ELECTRA HEALTHCARE CENTER
Government - Hospital district
62 Beds
Independent
Data: November 2025
1 Immediate Jeopardy citation
Trust Grade
23/100
#969 of 1168 in TX
Last Inspection: January 2025
Within standard 12-15 month inspection cycle. Federal law requires annual inspections.
Overview
Electra Healthcare Center has a Trust Grade of F, indicating significant concerns about the facility's quality and care. They rank #969 out of 1168 nursing homes in Texas, placing them in the bottom half of all facilities. The situation is improving, with the number of issues reported decreasing from 24 in 2023 to 7 in 2025, suggesting some progress is being made. While staffing turnover is impressively low at 0%, indicating staff stability, the overall staffing rating remains poor at 1 out of 5 stars. Concerns include a critical incident where a resident with an open wound was not treated promptly, as well as ongoing issues with food safety and sanitation in the kitchen, which could pose health risks to residents. Although the facility has been fined $32,487, this is in line with the average for Texas facilities, but it still points to compliance problems. Overall, while there are some strengths, such as low staff turnover, the number of safety and care issues raises serious concerns for families considering this home.
- Trust Score
- F
- In Texas
- #969/1168
- Safety Record
- High Risk
- Inspections
- Getting Better
- Staff Stability ○ Average
- Turnover data not reported for this facility.
- Penalties ✓ Good
- $32,487 in fines. Lower than most Texas facilities. Relatively clean record.
- Skilled Nurses ○ Average
- RN staffing data not reported for this facility.
- Violations ⚠ Watch
- 34 deficiencies on record. Higher than average. Multiple issues found across inspections.
23/100
Bottom 18%
Review needed
24 → 7 violations
★☆☆☆☆
1.0
Overall Rating
★☆☆☆☆
1.0
Staff Levels
★★☆☆☆
2.0
Care Quality
★★☆☆☆
2.0
Inspection Score
↔
Stable
2023: 24 issues
2025: 7 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
Federal Fines: $32,487
Below median ($33,413)
Moderate penalties - review what triggered them
The Ugly 34 deficiencies on record
1 life-threatening
Jan 2025
7 deficiencies
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 adequate supervision and assistance devices 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 adequate supervision and assistance devices was provided for 1of 2 residents reviewed for transfers. (Resident # 119).
The facility did not assess Resident #119 for use of a lift device even though he was non-weight bearing.
The facility failed to ensure staff transferred Resident #119 in a manner to prevent injuries. The staff performed one-person lifts by hugging the resident or hooking their arms under his shoulders.
This failure could place residents who required assistance during transfers at risk for pain and injury.
Findings included:
Review of Resident #119's admission Record dated 1/7/25 revealed he was a [AGE] year-old male admitted to the facility on [DATE] with diagnosis including Lowe's Syndrome (a rare genetic order that causes weak muscle tone and abnormal spine).
Review of Resident #119's Quarterly MDS assessment dated [DATE] revealed:
He had severely impaired decision-making skills and signs of delirium to include inattention and disorganized thinking,.
He used a wheelchair,
He was completely dependent on staff for all ADL's including transfers, and
He weighed 93 pounds.
Review of Resident #119's care plan initiated 10/19/24 revealed:
Focus: The resident has an ADL self-care performance deficit.
Goal: The resident will achieve maximum functional mobility.
Interventions included: Transfer: The resident is totally dependent on 1 staff for transferring.
Review of Resident #119's Order Summary Report, dated 1/7/25, revealed orders:
Non weight bearing bilateral (both) lower extremities dated 8/4/24.
Review of Resident #119's vital signs revealed Resident #119 weighed 90 pounds on 1/2/25.
Review of Resident #119's electronic record to include assessments and miscellaneous revealed no assessment on safe transfer ability.
Interview on 1/6/25 at 1:51 p.m., CNA E stated Resident #119 was not weight bearing and was a one-person transfer. CNA E described a transfer Resident #119 as a hug, that Resident #119 would hug the staff and then the staff would just pick him up. CNA E said Resident #119 was 90 pounds if that. CNA E said Resident #119 was not weight-bearing and his feet would not touch the ground during the transfer.
Observation on 1/6/25 at 4:32 p.m., CNA E locked Resident #119's wheelchair and then put Resident #119's hands on her shoulders. CNA E was observed putting her arms around Resident #119 under his arms and pulled him out of the wheelchair, pivoted, and placed Resident #119 in the bed. Resident #119 feet did not drag on the ground.
Interview on 1/6/25 at 4:52 p.m., COTA G stated a safe one-person transfer would be to use a gait belt. COTA G stated the process was to put the gait belt on the resident, get the foot pedals out of the way if necessary, turn the resident's feet a little bit in the direction of the turn, have the resident put their hands on the aide's shoulder and on the count of three have the resident stand, assist to pivot and have the resident sit where they were transferring to. COTA G stated she did not think it was safe to transfer one-person if the person was non-weight bearing and the person would need some help to do it safely. COTA G stated in Resident #119's situation it would be safe because all he knew was, he wanted up at that moment and would not wait for another person to come. COTA G stated a gait-belt should be used. COTA G said if not gait belt was used the person could throw their arms up and slide out of the aide's arms and fall right out. COTA G stated she talked to the staff about transfers multiple times and the last time was right before Christmas.
Interview on 1/6/25 at 5:22 p.m., the DON stated her expectation for a non-weight bearing transfer for someone like Resident #119 was he could be safely transferred one-person because he was 90 pounds. The DON said if he was having behaviors, she would expect the aides to ask for help The DON said the care plan was to pick him up and scoot him over so he does not fight the aides. The DON said alternates to the one-person transfer could be a slide-board if the wheelchair could accommodate it or a mechanical lift with a sling.
Interview on 1/7/25 at 11:21 a.m. CNA F said Resident #119 had cysts on his back and the aides were afraid if they used the gait belt the cysts would be ripped open, and Resident #119 would become combative. CNA F and CNA E who was also present said Resident #119 would be appropriate for a mechanical lift transfer if someone held his hands during the transfer.
Review of the facility's policy and procedure on Safe Lifting and Movement of Residents, dated 2001, revealed:
In order to protect the safety and well-being of staff and residents, and to promote quality of care, this facility uses appropriate techniques and devices to lift and move residents.
Policy Interpretation and Implementation:
2. Manual lifting of residents shall be eliminated when feasible.
3. Nursing staff, in conjunction with the rehabilitation staff, shall assess the individual residents' needs for transfer assistance on an ongoing basis. Staff will document transferring and lifting needs in the care plan. Such assistance shall include the following:
Resident's mobility (degree of dependency);
Resident's size;
Weight-bearing ability;
Cognitive status;
Whether the resident is usually cooperative with staff.
CONCERN
(E)
Potential for Harm - no one hurt, but risky conditions existed
Abuse Prevention Policies
(Tag F0607)
Could have caused harm · This affected multiple residents
Based on interview and record review the facility failed to develop and implement written policies and procedures that prohibit and prevent abuse, neglect, and exploitation of residents for 3 of 6 (DO...
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Based on interview and record review the facility failed to develop and implement written policies and procedures that prohibit and prevent abuse, neglect, and exploitation of residents for 3 of 6 (DON, DM, SW) staff reviewed for abuse protocol.
The facility failed to complete annual Criminal Background Checks for the DON, DM, and SW.
This failure could place residents at risk for abuse, neglect, and exploitation.
Findings included:
Record review of the DON's personnel file revealed no annual criminal background check completed since 07/03/2012. The DON had a hire date of 07/09/2012.
Record review of the DM's personnel file revealed no criminal background check completed previously. The DM had a hire date of 11/06/1995.
Record review of the SW's personnel file revealed no criminal background check completed previously. The SW had a hire date of 10/06/2008.
In an interview on 01/07/25 at 04:45 PM, the CSM stated she was the staff member responsible for completing all background checks and that she did the DON, DM, and SW background checks on 1/7/25. She said when she pulled staff records for the survey, she realized they had not been done. CSM stated, I did not realize background checks are required on every staff member. I also did not know that background checks are required annually.
Record review of the facility's Abuse, Neglect, Exploitation and Misappropriation Prevention Program policy (revised 04/2021) read in part Protect residents from abuse, neglect, exploitation or misappropriation of property by anyone including, facility staff .
Conduct employee background checks and not knowingly employ or otherwise engage any individual who has: been found guilty of abuse, neglect, exploitation, misappropriation of property, or mistreatment by a court of law.
CONCERN
(E)
Potential for Harm - no one hurt, but risky conditions existed
Deficiency F0645
(Tag F0645)
Could have caused harm · This affected multiple residents
Based on interview and record review, the facility failed to ensure all Preadmission Screening and Resident Review (PASARR) Level I (PL1) Screening residents diagnosed with mental illness were provide...
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Based on interview and record review, the facility failed to ensure all Preadmission Screening and Resident Review (PASARR) Level I (PL1) Screening residents diagnosed with mental illness were provided with a PASARR Level II (PE) Screening for 2 of 3 residents (Resident #10 and Resident #15) reviewed for a mental illness, intellectual disability, or developmental disability.
The facility failed to ensure Resident #10 and #15 who had a diagnosis of mental illness had a PASARR Level II (PE) screening completed.
This failure placed residents at risk of mental health needs not being met.
The findings included:
Resident #10
A record review of Resident #10's admission Record, dated 01/07/2025, revealed Resident #10 had an admission date of 12/06/2024. Resident #10 had a primary diagnosis of Infection following a procedure, deep incisional surgical site, and Major Depressive Disorder (a mood disorder that causes a persistent feeling of sadness and loss of interest).
A record review of a PASARR Level I (PL1) Screening, dated 12/04/2024, indicated Resident #10 had no evidence of mental illness. No PASARR Level II (PE) Screening or a form 1012 (Mental Illness/Dementia Resident Review) was found in the clinical record.
A record review of the Resident #10's admission MDS assessment, dated 12/18/2024, revealed Active Diagnosis of Depression. The resident had a BIMS score of 15 which indicates the resident was cognitively intact.
A record review of Resident # 10's Care Plan, with a revision date of 12/17/2024, indicated Resident #10 may develop Impaired coping related to diagnosis of Major Depressive Disorder.
A record review of Resident #10's Physician Order Summary Report, dated 01/07/2025, indicated Resident #10 received duloxetine 90mg daily for diagnosis of Major Depressive Disorder.
Resident #15
A record review of Resident #15's admission Record, dated 01/07/2025, revealed Resident #15 had an admission date of 11/15/2024. Resident #15 had a primary diagnosis Parkinson's Disease (a neurodegenerative disease primarily of the central nervous system, affecting both motor and non-motor systems), Major Depressive Disorder (a mood disorder that causes a persistent feeling of sadness and loss of interest), and anxiety disorder (a group of mental disorders characterized by significant and uncontrollable feelings of anxiety and fear such that a person's social, occupational, and personal functions are significantly impaired).
A record review of the Resident # 15's admission MDS assessment, dated 11/22/2024, revealed Active Diagnosis of Anxiety Disorder and Depression. The resident had a BIMS score of 15 which indicates the resident was cognitively intact.
A record review of a PASARR Level I (PL1) Screening, dated 11/15/2024, indicated Resident #15 had no evidence of mental illness. No PASARR Level II (PE) Screening or a form 1012 (Mental Illness/Dementia Resident Review) was found in the clinical record.
A record review of Resident # 15's Care Plan, with a revision date of 01/05/2025, indicated Resident #15 has depression related to disease process (Parkinson's).
A record review of Resident #15's Physician Order Summary Report, dated 01/07/2025, indicated Resident #15 received sertraline 100mg daily for diagnosis of Major Depressive Disorder.
In an interview on 01/07/2025 at 11:23 am, the DON stated the Social Worker was responsible for updating the PASARR's. She did not know a PASARR needed to be updated when they came from the hospital. She said a potential failure would be the resident would not receive services they would be eligible for.
In an interview on 01/07/2025 at 2:04 pm, the Social Worker said she was responsible for PASARR's. She said Resident #10 and Resident #15 should have a new PASARR (PL1) screening completed due to having a diagnosis of Major Depressive Disorder but was not aware the residents had a diagnosis of a mental illness. She said a potential negative outcome of this failure would be a resident might not receive PASSAR services if they were eligible.
Record review of the facility policy admission Criteria, dated as last revised March 2019, revealed the following [in part]:
Policy Interpretation and Implementation:
9. All new admission and readmissions are screened for mental disorders (MD), intellectual disabilities (ID) or related disorders (RD) per the Medicaid Pre-admission Screening and Resident Review (PASAR) process.
a. The facility conducts a Level I PASARR screen for all potential admissions, regardless of payer source, to determine if the individual meets the criteria for MD, ID or RD.
b. If the Level 1 screen indicates that the individual may meet the criteria for a MD, ID, or RD, he or she is referred to the state PASARR representative for the Level II (evaluation and determination) screening process.
CONCERN
(E)
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 included measurable objectives and time frames to meet, attain, and/or maintain the resident's highest practicable physical, mental, and psychosocial well-being for 1 of 14 residents (Residents #120) reviewed for care plans.
The facility failed to have a care plan for Resident #120's Hospice status.
These failures could affect residents by placing them at risk of not receiving individualized care and services to meet their needs.
The findings included:
Review of the most recent Minimum Data Set (MDS), dated [DATE], revealed: Resident #120 was a [AGE] year-old female admitted to the facility on [DATE] with diagnoses included stroke, Non-Alzheimer's Dementia, seizure disorder, and malnutrition. Resident #120 had a BIMS of 15 of 15 (indicating cognitively intact).
Review of Resident #120's Care Plan last revised on 12/16/2024, revealed: Hospice status was not included in the care plan.
Review of Resident #120's Physician Orders revealed order dated 07/31/2024: Admit to Hospice, Diagnosis Senile Dementia written by Resident #120's primary care physician.
Review of Resident #120's Face Sheet revealed: Hospice Medicaid as the Primary Payer and a Hospice company as an External Facility involved in Resident #120's care.
In an interview on 01/07/25 at 4:40 PM, the DON stated she was responsible for the Care Plans. The DON stated she did not realize that Hospice services needed to be care planned. The DON said she thought a hospice care plan would be necessary because so all staff are aware of the resident's needs.
Record review of the facility's Care Plans, Comprehensive Person-Centered policy (revised 03/2022) read in part The comprehensive, person-centered care plan: describes the services that are to be furnished to attain or maintain the resident's highest practicable physical, mental, and psychosocial well-being .
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 F0657
(Tag F0657)
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 include resident or the resident's representative in the IDT (Inter...
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**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on interview and record review, the facility failed to include resident or the resident's representative in the IDT (Interdisciplinary team) in the comprehensive care planning within 7 days after completion of the comprehensive assessment for 2 of 4 residents (Resident #8 and Resident #10) reviewed for care plan timing/revision.
The facility failed to ensure Resident #8 and Resident #10's care plan was reviewed by the IDT (Interdisciplinary team), which failed to include the resident or the resident's representative after the Comprehensive MDS assessment.
This failure placed the residents at risk for not having individual needs identified and care and services provided to meet their needs and promote quality of care, feelings of well-being and quality of life.
The findings included:
Resident #8
A record review of Resident #8's admission Record, dated 01/07/2025 revealed Resident #8 had an admission date of 10/10/2024. Resident #8's had a primary diagnosis was unspecified dementia (a group of symptoms affecting memory, thinking and social abilities).
A record review of the Resident #8's Quarterly MDS assessment, dated 12/12/2024, revealed a BIMS score of 00, which means the resident was severely impaired.
A record review of Resident #8's comprehensive care plan revealed it was last Reviewed/Revised on 01/05/2025. There was no documented evidence that a care plan meeting was conducted for this care plan.
A record review of Resident #8's progress notes revealed there was not a care plan meeting conducted since admission on [DATE].
In an interview with Resident #8 on 01/05/2025 at 10:25 am, he failed to answer if he had been invited or had participated in a care plan meeting.
Resident #10
A record review of Resident #10's admission Record, dated 01/07/2025, revealed Resident #10 was a [AGE] year-old male/female who had an admission date of 12/06/2024. Resident #10 had a primary diagnosis of Infection following a procedure, deep incisional surgical site, and Major Depressive Disorder (a mood disorder that causes a persistent feeling of sadness and loss of interest).
A record review of the Resident #10's admission MDS assessment, dated 12/18/2024, revealed a BIMS score of 15, which means the resident was cognitively intact.
A record review of Resident #10's comprehensive care plan revealed it was last Reviewed/Revised on 01/05/2025. There was no documented evidence that a care plan meeting was conducted for this care plan.
A record review of Resident #10's progress notes revealed there was not a care plan meeting conducted since admission on [DATE].
In an interview with Resident #10 on 01/05/2025 at 1:36 pm, she said she had not been invited or had participated in a care plan meeting.
In an interview with the DON on 01/07/2024 at 11:17 am, she said she was responsible for scheduling the care plan meetings. She said there was no documentation of a care plan meeting or that she can remember having a care plan meeting for Resident #8 since admission. The DON said she attempted to contact Resident #10's family for a care plan meeting and they never responded. She said it got pushed back due to the holiday activities. The DON said potential negative outcomes of not including the resident or their representative in a care plan meeting would be the resident or representative would not understand the care they were receiving, and the facility wouldn't know of resident's needs.
A record review of the facility policy Care Planning - Interdisciplinary Team, dated as revised March 2022, revealed the following [in part]:
Policy Statement: The Interdisciplinary Team is responsible for the development of resident care plans.
Policy Interpretation and Implementation:
2. Comprehensive, person-centered care plans are based on resident assessments and developed by an Interdisciplinary Team (IDT).
3. The IDT includes but is not limited to:
e. to the extent practicable, the resident and/or resident's representative.
6. If it is determined that participation of the resident or representative is not practicable for development of the care plan, an explanation is documented in the medical record.
CONCERN
(F)
Potential for Harm - no one hurt, but risky conditions existed
Food Safety
(Tag F0812)
Could have caused harm · This affected most or all residents
Based on observation, interview and record review the facility failed to store, prepare, distribute and serve food in accordance with professional standards for food service safety for 1 of 1 kitchen ...
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Based on observation, interview and record review the facility failed to store, prepare, distribute and serve food in accordance with professional standards for food service safety for 1 of 1 kitchen reviewed for food safety.
These failures could place residents at risk of food-borne illness and a diminished quality of life.
1.
The trash can at the hand sink was full, smelled of rotten food, and had a pan of individually wrapped cookies on top of the lid.
2.
Staff B touched food surfaces while filling plates with food.
3.
The kitchen drawers had an accumulation of food debris in the bottom.
4.
The dry storage room had plastic bins that were greasy and had debris in the bottoms.
5.
The freezer had chicken and ham in it with freezer burn.
6.
Dietary staff had hair that was not completely covered and hand washing was not done correctly.
7.
The facility failed to ensure all food in the dry pantry and cold storage areas were properly sealed, labeled and dated.
8.
Dishes were stored face up (open to air contamination
9.
Aluminum cans of resident juices stored on the shelf with dishwasher chemicals
10.
Cans in the dry storage room are dusty and dented.
11.
Single use plastic lids for cups and bowls, and plastic soup spoons are stored open to air.
12.
Chemicals were stored with the food.
These failures could place residents at risk of food-borne illness and a diminished quality of life.
Findings included:
Initial observation and interview on 1/5/25 beginning at 9:40 a.m. revealed:
-
The trash can at the handwashing sink was full and smelled of rotten food. On top of the trashcan lid was a cookie pan with individually wrapped cookies on it dated 1/4/25.
-
By the handwashing sink was chemicals for the dishwasher stored next the resident juices.
-
Observation of the refrigerator revealed a pitcher of a red liquid that was unlabeled and undated. Staff A said it was fruit punch prepared on 1/4/25. There were also 3 bags of cheese left open to air.
-
Observation of the dry storage revealed:
- storage bins holding condiments had an accumulation of grime on the outside. On the inside of the bin holding syrup was a puddle of syrup in the bottom. The other bins had an accumulation of food debris on the bottom of them.
- the cans were dusty. Some of the cans were dented and mixed with undented cans. Staff A stated dented cans were not separated from undented cans and dented cans were used like undented cans.
-Prepackaged coffee bags, box was left open leaving the contents open to air.
- Observation of the freezer revealed freezer-burnt ham and chicken with an accumulation of ice crystal on them.
- In boxes next to the freezer were open bags of plastic spoons, Styrofoam cups and lids all left open to air.
Observation of the meal preparation and service on 1/6/25 beginning at 10:45 a.m. revealed:
-
At 11:20 a.m., Staff B rinsed with water for less than 5 seconds and put on gloves. Staff B began to plate food. Staff B touched the eating surface of every plate she served with both hands.
-
The two drawers holding knives and serving utensils had an accumulation of crumbs, splashes of dried liquid and dust.
-
Staff B, Staff C and the DM did not have effective hair restraints.
Interview on 1/6/25 at 11:45 AM, the DM said eating surfaces on the plates should not be touched with either gloved or bare hands.
Interview on 1/7/25 at 10:04 AM, the DM stated the expectation of the freezer burnt food in the freezer was it was not to be served. The DM said there was no training about what to do with freezer burnt food. The DM stated about the bins in the dry storage, some cleaning has been done since the hospital took over, we still have more to go. The DM stated the cookies on top the trash can were trashed and the expectation was to not serve it. The DM said there was no training about not serving food off an unsanitary surface. The DM stated the expectation was things were not left open to air, and that should not be happening. The DM stated it was in the policy to keep sealed but she no training on it. The DM said the staff should know better than to leave dented cans in the dry storage. The DM said her expectation on dented cans was the staff were not to use them and for them to be separated from the other cans; the DM stated there was a space in her office which was accessible at all times for the dented cans. The DM said this was not in policy and did not have any training for the staff on it. The DM said her expectations was hair be covered at all times in the kitchen. The DM admitted her hairnet was not on effectively because her bangs just slipped out. The DM was informed 3 of 4 staff including the DM during the lunch observation did not have on an effective hair net. The DM said it was not in the policy and she did not have any in-services on it. The DM said the juice mixed with dishwashing chemicals was not appropriated storage and that was covered in the facility's policies.
Interview on 1/7/25 at 10:25 a.m., the Administrator was informed of the kitchen observations.
Record review of the facility's policy titled Food Receiving and Storage dated 11/2022, revealed the following in part: .Non-refrigerated foods, disposable dishware and napkins are stored in a designated dry storage unit which is temperature and humidity controlled, free of insects and rodents and kept clean.
.Food services, or other designated staff, maintain clean and
.Non-refrigerated foods, disposable dishware and napkins are stored in a designated dry storage unit.
.Foods may not be stored: under other sources of contamination.
: .Housekeeping personnel will empty garbage and refuse containers daily.
.Foods may not be stored: in garbage rooms.
.Foods may not be stored: under other sources of contamination.
.Dry foods and goods are handled and stored in a manner that maintains the integrity of the packaging until they are ready to use.
.All foods stored in the refrigerator or freezer are covered, labeled and dated (use by date).
MINOR
(C)
Minor Issue - procedural, no safety impact
Deficiency F0912
(Tag F0912)
Minor procedural issue · This affected most or all residents
Based on record review and interview, the facility failed to provide the required minimum of 80 square feet of space per resident in multiple occupancy rooms for 35 of 36 rooms (Rooms #1, 2, 3, 4, 5, ...
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Based on record review and interview, the facility failed to provide the required minimum of 80 square feet of space per resident in multiple occupancy rooms for 35 of 36 rooms (Rooms #1, 2, 3, 4, 5, 6, 7, 8, 9, 10, 11, 12, 13, 14, 15, 18, 19, 20, 21, 22, 23, 24, 25, 26, 27, 28, 29, 30, 31, 32, 33, 34, 35 and 36) reviewed for square footage.
The facility failed to ensure multiple-bed resident rooms had the required 80 square feet of floor space per resident for rooms 1, 2, 3, 4, 5, 6, 7, 8, 9, 10, 11, 12, 13, 14, 15, 18, 19, 20, 21, 22, 23, 24, 25, 26, 27, 28, 29, 30, 31, 32, 33, 34, 35 and 36.
This failure could place residents residing in these rooms at risk for not having adequate living space and could adversely affect residents from attaining his or her highest practicable well-being.
The findings included:
Interview on 1/5/25 at 10:48 a.m. the Administrator stated he was aware the facility had a room waiver granted on the 11/29/23 survey and wanted to continue to have the room waiver.
Review of the facility's Form 3740 Bed Classifications, completed by the Administrator and dated 11/29/2023, revealed room numbers 1, 2, 3, 4, 5, 6, 7, 8, 9, 10, 11, 12, 13, 14, 15, 18, 19, 20, 21, 22, 23, 24, 25, 26, 27, 28, 29, 30, 31, 32, 33, 34, 35 and 36, were included in the licensed bed capacity as double occupancy rooms.
Review of the Texas Health and Human Services letter dated 6/9/22 revealed the rooms 3, 5, 8, 9, 10, 11, 12, 13, 14, 15, 18, 19, 20, 21, 22, 23, 24, 25, 26, 27, 28, 29, 30, 31, 32, 33, 34, and 35 had the waiver for less square footage than required granted.
In an interview on 1/7/24 at 11:42 a.m., the Administrator stated he wished to continue the room size waiver for all the rooms listed on the past Form 3762.
Nov 2023
6 deficiencies
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, interview and record review, the facility failed to ensure that drugs and biologicals used in the facility were secured and stored in accordance with state and federal laws for 2...
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Based on observation, interview and record review, the facility failed to ensure that drugs and biologicals used in the facility were secured and stored in accordance with state and federal laws for 2 of 2 med carts ( Med Cart A and Med Cart B ).
The facility failed to keep loose unidentified pills secured in their pharmacy labled packaging in medication cart A drawer .
The Controlled Drug change of shift count logs were missing signatures on both medication carts.
These failures could affect residents who receive medications in the facility and place them at risk of receiving incorrect medications, ineffective therapeutic doses, and drug diversion.
The findings include:
Medication Carts
1.An observation on 11/29/23 at 8:30 AM of the Back Hall Medication Cart A revealed the second drawer contained unidentified pills littering the bottom of the drawer.
In an interview and with the ADON/ LVN charge nurse on 11/29/23 at 10:10 AM she stated it was each Nurses responsibility to see that the medication carts were clean and orderly. She stated her cart did not normally contain loose, unidentified pills. She stated she had not checked the cart for cleaning today. She stated she had not had time to clean the cart, the loose pills were due to the cart containing so many medication cards. She denied knowledge of what pills were laying in the bottom of the drawer. She stated unidentified pills laying in the med cart could result in a drug diversion, or residents not receiving the correct dosage of medication.
In an interview on 11/23/23 at 10:45 AM with the DON, she revealed it was each nurse's responsibility that medication carts were kept clean. She stated it was her expectations that drugs should be stored in the original labeled packaging and that nurses be responsible for cleaning their own carts. She stated carts are checked by the pharmacy consultant during their monthly visit.
2.Record review of the Second Shift Controlled Drug Count Record revealed the facility worked 12-hour shifts. The sheets were missing signatures on the following dates and shifts in November of 2023:
Cart A
*11/14/23 off going nurse signature,
*11/15 oncoming and off going nurse signature missing,
*11/21/23 off going nurse signature missing, and
*11/26/23 on coming and off going nurse signatures missing.
Cart B
*11/25/23 and 11/26/23 on coming and off going shifts signatures missing; on coming and off going shifts signatures missing.
During an interview on 11/29/23 at 8:30 AM with the ADON who was the 7AM - 7PM charge nurse, she said staff should be signing in and out when taking possession of the medication cart and be documenting medications in the MAR when they are signed out of the Narcotic Log. She said it was the responsibility of the charge nurse to monitor the sign in sheets as well as review they are being completed. She stated nurses were to count drugs at the beginning and end of their shift with the oncoming nurse, and both shifts should sign the log signifying that they accepted the count of the narcotics as correct, and they are accepting responsibility for the contents of the cart. She stated failure to do so could result in a drug diversion.
During an interview with the DON on 11/29/23 at 10:30 AM, she said staff should be signing the sign in and out narcotic log (Control Count Sheet) when they take possession of the cart. She stated it was her responsibility as the DON to be monitoring to see that it was done. She stated failure to count narcotics, could result in a drug diversion.
Review of facility policy titled Storage of Medications dated revised November 2020 revealed in part:
The facility stores all drugs and biologicals in a safe, secure, and orderly manner. Drugs and biologicals used in the facility are stored in locked compartments and under proper temperature, light and humidity controls. Drugs and biologicals are stored in the containers in which they are received. The nursing staff is responsible for maintaining medications storage and preparation areas in a clean safe and sanitary manner .At the end of each shift the nurse coming on duty and the nurse going off duty determine the count together. Any discrepancies in the controlled drug count are documented and reported to the DON immediately.
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 interview and record review, the facility failed to ensure that residents with PRN orders for psychotropic drugs were l...
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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 residents with PRN orders for psychotropic drugs were limited to 14 days for 1 of 4 residents (Resident #1) whose medication regimens were reviewed for unnecessary medications in that:
Resident #1 had an order for the benzodiazepine medication Alprazolam (Xanax) 0.5 mg by mouth 1 tablet daily as needed (PRN) for anxiety, dated 10/21/2023, which did not have an end/stop date.
This failure could place residents administered PRN and routinely scheduled psychotropic medications at risk of adverse side effects from prolonged use of psychotropic medications.
The findings included:
Record review of Resident #1's face sheet, dated 11/28/2023, revealed a [AGE] year-old female who was admitted to the facility on [DATE]. Diagnosis of generalized anxiety disorder (intense, excessive, and persistent worry and fear about everyday situations).
Record review of Resident #1's care plan, last reviewed/revised on 09/08/2023 revealed the care plan I receive antianxiety medication, Buspar and Xanax for treatment of anxiety.
Record review of Resident #1's Physician Orders, undated revealed an order for Alprazolam (Xanax) 0.5mg 1 tablet daily PRN for anxiety. Start date of 10/21/2023. The order did not specify a stop date.
Record Review of Resident #1's Medication Administration Records dated 11/01/2023 through 11/28/2023 revealed the resident received Alprazolam (Xanax) 0.5mg PRN on 10/28/23, 11/14/23, 11/15/23, 11/24/23, and 11/25/23.
Record review of physician's progress notes for the month of November 2023 did not reveal any documentation of justification for not having a stop date for Alprazolam (Xanax) PRN.
In an interview on 11/29/23 at 11:30 AM, the Regional Corporate Nurse said the order for Xanax PRN should have a stop date no later than 14-days. She said a possible negative outcome would be the resident would receive medication they did not need.
In an interview on 11/29/23 at 2:08 PM, the DON said there was not a stop date for the Xanax PRN as the Nurse Practitioner was charting a justification each week so it would not have to reordered every 14-days. The DON said a possible negative outcome would be the resident was using the medication for a prolonged time and they did not need it due to sedation. The DON said it was her responsibility to ensure psychotropic PRN medications are not prescribed for more than 14-days.
Record Review of the facility policy Medication Orders - Stop Orders, dated 06/01/2022, revealed the following [in part]:
Policy: New medication orders are subject to automatic stop orders unless the medication orders specify the number of doses or duration of medication. A time limit is included in recapped orders.
Procedures: The following classes of medications, whether the order is for routine or as needed (PRN) use, are stopped automatically after an established number of days .
7. PRN psychotropic medication orders 14 days.
CONCERN
(D)
Potential for Harm - no one hurt, but risky conditions existed
Deficiency F0761
(Tag F0761)
Could have caused harm · This affected 1 resident
**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, interview and record review, the facility failed to ensure that drugs and biologicals used in the facility...
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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 drugs and biologicals used in the facility were secured and labeled in accordance with currently accepted professional principles for 1 of 2 medication carts (med Cart A) reviewed for proper drug storage and labeling.
In medication cart A there was an opened vial of insulin belonging to Resident # 7 that was not dated when opened and was not in the original pharmacy labeled box that it was dispensed in.
This failure could affect residents who receive medications in the facility and place them at risk of receiving incorrect medications or ineffective therapeutic doses related to expired medication.
The findings include:
An observation on [DATE] at 8:30 AM of medication cart A, revealed the top drawer contained an open, bottle of undated insulin belonging to Resident # 7. The vial was laying in the drawer with no box, dosing information or expiration date. It was labedled with the residents name and medication name.
In an interview with the ADON/LVN that was charge nurse, on [DATE] at 8:30 AM she stated the vial of insulin should have the opened date on the bottle and should be stored in the original box labeled with the resident's name and directions for use. She stated failure to date the vial when opened could result in an ineffective therapeutic response for the resident . She stated she would dispose of the insulin, open a new vial, and date it as certain insulins are only good for 28-30 days after opening
In an interview on [DATE] at 10:45 PM the DON revealed it was her expectation that insulin vials be dated when opened and kept in the box with the resident's name, directions for use and expiration date.
Review of facility policy titled Storage of Medications revised November of 2020 revealed in part:
Drugs and biologicals are stored in the packaging, containers, or other dispensing systems in which they are received. Only the dispensing pharmacy is authorized to transfer medications between containers.
CONCERN
(E)
Potential for Harm - no one hurt, but risky conditions existed
Accident Prevention
(Tag F0689)
Could have caused harm · This affected multiple residents
**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, interview, and record review, the facility failed to ensure the resident's environment remained free of ac...
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**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, interview, and record review, the facility failed to ensure the resident's environment remained free of accidents and hazards and each resident received adequate supervision and assistance devices to prevent accidents for 2 of 2 residents (Resident #2 and # 170) whose records were reviewed for accidents and supervision.
The facility failed to ensure Resident #2 and Resident #170's wander guards were checked for functionality.
This failure could place residents at risk of elopement or leaving area without supervision.
The findings include:
1.Record review of Resident #2's face sheet, undated, revealed the resident was an [AGE] year-old female admitted to facility on 01/07/19 with diagnoses of Dementia with behavioral disturbance, Bipolar Disorder II (a mental health condition defined by periods of mood disturbances), Anxiety (an emotion which is characterized by an unpleasant state of inner turmoil and includes feelings of dread over anticipated events), muscle wasting (loss of muscle mass), abnormal posture, Chronic pain, and hypertension (high blood pressure).
In an observation on 11/28/23 at 09:28 AM Resident #2s wander Guard was placed on the wheelchair. Resident #2 had contractures of all extremities but could self-propel in a wheelchair around the facility without assistance.
In an interview on 11/28/23 at 09:30 AM The ADON stated she checked the wander guard system every shift by pushing Resident #2 and wheelchair by the alarm. The ADON was not observed checking placement.
2.Record review of Resident # 170's face sheet, undated, revealed the resident was admitted to facility on 11/16/23 was a [AGE] year-old female with diagnoses of psychotic disorder with delusions due to known physical condition (fixed, false conviction in something that is not real or shared by other people).
Record review of progress note dated 11/16/23 at 7:12 PM, written by unidentified LVN revealed Resident #170 had exit seeking behavior. Orders for Wander Guard documented.
In an interview with the DON on 11/28/23 at 10:00 AM she said they check the alarms by placing the Resident #'s 2 and 170 in the wheelchair by the door alarm each shift in order to check its function by setting off the alarm. The DON said that there was not a device that checked function of the wander guard.
In an interview with the Corporate RN on 11/28/23 at 4:00 PM she stated the facility should be check the wander guard for function with a device designed to check it's function per the facilities policy. She stated she had placed an order for the device. She stated failure to check function of the device each shift could result in elopement of the resident.
In a record review of Facility Policy for Wandering and Elopements on 11/28/23 at 4:20 PM (in-part)
2. check placement every shift, and functionality daily.
CONCERN
(F)
Potential for Harm - no one hurt, but risky conditions existed
Food Safety
(Tag F0812)
Could have caused harm · This affected most or all residents
Based on observation, interview, and record review, the facility failed to store, prepare, distribute, and serve food in accordance with professional standards for food service safety, observed for ki...
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Based on observation, interview, and record review, the facility failed to store, prepare, distribute, and serve food in accordance with professional standards for food service safety, observed for kitchen sanitation.
The facility failed to ensure the following:
A. Appliances were clean.
B. Food items in the refrigerator had not expired.
C. Floors were clean.
D. Dish machine temperature and sanitizing logs were documented.
These failures could affect residents who received their meals from the facility's kitchen, by placing them at risk for food-borne illness and food contamination.
The findings include:
In an observation and interview on 11/27/23 at 9:15 AM, during the initial tour of the kitchen revealed the following:
- the exterior surface of the stove were soiled with dried food and grease;
- the top exterior surface of the deep fryer were soiled with food crumbs and grease;
- the interior of the microwave were soiled with dry food splatters;
- the floor under the stove were soiled with food, grease and dirt;
- the floor in the kitchen was sticky;
- 3 expired quart containers of chicken salad were in the refrigerator, dated 10/31/23 with a best used date by 11/11/23;
- dish washing machine temperature and sanitizing log had not been completed from 11/01/23 to 11/26/23.
The Dietary Manager said she has been off for a month, and this was her first day back on the job. She said her expectation was for the stove, microwave, fryer, and floor to be cleaned daily. She said all expired food should be thrown away. She said the dish machine should be tested at breakfast, lunch and dinner and results logged. She said failure to do so has the potential to make the residents sick.
In an interview on 11/28/23 at 11:21 AM, [NAME] A said she tested the dish machine but does not always log it in the book. [NAME] A stated When asked what the dates on the food represents, she did not know if the date written on the food was when the food was opened or when the food expired.
In an interview on 11/29/23 at 3:05 PM, the Administrator said the Dietary Manager walked out of the job on 11/27/23. She was aware the stove needed to be cleaned and someone was scheduled to come out next week. She said she was unaware of expired food in the refrigerator. She said the dish machine should be tested at each meal. Failure to do so has the potential for the dish machine to not be sanitizing the dishes and the risk of food contamination and infection.
A facility policy regarding kitchen sanitation was requested but not provided by exit.
According to the Food Code, (https://www.fda.gov/food/fda-food-code/food-code-2022 accessed 12/01/23), 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 on the PREMISES, sold, or discarded when held at a temperature of 5ºC (41ºF) or less for a maximum of 7 days.
MINOR
(C)
Minor Issue - procedural, no safety impact
Deficiency F0912
(Tag F0912)
Minor procedural issue · This affected most or all residents
Based on record review and interview, the facility failed to provide the required minimum of 80 square feet of space per resident in multiple occupancy rooms for 35 of 36 rooms (Rooms #1, 2, 3, 4, 5, ...
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Based on record review and interview, the facility failed to provide the required minimum of 80 square feet of space per resident in multiple occupancy rooms for 35 of 36 rooms (Rooms #1, 2, 3, 4, 5, 6, 7, 8, 9, 10, 11, 12, 13, 14, 15, 18, 19, 20, 21, 22, 23, 24, 25, 26, 27, 28, 29, 30, 31, 32, 33, 34, 35 and 36) reviewed for square footage.
The facility failed to ensure multiple-bed resident rooms had the required 80 square feet of floor space per resident for rooms 1, 2, 3, 4, 5, 6, 7, 8, 9, 10, 11, 12, 13, 14, 15, 18, 19, 20, 21, 22, 23, 24, 25, 26, 27, 28, 29, 30, 31, 32, 33, 34, 35 and 36.
This failure could place residents residing in these rooms at risk for not having adequate living space and could adversely affect residents from attaining his or her highest practicable well-being.
The findings included:
Review of the facility's Form 3740 Bed Classifications, completed by the Administrator and dated 11/29/2023, revealed room numbers 1, 2, 3, 4, 5, 6, 7, 8, 9, 10, 11, 12, 13, 14, 15, 18, 19, 20, 21, 22, 23, 24, 25, 26, 27, 28, 29, 30, 31, 32, 33, 34, 35 and 36, were included in the licensed bed capacity as double occupancy rooms.
Review of the prior completed Form 3762, Room Size Waiver for Facilities, dated 09/27/2022 revealed resident bedroom numbers 1, 2, 3, 4, 5, 6, 7, 8, 9, 10, 11, 12, 13, 14, 15, 18, 19, 20, 21, 22, 23, 24, 25, 26, 27, 28, 29, 30, 31, 32, 33, 34, 35 and 36 were listed as meeting the justification criteria for a room size waiver.
In an interview on 11/29/23 at 2:57 PM, the Administrator stated she wanted to continue the room size waiver for all the rooms listed on the past Form 3762.
May 2023
17 deficiencies
1 IJ (1 affecting multiple)
CRITICAL
(K)
📢 Someone Reported This
A family member, employee, or ombudsman was alarmed enough to file a formal complaint
Immediate Jeopardy (IJ) - the most serious Medicare violation
Quality of Care
(Tag F0684)
Someone could have died · 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, based on the comprehensive assessment of a res...
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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, based on the comprehensive assessment of a resident, residents received treatment and care in accordance with professional standards of practice, the comprehensive person-centered care plan, and the residents' choices for one of three residents (Resident #5) reviewed for quality of care.
The facility failed to ensure skin assessments, wound care and skin treatments were provided, since Resident #5 was admitted into the facility on 4/17/23. His diagnoses included skin and bone infection and toe amputation of his right foot. On 4/24/23 an open wound was discovered to his right foot. No action was taken until 4/25/23 when he was taken to the emergency room and given antibiotic treatment for an open wound to the right foot with purulent drainage.
An Immediate Jeopardy (IJ) situation was identified on 5/15/2023 at 4:15 PM. While the IJ was removed on 5/17/2023 at 2:05 PM, the facility remained out of compliance at a scope and severity of isolated with potential for more than minimal harm, due to the facility's need to evaluate the effectiveness of the corrective systems.
This failure could place residents at risk of pain, worsening of wounds, wound infection, emotional distress, harm or even death.
The findings included:
Record review of Resident #5's face sheet revealed a [AGE] year-old male who was admitted to the facility, on 04/17/2023, from the hospital. Resident #5 had diagnoses which included: displaced fracture of right femur; (longest, strongest bone in your body that supports your weight); unspecified open wound of right great toe, without damage to nail; acquired absence of other right toe, post second toe amputation (great right toe and second toe is missing); cellulitis of right toe (bacterial infection involving inner layers of the skin); non-pressure chronic ulcer of other part of right foot, with unspecified severity; type 2 diabetes mellitus, with foot ulcer (disease that results in high blood sugar and inadequate circulation to the feet which results in diabetic ulcers), and hypertension (high blood pressure).
Record review of the Hospital Discharge notes, dated 04/15/2023, revealed the following: Active Problems Cellulitis of right toe (bacterial infection involving inner layers of the skin); Osteomyelitis of second right toe (infection of the bone); Neuropathic Ulcer limited to skin breakdown; and Neuropathic ulcer with fat layer exposed (diabetic ulcer on the foot).
Record review of Resident #5's progress notes, made by the MDS/LVN, dated 04/18/2023 at 10:42 AM, revealed Integumentary Monitoring and Evaluation: Pressure Reducing Mattress, Diabetic Ulcer Monitoring and Surgical Incision Monitoring.
Record review of Resident #5's facility record revealed there were no admission notes or assessments completed. There was no documentation regarding the condition of his skin and the wounds he admitted with.
Record review of Resident #5's Skilled Observation notes, dated 04/18/2023, revealed all skin areas, in the observation, were left blank and the note was signed, as completed.
Record review of Resident #5's care plan, dated 04/20/2023, revealed the following: Weekly Head to Toe Skin Check. There was no diabetic ulcer or wound care areas care planned.
Record review of Resident #5's Skilled Observation Notes revealed there were no weekly head to toe skin checks.
Record review of Resident #5's admission MDS, dated [DATE], revealed a BIMS score of 10, which indicated the resident had moderately impaired cognition. Resident #5 had, occasional pain, with an intensity of 5, reported within the past 5 days, and no venous or arterial ulcers were noted as being present.
Record review of Resident #5's therapy notes, dated 04/24/2023, revealed an open area on right lower extremity where toes were previously amputated, no dressing. The DOR notified about findings and possible need for wound care.
Record review of Resident #5's clinical record, dated 04/25/2023 at 7:10 AM, revealed there were no documented skin assessments, no head-to-toe assessments, and no documented skin treatments since admission and there was no documented wound care, done on this resident, since admission.
Record review of Resident #5's Wound Management revealed the resident had no wounds or skin issues identified.
Record review of Resident #5's Skilled Observation Notes revealed the resident had no Braden Skin Assessments completed, since his admission to the facility, on 04/17/2023.
Observation and interview, on 04/25/2023 at 7:00 AM, with Resident #5, revealed he was sitting in his wheelchair. RN A removed Resident #5's walking boot, to show the resident's foot. There were 2 toes missing, which were the great toe and the second toe. There were no bandages covering the area. There was a large open area with no scab where the second toe used to be. Resident #5 revealed he had hit his toe on the doorway 2 days after admission, which would have been 04/19/2023. He stated he had notified the DON immediately after the incident. The resident stated he had not had any type of wound care since admission into the facility. He stated RN A was working at that time, was the only nurse who had cleaned the area and kept it covered. He stated it caused pain at times, but not every day.
Interview on 04/25/2023 at 7:05 AM with RN A revealed that when she was working, she provided care to the resident's foot. She stated that there were no orders, but with any resident she would make sure the area was clean, dry, and not infected.
Interview with the DON, on 04/25/2023 at 7:20 AM, revealed there were no skin assessments documented for the Resident #5. The DON stated she had completed skin assessments since the resident entered the facility. The DON stated she stated she could not provide a copy of the assessments because they were only in her head. She revealed she had not had time to document the assessments due to working the floor. She revealed she knew the resident had wound issues and she had gotten behind on documentation and treatments. She stated that she did not notify the MD of the resident's skin issues and the diagnosis related to his foot. She stated she knew the resident injured his foot on the door, but she was unsure when it occurred since she had not documented it. She said when she had time, she would complete the skin care assessments, and do a wound care referral. She said that skin assessments and wound care referrals should be completed as soon as the resident admits to the facility and when the problem is identified.
Interview on 04/25/2023 at 11:50 AM with the DOR revealed she was notified of Resident #5's wound issues on 04/24/2023. She reported the wounds to the DON immediately. She was notified of the wounds by the physical therapist.
Interview on 04/27/2023 at 9:54 AM with the Facility's Medical Director revealed that her expectations were that the resident should receive an accurate skin assessment upon admission and weekly to reflect the resident's current condition for treatment. She stated treatments should have been performed when the resident entered the facility if there were skin issues present. She revealed that she did not know that the resident had skin issues or needed wound care orders when the resident admitted to the facility.
Interview on 04/27/2023 at 11:00 AM with the DON revealed that she sent the resident out to the hospital on [DATE], after concerns were made by RN A about the resident's foot. She stated that he was sent to the hospital to receive wound care orders and treatments.
Interview and observation on 05/17/2023 at 2:00 PM Resident #5 revealed that he did attend the 04/28/2023 wound care appointment, and that he was now receiving wound care treatments in and out of the facility. There was a calendar posted in his room that showed his future appointments.
Record review of Resident #5's Physician's Orders, dated 04/25/2023, revealed the following orders:
1) Transfer to the Hospital ER for evaluation of possible right foot wound infection with drainage and temperature 99-100F.
2) Wound Care Clinic to Evaluation and Treat wound to right foot. HX of right foot hemi-amputation and HX of PVD. Special Instructions: Daily ensure that this order is taken care of until an appointment is made with wound care.
3) Wound care Right foot hemi amputation site where an old scab had come off. Cleanse wound with NSS, pat dry, swab with Betadine solution, cover with non-adhering dressing, wrap with kelix and secure with paper tape. Q shift and PRN drainage or dislodgment. Special Instructions: Q shift and PRN drainage of dislodgement.
Record review of Resident #5's ER documentation, revealed, on 04/25/2023 at 9:30 PM, Resident #5 was treated for an open wound to the right foot with purulent drainage and eschar present. The resident received 1GM IM Rocephin (antibiotic); and Augmentin (antibiotic) 875MG to be taken for 10 days. The resident received a referral for wound care. This was completed after surveyor intervention.
Record review of Resident #5's Physician's Ordered Treatment Flow Sheet, dated 04/26/2023, revealed the following order: Wound treatment to Right 2nd toe amputation site: Clean with wound cleanser and gauze, apply honey and alginate or honey fiber dressing and cover with foam, secure with tape. May use super absorbent pad if draining and may wrap foot with kerlix and tape if necessary. Once A Day; 07:00 AM - 07:00 PM.
Record review of Resident #5's Observation titles Facility Wound Summary Report entered and dated 04/26/2023 revealed: Surgical Incision identified on 04/17/2023 at 08:20 PM, with the most recent observation (documentation) on 04/26/2023 at 8:20 PM: Type- Surgical Location- Incision Right 2nd toe nonhealing toe amputation site. Number of days wound has been open-11. Initial size- 3 x 5 3 x 5. Current Size- 3 x 5 3 x 5. Last Wound Healing Status- Declining.
Record review of Resident #5's Physician Orders dated 04/27/2023 revealed the following order: Appt: Wound Care Clinic. Friday 4-28-23 10:15 AM. Special Instructions: Eval and treatment of right foot wound. Facility to take resident to this appointment. [DX: Unspecified open wound
Record review of Resident #5's Summary Wound Care Report revealed that resident attended his wound care appointment on 04/28/2023, where he received new orders and to continue treatments until healed.
Review of Resident #5's Wound Care Progress Note from the 4/28/23 visit indicated he had a full thickness wound to the area where his right second toe had been amputated. There was a small amount of drainage. The wound was 2.6 cm by 2.2 cm by 0.1 cm in size. The wound was cleaned and dressed during his visit.
Record review of Resident #5's Progress Notes made by RN A dated 05/02/2023 at 1:29 PM, revealed: Wound Care Evaluation from residents 4-28-23 visit and noted the following new orders: Multivitamin 1 po QD, Wound care to the right foot non healing surgical Wound: Cleanse with NSS, pat dry, apply skin prep to the peri wound, apply silvasorb gel to the wound be Q Monday/ Wed/ Friday and PRN draining or dislodgement. Resident denies pain or discomfort to his right foot. Dressing dry and intact to his right foot and he wears his protective. Dressing due to be changed per order tomorrow. Will continue to monitor.
Record review of Resident #5's Progress Notes made by RN A dated 05/17/2023 at 9:03 AM, revealed: Resident left via facility staff with facility staff to go to Wound Care Center. He wore his right foot walking shoe, and his right foot dressing was dry and intact when he left. Denies pain or discomfort.
Record review of Resident #5's Progress Notes made by RN A dated 05/17/2023 at 12:35 PM, revealed: Right foot has a fresh dry intact dressing, and he is wearing his sock and walking shoe. He also stated that they looked at his left foot and cleaned his left toes and put his sock back on.
This was determined to be an Immediate Jeopardy (IJ) on 05/15/2023 at 4:15 PM. The Clinical Company Leader and the Administrator were notified. The Clinical Company Leader and the Administrator were provided with the IJ template on 05/15/2023 at 4:15 PM.
The following Plan of Removal submitted by the facility was accepted on 05/17/2023 at 2:05 PM and included the following:
Please accept this Plan of Removal as a credible allegation of compliance for immediate jeopardy initiated on 05/15/2023.
[Resident #5] received skin assessments on 05/07/2023, 05/11/2023, and 05/14/2023. [Resident #5] received wound care treatment orders on 05/02/2023. [Resident #5] is scheduled for a wound care appointment with an external provider on 05/17/2023. On 04/26/2023 [Resident #5's] information was input it into the wound management system, [Resident #5's] information was updated on 05/12/2023 to reflect the current status of the wound and on 05/13/2023 and 05/15/2023. [Resident #5's] weekly skin assessment scheduled and verified on 05/06/2023, 05/11/2023 and 05/14/2023.
Action 1:
Clinical Resource Nurse to audit new admissions for the previous 14 days to ensure all admission skin assessments have been completed. Missing skin assessments will be completed immediately and documented in the medical record. The Clinical Resource Nurse will monitor that admission skin assessments are completed timely. The DON will notify the MD for newly identified skin issues and to request additional clarification of treatment orders.
Date: 05/16/2023
Person responsible: Clinical Resource Nurse
Action 2:
Clinical Resource Nurse to audit weekly skin assessments for the previous 14 days to ensure all weekly skin assessments have been completed. Missing skin assessments will be completed immediately and documented in the medical record. The Clinical Resource Nurse will monitor weekly wound documentation going forward. The CNA's will notify the charge nurse have any newly identified skin issues. The charge nurse will document the skin issue in obtain treatment orders.
Date: 05/16/2023
Person responsible: Clinical Resource Nurse
Action 3:
Education provided to charge nurses regarding the skin system in the wound management documentation workflow. Any newly hired and or temporary (agency) charge nurses will be in-serviced prior to working the floor. Staff nurses will be educated and observed for competency. The Clinical Resource Nurse is educating the DON in on the event accident and incident process including timely completion of the event the investigation process involved and closure of the event.
Date: 05/16/2023
Person responsible: Clinical Resource Nurse
Action4:
New admissions and weekly skin assessment will be audited, daily, (Monday through Friday), during clinical meetings by the Director of nursing/designee. Any missing assessments will be completed immediately, and findings will be documented in the medical record. [NAME] Clinical Resource Nurse will monitor the daily clinical stand-up meetings to validate discussion of skin assessments. The DON will notify the MD of newly identified skin issues and clarify and/or obtain treatment orders.
Date: 05/16/2023
Person responsible: Clinical Resource Nurse
POR monitoring included the following:
Record review of documentation, provided by the Clinical Resource Nurse, of reviewing all current skin injuries with entries into the Wound Management Report and each skin injury had an order for treatment; performance improvement plans regarding skin system to include education, review of weekly skin assessments, skin sweeps, documentation, and action taken once skin issues identified, facility's wound management report for each resident with identified skin injuries.
Record review of facility provided documentation revealed all residents had skin assessments and Ad Hoc QAPI meeting performed.
Interviews on 05/17/2023 at 1:30 PM with the DON revealed she was educated on documentation on wound assessments that included admission and weekly. She revealed she had been educated on notifying the MD to facilitate orders, treatments, and notification of any changes.
Interviews on 05/17/2023 at 1:00 PM with CNA B revealed they had been educated on notifying the charge nurse or DON of any skin changes or incidents.
Interview on 05/17/2023 at 1:55 PM Resident #5 revealed that he has been receiving wound care treatments since his admission on [DATE].
Interview on 05/17/2023 at 2:05 PM Resident #8 revealed that he has been receiving wound care treatments since his admission on [DATE].
Observation on 05/17/2023 at 2:45 PM revealed the DON educating an RN A on wound management and documentation.
The Administrator, Clinical Resource Nurse, DON, and the Clinical Company Leader were informed the Immediate Jeopardy was removed on 05/17/2023 at 2:05 PM. The facility remained out of compliance at a potential for more than minimal harm with a scope of isolated due to the facility's need to evaluate the effectiveness of the corrective systems that were put into place.
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 promote care for residents in a manner and in an envir...
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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 promote care for residents in a manner and in an environment that maintained or enhanced each resident's dignity for 1 of 2 residents (Resident #1) reviewed for dignity in that:
Resident #1's indwelling urinary catheter did not have a privacy bag.
This deficient practice could affect six residents who had urinary catheters at risk of feeling uncomfortable, humiliated or unhappiness.
The findings included:
Review of Resident #1's face sheet revealed Resident #1 was a [AGE] year-old male who was admitted to the facility on [DATE] with primary diagnosis of Metabolic Encephalopathy (chemical imbalance in the blood that affects the brain), Chronic Pain (pain that is long term), Hypertension (high blood pressure), Type 2 Diabetes Mellitus (chronic condition that affects the way the body processes blood sugar) Morbid Obesity (more than 80-100 pounds above their ideal body weight) and Chronic Kidney Disease (long standing disease of the kidneys leading to Renal Failure).
Review of Resident #1's admission MDS assessment dated [DATE] revealed the following: Section C revealed a BIMS score of 13 (cognitively intact). Section K revealed a weight of 369 pounds. Section G revealed: Bed mobility- extensive, Transfers- extensive, walk-in room- did not occur, walk in corridor- did not occur, locomotion on unit- occurred on once or twice, locomotion off unit- occurred only once or twice, dressing- extensive, toilet use- extensive and personal hygiene- extensive. Had an indwelling urinary catheter and bowel continence was not rated.
Record review of Resident #1's Care Plan dated 04/18/2023, edited on 04/23/2023 revealed the following:
(Problem) Indwelling Catheter; (Goal) Resident will establish an individual bowel and
bladder routine: (Approach) Catheter care per policy, check for incontinence Q 2 hours and PRN, keep call light in reach and Toileting Q 2 hours and PRN.
Record review on 04/26/2023 of Resident's #1's Physician's Orders did not reflect an order for a catheter.
Observation and interview of Resident #1 on 04/25/2023 at 9:47 AM. revealed Resident #1's indwelling catheter drainage bag was not in a privacy bag and was viewable from the hallway. He revealed he was embarrassed by it and that he cannot cover it himself due to his immobility. He stated he had requested for the bag to be covered. He stated staff will put the sheet over it most of the time.
Observation on 04/25/2023 at 2:40 PM revealed Resident #1 was lying in his bed watching TV. The resident's room door was open, and his catheter bag was viewable from the hallway.
Observation on 04/26/2023 at 11:30 AM revealed that Resident #1 was lying in his bed watching TV. The resident's room door was open, and his catheter bag was viewable from the hallway.
Interview with the DON on 04/25/2023 at 10:35 AM, revealed she was made aware of the observations regarding each catheter bag should be in a privacy bag. The DON revealed that she was also the nurse working the floor. The DON stated the catheter bags should be in a privacy bag for dignity. The DON stated the facility did not have a policy and procedure regarding catheters, but she would get one.
The facility was unable to provide a copy of their policy covering catheter bags or dignity at the time of exit.
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 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 1 of 1 resident (Resident #1) with limited rang...
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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 1 of 1 resident (Resident #1) with limited range of motion to the upper and lower extremities received services with reasonable accommodation of resident needs.
Resident #1 did not have a wheelchair that accommodated his size, or a sling mesh to accommodate his assisted transfers.
This failure could place residents with limited ROM to the upper and lower extremities at risk for a decline in their functional abilities.
Findings Included:
Review of Resident #1's face sheet dated 04/27/2023 revealed Resident #1 was [AGE] year-old male who was admitted to the facility 04/07/2023 with primary diagnosis of Metabolic Encephalopathy (chemical imbalance in the blood that affects the brain), chronic pain (pain that is long term), hypertension (high blood pressure), Type 2 Diabetes Mellitus (chronic condition that affects the way the body processes blood sugar) Morbid Obesity (more than 80-100 pounds above their ideal body weight) and chronic kidney disease (long standing disease of the kidneys leading to renal failure).
Review of Resident #1's admission MDS assessment dated [DATE] revealed the following: Section C revealed a BIMS score of 13 (cognitively intact). Section G revealed the resident used a wheelchair for mobility. Section K revealed a weight of 369 pounds. Section G revealed: Bed mobility- extensive, Transfers- extensive, walk-in room- did not occur, walk in corridor- did not occur, locomotion on unit- occurred on once or twice, locomotion off unit- occurred only once or twice, dressing- extensive, toilet use- extensive and personal hygiene- extensive. Section Z revealed that the RN signature date was for 04/27/2023.
Record review of Resident #1's care plan dated 04/23/2023 revealed ACTIVITIES OF DAILY LIVING: I am dependent of all activities of daily living. I will need extensive assistance to have my personal care needs met while supporting my strengths and personal goals. Category: ADLs Functional Status/Rehabilitation
Potential: I require assist with ADL's r/t weakness.
Observation and interview on 04/25/2023 at 9:47 a.m. Resident #1 was observed awake in bed. He stated that he had not been attending activities since the facility had not yet provided a wheelchair for him and the sling for transfers does not fit him. He revealed that his previous wheelchair was given to another resident and that they were supposed to order him another one. He said that being isolated has made him extremely lonely and that he does not have visitors or gets to interact with anyone. He stated that he enjoyed surveyors being in the building so that he was able to have someone to visit with. He revealed that the activity director had never conducted a one-on-one activity with him before or invited him to an activity. He did not appear distressed or angry during the observation.
Interview and record review on 04/26/2023 at 10:30 AM with the Administrator, revealed a Purchase Order (28882402) dated 04/25/2023 for a X-Large Hoyer lift sling. He stated that he had previously ordered one, but it had not come in. He had not checked up on it until surveyors were in the building. He revealed that since he was unable to track the order, he just ordered a new one.
Observation on 04/26/2023 at 11:20 AM revealed Resident #1 was still lying-in bed watching TV. He stated he still had not been up or received a wheelchair that could accommodate his size.
Interview on 04/27/2023 at 9:54 AM the Medical Director revealed she has the expectation of the facility for Resident #1 to be getting up out of bed. She revealed she does not want any resident to be bed bound. She stated that Resident #1 was to get up from bed and attend therapy as tolerated.
A policy titled Accommodation of Needs dated March 2021 revealed the following:
Policy Statement:
Our facility's environment and staff behaviors are directed toward assisting the resident in maintaining and/or achieving safe independent functioning, dignity and well-being.
Policy Interpretation and Implementation
1. The resident's individual needs and preferences are accommodated to the extent possible, except when the health and safety of the individual or other residents would be endangered.
2. The resident's individual needs and preferences, including the need for adaptive devices and modifications to the physical environment, are evaluated upon admission and reviewed on an ongoing basis.
3. In order to accommodate individual needs and preferences, adaptations may be made to the physical environment, including the resident's bedroom and bathroom, as well as the common areas in the facility. Examples of such adaptations may include:
g. providing a variety of types (for example, chairs with and without arms), sizes (height and depth), and firmness of furniture in rooms and common areas so that residents with varying degrees of strength and mobility can independently arise to a standing position; and/or
4. In order to accommodate individual needs and preferences, staff attitudes and behaviors are directed towards assisting the residents in maintaining independence, dignity and well-being to the extent possible and in accordance with the residents' wishes. For example:
a. interacting with the residents in ways that accommodate the physical or sensory limitations of the residents, promote communication, and maintain dignity.
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 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 individuals with mental disorders were evaluated and receive...
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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 individuals with mental disorders were evaluated and received care and services in the most integrated setting appropriate to their needs for 2 of residents , (Resident #1 and #5) reviewed for PASRR Level 1 screenings.
-The facility failed to ensure that they had received a PASRR Level 1 form for Resident #1 and Resident #5 prior to admission.
These failures placed additional resident with possible mental illness at risk of a diminished quality of life and not receiving necessary care and services in accordance with individually assessed needs.
Findings Include:
Resident #1-
Review of Resident #1's face sheet dated 04/27/2023 revealed Resident #1 was [AGE] year-old male who was admitted to the facility 04/07/2023 with primary diagnosis of Metabolic Encephalopathy (chemical imbalance in the blood that affects the brain), chronic pain (pain that is long term), hypertension (high blood pressure), Type 2 Diabetes Mellitus (chronic condition that affects the way the body processes blood sugar) Morbid Obesity (more than 80-100 pounds above their ideal body weight) and chronic kidney disease (long standing disease of the kidneys leading to renal failure).
Record review of the PASRR Level 1 screening for Resident #1 reflected it was entered in the online portal on 04/10/2023 at 1:02 PM, after the resident's admission into the facility.
Review of the admission MDS dated [DATE] for Resident #1 revealed in Section A entitled, Preadmission Screening and Resident Review PASSR revealed the resident was not considered to have serious mental illness and/or intellectual disability. Review of Section A1510 entitled Level II Preadmission Screening and Resident Review (PASRR) Conditions was marked none of the above, indicating Resident #1 did not have Serious Mental Illness, Intellectual Disability (mental retardation) in federal regulation or other related conditions Section C entitled; Brief Interview for Mental Status (BIMS) score of 13, which indicates the resident is cognitively intact.
Resident #5
Record review of clinical records for Resident #5 revealed the [AGE] year-old resident was admitted to the facility on [DATE] with diagnoses of Displaced intertrochanteric fracture of right femur, subsequent encounter for closed fracture (longest, strongest bone in your body that supports your weight), anxiety disorder due to known physiological condition (state of anxiousness), and generalized anxiety disorder (severe ongoing anxiety that interferes with daily activities).
Record review on 04/25/2023 of the PASRR Level 1 screening for Resident #5 showed it was entered in the online portal on 04/18/2023 at 1:52 PM, after the resident's admission into the facility.
Record review of the PASRR Level 1 for Resident #5 revealed the form was pulled and printed from the online portal by the facility on 04/18/2023, and the resident was negative for Mental illness, Developmental disability, and Intellectual disability.
Review of the admission MDS dated [DATE] revealed in Section A entitled, Preadmission Screening and Resident Review PASSR revealed that Resident #5 was not considered to have serious mental illness and/or intellectual disability. Review of Section A1510 entitled Level II Preadmission Screening and Resident Review (PASRR) Conditions was marked none of the above, indicating Resident #5 did not have Serious Mental Illness, Intellectual Disability (mental retardation) in federal regulation or other related conditions Section C entitled; Brief Interview for Mental Status (BIMS) score of 10, which indicates the resident is moderately impaired.
Interview with the MDS/LVN on 04/25/2023 at 12:30 PM, she stated that she got behind sometimes in putting the residents in the portal due to not being in the facility. She revealed she did not even have their form when they admitted , and she had to look it up. She stated that she does not do the admission packets and that it comes from corporate, which contains the PASRR Level 1 form. She said she comes to the building at times and finds there has been a new admission and she enters them into the online portal as soon as she gets the form. She stated the failure could place some resident with a positive PASRR diagnosis at risk for not being screened properly. She revealed that the form should be entered prior to the resident being admitted to the building.
Interview with the Admin on 04/25/2023 at 2:00 PM revealed that the MDS/LVN was responsible for entering them. He stated that she was not in the building at times when they are accepting admissions. He revealed that he would be gaining access to the online portal so that he could do them.
Record review of Policy for
Behavioral Assessment, Intervention and Monitoring, dated December 2021 revealed,; as part of the initial assessment, the nursing staff and Attending Physician will identify individuals with a history of impaired cognition, altered behavior, substance use disorder, or mental disorder.
A) All residents will receive a Level I PASRR screen prior to admission
CONCERN
(D)
📢 Someone Reported This
A family member, employee, or ombudsman was alarmed enough to file a formal complaint
Potential for Harm - no one hurt, but risky conditions existed
Deficiency F0657
(Tag F0657)
Could have caused harm · This affected 1 resident
**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, interview and record review, the facility failed to ensure the comprehensive care plan must describe the s...
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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 comprehensive care plan must describe the services that are to be furnished to attain or maintain the resident's highest practicable physical, mental, and psychosocial well-being for one (Residents #1) of 6 residents reviewed for comprehensive care plans.
Resident #1 who was primarily bedfast, did not have a care plan to address activities.
Resident #1 who was dependent on a transfer lift for transfers, did not have a care plan to address transfers with the transfer lift.
Resident #1 who has 2 stage 2 pressure ulcers admitted upon admission, did not have a care plan to address pressure ulcer treatments or wound care.
Resident #1's admission Comprehensive MDS assessment dated [DATE] was completed on 04/27/2023, the Comprehensive Care plan meeting was conducted on 04/18/2023, before the MDS assessment was completed.
Resident #1's Comprehensive admission Care Conference on 04/18/2023 did not include a Registered Nurse for the IDT team.
This failure had the potential to affect residents in the facility who have scheduled care plans and conferences, to not have their care plans completed accurately and completely, as well as having the required IDT present for the Comprehensive Care conferences.
Findings included:
Review of Resident #1's face sheet revealed Resident #1 was [AGE] year-old male who was admitted to the facility 04/07/2023 with primary diagnosis of Metabolic Encephalopathy (chemical imbalance in the blood that affects the brain), chronic pain (pain that is long term), hypertension (high blood pressure), Type 2 Diabetes Mellitus (chronic condition that affects the way the body processes blood sugar) Morbid Obesity (more than 80-100 pounds above their ideal body weight) and chronic kidney disease (long standing disease of the kidneys leading to renal failure).
Review of Resident #1's admission MDS assessment dated [DATE] revealed the following: Section C revealed a BIMS score of 13 (cognitively intact). Section K revealed a weight of 369 pounds. Section G revealed: Bed mobility- extensive, Transfers- extensive, walk-in room- did not occur, walk in corridor- did not occur, locomotion on unit- occurred on once or twice, locomotion off unit- occurred only once or twice, dressing- extensive, toilet use- extensive and personal hygiene- extensive. Section M revealed 2 stage 2 pressure ulcers that were present upon admission into the facility, it revealed 2 venous and arterial ulcers present, it revealed that pressure reducing devices were used for the bed and pressure ulcer/injury care was being completed. Section O revealed: Oxygen in use while in the facility. Section Z revealed that the RN signature date was for 04/27/2023.
Record review of Resident #1's care plan dated 04/18/2023 for activities reflected: Resident will attend/participate in 1 activity per week. Staff will evaluate time awake and readiness for activity and introduce to activities as offered.
Record review of Resident #1's care plan dated 04/18/2023 for transfer lift transfers were not care planned.
Record review of Resident #1's Care Conference dated 04/18/2023 did not have a Registered Nurse attend the Comprehensive admission Care Conference.
Observation and interview on 04/25/2023 at 9:47 a.m. revealed Resident #1 was awake in bed. He stated he had not been attending activities since the facility had not yet provided a wheelchair for him. He revealed his previous wheelchair was given to another resident and they were supposed to order him another one. He said that being isolated has made him extremely lonely and that he did not have visitors or gets to interact with anyone. He states he enjoyed surveyors being in the building so that he was able to have someone to visit with. He revealed the activity director had never conducted a one-on-one activity with him before or invited him to an activity.
Interview on 04/25/2023 at 11:40 AM the SW revealed the DON did not attend the Care Conference and she went over what was shown or reflected in the care plan .
0n 04/25/2023 at 11:45 AM the MDS-LVN stated she did not complete the comprehensive MDS on Resident #1 in time for the care plan, so she was not able to complete the comprehensive care plan. She stated she was behind due to completing MDS's and care plans for two buildings. She revealed the CAAS summary was not completed by the care conference date of 04/18/2023.
On 04/25/2023 at 1:00 PM the DON revealed she was unable to attend the Comprehensive Care plan due to working the floor. She revealed that she was responsible for the IDT meeting and attending. She stated she was unavailable due to working the floor.
The facility's care planning policy dated revised December 20202 titled Care Plans, Comprehensive Person- Centered revealed:
Policy Statement: A comprehensive person-centered care plan that includes measurable objectives and timetables to meet the residence physical, psychosocial, in functional needs is developed and implemented for each resident. The services provided or arranged by the facility, as outlined by the comprehensive care plan, are provided by the qualified persons, are culturally- competent and trauma informed.
Policy Interpretation and Implementation:
1)
The intra-disciplinary team, in conjunction with the resident and his or her family or legal representative, develop and implement a comprehensive, person- centered care plan for each resident. The 80 team may include but not limited to the attending physician a registered nurse who has responsibility for the resident.
2)
The care plan interventions are derived from a thorough analysis of the information gathered as part of the comprehensive assessment.
3)
The IDT may include but not limited to: A registered nurse who has responsibility for the resident
8)
The comprehensive person-centered care plan will: Include measurable objectives and time frames. Describe any specialize services. Incorporate identify problem areas reflect treatment goals, timetables, and objectives in measurable
9) Areas of concern that are identified during the resident assessment will be evaluated before interventions are added to the care plan.
12) The comprehensive, person-centered care plan is developed within seven days of the completion of the required comprehensive assessment MDS.
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 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 needs respiratory care was provided such care, consistent with professional standards of practice for 1 of 3 residents (Resident#1) reviewed for oxygen orders in that:
Resident #1 did not have orders oxygen, assessments for respiratory care, oxygen tubing that was dated, or an oxygen in use sign outside of his door.
This failure deficient practice could affect the residents who used oxygen and could result in residents receiving incorrect or inadequate respiratory support and could result in a decline in health.
The findings were:
An observation and interview of Resident #1 on 04/25/2023 at 2:30 PM revealed that this resident was lying in bed with Oxygen via nasal cannula that was not dated. He revealed that he had to have oxygen continuously or that he would not be able to breathe. He stated that he has been oxygen dependent for a while. He revealed that he came into the facility with it and that the DON has helped him put his tubing back on when it falls off or he drops it. There was not a oxygen use sign outside on the residents door.
Review of Resident #1's face sheet dated 04/27/2023 revealed Resident #1 was a [AGE] year-old male who was admitted to the facility 04/07/2023 with a diagnosis of Morbid Obesity with alveolar hypoventilation, (more than 80-100 pounds above their ideal body weight with breathing that is too shallow or too slow to meet the needs of the body).
Review of Resident #1's admission MDS assessment dated [DATE] revealed the following: Section C revealed a BIMS score of 13 (cognitively intact). Section O revealed: Oxygen in use while in the facility.
Record review of Resident #1's care plan dated 04/23/2023 revealed the following:
Problem- Cardiac Acute embolism and thrombosis of right popliteal vein
Approach- Oxygen therapy/O2 saturation as ordered. Assess for dyspnea
Review of Resident #1's Consolidated Physician's Orders dated 04/27/2023 revealed there were no orders for a oxygen, oxygen settings or the oxygen tubing to be changed.
An interview with the DON on 04/25/23 at 3:30 revealed that she was the one who was responsible for ensuring the orders were entered and accurate. She stated that he should have an order for oxygen when he admitted into the facility, but she missed it due to working the floor as a nurse and doing the DON responsibilities. She stated that this failure did not change how she cared for him and that there really was no failure. She stated that she knew the resident's orders and needs even if it wasn't entered in the electronic medical records. She stated she knew how to care for the resident without any orders since it was common sense. She said that she takes care of everything concerning the resident since she is working the floor, so she would know all of his respiratory needs.
A review of the facility policy titled Oxygen Administration dated October 2010 revealed the following:
Purpose
The purpose of this procedure is to provide guidelines for safe oxygen administration.
Preparation
1. Verify that there is a physician's order for this procedure. Review the physician's orders or facility protocol for oxygen administration.
2. Review the resident's care plan to assess for any special needs of the resident.
3. Assemble the equipment and supplies as needed.
General Guidelines
1. Oxygen therapy is administered by way of an oxygen mask, nasal cannula, and/or nasal catheter.
a. The oxygen mask is a device that fits over the resident's nose and mouth. It is held in place by an elastic band placed around the resident's head.
b. The nasal cannula is a tube that is placed approximately one-half inch into the resident's nose. It is held in place by an elastic band placed around the resident's head.
c. The nasal catheter is a piece of tubing inserted through the resident's nostrils into the back of his/her mouth. It is held in place by a piece of skin tape attached to the resident's forehead and/or cheek.
Equipment and Supplies
The following equipment and supplies will be necessary when performing this procedure.
2. Nasal cannula, nasal catheter, mask (as ordered);
3. Humidifier bottle;
4. No Smoking/Oxygen in Use signs;
Assessment
Before administering oxygen, and while the resident is receiving oxygen therapy, assess for the following:
1. Signs or symptoms of cyanosis (i.e., blue tone to the skin and mucous membranes);
2. Signs or symptoms of hypoxia (i.e., rapid breathing, rapid pulse rate, restlessness, confusion);
3. Signs or symptoms of oxygen toxicity (i.e., tracheal irritation, difficulty breathing, or slow, shallow rate of breathing);
4. Vital signs;
5. Lung sounds;
6. Arterial blood gases and oxygen saturation, if applicable; and
7. Other laboratory results (hemoglobin, hematocrit, and complete blood count), if applicable.
Steps for the Procedure
2. Place an Oxygen in Use sign on the outside of the room entrance door. Close the door.
20. Instruct the resident, his/her family, visitors and roommate (if any) of the oxygen safety precautions. Provide the resident with a written copy of the Oxygen Safety handout.
Documentation
After completing the oxygen setup or adjustment, the following information should be recorded in the resident's medical record:
1. The date and time that the procedure was performed.
2. The name and title of the individual who performed the procedure.
3. The rate of oxygen flow, route, and rationale.
4. The frequency and duration of the treatment.
5. The reason for p.r.n. administration.
6. All assessment data obtained before, during, and after the procedure.
7. How the resident tolerated the procedure.
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
Based on observation, interview and record review, the facility failed to store all drugs and biologicals in locked compartments and to permit only authorized personnel to have access to controlled me...
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Based on observation, interview and record review, the facility failed to store all drugs and biologicals in locked compartments and to permit only authorized personnel to have access to controlled medications for 1 of 1 closet in the DON's office.
Controlled medications were stored in an unlocked closet in the unlocked DON's office.
This failure could the residents who resided in the facility at risk of a drug diversion.
Findings included:
During an interview and observation on 04/27/2023 at 1:55 PM, the DON opened her closet door located in her office. The controlled medications Morphine, Alprazolam, Hydrocodone, Norco and Soma) were lying in the closet on a shelf. The closet door was unlocked, and her office door had been opened then, and throughout the week. She stated that she had been unable to put them in the controlled medication locked box that was in another office, since she was working the floor. She stated that she knew that she had to have the controlled drugs behind 2 locks but that she had forgot those were in there. She said that this failure could result in a drug diversion and that she would be doing some additional training.
During an interview on 04/27/2023 at 1:57 PM, the Administrator said that their policy was to have all controlled drugs locked behind 2 locks. He stated that as soon as they had adequate nursing coverage, she would be taken off the floor to complete the other DON duties she had.
During an interview on 04/27/2023 at 2:00 PM, the Regional Nurse stated that she would do a final count on the medications with the DON and do an in-service to correct the issue. The medications in the closet were medications that had been discontinued.
Review of the policy and procedures on Discarding and Destroying Medications, dated October 2014 revealed: Medications will be disposed of in accordance with federal, state, and local regulations governing management of non-hazardous pharmaceuticals, hazardous waste and controlled substances.
-That all unused controlled substances shall be retained in a securely locked area with restricted access until disposed of.
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 observation, interview, and record review the facility failed to maintain clinical records that were complete and/or ac...
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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 clinical records that were complete and/or accurate for 1 of 3 residents (Resident #5) reviewed for clinical records, in that:
The facility did not maintain or complete an initial admission head to toe skin assessment, weekly skin assessments and wound management on Resident #5.
This failure could place 3 residents who were identified as receiving wound care services at risk for inaccurate documentation by staff.
The findings were:
Record review of clinical records for Resident #5 revealed the [AGE] year-old resident was admitted to the facility on [DATE] with diagnoses of Displaced intertrochanteric fracture of right femur, subsequent encounter for closed fracture (longest, strongest bone in your body that supports your weight), Unspecified open wound of right great toe without damage to nail, Acquired absence of other right toe (right toe is missing), Cellulitis of right toe, Non-pressure chronic ulcer of other part of right foot with unspecified severity, Type 2 diabetes mellitus with foot Ulcer (disease that results in high blood sugar and inadequate circulation to the feet which results in diabetic ulcers), hypertension (high blood pressure).
Record review of Resident #5's progress notes made by the MDS/LVN date 04/18/2023 at 10:42 AM revealed Integumentary Monitoring and Evaluation: Pressure Reducing Mattress, Diabetic Ulcer Monitoring, Surgical Incision Monitoring.
Record review of Resident #5's Skilled Observation dated 04/18/2023 revealed all skin areas in the observation were left blank.
Record review of Resident #5's Care plan dated 04/20/2023 revealed the following: General- Weekly Head to Toe Skin Check. There was no Diabetic Ulcer areas care planned.
Record review of the admission (MDS) dated [DATE] revealed the following:
Section C entitled (BIMS) revealed a score of 10, which indicates the resident was moderately impaired. Section J entitled Pain Assessment revealed: Have you had pain within the last 5 days? Yes. How much of the time have you experienced pain or hurting within the last 5 days? Occasionally. Pain Intensity from 0-10? Resident responded with a 05. Section M entitled Skin Assessment revealed no venous or arterial ulcers were present and that application of dressing to feet were applied.
Observation and interview on 04/25/2023 at 7:00 AM revealed Resident #5 sitting in his wheelchair. RN A removed his boot to show the resident's right foot. There were no bandages covering the toe area. There were 2 toes missing, which were the great toe and the second toe. There was a large open area on the second toe with drainage present, no scab, slough or covering, the area was open. The resident stated that he had not had any type of wound care since admission into the facility. He stated that RN that was working was the only nurse that had cleaned the area and kept it covered. He stated that it did cause pain at times, but it was not bad due to his neuropathy.
Interview on 04/25/2023 at 7:05 AM with RN A revealed that when she was working, she provided care to the resident's foot. She stated that there were no orders, but with any resident she would make sure the area was clean, dry, and not infected.
Record review of Resident #5's clinical record dated 04/25/2023 at 7:10 AM revealed there were no skin assessments done on the resident upon admission or head-to-toe assessments done on the resident upon Admission.
Record review and Interview with the DON on 04/25/2023 at 7:20AM revealed that there were no skin assessments documented for the resident. When asked if she had done them when the resident entered the building or since then, she stated that she had. When asked if she could provide a copy of the assessment, she stated she could not because they were only in her head. She revealed that she had not had time to document the assessments due to working the floor. She said that when she had time, she would complete them.
Record review of Resident #5's Wound Management on 04/25/2023 revealed the resident had no wounds or skin issues identified for this resident.
Record review of Resident #5's Observations on 04/25/2023 revealed the resident had no Braden Skin Assessments.
Record review of Resident #5's clinical record by RN A dated 04/25/2023 recorded late entry on 9:57 PM revealed, His right foot is in a walking shoe that he states he brought into the facility. The last time I saw his right foot on 4-23-23 he had a hard tan scab or callous over where the right great toe and second toe had been. He has had a right foot hemi amputation. He states he is homeless and had gotten frost bite on his right foot approximately 1 1/2 years ago that lead to him having to have part of his right foot amputated at that time and a thick callous area over that area that will periodically open and drain. The right foot scab or callous is now off of the area of the hemi amputation. He states he accidently bumped it into the doorframe and the scabs opened. The wound appears to be a 2.0 cm X 2.0 cm square shaped open wound that appears superficial with an area in the center that is draining a small amount of thick dark amber, dark red drainage. Non odorous. He denies pain or discomfort. Pedal and post tibial pulses are faintly palpable. He has good motion and sensation to the right foot and the foot is warm. O edema to the right foot. I encouraged him to drink fluids and keep his right foot elevated. I asked him if it hurt, and he denied pain but stated he would take a pain pill for discomfort when he moves his foot about. Tramadol 50 mg 1 po as a PRN given after the AM assessment and I assisted him to elevate his right foot and told him I would contact Dr. 9:30 AM- Dr. notified of assessment findings this morning. New orders: Labs: CBC, CMP, Wound Care orders: Right foot, cleanse with NSS, pat dry, swab with Betadine, cover with a non-adhering dressing and wrap with Kerlix and secure with tape Q shift until healed, make an appointment with URHCS wound Care clinic for eval and treatment of right foot wound. Resident notified of new orders. He is his own responsible party and no other responsible parties to contact. 10:00 I performed the wound care as ordered. The right foot wound was cleansed with NSS, patted dry, swabbed with betadine and a non-adhering dressing applied and the foot wrapped with kerlix and secured with tape. His walking boot applied and his right foot elevated. No change in the right foot assessment from my earlier assessment. 11:00 AM Wound Care Clinic for Friday 4-28-2-23 at 1015 am. Resident notified
Record review on 04/27/2023 revealed Hospital discharge date d 04/15/2023 revealed that following:
Active Problems: Cellulitis of the right toe, Osteomyelitis of second right toe, Neuropathic Ulcer limited to skin breakdown, Neuropathic ulcer with fat layer exposed.
Record review of the A policy titled: Skin Management Documentation Workflow dated 05/23/2023 revealed the following:
admission
- Complete admission Observation -> Skin Section. Note all skin alterations on the admission Observation. (Alterations in skin include abrasion, bruise, burn, dermatitis, laceration, rash, skin graft, skin tear, surgical incision, ostomies and other.)
-Upon Admission, each identified area on the admission Observation Skin Section will be entered in the Resident -> Wound Management Module to complete a full nursing assessment of each site.
-Complete Braden Observation on admission
-Initiate Wound Care Plan
-Validate the Care Plan template for POC Task Documentation has been initiated. This includes the scheduling of the weekly head to toe skin check.
-Validate that each identified skin alteration has a Treatment Order.
-If your center uses an in-house wound care practitioner (MD/NP), make referral.
CONCERN
(D)
📢 Someone Reported This
A family member, employee, or ombudsman was alarmed enough to file a formal complaint
Potential for Harm - no one hurt, but risky conditions existed
Infection Control
(Tag F0880)
Could have caused harm · This affected 1 resident
**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observations, interview and record review, the facility failed to provide a safe, sanitary, and comfortable environment...
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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 a safe, sanitary, and comfortable environment and to help prevent the development and transmission of communicable diseases and infections for 2 (Resident #3 and Resident #6) of 2 residents reviewed for infection control techniques in that:
1. The DON did not wash her hands in between feeding Resident #3 and Resident #6, while touching her hair, the resident's hair, and other surface areas.
2. The DON did not wash her hands after going to the kitchen for additional utensils for Resident #3.
These failures could affect feeding assisted residents in the building who receive assistance with ADL's and could result in infections.
The findings were:
Review of Resident #3's face sheet dated 04/27/2023 revealed Resident #3 was a [AGE] year-old female who was admitted to the facility 08/17/2022 with primary diagnosis of Cerebral Palsy (abnormal brain development) and Dysphagia (difficulty swallowing).
Review of Resident #3's Quarterly MDS assessment dated [DATE] revealed the following: Section C revealed a staff assessment of the BIMS score of 3 (severely impaired). Section G revealed the resident required total assistance with eating.
Review of Resident #3's comprehensive plan of care dated 04/11/2023 revealed the following:
-Nutritional Status: Provide assistance for meals.
- Diagnosis: Resident has dx of Cerebral Palsy and is at risk for complications such as: seizures, speech and communication problems, mental retardation, and visual deficits, hearing loss, swallowing problems, drooling, osteoporosis, and behavior problems: Assist with ADLs
- Nutritional Status: Nutritional Status Diet- Puree diet with Large Portions at Lunch and Dinner. Nectar Thickened
Liquids. Nose cup for Liquids.
- ADLs Functional Status/Rehabilitation Potential ADL Function/Rehab Potential: Eating amount of assist- Total dependence X1
- General: Resident IS AT RISK for COVID-19. Resident is at Risk for related complications due to associated co-morbidities. Resident is at increased risk of social isolation due to social distancing precautions- Assist resident with hand hygiene. Minimize resident to resident and unnecessary staff contacts.
Review of Resident #6's face sheet dated 04/27/2023 revealed Resident #3 was [AGE] year-old male who was admitted to the facility 03/20/2023 with primary diagnosis of Metabolic encephalopathy (problem in the brain which is caused by a chemical imbalance in the blood).
Review of Resident #6's Quarterly MDS admission assessment dated [DATE] revealed the following: Section C revealed a staff assessment of the BIMS score of 3 (severely impaired). Section G revealed the resident required supervision with eating.
Review of Resident #6's comprehensive plan of care dated 04/11/2023 revealed under ADLs Functional Status/Rehabilitation Potential- I require assist with ADL's r/t weakness and poor
Cognition; Resident care as per facility protocol.
Observation and Interview on 04/26/2023 at 7:15 AM revealed the DON feeding Resident #3 and Resident #6 at the same time. She stated that Resident #3 has always been a dependent feeder and that Resident #6 has just become one due to not eating without assistance. During this observation she would give Resident #3 a bite of food and wipe her mouth, then turn and give Resident #6 a bite. The DON was touching Resident #3's hair, the top of her glass and wipe her mouth without performing hand hygiene. She was touching Resident #6's straw and wiping his mouth. When asked why she had not performed hand hygiene before feeding them and in between resident's, she stated that she was only one person, and these people have to be fed. She revealed that she was working as the DON, the LVN and the CNA that morning/day due to people calling in.
Observation and Interview on 04/26/2023 at 7:30 AM revealed the DON getting up from the table, moving her long hair off of her shoulders with her right hand and entering the kitchen to get another spoon for Resident #3. She touched various surface areas while doing this. She did not perform hand hygiene before sitting back down to feed Resident #3 and Resident #6. When asked the reason why she did not hand sanitize or perform hand hygiene, she stated that she knew she was supposed to but she was trying to get the residents fed their breakfast so she could finish med pass. She revealed that this failure could place the residents at risk for infections and that she should have washed her hands.
Review of facility policy and procedure dated January 2022 on Infection Control revealed the following:
Policy Statement
-An infection prevention and control program (IPCP) is established and maintained to provide a safe, sanitary and comfortable environment and to help prevent the development and transmission of communicable diseases and infections.
-Each center should refer to and follow CDC guidance and their state guidance for Infection Prevention and Control.
- Texas Health and Human Services, COVID-19 Response for Nursing Facilities most current version, should be referred to and followed by centers located in the state of Texas.
Policy Interpretation and Implementation
1. The infection prevention and control program is developed to address the facility-specific infection control needs and requirements identified in the facility assessment and the infection control risk assessment. The program is reviewed annually and updated as necessary.
2. The program is based on accepted national infection prevention and control standards.
3. The infection prevention and control program is a facility-wide effort involving all disciplines and individuals and is an integral part of the quality assurance and performance improvement program.
4. The elements of the infection prevention and control program consist of coordination/oversight, [NAME]-ices/procedures, surveillance, data analysis, antibiotic stewardship, outbreak management, prevention of infection, and employee health and safety.
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 Assessments
(Tag F0636)
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 conduct an accurate timely assessment for 4 (Resident #1, Resident #...
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**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on interview and record review the facility failed to conduct an accurate timely assessment for 4 (Resident #1, Resident #2 and Resident #3 and Resident #4) of 8 residents reviewed for assessments.
This failure could affect residents by placing them at risk of not having comprehensive or timely quarterly assessments that reflected the physical condition of the resident which is used to determine the plan of care for the resident
The findings included:
Resident #1
Review of Resident #1's face sheet revealed Resident #1 was a [AGE] year-old female who was admitted to the facility on [DATE] with primary diagnosis of Metabolic Encephalopathy (chemical imbalance in the
blood that affects the brain), chronic pain (pain that is long term), hypertension (high blood pressure), Type 2 Diabetes Mellitus (chronic condition that affects the way the body processes blood sugar) Morbid Obesity (more than 80-100 pounds above their ideal body weight) and Chronic Kidney Disease (long standing disease of the kidneys leading to Renal Failure).
Review of Resident #1's admission MDS assessment dated [DATE] revealed the following: Section C revealed a BIMS score of 13 (cognitively intact). Section G revealed: Bed mobility- extensive, Transfers- extensive, walk-in room- did not occur, walk in corridor- did not occur, locomotion on unit- occurred on once or twice, locomotion off unit- occurred only once or twice, dressing- extensive, toilet use- extensive and personal hygiene- extensive. Section K revealed a weight of 369 pounds.
Record review on 04/27/2023 of Resident #1's Comprehensive admission MDS dated [DATE], showed reflected the assessment had been completed on 04/27/2023.
Resident #2
Review of Resident #2's face sheet on 04/27/2023 revealed Resident #2 was [AGE] year-old male who was admitted to the facility 09/30/2022 with primary diagnosis of Autistic Disorder (developmental disorder that impairs the ability to interact or communicate), Muscle wasting and atrophy (decrease and size of wasting of muscle tissue), Renal osteodystrophy-phosphate (bone disease), Muscle weakness (generalized), End stage renal disease (kidney's no longer function well enough to meet the body's demands), Cardiomegaly (heart is enlarged), Other seizures (uncontrolled electrical activity between brain cells), Lowe's syndrome (condition that affects the eyes, brain, and kidney's), Dysphagia (difficulty swallowing).
Review of Resident #2's Quarterly MDS assessment dated [DATE] revealed the following: Section C revealed a staff assessment of the BIMS score of 3 (severely impaired). Section G revealed: Bed mobility- extensive, Transfers- extensive, walk-in room- did not occur, walk in corridor- did not occur, locomotion on unit- total dependence, locomotion off unit- total dependence, dressing- total dependence, toilet use- extensive and personal hygiene- total dependence.
Record review on 04/27/2023 of Resident #2's Quarterly MDS dated [DATE], showed the assessment had not been completed.
Resident #3
Review of Resident #3's face sheet revealed Resident #3 was [AGE] year-old female who was admitted to the facility 08/17/2022 with primary diagnosis of Cerebral Palsy (abnormal brain development) and Dysphagia (difficulty swallowing).
Review of Resident #3's Quarterly MDS assessment dated [DATE] revealed the following: Section C revealed a staff assessment of the BIMS score of 3 (severely impaired). Section G revealed: Bed mobility- total dependence, Transfers- total dependence, walk-in room- did not occur, walk in corridor- did not occur, locomotion on unit- total dependence, locomotion off unit- total dependence, dressing- total dependence, toilet use- total dependence and personal hygiene- total dependence.
Record review on 04/27/2023 of Resident #2's Quarterly MDS dated [DATE], showed the assessment had not been completed.
Resident #4
Review of Resident #4's face sheet revealed Resident #4 was [AGE] year-old female who was admitted to the facility 03/19/2022 with primary diagnosis of Chronic obstructive pulmonary disease with (acute) exacerbation (Chronic Obstruction Pulmonary Disease with a sudden worsening of symptoms) and Acute and chronic respiratory failure with hypoxia (short- and long-term disease that makes it difficult to breathe on your own)
Review of Resident #4's Quarterly MDS assessment dated [DATE] revealed the following: Section C revealed a BIMS score of 10 (moderately impaired). Section G revealed: Bed mobility- independent, Transfers- independent, walk-in room- independent, walk-in corridor- independent, locomotion on unit- independent, locomotion off unit- independent, dressing- limited assistance, toilet use- independent and personal hygiene- independent.
Record review on 04/27/2023 of Resident #4's Quarterly MDS dated [DATE], showed the assessment had not been completed.
During an interview 04/27/2023 at 4:16 PM, the MDS-LVN stated she was completing the MDS's for more than one building and had gotten behind on the assessments. She revealed it was her responsibility and that she should have completed them timely. She revealed Resident #1's Comprehensive admission assessment should have been completed on or before 04/21/2023. She revealed Resident #2's should have been completed 90 days after the 01/06/2023 Quarterly assessment. She revealed Resident #3's should have been completed 90 days after the 01/03/2023 Quarterly assessment. She revealed Resident #4's should have been completed 90 days after the 01/06/2023 Quarterly assessment. She stated that the failure could place residents at risk for not having an accurate assessment that reflected their current needs. She revealed they used the RAI manual for guidelines on MDS's.
During an interview on 04/27/2023 at 3:30 PM, the Regional RN stated that she was responsible for signing section Z of the MDS, but the MDS-LVN was responsible for setting the ARD date and completing the MDS.
A policy on MDS completion and submission dated July 2017 revealed: Our facility will conduct and submit resident assessments in accordance with current federal and state submission timeframes.
Policy Interpretation and Implementation
1. The Assessment Coordinator or designee is responsible for ensuring that resident assessments are submitted to CMS' QIES Assessment Submission and Processing (ASAP) system in accordance with current federal and state guidelines. 2. Timeframes for completion and submission of assessments is based on the current requirements published in the Resident Assessment Instrument Manual.
Review of CMS'S RAI Version 3.0 Manual version 1.17.1 dated October 2019 revealed:
The RAI process has multiple regulatory requirements. Federal regulations at 42 CFR 483.20 (b)(1)(xviii), (g), and (h) require that
(1) the assessment accurately reflects the resident's status
(2) a registered nurse conducts or coordinates each assessment with the appropriate participation of health professionals
(3) the assessment process includes direct observation, as well as communication with the resident and direct care staff on all shifts.
Nursing homes are left to determine
(1) who should participate in the assessment process
(2) how the assessment process is completed
(3) how the assessment information is documented while remaining in compliance with the requirements of the Federal regulations and the instructions contained within this manual.
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 F0679
(Tag F0679)
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 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 one (Resident #1) of 3 residents reviewed for activities.
Resident #1 who was primarily bedfast, was not provided in-room activities.
This failure had the potential to affect residents identified by the facility who required in room activities by placing them at risk of boredom, loneliness, social isolation, and a decline in their quality of life.
Findings included:
Review of Resident #1's face sheet revealed Resident #1 was [AGE] year-old male who was admitted to the facility 04/07/2023 with primary diagnosis of Metabolic Encephalopathy (chemical imbalance in the blood that affects the brain), chronic pain (pain that is long term), hypertension (high blood pressure), Type 2 Diabetes Mellitus (chronic condition that affects the way the body processes blood sugar) Morbid Obesity (more than 80-100 pounds above their ideal body weight) and chronic kidney disease (long standing disease of the kidneys leading to renal failure).
Review of Resident #1's admission MDS assessment dated [DATE] revealed the following: Section C revealed a BIMS score of 13 (cognitively intact). Section K revealed a weight of 369 pounds. Section G revealed: Bed mobility- extensive, Transfers- extensive, walk-in room- did not occur, walk in corridor- did not occur, locomotion on unit- occurred on once or twice, locomotion off unit- occurred only once or twice, dressing- extensive, toilet use- extensive and personal hygiene- extensive. Section M revealed 2 stage 2 pressure ulcers that were present upon admission into the facility, it revealed 2 venous and arterial ulcers present, it revealed that pressure reducing devices were used for the bed and pressure ulcer/injury care was being completed. Section O revealed: Oxygen in use while in the facility. Section Z revealed that the RN signature date was for 04/27/2023.
Record review of Resident #1's care plan dated 04/18/2023 for activities reflected: Resident will attend/participate in 1 activity per week. Staff will evaluate time awake and readiness for activity and introduce to activities as offered.
Record review on 04/25/2023 at 9:39 AM, revealed Purchase Order #28882402 dated 04/25/2023 for a X-Large Hoyer lift sling.
Observation and interview on 04/25/2023 at 9:47 AM, revealed Resident #1 was observed awake in bed. He stated he had not been attending activities since the facility had not yet provided a wheelchair for him and the sling for transfers did not fit him. He revealed his previous wheelchair was given to another resident and that they were supposed to order him another one. He said that being isolated has made him extremely lonely and depressed. He revealed that he does not have visitors or gets to interact with anyone. He stated he enjoyed surveyors being in the building so that he was able to have someone to visit with. He revealed that the Activity Director had never conducted a one-on-one activity with him before or invited him to an activity.
Observation and interview on 04/26/2023 at 11:20 AM, revealed Resident #1 was still lying in bed watching TV. He stated he still had not been up or received a wheelchair that could accommodate his size.
Interview on 04/26/2023 at approximately 2:20 PM, with the Activity Director revealed she was new in her position, and she was also working as the Business Office Manager. She stated she worked up to 30 hour a week and she was not able to complete everything. She revealed that the Business Office Manager position took up most of her time. She stated she was barely able to do the group activities and she had not been able to do any 1 on 1 activities with resident's that did not attend the group activities. She stated she would like to start, but she is just learning her position. She revealed she has never provided any type of activities or observations to resident #1. She revealed they had hired one of the cooks as her assistant to help her with activities when she is not working in the kitchen, but she had not started in the new position yet.
Interview on 04/26/2023 at 3:00 PM, with the Administrator revealed he has hired additional staff to help in the Activity Department. He said they had a difficult time getting people at first but that they had a game plan. He stated it was the Activity Director's responsibility to ensure residents went to activities or were offered one-on-one activities if they preferred.
Review of the facility policy titled Documentation/ Activities dated January 2020 revealed:
Policy Statement
The Activity Director/Coordinator is responsible for maintaining appropriate departmental documentation.
Policy Interpretation and Implementation
1. Recordkeeping is a vital part of the activity programs.
2. The following records, at a minimum, are maintained by Activity Department personnel:
Activities evaluation; Attendance records; Activities calendar; Activity progress notes; and
Individualized Activities Care Plan or activities portion of the Comprehensive Care Plan.
3. The Activity Director/Coordinator is responsible for ensuring that activity documentation is completed and maintained.
4. The Activity Director/Coordinator is responsible for participating in the Quality Assessment Performance Improvement (QAPI) meeting and for addressing activity-related issues brought to the attention of the committee.
5. All resident records relative to Activity Services are confidential and shall be maintained in accordance with the facility's established policies governing confidentiality and maintenance of resident records.
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 F0711
(Tag F0711)
Could have caused harm · This affected multiple residents
Based on interview and record review, the facility failed to obtain written, signed and dated progress notes for each visit from the attending physician for 7 of 12 residents (Resident #s 1, 2, 3, 4, ...
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Based on interview and record review, the facility failed to obtain written, signed and dated progress notes for each visit from the attending physician for 7 of 12 residents (Resident #s 1, 2, 3, 4, 6, 7, and 14) whose records were reviewed for physician progress notes, in that:
1Resident #1, Resident #2, Resident #3, Resident #4, Resident #6, Resident #7, and Resident #14 had no documented physician visit progress notes in their electronic health records for the visit made to the residents on 4/08/2023.
This failure could place the residents at risk for any physician identified concerns and orders not being addressed and followed up on by the facility and a potential decline in resident health status.
The findings included:
Record review of the list of residents by the Physician, provided on 5/12/2023, revealed the names of the entire resident census of 27.
Record review of the electronic health records for Resident #1, Resident #2, Resident #3, Resident #4, Resident #6, Resident #7, and Resident #14 revealed no documented evidence of physician progress notes for the physician's visit dated 4/08/2023.
In an interview on 5/15/2023 at 4:55 PM, the facility Administrator stated there was one physician who was over all the facility residents .
In an interview on 5/17/23 at 11:49 AM, the Corporate RN Clinical Company Leader stated she called and spoke with the physician this morning. She stated the physician's last visit was on Saturday, 4/08/23 , where she made rounds and saw all of the residents in the facility. The RN stated no physician visit progress notes were provided to the facility. The RN stated the physician came to the facility on Saturdays and the DON came to the facility on Saturday 4/08/23 due to the physician coming to make rounds .
In an interview on 5/17/23 at 12:13 PM, the DON stated she called the physician during March 2023 to schedule a visit and the physician said she had not been to the facility for a while. The DON stated the physician came to the facility to see the residents on 4/08/23, which was a Saturday. She stated the physician would hand-write progress notes and then they were scanned into the residents' electronic health records. The DON stated the facility had not received any progress notes for the 4/08/23 visit . She stated that the physician usually faxes them back to the facility, but she did not do that for this visit.
During an interview and record review on 5/17/23 at 12:56 PM, the DON provided a copy of the Physician Progress Note form used when the physician went to the facility to make rounds. The first page of the form populated each resident's name, diagnoses, and had sections for documenting a chief complaint, history of present illness, functional status, and review of systems. The second page had the current blood pressure and weight and had sections for review of systems, physical evaluation, and documenting labs, action/plan of care, and the reason current level of care necessary. The third page was for the physician's signature and date. The DON stated she printed one form for each resident and the physician documented on each form. The DON stated the physician took the progress note forms with her to sign and scan into her files and then would send them back to the facility within the week. The DON stated she spoke with the physician on the telephone, who reportedly said she was behind and was trying to get caught up .
Record review of the facility's policy and procedure for Physician Progress Notes, dated as revised 2008, revealed the following:
Policy Statement
Physician progress notes must be maintained for each resident.
Policy Interpretation and Implementation
1. Physician progress notes are maintained for each resident residing in this facility .
2. Physician progress notes reflect the resident's progress and response to his or her care plan, medications, etc.
3. The resident's Attending Physician must write, sign, and date the physician progress notes upon each visit
Record review of the facility's policy and procedure for Attending Physician Responsibilities, dated as revised October 2021, revealed the following:
Policy Statement
The Attending Physicians shall be the primary practitioners responsible for providing medical services and coordinating the healthcare of each resident in the center.
Policy Interpretation and Implementation
Resident Visits
1. The Attending Physician will visit residents in a timely fashion, consistent with applicable state and federal requirement, and depending on the individual's medical stability, recent and previous medical history, and the presence of medical conditions or problems that cannot be handled readily by phone .
5. At each visit, the Attending Physician will provide a progress note (written, typed, or electronic) in a timely manner for placement in the medical record.
a. The note should either be written or entered at the time of the visit or, if dictated or otherwise prepared after the visit, should be returned to the center for placement on the chart within a week.
b. Over time, these progress notes should address significant active problems and risk factors, reasons for changing or maintaining current treatments or medications, and an evaluation of how medical treatments relate to the individual's overall function and quality of life
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 F0712
(Tag F0712)
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 residents were seen by the physician at least every 30 days ...
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**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on interview and record review, the facility failed to ensure residents were seen by the physician at least every 30 days for the first 90 days after admission, and at least once every 60 thereafter for one of one physicians.
The facility failed to ensure the physician made scheduled visits to see residents every 60 days, with the prior documented visit made to the facility on [DATE].
This failure could place the residents at risk for medical conditions not being identified, care needs not being met, and a decline in health status.
The findings included:
Record review of the list of residents by the Physician, provided 5/12/2023, revealed the names of the entire resident census of 27.
Record review of the list of recent physician visits, provided by the Corporate RN Clinical Resource Nurse, on 5/17/2023, revealed the physician made visits to the facility to see the residents on 10/02/2022, 12/11/2022, and 4/08/2023.
In an interview on 5/15/2023 at 4:55 PM, the facility Administrator stated there was one physician who was over all the residents.
In an interview on 5/17/23 at 11:49 AM, the Corporate RN Clinical Company Leader stated she called and spoke with the Physician this morning. She stated the Physician's last visit was on Saturday, 4/08/23. The RN Clinical Company Leader stated the physician came to the facility on Saturdays and the DON had come to the facility on Saturday 4/08/23 due to the physician coming to make rounds. She stated the DON did not document the physician making monthly rounds. The RN Clinical Company Leader stated she did not think the physician had a nurse practitioner.
In an interview on 5/17/23 at 12:13 PM, the DON stated she called the physician during March 2023 to schedule a visit and the physician said she had not been to the facility since December 2022 . The DON stated the physician came to the facility to see the residents on 4/08/23, which was a Saturday. The DON stated she started employment on 3/06/23 and the physician did not come to the facility during March 2023.
During an interview and record review on 5/17/23 at 12:56 PM, the DON provided a copy of the Physician Progress Note form used when the physician came to the facility to make rounds. The DON stated she printed one form for each resident and the physician documented on each form. The DON stated she spoke with the physician on the telephone, who reportedly said she was behind and was trying to get caught up. The DON stated she arranged with the physician to come to the facility on the last Saturday in March 2023 and April 1, 2023. [The physician did not come as scheduled and arranged.]
Record review of the facility's policy and procedure for Attending Physician Responsibilities, dated as revised October 2021, revealed the following:
Policy Statement
The Attending Physicians shall be the primary practitioners responsible for providing medical services and coordinating the healthcare of each resident in the center.
Policy Interpretation and Implementation
Accepting Responsibility for Resident Care
1. The Attending Physician will assess new admissions in a timely fashion, according to the individual's medical stability.
a. The visit schedule will be at least every 30 days for the first 90 days after admission, and then at least every 60 days thereafter.
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 F0727
(Tag F0727)
Could have caused harm · This affected multiple residents
Based on record review and interview the facility failed to provide the services of a registered nurse for at least 8 consecutive hours a day, 7 days a week in that:
The facility had no Registered Nu...
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Based on record review and interview the facility failed to provide the services of a registered nurse for at least 8 consecutive hours a day, 7 days a week in that:
The facility had no Registered Nurse coverage on April 9, 2023
This failure could affect residents and put them at risk of improper care.
The findings were:
Record Review of the facility's time sheets, not dated, revealed there was not 8 hours of Registered Nurse coverage on April 9, 2023.
During an interview on April 26, 2023, at 1:45 PM the DON and Administrator stated there was no RN coverage for April 9, 2023. The DON stated that she had been working every day and weekend and they were short staffed.
Record review of the form CMS 672 dated 04/9/2023 revealed there was a census of 25.
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
Laboratory Services
(Tag F0770)
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 or obtain laboratory services to meet the needs of its resi...
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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 or obtain laboratory services to meet the needs of its residents and the quality and timeliness of services for 2 of 9 residents (Residents #7 and #14) reviewed for laboratory test results:
1. The facility failed to obtain and complete the lab services as ordered by Resident #7's on [DATE]. Labs were not completed until [DATE].
2. The facility failed to obtain lab results for Resident #14 in a timely manner. The resident received an order from the attending physician on [DATE] to repeat lab tests on [DATE]. The lab tests were not obtained until [DATE].
3. The facility failed to implement a system for obtaining and tracking laboratory services for residents with physician orders for routine scheduled lab tests per facility policy.
These failures could place residents at risk for a delay in identifying or diagnosing a problem, adjusting medications, ensuring treatment needs were identified and addressed, and a decline in health status.
The findings included:
1. Record review of Resident #7's, undated, face sheet, revealed a [AGE] year-old female who was admitted to the facility on [DATE].
Record review of Resident #7's admission MDS assessment, dated [DATE], revealed Resident #7 had a BIMS score of 5 out of 15, which indicated (severe cognitive impairment). Resident #7's had diagnoses which included renal failure (kidney's not working properly), hypertension (high blood pressure), heart failure (inadequate pumping of blood from the heart), and anemia (blood doesn't have enough healthy red blood cells).
Record review of Resident #7's Nursing Progress Notes, dated [DATE], revealed the physician's office requested labs for the resident. Her vital signs were noted to be within normal limits.
Record review of Resident #7's Nursing Progress Note, dated [DATE], revealed an order for labs to be drawn.
Record review of Resident #7's Nursing Progress Notes, dated [DATE] at 9:58 PM, revealed RN A notified the physician that the labs ordered on [DATE] had not been obtained. RN A also notified the Administrator and the DON. The physician ordered RN A to attempt to draw the labs at that time RN A documented the labs were obtained and sent to the local hospital lab for results. Resident #7 was noted to be stable and in no apparent distress.
Record review of Resident #7's Nursing Progress Notes, dated [DATE] at 11:19 AM, revealed the DON documented the lab results were received and faxed to the physician. No critical lab results were revealed.
In an interview on [DATE] at 2:40 PM, the DON stated the facility did not have a place to take residents to have their labs obtained and the equipment in the facility had expired. She stated it had been a couple of months since residents received their routine labs. The DON stated the facility was going to try to get a contract with someone to provide laboratory services for the residents. She said she took the order, on [DATE] for Resident #7, but did not enter it in the electronic health record, due to not having anywhere to take the labs and it not being an emergency. The DON stated routine labs for other residents had also been missed, during this time. The DON stated if a resident had a severe decline or was unresponsive, she would send them to the hospital.
In a telephone interview on [DATE] at 9:54 AM, the Physician said she expected all labs to be completed within a 24-hour turnaround time. She said she had ordered Resident #7's labs on [DATE]. The Physician believed the labs would be drawn the day she ordered them. The Physician realized on [DATE] they had not been drawn and she instructed the facility to draw the labs at that time. The Physician said the labs were completed for the resident [on [DATE]]. The results were faxed to her with no critical findings and no change in the residents care.
2. Record review of Resident #14's, undated, face sheet revealed a [AGE] year-old male who was admitted to the facility on [DATE]. The resident had diagnoses which included: Alzheimer's disease with early onset; diarrhea; generalized edema (swelling from fluid); essential (primary) hypertension (high blood pressure); angina pectoris (chest pain); and peripheral vascular disease (poor circulation).
Record review of Resident #14's Nursing Progress Notes, dated [DATE] at 8:16 PM, revealed the DON documented a new order was received to obtain labs for CBC and CMP on Tuesday, [DATE].
Record review of Resident #14's Nursing Progress Notes revealed no further documentation regarding the order for the resident to have labs drawn.
Record review of Resident #14's Nursing Progress Notes, dated [DATE] at 1:59 PM, recorded as Late Entry on [DATE] at 2:09 PM, revealed the DON documented [in part] she attempted unsuccessfully to draw lab per the lab order. Resident refused to allow the other RN to attempt to draw and the resident refused to go to the hospital.
In an interview and record review on [DATE] at 1:58 PM, the DON reviewed the Nursing Progress Notes in Resident #14's electronic health record for indication of the resident having labs drawn on Tuesday, [DATE]. There was no documentation the lab had been obtained. The DON stated no the lab had not been obtained and he refused. The DON stated she had not documented a note about the resident's refusal and stated she would document one as a late entry for [DATE].
In an interview on [DATE] at 2:30 PM, Resident #14 stated he had not been asked to have labs drawn and had not refused. He stated he would allow labs to be drawn, if the nurse could do it.
In an interview on [DATE] at 3:30 PM, the DON stated Resident #14 was going to the hospital to have labs drawn for CMP.
Record review of Resident #14's lab result report, dated [DATE] at 5:12 PM, revealed it was documented as noted by the DON on [DATE] at 5:24 PM and faxed to the physician. There were no critical lab results.
3. In an interview on [DATE] at 8:25 AM, the RN Corporate Clinical Resource Nurse stated she had started coming to the facility during [DATE]. She stated the facility had never had a contract with the local hospital to process labs. She stated the hospital would not sign a contract and there had only been a verbal agreement. The RN Corporate Clinical Resource Nurse stated the corporate office would send a contract to the hospital, and it was not signed and returned. She stated the facility nurses drew the labs which were then taken to the hospital for processing. The RN Corporate Clinical Resource Nurse stated something happened during the transition in facility administration a few months ago and the hospital refused to continue processing labs for the facility.
Record review of a stack of lab result reports for six residents, provided by the RN Clinical Resource Nurse on [DATE], revealed Lab Results dated [DATE]. There were no critical abnormal lab results.
In an interview on [DATE] at 12:46 PM, the DON stated she started working in the facility on [DATE]. She stated there was not a lab tracking system in place at that time. The DON stated she thought most of the residents had labs drawn in [DATE] and [DATE]. She stated the majority of residents had their routine annual labs due in [DATE], and they were not done. The DON stated she started a lab tracking log when labs were drawn during the end of [DATE].
In an interview on [DATE] at 9:20 AM, the RN Clinical Resource Nurse stated the Lab Tracking Log system had just been started.
Record review of the facility's, undated, policy and procedure entitled Laboratory Guidelines revealed the following:
PURPOSE:
To enable prompt communication between the laboratory, facility staff and physician on all laboratory work drawn on residents in the facility, and to ensure residents receive appropriate interventions as justified by any abnormal lab values .
PROCEDURE:
-Labs will be drawn per physician orders.
-The lab results will be given to the DON / designee for review. The attending physician will be notified on any abnormal values. There will be follow-up documentation in the medical record.
-When lab orders are taken by licensed staff, a T.O. will be written and transcribed in the Lab Tracking Book .
Record review of the facility's policy for Laboratory Tracking System, dated [DATE], revealed the following:
Each facility is to have a system in place to ensure that all ordered laboratory procedures are performed accurately and timely. It is the responsibility of the facility to report the results of ordered laboratory test to the physician in a timely manner, with follow-up documentation in the medical record.
System
Using the Lab Tracking form enter the resident's name and each month the procedures are due.
This form acts as a yearly calendar for all ordered lab procedures .
One-time orders will also be placed on the Lab Tracking form.
The Lab Tracking form is to be filled out completely each time a lab is ordered.
When lab results are received in the facility a copy should be placed immediately into the resident's chart. With a notation of the date that the physician was notified and nurse's signature. If the facility uses EHR the document is to be scanned and uploaded into the residents document section .
Routine Lab orders will be entered on the Monthly Physicians Orders, with the months that they are due
CONCERN
(F)
📢 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 F0772
(Tag F0772)
Could have caused harm · This affected most or all residents
**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on interview and record review, the facility failed to have an agreement to obtain laboratory services for all residents.
...
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**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on interview and record review, the facility failed to have an agreement to obtain laboratory services for all residents.
The facility did not have a written contract or agreement for laboratory services to meet the needs of their residents.
This failure placed residents at risk of not having laboratory services conducted as ordered by the physician, which could place them at risk of unwanted medication side effect or delayed treatment of medical conditions.
The findings include:
In an interview on [DATE] at 2:40 PM, the DON stated the facility did not have a place to take residents to have their labs obtained and the equipment in the facility had expired. She stated it had been a couple of months since residents received their routine labs. The DON stated the facility was going to try to get a contract with someone to provide laboratory services for the residents. She said she took the order, on [DATE] for Resident #7, but did not enter it in the electronic health record, due to not having anywhere to take the labs and it not being an emergency. The DON stated routine labs for other residents had also been missed, during this time. The DON stated if a resident had a severe decline or was unresponsive, she would send them to the hospital.
In an interview on [DATE] at 8:25 AM, the RN Corporate Clinical Resource Nurse stated she had started coming to the facility during [DATE]. She stated the facility had never had a contract with the local hospital to process labs. She stated the hospital would not sign a contract and there had only been a verbal agreement. The RN Corporate Clinical Resource Nurse stated the corporate office would send a contract to the hospital, and it was not signed and returned. She stated the facility nurses drew the labs which were then taken to the hospital for processing. The RN Corporate Clinical Resource Nurse stated something happened during the transition in facility administration a few months ago and the hospital refused to continue processing labs for the facility.
In an interview on [DATE] at 12:00 PM, the Administrator stated that they are working to obtain a contract for lab services.
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 and interview the facility failed to ensure that the daily nurse staffing was posted as required.
The facility failed to update the daily staffing information posting.
This failu...
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Based on observation and interview the facility failed to ensure that the daily nurse staffing was posted as required.
The facility failed to update the daily staffing information posting.
This failure could affect residents, their families, and facility visitors by placing them at risk of not having access to information regarding staffing data and facility census.
Findings included:
Observation on 04/25/23 at 10:00 am, revealed the daily staffing pattern was posted on the wall by the copier room, however the information was incorrect for 3 of 3 days (04/25/23, 04/26/23, 04/27/23).
Observation on 04/25/23 at 10:00 am, revealed the daily staffing pattern was posted on the wall by the copier room was dated 04/14/23, it did not reflect the correct date, correct resident census or actual hours worked by licensed and unlicensed staff.
Observation on 04/26/23 at 9:30 am, revealed the daily staffing pattern was posted on the wall by the copier room and dated 04/25/23, it did not reflect the correct resident census or actual hours worked by licensed and unlicensed staff.
During an interview with the DON on 4/25/23 at 10:20 am, she stated she knew I know that it was is a requirement that the Nurse Staffing Posting should be updated and posted daily, but she does not have time due to update it always. She further stated, the failure could cause confusion on staffing and resident care issues.
During an interview with the Administrator on 4/25/23 at 10:30 am, he stated, the facility DON was responsible for the daily Nurse Staffing Posting.
During an interview with the DON on 4/25/23 at 10:55 am, she said the facility did not have a policy for Nurse Staffing postings.
Apr 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
Deficiency F0637
(Tag F0637)
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 complete a comprehensive assessment within 14 days after a signif...
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**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on interviews and record reviews, the facility failed to complete a comprehensive assessment within 14 days after a significant change in the physical condition for 1 of 3 residents (Residents #1) whose records were reviewed for assessments.
The facility failed to recognize and assess Resident #1 after a significant weight loss and pressure ulcers were identified.
This failure placed residents at risk for not being assessed for a change in condition and the need to revise their care plans to address changes in condition and develop interventions to meet their needs for care assistance and treatments.
The findings included:
Review of Resident #1's Face Sheet generated 4/09/2023, reflected Resident #1 was a [AGE] year-old female who was initially admitted to the facility on [DATE]. The resident had the following diagnosis: Aftercare following joint replacement surgery, other disorders of bone density and structure and age-related cognitive decline.
Review of Resident #1's Nursing Notes noted the following:
1)
On 3/16/2023 at 6:56 AM- During brief change and peri care resident states to be careful as she has a tear down there. Assessment performed noted 2 ulcers to the left inner groin area where foley catheter wraps under leg. Foley repositioned; wound care performed. Admin notified to notify Dr. and DON.
2)
On 3/18/2023 at 4:56 PM- Resident has dark purple areas to sacrum related to resident having edema and not changing position frequently enough to circulation area. Dark purple area with red wound edges not open but tissue is delicate. Unable to determine depth and a suspected DTI from sheering and pressure and edema. Resident will be turning reposition every two hours around the clock by staff with pillows to support position.
3)
On 3/24/2023 at 3:30 PM- Low air loss mattress supplied to bed for pressure relief intervention due to saw right down. Resident has an unstageable pressure friction ulcer to sacrum. Resident had a two days when resident stayed in bed with a windswept to the left positioning refused to be assisted or to get out of bed. The discoloration to the sacrum was evident upon allowing staff to assist her in her care. Resident was immediately placed on cue to our turn and reposition as intervention. Resident and family are in agreement that resident needs to be more compliant with allowing care and get out of bed every day.
4)
On 3/27/2023 at 4:22 PM- Resident up in wheelchair more alert and interactive. Close monitoring of food and fluid intake due to weight loss and need for good nutrition and hydration to prevent infections and ate and wound healing. Resident has been taking food and snacks in the room and family suspicious that she is not eating the food or snacks and request that we take her to the table for two meals a day as add an intervention. Dietitian to see resident tomorrow.
Review of Resident #1's MDS Schedule reflected last assessment as a Quarterly assessment on 3/16/2023.
Review of Resident #1's weight Variance report reflected the following dates and weight:
1)
Date: 11/07/2022- Weight: 126.00
2)
Date: 11/14/2022- Weight: 122.60
3)
Date: 11/22/2022- Weight: 120.80
4)
Date: 12/31/2022- Weight: 116.40
5)
Date: 1/02/2023- Weight: 116.40
6)
Date: 1/30/2023- Weight: 116.30
7)
Date: 2/27/2023- Weight: 111.00
8)
Date: 3/27/2023- Weight: 100.00
9)
Date: 4/2/2023- Weight: 92.60
Interview with the DON on 4/09/2023 at 7:00 PM revealed that the MDS Coordinator was responsible for creating and completing Significant Change Assessments. She said that the resident did have a significant decline since she started the beginning of March and that she was unsure why a Comprehensive Assessment was not completed. She said that she had updated the care plan and care areas to make sure the resident received her treatments that reflected her current health status.
Interview with the MDS Coordinator on 4/09/2023 at 7:05 PM revealed that she was responsible for completing an accurate resident assessment. She stated that she should have completed a Significant Change assessment once she saw the resident had a significant weight loss on February 27, 2023. She said this failure could place the resident at risk for not receiving the care they needed. She said that she was going to complete the assessment, but they had her covering two additional buildings. She stated she was behind on all assessments while she was going to another facility, she said she was trying to catch up, but she is the only one.
Review of the facility's policy and procedure for Resident Assessments and/or Significant Changes was not provided at the time of exit.
Sept 2022
3 deficiencies
CONCERN
(D)
Potential for Harm - no one hurt, but risky conditions existed
Deficiency F0637
(Tag F0637)
Could have caused harm · This affected 1 resident
**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on interview and record review, the facility failed to complete a significant change MDS assessment within 14 days after 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 complete a significant change MDS assessment within 14 days after a significant change in the resident's physical condition for 1 of 6 residents (Resident #17) reviewed for assessments in that:
1. Resident #17 experienced a decline in ADLs, along with a significant weight loss. The facility did not complete a Significant Change MDS assessment.
This failure placed residents who had recent health declines at risk for not having their individually assessed needs met which could result in a diminished quality of life and injury.
Findings Include:
Record review of Resident #17's admission sheet revealed he was a [AGE] year-old male who was admitted to the facility on [DATE] with a diagnosis of Cerebrovascular disease (group of conditions that affects the blood flow and blood vessels in the brain), Hemiplegia and Hemiparesis (weakness and partial paralysis) following Cerebral Infarction (disrupted blood supply that causes parts of the brain to die) and Aphasia (deficit in language due to brain injury).
Record review of Resident #17's MDS Quarterly assessment dated [DATE] revealed he was assessed as having a BIMS (Brief Interview of Mental Status) score of 6 indicating severely impaired cognitive skills for daily decision making. He was assessed as requiring limited assistance with 1-person physical assist with bed mobility, transfers, dressing, toileting, and personal hygiene.
Record review of Resident #17's MDS Quarterly assessment dated [DATE] revealed he was assessed as having a BIMS score of 4 indicating severely impaired cognitive skills for daily decision making. He was assessed as requiring extensive assistance with 1-person physical assist with bed mobility, transfers, dressing, toileting, and personal hygiene.
Record review of Resident #17's Weight Variance Report showed a weight on 06/02/2022 of 152.30 lbs, a weight on 07/05/2022 of 149.20 lbs, a weight on 08/04/2022 of 147.80 lbs and a weight on 09/06/2022 of 140.80 lbs. Section K0200 was checked yes on a physician weight loss regimen for a loss of 5% or more in the last month or 10% or more in the last 6 months,
During an interview with the CCM on 09/28/2022 at 3:00 PM, she stated she should have done a Significant Change Assessment to show the resident's recent decline. She had previously opened a Quarterly Assessment and forgot to change it to a Significant Change. She stated Resident #17 did have a recent weight loss, that was not physician prescribed. She stated that he did have a decline in his ADLs that was coded correctly in section G, but that should have triggered a Significant Change Assessment for the 09/05/2022 assessment. She said that she would be opening a new assessment to correctly capture the decline.
During an interview on 09/29/2022 at 1:30 PM, the ADON stated Resident #17 did have a recent significant decline and it was the CCM's responsibility to capture the assessment correctly.
Record review of the facility's policy and procedures showed that CMS's RAI Version 2.0 Manual, dated August 2003, page 2 directed that a Significant Change in Status Assessment (SCSA) must be completed by the end of the 14th calendar day following determination that a significant change has occurred.
CONCERN
(E)
Potential for Harm - no one hurt, but risky conditions existed
Abuse Prevention Policies
(Tag F0607)
Could have caused harm · This affected multiple residents
Based on interview and record review the facility failed to implement their written policies and procedures to prohibit abuse, neglect, exploitation, and misappropriation of resident property for 3 of...
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Based on interview and record review the facility failed to implement their written policies and procedures to prohibit abuse, neglect, exploitation, and misappropriation of resident property for 3 of 6 employees (CNA A, LVN B, and the Maintenance Supervisor) whose personnel files were reviewed for pre-employment screening.
1. The facility did not check the Employee Misconduct Registry (EMR) and Nurse Aide Registry (NAR) for CNA A prior to her being hired for employment in the facility.
2. The facility did not complete reference checks for LVN B prior to her beginning employment in the facility.
3. The facility did not complete reference checks for the Maintenance Supervisor prior to him beginning employment in the facility.
This failure placed residents at risk for abuse, neglect, and exploitation.
Findings include:
During an interview and record review on 9/29/22 at 1:32 PM, the Administrator stated the current Business Office Manager had been hired on 7/28/22 and she had completed the reference checks for her. The Administrator stated the prior BOM left due to a family emergency/situation and was not able to return to work due to family obligations. She stated the prior BOM's employment end date was on 6/27/22, but she was gone about 3 weeks before that date. The Administrator stated the BOM was responsible for new employee reference checks and the Administrator had done some of them. Administrator stated no one was doing HR stuff and the current/new BOM had not yet been trained to complete HR tasks.
Review of personnel files for new employees revealed the following:
- CNA A - Date of Hire: 8/15/22; no documented evidence the EMR and NAR search had been completed.
- LVN B - Date of Hire: 5/24/22; the employee application listed the last place of employment in the town where she had worked but did not list where she had been employed. The employee wrote the reason for leaving was it was too dangerous. No supervisor name or contact phone number was provided. The name of a co-worker was provided as a personal reference, and the Administrator documented no answer on 6/22/22. No further attempt to conduct a reference check was documented.
- Maintenance Supervisor - Date of Hire: 9/19/22; no reference check was documented.
In an interview on 9/29/22 at 1:55 PM, the Administrator stated she knew she had done the EMR and NAR search for CNA A but was unable to locate it and did not know the date when she had done it. She stated the CNA was hired to work PRN and had not yet worked in the facility. The Administrator stated she thought LVN B had been employed at the mental health hospital in a nearby community. She stated the Maintenance Supervisor had worked in the oil field and had been employed by someone in the local community, and she had not done a reference check to verify his prior employment.
Review of the facility's policy and procedure for Abuse Prevention Program, dated as revised May 2020, revealed the following [in part]:
Policy Statements
1. The Administrator is responsible for the overall coordination and implementation of our facility's abuse prevention program policies and procedures .
2. Our residents have the right to be free from abuse, neglect, misappropriation or resident property and exploitation .
3. Our facility conducts employment background screening checks, reference checks and criminal conviction investigation checks on direct access employees .
Screening
Background Screening Investigations
1. The Personnel/Human Resources Director, or other designee, will conduct background checks, reference checks and criminal history checks (including fingerprinting as may be required by state law) on all potential employees and contract personnel who meet the criteria for direct access employee . Such investigation will be initiated within two days of an offer of employment or contract agreement.
2. For any individual applying for a position as a Certified Nursing Assistant, the state nurse aide registry will be contacted to determine if any findings of abuse, neglect, mistreatment of individuals, and/or theft of property have been entered into the applicant's file .
MINOR
(B)
Minor Issue - procedural, no safety impact
Deficiency F0912
(Tag F0912)
Minor procedural issue · This affected multiple residents
Based on record review and interview, the facility failed to provide the required minimum of 80 square feet of space per resident in multiple occupancy rooms for 28 of 30 rooms (Rooms 3, 5, 8, 9, 10, ...
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Based on record review and interview, the facility failed to provide the required minimum of 80 square feet of space per resident in multiple occupancy rooms for 28 of 30 rooms (Rooms 3, 5, 8, 9, 10, 11, 12,13, 14, 15, 18, 19, 20, 21, 22, 23, 24, 25, 26, 27, 28, 29, 30, 32, 32, 33, 34, and 35) reviewed for square footage.
The facility failed to ensure multiple-bed resident rooms had the required 80 square feet of floor space per resident for rooms 3, 5, 8, 9, 10, 11, 12,13, 14, 15, 18, 19, 20, 21, 22, 23, 24, 25, 26, 27, 28, 29, 30, 32, 32, 33, 34, and 35.
This failure could place residents residing in these rooms at risk for not having adequate living space, and could adversely affect residents from attaining his or her highest practicable well-being.
The findings included:
Review of the facility's Form 3740 Bed Classifications, completed by the Administrator and dated 09/27/2022, revealed room numbers 3, 5, 8, 9, 10, 11, 12,13, 14, 15, 18, 19, 20, 21, 22, 23, 24, 25, 26, 27, 28, 29, 30, 32, 32, 33, 34, and 35 were included in the licensed bed capacity as double occupancy rooms.
Review of the prior completed Form 3762, Room Size Waiver for Facilities, dated 07/08/2021 revealed resident bedroom numbers 3, 5, 8, 9, 10, 11, 12,13, 14, 15, 18, 19, 20, 21, 22, 23, 24, 25, 26, 27, 28, 29, 30, 32, 32, 33, 34, and 35 were listed as meeting the justification criteria for a room size waiver.
In an interview on 9/27/22 at 10:02 AM, the Administrator stated she wanted to continue the room size waiver for all the rooms listed on the past Form 3762.
*
Understanding Severity Codes (click to expand)
Life-Threatening (Immediate Jeopardy)
J - Isolated
K - Pattern
L - Widespread
Actual Harm
G - Isolated
H - Pattern
I - Widespread
Potential for Harm
D - Isolated
E - Pattern
F - Widespread
No Harm (Minor)
A - Isolated
B - Pattern
C - Widespread
Questions to Ask on Your Visit
- "What changes have you made since the serious inspection findings?"
- "Can I speak with families of current residents?"
- "What's your RN coverage like on weekends and overnight?"
Our Honest Assessment
Strengths
- • Licensed and certified facility. Meets minimum state requirements.
Concerns
- • Multiple safety concerns identified: 1 life-threatening violation(s), $32,487 in fines, Payment denial on record. Review inspection reports carefully.
- • 34 deficiencies on record, including 1 critical (life-threatening) violation. These warrant careful review before choosing this facility.
- • $32,487 in fines. Higher than 94% of Texas facilities, suggesting repeated compliance issues.
- • Grade F (23/100). Below average facility with significant concerns.
Bottom line: Trust Score of 23/100 indicates significant concerns. Thoroughly evaluate alternatives.
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About This Facility
What is Electra Healthcare Center's CMS Rating?
CMS assigns ELECTRA HEALTHCARE CENTER 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 Electra Healthcare Center Staffed?
CMS rates ELECTRA HEALTHCARE CENTER's staffing level at 1 out of 5 stars, which is much below average compared to other nursing homes.
What Have Inspectors Found at Electra Healthcare Center?
State health inspectors documented 34 deficiencies at ELECTRA HEALTHCARE CENTER during 2022 to 2025. These included: 1 Immediate Jeopardy (the most serious level, indicating potential for serious harm or death), 29 with potential for harm, and 4 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 Electra Healthcare Center?
ELECTRA HEALTHCARE CENTER is owned by a government entity. Government-operated facilities are typically run by state, county, or municipal agencies. The facility operates independently rather than as part of a larger chain. With 62 certified beds and approximately 26 residents (about 42% occupancy), it is a smaller facility located in ELECTRA, Texas.
How Does Electra Healthcare Center Compare to Other Texas Nursing Homes?
Compared to the 100 nursing homes in Texas, ELECTRA HEALTHCARE CENTER's overall rating (1 stars) is below the state average of 2.8 and health inspection rating (2 stars) is below the national benchmark.
What Should Families Ask When Visiting Electra Healthcare Center?
Based on this facility's data, families visiting should ask: "What changes have been made since the serious inspection findings, and how are you preventing similar issues?" "Can you walk me through typical staffing levels on day, evening, and night shifts?" "Can I visit during a mealtime to observe dining assistance and food quality?" "How do you handle medical emergencies, and what is your hospital transfer rate?" These questions are particularly relevant given the facility's Immediate Jeopardy citations and the below-average staffing rating.
Is Electra Healthcare Center Safe?
Based on CMS inspection data, ELECTRA HEALTHCARE CENTER has documented safety concerns. Inspectors have issued 1 Immediate Jeopardy citation (the most serious violation level indicating risk of serious injury or death). The facility has a 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 Electra Healthcare Center Stick Around?
ELECTRA HEALTHCARE CENTER has not reported staff turnover data to CMS. Staff turnover matters because consistent caregivers learn residents' individual needs, medications, and preferences. When staff frequently change, this institutional knowledge is lost. Families should ask the facility directly about their staff retention rates and average employee tenure.
Was Electra Healthcare Center Ever Fined?
ELECTRA HEALTHCARE CENTER has been fined $32,487 across 1 penalty action. This is below the Texas average of $33,404. While any fine indicates a compliance issue, fines under $50,000 are relatively common and typically reflect isolated problems that were subsequently corrected. Families should ask what specific issues led to these fines and confirm they've been resolved.
Is Electra Healthcare Center on Any Federal Watch List?
ELECTRA HEALTHCARE CENTER is not on any federal watch list. The most significant is the Special Focus Facility (SFF) program, which identifies the bottom 1% of nursing homes nationally based on persistent, serious quality problems. Not being on this list means the facility has avoided the pattern of deficiencies that triggers enhanced federal oversight. This is a positive indicator, though families should still review the facility's inspection history directly.