AVIR AT PATRIOT
For profit - Limited Liability company
124 Beds
AVIR HEALTH GROUP
Data: November 2025
3 Immediate Jeopardy citations
Trust Grade
0/100
#922 of 1168 in TX
Photo by Avir at Patriot
Photo by David Solem
Photo by David Solem
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Last Inspection: August 2025
Inspected within the last 6 months. Data reflects current conditions.
Overview
Avir at Patriot has received a Trust Grade of F, indicating significant concerns and poor overall performance. Ranking #922 out of 1168 facilities in Texas places it in the bottom half, and #15 out of 22 in El Paso County suggests there is only one local option that performs worse. While the facility is reportedly improving, having reduced its issues from 28 in 2024 to 15 in 2025, its staffing situation is concerning with a low rating of 1 out of 5 stars and a high turnover rate of 74%. The facility has incurred $78,322 in fines, which is higher than 75% of Texas facilities and indicates ongoing compliance issues. Moreover, serious incidents have raised alarm, including a resident who was allowed to exit the building unsupervised and was left outside overnight, posing risks of injury; another incident involved a resident choking due to inadequate supervision and ultimately resulting in death. While the facility does provide some average quality measures, the critical incidents highlight serious weaknesses in care and supervision that families should consider carefully.
- Trust Score
- F
- In Texas
- #922/1168
- Safety Record
- High Risk
- Inspections
- Getting Better
- Staff Stability ⚠ Watch
- 74% turnover. Very high, 26 points above average. Constant new faces learning your loved one's needs.
- Penalties ⚠ Watch
- $78,322 in fines. Higher than 96% of Texas facilities. Major compliance failures.
- Skilled Nurses ⚠ Watch
- Each resident gets only 7 minutes of Registered Nurse (RN) attention daily — below average for Texas. Fewer RN minutes means fewer trained eyes watching for problems.
- Violations ⚠ Watch
- 75 deficiencies on record. Higher than average. Multiple issues found across inspections.
0/100
Bottom 22%
Review needed
28 → 15 violations
★☆☆☆☆
1.0
Overall Rating
★☆☆☆☆
1.0
Staff Levels
★★★☆☆
3.0
Care Quality
★★☆☆☆
2.0
Inspection Score
↔
Stable
2024: 28 issues
2025: 15 issues
The Good
-
Full Sprinkler Coverage · Fire safety systems throughout facility
-
No fines on record
Facility shows strength in fire safety.
The Bad
1-Star Overall Rating
Below Texas average (2.8)
Significant quality concerns identified by CMS
Staff Turnover: 74%
28pts above Texas avg (46%)
Frequent staff changes - ask about care continuity
Federal Fines: $78,322
Well above median ($33,413)
Moderate penalties - review what triggered them
Chain: AVIR HEALTH GROUP
Part of a multi-facility chain
Ask about local staffing decisions and management
Staff turnover is very high (74%)
26 points above Texas average of 48%
The Ugly 75 deficiencies on record
3 life-threatening 1 actual harm
Aug 2025
8 deficiencies
CONCERN
(D)
Potential for Harm - no one hurt, but risky conditions existed
Grievances
(Tag F0585)
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 prompt resolution of all grievances to include providing...
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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 prompt resolution of all grievances to include providing a written summary of investigation to resident or resident representative filing the grievance for 1 (Resident #114) of 6 residents reviewed for resident rights. -The facility failed to provide a written summary of the investigation to resident or resident representative who filed the grievance as per facility policy for Resident #114. - The facility Administrator failed to follow up on grievances related to misappropriation of personal property for Resident # 114.This failure could place residents at risk of not receiving resolutions to their grievances. Findings included: Record review of Resident #114's face sheet dated 08/29/2025 revealed a 77 y/o female admitted on [DATE]. Record review of Resident #114's history and physical dated 07/23/2025 revealed Resident #114 with a diagnosis of dementia. Record review of Resident #114's quarterly MDS assessment dated [DATE] revealed a BIMS score of 02 meaning severe cognitive impairment. In an interview on 08/27/2025 at 11:30 a.m., Resident # 144's responsible party, she stated that she let facility social worker know when Resident #144's phone went missing. She filed a grievance form on 07/25/25 concerning this matter. She stated that she was advised to file a police report by the social worker. She stated that she had also asked the social worker to speak to the facility administrator, and he had yet to follow up with her, from 08/01 to present. She stated that she was frustrated due to the lack of communication on following up with her on filed grievance. She stated that she had not received any type of documentation regarding the investigation done on part of the facility regarding lost phone. Record review of Grievance report on 08/28/2025 dated 07/25/2025 revealed that the grievance form was completed by facility social worker and grievance was reported and reviewed by facility administrator that same day on 07/25/2025 per his signature. Resolution of grievance section was left blank, not noting whether resolution was reached or not. In an interview on 08/29/2025 at 10:15 a.m., the social worker said that she assisted with reviewing grievances and providing recommendations as the facility grievance officer. She stated that when a grievance was filed, she discusseds with the team to include the DON and administrator to reach a solution regarding each grievance. She stated that she then talked to the family or resident to let them know what the conclusion was. She stated that if the person who filed a grievance was not happy with the outcome there was other available solutions such as offering a care plan meeting with the care team to be able to address concerns. She stated that typically resolutions were documented on grievance form along with the investigation that was done by the facility. Social worker stated that the resolution of grievance section of Resident #144's grievance form was left blank because, resident representative did not provide follow up on missing phone location as she was instructed by local Police Department and because resident representative had stopped speaking to facility social worker making it difficult to establish contact. She stated that she did not provide a written summary of findings/ resolutions to resident representative because she did not ask for it. She stated that she was not sure that as per facility policy she had to provide a written summary of findings or interventions taken by the facility to correct issues. She stated that she did not provide a written summary of findings and actions taken to person filing grievance unless they directly asked for it. In an interview on 08/29/2025 at 3:30 p.m., the Administrator said that he was made aware of this grievance on 08/26/2025 although he acknowledged signing the grievance form on 07/25/2025 and stated that he did not pay attention to what the grievance was about when he signed it. He stated that today he saw an email that was sent from Resident #144's representative on 08/26/2025 and replied to that email today 08/29/2025. He stated that typically he communicated with the social worker regarding following up on grievances but overlooked this grievance and stated that facility did not follow policy and procedure regarding grievances. He stated that social worker let him know that she provided guidance to resident representative on steps to take to correct concern. He stated that he was not sure that a written summary of findings/investigation actions was supposed to be provided to the person filing grievance. He stated that by not following up with grievances filed, a resident and any person filing a grievance could be affected by developing lack of trust, and fear of filing a grievance due to it not being followed up promptly and not knowing the outcome of the grievance. Review of grievances/ complaints, filing policy and procedure revised 04/2017 read in part . The resident, or person filling the grievance and/or complaint on behalf of the resident, will be informed (verbally and in writing) of the findings of the investigation and the actions that will be taken to correct any identified problems. A written summary of the investigation will also be provided to the resident, and a copy will be filed in the business office.
CONCERN
(D)
Potential for Harm - no one hurt, but risky conditions existed
Respiratory Care
(Tag F0695)
Could have caused harm · This affected 1 resident
**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, interview and record review, the facility failed to ensure residents who needed respiratory care were prov...
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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 residents who needed respiratory care were provided such care, consistent with professional standards of practice, for 1 (Resident #131) of 6 residents reviewed for oxygen use. The facility failed to maintain Resident #131's oxygen concentrator filter free from lint and dust. This deficient practice could place residents who receive continuous oxygen at risk for not having their air properly filtered. Findings Include:Record Review of Resident #131's face sheet dated 08/27/25 revealed a [AGE] year-old female with admission date 08/12/25. Record review of Resident #131's Nursing Home PPS (Prospective Payment System) MDS dated [DATE] revealed a BIMS score of 14, which indicated the resident was cognitively intact. Record review of Resident #131's history and physical dated 08/21/25 revealed a medical history which included: Hypertension (high blood pressure), Chronic Pain, impaired mobility and cognition. Record review of Resident #131's care plan revealed the resident received oxygen via nasal cannula (a flexible tubing with two prongs that fit into a patient's nostrils and provides continuous oxygen from an oxygen source such as a tank or concentrator). The interventions noted included for staff to keep room cool and free of irritants (smoke, dust, cleaning agents). Observation on 08/26/25 at 2:22 PM of Resident #131 in her room, revealed the resident was lying in her bed with oxygen on via nasal cannula at 4 liters per minute. The oxygen concentrator air filter was observed with dust and lint. During an interview on 08/29/25 at 10:47 AM with CNA G, she stated Sunday night shift nursing staff were responsible for cleaning the oxygen concentrator filters. She stated cleaning the oxygen concentrator filters could be completed as needed if observed dirty, including day shift nursing staff. She stated the nurses were responsible for monitoring the CNAs to ensure they completed tasks such as cleaning the oxygen concentrator filters. CNA G stated the risks of dirty oxygen filters included bacteria and potential illness to residents. In an interview on 08/29/25 at 11:36 AM with LVN F, she stated the Sunday night shift nursing staff were responsible for cleaning oxygen filter concentrators. She stated Central Supply was also responsible for the supplies including clean oxygen filters. She stated the risks of dust on oxygen filters included residents potentially being exposed to infections. In an interview on 08/29/25 at 12:13 PM with Central Supply, she stated night shift CNAs cleaned residents' oxygen concentrator filters. She stated she was not aware who was responsible for monitoring oxygen filters. She stated the risks of dirty oxygen concentrator filters included residents catching an infection. In an interview on 08/29/25 at 03:59 PM with the ADON, she stated all nurses were responsible for monitoring oxygen concentrators and their filters. She stated the ADONs and the DON were responsible for monitoring staff and residents which included residents' oxygen concentrators. She stated the risks of dusty oxygen concentrator filters for residents included infection or illness. In an interview on 08/29/25 at 4:25 PM with the DON, she stated the nurses on Sunday night shifts were responsible for cleaning oxygen concentrator filters. She stated oxygen concentrator filters were to be clean. She stated supervisors from different departments were assigned different residents which they round on daily throughout the week. She stated the residents' needs, and their environment was assessed including the oxygen concentrators. She stated the risks of dirty oxygen concentrators included bacteria and infections for residents who utilize oxygen. Record Review of the Patient Manual provided by the facility titled, Millenium M10: Respironics revealed in part: Maintenance: Cleaning and Changing the Air Inlet Filter- Cleaning the air inlet filter is the most important maintenance activity that you will perform and should be done at least once a week.
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 F0761
(Tag F0761)
Could have caused harm · This affected 1 resident
**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, interview, and record review the facility failed to ensure drugs and biologicals used in the facility were...
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**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, interview, and record review the facility failed to ensure drugs and biologicals used in the facility were labeled in accordance with currently accepted professional principles, included the appropriate accessory and cautionary instructions, and the expiration date when applicable for 1 of 4 nurse medication carts (400) reviewed for medication storage. The nurse medication cart used for hall 400 was inspected on [DATE] and had an insulin vial that had an open date of [DATE] which meant the insulin had already expired. This failure could place residents at risk of receiving medications that were expired and not produce the desired effect.The findings were: During an observation and interview on [DATE] at 11:46 AM revealed the nurse medication cart for hall 400 was inspected with LVN B present. In the top drawer of the medication cart was a 10ml insulin vial that had been opened and had an open date of 06-30-25. LVN B said she had not noticed the vial had expired and that it was each nurse's responsibility to monitor for that. LVN B said she would remove the vial from the cart as it had expired since they were only good for 30 days after being opened. LVN B said if that insulin was used on a resident, then it could lead to the medication not being as effective. During an interview on [DATE] at 1:22 PM the DON said the expectation was for nursing staff to remove expired insulins from the medication carts. The DON said once the insulin container was opened, they were usually good for 28 to 30 days. The DON said if insulin that had expired was used then it could lead to adverse effects and not be as effective. The DON said it basically was each nurse's responsibility to inspect their medication cart for any expired or undated medications and discard them. During an interview on [DATE] at 1:54 PM the Administrator was made aware of the observation of the expired insulin vial found in the nurse medication cart. The Administrator said it was expected for the nursing staff to remove the expired insulins from the cart. The Administrator said if that insulin was used it could lead to adverse effects and not the desired effect. Record review of the facility document titled Insulin administration and dated 2001 indicated in part: Steps in procedure - Check expiration date, if drawing from an opened multi-dose vial. If opening a new vial, record expiration date and time om the vial (follow manufacturer recommendations for expiration after opening). Record review of the facility document titled Medication storage and dated 01/25 indicated in part: Outdated, contaminated, discontinued or deteriorated medications and those in containers that are cracked, soiled or without secure closures are immediately removed from stock, disposed of according to procedures for medication disposal. Record review of the insulin manufacturer instructions dated 2022 indicated in part: After vials have been opened: Store opened vials in the refrigerator or at room temperature up to 86 F (30 C) for up to 31 days. Keep away from heat and out of direct light. Throw away all opened vials after 31 days, even if there is still insulin left in the vial.
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 maintain an infection prevention and control program ...
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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 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 1 of 2 residents (Resident #44) reviewed for incontinent care in that; CNA A failed to change her gloves after they became contaminated during incontinent care while assisting Resident #44. The failure could place resident's risk for cross contamination and the spread of infection.Finding included: Record review of Resident #44's electronic admission record dated 08/26/2025 indicated she was admitted to the facility on [DATE] with diagnoses of muscle weakness, muscle wasting and atrophy (waste away). She was [AGE] years of age. Record review of Resident #44's quarterly MDS dated [DATE] indicated in part: BIMS = 15 indicating the resident was cognitively intact. Bladder and bowel: Urinary continence = Always incontinent. Bowel continence = Occasionally incontinent. Record review of Resident #44's care plan indicated in part: I am Frequently incontinent of Bowel and Bladder. I will remain free from skin breakdown due to incontinence and brief use through the review date. INCONTINENT: Check me every 2hrs and as required for incontinence. Provide Incontinent care as needed. Change clothing PRN after incontinence episodes. Date Initiated: 07/08/2022. During an observation on 08/26/2025 at 9:28 AM revealed CNA A performed incontinent care for Resident #44. CNA A entered the resident's room, sanitized her hands and put some gloves on. CNA A proceeded to undo the resident's brief and took some wet wipes and wiped the resident's vaginal area while her gloved hands came in touch with the resident's vagina. CNA A then turned the resident on her side and with some wet wipes wiped the resident's rectal area. The CNA's gloved hand was noticed to come in contact with the resident's buttocks and rectal area during the wiping. CNA A then took a bottle of lotion from the resident's dresser while wearing the same gloves. CNA A then took a clean brief and fastened it to the resident while still wearing the same gloves. During an interview on 08/27/2025 at 1:04 PM CNA A said she should have changed her gloves before she took the clean brief and placed it on the resident. The CNA said not changing her gloves could lead to cross contamination and re-contaminating the new brief and other items touched with the contaminated gloves. CNA A said she just forgot to change her gloves and that she had been trained on when to change her gloves but again she just forgot to. During an interview on 08/28/25 at 1:22 PM the DON was made aware of the observation of the incontinent care performed by CNA A. The DON said it was expected for the CNA to change her gloves once they became contaminated to prevent cross contamination. The DON said that she was not sure as to why the CNA had not changed her gloves. The DON said ADON H was the infection preventionist and she would conduct random training and return demonstration for CNAs regarding infection control. The DON said they would be conducting more training. During an interview on 08/28/25 at 1:38 PM ADON H said she was the infection preventionist. The ADON was made aware of the observation of the incontinent care performed by CNA A. ADON H said CNA A should have changed her gloves, sanitized her hands and put on a pair of new gloves after the CNA had cleansed the resident's private areas. The ADON said if the CNA had not done that then she was contaminating the items she touched with those gloves. ADON H said that the CNA not changing her gloves could lead to cross contamination and the spread of infections for example UTI's. The ADON said she would conduct more training and in-services regarding incontinent care. During an interview on 08/28/25 at 1:55 PM the Administrator was made aware of the observation of the incontinent care performed by CNA A. The Administrator said it was expected for the CNA to change their gloves once they became contaminated to prevent cross contamination. Record review of the facility's policy titled Perineal Care dated 2001 indicated in part: Purpose - The purpose of this procedure is to provide cleanliness and comfort to the resident, to prevent infections and skin irritation and to observe the resident's skin condition. If resident is heavily soiled with feces, turn resident on side and clean away feces with tissue, wipes or incontinent brief. Discard soiled gloves along with the soiled brief and/or wipes in trash bag. Cover the resident, provide safety measures and wash hands with soap and water. Sanitize hands and put on gloves (PPE as indicated). Record review of the facility's policy titled Handwashing/Hand hygiene dated 2023 indicated in part: This facility considers hand hygiene the primary means to prevent the spread of healthcare-associated infections. Indications for hand hygiene - Hand hygiene is indicated after contact with blood, body fluids or contaminated surfaces; after touching a resident; Before moving from work on a soiled body site to a clean body site on the same resident and immediately after glove removal. Use an alcohol-based hand rub containing 60% alcohol for most clinical situations: Single-use disposable gloves should be used; before aseptic procedures; when anticipating contact with blood or body fluids; The use of gloves does not replace handwashing/hand hygiene. Record review of the facility's policy titled Monitoring compliance with infection control dated 08/2019 indicated in part: Routine monitoring and surveillance of the workplace are conducted to determine compliance with the infection prevention and control policies and practices. The infection preventionist or designee monitors the compliance and effectiveness of our infection prevention and control policies and practices. Monitoring includes regular surveillance of adherence to hand hygiene practices and availability of hand hygiene supplies and the availability of personal protective equipment and its appropriate use.
CONCERN
(E)
Potential for Harm - no one hurt, but risky conditions existed
Deficiency F0558
(Tag F0558)
Could have caused harm · This affected multiple residents
**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, interview and record review the facility failed to ensure residents were provided services with reasonable...
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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 residents were provided services with reasonable accommodation of needs and preferences for 3 of 12 residents (Resident #45, #46 and #47) reviewed for call lights. The facility failed to ensure resident call lights were within reach for 3 Resident #45, #46 and #47). This failure placed residents at risk of having their needs unmet when they are unable to contact staff.Findings included:Resident #45 Record review of Resident #45's admission record dated 08/29/2025 revealed a [AGE] year-old male with an original admission date of 12/07/2023 and a readmission date of 04/27/2025. Record review of Resident #45's history and physical dated 04/27/2025 revealed he had diagnosis of unspecified convulsions (a seizure event where the specific cause is not documented in patients' medical record) and high blood pressure. Record review of Resident #45's Quarterly MDS dated [DATE] revealed in section GG Functional Abilities Resident #45 needed supervision or touching assistance meaning Helper provides verbal cues and/or touching /steadying and/or contact guard assistance as resident completes activity. Assistance may be provided throughout the activity or intermittently. For showering, upper body dressing and lower body dressing. There was no BIMS score available. Record review of Resident #45's care plan reviewed on 04/27/2025 revealed Resident #45 was at risk for blurred vision, dizziness, headaches and nosebleeds related to high blood pressure and received medication for high blood pressure. Resident #45 was at risk of falls, and intervention included ensuring residents call light was within reach. In an observation on 08/26/2025 at 11:11 a.m., in Resident #45's room revealed residents call light was on the floor, not within reach of the resident. Resident # 46 Record review of Resident #46's admission record dated 04/25/2025 revealed a [AGE] year-old female with the original and initial admission date of 04/25/2025.Record review of Resident #46's history and physical dated 04/18/2025 revealed diagnoses of intractable epilepsy (seizures resistant to treatment), febrile illness (elevated body temperature), traumatic brain injury, and breakthrough seizures (seizure activity after a period of 12 months of not having one). Record review of Resident #46's quarterly MDS dated [DATE] revealed Resident # 46 had a BIMS score of 09, indicated moderate cognitive impairment. Section I-Active Diagnoses revealed Resident #46 was diagnosed with Anemia, Other neurological conditions, Seizure disorder, psychiatric/mood disorders, muscle weakness (generalized), unsteadiness on feet, and cognitive communication deficit. Section J-Health conditions revealed Resident #46 had two or more falls since admission without injury.Record review of Resident #46 care plan reviewed on 04/25/2025 revealed Resident #46 experienced five actual falls and ensure staff made frequent room rounds per shift and place and continue interventions on the at-risk plan.In an observation on 08/26/2025 at 10:50 AM, Resident #46's call light was wrapped around the nightstand and clipped to the drawer handle. During a revisit on 08/26/2025 at 2:46 PM, the call light was still in the same position while Resident #46 was asleep. Resident #47 Record review of Resident #47's admission record dated on 01/17/2025 revealed an [AGE] year-old female with an admission date of 11/08/2023.Record review of Resident #47's history and physical dated 01/17/2025 provided resident's diagnoses of left hip fracture, generalized weakness, Myotonic Dystrophy ( A muscle disease featuring an inability to relax muscles at will), and high blood pressure. Record review of Resident #47's quarterly MDS dated [DATE] revealed a BIMS score of 02, indicated severe cognitive impairment. Section GG-Functional Abilities revealed Resident #47 was coded for having impairment on both sides on her upper extremity and substantial/maximal assistance for completing activities for daily living and mobility.Record review of Resident #47's care plan enacted on 01/17/2025 revealed the resident had an actual fall while attempting to ambulate on 07/07/2024 and intervention implemented was to educate the resident on the importance of utilizing the call light for assistance. Resident #47 was previously identified as a fall risk beginning on 11/29/2023. In an observation made on 08/27/2025 at 09:29 AM, in Resident #47's room, the call light was observed on the visitor chair and wrapped around the front right leg approximately hanging one foot from the ground. Resident #47 was sitting in their wheelchair facing away from the call light. In an interview on 08/28/2025 at 1:53 PM, CNA G reported the purpose of the call light is to provide residents with means of communication to staff in need of assistance, care, and emergencies. She reported that CNA's and Nurses are responsible for ensuring that call lights are within reach for the resident. Photos of call lights observed in the facility was presented to CNA G, who confirmed that the call lights were out of reach. She denied having a recent in service on call lights since beginning employment at facility. CNA G stated the resident could fall, be soiled, thirsty, amongst other outcomes if the call light is not in proximal distance for resident's access. In an interview on 08/28/2025 at 2:14 PM, LVN F said call lights are utilized for residents to communicate needs, concerns, and assistance. She confirmed that CNAs and Nurses are responsible for monitoring call lights and adjusting call light position if out of reach. LVN F stated her last in-service training for call light use and positioning was this year. She reported the effect this could have on a resident could be frustration, being left in pain, and affect resident's dignity.In an interview on 08/29/2025 at 4:30 pm, the DON said call lights was for residents to use to be able to ask for assistance. She stated that it was a form of communication between staff and residents. She stated that call lights not being within reach of residents put the residents at risk of not receiving the assistance they were requesting. She stated that all staff, especially nursing and CNAs, were responsible for ensuring that call lights were within reach of the residents. She stated that the last Inservice done was in July 2025. In an interview on 08/29/2025 at 04:33 PM, the administrator said that call lights are used to assist residents with needs and provide a form of communication for assistance. The administrator said that a resident without a call light would limit that individual's ability to communicate with staff and provided examples of what a resident might need (soiled, be in pain, cause infections and skin irritation). The administrator said that everybody who is employed at the facility is responsible for repositioning call lights, to include non-nursing staff. Additionally, the administrator said MDSS, ADONs, and DON are responsible for ensuring nursing staff and CNAs are completing rounds and positioning call lights within reach. The administrator stated the call light should be within reach for residents and be placed on the bed, rail, wheelchair, shirt, or have it in their care plan for any variance of the previously mentioned. The administrator said the last in-service for call lights was conducted 2-3 months prior. The administrator agreed the photos provided displayed call lights outside of resident's immediate reach. The administrator said this deficiency limits the residents' ability to communicate which could result in the resident feeling frustrated, embarrassed, and infringe on their dignity. Record review on 8/29/2025 at 1:05 PM of Call System, Residents does not address accessibility of call light placement in relation to the resident. The facility's policy states, Each resident is provided with means to call staff directly for assistance from his/her bed, from toileting/bathing facilities and from the floor.
CONCERN
(E)
Potential for Harm - no one hurt, but risky conditions existed
ADL Care
(Tag F0677)
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 ADL care for 2 of 16 residents (Resident # 99...
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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 ADL care for 2 of 16 residents (Resident # 99 and #156) reviewed for ADLs.-The facility failed on 08/26/2025 to ensure Resident #99 and #156's fingernails were trimmed, clean and free from debris.-This failure could place residents at risk of not having their personal hygiene needs met and cause low self-esteem.The findings include: Resident # 99.Record review of Resident # 99's admission Record dated 8/27/2025 revealed a [AGE] year-old male with an admission date of 12/11/2023.Record review of Resident # 99's health and physical dated 08/11/2025 revealed medical diagnoses of anxiety disorder, panic attacks, depression, and hypertension. Record review of Resident # 99's quarterly MDS assessment dated [DATE] revealed a BIMS score of 14 indicating the resident was cognitively intact. It indicated the resident required supervision or touching assistance with his personal hygiene. MDS indicated the resident required substantial to maximal assistance with toileting hygiene, shower, bathing and lower body dressing. Record review of Resident # 99's care plan dated 08/26/2025 revealed the resident had an ADL self-care performance deficit related to cerebrovascular accident (a medical emergency that occurs when the blood flow to a part of the brain is suddenly interrupted). The care plan interventions stated the resident had been educated on the importance of hand hygiene as needed. The care plan revealed the resident required limited assistance with personal hygiene. Resident # 156. Record review of Resident # 156's admission Record dated 8/27/25 revealed a [AGE] year-old female with an admission date of 09/13/24. Record review of Resident # 156's health and physical dated 09/10/2024 revealed medical diagnoses of anxiety disorder, major depressive disorder, muscle wasting and atrophy, diabetes mellitus (a chronic metabolic disease characterized by elevated levels of blood sugar) and unspecified dementia. Record review of Resident # 156's quarterly MDS assessment dated [DATE] revealed a BIMS score of 10 indicating moderate cognitive impairment. The MDS revealed the resident required substantial to maximal assistance with toileting hygiene, showering and lower body dressing. Record review of Resident # 156's care plan dated 08/26/2025 revealed the resident had an ADL selfcare performance deficit. The care plan revealed interventions from staff to assist the resident with showering and personal hygiene.In an observation and interview with Resident #99 on 08/26/2025 at 10:30 AM, the resident was lying in bed. Resident #99's fingernails were long and dirty. He stated that he did not like to have long fingernails, and that the facility did not allow the residents to have nail clippers in their possession. Resident #99 stated he tried his best to keep his nails clean but without equipment to clean them, it was difficult for him. Resident # 99 stated he had requested the facility to help him trim his fingernails in the past couple of weeks, but they had not gotten back to him. In an observation and interview on 08/26/25 at 10:50 AM Resident #156 was found lying in bed watching TV. Resident #156's fingernails were long and had debris under her nails in both hands. Resident #156 stated she did not wish to have long fingernails and had requested assistance from the staff to trim them when she was assisted to take a shower, but they had not gone back to help her. She stated she needed to wait until she was assisted with toileting or showers to wash her hands and underneath her fingernails. In an interview on 8/28/25 at 1:22 PM with CNA C, she stated it was not acceptable for residents to have long fingernails. CNA C said that if staff found long fingernails on a resident, they were to report it to an RN who would decide whether to trim the fingernails or refer the resident to a podiatrist. CNA C stated that when staff assisted a resident with a shower, they had to report to the RNs of anything abnormal with the resident's skin or physiology, including nail length. CNA C said that the facility did not allow nail clippers to be left with residents as a preventative measure, so they do not harm themselves. CNA C stated that the risk of leaving a resident with their nails long could result in a risk of infections if they ate with their hands and their nails were long and dirty. CNA C explained there was also a risk of residents scratching themselves which could result in skin infections. In an interview on 8/28/25 at 1:29 PM with CNA D, she stated RNs was supposed to trim the residents' fingernails. CNA D explained that RNs was informed after assisting residents with hygiene or showers and they would assist the resident with nail clipping. CNA D stated the risk of them not being assisted with their nails getting clipped could result in them getting anxious or depressed, making them feel the facility did not care about them, and physically there was a risk for them scratching themselves or digging into their skin which could result in an infection.In an interview on 8/28/25 at 1:35 PM with CNA E, she stated that CNAs was responsible for assisting the residents with nail trimming their fingernails if they were not diabetic. CNA E stated it was not acceptable to leave the residents' nails long because there was a risk of them scratching themselves which could lead to infection or bleeding. In an interview on 8/28/25 at 1:41 PM with LVN F, she stated it was the CNAs' and LVNs' responsibility to trim the residents' fingernails. She said if the resident was diabetic, it would be an LVN who trimmed their nails. LVN F stated it was not acceptable for the residents not to be assisted with this ADL because this could make them feel like the facility and staff did not care about them and it could impact their mood and self-esteem. LVN F stated there was also a risk of infection if they scratched themselves with dirty fingernails and if the resident was in blood thinners, there was a risk of excessive bleeding if they scratched themselves or dug their nails into their skin. In an interview on 8/28/25 at 1:50 PM with the DON, she stated it is a correct statement that residents can't have nail clippers in their rooms because not all residents are alert and oriented and can harm themselves or other residents while trying to trim their nails. The DON stated that long fingernails could cause scratches, and they could open their skin. She explained that nails could get caught in sheets and cut or scratch the resident's skin. The DON said that mentally, leaving a resident with long fingernails could make them feel uncomfortable. The DON stated the possible outcome could be that a resident may scratch themselves and open their skin, creating irritation or bleeding. She stated that anybody can cut the resident's fingernails unless they had a diagnosis of diabetes and if it was a complicated case, the facility referred the resident to a podiatrist.In an interview on 8/29/25 at 3:50 PM with the Administrator, he stated that it was not acceptable for residents to have long fingernails if it was not their preference. The Administrator explained that CNAs were responsible for either trimming the resident's fingernails or reporting it to RNs or LVNs if a podiatrist referral was needed for a diabetic resident. The Administrator also noted that the potential outcome of long fingernails could be that residents would scratch themselves, and the resulting wounds could become infected, leading to sickness. Review of facility policy titled Fingernails/Toenails, Care of: revised in 2018, read in part: The purposes of this procedure are to clean the nail bed, to keep nails trimmed, and to prevent infections. 1. Nail care includes daily cleaning and regular trimming. 2. Proper nail care can aid in the prevention of skin problems around the nail bed. 4. Trimmed and smooth nails prevent the resident from accidentally scratching and injuring his or her skin.
CONCERN
(E)
Potential for Harm - no one hurt, but risky conditions existed
Incontinence Care
(Tag F0690)
Could have caused harm · This affected multiple residents
**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, interview, and record review, the facility failed to ensure residents who are incontinent of bladder recei...
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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 residents who are incontinent of bladder receives appropriate treatment and services to prevent urinary tract infections and to restore continence to the extent possible for 1 (Resident #39) of 6 residents reviewed for incontinent care. The facility failed to ensure adequate bladder incontinence absorbent products were provided to address urine leakage and dignity for Resident #39. This deficient practice could place residents at-risk for infection; skin break down and decrease in self-worth due to improper care practices. Findings included: Record review of Resident #39's admission record dated 08/29/2025 revealed a 69 y/o male admitted on [DATE]. Record review of Resident # 39's diagnosis report dated 08/29/2025 revealed diagnosis of cognitive communication deficit and Benign prostatic hyperplasia with lower urinary tract symptoms. Record review of Resident # 39's quarterly MDS dated [DATE]th, 2025, revealed a BIMS of 15 indicating the person was cognitively intact. Section GG functional abilities revealed Resident # 39 needed substantial/ maximal assistance (helper does more than half the effort) for toileting hygiene (the ability to maintain perineal hygiene, adjust clothing before and after voiding or having a bowel movement). Record review of Resident #39's care plan revealed resident was at risk for infections/pressure/venous/ statis ulcers, and skin desensitized to pain or pressure, slow healing process related to diabetes mellitus. He also had a potential for pressure ulcer development related to immobility. Nursing intervention was to follow the facility policy/ procedure/ protocols for the prevention/treatment of skin breakdown. He also had ADL self-care performance deficit related to dementia. Nursing intervention included extensive assistance x1 staff with all his toileting and incontinent care. In an interview on 08/26/2025 at 10:30 a.m., Resident # 39 revealed that he had trouble with the briefs that was being provided to him, he stated they did not fit, and he would have a lot of accidents. He stated that he had gotten urine on the bed sheets and his clothes, he stated that wetting himself made him uncomfortable. He stated that the briefs was small and uncomfortable around the inner thigh area and groin area. He stated that he did not recall telling staff about briefs being too small for him. In an interview on 08/29/2025 at 11:15 a.m., CNA G revealed that late July early August she had mentioned to the central supply coordinator and to ADON that Resident #39 had been found in bed with urinated sheets and clothes due to the brief not fitting properly as he had a long torso and current size brief fit him small. She had mentioned that he would benefit from a larger size. She stated after that, Resident #39 was still provided the same size brief, therefore resident was still being found urinated. In an interview on 08/29/2025 at 11:30 a.m., the central supply coordinator revealed that every morning she rounded and provided residents with their size of brief based off a list that she had listing each resident's size of brief. She stated that each resident was measured by a CNA and their size of brief was documented. She stated that if CNAs voiced to her that resident need a bigger size brief, then resident would be given the bigger size brief. Regarding Resident #39, she stated that she recalled a CNA mentioning to her about two weeks ago, that Resident #39 needed a bigger size brief due to him having a long torso and the brief being too short and it bunching up in inner thigh area. She stated that he was resized to a 2xl, however she stated that she sometimes provided the correct size and sometimes she does not and did not give a reason as to why. She stated that by not providing the right sized briefs the resident was at risk for cuts, rashes and skin breakdown. She stated that she was responsible for providing the rightsized briefs to each resident. In an interview on 08/29/2025 at 1:30 p.m., the ADON revealed that it was reported to her that Resident #39 needed a larger sized brief. She stated that she and the CNA that did weights and sizing, resized Resident #39 on 08/05/2025. She stated that he now uses a 2 extra Large. She stated that residents had the right to request the size they want even after being fitted. She stated that providing residents with the wrong sized brief could cause them to have skin break down, and she stated that it was a dignity issue as well. She stated that CNA staff and nurses were responsible to communicating any changes to brief sizes to central supply coordinator and she was responsible for providing the correct sized briefs to the residents. In an interview on 08/29/2025 at 2:00 p.m., the Administrator revealed that central supply coordinator was responsible for ordering and distributing briefs to each resident. He stated that she has a list of resident sizes that she follows and that was how she knew which size to provide for the resident. He stated that he did not know about Resident #39 having an issue with the briefs. He stated that he did not see an issue with providing the wrong sized briefs to residents, especially if it was a larger size. He stated that residents needed to be changed in a timely manner to prevent any skin breakdown from happening. He stated that there were a lot of residents requesting an extra-large brief and therefore sizing was done as an intervention to help each resident know their correct size of brief and make ordering briefs easier for central supply coordinator. Per facility administrator, there was no policy on each resident receiving supplies for ADLs.
CONCERN
(E)
Potential for Harm - no one hurt, but risky conditions existed
Room Equipment
(Tag F0908)
Could have caused harm · This affected multiple residents
Based on observations, interviews, and record reviews the facility failed to maintain all mechanical, electrical, and patient care equipment in safe operating condition for 1 of 1 of the facility's la...
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Based on observations, interviews, and record reviews the facility failed to maintain all mechanical, electrical, and patient care equipment in safe operating condition for 1 of 1 of the facility's laundry department reviewed for patient care equipment in safe operating condition. -The facility failed to maintain 1 of 3 washers in operating condition.The failure could place residents at risk for harm by the facility's inability to provide clean sanitary linens and could place residents at risk for poor hygiene and health.Findings include: During an observation on 08/28/25 at 1:30 PM, of the facility's laundry department revealed 1 commercial washer that was not operational. During an interview on 08/28/25 at 1:32 PM with the Housekeeping Supervisor revealed that the washer had been out of service for a year now. She stated that it broke down when the other company had ownership of the facility. She stated that when the new company took over, the parts for the washer were ordered. She stated that she believed that the parts for the washer were already received by the facility. She stated that since they had two working washers, the broken one did not affect residents receiving their laundry back, therefore she did not see the risk of affecting resident. During an interview on 08/28/25 at 2:00pm with Resident #41 revealed that she had not had any delays with getting her laundry back. During an interview on 08/28/25 at 2:10 pm with Resident #42 revealed that she had not had any delays with getting her laundry back. During an interview on 08/29/25 at 1:00 pm with the Maintenance Director, revealed that the washer had been broken for a year. He stated that before the new company took over, he had asked for the washer to be fixed, however it was never granted. When the new company took over, he asked for the washer to be fixed, and he was able to order the new parts for the washer. He stated that the new parts for the washer were received about a month ago, but it hads not been fixed because since there were two other washers, the third washer was not a priority and there was no excuse for that washer to still be out of service. He stated that to his knowledge, that had not delayed residents receiving their laundry back. He stated that he was the one who was responsible for ensuring the washer was in working condition. During an interview on 08/28/25 at 3:00 pm with the Administrator revealed, the washer had not been working since February 2025. He stated that they were waiting for installation. He could not confirm if the facility had received all the parts needed to fix the washer but stated that the facility would need to hire the right person to fix it as this was outside the scope of the Maintenance Director. He stated that the broken washer was mostly used to wash residents' individual clothes and napkins from the kitchen. He stated that he did not see a problem with two of the three washers being in a working condition because this had not caused a delay in residents receiving their clothes back. On 8/29/2025 at 10:30am, the Administrator stated that there was no policy regarding essential equipment.
Aug 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
Pressure Ulcer Prevention
(Tag F0686)
Could have caused harm · This affected 1 resident
**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observations, interviews, and record reviews, the facility failed to ensure residents who entered the facility received...
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**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observations, interviews, and record reviews, the facility failed to ensure residents who entered the facility received care and treatment consistent with professional standards of practice to prevent pressure ulcers and a resident with pressure ulcers receives necessary treatment and service to promote healing and/or prevent further development of skin breakdown or pressure ulcers, for one (Resident #2) of four residents reviewed for prevention and maintenance of pressure ulcers. The facility failed to ensure Resident #2's dressing was replaced when it became dislodged, allowing the sacral wound to be exposed to potential contamination with urine and fecal matter. This failure could place residents at risk of worsening of existing pressure ulcers and risk of infection. The findings included:Review of Resident #2's admission Record, dated 07/30/25, revealed an [AGE] year-old female who was admitted to the facility on [DATE] and re-admitted on [DATE]. Review of Hospital Physician Progress Note dated 07/07/25 for Resident #2 revealed, [AGE] year-old female with a history of dementia (a condition that causes a decline in thinking, memory, and reasoning skills) presented to the emergency room from nursing home for abdominal distention (belly is sticking out more than usual, making it look swollen or bloated). Stage 4 pressure ulcer (is a very deep crater on the skin in the area of the tailbone) present on admission. Review of Hospital Nutrition Progress Note dated 07/08/25 for Resident #2 revealed, History of Present Illness: admitted from nursing facility due to distended abdomen. Past Medical History of dementia, chronic kidney disease stage 3 (means that your kidneys have moderate damage), decubitus ulcer (is a type of skin wound that develops from prolonged pressure on the skin, usually over bony areas like the hips, heels, or tailbone), bedbound(someone is unable to get out of bed and move around due to illness, injury, or other physical limitations). Nutritional History: Spoke with CNA who reported that patient gets assistance with eating and is not consuming much of her food or liquids (only having bites and sips). Skin: Pressure injury to sacrum (is a wound that forms on the skin and underlying tissues over the tailbone). Review of Hospital Physical Therapy Wound Check dated 07/08/25 for Resident #2 revealed, Location: Sacrum. Etiology: Pressure Ulcer: Unstageable at this time. Review of Nursing Facility History & Physical dated 07/14/25 for Resident #2 revealed, History of Present Illness: This is an [AGE] year-old Hispanic female patient seen today for a Post Hospitalization where she was treated for Baseline dementia (is a condition where an individual's cognitive function does not return to normal even when all other diseases are under control), Metabolic encephalopathy/multifactorial (is a condition where the brain's function is affected due to metabolic disturbances, often caused by underlying health issues. It can cause confusion, memory loss, and altered consciousness). Per nursing the patient continues to eat very poorly. Will refer for a hospice evaluation and admission. Past Medical History Active Medical Problems: Diabetes Mellitus with PVD (means that a person with diabetes has a higher risk of developing a condition called Peripheral Vascular Disease (a condition that affects the blood vessels outside the heart and brain and lead to symptoms like painful muscle cramping, slow-healing wounds, and an increased risk of stroke or heart attack), homocysteine [NAME] (is an amino acid that plays a crucial role in protein metabolism), Chronic Kidney Disease stage 3, Alzheimer's dementia (is a group of symptoms that affect a person's ability to perform everyday activities due to a decline in cognitive functioning). Record review of Resident #2's Quarterly MDS, dated [DATE], revealed BIMS Score was 3 (severely impaired), Incontinent of bowel & bladder. Active Diagnoses: Renal Insufficiency, Diabetes Mellitus, Non-Alzheimer's Dementia, Depression, Morbid Obesity, Muscle weakness, muscle wasting and atrophy. Resident has one unhealed pressure ulcer. One Unstageable - Deep tissue injury. Pressure reducing device for chair/bed. Review of Care Plan for Resident #2's revealed:- Care Plan dated initiated: 07/24/25. Resident receiving hospice services r/t Terminal disease process. Interventions: Notify hospice nurse and MD for any decline in resident's condition. - Care Plan initiated: 06/19/25. The resident has an unstageable pressure ulcer to the coccyx and potential for pressure ulcer development r/t disease process (Muscle weakness, DMII, muscle wasting/atrophy and morbid obesity), Immobility. Interventions: Administer treatments as ordered and monitor for effectiveness. Treat pain as per orders prior to treatment/turning etc. to ensure the resident's comfort. Weekly treatment documentation to include measurement of each area of skin breakdown's width, length, depth, type of tissue and exudate. Review of Hospice Certification and Plan of Care for Resident #2 revealed, Start of Care Date: 07/23/25. Diagnoses: Senile degeneration of brain, Type 2 Diabetes Mellitus, Chronic Kidney Disease. Orders and Treatment: Facility to provide wound care as ordered. Goals: Skin breakdown and/or wounds will be managed without infection. DME-Low air loss mattress; incontinent care and wound supplies. Activities Permitted: Complete bedrest. Review of Hospice Communication Log for Resident #2 revealed, 07/28/25 Patient's wound to sacrum with purulent drainage. New wound care orders provided. 07/29/25 Started antibiotics and new wound care orders. Review of Hospice Physician's Telephone/Verbal Order dated 7/28/25 at 11:30 AM, revealed Regarding wound to sacrum, cleanse with normal saline, pat dry, apply Silvadene to wound bed, pack with 4 x 4 gauze moistened with normal saline, cover with 4 x 4 gauze, secure with foam dressing. Change daily and PRN when soiled.Review of Hospice Physician Order Summary dated 07/30/25 for Resident #2 revealed. Order Date: 07/28/25 Wound to sacrum, clean with N/S or wound cleanser, pat dry, apply Silvadene to wound bed, cover with 4x4 gauze, secure with foam dressing, change daily and PRN when soiled for Wound protection. Order Date: 07/28/25: Bactrim DS Oral tablet 800-160 mg give one tablet by mouth one time a day for wound infection for 14 days.Interview on 07/28/25 at 12:08 PM with CNA D assigned to Resident #2, said the resident had a pressure ulcer to the sacral area. During an interview on 07/28/25 at 2:46 PM, with LVN WCC, she said Resident #2 had been admitted from the hospital with a stage IV pressure ulcer to the sacrum. Observation and interview on 07/28/25 at 2:48 PM, revealed Resident #2 was lying in bed on her back. LVN WCC A and CNA B turned the resident to her right side and the resident did not have the dressing on the stage IV pressure ulcer on the sacrum. LVN WCC A stated that the CNAs had been trained to immediately report to her or the licensed staff if the dressing was not on the pressure wounds to prevent contamination of the wound with urine and feces. In an interview on 07/28/25 at 3:57 PM, with LVN C, 2-10 nurse assigned to Resident #2, he said the resident was in the Hospice case load and had a stage 4 pressure ulcer to the sacrum. He said that the CNAs had been trained, to immediately report to the charge nurse or the treatment nurse if the wound dressings were loose and/or if they found a resident without the dressing on the wounds, to prevent to prevent urine and feces from getting in the wound and to prevent infection. He said that no one had reported to him at the start of shift, that Resident #2 did not have the dressing on the wound to the sacrum. During an interview on 07/29/25 at 1:38 PM, with LVN A, 6-2 Shift assigned to Resident #2, revealed the resident was receiving Hospice services, had been refusing to eat for a while and had a stage 4 pressure ulcer on the sacrum. She said that the CNAs had been trained to immediately report to the nurses, if wound dressings are loose or have fallen off, to prevent urine and feces from getting into the wound and to prevent infection. She said, The Hospice CNA and CNA E did not report to me on 7/28/25 after they had finished the bed bath on that day, that the resident did not have a dressing on the stage IV pressure ulcer on the sacrum. She said that she did not know if the WCC had been informed by CNA E that the resident did not have the dressing to the stage IV pressure ulcer on the sacrum on that day. She said it was important to reapply the dressing as soon as possible to prevent urine and feces from getting into the wound, that could cause the wound to become infected. During an interview on 07/30/25 at 10:14 AM, with the DON, revealed that she had placed a telephone call to the Hospice CNA, and she had confirmed Resident #2, did not have a dressing on the wound to the sacrum, when she came on 07/28/25 in the morning shift to give the resident a bed bath and that she had not reported to the nurse that the resident did not have the wound dressing on the stage IV pressure on the sacrum. She said that the Hospice CNAs had been trained to immediately report to the nurse if the resident were found without the wound dressing on the sacrum to prevent urine and feces getting into the wound and prevent the risk for infection.During an interview on 07/30/25 at 11:08 AM, with CNA D on the 6-2 shift, revealed that on Monday 07/28/25, revealed the Hospice CNA had come to give Resident #2 a bed bath and did not mention to her that the resident did not have the wound dressing to the stage VI pressure ulcer on the sacrum when she changed the resident's brief to give the resident a bed bath on that day. CNA D said they had been trained to immediately report to the nurse if they found a resident without the dressing to the pressure wounds to prevent the urine and feces from getting into the wound and cause an infection. During an interview on 07/30/25 at 11:30 AM, with LVN E assigned to Resident #2 on the weekends, revealed resident had a stage IV pressure ulcer on her sacrum, and treatments were done by the weekend treatment nurse. She said the CNAs had been trained to immediately report to the nurses and/or the treatment nurses when the resident did not have a dressing on the pressure ulcer, to prevent the wound becoming contaminated with urine and feces, that could place the resident at risk of infection. Telephone interview with NP on 08/07/25 at 11:24 AM, revealed that Resident #2 was on Hospice Services for a diagnosis of dementia and had developed an unavoidable pressure ulcer to the sacrum. She said that the resident was immobile, had not been eating a substantial amount of food for over 5 weeks, several treatments to the existing wound were unsuccessful and that was why the resident had been referred to Hospice Services. She said the resident has had significant weigh loss due to not eating, so the poor nutritional intake, poor hydration, her diabetes mellitus and chronic kidney failure, and lack of adequate nutrition results in malnutrition so all these factors contributed to the development of the stage VI pressure ulcer. She said that the staff has also reported to her that the resident does not like to be turned & repositioned in bed and that she prefers to stay on her back. She said that the resident had the right to refuse care and that included not wanting to be turned and repositioned in bed. She said that she was also aware that Hospice had discontinued the appetite stimulant and all the vitamins that were ordered to promote wound healing. She said the physician was aware of the resident's status and agree with the Hospice treatment plan. She said that the pressure ulcer must be always covered with the wound dressing to prevent urine and feces from getting into the wound and cause an infection. Telephone interview on 08/07/25 at 12:58 PM, with Hospice Nurse revealed Resident #2 had been admitted to the nursing facility from the hospital with the stage IV pressure ulcer to the sacrum. She said that they were aware that the eating was eating very little and taking small amounts of water. She said the physician was also aware that the resident was not eating and did not allow the staff to turn & reposition her to the sides and preferred to stay on her back. She said that she remembered coming to see the resident on 07/28/25, when the Hospice Aide went to the nursing facility to give the resident a bed bath. She said, I saw the resident prior to the Hospice CNA starting the bed bath and noted that the sacral wound just had an abdominal pad hanging from the wound. She said that the Hospice staff had been trained to immediately report to the facility nurses to prevent urine and feces from getting inside the wound and cause an infection. Review of the facility's P&P on Prevention of Pressure Ulcers revised in April 2022, revealedInspect the skin daily when performing or assisting with personal care or ADLs. Use facility-approved protective dressings for at risk individuals. Review of facility on Pressure Ulcers/Skin Breakdown - Clinical Protocol dated 2001 revealed, Treatment/Management The physician/physician extender will authorize pertinent orders related to wound treatments, including wound cleansing and debridement approaches, dressings (occlusive, absorptive, etc.), and application of topical agents if indicated for type of skin alteration. The physician/physician extender will help identify medical interventions related to wound management; for example, treating a soft tissue infection surrounding an ulcer, removing necrotic tissue, addressing comorbid medical conditions, managing pain related to the wound or to wound treatment, etc.
CONCERN
(D)
📢 Someone Reported This
A family member, employee, or ombudsman was alarmed enough to file a formal complaint
Potential for Harm - no one hurt, but risky conditions existed
Medical Records
(Tag F0842)
Could have caused harm · This affected 1 resident
**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on interview, and record review, the facility failed to maintain clinical records on each resident that were complete and ...
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**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on interview, and record review, the facility failed to maintain clinical records on each resident that were complete and accurately documented in accordance with accepted professional standards and practices for 1 (Resident #1) of 6 residents reviewed for accuracy and completeness.The facility failed to ensure that LVN A completed a weekly skin assessment for Resident #1 on 7/22/25 in accordance with facility policy. This failure placed residents at risk for unmet care needs, as services may be documented as provided when they were not, potentially leading to delays in treatment or unidentified changes in condition. Findings include:Record review of Resident #1's face sheet dated 07/30/25 revealed an [AGE] year-old male who was admitted to the facility on [DATE] and re-admitted on [DATE]. Record review of Resident #1's history and physical dated 6/22/25 revealed diagnoses of malfunction of nephrostomy tube (the tube placed into the kidney to drain urine isn't working properly. It might be clogged, leaking, or not staying in place), bilateral hydronephrosis (both kidneys are swollen because urine can't flow out the way it should. It usually happens when there's a blockage somewhere in the urinary system), left hydroureter (the ureter on the left side (the tube that carries urine from the kidney to the bladder) is swollen, usually because something is blocking the urine from flowing), and displacement of the left percutaneous nephrostomy tube (the tube placed into the left kidney to help drain urine has moved out of place). Record review of Resident #1's quarterly MDS dated [DATE] revealed a BIMS score of 10, which indicated his cognition was moderately impaired. Section H revealed he had indwelling catheter and ostomy. Record review of Resident #1's care plan dated 5/21/25 revealed a focus care area for risk for impaired skin integrity and need for preventative measures with interventions that included skin checks per facility policy. He also had a focus area for has nephrostomy tube to his right side with interventions that included monitor/document for pain/discomfort due to the catheter. Record review of Resident #1's skin assessments for July 2025 revealed no assessment was completed for the week of 07/21-07/25. During an interview on 07/30/25 at 11:31 am, LVN A stated nurses were responsible for completing skin assessments and that they were scheduled per shift daily. LVN A stated Resident #1 assessments were scheduled every Wednesday. LVN A stated she did not complete the assessment on 7/22/25 because one had been completed on 7/19/25. LVN A stated she reviewed the skin assessment and assumed the nurse had completed a full head-to-toe assessment. When asked about weekly assessment expectations, LVN A changed her response and stated she had completed a full head-to-toe assessment on 7/22/25 because it was the resident's shower day, and she had checked the nephrostomy site but failed to document it. LVN A was unable to provide a reason for not documenting the skin assessment and remained silent, stating she should have completed the documentation. LVN A stated the risks of not completing the weekly skin assessment included lack of continuity of care and failure to complete job duties.During an interview on 07/30/25 at 11:41 am, LVN B stated she completed an assessment following an altercation involving the resident, but did not complete the scheduled weekly skin assessment because she believed the incident-related check was sufficient. LVN B stated a posted schedule at the nurse's station assigned weekly skin assessments to nurses per shift. LVN B stated that nurses were still expected to complete their assigned weekly skin assessments even if an assessment was performed during the week for another reason. LVN B stated that failing to complete the scheduled weekly assessment could impact continuity of care. LVN B stated she had received training on skin assessments but could not recall when.During an interview on 07/30/25 at 1:33 pm, DON stated the wound care nurse began conducting weekly audits on weekends to ensure all residents received weekly skin assessments. The DON stated that verification of weekly skin assessments was expected to be completed by the ADONs. The DON stated she would begin conducting spot checks moving forward. The DON stated there was no quality assurance process in place for the weekend audits conducted by the wound care nurse.Record review of facility's Charting and Documentation policy dated 2001 read in part The following information is to be documented in the resident medical record: a. Objective observations; b. Medications administered; c. Treatments or services performed; d. Changes in the resident's condition; e. Events, incidents or accidents involving the resident; and f. Progress toward or changes in the care plan goals and objectives.
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
Infection Control
(Tag F0880)
Could have caused harm · This affected multiple residents
**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, interview, and record review, the facility failed to establish and maintain an infection prevention and co...
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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 two of five residents (Residents #2 and #3) reviewed for Enhanced Barrier Precautions. The facility failed to implement their policy on Enhanced Barrier Precautions for residents with wounds and/or indwelling medical devices. These failures could place residents at risk for healthcare associated cross-contamination and at risk of the transmission of multi-drug-resistant organism (MDROs).The findings included: Resident #2 Review of Resident #2's admission Record, dated 07/30/25, revealed an [AGE] year-old female who was admitted to the facility on [DATE] and re-admitted on [DATE]. Review of Hospital Physician Progress Note dated 07/07/25 for Resident #2 revealed, [AGE] year-old female with a history of dementia (a condition that causes a decline in thinking, memory, and reasoning skills) presented to the emergency room from nursing home for abdominal distention (belly is sticking out more than usual, making it look swollen or bloated). Stage 4 pressure ulcer (is a very deep crater on the skin in the area of the tailbone) present on admission. Review of Nursing Facility History & Physical dated 07/14/25 for Resident #2 revealed, History of Present Illness: This is an [AGE] year-old Hispanic female patient seen today for a Post Hospitalization where she was treated for Possible aspiration pneumonia (An infection in the lungs that occurs when food, liquid, or saliva accidentally enters the lungs instead of the stomach), Baseline dementia (is a condition where an individual's cognitive function does not return to normal even when all other diseases are under control), Metabolic encephalopathy/multifactorial (is a condition where the brain's function is affected due to metabolic disturbances, often caused by underlying health issues. It can cause confusion, memory loss, and altered consciousness), During the visit the patient was awake in bed, responsive and alert. Per nursing the patient continues to eat very poorly. Will refer for a hospice evaluation and admission. Past Medical History Active Medical Problems: Diabetes Mellitus with PVD (means that a person with diabetes has a higher risk of developing a condition called Peripheral Vascular Disease (a condition that affects the blood vessels outside the heart and brain and lead to symptoms like painful muscle cramping, slow-healing wounds, and an increased risk of stroke or heart attack), homocysteine [NAME] (is an amino acid that plays a crucial role in protein metabolism), Chronic Kidney Disease stage 3, Alzheimer's dementia (is a group of symptoms that affect a person's ability to perform everyday activities due to a decline in cognitive functioning). Record review of Resident #2's Quarterly MDS, dated [DATE], revealed BIMS Score was 3 (severely impaired), Incontinent of bowel & bladder. Active Diagnoses: Renal Insufficiency, Diabetes Mellitus, Non-Alzheimer's Dementia, Depression, Morbid Obesity, Muscle weakness, muscle wasting and atrophy. Weight: 193 pounds. Resident has one unhealed pressure ulcer. One Unstageable - Deep tissue injury. Pressure reducing device for chair/bed. Review of Care Plan for Resident #2's dated 06/19/25 revealed, the resident has an unstageable pressure ulcer to the coccyx and potential for pressure ulcer development r/t disease process (Muscle weakness, DMII, muscle wasting/atrophy and morbid obesity), Immobility. Interventions: Enhanced barrier precautions. Review of Hospice Communication Log for Resident #2 revealed, 07/28/25 Patient's wound to sacrum with purulent drainage. New wound care orders provided. 07/29/25 Started antibiotics and new wound care orders. Review of Physician Order Summary dated 07/30/25 for Resident #2, revealed Order Date: 06/26/25 EBP: Staff must use gown and gloves during high contact resident care activities that could possibly to result in transfer of MDROs to hands and clothing of staff. Enhanced Barrier Precautions are recommended for residents known to be colonized or infected with a MDRO as well as those who are not confirmed to have an MDRO (e.g., residents with indwelling medical devices). Order Date: 07/28/25 Wound to sacrum, clean with N/S or wound cleanser, pat dry, apply Silvadene to wound bed, cover with 4x4 gauze, secure with foam dressing, change daily and PRN when soiled for Wound protection. Observation and interview on 07/28/25 at 12:08 PM revealed there was not a sign posted on the entrance door for Enhanced Barrier Precautions and there was no PPE in Resident #2's room. Hospice CNA was in the room giving the resident a bed bath. She had on an isolation gown and gloves. The resident was lying on her back on an air mattress. CNA D and CNA F entered the room to assist the Hospice CNA to turn and reposition the resident. CNA D put on gloves and did not put on a gown, assisted the Hospice CNA to turn the resident to her left side for the Hospice CNA to continue with the bed bath. Observation on 07/28/25 at 3:16 PM, with LVN ADON G revealed Resident #2 had stage IV pressure ulcer on sacral area and did not have EBP sign posted on the door to the entrance of the room and there was no PPE readily available by the entrance to the room and/or in the resident's room to use when providing direct care to the resident to prevent cross contamination and prevent the spread of infection. During an interview on 07/30/25 at 11:30 AM, with LVN A assigned to Resident #2 on the 6-2 shift, revealed resident had a stage IV pressure ulcer on her sacrum, and was supposed to be on EBP. She said, I do not recall if the EBP sign was posted on the entrance to the room and if PPE was kept by the entrance to the room on 07/28/25. She said that the ADON posted the EBP signs on the entrance door to the resident rooms and PPE was readily available for staff to use in the resident halls. She said, When residents are placed on EBP, the staff must use a gown and gloves when providing direct care to the resident to prevent cross contamination and prevent the spread of infection. Resident #3 Review of Resident #3's admission Record, dated 07/30/25, revealed a [AGE] year-old female who was admitted to the facility on [DATE]. Review of History & Physical dated 06/13/25 for Resident #3 revealed, Past Medical History: Lymphedema, heart failure, type 2 diabetes mellitus, chronic anemia, and chronic lower extremity wounds. Physical Examination: Alert and oriented x3. Right lower extremity below the knee amputation with Wound VAC (is a medical device that helps wound heal faster by using suction to remove fluid and promote new tissue. It's like a gentle vacuum cleaner for wounds, constantly removing excess fluid and debris while encouraging the wound to close) in place draining serial serosanguineous fluid. Dry dressing. Assessment: Sepsis secondary to right foot ulceration. Status post right below knee amputation on wound VAC. Bilateral venous stasis dermatitis, Morbid obesity, Hypertension, Diabetes mellitus type 2, Acute blood loss, Anemia status post BKA. Review of admission MDS dated [DATE] for Resident #3 revealed, indwelling catheter, occasionally incontinent of bowel; Active Diagnoses: Multidrug-Resistant Organism (MDRO) (is a germ that is resistant to many antibiotics), cellulitis (is a common bacterial infection of the deeper layers of the skin), osteomyelitis (is a bone infection), other major orthopedic surgery; surgical wound; surgical wound care. Review Care Plan for Resident #3 revised 06/13/25, revealed Resident had skin impairment to the Rt. BKA r/t surgical wound. Interventions: Interventions documented in part: Enhanced barrier precautions. Review of Physician Order Summary dated 07/30/25 for Resident #3 revealed, Order Date: 07/15/25 EBP: Staff must use gown and gloves during high contact resident care activities that could result in transfer of MDROs to hands and clothing of staff. Enhanced Barrier Precautions are recommended for residents known to be colonized or infected with a MDRO as well as those who are not confirmed to have an MDRO (e.g., residents with indwelling medical devices). Foley Catheter care every shift and prn. Gently cleanse the right BKA surgical wound with normal saline or wound cleanser, pat dry, apply oil emulsion, abdominal pad and wrap with kerlix daily. Observation on 7/28/25 at 12:18 PM, with Resident #3 revealed there was not a sign posted on the entrance door for Enhanced Barrier Precautions. The resident was alert, oriented to person, place, and time. She said that she needed total assistance with personal care. She said she was admitted with the indwelling catheter from the hospital. She said that she used a brief, because she was incontinent of bowel. She said she had her right lower leg amputated below the knee approximately 2 months ago. She said the treatment to her right leg was done daily by the Wound Care Nurse. Observation and interview on 07/28/25 at 2:26 PM, with LVN WCC, revealed Resident #3 was admitted from hospital with status post BKA to the right lower extremity and had an opened surgical wound. She said resident had an opened surgical wound on the right stump that was treated daily. She said the resident had an indwelling catheter and was incontinent of bowel. It was observed that the nurse put on an isolation gown and gloves prior to starting wound treatment. The nurse did not mention that resident was on EBP when she entered the resident's room. Observation and interview on 07/28/25 at 2:40 PM, with LVN ADON G, confirmed that there was no Enhanced Barrier Precaution signed on the entrance door to Resident #3's room while making rounds with the state surveyor. She said that she was responsible for posting The EBP signs on the doors for all residents that met the criteria for EBP, and the licensed staff were responsible for checking that EBP were posted on the entrance door to those residents that needed to be on EBP, to prevent the spread of MDROs and prevent cross contamination of uniforms and hands when direct care was provided. She said that she randomly checked during daily rounds that EBP signs were posted on the doors for those residents that were placed on EBP. She said that she was not aware that Resident #3 did not have an EBP sign posted on the door to the entrance to the room. She said that Resident #3 had a surgical wound due to BKA of the right lower extremity, an indwelling catheter and needed to be on EBP. During an interview on 07/28/25 at 3:04 PM, with LVN ADON G revealed that residents who had pressure ulcers, opened wounds, G-Tubes, or any type of indwelling tubes, history of MDROs were placed on Enhanced Barrier Precautions (EBP) to prevent cross contamination and the spread of infections. She said, I am responsible for posting the EBP signs on the entrance doors to the resident rooms and for making sure that PPE (gowns, gloves, and mask) are readily available for the staff to use when the staff provided direct care to the residents to prevent cross contamination and spread of infections. I know that several of the residents who have pressure ulcers, opened wounds, G-Tubes, or any type of indwelling tubes, history of MDROs, did not have the EBP signs posted on the doors because we ran out of signs and pending delivery. Observation and interview on 07/28/25 at 3:07 PM, with LVN ADON G revealed, Resident #3 had pressure ulcers, an indwelling catheter, and status post amputation of right lower extremity and had an opened surgical wound. She confirmed that there was not an EBP sign posted on the door to the entrance to the resident's room to prevent cross contamination and prevent the spread of infection. During an interview on 07/28/25 at 3:21 PM, with the DON in the presence of the Corporate Consultant said the LVN ADON G and licensed staff were responsible for posting the EBP signs on the door to the entrance to the resident rooms for those residents that meet the criteria listed on the EBP policy and procedure. The DON stated, The ADON just reported to me, that we did not have EBP signs posted on the entrance door to the rooms for Resident #2 and Resident #3 that met the criteria to be on EBP. The licensed staff and nursing administration are responsible for making sure that EBP signs are posted on the doors to prevent the spread of infection and cross contamination. I have not been checking that LVN ADON G and licensed staff are posting the EBP signs on the resident doors as needed. She said that this failure could result in the spread of infections. Interview on 07/29/25 at 1:38 PM, with LVN A on the 6-2 Shift, said that residents who had open wounds, pressure ulcers, indwelling catheters, or any type of tubes in their body were placed on EBP, to prevent contamination when staff provide direct care and prevent the spread of infection. She said the LVN ADON G, and licensed staff posted the EBP sign on the entrance door to the resident rooms and checked that PPE was readily available for the staff to use when they direct care was provided direct care to the residents who were on EBP. She said that she randomly checked during her rounds that the direct care staff put on a gown and glove when providing direct care to the resident who were on EBP. She said Resident #2 had a stage IV Pressure Ulcer of the sacrum and was on EBP. She said the staff had been trained to use a gown and gloves when direct care was provided for those residents that are on Enhanced Barrier Precautions (EBP), to prevent the risk of spread of infections. She said the nurses had been trained to report to the DON and ADONs if the direct care staff are not following the EBP policy and procedure. She said the license staff were responsible for checking that the EBP signs were posted, and the PPE was available for staff to use as needed when providing direct care to the residents. During an interview on 07/29/25 at 2:26 PM, with CNA D said that she forgot to use PPE on 07/28/25, when entered Resident #2's room, to assist the Hospice CNA to turn & reposition the resident so she could wash the resident's chest, arms and legs. She said, I only put on gloves and forgot to put on an isolation gown. She said they had been trained on EBP and use of isolation gowns and gloves to prevent cross-contamination and spread of infection when they had direct contact with those residents that had opened wounds, pressure ulcers, any type of ostomy, catheters, and certain infections. She said that she did not recall if the EBP sign was posted on the door to the entrance to the room on 07/28/25. During an interview on 07/29/25 at 3:30 PM with LVN ADON G revealed, she was assigned as the Infection Control Preventionist at the facility. She said the last time that the facility staff were trained on EBP was on 07/28/25. She said, I completed the in-service training after I made rounds with you on 07/28/25 and found that Resident #2 and Resident #3 did not have the EBP signs posted on the door to the entrance to the room. The EBP signs are posted on the entrance door for those residents that are placed on EBP, to remind the staff to use a gown, gloves, and goggles as needed when providing direct care to prevent cross contamination and spread of infection. She said, I am responsible for posting the EBP signs and for randomly checking that the EBP signs are posted on the doors as needed. During an observation on 07/29/25 at 4:03 PM, with the WCC revealed EBP sign was posted on the entrance door to the resident's room. The WCC entered that room and informed the resident that she was going to do her treatment to the right stump surgical wound. The WCC prepared the wound care supplies prior to entering resident's room. She washed her hands, put on a blue isolation gown and gloves. She placed an absorbent pad under the right stump, removed the Kerlix gauze, abdominal pad, and oil emulsion pads, and placed them in a plastic bag. She changed gloves and used hand sanitizer. She cleaned the wound with Dermal Wound Cleanser, pat dry the wound with gauze 4 x 4. The WCC changed gloves and applied oil emulsion dressing, covered with abdominal pad, and wrap the right stump with Kerlix gauze. She rolled the absorbent pad and placed in plastic bag, sealed the bag, changed her gloves, used hand sanitizer, and placed the plastic bag in the Red Biohazard bag on the side of the medication cart. She used hand sanitizer and wheeled her treatment cart down the hall. During an interview on 08/08/25 at 11:25 AM, with LVN H assigned to the 300 Hall on the 6-2 shift, revealed she checks during her rounds that EBP signs are posted on the entrance doors to resident's rooms and PPE is readily available for those residents with wounds and/or indwelling medical devices. She said that sometimes she finds during rounds that the EBP signs have fallen off the doors and will promptly re-post the signs. She said that EBPs remain in place for the duration of the resident's stay or until resolution of the wound or discontinuation of the indwelling medical device that places them at increased risk. During an interview on 08/08/25 at 11:29 AM, with CNA I assigned to the 200 Hall on the 6-2 shift, revealed that the nurses will notify them when a resident is placed on EBP. She said that residents that have opened wounds, catheters, and G-Tubes (is a tube inserted through the abdominal wall directly into the stomach. It's used when someone can't eat or drink enough by mouth to get the nutrients they need) are placed on EBP. She said that EBP signs are posted on the door to the entrance of the resident room, to remind them to put on an isolation gown and gloves when providing direct care to the residents to prevent cross contamination of their uniforms and prevent the spread of infection. She said, that sometimes the EBP fall off and are not posted on the doors and she will notify the nurse right away so they can repost the sign as soon as possible. During an observation and interview on 08/08/25 at 11:32 AM, with the DON, revealed the ADON assigned to infection control kept copies of the EBP signs at the nurse's stations for the nurses to post on the resident doors for after hour admissions and/or if EBP signs fell off the doors for those residents that needed to be placed on EBP precautions. She said that the ADON would follow up on the next working day, to check that EBP had been posted according to facility policy. During an observation and interview on 08/08/25 at 11:34 AM, with the Central Supply Clerk J, revealed that the ADON would send her a text message to inform her that they have a new admission that needs to be placed on EBP. She said she was responsible for placing and checking daily that PPE was readily available to the resident units and storage rooms in front of the nurse's station. She said she re-stocked the PPE on Fridays to make sure the staff had sufficient PPE readily available on the nursing units and storage room. She said the ADON posted the EBP signs on the entrance doors for those residents that needed to be placed on EBP precautions. She said that sometimes the EBP signs fall off the door and she will notify the nurse. She said that they had been trained on EBP, and that they needed to use the PPE when providing direct care to those residents with wounds, infections, foley catheters and G-Tube to prevent cross contamination and spread of infections. It was observed that the facility had an ample supply of PPE in the Central Supply room and storage room directly in front of the nurse's station. During an interview on 08/08/25 at 11:41 AM, with LVN H, revealed that the nurses and the ADON assigned to infection control checked during rounds that EBP were posted on the doors for those residents that had wounds or any type of indwelling medical device and to ensure that PPE was readily available on the unit for the direct care staff to use as needed. She said that he checked while he was doing his work in the hallway, that the CNAs were using the PPE when providing direct care to those residents who were on EBP to prevent cross contamination and spread of infections. Record review of facility's document titled In-Service Training completed on 07/08/25 on Enhanced Barrier Precautions presented to Licensed Staff and Certified Nurse Aides. Topic: Enhance Barrier Precaution Policy & Procedure. Record review of facility's document titled In-Service Training completed on 07/28/25 on Enhanced Barrier Precautions presented to Nursing Staff. Topic: Enhance Barrier Precaution Policy & Procedure. Record Review of facility's Policy & Procedure on Enhanced Barrier Precautions revised on February 2025 revealed, Policy Statement: Enhance Barrier Precautions (EBP) refer to an infection control intervention designed to reduce transmission of multidrug-resistant organisms that employs targeted gown and glove use during high contact resident care activities. Policy Interpretation and Implementation: Enhanced barrier precautions are used as an infection prevention and control intervention to reduce the transmission of multidrug resistant organisms to residents. EBPs employ targeted gown and glove use in addition to standard precautions during high contact resident care activities when contact precautions do not otherwise. Gloves and gowns are applied prior to performing the high contact resident care activities (as opposed to before entering the room). Personal protective equipment (PPE) is changed before caring for another resident. Face protection may be used if there is also a risk of splash or spray. Examples of high-risk contact resident care activities requiring the use of gowning gloves for EBPs Include: dressing, bathing/showering, transferring, providing hygiene, changing linens, changing brief or assisting with toileting, device care or use (central lines, urinary catheters, feeding tubes, tracheostomy/ventilators, etc.); and wound care (any skin opening requiring a dressing). EBPs are indicated (when contact precautions do not otherwise apply) for residents infected or colonized with a CDC targeted or epidemiologically important MDROs. EBP are indicated (when contact precautions do not otherwise apply) for residents with wounds and/or indwelling medical devices regardless of MDRO colonization. Wounds generally include chronic wounds. (ie., pressure ulcers, diabetic foot ulcers, venous stasis ulcers and unhealed surgical wounds), not shorter lasting wounds such as skin breaks or skin tears. Examples of indwelling medical devices include, but are not limited to, central vascular catheters (including hemodialysis catheters, peripherally inserted central catheters (PICCs), indwelling urinary catheters, feeding tubes and tracheostomy tubes. Peripheral Ivy catheters are not considered an indwelling medical device for purposes of EBPs. EBPs Remain in place for the duration of the resident stay or until resolution of the wound or discontinuation of the indwelling medical device that places them at increased risk. Staff are trained prior to caring for residents on EBPs. Signs are posted on the door or wall outside the resident room indicating the type of precaution and PPE required. PPE EBP's is available outside or inside the resident rooms. Residents, families and visitors are notified of the implementation of EBPs, throughout the facility.
Apr 2025
1 deficiency
CONCERN
(D)
📢 Someone Reported This
A family member, employee, or ombudsman was alarmed enough to file a formal complaint
Potential for Harm - no one hurt, but risky conditions existed
PASARR Coordination
(Tag F0644)
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 coordinate assessments in which a PE was not conducted after the pr...
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**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on interviews and record review the facility failed to coordinate assessments in which a PE was not conducted after the pre-admission screening indicated a yes for intellectual disability and resident review (PASARR) program under Medicaid for 1 (Resident #1) of 3 residents reviewed for PASRR.
The facility failed to submit a complete and accurate request for NFSS in the LTC online portal within 20 days after the IDT meeting on 05/28/24.
This failure could place residents who were PASRR positive at risk of not getting the PASARR services for a better quality of life and could lead to a decline in health.
Findings included:
Record review of Resident #1's face sheet dated 4/16/25 revealed a [AGE] year-old female who was admitted to the facility on [DATE] and readmitted on [DATE].
Record review of Resident #1's quarterly MDS assessment dated [DATE] revealed a BIMS score of 12, indicating her cognition was intact and diagnoses of cerebral palsy (a condition that affects muscle control, movement, and posture due to brain damage that usually happens before or during birth), non-Alzheimer's dementia (a type of memory loss or brain decline that isn't caused by Alzheimer's disease), hemiplegia (paralysis on one side of the body) and hemiparesis (with weakness on one side of the body), traumatic brain injury (a serious injury to the brain caused by a bump, blow, or jolt to the head), anxiety (feeling of constant worry, nervousness, or fear that doesn't go away), and depression (mood disorder that causes persistent sadness and loss of interest).
Record review of Resident #1's PASRR Level 1 Screening Summary dated 3/5/24 revealed Primary Diagnosis of Dementia - Marked Yes under Section C, field C0900; Indicators of Intellectual Disability - Marked Yes under C0200; Indicators of a Developmental Disability (Related Condition) - Marked Yes under C0300.
Record review of Resident #1's PASRR Evaluation dated 03/06/2024 revealed she met the criteria for IDD. Local Authority Compliance Confirmation was completed 03/08/2024 with comment PASRR services to include participation in IDT meetings, habilitation services, and monitoring for transition to the community if appropriate.
Record review of Resident #1' PCSP dated 5/28/24 revealed the team certified the need for habilitative therapies were discussed. Resident #1 was receiving OT services and was to be assessed for ST. Resident #1 had expressed a desire to continue OT within the facility and preferred receiving services in her room, as she did not want to be away from her room or wheelchair for extended periods. The DOR and habilitation coordinator indicated the resident had been receiving therapy and would begin ST to support continued functioning.
Record review of Resident #1's care plan revealed Resident #1 was identified as PASRR-positive due to an intellectual/developmental disability related to cerebral palsy. The care plan included maintaining the highest practicable level of wellbeing for the next 90 days. Interventions also included evaluating the need for habilitative services and/or durable medical equipment to support functional maintenance, and utilization of all available community resources.
Record review of Resident's #1's visit details report with date range 3/1/24-6/30/24 revealed she received a total of 29 documented OT sessions between March 1, 2024, and May 29, 2024 with no documented missed or incomplete visits and was scheduled for 9 speech therapy sessions between May 28, 2024, and June 14, 2024, of the 9 scheduled sessions, 8 were completed and 1 session (June 14, 2024) was marked as missed.
Record review of Resident #1's Occupational Therapy Discharge Summary with date of service range of 3/27/2024 - 5/29/2024 revealed she was discharged from services on 5/29/24 due to highest practical level achieved. She required continued support for ADLs but was appropriate for ongoing care at the LTC facility with 24-hour supervision and continued monitoring by nursing.
Record review of Resident #1's Speech Therapy Discharge Summary with date of service range of 5/28/24-6/13/24 revealed she was discharged from services on 6/13/24 due to refused treatment.
During an interview on 4/16/25 at 10:02 am, Resident #1 was alert and oriented ×4 but did not answer direct questions related to PASRR, OT, or ST.
During an interview on 4/16/25 at 1:43 pm, the DON stated Resident #1 was identified as a potential PASRR-positive case following the submission of a PL1, which triggered a portal alert to Emergence. The DON stated Local Mental Health Authority contacted the facility requesting Resident #1's demographics, diagnosis, medication list, and face sheet in order to conduct a PASRR evaluation. The DON stated that following Emergence's assessment, Resident #1 was determined to be PASRR-positive, requiring an annual IDT meeting with Local Mental Health Authority present, per regulation. The DON stated during the IDT, the LIDDA representative recommended habilitative services, including OT and ST. The DON stated an NFSS form was initiated to request authorization for therapy services to be reimbursed under PASRR. The DON stated the NFSS forms for Resident #1 were left in draft status and never submitted, resulting in no official authorization for payment, despite Resident #1 receiving therapy services consistently from March 2024 to June 2024. The DON stated the current MDS and therapy staff, including the DOR and MDS Coordinator, were not employed at the time and were unaware of why the forms were not submitted. The DON stated it was discovered that former staff may have assumed Resident #1's refusal of services negated the need for NFSS submission. The DON stated during the care plan meeting, all service sections related to specialized therapies and durable medical equipment were left blank. The DON stated the habilitation coordinator documented Resident #1 was already receiving OT and would be assessed for ST. The DON stated Resident #1 expressed a desire to continue residing in the facility and participating in OT. The DON stated the IDT meeting notes indicated the continuation of services already in place, rather than the initiation of new habilitation therapies, which likely contributed to the decision not to submit the NFSS form at that time. The DON stated a signature from the LIDDA representative dated 03/25/24 confirmed Resident #1's participation in the IDT and her request to continue OT, with ST to be initiated following that evaluation. The DON stated completion and submission of the NFSS form was a joint responsibility between the MDS Coordinator and therapy department. The DON stated the MDS Coordinator was responsible for completing the nursing section, while the respective therapy disciplines complete their sections based on IDT recommendations. The DON stated if only one therapy discipline was recommended, such as OT, only that section was completed before the form was submitted. The DON stated the NFSS was not submitted within the 20-day requirement; however, Resident #1 was already receiving therapy services as of March 2024. The DON stated there was no interruption in care and the failure to submit the NFSS did not pose a direct risk to Resident #1.
During an interview on 4/16/25 at 2:49 pm, the MDS Coordinator stated the PASRR process begins at admission, and they are responsible for initiating PASRR entries. The MDS Coordinator stated the initial form determined whether a resident was PASRR-negative or PASRR-positive. The MDS Coordinator stated PASRR-positive determinations typically involved residents with major mental illness or IDD diagnoses and triggered involvement from external agencies such as Emergence. The MDS Coordinator stated for PASRR-positive residents, quarterly care plan meetings and annual IDT meetings were conducted to reassess therapy needs and care planning. The MDS Coordinator stated the NFSS was generally completed after the annual IDT meeting and must be submitted within 20 days. The MDS Coordinator stated they were responsible for initiating and submitting the NFSS, while the therapy department completed the therapy-specific sections based on the IDT recommendations. The MDS Coordinator stated although employed during the March 2024 timeframe, they were not part of the MDS team and were not involved in the handling of the NFSS form. The MDS Coordinator stated the NFSS form for Resident #1 was not submitted but stated Resident #1 continued to receive therapy services throughout that period. The MDS Coordinator stated the failure to submit the NFSS within the 20-day period was a compliance issue affecting documentation and potential reimbursement but did not impact Resident #1's care.
During an interview on 4/16/25 at 3:46 pm, the DOR stated they were unaware of any NFSS submission delay following the May 2024 IDT meeting for Resident #1 and were unsure who was responsible at the time due to it being before her time working at the facility. The DOR stated Resident #1 received therapy services from 03/04/24 to 06/14/24, according to available documentation. The DOR stated that NFSS authorizations were typically approved for a six-month to one-year period and may be reviewed again during future IDT meetings. The DOR stated the NFSS was not submitted within the required 20-day timeframe following the May 2024 IDT meeting. The DOR stated there was no direct risk to Resident #1, as therapy services were habilitative in nature and aimed at maintaining her current level of functioning. The DOR stated Resident #1 received therapy throughout the identified period. The DOR stated the NFSS delay was a documentation compliance issue and did not impact care. The DOR stated ST services were discontinued on 06/14/24 due to refusals, and OT services were also discontinued at that time.
During an interview on 4/16/25 at 4/22/25 at 9:42 am, the Administrator deferred the PASSR related questions to the DON.
Record review if the facility's PASSR policy dated 06/2022 did not mention any 20-day deadline related to the NFSS (Nursing Facility Specialized Services) or submission timeframes for PASSR Level II evaluations or recommendations.
Record review of state agency website https://www.hhs.texas.gov/regulations/forms/2000-2999/form-2362-receipt-certification-a-qualified-rehabilitation-professional revealed: Requesting Habilitative Services: A speech, occupational or physical therapist may request habilitative therapies (physical, occupational or speech therapy) for a PASRR-positive person for up to 6 months at a time. Requests for Authorization of Specialized Services for Residents of Nursing Facilities Requesting Authorization of Habilitative Physical, Occupational or Speech Therapy. To request Habilitative therapies, nursing facility providers must submit a Nursing Facility Specialized Service (NFSS) form on the Texas Medicaid and Healthcare Partnership (TMHP) Long Term Care (LTC) Online Portal. Additionally, each request must be accompanied by corresponding signature sheets or other attachments. A licensed therapist must complete and submit the following for each type of habilitative therapy service requested. New Request: New (Submit initial assessment). An initial therapy assessment completed by a licensed therapist is required. The service request must include a treatment plan. PASRR NF Specialized Services (NFSS) - Therapy Signature Page (for Therapist, Referring Physician and Nursing Facility Administrator signatures).
Mar 2025
3 deficiencies
1 IJ
CRITICAL
(J)
📢 Someone Reported This
A family member, employee, or ombudsman was alarmed enough to file a formal complaint
Immediate Jeopardy (IJ) - the most serious Medicare violation
Accident Prevention
(Tag F0689)
Someone could have died · This affected 1 resident
**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, interview, and record review the facility failed to ensure each resident receives adequate supervision and...
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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 each resident receives adequate supervision and assistance devices to prevent accidents for 2 (Residents #2, and #3) of 3 residents reviewed for accidents and supervision.
The facility failed to provide supervision to prevent accidents for Residents #2 and #3 who exited the facility thru the front door on 2/26/25.
The noncompliance was identified as PNC . The IJ began on 2/26/25 and ended 2/27/25. The facility had corrected the noncompliance before the survey began.
These failures placed residents at risk of injuries.
Findings included:
Record review of Resident #2's face sheet dated 3/4/25 revealed a [AGE] year-old male who was admitted on [DATE] and readmitted [DATE] with diagnoses of Parkinson's disease with dyskinesia (an age-related degenerative brain condition, meaning it causes parts of your brain to deteriorate with involuntary movements of face, arms, or leg), muscle weakness, unspecified dementia, anxiety, repeated falls, restlessness and agitation, altered mental status, unspecified lack of coordination, attention and concentration deficit, cognitive communication deficit.
Record review of Resident #2's quarterly MDS dated [DATE] revealed a BIMS score of 01, indicating his cognition was severely impaired.
Record review of Resident #2's quarterly elopement assessment dated [DATE] revealed that the resident ambulated independently or with the use of a device. The resident frequently requested to go home and was severely impaired , as he never or rarely made decisions. He had a history of restless and wandering behavior. He had been residing in the facility for a year or more. The assessment indicated that he did not recognize stop lights or signs and was unaware of necessary precautions when crossing streets. Although he was able to state his name, he did not know the location of his current residence. He was able to recognize his physical needs.
Record review of Resident #2's care plan dated 2/8/24 revealed a focus area for elopement risk/wanderer related to resident wanders aimlessly with interventions that included distract resident from wandering by offering pleasant diversions, structured activities, food, conversation, television, books.
Record review of Resident #2's progress note written by LVN G dated 2/26/25 revealed at approximately 8:08 pm resident was found outside of the facility with another resident. Resident was brought back to the facility and given a head-to-toe assessment. Resident had no signs of injury and was put to bed. vital signs within normal limit. Respirations even and unlabored. DON notified.
Resident #3
Record review of Resident #3's face sheet dated 3/4/25 revealed a [AGE] year-old male who was admitted to the facility on [DATE] with diagnoses of speech and language deficits, cognitive communication deficit, dementia, anxiety, and paranoid schizophrenia.
Record review of Resident #3's quarterly MDS dated [DATE] revealed his cognition was moderately impaired, there was no BIMS score noted .
Record review of Resident #3's last quarterly elopement risk assessment dated [DATE] revealed that he ambulated independently or with the use of a device. His adjustment to the facility was marked by a confused expression when completing tasks. His cognitive skills were severely impaired. His behavior was noted as restlessness and wandering. He had been residing in the facility for one year or more. The assessment indicated that he did not recognize stop lights and did not know the precautions to take when crossing streets. Although he was able to state his name, he did not know the location of his current residence and did not recognize his physical needs.
Record review of Resident #3's progress note written by LVN F dated 2/26/25 revealed at around 8:08 pm resident was found wondering [sic] outside with another resident. Resident was brought back in, full head to toe assessment done, no visible injuries noted. vital signs within normal limit and respiration even and unlabored . Notified DON.
Observation of facility video revealed a total of 13 minutes from the time Residents #2 and #3 were seen walking out the front door to the time they were taken back inside the facility:
2/26/25 at 7:51 PM- Nurse station footage: Resident #2 and Resident #3 were walking towards the front door. A lab personnel passed by and opened the door for visitors. Both residents were seen crossing the first set of doors.
2/26/25 at 7:52 PM - Nurse station footage: Resident #2 and Resident #3 exit the front door. A lab personnel was noted walking back in.
2/26/25 at 7:53 PM- Camera from outside: captured Resident #2 and Resident #3 walking out the front door with a visitor holding the door open for them. Resident #2 had his walker, and both were wearing appropriate clothes and shoes. They both walked toward the left side of the building. Resident #2's walker appeared to get stuck in a dirt area, and the visitors assisted with Resident #2's walker .
2/26/25 at 7:53 PM - Camera from outside: The visitor walked away from Resident #2 and Resident #3, and they were no longer visible on camera.
2/26/25 at 8:07 PM - 8:08 PM - Both residents were assisted back into the facility.
During an interview and observation on 3/4/25 at 7:53 pm, CNA E stated that on 2/26/25 she was the assigned CNA for Resident #3. CNA E stated she had last seen Resident #2 and Resident #3 before her lunch break at around 7:30 pm. They were observed by CNA E walking down the 400 hall together, with no agitation or distress observed. CNA E stated Resident #2 and Resident #3 wandered and walked around the facility and tended to walk together; and Resident #3, who is severely cognitive impaired, followed Resident #2. CNA E stated she did not hear any exit door alarms go off. CNA E stated when her break was over around 8:00 pm she had noticed staff walking towards the front door and observed Resident #2 and Resident #3 being assisted back into the facility through the front door. CNA E traced the steps it appears Resident #2 and Resident #3 took during their elopement, with the Surveyor. CNA E and the Surveyor walked approximately 100 feet from the facility's front door, and no hazardous materials were noted on the concrete floor , there was good light due to light posts noted approximately 20 feet from where Resident #2 and Resident #3 were found.
During an observation and interview on 3/4/25 at 8:48 pm, Resident #2 was observed sitting at the edge of his bed, wearing appropriate shoes. He was alert and oriented to person only (AOx1) and appeared pleasantly confused, with no recollection of the elopement. He was unable to answer questions and showed no signs of distress.
During an observation and attempted interview on 3/5/25 at 9:05 am, revealed Resident #3 was observed walking down the 400 hall toward the door before turning around and walking back up the hallway. He appeared very confused and did not respond to any questions. Two CNAs were noted by the computer station in the middle of the hallway, observing him. No signs of distress were observed.
During an interview on 3/5/25 at 9:54 am, the DON stated that on 2/26/25 she received a text message from the Maintenance Director at 8:22 PM, informing her that two residents (Resident #2 and Resident #3) had been seen outside the facility. The DON stated she made her way to the facility and by the time she arrived, Dietary Aide D had already brought them back inside, and both residents were assessed with no injuries noted. The DON stated she notified the Administrator, and he took over the investigation. The DON stated she was later notified that the residents had exited the facility after a lab technician inadvertently held the front door open for them. The DON stated the next morning (2/27/25), the Maintenance Director reviewed security footage confirming that a lab technician and visitor had let Resident #2 and Resident #3 outside. The DON stated as a corrective action, the facility conducted an in-service training emphasizing that door codes should not be shared with any outside entities, including providers or family members. The DON stated the facility changed the door codes to prevent future unauthorized exits. The DON stated that both residents (Resident #2 and Resident #3) did not have any safety awareness and would have been at risk for falls and increased supervision was implemented.
During an interview on 3/5/25 at 10:33 am, the Maintenance Director stated he had been notified of Residents #2 and #3 elopement on 2/26/25 after hours. The Maintenance Director stated the following day on 2/27/25 he reviewed the camera and noticed that a lab technician had opened the door for two visitors around 7:53 PM after exiting the restroom. The Maintenance Director stated she inadvertently held the door open, allowing the visitors and Residents #2 and #3 to leave. The Maintenance Director stated he also reviewed footage from the front camera, which showed one of the visitors assisting Resident #2 with his walker, as it had gotten stuck. After a few minutes, they (visitors) walked away. The Maintenance Director stated he checked the alarm system and doors and confirmed there were no issues identified. The Maintenance Director stated in response to the incident, the facility conducted in-services on elopement response procedures, specifically regarding alarm door activations, and updated the door codes to prevent future unauthorized exits.
During an interview on 3/5/25 at 12:45 pm, Dietary Aide D stated that on the day of the incident (2/26/25), she had finished work around 8:05-8:10 PM. Dietary Aide D stated as she was driving off, she noticed Residents #2 and #3 near the flagpole in front of the premises (approximately 100-150 feet away from the front door). Dietary Aide D stated she immediately called Dietary Aide C, who was driving ahead of her, to confirm if she had seen them as well. Dietary Aide D stated Dietary Aide C did confirm seeing them, and she asked her to return to the facility to alert the staff while she stayed with the residents. Dietary Aide D stated it took a while to convince both residents to get into the car. Dietary Aide D stated that both residents appeared confused, with Resident #3 being the most confused of the two. Dietary Aide D stated she had recently attended an in-service about changing the door codes and was instructed not to share them.
During an interview with a Visitor on 3/25/25 at 12:36 pm she said she had received a call from the administrator, who inquired about the incident and educated her on the importance of safety for all residents. The administrator advised her not to allow residents to exit the facility, as it could pose a danger to them.
During an interview on 3/5/25 at 2:53 pm, the Administrator stated the DON notified him that Residents #2 and #3 had been found outside but had already returned to the facility. The Administrator stated the following morning, video footage revealed that a lab technician had opened the door for visitors, who then held it open, allowing Residents #2 and #3 to exit. The Administrator stated he contacted the lab facility to express concerns, and the lab stated they would address the issue with their staff. The Administrator stated the Maintenance Director was instructed to change all door codes, and in-service training was conducted.
During a follow up interview on 3/25/25 at 12:38 pm, the DON stated that because both residents (Residents #2 and #3) were ambulatory and tended to wander near the first set of front doors, they were flagged as an attempted elopement risk in order to increase supervision . There had been no reported attempts by either resident to actually open the door.
Record review of undated Elopement/Missing Resident policy revealed in part To provide an organized procedure to search for an eloped or missing resident. Staff will respond in timely and organized manner to search for a resident who has eloped or is missing. A- when a resident is noted missing from the room or unit, the staff shall inform the DON of the charge nurse in his/her absence, that we have an elopement or missing resident, the residents name, and the room number.
The facility completed the following corrective actions to address the non-compliance after the incident occurred but prior to the surveyor entering on 3/4/25.
Observations:
During an observation on 3/4/25 at 12:45 pm, there was a laminated sign on the front door that reflected: please do not open the door for anyone that is not in your party, as it may be a resident noted in red letters and highlighted in yellow for attention.
Observation on 3/4/25 at 8:48 pm, revealed CNA I pushed the front door, triggering the alarm. Four staff members at the nurses' station were observed getting up to respond.
Interviews from 3/4/25-3/7/25:
LVN A, CNA B, Dietary Aide D, CNA E, CNA I, CNA J, the Receptionist and Activities Director confirmed receiving in-services regarding door codes being changed with reinforcement of not providing the code to any outside entity and elopement policy that included increased supervision for high risk elopement residents.
Record review:
In-service to all staff: elopement policy (that included supervision) dated 2/26/25.
In-service to all staff: door codes dated 2/26/25- do not provide door code to anyone this includes lab techs, pharmacy, families, outside providers, etc., please notify Administrator, DON and ADON if code has been jeopardized.
CONCERN
(D)
📢 Someone Reported This
A family member, employee, or ombudsman was alarmed enough to file a formal complaint
Potential for Harm - no one hurt, but risky conditions existed
Report Alleged Abuse
(Tag F0609)
Could have caused harm · This affected 1 resident
**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on interview and record review, the facility failed to ensure all alleged violations involving abuse, neglect, exploitatio...
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**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on interview and record review, the facility failed to ensure all alleged violations involving abuse, neglect, exploitation or mistreatment, which included injuries of unknown source and misappropriation of resident property, were reported immediately, but no later than 2 hours after the allegation was made, if the events that caused the allegation involved abuse or resulted in serious bodily injury, or not later than 24 hours if the events that caused the allegation did not involve abuse and did not result in serious bodily injury, to the administrator of the facility and to other officials, which included the state survey agency, in accordance with State law through established procedures for 2 of 3 residents (Residents #2, and #3) reviewed for abuse and neglect.
The facility did not report to the State Survey Agency when Residents #2 and #3 eloped from the facility and staff were unaware the resident was missing.
This failure could place residents at risk of elopement or injury.
Findings include:
Resident #2
Record review of Resident #2's face sheet dated 3/4/25 revealed a [AGE] year-old male who was admitted on [DATE] and readmitted [DATE] with diagnoses of Parkinson's disease with dyskinesia(an age-related degenerative brain condition, meaning it causes parts of your brain to deteriorate), muscle weakness, unspecified dementia, anxiety, repeated falls, restlessness and agitation, altered mental status, unspecified lack of coordination, attention and concentration deficit, cognitive communication deficit.
Record review of Resident #2's quarterly MDS dated [DATE] revealed a BIMS score of 01, indicating his cognition was severely impaired.
Record review of Resident #2's quarterly elopement assessment dated [DATE] revealed that the resident ambulated independently or with the use of a device. The resident frequently requested to go home and was severely impaired, as he never or rarely made decisions. He had a history of restless behavior. He had been residing in the facility for a year or more. The assessment indicated that he did not recognize stop lights or signs and was unaware of necessary precautions when crossing streets. Although he was able to state his name, he did not know the location of his current residence. He was able to recognize his physical needs.
Record review of Resident #2's care plan dated 2/8/24 revealed a focus area for elopement risk/wanderer related to resident wanders aimlessly with interventions that included distract resident from wandering by offering pleasant diversions, structured activities, food, conversation, television, books.
Record review of Resident #2's progress note written by LVN G dated 2/26/25 revealed at approximately 8:08 pm resident was found outside of the facility with another resident. Resident was brought back to the facility and given a head-to-toe assessment. Resident had no signs of injury and was put to bed. vital signs within normal limit. Respirations even and unlabored. DON notified.
Resident #3
Record review of resident #3's face sheet dated 3/4/25 revealed a [AGE] year-old male who was admitted to the facility on [DATE] with diagnoses of speech and language deficits, cognitive communication deficit, dementia, anxiety, and paranoid schizophrenia.
Record review of resident #3's quarterly MDS dated [DATE] revealed his cognition was moderately impaired, there was no BIMS score noted.
Record review of resident #3's last quarterly elopement risk assessment dated [DATE] revealed that he ambulated independently or with the use of a device. His adjustment to the facility was marked by a confused expression when completing tasks. His cognitive skills were severely impaired. his behavior was noted as restlessness. He had been residing in the facility for one year or more. The assessment indicated that he did not recognize stop lights and did not know the precautions to take when crossing streets. Although he was able to state his name, he did not know the location of his current residence and did not recognize his physical needs.
Record review of resident #3's progress note written by LVN F dated 2/26/25 revealed at around 8:08 pm resident was found wondering[sic] outside with another resident. Resident was brought back in, full head to toe assessment done, no visible injuries noted. vital signs within normal limit and respiration even and labored. Notified DON.
Timeline based on evidence of video reviewed by the Surveyor: (total of 13 minutes from the time Resident #2 and #3 were seen walking out the front door and taken back inside the facility).
2/26/25 at approximately 7:30 PM- CNA E had last seen Resident #2 and Resident #3 walking down the hallway and did not observe any signs of agitation/distress. (per CNA E interview).
2/26/25 at 7:51 PM- Nurse station footage: Resident #2 and Resident #3 were walking towards the front door. A lab personnel passed by and opened the door for visitors. Both residents were seen crossing the first set of doors.
2/26/25 at 7:52 PM - Nurse station footage: Resident #2 and Resident #3 exit the front door. A lab personnel was noted walking back in.
2/26/25 at 7:53 PM- Camera from outside: captured Resident #2 and Resident #3 walking out the front door with a visitor holding the door open for them. Resident #2 had his walker, and both were wearing appropriate clothes and shoes. They both walk toward the left side of the building. Resident #2's walker appeared to get stuck in a dirt area, and the visitors assisted with Resident #2's walker.
2/26/25 at 7:53 PM - Camera from outside: The visitor walked away from the Resident #2 and Resident #3, and they were no longer visible on camera.
2/26/25 between 7:53 pm- 8:06 pm- Dietary Aide D identified Resident #2 and Resident #3 who were found 100-150 feet from the facility still within the premises. (per Dietary Aide D's interview).
2/26/25 at 8:07 PM - 8:08 PM - Both residents were assisted back into the facility.
During an interview and observation on 3/4/25 at 7:53 pm, CNA E stated that on 2/26/25 she was the assigned CNA for Resident #3. CNA E stated she had last seen Resident #2 and Resident #3 before her lunch break at around 7:30 pm. They were observed by CNA E walking down the 400 hall together, with no agitation or distress observed. CNA E stated Resident #2 and Resident #3 wandered and walked around the facility and tended to walk together; and Resident #3, who is severely cognitive impaired, followed Resident #2. CNA E stated she did not hear any exit door alarms go off. CNA E stated when her break was over around 8:00 pm she had noticed staff walking towards the front door and observed Resident #2 and Resident #3 being assisted back into the facility through the front door. CNA E traced Resident #2 and Resident #3's steps, it appears they took during their elopement, with the Surveyor. CNA E and the Surveyor walked approximately 100 feet from the facility's front door, and no hazardous materials were noted on the concrete floor, there was good light due to light posts noted approximately 20 feet from where Resident #2 and Resident #3 were found.
During an interview on 3/5/25 at 9:28 am, the NP stated he had been notified of Resident #2 and #3's elopements. The NP stated they were brought back into the facility and were safe. The NP stated he emphasized observations on residents and was told they were provided. The NP stated there were risks of falls and injuries but did not voice concerns due to how quickly the facility responded.
During an interview on 3/5/25 at 9:54 am, the DON stated that on 2/26/25 she received a text message from the Maintenance Director at 8:22 PM, informing her that two residents (Resident #2 and Resident #3) had been seen outside the facility by the flagpole approximately 100 feet from the front door. The DON stated she made her way to the facility and by the time she arrived, Dietary Aide D had already brought them back inside, and both residents were assessed with no injuries noted. The DON stated she notified the Administrator, and he took over the investigation. The DON stated she was later notified that the residents had exited the facility after a lab technician inadvertently held the front door open for them. The DON stated the next morning (2/27/25), Maintenance Director had reviewed security footage confirming that a lab technician and visitor had let Resident #2 and Resident #3 outside. The DON stated as a corrective action, the facility conducted an in-service training emphasizing that door codes should not be shared with any outside entities, including providers or family members. The DON stated the facility changed the door codes to prevent future unauthorized exits. The DON stated that based on policy, the facility should have reported the incident, but reporting decisions were ultimately made by the Administrator.
During an interview on 3/5/25 at 2:53 pm, the Administrator stated the DON informed him that Residents #2 and #3 had been found outside but had already returned to the facility. The Administrator stated the following morning, video footage revealed that a lab technician had opened the door for visitors, who then held it open, allowing Residents #2 and #3 to exit. The Administrator stated he contacted the lab facility to express concerns, and the lab stated they would address the issue with their staff. The Administrator stated the Maintenance Director was instructed to change all door codes, and in-service training was conducted. This incident was also not reported to the SO (State Office), as the residents had remained on the premises.
During an interview on 3/25/25 at 12:36 pm, the Visitor stated she had received a call from the Administrator, but did not remember the date and/or time, who inquired about the incident and educated her on the importance of safety for all residents. She stated the Administrator advised her not to allow residents to exit the facility, as it could pose a danger to them
During a follow up interview on 3/25/25 at 12:38 pm, the DON stated that because both residents (Residents #2 and #3) were ambulatory and tended to wander near the first set of front doors, they were flagged as an attempted elopement risk to increase supervision. There had been no reported attempts by either resident to actually open the door.
During a follow up interview on 3/25/25 at 2:18 pm, the Administrator stated that the residents (Resident #2 and #3) were not safe to be outside unsupervised. The Administrator stated that the situation was not considered neglect, as the residents were located within the premises in a short period of time and were found unharmed.
Record review of the facility's Elopements and Wandering Residents policy, dated 04/2022, revealed 4. Procedure for locating a missing resident: H. Appropriate reporting requirements to the State Survey agency shall be conducted.
Record review of the facility's Abuse, Neglect, and Exploitation dated 07/2022 revealed in part A. The facility will have written procedures that include:
1. Reporting of all alleged violations to the Administrator, state agency, adult protective services, and to all other required agencies (e.g., law enforcement when applicable) within specified timeframes:
a. Immediately, but not later than 2 hours after the allegation is made, if the events that cause the allegation involve abuse or result in serious bodily injury, or
b. Not later than 24 hours if the events that cause the allegation do not involve abuse and do not result in serious bodily injury.
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 F0726
(Tag F0726)
Could have caused harm · This affected 1 resident
**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, interview, and record review the facility failed to ensure nurse aides were able to demonstrate competency...
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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 nurse aides were able to demonstrate competency in skills and techniques to care for residents' needs for 1 (Resident #11) of 3 residents reviewed for accidents and supervision.
CNA B failed to place brakes on the mechanical lift when lifting Resident #11 from her bed and CNA J failed to place brakes on the wheelchair when the resident was lowered down.
These failures placed residents at risk of injuries.
The finidings include:
Record review of Resident #11's face sheet dated 3/7/25 revealed an [AGE] year-old female who was admitted to the facility on [DATE] with diagnoses of dementia, muscle weakness, and cognitive communication deficit.
Record review of Resident #11's quarterly MDS assessment dated [DATE] revealed her cognition was severely impaired and she was dependent on staff for transfers .
Record review of Resident #11's care plan dated 6/5/24 revealed a focus area for resident has an ADL self-care performance deficit with interventions that included requires mechanical lift with 2 staff assistance for transfers.
During an observation and attempted interview on 3/7/25 at 9:06 am, Resident #11 was in bed with a sling (device used for safe transfers) under her and did not respond to verbal questions. CNA B and CNA J washed their hands then assisted in transferring her from the bed to a wheelchair using a mechanical lift. CNA J positioned the sling, and CNA B operated the mechanical lift. CNA B lifted Resident #11 from the bed without engaging the mechanical lift breaks. CNA J did not engage the brakes on the wheelchair before positioning Resident #11 as she was being lowered down. The transfer was completed without incident or signs of distress.
During a joint interview on 3/7/25 at 9:12 am, CNA J and CNA B stated they last received training on mechanical lift transfers last year (2024) from the previous PT . CNA J stated that wheelchair brakes should be engaged before seating the resident but admitted she forgot, stating that the potential risk was movement and possible accidents. CNA B said that the mechanical lift brakes were only engaged when lowering a resident, not when lifting, as the base was positioned under the bed. CNA B stated that due to the resident's petite size, the lift did not move, minimizing the perceived risk.
During an interview on 3/7/25 at 11:03 am, the DON stated PT was responsible for mechanical lift training. The DON stated she expected the brakes to be engaged when lifting a resident from bed to prevent movement and the wheelchair brakes should be engaged before lowering the resident into the wheelchair to prevent falls due to chair movement.
During an interview on 3/7/25 at 1:12 pm, the DOR stated that the rehabilitation therapy department recently took over responsibility for mechanical lift transfers, which were previously managed by the former DOR. She stated CNAs were expected to secure the brakes on the lift before lifting the resident and secure the wheelchair brakes before lowering them to prevent movement. She also noted that failing to open the legs of the mechanical lift could cause it to rock sideways and lose balance, creating a safety risk. She was unsure how often training on mechanical lift transfers was conducted.
During an interview on 3/7/25 at 1:36 pm, the Administrator stated that both nursing and therapy were responsible for conducting mechanical lift transfer training upon hire and annually. He stated the mechanical lift transfers require two-person assistance but referred specific details to the nursing and therapy departments.
Record review of the facility's Safe Resident Handling/Transfers policy not dated revealed in part 15. Staff will perform mechanical lifts/transfers according to the manufacturer's instructions for use of the device.
Record review of mechanical lifts owner's manual, not dated, provided by the facility revealed it did not specify when to engage brakes during a transfer.
Dec 2024
3 deficiencies
CONCERN
(E)
📢 Someone Reported This
A family member, employee, or ombudsman was alarmed enough to file a formal complaint
Potential for Harm - no one hurt, but risky conditions existed
Resident Rights
(Tag F0550)
Could have caused harm · This affected multiple residents
**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, interviews and record review, the facility failed to ensure residents the right to reside and receive serv...
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**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, interviews and record review, the facility failed to ensure residents the right to reside and receive services in the facility with reasonable accommodation of resident needs and preferences for 1 (Residents #5) of 5 residents reviewed for call light button placement and 2 (Hall 300 and Hall 400) of 4 hallways reviewed for call light response.
The facility failed to ensure that Residents #5's call light was within reach on 12/10/24 and on 12/11/24, while he was in bed.
It was observed on 12/11/24, in Hall 300, room [ROOM NUMBER]'s call light was on for 26 minutes while facility staff walked up and down the hallway without entering the resident room.
It was observed on 12/11/24, in Hall 300, Room call light was on for 21 minutes while facility staff walked up and down the hallway without entering the resident room.
It was observed on 12/11/24, in Hall 400, room [ROOM NUMBER]'s call light was on for 31 minutes while no facility staff was seen in the hallway.
This failure put residents at risk of not being able to call for assistance when needed and injury.
Findings included:
Resident #5
Record review of Resident #5's face sheet dated 12/10/24, reveled, admission on [DATE] and re-admission on [DATE] to the facility diagnosed with muscle weakness, muscle wasting, lack of coordination, cognitive communication deficit, and repeated falls.
Record review of Resident #5's facility history and physical dated 11/06/24, revealed, a [AGE] year-old male diagnosed with Alzheimer Dementia and benign prostatic hypertrophy.
Record review of Resident #5's quarterly MDS dated [DATE], revealed, there was no BIMS score taken to measure the recall or daily cognition of the resident. Functional abilities revealed substantial/maximal assistance (Nursing staff does more than half the work) for rolling left or right in bed, sit to lying, lying to sitting on side of bed, sit to stand, chair to bed and bed to chair, and toilet transfer.
Record review of Resident #5's care plan dated 01/10/24, revealed, the resident had impaired thought process related to Alzheimer's Dementia. Provide me with a homelike environment. At risk of falls related to unaware of safety needs. Be sure call light was within reach and encourage me to use it for assistance as needed. Follow facility fall protocol. I need a safe environment free from clutter, a reachable call light. Floor mat beside my bed at all times when I'm in bed. ADLs requires extensive assistance x2 staff to turn and reposition when in bed for bed mobility.
During an interview on 12/10/24 at 11:03 AM, CNA F stated the call lights have to be within a reach of a resident. CNA F stated CNAs and nurses were responsible for ensuring the call lights were within reach of the resident. CNA F stated if the call light was not within reach and it was an emergency then the resident would not be able to call for help.
During an observation and interview on 12/10/24 at 2:00 PM, with Resident #5 and CNA B, Resident #5 was in his bed awake. Resident #5's call light was on the floor near his nightstand, 2 feet away from the resident. CNA B stated anytime the residents were in bed or in the room, the call light had to be within reach in case the resident needed something or in an emergency. CNA B stated not having the call light within reach the staff would not know what he wanted or in case of an emergency. CNA B extended the call light which touched the top left-hand corner of the bed where his pillow was. It was not long enough to reach Resident #5 while in bed. CNA B stated it needed to be longer. CNA B stated it was the responsibility of the CNAs to ensure that the call light was within reach.
During an interview on 12/10/24 at 2:19 PM, DON stated the call lights were to be within reach of the resident. The DON it was for the resident(s) to be able to call for help. The DON stated all staff were responsible for ensuring the call lights were within the residents' reach. The DON stated the risk of not having within the call light within reach was the resident would not be able to call for help.
During an observation and interview on 12/11/24 at 8:12 AM, with Resident #5 and LVN C. Resident #5's call light was on the floor. Resident #5 was in bed awake. Resident #5 when asked questions made some vocal sounds and moved his hands. LVN C stated the call light had to be within reach of Resident #5 and all the residents when in their rooms. LVN C stated the risk of not having the call light within reach would be the resident needing something.
Hallway 300
During an observation on 12/11/24 at 2:22 PM, in Hall 300, room [ROOM NUMBER]'s call light was on for 21 minutes while facility staff walked up and down the hallway without entering the resident room. Facility staff was observed going into the room and turning off the call light at 2:43 PM.
During an observation on 12/11/24 at 2:28 PM, in Hall 300, room [ROOM NUMBER]'s call light was on for 26 minutes while facility staff walked up and down the hallway without entering the resident room. Facility staff was observed going into the room and turning off the call light at 2:54 PM.
Hallway 400
During an observation on 12/11/24 at 2:12 PM, in Hall 400, room [ROOM NUMBER]'s call light was on for 31 minutes while no facility staff was seen in the hallway. At 2:43 PM, facility staff went into the room and call light was turned off.
During a follow-up interview on 12/12/24 at 10:52 AM, DON stated if a call light was turned on then the staff should be responsible as soon as possible. The DON stated the call lights should not be on no more than 30 minutes or an hour being considered unacceptable. The DON stated the resident could get agitated if they needed assistance and their needs would not be getting met. The DON stated the negative outcome would be their needs not getting met and agitation. The DON stated staff have been trained to respond to call lights and anyone can answer them. The DON stated there was not process during shift change when reports were being given to see who will be responding to the call lights. The DON stated it would definitely help if there was one.
Record review of the facility Call Lights: Accessibility and Timely Response policy not dated, revealed, Policy: The policy of this policy was to assure the facility was adequately equipped with a call light at each residents' bedside, toilet, and bathing facility to allow residents to call for assistance. Call lights will directly relay to a staff member or centralized location to ensure appropriate response.
All staff will be educated on ensuring resident access to the call light.
Staff will ensure the call light was within reach of the resident and secured as needed.
The call system will be accessible to residents while in their bed or other sleeping accommodations within the resident's room.
All staff members who see or hear an activated call light are responsible for responding.
Record review of the facility Resident Rights policy not dated, revealed, Policy: The facility will inform the resident both orally and in writing, in language that the resident understands, of his or her rights and all rules and regulations governing resident conduct and responsibilities during the stay in the facility.
The facility will ensure that all direct care and indirect care staff members, including contractors and volunteers, are educated on the rights of residents and the responsibility of the facility to properly care for its residents.
CONCERN
(E)
📢 Someone Reported This
A family member, employee, or ombudsman was alarmed enough to file a formal complaint
Potential for Harm - no one hurt, but risky conditions existed
Deficiency F0604
(Tag F0604)
Could have caused harm · This affected multiple residents
**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on the observation, interview, and record review, the facility failed to ensure residents had the right to be treated with...
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**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on the observation, interview, and record review, the facility failed to ensure residents had the right to be treated with respect and dignity, including the right to be free from any physical restraints imposed for purpose of discipline or convenicence, and not reuqired to treat the residnet's medical symptoms for 2 (Resident #4 and Residnet #5) of 5 residents reviewed for physical restraints.
The facility failed to ensure Resident #4 and Resident #5 were not restrained in bed by use of a fall mat being propped up next to the bed being held in place by faciliy furniture.
This failure could place residents at risk of unnecessary restriction of their freedom of movement, decrease quality of life, injury, suffocation, and falling.
Findings include:
Resident #4
Record review of Resident #4's face sheet dated 12/11/24, revealed, admission on [DATE] to the facility. Resident #4 was a [AGE] year-old female diagnosed with Dementia, muscle weakness (reduced muscle strength) muscle wasting (decrease in size and wasting of muscle tissue), attention (inattention (not being able to keep focus)) and concentration deficit (having trouble focusing your mind on a task for a sustained period of time), and cognitive deficit (someone has trouble thinking clearly, remembering things, making decisions, or understanding information).
Record review of Resident #4's admission MDS dated [DATE], revealed, a severely impaired cognition BIMS score of 3 to be able to recall or make daily decisions. Functional abilities revealed substantial/maximal assistance (Nursing staff does more than half the work) for rolling left or right in bed, sit to lying, lying to sitting on side of bed. Resident #4 was dependent (nursing staff does all the work) for sit to stand and chair to bed to chair transfer.
Record review of Resident #4's Order Recap dated 11/16/24, revealed, admitted to Skilled Services at facility due to Right femur fracture and traumatic hemorrhage of left cerebrum with loss of consciousness.'
Record review of Resident #4's Fall Risk Assessment generated by RN A dated 11/16/24, revealed, HIGH RISK. Level of consciousness/mental status was coded a 2 for Disoriented x3 (indicates that a patient was aware of three key aspects: who they are (person), where they are (place), and when it was (time) at all times. History of Falls (pasted 3 months) coded for 2 for 1-2 falls in pasted 3 months.
Record review of Resident #4's care plan dated 11/18/24, revealed, ADLs for bed mobility/transfers requiring assistances to maximize independence with turning and repositioning in bed. Had impaired cognitive function/dementia or impaired thought processes. Cue, reorient, and supervise as needed. At risk for falls related to dementia and history of falls. Follow facility fall protocol. Has a mood problem. Has impaired judgment or safety awareness.
observation of a photo of Resident #4 provided to state agency by unknown person not dated was reviewed on 12/09/24, revealed, Resident #4 was in bed lying on her rights side with her legs curled up against the blue fall mat. Resident #4 had her right arm up and her right hand over her eyes with her mouth open. Right hand was touching the blue fall mat. On the left side of the Resident #4's body were pillows, yellow blankets between the mattress and bar rail, and blankets rolled up and placed on her left side bed underneath the white sheet. The left side bed was close to the wall. On the other side 2 folded up blue fall mats were placed sideways standing up against Resident #4's bed with a chair and a nightstand pushed up against the 2 folded up blue mats.
During an interview on 12/11/24 at 4:15 PM, CNA K stated he walked into Resident #4's room on11/16/24 and saw the blue fall mat with a chair pushed up against it against Resident #4's bed while she was in it. CNA K stated he had only seen her and no other resident like this before. CNA K stated he immediately took down the fall mat and moved the chair. CNA K stated he had alerted LVN M about this and she had stated the fall mat against the Resident #4's bed pushed up against it by a chair was not supposed to happen as it was a restriction and considered a restraint. CNA K stated LVN M got up and went to check on Resident #4. CNA K stated he had not seen another fall mat placed against the resident's bed and the furniture pushed up against other than Resident #4. CNA K stated it did not look appropriate to him and that's why I took it down. CNA K stated CNA K stated this happened the first day she was admitted because she was too fidgety and tended to get up. CNA K stated restraints were not allowed but was not sure if it was a restraint. CNA K stated it could be seen as a restraint. CNA K stated the resident was at risk from falling off the bed. CNA K stated when he removed the fall mat and chair, Resident #4 was asleep in the bed.
During a telephone interview on 12/11/24 at 3:05 PM, LVN E stated she was the Weekend Supervisor working from 6AM-10PM. LVN E stated the fall mat was not used from preventing Resident #4 from getting out of bed. LVN E stated nurses do have it as an intervention for falls for residents' safety. LVN E stated chairs or other furniture could not be placed. LVN E stated resident safety comes first. LVN E stated her and LVN M used the fall mat as a precaution because Resident #4 was being combative. LVN E stated they put the fall mat in place for about 10-15 minutes while they got another bed to switch out that would lower down in position. LVN E stated it was on her admission on [DATE]. LVN E stated Resident #4 was a high risk for falls. LVN E stated that the bed mattress was placed on the floor along with Resident #4 who was laid on top of it, while they switched out the bed. LVN E stated it would not be appropriate placing a fall mat against the resident's bed with furniture pushed up against it. LVN E stated it would be considered a restraint. LVN E stated when they applied it and the way they had used it was used as an intervention to Resident #4 from falling. LVN E stated it was not done on any other residents.
During a follow-up interview on 12/12/24 at 11:15 AM, LVN E stated Resident #4 was combative and as per policy they could use the fall mat as an intervention as the least restrictive. LVN E stated Resident #4's bed was placed to the corner next to the wall near the bathroom. LVN E stated the bed rail created a gap between the bed and the wall and thought Resident #4 might have a fall in between the gap. LVN E placed pillows and blankets to keep Resident #4 from falling on the right side of the bed closet to the wall and on the other side a fall mat was placed leaning against Resident #4's bed. LVN E stated Resident #4 was able to yell out and move and LVN M and her did not tie her down. LVN E stated this took around 10 minutes while they got the other bed and conducted the switch of beds for Resident #4. LVN E stated Resident #4 was not along and had LVN M (the Floor Nurse for that hallway)in the room with CNA J working in and out of the room. LVN E stated it was an intervention for Resident #4.
During an interview on 12/11/24 at 4:34 PM, LVN M stated residents nor staff have reported to her staff placing fall mats against residents' beds with furniture pushed up against them. LVN M stated that was not appropriate as it was a restraint. LVN M stated Resident #4 during admission was impulsive and wanted to dance. LVN M stated Resident #4 was a high fall risk. LVN M stated Resident #4's bed was not changed out that day. LVN M stated her and LVN E did not place Resident #4 on the floor on top of her mattress. LVN M stated she had no reason to do that, and the facility staff know this. LVN E stated it was a dignity issue. LVN M stated she had not seen a fall mat placed against Resident #4's bed with furniture pushed up against it. LVN M stated she had been trained on Restraints and would consider it a restraint.
During an interview on 12/11/24 at 4:28 PM, with CNA J, he stated he worked on 11/16/24 and 11/23/24 on the weekend. CNA J stated he had not seen nor heard from staff or /residents saying staff were placing fall mats against residents' beds with furniture pushed up against it. CNA J stated this would not be right and would be a restraint. CNA J stated he had been trained on Abuse, Neglect, and Exploitation and Restraints.
During an interview on 12/10/24 at 2:19 PM, the DON stated she had not seen fall mats being placed against resident beds and held up by furniture. The DON stated that would be inappropriate and would be considered a restraint. The DON stated when Resident #4 got to the facility she was very anxious, but it would not warrant having the fall mats placed against the bed with furniture propped up against it.
During an interview on 12/10/24 at 2:42 PM, the Administrator stated no one had reported to him that a fall mat or nursing tray tables were being placed against the bed of a resident who was on the bed. The Administrator stated if the staff did that, he would think it was to prevent a fall. The Administrator stated he would think there would be better ways like placing the bed in the lowest position instead of placing the fall mat against the bed with furniture push up against the fall mat. The Administrator stated he would consider it a restraint at the minimum. The Administrator stated this was not acceptable practice and not acceptable because the facility has better interventions.
During an interview on 12/11/24 at 8:20 AM, Resident #4, stated she did not remember anything. Resident #4 looked downwards and did not say anything else.
During an interview on 12/12/24 at 8:35 AM, the DOR stated Resident #4 was weak. The DOR stated Resident #4 for bed mobility was max to moderate assistance to max assistance. The DOR stated if a fall mat was placed against the resident's bed and had furniture up against it then Resident #4 might not be strong enough to move it out of the way. The DOR stated it would be a hazard.
During an interview on 12/12/24 at 8:58 AM, NP D stated Resident #4 was a high risk for falls. NP D stated it had not been reported to him that the fall mats were being used to be placed against Resident #4's bed and had furniture pushed up against it. NP D stated the fall mat would be used as an intervention to prevent falls but would have to be laid on the floor next to the resident's bed. NP D stated having the fall mat pushed up against the resident's bed with furniture propped up against it was not allowed to happen. NP D stated he had never seen that before and was a risk as it was obstacle to the resident. NP D stated he was going to talk to the facility MD regarding the allegation as it was concerning. NP D stated Resident #4 might be able to move the objects out of the way.
Resident #5
Record review of Resident #5's face sheet dated 12/10/24, reveled, admission on [DATE] and re-admission on [DATE] to the facility diagnosed with muscle weakness, muscle wasting, lack of coordination, cognitive communication deficit, and repeated falls.
Record review of Resident #5's facility history and physical dated 11/06/24, revealed, a [AGE] year-old male diagnosed with Alzheimer Dementia and benign prostatic hypertrophy.
Record review of Resident #5's quarterly MDS dated [DATE], revealed, there was no BIMS score taken to measure the recall or daily cognition of the resident. Functional abilities revealed substantial/maximal assistance (Nursing staff does more than half the work) for rolling left or right in bed, sit to lying, lying to sitting on side of bed, sit to stand, chair to bed and bed to chair, and toilet transfer.
Record review of Resident #5's care plan dated 01/10/24, revealed, had swallowing problem and at risk for aspiration, aspiration pneumonia and upper respiratory infections. Maintain HOB elevated to 30-45 degrees angle during feedings. Had impaired thought process related to Alzheimer's Dementia. Provide me with a homelike environment. At risk of falls related to unaware of safety needs. Be sure call light was within reach and encourage me to use it for assistance as needed. Follow facility fall protocol. I need a safe environment free from clutter, a reachable call light. Floor mat beside my bed at all times when I'm in bed. ADLs requires extensive assistance x2 staff to turn and reposition when in bed for bed mobility.
Observation of a photo of Resident #5 provided to state agency by unknown person not dated but reviewed on 12/09/24, revealed, Resident #5 was in bed lying on his back with his left hand up. To the right side of Resident #5 was a blue fall mat placed sideways standing up against his bed, while on the left side of the bed was the room wall. Pushed up against the blue fall mat was a chair and a nurse's tray table.
During an observation and interview on 12/10/24 at 2:00 PM, with Resident #5 and CNA B. Resident #5 was in his bed awake. Resident #5 did not have a fall mat placed next to his bed. When Resident #5 was asked questions, he would just look and move his hands. CNA B stated when Resident #5 was in bed that the fall mat should be placed in case, he had a fall to prevent an injury. CNA B stated it was the responsibility of the CNAs to ensure the fall mat was placed.
During an interview on 12/10/24 at 2:19 PM, the DON stated the fall mat against Resident #5's bed pushed against by furniture was inappropriate. The DON stated she considered it a restraint. The DON stated Resident #5 was a high fall risk and his mat should be placed on the floor next to his bed. The DON stated staff understood they should not be doing that.
During a follow-up interview on 12/12/24 at 11:15 AM, LVN E stated she would not know why anyone would place a fall mat against Resident #5's bed with furniture pushed against it.
During a follow up interview on 12/12/24 at 8:35 AM, the DOR stated Resident #5 had been on case load for therapy. The DOR stated Resident #5 was total dependence (nursing staff assist with total assistance) for ADLs . The DOR stated Resident #5 was fidgety (constantly making small, restless movements with your body). The DOR stated if a fall mat was placed against the resident's bed and had furniture up against it then Resident #5 would not be able to move it out of the way because he was not strong enough to be able too. DOR stated it would be a hazard.
During an interview on 12/12/24 at 8:58 AM NP D stated Resident #5 was very confused but managed to get out of bed by himself. NP D stated Resident #5 had never been verbal with him. NP D stated if the fall mat was placed against the Resident #5's bed with propped furniture against it then Resident #5 would not have the strength to move the objects out of the way.
Record review of the Provider Investigation Report dated 11/25/24, for Resident #4 and Resident #5, revealed, Incident Date: 11/16/24. Description of allegation: On 11/16/24, Resident #4 was admitted to the facility for long term care. Resident #5 has been admitted to the facility since around 2022. On 11/16/24, in the evening, LVN E, restrained resident #4 and Resident #5 in their beds with fall mats held against the bed by furniture. The residents had a rolled-up blanket placed under their fitted sheet to further restrain them. This was reported to the Administrator. LVN E stated this was her solution to prevent providing one to one supervision to the resident who have been Fidgety (jittery, restless, or anxious). On 11/23/24, the residents were restrained in their beds again.
Record review of LVN E's Timesheet dated 11/16/24, revealed, LVN E working from 6AM-9:08 PM. On 11/23/24- worked 2:01PM-10:05PM. LVN E was not on any floor schedule as she was the Weekend Supervisor.
Record review of LVN M's Timesheet dated 11/16/24, revealed, LVN M working from 6:12 AM-10:50PM.
Record review of LVN M's floor schedule dated 11/16/24, revealed, working 100 hall from 6AM to 10PM. On 11/23/24 - worked 100 hall from 6AM to 10PM.
Record review of CNA J's Time sheet dated 11/23/24, revealed, CNA J working from 6:06AM-10:08PM. On 11/23/24 - worked 6:09AM-2:03PM.
Record review of CNA J's floor schedule 11/16/24, revealed, working 100 hall from 6AM to 10PM. On 11/23/24- worked 100 hall from 10:15AM-2PM.
Record review of CNA K's Timesheet dated 11/16/24, revealed, CNA K working from 6:17AM-10:08PM. On 11/23/24- worked 6:18PM-10:09 PM.
Record review of CNA K's floor schedule dated 11/16/24, revealed, working 100 hall from 10:30AM - 7:30 PM. On 11/23/24- worked 100 hall from 10AM to 7PM.
Record review of the facility Incidents and Accidents policy noted dated, revealed, Policy: It was the policy of this facility for staff to utilize) specify risk management system/tools used) to report, investigate, and review any accidents or incidents that occur or allegedly occur, on facility property and may involve or allegedly involve a resident.
Accident - refers to any unexpected or unintentional incident, which results or may result in injury or illness to a resident.
Incident was defined as an occurrence or situation that was not consistent with the routine care of a resident or with the routine operation of the organization.
If an incident/accident was witnessed by other people, the supervisor or designee will obtain written documentation of the event by those that witnessed it and submit that documentation to the Director of Nursing and or Administrator.
Record review of the facility Fall Prevention Program policy not dated, revealed, Policy: Each resident will be assessed for fall risk and will receive care and services in accordance with their individual level of risk to minimize the likelihood of falls.
High Risk Protocols: The resident will be placed on the facility's Fall Prevention Program.
Provide additional interventions as directed by the resident's assessment, including but not limited to: Assistive devices.
CONCERN
(E)
📢 Someone Reported This
A family member, employee, or ombudsman was alarmed enough to file a formal complaint
Potential for Harm - no one hurt, but risky conditions existed
Accident Prevention
(Tag F0689)
Could have caused harm · This affected multiple residents
**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on the observation, interview, and record review, the facility failed to ensure that the residents environment remains fre...
Read full inspector narrative →
**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on the observation, interview, and record review, the facility failed to ensure that the residents environment remains free of accidents hazards as possible and each resident receives adequate supervision to prevent accidents for 2 (Resident #4 and Resident #5) of 2 residents reviewed for accidents and supervision.
The facility failed to put appropriate fall precautions in place when staff blocked residnets in bed with furniture and fall mats for Resident #4 and Resident #5.
Resident #4 was in bed lying on her rights side with her legs curled up against the blue fall mat. Resident #4 had her right arm up and her right hand over her eyes with her mouth open. Right hand was touching the blue fall mat. On the left side of the Resident #4's body were pillows, yellow blankets between the mattress and bar rail, and blankets rolled up and placed on her left side bed underneath the white sheet. The left side bed was close to the wall. On the other side 2 folded up blue fall mats were placed sideways standing up against Resident #4's bed with a chair and a nightstand pushed up against the 2 folded up blue mats.
Resident #5 was in bed lying on his back with his left hand up. To the right side of Resident #5 was a blue fall mat placed sideways standing up against his bed, while on the left side of the bed was the room wall. Pushed up against the blue fall mat was a chair and a nurse's tray table.
On 12/10/24, It was observed that Resident #4 was lying in bed with no fall mat placed on the floor next to her bed.
On 12/10/24, It was observed that Resident #5 was lying down in bed with no fall mat placed on the floor next to his bed.
This failure could place residents at risk of decrease quality of life, injury, suffocation, and falling.
Findings include:
Resident #4
Record review of Resident #4's face sheet dated 12/11/24, revealed, admission on [DATE] to the facility. Resident #4 was a [AGE] year-old female diagnosed with Dementia, muscle weakness (reduced muscle strength) muscle wasting (decrease in size and wasting of muscle tissue), attention (inattention (not being able to keep focus)) and concentration deficit (having trouble focusing your mind on a task for a sustained period of time), and cognitive deficit (someone has trouble thinking clearly, remembering things, making decisions, or understanding information).
Record review of Resident #4's admission MDS dated [DATE], revealed, a severely impaired cognition BIMS score of 3 to be able to recall or make daily decisions. Functional abilities revealed substantial/maximal assistance (Nursing staff does more than half the work) for rolling left or right in bed, sit to lying, lying to sitting on side of bed. Resident #4 was dependent (nursing staff does all the work) for sit to stand and chair to bed to chair transfer.
Record review of Resident #4's Order Recap dated 11/16/24, revealed, admitted to Skilled Services at facility due to Right femur fracture and traumatic hemorrhage of left cerebrum with loss of consciousness.'
Record review of Resident #4's Fall Risk Assessment generated by RN A dated 11/16/24, revealed, HIGH RISK. Level of consciousness/mental status was coded a 2 for Disoriented x3 (indicates that a patient was aware of three key aspects: who they are (person), where they are (place), and when it was (time) at all times. History of Falls (pasted 3 months) coded for 2 for 1-2 falls in pasted 3 months.
Record review of Resident #4's care plan dated 11/18/24, revealed, ADLs for bed mobility/transfers requiring assistances to maximize independence with turning and repositioning in bed. Had impaired cognitive function/dementia or impaired thought processes. Cue, reorient, and supervise as needed. At risk for falls related to dementia and history of falls. Follow facility fall protocol. Has a mood problem. Has impaired judgment or safety awareness.
observation of a photo of Resident #4 provided to state agency by unknown person not dated was reviewed on 12/09/24, revealed, Resident #4 was in bed lying on her rights side with her legs curled up against the blue fall mat. Resident #4 had her right arm up and her right hand over her eyes with her mouth open. Right hand was touching the blue fall mat. On the left side of the Resident #4's body were pillows, yellow blankets between the mattress and bar rail, and blankets rolled up and placed on her left side bed underneath the white sheet. The left side bed was close to the wall. On the other side 2 folded up blue fall mats were placed sideways standing up against Resident #4's bed with a chair and a nightstand pushed up against the 2 folded up blue mats.
During an interview on 12/11/24 at 4:15 PM, CNA K stated he walked into Resident #4's room on11/16/24 and saw the blue fall mat with a chair pushed up against it against Resident #4's bed while she was in it. CNA K stated he had only seen her and no other resident like this before. CNA K stated he immediately took down the fall mat and moved the chair. CNA K stated he had alerted LVN M about this and she had stated the fall mat against the Resident #4's bed pushed up against it by a chair was not supposed to happen as it was a restriction and considered a restraint. CNA K stated LVN M got up and went to check on Resident #4. CNA K stated he had not seen another fall mat placed against the resident's bed and the furniture pushed up against other than Resident #4. CNA K stated it did not look appropriate to him and that's why I took it down. CNA K stated CNA K stated this happened the first day she was admitted because she was too fidgety and tended to get up. CNA K stated restraints were not allowed but was not sure if it was a restraint. CNA K stated it could be seen as a restraint. CNA K stated the resident was at risk from falling off the bed. CNA K stated when he removed the fall mat and chair, Resident #4 was asleep in the bed.
During a telephone interview on 12/11/24 at 3:05 PM, LVN E stated she was the Weekend Supervisor working from 6AM-10PM. LVN E stated the fall mat was not used from preventing Resident #4 from getting out of bed. LVN E stated nurses do have it as an intervention for falls for residents' safety. LVN E stated chairs or other furniture could not be placed. LVN E stated resident safety comes first. LVN E stated her and LVN M used the fall mat as a precaution because Resident #4 was being combative. LVN E stated they put the fall mat in place for about 10-15 minutes while they got another bed to switch out that would lower down in position. LVN E stated it was on her admission on [DATE]. LVN E stated Resident #4 was a high risk for falls. LVN E stated that the bed mattress was placed on the floor along with Resident #4 who was laid on top of it, while they switched out the bed. LVN E stated it would not be appropriate placing a fall mat against the resident's bed with furniture pushed up against it. LVN E stated it would be considered a restraint. LVN E stated when they applied it and the way they had used it was used as an intervention to Resident #4 from falling. LVN E stated it was not done on any other residents.
During a follow-up interview on 12/12/24 at 11:15 AM, LVN E stated Resident #4 was combative and as per policy they could use the fall mat as an intervention as the least restrictive. LVN E stated Resident #4's bed was placed to the corner next to the wall near the bathroom. LVN E stated the bed rail created a gap between the bed and the wall and thought Resident #4 might have a fall in between the gap. LVN E placed pillows and blankets to keep Resident #4 from falling on the right side of the bed closet to the wall and on the other side a fall mat was placed leaning against Resident #4's bed. LVN E stated Resident #4 was able to yell out and move and LVN M and her did not tie her down. LVN E stated this took around 10 minutes while they got the other bed and conducted the switch of beds for Resident #4. LVN E stated Resident #4 was not along and had LVN M (the Floor Nurse for that hallway)in the room with CNA J working in and out of the room. LVN E stated it was an intervention for Resident #4.
During an interview on 12/11/24 at 4:34 PM, LVN M stated residents nor staff have reported to her staff placing fall mats against residents' beds with furniture pushed up against them. LVN M stated that was not appropriate as it was a restraint. LVN M stated Resident #4 during admission was impulsive and wanted to dance. LVN M stated Resident #4 was a high fall risk. LVN M stated Resident #4's bed was not changed out that day. LVN M stated her and LVN E did not place Resident #4 on the floor on top of her mattress. LVN M stated she had no reason to do that, and the facility staff know this. LVN E stated it was a dignity issue. LVN M stated she had not seen a fall mat placed against Resident #4's bed with furniture pushed up against it. LVN M stated she had been trained on Restraints and would consider it a restraint.
During an interview on 12/11/24 at 4:28 PM, with CNA J, he stated he worked on 11/16/24 and 11/23/24 on the weekend. CNA J stated he had not seen nor heard from staff or /residents saying staff were placing fall mats against residents' beds with furniture pushed up against it. CNA J stated this would not be right and would be a restraint. CNA J stated he had been trained on Abuse, Neglect, and Exploitation and Restraints.
During an observation on 12/10/24 at 8:24 AM, Resident #4 was lying in bed asleep with no fall mat placed on the floor next to the bed. The fall mat was placed over on the dresser of the roommate.
During an interview on 12/10/24 at 2:19 PM, the DON stated she had not seen fall mats being placed against resident beds and held up by furniture. The DON stated that would be inappropriate and would be considered a restraint. The DON stated when Resident #4 got to the facility she was very anxious, but it would not warrant having the fall mats placed against the bed with furniture propped up against it.
During an interview on 12/10/24 at 2:42 PM, the Administrator stated no one had reported to him that a fall mat or nursing tray tables were being placed against the bed of a resident who was on the bed. The Administrator stated if the staff did that, he would think it was to prevent a fall. The Administrator stated he would think there would be better ways like placing the bed in the lowest position instead of placing the fall mat against the bed with furniture push up against the fall mat. The Administrator stated he would consider it a restraint at the minimum. The Administrator stated this was not acceptable practice and not acceptable because the facility has better interventions.
During an interview on 12/11/24 at 8:20 AM, Resident #4, stated she did not remember anything. Resident #4 looked downwards and did not say anything else.
During an interview on 12/12/24 at 8:35 AM, the DOR stated Resident #4 was weak. The DOR stated Resident #4 for bed mobility was max to moderate assistance to max assistance. The DOR stated if a fall mat was placed against the resident's bed and had furniture up against it then Resident #4 might not be strong enough to move it out of the way. The DOR stated it would be a hazard.
During an interview on 12/12/24 at 8:58 AM, NP D stated Resident #4 was a high risk for falls. NP D stated it had not been reported to him that the fall mats were being used to be placed against Resident #4's bed and had furniture pushed up against it. NP D stated the fall mat would be used as an intervention to prevent falls but would have to be laid on the floor next to the resident's bed. NP D stated having the fall mat pushed up against the resident's bed with furniture propped up against it was not allowed to happen. NP D stated he had never seen that before and was a risk as it was obstacle to the resident. NP D stated he was going to talk to the facility MD regarding the allegation as it was concerning. NP D stated Resident #4 might be able to move the objects out of the way.
Resident #5
Record review of Resident #5's face sheet dated 12/10/24, reveled, admission on [DATE] and re-admission on [DATE] to the facility diagnosed with muscle weakness, muscle wasting, lack of coordination, cognitive communication deficit, and repeated falls.
Record review of Resident #5's facility history and physical dated 11/06/24, revealed, a [AGE] year-old male diagnosed with Alzheimer Dementia and benign prostatic hypertrophy.
Record review of Resident #5's quarterly MDS dated [DATE], revealed, there was no BIMS score taken to measure the recall or daily cognition of the resident. Functional abilities revealed substantial/maximal assistance (Nursing staff does more than half the work) for rolling left or right in bed, sit to lying, lying to sitting on side of bed, sit to stand, chair to bed and bed to chair, and toilet transfer.
Record review of Resident #5's care plan dated 01/10/24, revealed, had swallowing problem and at risk for aspiration, aspiration pneumonia and upper respiratory infections. Maintain HOB elevated to 30-45 degrees angle during feedings. Had impaired thought process related to Alzheimer's Dementia. Provide me with a homelike environment. At risk of falls related to unaware of safety needs. Be sure call light was within reach and encourage me to use it for assistance as needed. Follow facility fall protocol. I need a safe environment free from clutter, a reachable call light. Floor mat beside my bed at all times when I'm in bed. ADLs requires extensive assistance x2 staff to turn and reposition when in bed for bed mobility.
Observation of a photo of Resident #5 provided to state agency by unknown person not dated but reviewed on 12/09/24, revealed, Resident #5 was in bed lying on his back with his left hand up. To the right side of Resident #5 was a blue fall mat placed sideways standing up against his bed, while on the left side of the bed was the room wall. Pushed up against the blue fall mat was a chair and a nurse's tray table.
During an observation and interview on 12/10/24 at 2:00 PM, with Resident #5 and CNA B. Resident #5 was in his bed awake. Resident #5 did not have a fall mat placed next to his bed. When Resident #5 was asked questions, he would just look and move his hands. CNA B stated when Resident #5 was in bed that the fall mat should be placed in case, he had a fall to prevent an injury. CNA B stated it was the responsibility of the CNAs to ensure the fall mat was placed.
During an interview on 12/10/24 at 2:19 PM, the DON stated the fall mat against Resident #5's bed pushed against by furniture was inappropriate. The DON stated she considered it a restraint. The DON stated Resident #5 was a high fall risk and his mat should be placed on the floor next to his bed. The DON stated staff understood they should not be doing that.
During a follow-up interview on 12/12/24 at 11:15 AM, LVN E stated she would not know why anyone would place a fall mat against Resident #5's bed with furniture pushed against it.
During a follow up interview on 12/12/24 at 8:35 AM, the DOR stated Resident #5 had been on case load for therapy. The DOR stated Resident #5 was total dependence (nursing staff assist with total assistance) for ADLs . The DOR stated Resident #5 was fidgety (constantly making small, restless movements with your body). The DOR stated if a fall mat was placed against the resident's bed and had furniture up against it then Resident #5 would not be able to move it out of the way because he was not strong enough to be able too. DOR stated it would be a hazard.
During an interview on 12/12/24 at 8:58 AM NP D stated Resident #5 was very confused but managed to get out of bed by himself. NP D stated Resident #5 had never been verbal with him. NP D stated if the fall mat was placed against the Resident #5's bed with propped furniture against it then Resident #5 would not have the strength to move the objects out of the way.
Record review of the Provider Investigation Report dated 11/25/24, for Resident #4 and Resident #5, revealed, Incident Date: 11/16/24. Description of allegation: On 11/16/24, Resident #4 was admitted to the facility for long term care. Resident #5 has been admitted to the facility since around 2022. On 11/16/24, in the evening, LVN E, restrained resident #4 and Resident #5 in their beds with fall mats held against the bed by furniture. The residents had a rolled-up blanket placed under their fitted sheet to further restrain them. This was reported to the Administrator. LVN E stated this was her solution to prevent providing one to one supervision to the resident who have been Fidgety (jittery, restless, or anxious). On 11/23/24, the residents were restrained in their beds again.
Record review of LVN E's Timesheet dated 11/16/24, revealed, LVN E working from 6AM-9:08 PM. On 11/23/24- worked 2:01PM-10:05PM. LVN E was not on any floor schedule as she was the Weekend Supervisor.
Record review of LVN M's Timesheet dated 11/16/24, revealed, LVN M working from 6:12 AM-10:50PM.
Record review of LVN M's floor schedule dated 11/16/24, revealed, working 100 hall from 6AM to 10PM. On 11/23/24 - worked 100 hall from 6AM to 10PM.
Record review of CNA J's Time sheet dated 11/23/24, revealed, CNA J working from 6:06AM-10:08PM. On 11/23/24 - worked 6:09AM-2:03PM.
Record review of CNA J's floor schedule 11/16/24, revealed, working 100 hall from 6AM to 10PM. On 11/23/24- worked 100 hall from 10:15AM-2PM.
Record review of CNA K's Timesheet dated 11/16/24, revealed, CNA K working from 6:17AM-10:08PM. On 11/23/24- worked 6:18PM-10:09 PM.
Record review of CNA K's floor schedule dated 11/16/24, revealed, working 100 hall from 10:30AM - 7:30 PM. On 11/23/24- worked 100 hall from 10AM to 7PM.
Record review of the facility Incidents and Accidents policy noted dated, revealed, Policy: It was the policy of this facility for staff to utilize) specify risk management system/tools used) to report, investigate, and review any accidents or incidents that occur or allegedly occur, on facility property and may involve or allegedly involve a resident.
Accident - refers to any unexpected or unintentional incident, which results or may result in injury or illness to a resident.
Incident was defined as an occurrence or situation that was not consistent with the routine care of a resident or with the routine operation of the organization.
If an incident/accident was witnessed by other people, the supervisor or designee will obtain written documentation of the event by those that witnessed it and submit that documentation to the Director of Nursing and or Administrator.
Record review of the facility Fall Prevention Program policy not dated, revealed, Policy: Each resident will be assessed for fall risk and will receive care and services in accordance with their individual level of risk to minimize the likelihood of falls.
High Risk Protocols: The resident will be placed on the facility's Fall Prevention Program.
Provide additional interventions as directed by the resident's assessment, including but not limited to: Assistive devices.
Oct 2024
1 deficiency
CONCERN
(D)
📢 Someone Reported This
A family member, employee, or ombudsman was alarmed enough to file a formal complaint
Potential for Harm - no one hurt, but risky conditions existed
Investigate Abuse
(Tag F0610)
Could have caused harm · This affected 1 resident
**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on interviews and record reviews, the facility failed to thoroughly investigate allegations of abuse, neglect, exploitatio...
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**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on interviews and record reviews, the facility failed to thoroughly investigate allegations of abuse, neglect, exploitation, or mistreatment for 1 of 10 (Resident #1) reviewed for abuse.
The facility failed to implement their abuse policy when they failed to immediately suspend CNA A after an allegation of mistreatment was reported.
This failure could place residents at risk of potential continued mistreatment and abuse.
Findings included:
Record review of Abuse, Neglect and Exploitation policy dated 2024 read in part VI protection of resident: the facility will make efforts to ensure all residents are protected from physical and psychosocial harm, as well as additional abuse, during and after the investigation. Examples include but are not limited to: D- room or staffing changes, if necessary, to protect the resident(s) from the alleged perpetrator.
Record review of Resident #1's face sheet dated 10/31/24 revealed an [AGE] year-old female who was admitted to the facility on [DATE] with diagnoses of muscle weakness, other abnormalities of gait and mobility, and unspecified lack of coordination.
Record review of Resident #1's admission MDS assessment dated [DATE] revealed a BIMS score of 14 which indicated her cognitive was intact and she required moderate assistance with transfers.
Record review of Resident #1's baseline care plan dated 10/18/24 revealed focus area for has an ADL self-care
performance deficit with interventions that included requires assistance by staff to maximize independence
with transferring.
Record review of Resident #1's late entry progress note dated 10/27/24 written by RN C revealed this nurse was approached by [Resident #1 RP], who stated that she want to take [Resident #1] home right now, this nurse did ask [Resident #1 RP] what had happened, she stated that [Resident #1] was treated bad, when we went to the room the [Resident #1 RP] stated had [Resident #1] state what has happened. [Resident #1] stated that on her second day here that [Resident #1] legs were thrown into the bed, she stated that she had never reported it. [Resident #1 RP] than stated that [Resident #1] got pushed on her wheelchair, and that [Resident #1] hit her knee, I did look at [Resident #1] knee and there was no skin issues noted no redness noted. this nurse ask if she wanted [Resident #1] moved and also stated that there would be an investigation. [Resident #1 RP] stated that no she was going to take [Resident #1] home. I did go over [Resident #1] medication and told her which ones would need a scrip and which ones she could buy over the counter. I follow up with CNAs in the hall and asked them to write a statement on what had happened. [Resident #1 RP] did signed AMA and left with her [Resident #1] in their car.
During an interview on 10/27/24 at 2:08 pm, RN C stated she had worked the weekend of the alleged incident and was the supervisor. RN C stated she was called in to Resident #1's room by Resident #1's family and was told they wanted to take Resident #1 AMA. RN C stated Resident #1 had stated that she had been pushed against the wall in the wheelchair and her knee was hurting. RN C stated she assessed Resident #1 and did not see any swelling, bruising, scratches, or redness. RN C stated she followed up with CNA A who was assigned to Resident #1 and the aide had denied the allegations of pushing Resident #1 in wheelchair and bumping knee on the wall. RN C stated she spoke to CNA B who had been in the room when the alleged incident happened, and she denied seeing CNA A push Resident #1 against the wall in the wheelchair and hitting her knee. RN C stated she asked CNA A and CNA B to write statements and reported the allegation to the DON.
During an interview on 10/27/24 at 2:15 pm, CNA A stated was not aware of any injury when moving Resident #1. CNA A stated Resident #1's family just came to her, and stated Resident #1 had hurt her knee and was in pain. CNA A stated when the resident was moved to allow Resident #11 to pass, (they were roommates) Resident #1 did not verbalize any pain or that she was hurt against the wall. CNA A stated that Resident #1 would transfer herself alone and was very limited in help, she was very independent. CNA A stated she was asked to leave a statement with the DON in her box yesterday (10/26/24). CNA A stated the DON had not addressed an investigation since she (DON) returned to work on Monday (10/28/24). CNA A stated CNA B was in the room present when she moved Resident #1.
During an interview on 10/27/24 at 2:23 pm, CNA B stated she was in the room present with CNA A as they were helping Resident #1's roommate Resident #11 to the restroom. CNA B stated CNA A moved Resident #1 slightly towards the wall to allow Resident #11's wheelchair to pass as Resident #1 was sitting in her wheelchair near the walkway area to the restroom. CNA B stated at the time of moving Resident #1, nothing was verbalized by Resident #1 that she was in pain or had gotten hit. CNA B stated after 20 minutes Resident #1 had voiced pain to her knee to her and she reported it to the charge nurse. CNA B stated Resident #1's family then showed up and she was confronted by the family asking how come Resident #1 was pushed into the wall. CNA B stated she was unaware of the allegation and had not seen any bruising, redness, scratches, or swelling to the resident's knee as she was very independent and was limited assisted with transfers. CNA B stated she reported to RN C. CNA B stated she was not suspended and had finished her shift.
During an interview on 10/27/24 at 2:27 pm, revealed Resident #11, who was alert and oriented to person, place, time and event was Resident #1 roommate. Resident #11 said she never heard any yelling or screaming from Resident #1 about being abused or neglected. Resident #11 stated she overheard Resident #1 telling family yesterday (10/26/24) that they had pushed her into the wall. Resident #11 stated Resident #1 would always complain of left knee pain but never heard her in pain until yesterday (10/26/24) when Resident #1's family arrived. Resident #11 stated the CNAs were helping Resident #1 transfer her into the restroom but didn't see her get pushed into the wall, nor did she complain of any pain or injury at the moment. Resident #11 stated she felt safe at the facility, and no one treated her badly. Resident #11 stated the CNAs were really nice and helped and she has no issues with them.
During an interview on 10/30/24 at 11:04 am, the DON stated she had been notified regarding Resident #1's AMA on Saturday 10/27/24. The DON stated she was out on vacation when the allegation occurred and returned to work on 10/30/24. The DON stated she had not received prior allegations against CNA A. The DON stated she was aware of RN C conducting a body assessment on the day of the allegation with no abnormal findings. The DON stated an abuse and neglect in-service had been initiated for all staff. The DON stated CNA A had not been suspended and did not know why they had not been suspended. The DON stated they should have been suspended and was not sure where the Administrator's investigation was at. The DON stated CNA A had finished her shift on 10/26/24. The DON stated failure to suspend CNA A could have placed residents at risk of retaliation against them. The DON stated the abuse coordinator was the Administrator.
During an interview on 10/30/24 at 3:33 pm, the Administrator stated he found out about Resident #1's allegation of mistreatment on Sunday 10/27/24. The Administrator stated he was told about Resident #1's knee hitting the wall when she was moved by CNA A. The Administrator stated he started his investigation on 10/27/24 and had not suspended CNA A and did not give reason. The Administrator did not give a potential risk for not suspending CNA A.
Aug 2024
2 deficiencies
CONCERN
(E)
📢 Someone Reported This
A family member, employee, or ombudsman was alarmed enough to file a formal complaint
Potential for Harm - no one hurt, but risky conditions existed
Assessment Accuracy
(Tag F0641)
Could have caused harm · This affected multiple residents
**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on interviews and record review the facility failed to ensure that the assessment accurately reflected the resident's stat...
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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 that the assessment accurately reflected the resident's status 2 (Resident #5, and Resident #6) of 5 resident reviewed for accuracy of MDS assessments.
Resident #5's quarterly and annual MDS did not accurately reflect the residents use for bed rails (enablers).
Resident #6's quarterly MDS did not accurately reflect the residents use for bed rails (enablers).
This deficient practice could affect residents at the facility who had been assessed for risk of bed rails (enablers) could contribute to inadequate care.
Findings included:
Resident #5
Record review of Resident # 5's Face Sheet dated 08/13/24, revealed, admission on [DATE] and re-admission on [DATE] to the facility.
Record review of Resident # 5's Clinic History and Physical dated 05/29/24, revealed, a [AGE] year-old male diagnosed with Rheumatoid Arthritis (chronic inflammatory disorder that can affect more than just your joints).
Record review of Resident #5's annual MDS dated [DATE], revealed, a severely impaired cognition to be able to recall and remember with a BIMS score of 6. Resident #5 ADLs indicated he needed substantial/maximal assistance (nursing staff does more than half the effort) to dressing his upper body, to dressing his lower body, personal hygiene, footwear, and toileting. Resident #5 was substantial/maximal assistance for sit to lying, roll left and right, lying to sitting on side of bed, sit to stand, chair/bed-to-chair transfer, and car transfer. Resident #5 was diagnosed with Arthritis (painful inflammation and stiffness of the joints), Diabetes Mellitus, Muscle Wasting and Atrophy (the wasting or thinning of muscle mass), Muscle Weakness (lack of muscle strength), and Abnormalities of gait (unusual walking pattern) and Mobility. Bed rails on section P - Restraints and Alarms (Physical restraints are any manual method or physical or mechanical device, material or equipment attached or adjacent to the resident's body that the individual cannot remove easily which restricts freedom of movement or normal access to the one's body) was not marked as 1 (used less than daily) or 2 (used daily).
Record review of Resident # 5's quarterly MDS dated [DATE], revealed, a moderately impaired cognition to be able to recall and remember BIMS score of 12. Resident #5 ADLs indicated he needed partial/moderate assistance nursing staff to do less than half the effort) to dressing his upper body and substantial/maximal assistance (nursing staff does more than half the effort) for dressing his lower body, personal hygiene, footwear, and toileting. Resident #5 was partial/moderate assistance for sit to lying, roll left and right, lying to sitting on side of bed, sit to stand, chair/bed-to-chair transfer, and car transfer. Resident #5 was diagnosed with Diabetes Mellitus, altered Mental Status (a change in mental function which stems from certain illnesses, disorders and injuries affecting your brain), Rheumatoid Arthritis, and Encephalopathy (a group of conditions that cause brain dysfunction). Bed rails on section P - Restraints and Alarms (Physical restraints are any manual method or physical or mechanical device, material or equipment attached or adjacent to the resident's body that the individual cannot remove easily which restricts freedom of movement or normal access to the one's body) was not marked as 1 (used less than daily) or 2 (used daily).
Record review of Resident # 5's Order Recap dated 06/23/23, revealed, May use assist bars to bed for bed mobility, positioning and transfers.
Record review of Resident # 5's Enabler assessment dated [DATE], revealed, the digital form stated the following: Has the resident expressed a desire to have enablers raised while in bed for their own safety and or comfort? No. Was the resident able to get in/out of bed? No. Was resident able to get out of bed safety? No. Does the resident use enablers for positioning or support? Yes. Do the enablers help the resident rise from a supine position to a sitting/standing positions? No. Digital form was not signed for consent for use of bed rails. Nor was a handwritten signed consent form given to state during visit.
Record review of Resident #5's Miscellaneous tap for documents/forms was reviewed on 08/13/24, revealed, there were not consent forms for use of the bed rails.
Record review of Resident # 5's Care Plan dated 06/23/23, revealed, may require the use of a supportive device: grab bars, as enablers to promote my independence and facilitate functional mobility, turning, repositioning and transferring while in bed. Grab bars - to assist with successful transfers, repositioning, turning in bed, and facilitate functional mobility. Staff should notify Licensed Nurse of concerns with the device/function. LN will review quarterly.
Record review of Resident #5's PT Evaluation & Plan of Treatment dated 05/29/24-07/27/24, revealed, Bed mobility was total dependence without attempts to initiate. Clinical Impression: Patient presents with decreased strength with decreased activity tolerance, standing balance/tolerance deficits, sitting balance/tolerance deficits, joint stiffness, impaired functional mobility and limiting independence. Risk factors: Due to the documented physical impairments and associated functional deficits, the patient was at risk for: falls, further decline in function, compromised general health, decreased ability to return to prior level of assistance, decreased ability to return to prior living environment, decreased in level of mobility, limited out-of-bed activity and decreased participation with functional tasks.
Observation and interview on 08/13/24 at 10:11 AM, with Resident #5, revealed, Resident #5 to be sitting on his wheelchair on the left side of the bed. His bed was made with call light within reach. Two bed rails (enablers) were seen on both sides of the bed positioned upwards. Resident #5 had stated the facility staff did not want him to be using the bed rails. Resident #5's fingers were contracted sideways going in an outwards direction. Resident #5 stated he was not able to use the bed rails because he could not hold on to them and did not have enough strength to be holding on to anything. Resident #5 showed the state surveyor his hands. Resident #5 stated no facility staff had gone to assess him to see if he needed the bed rails (enablers). Resident #5 stated he did not remember signing any consent forms or if any of his family had signed consent forms.
During an interview on 08/13/24 at 11:29 AM, with MDS Coordinator B, she stated when an MDS was generated by the MDS Department they gather all the information from interviews, from the IDT, looking at the residents, and from record review. MDS Coordinator B stated Resident #5 did have bed rails (enabler) and used it to assist with turning and with ADLs. MDS Coordinator B stated it was not checked off on the quarterly assessment of 06/01/24 and annual assessment of 04/05/24, because the bed rails were not considered a restraint. MDS Coordinator B stated to her knowledge it would not be coded in the MDS because it was used as an enabler and Resident #5 was still able to use them to turn himself as of now (08/13/24). MDS Coordinator B stated an enabler was to assist a patient with their transfers, bed mobility, and ADLs. MDS Coordinator B after reviewing the physician's orders dated 06/23/23 and the two MDSs dated 04/05/24 (annual) and 06/01/24 (quarterly) stated the MDSs were not inaccurate and were accurate form the information that she had acquired to her knowledge. It was noted that the MDS Coordinator B could not answer the question if she had looked at the physician's orders as the MDS department gathered all the information from interviews, from the IDT, looking at the residents, and from record review.
Resident #6
Record review of Resident # 6's Face Sheet dated 08/13/24, revealed, admission on [DATE] to the facility. Resident #6 was an [AGE] year-old female diagnosed with muscle wasting and atrophy (the wasting or thinning of muscle mass), muscle weakness (lack of muscle strength), abnormalities of gait (unusual walking pattern) and mobility, lack of coordination (not able to move different parts of the body together well or easily), and history of falls.
Record review of Resident # 6's quarterly MDS dated [DATE], revealed, a severely impaired cognition to be able to recall or make daily decisions with a BIMS score of 7. Resident #6's ADLs for putting on footwear, lower body dressing, shower, toileting was supervision or touch assistance. Resident #6 was supervision to touch assistance for sit to stand, toilet transfer, and shower. Sit to lying and lying to sitting on side of bed was setup or clean up assistance. Roll left and right on bed was independent. Resident #6 was diagnosed with diabetes mellitus, non-Alzheimer's dementia, muscle weakness, lack of coordination, abnormalities of gait and mobility, and repeated falls. Bed rails on section P - Restraints and Alarms (physical restraints are any manual method or physical or mechanical device, material, or equipment attached or adjacent to the resident's body that the individual cannot remove easily which restricts freedom of movement or normal access to the one's body) was not marked as 1 (used less than daily) or 2 (used daily).
Record review of Resident # 6's Order Recap dated 09/20/23, revealed, may use ¼ rails to bed (left, Right, or Both) for bed mobility, positioning, and transfers.
Record review of Resident # 6's Assessment on 08/13/24, revealed, there were no enabler assessments conducted at all for use of Enablers (bed rails) for Resident #6.
Record review of Resident # 6's Care Plan dated 06/23/23, revealed, required the use of a supportive device: grab bars, as enablers to promote independence and facilitate functional mobility, turning, repositioning, and transferring while in bed. Grab bars to assist with successful transfers, repositioning, turning in bed, and facilitate functional mobility. Staff should notify Licensed Nurse of concerns with the device/function. Licensed Nurse will review quarterly.
Record review of Resident #6's PT Evaluation & Plan of Treatment dated 02/29/24-04/28/24, revealed, Clinical Impression: Patient performs transfers and mobility at supervision. Patient performs ADLs at independence to supervision. Patient was a high risk for falls and was forgetful with decreased safety awareness. RISK factors: Due to the documented physical impairments and associated functional deficits, the patient was at risk for compromised general health and falls. Evaluation Summary: Patient presents with impairments in balance, mobility, and strength.
Observation on 08/13/24 at 9:09 AM, revealed, Resident #6 was not in her room at that time. Bed was made and had a bed rail (enabler) up on the left side of the bed with the call light cord wrapped around it.
During an interview on 08/13/24 at 2:01 PM, with the DON and MDS Coordinator A, MDS Coordinator A stated residents who have bed rails (enablers) will not be marked on the MDS as they were enablers and not considered to be restraints even though it had devices: indicated bed rails, it would not be coded. MDS Coordinator A stated the bed rails used by the residents were not bed rails such as the hospital used, that were the long bed rails and that slide out. MDS Coordinator A stated the facility bed rails (enablers) were smaller and move up and down and were considered enablers. MDS Coordinator A stated residents who need bed rails were evaluated by the therapy department and do not need a physician order. MDS Coordinator stated they generate an MDS by gathering all the information from the facility system and all departments. MDS Coordinator A stated he could not answer if the MDS was inaccurate as he does not generate the long-term MDSs, and his short-term residents do not stay at the facility long enough for him to really enter a lot of information in the MDS. He stated he would not know if coding the bed rails in Section P for devices of bed rails needed to be coded. The DON stated the MDS was an inaccurate MDS because it needed to be coded for bed rails in Section P.
Record review of the facility Maintain Minimum Data Set (MDS) Assessments not dated, revealed, policy did not relate to accuracy of MDS assessments. No other policy was brought forth prior to exit.
Record review of the facility Documentation in Medical Records policy not dated, revealed, Policy - Each resident's medical record shall contain an accurate representation of the actual experiences of the resident and include enough information to provide a picture of the resident's progress through complete, accurate, and timely documentation. Licensed staff and interdisciplinary team members shall document all assessments, observations, and services provided in the resident's medical record in accordance with state law and facility policy. Documentation shall be accurate, relevant, and complete, containing sufficient details about the resident's care and or responses to care.
CONCERN
(E)
📢 Someone Reported This
A family member, employee, or ombudsman was alarmed enough to file a formal complaint
Potential for Harm - no one hurt, but risky conditions existed
Deficiency F0700
(Tag F0700)
Could have caused harm · This affected multiple residents
**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observations, interviews, and record review the facility failed to assess the resident for risk of entrapment from an e...
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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 assess the resident for risk of entrapment from an enabler (bed rail) prior to installation or review the risks and benefits of bed rails with the resident or resident representative and obtain informed consent prior to installation for 2 ( Resident #5, and Resident #6) of 5 residents reviewed for enablers (bed rails).
Resident #5 did not have a signed consent form for use of bed rails, nor on-going Enabler Assessments being done to ensure the Enablers (bed rails) were still appropriate for the use of Resident #4's needs.
Resident #6 did not have a signed consent form for use of bed rails, nor was an Enabler Assessment conducted to ensure that the bed rails (Enablers) were appropriate for the residents, and on-going Enabler Assessments was not being done to ensure the Enablers (bed rails) were still appropriate for the use of Resident #6's needs.
This failure could place residents who have bed [NAME] (enablers) at risk of having inappropriate or unnecessary enablers in place increasing their risk of injury.
Findings included:
During an interview on 08/13/24 at 9:19 AM, with the PT, she stated the therapy department conducted bed rail assessments on residents in the facility. The PT stated she had done a PT Evaluation on Resident #4 sometime in February of 2024 and then Resident #4 had left to another facility. The PT stated Resident #4 had bed rails and was able to help nursing staff with ADLs. The PT stated she was not able to find the bed rail assessments for any residents to include Resident #4, Resident #5, and Resident #6 that the therapy department had done. The Pt stated bed rails were recommended by the Therapy department during evaluation of a resident. The PT stated she was not sure if the facility was conducting the Enabler Assessments (or any other bed rail assessments) quarterly or annually or at all. The PT stated Resident #4 was able to use the bed rails as an enabler.
During an interview on 08/13/24 at 10:17 AM, with the DON, she stated Resident #4 had an Enabler Assessment that was done last year on 07/18/23 and had not been done quarterly as there were no other enabler assessments for her. The DON stated the Enabler Assessments were done quarterly to see if the resident had a change of condition and to see if the bed rails were safe for her and other residents with bed rails. The DON stated the enablers were placed on Resident #4's bed as per family request and no alternatives were attempted prior to putting on the bed rails. The DON stated she did not know if any of the long-term residents have had any alternatives used before, they had bed rails installed. The DON stated the digital Enabler Assessments were inaccurately done as there were no signatures or digital signatures. The DON stated it was inaccurate documentation. The DON stated the nurses were responsible for documenting accurately. The DON stated it was required to have a physician's order for use of bed rails as enablers and did not see one for Resident #4.
Resident #5
Record review of Resident # 5's Face Sheet dated 08/13/24, revealed, admission on [DATE] and re-admission [DATE] to the facility.
Record review of Resident # 5's Clinic History and Physical dated 05/29/24, revealed, a [AGE] year-old male diagnosed with Rheumatoid Arthritis (chronic inflammatory disorder that can affect more than just your joints).
Record review of Resident #5 annual MDS dated [DATE], revealed, a severely impaired cognition to be able to recall and remember BIMS score of 6. Resident #5 ADLs indicated he needed substantial/maximal assistance (nursing staff does more than half the effort) to dressing his upper body, to dressing his lower body, personal hygiene, footwear, and toileting. Resident #5 was substantial/maximal assistance for sit to lying, roll left and right, lying to sitting on side of bed, sit to stand, chair/bed-to-chair transfer, and car transfer. Resident #5 was diagnosed with Arthritis (painful inflammation and stiffness of the joints), Diabetes Mellitus, Muscle Wasting and Atrophy (the wasting or thinning of muscle mass), Muscle Weakness (lack of muscle strength), and Abnormalities of gait (unusual walking pattern) and Mobility. Bed rails on section P - Restraints and Alarms (Physical restraints are any manual method or physical or mechanical device, material or equipment attached or adjacent to the resident's body that the individual cannot remove easily which restricts freedom of movement or normal access to the one's body) was not marked as 1 (used less than daily) or 2 (used daily).
Record review of Resident # 5's quarterly MDS dated [DATE], revealed, a moderately impaired cognition to be able to recall and remember BIMS score of 12. Resident #5 ADLs indicated he needed partial/moderate assistance nursing staff to do less than half the effort) to dressing his upper body and substantial/maximal assistance (nursing staff does more than half the effort) for dressing his lower body, personal hygiene, footwear, and toileting. Resident #5 was partial/moderate assistance for sit to lying, roll left and right, lying to sitting on side of bed, sit to stand, chair/bed-to-chair transfer, and car transfer. Resident #5 was diagnosed with Diabetes Mellitus, altered Mental Status (a change in mental function which stems from certain illnesses, disorders and injuries affecting your brain), Rheumatoid Arthritis, and Encephalopathy (a group of conditions that cause brain dysfunction). Bed rails on section P - Restraints and Alarms (Physical restraints are any manual method or physical or mechanical device, material or equipment attached or adjacent to the resident's body that the individual cannot remove easily which restricts freedom of movement or normal access to the one's body) was not marked as 1 (used less than daily) or 2 (used daily).
Record review of Resident # 5's Order Recap dated 06/23/23, revealed, May use assist bars to bed for bed mobility, positioning and transfers.
Record review of Resident # 5's Enabler assessment dated [DATE], revealed, the digital form stated the following: Has the resident expressed a desire to have enablers raised while in bed for their own safety and or comfort? No. Was the resident able to get in/out of bed? No. Was resident able to get out of bed safety? No. Does the resident use enablers for positioning or support? Yes. Do the enablers help the resident rise from a supine position to a sitting/standing positions? No. Digital form was not signed for consent for use of bed rails. Nor was a handwritten signed consent form given to state during visit.
Record review of Resident #5's Miscellaneous tap for documents/forms was reviewed on 08/13/24, revealed, there were not consent forms for use of the bed rails.
Record review of Resident # 5's Care Plan dated 06/23/23, revealed, may require the use of a supportive device: grab bars, as enablers to promote my independence and facilitate functional mobility, turning, repositioning and transferring while in bed. Grab bars - to assist with successful transfers, repositioning, turning in bed, and facilitate functional mobility. Staff should notify Licensed Nurse of concerns with the device/function. LN will review quarterly.
Record review of Resident #5's PT Evaluation & Plan of Treatment dated 05/29/24-07/27/24, revealed, Bed mobility was total dependence without attempts to initiate. Clinical Impression: Patient presents with decreased strength with decreased activity tolerance, standing balance/tolerance deficits, sitting balance/tolerance deficits, joint stiffness, impaired functional mobility and limiting independence. Risk factors: Due to the documented physical impairments and associated functional deficits, the patient was at risk for: falls, further decline in function, compromised general health, decreased ability to return to prior level of assistance, decreased ability to return to prior living environment, decreased in level of mobility, limited out-of-bed activity and decreased participation with functional tasks.
Observation and interview on 08/13/24 at 10:11 AM, with Resident #5, revealed, Resident #5 to be sitting on his wheelchair on the left side of the bed. Bed was made with call light within reach. Two bed rails (enablers) were seen on both side of the bed positioned upwards. Resident #5 had stated the facility staff did not want him to be using the bed rails. Resident #5's fingers were contracted sideways going in an outwards direction. Resident #5 stated he was not able to use the bed rails because he could not hold on to them and did not have enough strength to be holding on to anything. Resident #5 showed State his hands. Resident #5 stated no facility staff had gone to assess him to see if he needed the bed rails (enablers). Resident #5 stated he did not remember signing any consent forms or if any of his family had signed consent forms.
During an interview on 08/13/24 at 9:19 AM, with the PT, she stated Resident #5 was on case load but was not anymore as he had reached a certain point and could not go any higher (was not declining nor approving) from that point and was released from therapy. The PT stated Resident #5 required maximum assistance to total assistance (dependent on nursing staff for help) especially on his bad days. The PT stated Resident #5 was weak in his hands and arms, and they were not functional to be able to grab or pull on the bed rails. The PT stated Resident #5 having the bed rails right now would not be considered as enablers for him. The PT stated even if the bed rails are in or down resident #5 would not be able to get out of bed because he requires max to total assistance from nursing staff. The PT stated she would see the need for the residents who have bed rails to be assessed for the use of the bed rail and having on-going assessments for the use of bed rails as enablers. The PT stated it would benefit the residents and would make sure the residents can use the enablers, for safety, and not to be a restraint.
During an interview on 08/13/24 at 10:17 AM, with the DON, she stated Resident #5 Enabler Assessment was done on 01/22/23 and has not had any other Enabler Assessments conducted since. The DON stated the risk of not conducting the enable assessments was that the facility could overlook any changes of condition and see if they were appropriate for the resident to be using the bed rails as enablers. The DON stated the facility had not done had any other alternative that were used first before using the bed rails for Resident #5 as stated in the facility Side Rails policy where alternative should be used first before using bed rails as enablers. The DON stated there were not consent forms signed for Resident #5. The DON stated she had seen Resident #5 and he would not benefit form the use of bed rails (enablers).
Resident #6
Record review of Resident # 6's Face Sheet dated 08/13/24, revealed, admission on [DATE] to the facility. Resident #6 was an [AGE] year-old female diagnosed with Muscle Wasting and Atrophy (the wasting or thinning of muscle mass), Muscle Weakness (lack of muscle strength), Abnormalities of gait (unusual walking pattern) and Mobility, Lack of Coordination (not able to move different parts of the body together well or easily), and History of Falls.
Record review of Resident # 6's quarterly MDS dated [DATE], revealed, a severely impaired cognition to be able to recall or make daily decision BIMS score of 7. Resident #6's ADLs for putting on footwear, lower body dressing, shower, toileting was supervision or touch assistance. Resident #6 was supervision to touch assistance for sit to stand, toilet transfer, and shower. Sit to lying and lying to sitting on side of bed was Setup or clean up assistance. Roll left and right on bed was independent. Resident #6 was diagnosed with diabetes Mellitus, Non-Alzheimer's Dementia, Muscle Weakness, Lack of Coordination, Abnormalities of gait and mobility, and repeated falls. Bed rails on section P - Restraints and Alarms (Physical restraints are any manual method or physical or mechanical device, material or equipment attached or adjacent to the resident's body that the individual cannot remove easily which restricts freedom of movement or normal access to the one's body) was not marked as 1 (used less than daily) or 2 (used daily).
Record review of Resident # 6's Order Recap dated 09/20/23, revealed, May use ¼ rails to bed (left, Right or Both) for bed mobility, positioning and transfers.
Record review of Resident # 6's Assessment on 08/13/24, revealed, there were no Enabler Assessments conducted at all for use of Enablers (bed rails) for Resident #6.
Record review of Resident # 6's Care Plan dated 06/23/23, revealed, requires the use of a supportive device: grab bars, as enablers to promote independence and facilitate functional mobility, turning, repositioning and transferring while in bed. Grab bars to assist with successful transfers, repositioning, turning in bed, and facilitate functional mobility. Staff should notify Licensed Nurse of concerns with the device/function. Licensed Nurse will review quarterly.
Observation on 08/13/24 at 9:09 AM, revealed, Resident #6 was not in her room at that time. Bed was made and had a bed rail (enabler) up on the left side of the bed with the call light cord wrapped around it.
Record review of Resident #6's PT Evaluation & Plan of Treatment dated 02/29/24-04/28/24, revealed, Clinical Impression: Patient performs transfers and mobility at supervision. Patient performs ADLs at independence to supervision. Patient was a high risk for falls and was forgetful with decreased safety awareness. RISK factors: Due to the documented physical impairments and associated functional deficits, the patient was at risk for compromised general health and falls. Evaluation Summary: Patient presents with impairments in balance, mobility, and strength.
During an interview on 08/13/24 at 9:19 AM, with the PT, she stated Resident #6 was able to use the bed rails as an enabler.
During an interview on 08/13/24 at 10:17 AM, with the DON, she stated what qualified residents to have bed rails were family requests and the resident being able to turn using the bed rail. The DON stated if the resident was not able to turn themselves using the bed rail and the family still requested to have them on then the facility will comply with the family request and put on the bed rails. The DON stated the resident will have an Enabler Assessment done to evaluate if they were able to use the enablers or not. The DON stated the facility had to have had consent forms signed for the use of the bed rails (Enablers). She noted that there were consent forms that were not signed for Resident #4, Resident #5, Resident #6, and some other residents that she had looked up that were using bed rails and had Enabler Assessments done. The DON stated the facility was in violation of not following its facility side policy on having consent forms signed. The DON stated it was the responsibility of the DON/ADONs to oversee and ensure that the facility nurses were documenting accurately.
Record review of the facility Proper Use of Bed Rails policy noted dated, revealed, Policy- It was the policy of this facility to utilize a person-centered approach when determining the use of bed rails. Appropriate alternative approaches are attempted prior to installing or using bed rails. If bed rails are used the facility ensures correct installation, use, and maintenance of the rails. Bed rails are adjustable metal or rigid plastic bars that attach to the bed. They are available in a variety of types, shapes, and sizes ranging from full to one-half, one-quarter, or one-eighth lengths. Also, some bed rails are not designed as part of the bed by the manufacturer and maybe installed on or used along the side of the bed. Examples of bed rails include, but are not limited to side rails, bed side rails, safety rails, grab bars and assist bars. Physical Restraint was defined as any manual method, physical or mechanical device, equipment, or material that meets all of the following criteria: A. Was attached or adjacent to the resident's body; Cannot be removed easily by the resident; and C. Restricts the resident's freedom of movement or normal access to his/her body. Resident Assessment - the following will be considered when determining the resident's needs, and whether or not the use of bed rails meets these needs: Mobility (in and out of bed), underlying medical conditions, medical diagnoses, conditions, symptoms. The resident assessment must include an evaluation of the alternatives that were attempted prior to the installation or use of a bed rail and how these alternatives failed to meet the resident's assessed needs. Informed Consent - from the resident or resident representative must be obtained after appropriate alternatives have been attempted prior to installation and use of bed rails. Ongoing Monitoring and Supervision - ongoing assessment to assure that the bed rails was used to meet the resident's needs.
Ongoing evaluation of risk.
Record review of the facility provided Assist Bar/Barre d'aide manual not dated, revealed, The purpose of the Assist Bar was to provide the resident a grab bar in which they can use to assist themselves form a sitting position to standing while exiting a long-term care bed. Clinical staff must decide whether a resident would benefit from the use of this aid. Vulnerable patient needs should be considered before using this product. The Assist bar should not be used as a rail. The assist bar was not intended to prevent the resident from rolling out of bed. The facility did not provide any other information from the manual.
Aug 2024
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
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 that included measurable objectives and time frames to meet a resident's medical and nursing needs and described the services to be furnished to attain or maintain the resident's highest practicable physical, mental, and psychosocial well-being for 1 (Resident #9) of 7 residents reviewed for care plans
-The facility failed to follow the comprehensive person-centered care plan for Resident #9's fall risk, by failing to have a fall mat in place next to bed while resident was lying down in bed.
This deficient practice could place residents in the facility at risk of not receiving the necessary care or services as indicated in their comprehensive person-centered plans developed to address their needs.
Findings include:
Review of Resident #9's admission Record dated 08/05/2024, revealed an [AGE] year-old female with an admission date of 11/28/2023. Resident #9's diagnoses included: dementia (impaired ability to remember, think, or make decisions that interferes with doing everyday activities), muscle weakness and abnormalities of gait and mobility.
Review of Resident #9's quarterly MDS assessment dated [DATE], revealed a BIMS score of 02 indicating severe cognitive impairment. Section GG on Functional Abilities and Goals revealed resident requires substantial/maximal assistance with transfers. Section J - Health Conditions revealed resident had not had any falls since admission.
Review of Resident #9's Order Summary Report dated 08/05/2024, revealed an order for a Fall mat in place at bedside every shift with an active date of 02/14/2023 and no end date.
Review of Resident #9's comprehensive care plan dated 08/05/2024, revealed the resident was at risk for falls related to poor mobility. Part of the interventions included Fall Mat while in Bed for Safety.
Observation and interview on 08/05/2024 at 9:13 a.m., Resident #9 lying in bed and visited resident in bedroom. Resident observed lying down in bed. Fall mat folded and positioned behind the headboard. Resident was rocking in bed. Resident #9 did not provide any responses when greeted or asked her name. Resident had her eyes closed.
During an observation and interview on 08/05/2024 at 9:25 a.m., LVN I entered Resident #9's bedroom and observed the floor mat was folded and tucked behind Resident #9's headboard. LVN I said Resident #9 had breakfast and returned to her room where the CNAs assisted her to lay in bed. LVN I said Resident #9 was a fall risk and has a fall mat that is placed next to the bed while resident was on the bed. LVN I said the CNAs must have forgotten to put down the mat. LVN I said Resident #9 had not had any recent falls.
During an interview on 08/05/2024 at 9:32 a.m., CNA J said she assisted Resident #9 back to bed after breakfast a short time after 8:30 a.m. CNA J said Resident #9 was a fall risk and needs a floor mat next to bed for fall protection. CNA J said Resident #9 had not fallen in a long time. CNA J said the fall mat must be used anytime the resident was in bed. CNA J said she must have forgotten to put the mat in place.
During an interview on 08/05/2024 at 10:16 a.m., the DON said that Resident #9 requires the use of a fall mat anytime she was in bed due to fall risk. The DON said Resident #9 had not had any falls from bed and her last actual fall was 05/17/2024. The DON said the fall mat was a part of the interventions listed on the comprehensive care plan. The DON said the risk of failing to follow the care plan regarding fall protections was the resident could get hurt and have a possible serious injury.
Review of facility-provided Comprehensive Care Plans policy dated February 2023, reads in part It is the policy of this facility to develop and implement a comprehensive person-centered care plan for each resident, consistent with resident rights, that includes measurable objectives and timeframes to meet a resident's medical, nursing, and mental and psychosocial needs that are identified in the resident's comprehensive assessment. The comprehensive care plan will describe, at a minimum, the following: The services that are to be furnished to attain or maintain the resident's highest practicable physical, mental, and psychosocial well-being.
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
Respiratory Care
(Tag F0695)
Could have caused harm · This affected 1 resident
**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, interview, and record review the facility failed to ensure that a resident who needs respiratory care is p...
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**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, interview, and record review the facility failed to ensure that a resident who needs respiratory care is provided such care, consistent with professional standards of practice for 1 (Resident #10) of 3 residents observed for oxygen management.
-Resident #10 was on oxygen and did not have oxygen signs posted outside his bedroom.
This failure could place residents on oxygen therapy at risk of receiving incorrect or inadequate oxygen support and decline in health; and place them at risk of an unsafe environment which could lead to accidents and injuries.
Findings included:
Review of Resident #10's admission Record dated 07/31/2024, revealed a [AGE] year-old male who was admitted to the facility on [DATE]. Resident #10's diagnoses included pulmonary embolism (condition in which one or more arteries in the lungs become blocked by a blood clot).
Review of Resident #10's initial MDS assessment dated [DATE], revealed a BIMS score of 14 indicating the person is intact cognitively. Section O - Special Treatments, Procedures, and Programs revealed resident was on oxygen therapy.
Review of Resident #10's Order Summary Report dated 08/05/2024, reflected in part an order for oxygen continuously via nasal cannula (NC), may titrate between 2-5 LPM via NC to maintain O2 sats above 90%.
Review of Resident #10's care plan dated 08/05/2024, reflected in part, Resident #10 at risk for respiratory infections/distress, hypoxia (low levels of oxygen in body tissues), SOB, and cough. Resident is on 2LPM of continuous oxygen via nasal cannula.
During an observation on 07/31/2024 at 3:35 p.m., revealed Resident #10 lying in bed using oxygen via nasal cannula. Observation outside of the bedroom entrance door revealed there was not a sign indicating oxygen in use/no smoking.
During an interview on 07/31/2024 at 3:37 p.m., RN D said she believes there should have been an oxygen in use sign posted outside of Resident #10's bedroom entrance. RN D said the purpose of the sign was to let everyone know that the resident was on oxygen for safety purposes. RN D said nurses are responsible for posting the signs. RN D said she did not know why the sign was not posted.
During an interview on 08/05/2024 at 10:16 a.m., the DON said the purpose of an oxygen in-use sign was to let visitors and others know that oxygen was being used in the room. The DON said the nurses in the hall are responsible for posting the signs. The DON said the risk was the patient could get harmed from someone not being aware that the patient is using oxygen, and the patient might not be monitored properly for oxygen use.
Review of facility provided Oxygen Administration policy dated 2024, reflected in part, Oxygen is administered to residents who need it, consistent with professional standards of practice, the comprehensive person-centered care plans, and the resident's goals and preferences. Policy Explanation and Compliance Guidelines: 6. Oxygen warning signs must be placed on the door of the resident's room where oxygen is in use. 11. Staff shall monitor for complications associated with the use of oxygen and take precautions to prevent them. Possible risks and complications include but are not limited to: a. Fire; b. Respiratory infections related to contaminated humidification systems; c. Oxygen toxicity (signs include vertigo, nausea, convulsions); d. Ventilatory depression (slowed respiratory rate) associated with elevated carbon dioxide levels; e. Medical device-related pressure injuries.
CONCERN
(D)
📢 Someone Reported This
A family member, employee, or ombudsman was alarmed enough to file a formal complaint
Potential for Harm - no one hurt, but risky conditions existed
Medical Records
(Tag F0842)
Could have caused harm · This affected 1 resident
**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on interview and record review the facility failed to ensure medical records, in accordance with accepted professional sta...
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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, in accordance with accepted professional standards and practices, were maintained on each resident that were accurately documented for 2 (Resident #1, and #2) of 8 residents reviewed for medical records.
-The facility failed to ensure the right diet texture was documented in the orders of Resident #1.
-The facility failed to ensure the right diet texture was documented in the care plan of Resident #1.
-The facility failed to ensure accurate documentation was reflected in the Medication Administration Record of Resident #2.
These failures could lead to errors in treatment and services provided based on incorrect information.
Findings included:
Resident #1:
Review of Resident #1's admission Record printed on 08/02/2024, revealed a [AGE] year-old male who was admitted to the facility on [DATE]. Resident #1 was discharged from the facility on 06/30/2024. Resident #1's diagnoses included gastro-esophageal reflux disease (condition in which acidic gastric fluid flows backward into the esophagus, resulting in heartburn), irritable bowel syndrome (intestinal disorder causing pain in the belly, gas, and constipation), and unspecified protein-calorie malnutrition (lack of sufficient energy or protein to meet the body's metabolic demands).
Review of Resident #1's initial MDS assessment dated [DATE], revealed a BIMS score of 11 indicating moderate cognitive impairment. Section K - Swallowing/Nutritional Status reflected that resident with following possible swallowing disorder: loss of liquids from mouth when eating or drinking; and holding food in mouth/cheeks or residual food in mouth after meals. No weight loss of 5% in the last month. Resident on mechanically altered diet.
Review of Resident #1's Orders printed on 08/02/2024, reads an order started on 06/27/2024 for regular diet, pureed texture, and clear liquids consistency diet.
Review of Resident #1's care plan printed on 08/02/2024, reads in part, resident was receiving a therapeutic or altered consistency diet and was at risk for nutritional impairment. Regular diet, pureed texture, clear liquids consistency.
Review of Resident #1's admission Report Sheet dated 06/26/2024, reads in part that resident's diet was Regular with thin liquids.
Review of Resident #1's hospital discharge documentation revealed resident was on regular diet with no modified textures.
During an interview on 07/31/2024 at 11:06 a.m., Resident #1's RP/FM said Resident #1 was at the facility for about four days. RP/FM said Resident #1 was eating a regular diet without a modified texture at the hospital and when he went to the facility, he started receiving pureed textured food at the facility and did not know why. RP/FM said the facility did not tell her why Resident #1 was given pureed food texture.
During an interview on 07/31/2024 at 1:43 p.m., the DON said regarding Resident #1's diet, the facility follows the orders provided by the hospital. The DON said the facility received a report from the hospital on the diet and document on the admission Report Sheet. The DON reviewed the admission Report Sheet and discharge documentation and said Resident #1 came from the hospital with regular texture diet. The DON said she believes that she made a mistake and put the order in for pureed. The DON said she was the responsible person who had to complete orders for Resident #1. The DON said she put in the incorrect order. The DON said if it was brought to her attention, she would have addressed it. The DON said the issue was not brought to her attention at any time when the resident was here. The DON said that the order stayed that way until he was discharged on 6/30/2024. The DON said she did not receive any reports of the patient not eating his food. There were no weights documented for the resident's stay from 06/26/2024 to 06/30/2024. The DON said the risk of not accurately documenting the correct orders was the patient may not receive the proper treatment.
During an interview on 08/01/2024 at 11:21 a.m., LVN E said he worked with Resident #1. LVN E said Resident #1 ate well and did not complain about the food.
During an interview on 08/01/2024 at 11:28 a.m., CNA F said she worked with Resident #1. CNA F said he was independent and had no issue with eating. CNA F said resident ate well and he had no complaints about the food at the facility.
Resident #2:
Review of Resident #2's admission Record printed on 08/01/2024, revealed a [AGE] year-old female who was admitted to the facility on [DATE]. Resident #2 was discharged from the facility on 06/29/2024. Resident #2's diagnoses included Chronic Obstructive Pulmonary Disease (lung diseases that block airflow and make it difficult to breathe).
Review of Resident #2's initial MDS assessment dated [DATE], revealed a BIMS score of 05 indicating severe cognitive impairment. Section J - Health Conditions reflected under Other Health Conditions that resident had shortness of breath or trouble breathing with exertion (e.g. walking, bathing, transferring), and shortness of breath or trouble breathing when lying flat.
Review of Resident #2's Order Summary Report printed on 08/01/2024, reflected an order for Formoterol Fumarate Inhalation Nebulization Solution 10 MCG/21ML , 1 applicator inhale orally via nebulizer two times a day for COPD.
Review of Resident #2's Care Plan printed on 08/01/2024, revealed Resident #2 was at risk for Respiratory infections/distress, hypoxia (low levels of oxygen in body tissues), SOB and cough related to diagnosis of COPD. Part of the interventions included administer medications/nebulizer treatment as ordered.
Review of Resident #2's Medication Administration Record for June 2024, revealed missing initials on 06/20/2024, 06/23/2024, and 06/24/2024 for 9:00 a.m. administration of Formoterol Fumarate Inhalation Nebulization Solution.
Review of Resident #2's Medication Administration Record for June 2024, revealed Resident #2's oxygen was checked every shift noting the following: on 06/20/2024: AM - 95, PM - 93, night - 94; 06/23/2024: AM - 97, PM - 95, night - 95; 06/24/2024: AM - 96, PM - 96, night - 96.
During an interview on 08/05/2024 at 9:05 a.m., LVN H said she was responsible for the nebulizer treatment for Resident #2 on the dates with missing initials. LVN H said she knows that treatment was done. LVN H said Resident #2 did not have refusal behaviors. LVN H said medication was on hand. LVN H said the issue was most likely a computer glitch not showing administration was done.
During an interview on 08/05/2024 at 10:16 a.m., the DON said she reviewed documentation regarding Resident #2 and did not find any medication errors or treatments. The DON said the nurse administering the medication was responsible to ensure they documented accurately. The DON said the risk of failing to document accurately could be being unable to verify if the patient got proper care and if they received proper treatment.
Review of facility provided Documentation in Medical Record policy dated 2024, reads in part Each resident's medical record shall contain an accurate representation of the actual experiences of the resident and include enough information to provide a picture of the resident's progress through complete, accurate, and timely documentation. Documentation shall be completed at the time of service, but no later than the shift in which the assessment, observation, or care service occurred. Documentation shall be accurate, relevant, and complete, containing sufficient details about the resident's care and/or responses to care.
Jul 2024
11 deficiencies
CONCERN
(D)
Potential for Harm - no one hurt, but risky conditions existed
Deficiency F0558
(Tag F0558)
Could have caused harm · This affected 1 resident
**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, interview and record review the facility failed to ensure the right to reside and receive services in the ...
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**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, interview and record review the facility failed to ensure the right to reside and receive services in the facility with reasonable accommodation of resident needs for one (Resident #23) of 24 residents reviewed for accommodation of needs.
Resident #23's call light was not within reach and was difficult for him to use.
This failure could place residents at risk of not being able to call for assistance when needed.
Findings included:
Record review of Resident #23's face sheet dated 07/18/2024 revealed he was [AGE] years old and was admitted to the facility on [DATE].
Record review of Resident #23's electronic diagnosis listing dated 07/18/2024 revealed he had diagnoses including metabolic encephalopathy (chemical imbalance in the blood that impairs brain function), cerebral infarction (stroke), and vascular dementia (brain damage caused by strokes).
Record review of Resident #23's admission MDS dated [DATE] revealed he had a BIMS score of 6 (Severe Cognitive Impairment). He had functional limitation in his range of motion on his arm and leg on one side. He was dependent on staff to eat, for oral hygiene, toileting, bathing, dressing, moving around in bed, sitting up, and transferring between surfaces. His diagnoses included cerebrovascular accident (stroke) and non-Alzheimer's Dementia. His occupational therapy start date was 06/05/2024 and he had received 35 minutes of occupational therapy across two days.
Record review of Resident #23's Care Plan dated 06/06/2024 revealed he needed assistance turning in bed, eating, dressing, personal hygiene and oral care, using the toilet and transferring. He was at risk for falls and his call light was to be within reach.
Observation and interview on 07/16/24 at 03:21 PM revealed Resident #23 was in his room in his wheelchair. His call light was not visible, and he was not able to find it when asked. It was observed that his call light was wedged between the side of the wheelchair and the wheel on his left. The call light and cord did not have any type of a securing device on it such as a clip. The resident was not able to reach the call light when told where it was located. When the call light was placed on his bed at his request, he said it was not his call light. It was observed that the call light was 2.25 inches long and cylindrical in shape, with a button on the end to be pressed to call for help. He said his call light was flat and round and had a red cross on it, and it was the only type he had ever had. Resident #23 said he had the other flat round call light with the red cross on it because it was easy to use.
In an interview and observation on 07/16/24 at 03:21 PM the DON revealed that Resident #23's call light should be where he could reach it. She said that determination of need for a particular type of call light depended on the resident's ability to use the call light. The DON stated she had never noticed the type of call light the resident had. She said it was important for a resident to have a call light that could be used so the resident could call staff for assistance. She said the risk to the resident of not having a call light within reach or a call light they could use was the resident would not be able to get what they needed or wanted. She said that if a resident was receiving skilled therapy their ability to use call lights would be assessed.
In an interview on 07/18/24 at 04:20 PM the Therapy Director revealed that recommendations for assessments such as one for call lights could be made by either nursing or the therapy department during IDT meetings. He did not recall any recommendations regarding call lights for Resident #32 having been made.
Record review of the facility policy and procedure Call lights: Accessibility and Timely Response dated 07/2022 revealed each resident would be evaluated for unique needs and preferences to determine any special accommodations that might be needed in order for the resident to utilize the call system. Special accommodations would be identified on the resident's person-centered plan of care and provided accordingly. Examples included touch pads. Staff were to ensure that that call lights were within reach of the resident and secured as needed.
CONCERN
(D)
Potential for Harm - no one hurt, but risky conditions existed
Deficiency F0688
(Tag F0688)
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 that a resident with limited range of motion receives appropr...
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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 that a resident with limited range of motion receives appropriate treatment and services to increase range of motion and/or to prevent further decrease in range of motion for 1 (Resident #111) of 7 residents reviewed for treatment and services related to range of motion.
The facility failed to ensure that Resident #111 received services to increase or maintain his range of motion.
This failure could put residents at risk of decreased range of motion, decreased quality of life, and increased risk of contractures and threats to skin integrity.
Findings included:
Record review of Resident #111's face sheet dated 07/17/2024 revealed he was [AGE] years old and was initially admitted to the facility on [DATE] and readmitted on [DATE].
Record review of Resident #111's history and physical dated 06/14/2024 revealed he had diagnoses including cerebral infarction (stroke), use of a tracheostomy (opening into the windpipe to breathe through), and a feeding tube. He was unable to speak or communicate his needs.
Record review of Resident #111's 5-day MDS assessment dated [DATE] revealed he was unable to speak and was rarely or never understood by others. He usually understood others. He was unable to participate in the BIMS interview. He had no symptoms of delirium, some symptoms of depression, no symptoms of psychosis and no behavioral symptoms. He had functional limitation in range of motion to his arms and legs. He was totally dependent on others for all of his activities of daily living and was totally dependent on others to move. His diagnoses included pneumonia, CVA (stroke) and respiratory failure. He had been administered antipsychotic medications during the seven days before the MDS assessment was completed. He received 30 minutes of speech therapy, 15 minutes of occupational therapy, and 30 minutes of physical therapy in the seven days prior to the assessment. His MDS assessment documented that no restorative therapy was provided during the 7-day look-back period.
Record review of Resident #111's care plan dated revealed he did not have a care plan to address limited range of motion. Care plans dated 04/19/2024 addressed the resident's need for assistance with ADLs such as turning in bed, dressing, and transferring, but did not address his need for any physical, occupational or restorative therapies to maintain or increase his range of motion.
Record review of Resident #111's physician's order dated 04/16/2024 revealed he was to be evaluated by Physical Therapy, Occupational Therapy and Speech Therapy and as indicated.
Record review of Resident #111's active physician's order dated 06/16/2024 revealed that the resident's occupational therapy evaluation and treatment were complete. The resident was to be seen for skilled Occupational Therapy services including self-care, therapeutic exercise, therapeutic activity, and manual treatment, wheelchair management, neuro reeducation and group treatment 5 to 6 times a week for 100 days for generalized weakness. The order had not been discontinued.
Record review of Resident #111's physician's order dated 04/21/2024 revealed that the resident's PT evaluation was completed. Recommend Skilled PT services were recommended 3 times a week for 4 weeks to include therapeutic
exercise, neuromuscular reeducation (rehabilitation to restore normal muscle and nerve function), gait training (therapy to improve walking), therapeutic activities, and wheelchair management for increased level of independence with reduced risk for falls. The order was discontinued on 06/13/2024.
In an interview on 07/18/24 at 09:17 AM the Director of Rehabilitation revealed that Resident #111 was not currently getting services from any therapy. He stated that Resident #111's speech, occupational and physical therapies had been discontinued on 7/8/24 because of change in payment source. He said that there were no plans to provide any additional therapy, and that the facility did not have a restorative program. He said the risk to Resident #111 of not having therapeutic interventions included contractures, increased muscle tone, and skin breakdown.
In an interview on 07/18/24 at 09:20 AM Physical Therapist I revealed that Resident #111 had no contractures but had joint stiffness, and that the resident had been receiving passive range of motion exercises during the time when physical therapy was being provided. Physical Therapist I stated Resident #111 would benefit from continued physical therapy or restorative therapy.
In an interview on 07/18/24 at 09:52 AM the DON revealed that the risk to Resident #111 of not receiving help maintaining his range of motion on a daily basis was contractures, atrophy of muscles and skin breakdown. She said that the facility did not have a program designed to provide these types of services, such as a restorative program. She did not know why the facility did not have this type of program. She said that staff members monitored residents for changes in functioning and changes would be reported to the therapy department so the resident could be evaluated for services.
CONCERN
(D)
Potential for Harm - no one hurt, but risky conditions existed
Accident Prevention
(Tag F0689)
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 each resident received adequate supervision and...
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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 each resident received adequate supervision and assistance devices to prevent accidents for 2 of 12 residents (Resident #103 and Resident #15) reviewed for supervision and accidents in that:
CNA A and NA B transferred Resident #103 from his wheelchair to the bed by grabbing him from the back of his pants and his under arms.
The fall mat for Resident # 15 was far away from his bed.
These failures could put residents at risk of accidents and serious injuries which could result in a reduced quality of life.
Findings included:
Record review of Resident #103's admission record dated 07/17/24 indicated he was admitted to the facility on [DATE] with diagnoses of Alzheimer's disease and muscle weakness. He was [AGE] years of age.
Record review of Resident #103's MDS dated [DATE] indicated in part: BIMS = 02 indicating resident had severe impairment. Impairment on both sides - upper and lower extremities. Chair/bed-to-chair transfer: The ability to transfer to and from a bed to a chair (or wheelchair). Resident is dependent - Helper does ALL of the effort. Resident does none of the effort to complete the activity. Or, the assistance of 2 or more helpers is required for the resident to complete the activity.
Record review of Resident #103's care plan dated 01/10/24 indicated in part: Focus: I have an ADL Self Care Performance Deficit. Goal: I will improve current level of function through the review date. Interventions/tasks: I require Extensive assistance x2 staff with transfer.
During an observation on 07/16/24 at 09:12 AM CNA A and NA B transferred Resident #103 from his wheelchair to the bed. Both aides took the resident from his armpits and by the back of his pants. Resident #103 was noted to drag his feet and did not assist with the transfer as it was noted that the resident was unable to bear weight.
During an interview on 07/18/24 at 10:04 AM NA B said that she had not used her gait belt during the transfer because Resident #103 was combative and the reason why they transferred the resident from his armpits and the back of his pants. NA B said that when they used the gait belt the resident would be more combative. NA B said if they transferred the resident by taking him from his underarms and from the back of his pants it could lead to an injury if his pants tore or injure his shoulders.
During an interview on 07/18/24 at 10:57 AM CNA A said she was aware that the transfer done with Resident #103 was not necessarily correct but that it was the safer way for them due to the resident being aggressive during the transfers with a gait belt. CNA A said they had attempted to use the gait belt before but that Resident #130 had become combative and now they were transferring him by taking him from his armpits and back of pants which again was probably not safe. CNA A said at one time it had taken 3 staff members to transfer the resident due to him being combative. CNA A said she did not know what other way to safely transfer Resident #130 besides taking him from under his arms and by the back of his pants.
During an interview on 07/18/24 at 11:52 AM the DON was made aware of the observation of Resident #103 being transferred to the bed by CNA A and NA B. The DON said that the staff were supposed to use a gait belt when conducting the transfer and not take the resident from underneath his armpits and the back of his pants as he could be injured. The DON said that they would look into figuring out a way to transfer the resident in a safer way.
During an interview on 07/18/24 at 03:48 PM the Administrator was made aware of the observation of Resident #103 being transferred to the bed by CNA A and NA B. The Administrator said he did not think that it was a proper way to transfer a resident. The Administrator said they would be working and looking into a safer way to transfer the resident.
Record review of Resident #15's admission record dated 07/18/24 indicated he was admitted to the facility on [DATE] with diagnoses of abnormalities of gait and mobility, weakness, nondisplaced (a fracture in which the bone cracks or breaks but retains its proper alignment) fracture of fourth cervical vertebra, unspecified fall and unspecified lack of coordination. He was [AGE] years old.
Record review of Resident #15's MDS dated [DATE] indicated in part: BIMS = 04 indicating resident had severe impairment.
Record review of Resident #15's care plan dated 04/04/24 indicated in part: Transfer; the resident requires assistance from staff to maximize independence. The resident is at risk of falling with a history of falling, follow facility all protocol. 6/12/2024 The resident has had an actual fall while attempting to ambulate without assistance, unwitnessed fall. Fall Mat in place to promote safety and prevent injury.
During an observation and interview on 07/16/24 at 04:09 PM it was revealed that the fall mat for Resident #15 was away from his bed. The family member was on the other bed and stated that earlier that morning she had heard the resident trying to get up from bed and that probably that's why the mat was moved to the side. She said he tried to get up from bed without assistance frequently.
During an interview on 07/16/24 at 04:11 PM with RN K revealed that the fall mat was not placed correctly. She stated the mat needed to be by the feet of Resident #15s bed and not where it was found by the surveyor. The RN stated that the potential outcome for the fall mat being away from his bed was he could fall to the floor while trying to get up from bed and potentially resulting in injuries to Resident #15. RN said Resident #15 is at fall risk.
During an interview on 07/17/24 with DON it was revealed that the placement of the fall mat was not acceptable because it was away from Resident's #15 bed. The DON stated that the potential outcome was that if the resident tried to get up from his bed and he fell, he would fall to the floor, and he could potentially get injured. The DON stated that Resident #15 is at fall risk.
Record review of the facility's policy titled Fall Prevention Program dated 06/22 indicated in part: High risk protocols, provide additional interventions as directed by resident's assessments, including but not limited to assistive devices, increased frequency if rounds.
Record review of the facility's policy titled Use of gait belts dated 06/08/24 indicated in part: It is the policy of this facility to use gait belts with residents that cannot independently ambulate or transfer for the purpose of safety. Each nursing department employee will be given a gait belt during orientation. All employees will receive education on the proper use of gait belt during orientation and annually. It will be the responsibility of each employee to ensure they have it available for use at all times when at work. Any and all repairs needed or issues with gait belt will be reported to the supervisor immediately for replacement. Failure to use gait belt properly may result in termination.
Record review of the facility's policy titled Safe resident handling/transfers dated 06/08/24 indicated in part: It is the policy of this facility to ensure that residents are handled and transferred safely to prevent or minimize risks for injury and provide and promote a safe, secure and comfortable experience for the resident while keeping the employees safe in accordance with current standards and guidelines. All residents require safe handling when transferred to prevent or minimize the risk for injury to themselves and the employees that assist them. While manual lifting techniques may be utilized dependent upon the resident's condition and mobility, the use of mechanical lifts are a safer alternative and should be used. Handling aids may include gait belts, transfer boards, and other devices (specify as applies).
Policies and Procedures were requested regarding fall mats but were not provided to surveyor before exit.
CONCERN
(D)
Potential for Harm - no one hurt, but risky conditions existed
Tube Feeding
(Tag F0693)
Could have caused harm · This affected 1 resident
**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, interview and record review the facility failed to ensure that a resident who is fed by enteral means rece...
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**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, interview and record review the facility failed to ensure that a resident who is fed by enteral means received the appropriate treatment and services to prevent complications of enteral feeding for one (Resident #111) of 4 residents reviewed for feeding by enteral means.
The facility failed to ensure that Resident #111's enteral feeding formula was properly labeled.
This failure put residents at risk of not receiving adequate nutrition by way of enteral feeding.
Findings included:
Record review of Resident #111's face sheet dated 07/17/2024 revealed he was [AGE] years old and was initially admitted to the facility on [DATE] and readmitted on [DATE].
Record review of Resident #111's history and physical dated 06/14/2024 revealed he had diagnoses including cerebral infarction (stroke), respiratory failure with hypoxia (not having enough oxygen in the blood), use of a tracheostomy (opening into the windpipe to breathe through), and a feeding tube. He was unable to speak or communicate his needs.
Record review of Resident #111's 5-day MDS assessment dated [DATE] revealed he was unable to speak and was rarely or never understood by others. He was totally dependent on others for all of his activities of daily living and was totally dependent on others to move. His diagnoses included pneumonia, CVA (stroke) and respiratory failure. He had been receiving nutrition through a feeding tube before he was a resident and was continuing to receive nutrition through a feeding tube as a facility resident.
Record review of Resident #111's care plan dated 04/20/2024 revealed he was receiving enteral feedings (tube feedings)
Record review of Resident #111's physician's order dated 06/14/2024 revealed he was to receive Jevity 1.2 (a type of enteral feeding formula) every shift at a rate of 70 ml per hour.
Observation on 07/16/24 at 2:52 PM revealed that Resident #111 was lying in bed. His eyes were open but he did not respond to questions. A plastic bottle with beige liquid was hanging from a pole next to Resident #111's bed, and a tube from the bottle led through a feeding pump and under the resident's bed clothes. Observation of all sides of the plastic bottle revealed no labels with information about who the feeding was for, the rate it was to be administered or any other information.
In an interview on 07/16/24 t 02:56 PM LVN J revealed she had hung Resident #111's tube feeding at mid-day and forgot to label it. She stated the purpose of the label was to document when the feeding was started, times, rate of administration and the patient who was to receive the tube feeding. She said that the risk to the resident was that he might get the wrong feeding or it might not be know how much he should receive.
Record review of the facility policy Enteral Formula Via Feeding tube, Bolus, Gravity Pump, dated 3/3/2020 revealed the bottle should be labeled with the resident name, room number, date changed and the nurse's signature/initials. The bag or bottle should also specify the physician order for formula, rate, route, and means of administration.
CONCERN
(D)
Potential for Harm - no one hurt, but risky conditions existed
Respiratory Care
(Tag F0695)
Could have caused harm · This affected 1 resident
**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, interview, and record review the facility failed to ensure that a resident who needed respiratory care was...
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**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, interview, and record review the facility failed to ensure that a resident who needed respiratory care was provided such care consistent with the comprehensive person-centered care plan, the resident's goals and preferences for 1 of 8 (Resident #19) residents reviewed for respiratory care.
The facility failed to ensure Resident #19 had her nasal cannula on per physicians' orders.
The findings included:
Record review of Resident #19's face sheet dated 07/17/24 revealed an [AGE] year-old female who was re-admitted to the facility on [DATE] with diagnoses of altered mental status, dementia (group of symptoms affecting memory, thinking and social abilities), anxiety (a feeling of worry, nervousness, or unease), cognitive communication deficit.
Record review of Resident #19's significant change in status MDS assessment dated [DATE] revealed a BIMS score 05, indicating her cognitive was severely impaired and was on oxygen therapy.
Record review of Resident #19's physician orders dated 02/20/24 revealed oxygen at 2 lpm via nasal cannula, every shift for shortness of breath and to maintain pulse oximeter above 90%.
Record review of Resident #19's care plan revealed focus area for risk for Respiratory infections/distress, Hypoxia (low levels of oxygen in your body tissues. It causes symptoms like confusion, restlessness, difficulty breathing, rapid heart rate, and bluish skin), SOB (shortness of breath), and cough related to DX (diagnoses) of COPD (Chronic obstructive pulmonary disease is a chronic inflammatory lung disease that causes obstructed airflow from the lungs). Resident on 2 L of continuous oxygen via nasal cannula with goal of will not exhibit signs of respiratory distress (restlessness, wheezing, dyspnea (shortness of breath), difficulty with expectoration (coughing up and spitting out the material produced in the respiratory tract), diaphoresis (cold sweats), crackles(abnormal lung sounds), tachycardia (heart beat faster than usual, greater than 100 beats per minute), cyanosis (bluish discoloration of your skin, lips or nails due to low oxygen in your blood), decreased breath sounds) through next review date and interventions administers oxygen as ordered, monitor and report signs of respiratory distress, monitor oxygen saturation via pulse oximetry as ordered.
During an observation on 07/16/24 at 10:53 am, Resident #19 was alert and oriented to person only, she was confused and could not answer questions. Resident #19 was in her room in her wheelchair with nasal cannula noted under her chin and was receiving oxygen therapy at 2 lpm. The oxygen tank was not empty. No signs of respiratory distress were noted.
During an observation on 07/16/24 at 10:56 am, CNA F walked in Resident #19's room with a comb to comb her hair, she washed her hands and exited Resident #19's room at 10:58 am. CNA F did not place nasal cannula in place for Resident #19.
During an observation and interview on 07/16/24 at 10:59 am, CNA G walked in Resident #19's room with oxygen tank and replaced her oxygen tank, CNA G stated Resident #19 had probably taken off the nasal cannula and exited Resident #19's room without placing the nasal cannula back on Resident #19.
During an observation and interview on 07/16/24 at 11:00 am, LVN H assessed Resident #19 and stated her oxygen saturation was at 71%, he placed the nasal cannula in place and her oxygen went up to 96%. LVN H asked Resident #19 questions, she denied shortness of breath and LVN H stated the CNAs were responsible of ensuring residents who received oxygen therapy always had their nasal cannula in place. LVN H stated the CNAs were to check the nasal cannula during their rounds and ensure it was in place before exiting the room and/or walking away from the resident. LVN H stated it was expected for CNA F and CNA G to check for Resident #19's nasal cannula placement and place back in place before they had exited the room. LVN H stated the charge nurses were responsible for ensuring the oxygen therapy was administered as prescribed by checking oxygen tanks and nasal cannula placement during the Q2 hour rounds and as needed. LVN H stated risk for not ensuring nasal cannula was in place for residents who received oxygen therapy was possible for respiratory distress.
During an interview on 07/16/24 at 11:04 am, CNA G stated she had been working at the facility for 8 months and had received training in oxygen therapy upon hire. CNA G stated she was trained to check for oxygen tanks to ensure they were always full and ensure residents had their nasal cannula in place. CNA G stated CNAs were responsible for ensuring oxygen therapy was administered as prescribed by ensuring nasal cannula was in place and oxygen tanks were full during their daily rounds at least every 2 hours and as needed. CNA G stated when did not check for Resident #19's nasal cannula placement after she replaced her oxygen tank. CNAA G stated she wanted to ensure the oxygen tank was replaced before it was empty and failed to check for nasal cannula placement because she became nervous. CNA G stated the risk for not placing nasal cannula in place was the risk of respiratory distress.
During an interview on 07/16/24 at 11:08 am, CNA F stated she forgot to check for Resident #19's nasal cannula after she finished combing her hair because she became nervous. CNA F said she received training on oxygen therapy upon hire and was told to ensure oxygen tanks were full and nasal cannulas were in place during her rounds. CNA F stated risk for not checking nasal cannula placement was possible respiratory distress.
During an interview on 07/17/24 at 10:54 am, the DON stated CNAs and LVNs were responsible for ensuring residents who received oxygen therapy had a full oxygen tank and nasal cannula was properly placed. The DON stated the CNAs were expected to check for oxygen tank and nasal cannula during their rounds and as needed, before exiting the resident's room. The DON stated CNAs received training on oxygen treatment upon hire and annually. The DON stated risk for not ensuring nasal cannulas were properly placed was respiratory distress.
Record review of Oxygen Administration policy dated 06/03/24 read in part oxygen is administered to residents who need it, consistent with professional standards of practice, the comprehensive person-centered care plans, and the resident's goals. Oxygen is administered under the orders of a physician, except in the case of an emergency. The resident's care plan shall identify the interventions for oxygen therapy, based upon the resident's assessment and orders, such as, but not limited to: the type of oxygen delivery system; when to administer, such as continuous intermittent and/or when to discontinue; equipment setting for prescribed flows rates; monitoring of oxygen saturation levels and/or vital signs, as ordered; monitoring for complications associated with the use of oxygen.
CONCERN
(D)
Potential for Harm - no one hurt, but risky conditions existed
Garbage Disposal
(Tag F0814)
Could have caused harm · This affected 1 resident
Based on observations and interviews, the facility failed to dispose of garbage and refuse properly for 1 barrel of used cooking oil outside of the facility.
One barrel used to dispose of used cooking...
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Based on observations and interviews, the facility failed to dispose of garbage and refuse properly for 1 barrel of used cooking oil outside of the facility.
One barrel used to dispose of used cooking oil was open without a lid and it had trash inside.
This failure could place residents at risk of decreased quality of life due to an exterior environment which could attract pests, rodents, and other animals.
Findings included:
Observation and interview on 07/17/24 at 11:21 AM with the DM revealed that the oil dump barrel was not covered . I was almost full to the brim of the barrel, and it had trash and debris inside floating on the used oil. The DM said that by having the barrel uncovered, there was a risk of it spilling and attracting pests such as flies and bugs. The DM said that the potential outcome could be that it affects the residents and staff from the facility and by attracting pests the residents could get sick if food from the kitchen is contaminated.
In an interview on 07/17/24 at 12:00 PM with the maintenance director revealed that when the equipment in the kitchen was cleaned such as the deep fryer, the cooking oil that had been used was dumped in the container located outside at the back of the facility to dispose of it. He said that there's a company that disposes of that oil, but he was not sure when that oil was picked up. He said the container must be closed and it should have a lid on top. The maintenance director said that if the container is not closed and if it rains, the oils and grease might overflow. He stated that people can get into the facility premises because there's a skate park at the back and it was possible they could do something to it like tipping it over. Upon looking at the picture of the container not covered, he said that it was not acceptable. The maintenance director said there was also a risk of attracting pests such as roaches and flies by not covering the container which could impact the safety and quality of life of the residents.
In an interview on 07/17/24 at 04:00 PM with the DON she stated that by the oil barrel not being sealed there was a potential risk for it to be spilled and that it could attract pests such as roaches and flies that could potentially harm the living situation of her residents. DON said there was a risk of harming the health and wellbeing of the residents of the facility.
In an interview on 07/18/24 09:36 AM with the administrator he stated that the risk of having the container exposed and without a lid is that it can attract insects such as flies and roaches and that can create a problem for the residents and staff at the facility. The administrator said that if it was to rain, the contents of the barrel could spill over, and it would create a potential hazard for the residents and staff in the facility.
Policies and Procedures for proper storage and disposal of garbage and refuse, was requested on 7/18/2024 but were not provided to the surveyor by the time of exit.
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 maintain an infection prevention and control program ...
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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 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 1 (Resident #25) of 12 residents reviewed for infection control in that:
NA B failed to wash her hands and change her gloves after they became contaminated during incontinent care while assisting Resident #25.
These failures could place resident's risk for cross contamination and the spread of infection.
Findings included:
Record review of Resident #25's admission record dated 07/17/2024 indicated he was admitted to the facility on [DATE] with diagnoses of dementia, muscle wasting and atrophy (muscle weakness). He was [AGE] years of age.
Record review of Resident #25's MDS dated [DATE] indicated in part: BIMS = 00 indicating resident had severe impairment. Bladder and bowel: Urinary/bowel continence = Always incontinent.
Record review of Resident #25's care plan initiated on 03/22/2024 indicated in part: Focus: I have bowel incontinence. Goal: I will remain free from skin breakdown due to incontinence and brief use through the review date. Interventions/Tasks: I use disposable briefs to enhance dignity. Change every 2 hours and prn. INCONTINENT: Check me every 2hrs and as required for incontinence. administer Pericare PRN. Change clothing PRN after incontinence episodes.
During an observation on 07/16/24 at 09:35 AM CNA A and NA B performed incontinent care for Resident #25. Upon entering the resident's room CNA, A washed her hands and NA B did not and proceeded to put on a gown and some gloves. Both aides undid the resident's brief, and he was noted to have a bowel movement. NA B took some wet wipes and wiped the bowel movement from the resident's rectal area. While still wearing the same gloves NA B turned the resident on his side as she placed her hands on the resident's back and arms. While still wearing the same gloves NA B took the soiled brief and placed it in the trash can then took a new brief and fastened it to Resident #25.
During an interview on 07/18/24 at 09:56 AM NA B said that she normally washed her hands or sanitized them before putting gloves on, but she was so nervous that she forgot to do that. NA B said that during the incontinent care of Resident #25 after her gloves became contaminated, she should have changed them to prevent any cross contamination. NA B said they received training regarding infection control and that she knew about washing her hands and changing her gloves but that she had gotten nervous due to the surveyor observing her and forgotten the steps. NA B said if she did not change her gloves after they became contaminated it could lead to cross contamination and the spread of infections.
During an interview on 07/18/24 at 10:12 AM ADON C was made aware of the observation of incontinent care performed by NA B. The ADON said she was in charge of doing the infection control training for staff such as handwashing but had not had a chance to do the training just yet as she had just started working at the facility on 06/24/2024. ADON C said it was expected for staff to wash or sanitize their hands before putting gloves on to perform resident care. The ADON said the staff were supposed to change their gloves after they became contaminated to prevent the spread of infections. ADON C said she felt the failure occurred because the staff member got nervous.
During an interview on 07/18/24 at 11:46 AM the DON was made aware of the observation of incontinent care performed by NA B. The DON said that staff were expected to wash their hands before putting gloves on and that they were supposed to change their gloves after they became contaminated. The DON said if the staff did not wash their hands or change their gloves that could lead to possible spread of infections. The DON said the ADONs were in charge of training and overseeing the CNAs regarding incontinent care and infection control.
During an interview on 07/18/24 at 03:48 PM the Administrator was made aware of the observation of incontinent care performed by NA B. The Administrator said the staff member was expected to wash her hands before putting gloves on and to change her gloves after they became contaminated. The Administrator said if the staff did not wash their hands or changed their gloves at the appropriate time that could lead to cross contamination. The Administrator said he would be meeting with the DON and discussing what they needed to do next regarding the training of staff.
Record review of the facility's policy titled Incontinence dated 02/2023 indicated in part: Based on the resident's comprehensive assessment, all residents that are incontinent will receive appropriate treatment and services. Residents that are incontinent of bladder or bowel will receive appropriate treatment to prevent infections and to restore continence to the extent possible.
Record review of the facility's policy titled Personal Protective Equipment dated 06/2024 indicated in part: This facility promotes appropriate use of personal protective equipment to prevent the transmission of pathogens to residents, visitors, and other staff. Personal protective equipment, or PPE, refers to a variety of barriers used alone or in combination to protect mucous membranes, skin, and clothing from contact with infectious agents. It includes gloves, gowns, face protection (facemasks, goggles, and face shields), and respiratory protection (respirators). All staff who have contact with residents and/or their environments must wear personal protective equipment as appropriate during resident care activities and at other times in which exposure to blood, body fluids, or potentially infectious materials is likely. PPE will be utilized as part of standard precautions regardless of a resident's suspected or confirmed infection status. Indications/considerations for PPE use: Gloves: Wear gloves when direct contact with blood, body fluids, mucous membranes, non-intact skin, or potentially contaminated surfaces or equipment is anticipated. Perform hand hygiene before donning gloves and after removal. Gloves are not a substitute for hand hygiene. Change gloves and perform hand hygiene between clean and dirty tasks, when moving from one body part to another, when heavily contaminated, or when torn.
Record review of the facility's policy titled infection prevention and control program dated 05/27/24 indicated in part: This facility has established and maintains 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 as per accepted national standards and guidelines. Standard precautions: all staff shall assume that all residents are potentially infected or colonized with an organism that could be transmitted during the course of providing resident care services. Hand hygiene shall be performed in accordance with our facility's established hand hygiene procedures. Direct care staff shall demonstrate competence in resident care procedures established by our facility.
CONCERN
(D)
Potential for Harm - no one hurt, but risky conditions existed
Room Equipment
(Tag F0908)
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 maintain all mechanical, electrical, and patient care e...
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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 maintain all mechanical, electrical, and patient care equipment in safe operating condition for 1 of 1 kitchen reviewed for safe operating equipment in safe operating condition.
The facility failed to maintain the stove in operational condition.
This failure could place residents at risk of foodborne illnesses; and potential for injury to residents and staff by not maintaining essential equipment in safe operating condition.
Findings include:
Observation and interview on 7/16/24 at 9:20 am with DM revealed that the oven on the right side of the stove was not working. She said it was reported to maintenance and documented in the work order log in the nurse's station. The DM showed the surveyor that she had logged in a request to repair the oven on 3/24/2024. The DM said she did not know what happened and why the oven was not fixed. The DM stated the risk of not having an oven in good condition could impact the residents at the facility who eat the food prepared in the kitchen by delaying services. The DM said another potential risk could be that if the oven did not show the correct temperature, it could result in the food not being cooked properly and that could potentially make the residents sick.
Observation and interview on 07/17/24 at 11:38 AM with the maintenance director revealed that staff were trained in how to report if something needed to be repaired. He explained staff needed to go to the rotunda or nursing station and make a note in the work order binder for whatever needed to be repaired. He said he reviewed the maintenance work order binder every morning to follow up. The maintenance director said he worked Monday to Friday and on-call on the weekends. He stated once he reviewed the binder, he checked on the equipment that needed to be repaired. The maintenance director said he reviewed the work order for the oven, and he determined he could not fix it himself. He contacted the vendor they had for the oven, they inspected the oven, and they sent him a quote explaining what was broken, what needed to be fixed and the cost of parts and labor. He said the work order was approved; it took about 3 weeks for them to repair the equipment, however it broke down again about 2 days after it was fixed. He called them back, told them they were under warranty for the repairs, the vendor went back about a week after, repaired the oven again and informed him a valve was blocked which was creating the issue. The maintenance director said the oven broke down again towards the end of April. He called them again, but he did not make a work order for it. They came back about a week after, inspected the oven and they disarmed the entire oven. The technicians found out that a solenoid (a solenoid gas valve is designed to control the gas flow in cooking appliances) relay was burned out and that made the oven short. They told him that the part was in back order and that's why they had not gone back to repair the oven. He said the facility had been waiting for about 3 months for the part. He said he called them back to follow up and they told him they would send an email letting him know what had happened. The maintenance director had not checked his email up until 07/17/24 11:53 AM. He stated that the oven was part of the essential equipment for the facility because that is how they prepared the food for the residents. The potential outcome was if the other oven from the stove broke down, the kitchen would not be able to prepare food for the residents and that could impact on how the residents are fed. He also stated if the temperature from the oven is not regulated, it could potentially get the residents sick if food was not prepared properly.
During an interview with the DON on 07/17/24 at 04:00 PM she stated that the oven is considered essential equipment because it is used to cook meals for most of the residents in the facility. The DON said the potential outcome of having an oven that is not working properly could result of the food not being cooked properly and get the residents sick.
During an interview on 07/18/24 at 09:36 AM with the administrator revealed that staff reported to the maintenance department about any broken appliances that must be fixed through the maintenance log which was in the rotunda or nursing station and the binder was blue in color so that way it was easy to identify; then the maintenance department director inspected the binder to see what needed to be addressed. The administrator said the binder was reviewed every morning when the maintenance director gets to his shift. He said he was aware that the oven was repaired around April and that they found out that the part was not the correct one and they were told by them that the part was in back order. When asked by the surveyor if the facility could use a different vendor to repair the oven or other appliances, the administrator said that it was possible to use a different vendor other than the current one. He said that there were no other efforts to find a different vendor because they were happy with their services. He said that the oven was not essential equipment. The surveyor requested from the administrator a policy stating what is considered essential equipment for the facility. He said that he did not think there was a risk for the residents if the oven was not functioning. He said there would be a risk if the oven was not functioning correctly and if food was not being cooked well because of it, but the oven not working did not present a risk for the residents.
Record review of a work order placed on 3/24/24 in the work order binder revealed that the oven was inspected by the maintenance director and it stated oven in kitchen keeps tripping the breaker after being plugged in.
Record review of a quote dated 4/30/2024 provided to the facility by [NAME] Heating, Cooling and Plumbing stated that the parts and labor included replacing the pilot safety valve, replacing the variable speed motor and that technicians would perform all repairs to manufacturers specifications and would test for a proper operation.
Record review of a policy titled work order request dated 07/2022, stated in part: When orders are completed, maintenance personnel will complete the assignment on the work order log in the maintenance book. Records of the work order for repairing the oven were not given to the surveyor by exit.
Policies and Procedures for what is considered essential equipment for the facility was requested on 7/18/2024 but were not provided to the surveyor by the time of exit.
CONCERN
(E)
Potential for Harm - no one hurt, but risky conditions existed
Medication Errors
(Tag F0758)
Could have caused harm · This affected multiple residents
**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on interviews and record review the facility failed to ensure that residents who have not use psychotropic drugs were not ...
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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 that residents who have not use psychotropic drugs were not given these drugs unless the medication was necessary to treat a specific condition as diagnosed and documented in the clinical record for 2 (Resident #274, Resident #111) of 8 residents reviewed for unnecessary medications.
The facility failed to ensure Resident #111 had an appropriate diagnosis for the use of Seroquel (an antipsychotic used to treat schizophrenia and bipolar disorder).
The facility failed to ensure Resident #274 had an end date for Zyprexa that was ordered PRN (as needed).
These failures could place residents at risk for adverse consequences such as impairment or decline in an individual's mental or physical condition of functional or psychosocial status from receiving unnecessary antipsychotic medications.
Findings included:
Resident #274
Record review of Resident #274's face sheet dated 07/17/24 revealed an [AGE] year-old who was admitted to the facility on [DATE] with diagnoses of altered mental status and cognitive communication and he was his own RP.
Record review of Resident #274's admission MDS dated [DATE] was still in progress of completion and BIMS was not yet completed.
Record review of Resident #274's physician order dated 07/13/24 revealed Seroquel oral tablet give 1 tablet by mouth two times a day for . The medication did not have any indication for use.
Record review of Resident #274's physician order dated 07/13/24 revealed Zyprexa intramuscular solution reconstituted 10 mg, (olanzapine) inject 5 mg intramuscularly every 24 hours as needed for acute manic (manic episode is a period of elevated mood or euphoria, racing thoughts, pressured speech, increased risk-taking, an inflated sense of self, and decreased need for sleep. These symptoms must persist for at least one week to be considered a manic episode) episodes. The medication did not have an end date.
Record review of Resident #274's care plan dated 07/11/24 revealed focus area for uses psychotropic medications and goals of will be/remain free of psychotropic drug related complications, including movement disorder, discomfort, hypotension, gait disturbance, constipation/impaction or cognitive/behavioral impairment through review date with interventions of administer psychotropic medications as ordered by physician, monitor side effects and effectiveness every shift; Consult with pharmacy, MD to consider dosage reduction when clinically appropriate at least quarterly; Discuss with MD, family re ongoing need for use of medication. Review behaviors/interventions and alternate therapies attempted and their effectiveness as per facility policy.
Record review of Resident #274's psychotropic consent dated 7/13/24 revealed Resident #274 had signed consent for Seroquel and Zyprexa.
During an interview on 07/17/24 at 11:00 am, the DON stated Resident #274's Seroquel did not have indication of use and that was not correct. The DON stated Resident #274 Zyprexa medication that was as needed did not have an end date and was also not correct. The DON stated the nurse who placed the medication in the computer was responsible for putting indication of psychotropic use and end date on as needed medication. The DON stated she was the nurse who had placed Resident #274 orders in over the weekend to assist her staff from home. The DON stated ADONs, and DON were responsible for ensuring psychotropic medications had indication of use and end date for those as needed medications and this was completed during weekly psychotropic medication audits. The DON stated failure to put indication for psychotropic mediation and end date for the as needed medication was administering unnecessary medication to the residents.
Resident 111
Record review of Resident #111's face sheet dated 07/17/2024 revealed he was [AGE] years old and was initially admitted to the facility on [DATE] and readmitted on [DATE].
Record review of Resident #111's history and physical dated 06/14/2024 revealed he had diagnoses including cerebral infarction (stroke), respiratory failure with hypoxia (not having enough oxygen in the blood), use of a tracheostomy (opening into the windpipe to breathe through), and a feeding tube. He was unable to speak or communicate his needs.
Record review of Resident #111's 5-day MDS assessment dated [DATE] revealed he was unable to speak and was rarely or never understood by others. He usually understood others. He was unable to participate in the BIMS interview. He had no symptoms of delirium, some symptoms of depression, no symptoms of psychosis and no behavioral symptoms. He had functional limitation in range of motion to his arms and legs. He was totally dependent on others for all of his activities of daily living and was totally dependent on others to move. His diagnoses included pneumonia, CVA (stroke) and respiratory failure. He had been administered antipsychotic medications during the seven days before the MDS assessment was completed. He had received 30 minutes of speech therapy, 15 minutes of occupational therapy, and 30 minutes of physical therapy in the seven days prior to the assessment. No restorative therapy was provided during the 7 day look-back period.
Record review of Resident #111's care plan dated 04/19/2024 revealed he was receiving psychotropic medications (medications that affect a person's mental state).
Record review of Resident 111's physician's order for olanzapine (an antipsychotic medication) 5 MG tablets dated 6/14/2024 revealed he was to receive one tablet every six hours as needed for agitation.
In an interview on 07/18/24 at 02:48 PM the DON revealed that an antipsychotics such Olanzapine should not be prescribed for agitation, such as was the case for Resident #111. She stated that antipsychotics should be avoided because of long term side effects, such as dependence, and extrapyramidal effects (involuntary movements). She stated that all PRN orders for psychotropic medications such as Olanzapine should have a 14 day limit. The 14 day limit was so the physician could review the medication to see if it was still appropriate for the resident, otherwise the resident might be receiving a medication that was unnecessary.
Record review of use of Psychotropic Medication policy dated 06/15/24 read in part Residents are not given psychotropic drugs unless the medication is necessary to treat a specific condition, as diagnosed and documented in the clinical record, and the medication is beneficial to the resident, as demonstrated by monitoring and documentation of the resident's response to the meditation. Policy Explanation and Compliance Guidelines: 4. The indications for use of any psychotropic drug will be documented in the medical record. a. Pre-admission screening and other pre-admission data shall be utilized for determining indications for use of medications ordered upon admission to the facility. b. For psychotropic drugs that are initiated after admission to the facility, documentation shall include the specific condition as diagnosed by the physician. i. Psychotropic medications shall be initiated only after medical, physical, functional, psychosocial, and environmental causes have been identified and addressed. ii. Non-pharmacological interventions that have been attempted, and the target symptoms for monitoring shall be included in the documentation. 9. PRN orders for all psychotropic drugs shall be used only when the medication is necessary to treat a diagnosed specific condition that is documented in the clinical record, and for a limited duration (i.e. 14 days). a. If the attending physician or prescribing practitioner believes that it is appropriate for the PRN order to be extended beyond 14 days, he or she shall document their rationale in the resident's medical record and indicate the duration for the PRN order.
CONCERN
(E)
Potential for Harm - no one hurt, but risky conditions existed
Food Safety
(Tag F0812)
Could have caused harm · This affected multiple residents
Based on observations, interviews, and record review the facility failed to store, prepare, distribute, and serve food in accordance with professional standards for food service safety in 1 of 1 kitch...
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Based on observations, interviews, and record review the facility failed to store, prepare, distribute, and serve food in accordance with professional standards for food service safety in 1 of 1 kitchen reviewed for sanitation and food storage.
The facility failed to store food in sealed containers.
The facility failed to keep bottles free of dry drippings.
The facility failed to store food above the floor in the walk-in freezer.
These failures could affect residents by placing them at risk of food borne illness.
Findings include:
Interview and observation on 7/16/24 at 8:20 am with cook, revealed a bag of chips open an unsealed inside the pantry. She stated that there was a potential for the contents of the bag to be contaminated and if residents were to eat from those chips, they could get sick, and if chips were mushy, there was a risk of chocking for those who have issues with consistency if they need to be chewing on them.
During an observation inside the walk-in freezer revealed a box of frozen vegetables on the floor. The cook stated that the box should not be on the floor because there was a risk of contamination and that the residents could get sick. The surveyor showed to dietary manager the picture of the open bag containing chips that was found inside the pantry and she stated it was unacceptable because every item needed to be inside a sealed bag or container and the risk of having food unsealed was the potential of things such as dust getting inside the unsealed bag creating bacteria in the food which could potentially make the residents sick.
In an interview on 07/16/24 at 08:29 AM with the dietary manager revealed there was a risk of bacteria growing on the vegetables if they were to be in contact with the floor. A box of mini muffins was observed on the top of a metal rack inside the walk-in freezer. They were soaked with water dripping from the condensation on the ceiling of the freezer and the dietary manager said that no boxes should be stored there. She said that there was a risk of mold and bacteria growing on the bread caused by the accumulation of water inside the box from the ice condensation from the freezer.
During Observation and Interview on 07/16/24 09:16 AM with Dietary Manager revealed a container with jelly not properly closed. A chocolate dessert topping bottle had dry chocolate drippings. Interview with cook revealed that if the jelly container was not properly closed, there was a risk of the contents spilling inside the refrigerator and that could potentially contaminate the rest of the food stored inside. She also said that there was a risk of bacteria growing inside the container, contaminating the jelly and there was a risk if the food was served to the residents, they could get sick if they ate it. She said the same could happen with the chocolate drippings on the bottle. Upon showing the pictures of the container with the jelly and the dry chocolate drippings to the dietary manager, she stated that it was not acceptable to have unsealed containers inside the refrigerator because they can spill its contents inside potentially contaminating the rest of the food stored as well as potentially growing bacteria which could make the resident sick if they ingested the contaminated food. She said that dry drippings can also grow bacteria which could contaminate the food inside the refrigerator and that they could make the resident sick. The dietary manager said the expectation was for kitchen staff to clean the containers or bottles each time they finish using them to avoid the risk of contamination .
In an interview on 07/17/24 04:00 PM with the DON, the surveyor showed the pictures of the box with vegetables on the floor of the walk-in freezer, the wet box of muffins on the top the metal rack below the ice condensation inside the freezer, the open bag of chips inside the pantry, and the dried drippings on the chocolate bottle. The DON said it was not acceptable because all those food items could get contaminated; she said if the box of vegetables found on the floor of the freezer were to be contaminated and they were to be used, the risk was the residents could get sick. DON said that the possible outcome would be the same for the box with the mini muffins, the open bag of chips and the dry drippings of chocolate on the bottle and said that there was a potential risk of all those items growing bacteria which could get the residents sick if they were served that food.
In an interview on 07/18/24 at 09:36 AM with the administrator, revealed a box of vegetables found on the floor of the walk-in freezer, he said that it was not acceptable because there was a risk of cross contamination. For the wet box containing mini muffins with the ice condensation on top, he stated that there was risk that the condensation could leak into the box creating bacteria on the muffins. He stated that same outcome could happen with the open bag of chips from the pantry and the dry drippings from the bottle with chocolate. He stated that the risk of the residents ingesting food prepared with any of these items could result in them getting sick from their stomach if bacteria had grown on the food.
Record Review of the policy titled Food Safety Requirements dated 07/2022 states in part: Policy Explanation and Compliance Guidelines. Storage of food in a manner that helps prevent deterioration or contamination of the food, including growth of microorganisms.
B. Dry food storage - keep foods/beverages in a clean, dry area off the floor and clear of ceiling sprinklers, sewer/waste disposal pipes, and vents.
C. Refrigerated storage - foods that require refrigeration shall be refrigerated immediately upon receipt or placed in freezer, whichever is applicable. Practices to maintain safer refrigerated storage include keeping foods covered or in tight containers.
8. Additional strategies to prevent foodborne illness include preventing cross-contamination of food.
MINOR
(B)
Minor Issue - procedural, no safety impact
MDS Data Transmission
(Tag F0640)
Minor procedural issue · This affected multiple residents
**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on interviews and record review the facility failed to electronically transmit within 14 days after the facility completed...
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**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on interviews and record review the facility failed to electronically transmit within 14 days after the facility completed a resident's assessment, encoded MDS data including a subset of items upon a resident's transfer, reentry, discharge, and death for 5 (Residents #2, #201, #104, #92 and #74) of 6 residents reviewed for electronic transmission of MDS data to the CMS system.
The facility failed to transmit discharge MDS data to the CMS system for Residents #2, #201, #104, #92 and #74 within 14 days of Resident s discharge from the facility.
This failure could place residents at risk of not having specific information transmitted in a timely manner.
Findings included:
Record review of Resident #2's face sheet dated 07/18/2024 revealed she was [AGE] years old, was initially admitted on [DATE] and readmitted on [DATE].
Record review of Resident #2's Annual assessment MDS dated [DATE] revealed she had a BIMS score of 2 (Severe cognitive impairment). Her diagnoses included dementia, depression and psychotic disorder.
Record review of Resident #2's electronic census log revealed she was discharged from the facility on 04/19/2024.
Record review of Resident #2's MDS electronic log page accessed 07/18/2024 revealed her discharge ARD date was 04/19/2024, the discharge ARD was to be completed on 05/03/2024 and was 76 days overdue.
In an interview on 07/18/24 at 02:14 PM MDS Nurse D revealed that Resident #2's discharge MDS was pending transmission and should have already been transmitted by MDS Nurse E. He did not know why MDS Nurse E had not transmitted the file.
Record review of Resident #102's face sheet dated 07/18/2024 revealed he was [AGE] years old and was initially admitted to the facility on [DATE] and readmitted on [DATE].
Record review of Resident #102's 5-day MDS dated [DATE] revealed he had a BIMS score of 13 (cognitively intact). His diagnoses included Parkinson's Disease, Chronic Obstructive Pulmonary Disease (lung condition that causes breathing difficulties), and epilepsy.
Record review of Resident #102's electronic census log revealed he was discharged from the facility on 02/01/2024.
Record review of Resident #102's MDS electronic log page accessed 07/18/2024 revealed his Medicare 5-Day MDS report dated 02/02/2024 was incomplete.
In an interview on 07/18/2024 at 02:14 PM MDS Nurse D revealed that since a Modification of Medicare - 5 Day MDS for Resident #102 went out on 02/01/2024, another MDS did not need to go out.
Record review of Resident #104's face sheet dated 07/18/2024 revealed he was [AGE] years old and was admitted to the facility on [DATE].
Record review of Resident #104's admission MDS dated [DATE] revealed he was not able to participate in the BIMS interview because he was rarely or never understood. His diagnoses included diabetes, a seizure disorder, and an unspecified disorder of the brain.
Record review of Resident #104's electronic census log revealed he was discharged from the facility on 04/22/2024.
Record review of Resident #104's MDS electronic log page accessed 07/18/2024 revealed his Death MDS had an ARD date of 04/22/2024, that the MDS was to be completed by 4/29/2024 and was 80 days overdue.
In an interview on 07/18/2024 at 02:14 PM MDS Nurse D revealed that another MDS for Resident #104 should have gone out after a Modification of Medicare - 5 Day MDS went out on 02/01/2024. He did not know why the Death MDS did not go out.
Record review of Resident #92's face sheet dated 07/18/2024 revealed she was [AGE] years old and was admitted to the facility on [DATE].
Record review of Resident #92's 5-Day MDS dated [DATE] revealed her BIMS score was 3 (Severe cognitive impairment). Her diagnoses included diabetes, and a urinary tract infection.
Record review of Resident #92's electronic census log revealed she was discharged from the facility on 03/01/2024.
Record review of Resident #92's MDS electronic log page accessed 07/18/2024 revealed she had a Medicare 5-day MDS dated [DATE] that was incomplete.
In an interview on 07/18/2024 at 02:14 PM MDS Nurse D revealed he did not think another MDS needed to go out for Resident #92 since another 5-day MDS had been submitted.
Record review of Resident #74's face sheet dated 07/18/2024 revealed he was [AGE] years old and was admitted to the facility on [DATE].
Record review of Resident #74's admission MDS dated [DATE] revealed his BIMS score was 14 (cognitively intact). His diagnoses included lung cancer and deep vein thrombosis (blood clot, usually in the leg).
Record review of Resident #74's electronic census log revealed he was discharged from the facility on 03/25/2024.
Record review of Resident #74's MDS electronic log page accessed 07/18/2024 revealed his discharge MDS ARD 03/25/2024 was to be completed by 04/08/2024 and was 101 days overdue.
In an interview on 07/18/2024 at 02:14 PM MDS Nurse D revealed Resident #92 had insurance through an HMO and that was probably why the MDS had not been transmitted.
In an interview on 07/18/24 at 02:51 PM the DON revealed that the MDS department was overseen by a corporate supervisor who was responsible for ensuring that MDS assessments were transmitted.
In an interview on 07/18/24 at 02:53 PM MDS Nurse E said she had consulted with the MDS corporate supervisor who had told her that the MDSs in question did not need to be modified and had been transmitted. She provided a document CMS Submission Report dated 07/18/2024.
Record review of the CMS Submission Report dated 07/18/2024 revealed that on 07/18/2024 MDS records were transmitted for Residents #2, #201, #104, #92 and #74.
Record review of the facility policy MDS 3.0 Completion dated 2023 revealed that transmissions would be transmitted to the designated CMS system within 14 days of completion.
Jul 2024
1 deficiency
1 IJ
CRITICAL
(J)
📢 Someone Reported This
A family member, employee, or ombudsman was alarmed enough to file a formal complaint
Immediate Jeopardy (IJ) - the most serious Medicare violation
Accident Prevention
(Tag F0689)
Someone could have died · This affected 1 resident
**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, interview, and record review the facility failed to ensure each resident receives adequate supervision and...
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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 each resident receives adequate supervision and assistance devices to prevent accidents for 1 (Resident #1) of 10 residents reviewed for missing person.
The facility failed to provide supervision to prevent accidents for Resident #1 who exited the building on 4/19/24 and was left to sleep outside overnight.
This failure placed Resident #1 at risk of insect bites, a fall, and weather exposure, which could result in injuries, hospitalization, or death.
The noncompliance was identified as PNC. The IJ began on 4/19/24 and ended 04/22/24. The facility had corrected the noncompliance before the survey began.
Findings included:
Record review of Resident #1's face sheet dated 07/09/24 revealed a [AGE] year-old male with diagnosis of Parkinson's disease, altered mental status, muscle wasting and atrophy, muscle weakness, unspecified lack of coordination, cognitive communication deficit. He did not have a history of wandering and/or exit seeking.
Record review of Resident #1's quarterly MDS assessment dated [DATE] revealed a BIMS score of 11, indicating he had moderate cognitive impairment and required x1 person assist with transfers.
Record review of Resident #1's elopement risk dated 02/07/24 revealed his physical capability was total dependence, he understood and verbalized acceptance of needs for nursing home, no history of attempts to leave own residence/facility, no restless or anxiety, he was a new admission, he recognized stop lights and signs, knows precautions when crossing streets, can state his name, knew location of current residence and recognized his physical needs. He was scored low for elopement risk.
Record review of Resident #1's baseline care plan dated 02/08/24 revealed I am a smoker; I have been assessed to be: independent smoker with goals My desire to smoke will be honored daily and will smoke in designated area through next review date and interventions of complete smoking assessment as per facility policy, ensure I am aware of smoking times and assist if needed, ensure staff aware of my smoking desire. There was also a focus area for ADL self-care perform ance deficit with goal will improve current level of function with all ADL's through the review date and interventions of [Resident #1] requires assistance by staff to maximize independence with transferring.
Record review of Resident #1's smoking assessment dated [DATE] revealed he was cognitively capable of making the decision to smoke. He was able to understand the facility smoking policy. Resident #1 was able to indicate designated smoking area verbally/physically. Resident #1 did not have any functional limitation to prevent him from smoking without assistance or supervision. Resident #1 was able to independently light his own cigarette and had adequate vision. Resident #1 did not have a history of smoking related problems that would be hazardous to self or others. He was able to verbalize understanding of the facility's smoking policy and issues related to smoking. Resident #1 did not show any physical signs that he may have a problem with smoking safely such as cigarette burn holes in clothing, burns in body, burn on Resident #1 or/in furniture . Resident #1 did not require smoking apron, cigarette holder and supervision while smoking,
Record review of Resident #1's MARS dated April 2024 revealed no medications were missed between 9:27 pm to 6:52 am Last scheduled medication was administered at 8pm on 04/19/24.
Record review of facility's incident report log for April 2024, revealed no incidents noted the night of 04/19/24.
Record review of patio footage revealed:
4/19/24 at 09:21:01 PM door is seen being pushed (in the bistro area).
4/19/24 at 09:27:18 PM Resident #1 was seen pushing door with hands and feet and he is on a wheelchair.
4/19/24 at 09:30:17 PM Resident #1 pushed door wider with feet. The footage did not have audio.
4/19/24 at 09:34:33 PM Resident #1 made his way out from door.
4/19/24 at 09:39:51 PM Resident #1 was seen making his way down the walkway outside.
4/19/24 at 09:43:12 PM Resident #1 was last seen on video.
4/20/24 at 06:28:47 AM empty wheelchair seen by the fence in patio area, Resident #1 was not seen.
4/20/24 at 06:40 AM Resident #1's head was seen as if raising his head.
4/20/24 at 06:52:50 AM LVN E was seen walking out and walked over to wheelchair.
4/20/24 at 06:53:32 AM LVN E approached Resident #1.
4/20/24 at 06:54:50 AM RN D was seen walking out to both LVN E and Resident #1.
4/20/24 at 06:55:52 AM both nurses assisted Resident #1 to wheelchair.
4/20/24 at 06:56:26 AM LVN E, RN D and Resident #1 entered facility.
Record review of nurses' station footage revealed:
04/19/24 at 09:28:43 PM CNA A seen walking by bistro looking to the bistro direction and continued walking.
Refence timeline above.
4/19/24 at 09:27:18 PM Resident #1 was seen pushing door with hands and feet. He is on a wheelchair.
4/19/24 at 09:30:17 PM Resident #1 pushed door wider with feet and went outside.
During an interview on 07/09/24 at 5:36 am, CNA B stated she had worked the night shift (10 pm-6 am) on 04/19/24. CNA B stated when she arrived for report at around 9:50 pm, no unusual reports were provided. CNA B stated when she did her first round around little after 10 pm, she had noticed Resident #1 was not in his room and assumed he had gone out with family. CNA B stated she did her second round around midnight and had noticed Resident #1 was not in his room and reported to LVN C whose response was OK and continued to be on her phone. CNA B stated her 3rd round at approximately 2 am, she noticed Resident #1 was not in his room and reported it again to LVN C whose response was the same. CNA B stated she did not ask any other staff for Resident #1's whereabouts due to LVN C's unbothered response to both reports. CNA B stated 2 days later she had been questioned by the Administrator in which she realized Resident #1 had been left outside the night she had reported him not being in his room. CNA B stated she had received in-services on conducting head count at beginning of shift, alternating Q2 hour checks by CNAs and LVNs for hourly rounds to be achieved, code purple (missing person), and change of shift report to be completed room by room at bedside. CNA B stated prior to the incident she had been trained to report a missing person to her supervisor and on 04/19/24 the charge nurse (LVN C) was her supervisor.
During interview on 07/09/24 at 9:01 am, Resident #1 stated he remembered the incident but does not remember the date. Resident #1 stated he wanted to go smoke and did not ask anyone. He stated he went to the back patio and pushed on the door hard enough and eventually it opened. Resident #1 stated he stared at the moon and lost track of time. He stated he remembered he fell and was not hurt. Resident #1 stated he stayed on the floor of the patio and woke up on the floor the next day. Resident #1 stated he did not sustain injuries and was not cold. Resident #1 stated he was wearing pajama pants and a tshirt. Resident #1 stated he felt safe and comfortable at the facility. Resident #1 stated he was shocked that he stayed outside all night but has not been affected by it.
During an interview on 7/9/24 at 9:25 am, The Administrator stated during his investigation related to Resident #1's incident on Monday 04/23/24 he had asked the Maintenance Director to check the patio and nurse's station footage. The Administrator stated during his review of the nurse's station footage he identified CNA A looking in the direction of Resident #1 when attempting to exit the door and he continued walking as if he did not care. The Administrator stated he also identified LVN C had not been conducting her night rounds. The Administrator stated when he reviewed the footage in pieces as it allows, LVN C was seen either in the nurse's station on her phone or walking in and out of rooms but did not see her checking Resident #1's room. The Administrator stated he did not talk to CNA A due to him not returning call back since he no longer worked at the facility. The Administrator stated he had intended to suspend LVN C, but she had resigned as soon as she was questioned about the incident. The Administrator stated LVN C had stated she was busy attending to residents with tracheostomies because their alarm had gone off at least twice during the night shift and continued with medication administration and restocking supplies. The Administrator stated CNA B had reported and gave written statement she had voiced concern of Resident #1 not being in his room the night of 04/19/24 on 2 occasions and LVN C had dismissed her concerns with OK and continued to be on her phone. The Administrator stated he spoke to Resident #1 who had reported he was ok; he had mentioned wanting to go out to smoke and got distracted by watching the moon. The Administrator stated Resident #1 had alleged he had a fall and eventually dozed off and fell asleep on the floor. The Administrator stated no injuries were identified and Resident #1 had denied any pain/discomfort and denied being cold overnight. The Administrator stated he had referenced the weather and had been a little chilly over the weekend. The Administrator stated he referred LVN C's license to the Texas Board of Nursing due to lack of monitoring that placed Resident #1 at risk and about 60 residents that had been under her care on 04/19/24. The Administrator stated the facility-initiated in-services for conducting head count at beginning of shift, alternating Q2 hour checks by CNAs and LVNs for hourly rounds to be achieved, code purple (missing person), and change of shift report to be completed room by room at bedside. The Administrator stated someone had not reactivated the bistro door exit alarm that resulted in the alarm not activating when Resident #1 had pushed on the bistro exit door. The Administrator stated the bistro exit door had a delayed egress bar. The Administrator stated the Maintenance Director completed an in-service to ensure the exit doors are reactivated with pin pad by door that was alarming after silencing the alarm in the alarm panel. The Administrator stated a notice was placed over the alarm pad that instructed and reminded staff on the steps to check what door was alarming, how to silence the alarm, and to reset the door alarm by the keypad where the door was alarming. The Administrator stated this failure could have placed Resident #1 at risk of injury and insect bites. The Administrator stated the DON was responsible for overseeing the CNAs and charge nurses regarding bedside shift change report to ensure all residents were in their assigned room. The Administrator stated no other incidents were identified/reported for the night of 04/19/24.
During an interview on 07/09/24 at 10:01 am, the DON stated she had started working at the facility after the incident with Resident #1 occurred. The DON stated she had been notified of the incident by the Administrator and had continued to monitor the at bedside change of shift report by spot checking at random. The DON stated there had not been similar incidents reported. The DON stated per Resident #1 elopement assessment he did not have elopement/ wandering behavior. The DON stated residents who had history of wandering and/or elopement had been moved to be placed in front of the nurse's station for closer monitoring. The DON stated this had been completed prior to her starting her job at the facility. The DON stated she had not received any report on missing person since she had started working at the facility. The all-door exits were delayed egress bar no issues have [NAME] identified with alarms not working. The DON stated maintenance had in-serviced staff on reactivating the alarm when coming back inside.
A call was placed on 07/09/24 at 10:31 am to CNA A, but the mailbox was full and was unable to leave a VM with information to return call.
During an interview on 07/09/24 at 1:19 pm, RN D stated Resident #1 was her patient on 04/20/24 coming on the 6am-2pm shift. RN D stated when she received report from LVN C she had mentioned there had been a few room changes and she was not going to go look for them. RN D stated LVN C did the narcotic count with her and gave report with minimal information, and she left. RN D stated when she started her initial rounds, she had noticed Resident #1 was not in his room, and she alerted CNAs to assist with room checks as she continued her rounds. RN D stated when she was notified by CNAs that Resident #1 was not in any of the rooms in his assigned hallway, she initiated code purple (missing person) and LVN E had called her to notify her that Resident #1 was found outside in the patio by him and was on the floor. RN D stated she went outside to the patio and saw LVN E with Resident #1 who was on the floor. LVN E stated she had assessed him and did not find any injuries; Resident #1 had denied any pain and denied any discomfort. RN D stated LVN E and she assisted Resident #1 back to his wheelchair and took him inside to get bathed and cleaned up. RN D stated Resident #1 was monitored closely the rest of the day with no changes in condition noted. RN D stated she notified NP who gave orders for continued monitoring. RN D stated the facility-initiated in-services for conducting head count at beginning of shift, alternating Q2 hour checks by CNAs and LVNs for hourly rounds to be achieved, code purple (missing person), to ensure the alarm was reactivated and where to find instructions to activated the alarms, and change of shift report to be completed room by room at bedside.
During interview on 07/09/24 at 1:32 pm, LVN C stated she had arrived around 10 pm on 4/19/24, received report from one hallway at around 10:10 pm and proceeded to get report from the second hallway she was responsible for. LVN C stated she was the nurse responsible for the hallway where Resident #1 allegedly resided. (reviewed census dated 04/19/24; Resident #1 was on one of the hallways under LVN C's care). LVN C stated after she received report she had intended to start initial rounds but was side tracked by 2 residents with tracheostomies whose alarm started going on. LVN C stated that took some time to take care of. LVN C stated she then attempted to initiate rounds but was pulled by one of the CNAs who had stated a female resident who was on the census was not in the room. LVN C stated they looked around and the female resident was located on a different hallway. LVN C stated after that was settled, she started restocking and getting her things ready for blood sugar checks. LVN C stated she had asked the CNAs if everyone was in their room and they had stated yes. LVN C stated she got busy with medication administration and her residents with tracheostomies required treatments. LVN C stated she was not notified of Resident #1 not being in his room and had not rounded on Resident #1 due to being busy with what was explained.
A call was placed on 07/09/24 at 2:53 pm to CNA A, but the mailbox was full and was unable to leave a VM with information to return call. The call was not returned by date and time of exit on 07/10/24.
Record review of undated Elopement/Missing Resident policy read in part To provide an organized procedure to search for an eloped or missing resident. Staff will respond in timely and organized manner to search for a resident who has eloped or is missing. A- when a resident is noted missing from the room or unit, the staff shall inform the DON of the charge nurse in his/her absence, that we have an elopement or missing resident, the residents name, and the room number.
The facility completed the following corrective actions to address the non-compliance after the incident occurred but prior to the surveyor entering on 07/03/24.
In-services conducted and completed on 04/22/24 for:
In-service on conducting head count at beginning of shift.
In-service on alternating Q2 hour checks by CNAs and LVNs for hourly rounds to be achieved. (i.e., CNAs do 10pm, 12 am, 2 am, 4 am rounds and charge nurses do 11pm, 1am, 3am, 5 am rounds)
In-service on code purple (missing person)
In-service on change of shift report to be completed room by room at bedside.
In-service on reporting to charge nurse, verifying with other staff on all hallways (CNAs and nurses) for resident accountability, and when not found in premises report to DON.
In-service on ensure the adjacent door is checked and verified for closure and potential missing residents.
In-service on ensure the alarm was reactivated, the alarms are to prevent elopement, checking to ensure no one has left is essential to alarm process.
Record review of Resident #1's skin assessment dated [DATE] revealed no injuries noted.
Record review of Resident #1's pain assessment dated [DATE] revealed no pain/distress noted and no pain voiced by Resident #1.
Record review of Resident #1's SBAR dated 04/20/24 revealed no injuries noted, family member and physician were notified with no new orders provided.
LVN C's license was reported to TBON (Texas Board of Nursing) on 05/02/24.
LVN C's timesheet for month of April 2024 revealed 04/19/24 night shift was last day worked.
CNA A's timesheet for month of April 2024 revealed 04/19/24 night shift was last day worked.
Observation and interviews on 7/9/24 from 4:30 am- 6:30 am revealed CNAs B, H, I J and LVNs F, G, L, M received and understood in-services on conducting head count at beginning of shift, alternating Q2 hour checks by CNAs and LVNs for hourly rounds to be achieved, code purple (missing person), to ensure the alarm was reactivated and where to find instructions to activated the alarms, and change of shift report to be completed room by room at bedside. CNBs A, H, I J and LVNs F, G, L, M observed going in room by room for change of shift report. LVN E pushed bistro exit door and the alarm activated, CNA H and LVN G responded to the door alarm, and they pointed at the instructions over the alarm panel that read open the alarm panel, silence the alarm, light should be green. Check the surroundings with nurse in the area by that door is alarming making sure nobody gets out, then, reset the door at keypad by door alarming. Go back to panel to arm the alarm, light should be green.
Apr 2024
6 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
Resident Rights
(Tag F0550)
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 treat each resident with respect and dignity and care f...
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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 treat each resident with respect and dignity and care for each resident in a manner and in an environment that promotes maintenance or enhancement of his or her quality of life, recognizing each resident's individuality for 1 (Resident #2) of 3 residents reviewed for dignity.
Resident #2 did not have a privacy bag on his catheter bag.
This failure could place residents at risk of diminished quality of life.
Findings included:
Record review of Resident #2's face sheet dated 04/23/24, revealed, admission on [DATE] to the facility.
Record review of Resident #2's facility history and physical dated 03/01/24, revealed, an [AGE] year-old male diagnosed with Dementia, Diabetes, Urinary Tract Infection.
Record review of Resident #2's admission MDS dated [DATE], revealed, a severe cognitive impairment to be able to recall and make daily decisions BIMS (used to get a quick snapshot of how well you are functioning cognitively at the moment) score of a 4. Resident #2 was not rated for urinary continence but did have an indwelling catheter. Was diagnosed with Diabetes Mellitus, Metabolic encephalopathy (a problem in the brain), and Dementia.
Record review of Resident #2's care plan dated 03//04/24, revealed, foley catheter 16 French10 cc (measures the diameter of the tube, larger sizes will be a higher number. Smaller sizes will be a lower number). Monitor and document intake and output as per facility policy, discomfort on urination and frequency, pain/comfort due to catheter.
Record review of Resident #2's order recap dated 03/01/24, revealed, Privacy bag for urinary drainage at all times while in bed, while walking or in wheelchair every shift.
Observation on 04/17/24 at 11:26 AM, revealed, Resident #2's catheter bag hung on the side of his bag. The catheter bag could be seen from the hallway with no privacy bag cover on. The catheter bag had dark yellow brownish urine in it about half ways.
During an interview on 04/23/24 at 1:54 PM, with LVN I, she stated all catheter bags needed to have privacy covers on at all times. LVN I stated the privacy covers were meant to be on for the residents dignity and infection control.
Observation on 04/23/24 at 2:59 PM, revealed, Resident #2 lying down in bed. Catheter bag was hung off the side of the bed. Catheter bag was tilted, the urine inside was dark yellow brownish indicating leveled at 7- 100 milliliters. Off the foot board of the bed was Resident #2's wheelchair with the privacy bag clipped onto the back of the wheelchair bars.
During an interview on 04/23/24 at 4:41 PM, with the DON, she stated resident catheter bags need to have a privacy cover. The DON stated Resident #2 needed to have a privacy cover on his catheter bag. The DON stated the reason for the privacy cover was for their dignity and so they could keep their medical issues private.
Record review of the facility Catheter Care policy dated 01/31/24, revealed, It was the policy of this facility to ensure that residents with indwelling catheters receive appropriate catheter care and maintain their dignity and privacy when indwelling catheters are in use.
Privacy bags will be available and catheter drainage bags will be covered at all times while in use (per resident preference).
CONCERN
(D)
📢 Someone Reported This
A family member, employee, or ombudsman was alarmed enough to file a formal complaint
Potential for Harm - no one hurt, but risky conditions existed
PASARR Coordination
(Tag F0644)
Could have caused harm · This affected 1 resident
**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on interviews and record reviews the facility failed to coordinate the assessment following the PASRR Completion PCSP for ...
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**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on interviews and record reviews the facility failed to coordinate the assessment following the PASRR Completion PCSP for 1 (Resident #8) of 2 residents with the pre-admission screening and resident review (PASRR) program, of resident assessments reviewed for PASRR services.
The facility to provide PASRR services for Resident #8 who was PASRR positive for intellectual disabilities by not submitting a request to the state agency for PASRR services.
This failure could affect residents who are PASRR positive of not receiving needed PASRR services which could lead to a decline in health and well-being.
Findings included:
Record review of Resident #8's face sheet dated 04/17/24, revealed, admission on [DATE] and re-admission on [DATE] to the facility.
Record review of Resident #8's facility history and physical dated 10/02/23, revealed, a [AGE] year-old female diagnosed with Epilepsy (a chronic noncommunicable disease of the brain that affects people of all ages), delusional disorders (an unshakable belief in something that's untrue), history of traumatic brain injury (a sudden injury that causes damage to the brain), seizures (a sudden, uncontrolled burst of electrical activity in the brain).
Record review of Resident #8's quarterly MDS dated [DATE], revealed, no BIMS score was taken due to the resident not being interviewed. Unknown severity of cognition Resident #8 diagnosed with anxiety disorder, traumatic brain injury, seizure disorder, altered mental status (a change in mental function that stems from illnesses, disorders and injuries affecting your brain), surgery on nervous system.
Record review of Resident #8's PASRR Level 1 Screening dated 09/25/23, revealed, positive for mental illness, intellectual disability, and developmental disability.
Record review of Resident #8's orders dated 09/25/23, revealed, physical therapy, occupational therapy, and speech therapy to evaluated and treat as indicated.
Record review of Resident #8's PASRR Evaluation dated 10/05/23, revealed, PASRR positive for intellectual disability and developmental disability. Negative for mental illness.
Record review of Resident #8's PSCP dated 10/17/23, revealed, the local mental health authority B & C, Resident #8, RN A, Director of Rehabilitation, and the Social Worker met to discuss PASRR services. PASRR Services were marked as not needed. Nursing Facility Comments - Care plan goals reviewed: Plan of Care reviewed, not eligible for state PASRR Services at this time.
Local Authority Specialized Services Comments - Resident #8 as per nursing required extensive assistance for dressing, supervision for eating and frequently incontinent. Resident #8 had behaviors of hitting herself, fall(s), and had out of state insurance.
Record review of Resident #8's care plan dated 11/01/23, revealed, PASRR positive related to intellectual/developmental disability. Administer medication as ordered, monitor for effectiveness and side effects. Invite the LIDDA representative and responsible party to the quarterly care plan meeting to discuss my function status. Level PASRR completed. Psych consult as needed. Notify Medical Doctor and Representative party.
Record review of Resident #8's Administration report dated 03/01/24-03/31/24, revealed no order data found for skilled admin.
During an interview on 04/17/24 at 1:01 PM, with the Administrator, he stated Resident #8 was not receiving PASRR services due to Resident #8 having insurance form another state. The Administrator stated the facility had been trying to refer her to another facility suable for Resident #8 that had an Alzheimer's unit as Resident #8's cognition was not that good. The Administrator stated he did not know much about the PASRR process and was referred to the MDS Coordinator D.
During an interview on 04/17/24 at 1:37 PM, with MDS Coordinator D, she stated Resident #8 was PASRR positive for IDD and a diagnosis of seizure qualified her for PASRR services. MDS Coordinator D stated Resident #8 was not receiving PASRR services due to Resident #8 having insurance from another state. MDS Coordinator D stated she spoke to the out-of-state health and human services regarding PASRR and they did not have an answer for why the current state Resident #8 lived in now did not accept the out-state insurance. MDS Coordinator stated the out-of-state insurance did not pay for PASRR services. MDS Coordinator D stated the local mental health authority was notified of it and that they could not do anything about it. MDS Coordinator D stated the purpose of PASRR services was so resident(s) could get services that they needed to get so that the resident(s) will not have a decline in health. MDS Coordinator D stated after the meeting was held with the mental health authority there was nothing submitted to state on LTC Simple requesting PASRR services for Resident #8. MDS Coordinator D stated she was unaware if the therapy department had pick up Resident #8 for services.
During an interview on 04/17/24 at 3:51 PM, Local Mental Health Authority B, she stated Resident #8 was not eligible for PASRR services due to the resident having out-of-state insurance that this state would not accept. Local Mental Health Authority B stated that was the only reason they had marked that on the PSCP. Local Mental Health Authority B stated they were not able to bill the out-of-state insurance as they would not pay for the PASRR services. Local Mental Health Authority B stated Resident #8 did need and required PASRR services as she was PASRR positive for IDD. Local Mental Health Authority B stated the risk of not getting PASRR services would be Resident #8 not getting the therapy or services she needed. Local Mental Health Authority B stated not receiving the PASRR services could led to a decline in health.
During an interview on 04/18/24 at 9:10 AM, with the DON, she stated Resident #8 was receiving psychiatric treatment for a TBI Resident #8 had. The DON stated she did not know if Resident #8 was receiving PASRR services but would assume she was.
Record review of the facility Resident Assessment-Coordination with PASRR Program dated 01/31/24, revealed, This facility coordinates assessments with the preadmission screening and resident review (PASRR) program under Medicaid to ensure that individuals with a mental disorder, intellectual disability, or a related condition receives care and services in the most integrated setting appropriate to their needs.
All applicants to this facility will be screened for serious mental disorders or intellectual disabilities and related conditions in accordance with State's Medicaid rules for screening.
The facility will only admit individuals with a mental disorder or intellectual disability who the State mental health or intellectual disability authority has determined as appropriate for admission.
Recommendations, such as any specialized services, from a PASRR Level II determination and/or PASRR evaluation report will be incorporated into the resident's assessment, care planning, and transitions.
Record review of facility Out of State Nursing Facility Admissions not dated, revealed, This process provides guidance to entities who refer a person living outside of Texas to a nursing facility within Texas.
When a person moves from another state and was admitted to a Texas Medicaid-certified nursing facility (NF), the referring entity in the other state must complete the Texas PASRR Level 1 Screening form.
Purpose: The PASRR Level 1 Screening Form was designed to identify people who are suspected of having mental illness, an intellectual disability, or a development disability diagnosis.
If the documentation on the PL1 entered indicated a suspicion of MI, ID, or DD, one of the state local intellectual and development disability authorities will complete a PASRR Evaluation.
The PASRR Evaluation was designed to confirm or deny the suspicion of MI, ID, or DD and ensure the person was placed in the most integrated residential setting to receive the specialized services needed to improve and maintain the person's level of function.
Record review of state agency website (www.hhs.texas.gov) of PASRR reviewed on 04/17/24, revealed, Many people with mental illness and /or intellectual and developmental disabilities can safely live in a community setting while receiving the support services they need. Preadmission Screening and Resident Review was a process that helps ensure people who need these supports are only placed in a nursing facility when appropriate.
PASRR was a federally mandated program that requires all states to prescreen all people, regardless of payer source or age, seeking admission to a Medicaid-certified nursing facility.
PASRR has 3 goals - to identify people, including adults and children, with mental illness and or IDD. To ensure appropriate placements, whether in the community or the nursing facility. To ensure people receive the required services for mental illness and/or IDD.
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
Pressure Ulcer Prevention
(Tag F0686)
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 provide the necessary treatment and services based on ...
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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 the necessary treatment and services based on the comprehensive assessment and consistent with professional standards of practice to promote healing and prevent worsening of pressure injuries for 2 (Resident #6 and Resident #3) of 2 residents reviewed for wound care.
The Wound Care Nurse grabbed a gaze without gloves and placed it into a clear cup that was soaked in betadine and then used it to provide wound care for Resident #6 who had a right lateral foot wound.
The Wound Care Nurse did not date or initial Resident #3's patches after providing wound care.
This deficient practice could place residents at risk for worsening pressure injuries, pain, and a decline in health.
Findings include:
Resident #6
Record review of Resident #6's face sheet dated 04/17/24, revealed, admission on [DATE] and re-admission on [DATE] to the facility.
Record review of Resident #6's facility history and physical dated 02/21/24, revealed a [AGE] year-old male diagnosed with Diabetes Mellitus and Renal failure secondary to severe dehydration.
Record review of Resident #6's order recap dated 03/14/24, revealed, right lateral foot arterial eschar (a collection of dry, dead tissue within a wound): Clean with wound cleanser, pat dry, apply betadine, leave open to air 3 times a week and as needed every 24 hours as needed and everyday shift, and every Monday, Wednesday, Friday.
Record review of Resident #6's care plan dated 03/20/24, revealed, Wound Management- right lateral foot. Notify provider if no signs of improvement on current wound regimen. Provide wound care per treatment order.
Observation and interview on 04/11/24 at 2:09 PM, with the Wound Care Nurse. The Wound Care Nurse stated Resident #6 had a right lateral foot wound that was cleaned and left to air dry to heal. The Wound Care Nurse grabbed a 4 inch by 4 inch gauze and cut it into smaller 2 inch by 2 inch pieces. The Wound Care Nurse placed the piece of gauze into a clear cup and soaked it with Betadine. While providing the wound care the Wound Care Nurse then put on gloves and grabbed the gauze with the Betadine-soaked solution and wiped it on Resident #6's right lateral wound. The Wound Care Nurse stated she was supposed to have used gloves when touching and cutting the gauze into pieces when she had prepped. The Wound Care Nurse stated she always used gloves but did not know what had happened. The Wound Care Nurse stated the risk could be infection.
During an interview on 04/18/24 at 9:10 AM, with the DON, she stated nurses are trained on how to provide wound care for residents with pressure ulcers or wounds. The DON stated the Wound Care Nurse should have been using gloves because the nurses should be trying to be as clean as possible with then performing wound care on a resident. The DON stated nursing staff performing wound care would just be touching everything and the wound care items used for the treatment would not be protected which could be a risk of infection to the resident.
Resident #3
Record review of Resident #3's face sheet dated 04/17/24, reveled, admission on [DATE] and re-admission on [DATE] to the facility.
Record review of Resident #3's facility history and physical dated 02/19/24, revealed, a [AGE] year-old female diagnosed with Osteoporosis (a health condition that weakens bones, making them fragile and more likely to break), muscle wasting (the wasting (thinning) or loss of muscle tissue), and muscle weakness (no muscle strength), repeated falls.
Record review of Resident #3's admission MDS dated [DATE], revealed, a moderate impairment to recall and make daily decisions BIMS (used to screen and identify the cognitive condition of residents upon admission into a long-term care facility) score of 7. Resident #3 was diagnosed with cancer, non-Alzheimer's Dementia, malnutrition, adult failure to thrive (syndrome of weight loss, decreased appetite and poor nutrition, and inactivity, often accompanied by dehydration, depressive symptoms, impaired immune function, and low cholesterol). Resident #3 had a pressure reducing device for chair and for bed.
Record review of Resident #3's care plan dated 04/04/24, revealed, left hip surgical incisions. Notify provider if no signs of improvement on current wound regimen. Provide wound care per treatment order.
Record review of Resident #3's order recap dated 04/11/24, revealed surgical incisions times 3 to left hip: Clean with wound cleanser, pat dry, apply dry protective dressing times 3 every week and as needed every 24 hours and as needed and every day shift every Monday, Wednesday, and Friday.
Observation and interview on 04/11/24 at 2:52 PM, with the Wound Care Nurse. The Wound Care Nurse uncovered Resident #3 and exposed her left side hip. Resident #3 had three white patches that were not dated. The Wound Care Nurse stated she had done the wound care for Resident #3 the day before. The Wound Care Nurse stated she had lost her marker and that was why she had not placed a date or initiated the patches. The Wound Care Nurse stated it was expected to date and initial all the dressings and patches. The Wound Care Nurse stated the dressings and patches had to be dated and initialed, so the nursing staff knew when it was changed and who did it. The Wound Care Nurse stated she did not think there was a risk to Resident #3 with not dating or initialing it.
During an interview on 04/18/24 at 9:10 AM, with the DON, she stated wound conducting wound care the dressing and patches had to be labeled with the date and initials of who did the wound care. The DON stated this was so everyone knew when the dressing/patches were changed. The DON stated the risk of not dating or initialing could be not knowing who conducted the wound treatment, if it was done correctly, and when it was done.
Record review of the facility Wound Treatment Management policy dated 06/2022, revealed, To promote wound healing of various types of wounds, it was the policy of this facility to provide evidence-based treatments in accordance with current standards of practice and physician orders.
Wound treatments will be provided in accordance with physician orders, including the cleaning method, type of dressing, and frequency of dressing change.
Record review of the facility Clean Dressing Change policy dated 01/31/24, revealed, It was the policy of this facility to provide wound care in a manner to decrease potential for infection and/or cross-contamination. Physician's orders will specify type of dressing and frequency of changes.
Multi-use wound care supplies will be dated and initiated when opened. They will be maintained as clean after initial use. Sterile items will not be used if the sterility cannot be assured at the time of initial use (i.e., open packages, broken seal).
Secure dressing. [NAME] with initials and date. (Add time if dressing was more than once daily)
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
Staffing Data
(Tag F0851)
Could have caused harm · This affected 1 resident
Based on the interview and record review the facility failed to follow guidelines for mandatory submission of staffing information based on payroll data in a uniform format. Long-term care facilities ...
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Based on the interview and record review the facility failed to follow guidelines for mandatory submission of staffing information based on payroll data in a uniform format. Long-term care facilities must electronically submit to CMS complete and accurate direct care staffing information, including information for agency and contract staff, based on payroll and other verifiable and auditable data in uniform form format according to specifications established by CMS for 1 of 4 quarters (1st Quarter October 1, 2022 to December 31, 2022) reviewed for administration (Fiscal year 2023, for the first quarter October 1, 2022, to December 31, 2022).
The facility failed to submit PBJ (Payroll Based Journal) staffing information to CMS for the 1st quarter of the fiscal year 2023.
The facility's failure could place residents at risk for personal needs not being identified and met decreased quality of care, decline in health status, and decreased feelings of well-being within their living environment.
Findings included:
Record review of the facility CMS reports for PBJ provided by HR Coordinator dated 02/14/24, revealed, status - failed to send-quarter unavailable.
Record review of the facility e-mail provided by Administrator dated 02/15/24, revealed, Corporate Administrator - Your PBJ Submission has failed because CMS was no longer accepting submissions for this reporting quarter.
2024 - 1st Quarter (10/01/23-12/31/23)
Requested Submission: 02/14/24 11:08:03 PM
Submitted to CMS: 02/14/24 11:08:29 PM
Record review of the CMS PBJ Staffing Data Report (payroll-based staffing), CASPER Report (Certification and Survey Provider Enhanced Report) dated Fiscal Year Quarter 01/2024 (October 1 - December 31), indicated the following entry. Failed to Submit Data for the quarter . Triggered . Triggered = NO Data Submitted for the Quarter.
During an interview on 04/23/24 at 3:40 PM, with the Administrator, he stated HR Coordinator was responsible for submitting the PBJ to state. The Administrator stated he was not familiar with the process of the PBJ and referred surveyor to the HR Coordinator.
During an interview on 04/23/24 at 3:56 PM, with HR Coordinator, she stated she had submitted the PBJ to the state and had to be done quarterly. HR Coordinator stated the PBJs are used for staffing and grading/rating of the facility. HR Coordinator stated rating the facility lets families know if the facility was a good place to place their loves ones. HR Coordinator stated the process of submitting the PBJ went as follows: HR Coordinator does and completes the PBJ and then submits it to the Corporate Administrator who reviews it and then submits it to state. HR Coordinator stated she submitted it early to the Corporate Administrator and did not know what happened from there on. HR Coordinator stated she was not sure how not submitting the PBJ on time would affect the facility.
CONCERN
(E)
📢 Someone Reported This
A family member, employee, or ombudsman was alarmed enough to file a formal complaint
Potential for Harm - no one hurt, but risky conditions existed
Accident Prevention
(Tag F0689)
Could have caused harm · This affected multiple residents
**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on the observations, interviews, and record reviews the facility failed to ensure that the residents environment remains f...
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**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on the observations, interviews, and record reviews the facility failed to ensure that the residents environment remains free of accidents hazards as is possible and each resident receives adequate supervision to prevent accidents for 1 (Resident #8) of 8 residents and 1 Employee Lounge of 1 reviewed for accidents.
1.Resident #8 was placed 1:1 supervision for hitting a prior resident and Lead CNA left Resident #8 to go assist another staff and did not ensure another nursing staff member was 1:1 with Resident #8 that lead to Resident #8 hitting another Resident #9.
This failure was determined to be past non-compliance on 03/22/24 and ended 03/22/24 the facility implemented action that corrected the non-compliance prior to the beginning of the investigation.
2. The facility Employee Lounge door was left open for anyone to enter the employee lounge.
This failure could place residents at risk of lack of supervision, accidents, and potential for harm.
Findings include:
1.Resident #8
Record review of Resident #8's face sheet dated 04/17/24, revealed, admission on [DATE] and re-admission on [DATE] to the facility.
Record review of Resident #8's facility history and physical dated 10/02/23, revealed, a [AGE] year-old female diagnosed with Epilepsy (a chronic noncommunicable disease of the brain that affects people of all ages), delusional disorders (an unshakable belief in something that's untrue), history of traumatic brain injury (a sudden injury that causes damage to the brain), seizures (a sudden, uncontrolled burst of electrical activity in the brain).
Record review of Resident #8's quarterly MDS dated [DATE], revealed, no BIMS score was taken due to resident not being interview able. Resident #8 diagnosed with anxiety disorder, traumatic brain injury, seizure disorder, altered mental status (a change in mental function that stems from illnesses, disorders and injuries affecting your brain), surgery on nervous system.
Record review of Resident #8's order recap dated 03/19/24, revealed, 1:1 monitoring for aggressive behavior. Discontinues on 03/22/24, at 10:59 AM.
Record review of Resident #8's care plan dated 11/15/23, revealed, has history of being physically aggressive towards staff/residents due to anger, history of harming others, poor impulse control. Hits staff and punches staff/residents. Administer medications as ordered. Analyze times of day, places, triggers, and what de-escalates behavior and document. Assess and address for contributing sensory deficits. Monitor and document signs and symptoms of posing danger to self and others.
Record review of Resident #8's progress notes dated 03/22/24, revealed, Resident had an outburst this morning before breakfast, and hit another resident #9. Resident #8 was redirected and was sent back to her room.
Resident #9
Record review of Resident #9's face sheet dated 03/22/24, revealed, admission on [DATE] to the facility. Resident #9 was a [AGE] year-old female diagnosed with Muscle weakness (no muscle strength) depressive disorder, Cerebral infarction (occurs as a result of disrupted blood flow to the brain due to problems with the blood vessels that supply it), and Diabetes Mellitus.
Record review of Lead CNA's witness statement dated 03/22/24, revealed, To whom it may concern: Today in the morning, I was taking care of Resident #8 on room [ROOM NUMBER]-A, when my CNA F, asked me to help her with the transfer of another resident. It was around 7:20 AM, when I was going back to see Resident #8 and I heard Resident #9 yelling. I saw that Resident #8 hit Resident #9. I took Resident #8 back to her room and I checked her again. Everything happened in less than 10 minutes.
During an interview on 04/17/24 at 1:01 PM, with the Administrator, he stated Resident #8 was one-to-one. The Administrator stated Resident #8 does not have the willingness to hit residents. The Administrator stated Resident #9 did not have any injuries as she was assessed by nursing. The Administrator stated after the incident the facility placed Resident #8 one-to-one, educated facility staff, and redirection for Resident #8.
During an interview on 04/18/24 at 10:47 AM, with Lead CNA, he stated Resident #8 was placed on 1:1 supervision due to hitting another resident prior to this incident where she hit Resident #9. Lead CNA stated he was called to assist another CNA with another resident. Lead CNA stated he had told two of his CNAs who were working the floor with a resident to keep an eye out for Resident #8 who was sleeping her bed in her room and that they could keep on eye on Resident #8, while doing their duties. Lead CNA stated Resident #8 went into the dining room and saw Resident #9 and punched Resident #9 on her right arm as he heard Resident #9 yelling. Lead CNA stated the resident-to-resident altercation between Resident #8 and Resident #9 happened around 7:30AM-8AM. Lead CNA stated he did not consider telling the two CNAs on the floor to watch Resident #8 and to keep doing their duties a 1:1 . Lead CNA stated leaving Resident #8 who was on 1:1 supervision, was not considered appropriate 1:1 supervision, because he left her. Lead CNA stated he was suspended that day pending the investigation. Lead CNA stated it was confirmed on the investigation that he did leave Resident #8 unattended and was written up. Lead CNA stated he received 1:1 training from the DON.
During an interview on 04/23/24 at 10:27 AM, with Resident #8 and CNA G, she did not speak to surveyor. Resident #8 when questioned would smack her lips and look down. CNA G stated Resident #8 was 1:1 due to hitting a resident. CNA G stated if she had to go to the restroom or on break that another staff member needed to replace her because Resident #8 could not be left alone as she was a 1:1. CNA G stated if one of the nursing staff left while Resident #8 was on 1:1, if left alone by 1:1 staff, that nothing would happen because there was enough staff in the facility.
During an interview on 04/23/24 at 11:16 AM, LVN H, she stated if a resident was on 1:1 a staff member could only leave the resident if they were switched out. LVN H stated the current staff member could not leave the resident alone for safety, protection of self and other residents.
During an interview on 04/23/24 at 3:40 PM, with the Administrator, he stated Resident #8 was 1:1 and another nursing staff member was calling Lead CNA for help. The Administrator stated Resident #8 was left alone as Lead CNA left her. The Administrator stated if a facility member becomes 1:1 with a resident then that staff member needs to be relieved by another staff member. The Administrator stated the facility staff had been trained on one-to-one expected Lead CNA at that time who was not trained on how to be a 1:1. The Administrator stated Lead CNA was suspended pending the investigation which came out confirmed. The Administrator stated Lead CNA was written up and trained on one-to-one before coming back onto work.
The facility completed the following corrective actions to address the non-compliance after the incident occurred but prior to the surveyor entering:
Record review of Lead CNA's Employee Warning Notice of Suspension dated 03/22/24, revealed, Suspension pending investigation.
Description of infraction (violations or infringements; or breach of statutes, contracts, or obligations): Resident #8 left without supervision.
Plan of improvement: Educated over one to one supervision.
Consequences of further infractions: Potential termination depending on severity.
Record review of facility in-service training report for One-to-One dated 03/22/24, revealed, training for Lead CNA.
Record review of local police incident information card dated 03/22/24, revealed, the local police was notified and a report was made.
2. Observation on 04/11/24, revealed, in 100 Hall, Housekeeper, she had come out of the employee lounge and left the door open. There was a sign in blue posted in English and Spanish that read to keep the door closed at all times.
During an interview on 04/17/24 at 2:34 PM, with the Housekeeping Manager, she stated the employee lounge needed to be closed. The Housekeeping Manager stated it was closed so the residents would not go in. The Housekeeping Manager stated resident would go into the employee lounge looking for stuff to eat or drink but it was not safe for them to be eating or drinking the items that were in the employee lounge. The Housekeeping Manager stated it could be a risk if the resident was diabetic.
During an interview on 04/18/24 at 9:10 AM, with the DON, she stated the employee lounge door had to be closed. The DON stated this was because there were residents who would go into the employee lounge and would look for food. The DON stated she did not know if there would be a risk of having the employee lounge door open. The DON stated if the resident was diabetic then there could be a risk if the resident entered the employee lounge.
During an interview on 04/18/24 at 9:59 AM, with the Administrator, he stated the facility did not have a break room/Employee Lounge policy for keeping the door closed.
Record review of the facility Notice poster not dated, revealed, Notice-Keep door closed at all times. Spanish: Aviso-Mantenga la [NAME] cerrade en todo momento.
Record review of the facility Accidents and Supervision policy not dated, revealed, the resident environment will remain as free of accidents as was possible. Each resident will receive adequate supervision and assistive devices to prevent accidents.
Identifying hazards and risks.
Evaluating and analyzing hazards and risks.
Implementing interventions to reduce hazards and risks.
Monitoring for effectiveness and modifying the interventions when necessary.
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
Infection Control
(Tag F0880)
Could have caused harm · This affected multiple residents
Based on observation, interview and record review the facility failed to maintain an infection prevention and control program designed to provide a safe, sanitary and comfortable environment and to he...
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Based on observation, interview and record review the facility failed to 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 disease and infection for 1 (Hall 100 Nurse station trash can) of 4 trash cans and 1 (Housekeeper ) of 1 Housekeepers reviewed for infection control in that:
The hall 100 nurse station trash can was overflowing with trash and it was on the ground.
The sick Housekeeper did not follow the Covid policy by calling work to find out if she had to go into work. As stated by the DON stated, anyone feeling sick before work needs to call into work to let someone know they are not feeling well.
The Housekeeper failed to follow the employee lounge warning sign of, keep door closed, when she exited the employee lounge.
These deficient practices could place residents at risk for infection due to improper care practices.
Finding included:
Observation on 04/17/24 at 11:24 AM, revealed, 100 hall trash can at the nurse's station to be full and overflowing with trash. There were brown bags of fast food, paper towels, used clear gloves on the ground, white pieces of an unknown stick, box of masks, a white 1 inch by 1 inch pad or gauze.
During an interview on 04/17/24 at 11:30 AM, with LVN J, she stated the housekeeper usually gets to her hall (100) around 1:30 PM. LVN J stated in the mean time before the housekeeper got to her hall anytime the trash was overflowing and on the ground at the nurses station it was expected for the nurse or the CNAs to throw away and pick up the trash. LVN J stated the negative impact of not picking up the trash or throwing it would be infection.
During an interview on 04/17/24 at 2:34 PM, with Housekeeping Manager, she stated at 7AM-3PM she has housekeeping staff working in halls 300-400 and at 10AM-6PM, she had another housekeeper working halls 200-100. The Housekeeper stated while the housekeepers are busy in other halls the nursing staff are able to throw the trash themselves or call the housekeepers to have it thrown away. The Housekeeper stated having the trash over flowing and on the ground could be a risk of a resident picking it up and infection.
During an interview on 04/18/24 at 9:10 AM, with the DON, she stated she was not sure if housekeeping would pick up the trash around and on the ground of the nurse's station. The DON stated anyone seeing the trash overflowing or on the ground was responsible for picking it up and throwing the trash out. The DON stated the risk could be infection.
Observation on 04/11/24, revealed, in 100 Hall, Housekeeper, she had come out of the employee lounge wearing a blue surgical mask.
During an interview on 04/17/24 at 2:34 PM, with Housekeeping Manager, she stated she spoke with the Housekeeper, which mentioned she was not feeling well and felt sick and still came into work. The Housekeeper Manager stated the Housekeeper did not call her to tell her she felt sick and was not well. The Housekeeping Manager stated the Housekeeper was new but had been trained on Covid-19 precautions and infection prevention control. The Housekeeping Manager stated the Housekeeper did not following facility protocol when feeling sick and should have called before coming into the facility. The Housekeeping Manager stated the risk of not following facility protocol was getting everyone sick in the facility.
During an interview on 04/18/24 at 9:10 AM, with the DON, she stated the facility staff have been in-serviced and trained on Covid-19 precautions and infection prevention control. The DON stated anyone feeling sick before work needs to call into work to let someone know they are not feeling well. The DON stated the facility staff not feeling well are told to stay home and not come into work. The DON stated the risk could be spreading Covid-19 or whatever the facility staff had. The DON stated the facility staff coming into work and not calling before coming into work did not follow the Covid-19 precautions and infection prevention control.
Record review of the facility Infection Prevention and Control Program policy dated 01/31/24, revealed, This facility has established and maintains 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 as per accepted national standards and guidelines.
All staff are responsible for following all policies and procedures related to the program.
Mar 2024
1 deficiency
CONCERN
(E)
📢 Someone Reported This
A family member, employee, or ombudsman was alarmed enough to file a formal complaint
Potential for Harm - no one hurt, but risky conditions existed
Quality of Care
(Tag F0684)
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 treatment and care in accordance with profess...
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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 treatment and care in accordance with professional standards of practice, the comprehensive person-centered care plan, and the residents choices for 2 of 7 (Resident #4 and Resident #5) reviewed for quality of care.
The facility failed to complete one quarterly fall assessment for Resident #4.
The facility failed to complete two quarterly and/or readmission fall assessments for Resident #5.
These failures could place residents at risk for diminished quality of care.
Findings included:
Record review of Resident #4's face sheet dated 3/18/24 revealed a [AGE] year-old female who was admitted to the facility on [DATE] and readmitted on [DATE] with diagnoses of dementia, ither impulse disorders, major depressive disorder, attention and concentration deficit, weakness, muscle wasting and atrophy, unspecified abnormalities of gait and mobility, lack of coordination, generalized anxiety disorder, and age-related osteoporosis.
Record review of Resident #4's quarterly MDS dated [DATE] revealed a BIMS score of 0, her cognitive was severely impaired.
Record review of Resident #4's care plan dated 3/1/24 revealed focus area for potential injury related to at risk for falls related to cognitive impairment safety awareness due to diagnoses of dementia with incontinence and poor balance; interventions included: assure the floor was free of glare, liquids, foreign objects, keep bed at lowest position with brakes locked, leave light on in room if resident desires, provide proper, well-maintained footwear.
Record review of Resident #4's fall assessment dated [DATE] revealed a score of 15, she was high risk for falls.
Record review of Resident #4's electronic fall assessments revealed fall risk was due on 03/15/24 upon readmission.
Record review of Resident #5's face sheet dated 3/18/24 revealed a [AGE] year-old female who was admitted to the facility on [DATE] with diagnoses of epilepsy, unspecified abnormalities of gait and mobility, pain, anxiety disorder, muscle weakness, unspecified lack of coordination, cognitive communication deficit, and generalized anxiety disorder.
Record review of Resident #5's quarterly MDS assessment dated [DATE] revealed a BIMS score of 15, her cognitive was intact.
Record review of Resident #5's care plan dated 2/9/24 revealed a focus area for potential for injury related to risk for falls related to cognitive impairment with impaired safety awareness and gait/balance impairment.
Record review of Resident #5's fall assessment dated [DATE] revealed a score 17, she was high risk for falls.
Record review of Resident #5's electronic fall assessments revealed a fall assessment was due on 2/22/24.
During an observation on 3/15/24 at 10:35 am, Resident #5 was sleeping, no signs of distress noted and had bed at low position, call light within reach and adequate lighting.
During an interview on 3/15/24 at 2:30 pm, LVN D stated Resident #5 has not had a recent fall. LVN D stated Resident #5 had fall interventions of low bed, call light in reach, adequate lighting, and continuous monitoring. LVN D stated the CNAs and nurses were responsible of ensuring the fall interventions were followed.
During an interview on 3/15/24 at 3:43 pm, Resident #4's RP stated Resident #4 had history of falls and was due to her dementia. Resident #4's RP stated she has been notified in the past whenever she (Resident #4) sustained a fall. Resident #4's RP denied any concerns with care provided to Resident #4. Resident #4's RP stated she was aware of Resident #4 noncompliance with call light use and constant trying to get out of bed and stated the facility had been very helpful with her care.
Observation and interview on 3/18/24 at 10:49 am, Resident #4 was in bed with CNA A at bedside who stated she was about to provide brief change. Resident #4's bed was at lowest position, floor mat at bedside, call light in place, and bedside lamp was on for adequate lighting. CNA stated Resident #4 required a lot of redirecting with call light use and constant monitoring dur to her history of falls. CNA stated fall interventions that were in place for Resident #4 were low bed, call light in place, constant monitoring and redirecting to use the call light, and leave the light on for good lighting.
During an interview on 3/18/24 at 10:54 am, LVN B stated standard fall preventions used were low bed, call light in reach, constant monitoring, and floor mat at bedside. LVN B stated fall assessments were completed upon admission, quarterly and post fall by the charge nurses. LVN B stated nurses were responsible for completing fall assessments. LVN B stated Resident #4 had one missed quarterly fall assessment that and Resident #5 had 2 quarterly fall assessment missing and/or the readmission fall assessment when she retu rned from the hospital on 3/15/24. LVN B stated risk for not completing the fall assessments were lack of monitoring for falls. LVN B stated she had overlooked the fall assessments .
During an interview on 3/18/24 at 11:01 am, LVN C stated standard fall preventions used were low bed, call light in reach, constant monitoring, and floor mat at bedside. LVN C stated fall assessments were completed upon admission, quarterly and post fall by the charge nurses. LVN C stated nurses were responsible for completing fall assessments. LVN C stated risks for not completing fall assessments were lack of monitoring for falls, the resident may have a decline that may require more interventions and would go unnoticed.
During an interview on 3/18/24 at 11:09 am, the DON stated the nurses were responsible for completing fall assessment upon admission, quarterly, and as needed post falls. The DON stated the ADONs and MDS Nurses were responsible for ensuring fall assessment were completed by checking daily. The DON stated risk for not completing fall assessments were lack of monitoring due to not knowing If residents required more/less interventions.
Record review of Fall Prevention Program policy dated 3/11/24 read in part each resident will be assessed for fall risk and will receive care and services in accordance with their individualized level of risk to minimize the likelihood of falls. Implement universal environmental interventions that decrease the risk of resident falling, including, but not limited to: clear pathway to the bathroom and bedroom doors, bed is locked and lowered to a level that allows the resident's feet to be flat on the floor when the resident is sitting on the edge of the bed, call light and frequently used items are within reach, adequate lighting, wheelchairs and assistive devices are in good repair. Complete a fall risk assessment every 90 days and as indicated when the resident's condition changes.
Dec 2023
5 deficiencies
CONCERN
(E)
📢 Someone Reported This
A family member, employee, or ombudsman was alarmed enough to file a formal complaint
Potential for Harm - no one hurt, but risky conditions existed
Comprehensive Care Plan
(Tag F0656)
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 develop and implement a comprehensive person-centered care plan for ...
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**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on interview and record review the facility failed to develop and implement a comprehensive person-centered care plan for each resident that includes measurable objectives and timeframes to meet a resident's medical, nursing, and mental and psychosocial needs that are identified in the comprehensive assessment for 3 (Resident #3, #4, and #7) of 10 residents reviewed for comprehensive care plans.
1. The interdisciplinary team failed to have a care plan in place for Resident #3 refusing to be repositioned.
2. The interdisciplinary team failed to have care plans in place for urinary catheters for Residents #4 and #7.
These failures could place residents at risk of not having their catheter care needs met and not having a consistent approach to addressing behavioral issues.
Findings included:
Resident #3
Record review of Resident #3's face sheet dated 12/16/2023 revealed she was [AGE] years old, was initially admitted to the facility on [DATE] and readmitted [DATE].
Record review of Resident #3's History and Physical dated 03/30/2022 revealed she had diagnoses including Alzheimer's Dementia with behavioral disturbance.
Record review of Resident #3's annual MDS assessment dated [DATE] revealed a BIMS score of 1 (Severe cognitive impairment). No symptomatic behaviors were documented. She required extensive assistance from one staff member to move around in bed, transfer between surfaces, for locomotion around her room and facility, for dressing, for toilet use and for personal hygiene. She was at risk of pressure ulcers.
Record review of Resident #3's care plans revealed a care plan for noncompliance with fall precautions (dated 02/24/2022) and for monitoring for abnormal behaviors due to anxiety (dated 02/05/2023). Further review of the care plans revealed there was no care plan in place for refusal of care.
Record review of Resident #3's nursing progress notes revealed the following:
-11/29/2023 at 2:42 PM the resident was lying in bed all shift and refused to sit on wheelchair.
-11/23/2023 at 12:37 PM, resident laying in bed all shift, and refused to sit on wheelchair.
-11/21/2023 at 9:42, resident refused shower stated, I feel weak , and 11/21/2023 Resident refused to get out of bed.
In an interview on 12/19/23 at 4:03 PM LVN C revealed that on 12/19/2023 at 2:38 PM he had entered Resident #3's room to check her vitals and at that time asked if she wanted to be turned but that she had refused. He stated that he would document that the resident refused services in nurses notes. He stated that Resident #3 had refused to be turned in the past. He said that repositioning was important because it helped avoid ulcers and skin issues. He stated that Resident #3 was at risk for skin breakdown, that she had pain in the coccyx, currently has redness in that area and had barrier creams.
In an interview on 12/20/2023 at 8:30 AM LVN E revealed that Resident #3 required assistance repositioning and at times would refuse. The LVN stated if a resident refuses the CNA will educate the resident and report to the nurse if it continues. CNAs should also document refusals in the computer. The risk to resident of not turning was they could begin to develop pressure ulcer.
In an interview on 12/21/2023 at 11:31 AM CNA F revealed that Resident #3 did not like to be moved and if she was repositioned would turn back to her original position. The CNA stated the Resident #3 would complain a lot about being repositioned and when she refused completely the CNA would tell the nurse and go back later to try again.
Resident #4
Record review of Resident #4's face sheet dated revealed she was [AGE] years old was first admitted to the facility on [DATE] and was readmitted on [DATE].
Record review of Resident #4's physician's progress note dated 12/08/2023 revealed she had diagnoses including a urinary tract infection. She was to continue with proper toilet hygiene and completion of antibiotics as prescribed.
Record review of Resident #4's five-day MDS assessment dated [DATE] revealed a BIMS score of 11 (moderate cognitive impairment). She was dependent on others for toileting hygiene. She had an indwelling catheter.
Record review of Resident #4's care plan dated 10/12/2023 revealed she had an ADL self-care performance deficit and required assistance by staff for toileting.
Record review of Resident #4's care plan dated 10/03/2023 revealed she had intermittent bowel and bladder incontinence. Further review of her entire care plan revealed no specific care plan for a urinary catheter.
Record review of Resident #4's Order Summary Report for active orders as of 12/16/2023 revealed no orders for a urinary catheter.
Review of Resident #4's Order Recap Report for 11/01/2023 through 12/19/2023 revealed no orders for a urinary catheter.
Record review of Resident #4's MAR/TAR for November 2023 revealed no medications/treatments interventions related to catheter care.
Observation and interview on 12/16/2023 at 9:17 AM revealed that Resident #4 was lying in bed. Clipped to the side of her bed and touching the floor was a urinary catheter collection bag. The catheter tubing was also lying partially on the floor. She stated she had urinary tract infections in the past.
In an interview on 12/16/2023 at 9:20 AM CNA A revealed the catheter bag should not be on floor because it could get contaminated. She said both the nurse and CNA are responsible for keeping it off the floor.
In an interview on 12/21/2023 at 2:27 PM MDS Nurse B revealed that information for formulation of the initial care plan was derived from hospital paperwork. When asked about a care plan for Resident #4's catheter he said he would have to look at her paperwork to figure out what happened.
Resident #7
Record review of Resident #7's face sheet dated revealed she was [AGE] years old, was first admitted to the facility on [DATE] and readmitted on [DATE]. Her principal diagnosis was a urinary tract infection with an onset date of 10/13/2023.
Record review of Resident #7's History and Physical dated 10/13/2023 revealed she had diagnoses including diabetes and chronic sacral wounds (bed sores on the lower back). Further review revealed the use of a urinary catheter was not mentioned.
Record review of Resident #7's Indwelling Catheter assessment dated [DATE] revealed that the resident was admitted to the facility with a urinary catheter which had been placed on 10/01/2023.
Record review of Resident #7's admission MDS assessment dated [DATE] revealed a BIMS score of 3 (severe cognitive impairment). She was dependent on others for toileting hygiene. She had an indwelling catheter.
Record review of Resident #7's care plan dated 10/20/2023 revealed she had an ADL self-care performance deficit. Assistance for toileting was not addressed on the care plan. Further review of her entire care plan revealed no specific care plan for a urinary catheter.
Record review of Resident #7's Order Summary Report for active orders as of 12/16/2023 revealed no orders related to urinary catheters.
Record review of Resident #7's MAR for November 2023 revealed no documentation of any action to care for her urinary catheter.
Record review of Resident #7's MAR for December 2023 revealed no documentation of any action to care for her urinary catheter.
Observation on 12/16/2023 at 10:38 revealed that Resident #7 was in bed asleep. A urinary catheter collection bag was attached to her bed with the catheter tubing running up under her bedding.
In an interview on 12/21/2023 at 2:27 PM MDS Nurse B revealed that information for formulation of the initial care plan was derived from hospital paperwork. He said that if a resident came in without a catheter and then had one inserted it would be discussed in morning meetings and as a result, he would add the catheter to the care plan. He said the purpose of the care plan was to show how residents would be cared for. He stated that nurses did not look at care plans and instead looked at orders, and that the orders guided resident's care. He stated residents' catheters should be on their care plans and did not know why they would not be.
In an interview on 12/21/2023 at 2:42 PM the ADON revealed that a care plan was needed as a standard for care, that the care plan indicated what was being done for a resident and what to try in relation to a resident's particular problem. She said that for established residents care-plan related information was communicated from floor nurses to the rest of the team in morning and afternoon meetings sand should be picked up by the MDS nurse for revision of care plans. She said catheters should be on the residents' care plan.
Record review of facility policy Comprehensive Care Plans dated 10/2022 revealed that comprehensive care plans would describe the services to be provided to attain or maintain the resident's highest practicable physical wellbeing, and any service that would otherwise be furnished but are not provided due to the resident's exercise of his or her right to refuse treatment.
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
Incontinence Care
(Tag F0690)
Could have caused harm · This affected multiple residents
**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observations, interviews, and record reviews, the facility failed to ensure a resident who was incontinent of bladder r...
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**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observations, interviews, and record reviews, the facility failed to ensure a resident who was incontinent of bladder received appropriate treatment and services to prevent urinary tract infections for 6 (Residents #3, #4, #5, #6, #8, and #10) of 8 residents reviewed for indwelling catheters, in that:
-The facility failed to ensure Residents #3, #4, #5, #6, #8, and #10 foley bags were kept off the floor.
-The facility failed to ensure Resident #8's foley bag was kept out of the trash can.
- The facility failed to obtain orders to provide urinary catheter care for Residents #2, #4, #6 and #7 who had urinary catheters in place.
These failures could place residents at risk for urinary tract infections.
Findings included:
Resident #3
Record review of Resident #3's face sheet dated 12/16/2023 revealed she was [AGE] years old, was initially admitted to the facility on [DATE] and readmitted [DATE].
Record review of Resident #3's History and Physical dated 03/30/2022 revealed she had diagnoses including Alzheimer's Dementia with behavioral disturbance and dysuria (painful or difficult urination).
Record review of Resident #3's annual MDS assessment dated [DATE] revealed a BIMS score of 1 (Severe cognitive impairment). No symptomatic behaviors were documented. She required extensive assistance from one staff member to move around in bed, transfer between surfaces, for locomotion around her room and facility, for dressing, for toilet use and for personal hygiene. She had an indwelling catheter (tube into the bladder to drain urine).
Record review of Resident #3's care plan dated 10/19/2021 revealed she had a Foley (urinary) catheter with a goal that she would not have increased incidence of urinary tract infections. Interventions included that staff would be aware of the correct placement of catheter drainage bag and tubing.
Record review of Resident #3's MAR/TAR for November 2023 revealed orders dated 08/25/2022 to change the foley bag as needed and document changes of the foley catheter or drainage bag in nurse's notes.
Record review of Resident #3's MAR/TAR for December 2023 revealed orders dated 08/25/2022 to change the foley bag as needed and document changes of the foley catheter or drainage bag in nurse's notes.
Observation and interview on 12/22/2023 at 9:19 AM revealed Resident #3 was in bed. Catheter tubing was observed coming from under her bedding and into a catheter bag hanging from her bed and touching the ground. She said she did not have any discomfort from the catheter.
In an interview on 12/22/2023 at 9:23 AM LVN C revealed the catheter bag should not be touching the floor because of increased risk of infection. He said staff had gotten in-services regarding placement of catheter bags and CNAs were supposed to monitor the placement of catheter bags when they made rounds every two hours. He said he checked the placement of catheter bags when he went an into resident rooms to pass medications, check blood sugars, take vital signs or when something else was needed by the resident.
Resident #4
Record review of Resident #4's face sheet dated 12/16/2023 revealed she was [AGE] years old, was originally admitted to the facility on [DATE] and readmitted on [DATE].
Record review of Resident #4's Physician's progress note dated 12/08/2023 revealed she had diagnoses including urinary tract infection without hematuria (blood in the urine). The progress note did not indicate the resident had a urinary catheter. The physician noted that she was continue with proper toilet hygiene and completion of antibiotics as prescribed. She was to continue drinking plenty of fluids and stay away from caffeinated drinks.
Record review of Resident #4's Post Care Summary dated 12/14/2023 revealed she was being admitted to the facility (no date provided) after hospitalization for a urinary tract infection with E. coli (a type of bacteria). The resident was Foley (a type of urinary catheter) dependent and the plan for Foley care was, in part, that each shift was to ensure the urinary drainage bag was to be off the of floor at all times.
Record review of Resident #4's 5-day MDS assessment dated [DATE] revealed she had a BIMS score of 11 (moderate cognitive impairment). She was dependent on staff for toileting and had not been transferred out of bed for toileting. She had a urinary catheter.
Record review of Resident #4's Care Plan dated 10/03/2023 revealed she had intermittent bladder incontinence. Interventions included to monitor for causes of incontinence such as urinary tract infection. There was no care plan in place that stated the resident had a urinary catheter or how to care for the catheter.
Record review of Resident #4's nurse's progress note dated 11/11/2023 revealed the resident had returned from the hospital with a foley catheter in place due to urinary retention.
Record review of Resident #4's physician orders from 11/01/2023 to 12/19/2023 revealed no orders related to a urinary catheter.
Record review of Resident #4's MAR/TAR for November 2023 revealed no orders for or provision of urinary catheter care.
Record review of Resident #4's MAR/TAR for December 2023 revealed no orders for or provision of urinary catheter care.
In observation and interview on 12/16/2023 at 9:17 AM revealed Resident #4 was in bed with her urinary catheter tubing coming out from under her bedding and into a catheter bag that was touching the floor. Resident #4 stated she had problems with infections in her urine.
In observation and interview on 12/16/2023 at 9:20 AM CNA G observed the placement of Resident #4's catheter bag and said it should not be on the floor. She said if a catheter bag or tubing was on the floor it could cause contamination of the catheter bag or tubing. She said that CNAs and nurses were responsible for making sure the catheter bags and tubing were off the floor.
Resident #5
Record review of Resident #5's face sheet dated 12/21/2023 revealed he was [AGE] years old, was first admitted to the facility on [DATE] and readmitted on [DATE].
Record review of Resident #5's hospital History and Physical dated 11/03/2023 revealed he had sepsis (blood infection) due to Pyelonephritis (swelling of kidneys due to infection) and pneumonia. He had a large amount of urine on his Foley bag.
Record review of Resident #5's quarterly MDS dated [DATE] revealed he had a BIMS of 9 (moderate cognitive impairment). He had an indwelling urinary catheter.
Record review of Resident #5's Care Plan dated 06/29/2023 revealed he had an indwelling catheter and would show no signs or symptoms of urinary infections.
Observation and interview on 12/20/2023 at 8:46 AM revealed Resident #5 in his wheelchair in the dining room. It was observed that Resident #5's catheter bag was dragging on the floor. The resident said the catheter did not bother him.
In an interview on 12/20/2023 at 8:47 AM CNA I said the catheter bag should not be dragging on the floor.
Resident #6
Record review of Resident #6's face sheet dated 12/19/2023 revealed she was [AGE] years old and was admitted to the facility on [DATE].
Record review of Resident #6's History and Physical dated 12/08/2023 revealed she had endometrial cancer (uterine cancer), a urinary tract infection, and renal failure (kidney failure).
Record review of Resident #6's admission assessment dated [DATE] revealed she had a UTI and endometrial cancer complications. Her short term memory was intact. She was totally dependent on two people for transfers and required extensive assistance from one person to use the toilet. Her urinary continence was not rated. She had an indwelling catheter.
Record review of Resident #6's Care Plan dated 12/08/2023 revealed she had a foley catheter and would show no signs or symptoms of urinary infection through the review date. Staff would monitor for signs or symptoms of urinary tract infection.
Record review of Resident #6's physician orders from 12/07/2023 through 12/19/2023 revealed no orders related to the urinary catheter.
In observation and interview on 12/16/2023 at 10:14 AM Resident #6 was in bed. Urinary catheter tubing was observed coming out from under her bedding and into a urinary collection bag that was laying on the floor under the bed. The resident said she did not have any discomfort from the urinary catheter.
In observation and interview on 12/16/2023 at 10:16 AM the ADON observed Resident #6'ds catheter bag laying uncovered under her bed. The ADON said the catheter bag should not be on the floor due to infection control concerns, and that CNAs and nurses were responsible for ensuring the catheter bag and tubing were off the floor.
Resident #8
Record review of Resident #8's face sheet dated 12/16/2023 revealed she was [AGE] years old, was first admitted to the facility on [DATE] and readmitted on [DATE].
Record review of Resident #8's physician's visit note dated 07/31/2023 revealed she had a suprapubic catheter (a tube to drain urine from the bladder through a cut in the abdomen). The catheter was to be changed on the 16th of each month and care of the insertion site was to be provided daily and as needed.
Record review of Resident #8's quarterly MDS dated [DATE] revealed she had a BIMS of 10 (moderate cognitive impairment). She had an indwelling catheter.
Record review of Resident #8's Care Plan dated 03/30/2020 revealed she had a suprapubic catheter and would have no complications related to its use. Staff were to be aware of the correct placement of catheter gravity drainage bag and tubing.
Record review of Resident #8's electronic Medical Diagnosis listing accessed 12/16/2023 revealed she had diagnoses including an artificial opening of the urinary tract, and neuromuscular dysfunction of the bladder (lack of bladder control due to a brain, spinal cord or nerve problem).
Record review of Resident #8's nurses progress notes dated 11/16/2023, 11/202023, 11/21/2023, and 11/22/2023 revealed she was receiving 100 MG of doxycycline (an antibiotic) twice a day for 7 days to treat a UTI.
Record review of Resident #8's physician orders dated 08/25/2022 revealed she was to have a suprapubic catheter to address neuromuscular dysfunction of the bladder.
Record review of Resident #8's MAR for November 2023 revealed staff were checking her catheter every shift for positioning and cleanliness.
Record review of Resident #8's MAR for December 2023 revealed staff were checking her catheter every shift for positioning and cleanliness.
In observation and interview on 12/16/2023 at 11:22 AM revealed Resident #8 was in bed. Catheter tubing was observed extending from under her bedding and into a catheter bag that was in a trash can next to her bed. A used facial tissue and an empty plastic glass were observed on top of the catheter bag. The resident said she put the catheter bag in the trash can about 8:00 AM that morning because she thought the bag was leaking.
In an interview on 12/16/2023 at 11:25 AM in Resident #8's room, the Weekend Supervisor revealed the catheter bag should not be in the trash due to infection control concerns. She said the CNAs should round at least once or twice and hour and should have noticed that the catheter bag was in the trash and removed it. She said the CNAs should put on gloves and inspect the bag if there was a concern about leaks.
Resident #10
Record review of Resident #10's face sheet dated 12/20/2023 revealed she was [AGE] years old and was admitted to the facility on [DATE].
Record review of Resident #10's physician's Progress Note dated 11/01/2023 revealed she had fallen and broken her left hip resulting in admission to the hospital and then to the facility. She had diagnoses including retention of urine, and urinary tract infection.
Record review of Resident #10's admission MDS dated [DATE] revealed she had a BIMS of 11 (moderate cognitive impairment). She had an indwelling catheter.
Record review of Resident #10's Care Plan dated 11/06/2023 revealed she had a foley catheter and was to show no signs or symptoms of UTIs. Staff were to monitor for signs or symptoms of UTIs.
Record review of Resident #10's physician order dated 11/10/2023 revealed staff were to provide catheter care every shift and as needed.
In observation and interview on 12/16/2023 at 10:35 AM revealed that Resident #10 was in bed. A urinary catheter tube was observed coming from under her bedding and into a urinary collection bag, the bottom of which was touching the floor. The resident said she did not have any problems with the catheter.
In an interview on 12/16/2023 at 10:39 AM LVN H said Resident #10's catheter bag should not be touching the floor because it was an infection control concern. She said it probably happened with the CNAs came to empty the catheter bag and did not pay attention to the position of the bag when they were done.
In an interview on 12/20/2023 at 8:46 AM LVN J said that catheter bags and tubing should be kept off the floor. This was something CNAs should do, and nurses should make sure that it was done by observing the placement of catheter bags and tubing.
In an interview on 12/20/2023 at 8:53 AM CNA K said he had received training about the placement of catheter bags with the last training being 3 to 4 months ago. He said CNAs were responsible for making sure the catheter bag did not touch the floor and that keeping them off the floor was to help prevent infections.
In an interview on 12/21/2023 at 2:22 PM the ADON revealed the catheter bags should not be touching the floor because of the risk of infection. She said since the catheter bag has to be emptied every shift, the CNAs should be looking at the placement of the bags. She said the floor nurses are responsible for monitoring the placement of catheter bags and tubing.
In an interview on 12/21/2023 at 2:42 PM the ADON revealed that Residents #2, #4, #6 and #7 should have physician's orders for catheters. She said that the facility was able to trigger the inclusion of several related catheter care orders (batch order) for those residents with catheters. She did not know how it happened that Residents #2, #4, #6 and #7 did not have orders related to catheter care. She said a good nurse knows what needs to be done in terms of catheter care. She stated that the facility could not insert a catheter without a physician's order, and if a catheter was dislodged, the facility would need to notify the physician. She said that at admission, the nurse admitting the resident was responsible for inputting resident's orders.
Record review of the facility's Policy and procedure on prevention of catheter contamination was requested on 12/16/20 3 at 2:39 PM from the ADON but was not received prior to exit. Policy and procedure on catheter care was requested on 12/20/2023 at 10:25 PM from the ADON.
Record review of the facility policy Catheter Care dated 2023 revealed it was the policy of the facility to ensure that residents with indwelling catheters receive appropriate catheter care. The policy did not address avoidance of having the catheter tubing or bag touching the floor.
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
Pharmacy Services
(Tag F0755)
Could have caused harm · This affected multiple residents
**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on interview and record review, the facility failed to provide pharmaceutical services to ensure accurate administration a...
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**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on interview and record review, the facility failed to provide pharmaceutical services to ensure accurate administration and documentation of medications for 2 residents (Residents #1 and #3) of 10 reviewed for pharmacy services and medication administration in that:
The facility failed to obtain and administer Advair Diskus or Fluticasone Propionate (breathing treatments) to Resident #1 as prescribed.
The facility failed to obtain orders to hold Levimir (a diabetic medication) for Resident #3 when her blood sugars were low.
This failure placed residents at risk of inadequate therapeutic outcomes, increased negative side effects, and a decline in health due to not having orders for diabetic medication and respiratory treatments administered as ordered.
The findings included:
Resident #1
Record review of Resident #1's face sheet dated 12/19/2023 revealed she was [AGE] years old, was first admitted to the facility on [DATE] and readmitted on [DATE].
Record review of Resident #1's physician's progress note dated 12/08/2023 revealed she had diagnoses including chronic obstructive pulmonary disease (disease that cause airflow blockage and breathing-related problems), acute respiratory failure with hypoxia (not having enough oxygen in the blood); shortness of breath; Chronic obstructive pulmonary disease with exacerbation; dependence on supplemental oxygen; and Chronic Respiratory failure with hypoxia.
Record review of Resident #1's electronic Medical Diagnosis listing accessed 12/19/2023 revealed she had diagnoses including acute respiratory failure with hypoxia (not having enough oxygen in the blood); Influenza due to identified novel influenza A virus with other respiratory manifestations (Flu affecting breathing); shortness of breath; Chronic obstructive pulmonary disease with exacerbation; dependence on supplemental oxygen; and Chronic Respiratory failure with hypoxia.
Record review of Resident #1's admission MDS dated [DATE] revealed she had a BIMS of 13 (cognitively intact). She was receiving oxygen therapy.
Record review of Resident #1's Care Plan dated 09/11/2023 revealed she was at risk of respiratory infections or distress, hypoxia, shortness of breath and cough. Medications and treatments were to be administered as ordered. Care plan for flu dated 12/06/2023 revealed medications were to be administered as ordered.
Record review of Resident #1's physician orders revealed an order dated 09/09/2023 for Fluticasone Propionate Inhalation Aerosol Powder Breath Activated 50 MCG/ACT 2 puff inhale orally two times a day for breathing support.
Record review of Resident #1's physician orders revealed an order dated 12/05/2023 for a breathing treatment, Advair Diskus Inhalation Aerosol Powder Breath Activated 250-50 MCG/ACT (Fluticasone-Salmeterol), to be inhaled two times a day for the Flu or shortness of breath, which was discontinued on 12/08/2023.
Record review of Resident #1's physician orders revealed an order dated 12/08/2023 for Advair Diskus Inhalation Aerosol Powder Breath Activated 250-50 MCG/ACT (Fluticasone-Salmeterol), to be inhaled two times a day for the Flu or shortness of breath.
Record review of Resident #1's nursing progress notes beginning 11/20/2023 through 12/19/2023 revealed progress notes that a Fluticasone Propionate Inhalation Aerosol Powder Breath Activated 50 MCG/ACT 2 puff inhaled orally two times a day had not been received from the pharmacy so Resident #1 did not receive the medication on the following days:
-
11/20/2023 AM dose
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11/21/2023 AM dose
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11/21/2023 PM dose
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11/22/2023 AM dose
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11/23/2023 AM dose
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11/24/2023 AM dose
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11/27/2023 AM dose
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11/28/2023 AM dose
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11/29/2023 AM dose
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11/30/2023 AM dose
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12/02/2023 AM dose
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12/05/2023 AM dose
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12/05/2023 PM dose
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12/07/2023 AM dose
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12/08/2023 AM dose
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12/11/2023 AM dose
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12/12/2023 AM dose
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12/13/2023 AM dose
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12/15/2023 AM dose
An SBAR Summary dated 12/02/2023 revealed Resident #1 complained of shortness of breath, had diminished lung sounds with rales and labored breathing and was sent to the emergency room.
Review of the Resident #1's electronic census sheet accessed 12/21/2023 revealed she returned to the facility on [DATE].
Record review of Resident #1's MAR for December 2023 revealed documentation referring to nursing progress notes regarding missed administration of Fluticasone Propionate Inhalation Aerosol Powder Breath Activated 50 MCG/ACT for the mornings of 12/1/23, 12/7/23, 12/8/23, 12/11/23, 12/12/23, 12/14/23, and 12/15/23. The evening doses of the medication were all documented as administered.
Record review of Resident #1's nursing progress notes beginning 11/20/2023 through 12/19/2023 revealed she had not received Advair Diskus Inhalation Aerosol Powder Breath Activated 250-50 MCG/ACT (Fluticasone-Salmeterol), to be inhaled two times a day for the Flu or shortness of breath on five occasions: 12/06/23 AM, 12/7/23 AM, 12/08/23, 12/15/23 AM, 12/18/23 because it was pending receipt from the pharmacy.
Record review of Resident #1's MAR for December 2023 revealed that for the order with start dates of 12/5/2023 for Advair Diskus Inhalation Aerosol Powder Breath Activated 250-50 MCG/ACT (Fluticasone-Salmeterol) two times a day, no AM doses were recorded as given.
Record review of Resident #1's MAR for December 2023 revealed that for the order with start dates of 12/8/2023 for Advair Diskus Inhalation Aerosol Powder Breath Activated 250-50 MCG/ACT (Fluticasone-Salmeterol) two times a day, with blanks in the documentation from 12/08/2023 in the PM through 12/13/2023 in the AM. The MAR referred to nurse's progress notes the AMs of 12/14/23, 12/15/23, and 12/19/23.
In an interview on 12/21/2023 at 2:42 PM the ADON revealed that Resident #1's Advair Diskus Inhalation Aerosol Powder were pending receipt from the pharmacy. She said the original order received for 12/05/2023 had to be discontinued and a new order received because the medication had not come in from the pharmacy. She said that when a nurse puts a new order into the computer, the computer automatically sends the new order out to the pharmacy. The nurse who inputs the order advises the team in the morning or afternoon team meeting so the nurse on the next shift will be aware of the pending order. Generally, the newly ordered medication arrives the next day, with the responsibility for monitoring for the arrival of the medication being passed from shift to shift. The ADON stated that there was no process in place for making sure the process for monitoring for the arrival of the medication was working. She states that reports of medications pending deliver also appeared on computer-generated 24-hour reports but these were not reviewed for this information. Medications were sometimes delayed if the pharmacy did not have the prescribed medication in stock. She stated that Resident #1 had orders in place for both Advair Diskus Inhalation Aerosol Powder Breath Activated 250-50 MCG/ACT (Fluticasone-Salmeterol) two times a day, and the generic form of the medication, Fluticasone Propionate Inhalation Aerosol Powder Breath Activated 50 MCG/ACT that had been delayed. She said that the delivery of the medications should been monitored for delivery, otherwise the resident would not get her prescribed medications.
Resident #3
Record review of Resident #3's face sheet dated 12/16/2023 revealed she was [AGE] years old, was initially admitted to the facility on [DATE] and readmitted [DATE].
Record review of Resident #3's History and Physical dated 03/30/2022 revealed she had diagnoses including diabetes.
Record review of Resident #3's annual MDS assessment dated [DATE] revealed a BIMS score of 1 (Severe cognitive impairment. She had diagnoses including diabetes.
Record review of Resident #3's care plan dated 01/02/2023 revealed a care plan for diabetes mellitus. Goals included the resident would be free from any signs or symptoms of hypoglycemia (low blood sugar). Interventions included that she would receive diabetes medication as ordered by doctor.
Record review of Resident #3's physician's order dated 11/03/2023 revealed she was to receive 5 units of Levemir (a diabetic medication) FlexPen Subcutaneous Solution Pen-Injector 100 units/ML once a day after breakfast.
Record review of Resident #3's physician's order dated 11/25/2023 revealed she was to receive 20 units of Levemir Solution
(Insulin Detemir) at bedtime. The facility was to notify the physician if her blood sugars were over 400 or below 70.
Record review of Resident #3's MAR for November 2023 revealed that 5 units of Levemir was not administered after breakfast on the following dates:
*11/07/2023 (blood sugar 77),
*11/09/23 (blood sugar not recorded),
*11/10/23 (blood sugar not recorded),
*11/15/23 (blood sugar 89), or
*11/22/23 (blood sugar 74) and were coded as Vitals Outside of Parameters for Administration. There was no documentation of administration of 20 units of Levemir at bedtime from 11/25/2023 through 11/30/2023.
Record review of Resident #3's MAR for December 2023 revealed that 5 units of Levemir was not administered after breakfast on the following dates:
*12/01/23 (blood sugar 72),
*12/07/23 (blood sugar 92),
*12/08/23 (blood sugar 79),
*12/12/23 (blood sugar not recorded),
*12/13/23 (blood sugar not recorded),
*12/14/23 (blood sugar 82), or
*12/15/23 (blood sugar not recorded) and were coded as Vitals Outside of Parameters for Administration. There was no documentation of administration of 20 units of Levemir at bedtime from 12/01/2023 through 12/07/2023.
Review of Resident #3's Nurses notes from 11/16/2023 through 12/16/2023 revealed no notes documenting contact with physicians regarding holding Resident #3's Levemir due to low blood sugar.
In an interview on 12/16/2023 at 4:35 the ADON revealed that nurses were holding Resident #3's Levemir because she had low blood glucose levels. She stated that the nurses were supposed to get consent from the physician MD to hold the Levemir. She said the resident had not been eating well so her blood glucose was getting low and so the nurses were deciding to hold her Levemir. She said the nurses were checking the resident's blood glucose every morning and evening.
In an interview on 12/16/2023 at 5:26 PM with the Corporate Nurse and the ADON, the ADON revealed that Resident #3's Levemir should not have been held without prior approval from a physician. She stated that the facility's Medical Director was always available, and a medication should be held pending approval by the medical director.
In an interview on 12/20/2023 at 8:30 AM LVN E revealed that if a resident had a sliding scale for administering a diabetic medication, the sliding scale must be followed, thus bringing blood sugars down at a rate ordered by the physician. She stated that if a resident's blood sugars were outside of the physician-ordered parameters the physician would be called before administering insulin.
Record review of facility policy Medication Orders dated 2023 revealed that the facility would administer medications only upon the signed order of a person lawfully authorized to prescribe. The charge nurse on duty at the time the order is received should note the order and enter it on the electronic order format.
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
Infection Control
(Tag F0880)
Could have caused harm · This affected multiple residents
**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, interview, and record review the facility failed to establish and maintain an infection prevention and 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 or ensure standard and transmission-based precautions were followed to prevent spread of infections for 6 (Residents #1, #3, #4, #5, #8, and #10) of 10 residents reviewed for infection control, and failed to report a newly detected case of COVID-19 for one resident (Resident #9) of 10 residents reviewed for accurate reporting of communicable diseases.
1.
The facility failed to report Resident #9's diagnosis of COVID-19 detected on 12/17/2023 until 12/22/2023 (5 days)
2.
The facility failed to ensure Residents #3, #4, #5, #8, and #10 foley bags were kept off the floor.
3.
The facility failed to ensure Resident #8's foley bag was kept out of the trash can.
4.
The facility failed to ensure Resident's #1 and #6's respiratory treatment masks were covered when not in use.
These failures placed residents at risk for infections, the transmission of infectious disease, and a decline in health status.
Findings included:
Resident #9
Record review of Resident #9's face sheet dated 12/20/2023 revealed she was [AGE] years old and was admitted to the facility on [DATE].
Record review of Resident #9's Nursing Progress note dated 12/17/2023 revealed she was tested for COVID-19 on 12/17/2023 and was found to be COVID positive.
Observation and interview on 12/20/2023 at 9:15 AM in the 200 hall revealed isolation signs were on the outside of the closed door of Resident #9's room, and a container of PPE tower was outside her door. LVN H stated that the isolation signs and PPE were outside Resident #9's room because she had been diagnosed with COVID-19 on 12/17/2023.
In an interview on 12/21/2023 at 2:42 PM the ADON revealed that she was the Infection Disease Preventionist and on 12/17/2023 she was contacted by the floor supervisor reporting that Resident #9 had tested positive for COVID 19. She stated on 12/17/2023 she notified the Administrator that the resident had tested positive for COVID 19. She stated it was the Administrator's responsibility to report COVID to the local and state authorities.
In an interview on 12/21/2023 at 3:54 PM the Administrator revealed that he had not reported the COVID positive case to the state authorities. He stated that notification of a positive COVID-19 case was required within 48 or 72 hours. He stated he was not made aware that there was a resident with COVID until the morning of 12/21/2023 and had not yet reported this to the state. He stated it was to report positive cases of COVID-19 in order to prevent the spread of new cases.
Record review of the facility policy COVID-19 Prevention, Response and Reporting dated 2023 revealed it was the policy of the facility to report COVID-19 infections per federal, state and local health authority guidelines.
Resident #3
Record review of Resident #3's face sheet dated 12/16/2023 revealed she was [AGE] years old, was initially admitted to the facility on [DATE] and readmitted [DATE].
Record review of Resident #3's History and Physical dated 03/30/2022 revealed she had diagnoses including Alzheimer's Dementia with behavioral disturbance and dysuria (painful or difficult urination).
Record review of Resident #3's annual MDS assessment dated [DATE] revealed a BIMS score of 1 (Severe cognitive impairment. No symptomatic behaviors were documented. She required extensive assistance from one staff member to move around in bed, transfer between surfaces, for locomotion around her room and facility, for dressing, for toilet use and for personal hygiene. She had an indwelling catheter (tube into the bladder to drain urine).
Record review of Resident #3's care plan dated 10/19/2021 revealed she had a Foley (urinary) catheter with a goal that she would not have increased incidence of urinary tract infections. Interventions included that staff would be aware of the correct placement of catheter drainage bag and tubing.
Record review of Resident #3's MAR/TAR for November 2023 revealed orders dated 08/25/2022 were in place to change the foley bag as needed and document changes of the foley catheter or drainage bag in nurse's notes.
Record review of Resident #3's MAR/TAR for December 2023 revealed orders dated 08/25/2022 were in place to change the foley bag as needed and document changes of the foley catheter or drainage bag in nurse's notes.
Observation and interview on 12/22/2023 at 9:19 AM revealed Resident #3 was in bed. Catheter tubing was observed coming from under her bedding and into a catheter bag hanging from her bed and touching the ground. She said she did not have any discomfort from the catheter.
In an interview on 12/22/2023 at 9:23 AM LVN C revealed the catheter bag should not be touching the floor because of infection control concerns. He said staff had gotten in-services regarding placement of catheter bags and CNAs were supposed to monitor this when they made rounds every two hours. He said he checked the placement of catheter bags when he went an into resident rooms to pass medications, check blood sugars, take vital signs or when something else was needed by the resident.
Resident #4
Record review of Resident #4's face sheet dated 12/16/2023 revealed she was [AGE] years old, was originally admitted to the facility on [DATE] and readmitted on [DATE].
Record review of Resident #4's Physician's progress note dated 12/08/2023 revealed she had diagnoses including urinary tract infection without hematuria (blood in the urine). The progress note did not indicate the resident had a urinary catheter. The physician noted that she was continue with proper toilet hygiene and completion of antibiotics as prescribed. She was to continue drinking plenty of fluids and stay away from caffeinated drinks.
Record review of Resident #4's Post Care Summary dated 12/14/2023 revealed she was being admitted to the facility (not date provided) after hospitalization for a urinary tract infection with E. coli (a type of bacteria). The resident was Foley (a type of urinary catheter) dependent and the plan for Foley care was, in part, that each shift was to ensure the urinary drainage bag was to be off the of floor at all times.
Record review of Resident #4's 5-day MDS assessment dated [DATE] revealed she had a BIMS score of 11 (moderate cognitive impairment). She was dependent on staff for toileting and had not been transferred out of bed for toileting. She had a urinary catheter.
Record review of Resident #4's Care Plan dated 10/03/2023 revealed she had intermittent bladder incontinence. Interventions included to monitor for causes of incontinence such as urinary tract infection. There was no care plan in place that stated the resident had a urinary catheter or how to care for the catheter.
Record review of Resident #4's nurse's progress note dated 11/11/2023 revealed the resident had returned from the hospital with a foley catheter in place due to urinary retention.
Record review of Resident #4's physician orders from 11/01/2023 to 12/19/2023 revealed no orders related to a urinary catheter.
Record review of Resident #4's MAR/TAR for November 2023 revealed no orders for or provision of urinary catheter care.
Record review of Resident #4's MAR/TAR for December 2023 revealed no orders for or provision of urinary catheter care.
In observation and interview on 12/16/2023 at 9:17 AM revealed that Resident #4 was in bed. Urinary catheter tubing was observing coming out from under her bedding and into a catheter bag that was touching the floor. Resident #4 stated she had problems with infections in her urine.
In observation and interview on 12/16/2023 at 9:20 AM CNA G observed the placement of Resident #4's catheter bag and said it should not be on the floor. She said if a catheter bag or tubing was on the floor it could cause contamination of the catheter bag or tubing. She said that CNAs and nurses were responsible for making sure the catheter bags and tubing were off the floor.
Resident #5
Record review of Resident #5's face sheet dated 12/21/2023 revealed he was [AGE] years old, was first admitted to the facility on [DATE] and readmitted on [DATE].
Record review of Resident #5's hospital History and Physical dated 11/03/2023 revealed he had sepsis (blood infection) due to Pyelonephritis (swelling of kidneys due to infection) and pneumonia. He had a large amount of urine on his Foley bag.
Record review of Resident #5's quarterly MDS dated [DATE] revealed he had a BIMS of 9 (moderate cognitive impairment). He had an indwelling urinary catheter.
Record review of Resident #5's Care Plan dated 06/29/2023 revealed he had an indwelling catheter and would show no signs or symptoms of urinary infections.
Observation and interview on 12/20/2023 at 8:46 AM revealed Resident #5 in his wheelchair in the dining room. It was observed that Resident #5's catheter bag was dragging on the floor. The resident said the catheter did not bother him.
In an interview on 12/20/2023 at 8:47 AM CNA I said the catheter bag should not be dragging on the floor.
Resident #8
Record review of Resident #8's face sheet dated 12/16/2023 revealed she was [AGE] years old, was first admitted to the facility on [DATE] and readmitted on [DATE].
Record review of Resident #8's physician's visit note dated 07/31/2023 revealed she had a suprapubic catheter (a tube to drain urine from the bladder through a cut in the abdomen). The catheter was to be changed on the 16th of each month and care of the insertion site was to be provided daily and as needed.
Record review of Resident #8's quarterly MDS dated [DATE] revealed she had a BIMS of 10 (moderate cognitive impairment). She had an indwelling catheter.
Record review of Resident #8's Care Plan dated 03/30/2020 revealed she had a suprapubic catheter and would have no complications related to its use. Staff were to be aware of the correct placement of catheter gravity drainage bag and tubing.
Record review of Resident #8's electronic Medical Diagnosis listing accessed 12/16/2023 revealed she had diagnoses including an artificial opening of the urinary tract, and neuromuscular dysfunction of the bladder (lack of bladder control due to a brain, spinal cord or nerve problem).
Record review of Resident #8's nurses progress notes dated 11/16/2023, 11/202023, 11/21/2023, and 11/22/2023 revealed she was receiving 100 MG of doxycycline (an antibiotic) twice a day for 7 days to treat a UTI.
Record review of Resident #8's physician orders dated 08/25/2022 revealed she was to have a suprapubic catheter to address neuromuscular dysfunction of the bladder.
Record review of Resident #8's MAR for November 2023 revealed staff were checking her catheter every shift for positioning and cleanliness.
Record review of Resident #8's MAR for December 2023 revealed staff were checking her catheter every shift for positioning and cleanliness.
In observation and interview on 12/16/2023 at 11:22 AM revealed Resident #8 was in bed. Catheter tubing was observed extending from under her bedding and into a catheter bag that was in a trash can next to her bed. A used facial tissue and an empty plastic glass were observed on top of the catheter bag. When asked how the catheter bag got in the trash the resident said she put in in the trash can at about 8:00 AM that morning because she thought the bag was leaking.
In an interview on 12/16/2023 at 11:25 AM in Resident #8's room, the Weekend Supervisor revealed the catheter bag should not be in the trash due to infection control concerns. She said the CNAs should round at least once or twice and hour and should have noticed that the catheter bag was in the trash and removed it. She said the CNAs should put on gloves and inspect the bag if there was a concern about leaks.
Resident #10
Record review of Resident #10's face sheet dated 12/20/2023 revealed she was [AGE] years old and was admitted to the facility on [DATE].
Record review of Resident #10's physician's Progress Note dated 11/01/2023 revealed she had fallen and broken her left hip resulting in admission to the hospital and then to the facility. She had diagnoses including retention of urine, and urinary tract infection.
Record review of Resident #10's admission MDS dated [DATE] revealed she had a BIMS of 11 (moderate cognitive impairment). She had an indwelling catheter.
Record review of Resident #10's Care Plan dated 11/06/2023 revealed she had a foley catheter and was to show no signs or symptoms of UTIs. Staff were to monitor for signs or symptoms of UTIs.
Record review of Resident #10's physician order dated 11/10/2023 revealed staff were to provide catheter care every shift and as needed.
In observation and interview on 12/16/2023 at 10:35 AM revealed that Resident #10 was in bed. A urinary catheter tube was observed coming from under her bedding and into a urinary collection bag, the bottom of which was touching the floor. The resident said she did not have any problems with the catheter.
In an interview on 12/16/2023 at 10:39 AM LVN H said Resident #10's catheter bag should not be touching the floor because it was an infection control concern. She said it probably happened with the CNAs came to empty the catheter bag and did not pay attention to the position of the bag when they were done.
In an interview on 12/20/2023 at 8:46 AM LVN J said that catheter bags and tubing should be kept off the floor. This was something CNAs should do, and nurses should make sure that it was done by observing the placement of catheter bags and tubing.
In an interview on 12/20/2023 at 8:53 AM CNA K said he had received training about the placement of catheter bags with the last training being 3 to 4 months ago. He said CNAs were responsible for making sure the catheter bag did not touch the floor and that keeping them off the floor was to help prevent infections.
In an interview on 12/21/2023 at 2:22 PM the ADON revealed the catheter bags should not be touching the floor because of the risk of infection. She said since the catheter bag has to be emptied every shift, the CNAs should be looking at the placement of the bags. She said the floor nurses are responsible for monitoring the placement of catheter bags and tubing.
Resident #6
Record review of Resident #6's face sheet dated 12/19/2023 revealed she was [AGE] years old and was admitted to the facility on [DATE].
Record review of Resident #6's History and Physical dated 12/08/2023 revealed she had endometrial cancer (uterine cancer), a urinary tract infection, and renal failure (kidney failure). Further review revealed she had hypercapnic respiratory failure (too much carbon dioxide in the blood).
Record review of Resident #6's admission assessment dated [DATE] revealed she had a UTI and endometrial cancer complications. Her short term memory was intact. She was totally dependent on two people for transfers and required extensive assistance from one person to use the toilet. Her urinary continence was not rated. She had an indwelling catheter. Further review revealed she had had shortness of breath with activity. The assessment did not assess the use of oxygen.
Record review of Resident #6's Care Plan dated 12/08/2023 revealed she had a foley catheter and would show no signs or symptoms of urinary infection through the review date. Staff would monitor for signs or symptoms of urinary tract infection. Further review revealed she was at risk for respiratory infections/distress, Hypoxia (shortness of breath) and cough. Oxygen, medications and treatments were to be administered as ordered.
Record review of Resident #6's physician orders from 11/01/2023 through 12/19/2023 revealed an order dated 12/07/2023 for Ipratropium-Albuterol Inhalation Solution 0.5-2.5(3) MG/3ML (Ipratropium-Albuterol) (inhaled breathing treatment) as needed for shortness of breath and an order dated 12/07/2023 for one vial of Albuterol Sulfate Inhalation Nebulization Solution(2.5 MG/3ML) 0.083% (Albuterol Sulfate) (inhaled breathing treatment) every four hours as needed for shortness of breath or wheezing .
Record review of Resident #6's physician orders from 12/07/2023 through 12/19/2023 revealed no orders related to the urinary catheter.
In observation and interview on 12/16/2023 at 10:14 AM Resident #6 was in bed. Urinary catheter tubing was observed coming out from under her bedding and into a urinary collection bag that was laying on the floor under the bed. A respiratory treatment mask attached to a treatment machine via plastic tubing was observed on top of the resident's dresser across the room from the resident's bed. The treatment mask was lying on a paper towel and was touching a boot intended to prevent pressure ulcers on the heels. Also laying on the dresser attached to a C-pap machine (a machine to help breathing while sleeping) was an uncovered c-pap mask. The resident said she did not have any problem with discomfort from the urinary catheter. She said sometimes she would get confused because her carbon dioxide got too low.
In observation and interview on 12/16/2023 at 10:16 AM the ADON observed Resident #6's catheter bag laying uncovered under her bed. The ADON said the catheter bag should not be on the floor due to infection control concerns, and that CNAs and nurses were responsible for ensuring the catheter bag and tubing were off the floor.
In an interview on 12/16/2023 at 10:30 AM LVN H revealed that the respiratory treatment mask and C-Pap mask should be covered up to prevent them from getting dirty. She said that having them uncovered put resident at increased risk of respiratory infections. She said the person who last helped the resident with treatments or the C-pap should have covered them up.
Resident #1
Record review of Resident #1's face sheet dated 12/19/2023 revealed she was [AGE] years old, was first admitted to the facility on [DATE] and readmitted on [DATE].
Record review of Resident #1's physician's progress note dated 12/08/2023 revealed she had diagnoses including chronic obstructive pulmonary disease (disease that cause airflow blockage and breathing-related problems), acute respiratory failure with hypoxia (not having enough oxygen in the blood); shortness of breath; Chronic obstructive pulmonary disease with exacerbation; dependence on supplemental oxygen; and Chronic Respiratory failure with hypoxia.
Record review of Resident #1's electronic Medical Diagnosis listing accessed 12/19/2023 revealed she had diagnoses including Influenza due to identified novel influenza A virus with other respiratory manifestations (Flu affecting breathing).
Record review of Resident #1's admission MDS dated [DATE] revealed she had a BIMS of 13 (cognitively intact). She was receiving oxygen therapy.
Record review of Resident #1's Care Plan dated 09/11/2023 revealed she was at risk of respiratory infections or distress, hypoxia, shortness of breath and cough. Medications and treatments were to be administered as ordered.
Record review of Resident #1's electronic order listing accessed 12/19/2023 revealed there were no physician orders for oxygen or respiratory treatments using a mask.
Record review of Resident #1's MAR for December 2023 revealed no documentation of administration of oxygen or administration of treatments using a mask.
Observation and interview on 12/16/2023 at 10:43 AM revealed that Resident #1 was seated in bed. Next to her bed was a tray table on which a respiratory treatment mask was resting touching a cell phone. The resident stated she had received a respiratory treatment yesterday (12/15/2023).
In an interview on 12/16/2023 at 10:45 AM LVN H revealed that Resident #1 would use the face mask when she felt anxious. The LVN said they had educated Resident #1 on covering it up after she used it but that the resident was forgetful due to dementia. The LVN stated that the uncovered respiratory treatment mask increased the resident's risk of a respiratory infection. She said the treatment mask should be covered by the last staff member who administered a treatment.
Record review of the facility policy Infection Prevention and Control Program implemented 03/2022 revealed that the infection prevention program utilized a system of surveillance to prevent infections and communicable diseases for all residents.
CONCERN
(E)
📢 Someone Reported This
A family member, employee, or ombudsman was alarmed enough to file a formal complaint
Potential for Harm - no one hurt, but risky conditions existed
Deficiency F0887
(Tag F0887)
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 implement COVID-19 immunizations policies and procedures to ensure 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 implement COVID-19 immunizations policies and procedures to ensure that resident's medical record includes documentation that indicates that the resident or resident representative was offered provided education regarding the benefits and potential risks associated with COVID-19 vaccine for 6 (Residents #1, #4, #6, #7, #9 and #10) of 10 residents reviewed for COVID-19 vaccination status.
The facility failed to provide documentation that Residents #1, #4, #6, #7, #9 and #10 or their representatives had received education regarding the benefits and potential risks associated with COVID-19 vaccine.
These failures placed residents at risk for infections, the transmission of infectious disease, and a decline in health status.
Findings included:
Resident #1
Record review of Resident #1's face sheet dated 12/19/2023 revealed she was [AGE] years old, was first admitted to the facility on [DATE] and readmitted on [DATE].
Record review of Resident #1's physician's progress note dated 12/08/2023 revealed she had diagnoses including chronic obstructive pulmonary disease (disease that cause airflow blockage and breathing-related problems), acute respiratory failure with hypoxia (not having enough oxygen in the blood); shortness of breath; Chronic obstructive pulmonary disease with exacerbation; dependence on supplemental oxygen; and Chronic Respiratory failure with hypoxia.
Record review of Resident #1's electronic Medical Diagnosis listing accessed 12/19/2023 revealed she had diagnoses including Influenza due to identified novel influenza A virus with other respiratory manifestations (Flu affecting breathing.
Record review of Resident #1's admission MDS dated [DATE] revealed she had a BIMS of 13 (cognitively intact).
Record review of Resident #1's Care Plan dated 07/21/2023 for COVID-19 said she was at risk for contracting COVID-19 because she was residing in a long-term care facility.
Record review of Resident #1's electronic Immunization Record accessed 12/21/2023 revealed no documentation that she had been educated about COVID-19 vaccinations.
Resident #4
Record review of Resident #4's face sheet dated 12/16/2023 revealed she was [AGE] years old, was originally admitted to the facility on [DATE] and readmitted on [DATE].
Record review of Resident #4's Physician's progress note dated 12/08/2023 revealed she had been in the hospital for generalized weakness, chest , abdominal and back pain, and episodes of vomiting. She had been admitted to the facility for further care and management. She denied having pneumonia.
Record review of Resident #4's 5-day MDS assessment dated [DATE] revealed she had a BIMS score of 11 (moderate cognitive impairment). She was dependent on staff for toileting and had not been transferred out of bed for toileting. She had a urinary catheter.
Record review of Resident #4's Care Plan dated 10/03/2023 revealed she was at risk for contracting COVID-19 since she was residing in a long-term facility.
Record review of Resident #4's electronic Immunization Record accessed 12/21/2023 revealed no documentation that she had been educated regarding COVID-19 vaccinations.
Resident #6
Record review of Resident #6's face sheet dated 12/19/2023 revealed she was [AGE] years old and was admitted to the facility on [DATE].
Record review of Resident #6's History and Physical dated 12/08/2023 revealed she had hypercapnic respiratory failure (too much carbon dioxide in the blood).
Record review of Resident #6's admission assessment dated [DATE] revealed she had had shortness of breath with activity. The admission assessment did not assess use of oxygen.
Record review of Resident #6's Care Plan 12/08/2023 for COVID-19 said she was at risk for contracting COVID-19 because she was residing in a long-term care facility.
Record review of Resident #6's electronic Immunization Record accessed 12/21/2023 revealed no documentation that she had been educated regarding COVID-19 vaccinations.
Resident #7
Record review of Resident #7's face sheet dated revealed she was [AGE] years old, was first admitted to the facility on [DATE] and readmitted on [DATE].
Record review of Resident #7's History and Physical dated 10/13/2023 revealed she had been admitted to the facility for ongoing therapy services, wound care and medical management.
Record review of Resident #7's admission MDS assessment dated [DATE] revealed a BIMS score of 3 (severe cognitive impairment).
Record review of Resident #7's care plan dated 10/20/2023 revealed she had an ADL self-care performance deficit. There were no care plans related to risk of COVID-19.
Record review of Resident #9's electronic Immunization Record accessed 12/21/2023 revealed no documentation that she had been educated regarding COVID-19 vaccinations.
Resident #9
Record review of Resident #9's face sheet dated 12/20/2023 revealed she was [AGE] years old and was admitted to the facility on [DATE].
Record review of Resident #9's History and Physical dated 12/07/2023 revealed she was transferred from a local hospital to the facility for medical management.
Record Review of Resident #9's admission assessment dated [DATE] revealed no recurrent pneumonia. No assessments for COVID were documented.
Record Review of Resident #9's Baseline Care Plan dated 12/07/2023 did not address COVID-19.
Record review of Resident #9's Nursing Progress note dated 12/17/2023 revealed she was tested and found to be COVID-19 positive.
Record review of Resident #9's electronic Immunization Record accessed 12/21/2023 revealed no documentation that she had been educated regarding COVID-19 vaccinations.
Resident #10
Record review of Resident #10's face sheet dated 12/20/2023 revealed she was [AGE] years old and was admitted to the facility on [DATE].
Record review of Resident #10's physician's Progress Note dated 11/01/2023 revealed she had fallen and broken her left hip resulting in admission to the hospital and then to the facility.
Record review of Resident #10's admission MDS dated [DATE] revealed she had a BIMS of 11 (moderate cognitive impairment).
Record review of Resident #10's Care Plan dated 11/06/2023 for COVID-19 revealed she was at risk for contracting COVID-19 because she was residing in a long-term care facility.
Record review of Resident #9's electronic Immunization Record accessed 12/21/2023 revealed no documentation that she had been educated or offered immunizations for COVID-19.
In an interview on 12/21/2023 at 8:35 AM the ADON revealed that the facility did offer COVID-19 education to residents and information on how to obtain immunizations but was not able to find the documentation that this had been done.
Record review of the facility policy Infection Prevention and Control Program implemented 03/2022 revealed that the infection prevention program utilized a system of surveillance to prevent infections and communicable diseases for all residents. COVID-19 immunizations would be offered to residents when available. Education would be provided to residents and/or representatives regarding the benefits and potential side effects of the COVID-19 vaccine. Documentation would reflect the education provided and details regarding whether or not the resident received the vaccine.
Nov 2023
2 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
Comprehensive Care Plan
(Tag F0656)
Could have caused harm · This affected 1 resident
**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on interview and record review the facility failed to develop and implement comprehensive person-centered care plan that i...
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**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on interview and record review the facility failed to develop and implement comprehensive person-centered care plan that included measurable objectives and time frames to meet a resident medical and nursing needs to be furnished to attain or maintain the residents highest practicable physical, mental, and psychosocial well-being for 1 of 6 residents (Resident #1) reviewed for care plans in that:
The facility failed to develop and implement a comprehensive person-centered care plan for Resident #1's transfer for activities of daily living.
This deficient practice could place residents in the facility at risk of not receiving the necessary care or services and having personalized plans developed to address their needs.
Findings included:
Record review of Resident #1's face sheet dated 11/13/23 revealed admission on [DATE] and readmission on [DATE] to the facility. Resident #1 was a [AGE] year-old female diagnosed with fracture of the neck of left femur and osteoarthritis (degenerative joint disease or wear and tear arthritis).
Record review of Resident #1's quarterly MDS assessment dated [DATE] revealed a BIMS (test is used to get a quick snapshot of how well you are functioning cognitively at the moment) score of 10, which indicated a moderate impairment of cognition. Resident #1's MDS revealed their activity of daily living for chair/bed to chair transfer and tub/shower transfers were substantial/maximal assistance (helper does more than half the effort. Helper lifts or holds truck or limbs and provides more than half the effort).
Record review of Resident #1's care plan dated 11/13/23 revealed Resident #1 had no focus, goal, or interventions for transfers .
Interview on 11/17/23 at 9:12 AM with MDS B, she stated Resident #1 did not have transfers on her care plan and needed to have it care planned. MDS B stated the purpose of the care plan was to provide the plan of care for the resident, provide the needs, and how to care for the resident. MDS B stated the staff would not know how much assistance the resident would need.
Interview on 11/17/23 at 11:00 AM with the DON. The DON stated it was expected for care plans to be updated for interventions or changes with a resident. The DON stated it was the responsibility of the nurses and MDS coordinators to ensure the care plans are updated and correct. The DON stated the risk was a resident not getting the proper services needed to care for them. The DON stated Resident #1 could have had an improper transfer done.
Record review of the facility comprehensive care plans policy not dated revealed, it was the policy of this facility to develop and implement a comprehensive person-centered care plan for each resident, consistent with resident right, that includes measurable objectives and timeframes to meet a resident's medical, nursing, and mental and psychosocial needs that are identified in the resident's comprehensive assessment.
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The comprehensive care plan will describe the services that are to be furnished to attain or maintain the resident's highest practicable physical, mental, and psychosocial well-being.
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
Based on observation, interview, and record review the facility failed to maintain an infection prevention and control program designed to provide a safe, sanitary, and comfortable environment and to ...
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Based on observation, interview, and record review the facility failed to 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 disease and infection for 1 of 4 (Clean Linen Closet in hall 100 ) closets reviewed for infection control in that:
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The clean linen closet door in hall 100 was propped open by a white towel and not securely closed.
These deficient practices could place residents at risk for infection due to improper care practices.
Findings included:
Observation on 11/16/23 at 9:00 AM revealed a white towel seen folded and placed on top to the right of the door. On the door frame of the strike plate where the door latch ( a device for keeping a door or gate closed, consisting of a metal bar that fits into a hole and is lifted by pushing down on another bar) entered into was taped with white scotch tape (a clear sticky tape that is sold in rolls and that you use to stick paper or card together or onto a wall). At 9:02 AM inside of the closet were foley catheters, gowns, briefs, shampoos, body wash, mouth wash, wipes, gloves, towels, blankets, and sheets. The closet doorknob was broken and dangling downwards.
Interview on 11/16/23 at 9:05 AM with Housekeeping Manager, she stated she had placed a work order last week for the clean linen closet door to be fixed. The Housekeeping Manager stated the clean linen closet door was to be closed and locked to prevent residents from going into the clean linen closet. The Housekeeping Manager stated there was a risk of residents being locked in and infection control. The Housekeeping Manager stated it was everyone's responsibility to keep the clean linen closet door closed and locked.
Observation and Interview on 11/16/23 at 11:00 AM with the ADON A. The ADON A observed the clean linen closet in hall 100 to be propped open with a white towel on the top right of the clean linen closet door. ADON A stated the clean linen closet door was to be closed to prevent residents from going into them and was not appropriate with the towel keeping it open. ADON A stated it was for the resident's safety and infection control. The ADON A stated it was the CNAs responsibility to ensure the clean linen closet doors remain closed.
Interview on 11/16/23 at 3:12 PM with the Maintenance Director, he/she stated the clean linen closet doors are to be closed because residents could go inside and lock themselves in. The Maintenance Director stated items in the clean linen closet could fall on the residents, drink chemicals, and could be an infection. The Maintenance Director stated it was everyone's responsibility to keep the clean linen closet doors closed.
Interview on 11/17/23 at 11:00 AM with the DON. The DON stated the clean linen closets needed to have their doors closed because leaving them open can have anybody going into them and residents can get lost in them. The DON stated residents could touch the clean linen and it could be an infection control issue. The DON stated the CNAs were responsible for ensuring the clean linen closet doors were closed and secure.
Record review of the facility infection prevention and control program policy not dated revealed, this facility had established and maintains an infection prevention and control program designed to provide a safe, a sanitary, and comfortable environment and to help prevent the development and transmission of communicable diseases and infections as per accepted national standards and guidelines.
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Laundry and direct care staff shall handle, store, process, and transport linens to prevent spread of infection.
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Linen shall be stored on all resident care units on covered carts, shelves, in bins, drawers, or linen closets.
Oct 2023
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
Transfer Notice
(Tag F0623)
Could have caused harm · This affected 1 resident
**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on interviews and record reviews, the facility failed to send a copy of the notice to a representative of the Office of th...
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**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on interviews and record reviews, the facility failed to send a copy of the notice to a representative of the Office of the State Long-Term Care Ombudsman for 1 resident (Resident #11) of 1 reviewed for discharges.
-The facility failed to provide an immediate discharge notice to Resident #11 and failed to notify to the State Ombudsman.
This failure could place residents at risk of being wrongfully discharged if the process for discharge is not followed.
Findings included:
Record review of Resident #11's Face sheet dated 10/13/2023 revealed a [AGE] year-old male with an admission date to the facility of 09/06/2023.
Record review of Resident #11's electronic diagnosis list revealed diagnoses of alcohol abuse with alcohol-induced anxiety disorder and schizoaffective disorder.
Record review of Resident #11's Discharge MDS assessment dated [DATE] revealed Resident #11 had a BIMS score 7 indicating severe cognitive impairment. It also revealed the resident's return was anticipated after discharge.
Record review of Resident #11's comprehensive care plan dated 09/07/2023 revealed Resident# 11 had a behavior problem related to
schizoaffective disorder with a goal of resident having no evidence of behavior problems. Interventions included intervene as necessary to protect the rights and safety of others and remove from situation and take to alternate location as needed.
Record review of Resident #11's History and Physical dated 09/08/2023 revealed he had been referred to psychiatric services due to being non-compliant with care and stating he wanted to hurt self. He had a diagnosis of alcohol abuse with alcohol-induced anxiety disorder and schizoaffective disorder.
Record review of Resident #11's progress notes dated 09/19/2023 revealed Patient is being verbally and physically aggressive towards staff. Patient has been safely redirected into bed and into wheelchair for breakfast, but patient continues to be verbally and physically aggressive. Patient is removing his gown and his diaper and throwing diaper and gown at CNAs and Staff and is playing with his feces. Patient was asked if he was in pain, but patient denies having pain at this time. Will continue to monitor patient.
Record review of Resident #11's progress note dated 09/19/23 revealed SW has been informed of resident behavior. Resident is seen throwing feces and smearing feces. SW submitted referral to in-patient psychiatric facility. SW will follow up . [Resident #11] not accepted to in-patient psychiatric facility due to no bed availability .SW sent referral for EDO.
Record review of Resident #11's progress note dated 09/20/23 revealed [Resident #11] is very aggressive and agitated and looking for items as he stated that he wants to hurt himself. SW was called for assistance and patient voiced to her that he wants to hurt himself. Patient was trying to grab items from nurses' station and from other locations. [Resident #11] was attempted to be redirected safely but patient became belligerent, physically and verbally aggressive. [Resident #11] attempted to physically strike nurse and medication aide. [Resident #11] was asked if he was in pain or if he needed anything, but patient refused any help or aide. [Resident#11] continued to be verbally aggressive towards staff as well as physically aggressive. [Resident#11] is not to be left alone at this time because patient is at risk for hurting himself. Will continue to monitor.
Review of Resident #11's progress note dated 09/23/23 revealed [Resident #11] continues to be verbally abusive to staff and other residents, yelling at the top of his lungs using profanity. Started swinging at a female staff when another resident stepped in . [Resident #11] continues to be agitated, repeatedly trying to go into other resident's room. When he tried to go into another residents' room, nurse told him to scoot back because it was not his room. [Resident #11] started scooting back, he had a fork in his
hand and lifted his arm up as if to stab a cna on her back. Cna was able to turn in time to grab his arm before he could strike down and stab her.
Review of Resident #11's progress note dated 09/24/23 revealed [Resident#11] continues with verbal aggression. Status-post day 1/3 physical altercation. Emotional and mental well-being assessed. [Resident #11] continues with behaviors, charge nurse to medicate as per doctors' orders. Will continue to monitor.
Review of Resident #11's progress note dated 09/25/23 revealed SW initiated EDO for resident. EDO has been approved. PD will arrive with CIT team to collect resident for admission to psych .CIT unit have arrived to collect resident via ambulance to transport to ER to be evaluated. [Resident #11] has been accepted to psychiatric facility pending medical evaluation.
Review of Resident #11's progress note dated 09/26/23 revealed Received phone call, [Resident#11] still being evaluated. Depending on the outcome of evaluation resident will either be sent for psychiatric admission or be sent back to facility.
Record review of Resident #11's physician order dated 09/26/2023 revealed Ok to transfer to ER for medical clearance.
In a text message exchange on 10/13/23 at 8:10 AM with State Ombudsman , he revealed a discharge notice had not been provided to him to indicate that Resident #11 had been discharged from the facility after being transferred to psychiatric facility. The only information he had received was an email on 09/25/23 informing him about EDO for Resident #11. He revealed the notification of EDO was not an official discharge notice.
In an interview on 10/13/23 at 5:52 PM with Social Worker revealed once Resident #11 was out of the facility, he was discharged . She stated the case worker for the in-patient facility had notified her that Resident #11 had been transferred out to a different rehab center and he would not be returning to the facility. She stated it had not been a planned discharge since he had been sent out as EDO, but it was a facility-initiated discharge. She confirmed she had not notified the resident or the ombudsman of the discharge. She revealed all she relayed to the ombudsman was the EDO notification. She stated the facility was not expecting Resident #11 to be discharged and had planned on him returning after he was stabilized. She stated the decision had been made by the other facility when they transferred him to another rehab center. She could not state if a discharge notice should have been provided to the resident or the ombudsman. She revealed the importance of notifying the ombudsman of discharges was because the ombudsman served as an advocate and resource for the residents.
Record review of facility policy titled Transfer and Discharge dated February 2023 read in part .The facility's transfer/discharge notice will be provided to the resident and the resident's representative in a language and manner in which they can understand. The notice will include all of the following at the time it is provided: the specific reason and basis for transfer or discharge .an explanation of the right to appeal the transfer or discharge to the State .The notice must be provided to the resident, resident's representative, and the LTC ombudsman as soon as practicable .in situations where the facility has decided to discharge the resident while the resident is still hospitalized , the facility will send a notice of discharge to the resident and resident representative before the discharge, and must also send a copy of the discharge notice to a representative of the Office of the State Long-Term Care Ombudsman. Notice to the ombudsman will occur at the same time the notice of discharge is provided to the resident .
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 maintain clinical records that were accurately documented for 3 (Re...
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**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on interview and record review, the facility failed to maintain clinical records that were accurately documented for 3 (Resident #4, Resident #8, and Resident #9) of 15 residents reviewed for clinical records.
-The facility failed to document administration of Tramadol on several shifts in Resident #4, Resident #8 and Resident #9's clinical records.
This failure could cause an effect in residents if more doses of medication were to be given based on inaccurate documentation of medication administration.
Findings include:
Record review of Resident #4's face sheet dated 10/13/2023 revealed an [AGE] year-old male with an admission date to the facility of 08/10/2023.
Record review of Resident #4's electronic diagnosis sheet revealed a diagnosis of acute cholecystitis (inflammation of the gallbladder).
Record review of Resident #4's Comprehensive MDS assessment dated [DATE] revealed a BIMS score of 13, indicating resident was cognitively intact and revealed his diagnosis of cholecystitis.
Record review of Resident #4's comprehensive care plan dated 08/11/2023 revealed Resident #4 had pain related to acute cholecystitis with a goal of resident to verbalize adequate relief of pain or ability to cope with incompletely relieved pain. Interventions included to monitor, record, report to nurse resident complaints of pain or requests for pain treatment.
Record review of Resident #4's physician order dated 08/14/2023 revealed Tramadol HCl oral tablet 50 mg give 1 tablet by mouth every 6 hours as needed for severe pain.
Record review of Resident #4's Narcotic count sheet for Tramadol 50 mg revealed the medication was administered on the following dates: 8/17, 8/18, 8/21, 8/22, 8/23, 9/6, 9/9, 9/10, 9/11, 9/13, 9/16, 9/18, 9/19, 9/20, 9/21, 9/22 and 9/24.
Record review of Resident #4's MAR for August 2023 revealed blanks in documentation for Tramadol 50mg for the following dates: 8/17, 8/18, 8/21, 8/22, and 8/23.
Record review of Resident #4's MAR for September 2023 revealed blanks in documentation for the following dates: 9/6, 9/9, 9/10, 9/11, 9/13, 9/16, 9/18, 9/19, 9/20, 9/21, 9/22 and 9/24.
An interview on 10/12/23 11:08 AM with Resident #4 revealed he was taking Tramadol for pain but had not been asking for it lately because he was not in pain. He was not able to disclose what exact dates he had received the medication but revealed he took it for a while.
Resident #8
Record review of Resident #8's face sheet dated 10/13/2023 revealed a [AGE] year-old female with an admission date to the facility of 09/28/2023.
Record review of Resident #8's electronic diagnosis sheet revealed a diagnosis of fracture of right femur (long bone of the upper leg).
Record review of Resident #8's 5-Day MDS assessment dated [DATE] revealed a BIMS score of 5, indicating a severe cognitive impairment and revealed her diagnosis of a hip fracture.
Record review of Resident #8's comprehensive care plan dated 09/29/2023 revealed Resident #8 had pain related to fracture of
right femur with a goal of resident to verbalize adequate relief of pain or ability to cope with incompletely relieved pain. Interventions included to administer analgesia as per orders, and monitor/document for probable cause of each pain episode.
Record review of Resident #8's physician order dated 10/03/2023 revealed Tramadol HCl oral tablet 50 mg give 1 tablet by mouth every 6 hours as needed for pain.
Record review of Resident #8's Narcotic count sheet for Tramadol 50 mg revealed the medication was administered on the following dates: 10/4, 10/7, and 10/8.
Record review of Resident #8's MAR for October 2023 revealed blanks in documentation for Tramadol 50mg for the following dates: 10/4, 10/7, and 10/8.
An interview on 10/13/2023 at 2:51 PM with Resident #8's RP revealed she would visit with Resident #8 most of the day every day and would be present when medications were administered. She revealed when Resident #8 was in pain, she would ask the nurse for medication, and it would be given to her. She denied having concerns of her pain being managed.
Resident #9
Record review of Resident #9's face sheet dated 10/04/2023 revealed a [AGE] year-old male with an admission date to the facility of 09/15/2023.
Record review of Resident #9's electronic diagnosis sheet revealed a diagnosis of fracture to the left femur.
Record review of Resident #9's Comprehensive MDS assessment dated [DATE] revealed a BIMS score of 11, indicating a moderate cognitive impairment and revealed his diagnosis of a hip fracture.
Record review of Resident #9's comprehensive care plan dated 09/18/2023 revealed Resident #9 had pain related to fracture of
left femur with a goal of resident to verbalize adequate relief of pain or ability to cope with incompletely relieved pain. Interventions included to identify and record previous pain history and management of that pain and monitor/document for side effects of pain medication.
Record review of Resident #9's physician order dated 09/15/2023 revealed Tramadol HCl oral tablet 100 mg give 100 mg by mouth every 6 hours as needed for moderate pain.
Record review of Resident #9's Narcotic count sheet for Tramadol 50 mg revealed the medication was administered on the following dates: 9/29, 9/30, 10/2, and 10/7.
Record review of Resident #9's MAR for September 2023 revealed blanks in documentation for Tramadol 50mg for the following dates: 9/29, and 9/30.
Record review of Resident #9's MAR for October 2023 revealed blanks in documentation for Tramadol 50mg for the following dates: 10/2 and 10/7.
An interview on 10/10/23 3:25 PM with Resident #9 revealed staff would give him pain medication but could not state the name of it. He stated, well it must help because I am not in pain right now.
An interview on 10/13/23 at 2:03 PM with the DON revealed she told the nursing staff time and time again that they had to document on the MAR anytime a medication had been given. She stated the nurses knew to document when a medication was given.
An interview on 10/13/23 at 3:14 PM with LVN C revealed she has been working at the facility for 3 months and worked night shift from 10 PM-6 AM. She stated anytime she administered pain medication, she would look at the order to see if it was scheduled or PRN. If it was a narcotic, she would pull the medication and document it on the narcotic sheet. After it has been documented on sheet, she would administer the medication to the resident. After it had been administered, she documented it on the MAR. She revealed she remembered administering the medication to Resident #9, but could not remember if she had marked it as given on the MAR. She revealed she did not know why she had not documented it, but before she left her shift, she ensured there was no missing documentation of resident electronic records. She revealed it was important to ensure documentation was done for medication administration to make sure pain management was being controlled. It was also important to make sure there was an accurate account of what was being given.
A follow-up interview on 10/13/23 at 3:53 PM with the DON revealed she had begun in-servicing staff on medication administration for all medications being administered. She revealed if a resident was requesting pain medication, the nurse was to check the MAR and the discrepancy to ensure there was no discrepancy. Next, the medication was given and signed on both the narcotic sheet and MAR once it was given. She revealed training on documentation was provided to nursing staff during orientation and as needed. She revealed the importance of doing so was to ensure there was no drug diversion, make sure the residents' received the medication and ensure that residents did not receive multiple doses of medication .
An interview on 10/13/23 at 4:33 PM with LVN D revealed he had been assigned to Resident #4, back in August and September 2023. He remembered giving Resident #4 tramadol several times for pain on his right side of the abdomen. He stated the medication has been effective and had been given to the resident when he requested it. He revealed he probably forgot to document on the MAR when he administered the medication. He stated it should have been documented in order to keep track of the medications that were given and to evaluate the pain. He also stated it served as a way to let the oncoming nurse know if medications had been given. He stated there could have been a risk to the residents if not done but was not sure what it was.
An interview on 10/13/23 at 4:39 PM with LVN E revealed he had been assigned to Resident #8 and had provided her with pain medication. He revealed he would at times forget to document the administration of the medication on the MAR because he would get busy. He revealed the process was for him to pull the medication and sign the narcotic sheet, then sign the MAR. He stated he had been taught to document and sign off on the medication and revealed it had to be done in order for doctors and other staff to see the record of what medications are being given.
In an interview on 10/13/23 at 5:13 PM with LVN F revealed she was assigned to Resident #9 and was sure she had administered him with Tramadol pain medication. She revealed she was not sure how she could have forgotten to document that she had administered the medication. She stated what happened was that she pulled the narcotic medication and signed it on the narcotic count sheet but did not mark it on the computer. She revealed it was important to document the administration of the medication in order for everyone to know what medication was being given.
Record review of facility policy titled Medication Administration dated February 2023 read in part .Sign MAR after administered .correct any discrepancies and report to nurse manager .
Record review of facility policy titled Documentation in Medical Record dated October 2022 read in part .Documentation shall be completed at the time of service .documentation shall be factual, objective, and resident centered .documentation shall be accurate, relevant, and complete, containing sufficient details about the resident's care .
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
Infection Control
(Tag F0880)
Could have caused harm · This affected multiple residents
**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observations, interviews, and record review, the facility failed to establish and maintain an infection prevention and ...
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**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observations, interviews, and record review, the facility failed to establish and maintain an infection prevention and control program designed to provide a safe, sanitary, and comfortable environment and to help prevent the development and transmission of communicable diseases and infections for 1 room (room [ROOM NUMBER]) of 12 rooms reviewed for infection control in that:
1. The facility failed to ensure CNA A provided care in COVID positive room [ROOM NUMBER] with proper PPE.
This deficient practice could cause the spread of disease and cross contamination in the facility.
Findings included:
Observations on 10/10/23 at 2:55 PM revealed CNA A in bathroom of COVID positive room [ROOM NUMBER]. She was observed wearing an N-95 mask and gloves while providing a shower to the resident.
An interview on 10/10/23 at 3:10 PM with CNA A revealed she had put on a gown before entering the room. She stated that once in the room, the gown had become soiled, and she had removed it while in the room. She revealed she was going to call a colleague to bring her a gown, but she had not called for one. She could not state a risk to the resident by not doing so.
An interview on 10/10/23 at 3:13 PM with LVN B revealed that if PPE was removed in the room, the staff had to come out of the room and gather the necessary supplies. She stated that was to be followed to prevent infections and contamination.
An interview on 10/13/23 at 3:53 PM with the DON revealed staff had to wear the appropriate PPE while working with COVID residents. She stated the appropriate PPE included gown, mask, gloves and eye wear. She revealed the CNA should have washed her hands and come out of the room to put on a new gown. She stated the importance of staff wearing the appropriate PPE was to prevent the spread of disease and prevent it from affecting other residents.
An interview on10/13/23 at 4:46 PM with the Infection Preventionist revealed if a staff member removed their gown in the COVID positive room, they had to go out of the room and re-gown. She stated it was important to do so to prevent other residents from becoming sick since they did not have a strong immune system.
Record review of facility policy titled COVID-19 Visitation dated May 8, 2023, read in part .Staff will adhere to the appropriate use of personal protective equipment (PPE) .visits will be conducted in a manner that adheres to the core principles of COVID-19 infection prevention .
Record review of facility policy titled COVID-19 Prevention, Response and Reporting dated May 8, 2023, read in part .Health Care Providers who enter the room of a resident with suspected or confirmed SARS CoV-1 infection should adhere to standard precautions and use a National Institute for Occupational Safety and Health -approved particulate respirator with N95 filters or higher, gown, gloves and eye protection .
Sept 2023
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 F0655
(Tag F0655)
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 baseline care plan for each re...
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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 baseline care plan for each resident that includes the instructions needed to provide effective and person-centered care of the resident that meet professional standards of quality care for 1 of 8 (Resident #7) residents reviewed for base line care plans.
The facility failed to develop a baseline care plan for Resident #7.
This failure could put residents newly admitted at risk of needs not being identified affecting the quality of care they receive.
Findings included:
Record review of Resident #7's face sheet dated 09/26/2023 revealed an [AGE] year-old female who was admitted to the facility on [DATE] with diagnoses of hemiplegia (paralysis of one side of the body) and cerebral infarction (occurs as a result of disrupted blood flow to the brain due to problems with the blood vessels that supply it).
Record review of Resident #7's MDS revealed it was not yet completed, and was still in the 5-day admission window. The BIMS had not yet been obtained.
Record review of Resident #7's local hospital final report dated 09/22/23 revealed diagnoses of right-side weakness and an admitting diagnosis of stroke. The mental status revealed Resident #7 was alert and oriented to person, place, time, and event, and was coherent.
Record review of Resident #7's electronic record revealed there was no evidence a baseline care plan was completed.
During an observation and interview on 09/26/23 at 10:01 am, revealed Resident #7 was alert and oriented to person, place, time, and event. Resident #7 stated she had been in the facility in the past and had been discharged home. Resident #7 stated she had been admitted 2 days ago (09/23/23). Resident #7 stated she was able to do her own ADL's and required minimal assistance. Resident #7 stated she was continent to bladder and bowel and was able to transfer in and out of bed on her own.
During an interview on 09/26/23 at 1:24 pm, LVN B stated baseline care plans were completed by the admitting nurse and were required to be completed within 48 hours of admission. LVN B stated Resident #7 had been at the facility in the past and the staff were familiar with her. LVN B stated Resident #7 required minimal supervision assistance with ADL's, and stated Resident #7 was independent and continent to bowel and bladder. LVN B stated CNAs were very good about asking for residents' status if they were not familiar with someone. LVN B stated risks for not having baseline care plan included a change in condition from last time Resident #7 was at the facility and required different type of care, in which her needs would not be met affecting their quality of care.
During interview on 09/26/23 at 1:47 pm, CNA C stated she had worked with Resident #7 in the past and was familiar with her care. CNA C stated Resident #7 did not require much assistance, and stated she was continent to bowel and bladder. CNA C stated she had access to [NAME] (care plan for CNAs) through PCC (electronic records) where she could reference any changes or type of care the residents require. CNA C stated Resident #7 had her previous care plan still showing from the previous stay but did not have a current care plan for her current admission. CNA C stated she would ask the charge nurse for updates at the beginning of her shift daily to ensure there were no changes that could affect the care provided.
During interview on 09/23/23 at 1:54 pm, ADON A stated the MDS Nurses were responsible for completing the baseline care plans. ADON A stated the admitting nurse should start the residents' assessments when admitting the resident and that would trigger the baseline care plan to generate. ADON A stated once the baseline care plan was generated, the system would require an RN signature to complete after being reviewed. ADON A stated Resident #7 baseline care plan had been created and was just pending an RN signature. ADON A stated Resident #7's electronic records did not show her baseline care plan and risks included needs not being met.
During interview on 09/26/23 at 2:12 pm, the DON stated the admitting nurse were responsible to develop a baseline care plan and RNs were expected to review and sign for approval within 48 hours of admission. The DON stated Resident #7's baseline care plan was pending RN approval. The DON stated risks included staff would not know appropriate care residents required.
Record review of the Baseline Care Plan policy dated February 2023 revealed in part The facility will develop and implement a baseline care plan for each resident that includes the instructions needed to provide effective and person-centered care of the resident that meet professional standards of quality of care. 1: The baseline care plan will: be developed within 48 hours of a resident's admission; include the minimum healthcare information necessary to properly care for a resident including, but not limited to: initial goals based on admission orders, physician orders, dietary services, social services, PASSAR recommendation, if applicable; 2: The admitting nurse, or supervising nurse on duty, shall gather information from the admission physical assessment, hospital transfer information, physician order, and discussion with resident and resident representative; 3: The supervising nurse shall verify within 48 hours that a baseline care plan has been developed.
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 F0679
(Tag F0679)
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 provide an ongoing program to support residents in the...
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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 an ongoing program to support residents in their choice of activities, both facility-sponsored group and individual activities and independent activities, designed to meet the interests of and support the physical, mental, and psychosocial well-being of each resident, encouraging both independence and interaction in the community for 1 of 8 (Resident #7) residents reviewed for individual activities.
The facility failed to provide Resident #7 with a word search to work on individually in her room per her preference.
This failure could result in residents being bored resulting in a diminished quality of life.
Record review of Resident #7's face sheet dated 09/26/2023 revealed an [AGE] year-old female who was admitted on [DATE] with diagnoses of hemiplegia (paralysis of one side of the body) and cerebral infarction (occurs as a result of disrupted blood flow to the brain due to problems with the blood vessels that supply it).
Record review of Resident #7's MDS was not yet completed, was still in their 5-day admission window. BIMS had not yet been obtained.
Record review of Resident #7's electronic record revealed there was no baseline care plan completed.
Record review of the facility's September 2023 Activity Calendar revealed 09/26/2023 had Jehovah Witness scheduled at 10 am, Reading club at 11 am, and manicure at 2 pm.
During an observation and interview on 09/26/23 at 10:01 am, revealed Resident #7 was alert and oriented to person, place, time, and event. Resident #7 stated no one had asked her to join any type of activity since her admission.
During an interview on 09/26/23 at 11:06 am, Resident #7 stated a lady, whose name she did not remember, had stopped by the day before (09/25/23) and had asked her what she liked to do. Resident #7 stated she had requested a word search and had been waiting for her to drop it off because she was bored.
During an interview on 09/26/23 at 1:16 pm, Resident #7 stated no one had brought her or offered her any activities in the room. Resident #7 stated she was bored and was still waiting for the word search.
During an observation on 09/26/23 at 1:17 pm, revealed an activities calendar for the month of September 2023, was located against the wall with good visualization from Resident #7's bed.
During an interview on 09/26/23 at 1:19 pm, the Activities Director stated she had a standard calendar with activities scheduled for the month that was posted in all rooms and the hallway. Activities Director stated for any new admission, she would meet with residents almost immediately and question their preferences to see if she could accommodate their likings. Activities Director stated she had met with Resident #7 the day before (09/25/23) and she had requested a word search book and had not had the opportunity to take it to her. Activities Director stated she had not asked for help to deliver the word search to Resident #7 as she had requested the day before and she was probably bored.
During an interview on 09/26/23 at 3:37 pm, the Administrator stated expectations were for all residents to receive activities promptly, even those who wished to stay in their room. Administrator stated risks of not providing in room activities could result in resident getting bored and possibly increase in anxiety.
Record review of the Activities policy dated October 2022 revealed in part It is the policy of this facility to provide an ongoing program to support residents in their choice of activities based on their comprehensive assessment, care plan, and preferences. Facility sponsored group, individual, and independent activities will be designed to meet the interests of each resident, as well as support their physical, mental, and psychosocial well-being. Activities will encourage both independence and interaction within the community. 8- Activities will include individual, small and large group activities as well as: in-room activities.
MINOR
(C)
📢 Someone Reported This
A family member, employee, or ombudsman was alarmed enough to file a formal complaint
Minor Issue - procedural, no safety impact
Staffing Information
(Tag F0732)
Minor procedural issue · This affected most or all residents
Based on observation, interview, and record review the facility failed to ensure nurse staffing data was posted and readily accessible to residents and visitors for one of twenty-six days reviewed for...
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Based on observation, interview, and record review the facility failed to ensure nurse staffing data was posted and readily accessible to residents and visitors for one of twenty-six days reviewed for nurse staffing information.
The facility failed to post the required staffing information for September, 09/26/2023.
This failure could place residents, their families, and facility visitors at risk of not having access to information regarding staffing data and facility census.
Finding include:
During an observation on 09/26/23 at 9:59 am, of the public access area wall located in the center of nursing station area revealed a daily staffing sheet posting information was dated 09/25/23. The current date and information on staff scheduled and total hours worked were not posted.
During an observation on 09/26/23 at 1:16 pm, of the public access area wall located in the center of nursing station area revealed a daily staffing sheet posting information was dated 09/25/23. The current date and information on staff scheduled and total hours worked were not posted.
During an interview on 09/26/23 at 1:54 pm, ADON A stated the ADONs, and DON were responsible for updating the staffing posting daily and did not have reason for daily posting not being updated. The ADON A stated risks for not updating daily included residents did not have accurate information related to current census and staffing.
During an interview on 09/23/23 at 2:12 pm, the DON stated the ADONs were responsible for updating the staffing posting daily. The DON stated she did not know what the risks were for not having updated census and staffing.
Record review of the Facility Required Postings policy dated 02/2023 revealed in part The facility will post required postings in an area that is accessible to all staff and residents. (2) The facility must also post the following: A. Staffing Information.
May 2023
11 deficiencies
1 Harm
SERIOUS
(G)
Actual Harm - a resident was hurt due to facility failures
Accident Prevention
(Tag F0689)
A resident was harmed · This affected 1 resident
**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on the observations, interviews, and record reviews the facility failed to ensure that the residents environment remains f...
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**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on the observations, interviews, and record reviews the facility failed to ensure that the residents environment remains free of accidents hazards as possible and ensure each resident receives adequate supervision to prevent accidents for 3 (Residents #22, Resident #8 & Resident #35) of 24 residents reviewed for accidents.
1. The facility failed to make sure Resident #22 had preventive measures added when Resident #22 got her hand stuck between PVC pipe of the bed that reulted in a fractured right thumb and despite the injury the facility took no steps to prevent future injuries.
2. The plastic arm of Resident #8's wheelchair was torn and exposed.
3. The plastic on the arms of Resident #35's wheelchair was torn and sticking up.
This failure could place residents at risk of getting their fingers caught in beds made of PVC pipes, and at risk of equipment not staying in safe operating condition and could cause irritationed, scraped, and torn skin to residents
Findings included:
Record review of Resident #22's Face Sheet admission on [DATE] to the facility.
Record review of Resident #22's History and Physical dated 09/09/2021 revealed an [AGE] year-old female with a diagnosis of Alzheimer's Dementia and mixed anxiety and depressive disorder.
Record review of Resident #22's Order Recap 03/07/2023 admitted under 2 Oaks Hospice with dementia with other behavioral disturbance. 04/08/2023 behavior monitoring for withdrawn, lack of interest, feeling helpessness; 04/22/2023 right hand x-ray to rule out fracture use of portable (xray) due to bed bound status.
Record review of Resident #22's Care Plan dated 03/10/2023 potential for spontaneous fractures of Osteoporosis, will be kept safe, comfortable, and functional without experiencing any fractures. 03/29/2023, Resident was at risk for falls cognitive impairment with impaired safety awareness. Attempt to identify cause of fall and alleviate problem to extent possible, educate on noncompliance with safety interventions and explain possible risks/outcomes, observe frequently and place in supervised area when out of bed.
Observation on 05/22/2023 at 9:02 AM Resident #22 was sitting down on her fall mat leaning against her PVC piped bed that exposed holes in between the mattress and the pipes.
Interview on 05/22/2023 at 3:53 PM Weekend Supervisor stated Resident #22 had caught her finger in between the PVC piping of the bed when she was trying to get out of bed. Weekend Supervisor stated Resident #22 tried to transfer herself and got it stuck which led to a right thumb fracture. Weekend Supervisor stated she was not aware of any alterations to the PVC piping bed to ensure that Resident #22 would not get her fingers caught again. Weekend Supervisor stated resident was restless, constantly moving in bed and sitting on the side of the bed or on the floor mat. Weekend Supervisor stated when resident sustained the fall her finger got stuck in a gap that was between the bed frame and mattress. Weekend Supervisor stated resident was able to stand up without assistance and had unsteady gait. Weekend Supervisor stated resident was able to walk with assistance. Weekend Supervisor stated the staff would not ambulate the resident when resident was restless and constantly kept sitting on the side of the bed reaching out for objects in her room. Weekend Supervisor stated resident's daughter visited the resident and did not walk the resident. Weekend Supervisor stated the incident was an unwitnessed fall and had to be categorized as a fall since it was unwitnessed.
Interview on 05/22/2023 at 4:26 PM LVN B stated Resident #22 had a fracture to her right thumb when she got it stuck in between the PVC piping of the bed. LVN B stated they have not put any interventions to prevent another incident of Resident #22 getting her fingers stuck again.
Observation on 05/22/2023 at 4:26 PM with LVN B, Resident #22 bed was all PVC piping with no padding or interventions to keep Resident #22 from getting her fingers caught within the piping.
Interview on 05/23/2023 at 9:54 AM LVN C stated she was told in report that Resident #22 had got her finger stuck with in the piping of the bed. LVN C stated there had been no modifications or interventions put in place for Resident #22 to prevent another injury other than placing pillows in the openings of the piping of the bed. LVN C stated the facility had to come up with a solution to prevent another injury but had not. LVN C stated the risk of Resident #22 getting her fingers caught still existed.
Interview attempt on 05/23/2023 at 1:54 PM with CNA W who reported the incident was condcuted but received no answer.
Interview on 05/23/2023 at 3:48 PM LVN D stated she was notified of Resident #22 who was holding her finger the day of the incident where she got the finger stuck in between the mattress and PVC piped bed. LVN D stated Resident #22 was holding her right hand where her right thumb was very swollen. LVN D stated it was getting bruised and x-ray was ordered to confirm if the finger was fractured. LVN D stated it was confirmed fractured. LVN D stated the CNA had told her that she found Resident #22 with her hand caught between the PVC piped bed pipes. LVN D stated the facility did not do any interventions to address the piped bed to prevent any future injuries.
Observation on 05/24/2023 at 2:26 PM revealed Resident #22's bed PVC piping had been wrapped in a green padding.
Interview on 05/24/2023 at 3:57 PM DON stated Resident #22 was trying to get up from bed and got her finger stuck with the bed resulting in a fracture. DON stated she had instructed for the staff to place pillows in the areas where the pipes were exposed so that Resident #22 would not get caught and further injury herself. DON stated that the risk still existed, and Resident #22 could still get injured.
Interview on 05/24/2023 at 5:24 PM Administrator stated the incident for resident #22 was not discussed in the morning meeting and nothing had been done to prevent recurrence of injury. DON did not mention if the bed was reevaluated for Resident #22 to make sure it was appropriate for Resident #22's needs.
Record review of the facility incident report dated 05/22/2023 indicated Resident #22 had a fall due to to trying to get out of bed, trying to stand up. Resident #22 had fractured her right thumb and was going to be sent out to the hospital. It was reported that the doctor, family, and hospice were notified of the incident. It was stated that the family and hospice had agreed to not send out the resident and care was given by the facility. Incident Report did not indicate any interventions to prevent future injury to Resident #22.
Review of Resident #8's face sheet dated 05/24/2023 documented that she was a [AGE] year-old female with an admission date to the facility of 01/17/2020.
Review of History and Physical dated 08/10/2022 documented she had a diagnosis of dementia and had decreased mobility.
Review of Resident #8's comprehensive care plan dated 02/04/2023 documented Resident #8 required assistance with ADLs: transfer and bed mobility. Goal was that resident would not decline in transferring/ bed mobility. Interventions included to assist resident with 1 staff for transfers and encourage the resident to participate to the fullest extent possible with each interaction.
Review of Resident #8's quarterly MDS assessment dated [DATE] documented she had a BIMS score of 2 (severely cognitively impaired). She required extensive assistance with one person assistance to transfer and to move around the facility. She used a wheelchair.
Record review of Resident #35's face sheet dated 05/22/2023 documented that she was [AGE] years old and was admitted to the facility on [DATE].
Record review of Resident #35's History and Physical dated 03/03/2023 documented in part that she had diagnoses including multiple sclerosis, repeated falls, and morbid obesity.
Record review of Resident #35's quarterly MDS dated [DATE] documented in part that her BIMS was 14 (cognitively intact). She did not walk during the lookback period. She required extensive assistance from two people to transfer between surfaces and extensive assistance from one person to move around the facility. She used a wheelchair.
Record review of Resident #35's care plan dated 02/06/2023 documented that she had an ADL self-care performance deficit. The care plan did not address the level of assistance she needed to move around the facility.
In interview and observation on 05/21/23 beginning at 09:31 AM in Resident #35's room a wheelchair was observed next to her bed. It was observed with the cracked plastic cover on the arms of a wheelchair, and that the cracked plastic was curled up and felt stiff to the touch. Resident #35 said that it was her wheelchair and that she got bruising on her arms from rubbing against the wheelchair arms.
Observation on 05/21/23 at 12:43 PM revealed Resident # 8's wheelchair arm rest on right side was torn and part of the exposed cushion was missing.
In an interview on 05/23/23 at 8:55 AM with CNA V, she revealed Resident # 8's wheelchair had been torn for a while. She said maintenance could probably fix it. CNA V did not know why Resident # 8 had not had her wheelchair fixed. She said the risk to the resident could be a skin tear or a scrape.
In an interview on 05/23/23 at 8:59 AM, LVN C revealed she did not know how long Resident # 8's wheelchair had been torn. She said the maintenance worker was the one responsible for addressing issues with wheelchairs. She said the risk of the wheelchair not being fixed could be that Resident # 8's skin could develop a skin tear.
In an interview on 05/24/23 at 8:51 AM, CNA A revealed she was aware Resident # 8's wheelchair had been exposed but did not know how long. She said she would be responsible for telling the nurse but had not done so and could not state why. She said the risk of wheelchair being torn could be resident's skin breaking.
In an interview on 05/24/23 at 2:13 PM with Maintenance, he revealed he had changed Resident #8's armrest after ADON had informed him it was torn. He said before then, he had not known about the wheelchair. He said the correct process was for staff to write the work order in the Maintenance binder. He said the risk of not informing him of issues with medical equipment could be that residents could get hurt.
In an interview on 05/24/23 at 04:36 PM the DON said that Resident #35's broken wheelchair arm covers could cause skin tears and trauma to the patient. It was the responsibility of Central Supply to monitor equipment condition. The DON said that reports of equipment that needed repair should be put in the maintenance log, but staff may not have been aware of the log until concerns were raised recently.
Record review of Maintenance book revealed no work order for Resident # 8 's or Resident #35's wheelchair had been completed.
Record review of facility policy titled Preventative Measures for Wheelchairs dated 2023 read in part .All staff have a responsibility to ensure that wheelchairs in need of repairs are not used and are reported for repairs. Preventative maintenance should be performed weekly or as indicated .check arm rests .for tears .
Record review of the facility Accidents and Supervision policy dated 2022 revealed the resident environment will remain free of accidents hazards as was possible. Each resident will receive adequate supervision and assistive devices to prevent accidents. This includes Identifying hazards and risk, evaluating and analyzing hazards and risk, implementing interventions to reduce hazards and risk, and monitoring for effectiveness and modifying interventions when necessary.
CONCERN
(D)
Potential for Harm - no one hurt, but risky conditions existed
Transfer Notice
(Tag F0623)
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 notify the ombudsman of the transfer or discharge and the reasons fo...
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**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on interview and record review the facility failed to notify the ombudsman of the transfer or discharge and the reasons for the transfer/discharge in writing and in a language and manner they understood for 1 (Resident #116) of 4 Residents reviewed for transfer/discharge.
The facility did not send a written discharge notice to the state's long term care ombudsman of the effective date of transfer or discharge, the reason for the transfer/discharge, or the right to appeal.
This deficient practice could affect residents at the facility at risk of having their discharge rights violated.
Findings included:
Record review of Resident #116's Face Sheet dated 05/17/2023 admission was 10/28/2022 to the facility.
Record review of Resident #116's History & Physical dated 04/28/2023 revealed a [AGE] year-old male diagnosed with dementia, depression, psychiatric disorders.
Record review of Resident #116's Progress Notes dated 02/24/2023 revealed Administrator entered - Resident #116 was being physically aggressive towards other residents and staff. Resident #116 was discharged from the facility. Progress note documented Administrator had conversed with Ombudsman and was notified by Ombudsman to following proper discharge protocol of giving a 30-day notice or providing an Emergency Detention Order (EDO).
Interview on 05/23/2023 at 8:44 AM Ombudsman stated he did not receive any discharge paperwork from the Administrator regarding Resident #116's discharge from the facility.
Interview on 05/23/2023 at 10:35 AM Administrator stated they did not provide or have a 30-day discharge letter or an emergency detention order for the Ombudsman.
Interview on 05/24/2023 at 5:24 PM Administrator stated Resident #116 was physically aggressive to a resident and assaulted his staff. Administrator stated Resident #116 was sent to a behavioral facility the family did not want to send him back to the facility. Administrator stated he notified the Ombudsman by telephone but not in writing. Administrator stated he was not aware that the facility had to send written notice of the transfer/discharge to the Ombudsman.
Record review of facility Transfer, and discharge policy (including AMA (Against Medical Advice)) dated 2022 revealed in these exceptional cases, the notice must be provided to the resident, resident's representative if appropriate, and LTC (Long Term Care) Ombudsman as soon as practicable before the transfer or discharge. The facility will maintain evidence that the notice was sent to the Ombudsman.
Record review of facility Statement of Resident Rights not dated revealed to not be discharged from the facility, except as provided in the nursing facility regulations.
Record review of facility Rights of the Elderly not dated revealed pursuant to Texas Law, and as listed in Texas Human Resources, Code, Title 6, Chapter 102, ever Texas nursing facility resident has the following rights: Except in an emergency a person providing services may not transfer or discharge an elderly individual from a residential facility until the 30th day after the date the person providing services provides written notice to the elderly individual, the individual's legal representative, or a member of the individual stating: the reason for the transfer or discharge listed in Subsection ( r); the individual's right to appeal the action and the person to whom the appeal should be directed.
CONCERN
(D)
Potential for Harm - no one hurt, but risky conditions existed
Deficiency F0645
(Tag F0645)
Could have caused harm · This affected 1 resident
**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on, interview, and record review the facility failed to ensure that new residents with mental disorder were provided with ...
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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 that new residents with mental disorder were provided with a PASRR Level II Screening for one resident (Resident #43) of 5 residents reviewed for PASARR coordination.
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The facility failed to notify the local authority when a PASSR 1 for Resident #43 indicated a positive MI status, a PASRR Level II evaluation was not completed.
This failure put residents with mental illness at risk of at risk of not receiving appropriate care and services from the local authority, which could result in failure to maintain or a possible decline in mental health.
Findings included:
Record review of Resident #43's face sheet dated 05/24/2023 documented that he was [AGE] years old, was initially admitted to the facility on [DATE] and again on 12/02/2022.
Record review of Resident #43's History and Physical dated 08/24/2022 documented diagnoses including recurrent chronic major depression and major neurocognitive disorder.
Record review of Resident #43's quarterly MDS dated [DATE] documented that he was not able to complete the BIMS interview and that based on staff assessment he had short- and long-term memory problems. His cognitive skills for daily decision making were moderately impaired. He had no symptomatic behaviors. His diagnoses included non-Alzheimer's Dementia, Anxiety Disorder, Depression and Psychotic disorder.
Record review of Resident #43's electronic diagnosis listing dated 05/24/2023 documented diagnoses including dementia, depression, anxiety, and delusional disorder.
Record review of Resident #43's PASRR Level 1 Screening dated 08/23/2022 documented an assessment date of 08/24/2022. It documented that the that there was evidence or indications that he had a mental illness.
In an interview on 05/22/23 at 09:59 AM MDS Nurse O stated that MDS nurses were responsible for monitoring resident PASRR status and reporting changes in status to the local authority. MDS Nurse O confirmed that Resident #43's records indicated that the PASRR Level 1 Screening assessment conducted 08/24/2022 indicated that the resident had mental illness. She confirmed that there was no record of a notice being sent to the local authority about this change, so the resident did not receive a PASRR Level II evaluation in response to the PASRR Level 1 screening. MDS Nurse O was not able to explain why Resident #43's positive PASRR Level 1 screening results had not been sent into the local authority resulting in the resident not receiving a PASRR Level II evaluation. He stated that the risk to Resident #43 of not having the PASRR Level II screening evaluation completed was that Resident #43 might not receive special services and additional resources the local authority could provide.
In an interview on 05/24/23 at 04:30 PM DON said he had been made aware that Resident #43 had a positive Level 1 PASRR screening that did not result in a PASRR Level II Evaluation by the local authority. He said the PASRR program provided special services to residents with special needs, ensured individuals were placed in the proper setting, and received the service they needed. The DON said the risk to residents was that they might not get services they needed and that would benefit them.
CONCERN
(D)
Potential for Harm - no one hurt, but risky conditions existed
Deficiency F0679
(Tag F0679)
Could have caused harm · This affected 1 resident
**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, interview, and record review the facility failed to provide an ongoing program of facility sponsored activ...
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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 an ongoing program of facility sponsored activities designed to meet the mental well-being of 1 (Resident #22) of 6 residents reviewed for facility activities.
The facility failed to provide activities program to meet the needs of Resident #22.
This failure could result in residents decreased physical, mental, and psychosocial well-being.
Findings included:
Record review of Resident #22's Face Sheet admission on [DATE] to the facility.
Record review of Resident #22's History and Physical dated 09/09/2021 revealed an [AGE] year-old female with a diagnosis of Alzheimer's Dementia and mixed anxiety and depressive disorder.
Record review of Resident #22's Order Recap dated 03/06/2023 revealed may participate in social/physical activities as tolerated.
Record review of Resident #22's Care Plan dated 03/10/2023 revealed resident needed encouragement to attend activities 1-3 times a week. Encourage resident to become involved with activities, expand activity program to include my choices, if possible, interview me for daily preferences, inform me of upcoming activities.
Record review of Resident #22's Progress Notes from 04/24/2023 to 05/21/2023 did not indicate that Resident #22 had done any activities of any kind or refused.
Observation on 05/22/2023 at 9:02 AM Resident #22 was sitting down on the floor mat leaning against the PVC piped bed holding a teddy bear, no activities being done.
Observation on 05/23/2023 at 11:02 AM Resident #22 was in her room sitting down on the floor manipulating the call light leaning on her PVC pipped bed, no activities being done.
Interview on 05/23/2023 at 3:48 PM LVN D stated the activity Resident #22 does not talk to her daughter when she comes to visit her. LVN D stated when daughter was not at the facility Resident #22 was taken to bingo.
Interview on 05/24/2023 at 8:40 AM Activities Director stated he goes to residents' rooms and ask if they would like to join the activity. Activities Director stated if they refuse, he will write a progress note with the refusal or the activity the resident did. Activity Director viewed the progress notes for Resident #22 and stated there were no notes or refusals put in by him from 04/24/2023 to 05/21/2023. Activities Director stated Resident #22 had declined and was placed on hospice. Activities Director stated he talks to her but refuses most of the time and indicated she did not feel well most of the time. Activities Director stated she does not attend group activities. Activities Director stated he did not have a customized activities plan for her or had a customized activities plan tailored to residents like Resident #22 who had declined and stayed in their rooms.
Interview on 05/24/2023 at 9:25 AM LVN C stated Resident #22 stays in her room more after her significant change and that they do not have anything in place for activities that fit Resident #22's new condition.
Observation on 05/24/2023 at 10:08 AM Resident #22 remained in her room asleep on her bed, no activities provided.
Observation on 05/24/2023 at 1:12 PM Resident #22 remained in her room asleep turned the other way, no activities provided.
Interview on 05/24/2023 at 1:51 PM MDS T stated a significant change was when a resident had a major change in the medical condition which they would have to reevaluate the residents care plans. MDS T stated the Activities Director would update the care plan section pertaining to activities. MDS T stated Resident #22 care plan was appropriate for her before she had the significant change with going to hospice. MDS T stated the activities on her care plan would have to be revisited and customized for her. MDS T observed the activities calendar and stated the Activities Director would need to have a calendar for residents that are always in their rooms and don't come out or for the preference when they stay in the room. MDS T stated the Activities Director would have to report the customized activities plan in the care plans. MDS T stated the adverse outcome for residents who do not have a customized activities care plan would lack activities, not be informed of activities, and could have an effect in their psychological state for the day. MDS T stated he wished the Activities Director had daily activities plan for each resident.
Interview on 05/24/2023 at 3:57 PM DON stated Resident #22's daughter comes to visit her and do her hair. DON stated she had not seen Resident #22 come out of her room. DON stated she does not know if Resident #22 does any activities. DON viewed the activities calendar and stated the calendar was not appropriate for Resident #22's needs. DON stated she did not have a system tailored for her significant change in activities and there was no system for other residents with similar needs as Resident #22 where they stay in the room and have a significant change. DON stated the risk to Resident #22 with no customized activities plan would be her getting bored, sad, or depressed.
Interview and record review on 05/24/2023 at 5:24 PM Administrator stated Resident #22 had been declining and was placed into hospice. Administrator stated he noticed Resident #22 spending a lot of time in here room. Administrator stated the activities calendar had some appropriate activities for her and the activities Director had a customized program for residents like Resident #22. Administrator stated if residents refused or attended an activity it would have to be documented in the resident's progress notes. Administrator stated the risk of Resident #22 not having a customized activities plan could lead to anxiety and boredom.
Record review of facility activities policy dated 2023 revealed special considerations will be made for developing meaningful activities for residents with dementia and/or special needs. These include, but are not limited to, considerations for: Residents who have withdrawn from previous activity interest/customary routines, and isolates self in room/bed most of the day.
CONCERN
(D)
Potential for Harm - no one hurt, but risky conditions existed
Pharmacy Services
(Tag F0755)
Could have caused harm · This affected 1 resident
Based on observation, interviews, and record review, the facility failed to provide pharmaceutical services (including procedures that assure the accurate acquiring, receiving, dispensing, and adminis...
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Based on observation, interviews, 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 1 of 2 medication carts (100 Hall) reviewed for expired medications.
-100 hall medication cart had expired medication.
This deficient practice could cause a decline in health in residents if expired medication was to be given.
Findings included:
Observations on 05/22/23 at 1:22 PM revealed an open package of 3 Monistat (medication for yeast infections) pre-filled tubes with an expiration date of 08/2022. The package had a date of 03/18/2023, indicating it had been opened on that date.
In an interview on 05/22/23 at 1:23 PM with LVN P, she revealed all nurses were responsible for checking the medication carts and ensuring all medications were dated, labeled and not expired. She said the expiration date on the medication was 08/2022. She said it should not have been in the medication cart because it was expired. She said she had not been trained in the subject, but it was nursing knowledge.
In an interview on 05/22/23 at 1:30 PM with DON, she revealed all nurses were responsible for checking their medication carts and ensuring the medications were not expired. She said the medication was not supposed to be in the medication cart because the medication was expired. She said the chemistry of the medication would change and would not be effective if it were to be given.
Review of facility policy titled Medication Storage dated 10/2022 read in part .The pharmacy and all medication rooms are routinely inspected by the consultant pharmacist for discontinued, outdated, defective, or deteriorated medications .
CONCERN
(D)
Potential for Harm - no one hurt, but risky conditions existed
Medication Errors
(Tag F0758)
Could have caused harm · This affected 1 resident
**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on interviews and record reviews, the facility failed to ensure that a PRN order for psychotropic drugs was limited to 14 ...
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**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on interviews and record reviews, the facility failed to ensure that a PRN order for psychotropic drugs was limited to 14 days and if the attending physician believed that it was appropriate for the PRN order to be extended beyond 14 days, failed to document their rationale for 1 resident (Resident #114) of 3 reviewed for psychoactive medications in that:
The facility failed to ensure that Resident #114 had an order for psychotropic medication (Haldol) that did not contain PRN orders beyond 14 days without an end date.
This deficient practice could place residents at risk of receiving unnecessary medication and adverse drug reactions.
Findings included:
Review of Resident #114's face sheet 05/23/2023 revealed a [AGE] year-old male with an admission date of 04/28/2023. It revealed he had a diagnosis of psychosis. Psychosis occurs when one loses touch with reality with symptoms of delusion.
Review of History and Physical dated 04/28/2023 revealed he had a history of alcohol abuse and insomnia.
Review of admission MDS assessment dated [DATE] revealed Resident #114 had a BIMS score of 0, indicating he was severely cognitively impaired meaning he had memory loss and difficulty with making decisions. It also showed an antipsychotic had been given in the last 7 days of the assessment.
Review of comprehensive care plan dated 05/02/2023 revealed Resident #114 used psychotropic medications related to behavior management. Goal was for resident to remain free of psychotropic drug related complications including movement disorders, discomfort, hypotension, gait disturbance, or cognitive/behavioral impairment. Interventions included administering medication as ordered, monitoring for side effects, monitoring behavior symptoms and monitoring occurrence of target behaviors.
Review of physician orders dated 05/06/2023 revealed Haldol Injection Solution 5 mg/ml : Inject 5 mg intramuscularly every 6 hours as needed for agitation related to unspecified psychosis. There was no end date on the order, and it was marked as indefinite. Order had been placed by NP.
Review of MAR for the month of May 2023 revealed Resident #114 had been given Haldol (antipsychotic for mood disorder) 4 times since it had been ordered. The dates were 05/06, 05/07 and 05/20.
In an interview on 05/24/23 at 2:25 PM with LVN R she revealed she had never administered Resident #114 the Haldol injection. She stated antipsychotic medications lasted for 2 weeks and then would have to be re-ordered but was not sure on the policy at the facility.
In an interview on 05/24/23 at 2:59 PM with NP, he revealed he was not aware that Resident #114 had a PRN antipsychotic medication that did not have an end date. He stated the pharmacy would give him a reminder through the facility that there had to be changes made to medication orders. He stated he had not received a document from the facility for Resident #114. He revealed he could not state the risk of having a PRN order for longer than 14 days.
In an interview on 05/24/23 at 3:58 PM with DON, she revealed PRN antipsychotic medications were only good for 14 days; and should not be ordered past it. She stated there had not been a stop date for Resident #114's Haldol order. She stated any nurse could have called the physician to ask for a new order if the resident needed the medication. She revealed if the resident needed the medication, there would not be risks to the resident. However, she stated that if the resident did not need the medication, there could be a negative outcome such as tardive dyskinesia or EPS. Tardive dyskinesia was defined as involuntary and repetitive body movements. EPS was a group of symptoms such as muscle contractions, tremors, stiff muscles, and involuntary facial movements.
Review of facility policy titled Use of Psychotropic Medication dated 2022 read in part .PRN orders for all psychotropic drugs shall be used only when the medication is necessary to treat a diagnosed specific condition that is documented in the clinical record, and for a limited duration (14 days). If the attending physician or prescribing practitioner believes that it is appropriate for the PRN order to be extended beyond 14 days .shall document their rationale if the resident's medical record and indicate the duration for the PRN order .
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
ADL Care
(Tag F0677)
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 a resident who was unable to carry out activities of daily ...
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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 a resident who was unable to carry out activities of daily living receives the necessary services to maintain good nutrition, grooming, and personal and oral hygiene for 5 (Resident #114, Resident #58, Resident #4, Resident #37 and Resident #41) of 15 residents observed for assistance with ADL's.
The facility failed to ensure facility staff provided showers to maintain good grooming, personal and oral hygiene for Resident #114, Resident #58, Resident #4, and Resident #41.
The facility failed to ensure staff helped resident #37 to the bathroom in a timely manner resulting in him having to urinate in his brief.
This deficient practice could affect residents who were dependent on assistance with ADL's and could result in poor care, skin breakdown, feelings of poor self-esteem, and lack of dignity.
Findings included:
Resident #114
Record review of Resident #114's Face Sheet dated 05/23/2023 reflected admission on [DATE] to the facility.
Record review of Resident #144's History and Physical dated 04/28/2023 revealed a [AGE] year-old male diagnosed with spinal stenosis (happens when the spaces in the spine narrow and create pressure on the spinal cord and nerve roots) with radiculopathy (injury or damage to nerve roots in the area where they leave the spine) cervical decompressive laminectomy (involves the removal of the lamina, the back portion of a spinal bone in the neck).
Record review of Resident #114 admission MDS dated [DATE] revealed an interview for a brief interview of mental status did not take place, ADLs for personal walking/hygiene/bathing indicated activity did not occur and there was no staff support provided, resident was frequently incontinent with urinary/bowel, diagnosis of spinal stenosis, cervical region (happens when the spaces in the spine narrow and create pressure on the spinal cord and nerve roots), was not marked for spinal surgery as Resident #114 did have spinal surgery.
Record review of Resident #114's Care Plan dated 05/02/2023, ADLs for bathing/showering to avoid scrubbing and pat dry sensitive skin, check nail length and trim and clean on bath day and as necessary. Requires assistance by staff with personal hygiene and oral care but was not specific on how often and when the Resident #114 was to be showered.
Record review of Resident #114's Progress Notes 04/28/2023-05/24/2023 did not document anything regarding the resident was showered or that he refused to shower.
Record review of Resident #114's POC (Plan of Care) from 05/08, 05/09, 05/10, 05/11, 05/12, 05/13, 05/14, 05/16, 05/17, 05/18, 05/19, 05/20, 05/21, to 05/23/2023 revealed that these 12 days were marked as activity did not occur bathing/showering for Resident #114. (05/13/23, 05/14/23, 05/20/23, 05/21/23 were weekends)
Interview and observation on 05/21/2023 at 10:30 AM Resident #114 stated he had not had a shower in 3 weeks. Resident #114 stated he did not know why but wanted to be showered. Resident #114 was observed
with beard growing on his chin and mouth area. Resident #114 had greasy hair and body odor.
Interview on 05/21/2023 at 12:11 PM Weekend Supervisor stated the facility does not have enough staff since she has been employed with the facility for a year. Weekend Supervisor stated she had 1 CNA on each hall but needed 2 CNAs on each hall because of the number of residents they had to attend to. Weekend Supervisor stated she worked with what she had. Weekend Supervisor stated because they did not have enough staff there was a risk to the residents from not receiving the best care, they have to cut corners, and skip resident showers.
Interview on 05/21/2023 at 12:29 PM LVN L stated she had been working for the facility for 6 weeks and they are always short staff on the weekends. LVN L stated she had voiced it out to her supervisor. LVN L stated she was supposed to have 2 CNAs on the hall and usually has 1 CNA. LVN L stated the facility was understaffed and because of this the residents don't get showered.
Interview and record review on 05/22/2023 at 10:08 AM LVN M stated the CNAs document on the CNA body audit form and enter it as well in the TASKs in the Kiosk system. LVN M stated on the POC if it was indicated as activity did not occur then the showers had not occurred. LVN M stated Resident #114's POC for showers indicated that he had not been showered 10 times out of 15 days. LVM M stated Resident #114 had refused showers and should be documented in the progress notes. LVN M stated the progress notes did not document Resident #114 had refused to shower. LVN M stated the importance of showering was to make sure the resident was clean, and it was the residents right to shower/bath. LVN M stated the risk of not showering the residents was infection because some residents have fecal matter on them, and bacteria can form.
Interview on 05/22/2023 at 10:55 AM CNA N stated they document on the shower sheets and on the tasks in the kiosk system. CNA N stated on the POC for Resident #114 it revealed that the activities for the shower did not occur. CNA N stated that it meant the resident was not showered. CNA N stated when the facility was short on staff, they do not shower the residents because they do not have enough CNAs to assist and could be why Resident #114 was not showered. CNA A stated it was an issue with short staffing. CNA A stated last week she had only showered 1 or 2 residents because they were short staffed. CNA N stated not showering the residents could lead to UTIs (Urinary Tract Infections). CNA N stated if she was not showered, she would feel horrible because she would not feel clean.
Interview on 05/24/2023 at 4:06 PM CNA G stated when the CNAs shower a resident, they mark the bathing TASK on the Kiosk to indicate if the resident was or was not showered. CNA G stated if it was marked on the POC as activities did not occur then that meant the shower was not given to the resident. CNA G stated the CNAs do not chart most of the time because they are short staff and do not have time to chart. CNA G stated do to being short staff and being left alone on the hall they are not able to shower residents. CNA G stated last week I was in 400 hall and was not able to shower some of the residents. CNA G stated that when residents do not get showered, and you turn them they smell bad. CNA G stated the residents not getting showered and are here at the facility to receive a service and they are not getting the service they deserve.
Interview and record review on 05/24/2023 beginning at 3:57 PM DON stated the facility have two methods to record showers/bathing which are the task on the kiosk and the shower sheets. DON stated the CNAs have been informed that they must document the showers on both documents. DON stated they do not have an in-service that the CNAs are to record the showers in both areas. DON looked at the shower sheets for Resident #114 and the POC indicating an inaccuracy of recording with showers on the POC indicating they had not been done and shower sheet indicating they had. DON stated this inaccuracy can be a risk to the residents if residents do not actually get showered. DON stated residents would be dirty and they would smell bad. DON stated they have 1 CNA and 1 nurse on the hall to make it work with showering. DON stated they try for 2 CNAs but don't have a requirement for the number of CNAs on each hall.
Resident #58
Review of Resident # 58's face sheet dated 05/23/2023 revealed a [AGE] year-old female with an admission date of 12/08/2022.
Review of History and Physical dated 09/10/2022 revealed she had a history of ankle and wrist fractures that contributed to decreased mobility.
Review of Quarterly MDS assessment dated [DATE], revealed Resident #58 had a BIMS score of 15 indicating she was cognitively intact, meaning she was able to recall events and answer questions. It also revealed she required one person assistance with bathing activities.
Review of comprehensive care plan dated 03/12/23 revealed Resident #58 required assistance with ADLs and was at risk for deterioration in ADLs such as bathing related to right ankle fracture and physical impairment. Goal was for to maintain a sense of dignity by being clean, dry, odor free, well-groomed. Interventions in place were to provide sponge bath when a full bath or shower could not be tolerated with the assistance of 1 person per shower schedule and as necessary.
Review of shower schedule revealed Resident #58 was scheduled for showers Tuesday, Thursday, and Saturdays.
Review of POC bathing sheet for the month of May 2023, revealed Resident #58 had missed a shower 4 times on her scheduled shower days on: 5/9/23, 5/13/23, 5/16/23 and 5/20/23. It also revealed she received showers 8 times for the month of May. (05/13/23 and 05/20/23 were weekends)
Review of CNA shower sheets confirmed Resident #58 had not received showers on those 4 days.
Observation and interview on 05/21/2023 at 8:47 AM with Resident #58, revealed she was laying in bed with hair unkept and not brushed. Resident #58 stated she required assistance with bathing and showering. She said it would happen often where she would miss showers due to low staffing. She said her schedule was Tuesday, Thursday and Saturday. She said it affected her when she would not receive a shower because she would not feel clean.
Resident #4
Review of Resident #4's face sheet dated 05/24/2023 revealed a [AGE] year-old female with an admission date of 01/26/2022.
Review of History and Physical dated 02/25/2023 revealed she had a diagnosis of rheumatoid arthritis and muscle atrophy. Muscle atrophy was loss of muscle.
Review of Quarterly MDS assessment dated [DATE], revealed Resident #4 had a BIMS score of 05, which indicated she was cognitively impaired. That meant she could have some memory loss and trouble making decisions. The assessment also revealed she required one person assistance with bathing activities.
Review of comprehensive care plan dated 02/12/2023 revealed Resident #4 had an ADL self-care performance deficit related to rheumatoid arthritis and would need assistance with personal care. Goal was for resident to maintain current level of function in ADLs. Interventions in place were to provide sponge bath when a full bath or shower could not be tolerated with the assistance of 1 person per shower schedule and as necessary.
Review of shower schedule revealed Resident #4 was scheduled for showers Tuesday, Thursday, and Saturdays.
Review of POC bathing sheet for the month of May 2023, revealed Resident #4 had missed a shower 3 times on her scheduled shower days on: 5/13/23, 5/16/23, and 5/18/23. It also revealed she received showers 6 times for the month of May. (05/13/23 was a weekend)
Review of CNA shower sheets confirmed that Resident #4 had not received showers on those 3 days.
In an interview on 05/21/2023 at 12:30 PM with family representative, she said Resident #4 would miss showers often. She said it would occur when the facility was short in staff. She said she would be able to tell when resident had not showered because she would appear unkept. She could not state what days she had not been bathed.
Observations and interview on 05/21/23 at 04:22 PM with Resident # 4, revealed she had her hair brushed and had clean clothes on. She stated she would miss her shower at times. She could not state what days she had missed her showers.
Resident #41
Review of Resident #41's face sheet dated 05/24/2023 revealed a [AGE] year-old female with an admission date of 03/05/2020.
Review of History and Physical dated 08/10/2022 revealed she had a diagnosis of right leg paralysis due to shot gun wound which contributed to being dependent on care.
Review of Annual MDS assessment dated [DATE], revealed Resident #41 had a BIMS score of 12, which indicated she had some moderate cognitive impairment. The assessment also revealed Resident #4 was total dependent with bathing activities.
Review of comprehensive care plan dated 02/08/2023 revealed Resident #41 required assistance with ADLs and was at risk
for deterioration in ADLs such as bathing related to immobility and physical impairment. Goal was for to maintain a sense of
dignity by being clean, dry, odor free, well-groomed. Interventions in place were to assist with one person to provide showers or a bed bath.
Review of shower schedule revealed Resident #41 was scheduled for showers Tuesday, Thursday, and Saturdays.
Review of POC bathing sheet for the month of May 2023, revealed Resident #41 had missed a shower 2 times on her scheduled shower days. The dates were 5/13 and 5/20.
Review of CNA shower sheets confirmed that Resident #41 had not received showers on either of those days.
In an interview on 05/21/23 at 09:26 AM with Resident # 41, she said she had missed her showers in the past due insufficient staff. She said when she would miss her showers, she felt dirty.
In an interview on 05/24/23 08:47 AM with CNA A, she said there were times residents would not shower due to short staffing. She said she would try to shower everyone, but there were times where she could not. She said the risks of not showering the residents would be a resident could develop skin alterations, rashes and they could develop a smell.
Resident # 37
Record review of Resident #37's face sheet dated 05/23/2023 documented in part that he was [AGE] years old, was initially admitted to the facility on [DATE] and again on 03/29/2023.
Record review of Resident #37's History and Physical dated 12/06/2022 documented in part that he had diagnoses including traumatic brain injury and benign prostatic hyperplasia (an enlarged prostate)
Record review of Resident #37's quarterly MDS dated [DATE] documented in part that his BIMS was 9 (moderate cognitive impairment. He was able to move around in bed without assistance, required limited assistance from one person to transfer between surface, for locomotion around the facility, and for toilet use. Diagnoses included urinary tract infection in the past 30 days. It documented that he was occasionally incontinent of bowel and bladder.
Record review of Resident #37's electronic diagnosis listing dated 05/23/23 documented in part that he had diagnoses including urinary tract infection, site not specified; repeated falls; hemiplegia unspecified affecting left nondominant side.
Record review of Resident #37's care plan dated 01/18/2023 documented that he had an ADL self-care performance deficit and required assistance from staff for toileting.
In an interview on 05/21/23 at 01:35 PM Resident #37 stated that about twice a week staff did not get him up to the bathroom quickly enough and he ended up wet (urinated on himself) of the delay in responding to his call light. He stated he is able to get up and go to the bathroom with help and is continent unless there is too much of a delay. When asked how this made him feel he did not reply.
Record review of Resident #37's Point of Care Bladder Elimination flow chart dated 04/23/2023 through 05/22/2023 documented that he was incontinent on 12 occasions and continent on 66 occasions.
Record review of facility Activities of Daily Living (ADLs) dated 03/2022 indicated the facility will, based on the resident's comprehensive assessment and consistent with the resident's needs and choices, ensure a resident's abilities in ADLs do not deteriorate unless deterioration was unavoidable. Care and services will be provided for ADLs of bathing. A resident who was unable to carry out activities of daily living will receive the necessary services to maintain good nutrition, grooming, and personal and oral hygiene.
Record review of facility Resident Showers Policy dated 2002 revealed it was the practice of the facility to assist residents with bathing to maintain proper hygiene, stimulate circulation and help prevents skin issues as per current standards of practice. Residents will be provided showers as per request or as per facility schedule protocols and based upon resident safety.
CONCERN
(E)
Potential for Harm - no one hurt, but risky conditions existed
Tube Feeding
(Tag F0693)
Could have caused harm · This affected multiple residents
**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, interview, and record review the facility failed to ensure that a resident who was fed by enteral means re...
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**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, interview, and record review the facility failed to ensure that a resident who was fed by enteral means receives the appropriate treatment and services for 3 of 10 residents (Resident #12, Resident #22 and Resident #70) reviewed for enteral feeding.
1.Resident 12's enteral feeding bag labels did not have the rate of administration, the initials of nurse, amount, and expiration date. The feeding pump did not correctly reflect the amount of formula that had been delivered to the resident.
2.Resident #22's feeding tube valve was not clean as it was dirty.
3.Resident #70's bag of tube feeding formula did not have the rate of administration, the initials of nurse, amount, and expiration date.
These failures could place residents receiving enteral feedings at risk of insufficient nutritional supplementation and possible weight loss.
Findings included:
Resident #12
Record review of Resident #12's Face Sheet admission on [DATE], 12/16/2022, and readmission on [DATE] to the facility.
Record review of Resident #12's History and Physical dated 02/15/2022 revealed a [AGE] year-old female with a diagnosis of Gastroesophageal reflux disease (GERD), dysphagia (trouble swallowing), and PEG-tube (A tube inserted through the wall of the abdomen directly into the stomach) placement.
Record review of Resident #12's Care Plan dated 01/16/2023 revealed required tubing feeding and will be free of aspiration.
Record review of Resident #12's quarterly MDS dated [DATE] revealed resident did not have a brief interview of mental status score, total dependence with one-person physical assist with eating, diagnosis of esophagitis (Inflammation of the esophagus), resident is on a feeding tube.
Record review of Resident #12's Order Recap dated 03/22/2023 was NPO diet- NPO texture (nothing by mouth), order date 01/27/2023 enteral feed orders every shift related to dysphagia.
Observation on 05/22/2023 at 8:45 AM Resident #12's feeding bag and were not labeled correctly. It was missing the rate of administration, initials, expiration date, and amount.
Interview and observation on 05/22/2023 beginning at 10:08 AM LVN M stated the labeling feeding bags should have the flow rate, initials of nurse who gave it, amount, and expiration date on both the feeding bag and flush bag. LVN M stated the feeding label on Resident #12's feeding bag was missing the rate, expiration, room, and the flush was not label correctly either as it was missing the same thing. LVN M stated the risk of labeling the feeding bag incorrectly was giving the resident the wrong feed or the wrong rate.
Resident #22
Review of Resident #22's face sheet dated 05/24/2023 revealed an [AGE] year-old female with an admission date of 08/30/2022.
Review of History and Physical dated 05/09/2023 revealed she had a diagnosis of dysphagia, which is difficulty swallowing.
Review of Quarterly MDS assessment dated [DATE] revealed Resident #22 had a feeding tube.
Review of comprehensive care plan dated 01/16/2023 revealed Resident #22 required tube feeding. Goal was for resident to be free of aspiration. Interventions included to provide local care to G-Tube site as ordered and monitor for signs of infection.
Review of physician orders dated 03/02/2023 revealed there was an order for tube feedings to be given at 65 ml an hour for 10 hours a day. There was no physician order with directions on how often to clean the feeding tube.
Observation on 05/22/23 at 3:39 PM, revealed brown crusty substance around and inside the [NAME] valve of the feeding tube. A [NAME] valve is an attachment on feeding tube that allows for entry of medications or feeding without having to open the feeding tube. It allows for it to remain capped when not in use.
In an interview on 05/22/23 at 3:40 PM with LVN B, she said she was not sure how often or when the last time it had been cleaned. She said the feeding tube looked nasty. LVN B stated the morning shift nurse was responsible for cleaning the feeding tube. She said it had to be cleaned to prevent infections.
In an interview on 05/22/23 at 3:48 PM with Resident # 22, she said she did not think the nurses had cleaned her tube. She said with DON cleaning the tube, it would be the first time it would be cleaned.
In an interview on 05/22/23 at 3:50 PM with DON, revealed she could clean and change the [NAME] valve herself. She stated the nurses were expected to check the tube and [NAME] valve clean it every day while doing care. She stated it was important to do so to prevent whatever accumulated in the valve to be flushed into the resident.
In an interview on 05/23/2023 at 9:01 AM with LVN C, revealed feeding tube site would be cleaned daily and assessed. She stated the [NAME] valve was able to be removed and washed to ensure it was clean. LVN C stated the importance of doing so was to prevent bacteria and to keep it sanitary.
In a follow-up interview on 05/24/2023 at 4:12 PM with DON, she revealed any resident with a feeding tube should have orders for cleaning the feeding tube site daily. She stated she did not know why the order had not been there, but the nurses could have called the physician to receive one.
Resident #70
Record review of Resident #70's face sheet dated 05/24/2023 documented he was [AGE] years old, was first admitted to the facility on [DATE] and again on 05/02/2023.
Record review of Resident #70's 5/24/2023 quarterly MDS dated [DATE] documented in part that he was in a persistent vegetative state or had no discernible consciousness. His primary medical condition was traumatic spinal cord dysfunction. His diagnoses included dysphagia (difficulty swallowing), quadriplegia (paralysis from the neck down), tracheostomy status (an opening in the windpipe for breathing), and gastrostomy status (a tube in the stomach for feeding). He received 51% or more of his nutrition and hydration through a feeding tube.
Record review of Resident #70's Care Plan dated 02/26/2023 documented that he had an ADL self-care performance deficit for eating, took nothing by mouth, and was to be provided PEG feeding as ordered.
Record review of Resident #70's physician's orders dated 08/09/2022 documented that he was to have enteral feedings. He was to receive 1.5 ml/hr of Isosource (a tube feeding formula) and water flush 50 ml/hr each shift with the feeding being off between 4:00 and 5:00 PM daily.
Observation on 05/21/23 at 9:05 AM in Resident #70's room revealed that the bag of Isosource was being administered to the resident through a feeding tube. The tube feeding bag was not labeled on either the front or the back. There was nothing to indicate the time or date the bag was hung, or the correct feeding rate, or who hung the bag.
In an interview on 05/21/23 at 9:07 AM LVN S said he had hung the tube feeding bag the morning of 05/21/23 and had forgotten to label it. He said that the label should have information like the time and date it was hung, and the correct feeding rate. He said the label was so people would know how long the tube feeding bag had been up and what the rate of formula delivery should be. He said that the risk of not having the label on that bag was that others would not know the rate at which the feeding was to be delivered.
In an interview on 05/23/2023 at 8:57 AM with LVN C, she revealed the tube feeding label should include the residents name, time and date it was hung, who it was hung by and the type of formula and the rate the formula was running at. She stated the importance of labeling the formula correctly was to ensure that it matched the physicians' orders.
In an interview on 05/24/23 4:12 PM the DON said that the purpose of the feeding tube bag label was so staff could know is so how much formula the resident was to receive per hour and check that it matched with the rate on the feeding pump. The label should have the resident's name and other information and would be a point of reference for staff going into the room so they know how much feeding and water the resident should receive.
Review of facility policy titled Care and Treatment of Feeding Tubes dated 2022 read in part .Direction for staff on how to provide the following care will be provided .examination and cleaning of the insertion site in order to identify, lessen or resolve possible skin irritation and local infection .Feeding tubes will be utilized according to physician orders, which typically include:The kind of feeding and its caloric value, volume, duration, mechanism of administration, and frequency of flush .
CONCERN
(E)
Potential for Harm - no one hurt, but risky conditions existed
Respiratory Care
(Tag F0695)
Could have caused harm · This affected multiple residents
**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation , interview, and record review the facility failed to ensure that a resident who needs respiratory care is ...
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**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation , interview, and record review the facility failed to ensure that a resident who needs respiratory care is provided such care, consistent with professional standards of practice for 1 (Resident #271) of 10 residents observed for oxygen management.
1.
Resident #271 was using oxygen while his Room (room [ROOM NUMBER]) and did not have an oxygen sign posted outside his bedroom.
This failure could place residents on oxygen therapy at risk of a hazard and inappropriate care.
Findings included:
Record review of Resident #271's Face Sheet admission on [DATE] to the facility.
Record review of Resident #271's History and Physical dated 05/17/2023 revealed an [AGE] year-old male with a diagnosis of COVID-19 pneumonia.
Record review of Resident #271's admission MDS dated [DATE] indicated a brief interview of mental status score of 15 , diagnosis of pneumonia, cancer, and was on oxygen therapy.
Record review of Resident #271's Order Recap dated 05/18/2023 reflected oxygen at 3 liters per minute via nasal cannula every shift for shortness of breath and to maintain pulse greater than 90 percent oxygen.
Record review of Resident #271's Care Plan dated 05/21/2023 reflected the resident was at risk for hypoxia, shortness of breath, covid-19 pneumonia and will exhibit sings of respiratory distress. Administer oxygen as ordered and monitor oxygen saturation via pulse oximetry as orders.
Observation and interview on 05/21/2023 at 10:03 AM Resident #271 was sitting down on his bed looking outside the window with his nasal cannula on and concentrator in use. It was observed that there was no oxygen sign posted outside of the residents room. Resident#27 stated the nursing staff had not changed his nasal tubing and had not checked the concentrator.
Interview on 05/21/2023 at 10:23 AM ADON Q stated the oxygen sign means there was oxygen in the room whether as needed or continuous and no lighter are allowed. ADON Q stated if the there was a tank or concentrator in the room an oxygen sign was required. ADON Q stated posting the oxygen sign lets other residents who smoke know not to smoke around the area. ADON Q stated there was a risk not having the oxygen sign posted outside a resident's room who was using oxygen. ADON Q stated there could be a combustion resulting in a resident or staff's injury.
Interview on 05/22/2023 at 10:08 AM LVN M stated if a room had an oxygen sign posted outside of the room, that meant a concentrator or oxygen tank was in the room. LVN M stated the oxygen sign was to warn people that they are not to smoke in and around the area where oxygen was being used. LVN M stated it was dangerous to the residents and staff if they did. LVN M stated having no oxygen sign up could result in an explosion, combustion, or flare up to the residents.
In an interview on 05/23/23 at 8:57 AM with LVN C, revealed any resident who was receiving oxygen had to have an oxygen sign outside of their bedroom. She stated when a new admission arrived and they were wearing oxygen, the sign had to be placed outside the resident's bedroom. She stated when a resident had orders to begin oxygen, the sign also had to be placed. She stated the signs were placed by nursing staff and said the importance to do so was to ensure everyone was aware that oxygen would be present in the room.
In an interview on 05/24/23 at 4:14 PM with DON, she revealed as soon as a resident was admitted with oxygen, the nurses would place the oxygen sign outside the resident bedroom so everyone could see it. The oxygen signs were placed for safety reasons, for safety of residents and staff. If there was a fire, the facility would know what residents were on oxygen.
Record review of facility Oxygen Administration policy dated 03/2022 revealed oxygen warning signs must be placed on the door of the resident's room where oxygen was in use.
CONCERN
(E)
Potential for Harm - no one hurt, but risky conditions existed
Deficiency F0725
(Tag F0725)
Could have caused harm · This affected multiple residents
**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on interview and record review the facility failed to ensure that there were sufficient nursing staff with the appropriate...
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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 that there were sufficient nursing staff with the appropriate competencies and skills sets to provide nursing and related services to assure resident safety and attain or maintain the highest practicable physical, mental, and psychosocial well-being of eight residents who attended a confidential group meeting, and for 5 (Resident #114, Resident #58, Resident #4, Resident #37, and Resident #41) of 15 residents reviewed for assistance with ADL's.
1.The facility was short of CNA FTEs (Full-time equivalents) on 39 of 51 days reviewed for CNA Per Patient Days
2.Residents who attended a confidential group meeting reported that staff shortages on the weekends resulted in missed showers, missed, or delayed response to call lights, having to eat in their rooms because there were not enough staff member to take them to the dining room and delayed delivery of meals.
3.The facility failed to ensure sufficient staff to provide showers for Resident #114, Resident #58, Resident #4, and Resident #41.
4. Resident #37 had to urinate in his brief because staff did not come quickly enough to help him to the bathroom.
These failures put residents at risk of decreased physical, mental, and psychosocial well-being.
Findings included:
In a confidential group interview on 05/21/23 beginning at 01:09 PM with 8 residents, residents reported that the facility was short on help on the night shift, and very short on staff on weekends. One example was that three days before the meeting the facility had one CNA for the entire building. This shortage of staff affected mealtimes with residents eating in their rooms, and not receiving scheduled baths or showers. Residents in attendance reported that this had been going on for a while, and they thought it was due to the facility not paying staff. Residents stated that they had to wait a long time for responses to the call lights. One resident said he had to go out into the hall in the late evening to find someone to assist with his care and found staff doing work. Residents said that these shortages were normal and that they had not seen any changes in staffing although the staff and administrator were trying to better themselves.
Resident #114
Record review of Resident #114's Face Sheet dated 05/21/2023 documented admission to the facility on [DATE].
Record review of Resident #144's History and Physical dated 04/28/2023 revealed a [AGE] year-old male diagnosed with spinal stenosis (when the space inside the spine is too narrow) with radiculopathy (pinched nerve), and cervical decompressive laminectomy (spinal surgery).
Record review of Resident #114 admission MDS dated [DATE] revealed a BIMS of 0 (severe cognitive impairment). He was totally dependent on staff for bed mobility and transfers. The MDS documented that he did not receive ADLs for personal hygiene, dressing, toilet use, and bathing did not occur during the seven-day look back period. The resident was frequently incontinent of bowel and bladder.
Record review of Resident #114's Care Plan dated 05/02/2023 for ADLs for bathing/showering to avoid scrubbing and pat dry sensitive skin, check nail length and trim and clean on bath day and as necessary. He required assistance from staff with personal hygiene and oral care.
Record review of Resident #114's Progress Notes from 04/28/2023 to 05/24/2023 did not document anything indicating that the resident had been bathed or that he refused showers or baths.
Record review of Resident #114's POC (Point of Care flow sheet) from 05/08/2023 to 05/23/2023 revealed 12 days where bathing/showering were marked activity did not occur.
Interview on 05/21/2023 at 10:30 AM Resident #114 stated he had not had a shower in 3 weeks. Resident #114 stated he did not know why but wanted to be showered.
Interview on 05/21/2023 at 12:11 PM Weekend Supervisor stated they did not have enough staff. Weekend Supervisor stated they only had 1 CNA on each hall in which they need 2 and that was why the residents were eating in their rooms. Weekend Supervisor stated the facility had been short on staff since she started working for the facility a year ago. Weekend Supervisor stated she worked with what staff she had. Weekend Supervisor stated the risk to the residents being short staff was that they were not receiving the best care, staff cut corners, and skipped showers because of they were short staffed.
Interview on 05/21/2023 at 12:29 PM LVN L stated she had voiced out to her supervisor that they were short staff, and they needed more staff. LVN L stated she was always short of staff when she worked. LVN L stated they need 2 CNAs per hall, and they usually had 1 CNA. LVN L stated sometimes because of the short staff, residents did not get showered. LVN L stated due to the short staffing the residents have to wait crazy times to just get fed. LVN L stated something bad could happen to the residents because they did not have enough staff to attend to them.
Interview on 05/22/2023 at 9:54 AM LVN C stated sometimes the facility does not have enough staff. LVN C stated she needed 2 CNAs and only had 1 CNA. LVN C stated last week on Monday or Tuesday due to the short staffing she had to help the other CNA tend to the residents with care and was not able to get to residents fast enough to assist them with their care.
Interview on 05/22/2023 at 10:08 AM LVN M stated the CNAs document on the CNA body audit form and enter it as well in the TASKs in the Kiosk system indicating residents were showered or not. LVN M viewed the Resident #114's POC and stated that showers had not occurred where it was marked activity did not occur. LVM M stated Resident #114 had refused showers and so this should be documented in the progress notes. LVN M stated the progress notes did not reflect any refusals for Resident #114. LVN M stated the importance of showering was to make sure the resident was clean, and it was the residents right to shower/bath. LVN M stated the risk of not showering the residents was infection because some residents have fecal matter on them, and bacteria can form.
Interview on 05/22/2023 at 10:55 AM CNA N stated they document on the shower sheets and on the tasks in the kiosk system. LVN N stated the shower sheets are used to document showers. LVN N stated on the POC for Resident #114 it revealed that the activities for the shower did not occur. CNA N stated that it meant the resident was not showered. CNA N stated when the facility was short on staff, they do not shower the residents because they do not have enough CNAs to assist and could be why Resident #114 was not showered. CNA A stated it was an issue with short staffing. CNA A stated last week she had only showered 1 or 2 residents because they were short staffed. CNA N stated not showering the residents could lead to UTIs (Urinary Tract Infections). CNA N stated if she was not showered, she would feel horrible because she would not feel clean.
Interview on 05/24/2023 at 4:06 PM CNA G stated they mark the bathing TASK on the Kiosk to indicate if the resident was or was not showered. CNA G stated if it was marked on the POC as activities did not occur then that meant the shower was not given to the resident. CNA G stated the CNAs do not chart most of the time because they are short staff and do not have time to chart. CNA G stated do to being short staff and being left alone on the hall they are not able to shower residents. CNA G stated last week I was in 400 hall and was not able to shower some of the residents. CNA G stated that when resident do not get showered, and you turn them they smell bad. CNA G stated the residents not getting showered are here at the facility to receive a service and they are not getting the service they deserve.
Interview on 05/24/2023 at 3:57 PM DON stated the facility have two methods to record showers/bathing, which are the Task on the kiosk, and the shower sheets. DON stated the CNAs had been informed that they must document showers on both documents. DON stated they did not have an in-service that the CNAs are to record the showers in both areas. DON looked at the shower sheets for Resident #114 and the POC indicating an inaccuracy of recording with showers on the POC indicating they had not been done and shower sheet indicating they had. DON stated this inaccuracy can be a risk to the residents if residents do not actually get showered. DON stated residents would be dirty and they would smell bad. DON stated they have 1 CNA and 1 nurse on the hall to make it work with showering. DON stated they try for 2 CNAs but don't have a requirement for the number of CNAs on each hall.
Resident #58
Review of Resident # 58's face sheet dated 05/23/2023 revealed a [AGE] year-old female with an admission date of 12/08/2022.
Review of History and Physical dated 09/10/2022 revealed she had a history of ankle and wrist fractures that contributed to decreased mobility.
Review of Quarterly MDS assessment dated [DATE], revealed Resident #58 had a BIMS score of 15 indicating she was cognitively intact, meaning she was able to recall events and answer questions. It also revealed she required one person's assistance with bathing activities.
Review of comprehensive care plan dated 03/12/23 revealed Resident #58 required assistance with ADLs and was at risk
for deterioration in ADLs such as bathing related to right ankle fracture and physical impairment. Goal was for her to maintain a sense of dignity by being clean, dry, odor free, well-groomed. Interventions in place were to provide sponge bath when a full bath or shower could not be tolerated, with the assistance of 1 person, per the shower schedule and as necessary.
Review of shower schedule revealed Resident #58 was scheduled for showers Tuesday, Thursday and Saturdays.
Review of POC bathing sheet for the month of May 2023, revealed Resident #58 had missed a shower 4 times on her scheduled shower days on: 5/9/23, 5/13/23, 5/16/23 and 5/20/23.
Review of CNA shower sheets confirmed that Resident #58 had not received showers on those 4 days.
In an interview on 05/21/2023 at 8:47 AM with Resident #58, she revealed she required assistance with bathing and showering. She said it would happen often where she would miss showers due to low staffing. She said her schedule was Tuesday, Thursday and Saturday. She revealed there were times where her hallway only had one CNA. She said she knew that because the CNA staff would tell her that they were busy with other residents. She said the facility being short staffed affected the residents because they wouldn't be able to get bathed. She said it affected her when she would not receive a shower because she would not feel clean.
Resident #4
Review of Resident #4's face sheet dated 05/24/2023 revealed a [AGE] year-old female with an admission date of 01/26/2022.
Review of History and Physical dated 02/25/2023 revealed she had a diagnosis of rheumatoid arthritis and muscle atrophy. Muscle atrophy was loss of muscle.
Review of Quarterly MDS assessment dated [DATE], revealed Resident #4 had a BIMS score of 05, which indicated she was cognitively impaired. That meant she could have some memory loss and trouble making decisions. The assessment also revealed she required one person assistance with bathing activities.
Review of comprehensive care plan dated 02/12/2023 revealed Resident #4 had an ADL self-care performance deficit related to rheumatoid arthritis and would need assistance with personal care. Goal was for resident to maintain current level of function in ADLs. Interventions in place were to provide sponge bath when a full bath or shower could not be tolerated with the assistance of 1 person per shower schedule and as necessary.
Review of shower schedule revealed Resident #4 was scheduled for showers Tuesday, Thursday, and Saturdays.
Review of POC bathing sheet for the month of May 2023, revealed Resident #4 had missed a shower 5 times on her scheduled shower days on: 5/11/23, 5/13/23, 5/16/23, 5/18/23 and 5/20/23.
Review of CNA shower sheets confirmed that Resident #58 had not received showers on those 5 days.
In an interview on 05/21/2023 at 12:30 PM with family representative, she said Resident #4 would miss showers often. She said it would occur when the facility was short of staff. She said she would be able to tell when resident had not showered because she would appear unkept. She could not state what days she had not been bathed.
In an interview on 05/21/23 at 04:22 PM with Resident # 4, she said she would miss her shower at times. She could not state what days she had missed her showers.
Resident #41
Review of Resident #41's face sheet dated 05/24/2023 revealed a [AGE] year-old female with an admission date of 03/05/2020.
Review of History and Physical dated 08/10/2022 revealed she had a diagnosis of right leg paralysis.
Review of Annual MDS assessment dated [DATE], revealed Resident #41 had a BIMS score of 12 (moderate cognitive impairment). She was totally dependent on staff for help with bathing activities.
Review of comprehensive care plan dated 02/08/2023 revealed Resident #41 required assistance with ADLs and was at risk
for deterioration in ADLs such as bathing related to immobility and physical impairment. Goal was for to maintain a sense of
dignity by being clean, dry, odor free, well-groomed. Interventions in place were for one person to assist with showers or bed baths.
Review of shower schedule revealed Resident #41 was scheduled for showers Tuesday, Thursday, and Saturdays.
Review of POC bathing sheet for the month of May 2023, revealed Resident #41 had missed showers on 5/13/23 and 5/20/2023.
Review of CNA shower sheets confirmed that Resident #41 had not received showers on either of those days.
In an interview on 05/21/23 at 09:26 AM with Resident # 41, she said she had missed her showers in the past due to insufficient staff. She said when she would miss her showers, she felt dirty.
In an interview on 05/24/23 08:47 AM with CNA A, she said there were times residents would not shower due to short staffing. She said she would try to shower everyone, but there were times when she could not. She said she could not remember if any resident specifically had missed their shower. She said the risks of not showering the residents would be a resident could develop skin alterations, rashes and they could develop a smell.
Resident # 37
Record review of Resident #37's face sheet dated 05/23/2023 documented in part that he was [AGE] years old, was initially admitted to the facility on [DATE] and again on 03/29/2023.
Record review of Resident #37's History and Physical dated 12/06/2022 documented in part that he had diagnoses including traumatic brain injury and benign prostatic hyperplasia (an enlarged prostate)
Record review of Resident #37's quarterly MDS dated [DATE] documented in part that his BIMS was 9 (moderate cognitive impairment. He was able to move around in bed without assistance, required limited assistance from one person to transfer between surface, for locomotion around the facility, and for toilet use. Diagnoses included urinary tract infection in the past 30 days. It documented that he was occasionally incontinent of bowel and bladder.
Record review of Resident #37's electronic diagnosis listing dated 05/23/23 documented in part that he had diagnoses including urinary tract infection, site not specified; repeated falls; hemiplegia unspecified affecting left nondominant side.
Record review of Resident #37's care plan dated 01/18/2023 documented that he had an ADL self-care performance deficit and required assistance from staff for toileting.
In an interview on 05/21/23 at 01:35 PM Resident #37 stated that about twice a week staff did not get him up to the bathroom quickly enough and he ended up wet (urinated on himself) of the delay in responding to his call light. He stated he is able to get up and go to the bathroom with help and is continent unless there is too much of a delay. When asked how this made him feel he did not reply.
Record review of Resident #37's Point of Care Bladder Elimination flow chart dated 04/23/2023 through 05/22/2023 documented that he was incontinent on 12 occasions and continent on 66 occasions.
Interview on 05/21/2023 at 12:29 PM LVN L stated they were short of staff and had told her supervisor. LVN L stated she was supposed to have 2 CNAs on the hall and usually had 1 CNA. LVN L stated the facility was understaffed and because of this the residents did not get showered.
Record review of an untitled undated document provided by the Administrator on 05/24/2023 documented that the budgeted per patient day (PPD) for the facility for CNAs (the number of CNA work hours needed to provide adequate care to one patient for one day) was 1.8.
Record review of Daily Staffing Sheets dated 04/01/23 - 05/23/2023 indicating daily census and CNA hours worked each day documented in part that the facility was short CNA PPD work hours on 15 of 15 weekend days and was short CNA PPD work hours on 24 of 37 weekdays. When converted into FTEs (full time equivalents), the CNA shortages on either weekends or weekdays ranged from one to eight CNAs. Shortages on weekends were as follows: 2 FTEs on 4 days; 4 FTEs on 2 days; 5 FTEs on 3 days; 6 FTEs on 4 days, 7 FTEs on 1 day and 8 FTEs on one day. Shortages on weekdays were as follows: 1 FTEs on 3 days, 2 FTEs on 7 days, 3 FTEs on 4 days, 4 FTEs on 2 days, 5 FTEs on 5 days and 7 FTEs on 3 days.
Record review of the facility policy Nursing Services and Sufficient Staff dated 02/2023 documented in part that it was the facility policy to provide sufficient staff to assure resident safety and to attain or maintain the highest practicable physical, mental and psychosocial well-being of each resident. The facility will supply services on a 24-hours basis with sufficient numbers of nurse aides.
CONCERN
(E)
Potential for Harm - no one hurt, but risky conditions existed
Food Safety
(Tag F0812)
Could have caused harm · This affected multiple residents
Based on observation and interview the facility failed to store food in accordance with professional standards for food service safety for one of one kitchen observed for safe food storage.
Observatio...
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Based on observation and interview the facility failed to store food in accordance with professional standards for food service safety for one of one kitchen observed for safe food storage.
Observation of the facility kitchen included:
-
A large container of salsa was not labeled.
-
A container of noodle soup was mislabeled and expired.
-
A tray of individually wrapped peanut butter and jelly sandwiches had no label on the sandwiches or the tray.
This failure could put residents at increased risk of food-borne illness.
Findings included:
In an interview on 05/21/2023 beginning at 8:04 AM when asked which items required labels, [NAME] U said that everything should have labels. She said that labels for items in the refrigerator showed the date the item was opened or prepared, and a date seven days after the first date indicated when the item was expired and should be discarded.
Observation of the walk-in refrigerator with [NAME] U at 8:08 AM revealed a clear 12-cup container (no manufacturer label) that held 8 cups of green salsa. When asked, [NAME] U was unable to find a date of preparation or expiration on the container. She said that she checked expiration dates daily when she arrived at the facility but did not check that container that morning.
In observation and interview on 05/21/2023 beginning at 8:07 AM a clear 4-quart container containing 2 quarts of noodle soup was observed to have a label saying tomatoe soup with a preparation date of 05/13/2023 and a Use By date of 05/20/2023. [NAME] U said that the label was wrong, so she did not know when the soup was actually prepared and when it needed to be discarded. She said she would need to discard the noodle soup, and that if it was spoiled and served to residents it could make them sick.
In observation and interview on 05/21/2023 beginning at 8:08 AM with [NAME] U, a large tray of peanut butter and jelly sandwiches was observed to have no label. The individually wrapped ½ sandwiches did not have any dates on them and neither did the tray. The cook was observed examining the tray on all four sides and stated there was no label on the tray. She said the tray should have a label and showed the surveyor two other trays of sandwiches that were labeled.
Record review of the United States Food and Drug Administration 2002 Food Code dated January 18, 2023 reflected in part, regarding Date Marking (3-501.17), refrigerated, ready-to eat food prepared and held in a food establishment for more than 24 hours shall be clearly marked to indicate the date or day by which the food shall be consumed or discarded when held at a temperature of 5ºC (41ºF) or less for a maximum of 7 days. The day of preparation shall be counted as Day 1. A date marking system that meets criteria of this section may include marking the date or day of preparation, with a procedure to discard the food on or before the last date or day by which the food must be consumed.
Feb 2023
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
Report Alleged Abuse
(Tag F0609)
Could have caused harm · This affected 1 resident
**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on interview and record review the facility failed to ensure all alleged violations involving abuse, neglect, exploitation...
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**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on interview and record review the facility failed to ensure all alleged violations involving abuse, neglect, exploitation or mistreatment, which included injuries of unknown source and misappropriation of resident property, were reported immediately, but no later than 2 hours after the allegation was made, if the events that caused the allegation involved abuse or resulted in serious bodily injury, or not later than 24 hours if the events that caused the allegation did not involve abuse and did not result in serious bodily injury, to the administrator of the facility and to other officials, which included the state survey agency, in accordance with State law through established procedures foe 1 of 8 residents (Resident #5) reviewed for abuse and neglect.
A.
The facility did not report to the State Survey Agency when Resident #5 eloped from the facility and staff were unaware the resident was missing.
This failure could place residents at risk of elopement or injury.
Findings include:
Record review of Resident #5's face sheet, dated 2/13/23, revealed a [AGE] year-old male who was admitted to the facility on [DATE].
Record review of Resident #5 history and physical, dated 1/30/23, revealed the resident had diagnoses of which included traumatic brain injury with multiple bone fractures.
Record review of Resident #5's admission MDS assessment, dated 2/4/23, revealed a BIMS of 15 which indicated he was cognitive.
Record review of Resident #5's progress notes, dated 2/3/23 at 2:04 PM, revealed This nurse went by patients' room to check if he was there since a visitor from his church had come to visit, but resident not in room. Went to check lounge area where he usually sits and sometimes falls asleep but not there either. continued to check all other activity areas and his room again including restroom, but he was nowhere to be found. At this point. I notified DON and a code Purple (missing person code) was called in facility.
Record review of Resident #5's progress notes, dated 2/3/23 at 2:44 PM, revealed At 3:05 PM resident's charge nurse notified DON that she didn't know where resident was. She stated that he was not in his room, and she couldn't find him. DON went to residents' room, and he was not in his room. Facility team notified and CODE Purple was initiated. All staff assisted in search for resident. Resident signed out on pass at 10:35 AM and returned at 12:00 PM per sign out book. Charge nurse last saw resident at 1:30. Staff looked at cameras and was seen leaving facility at 1:34 pm. Facility staff drove around facility and to surroundings stores. Resident was not any of the surrounding stores. At 3:48 pm. Staff drove to his address to check to see if he was walking, did not see him. At approx. 4:00 pm resident's Chaplain arrived, explained the situation to him and he stated he was going to go and drive around and look for him as well. As Chaplain was leaving his commander notified him that resident was at his home. Resident verbalized that he went home so he could do his laundry and take a shower. Resident's RP and MD notified.
Interview on 2/12/23 at 8:49 AM, the Administrator stated he was notified of Resident #5 missing on 2/3/23 at approximately 3:05 PM. The Administrator stated cope code purple was initiated and all facility staff started looking for Resident #5 in all rooms, outside near parameter and had few staff drive around the premises to gas stations and stores asking if they had seen Resident #5. The Administrator stated he called Resident #5's RP to notify her about Resident #5 not found in the facility. The Administrator stated he called the local police department to place a missing person report at approximately 3:50 PM. The Administrator stated while he was placing the report, he received notification of Resident #5 being located at his home and then cancelled the missing person report with the police department. The Administrator stated he did not notify the State Survey Agency because Resident #5 was found safely at his home.
Record review of the facility's Elopements and Wandering Residents policy, dated 04/2022, revealed 4. Procedure for locating a missing resident: H. Appropriate reporting requirements to the State Survey agency shall be conducted.
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
Respiratory Care
(Tag F0695)
Could have caused harm · This affected 1 resident
**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, interview, and record review the facility failed to ensure that a resident who needed respiratory care was...
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**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, interview, and record review the facility failed to ensure that a resident who needed respiratory care was provided such care, consistent with professional standards of practice and the comprehensive person-centered care plan, the residents' goals and preferences for 2 of 8 residents (Resident #7 and #8) reviewed for oxygen therapy.
1. The facility failed to obtain a physician's order for Resident #8 oxygen he received via nasal cannula.
2. The facility failed to administer oxygen at 3 LPM via nasal cannula as prescribed by the physician for Resident #7.
These failures could place residents risk of inadequate oxygen support and monitoring that could result in a decline in health.
Findings include:
1. Record review of Resident #8 face sheet dated 2/13/23 revealed an [AGE] year-old male admitted on [DATE]
Record review of Resident #8 medical visit- initial assessment/ evaluation dated 2/8/23 revealed diagnoses/ history of traumatic brain injury, delirium with acute psychosis. The patient has a follow up visit with pulmonary disease for hypoxia during hospital stay. Section 4. Respiratory was marked no problems noted. Section F. Physical exam: 1f- most recent oxygen saturation revealed 96%at room air.
Record review of Resident #8 local hospital discharged medications dated 2/8/23 revealed no orders for either PRN or continuous oxygen therapy.
Record review of Resident #8 physician orders as of 2/13/23 at 11:53 AM revealed no order for oxygen therapy.
Record review of Resident #8 baseline care plan dated 2/9/23 page 7-8 section L. treatment/ procedures: 1- current treatment/ procedure revealed section 1H for oxygen was not marked. Page 8 section M. physician orders revealed no orders for oxygen therapy.
Interview on 2/11/23 at 1:49 PM CNA B stated Resident #8 had received a new oxygen tank around 9:30 AM. CNA B stated she transferred Resident #8 to his wheelchair and had just taken him out to the hallway because he had a family visit and did not check the oxygen tank because she assumed it was still full due to it been replaced earlier this morning. CNA B stated while Resident #8 was in bed he was connected to the oxygen concentrator at his bedside CNA B stated since he was not connected to the oxygen tank, she thought it would have been full.
Observation and interview on 2/13/23 at 12:26 PM MDS Nurse stated the nurse admitting a new resident was the one responsible of verifying medications with NP/ MD and then adding them on PCC. MDS Nurse stated the medications listed under order on PCC were usually the current active orders. MDS Nurse looked at Resident #8 orders on PCC and stated there was no order for oxygen. MDS nurse stated if Resident #8 was on receiving oxygen therapy it should reflect on PCC orders.
Observation and interview on 2/13/23 at 12:42 PM Resident #8 was in bed had nasal cannula and receiving 5LPM. MDS Nurse stated Resident #8 was receiving oxygen therapy and stated she did not know about his current oxygen orders and stated should ask his nurse for further information.
Interview on 2/13/23 at 12:43 PM Resident #8 RP was at the resident's bedside and stated she did not know he was receiving oxygen, stated he never received oxygen even when at the hospital. Resident #8 RP stated the facility started oxygen therapy shortly after being admitted but could not remember a date.
Observation and interview on 2/13/23 at 12:55 PM LVN C was seen inputting new order for Resident #8 related to oxygen therapy on PCC. LVN C stated she was the nurse in charge of Resident #8 and stated she noticed this morning he was receiving oxygen therapy. LVN C stated Resident #8 had been admitted to facility with a PRN order for oxygen therapy that was not inputted in the system. LVN C stated she called the NP to ask if they wanted him to continue with PRN order and was given verbal conformation. LVN C stated the order was obtained for oxygen 2LPM PRN snd stated that was what he should be receiving. LVN C walked to Resident #8 room and stated he was receiving 5LPM.
Observation and interview on 2/13/23 at 1:02 PM Regional Director of Clinical Services printed out Resident #8 history and physical, baseline care plan and physician orders. Physician orders given had new order of oxygen at 2LPM via nasal cannula. To maintain oxygen above 90% saturation every 8 hours as needed for shortness of breath and to maintain pulse oxygen above 90% every shift. The Regional Director of Clinical Services stated she was not aware Resident #8 had been receiving oxygen.
2. Record review of Resident #7 face sheet, dated 2/13/23, revealed an [AGE] year-old female who was admitted to the facility on [DATE].
Record review of Resident #7 history and physical, dated 11/25/22, reveled a diagnoses which included of dementia (impaired ability to remember, think, or make decisions that interferes with doing everyday activities), COPD (disease that cause airflow blockage and breathing-related problems), and CAD (disease in which there is a narrowing or blockage of the coronary arteries [blood vessels that carry blood and oxygen to the heart]).
Record review of Resident #7 care plan revealed the resident has oxygen therapy related to COPD; interventions: oxygen settings- the resident has oxygen via nasal prongs/ mask at 3 liters continuously.
Record review of Resident #7 electronic physician order, dated 3/15/22, revealed an order for continuous oxygen 3 lpm via nasal cannula may titrate to maintain oxygen saturation above 90%.
Observation and interview on 2/11/23 at 1:55 PM revealed Resident #7 was in her wheelchair out in the hallway, the oxygen tank was noted on the back of the wheelchair halfway full with no nasal cannula connected. Resident #7 was alert and oriented to person only. Resident #7 stated she required oxygen but did not know where the tubing was. Resident #7 started looking around her wheelchair for the tubing and stated she did not have it.
Observation and interview on 2/11/23 at 2:03 PM, LVN D stated Resident #7 required oxygen therapy. LVN D asked Resident #7 if she was okay and Resident #7 said yes. LVN D attempted to obtain the oxygen level out in the hallway and had a hard time getting a reading. LVN D wheeled Resident #7 to her room for further assessment. Nasal cannula observed on the floor connected to the oxygen concentrator on Resident #7 bedside. LVN D stepped out the room to obtain new nasal cannula.
Observation and interview on 2/11/23 at 2:14 PM, LVN D and the DON were both trying to obtain Resident #7 oxygen saturation reading. Resident #7 stated she had difficulty breathing. LVN D and the DON stated signs of oxygen deprivation included shortness of breath, discoloration to lips and fingers. LVN D stated Resident #7 right hand fingertips were blue in color. Resident #7 oxygen level was 76%.
Observation and interview on 2/11/23 at 4:21 PM Resident #7 stated did not have any difficulty breathing. Weekend Supervisor attempted to assess Resident #7 but she refused multiple times. Resident #7 would bring her hands up in the air and point at objects, weekend supervisor stated she was observing her hands and could not see any discoloration to hand extremities.
Interview on 2/14/23 at 11:07 AM, CNA E stated she worked Saturday, 2/11/23, morning shift in the 100 hall. CNA E stated Resident #7 was under her care that morning. CNA E stated she took the nasal cannula off Resident #7 for lunch around 11:00 AM when she transferred her from the bed to the wheelchair. CNA E stated she then took Resident #7 to the dining room but did not connect the nasal cannula to the oxygen tank that was placed behind Resident #7 wheelchair. CNA E stated she had forgotten to connect her nasal cannula back to the oxygen tank. CNA E stated she had received training regarding oxygen therapy upon hire and continuous verbal reminders from the DON. CNA E stated all nursing staff were required to ensure residents who required oxygen therapy were always connected and checking for the oxygen tank to ensure they were full every time they did their rounds. CNA E stated nursing staff had access to the resident's care plans and nurses were good about notifying them of who required oxygen therapy at all times. CNA E stated she did not check care plan because she had previously worked with Resident #7 and knew she required oxygen. CNA E stated she simply forgot to place the oxygen back on Resident #7. CNA E stated by not ensuring residents were receiving oxygen therapy could put them at risk of respiratory issues.
Interview on 2/14/23 at 1:16 PM, the NP stated he received a text on 2/11/23 a little after noon notifying him about an incident that occurred with Resident #7 related to her being without oxygen for a long period of time. The NP stated he did not give new orders but did instruct the nurse to maintain oxygen saturation above 90%. The NP stated Resident #7 had a diagnosis of COPD and CAD. The NP stated most people diagnosed with COPD were dependent on oxygen therapy but not all. The NP stated Resident #7 was dependent on oxygen therapy given the incident where she was not receiving oxygen her oxygen saturation dropped very low. The NP stated he expected nursing staff to check on residents who received oxygen therapy at least every 2 hours. The NP stated by not ensuring residents were receiving appropriate oxygen therapy, especially the ones with COPD diagnosis, could result in respiratory distress, discoloration of lips and fingertips due to lack of oxygen in their system, and the extreme case scenario death.
Interview on 2/14/23 at 2:22 PM LVN D stated she had received training regarding oxygen therapy morning upon hire and as needed. LVN D stated all nursing staff were in charge of ensuring residents were receiving appropriate oxygen therapy as ordered by physician. LVN D stated they were trained to check on resident oxygen therapy at least every 2 hours and during their medication rounds. LVN D stated she had not seen Resident #7 since her morning medication pass at around 6:30 AM. LVN D stated by not receiving appropriate monitoring could result in respiratory distress, discoloration to fingertips, and even death.
Interview on 2/13/23 at 4:27 PM, the DON stated nursing staff received oxygen training upon hire and as needed. The DON stated all nursing were trained on monitoring oxygen at least every two hours during their rounds. The DON stated CNA's had access to resident's care plans and floor nurses would give verbal report as to who required oxygen therapy. The DON stated all nursing staff were required to check oxygen tanks to ensure they were full, check if nasal cannulas were appropriately placed on residents, and check the oxygen tank/ concentrator to ensure they were receiving appropriate oxygen flow. The DON stated by not having full oxygen tanks and ensuring residents had nasal cannulas placed could results in hypoxic episodes and respiratory issues.
Record review of the facility's Oxygen Administration policy, dated 03/2022, revealed oxygen is administered to residents who need it, consistent with professional standards of practice, the comprehensive person-centered care plans and the residents' goals and preferences. 1. Oxygen is administered under orders of a physician, except in the case of an emergency.
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 observation, interview, and record review the facility failed to ensure in accordance with accepted professional standa...
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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 in accordance with accepted professional standards and practices, medical records were maintained on each resident that were complete and accurately documented for 3 of 8 residents (Resident #1, #7 and #8) reviewed for accuracy of clinical records.
A.
1. The facility failed to document weekly skin assessments for Resident #7 from 12/31/22 to 2/10/22.
B.
2. The facility failed to obtain oxygen order for Resident #8 who was observed receiving oxygen therapy.
C.
3. The facility failed to document wound care was provided for Resident #1.
These failures could place residents at risk of inaccurate medical records that could affect monitoring and medical services provided.
Findings include:
1. Record review of Resident #7 face sheet, dated 2/13/23, revealed an [AGE] year-old female who was admitted to the facility on [DATE].
Record review of Resident #7 history and physical, dated 11/25/22, reveled diagnoses which included dementia (impaired ability to remember, think, or make decisions that interferes with doing everyday activities), COPD (disease that cause airflow blockage and breathing-related problems), and CAD (disease in which there is a narrowing or blockage of the coronary arteries [blood vessels that carry blood and oxygen to the heart]).
Record review of Resident #7 care plan, dated 12/21/22, revealed potential for impaired skin integrity related to decreased mobility; interventions: skin assessment every week.
Record review of Resident #7 clinical assessment, dated 2/11/23, section skin assessment revealed only 2 skin assessments completed for 12/31/22 and 2/10/23.
2. Record review of Resident #8 face sheet, dated 2/13/23, revealed an [AGE] year-old male who was admitted to the facility on [DATE].
Record review of Resident #8's medical visit- initial assessment/ evaluation, dated 2/8/23, revealed diagnoses/ history of traumatic brain injury, delirium with acute psychosis. The patient has a follow up visit with pulmonary disease for hypoxia during hospital stay. Section 4. Respiratory was marked no problems noted. Section F. Physical exam: 1f- most recent oxygen saturation revealed 96% at room air.
Record review of Resident #8 local hospital discharged medications, dated 2/8/23, revealed no orders for either PRN or continuous oxygen therapy.
Record review of Resident #8 physician orders as of 2/13/23 at 11:53 AM, revealed no order for oxygen therapy.
Record review of Resident #8's baseline care plan, dated 2/9/23, page 7-8 section L., treatment/ procedures: 1- current treatment/ procedure revealed 1H for oxygen was not marked. Page 8 section M, physician orders revealed no orders for oxygen therapy.
Observation on 2/11/23 at 1:47 PM Resident #8 was in his wheelchair out in the hall with nasal cannula receiving oxygen at 2LPM.
Observation and interview on 2/13/23 at 12:42 PM Resident #8 was in bed had nasal cannula and receiving 5LPM. MDS Nurse confirmed Resident #8 was receiving oxygen therapy and stated she did not know about his current oxygen orders and stated I should ask his nurse for further information.
3. Record review of Resident #1's face sheet, dated 2/11/23, revealed a [AGE] year-old male who was admitted to the facility on [DATE] and was discharged on 2/7/23.
Record review of Resident #1's physician order, dated 1/27/23, revealed an order for Pressure Injury to coccyx clean with wound cleanser, pad dry apply Medi honey, cover with protective dressing, everyday shift for wound healing.
Record review of Resident #1 MAR/TAR, dated January 2023, revealed an order Pressure Injury to coccyx, clean with wound cleanser, pad dry apply Medi honey, cover with protective dressing. Everyday shift for wound healing was not marked as administered or completed for 1/28/23-1/31/23.
Record review of Resident #1 MAR/TAR, dated February 2023, revealed order Pressure Injury to coccyx clean with wound cleanser, pad dry apply Medi honey, cover with protective dressing. Every day shift forwound healing was not marked as administered or completed for 2/1/23 and 2/3/23-2/5/23.
Observation and interview on 2/13/23 at 3:51 PM, the Wound Care Nurse stated Resident #1 was admitted to the facility with a pressure ulcer to the coccyx area. The Wound Care Nurse stated he had orders for daily treatment. The Wound Care Nurse stated she waited until the end of her shift to document and check off the MAR/TAR that treatment was completed. The Wound Care Nurse stated she did not take her computer with her while she did wound care because of infection control concerns. The Wound Care Nurse referred to her laptop on PCC for Resident #1's MAR/TAR for January 2023 and February 2023 and stated when marking off that treatment was given it should have a check mark with her initials at the bottoms. The Wound Care Nurse confirmed 1/28/23-1/31/23 and 2/3/23-2/5/23 were blank. The Wound Care Nurse stated she was trained to check off on the MAR/TAR as soon as she completed treatment upon hire. The Wound Care Nurse stated she might had forgotten to check off at the end of her shift and if she didn't, it would be considered an inaccurate medical record.
Interview on 2/14/23, 3:45 at the Regional Director of Clinical Services stated nursing staff were trained upon hire regarding accurate documentation. The Regional Director of Clinical Services stated nursing administration were in charge of ensuring medical records were accurate to reflect the type of services and treatment residents received. The Regional Director of Clinical Services stated inaccurate medical records could affect the monitoring and treatment residents received.
Record review of Documentation in the Medical Record, dated 12/2022, revealed each resident's medical record shall contain an accurate representation of the actual experiences of the resident and include enough information to provide a picture of the resident's progress through complete, accurate, and timely documentation. 1. Licensed staff and interdisciplinary team members shall document all assessments, observations, and services provided in the resident's medical record in accordance with state law and facility policy. 2. Documentation shall be completed at the time of service, bit no later than the shift in which the assessment, observation, or care service occurred. 3. Principles of documentation include but are not limited to: A. documentation shall be factual, objective, and resident centered.
Jan 2023
1 deficiency
CONCERN
(D)
📢 Someone Reported This
A family member, employee, or ombudsman was alarmed enough to file a formal complaint
Potential for Harm - no one hurt, but risky conditions existed
Infection Control
(Tag F0880)
Could have caused harm · This affected 1 resident
Based on observation, interview and record review the facility failed to maintain an infection prevention and control program designed to provide a safe, sanitary, and comfortable environment and to h...
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Based on observation, interview and record review the facility failed to 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 (Resident #6) of 2 residents observed for perineal care in that:
CNA B did not change soiled gloves after providing incontinent care to Resident #6 and cross-contaminated clean areas in the resident's room with the soiled gloves
This failure could place residents at risk for cross contamination resulting in infection.
Findings included:
Observation on 1/12/23 at 1:19 PM, CNA B and CNA E provided perineal care to Resident #6. Both CNAs washed hands prior to starting and put gloves on. CNA B provided perineal care and CNA E assisted with turning and repositioning. Resident #6 only had urine in her brief. After providing care, CNA B grabbed call light and remote to reposition the bed with the same gloves she used for brief change. CNA B fixed the sheets and opened curtain. CNA B removed gloves before exiting bedroom.
Interview on 1/12/23 at 3:02 PM, the IDON stated nursing staff were trained regarding infection control upon hire, as needed and daily verbal reminders. The IDON stated staff were required to wash hands before and after providing care. The IDON stated staff were required to remove dirty gloves after providing perineal care. The IDON stated staff should not be touching call lights, clothes or anything with dirty gloves. The IDON stated by CNA not removing dirty gloves before arranging bed, put residents and staff at risk of cross contamination.
Record review of Incontinent Care/ Perineal Care policy dated 02/2022 revealed to keep residents clean and dry in a manner which provides privacy, promotes dignity. Steps for glove use: 3. Change gloves during patient care if the hands will move from contaminated body site (e.g., perineal area) to clean body site (e.g., face). 4. Remove gloves after contact with a patient and/or the surrounding environment using proper technique to prevent hand contamination. Failure to remove gloves after caring for a patient may lead to the spread of potentially deadly germs from one patient to another.
Dec 2022
4 deficiencies
1 IJ
CRITICAL
(J)
📢 Someone Reported This
A family member, employee, or ombudsman was alarmed enough to file a formal complaint
Immediate Jeopardy (IJ) - the most serious Medicare violation
Accident Prevention
(Tag F0689)
Someone could have died · This affected 1 resident
**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observations, interview, and record review, the facility failed to provide adequate supervision to prevent accidents, f...
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**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observations, interview, and record review, the facility failed to provide adequate supervision to prevent accidents, for 1 (Resident #1) of 9 residents reviewed for quality of care in that:
-The facility staff did not supervise Resident #1 who had a diagnosis of dysphagia (difficulty swallowing) and an altered diet. On 12/9/22 he had a choking incident and on 12/11/22 had another choking incident which resulted in his death.
This failure resulted in the identification of Immediate Jeopardy (IJ) on 12/21/22 at 3:25PM. While the immediacy was removed on 12/23/22, the facility remained out of compliance at a level of actual harm that is not immediate jeopardy with a scope identified as isolated due to the facility's need to monitor the implementation of the plan of removal.
This failure could place residents who were on an altered diet and had a diagnosis of dysphagia at risk for choking.
Findings included:
Review of Resident #1's Face sheet dated 12/23/22 showed a [AGE] year-old male with an admission date to the facility on [DATE]. He had diagnoses of dysphagia and Alzheimer's disease.
Review of Care Plan dated 11/20/22 showed Resident #1 had a swallowing problem and was at risk for aspiration. The goal was for Resident #1 to be free from symptoms of aspiration through interventions of maintaining HOB to 30-46 degrees during feedings, crushing medications, provide thickened liquids, and monitor for respiratory status. ADLs for eating: Supervision. Interventions included to monitor food and fluid intake, provide assistance with ADL to extent necessary, and report any episodes of choking/coughing.
Review of quarterly MDS assessment dated [DATE] showed Resident #1 had a BIMS score of 11 showing he was moderately cognitive impaired. This meant he had memory impairment and mental delays. Quarterly MDS showed Resident #1 had a therapeutic diet.
Review of physician orders dated 10/21/22, showed Resident #1 had a mechanical soft texture with honey thick consistency fluids. Orders also included ST initial evaluation dated 9/22/22.
Review of nursing note dated 12/9/22 showed Resident observed to be struggling to eat due to texture of food. Resident assisted to spit out the food. Resident provided with PRN breathing treatment for bilateral anterior and posterior congestion. Resident is calm and relaxed oxygen upon inhalation treat at 1200 was 94 oxygen. Resident will continue to monitor.
Review of progress note dated 12/11/2022 showed Around 1245 this nurse was called to Resident #1's room, upon nurse arrival to room this nurse noted wheezing sound on pt.pt was sitting up on bed. pt was awake but unable to speak. Food plate was on the table tray, food on the plate was shredded beef, mashed potatoes, and broccoli in little pieces about 1cm, tick honey liquids. No obstruction noted on pt throat. This nurse immediately started Heimlich maneuver and ask CNA to get the other nurses and call 911. Nurses took turns performing Heimlich maneuver until EMS arrived around 1255. Pt was placed on supplemental 02 by face mask. Report given. Last VS BP 102/66, HR 54, T 97.4, RR 18, O2 room air 94%. weekend supervisor and NP aware.
Review of progress note dated 12/11/22 showed This nurse called upon CNA from 100 hall. Code initiated. all nurses reported to Resident #1's room. Resident was noted to be in sitting position on side of the bed. Upon assessment resident noted with asphyxiation, related to possible obstructed airway upon oral intake. Inspection of room noted tray at bedside, resident with correct diet order of Mechanical Soft diet, and honey thick liquids. On plate resident eating mashed potatoes, smushed broccoli and shredded beef. Nurse performing Heimlich maneuver, resident non-responsive to maneuver, at this time nurses continued to attempt to dislodge obstructed airway. nurses taking turns to alleviate burn out. Paramedics previously called by charge nurse, awaiting arrival. At this time, resident was placed on a non-rebreather to alleviate breathing patterns. Resident vital signs are as follows: Last VS BP 102/66, HR 54, T 97.4, RR 18. Paramedics left facility with resident on stretcher with continuous oxygen. Resident alive and left via front door on stretcher. POA was attempted to be found in chart. Resident own POA, DON notified, ADMIN notified.
Review of Hospital records dated 12/21/22 showed that Resident #1 had been transferred to the hospital on [DATE] due to choking incident. It showed that upon arrival to the ER, he was found to be expired. He was cold to touch and had no pulse, his oxygen level was 60 and his temperature was 97 degrees. He was pronounced dead at 13:22.
Review of EMS report showed Resident #1 was a [AGE] year-old c/o choking as per nursing staff. Staff stated that Pt was eating. When staff came back to check on him Pt. was choking. Nursing staff stated that they checked Pt. airway and did not see anything in his mouth. (EMS) made Pt contact and found Pt in agonal respirations and not responding. As (EMS) was repositioning Pt to assess his airway Pt became pulseless and apneic. Pt. airway was assessed, and a big, long piece of meat was removed from his trachea. Pt improved with O2 saturations via PPV. CPR was initiated and Pt was packaged and loaded. Pt was transported .
In an interview on 12/19/22 at 10:28 AM with CNA A, she said Resident #1 had a choking incident on 12/9/22 during his lunch mealtime. She said he later had another choking incident on 12/11/22 where he died.
In an interview on 12/19/22 at 11:53 with CNA B, she said on 12/9/22, Resident #1 was struggling to breathe during his lunch meal. When she found that he was chocking, she ran out to get help. LVN C stayed with him while she ran out to get help. When she returned with the DON, she said LVN C showed them the piece of food that he was choking with by his bedside. After removal of food, the resident began to breathe better.
In an interview on 12/19/22 at 12:00 PM with the Speech Therapist, she said she was at the facility on 12/9/22, but was not notified of the choking incident. She said prior to the incident, she had been working with Resident #1 because he had a history of dysphagia. She stated that on 10/21/22, he was upgraded from puree diet to mechanical soft with honey thick liquids after he had completed his speech therapy sessions. She stated she had not been notified of a diet downgrade for 12/9/22 and that for any choking incidents such as the one that occurred on 12/9/22, she should have been notified of the situation. She stated with the notification, it would prompt Resident #1's diet to be changed.
In an interview on 12/19/22 at 12:01 PM with the Weekend Supervisor she said on 12/11/22 CNA F had called her and told her that she needed help with Resident #1 because he was choking. She called a code, and all the nurses went with her and went into Residents #1's room. Upon arrival, she saw LVN E doing the Heimlich maneuver, and switched out with her to continue the maneuver. After 2 minutes, she said a brown substance came out of his mouth. At that point, he started to wheeze breathe. 911 arrived 7 minutes after code started. She said that when Resident #1 was sent to the hospital, he was still wheeze breathing .She said she was told by LVN E that Resident #1 had later passed away.
In an interview on 12/19/22 at 12:48 PM with LVN C, she said on 12/9/22 after 12:30 PM, she was charting in the nurse's station near Resident #1's room when she heard some coughing. When she walked in, he was coughing and chewing at the same time. She said she called for help from the CNAs, and she began to help him. She said she patted his back and pushed his chin down and he was able to cough up a small piece of bread from his mouth. She said CNA B, DON, and ADON were in the room. She assessed Resident #1's lungs and found them to be congested. She administered PRN breathing treatments and continued to monitor him. She said he seemed perfectly fine , and she did not call the physician because she figured he already had orders. She said she figured she had everything in place and everything she needed for Resident #1; therefore, she did not notify him.
In an interview on 12/19/22 at 1:07 PM with the ADON, he said on 12/9/22, he had been called by the DON to Resident #1's room. When he walked in, he saw Resident #1 on the bed and a dime size piece of bread on the bedside table. He said the resident received breathing treatments and appeared fine the rest of the evening. He said he did not struggle with his dinner meal. He stated he did not notify the physician.
In an interview on 12/20/22 at 10:54 AM with CNA D, she said that on 12/11/22, she walked in to remove Resident #1's meal tray and noticed that he looked light, pale. She said she could not hear any noises from his mouth, but she could tell he was choking. She said he was sitting up on his bed with his eyes wide open. She called for help, and LVN E began the Heimlich maneuver. The Weekend Supervisor also walked in and took over the Heimlich maneuver.
In an interview on 12/21/22 at 11:06 AM with LVN E, she said it was about 12:30 PM on 12/11/22 when CNA F told her that Resident #1 was choking. When she walked in, he was sitting up on the bed and she saw him wheezing. She stated she started doing the Heimlich maneuver and the CNAs called the weekend supervisor. She said she had checked his throat but there had been nothing there. She said EMS arrived and they connected him to pulse oximeter to check his vitals. She said when he left, he was alive, was breathing and had a pulse.
In an interview on 12/19/22 at 12:18 PM with the DON, she said on 12/9/22 CNA B came to her office and told her they needed help with Resident #1. She told the ADON, and they both went into Resident #1's room. She said when she walked into the room, she saw that Resident #1 was good and LVN C was showing her the piece of bread that he had been choking on. She said it was dime size. She said he looked fine, and that he was not in state of emergency. She said no changes had been made to his treatment, and the staff continued to monitor him. She stated that her nurses and herself would usually notify the physician in situations like that. She said, I did not notify him; I don't know if the nurse notified him. She stated she was not concerned with him having any more issues after the incident of 12/9/22. She said she was not aware of resident having history of dysphagia. She stated that on 12/11/22, he had another chocking incident. The charge nurse had notified EMS, the physician, DON and Administrator. She said Resident #1 was transferred to the ER and later died at the hospital.
In an interview on 12/19/22 at 2:29 PM with NP, she said the facility had notified her on 12/11/22 that Resident #1 had been choking on his meal and was sent out to the hospital. She stated she could not recall if the facility had notified her about a previous choking incident. She stated with the notification, there would have been interventions in place for Resident #1.
Review of facility's policy titled Changes of Condition dated 03/2022 read An accident or incident involving the resident, which results in injury and has the potential for requiring physician intervention; a significant change in the resident's physical, mental or psychosocial status, such as a deterioration in health, mental or psychosocial status, in the life-threatening conditions or clinical complications; a need to alter treatment significantly.
1.
When non-licensed staff note a change in a resident, they should immediately notify the charge nurse.
2.
When a resident is noted to have a change in condition including health and psychosocial status conduct a thorough evaluation using the SBAR form
3.
Complete an incident/accident report if indicated
4.
The nurse should document on the 24-hour report that an SBAR was completed
5.
The licensed nurses and nursing assistant will communicate to the oncoming shift orally and thorough the 24-hour report the change in conditions and interventions .
On 12/21/22 at 3:25PM the IJ was identified and the Administrator, DON and ADON were informed. The IJ template was provided at this time . The POR was requested at this time.
The facility's Plan of Removal was accepted on 12/22/22 at 3:20 PM and reflected the following:
Problem: Failure to notify on Changes of Condition
Goal: Every Nurse will understand the process for following up on changes of conditions. All staff will recognize the signs & symptoms of choking.
Approaches:
All staff will be in-service on identified and reporting changes of conditions.
Licensed staff will be in-serviced on completing SBAR (Change of Condition). A change of condition would be a fall, skin tear, fever, congestion, etc.
Licensed staff are to notify MD, RP, and DON/ADON/ADMIN.
Licensed staff to notify appropriate departments, such as Therapy, Dietary, Social Services.
Licensed staff to communicate with IDT via 24hrs report for 72 hours and in clinical morning meeting. Q-shift charting
Education to be completed by 12/23/2022 documentation (SBAR, Progress note, Incident/Accident Report) will be completed/reviewed by nursing management
Clinical meeting form to be signed after review in clinical meeting that is done Monday thru Friday.
All resident who are altered diets have the potential to be affected.
All residents that are on mechanically altered diets will be assessed by a nurse to ensure residents are not showing signs or symptoms of aspiration.
All residents who are on altered diets have the potential to be affected. Pull report from PCC on Mechanical Diet will be posted on 24hrs for follow up.
All nursing staff will be educated on where to locate a resident's diet in PCC.
Staff will be in-serviced on visually looking at the while they are eating in their rooms throughout meals to ensure the resident is safe. Nursing staff will visual residents at least twice during their meal. Visual checks will be documented in PCC.
Licensed staff will follow the facility policy for what is considered a change of condition.
The facility will place educational material at the nurse's station for review prior to starting their first shift.
Charge nurses will give verbal report in morning meeting Monday thru Friday to report any changes of condition.
During the weekend the weekend supervisor will review all 24-hour sheets to ensure any changes of conditions have been documented & proper notification was done.
Nurse management will review the 24-hour shift reports at least twice daily to identify any changes of conditions.
Admin Team will pull 24-hour report from PCC daily to ensure all changes of conditions are identified.
Speech-Language Pathologist will educate staff on safeguards for residents with swallowing disorders such as watery eyes, coughing, clearing of the throat, spitting out food & drooling.
Licensed staff will educate to complete an SBAR for any change in swallowing patterns for all residents.
Weekend Supervisor will review 24hrs report on Saturday and Sundays. Report to DON/ADON for further follow-ups
Education Material provided to the staff will include in-service on Changes of Conditions, that will be continue with monthly education. Documents will be saved in designated area
In-service all staff how to recognize signs and symptoms of choking.
Staff will also be educated on the signs of choking: grasping their throat, turning blue, watery eyes, unable to speak.
Staff will be provided handouts on identifying swallowing problems and what choking looks like.
Staff will also be educated where the choking poster is located in the dining room.
Managers were educated on change of condition & will ask random staff daily during guardian angels if they know what a change of condition is & what to do if you suspect a resident has had a change.
Monthly education will be done with all staff on what to do if you think a resident has had a change of condition.
On 12/23/22 observations, interviews and record review were conducted to confirm the plan of removal had been implemented sufficiently to remove the Immediate Jeopardy:
Observations on 12/22/22 at 3:30 PM revealed a staff meeting took place led by the Administrator, ADON and Speech Therapist to discuss their plan of removal and begin in-service trainings.
Observations on 12/22/22 at 5:00 PM revealed LVN C checked meal trays on 300 hall to ensure meal correlated with diet order.
Observations on 12/23/22 at 8:45 AM revealed CNA I was educating 3 CNAs on different meal types to include: mechanical soft, puree, and regular. She also showed them the choking hazard poster.
Observations on 12/23/22 at 11:55 AM revealed LVN K checked meal trays in 400 hall to ensure meal correlated with diet order. CNA O was seen rounding on residents during mealtime.
Observations on 12/23/22 at 12:03 PM revealed LVN J checked every meal tray in 300 hall to ensure meal correlated with diet order. CNA I was seen rounding on residents during mealtime.
Review of Clinical meeting sign-in sheets showed there was a meeting on 12/22 and 12/23. At this meeting, the facility discussed changes for residents that occurred day before.
Review of in-services for 12/22 and 12/23 showed topics reviewed were: Identified Change of Condition documented on 24 and 72-hour reports, Reporting change of condition, assessing residents on mechanically altered diets, choking and identifying swallowing problems, visually observing residents eating at least 2 times per meal, altered food diets, daily guardian angel rounds, and identifying changes in condition. There were 58 signatures from staff on the in-service record.
Review of choking hazards and signs and symptoms of choking handouts dated 12/23/22. All staff were able to give examples of choking signs and what the process would be to treat it.
Interviews conducted on 12/23 at 8:00 AM-1:46 PM included 6 Licensed staff and 5 CNAs of 6-2, 2-10 and 10-6 shifts. It also included dietary staff, therapy staff, activities staff, and department heads. They all confirmed receiving training regarding Change of condition policy and reporting changes to managers. All staff interviewed reported they had been trained to look out for signs of choking, monitor for changes of condition, report changes and document those changes. They verbalized they understood how to monitor for changes and report them to clinicians.
On 12/23/22 at 2:05 PM, the Administrator was informed that the IJ was removed. However, the facility remained out of compliance at a severity of actual harm that is not immediate jeopardy with a scope identified as isolated. The facility continued to monitor its plan for effectiveness.
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 develop and implement a comprehensive person-centered care plan fo...
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**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on interviews and record review, the facility failed to develop and implement a comprehensive person-centered care plan for 2 (Resident #2 and Resident #3) residents of 10 reviewed for accurate care plans in that:
-The facility failed to complete a comprehensive care plan for Resident #2 and Resident #3.
This deficient practice could affect residents by placing them at risk of not receiving care and services to meet their needs.
Findings included:
Review of Resident #2's Face sheet dated 12/23/22 showed a [AGE] year-old male with an admission date of 11/09/22. He had a diagnosis of cerebral infarction which is a stroke and cognitive communication deficit.
Review of Resident #2's History and Physical dated 09/11/22 confirmed the diagnosis of ischemic stroke.
Review of Resident #2's clinical records on 12/23/22 revealed there was no comprehensive care plan.
Review of Resident #3's Face sheet dated 12/23/22 showed an [AGE] year-old male with an admission date of 08/24/22. He had a diagnosis of unspecified dementia, delusional disorder, and major depressive disorder.
Review of Resident #3's History and Physical dated 08/24/22 confirmed major depression disorder and showed that he would be seen by Psychiatry physician.
Review of Resident #3's clinical records on 12/23/22 revealed there was no comprehensive care plan.
Review of quarterly MDS assessment for Resident #3 dated 11/30/22 showed a BIMS score of 2 which indicated Resident #3 was severely cognitive impaired. This meant that there was a severe mental delay and memory impairment.
In an interview on 12/24/22 at 10:30 AM with Care Plan Nurse, she said she was responsible for doing care plans. She said the timeline was to complete the care plan within 14 days of admission and make changes if there was a change in condition. She said she was behind on her workload which was why she had not completed the care plans. She said the comprehensive care plan should include code status, allergies, behaviors, ADLs, medications, fall risk, skin wounds, or any issues for residents. She said the reason the comprehensive care plans should be completed is for all staff to be aware of residents' condition and plan of care.
Review of facility policy titled Comprehensive Care Plans dated 10/2022, read in part .It is the policy of this facility to develop and implement a comprehensive person-centered care plan for each resident, consistent with resident rights, that includes measurable objectives and timeframes to meet a resident's medical, nursing, and mental psychosocial needs that are identified in the resident's comprehensive assessment .The comprehensive care plans will be developed 7 days after completion of MDS assessment .
CONCERN
(E)
📢 Someone Reported This
A family member, employee, or ombudsman was alarmed enough to file a formal complaint
Potential for Harm - no one hurt, but risky conditions existed
Report Alleged Abuse
(Tag F0609)
Could have caused harm · This affected multiple residents
**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on interviews and record reviews, the facility failed to ensure that all alleged violations involving abuse, neglect, expl...
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**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on interviews and record reviews, the facility failed to ensure that all alleged violations involving abuse, neglect, exploitation or mistreatment, including injuries of unknown source, are reported immediately, but no later than 2 hours after the allegation is made, if the events that cause the allegation involve abuse or result in serious bodily injury, for 3 (Resident #1, Resident #2 and Resident #3) of 10 residents reviewed for incidents in that:
-The facility failed to report to the State agency Resident #1 had an incident of choking on 12/11/22. He was transferred to the hospital where he was pronounced dead on 12/11/22 at 1:32 PM.
-The facility failed to report to the State agency Resident #2 and Resident #3 had an altercation that resulted in Resident #3 needing stitches for a head laceration.
These deficient practices placed residents at risk of having an incident go unreported and uninvestigated which could lead to potential for harm.
Findings included:
Review of Resident #1's Face sheet dated 12/23/22 showed a [AGE] year-old male with an admission date to the facility on [DATE]. He had diagnoses of dysphagia and Alzheimer's disease.
Review of Care Plan dated 11/20/22 showed Resident #1 had a swallowing problem and was at risk for aspiration. The goal was for Resident #1 to be free from symptoms of aspiration through interventions of maintaining HOB to 30-46 degrees during feedings, crushing medications, provide thickened liquids, and monitor for respiratory status. ADLs for eating: Supervision. Interventions included to monitor food and fluid intake, provide assistance with ADL to extent necessary, report any episodes of choking/coughing.
Review of quarterly MDS assessment dated [DATE] showed Resident #1 had a BIMS score of 11 showing he was moderately cognitive impaired. This meant he had a memory impairment and mental delays. Quarterly MDS showed Resident #1 had a therapeutic diet.
Review of Physician orders showed Resident #1 had a Mechanical soft texture with Honey thick consistency fluids dated 10/21/22. Orders also included ST initial evaluation dated 9/22/22.
Review of progress note dated 12/9/22 showed Resident observed to be struggling to eat due to texture of food. Resident assisted to spit out the food. Resident provided with PRN breathing treatment for bilateral anterior and posterior congestion. Resident is calm and relaxed oxygen upon inhalation treat at 1200 was 94 oxygen. Resident will continue to monitor.
Review of progress note dated 12/11/2022 showed Around 1245 this nurse was called to room [ROOM NUMBER], upon nurse arrival to room this nurse noted wheezing sound on pt.pt was sitting up on bed. pt was awake but unable to speak. Food plate was on the table tray, food on the plate was shredded beef, mashed potatoes, and broccoli in little pieces about 1cm, tick honey liquids. No obstruction noted on pt throat. This nurse immediately started Heimlich maneuver and ask CNA to get the other nurses and call 911. Nurses took turns performing Heimlich maneuver until EMS arrived around 1255. Pt was placed on supplemental 02 by face mask. Report given to [NAME] RN at UMC. Last VS BP 102/66, HR 54, T 97.4, RR 18, O2 room air 94%. weekend supervisor and NP [NAME] aware.
Review of progress note dated 12/11/22 showed This nurse called upon CNA from 100 hall. Code initiated. all nurses reported to room [ROOM NUMBER]b. Resident was noted to be in sitting position on side of the bed. Upon assessment resident noted with asphyxiation, related to possible obstructed airway upon oral intake. Inspection of room noted tray at bedside, resident with correct diet order of Mechanical Soft diet, and honey thick liquids. On plate resident eating mashed potatoes, smushed broccoli and shredded beef. Nurse performing Heimlich maneuver, resident non-responsive to maneuver, at this time nurses continued to attempt to dislodge obstructed airway. nurses taking turns to alleviate burn out. Paramedics previously called by charge nurse, awaiting arrival. At this time, resident was placed on a non-rebreather to alleviate breathing patterns. Resident vital signs are as follows: Last VS BP 102/66, HR 54, T 97.4, RR 18. Paramedics left facility with resident on stretcher with continuous oxygen. Resident alive and left via front door on stretcher. POA was attempted to be found in chart. Resident own POA, DON notified, ADMIN notified.
In an interview on 12/19/22 at 10:28 AM with CNA A, she said Resident #1 had a choking incident on 12/9/22 during his lunch mealtime. She said he later had another choking incident on 12/11/22 where he died.
In an interview on 12/19/22 at 11:53 with CNA B, she said on 12/9/22, Resident #1 was struggling to breathe during his lunch meal. When she found that he was chocking, she ran out to get help. LVN C stayed with him while she ran out to get help. When she returned with the DON, LVN C had the piece of food that he was choking with by his bedside. After removal of food, the resident began to breathe better.
In an interview on 12/19/22 at 12:01 PM with Charge Nurse she said CNA F had called her and told her that she needed help with Resident #1 because he was choking. Charge nurse called a code, and all the nurses went with her and went into Residents #1's room. Upon arrival, she saw LVN E doing the Heimlich maneuver, and switched out with her to continue the maneuver. After 2 minutes, she said a brown substance came out of his mouth. At that point, he started to wheeze breathe. 911 arrived 7 minutes after code started. Resident #1 was sent to the hospital, and he was still breathing. She said she was told by LVN E that Resident #1 had later passed away.
In an interview on 12/19/22 at 12:48 PM with LVN C, she said on 12/9/22 after 12:30 PM, she was charting in the nurse's station near Resident #1's room when she heard some coughing. When she walked in, he was coughing and chewing at the same time. She said she called for help from the CNAs, and she began to help him. She said she patted his back and pushed his chin down and he was able to cough it up. She said CNA B, DON, and ADON were in the room. She assessed Resident #1's lungs and found them to be congested. She administered PRN breathing treatments and continued to monitor him. She stated Resident #1 did not have any more coughing spells or choking for the rest of the day.
In an interview on 12/20/22 at 10:54 AM with CNA D, she said that on 12/11/22, she walked in to remove Resident #1's meal tray and noticed that he looked light, pale. She said she could not hear any noises from his mouth, but she could tell he was choking. She said he was sitting up on his bed with his eyes wide open. She called for LVN E and started to perform Heimlich maneuver. LVN E walked into the room and started to do Heimlich maneuver. Charge Nurse then walked in and took over Heimlich maneuver.
In an interview on 12/21/22 at 11:06 AM with LVN E, she said it was about 12:30 PM on 12/11/22 when CNA F told her that Resident #1 was choking. When she walked in, he was sitting up on the bed and she saw him wheezing. She stated she started doing the Heimlich maneuver and the CNAs called the other nurses. She said she had checked his throat but there had been nothing there. She said EMS arrived and they connected him to pulse oximeter to check his vitals. She said when he left, he was alive, was breathing and had a pulse.
In an interview on 12/19/22 at 12:18 PM with DON, she on 12/9/22 CNA B came to her office and told her they needed help with Resident #1. She told the ADON, and they both went into Resident #1's room. She said when she walked into the room, she saw that Resident #1 was good and LVN C was showing her the piece of bread that he had been choking on. She said it was dime size. She stated that on 12/11/22, Resident #1 had another chocking incident, was transferred to the ER and later died at the hospital. She said she did not report the incident to Administrator because the Weekend Supervisor had reported it to him . She said the choking incident was reportable to the state. She said she was not sure whose duty it was to report it.
In an interview on 12/19/22 at 1:49 PM with Administrator, he said he heard about the choking incident of 12/11/22 but was not aware of the incident on 12/09/22 . He said the Weekend Supervisor had called him on 12/11/22 and notified him of incident. He stated he did not report it to the State agency because he did not think he had to . He said he was not aware that he had to and was not sure what category it would fall under. He stated the DON was also able to make reports to the state. He stated there had been no investigation done, but he has spoken to the nurses who were involved.
Review of Resident #2's Face sheet dated 12/23/22 showed a [AGE] year-old male with an admission date of 11/09/22. He had a diagnosis of Cerebral infarction which is a stroke and Cognitive communication deficit.
Review of Resident #2's History and Physical dated 09/11/22 confirmed the diagnosis of ischemic stroke.
Review of Resident #3's Face sheet dated 12/23/22 showed an [AGE] year-old male with an admission date of 08/24/22. He had a diagnosis of Unspecified dementia, delusional disorder, and major depressive disorder.
Review of Resident #3's History and Physical dated 08/24/22 confirmed major depression disorder and showed that he would be seen by Psychiatry physician.
Review of quarterly MDS assessment for Resident #3 dated 11/30/22 showed a BIMS score of 2 which indicated Resident #3 was severely cognitive impaired. This meant that there was a severe mental delay and memory impairment.
Review of progress notes dated 12/1/22 showed Patient (Resident #3) was struck in the right side of the head by Resident #2 due to Resident #3 going into his room several times to steal his belongings, the incident was unwitnessed. Resident #3 obtained a 3cm laceration to the right side of the head which caused slight bleeding. He was vitally stable and alert and oriented; he was sent out to local hospital for further evaluation. Doctor was notified and daughter was notified as well. Resident #3 was sent out at 9:15 pm via emergency ambulance daughter stated she would meet him at hospital.
Review of progress notes dated 12/2/22 showed Resident arrived from ER visit via ambulance at approximately 0130, 2 staples to laceration to the right side of head, right ear is bruised as well. Based on report and paperwork from hospital no abnormal findings present in the CT scan that was done. Nurse informs MD and NP about residents return, new orders for topical antibiotic and results from CT scan. No new orders given NP by at this time. Resident was left put in bed and left with bed at lowest position with call bell at reach.
In an interview on 12/17/22 at 10:30 AM with Resident #2, he said he was sleeping one night, and he woke up with Resident #3 hitting him with an arm brace. He got scared and tried to stop Resident #3 from hitting him and that is when Resident #3 fell on the floor. He said he did not go to the hospital or get stiches. He said the staff found out later but did not know who it was. He said he has not had any other problems and stated he felt safe.
Resident #3 was non-interviewable and was not able to answer questions.
In an interview on 12/17/22 at 10:40 AM with LVN G, she said she got a report that there had been an altercation between both Residents #2 and #3. She said that it had occurred on night shift. She did not know if it had gotten reported to the State.
In an interview on 12/17/22 at 11:00 AM with Weekend Supervisor, she stated on 12/1/22 Resident #3 went into a room that was not his . He thought it was his room and he went into Resident #2's room. Resident #3 got into an altercation with Resident #2, and Resident #3 initiated the altercation. Resident #3 went to the hospital because of a laceration. She stated she was not present during the incident and was not sure if it had been reported.
In an interview on 12/17/22 at 12:12 PM with LVN H, she said she worked the night of 12/1/22 after it had occurred during the 2-10pm shift. During report, Resident #3 had gone into Resident #2's room and was hitting him. She said a police report had been done and she let the Administrator know.
In an interview on 12/19/22 at 12:18 PM with DON, she stated that she received a message that Resident #3 had hit Resident #2 . She said Resident #3 had not had behaviors in the past prior to this incident. She stated some incidents were required to be reported but stated she did not report it to another leader because she did not know she had to.
In an interview with Administrator on 12/19/22 at 12:30 PM, he said he became aware of situation on 12/19/22.
Review of facility policy titled Abuse, Neglect and Exploitation dated 07/2022 read in part .The facility will have written procedures that include: Reporting of all alleged violations to the Administrator, state agency .within the specific timeframes: Immediately, but no later than 2 hours after allegation is made, if the events that caused the allegation involve abuse or result in serious bodily injury .An immediate investigation is warranted when suspicion of abuse, neglect .or reports of abuse or neglect occur .
Review of facility policy titled Reporting Abuse to Facility Management dated December 2013 read in part .it is the responsibility of our employees, facility consultants .to promptly report any incident or suspected incident of neglect or resident abuse .all personnel, residents are encouraged to report incidents of resident abuse or suspected incidents of abuse .
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
ADL Care
(Tag F0677)
Could have caused harm · This affected multiple residents
**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, interview, and record review, the facility failed to ensure a resident who is unable to carry out activiti...
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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 a resident who is unable to carry out activities of daily living receives the necessary services to maintain good nutrition, grooming, and personal and oral hygiene for 2 (Resident #4 and Resident #5) of 8 residents observed for assistance with ADL's.
1. The facility failed to prevent Resident #4's hair from appearing disheveled and not combed, and not being shaved.
2. The facility failed to prevent Resident #5's hair from not being combed and having body odor.
These failures placed residents at risk of poor care, feelings of poor self-esteem, and lack of dignity.
Findings included:
Review o f Resident #4's Face Sheet showed a [AGE] year-old male with an admission date of 9/14/22. He had diagnosis of Hemiplegia of right side (paralysis of right side).
Review of History and Physical dated 9/14/22 confirmed Resident #4 had right sided weakness and was at the facility for rehabilitation.
Review of quarterly MDS assessment dated [DATE] showed Resident #4 had a BIMS score of 15, indicating he was cognitively intact and could make his own decisions. It also showed he needed extensive assistance with ADLs.
Review of shower sheets on 12/23/22 showed Resident #4 had received a shower on 11/1, 11/14, 11/24, and 12/13.
An observation and interview on 12/17/22 at 4:40 PM with Resident #4 revealed he appeared with hair unkept and tangled. He said had been having problems with showers. He said there were days where he would not get showers because the CNAs did not have time. He stated he was supposed to receive a shower on 12/17/22, but it had not been done. He said he had not showered for a week. He said he felt dirty.
Review of Resident #5's Face Sheet showed a [AGE] year-old male with an admission date of 10/27/20. He had a diagnosis of Hemiplegia of left side (paralysis of left side), muscle wasting, and was morbidly obese.
Review of History and Physical dated 10/27/20 showed Resident #5 had left sided weakness due to a stroke, had decreased mobility, and was dependent on a wheelchair.
Review of Quarterly MDS dated [DATE] showed a BIMS score of 10, indicating a moderate mental impairment. It also showed he needed extensive assistance with ADLs.
Review of Care plan dated 5/2/22 showed Resident #5 had the potential for self-care deficit and decline in ADLS due to Stroke. The goal was for Resident #5 to participate in self-care activities and maintain current levels of ADLs through interventions such as allow sufficient time to complete self-care, encourage participation during self-care activities, and provide assistance for bathing and personal hygiene.
Review of shower sheets showed Resident #5 had received a shower on 11/01, 11/25, 11/30, 12/01, 12/02, 12/06, 12/07, 12/09, 12/14, and 12/15.
Review of Task Record for Bathing for the past 30 days since 12/24 showed Resident #5 had not received a shower on 11/26, 11/27, 11/28, 11/29, 12/2, 12/3, 12/5, 12/7, 12/10, 12/17, 12/18, 12/19, 12/20, 12/21, 12/22, and 12/22.
An observation an interview on 12/17/22 at 9:47 AM with Resident #5 revealed he had a dirty gown and had body odor. He said he had not been receiving his showers. He said his schedule was Tuesday, Thursday, and Saturday. He said he should have been getting a sponge bath on 12/17/22 but had not yet. He said the CNAs tell him that they run out of time and that is why he would miss showers at times. He said his last shower had been on 12/15/22.
In an interview on 12/17/22 at 10:40 AM with LVN G, she said she was aware that residents would miss showers. She said there were times where residents would not want to shower, but other times where there was not enough time to shower the residents.
In an interview on 12/19/22 at 10:28 AM with CNA A, she said there were times when residents did not shower because they got busy. She said the schedules for showering was Monday, Wednesday, and Friday. The other schedule was Tuesday, Thursday, and Saturday. She said when a resident refuses to shower, she will tell then nurse and they ask the resident again.
In an interview on 12/24/22 at 10:56AM with the Weekend Supervisor, she said it was common for residents to miss showers due to staff not having time . She said the problem was that CNAs would focus too much on the tasks that were not finished from the shift prior and would not get things that had to be done in the current shift. She stated that if the staff focused on providing resident care, they would have time get it done .
In an interview on 12/19/22 at 8:58 AM with ADON, he said there had been times when residents would not get shower due to them not wanting to shower or because of bad timing. He said bad timing meant that the resident had waited all day to shower and when they decide to have one it would be during shift report or when the nurses and CNAs are doing other tasks.
In an interview on 12/17/22 at 11:00 AM with DON, she said she implemented a shower schedule policy where if a resident refused a shower, the CNAs and LVNs must ask the residents 3 times before marking on their record as a refusal. She said with residents that had issues with no showers, she spoke to family and resolved the issue by implementing the shower schedule policy.
Record review of facility policy titled Activities of Daily Living (ADLs) dated 03/2022 read in part .The facility will based on the resident's comprehensive assessment and consistent with the resident's needs and choices, ensure a resident's abilities in ADLs do not deteriorate unless deterioration is unavoidable .Care and services will be provided for the following activities of daily living: Bathing, dressing, grooming and oral care .A resident who is unable to carry out activities of daily living will receive the necessary services to maintain good grooming and personal and oral hygiene .
Understanding Severity Codes (click to expand)
Life-Threatening (Immediate Jeopardy)
J - Isolated
K - Pattern
L - Widespread
Actual Harm
G - Isolated
H - Pattern
I - Widespread
Potential for Harm
D - Isolated
E - Pattern
F - Widespread
No Harm (Minor)
A - Isolated
B - Pattern
C - Widespread
Questions to Ask on Your Visit
- "What changes have you made since the serious inspection findings?"
- "Why is there high staff turnover? How do you retain staff?"
- "Can I speak with families of current residents?"
- "What's your RN coverage like on weekends and overnight?"
Our Honest Assessment
Strengths
- • Licensed and certified facility. Meets minimum state requirements.
Concerns
- • Multiple safety concerns identified: 3 life-threatening violation(s), 1 harm violation(s), $78,322 in fines, Payment denial on record. Review inspection reports carefully.
- • 75 deficiencies on record, including 3 critical (life-threatening) violations. These warrant careful review before choosing this facility.
- • $78,322 in fines. Extremely high, among the most fined facilities in Texas. Major compliance failures.
- • Grade F (0/100). Below average facility with significant concerns.
Bottom line: This facility has 3 Immediate Jeopardy findings. Serious concerns require careful evaluation.
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About This Facility
What is Avir At Patriot's CMS Rating?
CMS assigns AVIR AT PATRIOT an overall rating of 1 out of 5 stars, which is considered much below average nationally. Within Texas, this rating places the facility higher than 0% of the state's 100 nursing homes. A rating at this level reflects concerns identified through health inspections, staffing assessments, or quality measures that families should carefully consider.
How is Avir At Patriot Staffed?
CMS rates AVIR AT PATRIOT's staffing level at 1 out of 5 stars, which is much below average compared to other nursing homes. Staff turnover is 74%, which is 28 percentage points above the Texas average of 46%. High turnover can affect care consistency as new staff learn residents' individual needs. RN turnover specifically is 73%, which is notably high. RNs provide skilled clinical oversight, so turnover in this role can affect medical care quality.
What Have Inspectors Found at Avir At Patriot?
State health inspectors documented 75 deficiencies at AVIR AT PATRIOT during 2022 to 2025. These included: 3 Immediate Jeopardy (the most serious level, indicating potential for serious harm or death), 1 that caused actual resident harm, 69 with potential for harm, and 2 minor or isolated issues. Immediate Jeopardy findings are rare and represent the most serious regulatory concerns. They require immediate corrective action.
Who Owns and Operates Avir At Patriot?
AVIR AT PATRIOT is owned by a for-profit company. For-profit facilities operate as businesses with obligations to shareholders or private owners. The facility is operated by AVIR HEALTH GROUP, a chain that manages multiple nursing homes. With 124 certified beds and approximately 141 residents (about 114% occupancy), it is a mid-sized facility located in EL PASO, Texas.
How Does Avir At Patriot Compare to Other Texas Nursing Homes?
Compared to the 100 nursing homes in Texas, AVIR AT PATRIOT's overall rating (1 stars) is below the state average of 2.8, staff turnover (74%) is significantly higher than the state average of 46%, and health inspection rating (2 stars) is below the national benchmark.
What Should Families Ask When Visiting Avir At Patriot?
Based on this facility's data, families visiting should ask: "What changes have been made since the serious inspection findings, and how are you preventing similar issues?" "How do you ensure continuity of care given staff turnover, and what is your staff retention strategy?" "Can you walk me through typical staffing levels on day, evening, and night shifts?" "Can I visit during a mealtime to observe dining assistance and food quality?" These questions are particularly relevant given the facility's Immediate Jeopardy citations, the facility's high staff turnover rate, and the below-average staffing rating.
Is Avir At Patriot Safe?
Based on CMS inspection data, AVIR AT PATRIOT has documented safety concerns. Inspectors have issued 3 Immediate Jeopardy citations (the most serious violation level indicating risk of serious injury or death). The facility has a 1-star overall rating and ranks #100 of 100 nursing homes in Texas. Families considering this facility should ask detailed questions about what corrective actions have been taken since these incidents.
Do Nurses at Avir At Patriot Stick Around?
Staff turnover at AVIR AT PATRIOT is high. At 74%, the facility is 28 percentage points above the Texas average of 46%. Registered Nurse turnover is particularly concerning at 73%. RNs handle complex medical decisions and coordinate care — frequent RN changes can directly impact care quality. High turnover means new staff may not know residents' individual needs, medications, or preferences. It can also be disorienting for residents, especially those with dementia who rely on familiar faces. Families should ask: What is causing the turnover? What retention programs are in place? How do you ensure care continuity during staff transitions?
Was Avir At Patriot Ever Fined?
AVIR AT PATRIOT has been fined $78,322 across 5 penalty actions. This is above the Texas average of $33,862. Fines in this range indicate compliance issues significant enough for CMS to impose meaningful financial consequences. Common causes include delayed correction of deficiencies, repeat violations, or care failures affecting resident safety. Families should ask facility leadership what changes have been made since these penalties.
Is Avir At Patriot on Any Federal Watch List?
AVIR AT PATRIOT 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.