COLLEGE STREET HEALTH CARE CENTER
Government - Hospital district
50 Beds
HEALTH SERVICES MANAGEMENT
Data: November 2025
Trust Grade
48/100
#439 of 1168 in TX
Photo by College Street Health Care Center
Photo by College Street Health Care Center
Photo by College Street Health Care Center
1 / 5 photos
Last Inspection: August 2025
Inspected within the last 6 months. Data reflects current conditions.
Overview
College Street Health Care Center in Beaumont, Texas has a Trust Grade of D, indicating below-average performance and some concerns about the quality of care provided. It ranks #439 out of 1,168 facilities in Texas, placing it in the top half, and #6 out of 14 in Jefferson County, suggesting that there are better options available locally. Unfortunately, the facility's conditions are worsening, with issues increasing from 3 in 2024 to 9 in 2025. Staffing is below average with a rating of 2 out of 5 stars and a turnover rate of 60%, which is higher than the state average. Additionally, the facility has faced serious concerns, such as a resident being physically assaulted by another resident and failing to consult physicians regarding significant changes in residents' health, raising red flags about the care environment. While there are some strengths, such as average RN coverage, the overall situation indicates potential risks for residents that families should carefully consider.
- Trust Score
- D
- In Texas
- #439/1168
- Safety Record
- Moderate
- Inspections
- Getting Worse
- Staff Stability ⚠ Watch
- 60% turnover. Above average. Higher turnover means staff may not know residents' routines.
- Penalties ✓ Good
- $9,469 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
- 23 deficiencies on record. Higher than average. Multiple issues found across inspections.
48/100
Top 37%
Needs review
3 → 9 violations
★★★☆☆
3.0
Overall Rating
★★☆☆☆
2.0
Staff Levels
★★☆☆☆
2.0
Care Quality
★★★☆☆
3.0
Inspection Score
↔
Stable
2024: 3 issues
2025: 9 issues
The Good
-
Full Sprinkler Coverage · Fire safety systems throughout facility
-
No fines on record
Facility shows strength in fire safety.
The Bad
3-Star Overall Rating
Near Texas average (2.8)
Meets federal standards, typical of most facilities
Staff Turnover: 60%
14pts above Texas avg (46%)
Frequent staff changes - ask about care continuity
Federal Fines: $9,469
Below median ($33,413)
Minor penalties assessed
Chain: HEALTH SERVICES MANAGEMENT
Part of a multi-facility chain
Ask about local staffing decisions and management
Staff turnover is elevated (60%)
12 points above Texas average of 48%
The Ugly 23 deficiencies on record
1 actual harm
Aug 2025
6 deficiencies
CONCERN
(D)
Potential for Harm - no one hurt, but risky conditions existed
Unnecessary Medications
(Tag F0759)
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 the medication error rate was not five pe...
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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 the medication error rate was not five percent or greater. The facility had a medication error rate of 10%, based on 3 errors out of 29 opportunities, which involved 1 of 3 residents reviewed (Resident # 18) and 1 of 2 staff (LVN A) reviewed for medication errors. LVN A failed to administer Resident #18's senna (vegetable laxative) 8.6mg, hydromorphone (opioid pain medication used to treat moderate to severe pain) and artificial tears 1 drop to both eyes according to the physician's order. These failures could place residents at risk for decline in health and decreased quality of life. Findings include: Record review of a face sheet dated [DATE] indicated Resident #18 was a [AGE] year-old male admitted on [DATE]. His diagnoses included Parkinsonism (disorder of the central nervous system that affects movement, often including tremors), neurocognitive disorder with Lewy bodies (progressive brain disorder that causes a gradual decline in mental abilities), chronic pain, constipation, nonexudative age-related macular degeneration unspecified eye early dry stage (dry eye condition) and hypertension (high blood pressure). Record review of a care plan last revised [DATE] indicated Resident #18 had the following: -chronic pain related to old spinal surgery and received hydromorphone routine with interventions to administer hydromorphone and evaluate the effectiveness of pain interventions,-constipation and received senna,-impaired visual function and received artificial tears. Record review of a quarterly MDS dated [DATE] indicated Resident #18 had a BIMS score of 13 indicating his cognitive function was intact. During an observation on [DATE] at 08:25 a.m., LVN A administered medications to Resident #18 which included: 1. amlodipine 2.5 mg, 1 tablet, 2. buspirone 5 mg, 1 tablet,3. carbidopa-levodopa 25/100 mg, 2 tablets,4. finasteride 5 mg, 1 tablet,5. furosemide 20 mg, 1 tablet,6. Gemtesa 75 mg, 1 tablet,7. lisinopril 40 mg, 1 tablet,8. stool softener 100 mg, 1 softgel,9. meloxicam 7.5 mg, 1 tablet,10. pramipexole 0.5 mg, 1 tablet,11. alprazolam 0.5 mg, 1 tablet,LVN A did not administer senna 8.6 mg, hydromorphone 4mg, or artificial tears. Record review of Resident #18's [DATE] physician order summary indicated the following orders: -artificial tears ophthalmic solution, instill 1 drop in both eyes three times a day related to nonexudative age-related macular degeneration unspecified eye early dry stage,-hydromorphone oral tablet 4 mg, give 1 tablet by mouth four times a day for pain,-senna oral tablet 8.6 mg, give 1 tablet by mouth in the morning related to constipation. During an interview on [DATE] at 8:45 a.m., LVN A said she did not give artificial tears, hydromorphone 4 mg or senna 8.6 mg to Resident #18 during the medication pass. LVN A said the artificial tears on the cart were expired and she threw them away and had not replaced them. She said she did not give the hydromorphone 4mg morning dose because the medication had been reordered and had not arrived and the senna was not given because she did not have it on the cart to administer. LVN A said she told the ADON yesterday ([DATE]) that the medication was not available and that she would get them. She said she was nervous being watched and administering medications. She said the facility kept artificial tears and senna in stock, but she had not checked the medication room for the medications. She said Resident #18 did not receive all his medications as ordered by his physician. LVN A said she had worked at the facility for 2 years on the night shift and she had not been observed by the DON or Administration while giving medications. She said she had done education on the computer related to medication administration and medication errors if not administered. LVN A said omitting medications can lead to residents not having treatment of disease. During an interview [DATE] at 10:00 a.m., the ADON said she was the one responsible for ordering over the counter medications for the central supply in the medication room storage stock. The ADON said she had ordered senna 8.6mg a week ago and it was in stock but when she looked at it, she noticed it was not correct. The ADON said senna plus was delivered and it had docusate sodium in it, and she said it was not the same medication, and she would reorder it. She said artificial tears was available and the nurse just needed to look for it on the shelf and she was not sure why the hydromorphone had not arrived yesterday but that it was available today. The ADON said the only dose that was missed was the [DATE] morning dose but he got the next dose that was due around 12:00 p.m. She said she had been trained on medication and medication errors and the risk to the resident not getting the medication would cause their disease process to get worse. During an interview [DATE] at 10:20 a.m., the DON said the facility kept artificial tears in stock but did know why LVN A did not check the medication room over the counter stock. The DON said she expected the nurses to give medications as ordered and if the medication was not available to report it to her or the ADON so they could obtain it. She said she was not aware of the medications for Resident #18 were not on the medication cart. The DON said she would also review the errors with LVN A and re-educate her on medication administration. She said these medication errors could have a negative effect on Resident #18. During an interview on [DATE] at 11:00 a.m., the Administrator said the DON had reported the medication errors made during observation of med pass. The Administrator said she expected that all medications would be given as ordered by the physician. The Administrator said the possible negative outcome of medication errors was residents not receiving medications as ordered by the physician. Record review of facility undated policy titled, Medication Administration read in part: .medications are administered by licensed nurses or other staff who are legally authorized to do so in this state as ordered by the physician and in accordance with professional standards of practice in a manner to prevent contamination or infection. Record review of facility undated policy titled Medication Errors read in part: . 1. The facility shall ensure medications will be administered as follows: a. according to physician's orders. 2. The facility must ensure that it is free of medication error rates of 5% or greater.
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 observation, interview and record review, the facility failed to establish and maintain an infection prevention and con...
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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 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 #2) reviewed for infection control. The ADON failed to perform hand hygiene and change gloves while providing wound care to Resident #2's buttock area wound. CNA C failed to perform hand hygiene and change gloves while providing peri-care to Resident #2. These failures could place residents at risk for the spread of infection. Findings include:Record review of Resident 2's face sheet, dated 08/06/25, indicated a [AGE] year-old male who was admitted to the facility on [DATE], with diagnoses of having a pressure ulcer of his left buttock and hypertension (high blood pressure). Record review of Resident #2's admission MDS assessment dated [DATE] indicated Resident #2's skin conditions included an unhealed stage 2 and 3 pressure ulcer/injury over a bony prominence. Record review of Resident #2's care plan, dated 04/30/25, indicated the resident had a stage 2 pressure ulcer to outer his left buttock and stage 3 pressure ulcer to his left inner buttock, with interventions to .administer treatments as ordered and monitor for effectiveness. Resident #2 required enhanced barrier precautions related to his wounds, with interventions .to utilize ppe appropriate for enhanced barrier precautions: gown gloves Record review of physician orders for August 2025 for Resident #2 indicated: clean inner and outer left buttock with dermal wound cleanser and pat dry. Apply Medi-honey and calcium alginate and cover with dry dressing daily until healed. During an observation and interview on 08/06/25 at 8:15 a.m. of Resident #2's peri-care and pressure ulcer treatment, the ADON and CNA C washed their hands and donned gloves and gowns before the start of care. The ADON prepared a clean field before commencing care. The ADON took her supplies to the resident's room and placed on his bedside table. CNA C unfastened the brief and exposed Resident #2's peri-area. CNA C with the same soiled gloves on, entered the pack of cleansing wipes, obtained a wipe and wiped the resident's groin area and threw it in the trash. CNA C with the same soiled gloves re-entered the wipe pack to obtain a fresh wipe and wiped Resident #2's penis from base to the head of his penis, then on the other side of his penis wiped from head to base with the same wipe and threw the wipe in the trash. While wearing the same gloves, CNA C re-entered the wipe pack, obtained a fresh wipe and wiped Resident #2's head of his penis in a circular motion and threw the wipe in the trash. CNA C with the same soiled gloves on rolled Resident #2 on to his right side to expose his buttocks for wound care treatment. The ADON removed the old dressing that was contaminated with serosanguinous drainage and cleansed Resident #2's wounds with gauze and wound cleanser. Without removing her gloves to perform hand hygiene or change her gloves, the ADON touched items in her clean field and retrieved more gauze to cleanse Resident #2's buttock wounds. She did not wash hands, change gloves, or perform hand hygiene before going back into her now contaminated field to retrieve gauze to cleanse Resident #2's buttock wounds a second time. The ADON did not perform hand hygiene or change her contaminated gloves and retrieved the Medi-honey, Q-Tip and calcium alginate and placed them all in her left hand and applied to Resident #2's buttock wound. The ADON did not wash hands, change gloves, or perform hand hygiene before going back again into her now contaminated field to retrieve the dry dressing to cover Resident #2's buttock wound. The ADON with soiled wound care gloves and CNA C with the same soiled peri-care gloves placed a clean brief on Resident #2 without continuing per-care of his back side (buttocks) or inner thigh areas. CNA C then adjusted Resident #2's clothing and adjusted his bed linens while wearing the same soiled gloves. The ADON and CNA C removed there PPE and washed their hands before exiting Resident #2's room. During an interview on 08/06/25 at 8:20 a.m., the ADON said she should have washed her hands and changed her gloves during care. The ADON said she should have changed her gloves before retrieving a clean dressing and placing on Resident #2's wound. The ADON said she was wound care certified and was the Infection Control Preventionist for the facility. She said the resident could acquire an infection when she did not follow good infection control practices which included changing gloves, hand hygiene and washing hands when going from dirty to clean. During an interview on 08/06/25 at 8:30 a.m., CNA C said she did not realize that she used the same gloves to remove the soiled brief and apply the new brief. CNA C said she should have wiped Resident #2's penis from the head to the base of the shaft to decrease the risk of infection. CNA C also, said she should have changed her gloves before going into the pack of wipes, and should have continued peri-care to include the resident's back side but she got nervous, and she did not do it. CNA C said she was trained in orientation on incontinent care and how to/when to perform hand hygiene. She said she was taught to wash her hands before and after patient procedures and after changing gloves. CNA C said she should have done some type of hand hygiene and changing gloves when going into the wipe pack to prevent contamination of the other unused wipes in the packet. During an interview on 08/06/25 at 10:20 a.m., the DON said she was also the back-up Infection Control Preventionist and the ADON was the first. The DON said she was aware of some of the concerns raised about infection control. She said the staff were expected to wash their hands and don gloves before and after providing care, when going from dirty to clean and to keep their clean dressing field clean. She said staff were trained in orientation, annually and as the need arose. The DON said not washing their hands increased the risk of infection to the resident. Record review of the facility's undated policy titled, Perineal Care read in part: .12.Males. c.If using packaged product, open package and obtain the wet cloth.e. Hold the shaft of the penis with one hand and one with the other. Begin cleansing tip of penis at urethral meatus using circular motion and working outward.,,,g. cleanse the shaft of the penis, using downward strokes toward the scrotum, use a new disposable wipe with each stroke. Record review of the facility's undated policy titled , Clean Dressing Change read in part:.9.Loosen the tape and remove the existing dressing.10. Remove gloves.11. Wash hands and put on clean gloves.12. Cleanse the wound as ordered.14. Wash hands and put on clean gloves.15. Apply topical ointments or creams and dress the wound as ordered.17.wash hands.
CONCERN
(E)
Potential for Harm - no one hurt, but risky conditions existed
Notification of Changes
(Tag F0580)
Could have caused harm · This affected multiple residents
**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on interview and record review, the facility failed to ensure the physician was consulted regarding a need to alter treatm...
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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 physician was consulted regarding a need to alter treatment for 2 of 13 residents reviewed for notification of changes. (Resident #16 and Resident #24) The facility did not consult with Resident #16's physician about the pattern of low blood pressure over consecutive days and of the blood pressure medication being held for 52 of 60 opportunities in July 2025 or 9 of 12 opportunities for August 2025. The facility did not consult with Resident #24's physician about the pattern of low blood pressure over consecutive days and of the blood pressure medication being held for 7 of 31 opportunities in July 2025 or 3 of 6 opportunities for August 2025. This failure could place residents at risk for complications due to delayed or failed physician intervention.
Findings included:
1. Record review of the face sheet dated 08/06/25 Resident #16’s indicated Resident #16 was [AGE] year-old female admitted on [DATE] with diagnoses including end stage renal disease and high blood pressure.
Record review of physician orders date July 2025 and August 2025 indicated the orders for Resident #16 included the Coreg 3.125 mg twice a daily for high blood pressure. Parameter set by physician were to hold Coreg 3.125 mg if SBP less than 100, DBP less than 60 and HR less than 60 with a start date of 08/17/2024.
Record review of a quarterly MDS assessment dated [DATE] for Resident #16 included diagnoses of high blood pressure and renal disease. Her BIMS was 09 which indicated moderately impaired cognition.
Record review of the care plan dated 05/22/25 for Resident #16 indicated she had hypertension. The interventions included to monitor for side effects hypotension and increased heart rate. Report significant changes to the physician.
Record review of the “Record of Medication Regimen and Chart Review” dated 07/10/2025 indicated Resident #16’s clinical record was reviewed by the Pharmacy Consultant and there were no recommendations.
Record review of the MAR dated July 2025 indicated Coreg 3.125 mg twice daily for Resident #16 and to hold the medication when SBP less than 100, DBP less than 60 and HR less than 60 with a start date of 08/17/2024. On the following times and dates, the dose of the Coreg 3.125 mg was held:
07/01/2025 at a.m., B/P 99/55 and at p.m., B/P 92/44;
07/02/2025 at a.m., B/P 95/53 and at p.m., B/P 95/48;
07/03/2025 at a.m., B/P 95/53 and at p.m., B/P 98/57;
07/04/2025 at a.m., B/P 92/56 and at p.m., B/P 98/58;
07/05/2025 at a.m., B/P 91/50;
07/06/2025 at a.m., B/P 89/50;
07/07/2025 at a.m., B/P 97/56 and at p.m., B/P 98/48;
07/08/2025 at a.m., B/P 96/82 and at p.m., B/P 95/46;
07/09/2025 at a.m., B/P 94/57and at p.m., B/P 97/76;
07/10/2025 at a.m., B/P 94/54 and at p.m., B/P 98/53;
07/11/2025 at a.m., B/P 93/53 and at p.m., B/P 90/48;
07/12/2025 at p.m., B/P 90/49;
07/12/2025 at p.m., B/P 90/49 HR 53;
07/13/2025 at a.m., B/P 93/53 and at p.m., B/P 90/49 HR 48;
07/14/2025 at a.m., B/P 93/53 and at p.m., B/P 105/52;
07/15/2025 at a.m., B/P 92/56 and at p.m., B/P 92/46;
07/16/2025 at a.m., B/P 93/46 and at p.m., B/P 90/46;
07/17/2025 at a.m., B/P 94/52 and at p.m., B/P 94/54;
07/18/2025 at a.m., B/P 90/80 and at p.m., B/P 97/54;
07/20/2025 at p.m., B/P 91/52 HR 58;
07/21/2025 at a.m., B/P 92/52 and at p.m., B/P 90/40;
07/22/2025 at a.m., B/P 92/52 and at p.m., B/P 90/40;
07/23/2025 at a.m., B/P 95/50 and at p.m., B/P 95/50;
07/24/2025 at a.m., B/P 95/55 and at p.m., B/P 87/50;
07/25/2025 at a.m., B/P 94 and at p.m., B/P 84/53;
07/26/2025 at p.m., B/P 92/56 HR 59;
07/27/2025 at p.m., B/P 91/56;
07/28/2025 at p.m., B/P 90/48.
07/29/2025 at a.m., B/P 96/56 and at p.m., B/P 90/48;
07/30/2025 at a.m., B/P 93/56 and at p.m., B/P 98/50; and
07/31/2025 at a.m., B/P 96/56 and at p.m., B/P 89/48.
Record review of the MAR dated August 2025 indicated Coreg 3.125 mg twice daily for Resident #16 and to hold the medication when SBP less than 100, DBP less than 60 and HR less than 60 with a start date of 08/17/2024. On the following times and dates, the dose of the Coreg 3.125 mg was held;
08/01/2025 at a.m., B/P was 94/58;
08/02/2025 at a.m., B/P was 97/55 and at p.m., B/P was 90/45;
08/03/2025 at a.m., B/P was 91/53 and at p.m., HR was 43;
08/04/2025 at a.m., B/P was 92/56 and at p.m., B/P was 96/53;
08/05/2025 at a.m., B/P 94/42 and at p.m., B/P was 90/45; and
08/06/2025 at a.m., B/P was 96/42.
During an interview and record review on 08/06/2025 at 12:05 p.m., the DON reviewed Resident #16's July 2025 and August 2025's MAR with surveyor. The DON acknowledged the Coreg was documented as held due to the prescribed parameters. She said best practice would be for nursing staff to notify physician when medications with parameters were held 3 times, or even immediately. The DON said potential negative outcomes for residents could be dizziness or weakness. She said the physician or NP were able to see in residents electronic record to review the vital signs. The DON said the nursing staff document in the resident's electronic record when notifying physician of medications being held.
During an interview on 08/06/2025 at 1:45 p.m., LVN B said Resident #16's BP was low most days and Coreg was held more than it was given. LVN B said she thought she had notified the physician in the past and would have documented in the nurse notes. LVN B said possible negative outcomes could be dizziness, weakness, or falls leading to injuries. She said the physician needed to be notified in case the physician wanted to make changes with medications or new orders.
Record review of the nurse’s notes for Resident #16 dated from 07/03/25 to 08/06/25 indicated no documentation of the physician being notified.
2. Record review of Resident #24’s face sheet indicated admission to facility on 05/02/2025 with a diagnosis of hypertensive heart disease with heart failure (a condition where high blood pressure has caused structural and functional changes in the heart, leading to heart failure).
Record review of physician orders dated 05/02/2025 indicated Resident #24’s orders included metoprolol succinate ER 50mg tablet – Give one tablet daily related to hypertension (high blood pressure). Parameters set by physician were to hold for SBP less than 100, DBP less than 60 or HR less than 60.
Record review of an admission MDS dated [DATE] for Resident #24 included diagnoses of heart failure and high blood pressure. Resident #24’s BIMS score was 11, indicating moderately impaired cognition.
Record review of the care plan dated 05/08/2025 indicated Resident #24 had altered cardiovascular status related to hypertensive heart disease. Interventions included monitor vital signs daily. Notify physician of significant abnormalities. Monitor/document report PRN any signs/symptoms of altered cardiac output such as dizziness, shortness of breath, fatigue, or confusion.
Record review of the July and August 2025 MARs indicated Resident #24 was prescribed Metoprolol Succinate ER 50 mg - one tablet by mouth related to hypertension - hold for SBP less than 110, DPB less than 60 or HR less than 60.
Record review of the “Record of Medication Regimen and Chart Review” dated 07/10/2025 indicated Resident #24’s clinical record was reviewed by the Pharmacy Consultant and there were no recommendations.
Record review of the MAR dated July 2025 for Resident #24 indicated on the following dates, Resident #24's metoprolol succinate ER 50 mg was held when the vitals were outside the prescribed parameters:
07/01/2025 – B/P 109/62;
07/02/2025- B/P 90/63;
07/03/2025 – B/P 99/58;
07/14/2025 – B/P 99/66;
07/15/2025 – B/P 100/72;
07/16/2025 – B/P 99/63; and
07/17/2025 – B/P 98/56.
Record review of the MAR dated August 2025 for Resident #24 indicated on the following dates, Resident #24's metoprolol succinate ER 50 mg was held when the vitals were outside the prescribed parameters:
08/04/2025 – B/P 99/60;
08/05/2025 – B/P 99/56; and
08/06/2025 – B/P 98/56.
Record review of Nurse Notes dated 07/03/2025 through 08/06/2025 for Resident #24 gave no indication or documentation of physician notification of Resident #24’s metoprolol succinate ER 50 mg being held on 10 occasions from 07/01/2025 through 08/06/2025.
During an interview and record review 08/06/2025 at 12:05 p.m., the DON reviewed Resident #24's July 2025 and August 2025's MAR with surveyor. The DON acknowledged the metoprolol succinate ER was documented as held due to the prescribed parameters. She said best practice would be for nursing staff to notify physician when medications with parameters were held 3 times, or even immediately. The DON said potential negative outcomes for residents could be dizziness or weakness and physician unaware of change in condition. She said the physician or NP were able to see in residents electronic record to review the vital signs. The DON said the best practice would be for nursing staff to document in the resident's electronic record when notifying physician of medications being held and document the response.
During an interview on 08/06/2025 at 1:43 p.m., LVN A said Resident #24's B/P tended to fluctuate and the metoprolol was held more than it was given. LVN A said she believed she had notified the physician in the past and would have documented in the nurse notes. LVN A said possible negative outcomes could be dizziness, weakness, or falls leading to injuries.
During an interview and record review of Resident #24's nurse notes on 08/06/2025 at 1:45 p.m., LVN A said she had been mistaken and had not documented any notifications of Resident #24's medications as being held multiple occasions. Following surveyor intervention, the physician was notified by LVN A on 08/06/2025 at 1:48 p.m. of Resident #24’s BP trending 99/60 – 99/58.
During an interview on 08/06/02025 at 3:30 p.m., the Pharmacy Consultant said she had not been aware of Resident #16's Coreg and Resident #24’s Metoprolol Succinate ER 50 mg having been held frequently when the B/P had fallen outside the prescribed parameters. She said she would modify the regime of performing the review of vital signs and documentation of medications that were held.
During an interview on 08/06/2025 at 4:15 p.m., the Administrator said her expectation was for the physician to be notified each time a resident’s medications were held, or at least every few times. She said possible negative outcomes for the residents could be B/P going lower, possibly leading to falls, injuries, or dizziness. The Administrator said she expected nursing staff to always follow physician orders, to notify of any changes in condition, and to document notifications.
Record review of policy dated February 2023 titled Medication Administration” indicated the following: . Policy Explanation and Compliance Guidelines: … “8. Obtain and record vital signs, when applicable or per physician orders. When applicable, hold medication for those vital signs outside the physician’s prescribed parameters.”
CONCERN
(E)
Potential for Harm - no one hurt, but risky conditions existed
Pharmacy Services
(Tag F0755)
Could have caused harm · This affected multiple residents
Based on observation, interview, and record review, the facility failed to provide pharmaceutical services including procedures that assure the accurate acquiring, receiving, dispensing, and administe...
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Based on observation, interview, and record review, the facility failed to provide pharmaceutical services including procedures that assure the accurate acquiring, receiving, dispensing, and administering of all drugs and biologicals to meet the needs of each resident for 2 of 7 residents (CR #1 and CR #2) reviewed for pharmacy services. The facility failed to ensure 20 boxes of Fiberone chocolate donuts that expired 06/08/25, (58 days expired) were removed from use. The facility failed to ensure discharged residents' (CR #1 and CR #2) medications were removed from use. This failure could place residents at risk of not receiving medications as ordered by their physicians and exacerbations of their medical conditions.Findings included:During an observation and interview on 08/05/25 at 10:45 a.m. of the facility medication storage room with LVN A, indicated on a shelf there were 20 boxes of Fiberone chocolate donuts (each box had 4 donuts) with a manufacture expiration date of 06/08/25 (expired for 58 days). LVN A said no resident was receiving the Fiberone donuts and eating the expired donuts could lead to food poisoning or sickness. During an observation and interview on 08/05/25 at 11:00 a.m. of the facility medication storage room with LVN A, it was observed in the medication refrigerator two unused insulin pins with a pharmacy fill date 6/27/25 labeled for CR#2. On a cabinet in the medication room were 2 boxes (30 vials in each box) of the breathing treatment medication Ipratropium Bromide/Albuterol Sulfate pharmacy labeled for CR#1. LVN A said CR#1 and CR#2 had discharged about a month ago. She said the nurses were responsible for removing discharged residents' medication from the storage area to decrease the risk of someone using it for another resident. Record review of CR#1 face sheet indicated she was discharged from the facility on 07/22/25. Record review of CR#2 face sheet indicated she was discharged from the facility on 06/29/25. During an interview on 08/05/25 at 1:10 p.m., the DON said there should be no expired medications inside the medication room or inside the medication carts. The DON said the ADON checked the medication storage room on a weekly basis for expired medications and discharged residents' medication to be removed for disposal. The DON said she was responsible in ensuring that the ADON was checking the medication room for disposal medications. She said the effects of expired medications could range from reduced effectiveness to unfavorable side effects and keeping medication of residents no longer in the facility increases the risk of drug diversion. During an interview on 08/05/25 at 1:15 p.m., the ADON said the Fiberone donuts were expired and should not be inside the medication room. She said she was not aware of any resident ever receiving the donuts and they were supposed to be disposed of so they would not be used for the residents. She said she was responsible in auditing the medication room, but she had not had time to do so because of her working as a floor nurse. During an interview on 08/05/2025 at 1:13 p.m., the Administrator said expired medications lose their effectiveness and would not address the medical needs of the residents. She said the expectation was for the staff to be compliant with the policies regarding medication storage to ensure a safe medication administration. Record review of the facility undated policy titled Medication Storage reflected in part:. Policy: It is the policy of this facility to ensure all medications housed on our premises will be stored in the pharmacy and or medication rooms according to the manufacturer's recommendations and sufficient to ensure proper sanitation, temperature, light, ventilation, moisture control, segregation and security.5. Staff should observe proper storage and labeling requirements for all medications and vaccines during the performance of their daily task and should demonstrate safety in regards to the medication's integrity such duties should include but are not limited to: a. Report improper refrigeration storage temperatures. c. Remove any expired medications from active stock and discard medications according to facility policy.
CONCERN
(E)
Potential for Harm - no one hurt, but risky conditions existed
Drug Regimen Review
(Tag F0756)
Could have caused harm · This affected multiple residents
**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on interview and record review, the facility failed to ensure any drug regimen irregularities were accurately reported by ...
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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 any drug regimen irregularities were accurately reported by the pharmacist consultant for 2 of 13 residents reviewed for pharmacy services. (Resident #16 and Resident #24) The Pharmacy Consultant failed to thoroughly review the medication regimen and identify possible and/or actual irregularities in the blood pressure and heart rate for Residents #16 and #24. The failure could place residents at risk of receiving inaccurate administration of medications which could result in possible adverse effects or residents not receiving therapeutic benefits of medications.
Findings included:
1. Record review of the face sheet dated 08/06/25 Resident #16’s indicated Resident #16 was [AGE] year-old female admitted on [DATE] with diagnoses including end stage renal disease and high blood pressure.
Record review of physician orders date July 2025 and August 2025 indicated the orders for Resident #16 included the Coreg 3.125 mg twice a daily for high blood pressure. Parameter set by physician were to hold Coreg 3.125 mg if SBP less than 100, DBP less than 60 and HR less than 60 with a start date of 08/17/2024.
Record review of a quarterly MDS assessment dated [DATE] for Resident #16 included diagnoses of high blood pressure and renal disease. Her BIMS was 09 which indicated moderately impaired cognition.
Record review of the care plan dated 05/22/25 for Resident #16 indicated she had hypertension. The interventions included to monitor for side effects hypotension and increased heart rate. Report significant changes to the physician.
Record review of the “Record of Medication Regimen and Chart Review” dated 07/10/2025 indicated Resident #16’s clinical record was reviewed by the Pharmacy Consultant and there were no recommendations.
Record review of the MAR dated July 2025 indicated Coreg 3.125 mg twice daily for Resident #16 and to hold the medication when SBP less than 100, DBP less than 60 and HR less than 60 with a start date of 08/17/2024. On the following times and dates, the dose of the Coreg 3.125 mg was held:
07/01/2025 at a.m., B/P 99/55 and at p.m., B/P 92/44;
07/02/2025 at a.m., B/P 95/53 and at p.m., B/P 95/48;
07/03/2025 at a.m., B/P 95/53 and at p.m., B/P 98/57;
07/04/2025 at a.m., B/P 92/56 and at p.m., B/P 98/58;
07/05/2025 at a.m., B/P 91/50;
07/06/2025 at a.m., B/P 89/50;
07/07/2025 at a.m., B/P 97/56 and at p.m., B/P 98/48;
07/08/2025 at a.m., B/P 96/82 and at p.m., B/P 95/46;
07/09/2025 at a.m., B/P 94/57and at p.m., B/P 97/76;
07/10/2025 at a.m., B/P 94/54 and at p.m., B/P 98/53;
07/11/2025 at a.m., B/P 93/53 and at p.m., B/P 90/48;
07/12/2025 at p.m., B/P 90/49;
07/12/2025 at p.m., B/P 90/49 HR 53;
07/13/2025 at a.m., B/P 93/53 and at p.m., B/P 90/49 HR 48;
07/14/2025 at a.m., B/P 93/53 and at p.m., B/P 105/52;
07/15/2025 at a.m., B/P 92/56 and at p.m., B/P 92/46;
07/16/2025 at a.m., B/P 93/46 and at p.m., B/P 90/46;
07/17/2025 at a.m., B/P 94/52 and at p.m., B/P 94/54;
07/18/2025 at a.m., B/P 90/80 and at p.m., B/P 97/54;
07/20/2025 at p.m., B/P 91/52 HR 58;
07/21/2025 at a.m., B/P 92/52 and at p.m., B/P 90/40;
07/22/2025 at a.m., B/P 92/52 and at p.m., B/P 90/40;
07/23/2025 at a.m., B/P 95/50 and at p.m., B/P 95/50;
07/24/2025 at a.m., B/P 95/55 and at p.m., B/P 87/50;
07/25/2025 at a.m., B/P 94 and at p.m., B/P 84/53;
07/26/2025 at p.m., B/P 92/56 HR 59;
07/27/2025 at p.m., B/P 91/56;
07/28/2025 at p.m., B/P 90/48.
07/29/2025 at a.m., B/P 96/56 and at p.m., B/P 90/48;
07/30/2025 at a.m., B/P 93/56 and at p.m., B/P 98/50; and
07/31/2025 at a.m., B/P 96/56 and at p.m., B/P 89/48.
Record review of the MAR dated August 2025 indicated Coreg 3.125 mg twice daily for Resident #16 and to hold the medication when SBP less than 100, DBP less than 60 and HR less than 60 with a start date of 08/17/2024. On the following times and dates, the dose of the Coreg 3.125 mg was held;
08/01/2025 at a.m., B/P was 94/58;
08/02/2025 at a.m., B/P was 97/55 and at p.m., B/P was 90/45;
08/03/2025 at a.m., B/P was 91/53 and at p.m., HR was 43;
08/04/2025 at a.m., B/P was 92/56 and at p.m., B/P was 96/53;
08/05/2025 at a.m., B/P 94/42 and at p.m., B/P was 90/45; and
08/06/2025 at a.m., B/P was 96/42.
During an interview and record review on 08/06/2025 at 12:05 p.m., the DON reviewed Resident #16's July 2025 and August 2025's MAR with surveyor. The DON acknowledged the Coreg was documented as held due to the prescribed parameters. She said best practice would be for nursing staff to notify physician when medications with parameters were held 3 times, or even immediately. The DON said potential negative outcomes for residents could be dizziness or weakness. She said the physician or NP were able to see in residents electronic record to review the vital signs. The DON said the nursing staff document in the resident's electronic record when notifying physician of medications being held.
During an interview on 08/06/2025 at 1:45 p.m., LVN B said Resident #16's BP was low most days and Coreg was held more than it was given. LVN B said she thought she had notified the physician in the past and would have documented in the nurse notes. LVN B said possible negative outcomes could be dizziness, weakness, or falls leading to injuries. She said the physician needed to be notified in case the physician wanted to make changes with medications or new orders.
Record review of the nurse’s notes for Resident #16 dated from 07/03/25 to 08/06/25 indicated no documentation of the physician being notified.
2. Record review of Resident #24’s face sheet indicated admission to facility on 05/02/2025 with diagnosis including hypertensive heart disease with heart failure (a condition where high blood pressure has caused structural and functional changes in the heart, leading to heart failure).
Record review of physician orders dated 05/02/2025 indicated Resident #24’s orders included metoprolol succinate ER 50mg tablet – Give one tablet daily related to hypertension (high blood pressure). Parameters set by physician were to hold for SBP less than 100, DBP less than 60 or HR less than 60.
Record review of an admission MDS dated [DATE] for Resident #24 included diagnoses of heart failure and high blood pressure.
Record review of the care plan dated 05/08/2025 indicated Resident #24 had altered cardiovascular status related to hypertensive heart disease. Interventions included monitor vital signs daily. Notify physician of significant abnormalities. Monitor/document report PRN any signs/symptoms of altered cardiac output such as dizziness, shortness of breath, fatigue, or confusion.
Record review of the July and August 2025 MARs indicated Resident #24 was prescribed metoprolol succinate ER 50 mg - one tablet by mouth related to hypertension - hold for SBP less than 110, DPB less than 60 or HR less than 60.
Record review of the “Record of Medication Regimen and Chart Review” dated 07/10/2025 indicated Resident #24’s clinical record was reviewed by the Pharmacy Consultant and there were no recommendations.
Record review of the MAR dated July 2025 for Resident #24 indicated on the following dates, Resident #24's metoprolol succinate ER 50 mg was held when the vitals were outside the prescribed parameters:
07/01/2025 – BP 109/62;
07/02/2025- BP 90/63;
07/03/2025 - BP 99/58;
07/14/2025 – BP 99/66;
07/15/2025 – BP 100/72;
07/16/2025 – BP 99/63; and
07/17/2025 – BP 98/56.
Record review of the MAR dated August 2025 for Resident #24 indicated on the following dates, Resident #24's metoprolol succinate ER 50 mg was held when the vitals were outside the prescribed parameters:
08/04/2025 – BP 99/60;
08/05/2025 – BP 99/56; and
08/06/2025 – BP 98/56.
During an interview on 08/06/02025 at 3:30 p.m., the Pharmacy Consultant said she had not been aware of Resident #16's Coreg 3.125 mg and Resident #24’s metoprolol succinate ER 50 mg having been held frequently when the BP had fallen outside the prescribed parameters. She said she would modify the regime of performing the review of vital signs and documentation of medications that were held and give recommendations to the physician.
During an interview on 08/06/2025 at 4:15 p.m., the Administrator said her expectation was for the Pharmacy Consultant to also be held accountable due to failure to recognize medications being held when outside the prescribed parameters on a frequent basis. The Administrator said she did not have a policy regarding the Pharmacy Consultant.
CONCERN
(E)
Potential for Harm - no one hurt, but risky conditions existed
Deficiency F0761
(Tag F0761)
Could have caused harm · This affected multiple residents
Based on observation, interview, and record review, the facility failed to ensure all drugs and biological were labeled, stored under proper temperature controls and in accordance with currently accep...
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Based on observation, interview, and record review, the facility failed to ensure all drugs and biological were labeled, stored under proper temperature controls and in accordance with currently accepted professional principles for 1 of 1 medication rooms and 1 of 1 medication refrigerators reviewed for storage of medication and biologicals. The facility failed to store medications within recommended temperature range in the medication refrigerator in the medication storage room. The facility failed to ensure that there were not 3-4 inches of ice build-up and no standing water in the medication storage refrigerator. The facility failed to ensure there was no stool specimen comingled with medications and stored in the medication room refrigerator. These failures could place residents at risk of adverse reactions to medications, not receiving therapeutic effects of medication and possibly cross-contamination.Findings included:During an observation and interview on 08/05/25 at 11:00 a.m. of the facility medication storage room with LVN A, it was observed in the medication refrigerator, a clear liquid substance had pooled on the bottom floor of the refrigerator and approximately 3-4 inches thick of ice coated the mini freezer area (located in the left upper corner of the medication refrigerator). The ice had build-up enough to close the entry area to mini freezer and the temperature reading was 50 degrees Fahrenheit in the medication refrigerator. Stored in the medication refrigerator were the following: - A brown to black formed substance in a specimen container. LVN A said it was a stool sample, and she did not know who put it there, how long it was there or that it was in the refrigerator because she had not been in the medication room refrigerator. LVN A said specimens were to be collected and placed in the specimen cooler with ice if needed to be cooled. She said storing the stool sample in the medication room refrigerator could cause cross contamination of medications.- A facility locked emergency insulin kit (a small tackle box with plastic numbered lock), contained 3 unused insulin pens sitting in 0.5 to 1 inch of a clear liquid. LVN A said it was approximately 100cc of condensation water built-up and collected in the insulin kit.- 15 wet, unused facility stock laxative stool suppositories,-1 vial wet box of unused facility stock TB vaccine,-17 wet, unused insulin pins. Record review of facility daily temperature log checks for the facility medication room storage refrigerator indicated from 07/1/25 to current 08/06/25 temperature ranges were 35 to 46 degrees F. During an interview on 08/05/25 at 1:10 p.m., the DON said no medications should be stored inside the refrigerator if the temperature was 50 degrees Fahrenheit and if there was water build up. She looked at the emergency insulin kit and said there was 20 ccs of water condensation pooling in the kit and medications would have to be replaced. The DON said the ADON checked the medication storage room on a weekly basis for any concerns like expired medications or damaged equipment. The DON said she was responsible in ensuring that the ADON was checking the medication room. She said the effects of poor temperature control could be or stored in the pooled water could range from reduced effectiveness to unfavorable side effects. She said aside from the risk of cross contamination, no specimen should be stored in the medication refrigerator because there was a small cooler for the specimens. She said the expectation was for the staff to always scan the medication room to make sure storage of medications were in line with company policy. During an interview on 08/05/25 at 1:15 p.m., the ADON said she was responsible for auditing the medication room, but she had not had time to do so because of her working as a floor nurse. She said she did not know the medication room refrigerator was needing defrosting or that a stool specimen was being stored in it. She said the nurses were to use the cooler for specimens and storing them in the refrigerator with medication could lead to cross contamination. During an interview on 08/05/2025 at 1:13 p.m., the Administrator said expired medications lose their effectiveness and would not address the medical needs of the residents. She said the expectation was for the staff to be compliant with the policies regarding medication storage to ensure a safe medication administration. She said she would coordinate with the DON to do an in-service about medication storage and have the medication room refrigerator replaced. Record review of the facility undated policy titled Medication Storage reflected in part:. Policy: It is the policy of this facility to ensure all medications housed on our premises will be stored in the pharmacy and or medication rooms according to the manufacturer's recommendations and sufficient to ensure proper sanitation, temperature, light, ventilation, moisture control, segregation and security. 6. Refrigerator Products b. Temperatures are maintained at 36 to 46 degrees F. Charts are kept on each refrigerator and temperature levels are recorded daily by the charge nurse or other designee. Record review of the facility undated policy titled Storage of Medications Requiring Refrigeration reflected in part:.Policy: It is the policy of this facility to ensure proper and safe storage of medications requiring refrigeration to prevent the potential alteration of medications by exposure to improper temperature controls.3. The facility will ensure that all medications and biologicals will be stored at proper temperatures and other appropriate environmental controls according to manufacturers recommendations to preserve their integrity:.b. Refrigerated refers to temperatures maintained between 36 to 46 F. 4. Refrigerators used for the storage of medications and biologicals: a. Used solely for the purpose of storing medications and biologicals that require refrigeration according to manufacturers instructions. B. Not used for food blood or blood products or specimen storage.5. Staff should observe proper storage and labeling requirements for all medications and vaccines during the performance of their daily task and should demonstrate safety in regards to the medication's integrity such duties should include but are not limited to: a. Report improper refrigeration storage temperatures. c. Remove any expired medications from active stock and discard medications according to facility policy
Jun 2025
3 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
Deficiency F0602
(Tag F0602)
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 right to be free from misappropriation of resident proper...
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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 right to be free from misappropriation of resident property for 1 of 8 residents (Resident #1) reviewed for misappropriation of resident property.
The facility failed to ensure LVN A and CNA B did not use Resident #1's debit card to pay their electricity bills.
The noncompliance was identified as PNC. The past noncompliance began on 02/27/25 and ended on 04/09/25. The facility had corrected the noncompliance before the survey began.
This failure placed residents at risk for misappropriation, exploitation, financial and psychosocial distress.
Findings include:
Record review of Resident #1's face sheet dated 06/03/25, indicated she was was a [AGE] year old female, admitted on [DATE], and her diagnoses included acute respiratory failure with hypoxia (low levels of oxygen), cognitive communication deficit (trouble with one or more cognitive processes involved in communication such as attention and memory and problems staying on topic), diabetes (high blood sugar), major depressive disorder (persistently low or depressed mood and a loss of interest in activities), anxiety ( excessive persistent and uncontrollable worry and fear about everyday situations), and Huntington's disease (a rare inherited disease that causes the progressive breakdown of nerve cells in the brain).
Record review of Resident #1's quarterly MDS assessment indicated she was able to make herself understood and understood others, had moderate cognitive impairment (BIMS-9), and had no behaviors.
Record review of the facility investigation dated 04/09/25 confirmed the allegation of misappropriation. LVN A used Resident #1's debit card on 02/17/25 to pay $453.20 on her electricity bill. CNA B used Resident #1's debit card on 02/20/25 to pay $206 on her electricity bill.
Record review of LVN A's personnel file indicated she was suspended on 04/02/25 and terminated on 04/09/25 for violation of company policy and misappropriation. The criminal history check and EMR checks were completed with no violations listed. She had received Abuse, Neglect, Misappropriation and Exploitation training on hire.
Record review of CNA B's personnel file indicated she was suspended on 04/08/25 and terminated on 04/09/25 for violation of company policy and misappropriation. The criminal history check and EMR checks were completed with no violations listed. She had received Abuse, Neglect, Misappropriation and Exploitation training on hire.
During an interview on 06/02/25 at 8:46 a.m., the Administrator said she was the abuse coordinator. She said all staff were trained on abuse, neglect and exploitation. She said Resident #1 reported to CNA C on 04/01/25 that she wanted her pants back that she had loaned to LVN A. She said Resident #1 told CNA C she had loaned money to LVN A that was not paid back. She said LVN A said she did not ask to borrow the money but was begged to take the money. LVN A said she paid Resident #1 all the money but Resident #1 said she only got $100 back. She said during the investigation, on 04/08/25, it was determined CNA B paid back $200 but still owed for the fees. She said the staff knew they were not supposed to take money or property from the residents. She said the police were notified but there was no investigation because Resident #1 told the police she offered to pay the bills. She said both staff were suspended pending the outcome of the investigation . She said LVN A and CNA B were terminated for misappropriation and violation of company policy. She said staff were retrained on abuse, neglect, misappropriation, and exploitation. She said residents could be at risk of emotional/mental stress, financial strain, and depression.
During an interview on 06/02/25 at 11:31 a.m., Resident #1 said LVN A said she was sleeping in her car and needed money to pay her electricity bill or it would be cut off. She said she let LVN A use her debit card to pay the bill and it $452. She said LVN A paid back $100 after two weeks but still owed the rest. She said LVN A also borrowed a pair of pants due to an accident. She said the rest of the cash was supposed to be in the pocket of the pants when she returned the pants. She said she never got the pants or the money. She said CNA B came in the day after she loaned the money to LVN A and asked her to pay her electricity bill. She said CNA B used her (Resident #1) debit card to pay her electricity bill. She said it was over $200 but it was paid back. She said she felt bad for the staff having their problem with their bills. She said she knew she should not loan the money but they asked her to borrow so she did. She said the facility told her she should not loan money to staff and she would not do it again.
During an interview on 06/02/25 at 12:48 p.m., CNA B said she was talking with Resident #1 (she could not recall the exact date) and Resident #1 could tell something was wrong. She said Resident #1 asked her what was wrong. She said she told Resident #1 nothing was wrong but Resident #1 asked her and she told Resident #1 she she was short on her electricity bill. She said she told Resident #1 she was not supposed to take anything but Resident #1 said she was offering to help. She said she used Resident #1's debit card to pay the bill. She said it was $200. She said she repaid the $200 to Resident #1 in cash. She said she was trained on abuse, neglect, and exploitation. She said she was aware she should not borrow money from Resident #1.
During an interview on 06/02/25 at 1:45 p.m., CNA C said on 03/31/25 Resident #1 asked her to find a pair of pants that LVN A had borrowed. She said on 04/01/25, while searching for the pants, Resident #1 said LVN A borrowed the pants (due to an accident) and was returning the pants and the pants had $352 in the pocket. She said Resident #1 said there should be $352.00 in the pocket, as she loaned LVN A $452.00 to pay her electricity bill. She said the allegation of misappropriation to the Administrator immediately on 04/01/25.
During an interview on 06/03/25 at 12:44 p.m., LVN A said Resident #1 was aggressively trying to loan her the money to pay her electricity bill (she could not recall the exact date). She said she used Resident #1's debit card to pay her electricity bill. She said she paid it all back in cash and had no receipt. She said she was trained on abuse, neglect, and exploitation. She said she was aware she was not supposed to take or borrow money from resident.
The facility took the following actions to correct the non-compliance:
Record review of the facility's Provider Investigation Report dated 04/09/25 indicated an in-service titled Abuse, Neglect, and Exploitation was conducted on 04/02/25. Employee groups present included CNAs, Dietary, Housekeeping, Laundry, Nursing, Activities, and Business Office and was signed by 34 staff members. The report also indicated LVN A and CNA B were suspended pending investigation and were terminated following the investigation.
During interviews conducted on 06/02/25 between 8:30 a.m. and 3:30 p.m. and on 06/03/25 between 8:30 a.m. and 2:00 p.m., CNA C, LVN D, CNA E, CNA F, LVN G, RN H, Housekeeper I, Housekeeper J, ADON, Activity Director K, LVN L, LVN M, LVN N, LVN O, CNA P, CNA Q were all able to correctly identify abuse, neglect, exploitation, and misappropriation and the proper action for identification, prevention, and protection. They said they were not aware of any abuse, neglect, exploitation or misappropriation and if so, would report it to the abuse coordinator, (Administrator) immediately. They were able to give examples of misappropriation and were aware they were not to borrow or take money or property from residents.
Record review of a facility form titled Safe Survey Interviews dated 04/02/25 indicated that safe surveys were completed with 5 residents with no complaints of missing money or property, staff asking for money or property, and all verbalized they felt safe in facility.
Interviews with 8 residents (Resident #s 1, 6, 7, 9, 11, 10, 13, 14) during the course of investigation from 06/02/25 to 06/03/25 indicated no residents complained of resident abuse, neglect, misappropriation, or exploitation. They were aware they should not loan staff money. They would report to the Administrator or the DON if staff asked to borrow money or property.
Record review of facility incident/accident reports from 06/01/24 through 06/02/25 indicated no concerns in the area(s) of Resident Abuse, Neglect, Misappropriation or Exploitation.
Record review of facility grievances for the from 06/01/24 through 06/02/25 , indicated no concerns in the area(s) of Resident Abuse, Neglect, Misappropriation or Exploitation, and Resident Rights.
Record review of the facility's Abuse, Neglect and Misappropriation policy dated 2023 indicated .Exploitation means taking advantage of a resident for personal gain through the use of manipulation, intimidation, threats, or coercion. Misappropriation of Resident Property means the deliberate misplacement, exploitation, or wrongful, temporary or permanent, use of a resident's belongings or money without the resident's consent.
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
Comprehensive Care Plan
(Tag F0656)
Could have caused harm · This affected 1 resident
**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, interview, and record review, the facility failed to develop and implement a comprehensive person-centered...
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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 develop and implement a comprehensive person-centered care plan for each resident, consistent with the resident rights, which included measurable objectives and timeframes to meet a resident's medical, nursing, and mental and psychosocial needs that were identified in the comprehensive assessment for 1 of 8 residents (Resident #2) reviewed for care plans.
The facility failed to develop and implement Resident #2's care plan for falls and fall interventions after he fell and sustained a head laceration on 03/22/25.
This failure could place residents at risk for injury from falls.
Findings included:
Record review of Resident #2's face sheet dated 06/02/25 indicated he was a [AGE] year old male admitted on [DATE] and his diagnoses included diabetes (high blood sugar), muscle weakness (lack of muscle strength), unspecified lack of coordination, muscle wasting and atrophy (thinning or loss of muscle mass and strength), cognitive communication deficit (trouble with one or more cognitive processes involved in communication such as attention and memory and problems staying on topic), unsteadiness on feet, abnormalities of gait and mobility (unusual walking), seizures (sudden and temporary change in the electrical and chemical activity in the brain), and neuropathy (nerve damage that can cause symptoms such as weakness numbness and pain).
Record review of Resident #2's quarterly MDS assessment indicated he was able to make himself understood and understood others, had severe cognitive impairment (BIMS-5), had a history of fall since admission, and had two or more falls with injury (except major) since admission.
Record review of Resident #2's care plan dated 09/13/24 (revised on 09/25/24) indicated Resident #1 was at risk for falls related to impaired mobility and muscle weakness. Interventions included to anticipate and meet Resident #1's needs, encourage use of appropriate footwear, and needs a safe environment with call light in reach and personal items within reach. There was no review or revision related to Resident #1's fall on 03/22/25.
Record review of Resident #2's Un-witnessed Fall report dated 03/22/25 indicated LVN D found Resident #2 face down on the floor. He had dried blood on his forehead and face. The bed was in high position. Resident #2 said he was experiencing some head pain. Resident #1 was assessed. He was alert and oriented X3 (identity, location, and time). He was unable to verbalize what happened. He was transported to hospital.
Record review of progress note dated 03/22/25 at 7:42 a.m., competed by LVN D indicated Resident #2 was found face down on the floor. The bed was lowered to the floor and Resident #2 was assisted in to the bed by the LVN and 3 aides. Coagulated blood was noted to the crown of his head, forehead and over his left eyebrow. Bruising was noted over left eyebrow. Hospice was notified and recommended sending Resident #2 to ER for evaluation. Resident #2 was transported to hospital by ambulance. The DON was notified. RP notified three times with no response .
Record review of Resident #2's hospital records dated 03/22/25 indicated Resident #2 had an unwitnessed fall from his bed. The skin was fragile, thin and there was a superficial laceration (irregular cut in the skin caused by a sharp object) to forehead. The wound was cleaned and and repaired with steri-strips (thin adhesive bandages).
Record review of the facility investigation dated 03/28/25 indicated the provider action taken post-investigation included in-service with all staff regarding abuse, neglect, exploitation, misappropriation, and resident rights. Neurological assessments were completed. A new fall mat was delivered by hospice and the was bed kept in low position. The facility investigation did not include review of Resident #2's care plan review or revisions.
During an interview and observation on 06/02/25 at 12:10 p.m., indicated Resident #2 was lying in his bed. There was a low air flow mattress in working condition set at 320 psi. It was in a low position. There was a fall mat in place. Resident #2 said he did not recall how he fell out of his bed. He said he remembered being on the floor. He said he probably just rolled out of bed. He said he received butterfly bandages on the cut on his head. He said he did not know what he hit his head on.
During an interview on 06/02/25 at 1:45 p.m., CNA C said Resident #2 tended to use the bed remote and put his bed in a higher position. She said staff made rounds and checked for bed height and would lower his bed if necessary.
During an interview on 06/02/25 at 1:50 p.m., CNA E said Resident #2's bed was usually in the low position and he had a fall mat. She said Resident #2 would use the bed remote and move his bed up and staff would have to put the bed back down to a lower position.
During an interview on 06/02/25 at 2:57 p.m., LVN D said she found Resident #2 on the floor mat next to his bed. She said the bed was not in the lowest position and the remote was on the end of the bed. She said she did not know if staff left the bed up or if Resident #2 had raised the bed. She said she assessed Resident #2 and found he had a small cut on his forehead. She said he could have hit his head on the bed side dresser if he rolled out of the bed. She said she and 3 other staff assisted Resident #2 back into bed. She said hospice was notified and they recommended Resident #2 be sent out to the hospital for evaluation and treatment. She said he returned with butterfly bandages on his forehead.
During an interview on 06/03/25 at 10:30 a.m., the ADON said she worked on the night shift of 03/22/25 and did not recall Resident #2's bed being left in a high position. She said she walked the halls before she left her shift at 6:00 a.m. and his bed was in a low position and the fall mat was in place.
During an interview on 06/03/25 at 10:45 a.m., CNA F said Resident #2 would use the bed remote and raise his bed. He said he would make rounds and put Resident #2's bed in low position due to his risk for falls.
During an interview on 06/03/25 at 10:54 a.m., the DON said Resident #2's care plan should have been reviewed during the facility investigation and updated after his fall. She said accidents and incidents were reviewed daily and IDT meetings were held Thursdays and Fridays. She said the MDS LVN was part time and that may be the reason Resident #2's care plan was missed and not updated. She said she was going to develop and system to ensure care plans were reviewed for all incidents/accidents and re-educate the nurses on care plans. She said the risk for not reviewing and developing care plans could result in residents not receiving proper care or services.
During an interview on 06/03/25 at 10:54 a.m., MDS LVN G said she reviewed care plans annually and quarterly. She said the DON, ADON, and nurses were responsible for acute care plans.
During an interview on 06/03/25 at 11:34 a.m. RN H said she usually checked on Resident #2 between 5:30 a.m. and 5:45 a.m. She said she did not recall his bed being left in a high position and she would have lowered it if she found it in a high position. She said he required a lot of attention and would yell a lot and staff would have to check on him more frequently than other residents. She said he was always in a low bed and had a fall mat. She said he would use the bed controls and raise his bed and staff would have to lower the bed.
Record review of the facility's policy Care plan Revisions Upon Status Change dated 2023 indicated The purpose of this procedure is to provide a consistent process for reviewing and revising the care plan for those residents experiencing a status change. Policy Explanation and Compliance Guidelines: 1. The comprehensive care plan will be reviewed, and revised as necessary, when a resident experiences a status change. 2. Procedure for reviewing and revising the care plan when a resident experiences a status change: a. Upon identification of a change in status, the nurse will notify the MDS Coordinator, the physician, and the resident representative, if applicable. B. The MDS Coordinator and the Interdisciplinary Team will discuss the resident condition and collaborate on intervention options. c. The team meeting discussion will be documented in the nursing progress notes. d. The care plan will be updated with the new or modified interventions. e. Staff involved in the care of the resident will report resident response to new or modified interventions. f. Care plans will be modified as needed by the MDS Coordinator or other designated staff member. g. The Unit Manager or other designated staff member will communicate care plan interventions to all staff involved in the resident's care. h. The Unit Manager or other designated staff member will conduct an audit on all residents experiencing a change in status, at the time the change in status is identified, to ensure care plans have been updated to reflect current resident needs. 3. The MDS Coordinator will determine whether a Significant Change in Status Assessment is warranted. If so, the assessment will be completed according to established procedures.
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
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 maintain an infection prevention and control progra...
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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 maintain an infection prevention and control program designed to provide a safe, sanitary, and comfortable environment to help prevent the development and transmission of communicable diseases and infections for 2 out of 5 (Resident #3 and Resident #4) residents reviewed for enhanced barrier precautions (EBP) for infection control practices.
The ADON failed to follow enhanced barrier precautions during care for Resident #3 who had a Foley catheter and wound.
The facility failed to ensure the podiatrist followed enhanced barrier precautions for Resident #4 who had an indwelling medical device (g-tube).
The failures could place residents at risk for cross contamination and the spread of infection.
The findings included:
Record review of Resident #3's admission Record, dated 06/02/25, indicated she was a [AGE] year-old female admitted to the facility on [DATE] with diagnoses including insomnia, essential hypertension, muscle weakness, and cognitive communication deficit.
Record review of Resident #3's admission MDS Assessment, dated 04/17/25 indicated her BIMS score was 12, meaning she had moderate cognitive impairment. Further review indicated under the section bladder and bowel, she had an indwelling catheter and ostomy (an opening in the body for discharge of bodily waste). It also indicated under skin conditions, she had one or more unhealed pressure ulcers/injuries.
Record review of Resident #3's Care Plan with no date indicated revealed: The resident had an indwelling suprapubic catheter, initiated 04/11/25. The resident had a pressure ulcer (sacral (triangular shaped bone at the base of the back) stage II (exposes the dermis, partial skin loss)), initiated 04/11/25.
Record review of Resident #3's Order Summary Report, dated 06/02/25, indicated enhanced barrier precautions related to a colostomy and Foley every shift. This was an active order with an order date of 05/02/25. Cleanse sacral wound with dermal wound cleanser, apply xeroform gauze, apply bordered dressing every day until healed and PRN, soiled or dislodged dressing every 24 hours. This was an active order with an order date of 05/28/25. Urinary catheter: enhanced barrier precautions due to the presence of a urinary catheter. This was an active order with an order date of 04/14/25. Urinary catheter: (Specify: indwelling catheter in place. Size 16 FR bulb 10 ml).
During an observation on 06/02/25 at 11:28 a.m. of Resident #3's door indicated a sign for enhanced barrier precautions. The ADON performed hand hygiene and prepared all the wound care supplies needed and placed them on wax paper. The ADON entered the room, and not put on a gown, and set the supplies up on Resident #3's bedside table. The ADON proceeded with wound care, without wearing a gown. Once the wound care was completed, the ADON cleaned up all the supplies, cleaned the bedside table, and completed hand hygiene.
Record review of Resident #4's admission Record, dated 06/03/25, indicated he was a [AGE] year-old male admitted to the facility on [DATE] with diagnoses including insomnia, seizures, and major depressive disorder.
Record review of Resident #4's Quarterly MDS Assessment, dated 05/09/25, indicated his BIMS score was not completed due to Resident #4 being rarely/never understood. Further review revealed under the section swallowing and nutritional status, revealed he had a feeding tube, while a resident.
Record review of Resident #4's Care Plan with no date indicated: The resident received g-tube (gastrostomy tube, a tube that provides direct access to the stomach) feedings, initiated 10/30/23. The resident was at nutritional risk related to g-tube feeding, initiated 10/10/23. The resident was on enhanced barrier precautions related to indwelling medical device; feeding tube, initiated 04/09/24.
Record review of Resident #4's Order Summary Report, dated 06/03/25, indicated enhanced barrier precautions, with an active date of 04/09/24. This was an active order with an order date of 05/02/25. GT: Change feeding set/bag/piston syringe every night shift, this was an active order with an order date of 05/04/23. GT: Verify tube placement before each use. If unable to verify placement, notify physician. This was an active order with an order date of 01/30/25.
During an observation on 06/03/25 at 10:08 a.m. of Resident #4's door indicated a sign for enhanced barrier precautions and a bin of PPE (personal protective equipment) outside the door. Inside of the room providing patient care to the resident, was a podiatrist with gloves on and no gown. LVN B walked up, placed her own gown and mask on, handed a mask to the podiatrist, grabbed another gown, re-entered the room, and closed the door. When the door was opened, the podiatrist had a gown and mask on.
During an interview with the ADON on 06/03/25 at 10:07 a.m. she confirmed she was the Infection Preventionist. She stated the residents that were placed on enhanced barrier precautions either had a Foley catheter (drains urine), an IV (intravenous therapy), a colostomy (allows waste to exit the body), pressure wounds, ports (dialysis access), fistulas (dialysis access), or g-tubes. She confirmed a gown should be worn while providing wound care to residents. She stated she should have worn a gown during the wound care observation. She stated if the enhanced barrier precautions were not followed, it could contaminate clothes and pass from resident to resident.
During an interview with LVN B on 06/03/35 at 10:13 a.m., she stated Resident #4 was on droplet precautions. Everyone that provided care to Resident #4 was to wear a gown and mask. She stated his sputum was positive for MRSA (methicillin-resistant staphylococcus aureus). She stated, she informed the podiatrist of the precautions, and he thanked her. She explained what needed to be worn in the room to the podiatrist. She stated she would have told him before he entered, but she did not see him go into the room.
During an interview with the ADON on 06/03/25 at 10:20 a.m., she stated Resident #4 tested positive for MRSA per sputum. She stated a new culture had been done, and believed the droplet precautions could be removed today. She stated the resident had a g-tube, so even when cleared of MRSA, the enhanced barrier precautions would stay in place. She stated if the resident was still on droplet precautions, a gown, mask, and gloves should be worn. If the resident was on enhanced barrier precautions, a gown and gloves should be worn. She stated staff and other medical professionals knew to wear a gown and gloves due to the sign on or near the door which stated they were on enhanced barrier precautions, what to wear, and when. When asked if they were in-serviced, she stated, I think we in-service them, too. I would have to check. I know our wound care providers know. She stated, We are all responsible to ensure staff and visitors wear PPE for enhanced barrier precautions. All are in-serviced and educated.
During an interview with the DON on 06/03/25 at 11:03 a.m., she stated anyone with wounds, dialysis catheters, Foley catheters, IV's, drains, and anything inserted should be on enhanced barrier precautions. Staff and visitors should know because there were signs posted outside the door. When wound care was being done, a gown and gloves should be worn, and at times a face mask depending on what was being done. Anyone that provided hands-on care should wear enhanced barrier precautions. She stated, It is not needed to deliver food trays, only for direct care. She stated not following enhanced barrier precautions could cause spread of infection or contamination. The signage was used to make outside providers aware of the EBP, as well as verbally.
Record review of a facility in-service titled, Topic: Enhanced Barrier Precautions, dated 03/29/24, revealed it did not have the ADON's signature.
Record review of a facility in-service titled, Topic: HIPPA (Health Insurance Portability and Accountability Act), Infection Control/Prevention, Abuse, Neglect, and Exploitation, Misappropriation, and Resident Rights, dated 05/07/24, revealed it included the ADON's signature.
Record review of the facility's policy and procedure on Enhanced Barrier Precautions, no date, revealed:
Policy: It is the policy of this facility to implement enhanced barrier precautions for the prevention of transmission of multidrug-resistant organisms.
Definitions:
Enhanced barrier precautions (EBP) refer to an infection control intervention designed to reduce transmission of multidrug-resistant organisms that employs targeted gown and gloves use during high contact resident care activities.
Policy Explanation and Compliance Guidelines: .
An order for enhanced barrier precautions will be obtained for residents with any of the following: Wounds (e.g., chronic wounds such as pressure ulcers, diabetic foot ulcers, unhealed surgical wounds, and chronic venous stasis ulcers) and/or indwelling medical devices (e.g., central lines, urinary catheters, feeding tubes .PPE for enhanced barrier precautions is only necessary when performing high-contact care activities and may not need to be donned prior to entering the resident's room .high-contact resident care activities include: dressing, bathing, transferring, providing hygiene, changing linens, changing briefs or assisting with toileting, device care or use: central lines, urinary catheters, feeding tubes, tracheostomy/ventilator tubes, hemodialysis catheters, PICC (peripherally inserted catheter) lines, midline catheters, and wound care: any skin opening requiring a dressing .
Jul 2024
3 deficiencies
CONCERN
(D)
Potential for Harm - no one hurt, but risky conditions existed
Deficiency F0637
(Tag F0637)
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 complete a significant change MDS assessment within 14 days after t...
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**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on interview and record review, the facility failed to complete a significant change MDS assessment within 14 days after the facility determines, or should have determined, that there has been a significant change in the resident's physical or mental condition a significant change of condition for 1 of 14 residents reviewed for assessments. (Resident #25)
The facility failed to complete a Significant Change MDS for Resident #25 within 14 days after the resident was admitted to hospice services.
This failure could place residents who experienced a significant change in their condition requiring an MDS assessment at risk of not receiving needed services.
Findings Included:
Record review of a face sheet dated 07/15/24 indicated Resident #25 was a [AGE] year-old-male with a readmission date of 06/20/24 and an admission date of 09/15/22. Resident #25 was admitted with diagnoses including atherosclerosis (a buildup of fats and other substances in and on the artery walls) and heart failure (a chronic condition in which the heart does not pump blood as well as it should).
Record review of a Quarterly MDS assessment dated [DATE] indicated Resident #25's BIMS was 12 out of 15 indicating cognition was moderately impaired. The assessment indicated Resident #25 had a diagnosis of heart failure.
Record review of a care plan initiated on 06/28/24 indicated Resident #25 had chosen to have hospice care for heart failure.
Record review of physician orders indicated an order on 06/28/24 indicated Resident #25 was admitted to hospice services with a diagnosis of heart failure.
Record review of the electronic medical record on 07/16/24 indicated Resident #25's MDS section had a significant change MDS with an ARD of 7/5/24 in progress but not completed.
During an interview on 07/16/24 at 1:50 p.m., the MDS Nurse said she was responsible for all MDS in the facility. She said the Corporate MDS Coordinator was her back-up. She said she was educated on MDS completion and timing of significant change MDS. The MDS Nurse said Resident #25 was admitted to hospice services on 06/28/24 and she should have completed the significant change MDS by 07/11/24. She said she opened the MDS in the computer system but was unable to complete the MDS timely due to being part time and only working 3 days a week at the facility. She said at times she was unable to stay caught up, especially during the middle of the month when there were a lot of admissions. The MDS nurse said the possible negative outcome was an incorrect care plan. She said she completed the comprehensive triggered care plans.
During an interview on 07/16/24 at 2:10 p.m., the DON said the MDS Nurse was responsible for all MDS at the facility. She said the MDS nurse was educated on completion and timeliness of MDS. The DON said Resident #25's significant change MDS was not completed timely due to being possibly overlooked. She said there was no negative outcome, the care plan was updated but policy was not followed. The DON said her expectation was all MDS completed accurately and timely.
During an interview on 07/16/24 at 2:15 p.m., the Regional Nurse said the facility follows the RAI (Resident Assessment Instrument) for a MDS policy.
During an interview on 07/16/24 at 2:20 p.m., the Administrator said the MDS nurse was responsible for all MDS in the facility. She said the Corporate MDS nurse was a double check and audited some MDS assessments. The Administrator said the possible negative outcome was not following facility policy. The administrator said her expectation was all MDS completed accurately and timely.
Attempted phone interview on 07/16/24 at 3:00 p.m., with the Corporate MDS Coordinator was not successful.
Record review of the, Long-Term Care Facility Resident Assessment Instrument 3.0 User's Manual, dated, October 2023, indicated, . Chapter 2 . An SCSA {significant change in status assessment} is required to be performed when a terminally ill resident enrolls in a hospice program (Medicare-certified or State-licensed hospice provider) or changes hospice providers and remains a resident at the nursing home. The ARD {assessment reference date} must be within 14 days from the effective date of the hospice election (which can be the same or later than the date of the hospice election statement, but not earlier than). An SCSA must be performed regardless of whether an assessment was recently conducted on the resident. This is to ensure a coordinated plan of care between the hospice and nursing home is in place. The MDS completion date (item Z0500B) must be no later than 14 days from the ARD (ARD + 14 calendar days) and no later than 14 days after the determination that the criteria for an SCSA were met.
CONCERN
(D)
Potential for Harm - no one hurt, but risky conditions existed
Quality of Care
(Tag F0684)
Could have caused harm · This affected 1 resident
**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, interview and record review, the facility failed to ensure that residents received treatment and care 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 that residents received treatment and care in accordance with professional standards of practice, the comprehensive person-centered care plan, and the residents' choices for 1 of 14 residents reviewed for quality of care. (Resident #85)
The facility did not assess or obtain orders for a post-surgical incision to Resident #85's left hip.
This failure could place the residents at risk of not receiving the care and services to maintain their highest practicable physical, mental, and psychosocial well-being.
Findings included:
Record review of physician orders dated July 2024 indicated Resident #85, admitted [DATE], was a [AGE] year-old female with a diagnosis of displaced intertrochanteric closed fracture of the left femur (fracture of the hip that is made up of the thigh bone and the pelvis [socket]. The orders did not indicate the resident had orders to treat the left hip incision.
Record review of the clinical record dated 07/14/24 indicated the admission MDS was in progress and had not been completed.
Record review of the baseline care plan dated 07/14/24 indicated Resident #85 had potential/actual impairment to skin integrity. Focus: The resident has potential/actual impairment to skin integrity. Observe and identify any new affected skin area, intervene with treatment as necessary and notify MD. Does the resident have a surgical site? . Yes . Goal: The resident's surgical site will show signs of healing and/or remain free from infection by/through review date. Intervention: Documentation to include measurement of each area of skin impairment: width, length, depth, type of tissue, exudate, and any other notable changes upon observations. Intervention: Follow-up with surgeon per physician order. Treatment of surgical site to be provided per physician order. Monitor for s/s of infection, change in appearance, or increased pain/discomfort, intervene and notify surgeon/MD upon significant change.
Record review of a hospital emergency room record dated 07/03/24 indicated Resident #85 had a fall from the bed at home, was in pain to the left hip area and had a CT scan (a computer imaging test which can diagnose life threatening conditions) performed. The CT scan dated 07/10/24 indicated the resident had an acute impact fracture of the left intertrochanteric femur with minimal displacement. The Discharge summary dated [DATE] indicated Resident #85 had an open reduction and internal fixation repair (a surgical procedure that treats severe fractures and dislocations) of the left hip. The instructions indicated to contact your health care provider if: . you have more redness, swelling or pain at the incision area, if you have more fluid or blood coming from your incision or leaking through the dressing, you notice your incision feels warm to the touch, you have pus or a bad odor coming from the incision. There were no wound care instructions noted.
Record review of an admission assessment dated [DATE] at 2:46 p.m., indicated Resident #85 had a surgical dressing to the left trochanter. There was no documentation of the incision site.
During an interview on 07/16/24 at 10:16 a.m., the ADON/treatment nurse said she was responsible for making sure Resident #85's wound was assessed. She said she should have assessed the wound and obtained an order for the wound care yesterday on 07/15/24 and she did not. She said she did not have orders for the left hip dressing to be changed. She said the possible negative outcome of not assessing the incision site is that it could be infected, or the edges could possibly not be approximated.
During interview and record review on 07/16/24 at 1:36 p.m., the ADON/treatment nurse said the wound specialist NP came in today 07/16/24 and looked at Resident #85's incision and gave orders for treatment. She provided an order for Resident #85 dated 07/16/24 that read: cleanse surgical incision with dermal wound cleanser, pat dry, apply cut to fit adaptic gauze (a gauze designed to protect regenerating tissue), apply a non-adherent dressing and cover with tegaderm dressing (a transparent self-adhesive dressing), change today and then on 7/22/24. The ADON/treatment nurse said she was unable to get the surgeon to return her call. She said the wound specialist NP who was in the same group as the orthopedic surgeon, was familiar with the post orthopedic surgery protocol.
During an interview on 07/16/24 at 12:53 p.m., the DON said her expectation was for newly admitted residents to have orders from the hospital where they were coming from and if not, the physician should be notified to receive orders. She said Resident #85's incision should have been assessed and the physician called for orders. She said the possible negative outcome would be the site could possibly get infected or the resident would not receive treatment in a timely manner.
During observations on 07/16/24 at 1:46 p.m., Resident #85's surgical dressing to the left hip was not dated or initialed. The ADON/treatment nurse removed the dressing to the incision. The incision was clean, dry, without signs of infection and the edges were approximated. She performed wound care without concerns noted.
During an interview on 07/17/24 at 12:14 p.m., LVN A said she was working Sunday 07/14/24, when Resident #85 was admitted . She said it was her responsibility to assess the newly admitted residents from head to toe and make sure she had orders for Resident #85's incision. She said she did not take Resident #85's dressing off and she did not call the doctor for orders related to care of the incision. She said she should have assessed the incision and called the doctor. She said when the resident was admitted she was resisting care, and she did not take the dressing off. She said the possible negative outcome would be the incision could be infected or the sutures might not have been intact.
Record review of a Provision of Quality of Care policy with a copyright date of 2023 indicated: Based on comprehensive assessments, the facility will ensure that residents receive treatment and care by qualified persons in accordance with professional standards of practice, the comprehensive person-centered care plans, and the residents' choices. 1. Each resident will be provided care and services to attain or maintain his/her highest practicable physical, mental, and psychosocial well-being. 4. Qualified persons will provide the care and treatment in accordance with professional standards of practice, the resident's care plan, and the resident's choices.
CONCERN
(E)
Potential for Harm - no one hurt, but risky conditions existed
Pharmacy Services
(Tag F0755)
Could have caused harm · This affected multiple residents
**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, interview, and record review, the facility failed to provide pharmaceutical services (including procedures...
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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 pharmaceutical services (including procedures that assure the accurate acquiring, receiving, dispensing, and administering of all drugs and biologicals) for 4 of 14 residents (Residents #10, #20, #21, and #24) and failed to establish a system of records of receipt and disposition of all controlled drugs in sufficient detail to enable an accurate reconciliation and drug records were in order and that an account of all controlled drugs was maintained for 1 of 14 residents (Resident #10) to meet the needs of each resident for reviewed for pharmacy services.
LVN A did not prepare medications for Resident #21 per the facility policy.
RN D did not flush Resident #10's gastric tube (tube surgically inserted through the wall of the abdomen directly into the stomach) per gravity and did not destroy the used fentanyl (scheduled II controlled medication used for severe pain) patches in a sharps container per policy and with a witness for destruction.
LVN A did not prepare medications for Resident #20 and Resident #24 per the facility policy.
These failures could place residents at risk of not receiving the therapeutic effects of their prescribed medications and at risk of drug diversion.
Findings included:
1. Record review of Resident #21's face sheet, dated 06/10/24, indicated the resident was admitted to the facility on [DATE] with diagnoses including high blood pressure, diabetes, and post-surgical repair of fractured hip.
Record review of Resident #21's admission MDS indicated it was in process and had not been completed due to required timeframe.
Record review of Resident #21's care plan, dated 06/13/24, indicated the resident had impaired cognitive function related to short term memory loss.
During an observation and interview on 07/15/24 at 8:25 a.m., Resident #21 was eating breakfast in her room. A plastic medicine cup was observed next to the resident's breakfast tray containing 8 unidentifiable pills. Resident #21 said the staff gave her the medication daily before breakfast and she took them after she ate her meal. She said staff did not return to ensure the medications were consumed.
During an observation and interview on 07/15/24 at 8:35 a.m., LVN A said she only left Resident #21's morning medications with the resident during medication pass. She said Resident #21 preferred to have morning medications available to take after the morning meal. LVN A said she had been trained in safe medication administration and knew medication was not left at bedside. She said she had been trained to prepare medications and to observe residents consuming medications to ensure all were taken. She said potential negative outcomes of leaving the medications at a resident's bedside unsupervised, would be not knowing if the resident swallowed the medication or not, medications could be dropped, lost, or not taken. She said she always came back to check to see if the medications were taken.
During an interview on 07/17/24 at 10:45 a.m., the DON said her expectations were for nursing staff to never leave resident medications at their bedside. She said nurses should always stay with residents to ensure medications were taken. The DON said potential negative outcomes included resident not taking medications, not swallowing all medications, or even a resident with wandering behaviors could go into room and take medications that did not belong to them.
During an interview on 07/17/24 at 11:00 a.m., the Administrator said her expectations of staff included medications should not be left at any resident's bedside and should always be administered by licensed personnel while in attendance with the resident. She expected licensed nursing staff to abide by facility policies. She said staff were trained in medication administration policy and procedures.
2. Record review of the admission record dated 07/16/24 indicated Resident #10 was female [AGE] years old and was admitted on [DATE] with diagnoses of dementia, and pain.
Record review of the physician's orders dated 07/16/24 indicated Resident #10 was to receive a fentanyl transdermal patch 72 Hour (75 MCG/HR) Apply 1 patch transdermal every 72 HRS related to pain, unspecified and remove per schedule with start a date of 12/15/2023. The orders included dilute each medication with 5-10 cc of water and flush with 30 cc of water before and after medications with start date of 04/03/24.
Record review quarterly MDS assessment dated [DATE] indicated Resident #10 was severely impaired with cognition with BIMS of 00. A nutritional approach indicated feeding tube during last 7 days while she was a resident. The pain management section indicated she received routine pain medication.
Record review of the care plan revision dated 10/20/23 indicated Resident #10 had chronic pain and received fentanyl 75MCG/HR patch Q 72 HRS.
Record review of the MAR dated July 2024 indicated Resident #10's fentanyl patch was applied 07/07/24 and removed on 07/10/24 and the patch was applied on 07/10/24 and removed on 07/13/24.
Record review of the count sheet for Resident #10 dated 06/26/24 indicated no witnesses on 07/07/24, 07/10/24, and 07/13/24 for the disposal of the fentanyl patch.
During an observation and interview on 7/16/24 at 9:23 a.m., RN D went to apply Resident #10's fentanyl patch and RN D removed an old patch dated 7/13/24 on left arm. She reached over to apply a new patch on the r arm and there were 2 more fentanyl patches dated 7/7/24 and 7/10/24 on the resident right arm. RN D removed both patches and placed all 3 used fentanyl patches in the sharp's container without a witness. She looked on the residents back for any more patches, reviewed her v/s and applied the new patch dated 7/16/24. She said if the used patches were not removed the resident could receive too much fentanyl and could be over medicated. She said the resident should have only had one patch on as ordered.
During an observation and interview on 07/16/24 at 9:30 a.m., RN D checked placement with aspiration and auscultation and said the tube was in place, then flushed the gastric tube for Resident #10 with 30 cc of water per syringe not to gravity. RN D gave each medication mixed with 5-10 cc water per gravity then flushed with 30 cc of water per syringe not by gravity.
During an interview on 07/16/24 at 9:35 a.m., RN D said she thought the water flushes were to be pushed like an IV flush and had not been trained any differently here and works as needed here.
During an interview on 07/16/24 at 9:45 a.m., the DON said the fentanyl patch should be removed every 3 days before the new patch was applied and if a resident had multiple patches could receive more than what was ordered. She said the medications and water flush was to be given by gravity for all residents with gastric tubes per our policy.
During an interview on 7/16/24 2:30 p.m., LVN E said she had forgotten to remove Resident #10's fentanyl patch on 07/10/24 and 07/13/24. She said she initialed she had removed the patch, but she got busy and forgot to remove it and she was responsible. She said if the resident had multiple patches the resident might receive the wrong dose of medications.
Record review of the undated policy titled flushing a feeding Tube indicated it is the policy of this facility to ensure that staff providing care and services to the resident via a feeding tube are aware of, competent in and utilize facility protocol regarding feeding nutrition and care.
Record review of the Narcotic Pain Patch policy dated February 2023 indicated It is the policy of this facility to maintain records of all narcotic patches at the time of receiving in the facility until destruction.10. Upon placement of the new patch, the used patch will be disposed by folding the patch in half with sticky sides together and flush down the sink or toilet or disposed of via a DEA-compliant drug disposal system and verified by the nurse removing and the nurse verifying discard of the patch.
3. Record review of the admission record dated 07/16/24 indicated Resident #20 was male [AGE] years old and was admitted on [DATE] with diagnoses of Parkison's disease (disorder which affects movement) and high blood pressure.
Record review of the physician orders dated 07/16/24 indicate Resident #20's orders included buspirone (used for anxiety) 5 mg three times a day, and Carbidopa-Levodopa ( used for Parkinson's disease) 25-100 MG give 2 tablets twice daily, and colace (used for constipation) 100 MG daily, Lasix (used for edema) 20 MG daily.
Record review of the admission record dated 07/16/24 indicated Resident #24 was male [AGE] years old and was admitted on [DATE] with diagnoses of high blood pressure and heart disease.
Record review of the physician orders dated 07/16/24 indicate Resident #24's orders included amlodipine tablet (used for high blood pressure 10 MG, Coreg Oral Tablet 12.5 MG (used for high blood pressure, Gabapentin (used for nerve pain)100 MG three times a day, and Sertraline (used for depression) 100 MG daily.
During an observation and interview on 07/15/24 at 8:46 a.m., LVN A was administering medications to residents who resided on the 200 hall. She was standing in front of room [ROOM NUMBER] and said, I still have both of these residents to give medications but cannot give with you because I prepared them earlier. She said she knew the policy was not to set up medications ahead of time. She said she was to assess the resident vital signs then prepare medications and then give medications to prevent medication errors or having to dispose of medications.
During an interview on 07/15/24 at 11:00 a.m., the DON said medications should not be set up ahead of time because the assessment and vital signs should be done before medications were prepared. She said medications were to be prepared at the door of the resident's room or by the resident. She said this was to prevent medication errors or prevent medications from having to be wasted if not needed.
Record review of the undated Medication Administration indicated Policy: Medications are administered by licensed nurse, or other staff who are legally authorized to do so in this state, as ordered by the physician and in accordance with professional standards of practice . 8. Obtain and record vital signs . 10. Ensure that the six rights of medication are followed .11.Review MAR to identify medication to administered. 16. Observe resident consumption of medication.18 Sign MAR after administered. For those medications requiring vital signs, record the vital signs onto the MAR.
Jun 2023
11 deficiencies
1 Harm
SERIOUS
(G)
📢 Someone Reported This
A family member, employee, or ombudsman was alarmed enough to file a formal complaint
Actual Harm - a resident was hurt due to facility failures
Free from Abuse/Neglect
(Tag F0600)
A resident was harmed · 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 residents were free from abuse for 1 of 14 residents (Residen...
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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 residents were free from abuse for 1 of 14 residents (Resident #14) reviewed for resident abuse.
The facility did not ensure Resident #14 was free from abuse, as a result Resident #14 was physically assaulted by Resident #138 and was injured.
This failure could place residents at risk of physical harm, mental anguish, or emotional distress.
The noncompliance was identified as PNC. The noncompliance began on 4/9/23 and ended on 4/18/23. The facility had corrected the noncompliance before the survey began.
The findings included:
1. Record review of the face sheet, dated 06/14/2023, revealed Resident #14 was a [AGE] year-old female who admitted to the facility on [DATE] with diagnoses of hypertensive heart disease (group of heart conditions caused by high blood pressure), type 2 diabetes mellitus without complications (high blood sugar), and generalized anxiety disorder (condition with exaggerated tension, worrying, and nervousness about daily life events).
Record review of the MDS assessment, dated 06/08/2023, revealed Resident #14 had clear speech and was understood by staff. The MDS revealed Resident #14 was able to understand others. The MDS revealed Resident #14 had a BIMS score of 13, which indicated no cognitive impairment. The MDS revealed Resident #14 had no behaviors or refusal of care.
Record review of the comprehensive care plan, initiated on 02/02/2023, revealed Resident #14 was verbally aggressive at times by yelling and cursing at staff and other residents. The interventions included: When resident becomes agitated: intervene before agitation escalates; Guide away from source of distress; Engage calmly in conversation; If response is aggressive, staff to walk calmly away, and approach later.
2. Record review of the face sheet, dated 06/14/2023, revealed Resident #138 was a [AGE] year-old male who admitted to the facility on [DATE] with diagnoses of Parkinson's disease (chronic and progressive movement disorder that initially causes tremor in one hand, stiffness or slowing of movement), essential hypertension (high blood pressure), and history of cerebral infarction (stroke).
Record review of the MDS assessment, dated 04/17/2023, revealed Resident #138 had unclear speech and was understood by staff. The MDS revealed Resident #138 was usually able to understand others. The MDS revealed Resident #138 had a BIMS score of 14, which indicated no cognitive impairment. The MDS revealed Resident #138 had verbal behaviors 1 to 3 days during the 7-day look-back period. The MDS revealed his verbal behaviors put others at significant risk for physical injury.
Record review of the comprehensive care plan, initiated on 01/31/2022, revealed Resident #138 had verbally aggressive behaviors. The interventions included: When the resident becomes agitated: Intervene before agitation escalates; Guide away from source of distress; Engage calmly in conversation; If response is aggressive, staff to walk calmly away, and approach later. The care plan did not address his parole status.
Record review of the physical altercation incident report, dated 04/09/2023, revealed Resident #138 was playing inappropriate music on his phone in the dining room. LVN G asked Resident #138 to turn the music off because it was offensive. Resident #138 yelled out You're full of shit, then Resident #20 yelled back at him Just like you. Resident #138 then got up and went over to Resident #14, bumped her chair. Resident #14 spilled out his plastic bag on the floor, he then walked around to Resident #14's back and hit her in the left eye with closed fist. The incident report further revealed the immediate action taken was police notified, administrator notified, head to toe assessment completed.
Record review Resident #14's ER paperwork, dated 04/09/2023, revealed Resident #14 was seen at the ER for aggravated assault. Resident #14 returned to the facility with no new orders.
Record review of Resident #138's ER paperwork, dated 04/09/2023, revealed Resident #138 was seen at the ER for psych evaluation. Resident #138 returned to the facility with no new orders.
Record review of the Resident Checks log, dated 04/09/2023 at 1:00 PM to 04/12/2023 at 2:00 PM, revealed Resident #138 was checked every 15 minutes during the time frames.
Record review of the Resident Checks log, dated 04/09/2023 at 9:45 PM to 04/11/2023 at 11:45 PM, revealed Resident #14 was checked every 15 minutes during the time frames.
Record review of the eye doctor visit summary report, dated 04/10/2023, revealed Resident #14 had a contusion of eyeball and orbital tissues in the left eye.
Record review of the signed and notarized Affidavit of Resident #14, dated 04/11/2023, revealed Resident #138, a black man, told this white lady she was full of shit. Resident #20, the white lady, told him he was full of shit. He [Resident #138] got out of his wheelchair going towards her to hit her [Resident #20]. The aide that was standing by her [Resident #20] pulled her away so that he would not hit her. He [Resident #138] bumped my [Resident #14] wheelchair and pushed me back and he had a plastic bag in the seat of his wheelchair, and I dumped it. He [Resident #138] came at me and hit me [Resident #14] in my left eye with his fist .
Record review of an All Staff Inservice Training for Employees: Resident-To-Resident Altercations, dated 04/11/2023, revealed in-service training, which was signed by all employees, on resident-to-resident altercations and crisis and de-escalation techniques, including when to intervene.
During an interview on 06/12/2023 at 9:06 AM, Resident #14 was laying in the bed with a red toboggan on her head. There was no apparent bruising or swelling observed to her left eye. Resident #14 stated she remembered the incident that occurred in April 2023. Resident #14 stated Resident #138 hit her because they exchanged words in the hallway because he was playing nasty music. Resident #14 stated Resident #138 told another female resident (Resident #20) she was full of shit. Resident #14 stated Resident #138 got up to walk toward Resident #20 and the facility staff moved her out of the way. Resident #14 stated Resident #138 then turned on her and hit her in the left eye. Resident #14 stated the facility staff moved him away from her and the police took him to jail. Resident #14 stated she pressed charges on Resident #138 and went to the jail to give her statement. Resident #14 stated Resident #138 was on parole.
During an attempted interview on 06/12/2023 at 10:05 AM, Resident #20 was unable to be interviewed as evidenced by confused conversation.
During an interview on 06/12/2023 at 3:13 PM, CNA C stated the resident's had started arguing about 5 minutes before Resident #138 hit Resident #14. CNA C stated both residents were sitting in the dining room getting ready to eat dinner. CNA C stated Resident #14 kept picking and calling Resident #138 names, like pissy. CNA C stated Resident #138 stood up and walked over to Resident #14. CNA C stated Resident #14 poured Resident #138's things out on the floor. CNA C stated she left the dining room to answer a call light. CNA C stated she attempted to redirect Resident #14 by asking her to stop, but she kept (verbally) picking on him. CNA C stated Resident #14 had a history of picking at other residents including Resident #138. CNA C stated they had exchanged words earlier in the day and had been separated and were sitting at separate tables. CNA C stated after the incident, within approximately a couple of days, the staff was in-serviced on resident-to-resident altercations and de-escalation techniques and when to intervene during resident conflict.
During an interview on 06/12/2023 at 4:56 PM, LVN G stated Resident #14 and Resident #138 were sitting on opposite sides of the dining room on the day the incident happened. LVN G stated both residents frequently fussed with each other. LVN G stated she was normally able to defuse the situation. LVN G stated she had been at the facility for over a year and Resident #138 had no history of being physically aggressive. LVN G stated she and several other employees were passing out dinner trays. LVN G stated she was unaware that Resident #138 had gotten up, until someone hollered sit down. LVN G was unable to recall who was in the dining room or who told Resident #138 to sit down. LVN G stated when she saw Resident #138 standing up, all the staff members headed toward them. LVN G stated another staff member had pulled Resident #20 out of the way first. LVN G stated Resident #14 started calling Resident #138 degrading and mean names. LVN G stated she had attempted to redirect Resident #14 but was unsuccessful. LVN G stated Resident #138 was standing behind his wheelchair (using it as a walker), when Resident #14 grabbed his bag off the seat of his wheelchair and emptied it on the floor. LVN G stated then Resident #138 reached over the back of his wheelchair and hit Resident #14 in the left eye. LVN G stated she was not able to move fast enough to stop it. LVN G stated Resident #138 did have a history of verbally aggressive behavior toward staff and residents.
During an interview on 06/14/2023 at 10:17 AM, CNA D stated Resident #14 and Resident #138 had been going back and forth, verbally, for about 30 minutes. CNA D stated Resident #14 and Resident #138 had been separated and both had started joking around. CNA D stated she was down the hallway and heard a commotion and Resident #14 and Resident #138 were going at it. CNA D stated she had intervened and was de-escalating the situation because Resident #138 was starting to back away and sit down in his chair when Resident #14 dumped the stuff out of his bag. CNA D stated Resident #138 swung several times and hit Resident #14 in the face. CNA D stated about 3 or 4 employees were in the dining room during the altercation. CNA D stated the Residents were immediately separated and the police were called. CNA D stated the police obtained statements from the staff and Resident #14 was sent to the hospital. CNA D stated she was in-serviced on resident-to-resident abuse, and de-escalation techniques including when to intervene, within a couple of days after the incident occurred.
During an interview on 06/14/2023 at 11:33 PM, the Administrator stated the resident-to-resident incident was discussed in the monthly QAPI meeting. The Administrator stated the medical director, DON, Administrator, ADON, MDS Coordinator, treatment nurse and infection control preventionist, Housekeeping Supervisor, Maintenance Supervisor, and the dietary supervisor were present.
During an interview on 06/14/2023 at 1:57 PM, CNA K stated Resident #138 was a nice man and easy going. CNA K stated Resident #138 had a history of verbally aggressive behaviors toward the staff. CNA K stated Resident #138 had no history of physical aggression toward staff or other residents. CNA K stated before the day of the incident, there had not been any complaints about Resident #138 playing vulgar music. CNA K stated Resident #14 and Resident #138 had a history of verbal argument and then they would be okay. CNA K stated staff had tried to break them up all day and they had been separated. CNA K stated the incident occurred in the dining room while the staff were passing out meal trays and they were immediately separated. CNA K was able to verbalize the different types of abuse. CNA K stated the abuse coordinator was the administrator and he was the person abuse was reported to. CNA K stated if the administrator was unavailable, she would report abuse to the charge nurse. CNA K stated an in-service was provided after the incident, within a few days, and included resident-to-resident altercations and how to try and avoid them and redirect the residents.
During an interview on 06/14/2023 at 2:07 PM, CNA D was able to verbalize the different types of abuse. CNA D was unsure who the abuse coordinator was. CNA D stated she reported abuse to the charge nurse. CNA D stated if two residents were in a physical altercation, she would immediately separate them and report it to the charge nurse. CNA D stated Resident #138 had no history of physically aggressive behaviors toward staff or residents. CNA D stated he did have a history of verbal aggression toward staff and residents but had never threatened physical violence.
During an interview on 06/14/2023 at 5:11 PM, CNA C stated Resident #138 had no history of verbal or physical aggression towards staff or residents while she had been working. CNA C there had been no complaints of Resident #138 playing vulgar music prior to the day of the incident. CNA C was able to verbalize the different types of abuse. CNA C stated the abuse coordinator was the Administrator. CNA C stated she reported abuse to the charge nurse. CNA C stated the last in-service on abuse and neglect was approximately a month previous. CNA C stated if two residents were in a physical altercation she would attempt to stop and redirect them and then report it to the charge nurse.
During an interview on 06/14/2023 at 5:43 PM, LVN H was able to verbalize the different types of abuse. LVN H stated the abuse coordinator was the administrator. LVN H stated there was a number on the back of her name badge to report abuse. LVN H stated the last in-service on abuse and neglect was approximately a couple of weeks ago. LVN H stated if two residents got into a physical altercation, she would try to separate and redirect them and then report to the DON and Administrator.
During an interview on 06/14/2023 at 6:33 PM, the DON stated the interventions that were put in place after the resident-to-resident altercation was an immediate in-service on redirection and de-escalation techniques and when to start redirection. The DON stated that included when to act and find the source of why residents started raising their voices. The DON was able to verbalize the different types of abuse. The DON stated the Administrator was the abuse coordinator. The DON stated the last in-service on abuse and neglect was a little over a month ago. The DON stated she expected staff to intervene and separate residents who were having a physical altercation and then report to charge nurse and the abuse coordinator.
During an interview on 06/14/2023 at 6:47 PM, the Administrator stated he was immediately notified of the incident that occurred in April 2023. The Administrator stated when he got to the facility Resident #14 and Resident #138 were separated and being monitored by staff. Resident #14 and Resident #138 were both placed on every 15-minute monitoring. Resident #14 stated her eye was hurt and wanted to be checked out at the ER. The Administrator stated the nurse practitioner was notified and recommended Resident #138 go out to the ER for a psych evaluation. Resident #14 and Resident #138 came back from the ER that night with no new orders. The Administrator stated the 15-mintue checks continued for both residents. The Administrator stated the police arrived after the incident and provided a case number and obtained witness statements. The Administrator stated Resident #138's parole officer called the next day to obtain a statement from Resident #14, then a few days later he was arrested at the facility and effectively discharged . The Administrator stated an all-staff in-service was started and finished at the all-staff meeting on 04/11/2023 and included resident-to-resident altercations and what to do and de-escalation techniques. The Administrator stated he personally visited with every staff member and on-coming staff members to ensure the in-service was understood. The Administrator stated he was unable to determine a full timeline of events but seems the arguing to the hitting took place in a matter of 1 - 2 minutes. The Administrator stated Resident #138 had no history of physically aggressive behaviors and no complaints had been made regarding Resident #138 playing vulgar music. The Administrator stated after the incident Resident #138 remained agreeable and calm. The Administrator stated he expected staff to immediately secure a resident's safety during a resident-to-resident altercation and then call him for further guidance.
Record review of the Resident-to-Resident Altercations policy, revised December 2016, revealed 1 Facility staff will monitor residents for aggressive/inappropriate behavior towards other residents, family members, visitors, or to the staff. Occurrences of such incidents shall be promptly reported to the nurse supervisor, director of nursing services, and to the administrator.
Evidence presented supports the facility addressed the noncompliance prior to surveyor entrance. In-services conducted, Interviews with staff show they were knowledgeable regarding in-services about resident-to-resident altercations and crisis and de-escalation techniques, including when to intervene, 15 minutes checks were put into place, and Resident #138 was removed from the facility.
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 F0578
(Tag F0578)
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 medical records were maintained in accordance with accepted p...
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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 medical records were maintained in accordance with accepted professional standards and practices on each resident and accurately documented for 1 of 14 residents (Resident #28) reviewed for accuracy of medical records.
The facility did not ensure Resident #28's OOH-DNR was dated by the physician.
This failure could place residents at risk of not receiving care and services to meet their needs.
The findings included:
Record review of Resident #28's face sheet, dated 06/14/2023, indicated Resident #28 was a [AGE] year-old female, originally admitted to the facility on [DATE] with diagnoses which included diabetes mellitus (high blood sugar), essential hypertension (high blood pressure), and COPD (chronic inflammatory lung disease that causes obstructed airflow from the lungs).
Record review of Resident #28's physician order summary report, dated 06/14/2023, indicated an active physician's order for code status: DNR with an order date 06/01/2023.
Record review of the admission MDS dated [DATE], indicated Resident #28 understood others and made herself understood. The assessment indicated Resident #28 was cognitively intact with a BIMS score of 15.
Record review of Resident #28's care plan, with an initiated date of 06/01/2023, indicated Resident #28 had an DNR order. The care plan interventions included appropriate care within guidelines of advanced directives, and the DNR was signed and placed in clinical record.
Record review of the OOH-DNR form dated 09/30/2022 revealed a missing date by the physician.
During an interview on 06/14/2023 at 6:03 p.m., the Administrator stated he expected the DNR to be completed. The Administrator stated the social worker was responsible for ensuring Resident #28's DNR was accurately completed and documented. The Administrator stated the social worker resigned. The Administrator stated the physician should have dated the DNR. The Administrator stated he was unaware prior to surveyor intervention Resident #28's DNR was missing a physician date. The Administrator stated there was not a negative outcome of an incomplete DNR because the facility would abide by the resident wishes.
Record review of the Advance Directives policy, last revised on 12/2016, indicated . advance directive will be respected in accordance with state law and facility policy .
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
Assessment Accuracy
(Tag F0641)
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 ensure an accurate MDS was completed for 2 of 14 residents (Reside...
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**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on interviews, and record review the facility failed to ensure an accurate MDS was completed for 2 of 14 residents (Residents #6 and #37) reviewed for MDS assessment accuracy.
1. The facility failed to accurately code weight loss status for Resident #6 on the MDS assessment.
2. The facility failed to accurately document discharge status for Resident #37 on the MDS assessment.
These failures could place residents at risk for not receiving care and services to meet their needs.
Findings included:
1. Record review of Resident #6's order summary report, dated 06/14/2023, indicated Resident #6 was a [AGE] year-old female, readmitted to the facility on [DATE] with a diagnosis which included heart failure (chronic, progressive condition in which the heart muscle is unable to pump enough blood to meet the body's needs for blood and oxygen), hypertension (high blood pressure), and diabetes mellitus (high blood sugar).
Record review of Resident #6's annual MDS, dated [DATE], indicated Resident #6 understood others and made herself understood. The assessment indicated Resident #6 was cognitively intact with a BIMS score of 13. The assessment indicated Resident #6 was not on a physician prescribed weight loss regimen.
Record review of Resident #6's care plan, with an initiated date of 02/02/2023, indicated Resident #6 had an unplanned/beneficial weight loss r/t recent hospital stay r/t chronic CHF and received Lasix. The care plan interventions included, give the resident supplements as ordered, and offer substitutes as requested or indicated.
Record review of a weight loss notification dated 04/06/2023, indicated Resident #6 had two hospitals stays in the months of December/January and was prescribed Lasix. The notification indicated Resident #6 was on a physician prescribed weight loss regimen.
2. Record review of Resident #37's order summary report, dated 06/14/2023, indicated Resident #37 was a [AGE] year-old female, originally admitted to the facility on [DATE] with a diagnosis which included hypertension (high blood pressure), dementia (loss of memory, language, problem solving and other thinking abilities that were severe enough to interfere with daily life), and rhabdomyolysis (breakdown of muscle tissue that release damaging protein in blood).
Record review of Resident #37's discharge MDS, dated [DATE], indicated Resident #37 was discharged to an acute hospital.
Record review of a Discharge summary dated [DATE] indicated Resident #37 was discharged to home.
During an interview on 06/14/2023 at 2:21 p.m., the MDS Coordinator stated she was responsible for coding Resident #6's and #37 MDS accurately. The MDS Coordinator stated it was important to complete the MDS assessments accurately to show the best assessment of the resident at the time the assessment was completed. The MDS Coordinator stated prescribed weight loss regimen should have been coded on Resident #6 annual MDS. The MDS Coordinator stated not coding Resident #6 MDS correctly could potentially cause rehospitalization due to fluid overload. The MDS Coordinator stated Resident #37 discharge assessment should have indicated she was discharged home. The MDS Coordinator stated there was not a failure to have a safe discharge home due to incorrect coding on the MDS.
During an interview on 06/14/2023 at 2:52 p.m., the Regional MDS nurse stated the MDS nurse was responsible for coding accurately. The Regional MDS nurse stated Resident #6 annual MDS should have stated she was on a prescribed weight loss regimen. The Regional MDS nurse stated Resident #37 discharge MDS should have indicated she was discharged home. The Regional MDS nurse stated she monitors an accuracy audit during facility visits. The Regional MDS nurse stated the visits are done quarterly. The Regional MDS nurse stated the last visit was in February 2023. The Regional MDS nurse stated she was unable to verify if Residents #6 and #37 were part of the resident sample reviewed. The Regional MDS nurse stated there was not a failure to have a safe discharge home due to incorrect coding on the MDS. When asked the potential failure of coding Resident #6 MDS incorrectly, the regional MDS stated I'm not comfortable answering this question because I feel this is a leading question and it's not appropriate.
Record review of the Resident Assessments policy, last revised 11/2019 did not address MDS assessment accuracy.
Record review of the MDS 3.0 RAI Manual, dated 10/2019, revealed that physician-prescribed weight loss regimen included planned diuresis, which indicated weight loss was intentional. The RAI manual further revealed community (01) should have been coded (in A2100) if the discharge location was a private home, apartment, board, and care, assisted living facility, or group home.
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
Comprehensive Care Plan
(Tag F0656)
Could have caused harm · This affected 1 resident
**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on interviews and record review, the facility failed to implement a comprehensive person-centered care plan to meet reside...
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**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on interviews and record review, the facility failed to implement a comprehensive person-centered care plan to meet resident's medical, nursing, mental and psychosocial needs identified in the comprehensive assessment for 1 of 14 residents (Resident #18) reviewed for care plans.
The facility failed to ensure Resident #18's care plan reflected she had weight loss.
This failure could place the residents at increased risk of not having their individual needs met and a decreased quality of life.
Findings included:
Record review of Resident #18's face sheet, dated 06/14/2023, indicated Resident #18 was a [AGE] year-old female, originally admitted to the facility on [DATE] with a diagnosis which included anoxic brain damage (lack of oxygen to the brain), seizures (rapid electrical firing in the brain) and HTN (high blood pressure).
Record review of the order summary report dated 06/14/23 indicated Resident #18 was on a pureed diet with regular consistency related to anoxic brain damage. The order summary report indicated Resident #18 received a continuous tube feeding of Isosource 1.5 at 80 ml/hr x 16 hours with water flush of 250 mg three times a day. Feeding pump on at 1600 and off at 0800.
Record review of Resident #18's admission MDS assessment, dated 03/27/2023, indicated Resident #18 understood others and usually made herself understood. The MDS assessment indicated a BIMS score of 5 indicating moderately impaired. The MDS assessment indicated Resident #18's weight was 147 and did not indicate weight loss.
Record review of Resident #18's care plan (no date) did not indicate weight loss.
Record review of Resident #18's progress notes dated 06/09/23 by the nutrition/dietary department indicated Resident #18 had a 6.5% and 9.3 pound weight loss in one month. Dietician increased feeding to 14 Hr nocturnal feed on 6/2/23.
During an interview on 06/14/23 at 1:42 p.m., the ADON stated she was responsible for care planning after the IDT meetings. The ADON stated the weight loss should have been care planned after the last IDT meeting, but she was not present for the meeting and the and the dietitian should have care planned it for her on Resident #18. The ADON stated the importance of care planning weight loss was to make sure staff kept up with it and so they could monitor or act if the interventions did not work. The ADON stated if weight loss was not care planned, then the nurses might not know about the weight loss or follow up on it. The ADON stated the purpose of the care plan was to let everyone know of the weight loss and to alert the dietician so that she could keep up with it.
During an interview on 6/14/23 at 2:32 p.m., the dietician stated she was not responsible for care planning weight loss and only nursing staff was responsible for completing the care plans.
During an interview on 06/14/23 at 1:52 p.m., the DON stated the nursing department was responsible for care plans. The DON stated staff would go over care plans during the IDT meetings and make needed changes and updates. The DON stated they do not have a process in place for making sure the care plans are correct at this time. The DON stated the importance of making sure the care plan was correct, so everyone would know the plan of care for Resident #18 and did what they were supposed to be doing for Resident #18.
During an interview on 06/14/23 at 3:36 p.m., the Administrator stated the ADON was responsible for nursing care plans and the dietician was responsible for care planning weight loss. The Administrator stated the facility had IDT meetings weekly and they are responsible for discussing weight loss and interventions that should be put into place. The Administrator stated there was no harm in not care planning the weight loss on Resident #18 because there should be physician orders present to intervene for that weight loss. The Administrator stated not having Resident #18's weight loss care planned should not affect the care Resident #18 receives and the nurses should follow the policies and procedures on what should be reported.
Record review of the facility's policy titled, Care Plans, Comprehensive Person-Centered revised on 03/2022 indicated, .The interdisciplinary team, in conjunction with the resident and his/her family or legal representative, develops and implements a comprehensive, person-centered care plan for each resident .
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 F0657
(Tag F0657)
Could have caused harm · This affected 1 resident
**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on interview and record review the facility failed to develop, review, and revise a comprehensive care plan of each reside...
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**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on interview and record review the facility failed to develop, review, and revise a comprehensive care plan of each resident that included measurable objectives and timetables to meet a resident's medical, nursing, and mental and psychosocial needs for 1 of 14 residents (Resident #7) reviewed for care plans.
The facility failed to ensure Resident #7's care plan was updated and revised to reflect she was no longer on transmission-based precautions.
This failure could cause the resident to not receive the correct care impacting the patient's health and/or serious illness.
Findings included:
Record review of Resident #7's face sheet dated 06/14/23 indicated a [AGE] year-old female who was admitted to the facility on [DATE]. Resident #7 had a diagnosis which included type 2 diabetes (blood sugar disorder), cognitive communication deficit (difficulty with thinking and language) and metabolic encephalopathy (brain problem due to chemical imbalance).
Record review of Resident #7's Comprehensive MDS dated [DATE] indicated Resident #7 had a BIMS score of 2 which indicated severe impairment. The MDS indicated Resident #7 sometimes made herself understood and sometimes had the ability to understand others.
Record review of Resident #7's order summary report dated 06/14/23 did not reveal Resident #7 was on transmission-based precautions.
Record review of Resident #7's care plan initiated on 05/31/23 indicated Resident # 7 was on transmission-based precautions related to ESBL in urine. The interventions indicated to educate resident and direct care staff that the infection was contagious. Place resident in a private room and use disposable equipment.
Record review of Resident #7's progress notes dated 6/9/23 indicated Resident #7's urine culture showed no ESBL and to discontinue enhanced barrier precautions isolation.
During an observation on 06/12/23 at 9:16 a.m. Resident #7 was sleeping in her private room. No sign on Resident #7's door indicating TBP or PPE available outside of the door.
During an interview on 06/14/23 at 1:42 p.m., the ADON stated she was responsible for updating the care plans. The ADON stated she was not working on the day of the last IDT meeting and that was why the TBP did not get taken off the care plan. The ADON denied having a process in place for making sure the care plans were updated. The ADON stated the importance was to make sure staff knew they were no longer monitoring Resident #7's isolation and if they needed to wear PPE. The ADON stated not updating Resident #7's care plan could have resulted in Resident #7 being in isolation when it was not necessary.
During an interview on 06/1423 at 1:52 p.m., the DON stated the ADON was responsible for updating the care plans and there was no process in place for making sure they were correct. The DON stated the importance of updating the care plan was to make sure everyone was aware of the plan of care and did what they were supposed to do to care for the resident. The DON stated the importance of updating the TBP status was to let everyone know they did not need to take precautions and Resident #7 was no longer contagious.
During an interview on 06/14/23 at 3:36 p.m., the Administrator stated the ADON was responsible for updating the care plans. The Administrator stated not removing the TBP from the care plan would not negatively affect Resident #7 because there was a physician order in place and Resident #7 was taken off TBP.
Record review of the facility's policy titled, Care Plans, Comprehensive Person-Centered revised on 03/2022 indicated, .The interdisciplinary team, in conjunction with the resident and his/her family or legal representative, develops and implements a comprehensive, person-centered care plan for each resident .
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
ADL Care
(Tag F0677)
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 ensure necessary services to maintain grooming and p...
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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 ensure necessary services to maintain grooming and personal hygiene were provided for 2 of 3 residents reviewed for ADLs. (Resident #8 and Resident #27)
The facility did not ensure Resident #8, and Resident #27 received nail care.
These failures could place residents at risk of not receiving services or care, decreased quality of life, and decreased self-esteem.
The findings included:
1. Record review of the face sheet, dated 06/14/2023, revealed Resident #8 was a [AGE] year-old female who admitted to the facility on [DATE] with diagnoses of unspecified dementia, without behavioral disturbance (group of symptoms that affects memory, thinking and interferes with daily life), type 2 diabetes mellitus without complications (high blood sugars), unspecified glaucoma (condition where the eye's optic nerve, which provides information to the brain, is damaged with or without raised intraocular pressure).
Record review of the MDS assessment, dated 04/26/2023, revealed Resident #8 had clear speech and was understood by staff. The MDS revealed Resident #8 was able to understand others. The MDS revealed Resident #8 had a BIMS score of 08, which indicated moderately impaired cognition. The MDS revealed Resident #8 had no behaviors or refusal of care. The MDS revealed Resident #8 required an extensive, one-person physical assistance with personal hygiene.
Record review of the comprehensive care plan, revised on 05/04/2023, revealed Resident #8 had an ADL self-care performance deficit related to a stroke. The interventions included: check nail length and trim and clean by charge nurse as necessary.
During an observation and interview on 06/12/2023 at 8:55 AM, Resident #8 had long, uneven fingernails on her left hand with a brown, flakey substance under the fingernails. Resident #8 stated she would have liked to have her nails cleaned and trimmed but the staff did not help her.
During an observation on 06/12/2023 at 4:41 PM, Resident #8 had long, uneven fingernails on her left hand with a brown, flakey substance under the fingernails.
During an observation on 06/13/2023 at 5:14 PM, Resident #8 had long, uneven fingernails on her left hand with a brown, flakey substance under the fingernails.
During an observation on 06/14/2023 at 10:11 AM, Resident #8 had long, uneven fingernails on her left hand with a brown, flakey substance under the fingernails.
2. Record review of the face sheet, dated 06/14/2023, revealed Resident #27 was a [AGE] year-old male who admitted to the facility on [DATE] with diagnoses of unspecified dementia without behavioral disturbance (group of symptoms that affects memory, thinking and interferes with daily life), type 2 diabetes mellitus with diabetic polyneuropathy (high blood sugar that caused damage to peripheral nerves that can cause numbness in hands and feet), and white matter disease (an umbrella term for changes and damage to your brain's white matter - the nerve fibers in your brain that connect different areas of your brain to each other and to your spinal cord like highways).
Record review of the MDS assessment, dated 03/16/2023, revealed Resident #27 had clear speech and was understood by staff. The MDS revealed Resident #27 was able to understand others. The MDS revealed Resident #27 had a BIMS score of 05, which indicated severe cognitive impairment. The MDS revealed Resident #27 had no behaviors or refusal of care. The MDS revealed Resident #27 required total care, one-person physical assistance with personal hygiene.
Record review of the comprehensive care plan, revised 06/12/2023, revealed Resident #27 had an ADL self-care performance deficit related to muscle weakness. The interventions included: The resident requires total assistance by 1 staff with personal hygiene and oral care.
During an observation and interview on 06/12/2023 at 9:12 AM, Resident #27 was sitting up in his recliner. Resident #27 had long, jagged, and uneven fingernails on both hands with a brown, gel-like substance under the index (pointer) finger and middle finger on both hands. Resident #27 was non-interviewable as evidenced by confused conversation.
During an observation on 06/12/2023 at 4:30 PM, Resident #27 had long, jagged, and uneven fingernails on both hands with a brown, gel-like substance under the index (pointer) finger and middle finger on both hands.
During an observation on 06/13/2023 at 9:27 AM, Resident #27 had long, jagged, and uneven fingernails on both hands with a brown, gel-like substance under the index (pointer) finger and middle finger on both hands.
During an observation on 06/13/2023 at 3:22 PM, Resident #27 had long, jagged, and uneven fingernails on both hands with a brown, gel-like substance under the index (pointer) finger and middle finger on both hands.
During an interview on 06/14/2023 at 5:27 PM, CNA F stated nail care was dependent on the resident's diabetic status. CNA F stated if a resident was diabetic, the nurses were responsible for ensuring nails were cleaned and trimmed. CNA F was unsure if Resident #8 or Resident #27 were diabetic. CNA F was unsure why Resident #8 or Resident #27 were not provided nail care. CNA F stated nail care should have been performed on shower days and if it was needed. CNA F stated it was important to ensure nail care was performed to keep the fingernails clean and decrease the risk of infection.
During an interview on 06/14/2023 at 6:01 PM, CNA E stated nail care should have been performed as it was needed, whether it was a bath day or not. CNA E stated CNAs usually performed the nail care to residents that were not diabetic. CNA E was unsure if Resident #8 or Resident #27 were diabetic. CNA E was unsure why Resident #8 or Resident #27 were not provided nail care. CNA E stated it was important to ensure nail care was performed to decrease the number of germs and to maintain good hygiene.
During an interview on 06/14/2023 at 6:09 PM, LVN L stated CNAs were responsible for performing nail care and trimming resident's fingernails. LVN L stated the charge nurses were responsible for monitoring the CNAs. LVN L stated CNAs were not supposed to trim or cut diabetic resident's fingernails. LVN L stated nail care should have been performed during showers. LVN L stated the treatment nurse on the weekend was responsible for ensuring diabetic resident's fingernails were cut and trimmed during her down time. LVN L stated Resident #8 was a diabetic. LVN L stated Resident #27 was not a diabetic and the CNAs were responsible for nail care. LVN L stated nail care was important to ensure resident's maintained good hygiene.
During an interview on 06/14/2023 at 6:33 PM, the DON stated fingernails should not have been long, jagged, or uneven. The DON stated fingernails should not have brown substances under them. The DON stated CNAs were responsible for performing nail care during showers or as it was needed. The DON stated nail care was monitored by shower sheets that were turned into the nurse to sign off, then the nurses turned them into the treatment nurse to check off. The DON stated fingernails of the residents who were diabetic should have had their nails cut and trimmed by the nurse. The DON stated nail care was important to maintain good hygiene and prevent the spread of infection.
During an interview on 06/14/2023 at 6:47 PM, the Administrator stated he expected nursing staff to ensure nail care was provided to all residents. The Administrator stated nail care was important to maintain good hygiene.
Record review of the Fingernails/Toenails, Care of policy, revised February 2018, revealed General Guidelines 1. Nail care includes daily cleaning and regular trimming. 3. Unless otherwise permitted, do not trim the nail of diabetic residents or residents with circulatory impairments. 4. Trimmed and smooth nails prevent the resident from accidentally scratching and injuring his or her skin.
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 F0813
(Tag F0813)
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 ensure safe and sanitary storage of resident's food ...
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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 ensure safe and sanitary storage of resident's food items for 1 of 5 residents reviewed for personal food safety. (Resident #9)
The facility did not implement the personal food policy related to personal refrigerators for Resident #9 by failing to check and remove spoiled items that were unlabeled and undated.
This failure could place the residents at risk for food borne illnesses.
The findings included:
Record review of the face sheet, dated 06/14/2023, revealed Resident #9 was an [AGE] year-old female who admitted to the facility on [DATE] with diagnoses of hypertensive heart disease (heart problems caused by high blood pressure), heart failure (progressive heart disease that affects pumping action of the heart muscles), and gastro-esophageal reflux disease without esophagitis (GERD) (acid reflux).
Record review of the MDS assessment, dated 05/23/2023, revealed Resident #9 had clear speech and was understood by staff. The MDS revealed Resident #9 was able to understand others. The MDS revealed Resident #9 had a BIMS score of 15, which indicated no cognitive impairment. The MDS revealed Resident #9 required supervision with set-up help only assistance with eating.
Record review of the comprehensive care plan, revised on 05/30/2023, revealed Resident #9 had an ADL self-care performance deficit related to impaired mobility and function.
During an observation and interview on 06/12/2023 beginning at 9:24 AM, Resident #9 had a personal refrigerator beside her bed on a table. After obtaining permission to look inside, the door was opened, and a strong sour smelling odor was noted. Resident #9 had 1 unlabeled, undated clear cup (approximately 250 mL) of a brownish, cream-colored milk-like liquid that had a thin line of yellow clear liquid on top. Resident #9 stated her personal refrigerator should have been check daily. Resident #9 temperature log was filled out for 06/12/2023, indicating the refrigerator had been checked that morning.
During an observation and interview on 06/12/2023 at 11:43 PM, Resident #9 granted the surveyor permission to look inside her personal refrigerator. When the door was opened a strong sour smelling odor was noted. Resident #9 had 1 unlabeled, undated clear cup (approximately 250 mL) of a brownish, cream-colored milk-like liquid that had a thin line of yellow clear liquid on top. Resident #9 stated the girl in housekeeping normally took care of checking her refrigerator and she had worked yesterday (06/11/2023). Resident #9 stated her refrigerator did not normally get checked daily. Resident #9 stated she had told the staff her refrigerator needed to be checked but they had not cleaned it yet.
During an interview on 6/14/2023 at 6:14 PM, the Housekeeping Supervisor stated housekeeping staff was responsible for checking personal refrigerators daily. The Housekeeping Supervisor stated personal refrigerators were checked for proper temperature and expired food daily. The Housekeeping Supervisor stated personal refrigerators were defrosted and deep cleaned every Friday. The Housekeeping Supervisor stated anything placed into Resident #9's personal refrigerator should have been labeled and dated. The Housekeeping Supervisor stated the undated, unlabeled cup of spoiled milk-like substance should have been thrown out. The Housekeeping Supervisor stated ensuring personal refrigerators were checked daily for expired or spoiled food was important to prevent food poison or making the resident sick.
During an interview on 06/14/2023 at 6:47 PM, the Administrator stated Resident #9 should not have had an undated, unlabeled cup of spoiled milk-like substance in her personal refrigerator. The Administrator stated the Housekeeping Supervisor, and the Dietary Manager were responsible for monitoring to ensure personal refrigerators were checked daily for temperature and spoiled food. The Administrator stated it was important, so residents did not eat or drink anything that was spoiled.
Record review of the Foods Brought by Family/Visitors policy, revised October 2017, revealed 7. B.Containers will be labeled with the resident's name, the item and the use by date. 8. The nursing staff will discard perishable foods on or before the use by date. The policy further revealed 9. The nursing and/or food service staff will discard any foods prepared for the resident that show obvious signs of potential foodborne danger (for example, mold growth, foul odor, past due package expiration dates).
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
Infection Control
(Tag F0880)
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 an infection prevention and control program des...
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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 infection prevention and control program designed to provide a safe and sanitary environment and to help prevent the development and transmission of communicable diseases and infections for 1 of 1 residents (Resident #28) reviewed for infection control related to midline dressing changes.
LVN G and LVN H failed to maintain aseptic technique (a medical practice and procedure to prevent contamination) during a midline catheter (small tube used to give treatments that is inserted into a vein in your arm and stops in the vein near your armpit) dressing change for Resident #28.
This failure could place residents at risk for exposure to blood infection and health complications.
The findings included:
Record review of the face sheet, dated 06/14/2023, revealed Resident #28 was a [AGE] year-old female who admitted to the facility on [DATE] with diagnoses of sepsis (infection of the blood stream), diabetes mellitus (high blood sugar), and morbid obesity (excessive weight).
Record review of the order summary report, dated 06/13/2023, revealed Resident #28 had an order, which started on 06/02/2023, for Midline Catheter to the right arm - Change sterile transparent dressing to insertion site using sterile technique Weekly and as needed if wet, soiled, or not intact.
Record review of the MAR, dated June 2023, revealed Resident #28 received the sterile midline dressing change to right arm on 06/13/2023.
Record review of the MDS assessment, dated 06/01/2023, revealed Resident #28 had clear speech and was understood by staff. The MDS revealed Resident #28 was able to understand others. The MDS revealed Resident #28 had a BIMS score of 15, which indicated no cognitive impairment. The MDS revealed Resident #28 had no behaviors or refusal of care. The MDS revealed Resident #28 received IV medications during the 14-day look-back period.
Record review of the comprehensive care plan, revised on 06/12/2023, revealed Resident #28 had a midline located to her right upper arm and was receiving antibiotics. The interventions included: Change IV site dressing per physician order and as needed if integrity of dressing is compromised (wet, loose, or soiled). Use a transparent dressing to ensure visualization of the IV site.
During an observation on 06/13/2023 between 3:54 PM and 4:19 PM, LVN H gathered the supplies (sterile gloves, surgical mask, IV change kit) for a midline catheter dressing change and entered Resident #28's room with LVN G, who assisted with the procedure. LVN H explained the procedure to Resident #28, performed hand hygiene, and put on clean gloves. LVN H started removing the old tape and dressing. LVN G used hand sanitizer, put on clean gloves, and the placed her finger over the exposed midline catheter insertion site to stabilize the catheter. LVN G stated, It's just a midline dressing change, it's not a sterile procedure. LVN H finished removing the tape and dressing and performed hand hygiene. LVN G continued to hold the midline catheter insertion site with clean gloves. LVN H put on a surgical mask and wore it below her nose. LVN H put on the sterile gloves. LVN G stated again It's not a sterile procedure. LVN H then broke sterile field and opened the IV change kit with her sterile gloves. LVN H continued with dressing change and opened 8 individual alcohol prep pads with her non-sterile gloves. LVN H reached over her sterile field to discard the used alcohol prep pads. LVN G removed her finger and LVN H applied the transparent dressing to the midline catheter. LVN G and LVN H took off their non-sterile gloves, disposed of the trash, and performed hand hygiene.
During an attempted interview on 06/14/2023 at 5:40 PM to obtain more information LVN G did not answer the phone. A brief message was left with a return phone number.
During an interview on 06/14/2023 at 5:43 PM, LVN H stated she was unaware the physician order for the midline dressing change was written as a sterile procedure. LVN H stated she had to piece together the dressing change kit as the facility did not have any. LVN H stated she normally performed the dressing changes as needed and the treatment nurse usually changed them routinely. LVN H stated the midline dressing change was not as sterile as it could have been. LVN H stated the dressing change should have been a sterile procedure because the insertion site was exposed. LVN H stated it was important to maintain sterile technique during a midline dressing change to prevent blood infections or prolonged treatment with antibiotics, which could lead to multi-drug resistant bacteria.
During an interview on 06/14/2023 at 6:25 PM, the Treatment Nurse stated she was also the infection control preventionist. The Treatment Nurse stated the midline dressing change should have been a sterile procedure. The Treatment Nurse stated the nurses were responsible for performing the dressing change. The Treatment Nurse stated it was important to maintain sterile technique during a midline dressing change to protect and prevent the resident from infection.
During an interview on 06/14/2023 at 6:33 PM, the DON stated she was unsure if a midline dressing change should have been a sterile procedure. The DON stated the skills check offs that were used at the facility indicated a sterile procedure, however the policy stated to use an Aseptic Non-Touch technique (ANTT). The DON stated she expected nursing staff to follow the physician orders. The DON stated the midline insertion site should not have been touched without using sterile technique. The DON stated skills check offs were performed upon hire and annually. The DON stated it was important to ensure sterile technique was used to prevent infection or injury.
During an interview on 06/14/2023 at 6:47 PM, the Administrator stated he expected nursing staff to follow physician orders for a sterile procedure. The Administrator stated it was important to prevent an infection.
Record review of the Peripheral and Midline IV Dressing Changes policy, revised March 2022, revealed 2. Maintain sterile dressing for all peripheral catheter sites. 5. Adhere to Aseptic Non-Touch technique (ANTT) when performing this procedure. Adhere to standard or surgical ANTT based on the ability to prevent touching key parts or key sites.
CONCERN
(E)
📢 Someone Reported This
A family member, employee, or ombudsman was alarmed enough to file a formal complaint
Potential for Harm - no one hurt, but risky conditions existed
Food Safety
(Tag F0812)
Could have caused harm · This affected multiple residents
Based on observation, interview, and record review, the facility failed to store, prepare, distribute, and serve food in accordance with professional standards for food safety in the facility's only k...
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Based on observation, interview, and record review, the facility failed to store, prepare, distribute, and serve food in accordance with professional standards for food safety in the facility's only kitchen.
The facility failed to ensure:
1. Food items were dated and labeled.
2. Hair restraints were worn appropriately by dietary staff.
3. The microwave was clean and free of food debris.
4. The juice machine spigot was clean.
5. The ice machine was clean and free from debris.
These failures could place residents at risk for foodborne illness.
Findings include:
1. During an observation and interview with the Dietary Manager of the kitchen refrigerators on 06/12/2023 starting at 9:03 a.m. revealed a pitcher of a liquid substance identified by the Dietary Manager as grape juice unlabeled and undated; 2 packages of waffles undated; storage container of a liquid substance that the Dietary Manager stated she was unable to identify unlabeled and undated; 2 (20oz) squeeze grape jelly undated; plastic storage bag identified by the Dietary Manager as peaches unlabeled and undated; 1 container of potato salad undated; plastic storage bag identified by the Dietary Manager as rice unlabeled and undated; plastic storage bag identified by the Dietary Manager as bacon unlabeled and undated; plastic storage bag identified by the Dietary Manager as hot dogs unlabeled and undated; 2 clear bags identified by the Dietary Manager as cabbage unlabeled and undated; 1 clear bag identified by the Dietary Manager as salad mix unlabeled and undated; a brown, white and red gooey substance was observed at the bottom of the refrigerators.
2. During an observation in the kitchen on 06/12/2023 at 9:06 a.m., [NAME] A and the Dietary Manager were not wearing a hair restraint appropriately. [NAME] A and the Dietary Manager hair was visible outside of the hairnet at the ears and necks.
3. During an observation and interview with the Dietary Manager of the freezer located in the dry storage room on 06/12/2023 at 9:55 a.m. revealed 8 plastic bags identified by the Dietary Manager as potato wedges unlabeled and undated; 4 plastic bags identified by the Dietary Manager as garlic bread unlabeled; 1 plastic bag identified by the Dietary Manager as cinnamon rolls unlabeled and undated; 1 bag of frozen mixed berries undated; 2 bags of frozen strawberries undated; 1 bag of frozen blueberries undated.
4. During an observation in the kitchen on 03/20/2023 at 10:15 a.m., revealed brown build up inside the microwave, and an orange, green and yellow gooey substance was observed in the juice machine spigot.
5. During an observation and interview on 06/12/2023 at 11:45 a.m., revealed an ice machine with a red and orange residue on the interior part of the machine. The Maintenance Supervisor observed with the surveyor the interior of the ice machine. The Maintenance Supervisor agreed it needed to be cleaned. The Maintenance Supervisor stated he did a deep cleaning once a month but was not responsible for daily cleaning. The Maintenance Supervisor stated this failure could put residents at risk for an infection control.
During an interview on 06/14/2023 at 4:13 p.m., the Dietician Consultant stated she expected the kitchen to be clean and staff preventing cross contamination. The Dietitian Consultant stated her last visit was on 06/02/2023. The Dietician Consultant stated she expected all food to be labeled with date received and the date it was opened. The Dietician Consultant stated when the food was opened it should be labeled and dated. The Dietician Consultant stated she expected the juice spigot and microwave to be cleaned daily after every use. The Dietician Consultant stated all hair must be covered while in the kitchen area. The Dietitian Consultant stated the ice machine should be deep cleaned by the maintenance supervisor and cleaned as needed when visually soiled. The Dietician Consultant stated if she noticed any issues, she notified either the Dietary Manager or the cooks/aides and they corrected the issue immediately. The Dietary Consultant stated these failures could potentially cause a food borne illness or cross contamination.
During an interview on 06/14/2023 at 4:33 p.m., [NAME] A stated all kitchen staff were responsible for labeling, dating, and cleaning the microwave. [NAME] A stated the microwave should be cleaned after every use. [NAME] A stated the aides were responsible for cleaning the juice spigot. [NAME] A stated the juice spigot should be cleaned after every use and at the end of each shift. [NAME] A stated the hair restrained should cover her whole head. [NAME] A stated the risk for food items not being labeled or dated was the food could no longer be good because the food could have been sitting there for weeks which could make residents sick. [NAME] A stated the importance of the microwave being cleaned was to make sure old food did not get in the new food. [NAME] A stated the importance of cleaning the juice spigot was to make sure it did not mold which could make the residents sick.
During an interview on 06/14/2023 at 4:39 p.m., Dietary Aide B stated all kitchen staff were responsible for labeling, dating, and cleaning the microwave. Dietary Aide B stated the aides were responsible for cleaning the juice spigot after they pour the drinks. Dietary Aide B stated she did not know the black nob on the spigot comes off until surveyor intervention. Dietary Aide B stated she only wiped off the black nob with a dry town after every use. Dietary B stated these failures could cause the residents to get sick.
During an interview on 06/14/2023 at 5:24 p.m., the Dietary Manager stated she was responsible for making sure the kitchen was cleaned appropriately. The Dietary Manager stated all food should be labeled with date received and the date it was opened. The Dietary Manager stated all staff were responsible for labeling and dating items. The Dietary Manager stated she under the impression if you can see through the bag, it did not have to be labeled. The Dietary Manager stated the juice spigot should be cleaned daily by the dietary aides. The Dietary Manager stated all kitchen staff were responsible for ensuring the microwave was cleaned daily. The Dietary Manager stated the refrigerator should be cleaned daily and as needed when visually soiled. The Dietary Manager stated she was under the impression the maintenance supervisor was responsible for cleaning the ice machine daily until surveyor intervention. The Dietary Manager stated all hair must be covered while in the kitchen area. The Dietary Manager stated she did a have a cleaning log schedule with all items on it. The Dietary Manager stated all staff must follow and complete their duties on a daily basis. The Dietary Manager stated she did daily spot checks during the day and address any issues right then. The Dietary Manager stated these failures could potentially cause a food borne illness or cross contamination.
During an interview on 06/14/2023 at 6:03 p.m., the Administrator stated he expected
the kitchen to be clean and staff preventing cross contamination. The Administrator stated he conducted daily rounds in the kitchen to ensure compliance with regulations. The Administrator stated he has not noticed any consistent issues. The Administrator stated this failure could alter the taste/quality of food.
Record review of the Refrigerators and Freezers policy, last revised on 12/2014, indicated . this facility will ensure safe refrigerator and freezer maintenance, temperatures, and sanitation, and will observe food expiration guidelines .7. All food shall be appropriately dated to ensure proper rotation by expiration dates. Received dates (dates of delivery) will be marked on cases on and on individual items removed from cases for storage
Record review of the Sanitization policy, last revised 10/2008, indicated . the food service area shall be maintained in a clean and sanitary manner 3. All equipment, food contact surfaces and utensils shall be washed to remove or completely loosen soils by using the manual or mechanical means necessary and sanitized using hot water and/or chemical sanitizing solutions . 17. The Food Service Manager will be responsible for scheduling staff for regular cleaning of kitchen and dining areas. Food service staff will be trained to maintain cleanliness throughout their work areas during all task, and to clean after each task before proceeding to the next assignment
Record review of the Food and Nutrition Services policy and procedure manual dated 11/28/17, indicated Dietary staff must wear hair restraints to prevent hair from contacting food
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
Medical Records
(Tag F0842)
Could have caused harm · This affected multiple residents
**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on interview and record review, the facility failed to ensure the resident's medical record were complete for 4 of 5 resid...
Read full inspector narrative →
**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on interview and record review, the facility failed to ensure the resident's medical record were complete for 4 of 5 residents (Residents #21, #13, #5 and #18) reviewed for medical records.
1. The facility failed to ensure Resident #21's medical record contained evidence of education on the influenza vaccine when the vaccine was administered to the resident.
2.The facility failed to ensure Resident #13's medical record contained evidence of education on the influenza immunization when the vaccine was administered to the resident.
3.The facility failed to ensure Resident #5's medical record contained evidence of education on the influenza vaccine when the vaccine was administered to the resident.
4. The facility failed to ensure Resident #18's medical record contained evidence of education on the influenza immunization when the vaccine was administered to the resident.
These failures could place residents at risk for contracting a viral disease that could spread through the facility and cause respiratory complications, and potential adverse health outcomes.
Findings included:
1. Record review of Resident #21's face sheet, dated 06/14/2023, indicated Resident #21 was a [AGE] year-old female, admitted to the facility on [DATE] with a diagnosis which included schizoaffective disorder (a condition that can make you feel detached from reality and can affect our mood), dementia (brain disease that causes memory loss) and type 2 diabetes (blood sugar disorder).
Record review of Resident #21's quarterly MDS assessment, dated 03/20/2023, indicated Resident #21 was understood and able to understand others. The MDS assessment indicated a BIMS score of 7 indicating severely impaired cognition.
Record review of the immunization report (no date) indicated Resident #21 received her influenza vaccine on 10/19/2022.
Record review of Resident #21's electronic medical records indicated there was no information on influenza education being provided to Resident #21.
2. Record review of Resident #13's face sheet, dated 06/14/2023, indicated Resident #13 was a [AGE] year-old female, admitted to the facility on [DATE] with a diagnosis which included essential hypertension (high blood pressure), type 2 diabetes (blood sugar disorder) and peripheral vascular disease (blood vessels reduce blood flow to the limbs).
Record review of Resident #13's quarterly MDS assessment, dated 03/29/2023, indicated Resident #13 sometimes understood others and sometimes made herself understood. The assessment indicated Resident #13 had a BIMS score of 99 due to she was unable to complete the interview.
Record review of the immunization report (no date) indicated Resident #21 received her influenza vaccine on 10/19/2022.
Record review of Resident #13's electronic medical records indicated there was no information on the education being provided to Resident #13.
3. Record review of Resident #5's face sheet, dated 06/14/2023, indicated Resident #5 was a [AGE] year-old male, originally admitted to the facility on [DATE] with a diagnosis which included schizophrenia (affects the ability to think, feel and behave clearly), cerebral palsy (abnormal brain movement, muscle tone and posture) and dysphagia (difficulty swallowing).
Record review of Resident #5's quarterly MDS assessment, dated 01/04/2023, indicated Resident #5 rarely/never understood others and rarely/never made himself understood. The MDS assessment indicated Resident #5's BIMS score was a 99 due to not able to complete the interview.
Record review of Resident #5's electronic medical records indicated there was no information on the influenza education being provided to Resident #5.
4. Record review of Resident #18's face sheet, dated 06/14/2023, indicated Resident #18 was a [AGE] year-old female, originally admitted to the facility on [DATE] with a diagnosis which included anoxic brain damage (lack of oxygen to the brain), seizures (rapid electrical firing in the brain) and HTN (high blood pressure).
Record review of Resident #18's admission MDS assessment, dated 03/27/2023, indicated Resident #18 understood others and usually made herself understood. The MDS assessment indicated a BIMS score of 5 indicating moderately impaired.
Record review of the immunization report (no date) indicated Resident #18 received her influenza vaccine on 03/22/2023.
Record review of Resident #18's electronic medical records indicated there was no information on the influenza education being provided to Resident #18.
During an interview on 06/14/23 at 1:42 p.m., the ADON stated she was responsible for giving residents their vaccines. The ADON stated she was not aware that she was responsible for charting the education on the influenza vaccines that were given in the electronic health record until surveyor intervention, and she was not aware there was a box to check in the electronic chart that the education was provided to the resident. The ADON stated the admission packet and annual copy of the admission packet, addressed the benefits and side effects of all vaccinations. The ADON stated charting education on the vaccines during the time they were given was important due to possible allergies to the medication or the resident could of had an allergic reaction.
During an interview on 06/14/23 at 1:52 p.m., the DON stated the ADON was responsible for giving residents their vaccines and charting the education was given to the residents. The DON stated the importance was to know the vaccines were given to the resident and education was received to prevent the spread of the disease, and to keep the resident from getting ill from not receiving the vaccine.
During an interview on 06/14/23 at 3:36 p.m., the Administrator stated the ADON was responsible for giving residents their vaccines and charting the education was given. The Administration stated the vaccine information was given in the admission packet and it explained the benefits and complications of vaccines that would be given. The Administrator stated there was no harm done in not charting the vaccines were given and stated, it was paper compliance, and it did not indicate any decline. Most families were already aware of the vaccine side effects.
Record review of the facility's policy titled, Influenza Vaccine revised on 08/2026 indicated, . Prior to the vaccination, the resident (or resident's legal representative) or employee will be provided information and education regarding the benefits and potential side effects of the influenza vaccine. For those who receive the vaccine, the date of the vaccination, lot number, expiration date, person administering, and the site of vaccination will be documented in the resident's/employee's medical record .
Record review of the facility's policy title, Vaccination of Residents revised on 08/2016 indicated, .If the resident receives a vaccine, at least the following information shall be documented in the resident's medical record: a. site of administration, b. date of administration, c. lot number of the vaccine, d. expiration date, e. name of person administering the vaccine .
CONCERN
(E)
Potential for Harm - no one hurt, but risky conditions existed
Deficiency F0883
(Tag F0883)
Could have caused harm · This affected multiple residents
**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on interview and record review, the facility failed to ensure the resident's medical record included documentation that in...
Read full inspector narrative →
**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on interview and record review, the facility failed to ensure the resident's medical record included documentation that indicates the resident received education on the influenza immunizations of 4 of 5 residents (Residents #21, #13, #5 and #18) reviewed for immunizations.
1. The facility failed to ensure Resident #21's medical record contained evidence of education on the influenza vaccine when the vaccine was administered to the resident.
2.The facility failed to ensure Resident #13's medical record contained evidence of education on the influenza immunization when the vaccine was administered to the resident.
3.The facility failed to ensure Resident #5's medical record contained evidence of education on the influenza vaccine when the vaccine was administered to the resident.
4. The facility failed to ensure Resident #18's medical record contained evidence of education on the influenza immunization when the vaccine was administered to the resident.
These failures could place residents at risk for contracting a viral disease that could spread through the facility and cause respiratory complications, and potential adverse health outcomes.
Findings included:
1. Record review of Resident #21's face sheet, dated 06/14/2023, indicated Resident #21 was a [AGE] year-old female, admitted to the facility on [DATE] with a diagnosis which included schizoaffective disorder (a condition that can make you feel detached from reality and can affect our mood), dementia (brain disease that causes memory loss) and type 2 diabetes (blood sugar disorder).
Record review of Resident #21's quarterly MDS assessment, dated 03/20/2023, indicated Resident #21 was understood and able to understand others. The MDS assessment indicated a BIMS score of 7 indicating severely impaired cognition.
Record review of the immunization report (no date) indicated Resident #21 received her influenza vaccine on 10/19/2022.
Record review of Resident #21's electronic medical records indicated there was no information on influenza education being provided to Resident #21.
2. Record review of Resident #13's face sheet, dated 06/14/2023, indicated Resident #13 was a [AGE] year-old female, admitted to the facility on [DATE] with a diagnosis which included essential hypertension (high blood pressure), type 2 diabetes (blood sugar disorder) and peripheral vascular disease (blood vessels reduce blood flow to the limbs).
Record review of Resident #13's quarterly MDS assessment, dated 03/29/2023, indicated Resident #13 sometimes understood others and sometimes made herself understood. The assessment indicated Resident #13 had a BIMS score of 99 due to she was unable to complete the interview.
Record review of the immunization report (no date) indicated Resident #21 received her influenza vaccine on 10/19/2022.
Record review of Resident #13's electronic medical records indicated there was no information on the education being provided to Resident #13.
3. Record review of Resident #5's face sheet, dated 06/14/2023, indicated Resident #5 was a [AGE] year-old male, originally admitted to the facility on [DATE] with a diagnosis which included schizophrenia (affects the ability to think, feel and behave clearly), cerebral palsy (abnormal brain movement, muscle tone and posture) and dysphagia (difficulty swallowing).
Record review of Resident #5's quarterly MDS assessment, dated 01/04/2023, indicated Resident #5 rarely/never understood others and rarely/never made himself understood. The MDS assessment indicated Resident #5's BIMS score was a 99 due to not able to complete the interview.
Record review of Resident #5's electronic medical records indicated there was no information on the influenza education being provided to Resident #5.
4. Record review of Resident #18's face sheet, dated 06/14/2023, indicated Resident #18 was a [AGE] year-old female, originally admitted to the facility on [DATE] with a diagnosis which included anoxic brain damage (lack of oxygen to the brain), seizures (rapid electrical firing in the brain) and HTN (high blood pressure).
Record review of Resident #18's admission MDS assessment, dated 03/27/2023, indicated Resident #18 understood others and usually made herself understood. The MDS assessment indicated a BIMS score of 5 indicating moderately impaired.
Record review of the immunization report (no date) indicated Resident #18 received her influenza vaccine on 03/22/2023.
Record review of Resident #18's electronic medical records indicated there was no information on the influenza education being provided to Resident #18.
During an interview on 06/14/23 at 1:42 p.m., the ADON stated she was responsible for giving residents their vaccines. The ADON stated she was not aware that she was responsible for charting the education on the influenza vaccines that were given in the electronic health record until surveyor intervention, and she was not aware there was a box to check in the electronic chart that the education was provided to the resident. The ADON stated the admission packet and annual copy of the admission packet, addressed the benefits and side effects of all vaccinations. The ADON stated charting education on the vaccines during the time they were given was important due to possible allergies to the medication or the resident could of had an allergic reaction.
During an interview on 06/14/23 at 1:52 p.m., the DON stated the ADON was responsible for giving residents their vaccines and charting the education was given to the residents. The DON stated the importance was to know the vaccines were given to the resident and education was received to prevent the spread of the disease, and to keep the resident from getting ill from not receiving the vaccine.
During an interview on 06/14/23 at 3:36 p.m., the Administrator stated the ADON was responsible for giving residents their vaccines and charting the education was given. The Administration stated the vaccine information was given in the admission packet and it explained the benefits and complications of vaccines that would be given. The Administrator stated there was no harm done in not charting the vaccines were given and stated, it was paper compliance, and it did not indicate any decline. Most families were already aware of the vaccine side effects.
Record review of the facility's policy titled, Influenza Vaccine revised on 08/2026 indicated, . Prior to the vaccination, the resident (or resident's legal representative) or employee will be provided information and education regarding the benefits and potential side effects of the influenza vaccine. For those who receive the vaccine, the date of the vaccination, lot number, expiration date, person administering, and the site of vaccination will be documented in the resident's/employee's medical record .
Record review of the facility's policy title, Vaccination of Residents revised on 08/2016 indicated, .If the resident receives a vaccine, at least the following information shall be documented in the resident's medical record: a. site of administration, b. date of administration, c. lot number of the vaccine, d. expiration date, e. name of person administering the vaccine .
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
- "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
- • 23 deficiencies on record, including 1 serious (caused harm) violation. Ask about corrective actions taken.
- • Grade D (48/100). Below average facility with significant concerns.
- • 60% turnover. Above average. Higher turnover means staff may not know residents' routines.
Bottom line: Trust Score of 48/100 indicates significant concerns. Thoroughly evaluate alternatives.
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About This Facility
What is College Street Health's CMS Rating?
CMS assigns COLLEGE STREET HEALTH CARE CENTER 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 College Street Health Staffed?
CMS rates COLLEGE STREET HEALTH CARE CENTER's staffing level at 2 out of 5 stars, which is below average compared to other nursing homes. Staff turnover is 60%, which is 14 percentage points above the Texas average of 46%. High turnover can affect care consistency as new staff learn residents' individual needs.
What Have Inspectors Found at College Street Health?
State health inspectors documented 23 deficiencies at COLLEGE STREET HEALTH CARE CENTER during 2023 to 2025. These included: 1 that caused actual resident harm and 22 with potential for harm. Deficiencies causing actual harm indicate documented cases where residents experienced negative health consequences.
Who Owns and Operates College Street Health?
COLLEGE STREET HEALTH CARE CENTER is owned by a government entity. Government-operated facilities are typically run by state, county, or municipal agencies. The facility is operated by HEALTH SERVICES MANAGEMENT, a chain that manages multiple nursing homes. With 50 certified beds and approximately 32 residents (about 64% occupancy), it is a smaller facility located in BEAUMONT, Texas.
How Does College Street Health Compare to Other Texas Nursing Homes?
Compared to the 100 nursing homes in Texas, COLLEGE STREET HEALTH CARE CENTER's overall rating (3 stars) is above the state average of 2.8, staff turnover (60%) is significantly higher than the state average of 46%, and health inspection rating (3 stars) is at the national benchmark.
What Should Families Ask When Visiting College Street Health?
Based on this facility's data, families visiting should ask: "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?" "How do you handle medical emergencies, and what is your hospital transfer rate?" These questions are particularly relevant given the facility's high staff turnover rate and the below-average staffing rating.
Is College Street Health Safe?
Based on CMS inspection data, COLLEGE STREET HEALTH CARE CENTER has a clean safety record: no substantiated abuse findings (meaning no confirmed cases of resident harm), no Immediate Jeopardy citations (the most serious violation level indicating risk of serious injury or death), and is not on the Special Focus Facility watch list (a federal program monitoring the lowest-performing 1% of nursing homes). The facility has a 3-star overall rating and ranks #1 of 100 nursing homes in Texas. While no facility is perfect, families should still ask about staff-to-resident ratios and recent inspection results during their visit.
Do Nurses at College Street Health Stick Around?
Staff turnover at COLLEGE STREET HEALTH CARE CENTER is high. At 60%, the facility is 14 percentage points above the Texas average of 46%. High turnover means new staff may not know residents' individual needs, medications, or preferences. It can also be disorienting for residents, especially those with dementia who rely on familiar faces. Families should ask: What is causing the turnover? What retention programs are in place? How do you ensure care continuity during staff transitions?
Was College Street Health Ever Fined?
COLLEGE STREET HEALTH CARE CENTER has been fined $9,469 across 1 penalty action. This is below the Texas average of $33,174. While any fine indicates a compliance issue, fines under $50,000 are relatively common and typically reflect isolated problems that were subsequently corrected. Families should ask what specific issues led to these fines and confirm they've been resolved.
Is College Street Health on Any Federal Watch List?
COLLEGE STREET HEALTH CARE CENTER is not on any federal watch list. The most significant is the Special Focus Facility (SFF) program, which identifies the bottom 1% of nursing homes nationally based on persistent, serious quality problems. Not being on this list means the facility has avoided the pattern of deficiencies that triggers enhanced federal oversight. This is a positive indicator, though families should still review the facility's inspection history directly.