she initialed by her name on the Shift Assignment form acknowledging that she was on shift. She also confirmed that she administered to Resident #14 per the CMA EMAR record dated 03/15/22 at 08:00 A.M. Aspirin 81 mg Chewable tablet, 10:00 A.M. Metoprolol Tartrate 25 mg, Multiple Vitamin w-mineral, Probiotic, Pepcid 20 mg tablet, Amlodipine Besylate 10 mg tablet ,and Colace 100 mg capsule. She said that the medication administration process requires a review of the medication and order to assure the right resident is receiving the right medication dose and times. Once matched, the mediation can be administered to the resident while she is present. She said that on 03/15/22 sometime during 10:00 A.M. med pass, Resident #14 had a nauseated stomach and refused to take all of her medication. Resident told CMA B she would take the medication once her stomach felt better. CMA B left Metoprolol Tartrate 25 mg and Amlodipine Besylate 10 mg at beside for resident to take when her stomach felt better. CMA B told LVN B that resident did not take all her meds. LVN B told CMA B to hold the medication and loop back around and see if the resident was able to take the meds at a later time within the time parameters. CMA B then told LVN that the medication was left at the resident's bedside. LVN B told CMA B to go get the medication. CMA B did not go back right away. CMA B looped back around the resident still had her medication at bedside and still complained of stomach nausea. CMA B looped back around a third time she believes 15 minutes outside the medication's time parameter and the medication was gone. She assumed the resident had taken the meds. It is not med pass procedure to leave medication at bedside or with residents. Refused medication needs to be held within the allowed time parameters or discarded per medication discard procedure. The risk of leaving the medication with a resident is that staff are unable to assure the resident had taken the meds, residents could take the medication to close to other medication times and could affect the resident's condition, the meds could be taken by another resident or person and could harm those individuals. CMA B said she knows not to leave medication, it is not common practice, and is not supposed to be done. She said leaving the medication with resident was a poor decision and poor judgment on her part. She will not be leaving medication at bedside or with another resident in the future.
Interview on 03/22/22 at 04:20 PM with LVN H who said she had worked at the facility 8 years. She confirmed that she worked 3/15/22 from 6:00 A.M. to 02:00 P.M. in the 200 hall and confirmed that she initialed by her name on the Shift Assignment Report acknowledging that she was on shift. LVN H confirmed that on 03/15/22 during 8:00 AM med pass, she administered to Resident #16 2 TUMS tablets chewable per the 3/2022f CMA EMAR report. She said that the medication procedure is to ensure that the medication is verified by checking that the right medication is being given to the right resident prior to the administering of the medication and stays in the room to assure the resident has taken the medication. On 3/15/22 during 6:00 A.M. medication pass she did not leave 2 Tum tablets with Resident #16. She does not recall seeing 2 Tum tablets on resident #16's bedside. LVN H has not left any medication or Tum tablets for Resident #16 in the past. She always waits for Resident to take her mediation and witnessed Resident #16 take her tum mediation on 03/15/22 during the 06:090 A.M. medication pass. The risk of leaving medications with residents could result in the resident's taking medication at the wrong time, being taking by the wrong resident, or missed by the resident. It is not common practice to leave medication or Tums with residents. She does not know how the medication was left with Resident #16 and does not know of any staff leaving meds with residents.
Record Review Medications - Administering Policy undated revealed Policy Interpretation and Implementation.
Licensed/Authorized Personnel 1. Only persons licensed or permitted by this state to prepare, administer, and document the administration of medications my do so.
Supervision of Medication Administration Functions 2. The DON will supervise and direct all nursing personnel who administer medications and/or have related functions.
In Accordance with Orders 3. Medication must be administered in accordance with the orders, including and required time frame.
Medication Administration Timeframe 4. Medication must be administered within (1) hour of their prescribed time, unless otherwise specified (for example, before and after meal orders).
Charting Withholding/Refusal of Medications on the [DATE]. If a drug is withheld, refused, or given at a time other than the scheduled time, the individual administering the mediation shall document this in the record.
Self-Administration of Medication 20. Residents may self-administer their own medications only if the Attending Physician, in conjunction with the Interdisciplinary Care Planning Team, has determined that they have the decision-making capacity to do so safely.
Record Review of the Fall - Resident Policy undated contained no pertinent information pertaining to the prevent of falls and/or fall risks.
.
CONCERN
(D)
Potential for Harm - no one hurt, but risky conditions existed
Incontinence Care
(Tag F0690)
Could have caused harm · This affected 1 resident
**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, interview, and record review, the facility failed to ensure a resident with an indwelling urinary catheter...
Read full inspector narrative →
**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, interview, and record review, the facility failed to ensure a resident with an indwelling urinary catheter received treatment and services for 1 of 4 residents (Resident #22) reviewed for indwelling urinary catheters.
The facility failed to ensure LVN R followed proper hand hygiene and infection control precautions while providing foley catheter flush and insertion for Resident #22.
This deficient practice could affect any resident with an indwelling urinary catheter and place them at risk of developing or increased UTIs.
The finding included:
Record review of Resident #22's Face sheet revealed a [AGE] year-old male was admitted to the facility on [DATE]. His diagnoses include benign prostatic hyperplasia (overgrowth of prostate tissue) with lower urinary tract, hypertensive heart disease (heart problem because of high blood pressure for a long time), dementia (loss of thinking, remembering and reasoning), and hypertension (high blood pressure in the vessels).
Record review of Resident #22's quarterly MDS dated [DATE] revealed 99 (resident was unable to complete interview for mental status), the resident required limited assist with one staff assistance, and the resident had an indwelling foley catheter.
Record review of Resident #22's care plan dated 10/23/20 revealed the resident had a urinary indwelling catheter related to neurogenic bladder, and BPH (benign prostatic hyperplasia). Interventions: assess color, clarity, character of urine and catheter care every shift.
Record review of Resident #22's March 2022 physician's orders read Foley catheter (16 FR/10ML) related to diagnosis: neuromuscular dysfunction of bladder, change every month on the 14th and PRN (As needed) for leakage, occlusion, and dislodgement.
Record review of the facility infection control log from 11/15/21 through 03/15/21 did not reveal Resident #22 had a UTI (Urinary tract infection).
Observation and interview on 03/15/21 at 1:30 p.m., Resident #22 said he is having pain in his lower abdomen, and his catheter was changed this morning (03/15/22). Resident #22 said he had no urine coming out but had only this, and he showed his catheter leg bag, which had bright red blood. He said the bag had not been drained, and he did not pull on it either. He said he told the nurse about 30 minutes ago, and she said she would come back, and she had not come back.
Interview on 03/15/22 at 1:35 p.m., LVN R said she was the nurse for Resident #22, HHSC surveyor informed LVN R about the resident's complaint of pain and blood in his foley bag. LVN R said she went and assessed the resident and saw blood in his foley bag and called the NP, she said she is waiting for the NP to call her back. She also asked the aide if she drained the resident's catheter bag, and the aide said she had not drained the foley bag this shift.
Observation and Interview on 03/15/21 at 1:40 p.m., with LVN R, was walking towards Resident #22 room she had a bottle of NS and 60 ML syringe in her hand. She then placed it in her uniform pocket. She said the NP (nurse practitioner) called back and said to flush the foley catheter with 30 ML (milliliter) of NS (normal saline) and monitor.
Observation and interview on 03/15/22 at 1:45 p.m., of Resident #22's Foley flush provided by LVN R, she walked into the resident's room, took the NS and syringe from her uniform pocket, and placed it on the resident bedside table. She went into the resident restroom, took some gloves from the packet, and put it in her uniform pocket; upon getting to the resident bed, she took a pair of gloves from her pocket and donned the gloves, she did not wash her hands or sanitize her hand. She opened the syringe and NS, drew 30 Milliliters, disconnected the Foley tubing, placed it on the resident bed linen, and flushed the catheter. The residents doctor walked in and told her to change the catheter; she took off the gloves and left the resident room without washing or sanitizing her hands.
Observation on 03/15/22 at 2:05 p.m., LVN R carried supplies on her two arms against her breast into Resident #22's room.
Observation and interview on 03/15/22 at 2:08 p.m., of Resident #22's Foley catheter change provided by LNV R. LVN R placed the supplies (2- 10 ML syringes,16 French catheter, a leg bag, straight catheter kit) on the residents table without disinfecting the bedside table, parts of the table was wet. She went to the resident restroom, took more gloves, and put them in her uniform pocket. She deflated the bulb in Resident #22's catheter and pulled it out, a long string of blood clots came out with the catheter, and she left it on the residents bed linen for 5 minutes before she placed it in the red bag. LVN R did not take off the gloves before opening the new 16 French catheter, she tried to open the lubricant for the catheter, but she opened the betadine packet, and she trashed the kit and took off her gloves and left the resident room without washing or sanitizing her hands. LVN R left the room four times because each time she tried to put on the sterile gloves, they tore , and she went out to get another kit, she did not wash or sanitize her hands either time she left the room. LVN R donned the sterile gloves without washing her hands. While donning the gloves, she touched the outside of the sterile gloves instead of the inside. She did not drape the resident with the sterile drape from the kit, she squeezed the lubricant on the sterile paper and inserted the tip of the catheter in the lubricant, and the other parts of the catheter were touching the table. LVN R swabbed the residents penis with the betadine and inserted the catheter. She inflated the balloon with 10 ML of normal saline; without any urine return, she waited for about ten minutes, and she was asked when the balloon should be inflated. She said the balloon is inflated after you see urine return, she said she thought she saw urine return. When she deflated the balloon, she advanced the catheter, and 250 ML of urine returned within a few minutes, and the resident said he felt better now and had no more pain. The color of the urine changed from bright red blood to very light hues. She took off her gloves, washed her hands, and turned off the water faucet with her wet hands, she did not disinfect the resident table after use.
Interview on 03/15/22 at 2:50 p.m., LVN R said she did not wash her hands when she came into the resident room and when she left the resident room several times. LVN R said staff is supposed to wash or sanitize their hands upon entering and leaving the resident's room. She said she should have washed her hands when she donned the sterile gloves because the Foley insertion was an aseptic procedure, and the catheter was not supposed to touch the resident table because that part goes into the resident. She said she also did not disinfect the resident bedside table before and after use, and she did not place a barrier on the table before setting up her supplies. LVN R said she forgot to turn off the water tap with a dry paper towel instead of her wet hands. she stated supplies for resident care are not carried on staff body or in staff uniform pocket, but in a clean trash bag. She also said gloves are not placed in a staff pocket or used during care, and all these mistakes were infection control issues because she could have transferred germs from her to the resident, and it could cause harm to the resident, such as UTI. She said she had her skill checkoffs on Foley insertion, hand washing, and infection control in-service.
Interview on 03/16/22 at 2:08 p.m., with ADON (RN); she said LVN R should not have carried the supplies for a procedure in the staff uniform pocket or on her body. She said she should have washed her hands, introduced herself, and told the resident about the procedure. She should have disinfected the bedside table and placed a barrier on the table. She said catheter insertion is an aseptic procedure, and if it is broken, she should have started all over again. LVN R should have taken off her gloves and washed her hands as many times as she left the room and came back. ADON said LVN R should have washed her hand before she donned the sterile gloves because it was an aseptic procedure to prevent microorganism transmission to the resident bladder, which could cause UTI and pain. She said she should not have inflated the balloon without seeing any urine return, especially when the resident has complained of pain. She said when you see urine return, the catheter should be advanced a little more, inflate the balloon, and pull back to make sure the ball is in place to hold the catheter and allow the urine to drain appropriately. She said all nurses have skill checkoffs on Foley insertion before they start working on the floor by themselves and working with residents who have a Foley. She said when she washed her hands, she should have dried her hands and turned off the tap with a dry paper towel to prevent reinfection (cross-contamination) of her hands. She was supposed to wipe the resident's table and put it back where she found it.
Interview on 03/17/22 at 8:50 a.m. with DON, he stated his expectations for the nurses were to follow the facility policy and protocol for Foley catheter insertion. He said LVN R should have washed her hands before trying to don the sterile gloves because it is a sterile technique, and she should have washed her hands when she entered the resident's room and when she left the room. He said nurses are not supposed to carry gloves in their uniform pockets or use them to provide care for residents. Also, water faucets are turned off after handwashing with a paper towel, not with a wet, washed hand. All these are done to prevent cross-contamination or transfer germs to the resident that may cause harm to the resident. He stated there should be a urine return before the nurse inflated the balloon on the catheter. Finally, he said all the nurses have skill checkoffs on Foley care before working by themselves on the floor.
Interview on 03/17/22 at 8:59 a.m. with corporate nurse; she stated that sometimes you do not get a urine return before inflating the balloon depending on how long the Foley catheter has been off. She said the standard of care states that you should have a urine return before inflating the balloon on the catheter. She said the nurse should wash her hands with soap and water or sanitize them before donning the sterile gloves to prevent contamination because it is a sterile procedure. By not washing her hands, she contaminated the aseptic procedure, which could transfer germs to the resident and lead to a UTI. She said the nurse could leave the resident's room without washing her hands but must use the hand sanitizer closest to the resident's room in the hallway.
Record review of the facility charge nurse skills checklist for LVN R revealed indwelling bladder catheter assessment darted 11/29/21.
Record review of undated facility policy on urinary catheter insertion, indwelling and intermittent read . steps in the procedure .#1 wash your hands thoroughly before beginning the procedure . #9 discard glove . wash hands . #11 open the catheter tray using sterile technique . #12 put on sterile gloves . for Male: . #26 insert the catheter gently into the meatus (approximately 5 - 7 inches) or until urine begins to flow from the bladder. When urine begins to flow advance the catheter another 2 inches. Inflate balloon and remove the syringe. Pull gently on catheter to check
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 residents who need respiratory care, incl...
Read full inspector narrative →
**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, interview, and record review, the facility failed to ensure that residents who need respiratory care, including tracheostomy care and tracheostomy suctioning, were provided such care consistent with professional standards of practice for 1 of 1 resident (Resident #86) reviewed for respiratory care.
The facility failed to obtain ensure Resident #86 was administer oxygen as ordered by his physician.
This failure could place residents at risk for complications such as infections by not following professional standards of care during tracheostomy care, suctioning and oxygen administration.
The findings included:
Resident #86
Record review of the face sheet for Resident #86 revealed a [AGE] year-old male admitted to the facility on [DATE] and readmitted on [DATE]. Resident #86's diagnoses included: Chronic obstructive pulmonary disease (inflammatory lung disease that causes obstructed airflow from the lungs), heart disease, lack of coordination, altered mental status, and primary osteoarthritis - right hand.
Record review of Resident #86's physician orders dated February 2022 revealed the following:
Order date and start date of 11/15/2021 - Oxygen at 2-3 liters per nasal canula daily continuous to maintain o2 sats (saturations) above 95%.
Record review of Resident #86's Quarterly MDS dated [DATE] revealed Resident #86 had a BIMS of 5 which indicated severe cognitive impairment. Resident #86 has range of motion impairment on upper and lower extremities on the left side. Active diagnoses of COPD/chronic lung disease, hemiplegia -left side (paralysis of one side of the body). Special treatments - oxygen therapy.
Record review of Resident #86's care plan dated 3/18/2022 revealed the following in part:
Start date 12/17/2021
Diagnosis - CVA Hemiplegia - CVA affecting left upper and left lower extremity
Goal - will perform at maximum level of independence.
Interventions - administer medications as ordered.
Start date 11/24/2021
ADL's: Requires assistance for all ADL's - requires extensive assist with 1 to 2 person assist
Goal: Independent with all ADL's
Intervention - give verbal cues to help prompt. Break task up into smaller steps. Allow rest breaks between task.
Start date 11/24/2021
Requires Oxygen: DX COPD
Goal: Will maintain oxygen saturation levels
Interventions: Administer oxygen as ordered. Monitor O2 sats as ordered. Notify MD/NP of abnormals.
Record review of Resident #86's vitals documented in his electronic record revealed his oxygen saturation was 92% 3/18/2022 at 7:36 a.m.
Observation on 3/18/2022 at 9:50 a.m. of Resident #86 was in bed and a family member was in the room. The oxygen concentrator was off. Resident #86 did not have on his nasal cannula to administer oxygen. The nasal tubing was neatly wrapped in a circle and under the handle of the oxygen concentrator.
Interview on 3/18/2022 at 9:51 a.m. with Resident #86 said his oxygen had not been put on that day. Resident #86 said he felt tired but was able to breath. He said he could not remember the last time he had the oxygen on.
Interview on 3/18/2022 at 9:55 a.m. with Resident #86's family member said the oxygen concentrator was off when he came into the room. He said the oxygen was on sometimes and sometimes not on during his other visits. He said he thought the resident should have the oxygen on all the time.
Interview on 3/18/2022 at 9:59 a.m. with CNA F said she took the O2 saturation this morning for Resident #86's at 7:36 a.m. CNA F said she told LVN E that Resident #86's O2 saturation was 92%. CNA F said LVN E wrote it down on a piece of paper. CNA F said Resident #86 did not have on his oxygen. She said the concentrator was off. CNA F said it is the responsibility of the nurses to adjust the oxygen.
Interview on 3/18/2022 at 10:05 a.m. with LVN E said she was told by CNA F that Resident #86's O2 saturation was 92%. LVN E said it was her understanding that if Resident #68's O2 was below 90% then she would notify the doctor. LVN E said, for most residents that are not in distress she does not do anything. LVN E said she though Resident #86 had orders for prn oxygen. LVN F said she did not have verbal orders for prn oxygen for Resident #86. LVN F said it was her responsibility to ensure oxygen orders are followed and to make notifications to the physician. LVN E said a resident with low oxygen could have shortness of breath. LVN E said she should have made sure she knew the order and followed the orders as written. LVN N took the O2 saturation for Resident #86 during the interview and it was between 93%-94%.
Interview on 3/18/2022 at 10:24 a.m. with DON said, oxygen orders for Resident #86 should have been followed. DON said, we like to maintain oxygen saturation above 90% but if the orders are more specific then they should be followed. DON said the nurse aides are responsible for taking the O2 sats and should inform the nurse. DON said the nurse was responsible to notify the physician if the oxygen was not within the order's specified parameters. DON said, low oxygen could not be good for the resident.
Record review of facility policy Order - Medication not dated revealed the following in part:
Medication shall be administered only upon the written order .
Interview on 3/18/2022 at 11:01 a.m. with DON said the facility did not have a specific oxygen policy.
CONCERN
(D)
Potential for Harm - no one hurt, but risky conditions existed
Deficiency F0726
(Tag F0726)
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 licensed nurses have the competencies and skill...
Read full inspector narrative →
**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, interview and record review, the facility failed to ensure licensed nurses have the competencies and skill sets necessary to care for resident's needs, as identified through resident assessments, and described in the plan of care for 1 of 1 LVN (LVN R) and 1 of 4 residents (Residents #22) reviewed for competency of nursing services in that:
LVN R did not demonstrate or follow appropriate indwelling urinary catheter insertion procedure for Resident #22.
This failure placed facility residents with indwelling urinary catheters at risk for increase infections and hospitalization.
The finding included:
Record review of Resident # 22's Face sheet revealed a[AGE] year old male was admitted to the facility on [DATE]. His diagnose were, benign prostatic hyperplasia (overgrowth of prostate tissue) with lower urinary tract, hypertensive heart disease (heart problem because of high blood pressure for a long time), dementia (loss of thinking, remembering, and reasoning), and hypertension (high blood pressure in the vessels).
Record review of Resident # 22's quarterly MDS dated [DATE] revealed 99(resident was unable to complete interview for mental status), and the resident required limited assist with one staff assistance. It also revealed the resident has indwelling foley catheter.
Record review of Resident # 22's care plan dated 10/23/20 revealed the resident had urinary indwelling catheter related to neurogenic bladder, and BPH (benign prostatic hyperplasia). Interventions: assess color, clarity, character of urine and catheter care every shift.
Record review of Resident # 22's March physician's orders read Foley catheter (16 FR/10ML) related to diagnosis: neuromuscular dysfunction of bladder, change every month on the 14th and PRN (As needed) for leakage, occlusion, and dislodgement.
Record review of the facility infection control log from 11/15/21 through 03/15/21 did not reveal Resident #22 had UTI (Urinary tract infection).
Observation and interview on 03/15/21 at 1:30 p.m., with Resident #22, he said he is having pain in his lower abdomen, and his catheter was changed this morning (03/15/22). Resident#22 said he had no urine coming out but had only this, and he showed his catheter leg bag, which had bright red blood. He said the bag had not been drained, and he did not pull on it either. He said he told the nurse about 30 minutes, and she said she would come back, and she had not come back.
Interview on 03/15/22 at 1:35 p.m., with LVN R, she said she was the resident nurse, and the other surveyor told her about the resident's complaint of pain and blood in his foley bag. LVN R said she went and assessed the resident and saw blood in his foley bag. Then, she called the NP, waiting for the NP to call her back. She also asked the aide if she drained the resident's catheter bag, and the aide said she had not drained the foley bag this shift.
Observation and Interview on 03/15/21 at 1:40 p.m., with LVN R, was walking towards Resident #22 room she had a bottle of NS and 60 ML syringe in her hand. She then placed it in her uniform pocket. She said the NP (nurse practitioner) called back and said to flush the foley catheter with 30 ML (milliliter) of NS (normal saline) and monitor.
Observation and interview on 03/15/22 at 1:45 p.m., with Resident#22's Foley flush provided by LNV R, she walked into the resident's room, took the NS and syringe from her uniform pocket, and placed it on the resident bedside table. She went into the resident restroom, took some gloves from the packet, and put it in her uniform pocket; on getting to the resident bed, she took a pair of gloves from her pocket and donned the gloves, and she did not wash her hands or sanitize her hand. She opened the syringe and NS, drew 30 Milliliters, disconnected the Foley tubing, placed it on the resident bed linen, and flushed the catheter. The resident doctor walked in and told her to change the catheter; she took off the gloves and left the resident room without washing or sanitizing her hand even in the hallway after she left the resident room.
Observation on 03/15/22 at 2:05 p.m. revealed LVN R supplies on her two arms against her breast into the resident room.
Observation and interview on 03/15/22 at 2:08 p.m., with Resident #22 Foley catheter change provided by LNV R. she placed the supplies on the resident table without disinfecting the bedside table. Some part of the table was wet. She went to the resident restroom, took more gloves, and put them in her uniform pocket. The supply was 2 10 ML syringes,16 French catheter, a leg bag, straight catheter kit. she deflated the catheter in the resident. When she pulled it out, a long string of blood clots came out with the catheter, and she left it on the resident bed linen for 5 minutes before she placed it in the red bag. LVN R did not take off the gloves; she removed the catheter and put it in the trash bag before opening the new 16 French catheter, and she tried to open the lubricant for the catheter, but she opened the betadine packet, and she trashed the kit and took off her gloves and left the resident room without washing her hand or use the sanitizer even on the hallway. She left the room four times because each time she tried to put on the sterile gloves, they got torn, and she went to get another kit. She left the room and came back to the room. She did not wash or sanitize her hands all the time she left came back to the room. She donned the sterile gloves without washing her hands. While donning the gloves, she touched the outside of the sterile gloves instead of the inside. She did not drape the resident with the sterile drape from the kit. she squeezed the lubricant on the sterile paper and inserted the tip of the catheter on the lubricate, and the other parts of the catheter were touching the table. Then she swabbed the resident penis with the betadine and inserted the catheter. She inflated the balloon with 10 ML of normal saline; without any urine return, she waited for about ten minutes, and she was asked when the balloon should be inflated. She said the balloon is inflated after you see urine return, and she thought she saw urine return. When she deflated the balloon, she advanced the catheter, and urine returned, 250 ML of urine returned within a few minutes, and the resident said he felt better now and had no more pain. The color of the urine changed from bright red blood to very light hues. She took off her gloves, washed her hands, and turned off the water faucet with her wet hands. she did not disinfect the resident table after use.
Interview on 03/15/22 at 2:50 p.m., with LVN R; she said she did not wash her hand when she came into the resident room and when she left the resident room several times. LVN R said staff is supposed to wash or sanitize their hands upon entering and leaving the resident's room. She said she should have washed her hand when she donned the sterile gloves because the Foley insertion was an aseptic procedure, and the catheter was not supposed to touch the resident table because that part goes into the resident. She said she also did not disinfect the resident bedside table before and after use, and she did not place a barrier on the table before setting up her supplies. LVN R said she forgot to turn off the water tap with a dry paper towel instead of her wet hands. she stated supplies for resident care are not cared on staff body or in staff uniform pocket, but in a clean trash bag. She also said gloves are not placed in a staff pocket or used during care, and all these mistakes were infection control issues because she could have transferred germ from her to the resident, and it could cause harm to the resident, such as UTI. She said t she had her skill checkoffs on Foley insertion, hand washing, and infection control in-service.
Interview on 03/16/22 at 2:08 p.m., with ADON (RN); she said LVN R should not have carried the supply for a procedure in the staff uniform pocket or on her body. She said she should have washed her, introduced herself, and told the resident about the procedure. She should have disinfected the bedside table and placed a barrier on the table. She said catheter insertion is an aseptic procedure, and if it is broken, she should have started all over again. LVN R should have taken off her gloves and washed her hands as many times as she left the room and came back. ADON said LVN R should have washed her hand before she donned the sterile glove because it was an aseptic procedure to prevent microorganism transmission to the resident bladder, which could cause UTI and pain. She said she should not have inflated the balloon without seeing any urine return, especially when the resident has complained of pain. She said when you see urine return, the catheter should be advanced a little more, inflate the balloon, and pull back to make sure the ball is in place to hold the catheter and allow the urine to drain appropriately. She said all nurses have skill checkoffs on Foley insertion before they start walking on the floor by themselves and working with residents who have Foley. She said when she washed her hand, she should have dried her hand and turned off the tap with a dry paper towel to prevent reinfection (cross-contamination) of her hand. She was supposed to wipe the resident's table and put it back where she found it.
Interview on 03/17/22 at 8:50 a.m. with DON. He stated his expectations for the nurses were to follow the facility policy and protocol for Foley catheter insertion. He said LVN R should have washed her hands before trying to don the sterile gloves because it is a sterile technique, and she should have washed her hands when she entered the resident's room and when she left their room. He said nurses are not supposed to carry gloves in their uniform pockets or use them to provide care for residents. Also, water faucets are turned off after handwashing with a paper towel, not with a wet, washed hand. All these are done to prevent cross-contamination or transfer germs to the resident that may cause harm to the resident. He stated there should be a urine return before the nurse inflated the balloon on the catheter. Finally, he said all the nurses have skill checkoffs on Foley care before working by themselves on the floor.
Interview on 03/17/22 at 8:59 a.m. with corporate nurse; she stated that sometimes you do not get a urine return before inflating the balloon depending on how long the Foley catheter has been off. She said the standard of care states that you should have a urine return before inflating the balloon on the catheter. She said the nurse should wash her hands with soap and water or sanitize them before donning the sterile gloves to prevent contamination because it is a sterile procedure. By not washing her hands, she contaminated the aseptic procedure, which could transfer germs to the resident and lead to a UTI. She said the nurse could leave the resident's room without washing her hands but must use the hand sanitizer closest to the resident's room in the hallway.
Record review of undated facility policy on urinary catheter insertion, indwelling and intermittent read . steps in the procedure .#1 wash your hands thoroughly before beginning the procedure . #9 discard glove . wash hands . #11 open the catheter tray using sterile technique . #12 put on sterile gloves . for Male: . #26 insert the catheter gently into the meatus (approximately 5 - 7 inches) or until urine begins to flow from the bladder. When urine begins to flow advance the catheter another 2 inches. Inflate balloon and remove the syringe. Pull gently on catheter to check placement .
Record review of the facility charge nurse skills checklist for LVN R revealed indwelling bladder catheter assessment darted 11/29/21.
CONCERN
(E)
Potential for Harm - no one hurt, but risky conditions existed
Accident Prevention
(Tag F0689)
Could have caused harm · This affected multiple residents
**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, interview and record review, the facility failed to ensure resident environment remained free of accidents...
Read full inspector narrative →
**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, interview and record review, the facility failed to ensure resident environment remained free of accidents in hazards for 3 of 16 residents (Resident #80, #16 and #68) and in 2 of 2 laundry rooms, in that:
-
The facility failed to place wet floor signs during and after mopping resident's hall and rooms.
-
The facility failed to ensure Resident #16 was out of her room or in a position free of walking on the wet floor prior to mopping resident's room.
-
The facility failed to ensure Resident #80 was free of paraphernalia (lighter and cigarettes) stored in her room.
-
The facility failed to ensure two laundry facilities for resident use, secured laundry detergent out of residents' reach.
These failures could place all residents at risk for experiencing accidents/incidents resulting in possible injury or death.
Findings included:
Smoking Hazard
Record review of Resident #80's face sheet revealed a [AGE] year-old female who was admitted into the facility on [DATE] and was diagnosed with Alzheimer's disease, heart failure and COPD.
Record review of Resident #80's care plan revealed the resident was an unsafe smoker and had the intervention of keeping all smoking paraphernalia at the nurses station and to educate resident and reinforce as needed the risk for injury related to burns.
Record review of Resident #80's MDS, dated [DATE] revealed the resident had a BIMS score of 13 out of 15 indicating the resident cognition was intact.
Record review of Resident #80's smoking assessments, dated 11/25/2021, revealed the resident was deemed and unsafe smoker and required constant supervision by staff for safety during smoking.
Observations and interview on 03/17/2022 at 12:30PM, revealed Resident #80 feeding herself a lunch meal in her room. A lighter was observed on top of the resident's nightstand. Resident #80 stated she was unaware the lighter was there and it likely was left by her daughter who brought the lighter to her room instead of handing it off to the nurses' station. She stated the daughter forgets multiple times to give her paraphernalia to the nurses station.
Observations and interview with Charge Nurse LVN N on 03/17/2022 at 1:11PM, revealed the LVN finding the lighter on Resident #80's nightstand and an open pack of cigarettes inside the resident's drawer. LVN N stated she was not aware there was paraphernalia kept in Resident #80's room. She stated she worked at the facility as an LVN on a part-time basis and was not too familiar with the resident.
In an interview with CNA AO on 03/17/2022 at 1:30PM, she stated that just about everyday she has to check Resident #80's room for paraphernalia because the resident tends to keep her cigarettes and lighter after smoke breaks. She stated whenever she found the items, she confiscated and returned them to the nurses' station.
In an interview with CNA AT on 03/17/20222 at 3:09PM, CNA AT stated that Resident #80 was capable of lighting a cigarette and smoking but required supervision. She stated according to facility's policy and procedures, the staff needed to be supervising the resident while outside smoking and the residents were not given more than 1 to 2 cigarettes to smoke during a smoke break. She stated the resident had the habit of sneaking cigarettes and lighters back to her room and all staff who normally work her are aware of that and know to check her room of paraphernalia. She stated if the resident was found with a whole pack in her room, then it is usually because her family member brought it directly to the resident instead of their nurses' station like they are supposed to.
In an interview with the Regional Nurse and DON on 03/17/2022 at 3:53PM, the Regional Nurse stated if the resident was deemed a safe smoker, they were allowed to have possession of their own cigarettes as so long as they smoke only during the designated times and at the designated location. The DON stated they try to keep all paraphernalia checked in at the nurses station for added safety and that the risk of an unsafe smoker having possession of cigarettes and lighters was they could burn themselves or injure others. The DON said to monitor the resident, they have the CNA's checking on Resident #80 and just yesterday a pack of cigarettes were pulled from her room and he believed they were there because the family had brought them directly to the resident despite being educated multiple times to ensure paraphernalia were brought to the nurses station.
Observation on 03/17/22 at 8:10 a.m. of the washer and dryer in the 500 hall with ADON. Revealed a liquid soap, (Straplus Odor Blaster, the bottle is blue with a purple top and the volume is 1.7 gallons), was in the cupboard under the sink and the cupboard was open.
Interview on 03/17/22 at 8:14 a.m. with ADON, she said the laundry supervisor was off and the laundry supply should not be left in the closet that allows residents easy access. She said it will be hazardous for a resident if it is swallowed and stated she will call the administrator as she doesn't have anything to do with laundry. she came back at 8:21 a.m. and stated the administrator said the surveyor could speak to the laundry supervisor over the phone regarding any findings.
Observation and interview on 03/17/22 at 8:25 a.m. of the washer and dryer in the 100 hall with ADON. Revealed there was an open box of laundry detergent, (Gain, 2.8-pound box, had about 25% of detergent). ADON stated the same thing applied to residents in 100 hall as it did 500 hall.
Telephone interview on 03/17/22 at 8:40 a.m. with the laundry supervisor. She stated that the laundry rooms on the 100 and 500 halls are for resident and family members who prefer to do their own laundry and the laundry chemicals are kept in the main laundry room and it is supplied to resident or family members when they want to do their laundry. Laundry chemicals are not supposed to be where residents can reach or have access to because they could get sick if they eat or drink the laundry soap. She said that all the laundry and housekeeping staff do random sweeps of the laundry rooms on the 100 and 500 hall washer rooms to make sure there is no washing chemicals randomly and that since we the surveyor found some no one must have checked that area. She said the firs staff member comes at 6:00 a.m. and the last staff member leaves at 7:00 p.m. and she was not sure why they did make rounds to make sure chemicals were in the proper place.
Record review of the facility round checklist read . there are no chemicals with resident reach - unlocked closets, unlocked supply room, resident room, housekeeping cart, shower rooms, whirlpools .
Record review of the facility's policy on smoking, not dated, revealed, resident who are assessed as not being able to smoke safely will not be allowed to smoke without supervision . If a resident exhibits dangerous behaviors with smoking The resident will be considered unsafe to maintain smoking paraphernalia and it will be maintained for them at the nurses station or other specified location . All personnel caring for residents with smoking restrictions will be altered to the interventions .
Fall Hazards
Record Review Resident #16's Face Sheet revealed resident is diagnosed with major depressive disorder, recurrent sever without psycho features, anxiety disorder, unspecified, unspecified abnormalities of gait and mobility, muscle weakness, unspecified lack of coordination.
Record Review Resident #16's Care Plan dated 02/02/22. Resident has difficulty with decision making resident is diagnosed with mild cognitive impairment, at risk for falls
Record Review of the Incident and Accidents Report dated from 09/16/22 - 03/14/22 revealed the facility had 73 resident falls and 10 found on floor residents.
Record Review of the Fall - Resident Policy undated contained no pertinent information pertaining to the prevent of falls and/or fall risks.
Record Review of the housekeeping Operations Policy undated revealed The following operations re basic in proper housekeeping: Wet Mopping: It is extremely important that clean equipment be used, clean mop, clean bucket and clean water, using specified disinfectant. Usually, the water will need changing every (4) rooms. The mop should be wet, then squeezed damp dry. Mop thoroughly a portion of the floor, and then rinse the mop in the solution again. The wet mop heads should be cleaned thoroughly after each use by soaking in a bleach-cleaner solution for a least one hour, then rinsed thoroughly and allow to dry.
In an observation on 03/15/22 at 10:11 a.m. Housekeeper D mopping Resident #16's room, no wet floor signs posted. Resident #68 sitting in wheelchair inside the room.
In an observation on 03/15/22 at 10:37 a.m. wet floor in Resident #16's room with no wet floor sign posted. Resident #16 was dressed wearing laced shoestringed shoes and standing at the far end of resident's room. Resident began walking towards the door and grabbed the foot of her bed after her feet began to slip on the wet floor. Resident walked around her bed and sat on the end of her bed closest to the door.
In an observation on 03/17/22 at 10:16 a.m. Housekeeper D mopping wing 2. 9 wet floor signs placed outside 9 resident rooms.
In an interview on 03/15/22 at 10:02 a.m. Resident #394 stated to be careful, a housekeeper just mopped her room floor.
In an interview on 03/15/22 at 10:12 a.m. Housekeeper D stated she works the 1st shift Monday through Friday. She is responsible for emptying trash, mopping, and sweeping unit halls and resident rooms once a day or more as needed, and dustings blinds and bed rails as needed on wings 2 and 3. There are a total of 5 housekeepers on shift per day. She stated she did not use the wet floor sign after mopping wing 2, but she should have used it. She stated if residents are in their room when she comes to clean, she asks the residents may she enter to clean their room. If the resident allows housekeeping to enter, residents should either step out of the room or be in a seated or lying down position. The risk of a resident not sitting or lying down could result in falls and injuries. The risk of not placing wet floor signs during and after mopping could result in resident, staff, and visitor falls.
In an interview on 03/15/22 at 10:37 a.m. Resident #16 stated that housekeeping just left out of her room from mopping, the floor is slippery, and she better sit down so she does not fall.
In an interview on 03/18/22 at 09:05 a.m. Housekeeping Supervisor stated that she has worked for the facility for 8 years. She stated that prior to cleaning a resident's room, housekeeping staff are to knock and ask if they can come in and clean their room. Residents not already lying-in bed or sitting are asked to have a seat or come out of the room and do an activity until the housekeeping mops and the floor dries. If resident's decline housekeeping's entry, the housekeeper is to circle back around and check in with the resident again. Wet floor signage is to be placed on the floor at all times during and right after mopping. Staff are to only mop half a hallway, allow it to dry and then mop the remaining half. She stated that the facility uses a mopping solution and disinfectant floor cleaner. It is label 200 produced by the company Autoclo. The standard practice and recommended use of the dispenser is predetermined. the staff push the mounted solution and place a hose in their mop bucket and the devise mixes the correct amount of solution to water mix. The staff do not control the water to solution ratios. She stated that the mopping solution once placed on the floor is very slick. The facility recently replaced tile with new floor planks. When the humidity in the air is high, the slickness of the floor is greater since the new floor planks have been placed. The Administrator has been made aware of the [NAME] than normal floors after mopping.
In an interview on 03/18/22 at 01:48 p.m. Administrator stated that housekeeping is to announce to resident upon entering a resident's room that they are there to clean and mop. Administrator stated that no mopping is to take place if the resident is standing or walking around the room. The housekeeper should ask the resident to step out and asking nursing staff for assistance if the resident is uncooperative or has difficulty understanding. A resident is not to be in the room walking around while housekeeping is mopping. Otherwise, mopping is not permitted. Wet floor signs should be placed on the hall and in the freshly mopped rooms to alert residents and staff to be cautions and careful of the wet floor.
Chemical Hazards
Observation on 03/17/22 at 8:10 a.m. of the washer and dryer in the 500 hall with ADON, Revealed a liquid soap (Straplus Odor Blaster, the bottle is blue with a purple top and the volume is 1.7 gallons), was in the cupboard under the sink and the cabinet was open.
Interview on 03/17/22 at 8:14 a.m. with ADON; she said the laundry supervisor was off and the laundry supply should not be left in the closet that allows residents easy access. She said it would be hazardous for a resident if it is swallowed and stated she would call the administrator as she doesn't have anything to do with laundry. She returned at 8:21 a.m. and stated the administrator said the surveyor could speak to the laundry supervisor over the phone regarding any findings.
Observation and interview on 03/17/22 at 8:25 a.m. of the washer and dryer in the 100 hall with ADON, Revealed there was an open box of laundry detergent (Gain, 2.8-pound box, had about 25% of detergent). ADON stated the same thing applied to residents in 100 hall as it did 500 hall.
Telephone interview on 03/17/22 at 8:40 a.m. with the laundry supervisor. She stated that the laundry rooms on the 100 and 500 halls are for residents and family members who prefer to do their laundry, and the laundry chemicals are kept in the main laundry room. It is supplied to assist residents or family members when they want to do their laundry. Laundry chemicals are not supposed to be where residents can reach or have access because they could get sick if they eat or drink the laundry soap. She said that all the laundry and housekeeping staff do random sweeps of the laundry rooms on the 100 and 500 hall washer rooms to make sure there are no washing chemicals randomly, and since the surveyor found some, it meant no one had checked that area. She said the first staff member comes at 6:00 a.m., and the last staff member leaves at 7:00 p.m. She was unsure when they made the previous rounds to ensure certain laundry chemicals were in the proper place.
Record review of the facility round checklist read, . there are no chemicals with resident reach - unlocked closets, unlocked supply room, resident room, housekeeping cart, shower rooms, whirlpools .
CONCERN
(E)
Potential for Harm - no one hurt, but risky conditions existed
Pharmacy Services
(Tag F0755)
Could have caused harm · This affected multiple residents
**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on interview and record review, the facility failed to ensure that residents receive treatment and care in accordance with...
Read full inspector narrative →
**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on interview and record review, the facility failed to ensure that residents receive treatment and care in accordance with professional standards of practice for 7 of 7 residents (Resident #4, Resident 17, Resident #55, Resident #59, Resident #64, Resident #91, Resident #345) reviewed for quality of care.
- The facility failed to set orders and to ensure that pre-prandial insulin, (insulin that should be administered within 5-20 minutes before meals) was administered at 6 AM, 2 hours before the breakfast meal for Resident #4 and Resident #64.
- The facility failed to administer sliding scale insulin timely before meals as ordered by the physician for Resident #4, Resident #17, Resident #59, Resident #91, and Resident #345 by administering it before 6 AM, 2 hours before the breakfast meal.
- The facility failed to administer Insulin as ordered by the physician to Resident #55 when her BG was greater than 200.
- The facility failed to manage Resident #4, Resident #55, Resident #65 and Resident #91's pre-prandial insulin resulting in increase in HbA1c, a lab value that represents a 3 month average of blood glucose.
These failures could place residents receiving insulin at risk for hypoglycemic episodes, increased HbA1c hospitalization, and/or death.
Resident #4
Record review of Resident #4's face sheet dated 03/16/22 revealed, a [AGE] year-old male who admitted to the facility on [DATE] with diagnoses which included: stage 2 CKD, type 2 diabetes with diabetic nephropathy(deterioration of kidney function).
Record review of Resident #4's MDS dated [DATE] revealed, severely impaired cognition as indicated by a BIMS score of 5 out of 15, extensive assistance with most ADLs, and frequently incontinent of both bladder and bowel.
Record review of Resident #4's Care Plan started 03/11/21 revealed, Area- diabetes type 2 uncontrolled blood sugars, Goal- A1c will by below 6, Intervention- Administer oral hypoglycemic agents as ordered. There was no mention of the resident receiving insulin.
Record review of Resident #4's A1c Lab results revealed:
-04/21/21 was 8.7%,
-08/17/21 was 8.4%, and
-02/15/22 was 9.9%.
Interview on 03/17/22 at 1:05 PM, Resident #4 said the nurses checked his blood sugar in the morning at 5:00 AM and gave him his insulin. He said his blood sugar went up to 600mg/dl before he came to the facility and he does not feel different, but it has been up to 500mg/dl when he was in the facility.
Record review of Resident #4's Physician Order dated 01/20/22 revealed, Type 2 diabetes mellitus with diabetic nephropathy, accucheck (finger stick blood glucose reading) QAM with Novolog Flexpen s/s, with administration time code of 5:30 AM. 0-200 = none, 201-250= 2 units, 251-300= 4 units, 301-350= 6 units, 351-400= 8 units, 401-450= 10 units, 451-499= 10 units and call MD.
Record review of Resident #4's January 2022 MAR for Novolog revealed:
05:30 AM -01/21/22 BG-225, 2 units RLQ, 01/25/22 BG-335 6 units LUQ, 01/26/22 BG-450, 10 units LUARM. 01/27/22 BG-356, 8 units RUARM. 01/29/22 BG 353- 8 units LLQ. 01/30/21 BG-221, 2 units RLQ.
Record review of Resident #4's February 2022 MAR for Novolog revealed:
5:30 AM -02/02/22 BG-256, 4 RUQ. 02/06/22 BG 202, 2 units left thigh. 02/08/09 BG 240- 2 units right thigh. 02/09/22 BG-209, 2 units RLQ. 02/11/22 BG-397, 8 units LUQ. 02/15 BG-274, 4 units RUARM. 02/16/22 BG-301, 6 units LLQ. 02/18/22 BG-214, 2 units RLQ. 02/22 BG-279, 4 units LUQ.
Record review of Resident #4's March 2022 MAR for Novolog revealed,
5:30 AM -03/01/22 BG 202- 2 units RUQ. 03/02/22 BG-213, units unknown LLQ. 03/03/22 BG-320, 6 units LUARM. 03/4/22 BG-300, 4 units LUQ. 03/07/22 BG-361, 8 units LLQ. 03/08/22 BG-270, 4 units. 03/11/22 BG-324, 6 units RLQ, 03/11/22 BG-203, 2 units left mid-thigh, 03/12/22 BG-336, 6 units RUARM. 03/15/22 BG-391, 8 units LUQ. 03/16/22 BG-302, unknown units LLQ.
Record review of Resident #4's Physician Order dated 01/20/22 revealed, Humalog 100 unit/mL Kwikpen give 5 units SQ daily in AM Hold for BS <80 with administration time codes of 6 AM.
Record review of Resident #4's January MAR for Humalog Kwikpen revealed:
Resident received 5 units at 6 AM on 01/03/22, 01/07/22, 01/08/22, 01/15/22 and 01/18/22, 01/21/22, 01/25/22, 01/26/22, 01/27/22, 01/29,22, 01/30/22, 01/31/22.
Record review of Resident #4's February MAR for Humalog revealed:
Resident received 5 units at 6 AM on 02/02/22 to 02/11/22, 02/13/22, 02/15/22 to 02/19/22, 02/22/22 to 02/24/22, 02/26/22 and 02/27/22.
Record review of Resident #4's February MAR for Humalog revealed:
Resident received 5 units at 6 AM on 03/02/22, 03/04/22, 03/06/22, 03/7/22, 03/11/22, 03/12/22, 03/15/22, 03/16/22.
Resident #17
Record review of Resident # 17's face sheet dated 03/16/22 revealed, an [AGE] year-old female admitted to the facility on [DATE] with diagnoses which included: type 2 diabetes without complications.
Record review of Resident #17's Quarterly MDS dated [DATE] revealed, severely impaired cognition as indicated by a BIMS score of 5 out of 15, supervision with most ADLs, occasionally incontinent of bladder and always continent of bowel.
Record review of Resident #17's Care Plan with start date of 11/5/2019 revealed, Area- Diabetes Mellitus, Goal- will have blood glucose within normal range, Intervention- Administer insulin as ordered.
Record review of Resident #17's A1c Labs revealed:
-10/12/20 was 8.7%,
12/18/20 was 8.4%,
01/11/21 was 8.6%,
05/12/21 was 5.9%,
07/21/21 was 7.7%,
10/19/21 was 7.7%, and
01/18/22 was 7.5%.
Record review of Resident #17's Physician Orders dated 08/16/21 revealed, Type 2 diabetes mellitus without complication accucheck twice daily with Humalog 100 units/mL vial per s/s with administration time codes of 6AM and 4PM. 0-250 = 0 units, 251-400=3 units, >400= call MD for orders.
Record review of Resident #17's January 2022 MAR revealed:
6 AM- Resident did not receive any insulin at 6 AM for the month of January because her blood glucose reading was less than 250.
4 PM- 01/02/22 BG-256, 3 units LLQ. 01/03/22 BG-342, 3 units RUARM. 01/09/22 BG-254, 3 units RUARM. 01/11/22 BG-280, 3 units LUARM. 01/18/22 BG-266, 3 units LUARM. 01/19/22 BG-251, 3 units RUARM. 01/21/22 BG-262, 3 units RUARM. 01/22/22 BG-251, 3 RUARM. 01/24/22 BG-311, 3 units RUARM. 01/25/22 BG-268, 3 units LUARM. 01/26/22 BG-252, 3 units RUARM, 01/31/22 BG-318, 3 units LLQ.
Record review of Resident #17's February 2022 MAR revealed:
6 AM- Resident did not receive any insulin at 6 AM for the month of January because her blood glucose reading was less than 250.
4 PM- 02/01/22 BG-275, 3 units RUARM. 02/11/22 BG-332, 3 units RUARM.
Record review of Resident #17's March 2022 MAR revealed:
6 AM- Resident did not receive any insulin at 6 AM for the month of January because her blood glucose reading was less than 250.
4 PM- 03/04/22 BG-261, 3 units LLQ.
Resident #55
Record review of Resident #55's face sheet dated 03/16/22 revealed, a [AGE] year-old female who admitted to the facility on [DATE] with diagnoses which included: cellulitis of the left lower limb, type 2 diabetes without complications.
Record review of Resident #55's Quarterly MDS dated [DATE] revealed, intact cognition as indicated by a BIMS score of 15 out of 15, extensive assistance with most ADLs, occasionally incontinent of bladder and always continent of bowel.
Record review of Resident #55's Care Plan with start date 11/22/21 revealed, Area- Diabetes Mellitus, Goal- A1c will be below 6 through next review, Intervention- administer oral hypoglycemic agents as ordered. There was no mention of the resident receiving insulin.
Record review of Resident #55's A1c Labs revealed:
08/24/20 was 5.9%,
11/23/20 was 6%,
02/21/21 was 8.7%,
05/24/21 was 8.3%,
08/16/21 was 7.4%, and
02/21/22 was 9.5%.
In an interview on 03/17/22 at 01:07 PM, Resident #55 said she did not receive any insulin.
Record review of Resident #55's Physician Orders dated 12/02/19 revealed, type 2 diabetes mellitus without complications accucheck everyday with PRN Novolog SQ per sliding scale. 0-200 = 0 units, 201-250= 2 units, 251-300= 4 units, 301-350= 6 units, 351-400= 8 units, 401-450= 10 units, 451-499= 10 units and call MD
Record review of Resident #55's January 2022 MAR revealed, on 01/31/22 the resident had a BG of 233 but she did not receive 2 units of Insulin as ordered.
Record review of Resident #55's February 2022 MAR revealed, on 02/07/22 BG of 204, 02/14/22 BG of 252, 02/21/22 BG of 220, 02/28/22 BG of 249. Resident #55 did not receive any insulin per her sliding scale as ordered by her physician
Record review of Resident #55's March 2022 MAR revealed, on 03/07 BG of 250, 03/14/22 BG of 245. Resident #55 did not receive any insulin per her sliding scale as ordered by her physician.
Resident #59
Record review of Resident #59's face sheet dated 03/16/22 revealed, an [AGE] year-old male who admitted to the facility on [DATE] with diagnoses which included: polyneuropathy, type 2 diabetes with unspecified complications and hyperglycemia.
Record review of Resident #59's Quarterly MDS dated [DATE] revealed, moderately impaired cognition, extensive assistance with most ADLs and frequently incontinent of both bladder and bowel.
Record review of Resident #59's Care Plan started 02/05/20 revealed, area- type 2 diabetes uncontrolled blood sugars, goal- A1c will be below 6% and have no complications through next review. Intervention- Administer oral hypoglycemic agents as ordered. There was no mention of the resident receiving insulin.
Record review of Resident #59's HgbA1c Labs revealed:
07/16/21 was 7.9%,
10/01/21 was 7.9%, and
01/07/22 was 7.9%.
Record review of Resident #59's Physician Order dated 01/21/20 revealed, Type 2 diabetes with unspecified complications, Accucheck BID before meals with Humalog 100 unit/ml vial per s/s with time codes for administration at 6 AM and 4 PM.0-60 0 units 60-200 = 0 units, 201-250= 2 units, 251-300= 4 units, 301-350= 6 units, 351-400= 8 units, 401-450= 10 units, 451-499= 10 units and call MD
Record review of Resident #59's March 2022 MAR revealed,
4 PM 03/01/21 BG-229, 2 units RUARM. 03/06/21 BG-272, 4 units LUARM. 03/08/21 BG-217, 2 units LLQ. 03/14/22 BG-260, 4 units LLQ.
Resident #64
Record review of Resident #64's face sheet dated 03/16/22 revealed, [AGE] year-old-female who admitted to the facility on [DATE] with diagnoses which included type 2 diabetes with other diabetic neurological complications.
Record review of Resident #64's MDS dated [DATE] revealed, moderately impaired cognition as indicated by a BIMS score of 12 out of 15, limited assistance with most ADLs and frequently incontinent of both bladder and bowel.
Record review of Resident #64's Care Plan started 10/12/21 revealed, area- diabetes, goal- A1c will be below 6%, intervention- administer oral hypoglycemic agents as ordered. There was no mention of the resident receiving insulin.
Record review of Resident #64's HgbA1c Labs revealed:
- 04/15/21 was 6.6%,
- 08/02/21 was 10.3%, and
- 02/07/22 was 11%.
Record review of Resident #64's Physician Orders dated 02/06/22 revealed, Novolog 100 units/mL. Give 12 units SQ BID. Hold for BS less than 80 with administration time codes of 6 AM and 6 PM.
Record review of Resident #64's progress notes revealed, the resident had diabetic ulcers on both heels that were acquired in the facility.
Record review of Resident #64's wound assessment report, dated 03/15/2022, stated, made aware of new skin concerns by staff . noted diabetic ulcer to right heel. Blood blistered site measures 2.0 cm by 3.5 cm, skin remains intact at this time . Noted diabetic ulcer to left heel. Area maroon in color. Site measures 3.0 cm by 2.5 cm, skin intact .
Record review of Resident #64's March 2022 MAR revealed, resident received 10 units at 6 AM from 03/01/22 to 03/16/22 and 10 units at 4 PM from 03/01/22 to 03/15/22.
Resident #91
Record review of Resident #91's face sheet dated 03/16/22 revealed, an [AGE] year-old female who admitted to the facility on [DATE] with diagnoses which included: cellulitis of the upper limb, hypertension, progressive neuropathy (damage to one or more nerves that result in numbness, tingling, muscle weakness pain in the affected area) and type 2 diabetes with other circulatory complications.
Record review of Resident #91's MDS dated [DATE] revealed, severely impaired cognition, extensive assistance with most ADLs and always incontinent of both bladder and bowel.
Record review of Resident #91's Care Plan started 05/05/21 revealed, area- diabetes with diabetic polyneuropathy, goal- A1c will be below 6, intervention-administered oral hypoglycemic agents as ordered. There was no mention of the resident receiving insulin.
Record review of Resident #91's HgbA1c labs revealed:
- 04/26/21 was 4.9% and
- 02/08/22 was 7.1%.
Record review of Resident #91's Physician Orders dated 02/04/22 revealed, Type 2 diabetes with diabetic polyneuropathy, Accucheck BID AC with Novolog 100 unit/ml vial per s/s with time codes for administration at 6 AM and 4 PM. 60-200 = 0 units, 201-250= 2 units, 251-300= 4 units, 301-350= 6 units, 351-400= 8 units, 401-450= 10 units, 451-499= 10 units and call MD.
Record review of Resident #91's March 2022 MAR revealed:
6AM 03/01/22 BG-221, 2 units right lower, 03/02/22 BG-266, 4 units LLQ, 03/03/22 BG- 215, 2 units RLQ, 03/04/22 BG-301, 6 units RLQ. 03/05/22 BG-266, 4 units RLQ, 03/06/22 BG-274, 4 units RLQ, 03/07/22 BG-362, 8 units RLQ, 03/08/22 BG-355, 8 units LLQ, 03/09/22 BG-318, 6 units RUARM, 03/10/22 BG- 319, 6 units LLQ, 03/11/22 BG-391, 8 units RLQ, 03/12/22 BG-350, 6 units RLQ. 03/13/22 BG-424, 10 units LUQ,
03/14/22 BG-286, 4 units LUQ. 03/15/22 BG-342- left thigh, 03/16/22 BG, 396 right thigh.
4PM- 03/01/22 BG-250, 2 right upper arm, 03/02/22 BG-203, 2 units LLQ, 03/03/22 BG- 305, 6 units LLQ, 03/04/22 BG-241, 2 units LLQ. 03/05/22 BG-316, 6 units LLQ, 03/06/22 BG-417, 10 units LLQ, 03/07/22 BG-321, 6 units RUARM, 03/08/22 BG-323, 84 units LUARM, 03/09/22 BG-324, 6 units RUARM, 03/10/22 BG- 319, 6 units LLQ, 03/11/22 BG-309, 6 units LLQ, 03/13/22 BG-308, 6 units RLQ,
03/14/22 BG-364, 8 units RUQ.
Resident #345
Record review of Resident #345's face sheet dated 03/16/22 revealed, a [AGE] year-old female who admitted to the facility on [DATE] with diagnoses which included: type 2 diabetes, hypertension and vascular dementia without behavioral disturbance.
Record review of Resident #345's admission MDS dated [DATE] revealed, severely impaired cognition as indicated by a BIMS score of 7 out of 15, limited assistance for all ADLs and always continent of bladder and occasionally incontinent of bowel.
Record review of Resident #345's Care Plan started 03/02/22 revealed, Area- diabetes Mellitus (type 2): uncontrolled blood sugar levels, goal- A1c ( a % that represents a 3 month average of blood sugars) will be below 6%, interventions- administer oral hypoglycemic agents as ordered. There was no mention of the resident receiving insulin.
Record review of Resident #345's HgbA1c Lab revealed:
- 03/16/22 was 8.8%.
Record review of Resident #345's Physicians Orders dated 03/06/22 revealed, Accucheck BID AC with Humalog 100 unit/mL vial per s/s with Time Codes of administration at 6 AM and 4 PM. 0-200 = 0 units, 201-250= 2 units, 251-300= 4 units, 301-350= 6 units, 351-400= 8 units, 401-450= 10 units, 451-499= 10 units and call MD.
Record review of Resident #345's March 2022 MAR revealed:
6AM: 03/12/22 BG-215, 2 units Left thigh, 03/16/22 BG-209 2 units right upper quadrant.
4 PM: 03/07/22 BG-221 2 units, left upper arm. 03/08/22 BG-272, 4 units right lower quadrant. 03/09/22 BG-222, 2 units left upper arm. 03/10/22 BG-382, 8 units right upper quadrant. 03/12/22 BG-249 2 units, left lower quadrant. 03/13/22 BG-259, 4 units left lower quadrant. 03/14/22 288, 4 units left lower quadrant.
An observation at 03/16/22 at 07:25 AM revealed, LVN D shadowing LVN N at the nursing cart. LVN N said that there were no sliding scale insulins to administer that morning because they were already completed by the night shift prior to the beginning of her shift at 6 AM. She said that this was the time morning insulin was always administered.
An observation at 03/16/22 at 08:20 AM revealed, meal tray carts arriving on the 600 hall.
In an interview on 03/16/22 at 07:30 AM, the ADON said that all morning insulin's including sliding scale and pre-prandial insulin were completed by the night shift and that insulin administration was not in relation to meals but was scheduled for 6AM and 4 PM. She said breakfast was normally around 8 am and that residents had snacks available to them between 6 am and 8 am. The ADON said that when administered insulin earlier than meals the expectation was for them to monitor the residents for signs and symptoms of hypoglycemia.
In an interview on 03/16/22 at 07:44 AM, LVN R said that she had no insulin to administer that morning because it was completed by the night shift prior to her arrival at 6 am. She said that this was the time morning insulin were always administered.
In an interview on 03/16/22 at 08:25 AM, LVN D said that sliding scale insulin should be administered when you know the resident's tray is arriving and she would not administer them 2 hours before meals because it could place the resident at risk for hypoglycemia. She said the facility had night shift nurses complete morning insulin administration before the morning shift started at 6 AM.
In an interview on 03/16/22 at 11:22 AM, the Physician said that the facility night shift nurses had been administering pre-prandial insulin because it was easier to get it done. He said while there was a risk of hypoglycemia if pre-prandial insulin was administered without a meal the facility used low sliding scale doses to avoid hypoglycemia, so they have had no problems. The Physician said that pre-prandial insulin should be administered closer to meals and not at 2 hours before a meal but would not give a narrower timeframe. He said for LTC patients his goal was for an A1C <8 % which is an average glucose around 183.
In an interview on 03/16/22 at 02:00 PM, the DON said that pre-prandial insulin (Humalog and Novolog) are dosed per sliding scale in anticipation of increased blood glucose levels when a resident eats and that at most they should be administered close to a meal but no longer than 1 hour before. He said the risk of uncontrolled/ill managed blood sugars was hypoglycemia, impaired wound healing, and any condition which a consequence of uncontrolled blood sugars.
In an interview on 03/18/2022 at 12:50 PM, the DON said Novolog insulin peaks within 1 hour and continues to work within 2-4 hours, and if a resident had not eaten within that first hour, the resident would need to be watched for hypoglycemic effects such as nausea and vomiting and change in mental status. He said there was the need to balance the effect of the insulin with the timing of meals to keep blood glucose levels stable. He said each resident with diabetes is clinically different, some are stable, some are regular, for some insulin would need to be held if not eating, and some need to be monitored for symptoms. The DON said some people can become chronically hyperglycemic with the insulin. He said the goal was to keep resident blood glucose levels as normalized as possible to track trends and know when to adjust their diabetes management regimen and medication. The DON said those with diabetes generally have a risk for wounds and decreased healing abilities.
Record review of the Package Insert for Novolog revealed: Dosage and Administration- Subcutaneous injection: Inject subcutaneously within 5-10 minutes before a meal into the abdominal area, thigh, buttocks or upper arm.
Record review of the Package Insert for Humalog revealed, Dosage and Administration- Subcutaneous injection: Administer HUMALOG U-100 or U-200 by subcutaneous injection into the abdominal wall, upper arm or buttocks within 15 minutes before a meal or immediately after a meal.
Record review of the facility posted Meal Times revealed:
Hall Carts -Breakfast 07:15 AM, Lunch 11:15 AM, Dinner 05:15 PM
Dining Room- Breakfast closed, Lunch 11:30 AM, Dinner 05:30 PM
Not times for snacks were documented on the document.
Record review of the facility policy titled Medications- Administering with no revision date revealed, 3- medications must be administered in accordance with the orders including any required time frame. 4- Medications must be administered within one(1) hour of their prescribed time, unless otherwise specified (for example, before and after meal orders).
Record review of American Diabetes Association Standards of Medical Care in Diabetes-2021 revised 01/2021 revealed:
6- Glycemic Targets. Table 6.1-Estimated average glucose
A1C (%) to mg/dL
5% ~ 97 (76-120)
6% ~ 126 (100-152)
7% ~ 154 (123-185)
8% ~ 183 (147-217)
9% ~ 212 (170-249)
10% ~ 240 (193-282)
11% ~ 269 (217-314)
12% ~ 298 (240-347)
12-Older Adults. Table 12.1
Patient Characteristic- Complex, Reasonable A1C goal <8.0% = Fasting or pre-prandial glucose goal of 90-150 mg/dL, bedtime glucose goal 100-180mg/dL.
CONCERN
(E)
Potential for Harm - no one hurt, but risky conditions existed
Unnecessary Medications
(Tag F0759)
Could have caused harm · This affected multiple residents
**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, interview, and record review, the facility failed to ensure that the medication error rate was not five pe...
Read full inspector narrative →
**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, interview, and record review, the facility failed to ensure that the medication error rate was not five percent (%) or greater. The facility had a medication error rate of 6 %, based on two errors out of 32 opportunities, which involved 2 of 7 residents (Resident #6 and Resident #344); and 3 of 5 staff (RN L, MA C, MA S) reviewed for medication errors.
The facility failed to ensure
- LVN R did not administer medication MiraLAX (PEG-3350), a stool softener, that was labeled for another resident .
- CMA A administered the correct medication to Resident #344 by applying a Lidocaine 5% patch instead of Lidocaine 4% as ordered by the physicians
These failures could place all residents receiving medication at risk of inadequate therapeutic outcomes, increased negative side effects, and a decline in health.
Resident #6
Record review of Resident #6's face sheet dated 03/16/22 revealed, a [AGE] year-old female admitted to the facility on [DATE] with diagnoses which included: muscle weakness, dysphagia, schizophrenia, dementia without behavioral disturbance, anxiety disorder, constipation and type 2 diabetes without complications.
Record review of Resident #6's Quarterly MDS dated [DATE] revealed, severely impaired cognition skills, disorganized thinking, and always incontinent of both bladder and bowel.
Record review of Resident #6's care plan dated 02/15/22 revealed, Area- experiencing constipation, always incontinent of bowel. Goal- will have a bowel movement every 1 to 3 days without complications, no skin breakdown from incontinence. Intervention- assess for constipation/impaction, assess for abdominal distention, administer laxative or stool softener as ordered.
Record review of Resident #6's Physician Orders dated 10/27/21 revealed, MiraLAX 17 gm- 1 capful, mix with 6 OZs of water by mouth twice daily.
An observation on 03/16/22 at 07:44 AM, revealed LVN R preparing MiraLAX and 5 solid form medication, capsules, and tablets for Resident #6. She retrieved a bottle of MiraLAX labeled for another resident, measured 17 grams by pouring the powder into the cap, and emptied the contents of the cap into a cup. LVN R poured 6 ounces of water into the cup containing the powdered MiraLAX, dissolving the medication into the water. She crushed the pills and opened the capsule emptying its contents and mixed the medications in with pudding. LVN R retrieved the medications and began to enter into the resident's room before she was stopped by the surveyor. The surveyor asked LVN R if the bottle of MiraLAX was for Resident #6 and she after inspecting the bottle said no that it belonged to another resident. She said that she thought the bottle she used was a stock bottle and did not belong to another resident. After confirming that the MiraLAX she prepared was from another resident's prescription, LVN R entered into
Resident #6's room and administered the crushed medications as well as the MiraLAX dissolved in water that was made from a prescription bottle that did not belong to Resident #6.
In an interview on 03/16/22 at 07:45 AM, LVN R said that staff should only administer medication from a resident's prescription bottle or a stock bottle and never from another resident's prescription bottle. She said that when she prepared the medication, she was using a facility stock bottle and she should have discarded the medication even though it was the same medication once she was alerted by the surveyor. LVN R said she should have reprepared the MiraLAX from Resident #6's prescription bottle or the facility floor stock bottle if necessary. LVN R said administering medications from the wrong resident's prescription bottle placed residents at risk for medication errors due to administration of the wrong strength or wrong medication .
Resident #344
Record review of Resident #344's face sheet dated 03/16/22 revealed, a [AGE] year-old male admitted to the facility on [DATE] with diagnoses which included: heart failure, hypotension, atrial fibrillation and right-side Lumbago with sciatica (pain felt in the lower portion of the back radiating along the sciatic nerve).
Record review of Resident #344's admission MDS dated [DATE] revealed, severely impaired cognition as indicated by a BIMS score of 7 out of 15, no behavioral symptoms, extensive assistance with most ADLs, always continent of bladder and always incontinent of bowel.
Record review of Resident #344's Care Plan started 03/18/22 revealed, area- requires assistance with ADLs, goal- increased independence, intervention- refer to OT/PT/SF if needed.
Record review of Resident #344's Physician Orders dated 02/28/22 revealed, Lidocaine 4% patch apply one patch to lower back daily: on at 8AM off at 8PM.
An observation on 03/16/22 at 09:50 AM revealed, CMA B preparing medication for administration to Resident #344. She retrieved a Lidocaine 5% patch from a bag labeled with Resident #6's biographical information, she did not check the drug information against the MAR. CMA B entered into Resident #344's room and applied the Lidocaine 5% patch to the residents lower back.
In an interview on 03/16/22 at 12:52 PM, CMA B said prior to medication administration nursing staff should check the name, dosage, and medication against the resident's orders; and if the orders did not match the medication the resident's physician should be contacted to clarify the order. She said did not notice that the patch she applied was Lidocaine 5% and not Lidocaine 4% as ordered by Resident #344's physician. She said that she had non-prescription Lidocaine 4% patches in her cart but the Lidocaine 5% patch she applied was dispensed by the pharmacy specifically for Resident #344 and it must have been a filling error made by the pharmacy. CMA B said by administering the Lidocaine 5% patch instead of the Lidocaine 4% patch the resident was at risk of unwanted therapeutic effect .
In an interview on 03/16/22 at 01:30 PM, the DON said that the nursing staff are expected to verify the resident's Physician Order prior to administration to make sure it is the right medication, right resident, right drug as well as assuring parameters of administration such as vitals are met. He said it is never appropriate to dispense medications labeled for one resident to another even if the medication is the same. The DON said administering residents the wrong strength of medication and medication from another resident's container are medication errors that can place residents at risk for cross contamination and adverse effects.
Record review of the facility policy titled Medications- Administering with no revision date revealed, 3- Medications must be administered in accordance with the orders, including any required time frame.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. 19- Medications ordered for a particular resident may not be administered to another resident, unless permitted by state law and facility policy, and approved by the Director of Nursing Services.
CONCERN
(E)
Potential for Harm - no one hurt, but risky conditions existed
Deficiency F0761
(Tag F0761)
Could have caused harm · This affected multiple residents
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, ...
Read full inspector narrative →
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, included the appropriate accessory and cautionary instructions, the expiration date when applicable and stored all drugs and biologicals in locked compartments and under proper temperature controls, and permitted only authorized personnel to have access to the keys for 3 out of 3 medication carts ( Station 1 Nursing Cart, Station 1 Medication Aide Cart and Station 2 Medication Aide Cart) reviewed for medication storage.
- The facility failed to ensure that the Station 1 Nursing Cart did not contain expired medication, and proteins supplements outside of the manufacturer's specified beyond use date.
- The facility failed to ensure that the Station 1 Medication Aide Cart did not contain medication stored outside of manufacturers specified temperature ranges, medication with no visible expiration dates and expired protein supplements
- The facility failed to ensure that the Station 2 Medication Aide Cart did not contain medications stored outside.
These failures could place residents receiving medications at risk of adverse medication reactions.
Findings include:
Station 1 Nursing Cart
In an observation and Interview on 03/16/22 at 12:30 PM, inventory of the Station 1 Nursing cart with LVN B revealed:
- An open bottle of Liquid Protein with an open date of 10/10/21 with manufacturer instructions of 3-month shelf life from date opened (01/10/22).
- An open and expired container of Benecalorie, a supplement used to increase the calorie and protein contents in most foods, with a manufacturer's expiration date of 02/01/22.
LVN B said staff should check their carts daily for expired supplements and when supplements are expired they lose their efficacy so they should not be administered. She said all expired medications should be discarded in the drug disposal bin located in the medication storage room since the use of expired medications place resident's at risk for insufficient therapeutics.
Station 1 Medication Aide Cart
In an observation and Interview on 03/16/22 at 12:39 PM, inventory of the Station 1 Medication Aide Cart with CNA B revealed:
- An open bottle of Acidophilus, a probiotic, at room temperature in the drawer with manufacturer instructions of Refrigerate After Opening.
- An open bottle of Acetaminophen 500mg with no visible expiration date.
- An open bottle of Aspirin 81mg with no visible expiration date.
- An open bottle of Liquid Protein with an open date of 12/07/22 with manufacturer instructions of 3-month shelf life from date opened (03/07/22).
CNA B said she did not know the bottle of Acidophilus had to be refrigerated and since it wasn't it could no longer be used. She said when refrigerated medication was left at room temperature it deteriorates and the bottles Acetaminophen and Aspirin did not have a visible expiration date she could not determine if they were expired so they could not be used. She said that all expired medications or medications without expiration medications should be discarded in the drug disposal bin located in the medication room since use of such medication places residents at risk of insufficient therapeutic effects.
Station 2 Medication Aide Cart
In an observation and interview on 03/16/22 at 12:47 PM, inventory of the Station 2 Medication Aide Cart with LVN N revealed:
- An open bottle of Acidophilus, a probiotic, at room temperature in the drawer with manufacturer instructions of Refrigerate After Opening.
LVN N said that nursing staff are expected to check their carts monthly for expired medications and medications stored outside of manufacturer specified temperature monthly. She said she did not know that the bottle of acidophilus had to be refrigerated and when refrigerated medication is stored at room temperature it can deteriorate so it could not be used. LVN N said that the bottle of acidophilus had to be discarded in the drug disposal bin located in medication room.
In an Interview on 03/16/22 at 01:30 PM, the DON said that nursing staff are expected to check their carts on their shifts daily for loose pills, expired medications, inappropriately labeled medications and medications stored out of specified manufacturer temperature ranges. He said that all refrigerated medications should be stored as specified by the manufacture and that storage outside of the refrigerator could deteriorate. The DON said if a medication does not have a visible expiration date the assumption is that it is expired and all inappropriately labeled, expired or inappropriately stored medications should be immediately taken out of circulation and discarded in the drug disposal bin located in the Medication Storage room. He said when a medication expires or are stored at the wrong temperature they can deteriorate/experience a change in concentration and use places residents at risk for insufficient therapy.
Record review of the facility policy titled Medications- Storage with no revision date revealed, 3- Drug containers that have missing, incomplete, improper, or incorrect labels shall be returned to the pharmacy for proper labeling before storing. 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 nurse's station or other secured location .
CONCERN
(E)
Potential for Harm - no one hurt, but risky conditions existed
Infection Control
(Tag F0880)
Could have caused harm · This affected multiple residents
**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, interview, and record review, the facility failed to establish and maintain an infection prevention and co...
Read full inspector narrative →
**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** 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 5 of 5 staff and 1 of 1 laundry rooms.
The facility failed to ensure:
- CNA AG, [NAME] C and Dietary Manager wore their face mask according to policy.
- [NAME] C did not wear a hairnet or beard restraint according to policy.
-- CNA AG followed proper hand hygiene and infection control precautions while she filled residents' water cups.
- LVN R followed proper hand hygiene and infection control precautions while providing foley catheter flush and insertion for Resident #22.
- Laundry Aide B demonstrated proper hand hygiene after loading dirty linen in the laundry.
- Laundry Aide B did not place basket of dirty linen in the clean side of the laundry room.
- staff did not place their personal items on the clean linen folding table.
These failures could place residents at risk of cross contamination and infection.
The finding included:
Observation on 3/15/2022 at 9:00 a.m., [NAME] C did not have on a hair net or beard restraint. [NAME] C's mask was below his chin not covering his nose and mouth.
Interview on 3/15/2021 at 9:10 a.m., [NAME] C said the hair net would prevent cross-contamination and he forgot to put it on. [NAME] C said he had his mask down below his chin because it was hot in the kitchen. [NAME] C said he had to wear the mask because of COVID-19 and the mask stopped the spread. He said he had never worn a beard restraint
Observation on 3/15/2022 at 9:37 a.m., CNA AG wheeled a resident to a common area with her mask below her chin.
Observation of 3/15/2022 at 9:39 a.m., CNA AG went into 3 different rooms (4 different cups) and filled the resident water cups. CNA AG did not wash her hands or sanitize her hands after touching multiple resident cups or as she went in and out of the ice chest to refill the cups.
Interview on 3/15/2022 at 9:41 a.m., CNA AG said she was supposed to sanitize or wash her hands in between filling water cups or going in the ice chest. CNA AG said not sanitizing hands will lead to cross contamination. She said she had been trained on proper hand hygiene but forgot.
Interview on 3/15/2022 at 11:37 a.m., the Dietary Manager said all dietary staff should wear a hair net if they have hair because it is the rule and prevents cross-contamination. The Dietary Manger said he and the other dietary staff had not worn beard restraints because they did not have any to use. He said he and the staff never used them. The Dietary Manager said all dietary staff have been trained to wear their mask to cover their mouth and nose. The Dietary Manager said a mask should be worn to prevent the spread of COVID-19.
Interview on 3/17/2022 at 2:52 p.m., the Administrator said, she expected dietary staff to wear hair nets and beard restraints. She said beard restraints and hair nets are used to prevent cross-contamination. The Administrator said all staff have to wear a mask when they are in the building. She said all staff wear mask to prevent the spread of COVID-19. The Administrator said all staff are expected to perform hand hygiene when they have touched resident items. The Administrator said the staff should wash or sanitize their hands to prevent cross-contamination.
Resident #22
Record review of Resident # 22's Face sheet revealed a [AGE] year-old male was admitted to the facility on [DATE]. His diagnoses include benign prostatic hyperplasia (overgrowth of prostate tissue) with lower urinary tract, hypertensive heart disease (heart problem because of high blood pressure for a long time), dementia (loss of thinking, remembering, and reasoning), and hypertension (high blood pressure in the vessels).
Record review of Resident #22's quarterly MDS dated [DATE] revealed a 99 (resident was unable to complete interview for mental status), and the resident required limited assist with one staff assistance. It also revealed the resident has indwelling foley catheter.
Record review of Resident #22's care plan dated 10/23/20 revealed the resident had urinary indwelling catheter related to neurogenic bladder (urinary bladder problems due to disease or injury of the central nervous system ), and BPH (benign prostatic hyperplasia). Interventions: assess color, clarity, character of urine and catheter care every shift.
Record review of Resident #22's March 2022 physician's orders read Foley catheter(16 FR/10ML) related to diagnosis: neuromuscular dysfunction of bladder, change every month on the 14th and PRN(As needed) for leakage, occlusion, and dislodgement.
Observation and interview on 03/15/21 at 1:40 p.m., LVN R was walking towards Resident #22 room she had a bottle of NS and 60 ML syringe in her hand. She then placed it in her uniform pocket.
Observation and interview on 03/15/2 2 at 1:45 p.m., Resident #22's Foley flush provided by LVN R, she walked into the resident's room, took the NS and syringe from her uniform pocket, and placed it on the resident bedside table. She went into the resident restroom, took some gloves from the packet, and put it in her uniform pocket; on getting to the resident bed, she took a pair of gloves from her pocket and donned the gloves, and she did not wash her hands or sanitize her hand, she opened the syringe and NS, drew up 30 Milliliters.
Observation on 03/15/22 at 2:05 p.m., LVN R carried the supplies in her two arms against her breast into the Resident #22's room.
Observation and interview on 03/15/22 at 2:08 p.m., Resident #22 Foley catheter change provided by LVN R. she placed the supplies on the resident table without disinfecting the bedside table. Some part of the table was wet. She went to the resident restroom, took more gloves, and put them in her uniform pocket. She deflated the catheter in the resident, and she pulled it out, a long string of blood clots came out with the catheter, and she left it on the resident bed linen for 5 minutes before she placed it in the red bag. LVN R did not take off the gloves; she removed the catheter and put it in the trash bag before opening the new 16 French catheter. She left the room and came back to the room. She did not wash or sanitize her hands none of the four times she left and came back to the room. She donned the sterile gloves without washing her hands. While donning the gloves, she touched the outside of the sterile gloves instead of the inside. She took off her gloves after the procedure, washed her hands, and turned off the water faucet with her wet hands, she did not disinfect the resident table after use.
Interview on 03/15/22 at 2:50 p.m., LVN R said she did not wash her hands when she went into the resident room and when she left Resident #22's room several times. LVN R said staff is supposed to wash or sanitize their hands upon entering and leaving the resident's room. She said she should have washed her hand when she donned the sterile gloves because the Foley insertion was an aseptic procedure, and the catheter was not supposed to touch the resident table because that part goes into the resident. She said she also did not disinfect the resident bedside table before and after use, and she did not place a barrier on the table before setting up her supplies. LVN R said she forgot to turn off the water tap with a dry paper towel instead of her wet hands. LVN R stated supplies for resident care are not carried on staff body or in staff uniform pocket, but in a clean trash bag. She also said gloves are not placed in a staff pocket or used during care, and all these mistakes were infection control issues because she could have transferred germ from her to the resident, and it could cause harm to the resident, such as UTI.
Interview on 03/16/22 at 2:08 p.m., ADON (RN) said LVN R should not have carried the supplies for a procedure in the staff uniform pocket or on her body. She said she should have washed her hands, introduced herself, and told the resident about the procedure. She should have disinfected the bedside table and placed a barrier on the table. LVN R should have taken off her gloves and washed her hands as many times as she left the room and came back. The ADON said LVN R should have washed her hand before she donned the sterile gloves because it was an aseptic procedure to prevent microorganism transmission to the resident bladder, which could cause UTI and pain. She said when she washed her hands, she should have dried her hand and turned off the tap with a dry paper towel to prevent reinfection (cross-contamination) of her hand. She was supposed to wipe the resident's table and put it back where she found it.
Interview on 03/17/22 at 8:50 a.m., the DON said LVN R should have washed her hands before trying to don the sterile gloves because it is a sterile technique, and she should have washed her hands when she entered the resident's room and when she left the room. He said nurses are not supposed to carry gloves in their uniform pockets or use them to provide care for residents. Also, water faucets are turned off after handwashing with a paper towel, not with a wet, washed hand. All these are done to prevent cross-contamination or transfer germs to the resident that may cause harm to the resident.
Interview on 03/17/22 at 8:59 a.m., the corporate nurse said the nurse should wash her hands with soap and water or sanitize them before donning the sterile gloves to prevent contamination because it is a sterile procedure. By not washing her hands, she contaminated the aseptic procedure, which could transfer germs to the resident and lead to a UTI.
Observation on 03/16/21 at 1:30 p.m., Laundry Aide B demonstrated how to wash her hand after sorting and loading the washer with dirty linen in the dirty side of the laundry room. She washed her hand and turned off the water faucet with her wet hands, then dried her hand with a paper towel.
Interview on 03/16/21 at 12:38 p.m., Laundry Aide B said she turned off the faucet with her wet hands. Laundry Aide B stated she should have turned it off with a dry paper towel because the tap was dirty, and she contaminated her hands when she turned the tap with her wet hand, which is an infection control issue.
Observation on 03/16/222 at 12:43 p.m., revealed a cart with four trash bags filled with dirty linen in the clean section of the laundry room. Laundry Aide B pushed it over from the clean to the dirty and moved the dirty linen into another cart. Laundry Aide B washed her hand again and turned off the water faucet with her wet hands.
Observation on 03/16/22 at 1:44 p.m., revealed the clean folding table had personal staff items, a box of cornflake cereal, four plates, a Ziploc bag of sugar, and bread wrapped in a foil, snuggle bottle, and they were touching a stack of face towels, (about 20).
Interview on 03/16/22 at 12:45 a.m., Laundry Aide B said she was not supposed to put the dirty laundry in the clean section of the laundry room because of cross-contamination. She said she used the same basket for clean and dirty laundry and only sprayed it down after using it for dirty laundry. She stated the items on the table did not belong to her, and she did not know the staff was not supposed to put their things on the clean table used to fold clean clothes. Laundry Aide A said all those items were on the table when she folded the clean linen she delivered to the halls, and she was not sure how much of the clean linen touched the personal items.
Interview on 01/16/22 at 12:51 p.m., the Housekeeping Supervisor stated Laundry Aide B should not have turned off the water faucet with her wet hands and should have dried her hands first and then used a dry towel to turn off the tap to prevent cross-contamination. She also stated that dirty laundry bags are never placed in the clean side of the laundry room because of cross-contamination. She said if the laundry aide uses the same cart for dirt and clean linen, the carts must be sanitized (Sprayed with approved chemical, left to sit for the approved contact time, 5 minutes, sprayed again, and wiped before it is used for clean laundry). She said the folding table in the clean area is only used for clean linens, and personal staff items should not be on the table because it can contaminate the clean linens, which may transfer germs to residents and become sick.
Interview on 03/16/22 at 1:40 p.m., the Regional Administrator and Administrator said Laundry Aide B should use a paper towel to turn off the tap to prevent contamination of her hands. She said dirty laundry should not be on the clean side of the laundry to avoid cross-contamination. The Administrator stated personal staff items should not be on the clean linen table to prevent contaminating the clean linen, which may transfer germs to residents and cause the residents to be sick. The Regional Administrator said he agreed with the response given by the Administrator.
Record review of the facility Hand Hygiene policy updated [DATE] read . staff involved in direct resident contact will perform proper hand hygiene procedures to prevent the spread of infection to other personnel, resident . Hand Hygiene Table: . before performing resident care procedures . after handing contaminated objects . before and after handling clean or soiled linen .
Record review of the facility Laundry policy updated [DATE] read . it is the policy of this facility to follow infection control methods related to washing clothes . policy expectation and compliance guidelines: . # 3 . soiled laundry shall be handled as little as possible, with minimum agitation to avoid contamination of air, surfaces, and persons . #10 Linens: a. laundry and direct care staff shall handle, store, process and transport lines so as to prevent spread of infection .
Record review of facility in-service dated 2/15/2022 revealed the following in part:
All staff wearing surgical mask at all time while in facility .
Record review of TFER (Texas Food Establishment Rules) dated 10/2015 revealed the following in part:
§228.43. Hair Restraints . food employees shall wear hair restraints such as hats, hair coverings or nets, beard restraints, and clothing that covers body hair, that are designed and worn to effectively keep their hair from contacting exposed food; clean equipment, utensils, and linens; and unwrapped single-service and single-use articles.
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, record review, and interview the facility failed to store, prepare, distribute, and serve food in accordance with professional standards for food service safety for one of one ki...
Read full inspector narrative →
Based on observation, record review, and interview the facility failed to store, prepare, distribute, and serve food in accordance with professional standards for food service safety for one of one kitchen, one standalone refrigerator, one walk in refrigerator, for reviewed for kitchen sanitation and storage.
-The facility failed to ensure that open food and leftovers in the stand-alone refrigerator and walk in refrigerator were labeled, dated, and sealed.
- Boxes of food items were observed on the floor outside of the freezer and in dry goods storage.
- Boxes in walk-in freezer were crowded with no space for air circulation.
- Food was not dated with an open date.
- Two male staff did not wear beard and hair restraint.
- Two staff did not wear PPE (mask) appropriately.
-Two trash cans did not have lids.
These deficient practices could place the residents who received meals from the kitchen at risk of a food-borne illness.
Finding included:
Observation on 3/15/2022 at 9:00 a.m. in the kitchen revealed the following:
-
Walk-in Freezer - 7 boxes of food were on the floor and stacked approximately 6 ft. high.
-
Kitchen hallway - food not refrigerated - 12 boxes of food with labels of Keep Frozen printed on them.
-
Dry pantry - 3 boxes of food on the floor.
-
Walk-in Refrigerator - wilted heads of romaine lettuce in cardboard box - not dated or sealed
-
Standalone Refrigerator - 2 salad dressing did not have open dates
-
1 male cook staff did not have on a hair net, beard restraint and mask was not covering his nose and mouth.
Interview on 3/15/2022 at 9:10 a.m. with [NAME] C said the facility had a food delivery at 5 a.m. [NAME] C said he and the two other staff had been too busy to put the food in its' appropriate place and not on the floor. [NAME] C said he did not wear a beard restraint because he forgot. He said he forgot his hair net too. [NAME] C said the food that was supposed to be frozen or refrigerated should not have been sitting in the hallway. [NAME] C said the food could spoil and be a danger to the residents. He said he had never worn a beard restraint. [NAME] C said the hair net would prevent cross-contamination. [NAME] C said he had his mask down below his chin because it was hot in the kitchen. [NAME] C said he had to wear the mask because of COVID-19 and the mask stopped spread.
Observation on 3/15/2022 at 11:36 a.m. in the kitchen revealed the Dietary Manager and [NAME] C did not have a beard restraint on. The trash can in the kitchen near the door to exit into the dining room and the trash can next to the 3-compartment sink did not have a lid to cover the trash.
Interview on 3/15/2022 at 11:37 a.m. with the Dietary Manager said all dietary staff should wear a hair nets if they have hair because it is the rule and prevents cross-contamination. The Dietary Manger said he and the other dietary staff had not worn beard restraints because they did not have any to use. He said he and the staff never used them. The Dietary Manager said [NAME] C had been trained to receive the food deliveries and the food should not have been stored on the kitchen floor. He said the food should be put in the freezer if it was to be kept frozen to prevent the food from spoiling and prevent cross contamination. He said the freezer should not be crowded and he had not had time to unpack the boxes. He said the overcrowding may not allow air to properly keep the freezer temperature. The Dietary Manager said all food should have an open date, label and sealed so that it can be discarded timely and prevent foodborne illnesses that could possibly harm residents. The Dietary Manager said all dietary staff have been trained to wear their mask to cover their mouth and nose. The Dietary Manager said a mask should be worn to prevent the spread of COVID-19. He said the trash can lids should be on to prevent pest and cross-contamination.
Interview on 3/17/2022 at 11:35 a.m. with the DON said the kitchen staff should wear mask to prevent COVID-19. The DON said food should not be stored directly on the kitchen floor because it could cause cross-contamination. He said deliveries should be refrigerated as soon as possible.
Interview on 3/17/2022 at 2:52 p.m. the Administrator said, she expected dietary staff to wear hair nets and beard restraints. She said beard restraints and hair nets are used to prevent cross-contamination. The Administrator said all staff have to wear mask when they are in the building. She said all staff wear mask to prevent the spread of COVID-19. The Administrator said the dietary staff should follow the rules of TFER related to food storage, trash containers and how to label/date/and seal food to prevent spoilage. She said food deliveries should be refrigerated soon after delivery to prevent bacteria or food spoilage. The Admistrator said these protocols prevent cross-contamination.
Record review of TFER (Texas Food Establishment Rules) dated 10/2015 revealed the following in part:
.§228.69§228.69 (c)§228.69.
Preventing Contamination From the Premises.
(a) Food storage. (1) Except as specified in paragraphs (2) and (3) of this subsection, food shall be protected from contamination by storing the food:
(A) in a clean, dry location;
(B) where it is not exposed to splash, dust, or other contamination; and
(C) at least 15 cm (6 inches) above the floor.
(n) Covering receptacles. Receptacles and waste handling units for refuse, recyclables, and returnables shall be kept covered: (1) inside the food establishment if the receptacles and units: (A) contain food residue and are not in continuous use; . with tight-fitting lids or doors if kept outside the food establishment.
§228.43. Hair Restraints . food employees shall wear hair restraints such as hats, hair coverings or nets, beard restraints, and clothing that covers body hair, that are designed and worn to effectively keep their hair from contacting exposed food; clean equipment, utensils, and linens; and unwrapped single-service and single-use articles.
(g) Ready-to-eat, time/temperature controlled for safety food, date marking . (A) the day the original container is opened in the food establishment shall be counted as Day 1; and (B) the day or date marked
by the food establishment may not exceed a manufacturer's use-by date if the manufacturer determined the use-by date based on food safety.
(6) employees are verifying that foods delivered to the food establishment during non-operating hours are from approved sources and are placed into appropriate storage locations such that they are maintained at the required temperatures, protected from contamination, unadulterated and accurately presented;
Record review of facility policy Storage Dry Food undated revealed the following in part:
.1.
Store dry foods . 6 off the floor .
Record review of facility policy Storage: Freezer undated revealed the following in part:
1.
Keep frozen foods at 1- to 0 degrees F.
Record review of facility policy Storage: Refrigerator undated revealed the following in part:
1.
Keep all perishable foods below 41 degrees F (7 degrees C).
2.
Do not overcrowd refrigerator. Leave space between items so that cold air can circulate.
7. Keep refrigerated foods wrapped or covered and in sanitary containers.
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), 1 harm violation(s). Review inspection reports carefully.
- • 17 deficiencies on record, including 1 critical (life-threatening) violation. These warrant careful review before choosing this facility.
- • $14,901 in fines. Above average for Texas. Some compliance problems on record.
- • Grade C (56/100). Below average facility with significant concerns.
Bottom line: Mixed indicators with Trust Score of 56/100. Visit in person and ask pointed questions.
✓ Report will be sent to your email
About This Facility
What is St James House Of Baytown's CMS Rating?
CMS assigns ST JAMES HOUSE OF BAYTOWN an overall rating of 4 out of 5 stars, which is considered above average nationally. Within Texas, this rating places the facility higher than 99% of the state's 100 nursing homes. This rating reflects solid performance across the metrics CMS uses to evaluate nursing home quality.
How is St James House Of Baytown Staffed?
CMS rates ST JAMES HOUSE OF BAYTOWN's staffing level at 3 out of 5 stars, which is average compared to other nursing homes. Staff turnover is 47%, compared to the Texas average of 46%.
What Have Inspectors Found at St James House Of Baytown?
State health inspectors documented 17 deficiencies at ST JAMES HOUSE OF BAYTOWN during 2022 to 2025. These included: 1 Immediate Jeopardy (the most serious level, indicating potential for serious harm or death), 1 that caused actual resident harm, 14 with potential for harm, and 1 minor or isolated issues. Immediate Jeopardy findings are rare and represent the most serious regulatory concerns. They require immediate corrective action.
Who Owns and Operates St James House Of Baytown?
ST JAMES HOUSE OF BAYTOWN 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 105 certified beds and approximately 88 residents (about 84% occupancy), it is a mid-sized facility located in BAYTOWN, Texas.
How Does St James House Of Baytown Compare to Other Texas Nursing Homes?
Compared to the 100 nursing homes in Texas, ST JAMES HOUSE OF BAYTOWN's overall rating (4 stars) is above the state average of 2.8, staff turnover (47%) is near the state average of 46%, and health inspection rating (4 stars) is above the national benchmark.
What Should Families Ask When Visiting St James House Of Baytown?
Based on this facility's data, families visiting should ask: "What changes have been made since the serious inspection findings, and how are you preventing similar issues?" "Can I visit during a mealtime to observe dining assistance and food quality?" "How do you handle medical emergencies, and what is your hospital transfer rate?" "Can I speak with family members of current residents about their experience?" These questions are particularly relevant given the facility's Immediate Jeopardy citations.
Is St James House Of Baytown Safe?
Based on CMS inspection data, ST JAMES HOUSE OF BAYTOWN 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 4-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 St James House Of Baytown Stick Around?
ST JAMES HOUSE OF BAYTOWN has a staff turnover rate of 47%, which is about average for Texas nursing homes (state average: 46%). Moderate turnover is common in nursing homes, but families should still ask about staff tenure and how the facility maintains care continuity when employees leave.
Was St James House Of Baytown Ever Fined?
ST JAMES HOUSE OF BAYTOWN has been fined $14,901 across 1 penalty action. This is below the Texas average of $33,228. 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 St James House Of Baytown on Any Federal Watch List?
ST JAMES HOUSE OF BAYTOWN 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.