BEAUMONT NURSING AND REHABILITATION
For profit - Corporation
120 Beds
CREATIVE SOLUTIONS IN HEALTHCARE
Data: November 2025
2 Immediate Jeopardy citations
Trust Grade
16/100
#415 of 1168 in TX
Photo by Beaumont Nursing and Rehabilitation
Photo by Beaumont Nursing and Rehabilitation
Photo by Beaumont Nursing and Rehabilitation
1 / 5 photos
Last Inspection: June 2025
Inspected within the last 6 months. Data reflects current conditions.
Overview
Beaumont Nursing and Rehabilitation has a Trust Grade of F, indicating significant concerns about the quality of care provided. Ranking #415 out of 1168 facilities in Texas places them in the top half, but their county rank of #5 out of 14 shows that only four local facilities are better. Unfortunately, the trend is worsening, with issues increasing from 6 in 2024 to 11 in 2025, and the facility has accumulated $275,992 in fines, which is concerning and higher than 95% of Texas facilities. Staffing is a weakness, with a rating of 2 out of 5 stars and a turnover rate of 61%, which is above the state average. Specific incidents include a failure to properly supervise a resident at high risk for elopement, allowing them to leave the facility unsupervised, and inadequate training for staff preparing pureed food, which could pose a choking risk for residents. While the facility has some strengths, such as a quality measures rating of 5 out of 5, the negative aspects raise serious concerns for families considering this nursing home.
- Trust Score
- F
- In Texas
- #415/1168
- Safety Record
- High Risk
- Inspections
- Getting Worse
- Staff Stability ⚠ Watch
- 61% turnover. Above average. Higher turnover means staff may not know residents' routines.
- Penalties ✓ Good
- $275,992 in fines. Lower than most Texas facilities. Relatively clean record.
- Skilled Nurses ⚠ Watch
- Each resident gets only 18 minutes of Registered Nurse (RN) attention daily — below average for Texas. Fewer RN minutes means fewer trained eyes watching for problems.
- Violations ⚠ Watch
- 22 deficiencies on record. Higher than average. Multiple issues found across inspections.
16/100
Top 35%
Review needed
6 → 11 violations
★★★☆☆
3.0
Overall Rating
★★☆☆☆
2.0
Staff Levels
★★★★★
5.0
Care Quality
★★☆☆☆
2.0
Inspection Score
↔
Stable
2024: 6 issues
2025: 11 issues
The Good
-
5-Star Quality Measures · Strong clinical quality outcomes
-
Full Sprinkler Coverage · Fire safety systems throughout facility
-
No fines on record
Facility shows strength in quality measures, fire safety.
The Bad
3-Star Overall Rating
Near Texas average (2.8)
Meets federal standards, typical of most facilities
Staff Turnover: 61%
15pts above Texas avg (46%)
Frequent staff changes - ask about care continuity
Federal Fines: $275,992
Well above median ($33,413)
Significant penalties indicating serious issues
Chain: CREATIVE SOLUTIONS IN HEALTHCARE
Part of a multi-facility chain
Ask about local staffing decisions and management
Staff turnover is elevated (61%)
13 points above Texas average of 48%
The Ugly 22 deficiencies on record
2 life-threatening
Jun 2025
7 deficiencies
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
PASARR Coordination
(Tag F0644)
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 refer all residents with newly evident or possible serious mental di...
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**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on interview and record review the facility failed to refer all residents with newly evident or possible serious mental disorder, intellectual disability, or a related condition for level II resident review upon a significant change in status assessment for 1 (Resident #31) of 16 residents reviewed for PASRR .
The facility failed to refer Resident #31 for PASRR level II assessment, to the state-designated authority, upon receipt of a major depressive disorder recurrent severe diagnosis.
These failures could place residents at risk of not receiving necessary care and/or services.
Findings Included:
Record review of Resident #31's admission record dated 08/24/23 revealed an [AGE] year-old male admitted to the facility on [DATE] with diagnoses that included, but were not limited to, Huntington's Disease (a progressive neurodegenerative disorder that affects movement, thinking, and emotional abilities), Depressive Episodes (a period of time characterized by persistent sadness, loss of interest, and other related symptoms that significantly impact daily life), Anxiety Disorder (a group of mental health conditions characterized by excessive fear or worry that significantly interferes with daily life), and Major Depressive Disorder (a mental disorder characterized by persistent low mood, loss of interest or pleasure in activities, and other symptoms affecting sleep, appetite, energy, concentration, and self-worth). The diagnosis of major depressive disorder recurrent severe had an onset date of 08/24/23.
Record review of Resident #31's quarterly MDS completed on 04/18/25 revealed the following: Section C Cognitive Patterns revealed Resident #31 had a BIMS score of 11 which indicated moderate impaired cognition. Section I Active Diagnoses revealed Resident #31 had diagnoses of depression.
Record review of Resident #31's care plan revealed a problem initiated on 1/22/24, The resident is taking an anticonvulsant medication for diagnosis of other specified depressive episodes. The resident will have improved mood state happier,
calmer appearance, no sign or symptoms of depression, anxiety, or sadness through the review date.
Record review of Resident #31's most recent PASRR Level 1 Screening revealed an assessment date of 08/21/23. The PASRR was negative for mental illness.
During an interview on 6/11/25 at 9:37 a.m., the MDS Nurse said that Major Depressive Disorder qualifies for mental illness on a PASRR level one screening. She said that she would need to complete a 1017 form for a new diagnosis that a resident received after their admission and after their PASRR level one screening. She said that since Resident #31 needed to be re-assessed when a qualifying diagnosis was received. She said Resident #31 was placed at risk of not receiving the services he may have been eligible for.
During an interview on 6/11/2025 at 11:22 a.m., the Assistant Director of Nurses said that PASRR evaluations are the responsibility of the MDS nurse. She said that residents who are not evaluated properly are at risk of not receiving the services they may qualify for.
During an interview on 6/11/25 at 11:34 a.m., the Director of Nurses said that the MDS nurse is responsible for PASRR services. She said that residents may not get a proper evaluation and receive services they could qualify for if the PASRR evaluation was not completed properly.
During an interview on 6/11/25 at 11:44 a.m., the Administrator said that Major Depressive Disorder does trigger for a PASRR level two evaluation. She said that the evaluation should have been completed for Resident #31. She said that the MDS Nurse is responsible for completing PASRR. She said that residents were placed at risk of not receiving the services they could be eligible for.
Record review of facility policy titled PASRR Level 1 Screen Policy and Procedure and dated 3-6-2019 indicated, The Facility will review the PL1 Screening Form for completion and correctness prior to admission and submit the PL1 form per regulation.
CONCERN
(D)
Potential for Harm - no one hurt, but risky conditions existed
Deficiency F0645
(Tag F0645)
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 ensure the Pre-admission Screening and Resident Review (PASRR) Leve...
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**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on interview and record review, the facility failed to ensure the Pre-admission Screening and Resident Review (PASRR) Level I assessment accurately reflected the resident's status for 2 of 8 residents (Resident #4 and Resident #13) reviewed for PASRR Level I screenings.
1. The facility failed to ensure the accuracy of the PASRR Level 1 screening for Resident #4. The PASRR Level 1 screening did not indicate a diagnosis of mental illness, although the diagnosis (Disorganized Schizophrenia) was present upon Resident #4's admission date on 01/15/21.
2. The facility failed to ensure the accuracy of the PASRR Level 1 screening for Resident #13. The PASRR Level 1 screening did not indicate a diagnosis of mental illness, although the diagnosis (Schizophrenia) was present upon Resident #13's admission date on 02/02/24.
This failure could place residents who had a mental illness at risk of not receiving a needed assessment (PASRR Evaluation), individualized care, or specialized services to meet their needs.
Findings included:
1. Record review of Resident #4's face sheet, dated 06/09/25, indicated she was an [AGE] year-old female, admitted to the facility on [DATE]. Her diagnoses included disorganized schizophrenia (a chronic brain disorder characterized by symptoms like hallucinations, delusions, and disorganized thinking). The onset date for this diagnosis was 01/08/2005.
Record review of Resident #4's quarterly MDS assessment, dated 03/21/25, indicated she had a BIMS score of 03, which indicated severe cognitive impairment. She was sometimes able to make herself understood and she was sometimes able to understand others. She received an antipsychotic and an antianxiety medication routinely.
Record review of Resident #4's PASRR Level 1 Screening, dated 01/15/21, indicated that in Section C, Mental Illness was marked as no, which indicated Resident #4 did not have a mental illness.
2. Record review of Resident #13's face sheet, dated 06/09/25, indicated he was a [AGE] year-old male, admitted to the facility on [DATE]. His diagnoses included schizophrenia (a chronic brain disorder characterized by symptoms like hallucinations, delusions, and disorganized thinking). The onset date for this diagnosis was 02/18/14.
Record review of Resident #13's quarterly MDS assessment, dated 02/22/25, indicated he had a BIMS score of 15, which indicated intact cognition. He was able to make himself understood and he was able to understand others. He received an antipsychotic routinely.
Record review of Resident #13's PASRR Level 1 Screening, dated 06/03/22, indicated that in Section C, Mental Illness was marked as no, which indicated Resident #4 did not have a mental illness.
During an interview on 06/11/25 at 09:32 AM, the MDS Coordinator said she had worked at the facility about 7 years. She said both Resident #4 and Resident #13 should have been marked yes for mental illness on the PASRR Level 1. She said it was possible for these two residents to have received services since their admission if they had been marked positive for MI on admit. She said she was going to submit a 1017 form to notify the local health authority about their diagnoses.
During an interview on 06/11/25 at 11:21 AM, the ADON said she does not deal with PASRR. She said it
was mostly the MDS Coordinator that deals with that.
During an interview on 06/11/25 at 11:34 AM, the DON said she does not deal with PASRR.
During an interview on 06/11/25 at 11:44 AM, the Administrator said she expected the PASRR Level 1 form to have the mental illness section marked yes for both Resident #4 and Resident #13. She said that she expected the person that did the admission for these residents to have ensured the PASRR Level 1 was completed accurately. She said the risk was that the resident could have had PASRR services since they were admitted with this diagnosis.
Record review of the Facility's policy, PASRR Level 1 Screen Policy and Procedure, last revised 03/06/19, stated:
.The Facility will review the PL1 Screening Form for completion and correctness prior to admission and submit the PL1 form per regulations. The Type of admission is reviewed for correctness. Ensure the Name, SS number, Medicare/Medicaid numbers and DOB is correct. The Date of the PL1 is correct (i.e. correct day, month and year) and review each item on the PL1 to ensure accuracy and prevent a regulatory problem
CONCERN
(D)
Potential for Harm - no one hurt, but risky conditions existed
Infection Control
(Tag F0880)
Could have caused harm · This affected 1 resident
**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observations, interviews, and record review the facility failed to establish and maintain an infection prevention and c...
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**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observations, interviews, and record review the facility failed to establish and maintain an infection prevention and control program designed to provide a safe, sanitary, and comfortable environment and to help prevent the development and transmission of communicable diseases and infections for 1 of 2 residents (Resident #37) reviewed for infection control.
CNA T did not wash or sanitize her hands or change gloves while performing incontinent care for Resident #37.
These failures could place residents at risk of exposure to communicable diseases and infections.
Findings included:
Record review of an electronic Face Sheet dated 6/10/2025 for Resident #37 indicated she admitted to the facility on [DATE] and was [AGE] years old. Her diagnoses included: hypertensive chronic kidney disease (kidney damage caused by high blood pressure) dementia (a decline in cognitive abilities), acute cystitis with hematuria (irritation of the bladder with blood in the urine), muscle wasting and atrophy (decrease in muscle mass and strength).
Record review of a Quarterly MDS dated [DATE] for Resident #37 indicated a BIMS of 06 which indicated severe cognitive impairment. She was dependent on staff with toileting hygiene. She was always incontinent of bowel and bladder.
Record review of a Care Plan dated 1/25/2024 for Resident #37 indicated: The resident had an ADL self-care performance deficit with interventions that included: The resident requires assistance wash hands, adjust clothing, clean self, transfer on to toilet, transfer off toilet to use toilet. The care plan also indicated Resident #37 had bowel incontinence with interventions that included: Provide peri care after each incontinent episode.
During an observation on 6/9/2025 at 11:52 AM in Resident #37's room revealed, CNA T and CNA R were present to provide incontinent care. Both staff washed their hands in the bathroom of Resident #37's room and donned gloves. CNA T and CNA R positioned Resident #37 in supine position to perform incontinent care. CNA T removed the blanket from Resident #37. CNA T removed a disposable wipe from the container and began cleaning Resident #37. CNA T after cleaning Resident #37's peri area CNA T without changing gloves or washing her hands placed a clean brief on Resident #37. CNA T without changing gloves or washing her hands began repositioning Resident #37 in bed and placed covers back on her. CNA D without changing gloves or washing her hands repositioned Resident #37's pillows behind her head. After CNA T repositioned Resident #37 she doffed gloves washed her hands, gathered the trash, and exited the room.
During an interview on 6/9/2025 at 12:06 PM, CNA T said after the incontinent care that she should have changed her gloves and washed her hands when going from dirty to clean during incontinent care. She said by not performing incontinent care properly the resident could get an infection.
During an interview on 6/9/2025 at 12:06 PM, CNA R said CNA T should have changed her gloves and washed her hands when going from dirty to clean while providing incontinent care. She said by not providing incontinent care properly the resident could get an infection.
During an interview on 6/11/2025 at 11:21 am, the ADON said her, and the DON observed peri care at times. She said CNA T was normally a good CNA but was nervous due to being watched by state. She said they do competency skills check off yearly. She said CNA T should have changed her gloves and washed her hands when going from dirty to clean during incontinent care. She said by not providing incontinent care properly the resident could get an infection.
During an interview on 6/11/2025 at 11:34 am, the DON said they do competency skills check off upon hire and annually. She said her expectation was to wash hands in the beginning of incontinent care and then when going from dirty to clean hands needed to be washed. She said by not providing incontinent care properly they could spread infections to the residents.
During an interview on 6/11/2025 at 11:44 am, the Administrator said her expectation was for the CNAs to perform incontinent care the right way every day. She said CNA T should have washed her hands when going from dirty to clean. She said by not performing incontinent care properly they could have spread germs to the resident.
Record review of C.N.A Proficiency Audit dated 9/3/2024 for CNA T indicated she had been trained and had demonstrated handwashing and perineal care for females in accordance with the facility's standard of practice.
Record review of C.N.A Proficiency Audit dated 12/16/2024 for CNA R indicated she had been trained and had demonstrated handwashing and perineal care for females in accordance with the facility's standard of practice.
Record review of a facility policy titled Perineal Care dated 4/27/2022, indicated, .21. Gently perform care to the buttocks and anal area, working from front to back without contaminating the perineal are . 24. Doff gloves and PPE. 25. Perform hand hygiene. 26. Provide resident comfort and safety by re-clothing (if applicable-incontinence pad(s) and briefs), straightening bedding, adjusting the bed and/or side rails, and placing call light within resident's reach . 30. Tie off the disposable plastic bag of trash and/or linen. 31. Perform hand hygiene .
CONCERN
(E)
Potential for Harm - no one hurt, but risky conditions existed
Deficiency F0802
(Tag F0802)
Could have caused harm · This affected multiple residents
During an observation on 06/09/25 at 12:35PM the pureed food served in the facility was observed. On each puree tray there was a main plate with 3 foods including a brown ground meat, a white food, an...
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During an observation on 06/09/25 at 12:35PM the pureed food served in the facility was observed. On each puree tray there was a main plate with 3 foods including a brown ground meat, a white food, and a yellow food. The consistency of all three foods was mechanical soft.
During an interview on 06/09/25 at 02:30 PM, [NAME] F said he made the puree this day. He said he was not trained on how to make the puree. He said he was not sure if there was a recipe for the puree. He said he did not follow a recipe for the puree this day. He said his puree usually comes out more like mashed potatoes. He said he was running behind today and he was in a hurry. He said the old Dietary Manager left about a month ago. He said the risk to the resident was possible choking.
During an interview on 06/11/25 at 11:34 AM, the DON said she expected [NAME] F to have been trained to make puree foods. She said he came from a sister facility. She said he has been here a few months.
During an interview on 06/11/25 at 11:44 AM, the Administrator said she expected the cook to make the puree properly. She said a Dietary Manager should train and be able to expect the staff to do the puree correctly. She said she expected [NAME] F to have been trained on puree preparation. She said he normally does the puree when he works. She said he was trained at another facility on the puree.
Record review of [NAME] F's Dietary Staff/Cook Proficiency, dated 04/11/25, indicated he was marked as satisfactory on the section pertaining to the following topic:
Demonstrates understanding of:
*Therapeutic and mechanically altered diets, including regular with mech/ground meat vs. mechanical soft .
The proficiency did not specifically address pureed diets.
Record review of the Facility's undated policy, Employee Orientation, stated:
All individuals will have the basic information to perform their job efficiently and effectively.
All new employees will receive orientation to the facility an especially to the Dietary Department.
Procedure
1. The Dietary Service Manager conducts orientation on an individual basis with the new employee before being assigned a schedule.
2. In-Service Training sessions are scheduled monthly and conducted by either the dietitian or the dietary service manager. All dietary employees on duty are required to attend, with the goal of at least two hours of inservice training each quarter .training is also assigned to dietary employees monthly and must be completed by month's end. Possible topics include:
- General and Therapeutic diets .
Record review of the Texas Administrative Code chapter 228 subchapter (b) (d) indicated: All food employees, except for the certified food protection manager, shall successfully complete an accredited food handler training course, within 30 days of employment .
Based on interview and record review, the facility failed to employ sufficient staff with the appropriate competencies and skills sets to carry out the functions of the food and nutrition service for 4 out of 6 dietary staff (Cook F, Kitchen Staff BB, Kitchen Staff CC, and Kitchen Staff DD)
The facility failed to ensure Kitchen Staff BB, CC, and DD had a current food handlers certificate
The facility failed to ensure [NAME] F was trained and competent to prepare the pureed food.
This failure could place residents who consumed food prepared from the kitchen at-risk of foodborne illness or nutritional deficiencies.
Findings included:
During an observation of the kitchen on 6/9/2025 at 8:45 a.m., [NAME] F was preparing for the lunch meal.
Review of the food handler's certificates of completion provided by the facility on 6/10/2025, revealed Kitchen Staff BB, Kitchen Staff CC, Kitchen Staff DD did not have a food handler's certificate. Kitchen Staff BB had a hire date of 5/1/2025, Kitchen Staff CC had a hire date of 2/6/2025 and Kitchen Staff DD had a hire date of 4/3/2025.
During an attempted interview on 6/10/2025 at 10:00am Kitchen Staff BB, Kitchen Staff CC and Kitchen Staff DD were not available for interview.
During an interview on 6/11/2025 at 9:20 a.m., the travelling CDM H said the dietary manager was responsible for making sure staff got their food handlers certification but since the facility did not have a dietary manager it was the Administrators responsibility. The Dietary Manager stated the failure could potentially put residents at risk for food borne illness and cross contamination.
During an in interview on 6/11/2025 at 9:58 a.m., Registered Dietician G said by Kitchen Staff BB, Kitchen Staff CC, and Kitchen Staff DD working without having their food handler's certification was they could possibly handle food inappropriately which could cause residents to become sick by food borne illness.
During an interview on 6/11/2025 at 11:44 a.m., the Administrator said he expected the dietary staff have their food handler certificates within 30 days of hire. The Administrator said the importance of obtaining the food handler certificate training was to teach staff to follow proper procedures and prevent infection control issues. The Administrator said the facility did not have a specific policy for obtaining food handler's certifications and they followed the Texas Administrative Code.
CONCERN
(E)
Potential for Harm - no one hurt, but risky conditions existed
Deficiency F0805
(Tag F0805)
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 the each resident received food prepared in a ...
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**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, interview, and record review, the facility failed to ensure the each resident received food prepared in a form to meet their individual needs for 4 of 4 residents (Residents #4, #31, #30, and #16) reviewed for pureed diet consistency.
The facility failed to ensure Resident #4 was served a pureed diet as ordered by the physician.
The facility failed to ensure Resident #31 was served a pureed diet as ordered by the physician.
The facility failed to ensure Resident #30 was served a pureed diet as ordered by the physician.
The facility failed to ensure Resident #16 was served a pureed diet as ordered by the physician.
These failures could place residents at risk of choking, aspiration, and/or death.
Findings included:
1. Record review of Resident #4's face sheet, dated 06/09/25, indicated she was an [AGE] year-old female, admitted to the facility on [DATE]. Her diagnoses included dysphagia (difficulty swallowing food or liquids), dementia (loss of memory, language, problem-solving and other thinking abilities that are severe enough to interfere with daily life), and cognitive communication deficit (communication problem stemming from difficulties with cognitive processes, rather than with speech or language itself).
Record review of Resident #4's quarterly MDS assessment, dated 03/21/25, indicated she had a BIMS score of 03, which indicated severe cognitive impairment. She was sometimes able to make herself understood and she was sometimes able to understand others. She was completely dependent on staff for the activity of eating. The assessment indicated she has signs and symptoms of a possible swallowing disorder including holding food in mouth/cheeks or residual food in mouth after meals and coughing or choking during meals or when swallowing medications. She required a mechanically altered diet (require change in texture of food or liquids) while a resident at the facility.
Record review of Resident #4's Order Summary Report, dated 06/09/25, indicated she had an order for:
*Fortified/Enhanced diet. Pureed Texture. The start date was 02/12/24.
Record review of Resident #4's care plan, last revised 05/23/25, indicated a focus of Resident #4 has a fortified/enhanced diet with pureed texture. Interventions included the resident has a pureed diet, and speech therapy and treatment per physician's orders as condition warrants.
Record Review of Resident #4's Food Tray Ticket for Lunch 06/09/25 indicated .Regular/Puree Fortified Enhanced Diet .
.Entrée .Smashburger [with] grilled onions
Starch .Zesty Fry Sauce .
.waffle fries
Vegetable .Tomato Juice .
Dessert .Apple Fried Pie .
During an observation on 06/09/25 at 12:35 PM, Resident #4 was being fed lunch in the dining room by CNA A. There were 3 foods on the plate including a brown ground meat, a white food, and a yellow food. The consistency of all three foods was mechanical soft.
During an interview on 06/09/25 at 12:43 PM, Speech Therapist B said that the food on Resident #4's plate was a mechanical soft consistency. She said Resident #4 was supposed to have pureed consistency. She said the resident being served the wrong consistency could cause her to choke or aspirate.
During an interview on 06/09/25 at 12:46 PM, CNA A said the pureed food consistency varies. She said the DON and LVN C checked the tray before she took the tray to Resident #4. She said since the nurse checked the tray, she thought it was okay. She said the resident did not cough or choke. She said the risk was that the resident could choke or aspirate on her food.
2. Record review of Resident #31's face sheet, dated 06/09/25, indicated he was a [AGE] year-old male, admitted to the facility on [DATE]. His diagnoses included Huntington's disease (a progressive neurodegenerative disorder that affects movement, thinking, and emotional abilities).
Record review of Resident #31's quarterly MDS assessment, dated 04/18/25, indicated he had a BIMS score of 11, which indicated moderate cognitive impairment. He was able to make himself understood and he was able to understand others. He was completely dependent on staff for the activity of eating. He required a mechanically altered diet (require change in texture of food or liquids) while a resident at the facility.
Record review of Resident #31's Order Summary Report, dated 06/09/25, indicated he had an order for:
*Fortified/Enhanced diet. Pureed Texture. The start date was 05/30/25.
Record review of Resident #31's care plan, last revised on 06/09/25, indicated a focus of Resident #31 has a diet order other than regular and may be at risk for unplanned weight loss or gain. Interventions included the resident has a pureed diet and serve diet and snacks as ordered.
Record Review of Resident #31's Food Tray Ticket for Lunch 06/09/25 indicated .Regular/Puree Fortified Enhanced Diet .
.Entrée .Smashburger [with] grilled onions
Starch .Zesty Fry Sauce .
.waffle fries
Vegetable .Tomato Juice .
Dessert .Apple Fried Pie .
During an observation on 06/09/25 at 12:43 PM, Resident #31's lunch tray was in his room on his bedside table. There were 3 foods on the plate including a brown ground meat, a white food, and a yellow food. The consistency of all three foods was mechanical soft.
3. Record review of Resident #30's face sheet, dated 06/09/25, indicated she was a [AGE] year-old female, admitted to the facility on [DATE]. Her diagnoses included cerebral infarction (occurs when the blood supply to the brain is interrupted, leading to brain tissue death), and dementia (a general term for the loss of cognitive function, including memory, language, problem-solving, and reasoning, which can interfere with daily life).
Record review of Resident #30's quarterly MDS assessment, dated 03/31/25, indicated a BIMS was not conducted due to the resident being rarely/never understood. She was rarely/never able to make herself understood and she was rarely/never able to understand others. She was completely dependent on staff for eating. The assessment indicated she had signs and symptoms of possible swallowing disorder including loss of liquids/solids from mouth when eating or drinking and holding food in mouth/cheeks or residual food in mouth after meals. She required a mechanically altered diet (require change in texture of food or liquids) while a resident at the facility.
Record review of Resident #30's Order Summary Report, dated 06/09/25, indicated she had an order for:
* Fortified/Enhanced diet. Pureed Texture. Divided plate. Pleasure feedings as tolerated. The start date was 01/24/25.
Record review of Resident #30's care plan, last revised 05/27/25, indicated a focus of Resident #30 is at risk for unplanned weight loss or gain. Resident #30 is prescribed a fortified/enhanced diet, pureed texture. Interventions included serve diet and snacks as ordered and the resident has a pureed diet.
During an interview on 6/9/25 at 12:50 p.m., LVN D said that she already fed Resident #30. She said that Resident #30 was on a pureed diet. She said that pureed food should look like baby food. She said that the food that she fed Resident #30 looked like the food in the picture the surveyor showed her. She said that it was not pureed food.
4. Record review of Resident #16's face sheet, dated 06/09/25, indicated he was an [AGE] year-old male, admitted to the facility on [DATE]. His diagnoses included profound intellectual disabilities (Intellectual disability so severe that they are unable to live independently, require close supervision, and often have physical limitations), and cervicalgia (pain in the neck).
Record review of Resident #16's annual MDS assessment, indicated a BIMS was not conducted because he was rarely/never understood. He was rarely/never able to understand others. He required setup or clean-up assistance with eating. He required a mechanically altered diet (require change in texture of food or liquids) while a resident at the facility.
Record review of Resident #16's Order Summary Report, dated 06/09/25, indicated he had an order for:
*Regular diet, Pureed texture. The start date was 05/30/25.
Record review of Resident #16's care plan, last revised 03/21/25, indicated a focus of Resident #16 has a diet order other than regular and may be at risk for unplanned weight loss or gain. Regular diet, puree texture. Interventions included the resident has a pureed diet.
Record review of Resident #16's Food Tray Ticket for Lunch 06/09/25 indicated .Regular/Puree Fortified Enhanced Diet .
.Entrée .Smashburger [with] grilled onions
Starch .Zesty Fry Sauce .
.waffle fries
Vegetable .Tomato Juice .
Dessert .Apple Fried Pie .
During an observation on 06/09/25 at 12:44 PM, Resident #16 was sitting in his room eating his lunch. There were 3 foods on the plate including a brown ground meat, a white food, and a yellow food. The consistency of all three foods was mechanical soft. There was also a separate plate on the tray that had a regular slice of apple pie on the plate. It was regular consistency and was not altered.
Record review of the Facility's recipes for 06/09/25 at lunch stated:
.Beef Smashburger [with] [grilled] onion .
.To get the actual serving size, puree the number of portions needed, adding adequate liquid needed to achieve desired consistency as appropriate for resident, then divide the total amount equally by the number of portions pureed. Measure number of servings using the regular prepared recipe portion. Drain well to minimize the use of thickener to obtain appropriate consistency. Place in a blender or food processor.
Add liquid, if needed .to assist with pureeing. Puree with a blender or food processor until smooth .
.If needed, gradually add thickener .
.The desired thickness should be mashed potato or pudding. There should be no large lumps or particles .
.Waffle Fries .
.The desired thickness should be mashed potato or pudding. There should be no large lumps or particles .
.Pie, Fried Fruit Apple .
.Desired thickness should be mashed potato, pudding, or applesauce texture. There should be no large lumps or particles .
During an interview on 06/09/25 at 12:55 PM, Dietary Supervisor E said she was in the facility helping them out on this day. She said she normally works in another facility. She said the pureed diet food served at lunch on 06/09/25 was mechanical soft consistency. She said the risk was that the residents could choke or aspirate.
During an interview on 06/09/25 at 01:10 PM, LVN C said she checked the trays as they came out of the kitchen. She said she did not question the consistency of the pureed food because the dietary supervisor had just added some liquid to the pureed food before the tray came out. She said she thought the food was closer to mechanical soft than puree. She said the resident could choke or aspirate if they ate the wrong consistency food. She said her and the DON were checking the trays before they came out of the kitchen.
During an interview on 06/09/25 at 02:30 PM, [NAME] F said he made the puree this day. He said he was not trained on how to make the puree. He said he was not sure if there was a recipe for the puree. He said he did not follow a recipe this day. He said his puree usually comes out more like mashed potatoes, he said he was running behind today and he was in a hurry. He said the old Dietary Manager left about a month ago, He said the risk to the residents was possible choking.
During an interview on 06/09/25 at 02:33 PM, Regional Dietician G said she expected the kitchen staff to give the proper consistency food to the residents that require an altered diet. She said they have standardized recipes for the puree. She said she usually will visit the facility once a month and observe the puree. She said the risk of the residents not getting the pureed food as ordered was they could choke or aspirate or potentially die.
During an interview on 06/09/25 at 02:51 PM, the DON said she did not check off any of the pureed trays. She did not see the consistency of the pureed meals. She said she expected the staff to give the proper consistency of the meal to the residents that required an altered diet. She said the risk of the wrong consistency being served was the resident could aspirate or choke. She said she was not aware of any of the 4 residents who get pureed food choking. She said the kitchen should give the proper consistency, the nurse should check it and then the CNA should also check it.
During an interview on 06/09/25 at 05:06 PM, [NAME] F said no one in management had questioned him regarding the puree before this day. He said he thought he usually had a good consistency but this day he was rushing.
During an interview on 06/11/25 at 09:20 AM, Travel Certified Dietary Manager H said she was not in the facility on 06/09/25. She looked at the picture this surveyor showed her, and she said she did not think the puree was smooth enough and it was too dry. She said the risk to the resident's was choking and aspiration. She said she was last in the facility in Mid-May 2025. She said the typical procedure was that the cook would make the puree and the Dietary Manager would then check while it is on the line.
During an interview on 06/11/25 at 09:38 AM, Regional Dietician G said she thought the puree diet tray served at lunch on 06/11/25 was mechanical soft in consistency and the risk was potential choking and aspiration. She said the typical procedure was that the cook would make it and the Dietary Manager would check it off. She said the facility has not had a Dietary Manager as of recent, so she expected the Administrator to watch at least one meal a day. She said she expected the Dietary Manager to remove the Puree tray if it was the wrong consistency.
During an interview on 06/11/25 at 09:45 AM, Dietary Supervisor E said she did not see the puree tray before it went out of the kitchen on 06/09/25. She said she did not check the puree that [NAME] F made on 06/09/25. She said [NAME] F was plating the food that day. She said she should have checked the puree trays.
During an interview on 06/11/25 at 11:21 AM, the ADON said she expected the cook to ensure that the puree was the proper consistency. She said she expected the nurse and CNA to check the tray as well. She said the picture that this surveyor showed her looked like it was too thick for puree. She said the risk was that the resident could choke or aspirate and get pneumonia.
During an interview on 06/11/25 at 11:34 AM, the DON said she expected the kitchen to verify they made the proper consistency, and the nurse and CNA should also check the consistency before it was served to the residents.
During an interview on 06/11/25 at 11:44 AM, the Administrator said she expected the cook to make the puree properly. She said a Dietary Manager should train and be able to expect the staff to do the puree correctly. She said the Dietary Manager should check the puree to ensure the food consistency was correct. She said on 06/09/25 she expected Dietary Supervisor E to check the puree. She said she expected the nurse to check the tray before it was sent out. She said she expected the CNA if they are feeding a resident to stop the tray if they feel it is not the proper consistency. She said the risk was choking and aspiration and/or pneumonia.
Record review of the facility's undated policy, Consistency Modification, stated:
We will adequately meet nutritional needs of the resident and provide food in a consistency that the resident can tolerate .
.3. The pureed diet is given to residents with chewing, swallowing or choking problems. The desired consistency for blended foods is that of applesauce to mashed potatoes. Small grains may be present in some foods, but these are acceptable as long as they are no larger than the grains present in applesauce and of a consistent size. If a resident requires a smoother consistency, per speech therapist recommendation, an order for a strained puree diet can be obtained
CONCERN
(E)
Potential for Harm - no one hurt, but risky conditions existed
Food Safety
(Tag F0812)
Could have caused harm · This affected multiple residents
Based on observations, interviews, 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 kitch...
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Based on observations, interviews, 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 safety requirements and kitchen sanitation.
The facility failed to ensure all foods stored in the refrigerators were not kept past their expiration dates and did not contain mold.
These failures could place residents at risk of foodborne illness and food contamination.
Findings included:
During an observation of the refrigerator on 6/09/2025 at 8:45 AM, the following items were observed:
(1)
1 gallon of milk that was full with an expiration date of 6/8/2025.
(2)
1 container ¾ full with green beans dated 5/31/2025.
(3)
2 cucumbers with mold spots, 3 red onions with mold spots.
During an observation and interview on 6/9/2025 at 8:45 AM, [NAME] F said they should have checked the refrigerator and removed expired items. He said he did not know the cucumbers and onions had molded and they should have been removed from the refrigerator. He took the milk, cucumbers, and red onions out of the refrigerator and disposed of them. [NAME] F said they have not had a Dietary Manager for about 1 to 1 ½ months. He said the staff just do not care and do not check for expired foods. He said the residents could get sick by consuming expired foods.
During an interview on 6/11/2025 at 9:20 AM, the Travelling CDM H said the dietary manager or whoever is responsible should be making a walk through daily, but the cook should be checking for expired foods daily. She said if there is no dietary manager the Administrator should be checking daily. She said the residents could possibly get sick by consuming expired foods.
During an interview on 6/11/2025 at 9:32 AM, Registered Dietician G said that the dietary manager should be responsible for checking for expired food. She said if the facility did not have a dietary manager, then the Administrator was ultimately responsible for checking for expired foods, but all kitchen staff should be checking for expired foods. She said the resident could get sick by a food borne illness by consuming expired foods.
During an interview on 6/11/2025 at 11:44 AM, the Administrator said all foods should be used or disposed of by the use by date. She said food in the kitchen should be checked daily and weekly, to ensure foods are disposed of by the expiration date. She said food borne illness was a potential risk to the resident for consuming expired foods.
Record review of facility policy titled Food Storage and Supplies undated, indicated: .6. Any product with a stamped expiration date will be discarded once that date passes . 8 .If a food has developed such spoilage characteristics, it should not be eaten .
CONCERN
(E)
Potential for Harm - no one hurt, but risky conditions existed
Room Equipment
(Tag F0908)
Could have caused harm · This affected multiple residents
Based on observation, interview, and record review the facility failed to maintain all essential equipment in safe operating condition, for 1 of 1 stove and dishwasher in the kitchen reviewed for food...
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Based on observation, interview, and record review the facility failed to maintain all essential equipment in safe operating condition, for 1 of 1 stove and dishwasher in the kitchen reviewed for food service in that:
The facility did not ensure the gas stove was in working order. Two of six gas stove burners (left front and left back) did not light automatically, when the knob was turned, and all 6 burners had carbon buildup.
The facility did not ensure the dishwasher was in working order. The temperature did not reach 120-140 degrees.
This failure could place residents who eat out of the kitchen at risk for injury and under cooked food and risk of food borne illnesses by the dishwasher not appropriately sanitizing dishes.
Findings include:
During an observation on 6/9/2025 at 8:45 a.m., the gas stove had six burners total, two burners located in the left front and left back had excess carbon buildup. The left front and left back burner would not light automatically.
During an observation on 6/9/2025 at 8:45 a.m., the dishwasher was ran and reached temperature of 110 degrees. The dishwasher was ran a second time and reached 108 degrees. Observation of manufacturer signage posted on the wall behind the dishwasher indicated dishwasher temperatures should have been between 120-140 degrees.
During an interview on 6/9/2025 08:45 a.m., [NAME] F said the 2 burners on the stove that did not automatically light had been that way since he had been employed at the facility for the last 2-3 months. He said they had a lighter they kept in the kitchen that they used to light the burners on the stove.
During an observation and interview on 6/9/2025 at 8:45 a.m., Dietary Aide AA said he told the Administrator about a week ago that the dishwasher was not working properly but it had not been fixed. Dietary Aide AA said the dishwasher should be getting up to 125-130 degrees. The dishwasher had a log on the front that had not been completed since May 20, 2025. Dietary Aide AA said they had not been given a new log for June 2025.
During an interview on 6/11/2025 at 9:08 a.m., Maintenance Director EE said he had worked at the facility for 23 years. He said no one had notified him that the burner on the stove was not working. He said he had worked on the oven when it was reported to him that the oven was not working, but he was not told that the burners were not lighting. He said that it was reported to him 2-3 weeks ago that the dishwasher was not working properly. He said he looked at the dishwasher and called the manufacturer who was supposed to be sending a booster, but the dishwasher had not been fixed and had not been taken out of commission. He said if the stove burner was not lighting appropriately the kitchen could fill up with gas.
During an interview on 6/11/2025 at 9:20 a.m., the Travelling CDM H said the last time she was in the facility was May 2025. She said the last time she was here all equipment was in working order except for a microwave which she had replaced. She said the potential hazard for the dishwasher not working properly was diseases and cross contamination spreading throughout the building. She said by the stove not lighting properly gas could leak and cause an explosion.
During an interview on 06/11/2025 at 9:32 a.m., the Registered Dietician G said this was the first time she had been to the building. She said she was hired on to the company May 12th, 2025, and had not yet made it to the facility for a visit. She said it had not been reported to her that the kitchen equipment was not functioning properly. She said food borne illness was the potential hazard to the residents for the dishwasher not working properly. She said a gas leak, explosion and fire was a danger for the stove not lighting properly.
During an interview on 6/11/2025 at 11:44 a.m., the Administrator said she expected staff to notify her of issues with equipment. She said staff should not have to work with equipment that is not operational. She said food borne illness was a potential hazard for the dishwasher not working properly. She said the stove failure could cause food to not be cooked to the proper temperature and the stove could leak gas.
Record review of facility policy titled Dishwashing Preparation and Dishwashing undated indicated: .c. The wash period shall be at least 40 seconds with a temperature of 120 degrees Fahrenheit in dish machine. The sanitizing rinse period shall be at least 20 seconds with minimum temperature of 120 degrees Fahrenheit.
On 6/9/2025 surveyor requested a policy for the stove, and none was providing by the time of surveyor exit.
Feb 2025
4 deficiencies
1 IJ (1 affecting multiple)
CRITICAL
(K)
📢 Someone Reported This
A family member, employee, or ombudsman was alarmed enough to file a formal complaint
Immediate Jeopardy (IJ) - the most serious Medicare violation
Accident Prevention
(Tag F0689)
Someone could have died · 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 each resident received adequate supervision to prevent accid...
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**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on interview and record review, the facility failed to ensure each resident received adequate supervision to prevent accidents for 1 of 4 residents reviewed for accidents and supervision. (Resident #1)
The facility failed to provide adequate supervision for Resident #1 who was assessed as a high risk for elopement. On 11/08/2024 he was allowed to sit on the front porch without supervision, and facility received a phone call from another resident's family member informing facility Resident #1 was at the end of the facility's exit driveway entering the residential roadway.
The non-compliance was identified as past non-compliance. The Immediate Jeopardy began on 11/02/2024 and ended on 11/08/2024. The facility had corrected the non-compliance before the survey began.
This failure could prevent residents from receiving appropriate supervision which could lead to resident sustaining serious injury or harm.
Findings included:
Record review of Resident #1's admission Record dated 02/12/2025 indicated he was a [AGE] year-old male who was admitted to the facility on [DATE] with diagnoses which included congestive heart failure systolic (condition in which the heart's main pumping chamber (left ventricle) is weak), cognitive communication deficit (communication difficulty stems from an impairment in cognitive processes, these deficits can impact a person's ability to think, speak, listen, read, and interact with others ), hypertension (condition in which the force of the blood against the artery walls is too high), chronic obstructive pulmonary disease (a lung disease blocks airflow making it difficult to breathe), diabetes mellitus (chronic condition affects the way the body processes blood sugar), transient cerebral ischemic attack (temporary interruption of blood flow to the brain causes stroke-like symptoms resolve within 24 hours) and cataract, left eye (common eye condition characterized by the clouding and thickening of the natural lens in the eye, leading to decreased vision).
Record review of a quarterly Elopement Risk assessment dated [DATE] indicated Resident #1 was a low risk for elopement with a score of 7. The form was signed by the DON.
Record review of Resident #1's quarterly MDS assessment, dated 08/09/2024, indicated a BIMS score of 04 which indicated he was severely impaired cognitively and he was able to make himself understood and understood others. He was always continent of bowel and bladder. The Functional self-care assessment indicated he required moderate assistance with toileting hygiene, shower/bath, lower body dressing, putting on/taking of shoes, personal hygiene, and setup or clean up assistance for eating, oral hygiene, and upper body dressing. The Functional mobility assessment indicated he required moderate assistance for lying to sitting on side of bed, sit to stand, chair/bed-to-chair transfer, and walking 50 feet with two turns. He required supervision or touching assistance for tub/shower transfer and walking 10 feet. He was independent with rolling left to right and sitting to lying. He required a manual wheelchair for mobility and was independent wheeling himself 50 feet with two turns.
Record review of Resident #1's annual MDS assessment, dated 11/09/2024, indicated a BIMS score of 03 which indicated he was severely impaired cognitively and he was able to make himself understood and understood others. He was occasionally incontinent of bowel and bladder. The Functional self-care assessment indicated he required moderate assistance with toileting hygiene, shower/bath, lower body dressing, putting on/taking of shoes, personal hygiene, and setup or clean up assistance for eating, oral hygiene, and upper body dressing. The Functional mobility assessment indicated he required moderate assistance for sit to stand, chair/bed-to-chair transfer, toilet transfer, tub/shower transfer and walking 50 feet with two turns. He required supervision or touching assistance for walking 10 feet. He was independent with rolling left to right, sitting to lying and lying to sitting on side of bed. He required a manual wheelchair for mobility and was independent wheeling himself 50 feet with two turns.
Record review of Resident #1's care plan, dated 11/09/2024, indicated he resided in the secure unit related to actual elopement attempt. No interventions on care plan prior to 11/09/2024 related to Resident #1's change in elopement risk on 11/02/2024. Care plan indicated he had an ADL self-care performance deficit and required supervision as needed for bathing, bed mobility, eating, dressing, toilet use, and transfers.
Record review of Resident #1's progress note dated 10/25/2024 Resident #1 was found in the parking lot. The progress note did not address if any interventions were implemented following this incident.
Record review of a quarterly Elopement Risk assessment dated [DATE] indicated Resident #1 was a high risk for elopement with a score of 16. The form was signed by LVN B. The Elopement Risk assessment did not address if any interventions were implemented following this assessment.
Record review of Resident #1's progress note dated 11/04/2024 Resident #1 was found in the parking lot again. The progress note did not address if any interventions were implemented following this incident.
Record review of Resident #1's event note - elope or attempt dated 11/08/2024 Resident #1 had eloped from facility out the front door and was discovered in front of the facility, resident was in his wheelchair, fully dressed, on the street heading towards the convenient store. Resident #1 was returned to the facility and was placed in the secure unit for supervision.
Record review of Resident #1's physician orders dated 11/08/2024 indicated Resident #1 was moved to facility secure unit.
A Provider Investigation Report dated 11/08/2024 indicated the incident occurred on 11/08/24 at 04:45 p.m. Resident #1 sits on front porch with no behaviors and no supervision. Resident goes in and out of the front door frequently throughout the day. Resident #1 was reported to the charge nurse to have been leaving the facility driveway. Resident #1 said he was going to the gas station to get scratch-offs. Resident #1 was returned to the facility by CNA A. A head-to-toe assessment was conducted with no negative findings. Resident #1 was placed in secure unit for 1:1 monitoring. Resident #1's family and physician were notified of the elopement. Physician ordered Resident #1 be placed in the secure unit and family members agreed and consented. In-services were conducted with staff on elopement protocol, on accuracy of elopement assessments, and on residents sitting out front. All residents had updated elopement assessments conducted. Resident #1 remained in the facility's secure unit.
Unable to interview Resident #1, he no longer resided at the facility.
During an interview on 2/13/2025 7:33 a.m., LVN B said she had filled out the quarterly Elopement Risk Assessment on Resident #1 on 11/02/2024. She said she answered some of the questions based on the personal history of knowing Resident #1 and his cognitive skills, daily decision making, and behaviors and that was why it triggered him at high risk for elopement. LVN B said management staff was aware of Resident #1's high elopement risk. LVN B said the quarterly elopement risk assessment was completed to provide information for completing the quarterly MDS and updating care plan during care plan meetings if applicable. LVN B said Resident #1's family did not consent for the resident to reside on the facility secure unit until he eloped on 11/08/2024 and then they agreed with the intervention after the elopement.
During an interview on 02/12/2025 at 12:20 p.m., HR C said on 11/08/2024 at approximately 4:45 p.m., she received a phone call from another resident's family member reporting Resident #1 was in his wheelchair at the end of the facility exit driveway, headed down the residential roadway. HR C said she immediately responded and notified LVN D and CNA A regarding the elopement while exiting the facility. HR C said CNA A ran down the exit driveway and residential roadway and redirected Resident #1 back to the facility. HR C said Resident #1 had a history of sitting on the front porch of the facility and greeted staff, other residents, and visitors, and she was able to monitor him from her window. HR C said she did not recall Resident #1 attempting to elope in the past but Resident #1 would ask staff and visitors to go buy him a scratch off lottery ticket occasionally when his family had not brought him any.
During an interview on 02/13/2025 at 2:40 p.m., CNA A said she was working on 11/08/2024, returning from her break around 5:00 p.m. when she heard HR C said Resident #1 had eloped and was on the residential roadway headed towards the gas station. CNA A said she ran out the front door and down the roadway (approx. 50 yards from facility exit driveway) and retrieved Resident #1 and redirected him back to the facility. CNA A said Resident #1 said he was going to the gas station to buy himself a scratch-off lottery ticket. CNA A said she was not the assigned CNA working with Resident #1 on 11/08/2024 but when an elopement occurred everyone intervened. CNA A said she was familiar with Resident #1 because he moved around the facility independently in his wheelchair and would sit in the front lobby waiting for someone to disarm the alarm so he could go outside to sit on the porch. CNA A said Resident #1 would sit out on the front porch and greet visitors, staff, and other residents. CNA A said Resident #1 had been at the end of the sidewalk/parking lot area asking visitors for scratch off lottery tickets prior to the elopement but was easily redirected back into facility. CNA A said Resident #1 was allowed to sit on the facility front porch unsupervised, staff would disarm the front door, wheel him outside on porch, and frequently monitor him but would not stay outside with him. CNA A said she was not aware of any previous elopements with Resident #1 and that Resident #1 had never voiced to her about desire to leave the facility and even the day of the elopement he said he would return to the facility after he got his lottery tickets.
During an interview on 02/13/2025 at 11:00 a.m., the ADON said on 11/08/2024 she had just completed her orientation and was leaving the facility when CNA A and HR C was returning to the facility with Resident #1 and was informed that Resident #1 had just eloped from the facility. The ADON said that she interviewed with Resident #1, and he said he was going to the gas station to get scratch off lottery tickets and had intentions on returning to the facility afterwards. The ADON said she notified the Administrator and Resident #1's charge nurse of the incident. The ADON said Resident #1 was placed in the facility secure unit and the charge nurse was notified of the elopement incident.
During an interview on 02/13/2025 at 02:18 p.m., LVN D said she was the charge nurse for Resident #1 on 11/08/2025 and around 5:00 p.m. while in the dining room for dining observations, she noticed Resident #1 being wheeled into the facility by CNA A. CNA A reported to her that Resident #1 had eloped and was on the residential roadway between the facility and the gas station and she had redirect him back to the facility. LVN D said the ADON and CNA A took Resident #1 to the facility secure unit for monitoring. LVN D said she and LVN E contacted the physician, family and completed the required assessments. LVN D said she recalled seeing Resident #1 sitting on the front porch when entering the facility to start her shift at 2:00 p.m. LVN D said all staff monitored Resident #1 and when he wanted to go outside or inside, he would ask staff to disarm the door alarms for exiting or entering the facility. LVN D said if Resident #1 was outside that staff would check on him frequently and bring him back in the facility to provided care. LVN D said she was aware that Resident #1 had been found in the parking lot asking for scratch off lottery tickets in the past but was not aware of Resident #1 ever leaving the facility premises or requesting to leave the facility prior to the elopement on 11/08/2024.
During an interview on 02/13/2025 at 02:30 p.m., LVN E said she was working the secure unit on 11/08/2024, and Resident #1 was escorted to the secure unit by CNA A on 11/08/2025 around 5:00 p.m. LVN E said Resident #1 had eloped from the facility and was being placed in the secure unit for monitoring and possible permanent placement. LVN E said she and LVN D contacted the physician, family and completed the required assessments. LVN E said Resident #1 was not exit seeking while in the secure unit, he would just sit at the back door requesting someone to take him to sit outside because he liked to sit outside and enjoy the sunshine. LVN E said that staff would go outside and sit with him in the enclosed secure unit patio area.
During an interview on 02/13/2025 at 02:45 p.m., the DON said that Resident #1 liked to sit on the facility front porch and greet people entering the facility. The DON said all facility staff monitored Resident #1 while he was outside. The DON could not explain how Resident #1 got off the facility premises without any facility staff being aware. The DON said she was not aware of Resident #1's high elopement risk assessment on 11/02/2024 and the assessing facility staff should have notified her or the Administrator with the high elopement assessment risk so interventions could have been initiated to prevent elopement and keep resident safe. The DON said not intervening when residents have a high elopement risk could put the residents at risk for actual elopement and lack of supervision could cause possible harm or injury to the resident.
During an interview on 02/13/2025 at 03:00 p.m., the Administrator said Resident #1 liked to sit on the facility front porch and greet people entering the facility. The Administrator said she was not aware of Resident #1's high elopement risk assessment on 11/02/2024 until she began investigating the elopement on 11/08/2024. The Administrator said the assessing staff member should have notified her or the DON of the high-risk elopement assessment so interventions could have been put in place. The Administrator said following the incident on 11/08/24, the staff were reeducated on elopement, accuracy of elopement assessments, reporting residents with high elopement assessments to the DON and/or the Administrator; management reassessed all residents for elopement risk; the elopement log was updated; and elopement drills were being conducted randomly. She said the elopement attempt was included in the QAPI report. The Administrator said all door alarms were checked the day of the elopement and was found to be working properly. The Administrator said residents were allowed to be outside unsupervised if their elopement risk assessment was low and the safety assessment indicated it was safe for them to be left alone. The Administrator said facility staff developed an individualized plan for each resident to meet their needs and maintain the least restrictive environment. The Administrator said it was common for Resident #1 to be sitting out on the front porch and she was not sure if staff had let him out on the day of the elopement or if Resident #1 had followed a family member out the door when they were exiting. The Administrator said Resident #1 was redirected back to the facility within a few minutes of the facility being aware Resident #1 was off the facility premises. The Administrator said once Resident #1 was back in the facility, a head-to-toe assessment was completed with no injuries identified, the physician and family were notified, and orders were received for Resident #1 to be placed in the secure unit. The Administrator said Resident #1 was placed in the secure unit and monitored following the elopement. The Administrator said if a resident was identified as a high risk for elopement, the assessing nurse or staff should notify her and the DON so interventions could be put in place to prevent elopement and keep the resident safe. The Administrator said if she or the DON were not notified of the high elopement risk and interventions did not get initiated, it could put the residents at risk for actual elopement and lack of supervision could cause possible harm or injury to the resident.
Record review of the Elopement Prevention policy dated January 2023 indicated .1. The elopement risk assessments will be completed upon admission the assessment should be completed by reviewing the residents medical history and social history information may be obtained by reviewing current medical records if available interview with residents family or conference with the interdisciplinary team members the assessment tool should be completed and interventions implemented as indicated the elopement risk assessment is to be completed at least quarterly, after an elopement attempt, upon new exit seeking behaviors, and upon change of condition.
Record review of an In-Service Attendance Record with subject of Elopement Response and prevention, dated 11/08/2024, indicated that 49 staff members signed the in-service record including CNA A, LVN B, HR C, LVN D and LVN E.
Record review of Assessment History Elopement Risk Assessment list dated 02/11/2025 at 09:54 a.m. indicated all residents in the facility were reassessed on 11/09/2024.
Record review of Incident logs from 02/01/2024 through 02/11/2025 indicated there were no other actual resident elopements from the facility.
Record review of the Elopement Risk Assessment Log on 02/11/2025 indicated it was updated to include current residents assessed as high risk for elopement.
During observations on 02/11/2025 from 09:00 a.m. - 02/13/2025 to 5:30 p.m., of current residents at risk for elopement indicated staff-maintained residents within eye contact and staff did not allow them to go outside of the facility without a staff member with them and/or the resident resided in the facility secure unit.
During interviews on 02/11/2025 from 09:00 a.m. - 02/13/2025 to 5:30 p.m., 1 RN (RN N), and 4 LVN's (LVN B, LVN D, LVN E, and LVN O) were able to identify residents at risk for elopement, all were knowledgeable of the elopement policy and procedure, all were aware of the new expectations to notify the DON/ADON and the Administrator immediately of any assessments identifying a resident with a high elopement risk and/or residents exit seeking, attempting or actual elopement.
During interviews on 02/11/2025 from 09:00 a.m. - 02/13/2025 to 5:30 p.m., 7 CNA's (CNA A, CNA F, CNA G, CNA H, CNA I, CNA J, and CNA L), and 1 MA (MA K) were able to identify residents at risk for elopement, all were knowledgeable of the elopement policy and procedure, all aware of residents requiring supervision if outside, and all were aware to notify the CN, DON, ADON and the Administrator immediately of any residents exit seeking, attempting or actual elopement.
During interviews on 02/11/2025 from 09:00 a.m. - 02/13/2025 to 5:30 p.m., 1 Human Resource staff (HR C), 1 MDS Nurse (MDS M), Floor Tech (FT P), 1 Housekeeping staff (HSK Q), Business office staff (BO R) and maintenance staff (MT S) were able to identify residents at risk for elopement, all were knowledgeable of the elopement policy and procedure, they were aware of the new expectations to notify CN, DON, ADON before allowing any resident outside alone, and to notify the DON/ADON and the Administrator immediately of any resident trying to go outside alone.
On 02/13/2025 at 05:45 p.m., the Administrator was informed of the Immediate Jeopardy. The non-compliance was identified as past non-compliance. The Immediate Jeopardy began on 11/02/2024 and ended on 11/08/2024. The facility had corrected the noncompliance before survey began.
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
Abuse Prevention Policies
(Tag F0607)
Could have caused harm · This affected 1 resident
Based on interview and record review, the facility failed to implement written policies and procedures to prohibit and prevent abuse, neglect, and exploitation for 2 of 5 employees (LVN O & LVN T) rev...
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Based on interview and record review, the facility failed to implement written policies and procedures to prohibit and prevent abuse, neglect, and exploitation for 2 of 5 employees (LVN O & LVN T) reviewed for develop and implement abuse policies.
The facility failed to ensure the Administrator implemented the facility's abuse/neglect policy and procedure when she failed to document suspension timeframes and advise the employees of the outcomes of the investigation in the determination of disciplinary action and/or reinstatement.
The facility failed to document suspension time frames and advise the employee of the investigation outcome when LVN O allegedly verbally abused Resident #2 on 10/14/2024.
The facility failed to document suspension time frames and advise the employee of the investigation outcome when LVN T allegedly secluded residents in the TV room of the secure unit on 10/25/2024.
This failure could place residents at risk for abuse, neglect and/or exploitation.
Findings included:
Record review of the facility's policy Abuse/Neglect, date revised 03/29/2018, indicated . F. Investigation . 4. With an allegation of abuse, neglect, exploitation, mistreatment of residents or misappropriation of resident property, the employee(s) will immediately be suspended pending an investigation. The employee will have an opportunity to present a written statement to answer the allegation(s) of abuse, neglect, exploitation, mistreatment of residents or misappropriation of resident property. The employee will have the opportunity to be advised of the outcome of the investigation in the determination of disciplinary action and/or reinstatement. 5. Abuse, neglect, exploitation, mistreatment of residents or misappropriation of resident property of residents by employees of any facility will be grounds for immediate termination. 6. The Abuse Preventionist and/or administrator will conduct a thorough investigation of the incident(s). A copy of the written report will accompany any personnel action deemed necessary. If a personnel action occurs, a copy of all pertinent documents will be placed in the employee's personnel file. 7. The facility will report and cooperate with any and all investigations concerning reports of abuse, neglect, exploitation, mistreatment of residents, misappropriation of resident property and injuries of unknown source by the company's employees as set forth in state law (including to the state survey and certification agency).
Record review of the employee disciplinary report for LVN O indicated the employee was placed on an investigation suspension pending an investigation into allegation of abuse with the date of infraction of 10/24/2024. LVN O was placed on unpaid investigation suspension. LVN O will remain on investigation suspension until the investigation is completed into the abuse allegation. LVN O will be notified when the investigation is completed. If the investigation does no substantiate any wrong, LVN O will receive pay retro for any shifts they may have missed while on suspension on the next payroll date. LVN O ma provide a written statement regarding the allegations under investigation. LVN O may not use PTO or PDO for their suspension days. Employee Comments (may be submitted to the supervisor presenting the EDR within 5 days of presentation of EDR), indicated no comments from LVN O. Report signed by DON, the Administrator and LVN O on 10/25/2024.
Record review of LVN O's personnel files did not indicate suspension time frames or advisement to the employee of the investigation outcome when LVN O allegedly verbally abused Resident #2 on 10/14/2024.
Record review of the employee disciplinary report for LVN T indicated the employee was placed on an investigation suspension pending an investigation into allegation of abuse with the date of infraction of 10/24/2024. LVN T was placed on unpaid investigation suspension. LVN T will remain on investigation suspension until the investigation is completed into the abuse allegation. LVN T will be notified when the investigation is completed. If the investigation does no substantiate any wrong, LVN T will receive pay retro for any shifts they may have missed while on suspension on the next payroll date. LVN T ma provide a written statement regarding the allegations under investigation. LVN T may not use PTO or PDO for their suspension days. Employee Comments (may be submitted to the supervisor presenting the EDR within 5 days of presentation of EDR), indicated no comments from LVN T. Report signed by DON, the Administrator and
LVN T on 10/25/2024.
Record review of LVN T's personnel files did not indicate suspension time frames or advisement to the employee of the investigation outcome when LVN T allegedly secluded secure unit residents in the TV room on 10/25/2024.
During an interview on 2/13/2025 at 2:00 p.m., LVN O said she was aware of alleged abuse allegations against her and said she was suspended during the investigation process but does not recall how long she was suspended nor the dates of suspension. LVN O denied she verbally abused Resident #2 and witnesses confirmed she did not verbally abuse Resident #2. LVN O said she was suspended and later received a phone call the investigation was completed, and she could return to work. LVN O denied being offered or told the investigation outcome.
Attempted to interview LVN T on 02/12/2025 @ 5:30 p.m. and 02/13/2025 at 12:30 p.m., voice message left, and no return call received during the investigation survey.
During an interview on 02/13/2025 at 4:15p.m., the Administrator said the allegation of LVN O speaking rudely and loudly to Resident #2 was unfounded. The Administrator said the incident happened at shift change on 10/14/2024 and LVN O left. The Administrator said after reviewing the witness statements and conducting interviews on 10/14/2024 it was determined Resident #2 was not verbally abused by LVN O. The Administrator said Resident #2 was not aware of the incident and LVN O did not have direct verbal contact with Resident #2, so she did not report the allegation. The Administrator said when she was discussing the allegation with her ADO on 10/24/2024 she was informed the allegation should have been reported to the State Agency, so she reported the allegation at that time. The Administrator said when an abuse allegation occurs and staff involved, the information is submitted to the corporate staff and the employee disciplinary report is completed by the corporate staff and returned to her for review and completion. The Administrator said she reviews and discussed the disciplinary reports with the employees and had them sign and date the report. The Administrator said she did not recall the disciplinary report/form having a section to include the suspension dates just the date of infraction or a section for employee advisement of the outcome. The Administrator said when the investigation is completed, she notifies the employee if they are released to returned to work or terminated which is related to the outcome. The Administrator said not investigating and documenting information on employee disciplinary report could cause the staff to not be aware of the outcomes or make staff aware of the infraction, so it does not happen again. The Administrator said not investigating the alleged abuse and following facility disciplinary policies could place residents at risk for further abuse.
CONCERN
(D)
📢 Someone Reported This
A family member, employee, or ombudsman was alarmed enough to file a formal complaint
Potential for Harm - no one hurt, but risky conditions existed
Report Alleged Abuse
(Tag F0609)
Could have caused harm · This affected 1 resident
**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, interview, and record review, the facility failed to ensure that all alleged violations involving abuse we...
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**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, interview, and record review, the facility failed to ensure that all alleged violations involving abuse were reported, immediately but not later than 2 hours after the allegation was made, if the events that cause the allegation involves abuse or results in serious bodily injury, to the State Survey Agency for 1 of 4 residents (Residents #2) reviewed for reporting allegations of abuse.
The facility failed to report an allegation of abuse within 2 hours after LVN O allegedly verbally abused Resident #2 on 10/14/2024.
The failures could place residents at risk of abuse, physical harm, mental anguish, and emotional distress.
Findings included:
Record review of Resident #2's admission Record dated 02/12/2025 indicated he was an [AGE] year-old male who was initially admitted to the facility on [DATE] with diagnoses which included profound intellectual disabilities (severe disability which limits a person's ability to learn, communicate, and live independently), atrial fibrillation (a type of irregular heartbeat), muscle weakness, heart failure (serious condition occurs when the heart can't pump enough blood and oxygen to the body), hypertension (condition in which the force of the blood against the artery walls is too high), and diabetes (chronic condition affecting the way the body processes blood sugar).
Record review of Resident #2's admission MDS assessment, dated 09/26/2024, indicated resident had intellectual disabilities and was rarely or never understood and a brief interview for mental status (BIMS) was not conducted. He had continued behaviors of inattention and disorganized thinking. The Functional abilities self-care indicated he was independent with eating, oral care, upper body dressing and required moderate assistance with shower/bathing and lower body dressing. The Functional abilities mobility indicated he was independent with all tasks except toilet transfers which required supervision or touching assistance and car transfer was not applicable.
Record review of Resident #2's care plan, dated 09/17/2024, indicated he had impaired cognitive function/dementia or impaired thought processes. Interventions included communication techniques, effective strategies, monitor for confounding problems, frustration levels, physical/nonverbal indications, and report to MD if changes were identified.
During an observation on 02/11/2025 at 11:30 a.m., Resident #2 ambulated to the dining room using a walker. He appeared well groomed with no foul odors and no signs of abuse or neglect were identified. Resident #2 interacted with facility staff with no indication of fear or discomfort. Unable to interview Resident #2 due to his severely impaired cognition.
Record review of the Provider Investigation Report dated 10/24/2024 indicated on 10/14/2024 at 1:50 p.m., a staff member called and texted the Administrator regarding an incident that occurred with Resident #2 and LVN O. The allegation was LVN O hollered loudly at Resident #2 to stop singing. The Administrator requested witness statements from the facility staff involved and/or observed the incident. Resident #2 was interviewed, assessed, and monitored following the incident with no adverse findings. The Investigation Findings indicated it was unfounded after talking with the resident and the witness statements provided. It was determined LVN O did not tell Resident #2 to stop singing, she just asked co-workers who were making the noise or singing. Per the witnesses, Resident #2 was likely not within hearing range at the time. The Agency Action Post-Investigation included in-service performed on all staff on abuse and neglect, resident rights, code of conduct and professionalism, and timely reporting of allegations. The date and time reported to HHSC was on 10/24/2024 at 8:24 p.m. (10 days after the incident was initially reported).
During an interview on 02/13/2025 at 4:15 p.m., the Administrator said the allegation of LVN O speaking rudely and loudly to Resident #2 was unfounded. The Administrator said the incident happened at shift change on 10/14/2024 and LVN O left. The Administrator said after reviewing the witness statements and conducting interviews on 10/14/2024 it was determined Resident #2 was not verbally abused by LVN O. The Administrator said Resident #2 was not aware of the incident and LVN O did not have direct verbal contact with Resident #2, so she did not report the allegation. The Administrator said when she was discussing the allegation with her ADO on 10/24/2024, she was informed the allegation should have been reported to the State Agency, so she reported the allegation at that time. The Administrator said the allegation should have been reported within 2 hours of the allegation and then investigated. The Administrator said not reporting and investigating the alleged abuse could place residents at risk for further abuse.
Record review of the facility's policy Abuse/Neglect, date revised 03/29/2018, indicated .Reporting 1. Any person having reasonable cause to believe an elderly or incapacitated adult is suffering from abuse, neglect or exploitation must report this to the DON, administrator, state and/or adult protective services. State law mandates that citizens report all suspected cases of abuse, neglect, or financial exploitation of the elderly and incapacitated persons. 2. When a suspected abused, neglected, exploited, mistreated or potential victim of misappropriation of property comes to the attention of any employee, that employee will make an immediate verbal report to the Abuse Preventionist or designee. If the discovery occurs outside of normal business hours, the Abuse Preventionist and/or designee will be called. 3. Facility employees must report all allegations of: abuse, neglect, exploitation, mistreatment of residents, misappropriation of resident property or injury of unknown source to the facility administrator. The facility administrator or designee will report to HHSC all incidents that meet the criteria of Provider Letter 2024-14 dated 8/29/2024. a. If the allegations involve abuse or result in serious bodily injury, the report is to be made within 2 hours of the allegation b. If the allegation does not involve abuse or serious bodily injury, the report must be made within 24 hours of the allegation.
CONCERN
(D)
📢 Someone Reported This
A family member, employee, or ombudsman was alarmed enough to file a formal complaint
Potential for Harm - no one hurt, but risky conditions existed
Investigate Abuse
(Tag F0610)
Could have caused harm · This affected 1 resident
**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, interview, and record review, the facility failed investigate and report the findings of the investigation...
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**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, interview, and record review, the facility failed investigate and report the findings of the investigation to the State Survey Agency within 5 working days of the incident for 1 of 4 residents (Residents #2) reviewed for abuse.
The facility failed to investigate and submit the results of their investigation within 5 days after LVN O allegedly verbally abused Resident #2 on 10/14/2024.
These failures could place residents at risk of abuse, physical harm, mental anguish and emotional distress.
Findings included:
Record review of Resident #2's admission Record dated 02/12/2025 indicated he was an [AGE] year-old male who was initially admitted to the facility on [DATE] with diagnoses which included profound intellectual disabilities (severe disability which limits a person's ability to learn, communicate, and live independently), atrial fibrillation (a type of irregular heartbeat), muscle weakness, heart failure (serious condition occurs when the heart can't pump enough blood and oxygen to the body), hypertension (condition in which the force of the blood against the artery walls is too high), and diabetes (chronic condition affecting the way the body processes blood sugar).
Record review of Resident #2's admission MDS assessment, dated 09/26/2024, did not indicated a BIMS score identified resident was rarely/never understood and interview not obtained, and he was rarely/never able to make himself understood and rarely/never understood others. He was frequently incontinent of bowel and bladder. The Functional abilities self-care indicated he was independent with eating, oral care, upper body dressing and required moderate assistance with shower/bathing and lower body dressing. The Functional abilities mobility indicated he was independent with all tasks except toilet transfers which required supervision or touching assistance and car transfer was not applicable.
Record review of Resident #2's care plan, dated 09/17/2024, indicated he had impaired cognitive function/dementia or impaired thought processes. Interventions included communication techniques, effective strategies, monitor for confounding problems, frustration levels, physical/nonverbal indications, and report to MD if changes identified.
During an observation on 02/11/2025 @ 11:30 a.m., Resident #2 ambulating to dining room using walker, appears well groomed with no foul odors and no signs of abuse or neglect identified. Resident #2 interacts with facility staff with no indication of fear or discomfort. Unable to interview Resident #2 due to his severely impaired cognition.
Record review of the Provider Investigation Report dated 10/24/2024 indicated on 10/14/2024 at 1:50 p.m., A staff member called and texted the Administrator regarding an incident occurred with Resident #2 and LVN O. The allegation was LVN O hollered loudly at Resident #2 to stop singing. The Administrator requested witness statements from the facility staff involved and/or observed the incident. Resident #2 was interviewed, assessed, and monitored following the incident with no adverse findings. The Investigation Findings indicated it was unfounded after talking with the resident and the witness statements provided, it was determined LVN O did not tell Resident #2 to stop singing, she just ask co-workers who was making the noise or singing. Per the witnesses, Resident #2 may not have been within hearing range at the time. The Agency Action Post-Investigation included room changes made would remain permanent, psych evaluations in-service performed on all staff on abuse and neglect, resident rights, code of conduct and professionalism, and timely reporting of allegations. The date and time reported to HHSC was on 10/24/2024 at 8:24 p.m. (10 days after the incident was initially reported).
During an interview on 02/13/2025 at 4:15p.m., the Administrator said the allegation of LVN O speaking rudely and loudly to Resident #2 was unfounded. The Administrator said the incident happened at shift change on 10/14/2024 and LVN O left. The Administrator said after reviewing the witness statements and conducting interviews on 10/14/2024 it was determined Resident #2 was not verbally abused by LVN O. The Administrator said Resident #2 was not aware of the incident and LVN O did not have direct verbal contact with Resident #2, so she did not report the allegation. The Administrator said when she was discussing the allegation with her ADO on 10/24/2024 she was informed the allegation should have been reported to the State Agency, so she reported the allegation at that time. The Administrator said the abuse allegation should have been reported to HHSC within 2 hours of the allegation and the provider investigation report should have been sent to HHSC no later than 5 working days after the incident or initial report. The Administrator said not reporting and investigating the alleged abuse could place residents at risk for further abuse.
Record review of the facility's policy Abuse/Neglect, date revised 03/29/2018, indicated . F. Investigation . 1. The administrator in consultation with the Risk Management Department will be responsible for investigating and reporting cases to the HHSC. 2. After receipt of the allegation the Abuse Preventionist and administrator in conjunction with Risk Management will immediately evaluate the resident's situation using the criteria as stated in this policy. Determination will be made for required reporting to HHSC per reporting guidelines found in Provider letter 19-17.3. A report to the appropriate agency will include the following: the name and address of the suspected victim; the name and address of the suspected victim's care giver, if known; the nature and extent of any injuries resulting from the suspected abuse, neglect, exploitation, mistreatment of residents, misappropriation of resident property and injury of unknown source; the nursing facility will make an addendum to any reportable incident in its report to HHSC if the resident subsequently experiences a negative outcome; other pertinent information as available. The written report must be sent to HHSC no later than the fifth working day after the initial report. The facility will use the designated state reporting form.
Oct 2024
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
Deficiency F0849
(Tag F0849)
Could have caused harm · This affected 1 resident
**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on interviews and record review, the facility failed to collaborate with hospice representatives and coordinate the hospic...
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**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on interviews and record review, the facility failed to collaborate with hospice representatives and coordinate the hospice care planning process for each resident receiving hospice services, to ensure quality of care for the resident, ensuring communication with the hospice medical director, the resident's attending physician, and others participating in the provision of care for 1 of 3 residents (Resident #1) reviewed for hospice services.
The facility failed to obtain Resident #1's hospice plan of care, nurse visit notes, and aide visit notes.
This failure could place residents who receive hospice services at-risk of receiving inadequate end-of-life care due to a lack of documentation, coordination of care and communication of resident needs.
Findings included:
Record review of Resident #1's face sheet dated 10/02/24 indicated she was a [AGE] year old female, admitted on [DATE], and her diagnoses included gastrostomy (an opening in the abdomen and into the stomach to provide nutritional support), breast cancer, diabetes (chronic disease that occurs either when the pancreas does not produce enough insulin or when the body cannot effectively use the insulin), unspecified protein calorie nutrition (lack of proper nutrition to absorb nutrients from food), morbid obesity (weight is more than 80-100 pounds above their ideal body weight) due to excessive calories, seizures (sudden, uncontrolled burst of electrical activity in the brain), chronic pain syndrome (persistent pain), end stage heart failure (the heart is too weak to pump blood effectively), chronic embolism (blockage) and thrombosis (blood clots block veins or arteries) of deep veins, contracture (tightening of muscles, tendons, ligaments, skin, and nearby tissues that causes joints to shorten and stiffen), osteomyelitis (bone infection), and chronic kidney disease (kidneys slowly get damaged and can't do important jobs like removing waste and keeping blood pressure normal).
Record review of Resident #1's admission MDS dated [DATE] indicated she was sometimes understood and sometimes understood others, had severe cognitive impairment (BIMS-00), and received hospice care.
Record review of Resident #1's MDS OSA dated 09/02/24 indicated she was totally dependent on 2+ person physical assist for bed mobility, transfers, and toilet use.
Record review of Resident #1's facility care plan dated 08/27/24 (revised on 08/30/24) indicated she had a terminal prognosis and/or was receiving hospice services from (named hospice provider) for diagnoses of heart disease. Interventions included adjust provision of ADLS to compensate for Resident #1's changing abilities and if receiving hospice services, to work cooperatively with the hospice team to ensure the resident's spiritual, emotional, intellectual, physical, and social needs were met.
Record review of the Order Summary Report dated 08/27 indicated Resident #1 had an order to admit to the facility under care of (named hospice provider).
Record review of Resident #1's EHR indicated there was no hospice plan of care, nurse visit notes, and aide visit notes available for review.
Record review of the hospice plan of care dated 09/25/24 provided by the Administrator on 10/03/24 indicated there was no communication or coordination of care related to the provision of ADLS and sufficient staff to meet the need of Resident #1 as identified by the facility.
During an interview on 10/02/24 at 2:55 p.m., the DON said the administrator was responsible for the residents' medical records. She said if the facility did not have the residents' hospice records, the residents were at risk of not receiving care as required.
During an interview on 10/02/24 at 3:27 p.m., RNC A said the facility was responsible to obtain residents' hospice records. She said if the facility did not have the residents' hospice records, the residents were at risk of not receiving care as required.
During an interview on 10/03/24 at 4:43 p.m., the Administrator said the hospice providers usually send the residents' plan of care, nurse visit notes, and aide visit notes to the facility monthly. She said she was responsible for residents' medical records and uploading the hospice documents into the EHR. She said (named hospice provider) had not sent Resident #1's care plan, nurse visit notes, or aide visit notes as of 10/02/24. She said she received the hospice care plan on 10/03/24. She said she had not received any hospice nurse visit notes or hospice aide visit notes. She said it was important for the facility to have the hospice documents for the facility to be up to date on the hospice plan of care to ensure coordination of care and ensure residents received care as required.
Record review of the facility's Hospice Services policy dated 02/13/07 indicated .11. The DON or designee will be responsible for ensuring that documentation is a part of the current clinical record. At a minimum, the documentation will include: The current and past Texas Medicaid Hospice Recipient Election/Cancellation Form (#3071), Texas Medicaid Hospice-Nursing Facility Assessment Form (#3073), Physician Certification of Terminal Illness (#3074), Medicare Election Statement (if dual eligible), Verification that the recipient does not have Medicare Part A, Hospice Plan of Care, Current interdisciplinary notes to include nurses notes/summaries, physician orders and progress notes, and medications and treatment sheets during the hospice certification period.
Record review of the Hospice and Nursing Facility Services Agreement dated 04/01/22, indicated, .a. Hospice and Facility shall communicate with one another regularly and as needed for each particular Hospice patient. Each party is responsible for documenting such communications in its respective clinical records to ensure the needs of the Hospice patients are met 24-hours per day.Coordination of Services. Hospice shall: . c. Provide Facility with the following information specific to each Hospice Patient residing at the facility: (i) the most recent plan of care; (ii) the hospice election form and any advanced directives: (iii) the physician certification and recertification(s) of illness; (iv) the names and contact information for Hospice staff involved in the care of the patient; (v) Instructions on how to access the Hospice's 24-hour on-call system; (vi) Hospice medication information; and (vii) Hospice physician and attending physician (if any) orders.
Sept 2024
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
Transfer Requirements
(Tag F0622)
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 permit each resident to remain in the facility, and not transfer or...
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**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on interview and record review, the facility failed to permit each resident to remain in the facility, and not transfer or discharge the resident from the facility unless the discharge was necessary for the resident's welfare and the resident's needs could not be met in the facility for 1 of 5 residents (Resident #1) reviewed for discharge requirements.
The facility failed to ensure Resident #1 was readmitted to the facility, after being treated at a behavior hospital.
This failure could place discharged residents and residents residing in the facility at risk of being discharged and not allowed to return to the facility causing a disruption in their care and/or services.
Findings included:
Record review of Resident #1's face sheet dated 09/4/24 indicated Resident #1 was a [AGE] year-old male admitted to the facility on [DATE]. His diagnoses included unspecified dementia (loss of memory, language, problem-solving and other thinking abilities that are severe enough to interfere with daily life) unspecified severity, without behavioral disturbance, mood disturbance and anxiety, cerebral infarction (stroke), cognitive communication deficit (difficulty with communication), major depressive disorder (serious mental illness), and alcohol abuse.
Record review of Resident #1's physician orders dated 07/30/24 indicated to admit Resident #1 to the facility on [DATE], continue orders for 60 days, and he required nursing facility care for 180 days.
Record review of Resident #1's discharge MDS dated [DATE] indicated Resident #1's return anticipated, it was an unplanned discharge.
Record review of Resident #1's BIMS (dated 03/10/24 from a previous admission) indicated a score of 4 (severe cognitive impairment).
Record review of Resident #1's care plan dated 07/31/24 (revised 08/02/24) indicated he was at risk for wandering. Interventions included distract by offering pleasant diversions, structured activities, food, conversation, television, and books. If Resident #1 was exit seeking, stay with the resident and notify the charge nurse.
Record review of Resident #1's care plan dated 07/31/24 (revised 08/02/24) indicated Resident #1 had adjustment issues to admission. Interventions included encourage Resident #1 to participate in conversation with staff and other residents.
Record review of Resident #1's care plan dated 07/30/24 indicated he resided on the secure unit related to diagnoses of dementia and risk of elopement. Interventions included involve resident in daily activities.
Record review of Nursing Progress note dated 07/31/24 at 2:21 p.m., completed by LVN C indicated Resident #1 pushed LVN C, kicked the exit door which opened and then jumped over the fence and ran along a canal away from the facility.
Record review of Residents #1's Nursing Progress Note dated 07/31/24 at 4:01 p.m., completed by ADON D indicated Resident #1 was observed walking down (named street). ADON D attempted to talk to Resident #1 to get him back to the facility. Resident #1 continued under the overpass. Resident #1 continued walking on the feeder road. ADON D stopped his vehicle to block traffic and protect the resident from harm. Resident #1 entered the ADON's vehicle and returned to the facility. He was assessed and vitals were WNL. He had no injuries and no complaint of pain or discomfort.
Record review of the Disposition Agreement between the facility and the behavior hospital dated 07/31/24 and signed by ADON D indicated the facility acknowledged they would accept Resident #1 back upon his discharge from the behavior hospital and would not refuse to accept Resident #1.
Record review of Residents #1's Nursing Progress Note dated 08/02/24 at 9:43 a.m., completed by ADON D indicated RP was informed Resident #1 was transported from the hospital to the behavior hospital to be evaluated. RP expressed concerns about Resident #1's safety if he returned to the facility. RP agreed Resident #1 would be better placed in a facility that could assist his needs.
Record review of Residents #1's Nursing Progress Note dated 09/03/24 at 3:31 p.m., completed by LVN A indicated it was a late entry. On 08/28/24 at approximately 3:30 p.m., LVN A received a call from the behavior hospital and was informed the behavior hospital was trying to give report on Resident #1. LVN A explained the facility would not accept Resident #1 per the administrator. At approximately 6:00 p.m., LVN A received a call from DON B at the behavior hospital who attempted to give report for Resident #1. LVN A explained the Administrator had given LVN A instruction not to accept report on Resident #1 and discharge papers had been sent informing the behavior hospital of his (Resident #1) discharge from the facility. DON B said the facility Administrator had accepted Resident #1 and he was enroute to the facility. LVN A explained to DON B the facility would not accept Resident #1 and he would return to the behavior hospital. At approximately 9:45 p.m., a transport van arrived at the facility and the driver had a container with Resident #1's belongings. LVN A explained the facility would not accept Resident #1. The driver indicated Resident #1 was at the hospital due to attempts to jump out of the van while it was moving. LVN A instructed the driver to return Resident #1's belongings to the behavior hospital and to have her employer notify the behavior hospital of Resident #1's location.
Record review of Resident #1's Discharge Notification dated 08/28/24, completed by the Administrator, indicated Resident #1 was discharged from the facility on 08/28/24. The reasons for the discharge included 1. The discharge is necessary for the resident's welfare and the resident's needs cannot be met by the facility. 3. The safety of the individuals in the facility is endangered due to the clinical or behavioral status of the resident. 4. The health of individuals in the facility would otherwise be endangered. Due to (Resident #1's) ongoing physical aggression and lack of desire to resident in long term care facilities, the safety and well being of residents and staff is in jeopardy. (Resident #1) is also not safe and is a harm to himself due to his impulsive and aggressive behaviors. (Resident #1) expresses the desire to leave and states that he is not opposed to hurting others to get away.
Record review of the Discharge-Unable to Meet Needs Physician/NP/PA Statement signed and dated 08/28/24 by MD J for Resident #1's Discharge Notification indicated 1. What are the specific need the facility cannot meet? Resident aggression, Resident eloped from the facility through secure area. Resident is a danger to other residents and staff of facility. 2. What were the facility efforts to meet those needs? Resident was sent to behavioral hospital. Facility has sent his referral to more than 15 facilities including all men's unit; denied. Resident was only in the facility for less than 24 hours when elopement and aggressions started.
Record review of Residents #1's Psychiatric Progress Note from the behavior hospital dated 08/28/24 indicated .(Resident #1) . last PRN med was given on 08/25 and has no need for PRN medication meds since . currently at baseline with no aggression or agitation noted. Discharging Today .
Record review of Resident #'1's nurse note from the behavior hospital dated 08/28/24 indicated (Resident #1) is ambulating in the hallway, mood is congruent with the (Resident #1's) statement well and good . smiles and speaks when spoken to, denies any anxiety or depression at this time, has not shown an anxiousness, aggression, or combativeness at this time, (Resident #1) is set to discharge back to NH today, all safety needs were met at this time .
Record review of Residents #1's Nursing Progress Note dated 08/29/24 at 1:57 a.m., completed by LVN L indicated the hospital ER charge nurse called the NF and reported Resident #1 was being sent back to the NF. The hospital ER charge nurse was informed Resident #1 was discharged from the facility.
Record review of Residents #1's Nursing Progress Note dated 08/29/24 at 2:30 a.m., completed by LVN L indicated the hospital ER charge nurse called and stated he spoke with DON B from the behavior hospital and the facility's Administrator had approved Resident #1's return to the facility. LVN L indicated she would have to confirm with the facility's Administrator.
Record review of Residents #1's Nursing Progress Note dated 09/03/24 at 3:15 a.m., completed by LVN L indicated the charge nurse from the hospital ER called to send Resident #1 back to the facility. The charge nurse from the hospital ER was informed Resident #1 was discharged from the facility.
During an interview on 09/04/24 at 10:45 a.m., the Administrator said Resident #1 was sent to the behavior hospital on [DATE] because he eloped from the facility and was a danger to himself and others. She said Resident #1 kicked open the exit door on the secure unit, jumped the 7 foot fence, walked along a canal toward the highway. She said ADON D was able to follow Resident #1 in his truck and then convinced Resident #1 into his truck and returned to the facility. She said the police were called because Resident #1 refused to get out of ADON D's vehicle and go in to the facility. She said Resident #1 indicated he did not want to be in the facility and would hurt someone if he had to in order for him to leave the facility. Resident #1 was transported by the police to the hospital and the hospital wanted to return him to the facility. She said the behavior hospital agreed to admit Resident #1 and picked him up from the hospital on [DATE]. The administrator said she told the behavior hospital on [DATE] that the facility would not take Resident #1 back because his aggressive behaviors were not resolved. She said the behavior hospital continued to call the facility and sent Resident #1 back to the facility after she (the Administrator) had sent Resident #1's Immediate Discharge to the behavior hospital on [DATE].
During an interview on 09/04/24 at 11:10 a.m., ADON D said he observed Resident #1 walking down (named street) on 07/28/24. He said he attempted to talk to Resident #1 and get him to return to the facility. He said Resident #1 continued to the feeder road and then under the overpass on to the next feeder road toward the highway. He said he blocked traffic with his truck and convinced Resident #1 to get in his truck. He said Resident #1 refused to get out of his truck and enter the facility. He said the police were called to assist. He said Resident #1 got out of truck and was transported to the hospital by the police. He said the behavior hospital agreed to take Resident #1 and transported him to their facility on 08/01/24.
During an interview on 09/04/24 at 11:30 a.m., RD M said Resident #1 was not re-admitted to the facility due to continued aggression and being a threat to others. He said Resident #1 was ex-military, said he did not want to be in the facility, and threatened to hurt others if he was forced to be in the facility. He said Resident #1's family did not want to be involved or have anything to do with him.
During an interview on 09/04/24 at 1:12 p.m., LVN C said Resident #1 was pacing and getting more agitated on 07/31/24. She said the CNA left the secure unit to get ice and soda. She said Resident #1 kicked open the exit door and she attempted to stop his exit. She said she attempted to stop him and grabbed Resident #1's arm. LVN C said Resident #1 flung her against the brick wall, took off and jumped the fence and he was gone. She said she had tried to distract him with activities and TV. She said he never threatened or harmed any of the other residents on the secure unit. She said she called for help immediately and staff went to locate Resident #1.
During an interview on 09/04/24 at 1:55 p.m., CNL G said she reviewed Resident #1's chart and he exhibited no aggression or behaviors and it was time for his discharge back to the NF. She said she spoke with the facility Administrator and explained Resident #1's stay at the behavior hospital was over and she said o.k. She said the facility was notified transport was set up and then the facility indicated they would not take Resident #1 back.
During an interview on 09/04/24 at 2:11 p.m., Administrator F for the behavior hospital said they agreed to assist with finding alternate placement for Resident #1 but if they were not successful the NF would have to accept Resident #1's return to the NF. She said Resident #1 was assessed as stable and did not require further locked psych level care in the behavior hospital. She said CNL G spoke with the facility Administrator and explained Resident #1's stay at the behavioral hospital was over. She said the NF Administrator said she agreed. She said transportation was arranged for Resident #1's return to the NF.
During an interview on 09/04/24 at 2:33 p.m., the Administrator said when she spoke with CNL G on 08/28/24 and was informed the behavior hospital was sending Resident #1 back to the NF, she told them not send him back. She said she did not agree to take him back. She said CNL G said Resident #1 had not had any behaviors for two days and had to return to the facility. The Administrator said she told CNL G to find alternate placement for Resident #1. She said she then completed an immediate discharge notice for Resident #1 on 08/28/24 and sent it to the behavior hospital.
During an interview on 09/04/24 at 2:40 p.m., DON E said she took report from the behavior hospital on [DATE]. She said Resident #1 had continued aggression towards peers and there was no discharge date set.
During an interview on 09/05/24 at 8:49 a.m., SW H said Resident #1 resided in the facility for less than 24 hours when he eloped form the secure unit and jumped over the security fence. She said he was discharged to a behavior hospital. She said the behavior hospital was assisting with finding alternate placement but was not successful. She said she had not completed any discharge planning because an alternate placement was not found for Resident #1.
During an interview on 09/05/24 at 10:00 a.m., RCN I said she reviewed Resident #1's records from the behavior hospital on [DATE]. She said she did not feel the facility was a safe place for Resident #1 because he was able to jump the security fence of the secure unit and how close the facility was to the highway. She said she believed Resident #1 was not stable due to continued aggression and had required medications for aggression two days previously at the behavior hospital. She said Resident #1 was issued an immediate discharge from the facility on 08/28/24 and it was sent to the behavior hospital.
During an interview on 09/09/24 at 1:42 p.m., DON B said the behavior hospital's discharge planner spoke with the Administrator on 08/14/24 regarding finding placement for Resident #1. He said the facility Administrator was advised Resident #1 would have to return to the facility if no new placement was found. He said he spoke with DON H on 08/19/24 and informed her all the placement referrals were denied and he was asked to send a third referral which he did. DON B said on the 08/27/24 the behavior hospital planned Resident #1's discharge. He said he spoke to the SW H who indicated the facility IDT still had some concerns of Resident #1's behavior from 08/24/24. He said Resident #1 had confusion and disorientation due a UTI. He said he advised SW H he would forward the assessment and notes to the facility. He said he called the facility and the Administrator indicated she was taking over all of Resident #1's discharge planning.
Record review of the facility's Facility Initiated Discharge Protocol (undated) indicated Perform the following actions: (enter the date completed for each action) Discharge-Unable to Meet Needs-Physician/NP/PA Statement on page 2 completed. If financial discharge on ly, page 2 is not required. Discharge Notice on page 3 completed. Discharge Notice provided to the following: Resident, Resident Representative, Ombudsman, Other facility-Only required if resident is currently at another facility, i.e. hospital, psych center, etc.
Record review of the facility's Discharge Planning Procedure dated 11/28/16 does not include immediate discharge protocols.
May 2024
2 deficiencies
CONCERN
(E)
Potential for Harm - no one hurt, but risky conditions existed
Safe Environment
(Tag F0584)
Could have caused harm · This affected multiple residents
**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observations, interviews, and record review, the facility failed to provide a safe, clean, comfortable and homelike env...
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**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observations, interviews, and record review, the facility failed to provide a safe, clean, comfortable and homelike environment, including but not limited to receiving treatment and supports for daily living safely and housekeeping and maintenance services necessary to maintain a sanitary, orderly, and comfortable interior for 10 out of 10 residents in the secure unit reviewed for environment.
The facility failed to ensure housekeeping and maintenance services were provided for Resident #4. The facility failed to clean and lock an in-wall storage cabinet in Resident #4's room.
The facility failed to ensure the air conditioning was working properly to provide comfortable and safe temperature levels for residents in the secure unit and failed to keep cabinets secured and clean. Temperatures in resident rooms were above 81 degrees F.
These failure could place residents at risk of being uncomfortable and being in an institutional environment versus a homelike environment.
Findings included:
Record review of Resident #4's admission record, dated 05/16/2024, revealed an [AGE] year-old female who admitted on [DATE] and readmitted on [DATE] with diagnosis that included Alzheimer's Disease.
Record review of Resident #4's Quarterly MDS assessment, dated 04/02/2024, revealed a BIMS score of 3, indicating severe cognitive impairment.
Observation on 05/14/24 at 9:22 AM in Resident #4's room revealed resident was not in the room, bed was made, and room was clean. Upon entry to the room, the wall on the left had an in-wall cabinet with a latch. The cabinet was not locked and contained 2 black wires going through the ceiling into the side of the wall on the left side, dust, a sleeve of plastic cups, a white plastic mouse trap, what appeared to be rodent droppings, and rolls of wrapping paper.
Observation and interview on 05/15/2024 at 3:41 PM in Resident #4's room, revealed the in-wall cabinet was not locked. The Maintenance Supervisor opened the cabinet doors, stated it was dirty, and it looked like there were pest droppings inside. He said it should be locked and he would put a lock on the cabinet. He stated they used to have old records stored in there. He stated he would get it cleaned and the risk was the residents could catch something from the droppings.
Observation and interview on 05/15/224 at 4:05 PM in Resident #4's room, the Administrator looked inside the cabinet and stated there was possible rodent poop. She stated the risk to residents was rodents have diseases. The Administrator stated residents could lock themselves in and the cabinet should have a pad lock for resident safety. She stated there was one other room with a cabinet like this on unit one and it was locked.
Record review of Resident #31's admission record, dated 05/16/2024, reveled an [AGE] year-old male who admitted on [DATE] and readmitted on [DATE] with diagnoses that included unspecified dementia, congestive heart failure, and chronic kidney disease.
Record review of Resident #31's quarterly MDS assessment, dated 04/24/2024 revealed a BIMS score of 3, indicating severe cognitive impairment.
Record review of Resident #1's admission record, dated 05/16/2024, revealed a [AGE] year-old male who admitted on [DATE] and readmitted on [DATE] with diagnoses that included schizophrenia, polycythemia vera, and hypokalemia.
Record review of Resident #1's quarterly MDS assessment, dated 02/02/2024 revealed no BIMs score. Further review of the MDS revealed Resident #1 usually made self understood and understood others and had moderately impaired cognitive skills for daily decision making.
Record review of Resident #248's admission record, dated 05/16/2024, revealed a [AGE] year-old male who admitted on [DATE] with diagnoses that included unspecified dementia, leukemia, type 1 diabetes mellitus, and schizoaffective disorder.
Record review of Resident #248's admission MDS assessment, dated 05/08/2024 revealed a BIMS score of 0, indicating severe cognitive impairment.
Observation on 05/14/2024 at 08:41 AM in the secure unit revealed 2 large black coolers in the hallway not running. Temperature felt comfortable.
Interview on 05/15/2024 at 11:24 AM, the Maintenance Supervisor stated the coil on the AC unit needed to be replaced. He stated they had quotes and were waiting on approval. He said it had been out for about 2 weeks and he had not been monitoring the room temperatures. He stated he would check the thermostat and if it was under 80 degrees it was fine. He said they got 2 big coolers and just today they had installed the small portable AC on the hall to the right [in the secure unit].
Interview on 05/15/2024 at 3:20 PM, the Administrator stated by the end of the day she would know about the AC.
Observation and interview on 05/15/2024 at 3:24 PM, CNA A pushed the ice cart to the secure unit. Upon entry, she stated it was hot back here and it had been like that for 3 days. The temperature felt warm.
Observation on 05/15/2024 at 3:24 PM revealed the 2 swamp coolers on in the hall pointed towards the entrance door. The wall thermostat read 74 degrees and one cooler was adjacent to the thermostat.
Observation on 05/15/2024 at 3:29 PM, Resident #31 and Resident #1 were in their room. The room felt warm upon entering. Resident #31 was lying in bed with a cover pulled over him. Resident #1 was sitting on the side of bed B facing the window. Resident #31 stated he was not hot, and Resident #1 was not interviewable.
Observation and interview on 05/15/2024 at 3:41 PM, the Maintenance Supervisor took the temperature of Resident #4's room. The internal wall was 79 degrees and the outside wall was 83 degrees. The Maintenance Supervisor then took the temperature of Resident #31 and Resident #1's room and the internal wall was 87 degrees, and the outside wall was 91 degrees. He stated the room temperature should not be over 80 degrees. He said the residents should be moved because it was warm. He said he took room temperatures when the unit first went down but had not been taking the temperatures since they purchased the coolers.
In an interview on 05/15/2024 at 3:29 PM, LVN B stated the risk to the residents would be they could overheat and dehydrate. She stated the staff were moving the residents to the dining room because it was cooler.
Observation on 05/15/2024 at 4:03 PM, the Maintenance Supervisor took the temperature of the dining room, and the interior wall was 78 and the vent was 73 degrees.
In an interview on 05/15/2024 at 4:04 PM, the Administrator stated they were taking immediate action and were going to purchase 8 units, one for each resident room.
Observation and interview on 05/15/2024 at 4:20 PM, revealed Resident #1 sitting in the TV area, calm and nonverbal. LVN B checked Resident #1's vital signs which were BP 142/67, P 89, and Temporal temp 99.7 degrees. The DON was sitting in the dining room with Resident #31 and stated she checked his BP and P but LVN B checked his temp. A slip of paper with Resident #31's vitals read BP 128/64, P 68, O2 sat 98%, and temp was scribbled out but appeared to have read 99 and 97/1 was written beneath. LVN B stated she was going to recheck because she thought she may have used the thermometer incorrectly. Resident #31's temperature was rechecked and was 99.4 degrees.
In an interview on 05/16/2024 at 10:22 AM, the Administrator stated she had been monitoring the room temps in the secure unit but did not document. She stated they knew it was getting warmer but not out of compliance. She stated she would temp during the heat of the day, between 6-7 pm, and would temp the internal walls and the air coming out of the vent. The Administrator stated the regulation was for the temperature to be under 81 and the facility policy was under 80 degrees. She stated they were now monitoring the temps and started when alerted by the State Surveyors. She said they began at 2:45 pm and checked every 2 hours.
In an interview on 05/16/2024 at 11:30 AM, the Administrator stated they began getting quotes on either repair or replacement on 04/23/2024 and on 05/07/2024 was when they purchased the 2 big swamp coolers. She stated the staff would say it was really warm on the secure unit.
Record review of temperatures from https://www.accuweather.com/en/us/[NAME]/77701/may-weather/331129 revealed the following temperatures in degrees F since 05/07/2024:
-05/07/2024 high of 85, low of 76
-05/08/2024 high of 86, low of 77
-05/09/2024 high of 87, low of 78
-05/10/2024 high of 88, low of 68
-05/11/2024 high of 84, low of 66
-05/12/2024 high of 82, low of 65
-05/13/2024 high of 86, low of 66
-05/14/2024 high of 86, low of 64
-05/15/2024 high of 91, low of 63
Record review of screenshot of [store name] receipt revealed 2 swamp coolers were ready for pickup today, Tuesday May 7.
Review of screenshot of [store name] receipt revealed 8 Window Air Conditioners were ready for pickup today, Wednesday May 15.
Record review of handwritten sheet dated 05/15/2024 with all residents listed and vital signs revealed the following:
-Resident #31: BP 107/62, P 79, Temp 98.3, 98.6 and 98.2
-Resident #1: BP 142/67, P 89, Temp 99.7, 99.3, 99.4
-Resident #248: BP 144/77, P 65, Temp 99.8, 98.9, 98.2
Record review of monitoring chart dated 05/15/2024-05/16/2024 revealed the following room temperatures in degrees F:
room [ROOM NUMBER]:
-82 at 3:00 PM
-84 at 5:00 PM
-74 at 7:00 PM
-75 at 9:00 PM
-74.4 at 1:00 AM
-72.6 at 3:00 AM
-72.3 at 5:00 AM
-71.1 at 7:00 AM
room [ROOM NUMBER]:
-82 at 3:00 PM
-84 at 5:00 PM
-74 at 7:00 PM
-74 at 9:00 PM
-73.7 at 1:00 AM
-72.3 at 3:00 AM
-72.8 at 5:00 AM
-71.2 at 7:00 AM
room [ROOM NUMBER]:
-82 at 3:00 PM
-84 at 5:00 PM
-74 at 7:00 PM
-74 at 9:00 PM
-74.1 at 1:00 AM
-73.7 at 3:00 AM
-79.8 at 5:00 AM
-73.6 at 7:00 AM
room [ROOM NUMBER]:
-82 at 3:00 PM
-84 at 5:00 PM
-74 at 7:00 PM
-75 at 9:00 PM
-75.5 at 1:00 AM
-73.7 at 3:00 AM
-75.3 at 5:00 AM
-71.4 at 7:00 AM
room [ROOM NUMBER]:
-82 at 2:45 PM
-84 at 3:00 PM
-74 at 5:00 PM
-74 at 7:00 PM
-73.7 at 9:00 PM
-79 at 1:00 AM
-73.6 at 3:00 AM
-71.4 at 5:00 AM
Review of facility policy titled Resident Rights, undated, reflected, in part:
Safe environment - The resident has a right to a safe, clean, comfortable, and homelike environment, including but not limited to receiving treatment and supports for daily living safely. The facility must provide - . 6. Comfortable and safe temperature levels. Facilities initially certified after October 1, 1990 must maintain a temperature range of 71 to 81°F .
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 observations, interviews, and record reviews, the facility failed to ensure residents who needed respiratory care were ...
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**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observations, interviews, and record reviews, the facility failed to ensure residents who needed respiratory care were provided such care, consistent with professional standards of practice for 4 (Resident #19, Resident #27, Resident #28, and Resident #198) of 7 residents reviewed for respiratory care.
The facility failed to ensure there were cautionary and safety signs indicating the use of oxygen outside the resident's rooms where oxygen was used.
These failures placed the residents at increased risk of injury due to fire hazards.
Findings included:
Record review of Resident #19's admission Record dated 5/16/24 revealed he was a [AGE] year-old male admitted to the facility on [DATE] with diagnoses including Type 2 diabetes, hemiplegia, and hemiparesis (paralysis or weakness to one side of the body) following cerebral infarction (stroke), asthma, and history of falling.
Record review of Resident #19's Order Summary dated 5/16/24 revealed an order dated 5/14/24 that reflected: O2 at 2-4 LPM via nasal cannula [tube used to deliver oxygen through the nose] as needed for shortness of breath or O2 sat [percentage of oxygen saturation in the blood] less than 92%.
Record review of Resident #19's Treatment Administration Record for the month of May, 2024 reflected he had not been administered oxygen during the month of May.
Record review of Resident #27's admission Record dated 5/15/24 revealed he was a [AGE] year-old male admitted to the facility on [DATE] with diagnoses including chronic obstructive pulmonary disease, asthma, hypertension (high blood pressure), legal blindness, and anxiety.
Record review of Resident #27's Order Summary dated 5/15/24 revealed an order dated 7/18/23 that reflected: Continuous oxygen @ 2-5L via nasal cannula every shift related to Chronic Obstructive Pulmonary Disease.
Record review of Resident #27's Treatment Administration Record for the month of May 2024 reflected his oxygen was signed as administered every day.
Record review of Resident #28's admission Record dated 5/14/24 revealed she was a [AGE] year-old female admitted to the facility on [DATE] with diagnoses including dementia, pressure ulcers, aphasia (language disorder affecting the ability to understand and express language), and pneumonia.
Record review of Resident #28's Order Summary dated 5/16/24 revealed an order dated 5/14/24 that reflected: May use oxygen at 2-4 LPM via nasal cannula every shift.
Record review of Resident #28's Treatment Administration Record for the month of May 2024 reflected his oxygen was signed as administered every day except on 5/4/24 when she was out of the facility in the hospital.
Record review of Resident #198's admission Record dated 5/16/24 revealed she was a [AGE] year-old female admitted to the facility on [DATE] with diagnoses including acute pulmonary edema (fluid buildup in the lungs), epilepsy (condition that causes seizures), chronic obstructive pulmonary disease, and cognitive communication deficits.
Record review of Resident #198's Order Summary dated 5/16/24 revealed an order dated 5/14/24 that reflected: May use oxygen at 2-4 LPM via nasal cannula as needed for shortness of breath or O2 Sat less than 92%.
Record review of Resident #198's Treatment Administration Record for the month of May 2024 reflected her oxygen was signed as administered every day.
During an observation on 5/15/24 at 6:35 AM, Resident #28 was observed in her room, sleeping in bed. She was wearing oxygen running at 2 LPM via nasal cannula connected to an oxygen concentrator. There was no sign outside her room indicating oxygen use in her room.
An observation and interview on 5/15/24 at 12:37 PM revealed Resident #19 was in his room sitting in his wheelchair. An oxygen concentrator was observed in his room with tubing connected. The oxygen was turned off at the time of the observation. Resident #19 stated he used the oxygen when he needed it and had not used it in the past couple of days. There was no sign outside his room indicating oxygen use.
An observation and interview on 5/15/24 at 12:40 PM revealed Resident # 198 was out of her room. An oxygen concentrator was observed in Resident #198's room with tubing connected and was running at 4 LPM. Resident #198 entered the room during the observation and stated she always used her oxygen while in her room. There was no sign outside her room indicating oxygen use.
An observation and interview on 5/15/24 at 12:43 PM revealed Resident #27 was sitting up in bed eating lunch. He was wearing oxygen via nasal cannula connected to an oxygen concentrator running at 2 LPM. Resident #27 stated he always wore his oxygen. There was no sign outside his room indicating oxygen use.
During an interview on 5/15/24 at 12:49 PM, the DON stated she was responsible for ensuring oxygen signs were posted outside the rooms of residents utilizing oxygen. She stated the signs were important because they didn't want anyone smoking in the rooms and that smoking was not allowed anywhere in the building. The DON stated risks included fire and explosion hazards and posed a safety risk for the residents and entire facility. The DON stated she tried to check for signs as well as weekly tubing changes while doing her daily rounds. She was unsure how she missed the missing signs on the resident's doors.
During an interview on 5/15/24 at 12:52 PM, the Administrator stated she expected signs indicating oxygen use outside the residents' rooms any time there was oxygen equipment in the room. She identified the Central Supply staff as being responsible for monitoring to ensure there were signs on the doors. She stated she would hope the Charge Nurses, the ADON, and the DON would monitor for signs as well. The Administrator stated there was no smoking allowed in the building, but the signs would remind the nurses to check the residents and ensure they were wearing their oxygen. She stated oxygen could be a hazard if in contact with flammable ointment such as petroleum jelly and stated the main risk was fire.
During an interview on 5/15/24 at 1:46 PM, the Central Supply Staff stated she did not have any signs related to oxygen use and was not aware that placing signs on resident doors was part of her job duties. She stated the nurses placed the signs because they would know before she did whether the resident was receiving oxygen. She stated she was aware of the requirement for the signs and that it was important to let people know there was oxygen use in the room. She stated there was a risk for fire and oxygen could cause things to blow up.
In an interview on 5/15/24 at 1:54 PM, LVN D stated she was not aware of the oxygen signs missing from her resident's doors and was not aware she was supposed to be checking for them. She stated the risks of having oxygen running in a room included fire and explosions. She stated she would watch more closely for them in the future.
During a follow-up interview on 5/15/24 at 2:05 PM, the Central Supply Staff stated she had contacted her consultant for clarification and learned it was her responsibility to order the signs and provide them to the DON and the ADON. She stated she would make sure it was done.
Record review of the facility's policy and procedure titled, Oxygen Administration dated revised February 13, 2007, reflected the following:
Oxygen therapy includes the administration of oxygen (02) in liters/minute (I/min) by cannula or face mask to treat hypoxemic conditions caused by pulmonary or cardiac diseases. 02 therapy is also prescribed to ensure oxygenation of all body organs and systems . The administration, monitoring of responses, and safety precautions associated with it are performed by the nurse . Common oxygen sources for long-term administration include cylinder (portable or stationary) or wall system near the resident's bed or concentrator .
Jan 2024
2 deficiencies
1 IJ (1 facility-wide)
CRITICAL
(L)
📢 Someone Reported This
A family member, employee, or ombudsman was alarmed enough to file a formal complaint
Immediate Jeopardy (IJ) - the most serious Medicare violation
Infection Control
(Tag F0880)
Someone could have died · This affected most or all residents
⚠️ Facility-wide issue
**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, interview, and record review, the facility failed to ensure an effective infection prevention and control ...
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**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, interview, and record review, the facility failed to ensure an effective infection prevention and control program to prevent the development and transmission of communicable diseases was implemented by the facility for 8 of 8 residents (Residents #8, #9, #10, #11, #12, #13, #17, and #18) and 13 of 13 staff (CNA J, MA K, CNA N, HSK O, LVN X, LDY P, CNA Q, CNA R, CNA S, CNA T, LVN U, CNA V, and LVN W) in the facility reviewed for infection control practices and transmission-based precautions.
The facility failed to ensure facility staff (CNA J, MA K, CNA N and HSK O) wore appropriate PPE when entering COVID-19 (infectious disease caused by the SARS virus) positive residents' rooms. (Residents #8, #9 #10, #11, #12, and #13).
The facility failed to ensure staff was knowledgeable on current COVID-19 (infectious disease caused by the SARS virus) protocols and interventions.
The facility staff failed to follow facility infection prevention policies to prevent the spread of infections. Staff (LVN X, LDY P, CNA Q, CNA R, CNA S, CNA T, LVN U, CNA V, and LVN W) were not being tested routinely after a staff tested positive for COVID-19 (infectious disease caused by the SARS virus) on 12/15/2023. During the ongoing outbreak, staff were observed working with positive COVID-19 residents and negative residents. Residents # 8, #17, and #18 expired at the facility after testing positive.
The facility failed to ensure facility staff had readily available access to appropriate PPE supplies in 2 of the 6 isolation carts on Hall 200.
An IJ was identified on 1/26/2024. The IJ template was provided to the facility on 1/26/2024 at 1:50 p.m. While the IJ was removed on 1/27/2024, the facility remained out of compliance at a scope of widespread and a severity level of no actual harm with the potential for more than minimal harm because all staff had not been trained on 1/27/2024.
These failures could place residents at an increased risk for serious complications from a communicable disease that could diminish the resident's quality of life or possible death.
The findings included:
Record review of the Covid Positive Resident Log dated 1/24/2024 indicated on 12/15/2023 the first COVID-19 positive case was from a staff who worked the secured unit. Since the initial outbreak, 32 residents have tested positive for COVID. Three residents expired during their 14-day quarantine.
During an interview on 1/3/2024 at 8:30 a.m., the Administrator said facility census was 50 with 10 COVID-19 positive residents and with 3 staff COVID-19 positive.
During an interview on 1/25/2024 at 1:30 p.m., the DON said facility census was 46 with 11 new COVID-19 positive residents and with 5 new staff COVID-19 positive.
1. Record review of a face sheet dated 1/24/2024 indicated Resident #8 was a [AGE] year-old male, initially admitted to the facility on [DATE] with readmission date of 10/30/2023.His diagnoses included dementia (loss of cognitive functioning), type 2 diabetes (a disease that occurs when your blood glucose, also called blood sugar, is too high), end stage renal disease, and COVID-19.
Record review of Resident #8's MDS dated [DATE] revealed he had a BIMS score of 3 which indicated he was severely impaired cognitively. He usually could make self-understood and usually understood others. He required moderate assistance in performing most activities of daily living. He was always incontinent of bowel and bladder.
Record review of Resident #8's Care plan dated 1/19/2023 indicated he needs hemodialysis r/t renal failure, Resident goes to dialysis 3 x week with goals that resident will have immediate intervention should any s/s of complications from dialysis occur through the review period. had manipulative behavior with history of accusing people of slapping her/physically mishandling her with a goal that resident would have less than 1 episode of accusatory behavior for the next 90 days. Care plan dated 1/2/2024 indicates he requires isolation precautions r/t active Covid infection with a goal that resident's risk for complications r/t active COVID-19 will be minimized through next review date.
Record review of Resident #8's progress notes on 1/2/2024 at 12:17 p.m. authored by RN L indicated Resident #8 tested positive for COVID-19 on 1/2/2024. Resident expired on 1/7/2024 (5 days after testing positive for COVID-19).
Record review of the order summary report, dated 1/24/2024, indicated Resident #8 had an order, which started on 1/2/2024, for Aerosol precautions, every shift related to COVID-19 for 10 days.
Record review of a face sheet dated 1/9/2024 indicated Resident #9 was a [AGE] year-old male, initially admitted to the facility on [DATE] with readmission date of 1/18/2021.His diagnoses included dementia (loss of cognitive functioning), type 2 diabetes (a disease that occurs when your blood glucose, also called blood sugar, is too high), and COVID-19 (infectious disease caused by the SARS virus).
Record review of Resident #9's MDS dated [DATE] revealed he had a BIMS score of 15 which indicated he was cognitively intact. He is able to make needs known and understands others. He required supervision in performing most activities of daily living. He was continent of bowel and bladder.
Record review of Resident #9's Care plan dated 1/2/2024 indicates he requires isolation precautions r/t active Covid infection with a goal that resident's risk for complications r/t active COVID-19 will be minimized through next review date.
Record review of Resident #9's progress notes on 1/2/2024 at 11:12 a.m. authored by RN L indicated Resident #9 tested positive for COVID-19 on 1/2/2024.
Record review of the order summary report, indicated Resident #9 had an order, which started on 1/2/2024, for Aerosol precautions, every shift related to COVID-19 for 10 days.
During an observation on 1/03/2024 at 12:15 p.m., CNA J entered Resident #8 and Resident #9's room on Hall 200 to provide them with lunch trays. CNA J was wearing a N-95 mask and gloves. There was a sign on the door that stated, Droplet Precautions and listed the required PPE needed to be worn in the room, which included an N-95 mask, a face shield or goggles, an isolation gown, and gloves. CNA J remained in the room for approximately 5 minutes assisting and preparing lunch tray. Upon exiting the room, CNA J removed her gloves, sanitized her hands, and walked down the hallway toward the lunch tray cart wearing the same N-95 mask.
During observation 1/3/2024 @ 12:30 p.m., insolation carts outside of room [ROOM NUMBER] and room [ROOM NUMBER] had boxes of gloves, boxes of surgical mask and N-95 mask and face shields, no gowns noted in these 2 isolation carts.
During an interview on 1/3/2024 at 1:35 p.m., CNA J said she did not wear PPE (gown and face shield) into Resident #8 and Resident #9's room because the isolation supply cart outside of the residents' room did not have any gowns or face shields available. CNA J said, I was trying to get the residents lunch served, so I went into room without gown and face shield. CNA J said, I know I should have put a gown and face shield on, but it was not readily available in the isolation cart outside door, which happens sometimes, and we do not have access to supplies to restock isolation carts. CNA J said she had received training on infection control, COVID-19 protocol, and PPE application courses via computerized online training assigned to her by facility within the last month.
During an interview on 1/24/2024 at 2:15 p.m., LVN G said Resident #8 was asymptomatic when he tested positive for COVID-19. LVN G said Resident #8 was attending his dialysis treatments and was not experiencing any severe symptoms with his COVID-19. LVN G said resident was cognitive and able to report any illness or concerns to the facility staff. LVN G said she was the nurse providing care to the resident the day he passed on 1/7/2024, she said she had visited with him several times throughout the shift, and he had no complaints. She said she was notified by CNA that resident was not responding to verbal or tactile stimulus, when she entered the room, resident was unresponsive, no respirations, no pulse and body cool to the touch, appeared he had died in his sleep. LVN G said she provided care to positive and non-positive COVID-19 residents with her assigned residents. LVN G said that the electronic medical record identified residents positive for COVID-19, notification during shift change of all positive COVID-19 residents, signage on resident's room door identifies droplet precautions and COVID-19 precautions to follow. LVN G said that full PPE (gown, gloves, face mask and N-95 should be applied prior to entering COVID-19 positive residents' rooms, worn while providing care to resident and removed prior to exiting room and placed in red bag in room for disposal. LVN G said PPE was available in isolation cart when needed. LVN G said she had received training on COVID-19 and PPE precautions in the last month.
2. Record review of a face sheet date 1/26/2024 indicated Resident #18 was a [AGE] year-old, initially admitted to the facility on [DATE] with readmission date of 12/19/2023. Her diagnoses included dementia (loss of cognitive functioning), urinary tract infection, gastro-esophageal reflux disease without esophagitis (stomach contents leak backward from the stomach into the esophagus (food pipe), COVID-19, and history of COVID-19, history of cancer of the rectum and stomach and anxiety disorder (persistent and excessive worry that interferes with daily activities).
Record review of Resident #18's MDS dated [DATE] revealed she had a BIMS score of 0 which indicated he was severely impaired cognitively. She had cognitive loss/dementia with diagnosis of Alzheimer's Disease. She was noted to have disorganized thinking. She required total assistance in performing most activities of daily living. She was always incontinent of bowel and bladder.
Record review of Resident #18's Care plan dated 1/05/2024 indicates he requires isolation precautions r/t active Covid infection with a goal that resident's risk for complications r/t active COVID-19 will be minimized through next review date.
Record review of Resident #18's progress note dated 1/2/2024 authored by LVN G indicated resident was diagnosed with a urinary tract infection and started on antibiotic treatment ordered by hospice services.
Record review of Resident #18's progress notes dated 1/5/2024 authored by DON indicated resident tested positive for COVID-19 during routine testing for exposure. Resident #18 received antibiotic treatment for COVID-19.
Record review of Resident #18's progress note dated 1/15/2024 authored by LVN DD indicates resident was admitted to new hospice for a diagnosis of senile degeneration of the brain.
Record review of Resident #18's Covid Assessment date 1/17/203 authored by LVN G indicates that covid finding include a productive and non-productive Cough, with no new or worsen symptoms, regular respirations, and clear breath sounds. Interventions include monitoring/assessing every shift for Covid concerns. Indicates resident remain on droplet precautions and resides in room by herself.
Record review Resident #18's of the progress note dated 1/18/2024 (13 days after testing positive for COVID-19) authored by LVN BB indicated Resident #18 was provided care multiple times throughout the shift with no discomfort or complaints. The CNA entered the resident's room around 2:00 a.m. to find the resident unresponsive, no respirations or heart rate so CPR was initiated. EMS arrived and continued CPR and then discontinued CPR. The hospice nurse was notified, and hospice arrived to pronounce the resident had expired.
3. Record review of a face sheet dated 1/26/2024 indicated Resident #17 was a [AGE] year-old female, initially admitted to the facility on [DATE] with readmission date of 8/21/2023. Her diagnoses included personal history of cancer of the rectum, major depressive disorder (a mood disorder that causes a persistent feeling of sadness and loss of interest) and anxiety disorder (persistent and excessive worry that interferes with daily activities).
Record review of Resident #17's MDS dated [DATE] revealed she had a BIMS score of 0 which indicated she was severely impaired cognitively. She was noted to have disorganized thinking. She could make her needs known and understands other. She required minimal assistance in performing most activities of daily living. She was occasionally incontinent of bladder and continent of bowel.
Record review of Resident #17's Care plan dated 12/19/2023 indicates he requires isolation precautions r/t active Covid infection with a goal that resident's risk for complications r/t active COVID-19 will be minimized through next review date.
Record review of Resident #17's progress note dated 12/19/2023 authored by DON indicated resident tested positive for COVID-19 during exposure testing, facility staff (LVN A and CNA CC) working the secure unit tested positive for COVID-19 on 12/15/2023. Resident asymptomatic at time of testing. Resident expired on 12/29/2023 (14 days after testing positive for COVID-19).
Record review of Resident #17's Covid Assessment date 12/29/2023 authored by LVN A indicates under covid finding include no cough or covid findings, with no new or worsen symptoms, regular respirations, and clear breath sounds. Interventions include monitoring/assessing every shift for Covid concerns. Indicates resident remain on droplet precautions and resides in room by herself.
During an interview on 1/24/2024 at 2:15 p.m., LVN G said Resident #17 was asymptomatic with her COVID-19 positive test results. LVN G said Resident #17 had behavioral episodes including yelling and screaming out. LVN G said Resident #17 resided on the secure unit because of her cognitive state. LVN G said she works with positive and negative residents.
4. Record review of a face sheet dated 1/26/2024 indicated Resident #10 was a [AGE] year-old female, initially admitted to the facility on [DATE]. Her diagnoses included CVA/Stroke (occurs when something blocks blood supply to part of the brain or when a blood vessel in the brain burst), Diabetes (a chronic condition that affects the way the body processes blood sugar) and depressive disorder (a mood disorder that causes a persistent feeling of sadness and loss of interest).
Record review of Resident #10's MDS dated [DATE] revealed she had a BIMS score of 15 which indicated she was cognitively intact. She could make her needs known and understands other. She required total assistance in performing most activities of daily living. She was always incontinent of bladder and bowel.
Record review of Resident #10's Care plan dated 12/29/2023 indicates he requires isolation precautions r/t active Covid infection with a goal that resident's risk for complications r/t active COVID-19 will be minimized through next review date.
Record review of Resident #10's progress note dated 12/29/2023 authored by LVN A resident c/o stuffy nose, headache, and sore throat. The resident was tested for Covid and was positive for COVID-19.
Record review of the order summary report, dated 12/29/2023, indicated Resident #10 had an order, which started on 12/29/2023, for Aerosol precautions, every shift related to COVID-19 for 10 days.
During an observation on 1/03/2024 at 12:18 p.m., MA K entered Resident #10's room (resided on Hall 200) to provide her with a lunch tray. MA K was wearing a N-95 mask and gloves. There was a sign on the door that stated, Droplet Precautions and listed the required PPE needed to be worn in the room, which included an N-95 mask, a face shield or goggles, an isolation gown, and gloves. MA K remained in the room for approximately 5 minutes assisting and preparing lunch tray. Upon exiting the room, MA K, removed her gloves, sanitized her hands, and walked down the hallway toward the lunch tray cart wearing the same N-95 mask.
During an interview on 1/3/2024 at 1:50 p.m., MA K said she did not wear PPE (gown and face shield) into Resident #10's room because the isolation supply cart outside of the residents' room did not have any gowns or face shields. MA K said, I was trying to help the I get the lunch tray served. MA K said, I know I should have but a gown and face shield on, but it was not readily available in the isolation cart outside of the resident's room. MA K said she should have gone to central supply closet and got gowns or contacted central supply personnel regarding isolation cart needing to be restocked. MA K said she had received training on infection control, COVID-19 protocol, and PPE application courses via computerized online training assigned to her by facility within the last month.
During an interview on 1/03/2024 at 12:20 p.m., RN L said all staff was instructed to wear appropriate PPE when entering positive COVID-19 residents' room. RN L said the required PPE for entering a COVID-19 positive room was an isolation gown, gloves, an N-95 mask, and a face shield. RN L said it was important to wear the recommended PPE to protect other residents and staff. RN L said, I have spoken with CNA J and MA K and reeducated them on PPE when entering positive COVID-19 residents' rooms.
During observation 1/3/2024 @ 12:30 p.m., insolation carts outside of room [ROOM NUMBER] and room [ROOM NUMBER] had boxes of gloves, boxes of surgical mask and N-95 mask and face shields, no gowns noted in these 2 isolation carts.
During an observation and interview on 1/4/2024 at 9:00 am, CS M said she restocked the isolation carts twice a day (usually morning and evening prior to leaving) and more frequently if notified. CS M showed the location of the PPE supplies in the supply closet on each hall with PPE supplies (gowns, gloves, N-95 mask, and face shields) and a large supply room that had additional PPE supplies. CS M said nursing staff had access to the supply closets on the hall and she and management held the key to the large supply room. CS M said she was not aware of any needed PPE supplies and if the isolation carts were low, staff could notify her or collect the supplies from the supply closet on the halls.
5. Record review of a face sheet dated 1/26/2024 indicated Resident #11 was an [AGE] year-old male, initially admitted to the facility on [DATE] and readmitted on [DATE]. His Senile Degeneration of the Brain (is the mental deterioration (loss of intellectual ability) that is associated with or the characteristics of old age), Covid (infectious disease caused by the SARS virus) and Pressure ulcer of sacral (caused by something putting pressure on or rubbing your skin).
Record review of Resident #11's MDS dated [DATE] revealed he had a BIMS score of 00 which indicated he was severely impaired cognitively. He could usually make his needs known and usually understands other. He required total assistance in performing most activities of daily living. He was foley catheter for urinary incontinence and always incontinent of bowel.
Record review of Resident #11's Care plan dated 1/15/2024 indicates he requires isolation precautions r/t active Covid infection with a goal that resident's risk for complications r/t active COVID-19 will be minimized through next review date.
Record review of Resident #11's progress note dated 1/15/2024 authored by DON, resident was tested for Covid per facility protocol and was positive for COVID-19. Resident placed in Aerosol Precautions.
Record review of the order summary report, dated 1/15/2024, indicated Resident #11 had an order, which started on 1/15/2024, for Aerosol precautions, every shift related to COVID-19 for 10 days.
Record review of a face sheet dated 1/26/2024 indicated Resident #12 was a [AGE] year-old male, initially admitted to the facility on [DATE] and readmitted on [DATE]. His diagnosis is included Type 2 Diabetes (a disease that occurs when your blood glucose, also called blood sugar, is too high), Esophagitis (inflammation of the esophagus), and Covid (infectious disease caused by the SARS virus).
Record review of Resident #12's MDS dated [DATE] revealed she had a BIMS score of 00 which indicated he was severely impaired cognitively. He could sometimes make his needs known and sometimes understands other. He required supervision assistance in performing most activities of daily living. He was foley catheter for urinary incontinence and always incontinent of bowel.
Record review of Resident #12's Care plan dated 1/15/2024 indicates he requires isolation precautions r/t active Covid infection with a goal that resident's risk for complications r/t active COVID-19 will be minimized through next review date.
Record review of Resident #12's progress note dated 1/15/2024 authored by DON, resident was tested for Covid per facility protocol and was positive for COVID-19. Resident placed in Aerosol Precautions.
Record review of the order summary report, dated 1/15/2024, indicated Resident #12 had an order, which started on 1/15/2024, for Aerosol precautions, every shift related to COVID-19 for 10 days.
During an observation and interview on 1/24/2024 at 9:00 a.m., CNA N entered to provide care for Resident #11 and Resident #12 who resided on Hall 100. CNA N was wearing a N-95 mask and gloves. There was a sign on the resident's door that stated, Droplet Precautions and listed the required PPE needed to be worn in the room, which included an N-95 mask, a face shield or goggles, an isolation gown, and gloves. CNA N remained in the room for approximately 6 minutes providing care to residents. Upon exiting the residents' room, CNA N removed her gloves and sanitized her hands walked down the hallway past other residents and visitors wearing same N-95 mask. CNA N said Residents #11 and #12 were no longer under isolation precautions and they forgot to remove the isolation sign.
During interview on 1/24/2024 at 9:15 a.m. the DON said Resident #11 and Resident #12 were currently under droplet isolation precautions due to both residents' testing positive for COVID-19 on 1/15/2024. She said the residents' isolation was due to end on 1/25/2024. The DON said she informed CNA N that Residents #11 and #12 remained under droplet isolations and she should be wearing her PPE while providing resident care. The DON said she verbally instructed CNA N just now about properly applying PPE, droplet precautions protocols and facility residents who currently required droplet precautions.
6. Record review of a face sheet dated 1/26/2024 indicated Resident #13 was a [AGE] year-old female, initially admitted to the facility on [DATE]. Her diagnosis is included schizoaffective disorder (mental health condition with a combination of symptoms of schizophrenia and mood disorder), Dementia (loss of cognitive functioning), and Covid (infectious disease caused by the SARS virus).
Record review of Resident #13's MDS dated [DATE] revealed she had a BIMS score of 15 which indicated she was cognitively intact. She could make her needs known and understands other. She required limited assistance in performing most activities of daily living. She was always continent of bowel and bladder.
Record review of Resident #13's Care plan dated 1/22/2024 indicates he requires isolation precautions r/t active Covid infection with a goal that resident's risk for complications r/t active COVID-19 will be minimized through next review date.
Record review of Resident #13's progress note dated 1/22/2024 authored by DON, resident was tested for Covid per facility protocol and was positive for COVID-19. Resident placed in Aerosol Precautions.
Record review of the order summary report, dated 1/22/2024, indicated Resident #13 had an order, which started on 1/22/2024, for Aerosol precautions, every shift related to COVID-19 for 10 days.
During an observation and interview on 1/25/2024 at 9:45 a.m., HSK O was standing outside of Resident #13's room on Hall 100 in full PPE (gown, gloves, N-95 mask, face shield), with a trash can sitting on top of the housekeeping cart while HSK O replaced the trash liner. There was a sign on Resident #13's door that stated, Droplet Precautions and listed the required PPE needed to be worn in the room, which included an N-95 mask, a face shield or goggles, an isolation gown, and gloves. HSK O said she had just finished cleaning Resident #13's room and she forgot a trash liner on the cart, so I came back out to the cart to get trash liner for the resident's room trash can. HSK O identified the trash can on her housekeepers' cart as the trash can she brought out of Resident #13's room. HSK O said she had just started working at the facility the previous weekend but had been trained on droplet precautions and wearing PPE. When asked if she was supposed to wear the PPE out of the residents' room that was under droplet precautions, she said that during her observation training, other housekeeping staff had done it, so she thought it was OK.
During interview on 1/25/2024 at 9:55 a.m., RN L said Resident #13 remained under droplet isolation precautions due the resident testing positive for COVID-19 on 1/22/2024. RN L said she informed HSK O that Resident # 13 remained under droplet isolations, and she should be wearing her PPE while in the resident's room, and PPE should be removed prior to exiting the resident's room.
7. During an interview on 1/25/2024 at 11:45 a.m., LVN X said she was not tested routinely by facility since outbreak on 12/15/2023. LVN X said she was tested for COVID-19 by the facility on 1/14/2024 because she became symptomatic (cough and congestion) and tested positive. LVN X said she was sent home and quarantined for 7 days with 2 negative tests 48 hours apart before returning to work. LVN X said she has received training on infection control, COVID-19 precautions/protocol and PPE application. LVN X said that she applied PPE prior to entering COVID-19 positive residents' rooms. LVN X said staff were notified in the EMR on the communication board when residents were positive for COVID-19 and as a charge nurse she notified her staff when residents tested positive for COVID-19 and who required isolation precautions.
During an interview on 1/25/2024 at 12:30 p.m., LDY P said he was working in the laundry department today due to the laundry staff being out with COVID-19. LDY P said that if he was symptomatic, the facility would test him. LDY P said he wore full PPE (gloves, gowns, N-95 mask, face shield) while handling the dirty laundry as he was told to treat all dirty laundry as contaminated and to use PPE when handling. He said he received computer-based training on infection control, COVID-19 protocol, and PPE use at the end of December 2023. LDY P said he had not been tested for COVID-19 by the facility in over a week or maybe 2. LDY P said he did have contact with residents at various times while out in the halls and when he delivered laundry to the resident's rooms. He said he applied full PPE to deliver laundry to residents on isolation. He said he also worked in the housekeeping department and cleaned residents' rooms.
During an interview on 1/25/2024 at 1:45 p.m., CNA J said she had not been tested by the facility for COVID-19. CNA J said, if I was symptomatic, I would be tested. Do I need to go get tested? CNA J said she worked with both non-positive and positive COVID-19 residents.
During an interview on 1/25/2024 at 1:50 p.m., CNA Q said she had not been tested by the facility for COVID-19. CNA Q said she had not been having symptoms of COVID-19 and the facility was only testing staff who had symptoms. CNA Q acknowledged that residents/staff could be asymptomatic and have COVID-19. CNA Q said she worked with both non-positive and positive COVID-19 residents.
During an interview on 1/25/2024 at 2:15 p.m., CNA R said she had not been tested by the facility for COVID-19. CNA R said she had not been having symptoms of COVID-19, so she had not been tested. CNA R acknowledged that residents/staff could be asymptomatic and have COVID-19. CNA R questioned if she should be tested for COVID-19. CNA R said it had been over 2 weeks since she was last tested by the facility for COVID-19. CNA R said she worked with both non-positive and positive COVID-19 residents.
During an interview on 1/25/2024 at 2:30 p.m., CNA S said he had not been tested by the facility for COVID-19. CNA S said she had not been having symptoms of COVID-19, so she had not been tested. CNA S acknowledged that residents/staff could be asymptomatic and have COVID-19. CNA S questioned if she should be tested for COVID-19. CNA S said it had been over 2 weeks since she was last tested by the facility for COVID-19. CNA S said she worked with both non-positive and positive COVID-19 residents.
During an interview on 1/25/2024 at 2:35 p.m., CNA T said she had not been tested by the facility for COVID-19. CNA T said she had not been having symptoms of COVID-19, so she had not been tested. CNA T acknowledged that residents/staff could be asymptomatic and have COVID-19. CNA T questioned if she should be tested for COVID-19. CNA T said it had been over 2 weeks since she was last tested by the facility for COVID-19. CNA S said she worked with both non-positive and positive COVID-19 residents.
During an interview on 1/25/2024 at 2:41 p.m., LVN U said she had not been tested by the facility for COVID-19. LVN U said she had only been employed for a few weeks with facility. She said she received training on COVID-19, infection control and PPE application/use during orientation. She said she had not been tested for COVID-19 since she started working at the facility. LVN U said she wore a surgical mask when caring for non-positive COVID-19 residents and N-95 and full PPE while caring for positive COVID-19 residents. LVN U said she was assigned to work with both non-positive and positive COVID-19 residents.
During an interview on 1/25/2024 at 2:45 p.m., CNA V said she had not been tested by the facility for COVID-19. CNA V said she had not been having symptoms of COVID-19, so she had not been tested. CNA V said it had been over 1 week since she was last tested by the facility for COVID-19. CNA V said she worked with both non-positive and positive COVID-19 residents. CNA V said she had received training on COVID-19 protocols in the last month.
During an interview on 1/25/2024 beginning at 3:21 p.m., LVN W said she had not been tested by the facility for COVID-19. LVN W said she tested herself at home frequently before entering the facility because of her own medical concerns. LVN W said she received computer-based training on COVID-19, infection control and PPE application/use from facility in the last month. LVN W said she wore an N-95 mask when caring for non-positive COVID-19 residents and wore the full PPE (N-95 mask, gown, gloves, face shield) while caring for positive COVID-19 residents. LVN W said she was assigned to work with both non-positive and positive COVID-19 residents.
During an interview on 1/25/2024 at 3:30 p.m., the DON said the facility was only testing symptomatic staff for COVID-19. The DON was unable to provide a log of facility staff's COVID-19 test results. The DON said she thought the policy indicated only to test staff for COVID-19 if they were experiencing symptoms. The DON said nursing staff were working with positive and non-positive residents. The DON said they were following the Interim Infection Prevention and Control Recommendations for Healthcare Personnel During the Coronavirus Disease 2019 (COVID-19) Pandemic from the CDC for guidance for COVID-19 protocol.
During an interview on 1/25/2024 at 3:35 p.m., the DON said she was the infection preventionist for the facility and responsible for overseeing infection control, she said that the health department had been notified on the outbreak, but no guidance provided. She [TRUNCATED]
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
Report Alleged Abuse
(Tag F0609)
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 all alleged violations involving abuse of ...
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**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, interview and record review, the facility failed to ensure that all alleged violations involving abuse of residents were reported immediately to the administrator and to HHSC within the 2-hour period for 8 of 11 residents (Resident #1, #2, #3, #4, #5, #6, #7, and #14) reviewed for abuse.
The facility failed to ensure allegations of resident-to-resident altercations and resident and staff altercations were reported immediately to the administrator and to the State Agency no later than 2 hours after the incident occurred or was suspected.
This failure could place residents at risk of abuse, physical harm, mental anguish, and emotional distress.
Findings included:
1.Record review of a face sheet dated 1/9/2024 indicated Resident #1 was 77-years-old, initially admitted to the facility on [DATE] with readmission date of 11/13/2023. Her diagnoses included schizoaffective disorder, bipolar type (mental health condition with a combination of symptoms of schizophrenia and mood disorder), bipolar disorder (mental illness that causes unusual shifts in a person's mood, energy, activity levels, and concentration), drug-induced tremor (involuntary shaking due to the use of medicines), Alzheimer's disease ( a progressive disease beginning with mild memory loss and possibly leading to loss of the ability to carry on a conversation and respond to the environment ), anxiety disorder (persistent and excessive worry that interferes with daily activities) and major depressive disorder (a mood disorder that causes a persistent feeling of sadness and loss of interest).
Record review of a MDS assessment dated [DATE] indicated Resident #1 was able to make herself understood and understand others. She had a BIMS of 15 (cognitively intact). She required supervision for most ADLs . She was frequently incontinent of bladder and bowel.
Record review of Resident #1's care plan dated 4/23/2021 indicated Resident #1 has potential to demonstrate verbally abusive behaviors. Interventions included to assess and anticipate resident's needs: food, thirst, toileting needs, comfort level, body positioning, pain etc. Analyze of key times, places, circumstances, triggers and what de-escalates behavior and document.
Record review of Resident #1's care plan dated 11/15/2021 indicated she has potential to demonstrate physical behaviors related to poor impulse control, and she has had physical altercation with other residents. Interventions included to assess and anticipate resident's needs: food, thirst, toileting needs, comfort level, body positioning, pain etc. Analyze of key times, places, circumstances, triggers and what de-escalates behavior and document.
Record review of a face sheet dated 1/9/2024 indicated Resident #2 was a 85-years-old, initially admitted to the facility on [DATE] with readmission date of 12/02/2022. His diagnoses included Type 2 Diabetes (a disease that occurs when your blood glucose, also called blood sugar, is too high), Anemia in Chronic Kidney Disease (your kidneys cannot make enough EPO), Schizophrenia (a serious mental disorder in which people interpret reality abnormally), Dementia (loss of cognitive functioning), anxiety disorder (persistent and excessive worry that interferes with daily activities) and major depressive disorder (a mood disorder that causes a persistent feeling of sadness and loss of interest).
Record review of a MDS assessment dated [DATE] indicated Resident #2 was able to make himself understood and understand others. He had a BIMS of 03 (severely impaired cognitively). He required supervision for most ADLs . He was frequently incontinent of bowel and occasionally incontinent of bladder.
Record review of Resident #2's care plan dated 5/13/2022 indicated Resident #2 demonstrates verbally abusive behaviors towards peers and staff due to Ineffective coping skills, poor impulse control. Resident #2 gets aggravated at times in regard to his finances and in times of not being able to get his way. He is redirected easily. Interventions included to assess and anticipate resident's needs: food, thirst, toileting needs, comfort level, body positioning, pain etc. Analyze of key times, places, circumstances, triggers and what de-escalates behavior and document. Assess resident's understanding of the situation. Allow time for the resident to express self and feelings towards the situation. Assess resident's coping skills and support system.
Record review of Resident #1's progress note authored by DON indicated that on 8/7/2023 at 4:09 p.m., that the resident presented herself to the DON's office and showed a 2x3cm bruise to the left upper anterior arm, Resident stated that Resident #2 attacked her yesterday (Sunday) because he had the cordless phone and she wanted to use it. Resident was assessed with previous injuries to left hand noted. NP and RP notified.
During an interview on 1/3/2024 at 11:09 a.m., Resident #1 said she recalled the incident involving her and Resident #2 that happened on 8/8/2023. Resident #1 said Resident #2 would not let her use the cordless phone to call her family member, he got mad at me and hit me in the arm.
Unable to interview Resident #2, he no longer resides in the facility.
During an interview on 1/3/2024 at 11:30 a.m., the DON said that she learned about the incident between Resident #1 and Resident #2 when Resident #1 wheeled herself to the DON office door on 8/7/2023 and showed her a bruise on her left upper arm. DON said that she investigated the report and spoke with staff and CN reported that the residents got into a verbal altercation about the use of the cordless phone. DON said no physical altercation was observed by CN, CN intervened and separated the two residents. The CN reported that no visual skin altercations noted at the time, and she separated the two residents. The DON said allegation was reported to the state, facility investigation completed, and AC notified of the allegation. The DON does not recall the time the allegation of abuse for this intake was reported to the state agency but was aware that all allegations of abuse have to be reported to AC or designee immediately and to the state agency no later than 2 hours after the incident occurs or is suspected.
During an interview on 1/24/2024 at 3:11p.m., LVN A said she recalls the incident between Resident
#1and Resident #2. She said residents got into a verbal altercation regarding the use of the cordless phone. LVN A said that she intervened and separated the two residents, she said that she did not see any physical altercation between the two residents, just verbal. She said she does not recall seeing any marks or abrasions on the residents when she intervened and separated them. She said she has been trained on abuse and neglect and was aware to report any allegations of abuse to the administrator/AC immediately.
Record review of TULIP intake for Resident #1 and Resident #2 indicated information date received on 8/8/2023 at 1:23 p.m., read that the allegation of abuse occurred on 8/6/2023 at 12:05 p.m. and the facility first learned of the incident on 8/7/2023 at 10:00a.m. Caller information indicated the reporter of the allegation was the DON.
2. Record review of a face sheet dated 1/9/2024 indicated Resident #3 was 81-years-old, initially admitted to the facility on [DATE] with readmission date of 5/24/2022. His diagnoses included Diabetes (a chronic disease that occurs either when the pancreas does not produce enough insulin or when the body cannot effectively use the insulin it produces), Vitamin Deficiency (is the condition of a long-term lack of a vitamin), Alzheimer's disease ( a progressive disease beginning with mild memory loss and possibly leading to loss of the ability to carry on a conversation and respond to the environment), anxiety disorder (persistent and excessive worry that interferes with daily activities) and major depressive disorder (a mood disorder that causes a persistent feeling of sadness and loss of interest).
Record review of a MDS assessment dated [DATE] indicated Resident #3 was able to make himself understood and understand others. He had a BIMS of 06 (severely impaired cognitively). He required supervision for most ADLs . He was frequently incontinent of bladder and bowel.
Record review of Resident #3's care plan revised on 6/2/2023 indicated Resident #3 has potential to demonstrate verbally abusive behaviors. Interventions included to assess and anticipate resident's needs: food, thirst, toileting needs, comfort level, body positioning, pain etc. Analyze of key times, places, circumstances, triggers and what de-escalates behavior and document.
Record review of a face sheet dated 1/9/2024 indicated Resident #4 was a [AGE] year-old, initially admitted to the facility on [DATE] with readmission date of 11/01/2023. His diagnoses included Type 2 Diabetes (a disease that occurs when your blood glucose, also called blood sugar, is too high), Schizophrenia (a serious mental disorder in which people interpret reality abnormally), Dementia (loss of cognitive functioning), anxiety disorder (persistent and excessive worry that interferes with daily activities) and major depressive disorder (a mood disorder that causes a persistent feeling of sadness and loss of interest).
Record review of a MDS assessment dated [DATE] indicated Resident #4 was able to make himself understood sometimes and understand others sometimes. He had a BIMS of 00 (severely impaired cognitively). He required total care, assistance of 2 or more helpers for most ADLs . He was always incontinent of bowel and bladder.
Record review of Resident #4's care plan dated 7/11/2023 indicated Resident #4 has potential to demonstrate physical behaviors due to Poor impulse control. Resident #4 hit another resident with a walker. Interventions included to assess and anticipate resident's needs: food, thirst, toileting needs, comfort level, body positioning, pain etc. Analyze of key times, places, circumstances, triggers and what de-escalates behavior and document. Assess resident's understanding of the situation. Allow time for the resident to express self and feelings towards the situation. Assess resident's coping skills and support system. If the resident has physical behaviors toward another resident, immediately intervene to protect the residents involved and call for assistance. If intervening would be unsafe, call out for staff assistance immediately.
Record review of Resident #4's progress note authored by LVN B indicated that on 7/11/2023 at 11:05 a.m., that a CNA reported to LVN B that Resident # 4 was being yelled at by Resident #3, Resident #4 asked Resident #3 to leave him alone and to stop talking to him, Resident #3 continued to yell at Resident #4. CNA intervened and asked both residents to calm down and stop yelling at each other. CNA said they stopped yelling, so she went into hallway to get breakfast trays, CNA returned to area Resident #4 swung walker around CNA and hit Resident #3 in the face, Resident #4 was removed from the area and MD and DON notified. Resident #3 assess by staff with no injuries noted.
During an interview on 1/24/2024 at 11:39 a.m., Resident #4 said he does not recall the incident of him hitting Resident #3 and he would never hit or harm anyone.
Unable to interview Resident #3, he no longer resides in the facility.
During an interview on 1/3/2024 at 11:20 a.m., the Administrator said she was aware of the disagreement between Resident #3 and Resident #4, CNA C was present during the disagreement and reported it to DON and Administrator. She said Resident #3 was upset that Resident #4 did not call for help from him when he fell in the bathroom. Resident #3 repeatedly questioned Resident #4 about why he did not tell him he fell or ask him to help him when he fell, Resident #4 got upset and verbal altercation occurred, and later Resident #4 swung his walker around the CNA and hit Resident #3 in the head. The Administrator said they immediately separated the two residents and moved Resident #4 to another room since they were roommates. Facility staff assessed both residents with no injuries noted. Resident #3 went to a previously scheduled appointment out of the facility. The Administrator said this occurred after breakfast and at supper time they were requesting to sit together at the same table. The Administrator said that she reported the incident to the state within 2 hours of her being notified or made aware of the incident.
Record review of TULIP intake for Resident #3 and Resident #4 indicated information date received on 7/12/2023 at 4:58 p.m., read that the allegation of abuse occurred on 7/11/2023 at 1:45 p.m. and the facility first learned of the incident on 7/12/2023 at 2:00 p.m. Caller information indicates the reporter of the allegation was the Administrator.
3. Record review of a face sheet dated 1/8/2024 indicated Resident #5 was a 88-years-old, initially admitted to the facility on [DATE] with readmission date of 11/21/2023. her diagnoses included chronic obstructive pulmonary disease (a lung disease that blocks airflow making it difficult to breathe), diastolic congestive heart failure (a condition in which the heart's main pumping chamber (left ventricle) becomes stiff), chronic embolism and thrombosis of unspecified vein (a blockage of the pulmonary arteries that occurs when prior clots in these vessels don't dissolve over time despite treatment of an acute pe, or the result of an undetected or untreated acute pe).
Record review of a MDS assessment dated [DATE] indicated Resident #5 was able to make herself understood and understand others. She had a BIMS of 15 (cognitively intact). She required total care, assistance of 2 or more helpers for most ADLs . She was always incontinent of bowel and bladder.
Record review of Resident #5's care plan dated 12/21/2023 indicated Resident #5 potential/actual impairment to skin integrity r/t fragile skin. Interventions included Avoid scratching and keep hands and body parts from excessive moisture. Keep fingernails short. Educate resident/family/caregivers of causative factors and measures to prevent skin injury. Encourage good nutrition and hydration in order to promote healthier skin.
Follow facility protocols for treatment of injury. Keep skin clean and dry. Use lotion on dry skin.
Record review of Resident #5's progress note authored by LVN D indicated that on 8/26/2023 at 12:40 a.m., that a CNA reported to LVN D that Resident # 5 had a skin tear to back of right lower leg, Resident #5 said that the aide earlier that day that turned her caused the skin tear to her right lower leg. ADON RN notified & RP notified per phone.
During an interview on 1/4/2024 at 11:40 a.m., Resident #5 said she does recall the incident of skin tear to right lower leg, she said she had very fragile skin and the staff must be very careful, or they will tear her skin when they turn her. Resident #5 said that CNA D was rough when she turned her and caused the skin tear. She said she told the nursing staff about the incident.
During an interview on 1/4/2024 at 11:50 a.m., the Administrator said she was aware of the skin tear to Resident #5 right leg that was caused by CNA D when turning her, she said CNA D was suspended pending the investigation and later terminated. The Administrator said that she reported the incident to the state within 2 hours of her being notified or made aware of the incident.
Record review of TULIP intake for Resident #5 indicated information date received on 8/29/2023 at 5:42 p.m., read that the allegation of abuse occurred on 8/28/2023 at 5:17 p.m. and the facility first learned of the incident on 8/29/2023 at 4:30 p.m. Caller information indicated the reporter of the allegation was the Administrator.
4. Record review of a face sheet dated 1/8/2024 indicated Resident #6 was 55-years-old, initially admitted to the facility on [DATE] with readmission date of 05/04/2023. her diagnoses included Schizophrenia (a serious mental disorder in which people interpret reality abnormally), Dementia (loss of cognitive functioning), anxiety disorder (persistent and excessive worry that interferes with daily activities) and major depressive disorder (a mood disorder that causes a persistent feeling of sadness and loss of interest). Resident #6 resides in the secure unit at the facility.
Record review of a MDS assessment dated [DATE] indicated Resident #6 was able to make herself understood and understand others. She had a BIMS of 05 (severely impaired cognitively). She required supervised and limited assistance for most ADLs . She was always incontinent of bladder and frequently incontinent of bowel.
Record review of Resident #6's care plan dated 10/06/2021 indicated Resident #6 resident has impaired cognitive function, dementia, and impaired thought processes. Interventions Engage the resident in simple, structured activities that avoid overly demanding tasks. Keep the resident's, routine consistent and try to provide consistent care givers as much as possible in order to decrease confusion.
Record review of Resident #6's progress note authored by LVN F indicated that on 10/31/2023 at 5:18 p.m., that she heard a sound of a hit while resident was sitting down, and peer resident (Resident #7) was standing over this resident, nurse intervened resident from hitting peer resident with her fist and asked her to calm down, which she did and stated that peer resident was all over her, DON, NP was notified, new order is to keep resident separate. RP notified.
Record review of a face sheet dated 1/8/2024 indicated Resident #7 was 86-years-old, initially admitted to the facility on [DATE] with readmission date of 12/29/2023. Her diagnoses included Dementia (loss of cognitive functioning), and anxiety disorder (persistent and excessive worry that interferes with daily activities). Resident #7 resided in the secure unit at the facility.
Record review of a MDS assessment dated [DATE] indicated Resident #7 was able to make herself understood and usually understand others. She had a BIMS of 00 (severely impaired cognitively). She required supervised and moderate assistance for most ADLs . She was always incontinent of bladder and bowel.
Record review of Resident #7's care plan dated 09/25/2023 indicated Resident #7 has potential to demonstrate verbally abusive behaviors. Interventions Assess and anticipate resident's needs: food, thirst. toileting needs, comfort level, body positioning, pain etc. Give the resident as many choices as possible about care and activities. Notify the charge nurse of any abusive behaviors.
Record review of Resident #7's care plan dated 10/10/2023 indicated Resident #7 has potential to demonstrate physical behaviors due to Anger and Poor impulse control. Interventions included to assess and anticipate resident's needs: food, thirst, toileting needs, comfort level, body positioning, pain etc. Analyze of key times, places, circumstances, triggers and what de-escalates behavior and document. Assess and address for contributing sensory deficits. Notify the charge nurse of any physically abusive behaviors. Psychiatric/Psychogeriatric consult as indicated.
Record review of Resident #7's progress note authored by LVN F indicated that on 10/31/2023 at 4:58 p.m., that she was sitting in the nurses' station and heard a slap sound. Observed resident sitting in front of the TV Room door with Resident #7 standing with walker in front of her, Resident #6 had her fist up in the air swinging it toward this Resident #7, LVN F intervened and redirected resident from swinging fist at this Resident #7.
During an interview on 1/4/2024 at 1:40 p.m., Resident #6 said she does not recall the incident and denies any abuse or neglect from facility staff.
During an interview on 1/4/2024 at 1:45 p.m., Resident #7 was unable to answer questions appropriately.
During an interview on 1/4/2024 at 11:45 a.m., the Administrator said she became aware of the allegation of abuse on Resident #6 and Resident #7 when she was performing quarterly audits of the event notes. She said she was not aware of this incident until then and reported it to the state agency as soon as she realized it was a reportable incident.
Record review of TULIP intake for Resident #6 and Resident #7 indicated information date received on 12/12/2023 at 7:05 p.m., read that the allegation of abuse occurred on 10/31/2023 at 3:45 p.m. and the facility first learned of the incident on 12/12/2023 at 4:45 p.m. Caller information indicates the reporter of the allegation was the Administrator.
During an interview on 1/4/2024 at 2:15 p.m. with LVN G, she said she worked in the secure unit mostly and has been employed with facility over 5 years. She said we watch the residents back her closely but if an allegation of abuse occurs that we report it to the administrator or designee immediately.
During an interview on 1/8/2024 at 1:15 p.m. with CNA H, she said she works the secure unit mostly, been employed with facility over 3 years, she said if allegation of abuse or neglect occurred that she would report it to the charge nurse.
5. During observation tour on 1/24/2024 at 3:00 p.m. of the secure unit, revealed Resident # 14 with bruises to face, right forehead and left eye.
During interview on 1/24/2024 at 3:05 p.m., LVN G said that Resident #14 had a fall on 1/15/2024 causing the bruises to face area, was sent to ER and also had fracture rib. LVN G said that Resident # 14 has a history of falls.
Record review of a face sheet dated 1/24/2024 indicated Resident #14 was 76-years-old, initially admitted to the facility on [DATE]. Her diagnoses included Schizophrenia (a serious mental disorder in which people interpret reality abnormally), hypertension (a condition in which the force of the blood against the artery walls is too high), Alzheimer's disease (a progressive disease beginning with mild memory loss and possibly leading to loss of the ability to carry on a conversation and respond to the environment). Resident #14 resided in the secure unit at the facility,
Record review of a MDS assessment dated [DATE] indicated Resident #14 was able to make herself understood and usually understand others. She had a BIMS of 03 (severely impaired cognitively). She required supervision assistance for most ADLs . She was always incontinent of bladder and frequently incontinent bowel.
Record review of Resident #14's care plan dated 1/15/2024 indicated Resident # 14 was risk for further falls r/t Confusion and poor impulse control. Resident # 14 has poor safety awareness. Resident # 14 sustained sixth rib fracture to her left side. Interventions Anticipate and meet the resident's needs. Encourage the resident to participate in activities that promote exercise, physical activity for strengthening and improved mobility. Ensure that the resident is wearing appropriate footwear when ambulating or mobilizing in w/c. Pt evaluate and treat as ordered or PRN. Review information on past falls and attempt to determine cause of falls. Record possible root causes. Alter remove any potential causes if possible. Educate resident/family/caregivers/IDT as to causes. The resident needs a safe environment with even floors free from spills and/or clutter; adequate, glare-free light; a working and reachable call light, the bed in low position at night; handrails on walls, personal items within reach. The resident needs activities that minimize the potential for falls while providing diversion and distraction.
Record review of Resident #14's progress note authored by LVN A indicated that on 1/15/2024 at 12:40 a.m., Resident was in room and staff heard a loud noise, CNA and CN to room. Resident had been up and moving around and fell in room, she had diaper around her ankles torn off on one side. resident was lying on floor by bathroom door on stomach. She was crying out and moaning, attempting to get off floor by self. V/S were taken, and full skin assessment was done, found delayed bruising on hip from previous fall, resident was complaining of pain below L Breast and holding her chest and rib area. She was letting out yell in pain when palpated area, spoke with RN from hospice and she stated to send resident out to ER for evaluation and treatment. RP notified and stated to send resident to local ER as needed. Notified DON, Neuros started until EMS will come and monitor resident.
Record review of Resident #14's progress note authored by LVN A indicated that on 1/15/2024 at 5:29 a.m., resident returned to facility from local ER with diagnosis of a left 6th rib fracture and new orders for Tylenol 650mg 1 tab by mouth as needed every 4 hours for pain and resident to return to ER if any breath difficulties occur. Vital signs stable and no complaints of pain or discomfort. Resident to be monitored for any changes.
During an interview on 1/24/2024 at 9:45 a.m., Resident #14 just rambled and mumbled when asked questions. Unable to verbalize incident of falls and/or injuries.
During an interview on 1/24/2024 at 3:11 p.m., LVN A recalled the incident with Resident # 14 on 1/15/2024, said she and the CNA was in TV room with another resident that was actively dying, heard a noise in Resident # 14's room, so she and the CNA went to the room. Resident #14 was found on floor near the bathroom on her stomach with her diaper around her ankle, she said that resident was not cognitively intact, so she was not able to tell staff what had happened. LVN A said she complained of pain to breast/chest area, and she was sent to ER for evaluation and treatment. LVN A said this unwitnessed fall with injury was reported to DON on 1/15/2024.
During an interview on 1/24/2024 at 3:45 pm, the DON said that she was aware of Resident # 14's unwitnessed fall with injury but did not feel the incident meet the requirement to be reported to the state.
Record review of TULIP 1/24/2024 at 4:00 p.m. revealed no intake for Resident #14's unwitnessed fall with injury.
During an interview on 1/4/2024 at 9:15 a.m., the Administrator said the expectations was for the facility staff to report all suspicions or allegations of abuse immediately to her, as the abuse coordinator. She said if she was not available, staff should report to the supervisor in charge. She said the timeframe for reporting allegations of abuse to the state agency was to report within 2 hours of the allegation. The administrator said she or the designee should have reported allegations of abuse to the state agency within 2 hours of the allegation.
Record review of the facility's Abuse and Neglect policy dated 3/29/18 indicated . When a suspected abused, neglected, exploited, mistreated or potential victim of misappropriation of property comes to the attention of any employee, that employee will make an immediate verbal report to the Abuse Preventionist or designee. If the discovery occurs outside of normal business hours, the Abuse
Preventionist and/or designee will be called If the allegations involve abuse or result in serious bodily injury, the report is to be made within 2 hours of the allegation .
Mar 2023
5 deficiencies
CONCERN
(D)
📢 Someone Reported This
A family member, employee, or ombudsman was alarmed enough to file a formal complaint
Potential for Harm - no one hurt, but risky conditions existed
Investigate Abuse
(Tag F0610)
Could have caused harm · This affected 1 resident
**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on interview and record review, the facility failed to ensure all allegations of abuse, neglect, exploitation, or mistreat...
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**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on interview and record review, the facility failed to ensure all allegations of abuse, neglect, exploitation, or mistreatment had evidence that all alleged violations were thoroughly investigated for 1 of 13 residents (Residents #37) reviewed neglect.
1. The facility failed to obtain interviews or statements from staff members, LVN M, MA N, CNA O, NCNA Q, CNA R, and MA S who worked the day of Resident #37's elopement.
2. The facility failed to investigate contributing factors to Resident #37's elopement.
3. The facility did not give staff members an in-service on responding to door alarms to prevent residents' elopement.
4. The facility failed to perform an accurate elopement assessment for Resident #37 prior to his elopement on 03/01/23.
These failures could place residents at risk for unsafe wandering and injury.
Findings included:
Record review of the face sheet dated 03/20/23 revealed Resident #37 was [AGE] year-old male admitted on [DATE] with diagnoses including dementia (a group of thinking and social symptoms that interferes with daily functioning), Type 2 diabetes (a chronic condition that affects the way the body processes blood sugar (glucose)), and chronic kidney disease, stage 3 (a condition in which the kidneys are damaged and cannot filter blood as well as they should).
Record review of the quarterly MDS assessment dated [DATE] revealed Resident #37 was understood and understood others. The MDS revealed Resident #37 had a BIMS of 10 which indicated moderate cognitive impairment and required supervision for walking in room and corridors and locomotion on and off unit. The MDS revealed Resident #37 did not have inattention, disorganized thinking, or altered consciousness. The MDS revealed Resident #37 did not wander. The MDS revealed Resident #37 used a cane/crutch and walker as a mobility device.
Record review of Resident #37's elopement risk assessment dated [DATE] completed by LVN T revealed .resident is bedfast, in Geri-chair, or unable to self-propel wheelchair .score: N/A .category: N/A .
Record review of Resident #37's care plan dated 01/30/23 revealed impaired cognitive function, dementia, and impaired thought process due to Dementia. Interventions included communicate with resident/family/caregivers regarding resident's capabilities and needs, keep resident's, routine consistent and try to provide consistent care givers as much as possible in order to decrease confusion.
Record review of Resident #37's care plan dated 03/02/23 revealed at risk for feeling of isolation due to being on facility secured unit related to high-risk elopement. Resident #37 showed increased confusion and often walks around the facility looking for his car. Intervention included admit to secure unit per doctor orders (03/01/23).
Record review of a progress note dated 01/17/23 at 11:25 a.m., completed by the DON revealed .[Resident #37] assessed due to increased confused statements .resident [#37] thinks he has been put in jail, is waiting on his brother to drop off a car and needs a copy of his insurance card and driver license .resident [#37] has also stated his brother drove from Houston, left a car in the parking lot and [Resident #37] needs a copy of his CDL license and the keys to the car so that he can leave .Resident #37 has a history of chronic UTIs .new orders for labs in AM .
Record review of the nursing schedule dated 03/01/23 revealed .6AM-2PM: med cart- MA N .CNA O (209-215), CNA R (216-225B) .2PM-10PM: med cart- MA S, LVN M, NCNA Q (209-225) .
Record review of a witness statement completed by LVN H, dated 03/01/23, revealed .as I [LVN H] was leaving out of the front unit 1 hallway door, I observed [Resident #37] standing in front of the facility van .He stated ' I [Resident #37] was trying to find my car and I was looking for a way back in' .I assisted Resident #37 back in via Unit 1 door and walked him to Unit 3 .
Record review of an Incident Elopement report dated 03/01/23 at 5:01 p.m., completed by the DON revealed .[Resident #37] .incident location was outside .nursing description: [LVN H] was leaving the facility and exited Unit 1 front hallway door . she noted [Resident #37] standing in the parking lot beside the facility van .[Resident #37] stated he was trying to find his car and was looking for a way back in .resident description: 'I just pushed the door open and was looking for my car' .mental status: forgetful, oriented to person, lack of safety awareness .predisposing physiological factors: confused, impaired memory .no witnesses found .
Record review of an event note elope, or attempt dated 03/01/23 at 5:11 p.m., completed by the DON revealed .unknown what door exited .less than 10 minutes missing .family member left 15 minutes prior from visiting with resident .no injuries .cognition/behavior at time of event: cognitive impairment, refuse to call for assistance, wanders, exit seeking .exit seeking trying to find his car .
Record review of a progress note dated 03/01/23 at 5:12 p.m., completed by the DON revealed .[LVN H] was leaving the facility and exited Unit 1 front hallway door .she noted [Resident #37] standing in the parking lot beside the facility van .[Resident #37] stated he was trying to find his car and was looking for a way back in .[Resident #37] stated 'I was trying to find my car and looking for a way back in' .[Resident #37] was escorted back into the facility and relocated to the secured unit for monitoring .
Record review of a elopement risk assessment dated [DATE], completed by the DON revealed .Resident #37 .score of 18 .category: elopement risk .statements and/or threats to leave facility .frequent request to go home .confused expression related to tasks to complete .verbalizes anger and frustration regarding placement .restlessness behavior (pacing, wandering) .cannot state name, know location of current residence, recognizes physical needs .not new behavior or changes in resident's status .
During an interview on 03/20/23 at 5:38 p.m., a family member of Resident #37 said this was the first time Resident #37 had eloped from the facility. He said Resident #37 was trying to get in the facility van. The family member said Resident #37 had attempted to get in another vehicle at a doctor's appointment. He said Resident #37 had frequent UTIs and did not know if the facility tested him after the elopement. The family member said Resident #37 mentioned to staff frequently about going other places and talked to him about needing his car. He said he believed Resident #37 eloped from the front door of the facility. The family member said the front door could only be opened by using a keypad code. He said he felt Resident #37 could come off the secured unit and return to his room on Unit 2.
During an interview on 03/22/23 at 2:45 p.m., LVN H said some time after 4:00 pm on 03/01/23, she left work using the 100-hall door which had a keypad exit lock. She said as she was walking towards the facility's parking lot to left on the building, she noticed Resident #37 standing by the facility van. LVN H said Resident #37 said he was looking for his car and a way back in. She said she could not remember what assistive device he was using when he was found. LVN H said Resident #37 resided on the 200-hall prior to the incident, on the opposite side of the building. She said Resident #37 said no one let him out of the building. LVN H said residents who smoke had the keypad code to open the facility's doors, but the smokers knew not to let anyone out.
During an interview on 03/22/23 at 4:00 p.m., the Maintenance Supervisor said he had worked at the facility for 21 years. He said he turned the alarms on and off on the doors throughout the day. The Maintenance Supervisor said the disarmed doors were unattended. He said the door should be alarmed for wandering residents to prevent elopements. The Maintenance Supervisor said after Resident #37's elopement, he was not asked to perform a door alarm test.
On 03/22/23 at 4:15 p.m., attempted to contact LVN T by phone. Left message to return phone call. No return call received prior to exit.
During an interview on 03/22/23 at 5:00 p.m., LVN M said on 03/01/23, she arrived for her shift around 2 pm. She said Resident #37 was at the Unit 2 nursing station talking to MA N and CNA O. LVN M said she overheard Resident #37 saying he had to go get his car. She said MA N and CNA O escorted him back to his room. LVN M said around 3:00 PM, a family member of Resident #37 visited him, but she did not see them leave. She said she had not heard Resident #37 making statements like that before. LVN M said Resident #37 was not placed on the secured unit because it had been full. She said after Resident #37 made the statement, CNAs and MAs were alerted to watch him. LVN M said after the elopement incident, he was placed on the secured unit, but he did not seem confused. She said all the facility's doors are supposed to be locked or alarmed. LVN M said elopement risk assessments were completed quarterly or if there was a change in mental status. She said Resident #37 had never been bedfast so if that was on his elopement risk assessment, then it was incorrect. LVN M said elopement risk assessment should be accurate to determine if a resident is safe in the general population and prevent elopements.
On 03/22/23 at 5:05 p.m., attempted to contact MA N by phone. Left message to return phone call. No return call received prior to exit.
On 03/22/23 at 5:07 p.m., attempted to contact CNA O by phone. Left message to return phone call. No return call received prior to exit.
On 03/22/23 at 5:08 p.m., attempted to contact NCNA Q by phone. Left message to return phone call. No return call received prior to exit.
During an interview on 03/22/23 at 5:30 p.m., the DON said Resident #37 was on Unit 2, in the general population before his elopement on 03/01/23. She said Resident #37 had dementia, but he did not have any behaviors prior to indicate an elopement attempt. The DON said Resident #37 would think he was in a different time or said his car was in the shop, but he was always easily redirected. She said, Resident #37 had daily occurs of moments of confusion. The DON said for residents to be placed on the secured unit, they had to attempt elopement, made statements of needing to leave, or exit seeking. She said Resident #37 just made statements of needing to leave. The DON said Resident #37 would go to the dining room and play the piano. She said the dining room was located near the front door but Resident #37 was never left alone while he played the piano. The DON said the facility did not know how Resident #37 got out of the facility. She said she did not recall the secure unit being full or Resident #37 telling 2 staff members on the day he eloped, he needed to get his car. The DON said Resident #37 was not outside for long because she walked out with a visiting family member and 10-15 minutes later, LVN H was walking him back into the facility. She said as the DON investigating the incident, she assessed the resident, obtained statements, helped the ADM, and notified corporate. The DON said Resident #37 had an assessment done, only obtained statement from LVN H and did not get statements from all staff. She said the facility did not know if anyone saw him prior to the elopement but obviously no one did because he got out. The DON said after the elopement, the facility did not obtain labs to investigate if something clinical caused the confusion and elopement. She said she felt like the facility looked at all the contributing factors to Resident #37's elopement. The DON said the facility checked all the doors after the elopement but could not provide documentation. She said she could not recall seeing the maintenance supervisor unarming doors and leaving them unattended. The DON said she had seen the maintenance supervisor turn the alarm off the Unit 2 door which led to the front of the building, but he was always by the door. She said she felt like the facility had put measures in place to prevent further elopements.
During an interview on 03/22/23 at 6:00 p.m., the ADM said Resident #37 had dementia and was pleasantly confused. She said Resident #37 was always looking for his car but was redirected by telling him to call his family member. The ADM said Resident #37 told the visiting family member on the day of incident, he wanted to get his car. She said the visiting family member did not mention Resident #37 acting differently during the visit. The ADM said LVN H found Resident #37 outside and he told her he pushed on the door until it alarmed and opened. She said Resident #37 rarely came out of his room, but he did play the piano in the dining room. The ADM said Resident #37 would ask her if she knew where his car was. She said if Resident #37 pushed on a door and it alarmed, she expected the staff to address the alarm. The ADM said there were many factors contributing to staff not hearing the door alarm going off such as other residents pushing on the door until it opened so they could go smoke. The ADM said when alarms are not addressed, residents could elope. She said after the incident, she double checked alarms with maintenance supervisor, in-serviced staff on elopement and wandering risk, performed a clinical assessment and placed Resident #37 on the secured unit. The ADM said residents could wander if they did not exit seek and did not belong on the secure unit. She said if the facility believed he exited an alarming door and no one addressed it, she did not give staff members an in-service on addressing alarms. The ADM said the facility should have obtained more statements from staff members to get a picture of what happened before the incident. She said elopement assessment were done quarterly and with changes. The ADM said she did not know Resident #37's elopement assessment prior to his elopement was incorrect so an in-service was not given on that either. She said she expected accurate elopement assessment from the nursing staff members.
Record review of a facility Elopement Prevention policy dated 10/27/10 revealed .every effort will be made to prevent elopement episodes .the elopement risk assessment is to be completed at least quarterly and upon change of condition .the resident's current chart and assessments will be reviewed to determine what changes have occurred that would trigger elopement episodes .wandering may be an indication of worsening of confusion secondary to .infection .the wanderer may be simply unable to find his/her room or the bathroom .use door alarms or monitoring devices to notify staff when residents try to leave the facility .all facility exits that residents have access to will have a device in place to alert staff of possible elopement attempts .
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
Assessment Accuracy
(Tag F0641)
Could have caused harm · This affected multiple residents
**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** 2. Record review of the face sheet dated 03/20/23 revealed Resident #42 was [AGE] year-old female admitted on [DATE] with diagno...
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**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** 2. Record review of the face sheet dated 03/20/23 revealed Resident #42 was [AGE] year-old female admitted on [DATE] with diagnoses including Alzheimer's (a type of brain disorder that causes problems with memory, thinking and behavior) and stress incontinence (a condition (found chiefly in women) in which there is involuntary emission of urine when pressure within the abdomen increases suddenly, as in coughing or jumping).
Record review of Resident #42's quarterly MDS assessment dated [DATE] revealed Resident #42 was understood and understood others. The MDS revealed Resident #42 had a BIMS of 03 which indicated severe cognitive impairment and required extensive assistance for toilet use and bathing. The MDS revealed Resident #42 had frequent urinary incontinence. The MDS did not reveal Resident #42 had a urinary tract infection (an infection in any part of the urinary system, the kidneys, bladder, or urethra) in last 30 days. The MDS did not reveal Resident #42 had received antibiotic (used to treat or prevent some types of bacterial infection) in the last 7 days.
Record review of Resident #42's care plan dated 01/18/23 revealed Resident #42 had bladder incontinence. Intervention included monitor/document for signs and symptoms of UTI: pain, burning, blood-tinged urine, cloudiness, no output, deepening of urine color, increased temp, urinary frequency, foul smelling urine, fever, chills, altered mental status, change in behavior, and change in eating patterns.
Record review of Resident #42's MAR dated 01/01/23-01/31/23 revealed Cephalexin Oral Capsule 500 MG (utilized in the treatment of urinary tract infections, respiratory infections, and other bacterial infections), Give 1 tablet by mouth two times a day for UTI for 5 days, started 01/11/23.
Record review of Resident #42's MAR dated 01/01/23-01/31/23 revealed Levaquin (a prescription medicine used to treat the symptoms of various bacterial infections) Oral tablet 500 MG (Levofloxacin), Give 1 tablet by mouth one time a day for UTI for 7 days, started 01/17/23.
Record review of a progress note by LVN J dated 01/10/23 at 1:35 p.m., revealed new order for urinalysis with culture and screen (involves growing bacteria from a urine sample in a lab to diagnose urinary tract infections and other infections), one time only for urinary tract infection, site not specified until 01/11/23 23:59, start date 01/11/23 .
Record review of a progress note by Charge Nurse P dated 01/11/23 at 5:35 a.m., revealed urine sample collected via straight catheterization .
Record review of a progress note by LVN J dated 01/11/23 at 12:47 p.m., revealed new order per physician related to urinalysis results: Cephalexin Oral Capsule 500 MG, give 1 capsule by mouth two times a day for UTI for 5 days, Start date: 01/11/23, End date: 01/16/23 .
Record review of a progress note by LVN J dated 01/17/23 at 8:58 a.m., revealed new order Levaquin Oral Tablet 500 MG, give 1 tablet by mouth one time a day for UTI for 7 days, Start date: 01/17/23, End date: 01/24/23 .
Record review of Resident #42's urinalysis lab results dated 01/11/23 revealed .slightly cloudy clarity, moderate leukocytes (high levels of leukocytes may be a sign of a urinary tract infection or another condition), 100 protein, 8.0 PH, small blood, 2-4 white blood cells, moderate bacteria .new order Keflex (cephalexin) BID x 5 days until culture .
Record review of Resident #42's UTI ID Panel results dated 01/16/23 revealed .high Morganella morganii (is a species of Gram-negative bacteria) . high proteus mirabilis . growth (a urease-forming bacterium and may be associated with urinary tract infections) .new order Levaquin 500 MG QD .
Based on observation, interview and record review, the facility failed to ensure an accurate MDS assessment was completed for 3 of 13 residents reviewed for MDS accuracy. (#07, #42 and #19)
1. The facility failed to accurately document Residents #07 and #42's UTI (urinary tract infection) and antibiotic usage.
2. The facility failed to accurately document Resident # 19's limitation to her functional range of motion.
These failures could place residents at risk for not receiving needed care and services.
Findings included:
1.Record review of an undated face sheet revealed Resident #07 was an 57- year-old-male, admitted on [DATE] with the diagnoses of schizoaffective disorder (bipolar type- a combination of symptoms of schizophrenia and mood disorder, such as depression or bipolar disorder), glaucoma (a group of eye diseases that can cause vision loss and blindness by damaging a nerve in the back of your eye called the optic nerve), and dementia ( impaired ability to remember, think, or make decisions that interferes with doing everyday activities).
Record review of a quarterly MDS dated [DATE] for Resident #07 revealed a BIMS of 15, which indicated no memory or cognitive impairment. The MDS also revealed Resident #07 required no staff assistance with bed mobility, eating, transfers, and toileting. The MDS revealed Resident #07 had no diagnosis for UTI coded. The MDS revealed Resident #07 had not taken any antibiotic medications in the look back period (the time period over which the resident's condition or status is captured by the MDS assessment).
Record review of January 2023 consolidated physician orders revealed Resident #07 had an order for Cefdinir 300mg twice daily for 10 days for UTI.
Record review of Resident # 07's MAR dated 01/01/2023 to 01/31/2023 indicated Resident #23 had taken Cefdinir 300mg twice daily for 10 days beginning on 01/17/2023 and ending 01/26/2023.
Record review of a change of condition assessment completed on 01/16/2023 by LVN A indicated Resident #07 was complaining of flank pain, decreased bowel sounds, and abdominal tenderness. LVN A sent Resident #07 to the ER.
Record review of a urinalysis for Resident #07 dated 01/16/2023 taken at the local hospital indicated Resident #07 had an UTI.
Record review of a discharge assessment for Resident #07 signed by ER MD #1 indicated a diagnosis of UTI.
During an interview on 03/22/2023 at 1:15 p.m., the MDS Nurse said Resident #07 should have been coded for antibiotic use and a urinary tract infection (UTI). The MDS nurse said the facility followed the RAI (Resident Assessment Instrument) manual instructions for coding UTI infections. The MDS nurse said the criteria for coding a UTI according to the RAI manual was for the resident to have displayed symptoms, the resident to have a physician's signed diagnosis of UTI, lab work identifying a UTI, and treatment for an UTI. The MDS nurse said Resident #07 met each of the criteria and the UTI was not coded in error. The MDS nurse said coding errors could affect quality measures, reimbursement, and care planning for individual residents.
During an interview on 03/22/2023 at 2:20 p.m., the DON said the facility used the RAI manual for all coding instructions on the MDS. The DON said Resident #07 was sent to the ER (emergency room) on 01/16/2023 for complaints of flank pain and abdominal distention, was diagnosed with a UTI at the ER, and was sent back to the facility with an order for antibiotics for 10 days. The DON said she was not familiar with the coding guidelines for a UTI according to the RAI manual. The DON said it was the responsibility of the MDS nurse to code MDS's accurately to ensure the resident's needs were captured, a care plan was created, and the quality measures were as accurate as possible. The DON stated there were several corporate nurses that audited the MDS process monthly.
During an interview on 03/22/2023 at 4:45 p.m., the Administrator said it was important to code all information correctly on the MDS and it was the responsibility of the MDS nurse, as well as the corporate consultants who audited the MDS to ensure the MDS was correct. The Administrator said it could affect resident care, reimbursement, and quality measures when triggered items were miscoded.
3. Record review of Resident #19's face sheet dated 3/22/23 indicated she was [AGE] years old readmitted to the facility on [DATE] with diagnoses including, heart disease, COPD (chronic obstructive pulmonary disease is a group of lung diseases that block airflow and make it difficult to breathe), Alzheimer's disease (a progressive disease that destroys memory and other important mental functions), pain in unspecified joint, osteoarthritis (type of arthritis that occurs when flexible tissue at the ends of bones wears down), muscle wasting and atrophy (the wasting or thinning of muscle mass), lack of coordination, weakness, and contracture of the left shoulder (condition of shortening and hardening of muscles, tendons, or other tissue, often leading to deformity and rigidity of joints). The face sheet indicated Resident #19's diagnosis of contracture of the left shoulder had an onset date of 8/27/18.
Record review of the MDS assessment dated [DATE] indicated Resident #19 usually understood others and usually made herself understood. The MDS indicated Resident #19 had severe cognitive impairment (BIMS of 0). The MDS indicated she required extensive assistance with bed mobility, transfers, dressing, eating and toilet use. The MDS indicated she was totally dependent on staff for locomotion in her wheelchair, personal hygiene and bathing. The MDS indicated Resident #19 had no impairment of her functional range of motion in the upper extremities (shoulder, elbow, wrist or hand).
Record review of the MDS dated [DATE] indicated Resident #19 had no impairment of her functional range of motion in the upper extremities (shoulder, elbow, wrist or hand).
Record review of the MDS dated [DATE] indicated Resident #19 had no impairment of her functional range of motion in the upper extremities (shoulder, elbow, wrist or hand).
Record review of the MDS dated [DATE] indicated Resident #19 had no impairment of her functional range of motion in the upper extremities (shoulder, elbow, wrist or hand).
Record review of the MDS dated [DATE] indicated Resident #19 had no impairment of her functional range of motion in the upper extremities (shoulder, elbow, wrist or hand).
Record review of the MDS dated [DATE] indicated Resident #19 had no impairment of her functional range of motion in the upper extremities (shoulder, elbow, wrist or hand).
Record review of the care plan revised on 3/7/23 indicated Resident #19 had an ADL care Self-Care performance deficit. The care plan interventions included PT/OT evaluation and treatment per physician orders. The care plan did not specifically address Resident #19's contracture of her left shoulder.
Record review of the physician order with a start date of 4/1/22 indicated Resident #19 would benefit from skilled PT services and would undergo PT services 3 times per week for 30 days.
Record review of the physician order with a start date of 6/14/22 indicated Resident #19 would benefit from skilled PT services and would undergo PT services 3 times per week for 30 days.
Record review of the physician order with a start date of 09/10/22 indicated Resident #19 would benefit from continued skilled OT services and would undergo OT services 3 times per week for 30 days. The end date of this order was 10/10/2022.
Record review of the physician order with a start date of 10/4/22 indicated Resident #19 would benefit from continued skilled OT services and would undergo OT services 3 times per week for 30 days. The end date of this order was 11/3/22.
Record review of the restorative plan notes for November 2022 indicated Resident #19 had been on a restorative plan since 3/28/22. The restorative plan notes indicated Resident #19 would work on putting on/taking off clothing using a 1 handed technique with the assistance of 1 staff member. The restorative plan indicated Resident #19 was to perform this task 6 times a week (Monday through Saturday). The restorative plan notes indicated Resident #19 had not participated in the restorative plan of care regarding putting on/taking off clothing using a 1 handed technique with the assistance of 1 staff member during the month of November 2022. The restorative plan notes indicated Resident #19 would perform upper body AROM exercises in all joints and planes (planes of the Body-a vertical plane running from side to side; divides the body or any of its parts into anterior [front] and posterior [back] portions. A second vertical plane running from front to back; divides the body or any of its parts into right and left sides) as tolerated. The restorative plan notes indicated Resident #19 had not participated in the restorative plan of care regarding upper body AROM during the month of November 2022 except for the week of 11/24/22. The restorative plan notes documentation was completed by CNA F.
Record review of the physician order with a start date of 11/3/22 indicated Resident #19 would benefit from continued skilled OT services and would undergo OT services 3 times per week for 30 days. This order was discontinued on 11/20/2022.
Record review of the restorative plan notes for December 2022 indicated Resident #19 had been on a restorative plan since 3/28/22. The restorative plan notes indicated Resident #19 would work on putting on/taking of clothing using a 1 handed technique with the assistance of 1 staff member. The restorative plan indicated Resident #19 was to perform this task 6 times a week (Monday through Saturday). The restorative plan notes indicated Resident #19 had not participated in the restorative plan of care regarding putting on/taking off clothing using a 1 handed technique with the assistance of 1 staff member during the month of December 2022, except for 1 day the week of 12/22/22. The restorative plan notes indicated Resident #19 would perform upper body AROM exercises in all joints and planes as tolerated. The restorative plan notes indicated Resident #19 had participated when she was able in the restorative plan of care regarding upper body AROM during the month of December 2022. The restorative plan notes documentation was completed by CNA F.
Record review of the restorative plan notes for January 2023 indicated Resident #19 had been on a restorative plan since 3/28/22. The restorative plan notes indicated Resident #19 would work on putting on/taking of clothing using a 1 handed technique with the assistance of 1 staff member. The restorative plan indicated Resident performed this task 6 times a week (Monday through Saturday) starting January 2, 2023, through January 28, 2023. The restorative plan notes indicated Resident #19 would perform upper body AROM exercises in all joints and planes as tolerated. The restorative plan indicated Resident performed this task 3 times a week starting January 2, 2023, through January 28, 2023. The restorative plan notes documentation was completed by CNA F.
Record review of the physician order with a start date of 2/7/23 indicated Resident #19 would benefit from skilled PT services and would undergo PT services 3 times per week for 30 days. The end date of the order was 3/9/23.
Record review of the active physician order with a start date of 3/7/23 indicated Resident #19 would benefit from skilled PT services and was to undergo PT services 3 times per week for 30 minutes for 30 days.
During an observation on 3/20/23 at 10:32 a.m., Resident #19 sat in her wheelchair in the hallway. Her left arm was pulled closely of her body.
During an observation on 3/21/23 at 9:30 a.m., Resident #19 sat in her wheelchair. Her left arm was pulled closely of her body.
During an interview on 3/22/23 at 11:10 a.m., CNA G said Resident #19 always kept her left arm pulled close to her body. CNA G indicated Resident #19 could barely move her left arm. CNA G indicated she (Resident #19) had limited range of motion to the left arm.
During an observation and interview on 3/22/23 at 2:09 p.m., Resident #19 laid in her bed. Her left arm was pulled closely to her body. When asked if she could move her arm left arm, Resident #19 said No.
During an interview on 3/22/23 at 2:10 p.m., MA D said she regularly provided care to Resident #19. MA D said Resident #19 could not move her left arm.
During an interview on 3/22/23 at 2:15 p.m., RN B indicated Resident #19 had a limited range of motion to her left upper extremity. RN B said LVN H was responsible for completing MDS assessments for the facility and would have been the nurse that completed the most recent MDS on Resident #19.
During an interview on 3/22/23 at 2:17 p.m., LVN C said she regularly provided care to Resident #19. LVN C indicated Resident #19 had a limited range of motion of her left upper extremity for as long as she (LVN C) had worked at the facility. LVN C indicated she had worked at the facility approximately 3 years. LVN C indicated LVN H was responsible for the completion MDS assessments for the facility.
During an interview on 3/22/23 at 3:30 p.m., CNA F said she was the restorative nurse aide for the facility. CNA F said Resident #19 was not currently in restorative services because she was being seen by physical therapy. CNA F said she did have Resident #19 in restorative services until recently. CNA F could not provide the exact date but indicated she believed Resident #19 had been in therapy services since February 2023. CNA F indicated when Resident #19 was in restorative services she worked with her (Resident #19) to dress with one hand because she (Resident #19) could not use her left arm. CNA F indicated she worked the floor as a CNA when needed and continued to provide care to Resident #19 even though she (Resident #19) was not currently in restorative services. CNA F indicated Resident #19 continued to have limited ROM of her left upper extremity.
During an interview on 3/22/23 at 3:59 p.m., LVN H said she was the MDS nurse for the facility. LVN H indicated she had worked in the facility as the MDS nurse for the last 9 years. LVN H said she believed she coded Resident #19 as having no impairment of her functional range of motion in the upper extremities (shoulder, elbow, wrist or hand) on the MDS dated [DATE] because Resident #19 had not underwent treatment or services for such (impairment of her functional range of motion in the upper extremities [shoulder, elbow, wrist or hand]) at the time of the completion of the MDS assessment. When LVN H was asked if Resident #19's diagnosis of left shoulder contracture should have been considered when coding her MDS assessments she said It depends . LVN H then said .I'm not going to talk myself into a corner.
During an interview on 3/22/23 at 4:15 p.m., the DON said she expected MDS assessments to be coded accurately. The DON indicated Resident #19 did not have the range of motion of a young person but was not sure she would classify her left upper extremity as having limited range of motion. The DON said she was not aware of any process the facility had in place to ensure MDS accuracy.
During an interview on 3/22/23 at 4:35 p.m., the Administrator said she expected LVN H to code MDS assessments accurately. The Administrator indicated she could not believe there were MDS inaccuracies because the facilities system in place to check for MDS accuracy was thorough. The Administrator said the facility had just undergone a corporate review of MDS assessments and believed all resident's MDS assessments (most recent) were reviewed. The Administrator said this review was done quarterly.
During a phone interview on 3/27/23 at 4:13 p.m., the Rehab Director indicated Resident #19 had impairment of her functional range of motion for years. The Rehab Director said Resident #19 had received therapy services or restorative services for quite a long time. The Rehab Director indicated Resident #19 currently received physical therapy services in which her upper body and lower body limited range of motion was treated. The Rehab Director said her (Resident #19's) limited range of motion to both her upper extremities and lower extremities was a chronic situation and was not new. The Rehab Director indicated he had worked at the facility for years and had always known Resident #19 to have functional decreased ROM to her both her upper and lower extremities.
During a record review of the facility's Minimum Data Set Policy for MDS assessment Data Accuracy, undated, revealed the purpose of the MDS policy was to ensure each resident received an accurate assessment by qualified staff to address the needs of the resident who are familiar with his/her physical, mental, and psychosocial well-being. The assessment should accurately reflect the resident's status.
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
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 the resident environment remained free of accide...
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**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, interview and record review the facility failed to ensure the resident environment remained free of accident hazards for 1 of 13 residents (Resident #4) and 2 of 7 exit doors reviewed for accident hazards.
The maintenance director disengaged the alarm on 2 exit doors and failed to re-engage the alarmed doors after exiting them.
NCNA E did not lock Resident #4's bed before repositioning her during incontinent care.
These failures could place residents with decreased cognition/confusion at risk of elopement and injury. In addition, these failures could place dependent residents at risk for falls and injury.
Findings included:
1. During an observation on 03/20/2023 at 10:10 a.m., the Maintenance Supervisor disarmed the exit door at the end of the 100 hallway and exited the facility. At 10:20 a.m., the Maintenance Man reentered the exit door at the end of the 100 hallway and no alarm sounded.
During an observation on 03/20/2023 at 11:16 a.m., the Maintenance Supervisor disarmed the exit door at the end of 100 hallway and exited the facility. At 11:20 a.m., the Maintenance Man reentered the exit door at the end of the 100 hallway and no alarm sounded.
During an observation on 03/20/2023 at 11:45 a.m., the Maintenance Supervisor exited the left alarmed door at the back of the main dining room and no alarm sounded. The exit door was left unattended, and 6 residents were in the dining room. At 12:00 p.m., the Maintenance Supervisor reentered the dining room door from the outside and armed the door.
During an observation on 03/21/23 at 12:00 p.m., the door on the left side of the dining room was not fully closed. When the door was pushed open, no alarm sounded. The door lead to an unfenced, grass area with a street running horizontal to the area. No staff were seen outside near the door.
During an observation and interview on 03/21/23 at 12:05 p.m., the Maintenance Supervisor exited the left door in the dining room, no alarm sounded. The Maintenance Supervisor said he unlocked and the door to get to the maintenance closet in the back of the facility. He said he left it unarmed throughout the day, but it was okay because the door locked from the outside.
During an interview on 03/22/23 at 4:00 p.m., the Maintenance Supervisor said he had worked at the facility for 21 years. He said he turned the alarms on and off on the doors throughout the day. The Maintenance Supervisor said the unarmed doors were unattended. He said the door should be alarmed for wandering residents to prevent elopements. The Maintenance Supervisor said due to the doors locking after they closed, the residents were locked outside in the elements.
During an interview on 03/22/23 at 5:30 p.m., the DON said all the doors in the facility were supposed to be alarmed or opened with a keypad. She said the facility utilized alarmed door and keypads for the safety of the residents. The DON said the Maintenance Supervisor checked the alarms on the doors to ensure they worked weekly. She said when alarmed doors are disarmed and unattended, residents could exit. The DON said residents were at risk for injuries when alarmed doors are disarmed and unattended.
During an interview on 03/22/23 at 6:00 p.m., the ADM said the maintenance supervisor was responsible for ensuring the alarms on the doors were working and armed. She said the Maintenance Supervisor did weekly checks to ensure the door alarms worked. The ADM said she did not know until yesterday (03/21/23), the maintenance supervisor was disarming doors and leaving them unattended. She said that practice was unacceptable and created elopement risks for the residents. The ADM said unarmed, unattended created risks for falls and depending on the weather, certain injuries.
2. Record review of the face sheet for Resident #4 dated 3/22/23 indicated she was [AGE] years old re-admitted to the facility on [DATE] with diagnoses including dementia, Type II diabetes, high blood pressure, muscle wasting and atrophy (wasting or thinning of muscle mass), contracture of the left hand (shortening and hardening of muscles, tendons, or other tissue, often leading to deformity and rigidity of joints), muscle weakness, and lack of coordination.
Record review of the MDS assessment dated [DATE] indicated Resident #4 usually made herself understood and sometimes understood others. The MDS indicated Resident #4 had severe cognitive impairment (BIMS of 0). The MDS indicated Resident #4 required extensive assistance with bed mobility, transfers, locomotion in her wheelchair, dressing, eating, and toilet use. The MDS indicated she was totally dependent on staff for bathing and personal hygiene. The MDS indicated Resident #4 was always incontinent of bowel and bladder. The MDS indicated Resident #4 had 1 fall since her admission/entry or reentry or prior Assessment that resulted in no injury.
Record review of the care plan revised on 3/7/23 indicated Resident #4 had a history of multiple falls and was at risk for injury. The care plan interventions included, continue interventions on the at-risk care plan.
Record review of the at -risk care plan for Resident #4, revised on 3/7/23, indicated she was at risk for falls. The care plan interventions included, anticipate/meet the residents needs and keep furniture in the locked position.
Record review of the Incident Reports for Resident #4 from 10/1/22 to 3/22/23 indicated she had fallen out of her bed, with no significant injury on the following dates;
*10/12/22;
*10/21/22;
*10/31/22;
*1/19/23;
*2/9/23; and
*2/15/23.
During an observation on 3/22/23 at 1:57 p.m., NCNA E provided incontinent care to Resident #4. The wheels of Resident #4's bed were was not locked. NCNA E rolled Resident #4 to the right. As NCNA E rolled Resident #4 the bed moved to the right, away from the wall. NCNA E held Resident #4 at the edge of the bed and continued care while the bed remained unlocked. NCNA E rolled Resident #4 onto her (Resident #4's) back to secure the incontinent brief. The bed rolled back against the wall as NCNA E rolled Resident #4 to her back. NCNA E then rolled Resident #4 to the right a second time to place a gown on Resident #4. The bed remained unlocked.
During an interview on 3/22/23 at 2:08 p.m., NCNA E said she did not realize the bed was unlocked when she rolled Resident #4 in the bed. NCNA E said she should have ensured the bed was locked before she began to provide care to Resident #4. NCNA E said it was important to make sure the bed was locked before a resident was repositioned because the resident could fall and become injured. NCNA E indicated she knew it was important to make sure the bed was locked before Resident #4 was turned because she had been trained/checked off on bed safety.
During an interview on 3/22/23 at 2:15 p.m., RN B said staff should make sure beds were locked before a resident was turned or repositioned. RN B said if a bed was not locked the resident could fall out of the bed when repositioned. RN B said all staff performed skills checks upon hire and annually, which included ensuring a bed was locked before a resident was repositioned.
During an interview on 3/22/23 at 2:17 p.m., LVN C said staff should make sure a bed was locked before a resident was turned or repositioned. LVN C said if the bed was not locked the resident could fall out of the bed when repositioned and become injured.
During an interview on 3/22/23 at 3:30 p.m., CNA F said she had regularly taken care of Resident #4. CNA F said staff should make sure a bed was locked before a resident was turned or repositioned. CNA F said this (making sure a bed was locked before a resident was turned or repositioned) was especially true for Resident #4 because she had very little control of her body. CNA F said if the bed was not locked the resident could fall and become injured.
During an interview on 3/22/23 at 4:15 p.m., the DON she expected staff to ensure bed wheels were locked before a resident was turned or repositioned. The DON said if staff failed to do so (ensure bed wheels were locked before a resident was turned or repositioned) the resident could fall and become injured. The DON indicated the system in place to ensure bed wheels were locked before a resident was turned or repositioned included skills training upon hire and annually. In addition, the DON indicated she performed random checks to ensure staff followed the skills they had learned/been checked off on, which included ensuring brakes were locked on all devices (beds included) before a resident was repositioned or transferred.
During an interview on 3/22/23 at 4:35 p.m., the Administrator said she expected staff to ensure bed wheels were locked before a resident was turned or repositioned. The Administrator said if the bed was not locked the resident could fall out of the bed when repositioned and become injured.
The facility policy and procedure titled, Preventive Strategies to Reduce Fall Risk, revised 10/5/16, stated, Policy: The goal of fall prevention strategies is to design interventions that minimize fall risk . (7) Environment: Keep bed in low position. Keep the bed wheels locked .
Record review of a facility Elopement Prevention policy dated 10/27/10 revealed .all facility exits that residents have access to will have device in place to alert staff of possible elopement attempts .examples of these devices .keypad exit magnetic locks .keyed alarms .secured unit .all other exits not considered fire exits will be locked when not occupied by staff members .all exit devices will be maintained by the manufacturers recommendations and function of each door device will be verified weekly and log maintained .
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
Deficiency F0692
(Tag F0692)
Could have caused harm · This affected multiple residents
**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** 2. Record review of the face sheet dated 02/20/23 revealed Resident #1 was [AGE] year-old male admitted on [DATE] with diagnoses...
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**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** 2. Record review of the face sheet dated 02/20/23 revealed Resident #1 was [AGE] year-old male admitted on [DATE] with diagnoses including muscle wasting and atrophy (shortening), muscle weakness, and schizophrenia (a disorder that affects a person's ability to think, feel, and behave clearly).
Record review of Resident #1's order summary report dated as of 03/20/23 revealed Fortified/Enhanced Diet, Regular texture, Regular consistency, GLASS OF WHOLE MILK WITH ALL MEALS, LARGE PORTIONS, HEALTH SHAKE WITH ALL MEALS, ICE CREAM WITH LUNCH AND DINNER started on 12/20/21.
Record review of the annual MDS assessment dated [DATE] revealed Resident #1 was usually understood and sometimes understood others. The MDS revealed Resident #1 was unable to complete the BIMS and had short-and-long term memory problems. The MDS revealed Resident #1 had moderately impaired cognitive skill for decision making. The MDS revealed Resident #1 required limited assistance for eating. The MDS revealed Resident #1 had weight loss of 5% or more in the last month or loss of 10% or more in last 6 months and not on physician prescribed weight loss regimen. The MDS revealed Resident #1 had a therapeutic diet ordered.
Record review of the quarterly MDS assessment dated [DATE] revealed Resident #1 was sometimes understood and sometimes understood others. The MDS revealed Resident #1 was unable to complete the BIMS and had short-and-long term memory problems. The MDS revealed Resident #1 had moderately impaired cognitive skill for decision making. The MDS revealed Resident #1 required supervision for eating. The MDS revealed Resident #1 had weight gain of 5% or more in the last month or loss of 10% or more in last 6 months and not on physician prescribed weight loss regimen. The MDS revealed Resident #1 had a therapeutic diet ordered.
Record review of a care plan dated 01/06/23 revealed Resident #1 had potential risk for malnutrition. Intervention included offer diet as ordered by the physician. Resident #1 had potential for nutritional problems (weight loss) related to medication use and cognitive deficits. Interventions included provide, serve diet as ordered, monitor intake, and record every meal, and registered dietician to evaluate and make diet change recommendations as needed.
Record review of a dietary progress note for Resident #1, dated 11/19/22 by RD revealed .weight loss .current weight 111 lbs.ideal body weight 142 lbs.weight changes -6.6 lbs. x 1 month .15 lbs. x 5 months .diet: fortified diet with large portion, whole milk three times a day, snack at bedtime .supplement: health shakes three times a day .intake fair-good at most meals but resident refuses breakfast often .
Record review of a dietary progress note for Resident #1, dated 12/12/22 by RD revealed .current weight 112.6 lbs.ideal body weight 142 lbs.10% change (Comparison weight 07/05/22, 127lbs, -11.3 %, 14.4 lbs.) .diet: fortified/enhanced diet .supplement: health shakes three times a day plus ice cream twice a day plus snack at bedtime .consumes 25-75% of most meals .[Resident #1] does refuse some meals .recommendations: interventions in place, encourage good intake by mouth greater or equal to 75% of most meals .encourage supplements and snack intake .continue plan of care .
Record review of a dietary progress note for Resident #1, dated 01/09/23 by RD revealed . weight gain .current weight 117.2 lbs.plus 5% change (comparison weight 11/30/22 110.4 lbs. plus 6.2%, plus 6.8 lbs . Diet: fortified/enhanced diet .supplement: two times a day for supplement related to weight loss ice cream twice a day with lunch and dinner, health shake three times a day, snack one time a day, three times a day whole milk with all meals .intake: good intake at most meals, intake by mouth 50-100% per task report .weight gain is beneficial .
Record review of dietary progress note dated 02/09/23 by the RD revealed .weight loss .current weight 118 lbs.diet fortified/enhanced diet, regular texture, regular consistency, GLASS OF WHOLE MILK WITH ALL MEALS, LARGE PORTIONS, ICE CREAM WITH LUNCH AND DINNER .Supplements: snack at bedtime, health shake with all meals .intake: good intake at most meals, by mouth intake 50-100% per task report .Recommendations: DON asked for weight loss consult .resident weight generally stable x1 month .resident by mouth intake within normal limits .interventions in place .continue plan of care .
Record review of Resident #1's meal card dated 03/14/23 revealed red glass, 1 serving meat large portion only, ½ cup of ice cream, 1 each health shake, Special notes: Large Portion.
3. Record review of the face sheet dated 03/20/23 revealed Resident #42 was [AGE] year-old female admitted on [DATE] with diagnoses including Alzheimer's (a type of brain disorder that causes problems with memory, thinking and behavior), Vitamin D deficiency and muscle wasting and atrophy (shortening).
Record review of Resident #42's order summary report dated as of 03/20/23 revealed Fortified/Enhanced Diet, Regular texture, Regular consistency, Health shake TID with meals, ice cream with lunch and dinner start date 02/20/23.
Record review of Resident #42's quarterly MDS assessment dated [DATE] revealed Resident #42 was understood and understood others. The MDS revealed Resident #42 had a BIMS of 03 which indicated severe cognitive impairment and supervision with eating. The MDS revealed Resident #42 had weight loss of 5% or more in the last month or loss of 10% or more in last 6 months and not on physician prescribed weight loss regimen.
Record review of a care plan dated 01/18/23 revealed Resident #42 had a progressive unplanned/unexpected weight loss related to decline in cognition related to Alzheimer's. Interventions included diet as ordered, red glass program as indicated and give the resident supplements as ordered.
Record review of a progress note for Resident #42 dated 01/09/23 by RD revealed, .weight loss .current weight 134.2 lbs . ideal body weight 120 lbs .minus 10% change (comparison weight 08/05/22, 150.4 lbs., -10.8%, -16.2 lbs.) .diet: regular .Supplements: health shake three times a day, ice cream twice a day with lunch and dinner .intake: fair intake at most meals, by mouth intake 25-100% per task report .Recommendations: increased Mirtazapine to 30 mg every day on 12/28/22 to stimulate appetite .weight stable x 1 month .appetite stimulant plus supplements seem to be meeting estimated needs .
Record review of a progress note for Resident #42 dated 02/09/23 by RD revealed, .weight loss .current weight 133.8 lbs. ideal body weight 120 lbs. minus 10% change (comparison weight 08/05/22, 150.4 lbs., -11.0%, -16.6 lbs.) . diet: regular .ice cream with lunch and dinner .supplement: health shake three times a day .intake: varies at most meals, by mouth intake 25-100% per task report .Recommendations: triggered for weight loss, by mouth intake is below normal limits, discontinue regular diet, begin fortified/enhanced diet .
Record review of Resident #42's weights revealed on 09/02/2022, the resident weighed 146.6 lbs. On 03/06/2023, the resident weighed 132.2 pounds which is a -9.82 % Loss.
Record review of Resident #42's weights revealed on 01/17/2023, the resident weighed 136 lbs. On 03/06/2023, the resident weighed 132.2 pounds which is a -2.79 % Loss.
Record review of Resident #42's weights revealed on 02/03/2023, the resident weighed 133.8 lbs. On 03/06/2023, the resident weighed 132.2 pounds which is a -1.20 % Loss.
Record review of Resident #42's meal card dated 03/14/23 revealed red glass, ½ cup of ice cream, 4fl oz resource health shake, Special notes: Fortified/Enhanced.
During an observation on 03/20/23 at 12:00 p.m., Resident #1's lunch tray did not have ice cream or a glass of milk. Further observation revealed Resident #42's lunch tray did not have ice cream on her lunch tray.
During an observation on 03/21/23 at 12:15 p.m., Resident #1's lunch tray did not have ice cream or a glass of milk. Further observation revealed Resident #42's lunch tray did not have ice cream on her lunch tray.
During an observation on 03/22/23 at 11:59 a.m., Resident #1's lunch tray did not have ice cream, a glass of milk, or large meat portion. Further observation revealed Resident #42's lunch tray did not have ice cream on her lunch tray.
During an interview on 03/22/23 at 2:05 p.m., CNA G said Resident #42 had a regular diet with health shakes TID due to her poor appetite. She said Resident #42 did not get ice cream regularly. CNA G said she had seen ice cream on Resident #42's meal tray maybe once to twice a week. She said the nurses are supposed to make sure the meal tickets are correct. CNA G said Resident #1 had a regular diet with house shakes and was on the red cup program. She said she had never seen large meat portions or milk on the lunch trays. CNA G said Resident #1 sometimes got ice cream but not often.
During an interview on 03/22/23 at 3:00 p.m., the Dietary Manager said the dietary aides were responsible for putting supplements like ice cream and house shakes on the meal trays. She said the cooks were responsible for double or large portion sizes. The DM said she tried to be in the kitchen at the beginning of meal service to ensure meal tickets were correct. She said the facility had recently did an in-service on portion sizes and fortified/enhanced foods. The DM said the facility was going to start having a nurse in the dining room to check meal trays and tickets before they went on the halls to ensure diet orders were followed. She said following physician diet orders were important for weight gain.
During an interview and observation on 03/22/23 at 3:15 p.m., Dietary Aide K said she was responsible for putting silverware, condiments, drink, desserts, and health shakes on the meal trays. She said the residents did not get ice cream today (03/22/23). DA K said she did not check the freezer this morning to see if the facility had enough to give out. She said when she first started in January 2023, the cooks told her only Hall 100 needed 3-4 glasses of milk. DA K said she did not know any residents on Hall 300 (Resident #1) who were supposed to get milk with meals. She said there was a red glass program list on the kitchen refrigerator with residents who received supplements. DA K removed a red sheet of paper labeled Red Glass Program from refrigerator. Resident #1 and Resident #42 were listed to receive health shakes with all meals and ice cream for lunch and dinner. DA K said putting ice cream, health shakes or milk on residents' meal trays were important because they are not eating their main meal good.
During an interview on 03/22/23 at 5:30 p.m., the DON said the nurses should check the meal tray cards and plates for accuracy. She said it was interventions such as house shakes and ice cream were weight loss preventions. The DON said the process in place to ensuring the weight loss prevention were in place was the nurse checking the meal tray cards. She said the facility also had the red glass program which indicated weight loss monitoring and a list was provided to the dietary staff. The DON said the red glass program list was updated when changes occurred. She said if the diet order said milk with all meals, then it should not just be given at breakfast. The DON said the dietary manager was responsible for ensuring the facility had enough supplements to follow the diet orders. The DON said the ADON and herself were responsible for implementing care plan interventions. She stated the MDS coordinator, DON, and ADON were responsible for developing the care plan and interventions. The DON said it was important to meet the resident's specific needs.
During an interview on 03/22/23 at 6:00 p.m., the ADM said the facility was responsible for providing or meeting the resident's needs. She said everyone was responsible for implementing care plan interventions. She said intervention such as house shakes, milk, ice cream, and double portions were important for weight loss prevention and nutritional support. The ADM said diet orders were important to follow. The ADM said when interventions are not followed weight loss and loss of nutritional support could happen.
Record review of an in-service dated 03/17/23 by the DM and ADM revealed Training Topic: Portion Sizes. Four, cook signatures noted. No in-services topic related to following diet order was noted.
An undated policy titled Resident Meal Service indicated . a large portion diet can be ordered and served. If the resident had a physician's ordered snack, or one that was part of his/her plan of care, it would be individually prepared and labeled with the resident's name. If a resident wished to not eat a meal, food substitutions would be offered first, then nutritional supplements.
Based on observation, interview, and nd record review, the facility failed to ensure residents maintained acceptable parameters of nutritional status for 3 of 14 residents (Resident #07, Resident #1, and Resident #42) reviewed for nutrition/weight loss.
The facility failed to provide physician ordered dietary interventions for Resident #07, resulting in significant weight loss.
The facility failed to provide physician ordered dietary interventions for Resident #1 and Resident #42.
These failures could place residents at risk for decreased nutritional status, decline in health, serious illness, or hospitalization.
Findings included:
1. Record review of an undated face sheet revealed Resident #07 was an 57- year-old-male, admitted on [DATE] with the diagnoses of schizoaffective disorder (a combination of symptoms of schizophrenia and mood disorder, such as depression or bipolar disorder), glaucoma (a group of eye diseases that can cause vision loss and blindness by damaging a nerve in the back of your eye called the optic nerve), and dementia (impaired ability to remember, think, or make decisions that interferes with doing everyday activities).
Record review of a quarterly MDS dated [DATE] for Resident #07 revealed a BIMS of 15, which indicated no memory impairment. The MDS also revealed Resident #07 required no staff assistance with bed mobility, eating, transfer, and toileting. The MDS revealed Resident #07 was on therapeutic diet. No weight loss or gain was coded on the MDS.
Record review of a care plan for Resident #07 titled Risk for Malnutrition dated 11/21/2017 with a target date of 04/16/2023, revealed interventions to offer diet as ordered by the physician and to update food preferences as needed.
Record review of the physician orders for March 2023 revealed a diet order dated 01/23/2023 for a low fat, low cholesterol diet with large portions and a fortified food plan (when a food dish, such as custard, milk pudding, porridge or soup is adapted by adding everyday foods which are high in calories and protein). The record also revealed an order dated 03/01/2023 for Ensure three times daily.
Record review of the task sheet titled POC (plan of care) response history for Resident #07 dated 02/21/2023 to 03/22/2023 indicated Resident #07 consumed 0-25% for 20 meals, 26-50% for 12 meals, 51-75% for 43 meals, and 76-100% for 15 meals for a total of 90 meals in 30 days.
Record review of the Weight Summary list dated 03/2023 for Resident #07 indicated Resident #07's was:
*03/15/2023-181.8 lbs.- down 11% /16 lbs. in 30 days-most recent weight
*02/03/2023- 198 lbs.-down 16% /29 lbs. in 90 days
*09/01/2022 216.2 lbs.-down 18.9% /34 lbs. in 180 days
During an observation on 03/20/2023 at 12:45 p.m., Resident #07's meal ticket indicated low cholesterol, low fat diet with large portions and fortified foods. Resident #07's tray had a single portion ham, yams, and corn bread. No large portions and no fortified food were noted to on Resident #07's meal tray. Resident #07 consumed 75% of the meal.
During an observation and interview on 03/21/2023 at 12:55 p.m., Resident #07 had a single portion of hamburger steak, mashed potatoes, and cheesecake. No large portions and no fortified foods were noted to Resident #07's tray. Resident #07 said he was not hungry but would like an Ensure. Resident #07 said he felt like the facility served the same thing too often and the food was cold when it got to him.
During an observation on 03/21/2022 at 1:00 p.m., Resident #07 asked LVN C for an Ensure after eating 50% of the lunch meal. LVN C informed Resident #07 the facility currently did not have Ensure.
During an observation on 03/22/2023 at 12:20p.m., Resident #07 had a single portion of pot roast with gravy, mixed vegetables, corn bread and a piece of banana cake with chocolate icing. Resident #07 consumed 25% or less of the lunch meal and requested an Ensure from CNA G. CNA G said the facility was out of Ensure.
During an interview on 03/22/2023 at 2:00 p.m., LVN C stated the facility did not provide Ensure for Resident #07. LVN C stated the facility only provided health shakes for weight loss because Ensure was too expensive. LVN C stated she had purchased Ensure for Resident #07 in the past and just had not made it to the store to restock. LVN C stated Resident #07 refused health shakes in the past but willingly drank the Ensure. LVN C stated fortified food was served in the form of super cereal for breakfast (oatmeal with added butter and whole milk) and super pudding for lunch and dinner. LVN C stated she normally went back to the kitchen and requested the super pudding if she knew the residents were missing it on their tray.
During an interview on 03/22/2023 at 2:30 p.m., the DON stated the facility was not providing Ensure for Resident #07. The DON stated a staff member was providing the Ensure for Resident #07. The DON was not aware there was no Ensure in the facility since 03/20/2023. The DON stated Ensure was not the dietary supplement of choice for the facility but Resident #07 refused to drink the health shakes the facility provided. The DON stated she would make sure Ensure was ordered and available for Resident #07. The DON stated the facility was restructuring the kitchen so the kitchen staff would not miss important details like large portions and fortified foods being added to resident's trays.
During an interview on 03/22/2023 at 2:45 p.m., the Administrator stated she was unaware Resident #07 was not receiving large portions, fortified food and Ensure per physician orders. The Administrator stated it was important for all residents to get their physician prescribed diets to ensure overall health and skin integrity. The Administrator stated improper nutrition could lead to weight loss, weakness, and skin impairment.
2.
3.
An undated policy titled Resident Meal Service indicated . a large portion diet can be ordered and served. If the resident had a physician's ordered snack, or one that was part of his/her plan of care, it would be individually prepared and labeled with the resident's name. If a resident wished to not eat a meal, food substitutions would be offered first, then nutritional supplements.
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
Deficiency F0804
(Tag F0804)
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 provide food that was served at an appetizing tempera...
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**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, interview, and record review, the facility failed to provide food that was served at an appetizing temperature for 4 of 13 residents (Resident#7, #39, #27 and #43), and 2 of 2 lunch meals reviewed for appetizing temperature.
The facility failed to provide a test tray with food at an appetizing temperature.
The facility failed to ensure Resident#7, #39, #27 and #43 were served food at an appetizing temperature.
These failures could place residents at risk for decreased quality of life, significant weight loss, and associated health complications.
During an observation on 03/22/23 from 10:32 a.m., to 12:28 a.m., the following was noted:
*At 10:32 a.m., [NAME] L removed pork roast, squash, and Italian green beans from the oven and placed them on the steam table (a steam table is a type of food-holding equipment designed to keep hot foods at a safe holding temperature in high-volume businesses). [NAME] L removed the foil from the three pans and did not place a lid on top of the items.
*At 11:08 a.m., [NAME] L performed internal temperatures (food is safely cooked when the internal temperature gets high enough to kill germs that can make you sick. The only way to tell if food is safely cooked is to use a food thermometer) on the brown gravy (186 F), pureed corn bread (143 F), chicken breast (197 F), and mashed potatoes (138 F).
*At 11:11 a.m., [NAME] L performed internal temperature on the rice (186 F).
*At 11:21 a.m., [NAME] L performed internal temperature on the pork roast (163 F).
*At 11:24 a.m., [NAME] L performed internal temperatures for the squash (169 F) and Italian green (168 F). All food items were not at the appropriate temperature initially and had to be rewarmed to reach acceptable temps of 145-degree Fahrenheit for Fish and other meat and 135 degrees Fahrenheit for fruits and vegetables.
*At 11:37 a.m., [NAME] L began plating Hall 200 trays and finished at 11:54 a.m.
*At 11:56 a.m., [NAME] L began plating Hall 300 trays and finished at 12:08 p.m.
*At 12:10 p.m., [NAME] L began plating Hall 100 and finished at 12:17 p.m. All the plates were pulled from the plate heater but all carts were transferred with no covering.
*The last tray on Hall 100 was brought to the conference room at 12:28 p.m. The test tray was tasted by 3 surveyors and [NAME] L. The first food item tasted was pork roast which was warm. Next food item was rice with brown gravy which was lukewarm. The final food item was Italian green beans which were lukewarm with cold beans tasted intermittently.
During an interview on 03/22/23 at 12:32 p.m., [NAME] L said she realized after the Dietary Manager informed her, she should not have removed the foil without covering the food afterwards. She said then she had to rewarm all the food items to getting the to the acceptable temperatures. [NAME] L said she had to read the meal tickets and plate all the resident's trays without assistance from other dietary staff members. She said plating 40 plus meal trays with only the heated plates as a warming device was not good enough. [NAME] L said the trays are taken by the dietary aides to the halls, but cart covers were not used by the facility. She said the test tray food items were lukewarm and some items cold. [NAME] L said she was doing the best she could.
During an interview on 03/22/23 at 3:00 p.m., the Dietary Manager said she had been recently hired at the facility for about 1.5 weeks. She said she expected the dietary staff, especially the cooks to ensure the residents food was at the appealing temperature. The DM said the dietary staff had habits that needed to be corrected such as removing the foil without covering the food afterwards. She said she tried to be in the kitchen at the start of meal service to monitor the dietary staff. The DM said the facility had recently given the dietary staff members in-services on different topics. The DM said she had instructed the cooks to use clear wrap to cover the food to help keep the food warm. She said after today's meal service, the facility would be working on a better meal prep line and plating plan. The DM said the current plating process needed revamping. She said residents having warm food was important so it was appetizing, and residents would consume it for weight gain and nutrition.
During an interview on 03/22/23 at 5:30 p.m., the DON said she expected the food from the kitchen to be hot and tasteful. She the dietary cooks should be cooking meals per the recipe. The DON said the dietary staff should plate and serve the meals in a timely manner. She said cold food could lead to residents not eating it and causing weight loss.
During an interview on 03/22/23 at 6:00 p.m., the ADM said she expected warm, appetizing meals because no one wanted to eat nasty food. She said the food should look and taste good so residents would want to eat it and not spit it out. She said to ensure the meals are tasteful dietary staff should follow the recipes provided. The ADM said to ensure warm food CNAs, nurses, and dietary staff had to working together. She said the Dietary Manager was responsible for overseeing meals service and temperatures. The ADM said cold, unappetizing food could cause weight loss, upset stomach, or illness.
Record review of the 13 in-services dated 03/17/23 given by the DM and ADM did not reveal topics related to warm meals.
2.Record review of an undated face sheet revealed Resident #07 was an 57- year-old-male, admitted on [DATE] with the diagnoses of schizoaffective disorder (bipolar type) (Schizoaffective disorder is a combination of symptoms of schizophrenia and mood disorder, such as depression or bipolar disorder), glaucoma (a group of eye diseases that can cause vision loss and blindness by damaging a nerve in the back of your eye called the optic nerve), and dementia (impaired ability to remember, think, or make decisions that interferes with doing everyday activities).
Record review of an MDS dated [DATE] for Resident #07 revealed a BIMS of 15, which indicated no memory impairment. The MDS also revealed Resident #07 required no staff assistance with eating.
Record review of the MD orders dated March 2023 revealed an order for low fat/low cholesterol diet with large portions and fortified foods at each meal.
During an interview on 03/20/2023 at 10:15 a.m., Resident #07 stated the food was cold most of the time by the time it got to his room. Resident #07 stated cold food was unappetizing to him.
During an observation and interview on 03/22/2023 at 12:40 p.m., Resident #07 consumed less than 25% of the lunch meal. Resident #07 stated the food was not hot, it was barley warm, and he did not want it heated in the microwave.
3.Record review of an undated face sheet revealed Resident #39 was a 48- year-old-male, admitted on [DATE] with the diagnoses of diabetes mellitus (a metabolic disease, involving inappropriately elevated blood glucose levels), cerebral infarction (occurs because of disrupted blood flow to the brain due to problems with the blood vessels that supply it), and dysphagia (swallowing difficulties).
Record review of an MDS dated [DATE] for Resident #39 revealed a BIMS of 15, which indicated no memory impairment. The MDS also revealed Resident #15 required supervision of 1 staff for assistance with eating.
During an interview on 03/20/2023 at 9:55 a.m., Resident #39 stated the food tasted good, but it was often served cold. Resident #39 stated he ate in the dining room most meals and the kitchen staff would set the trays outside of the kitchen door and it would take the nursing staff 15 to 20 minutes to come in and pass the trays out.
During an observation on 03/20/2023 at 12:00 p.m., the kitchen staff rolled an open cart out into the dining area. Resident #39's lunch meal was on the cart. At 12:22 p.m., the nursing staff entered the dining room and distributed the lunch trays.
During an interview on 03/20/2023 at 1:00 p.m., Resident #39 stated the food was cold by the time he got his tray. Resident #39 stated he did not enjoy cold food.
4.Record review of an undated face sheet revealed Resident #27 was an 87- year-old-female, admitted on [DATE] with the diagnoses of chronic obstructive pulmonary disease (a group of diseases that cause airflow blockage and breathing-related problems), heart failure (a condition that develops when your heart doesn't pump enough blood for your body's needs), and hypothyroidism (when the thyroid gland doesn't make enough thyroid hormones to meet your body's needs).
Record review of an MDS dated [DATE] for Resident #27 revealed a BIMS of 14, which indicated no memory impairment. The MDS also revealed Resident #15 required supervision of 1 staff for assistance with eating.
During an interview on 03/20/2023 at 10:25 a.m., Resident #27 stated she despised the food served at the facility. Resident #27 stated it was not the taste that was bad it was the temperature. Resident #27 stated she ate in her room almost every meal and the food would be cold by the time the aide brought it to her room.
During an interview on 03/20/203 at 11:00 a.m., LVN C stated she occasionally got a complaint of cold food, and she would rewarm the food or ask the kitchen to make a fresh plate if the resident would eat it. LVN C stated it was less than monthly that she received a complaint of cold food.
5. Record review of the face sheet for Resident #43 indicated he was [AGE] years old and readmitted to the facility on [DATE] with diagnoses including, heart disease, hypothyroidism (abnormally low activity of the thyroid gland), COPD (group of lung diseases that block airflow and make it difficult to breathe) and history of traumatic brain injury.
Record review of the MDS assessment dated [DATE] indicated understood others and made himself understood. The MDS indicated Resident #43 was cognitively intact (BIMS of 15). The MDS indicated he required supervision only with ADLs including eating.
Record review of the care plan revised on 2/21/23 indicated Resident #43 was at risk for potential fluid deficit. The care plan interventions included, ensure that all beverages offered comply with diet. The care plan provided no further risk or interventions related to diet.
During an interview on 3/20/23 at 11:18 a.m., Resident # 43 said he always ate in his room. Resident #43 said his food was frequently brought to him cold. Resident #43 said all of his meals were frequently brought to him at a lukewarm or cold temperature. Resident #43 said he did not want to eat food that was cold.
Record review of the facility provided CMS 672 indicated the facility census of 45 residents ate from the cafeteria.
Record review of a facility Preparation of Foods policy dated 2012 revealed .food is to be prepared in such a manner as to maximize flavor, appearance, and nutritional value .all food will be prepared by methods that preserve nutritive value, flavor, and appearance with variety of color, and will be attractively served at the proper temperature .the Dietary Service Manager and cooks will taste and test meals daily .
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?"
- "Why is there high staff turnover? How do you retain staff?"
- "Can I speak with families of current residents?"
- "What's your RN coverage like on weekends and overnight?"
Our Honest Assessment
Strengths
- • Licensed and certified facility. Meets minimum state requirements.
Concerns
- • Multiple safety concerns identified: 2 life-threatening violation(s), $275,992 in fines, Payment denial on record. Review inspection reports carefully.
- • 22 deficiencies on record, including 2 critical (life-threatening) violations. These warrant careful review before choosing this facility.
- • $275,992 in fines. Extremely high, among the most fined facilities in Texas. Major compliance failures.
- • Grade F (16/100). Below average facility with significant concerns.
Bottom line: Trust Score of 16/100 indicates significant concerns. Thoroughly evaluate alternatives.
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About This Facility
What is Beaumont Nursing And Rehabilitation's CMS Rating?
CMS assigns BEAUMONT NURSING AND REHABILITATION an overall rating of 3 out of 5 stars, which is considered average nationally. Within Texas, this rating places the facility higher than 99% of the state's 100 nursing homes. This mid-range rating indicates the facility meets federal standards but may have areas for improvement.
How is Beaumont Nursing And Rehabilitation Staffed?
CMS rates BEAUMONT NURSING AND REHABILITATION's staffing level at 2 out of 5 stars, which is below average compared to other nursing homes. Staff turnover is 61%, which is 15 percentage points above the Texas average of 46%. High turnover can affect care consistency as new staff learn residents' individual needs. RN turnover specifically is 86%, which is notably high. RNs provide skilled clinical oversight, so turnover in this role can affect medical care quality.
What Have Inspectors Found at Beaumont Nursing And Rehabilitation?
State health inspectors documented 22 deficiencies at BEAUMONT NURSING AND REHABILITATION during 2023 to 2025. These included: 2 Immediate Jeopardy (the most serious level, indicating potential for serious harm or death) and 20 with potential for harm. Immediate Jeopardy findings are rare and represent the most serious regulatory concerns. They require immediate corrective action.
Who Owns and Operates Beaumont Nursing And Rehabilitation?
BEAUMONT NURSING AND REHABILITATION is owned by a for-profit company. For-profit facilities operate as businesses with obligations to shareholders or private owners. The facility is operated by CREATIVE SOLUTIONS IN HEALTHCARE, a chain that manages multiple nursing homes. With 120 certified beds and approximately 43 residents (about 36% occupancy), it is a mid-sized facility located in BEAUMONT, Texas.
How Does Beaumont Nursing And Rehabilitation Compare to Other Texas Nursing Homes?
Compared to the 100 nursing homes in Texas, BEAUMONT NURSING AND REHABILITATION's overall rating (3 stars) is above the state average of 2.8, staff turnover (61%) is significantly higher than the state average of 46%, and health inspection rating (2 stars) is below the national benchmark.
What Should Families Ask When Visiting Beaumont Nursing And Rehabilitation?
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?" "How do you ensure continuity of care given staff turnover, and what is your staff retention strategy?" "Can you walk me through typical staffing levels on day, evening, and night shifts?" "Can I visit during a mealtime to observe dining assistance and food quality?" These questions are particularly relevant given the facility's Immediate Jeopardy citations, the facility's high staff turnover rate, and the below-average staffing rating.
Is Beaumont Nursing And Rehabilitation Safe?
Based on CMS inspection data, BEAUMONT NURSING AND REHABILITATION has documented safety concerns. Inspectors have issued 2 Immediate Jeopardy citations (the most serious violation level indicating risk of serious injury or death). The facility has a 3-star overall rating and ranks #1 of 100 nursing homes in Texas. Families considering this facility should ask detailed questions about what corrective actions have been taken since these incidents.
Do Nurses at Beaumont Nursing And Rehabilitation Stick Around?
Staff turnover at BEAUMONT NURSING AND REHABILITATION is high. At 61%, the facility is 15 percentage points above the Texas average of 46%. Registered Nurse turnover is particularly concerning at 86%. RNs handle complex medical decisions and coordinate care — frequent RN changes can directly impact care quality. High turnover means new staff may not know residents' individual needs, medications, or preferences. It can also be disorienting for residents, especially those with dementia who rely on familiar faces. Families should ask: What is causing the turnover? What retention programs are in place? How do you ensure care continuity during staff transitions?
Was Beaumont Nursing And Rehabilitation Ever Fined?
BEAUMONT NURSING AND REHABILITATION has been fined $275,992 across 2 penalty actions. This is 7.7x the Texas average of $35,839. Fines at this level are uncommon and typically indicate a pattern of serious deficiencies, repeated violations, or failure to correct problems promptly. CMS reserves penalties of this magnitude for facilities that pose significant, documented risk to resident health or safety. Families should request specific documentation of what issues led to these fines and what systemic changes have been implemented.
Is Beaumont Nursing And Rehabilitation on Any Federal Watch List?
BEAUMONT NURSING AND REHABILITATION 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.