HENDERSON HEALTH & REHABILITATION CENTER
For profit - Limited Liability company
173 Beds
ADVANCED HEALTHCARE SOLUTIONS
Data: November 2025
3 Immediate Jeopardy citations
Trust Grade
4/100
#484 of 1168 in TX
Last Inspection: May 2025
Inspected within the last 6 months. Data reflects current conditions.
Overview
Henderson Health & Rehabilitation Center has received a Trust Grade of F, indicating significant concerns about the quality of care provided. Ranking #484 out of 1,168 facilities in Texas places them in the top half, but their county rank of #2 out of 3 suggests there is only one local option that is better. The facility is worsening, with issues increasing from 7 in 2024 to 10 in 2025. Staffing is relatively strong with a rating of 4 out of 5 stars and a turnover rate of 39%, which is better than the state average. However, the facility has incurred concerning fines totaling $366,445, which is higher than 94% of Texas facilities. In terms of RN coverage, it is average, meaning there is less oversight from registered nurses compared to better-rated facilities. Specific incidents of concern include a failure to notify physicians when residents experienced critical changes in their health, such as worsening shingles and ongoing diarrhea, which could lead to serious complications. Overall, while there are some strengths in staffing, the facility's poor trust grade and critical deficiencies present significant risks that families should consider carefully when researching this nursing home.
- Trust Score
- F
- In Texas
- #484/1168
- Safety Record
- High Risk
- Inspections
- Getting Worse
- Staff Stability ○ Average
- 39% turnover. Near Texas's 48% average. Typical for the industry.
- Penalties ✓ Good
- $366,445 in fines. Lower than most Texas facilities. Relatively clean record.
- Skilled Nurses ⚠ Watch
- Each resident gets only 23 minutes of Registered Nurse (RN) attention daily — below average for Texas. Fewer RN minutes means fewer trained eyes watching for problems.
- Violations ⚠ Watch
- 32 deficiencies on record. Higher than average. Multiple issues found across inspections.
4/100
Top 41%
Review needed
7 → 10 violations
★★★☆☆
3.0
Overall Rating
★★★★☆
4.0
Staff Levels
★★★★☆
4.0
Care Quality
★★★☆☆
3.0
Inspection Score
↔
Stable
2024: 7 issues
2025: 10 issues
The Good
-
4-Star Staffing Rating · Above-average nurse staffing levels
-
4-Star Quality Measures · Strong clinical quality outcomes
-
Full Sprinkler Coverage · Fire safety systems throughout facility
-
No fines on record
-
Staff turnover below average (39%)
9 points below Texas average of 48%
Facility shows strength in staffing levels, quality measures, fire safety.
The Bad
3-Star Overall Rating
Near Texas average (2.8)
Meets federal standards, typical of most facilities
Staff Turnover: 39%
Near Texas avg (46%)
Typical for the industry
Federal Fines: $366,445
Well above median ($33,413)
Significant penalties indicating serious issues
Chain: ADVANCED HEALTHCARE SOLUTIONS
Part of a multi-facility chain
Ask about local staffing decisions and management
The Ugly 32 deficiencies on record
3 life-threatening 1 actual harm
Sept 2025
1 deficiency
1 Harm
SERIOUS
(G)
📢 Someone Reported This
A family member, employee, or ombudsman was alarmed enough to file a formal complaint
Actual Harm - a resident was hurt due to facility failures
Free from Abuse/Neglect
(Tag F0600)
A resident was harmed · This affected 1 resident
**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observations, interviews, and records review the facility failed to ensure residents were free from abuse for 1 of 5 re...
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**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observations, interviews, and records review the facility failed to ensure residents were free from abuse for 1 of 5 residents (Resident #1) reviewed for abuse, neglect, and exploitation. The facility failed to ensure Resident #1 was free from physical abuse on 8/17/25 at approximately 4:00 p.m. when Resident #2 pushed her down and kicked her causing two skin tears and pain rated as a 10/10 on a numeric pain scale following the incident. This failure could place residents at risk of pain, injury, hospitalization, and diminished quality of life.Findings included:1.Review of an admission Record for Resident #1 dated 9/16/2025 indicated she was an [AGE] year-old female admitted to the facility on [DATE] with diagnoses of dementia (altered cognition), peripheral vascular disease (poor circulation in legs), and bilateral (both left and right sides) osteoarthritis of hip.Review of a quarterly MDS for Resident #1 dated 9/6/2025 indicated she had severely impaired thinking with a BIMS of 3. She had exhibited difficulty focusing attention and being easily distracted. She had exhibited no verbal or aggressive physical behaviors directed toward others.Review of the care plan for Resident #1 dated 2/1/24 indicated she resided in a secured unit related to cognitive impairment and elopement risk secondary to dementia. Review of the care plan for Resident #1 dated 4/15/24 indicated she had behavioral problem of rummaging in other residents' rooms and/or belongings. Appropriate interventions were in place including anticipating the resident's needs, intervening early, and providing as many daily care activity choices as possible for resident.Review of an admission Record for Resident #2 dated 9/16/25 indicated she was a [AGE] year-old female readmitted to the facility on [DATE] with diagnoses of dementia, cognitive communication deficit, and aphasia (communication disorder).Review of a quarterly MDS for Resident #2 dated 9/2/25 indicated a BIMS was not conducted due to the resident being rarely or never understood. She had exhibited difficulty focusing attention and being easily distracted. She had exhibited no verbal or aggressive physical behaviors directed toward others.Review of the care plan for Resident #2 dated 8/28/25 indicated she had a behavior problem as evidenced by potential for physical aggression if bathroom is used by another resident. Appropriate interventions were in place including intervening early when resident shows agitation by guiding away from source of distress, engaging calmy in conversation, or attempting over interventions, and if response is aggressive approach at a later time after ensuring resident's safety. Resident #2 had no aggressive behaviors identified in the care plan prior to 8/28/25.Review of an incident report titled Physical Aggression Initiated dated 8/17/25 by RN A indicated .staff stopped and removed [Resident #2] from another pt that was in her room. Staff witnessed pt pushing her. The same incident report indicated immediate action was taken in placing Resident #2 on 1-to-1 supervision and completing assessments and notifications to the family and providers for Resident #1.Review of an incident report titled Physical Aggression Received dated 8/17/25 by RN A indicated .Staff stopped other resident after she starting kicking this [Resident #1] after pushing her to the floor. the same incident report indicated Resident #1 was assessed for injuries and two new skin tears to her right arm were identified. Her level of pain on a PAINAD (observational pain scale) was assessed as 7/10 which indicated severe pain. Predisposing factors were identified as Resident #1 went into Resident #2's room.Review of a nurse's progress note dated 8/17/25 at 4:43 p.m. by RN A indicated .[Resident #1] received physical aggression from other patient.pt was assessed and Stat x-rays were ordered for R hip, pelvis, R femur (thigh bone), pain 10/10 after incident. Was witnessed by staff member, pt did not hit head, but hit right arm and caused two skin tears.Review of a provider progress note dated 8/18/25 indicated [Resident #1] has two skin tears on her RUE.X-rays were negative for fractures or dislocations. Neuro is intact.During an observation and interview on 9/16/25 at 10:30 a.m., Resident #2 was observed in a common sitting area, sitting on a couch. She appeared clean and well-groomed and she had no visible marks, bruises, or skin tears. Resident #2 was not able to recall the altercation with Resident #1 due to her diagnosis of dementia.During an interview on 9/16/25 at 10:33 a.m., LVN B said she did not witness the altercation between Residents #1 and #2 and only knew of the incident through report. LVN B said Resident #2 had a history of getting into verbal altercations with any resident who went into her room. LVN B said the CNA was responsible for monitoring the residents and redirecting them from entering other residents' rooms.During an interview on 9/16/25 at 10:43 a.m., CNA C said Resident #2 was known to be verbally aggressive toward residents who tried to enter her room. CNA C said she had not witnessed any physical aggression from Resident #2. CNA C said CNAs were responsible for monitoring the residents and redirecting them from entering other residents' rooms.During an observation and interview on 9/16/25 at 3:00 p.m., Resident #1 was observed in self-propelling herself in a wheelchair in the hallway on the secured memory care unit. She appeared clean and well-groomed and she had no visible marks, bruises, or skin tears. Resident #1 was not able to recall the altercation with Resident #2 due to her diagnosis of dementia.During a telephone interview on 9/16/25 at 3:45 p.m., CNA D said she was working on the memory care unit the day of the altercation between Residents #1 and #2. CNA D said she was in the hallway talking to CNA E when Resident #1 walked by her stating she was going to the restroom. CNA D said Resident #1 and Resident #2 had a shared bathroom. CNA D said Resident #2 went into her own room approximately 1 to 2 minutes later. CNA D said they heard Resident #1 yell out. CNA D said CNA E ran down to Resident #2's room and opened the door. CNA D said she saw Resident #2 stepping toward the door to leave the room as CNA E was going in. CNA D said she heard CNA E tell the residents to stop fighting so she went and alerted RN A for assistance.During an interview on 9/17/25 at 9:00 a.m., LVN F said Resident #2 had exhibited verbal aggression towards residents who wandered into her room in the past. LVN F said Resident #2 had not exhibited any physical aggression towards residents. LVN F said CNAs were responsible for monitoring the residents and redirecting them from entering other residents' rooms.During an interview on 9/17/25 at 10:45 a.m., the DON said Resident #2 had no previous aggressive behavior noted. The DON said she believed the incident occurred because Resident #2 valued her personal space and considered the shared bathroom to be her personal space. The DON said Resident #2 was put on 1-to-1 observation immediately and referrals were sent to two inpatient behavioral health facilities. The DON said Resident #2 was also moved to a room with a private bathroom. The DON said staff were expected to intervene and redirect any resident wandering into other resident rooms.During an interview on 9/17/25 at 11:00 a.m., CNA E said she was assigned to work on the hall next to the secured unit on 8/17/25 and witnessed the resident-to-resident altercation between Residents #1 and #2. CNA E said she was on the secured unit talking to CNA D when Resident #1 passed by them and went into her room. CNA E said approximately 1 to 2 minutes later Resident #2 went into her own room, which shared a bathroom with Resident #1's room. CNA E said she heard Resident #1 hollering and ran down to Resident #2's room. CNA E said she saw Resident #2 push Resident #1 down on the floor by the bed, with both hands and kick her in the side. CNA E said Resident #2 was jumping back as she was coming into the room. CNA E said she told the residents to stop fighting and told Resident #2 to leave the room. CNA E said CNA D ran and alerted the charge nurse, RN A, who conducted the post incident assessments.During an interview on 9/17/25 at 11:10 a.m., the ADM said Resident #2 had displayed verbal aggression with other residents, but there had been no previous physically aggressive behavior. The ADM said following the altercation between Residents #1 and #2 the residents were immediately separated; Resident #2 was placed on 1-to-1 supervision and referred to behavioral health inpatient facility. The ADM said Resident #2's medications were adjusted, and she was moved to a room with a private bathroom and there had been no more incidents of physical aggression. Attempted interviews with RN A by telephone and text message on 9/17/25 at 11:34 a.m. Review of progress note dated 8/17/25 at 4:30 p.m. by the DON indicated Resident #2 was placed on 1-to-1 supervision immediately following altercation with Resident #1.Review of a progress note dated 8/17/25 at 5:24 p.m. by RN A indicated Resident #2 was tolerating 1-to-1 supervision well.Review of a nursing follow-up dated 8/18/25 at 5:46 a.m. by FNP indicated Resident #2's Olanzapine dose was increased from 2.5mg to 5mg nightly and she was put on one-to-one observation.Review of a psychiatric hospital Discharge summary dated [DATE] at 2:40 p.m. indicated Resident #2 was admitted to the facility on [DATE] at 4:32 p.m. and discharged on 8/27/25 with medication changes including discontinuing Olanzapine and starting Uzedy.Review of an admission record dated 9/16/25 indicated Resident #2 was admitted to the facility from a psychiatric hospital and assigned to room [ROOM NUMBER]-B.During an observation on 9/17/2025 at 11:30 am, Resident #2's room [ROOM NUMBER]-B revealed the room to have a private bathroom. Review of facility policy titled Policy and Procedures: Abuse, Neglect, and Exploitation revised on 9/6/24 indicated .Identifying, correcting, and intervening in situations in which abuse.is suspected or identified.by taking immediate action to correct any issues that can reduce the risk of further harm continuing or occurring.
May 2025
7 deficiencies
CONCERN
(D)
Potential for Harm - no one hurt, but risky conditions existed
Assessment Accuracy
(Tag F0641)
Could have caused harm · This affected 1 resident
**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on interview, observation and record review, the facility failed to ensure the MDS assessment accurately reflected the res...
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**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on interview, observation and record review, the facility failed to ensure the MDS assessment accurately reflected the resident's status for 1 of 4 residents (Resident #12) reviewed for accuracy of assessments.
The facility failed to accurately code the 04/30/25 MDS for an in-dwelling catheter (tube inserted into the bladder to drain urine) used for Resident #12.
This failure could put residents at risk for lack of proper care and decreased quality of life.
Findings included:
Record review of a facility face sheet dated 5/14/25 for Resident #12 indicated he was a [AGE] year-old male admitted to the facility on [DATE] and subsequently readmitted on [DATE] with diagnosis of cerebrovascular disease (heart disease).
Record review of a Comprehensive MDS assessment dated [DATE] for Resident #12 indicated he had a BIMS score of 12, which indicated moderately impaired cognition. Question H0100 did not indicate he had an indwelling catheter.
Record review of a comprehensive care plan dated 3/13/25 for Resident #13 indicated that he had a urinary catheter.
Record review of a physician's order summary report dated 5/14/25 for Resident #13 indicated he had the following physician's order dated 4/24/25: .Urinary catheter 24 FR 20 CC bulb to gravity (BSD). Change the catheter if it becomes occluded, to obtain a urine specimen, or if the closed system has become compromised .
During an observation on 5/12/25 at 12:13 pm Resident #12 was observed lying in bed. He was observed to have a Foley catheter.
During an interview on 5/14/25 at 11:00 am MDS Nurse was not receptive to questioning.
During an interview on 5/14/25 at 11:15 am DON said the MDS nurse was responsible for MDS accuracy. She said MDS assessments were responsible for the payments to the facility. She said she did the care plans and nothing on the care plan was missed due to the MDS being inaccurately coded. She said going forward she would have a system of checks to ensure MDS assessments are coded correctly.
During an interview on 5/14/25 at 11:35 am Administrator said if MDS assessments are coded incorrectly it could possibly cause payment issues. She said going forward there would be multiple reviews and meetings to discuss the residents to hopefully prevent this from happening.
Record review of a facility policy titled MDS Completion dated 2/10/21 read: .According to federal regulations, the facility conducts initially and periodically a comprehensive, accurate and standardized assessment of each resident's functional capacity, using the RAI specified by the State .
CONCERN
(D)
Potential for Harm - no one hurt, but risky conditions existed
ADL Care
(Tag F0677)
Could have caused harm · This affected 1 resident
**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, interview, and record review the facility failed to ensure a resident who was unable to carry out activiti...
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**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, interview, and record review the facility failed to ensure a resident who was unable to carry out activities of daily living received the necessary services to maintain grooming, and personal and oral hygiene were provided for 1 of 12 residents (Resident #23) reviewed for ADL care.
The facility failed to ensure Resident #23 had a shower and shave from 4/15/2025 to 5/08/2025.
This failure could place residents at risk of not receiving care/services, decreased quality of life, and loss of dignity.
Finding included:
Record review of Resident # 23's facility face sheet revealed Resident #23 was a [AGE] year-old male and admitted on [DATE] with diagnosis of cerebral infarction (stroke).
Record review of Resident 23's Quarterly MDS assessment dated [DATE] revealed a BIMS score of 9 indicating moderately impaired cognition, relied on staff for assistance with bathing and personal hygiene and was incontinent of bowel and bladder at times.
Record review of Resident #23's comprehensive care plan dated 5/12/2025 revealed Resident #23 had an ADL self-care performance deficit and was at risk for not having their needs met in a timely manner and to provide shower, shave, oral care, hair care, and nail care per schedule and when needed.
During an observation and interview on 5/12/2025 at 10:43 AM Resident # 23 had long facial hair and faint urine odor. He said he had not had a shower in a while, and no one has offered to shave him. He said the staff had changed him and cleaned his private area but that was all. He said he was not able to shave himself and needed help.
Record review of an untitled and undated form listed Resident #23 for a shower on Wednesday and Saturday.
Record review of POC (point of care) response history dated 5/12/2025 for bathing revealed Resident # 23's nurse aide response for bathing was recorded as not applicable from 4/15/2025 to 5/08/2025. There was no entry for shaving.
During an interview on 5/13/2025 at 11:20 AM Resident # 23 was sitting in his room and clothes were different then yesterday and said the staff helped him change his clothes but did not get a shower and shave. He said he thought about it from yesterday's conversation and could not remember the last shower and shave he had. He said he would like a shower and shave at least 1-2 times a week. He said he didn't feel upset about not getting a shower but would like to be clean and free of odors.
During an interview on 5/13/2025 at 11:30 am CNA A said that each resident had a shower schedule and Resident #23 was scheduled on the night shift for a shower. CNA A said there was a shower book at the nurses station for the nurse aides and nurses and once the task was complete then the CNA entered the task into the computer. CNA A said if the task was checked as not applicable then the task was not done . CNA A said she could not speak on why Resident #23 had not been receiving a shower and he had not voiced any concerns to her, but she would ensure he was showered and shaved today. CNA A said residents that don't receive proper ADL care like a shower and shave could feel bad or have skin changes.
During an interview on 5/13/2025 at 11:35 am LVN C said she worked at the facility as needed as a charge nurse. She said she was to oversee resident care by the CNA's and observed their ADL care on her rounds. LVN C said she had noticed resident #23 had an odor on 5/12/25 but today 5/13/25 had clean clothes on and thought he had been showered. LVN C said that residents that don't receive ADL care like showers could have changes in skin and feel bad about not being clean.
During an interview on 5/14/2025 at 9:39 am the DON said that ADL care was now overseen by the treatment nurse and the facility had a new treatment nurse as of this week due to the previous treatment nurse not completing her job duties. DON said there was no alert for when care was not provided, and the nurses and aides should be aware of care that needed to be completed. She said she was not sure why Resident #23 did not have a shower recorded since before 04/15/25 and felt that was an error in documentation. She said she expected all residents to receive their ADL care and by not providing ADL care residents could have an adverse outcome.
During an interview on 5/14/2025 at 11:31 am the Administrator said all staff were responsible for ensuring resident's received ADL care and CNA's should be accurately recording ADL care and completing their job task as assigned. She said all staff made rounds and if they see something they should say something. She said she did not know why Resident #23 did not have a shower recorded since before 4/15/25 and felt it was a documentation error because she had seen him the shower room. Administrator said if ADL care was not provided it could affect resident skin and infection control and expected all staff to follow the ADL assignments and follow the residents care plan.
Record review of a facility policy titled Activities of daily Living Care Guidelines dated 01/23/2016 revealed, .residents will receive essential services for activities of daily living to maintain good nutrition, grooming, and personal and oral hygiene .
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 observations, interviews, and record review, the facility failed to ensure the residents' environment remained as free ...
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**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observations, interviews, and record review, the facility failed to ensure the residents' environment remained as free of accident hazards as possible for 1 of 4 residents (Resident #39) reviewed for accidents/hazards.
The facility failed to remove worn and damaged mechanical lift slings from service on 5/12/25.
This deficient practice place residents at risk of injuries.
Findings included:
Record review of a facility face sheet dated 5/12/25 for Resident #39 indicated that he was a [AGE] year-old male admitted to the facility on [DATE] with diagnoses including hypotension (low blood pressure) and muscle weakness.
Record review of a Quarterly MDS assessment dated [DATE] for Resident #39 indicated that he had a BIMS score of 15 which indicated that he had intact cognitive status. Resident #39 was dependent for transfers.
Record review of a Comprehensive Care Plan dated 3/7/24 for Resident #39 indicated that he had an ADL self-care performance deficit and required 2 staff for transfers.
During an observation on 5/12/25 at 9:27 am Resident #39 was observed being transferred by CNA E and LVN D using a mechanical lift. Mechanical lift sling loops were observed to be faded in color and the labels appeared to have been cut off of sling.
During an interview on 5/12/25 at 3:15 pm CNA E said she would check for broken hooks or loops. CNA E said that broken hooks or loops would indicate wear and tear on the sling. She said she did not know to look for faded colors on loops.
During an interview on 5/12/25 at 3:20 pm LVN E said nurses and CNAs check the slings before use and they look for signs of dry rotting, faded coloring. She said they have so many different kinds of lift pads that it's hard to notice the fading sometimes, because they are all different colors.
During an interview on 5/12/25 at 3:30 pm Laundry Aide said she did not use bleach on the lift pads, and she hangs them to air dry. She said she looks for rips/tears and colors fading. Laundry Aide said she would notify the ADON if she noticed anything out of the ordinary and let them make the decision on whether to remove them from service.
During an interview on 5/14/25 at 11:15 am DON said direct care staff using the slings were responsible to check them before use. She said faded or fraying slings could tear with any weight and cause accidents. She said she would be holding an in-service with all staff to ensure they knew to ensure the tag was on the sling and readable and the colors were bright and not faded. DON said she would also in-service laundry staff to ensure they did not use bleach or place slings in dryer.
During an interview on 5/14/25 at 11:35 am Administrator said if lift sling loops are faded the sling would need to be replaced. She said direct care staff are responsible for checking before using on a resident, but it also goes up the chain as well, so ultimately administrative staff were also responsible. She said if staff cannot discern the loop colors, they may not use the correct hooks and it could lead to resident injury. Administrator said she would put a new system in place to check slings going forward.
Record review of a facility policy titled Hydraulic Lift (Mechanical Lift) dated 9/13/24 indicated that policy did not address safety checks of lift slings.
Record review of the manufacturer instruction for Medline full body slings undated indicated, .Full body slings are made of durable materials and are ideal for patient transferring and toileting activities. Always inspect slings prior to each use. Signs of color fading, bleached areas, indicate improper laundering which is unsafe and could result in injury. Any slings with signs of wear or improper laundering should be immediately removed from use .
CONCERN
(D)
Potential for Harm - no one hurt, but risky conditions existed
Deficiency F0761
(Tag F0761)
Could have caused harm · This affected 1 resident
Based on observations, interviews, and record review the facility failed to ensure all drugs were only accessible by authorized personnel, 1 of 4 medication carts (hall two cart) reviewed for storage ...
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Based on observations, interviews, and record review the facility failed to ensure all drugs were only accessible by authorized personnel, 1 of 4 medication carts (hall two cart) reviewed for storage of medications.
The facility failed to ensure LVN C kept the hall two medication cart secured and was unable to be accessed by unauthorized personnel or residents on 05/12/25.
This failure could put residents at risk of unauthorized use of medication and accidental ingestions/use of an unprescribed medication.
Findings included:
During an observation on 5/12/2025 at 12:10 pm, medication cart for hall two was located at the nurses station and observed unlocked.
During an observation on 5/12/2025 at 12:15 pm, a visitor and two unlicensed staff members (CNA's) passed by the unlocked medication cart located on hall two.
During an observation on 5/12/2025 at 12:20 pm, two housekeepers passed by the unlocked medication cart located on hall two.
During an observation on 5/12/2025 at 12:25pm, a resident passed by the unlocked medication cart located on hall two.
During an observation and interview at 12:30 pm, LVN C returned to the unlocked medication cart and proceeded to lock the medication cart. LVN C said she had worked at the facility for two weeks and had been a nurse for about two years. She said that not locking the cart could cause a drug diversion if a visitor, resident, or unlicensed staff member entered the unlocked cart. LVN C said a confused resident might access medications and cause harm to themselves if medications that were not ordered for them were consumed.
During an interview on 5/12/2025 at 12:35 pm, the Administrator said it was the responsibility of the DON or her designee to train and in-service the nursing staff on medication storage. The Administrator said that the medication cart should be locked while not attended and the unopened cart could cause harm if the cart was accessed by a confused resident.
During an interview on 5/12/2025 at 2:00 pm, the DON said the medication carts should be always locked when unattended. She said there was a risk of harm if a resident entered the cart, and consumed medications. She said there was a risk of a drug diversion if visitors or unlicensed staff had access to medications.
Record Review of a facility Medication Storage policy dated1/20/2021
Policy . It is the policy of this facility to ensure all medications housed on our premises will be stored, dated and labeled according to the manufacturer's recommendations and sufficient to ensure proper sanitation, temperature, light, ventilation, moisture control, segregation, and security .Policy Explanation and Compliance Guidelines
1.
General Guidelines:
a.
All drugs and biologicals will be stored in locked compartments (i.e., medication carts, cabinets, drawers, refrigerators, medication rooms) under proper temperature controls.
b.
Only authorized personnel will have access to the keys to locked compartments
c.
During a medication pass, medications must be under the direct observation of the person administering medications or locked in the medication storage area/cart.
CONCERN
(D)
Potential for Harm - no one hurt, but risky conditions existed
Infection Control
(Tag F0880)
Could have caused harm · This affected 1 resident
**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observations, interviews, and record reviews, the facility failed to establish and maintain an infection prevention and...
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**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observations, interviews, and record reviews, the facility failed to establish and maintain an infection prevention and control program designed to provide a safe, sanitary, and comfortable environment and to help prevent the development and transmission of communicable diseases and infections for 1 of 8 residents (Resident #57) and 2 of 8 staff (CNA A and CNA B) reviewed for infection control.
The facility failed to ensure CNA A and CNA B followed enhanced barrier precautions and performed hand hygiene when providing incontinent care to Resident #57 on 5/12/2025.
These failures could place residents at risk for cross contamination and infection.
Findings included:
Record review of Resident # 57's facility face sheet revealed Resident #57 was a [AGE] year-old male and admitted on [DATE] with diagnosis of cerebral infarction (stroke).
Record review of Resident 57's Annual MDS assessment dated [DATE] revealed a BIMS score of 14 indicating intact cognition, relied on staff for all ADL's, was incontinent of bowel and bladder, and required a feeding tube.
Record review of Resident #57's comprehensive care plan dated 3/17/2025 revealed Resident #57 was incontinent of bowel and bladder and dependent on staff for care and required EBP due to feeding tube and staff to wear a gown and gloves during high-contact resident care activities.
Record review of nurse assistant skills review checklist dated 5/07/2024 revealed CNA B had been trained on infection control measures for EBP and hand hygiene.
Record review of nurse assistant skills review checklist dated 5/08/2024 revealed CNA A had been trained on infection control measures for EBP and hand hygiene.
During an observation on 5/13/2025 at 9:11 AM CNA A and CNA B provided incontinent care to Resident #57. Resident #57 had an EBP sign on his door indicating he required gloves and gown for direct care. Neither CNA applied a gown when providing incontinent care and personal care to Resident #57. During incontinent care both CNA's washed their hands and applied gloves prior to starting care. CNA B began care by cleaning Resident #57's front periarea with wipes. After care she continued to wear the soiled gloves while turning the resident. CNA A then cleaned the back periarea of Resident #57 of stool using wipes and then removed her gloves and applied new gloves without hand hygiene. CNA A then applied a clean pad and brief and applied skin barrier cream to Resident #57's buttocks. Resident #57 was then turned back to his right side and CNA B using the same soiled gloves from the beginning , placed clean linens, pad and brief. CNA B and CNA A then repositioned the resident and adjusted his linens and head of the bed with soiled gloves. CNA B gathered the soiled linen and left the room with soiled gloves on.
During an interview on 5/13/2025 at 9:45 am CNA A said that she forgot Resident #57 required EBP and should have put on a gown and gloves before providing care. CNA A said she should have performed hand hygiene between glove changes and should not use soiled gloves to touch clean objects. CNA A said she had been trained on EBP and proper hand hygiene but was nervous. CNA A said by not following infection control measures infections could spread.
During an interview on 5/13/2025 at 9:47 am CNA B said that she did not see the sign for EBP on the door and failed to put on proper PPE for Resident #57. CNA B said she should have removed her gloves and performed hand hygiene between dirty and clean task and before exiting the residents room. CNA B said by not following infection control measures infections could spread.
During an interview on 5/14/2025 at 9:39 am the DON said that she was the now the infection prevention nurse and that all staff were responsible for following the facilities infection control policies. DON said the staff were trained on hire, annual and throughout the year on infection control measures like hand washing and EBP. DON said if staff were not following the infection control program, then infections could spread.
During an interview on 5/14/2025 at 11:31 am the Administrator said the infection control program was the responsibility of the DON who was the infection prevention nurse. Administrator said all staff were trained on hire and throughout the year on infection control measures including EBP and hand hygiene. Administrator said if the infection control program measures were not followed by staff, infections could spread and expected all staff to follow the facilities infection control program.
Record review of a facility policy titled Hand Hygiene dated 02/11/2022 indicated, .all staff will perform proper hand hygiene procedures to prevent the spread of infections;6a. the use of gloves does not replace hand hygiene. If your task requires gloves, perform hand hygiene prior to donning gloves and immediately after removing gloves .
Record review of a facility policy titled Infection Prevention and Control Program dated 11/6/24 indicated .6. Enhanced Barrier Precautions: EBP are used in conjunction with standard precautions and expand the use of gown and gloves during high contact resident care activities .
CONCERN
(E)
Potential for Harm - no one hurt, but risky conditions existed
Smoking Policies
(Tag F0926)
Could have caused harm · This affected multiple residents
Based on observations, interviews, and record reviews, the facility failed to ensure it formulated, adopted, and enforced policies regarding smoking, smoking areas, and smoking safety that also consid...
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Based on observations, interviews, and record reviews, the facility failed to ensure it formulated, adopted, and enforced policies regarding smoking, smoking areas, and smoking safety that also consider non-smoking residents for 1 of 1 smoking area reviewed for smoking safety.
The facility failed to ensure cigarette butts were not discarded into a regular trash can that also contained paper trash on 5/12/25 causing a fire hazard.
The facility failed to ensure regular trash was not discarded into the red metal ashtray container on 5/12/25 causing a fire hazard.
This failure could place residents at risk of injury, burns, and an unsafe smoking environment.
Findings included:
During an observation on 5/12/25 at 10:50 am a red metal ashtray container was observed with paper trash in it. A metal trash can was also observed in the smoking area with a clear plastic liner in it. Observation revealed that can was full of cigarette butts along with cigarette boxes and regular trash.
During an interview on 5/13/25 at 1:50 pm DON said there was not one specific person responsible for emptying the ashtrays in the smoking area, but whoever took the residents out to smoke should be emptying the ashtrays into the ashtray container. DON said she would get with the maintenance man to correct this issue.
During an interview on 5/13/25 at 2:00 pm Maintenance man said staff that take residents out to smoke should be emptying the ashtrays into the red metal can. He said there was no one specific person responsible for this. He said ashtrays should not be emptied into the regular trash can, due to it being a fire hazard. Maintenance man said it was also a fire hazard for regular trash to be emptied into the red metal can.
Record review of a facility policy titled Smoking Policy dated 4/12/23 read: .It is the policy of this facility to provide a safe and healthy environment for residents, visitors, and employees as related to smoking .
CONCERN
(F)
Potential for Harm - no one hurt, but risky conditions existed
Deficiency F0887
(Tag F0887)
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 reviews, the facility failed to implement their policy to ensure the residents, or their responsib...
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**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on interview and record reviews, the facility failed to implement their policy to ensure the residents, or their responsible party, received education of the benefits and risks, or potential side effects of Covid -19(a severe acute respiratory syndrome ) immunizations, receipt of Covid-19 immunizations, or the residents did not receive the Covid-19 immunizations, due to medical contraindication, or refusal, for 74 of 74 residents living in the facility and 5 of 5 residents who were reviewed for immunizations (Resident #11, Resident #35, Resident #52, Resident #56 and Resident #57)
The facility failed to document, in Resident #11, Resident #35, Resident #52, Resident #56 and Resident #57 medical records, having had received education, whether by self or with their responsible party, of the benefits and risk, and potential side effects, of the Covid-19 immunization, receipt of the of the Covid-19 immunization, or having had not received the Covid-19 immunization due to medical contraindication or refusal.
This failure could place residents at risk of not being informed of complications and potential adverse health outcomes.
Findings included:
Record review of a facility face sheet dated 5/14/25 for Resident #11 indicated that she was an [AGE] year-old male admitted to the facility on [DATE] with diagnoses including: pain in right hip, altered mental status and repeated falls.
Record review of a physician order summary report dated 5/14/25 for Resident #11 indicated that she had no orders for Covid vaccination.
Review of a document titled, immunization audit report dated 5/13/2025, revealed Resident # 11 and/or her representative was not offered the Covid-19 vaccine since 01/19/21 The document indicated no education given.
Record review of a facility face sheet dated 5/14/25 for Resident #35 indicated that she was an [AGE] year-old male admitted to the facility on [DATE] with diagnoses including: chronic pain, atrial fibrillation (rapid heart rate) and anorexia (no desire to eat).
Record review of a physician order summary report dated 5/14/25 for Resident #35 indicated that she had no orders for Covid-19 vaccination.
Review of a document titled, immunization audit report dated 5/13/2025, revealed Resident #35 and/or her representative was not offered the Covid vaccine on admission and the document indicated there was no education given to Resident #35.
Record review of a facility face sheet dated 5/14/25 for Resident #52 indicated that she was a [AGE] year-old female admitted to the facility on [DATE] with diagnoses including: anemia (low blood volume), atrial fibrillation (rapid heart rate) and anorexia (no desire to eat).
Record review of a physician order summary report dated 5/14/25 for Resident #52 indicated that she had no orders for Covid-19 vaccination.
Review of a document titled, immunization audit report dated 5/13/2025, revealed Resident #52 and/or her representative was not offered the Covid-19 vaccine since 01/03/21. The document indicated there was no education given to Resident #52 or a representative.
Record review of a facility face sheet dated 5/14/25 for Resident #56 indicated that she was a [AGE] year-old male admitted to the facility on [DATE] with diagnoses including: atrial fibrillation (rapid heart rate), weakness and chronic cough.
Record review of a physician order summary report dated 5/14/25 for Resident #56 indicated that she had no orders for Covid-19 vaccination.
Review of a document titled, immunization audit report dated 5/13/2025, revealed Resident # 56 and/or her representative was not offered the Covid-19 vaccine since 07/22/22. The document indicated there was no education given to Resident #56 or a representative.
Record review of a facility face sheet dated 5/14/25 for Resident #57 indicated that he was a [AGE] year-old male admitted to the facility on [DATE] with diagnoses including: pain, weakness, and lack of coordination.
Record review of a physician order summary report dated 5/14/25 for Resident #57 indicated that he had no orders for Covid-19 vaccination.
Review of a document titled, immunization audit report dated 5/13/2025, revealed Resident #57 and/or her representative was not offered the Covid-19 vaccine. The document indicated there was no education given to Resident #57 or a representative.
During an interview on 5/14/2025 at 8:45 am, the DON said she was the Infection Preventionist for the facility. The DON could not provide documentation of any resident (74 residents in the facility) education for Covid immunization refusals. DON said the facility had no form for declination to be used when the resident or representative refused and there was no refusal scanned into the electronic system for residents that indicated they had been education on benefits or risks of the covid vaccine. She said there was no documentation of education provide after refusal of Covid vaccination for any resident in the facility. The DON said she would be responsible going forward to ensure that residents were educated on immunizations and providing documentation. She said residents could be at risk of not knowing what they were refusing if they were not provided education. The DON said residents could be at risk of contracting infections, severe respiratory problems and even death if they were not properly educated and did not receive vaccinations. DON said they would be providing education and have consent/declination forms signed going forward.
During an interview on 5/14/2025 at 9:00 am, the Administrator said there was no documentation of education provide after refusal of Covid vaccination for any of the 74 residents in the facility. She said the facility had not provided covid vaccinations or education on Covid vaccinations in the last two years due to no interest and refusal of the residents or families. The Administrator said the DON was responsible for immunizations and going forward residents will be provided education regarding benefits and risks. Administrator said that residents and families could possibly not have the knowledge to make informed decisions concerning covid vaccinations if risks and benefits were not provided.
Record Review of a facility policy titled Infection Control Program dated 10-24-2022 indicated .
COVID-19 Immunization :
a.
Residents and staff will have the opportunity to receive the COVID-19 vaccination, and change their decision based on current guidance.
b.
Residents and staff will be screened prior to offering the vaccination for prior immunization, medical precautions, and contraindications to determine candidacy for the vaccination.
c.
Education about the vaccine, risks, benefits, and potential side effects will be given to residents or resident representatives and staff prior to offering the vaccine.
d.
Documentation will reflect the education provided and details regarding whether or not the resident or staff received the vaccine.
Mar 2025
2 deficiencies
CONCERN
(D)
📢 Someone Reported This
A family member, employee, or ombudsman was alarmed enough to file a formal complaint
Potential for Harm - no one hurt, but risky conditions existed
Resident Rights
(Tag F0550)
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 treat each resident with respect and dignity and care for each 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 treat each resident with respect and dignity and care for each resident in a manner that promotes maintenance or enhancement of his or her quality of life, recognizing each resident's individuality for 1 of 8 (Resident #1) reviewed for dignity in that:
CNA A spoke to Resident #1 in a loud and harsh tone while attempting to assist the resident out of bed.
This failure placed residents in the facility at risk of diminished quality of life, and loss of dignity and self-worth.
Findings Include:
Review of Resident #1's undated face sheet revealed he was a [AGE] year-old male admitted to the facility on [DATE] with a primary diagnosis of heart failure and secondary diagnoses of shoulder pain, low back pain, and muscle wasting (loss of muscle mass due to disuse or nerve problems).
Review of a quarterly MDS assessment dated [DATE] indicated Resident #1 had a BIMS score of 12 which indicated moderate cognitive impairment, and he required total assistance with toileting, putting on/taking off footwear; he required maximum assistance with showering/bathing and lower body dressing; he required moderate assistance with upper body dressing; he required setup assistance with personal and oral hygiene; he required no assistance eating. He was occasionally incontinent of bladder and frequently incontinent of bowel.
A comprehensive care plan revised on 9/26/24 indicated Resident #1 had an ADL self-care performance deficit and Resident #1 did not always like to change his clothing daily or shower when scheduled. Interventions were in place to provide ADL care as needed, encouraging resident to participate to the fullest extent possible, and praising resident when attempts were made.
A comprehensive care plan revised on 9/30/24 indicated Resident #1 had impaired cognition and was at risk for further decline related to encephalopathy (group of conditions that cause brain dysfunction) and dementia (altered cognition). Interventions were in place including explaining all procedures to resident and stopping and returning later if resident becomes agitated during care.
During an interview on 3/24/25 at 12:21 PM, Resident #1 said CNA A came into his room and told him he needed to get up and out of bed. Resident #1 said he told CNA A he did not want to get up right then, and CNA A replied that he had to get up and then pulled his blanket off him. Resident #1 said the CNA attempted to assist him to his feet by pulling his legs over to the side of the bed and he told her again that he did not want to get up yet. Resident #1 said CNA A said, We don't play around here in loud and harsh voice and left the room.
During an interview on 3/24/25 at 12:30 PM, Resident #3, who was Resident #1's roommate, said he remembered CNA A coming into their room on the morning of the incident. He said CNA A yelled at Resident #1 and told him he had to get out of bed. He said he did not remember CNA A pulling Resident #1 out of bed or jerking his leg.
During an interview on 3/24/25 at 12:40 PM, Resident Representative said the facility notified him of the incident, and he accompanied Resident #1 to a meeting with the ADM. He said Resident #1 told the ADM he didn't think CNA A should be fired, but he did not want CNA A to be allowed in his room anymore.
Attempted a telephone interview on 3/24/25 at 1:00 PM with CNA A. An automated voice recording indicated the correct number was reached and there was no voicemail box setup.
During an interview on 3/24/25 at 3:10 PM, MA B said she went into Resident #1's room to check Resident #3's vital signs in preparation of a medication pass. MA B said she heard Resident #1 tell CNA A he did not want to get up and CNA A responded you need to get up or I'll get in trouble in a loud and harsh-sounding tone of voice. MA B said she left the room to get Resident #3's medication, and when she returned, Resident #1 was seated in his wheelchair dressing himself; CNA A was not in the room.
During an interview on 3/25/25 at 11:00 AM, the DON said there was nothing in CNA A's background checks or job performance that indicated a risk to residents in the facility. She said CNA A was a large woman with a loud voice and she could have been intimidating to some residents, but there had been no previous allegations of mistreatment from any resident in the facility against CNA A.
Second attempted telephone interview on 3/25/25 at 3:45 PM with CNA A. An automated voice recording indicated the correct number was reached and there was no voicemail box setup.
During an interview on 3/25/25 at 4:00 PM, the ADM said CNA A had nothing in her background or job history that indicated a concern for resident safety. She said there had been no allegations of abuse or neglect against CNA A from any resident before this incident. She said CNA A was suspended while the facility investigated the allegation, and the decision was made to terminate CNA A based off MA B's witness statement. The ADM said CNA A was too direct and did not respect Resident #1's personal choice and that would not be tolerated at the facility. She said all CNAs were trained and expected to fully explain all care being provided and encourage residents to participate in care.
Review of facility policy titled Promoting/Maintaining Resident Dignity last reviewed on 2/16/20 indicated all staff involved in providing resident care will promote and maintain resident dignity by .personal choices will be considered when providing care and services to meet the resident's needs and preferences . and .speak respectfully to residents .
CONCERN
(E)
📢 Someone Reported This
A family member, employee, or ombudsman was alarmed enough to file a formal complaint
Potential for Harm - no one hurt, but risky conditions existed
Safe Environment
(Tag F0584)
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 maintain a clean, sanitary, comfortable, and homelike...
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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 a clean, sanitary, comfortable, and homelike environment for 1 of 8 residents (Resident #2) in that:
1.
Resident #2's window, window blinds, and floor around his bed were soiled with visible dust, dirt, debris, and smudges.
2.
Resident #2's bed sheets and pillowcase had scattered brown stains on them.
This failure placed residents residing in the facility at risk for a diminished quality of life and a diminished clean, homelike environment.
The findings include:
Review of Resident #2's undated face sheet revealed he was a [AGE] year-old male readmitted to the facility on [DATE] with a primary diagnosis hemiplegia and hemiparesis following cerebral infarction of left non-dominate side (weakness or paralysis on one side of the body) and secondary diagnoses of cognitive or emotional deficit and aphasia (impaired ability to comprehend or formulate language).
Review of a quarterly MDS assessment dated [DATE] indicated Resident #2 had a BIMS score of 3 which indicated severe cognitive impairment and he required total assistance with oral hygiene, toileting hygiene, shower/bathing, lower body dressing, putting on/taking off footwear, and personal hygiene; he required maximum assistance for upper body dressing; he required setup and clean up assistance with eating. He was always incontinent of bowel and bladder.
A comprehensive care plan revised on 10/03/24 indicated Resident #2 exhibited verbal and physical aggressive behaviors with interventions in place including approaching and speaking to resident in a calm manner, clearly explaining all daily care activities, and early intervention when resident behaviors were escalating. Resident #2 had a history of violent behaviors and had hit staff at the facility on multiple occasions. The same comprehensive care plan included a revision on 12/05/25 which indicated Resident #2 had an ADL self-care performance deficit related to contracture of left hand, limited range of motion in upper and lower extremities, and hemiplegia/hemiparesis.
An observation on 3/24/25 at 11:36 AM of Resident #2's room revealed there were scattered brown stains on his sheets and pillowcase. The window in his room had green and brown smudges on the glass and the window blinds had an accumulation of dust on them. The floor around his bed had an accumulation of dirt and debris.
During an interview on 3/24/25 at 11:36 AM, Resident #2 said facility staff did change his bed linens and clean his room, but not daily.
During an interview on 3/24/25 at 11:45 AM Housekeeper C said all resident rooms were cleaned every day. She said the daily cleaning consisted of cleaning the restroom, wiping down all surfaces, sweeping and mopping the floors, and taking out the trash. She said she doesn't always clean behind resident beds or underneath them because she would need help to move the beds away from the wall. She said Resident #2 never exhibited any violent behaviors that interfered with housekeeping staff's ability to clean his room, and his room had already been cleaned today.
An observation on 3/25/25 at 9:00 AM Resident #2's room revealed what appeared to be the same soiled bed linens and pillowcase on his bed. The floor, window, and window blinds appeared to have not been cleaned from previous observation.
During an interview on 3/25/25 at 9:45 AM Housekeeper D said every resident room was cleaned daily and a daily cleaning included wiping down all surfaces, sweeping and mopping floors, and taking out the trash. Housekeeper C said she had enough time to complete all assigned duties and no resident behaviors had ever affected her ability to clean their rooms.
During an interview on 3/25/25 at 10:05 AM, CNA E said the facility had been having problems running out of clean linens in the morning. She said sometimes she had to delay changing bed linens until laundry staff washed more linens.
During an interview on 3/25/25 at 10:30 AM, EVS Manager said housekeepers were expected to clean each resident's room daily, which consisted of taking out the trash, wiping down all surfaces, and sweeping and mopping floors. She said, additionally, each housekeeper was assigned one room daily to be deep cleaned. She said a deep clean was cleaning everything in the room and it was also done for new resident admissions. She said CNAs were bringing soiled linens to the laundry room too late in the day to be washed and ready for the next morning, because laundry staff left at 2:00 PM. She said linens were provided late some days, but there was always clean linen available to accommodate resident needs.
During an interview on 3/25/25 at 11:00 AM, the ADON said the facility had identified an issue with their laundry processing. The ADON said CNAs recently changed to a 12-hour shift, and left at 6:00 PM instead of 2:00 PM. She said CNAs were waiting until the end of their shift to bring linens to the laundry room and laundry staff left at 2:00 PM. The ADON said she wasn't satisfied with the quality of housekeeping services, and administration was in discussion with the company they were contracted with.
An observation on 3/25/25 at 3:00 PM of Resident #2's room revealed what appeared to be the same soiled bed linens and pillowcase on his bed. The floor, window, and window blinds appeared to have not been cleaned from the initial observation.
During an interview on 3/25/25 at 3:00 PM, Resident #2 said staff had helped him change his clothing that day, but his linens had not been changed in a few days.
During an interview on 3/25/25 at 4:30 PM, the ADM said the facility had identified there was an issue with their laundry processing. She said CNAs were not emptying linen barrels early enough in the day to provide laundry staff time to wash them. The ADM said CNAs had been instructed to empty linen barrels earlier in the day. She said the facility always had clean linens available to accommodate resident needs.
Review of a policy dated May 2003 titled Housekeeping Standards indicated the following:
.The facility will provide a clean and sanitary living environment for the physical and emotional wellbeing of the resident .
And
.Daily cleaning schedules will be followed to provide a clean, safe, sanitary environment for residents, staff and visitors .
Apr 2024
7 deficiencies
CONCERN
(D)
Potential for Harm - no one hurt, but risky conditions existed
Resident Rights
(Tag F0550)
Could have caused harm · This affected 1 resident
**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, interview and record review the facility failed to treat each resident with respect and dignity and care i...
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**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, interview and record review the facility failed to treat each resident with respect and dignity and care in a manner and in an environment that promoted maintenance or enhancement of his or her quality of life, recognizing each resident's individuality for 2 of 18 residents (Resident # 28 and Resident # 42) reviewed for resident rights.
1. The facility failed to ensure Resident #28's dignity when dining while the Nurse Practitioner assessed the resident's foot callous at the dining room table while the resident was eating with other residents eating .
2. The facility failed to ensure Resident #42 had toilet paper, paper towels and soap in dispenser for personal hygiene use.
These failures could place residents at risk for a decreased quality of life, decreased self-esteem and increase anxiety.
Findings include:
1. Record review of Resident #28's face sheet, dated 04/17/2024, indicated an [AGE] year-old female who was admitted on [DATE]. Resident #28 had diagnoses which included Dementia with other behavioral disturbances (general term for loss of memory, language, problem solving and thinking was severe enough to interfere with daily life), Cognitive communication deficit (problems with communicating), Depression (loss of pleasure or interest in activities for long periods of time) and Anxiety (feeling of fear, dread, and uneasiness).
Record review of the MDS Quarterly Assessment, dated 2/22/2024, indicated Resident #28 was sometimes understood and sometimes understood others. Resident #28 had a BIMS score of 3, which indicated severe cognitive impairment. Resident #28 required supervision for most ADL's.
Record review of Resident #28's care plan, revised on 11/6/2023, indicated Resident #28 was at risk for behavioral problems. There was an intervention to intervene as necessary to protect the rights and safety of others by removing resident to an alternative location when needed to protect the rights and safety of others.
During an observation on 4/16/2024 at 12:18 p.m. revealed, Resident #28 was sitting at a table with all memory care residents in the dining area. The Nurse Practicioner was knelt beside Resident #28 assessing her right foot at the dinner table while other residents looked on. The Nurse Practitioner was spreading each toe out inspecting Resident #28 right foot and said she did not have a wound but a large callous. A resident to the right of Resident #28 was observing during the assessment while eating lunch.
During an interview on 4/16/2024 at 12:30 p.m., the Nurse Practitioner said it was not usual practice for her to assess her residents while they were eating. She stated she usually had the resident return to their room, and it depended on the situation. The Nurse Practitioner said she was going to make a referral for the resident to see the podiatrist . There were approximately 10-12 residents in the dining room at the time of the assessment.
During an interview on 4/17/2024 at 11:13 a.m., LVN D said it was not appropriate for a nurse, Nurse Practitioner or Physician to remove a resident's socks or shoes to assess their feet while at the dinner table. The resident could feel embarrassed. LVN D said he had not observed any staff assessing residents at mealtimes .
During an interview on 4/17/2024 at 11:26 a.m., LVN E said it would be a dignity issue to assess a resident's feet while eating at the table with other residents. LVN E said she would offer to take the residents to their room to be assessed privately even on the memory unit. LVN E said if she observed a clinician such as a doctor or Nurse Practitioner performing an assessment in a public area, she would report to management. LVN E said a resident could feel humiliated .
During an interview on 4/17/2024 at 11:34 a.m., the ADON said she would wait after the meal was completed to assess a resident. The ADON said she could see where assessing a resident while they were eating would make them feel uncomfortable. The ADON said she would check the resident's cognitive level. The ADON said it could make another resident wonder why they were performing an assessment at the table and may not want to observe. The ADON said she expected staff to perform assessments and care in a more private room area where other residents were not around.
During an interview on 4/17/2024, the DON said it depended on where you were and if the resident wore shoes. The DON said the resident initiated the encounter with the Nurse Practitioner and allowed the Nurse Practitioner to observe her foot at the dining table while she was eating. The DON said she did not have an issue due to the resident having a mentation that allowed her to know what was going on. The DON said there was 100% confusion on the memory care unit. The DON said she would assume the Nurse Practitioner would explain to the family what was going on if the family came in the facility. The DON said Resident #28 was willing to allow the Nurse Practitioner to observe her at the time and stuck her foot up. The DON said all residents with memory issues should be treated with dignity and respect but that was not what happened, and she did not feel it was a dignity issue with Resident #28.
During an interview on 4/17/2024, the ADM said resident's care was based on the resident's particular need. The ADM said the Nurse Practitioner making rounds should not have assessed the resident's feet during a meal. The ADM said the resident should have privacy when assessing a resident's skin or foot would not need to take place during their meal. The ADM said she would offer the resident go to another room, attempt to move resident to another area, or come back at another time if a resident offered to be assessed at the dining table. The ADM said she would redirect the resident and wait till after meal. The ADM said she would want to base care on the resident's memory needs.
2. Record review of Resident #42's face sheet, dated 4/17/2024, indicated Resident #42 was a [AGE] year-old female who was admitted on [DATE]. Resident #42 had diagnoses which included Hyperlipidemia (a condition in which there are high levels of fat particles in the blood), Dementia (general term for loss of memory, language, problem solving and thinking was severe enough to interfere with daily life), anxiety ((feeling of fear, dread, and uneasiness) and ulcerative (chronic) pancolitis with other complications (form of inflammatory bowel disease characterized by widespread inflammation affecting the entire colon).
Record review of the MDS Optional State Assessment, dated 1/11/2024, indicated Resident #42 was usually understood and sometimes understood others. Resident #42 had a BIMS score of 3, which indicated severe cognitive impairment. Resident #42 required limited assistance with toileting.
Record review of Resident #42's care plan, revised on 2/26/2024, indicated Resident #42 was at risk for behavioral problems and incontinence of bowel and bladder. There was an intervention to assess and anticipate resident's needs such as food, thirst, toileting needs, comfort level, body positioning and pain.
During an observation on 4/15/2024 at 9:47 a.m., Resident #42 bathroom had a brown residue in the sink, no paper towels, no soap in the dispenser and no toilet paper. Resident #42 said when she urinated, she would drip dry and she said if she had a bowel movement, she would use paper towels from the dining room she collected during meals from her tray. Resident #42 pulled open her top drawer of her dresser cabinet and she showed napkins from her dining room tray she had stacked in her dresser drawer. Resident #42 said she ran her hands under water in her bathroom sink and did not use soap. Resident #42 said the facility never had soap in her bathroom .
During an interview on 4/17/2024 at 9:25 a.m., CNA B said when she came in the morning, she would get the residents up for the day. CNA B said she would gather the resident's clothes and take them to the shower room for the residents with a scheduled shower. CNA B said she would get the residents ready for their day by changing their briefs if they were wet, performed perineal -care to freshen them up, brush hair, brush teeth, and wash their face. CNA B said there were residents who could go to the bathroom on their own. CNA B said the facility did not keep toilet paper in the resident's room because residents would wipe and clog the toilets. CNA B could not identify what the residents used to get clean after toileting. CNA B could not identify residents who washed their hands after leaving their bathroom. CNA B said residents who did not have proper hand hygiene would be at risk for infection if they got feces on their hands and then in their mouth. CNA B said she did touch doors and other objects the residents touched which could cause staff to become sick and affect others around her. CNA B said the staff checked the rooms to see if they needed to be cleaned and CNA B said she would take care of it if she could. CNA B said the residents did not use hand sanitizer while on the memory unit.
During an interview on 4/17/2024 at 9:40 a.m., CNA A said she would get the residents up before breakfast and took them down to the shower room to get them cleaned up and dressed by brushing their teeth, washing their face and hands. CNA A said the residents did not have wash cloths or soap in their rooms. CNA A said everyone should have soap, but residents would put it in their hair. CNA A said the housekeeper supplied the toilet paper. CNA A said the housekeeper knew which resident rooms to put toilet paper in. CNA A said she checked the residents every 2 hours to ensure they were clean. CNA A said she was not sure how the residents were wiping because the residents must ask staff, and staff brought them wipes. CNA A said if a resident did not have access to toilet paper, soap and paper towels, it would be nasty, and they could get an infection. CNA A said not being cleaned properly could place the residents at risk for skin issues or cause their bottom to get red. CNA A said staff were at risk for infection if objects were touched by residents who had not washed their hands, then staff touched objects the residents touched. CNA A said the majority of the residents did need supplies in their room.
During an interview on 4/17/2024 at 9:56 a.m., LVN E said residents started their day getting up and sitting in the main room or going to the shower room. LVN E said residents were scheduled for a shower, they would go to the shower room. LVN E said the staff performed morning care for all residents. LVN E said the evening shift would get up 6 residents to receive morning care. LVN E said there were certain residents who received paper towels and toilet paper. LVN E said she was not sure how the residents washed their hands. LVN E said she was unaware residents did not have soap in their dispenser and there was no way to determine who had washed their hands. LVN E said residents and other staff could get contaminated and become sick. LVN E said she expected resident's hands to be washed prior to meals and between meals as needed.
During an interview on 4/17/2024 at 10:11 a.m., Hospitality Aid F said she was the housekeeper for Hall 3 and the Memory care unit. Hospitality Aid F said she went in the morning and emptied the trash out of the rooms and checked the paper towels, toilet paper and soap dispensers. Hospitality Aid F said she was instructed by her supervisor not to place paper towels and toilet paper on the memory unit due to residents clogging the toilets. Hospitality Aid F said Aides told her not to put soap in the dispenser in the resident's rooms. She said residents not washing their hands could contaminate other surfaces other residents and staff touched placing them at risk for infection. Hospitality Aide F said this was the resident's home and they should have access to toilet paper, paper towels and soap.
During an interview on 4/17/2024 at 10:39 a.m., Hospitality Aide G said she was the supervisor for housekeeping. She said toilet paper and paper towels were not being placed in the resident's room. Hospitality Aid G said the residents were to use the dining room bathroom and shower room bathroom to wash their hands and use the bathroom. Hospitality Aide G said residents would put paper towels and toilet paper in their toilet. Hospitality Aide G said she was not sure which residents were independent with toileting. She said the facility was no longer putting soap in the dispensers in the resident's rooms on the memory hall due to residents putting soap on their face and hands. Hospitality Aide G said upper department heads made the decision not to put paper products in the resident's bathrooms and was told the staff would be responsible for washing and tending to the resident hygiene. Hospitality Aide G said handwashing was important for all residents and staff.
During an interview on 4/17/2024 at 11:34 a.m., ADON P said residents on the memory care unit did not have toilet paper in their rooms due to residents stopping up toilets, sinks and stuffing paper towels in the sinks which caused water to overflow. ADON P said the staff on the unit were responsible for washing all the resident's hands in the morning before breakfast and changed residents to prepare them for the day. ADON P said the staff kept rounding and identified residents who needed to be changed. ADON P said she was not aware of who was washing and getting personal care completed after residents toileted. ADON P said she would not want residents using a sock or drip dry after toileting.
During an interview on 4/17/2024 at 11:45 a.m., the DON said the facility staff talked about the toilet paper, paper towels in the past due to plumbing issues from resident's stuffing things in the toilet. The DON said the facility was going to take another look at the issue. The DON said she observed staff, and they made sure the residents had hand sanitizer. The DON said she discussed with staff to make more frequent rounds to make sure the residents were not taking off their brief and placing them in drawers or under the mattress. The DON said the facility needed to do a case-by-case evaluation.
During an interview on 4/17/2024 at 1:14 PM, the ADM said the residents on the memory unit were taking paper towels and toilet paper and sticking them in their own orifices. The ADM said paper towels, toilet paper and soap were not in the rooms on the memory hall. The ADM said there was not a policy just concern for the well-being of the residents. The ADM said the facility had plumbing issues related to the residents on the memory unit stuffing paper towels and toilet paper down the sink. The ADM said the unit staff had access to the main bathroom on the hall and the shower room they could take residents to use during the day. The ADM said the hand sanitizers and soap were removed due to resident putting it in their drinks. The ADM said the facility was re-evaluating and seeking alternative options for residents to ensure proper hygiene was achieved.
Record review of the facility policy, dated 2/16/2020, titled Promoting/Maintaining Resident Dignity, reflected . It is practice of the facility to promote care for residents in a manner and in an environment that maintains or enhances each resident's dignity and respect . What is dignity .innate quality of being a human .a person's self-esteem .Process: 1. All staff members are involved in providing care to residents to promote and maintain resident dignity .2. During interactions with residents, staff must report, document and act upon information regarding a resident preference .6. Respond to request for assistance in a timely manner which include but not limited to responding to call lights, toileting/incontinence, and personal needs .12. Maintain resident privacy
Record review of the facility's, undated and untitled, policy reflected Standard Bathroom Cleaning indicated .daily cleaning of the bathrooms, restrooms and tub-shower rooms help provide a sanitary environment, prevent odors, control infectious material, and prolong the useful life of the equipment .Procedure .empty and sanitize toilet, using bowl brush daily .add bowl cleaner one time per week, more if necessary
CONCERN
(D)
Potential for Harm - no one hurt, but risky conditions existed
Safe Environment
(Tag F0584)
Could have caused harm · This affected 1 resident
**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, interview and record review the facility failed to ensure residents had the right to a safe, clean, comfor...
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**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, interview and record review the facility failed to ensure residents had the right to a safe, clean, comfortable and homelike environment, including but not limited to receiving treatment and supports for daily living safely for 1 of 6 (Resident #33) residents reviewed for environment.
1. The facility failed to ensure Resident #33's bathroom sink was free of brown substances.
2. The facility failed to ensure soiled briefs were removed from Resident #33's trash can.
These failures could place residents at risk of an unsafe or uncomfortable environment and a decrease in quality of life and self-worth.
Findings include:
Record review of Resident #33's, undated face sheet reflected a [AGE] year-old female who was admitted to the facility on [DATE]. Resident #33 had diagnoses which included CVA (damage to the brain from interruption of its blood supply), hypertension (high blood pressure) and Alzheimer's disease (progressive disease that destroys memory and other important mental functions).
Record review Resident #33's quarterly MDS assessment, dated 02/14/2024, reflected Resident #33 had a BIMS of 02, which indicated severe cognitive impairment. Resident #33 had no behaviors, was frequently incontinent of bowel and bladder and was dependent on staff for personal hygiene and toileting.
Record review of Resident #33's care plan indicated no care plans for behaviors. The care plan, dated 02/14/2024, indicated Resident #33 was frequently incontinent of bowel and bladder and required assistance of 1 staff member for incontinent care.
During an observation on 04/15/2024 at 9:30 a.m. revealed the bathroom of Resident #33 was noted to have a brown foul-smelling substance smeared throughout the sink. There were no paper towels and no soap in the bathroom. There was a soiled brief in the trash can next to the toilet. The mirror was covered in a white film.
During an observation on 04/16/2024 at 10:20 a.m. revealed the bathroom of Resident #33 continued to have a brown foul-smelling substance smeared throughout the sink. There were still no paper towels or soap in the bathroom.
During an interview on 04/15/2024 at 10:00 a.m., the family member of Resident #33 stated the only complaint they had about Resident #33's care was the bathroom was always dirty and looked like a rundown truck stop bathroom. The family member stated there was rarely any soap or paper towels and she liked to wash Resident #33's hands prior to her eating meals. The family member of Resident #33 stated she was unsure if it was Resident #33 or the resident next door who shared the bathroom with her who was smearing what appeared to be feces on the lavatory and mirror. She stated she felt like housekeeping should be cleaning those areas more frequently for sanitation reasons. She also stated Resident #33 would have been devastated prior to her illness to have a bathroom in the state of filth her bathroom was currently in.
During an interview on 04/17/2024 at 11:00 a.m., CNA A stated there were several resident rooms and bathrooms that needed to be deep cleaned. CNA A stated the housekeepers were supposed to come and clean all the rooms and bathrooms each day. She stated the housekeepers were supposed to come back multiple times per day and clean, but they usually only came once a day. CNA A stated over the last 7 days she worked, today was the first day staff ensured all the soap dispenses and toilet paper holders were full for all residents. CNA A stated she alerted housekeeping when she saw them when a room was in need of cleaning.
During an interview on 04/17/2024 at 11:30 a.m., Housekeeper Y stated it was her job when she was assigned to the memory care unit to ensure all the rooms and bathrooms were cleaned daily. She stated she came back to the memory care after each meal and cleaned the dining rooms. She stated she was unaware of why no one had cleaned Resident #33's bathroom on 04/15/2024 and 04/16/2024. She stated it was the responsibility of the housekeeper working the memory care unit to make sure it was done. She stated the Housekeeping Supervisor had their own area to clean and was not always available to check behind the housekeeping staff.
During an interview on 04/17/2024 at 12:45 p.m., the ADM stated she expected the housekeeping policy to be followed by all housekeepers in each area of the building. The ADM stated there were a few residents on the memory care unit that were not provided soap in their rooms but were encouraged by the staff to wash their hands in the shower room for safety of the residents. The ADM viewed Resident #33's bathroom and stated the condition of the Resident #33's bathroom was unacceptable. The ADM stated the IDT would brainstorm as a team on a way to ensure all residents had access to a clean restroom and ways to wash their hands after using the bathroom and before meals.
Record review of the facility's, undated, policy titled Resident Room Cleaning indicated, Daily cleaning of the bathrooms, restrooms and tub-shower rooms helps to provide a sanitary environment, prevent odors, control infectious material, and prolong the useful life of the equipment, paint, and floor finish . Clean and dust all fixtures, use high duster on any hard-to-reach areas. Use cleanser on sink for any stains. Shine chrome with damp cloth and mild cleaning solution. Use glass cleaner on mirrors.
CONCERN
(D)
Potential for Harm - no one hurt, but risky conditions existed
Deficiency F0655
(Tag F0655)
Could have caused harm · This affected 1 resident
**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on interview and record review the facility failed to develop and implement a baseline care plan for each resident that in...
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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 baseline care plan for each resident that included the instructions needed to provide effective and person-centered care of the resident that met professional standards of quality care within 48 hours of a resident's admission and included the minimum healthcare information necessary to properly care for a resident for 2 of 7 residents (Resident #181 and Resident #182) reviewed for care plans.
The facility failed to develop and implement a baseline care plan within 48 hours of admission for Residents #181 and #182.
This failure could place residents at risk of not receiving care and services to meet their needs.
Findings include:
1. Record review of Resident #181's, undated, face sheet reflected a [AGE] year-old female who was admitted to the facility on [DATE]. Resident #181 had diagnoses which included traumatic subdural hematoma (bleeding fills the brain area very rapidly, compressing brain tissue), dementia (progressive disease that destroys memory and other important mental functions) and anxiety.
Record review of an incomplete admission MDS assessment, dated 04/15/2024, reflected Resident #181 had a BIMS of 02, which indicated severe cognitive impairment. The discharge plan for Resident #181 was to remain in the facility long-term.
Record review of the baseline care for Resident #181 reflected no baseline care plan was initiated prior to survey intervention.
2. Record review of Resident #182's, undated, face sheet reflected Resident #182 was a [AGE] year-old female who was admitted to the facility on [DATE]. Resident #182had diagnoses which included dementia (progressive disease that destroys memory and other important mental functions), hypertension (high-blood pressure) and hypothyroidism (progressive disease that destroys memory and other important mental functions).
Record review of an incomplete admission MDS assessment, dated 04/22/2024, reflected an incomplete MDS in progress.
Record review of the baseline care plan for Resident #182 reflected no baseline care plan was initiated prior to survey intervention.
During an interview on 04/17/2024 at 12:30 p.m., the DON stated the baseline care plan was an interdisciplinary team responsibility. The interdisciplinary team consisted of the Social Worker, Activities Department, the nurse, therapy and dietary department. The DON stated a meeting was to be scheduled by the Social Worker with the resident and their family and each department had a section to complete. The DON was not aware the baseline care plan was to be completed within 48 hours of admission. The DON stated the baseline care plans for Residents #181 and #182 were not completed until 04/16/2024 after surveyor intervention. The DON stated the facility completed an in-service about timeliness of the completion of baseline care plans on 04/12/2024 with all IDT members that included the timeline for completion of the baseline care plan. The DON stated the baseline care plan acted as a set of instructions to follow for the resident's care. The DON stated not having a baseline care plan would make it hard for staff to give accurate care to the individual needs of each resident.
During an interview on 04/17/2024 at 12:45 p.m., the Administrator stated she expected the staff members to do their part to complete the baseline care plans. She felt baseline care plans were important information to help the staff care for each resident. The ADM stated it was hard to care for new residents without having an outline and the baseline care plan gave the staff an outline until the MDS was completed and the comprehensive care plan was created to guide resident care.
Record review of an in-service, dated 04/12/2024, signed by the Dietary Manager, Activities Director, Social Worker, and therapy department indicated the facility must have a baseline care plan meeting within 48 hours of the admission of the resident and implement a baseline care plan for all newly admitted residents.
Record review of the facility policy, dated 11/08/2026, titled Baseline Care Plan, indicated the baseline care plans are developed and implemented within 48 hours of a resident's new admission Baseline care plans are developed by the Registered Nurses and other healthcare team members.
CONCERN
(D)
Potential for Harm - no one hurt, but risky conditions existed
Deficiency F0657
(Tag F0657)
Could have caused harm · This affected 1 resident
**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on interview and record review the facility failed to ensure the comprehensive care plan was reviewed and revised by the i...
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**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on interview and record review the facility failed to ensure the comprehensive care plan was reviewed and revised by the interdisciplinary team after each assessment, including both the comprehensive and quarterly review assessments for 1 of 20 residents (Resident #20) reviewed for care plans.
The facility failed to revise Resident #20's care plan to reflect his choice to be a DNR.
This failure could place residents at risk for not receiving appropriate care and interventions to meet their current choices and needs.
Findings include:
Record review of Resident #20's, undated, face sheet indicated an [AGE] year-old male who was admitted to the facility on [DATE].
Record review of Resident #20's physician's orders, dated [DATE] , indicated Resident #20 had diagnoses which included: Parkinson's Disease (a disorder of the nervous system that affects movement, often including tremors), Cerebrovascular Disease (affects blood flow to the brain) and dementia (persistent loss of intellectual functioning).
Record review of Resident #20's physician's order, dated [DATE], indicated Resident #20 was a DNR.
Record review of Resident #20's OOH-DNR indicated it was signed on [DATE] by Resident #20's family member.
Record review of the care plan, dated [DATE], indicated Resident #20 had impaired cognition with a risk for further decline and indicated he was a full code. Resident has physician's orders that include a status of full code. The goal indicated staff would administer CPR if resident had an arrest. The interventions were to ensure the full code order was on the chart and begin CPR after absence of vital signs, call 911, notify physician, and notify family/responsible party.
Record review of the admission MDS, dated [DATE], indicated Resident #20 had clear speech, was sometimes understood by others, and sometimes understood others. Resident #20 had a BIMS score of 6, which indicated severe cognitive impairment. He had inattention that was continuously present.
Record review of the care plan on [DATE] at 11:05 AM indicated Resident #20 was full code.
Record review of the physician's orders, dated [DATE], indicated Resident #20 was a DNR. The DNR was ordered by the physician on [DATE].
Record review of an OOH-DNR for Resident #20 was dated [DATE] .
During an interview on [DATE] at 11:39 AM, MDS Q said the care plan was an IDT approach. She said different staff were responsible for the care plan in the different disciplines put different things in the care plan. She said the person responsible for the code status of a resident was the SW .
During an interview and record review on [DATE] at 11:41 AM, the DON and the State Surveyor looked at Resident #20's care plan. The DON agreed the care plan indicated the resident was full code. She and she looked at his DNR, dated [DATE], and she stated she knew he was a DNR. She said his care plan should have been changed and updated to indicate he was a DNR, and it was not. She said his most recent care plan meeting was Wednesday [DATE] and the next day, [DATE] his family member came in and signed a DNR with the SW. She said the SW should have updated the care plan when she got the DNR paperwork. The SW and the DON reviewed the resident's physician's orders for a DNR, dated [DATE] and an OOH-DNR also dated [DATE]. She said the process was, whoever received the DNR paperwork should change the care plan. She said the SW did not change the care plan and it was her responsibility. She said ultimately, she was responsible for the care plan being updated to reflect the current status of Resident #20 because she was the DON.
During an interview on [DATE] at 12:34 PM, the DON said the advance directive policy indicated the SW should document all DNR's. She said the SW knew it was her responsibility, and it was she who met with the family to discuss and complete the DNR.
During an interview on [DATE] at 2:39 PM, the SW said she met with Resident #20's family to do the DNR on [DATE]. She said she was supposed to update the care plan but got busy and did not do it. She said it was her responsibility to update the care plan and she should have done it .
During an interview on [DATE] at 12:07 PM, LVN R said the importance of code status on the care plan was for nurses to know whether or not to perform CPR on a resident. She said she would not want to do CPR if a resident was a DNR because it could cause a poor quality of life. She said you would certainly want to do CPR on a resident who had chosen a full code status. She said nurses had to know whether a resident was a full code or a DNR and their information had to be documented correctly. She said if staff did CPR on a resident who chose a DNR, that resident could end up on a tracheostomy (surgically created hole in the neck to allow air into the lungs) or life support. She said a DNR or a full code was the resident/family's choice to make. She said resident choices were very important. She said the SW was responsible for making sure the code status was documented correctly on the care plan.
During an interview on [DATE] at 12:14 PM, LVN S said code status was important. She said if a resident was a DNR and they gave that resident CPR and revived them, they could be in a lot of trouble. She said if a resident was a full code and they thought the resident was a DNR, and did not try to revive them the resident could die. She said they had to be sure all information was in the care plan correctly. She said the residents choice was very important. She said the SW was responsible for making sure a resident's code status was correct in the care plan.
During an interview on [DATE] at 12:23 PM, ADON P said the resident's code status on the care plan was how they determined whether or not to initiate CPR for a resident. She said it was very important for the information to be correct regarding the resident's choices. She said if a resident was a DNR and they did CPR, it could cause harm to the resident because they could have broken bones during CPR, caused a poor quality of life, caused the resident's family to be upset, not acknowledged the resident's wishes or their right to choose. ADON P said if it was the other way around, and a resident was a full code and did not get CPR, they could die. She said the family would be very upset if the facility did not try to save them.
During an interview on [DATE] at 1:11 PM, the DON said she expected the SW or the licensed staff who received DNR paperwork to update the care plan. She said she thought Resident #20's care plan not being updated with the new DNR order was an oversite on the part of the SW. She said she expected the care plan to be updated with the resident's wishes regarding a full code or a DNR. The DON said it would be a big problem if a resident who was a DNR was given CPR because that was a dignity issue and not the resident's wishes. She said that could cause the resident depression and a poor quality of life. She said giving a DNR resident CPR would be the worst scenario ever. She said if you did not give CPR to a resident who was a full code it could cause a resident to die before they should and not attempting to save their life. She said that was playing with someone's life. She said if the wishes of the resident were not followed it could also cause the family to be grievous.
During an interview on [DATE] at 1:41 PM, the ADM said she expected the care plan to be correct regarding a resident's code status. She said the SW was responsible for making sure the care plan was updated to reflect the correct code status. She said the SW's responsibility for the care plan was the code status. She said regarding Resident #20's incorrect care plan (which indicated he was a full code when he was a DNR) that could have caused him to get CPR when that was against his wishes and it could be a dignity issue. She said they had a code book that ADON P updated with new information and staff could look in the book to see who was a DNR and who was a full code. She said she did not know if Resident #20's code status was updated in the Code Book . She said if a resident was a full code and incorrectly marked as a DNR the resident could die when they should not have, and that could cause legal issues. She said resident choices were important.
During an interview and record review on [DATE] at 1:46 PM, ADON P showed the State Surveyor the Code Book which included a DNR for Resident #20 and a copy of his OOH-DNR dated [DATE]. She said she put the information for Resident #20's code status in the Code Book but did not remember when.
Record review of an Advance Directives/Advance Care Planning Policy, dated 4/2007, revised 1/2023, and 4/2015, indicated:
Policy
It is the policy of this facility to recognize two fundamental rights of a person; the right to live and to continue treatment and the right to refuse or terminate unwanted treatment. This facility will honor a resident's wished and advanced directives pertaining to his/her own medical treatment, including wishes to withhold treatment .
In the absence of the Social Worker the Administrator appoints a staff member to assume the responsibility for advance directives and advanced care planning.
.8.Social Service communicates to a nursing a residents advanced directive/code status implementation or changes.
Record review of the Comprehensive Care Plans Policy, dated [DATE], indicated:
Policy
It is the policy of this facility to develop and implement a comprehensive person-centered care plan for each resident, consistent with resident rights, that includes measurable objectives and time frames to meet a resident's medical, nursing, and mental and psychosocial needs that are identified in the resident's comprehensive assessment.
.3.The comprehensive care plan will describe, at a minimum, the following:
a.
The services that are to be furnished to attain or maintain the resident's highest practicable physical, mental, and psychosocial well-being.
b.
Any services that would otherwise be furnished, but are not provided due to the resident's exercise of his or her right to refuse treatment .
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 the resident environment remained as free of acc...
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**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, interview and record review the facility failed to ensure the resident environment remained as free of accident hazards as was possible and residents received adequate supervision and assistance devices to prevent accidents for 2 of 6 residents (Residents #39 and #9) reviewed for accident hazards.
1. The facility failed to ensure Resident #39's shoulder seat belt was buckled prior to transport. Resident #39 slid out of the wheelchair to the floor when the facility transportation van stopped at a stop sign.
2. The facility failed to ensure CNA H and LVN I transferred Resident #9 safely when they tilted Resident #9's wheelchair back onto the anti-tip bars with all 4 wheelchair wheels not touching the floor and lowered Resident #9 into the wheelchair via mechanical lift.
3. The facility failed to ensure CNA H and LVN I ensured the mechanical lift legs were in the widest position while transferring Resident #9 from bed to her wheelchair.
These failures could place residents at risk of falls which could result in injury and hospitalization.
Findings include:
1. Record review of Resident #39's face sheet, dated 04/15/24, reflected a [AGE] year-old male who was admitted to the facility on [DATE]. Resident #39 had diagnoses which included: end stage renal disease (kidney failure), pressure ulcer of sacral region stage 4 (full-thickness skin loss extends through the fascia with considerable tissue loss) and peripheral vascular disease (a circulatory condition in which narrowed blood vessels reduce blood flow to the limbs).
Record review of Resident #39's quarterly MDS assessment, dated 3/25/24, reflected Resident #39 was usually understood and usually understood others. Resident #39 had a BIMS score 12, which indicated moderate cognitive impairment. Resident #39 required x2 assistance for bed mobility, transfer, toilet use and x1 assistance for personal hygiene and bathing.
Record review of Resident #39 care plan, dated 4/16/24, reflected he required pressure relieving/reducing devices on bed/chair. Resident #39 has an air mattress bed. Resident #39 required reposition frequently or more often as needed or requested. Interventions included to approach Resident #39 in a calm manner. Resident #39 requested to called by name, spoken to slowly, maintain eye contact, talked while care provided, allow time for a response and do not rush.
During an interview and observation on 04/16/24 at 08:27 AM revealed Resident #39 was sitting in his bedroom in wheelchair. Resident #39 said, the day I slipped out of the seat, [Driver X] did not hook me up right. Resident #39 said [Driver X] was going 80 miles per hour down the highway, then he got on the brake and I slipped out of the wheelchair. Resident #39 said when he slipped out of his wheelchair, he hurt his wounds: on his knee, right arm and buttock. Resident #39 said after Driver X realized he had slipped out of his wheelchair, Driver X pulled over to a gas station to place him back in his wheelchair. Resident #39 said Driver X asked him if he was hurt, if he wanted to go to the emergency room or did he want to go back to the facility. Resident #39 said he told Driver X he was fine and he still wanted to go to his appointment. Resident #39 said Driver X did not drive fast he just got to where he was going. Resident #39 said Driver X strapped down his wheelchair, but he forgot to put his seat belt on.
During an interview on 04/16/24 at 02:16 PM Resident #14 said she remembered the incident when Resident #39 slipped out of his wheelchair. Resident #14 said Driver X did not check Resident #39 before they left the facility. Resident #14 said Driver X put Resident #39 on the van and probably thought he had secured Resident #39, but evidently Resident #39 was not secured in the van. Resident #14 said Resident #39 was not in his chair good. Resident #14 said Driver X secured her and her wheelchair like he always did. Resident #14 said Driver X usually checked everyone before he left the facility. Resident #14 said it scared her when Resident #39 got out of his wheelchair. Resident #14 said Driver X did not drive fast. Resident #14 said she thought this was an accident and Resident #39 just was not in his wheelchair good. Resident #14 said she thought Resident #39 slid out of the chair and hit her wheelchair. Resident #14 said as soon as Driver X realized Resident #39 came out of his wheelchair, he immediately got off the highway and pulled over to the gas station. Resident #14 said Driver X checked on Resident #39 and got him back into his wheelchair. Resident #14 said she remembered Resident #39 said he was not hurt and he wanted to go to his appointment; after the incident. Resident #14 said after Driver X checked on Resident #39 and got him back in his chair they went to the doctor appointments, then back to the facility safely.
During an interview on 04/17/24 at 08:52 AM, Driver Z said she was in-serviced and checked off on the transportation van on 4/08/24. Driver Z said, the process of loading a resident was, let the emergency brake down on the van. Secure the resident on the lift with a seat belt and lock the wheelchair before going up with the lift. Driver Z said there were 4 straps that went around the wheelchair and locked the wheelchair to secure. Driver Z said place the over the body seat belt over the resident prior to leaving the facility. Driver Z said she felt confident to transport the residents safely.
During an interview on 04/17/24 at 09:53 AM, Driver X said he had two transports the morning of 4/1/24. Driver X said he secured Resident #14 in van first. Driver X said he thought he secured Resident #39's wheelchair and seat belt prior to departure from the facility. Driver X said, it does not make sense, why would I secure one resident and not the other one. Driver X said he felt like Resident #39 took the shoulder seat belt off his self. Driver X said they got to the four-way stop at the highway, then Resident #39 slid out of his wheelchair. Driver X said there were times when Resident #39 refused to wear his seat belt and said it made his stomach hurt and did not put it on tight, but Driver X would encourage Resident #39 he had to wear the seat belt. Driver X said in the past Resident #39 had refused to wear a seat belt and had taken off the seat belt during a previous transport. Driver X said he was terminated from the facility due to the incident.
During an interview on 4/17/24 at 2:42 PM, the DON said Resident #39 went to an appointment and Driver X forgot to put the shoulder strap across Resident #39. The DON said Resident #39 and Driver X were on their way to an appointment and Driver X got on the brake at a stop sign and Resident #39 slid out of his wheelchair to the floor. The DON said Resident #39 denied injuries due to the fall and denied hitting his head. The DON said Resident #39 said he just fell on the floor. The DON said Driver X did not notify the facility or Police and left the scene. The DON said there were no residents in the van at the time of the accident. The DON said after the accident with the hit and run Driver X and other van drivers were in-serviced. The DON said the staff was in-serviced over if an incident or accident happened while out on transport staff were expected to call the facility to notify management and Police, if necessary. The DON said after the accident with Resident #39 the van drivers were in-serviced on safety precautions, following policy and procedures. The DON said Driver X was terminated after the incident with Resident #39. The DON said there was a failure because Driver X forgot or got distracted and did not place the seat belt on Resident #39. The DON said, the bottom-line Resident #39 should have had a seat belt on prior to leaving the facility.
During an interview on 4/17/24 at 2:57 PM, the Administrator said Driver X returned to the facility from a transport with Resident #14 and Resident #39. The Administrator said Driver X notified management, he forgot to put Resident #39's shoulder strap on and the resident slid out of his wheelchair onto the floor of the van, due to Driver X stopped at a stop sign. The Administrator said Resident #39 had a lift pad between him and the seat and there was not a grip. The Administrator said Driver X pulled over to the gas station and checked to see if Resident #39 was injured, after Resident #39 denied injuries Driver X replaced Resident #39 back into his wheelchair. The Administrator said Driver X said he asked Resident #39 if he wanted to go back to the facility or Emergency Room. The Administrator said Driver X said Resident #39 refused and said he wanted to go to his appointment. The Administrator said Driver X assured the shoulder strap was secured and they went to appointments. The Administrator said when Resident #39 returned to the facility a nurse assessed him for injuries and Resident #39 said he was not injured. The Administrator said the nurse notified Resident #39's Physician and family of incident. The Administrator said x-rays were ordered and performed, no abnormal findings were noted. The Administrator said Resident #39 told staff his back hurt, but he had a history of back pain. The Administrator said Resident #39 had pain medication for back pain and the facility kept the pain controlled. The Administrator said staff checked on Resident #14 and got her statement of the incident. The Administrator said Resident #14's statement collaborated with Driver X's statement on the incident. The Administrator said the facility suspended Driver X while the investigation was pending. The Administrator said Driver X and three other staff members were certified to drive the facility van were in serviced on if an incident or accident happened while on a transport, they were to notify the facility as soon as possible or local police if necessary. The Administrator said the facility terminated Driver X, because the incident with Resident #39 and Driver X had incident in November 2023. The Administrator said Driver X was in facility van and was hit from behind. The Administrator said the driver of the car that hit the facility van ran and Driver X did not notify the facility or local police and left the scene to return to the facility. The Administrator said the facility in-serviced Driver X after an incident or accident to notify the facility, but he did not. The Administrator said her expectation was for Driver X to stop and notify the facility or 911 for assistance to ensure Resident #39 was able to be moved. The Administrator said Driver X did not have the credentials to make the decision to move Resident #39. The Administrator said Driver X admitted he felt rushed, Resident #39 was hard to deal with and he should have notified the facility of the incident when it happened. The Administrator said Driver X's defense for no notification to the facility was he was tried to make Resident #14 and Resident #39 to their appointments on time. The Administrator said the incident occurred and Driver X's failure could have caused more than potential harm to Resident #39.
Record review of in-services and staff signatures dated 4/1/24, on Properly securing passenger for transport, loading and unloading passenger.
Record review of van Orientation Checklists, dated on 4/1/24, for Driver X.
These 3 record reviews moved up and documented in section 1 with the info about the van driver incident. (That is a quote of what they said.)
Record review of the Maintenance Policy & Procedure Manual, dated 03/11/13, reflected . In order for our Residents to maintain the highest practical, physical, mental and psychological wellbeing it is the policy of this facility vehicle (Van) for residents who because of medical or special needs, require transportation.
Record review of the, undated, Van driver job Description reflected .The overall purpose of the Van Driver position is to transport Facility Residents to prearranged physician and/ or dialysis appointments and/or to transport Residents on scheduled outings arranged by the Facility.
Record review of Transportation Policy and Procedure for Center-Based Vehicle, dated 11/16/2023, reflected for our Residents to maintain the highest practical, physical, mental and psychological wellbeing it is the policy of this facility vehicle (Van) for residents who because of medical or special needs, require transportation.
2. Record review of Resident #9's face sheet, dated 4/16/2024, indicated a [AGE] year-old female who was admitted to the facility on [DATE]. Resident #9 had diagnoses which included: type 2 diabetes mellitus with hyperglycemia (high blood sugar), unspecified fall and morbid obesity (severely overweight).
Record review of Resident #9's quarterly MDS, dated [DATE], indicated Resident #9 had clear speech, sometimes made self-understood, and sometimes had the ability to understand others. Resident #9's BIMS was 10, which indicated mild cognitive impairment. Resident #9 was totally dependent with bed mobility, and transfers.
Record review of Resident #9's care plan, dated 11/10/2021, indicated Resident #9 had an ADL self-care deficit with an intervention: Transfers: staff x 2 hoyer lift. Resident #9 had the potential for falls with interventions that included: Anticipate and meet the resident's needs .Follow facility fall protocol.
During an observation on 4/15/2024 at 11:07 AM, CNA H and LVN I placed a lift sling under Resident #9 while she was lying in bed. CNA H pushed the Hoyer lift under the bed and CNA H and LVN I attached the straps of the sling onto the Hoyer lift bar. CNA H raised the Hoyer lift until Resident #9 was lifted off the bed. CNA H and LVN I turned the Hoyer lift without opening the Hoyer lift legs to the widest position until the Hoyer lift was facing the resident's wheelchair. LVN I then opened the Hoyer lift legs to the widest position and CNA H placed the wheelchair between the opened Hoyer lift legs. CNA H then braced her body against the wall in Resident #9's room and tilted the resident's wheelchair all the way back where it was on the anti-tip bars, all 4 wheels were off the floor and the back of the wheelchair was resting on CNA H's thighs. LVN I began lowering the Hoyer lift as CNA H was pulling the sling and Resident #9 to guide her placement in the wheel chair. Once Resident #9 was in the wheelchair CNA H then grabbed the wheelchair handles that were resting on her thighs and slowly pulled the wheelchair back into an upright position. CNA H and LVN I removed the sling straps from the Hoyer lift bar.
During an attempted interview on 4/15/2024 at 11:35 AM revealed Resident #9 was not able to answer questions due to cognitive impairment.
During an interview on 4/15/2024 at 11:22 AM, CNA H said she did not feel the transfer was a safe transfer. She said it was probably not the safest way to do the transfer. She said she should have gone and asked therapy to help with a safe transfer for the resident. She said the resident could have fallen out of the w/c on top of her on the floor and got hurt.
During an interview on 4/15/2024 at 11:28 AM, LVN I said she did not feel like the transfer was a safe transfer. She said the legs on the Hoyer lift should have been opened when the resident was raised in the Hoyer lift. She said it was not safe when CNA H tipped the wheelchair all the way back on the anti-tip bars and braced herself against the wall with the wheelchair in her lap. She said she thought maybe the staff were trained in a new way that she was not aware of to transfer Resident #9. She said she should have stopped the transfer at that time. She said Resident #9 could have fallen on the floor or on top of the CNA H and either one of them could have been hurt.
During an interview on 4/17/2024 at 10:51 AM, OT O said was is okay for the chair to be pulled back a little bit but once the anti-tip bars touch the floor that's where it should stop. She said the lift legs should have been opened earlier as soon as it was safe. She said if transfers were not performed correctly the resident was at risk of flipping back in the wheelchair and falling.
During an interview on 4/17/2024 at 11:04 AM, PTA N said she had worked at the facility for 1 1/2 years. She said in this facility therapy did not usually do Hoyer lift transfers due to it not being a skilled task. She said in her opinion the lift legs should be open before the resident was connected to the Hoyer lift. She said the legs being opened stabilized the Hoyer lift and was safer for the resident. She said the anti-tippers on the back of wheelchairs were to keep the resident from tipping the chair backwards. She said the anti-tippers were not made to support the weight of a resident. She said the anti-tippers could break and cause harm or injury to the resident.
During an interview on 4/17/2024 at 11:25 AM, ADON P said typically the Hoyer lift legs were closed while the Hoyer lift was under the bed, and prior to the resident being moved in the Hoyer lift, the Hoyer lift legs should be opened. She said no CNA should ever pull a resident back in the wheelchair to where only the anti-tipping bars were touching the floor. She said using Hoyer lifts or wheelchairs incorrectly could cause injury to the resident or staff.
During an interview on 4/17/2024 at 11:32 AM, the DON said it depended on the space in a resident's room as to when the Hoyer lift legs were opened. She said if there was space, they should be opened as soon as the lift was pulled out from under the bed. She said it was not possible to open the legs of the lift while the lift was still under the bed. She said a resident's wheelchair should never be pulled back on the anti-tip bars while transferring a resident into the wheelchair. She said incorrectly done transfers could cause staff and residents to get hurt.
During an interview on 04/17/24 at 11:48 AM, the Administrator said the lift legs should be opened as soon as there was enough space to open the legs. She said she did not see how it was possible for a wheelchair to be tipped back on the anti-tipping bars while transferring a resident. She said the anti-tip bars could break, and the resident could fall and get hurt.
Record review of the facility's, undated, policy titled Hydraulic Lift (Hoyer Lift) reflected the purpose: to enable one individual to lift and move a resident safely, with as little effort as possible .open lift to the widest point and set brakes . 13. Position wheelchair and lock brakes. Swing resident's feet off bed. When resident has been lifted clear of bed, grasp bar and move to chair . 14. Push gently on knees as resident is being lowered into chair to correct position and maintain balance. Lower resident slowly.
Record review of the, undated, manufacturer's instructions for the Span F600B mechanical lift reflected: The F600B is intended to be used for transfers of the patient in and out of bed, their wheelchair, to and from the commode, or any other type of surface. Page 13 of the manufacturer's instructions indicated: Operating Instructions .Preparation Before Lifting .Widen the base and disengage the caster brakes.
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, in accordance with State and Federal laws, stor...
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**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, interview and record review the facility failed to ensure, in accordance with State and Federal laws, store all drugs and biologicals in locked compartments under proper temperature controls, and permitted only authorized personnel to have access to the keys for 2 of 4 medication carts (Medication cart on hall 1 and medication cart hall 2) reviewed for pharmacy services.
The facility failed to lock the medication carts for hall 1 and hall 2.
This failure could place residents at risk of not having their medications available as prescribed, a drug diversion, and an adverse reaction if accessed.
Findings include:
During an observation on 4/17/2024 at 7:21 a.m., LVN D was observed preparing insulin during morning medication pass. LVN D had his medication cart pulled in front of the resident door and turned his back away from his medication cart to administer insulin to the Resident #25. LVN D did not to lock his medication cart LVN D returned to the cart and locked his medication cart and went to the resident's beside to administer the insulin as scheduled . There were no staff or residents observed in hallway while cart was unlocked.
During an observation and interview on 4/17/2024 at 7:50 a.m., CMA C's medication cart was located outside room [ROOM NUMBER] and was unlocked as CMA C was in the resident's room. CMA C came out of room and realized her medication cart was unlocked and locked her cart. There were no residents, staff or visitors passing through the hall during the identified unlocked cart. CMA C said she switched carts and grabbed the blood pressure cuff and went in another room. CMA C said the medication carts should always be locked when not in use and she failed to lock the cart while checking on another resident.
During an observation on 4/17/2024 at 7:50 a.m., the medication cart for hall 1 had the following medications:
1.
Drawer 1: Vitamins such as Vitamin D (supplement for Vitamin deficiency), Multiple Vitamins (supplements); Aspirin (medication used for pain or inflammation), stool softener, Fiber (supplement used for constipation) and eye drops (lubricant).
2.
Drawer 2: Liquid Levetiracetam 100 mg/ml (medication used to treat seizures)
3.
Drawer 3: Overflow with extra scheduled medications for resident room [ROOM NUMBER]-28 B. Metformin 1000 mg capsules (medication used to lower blood sugar), Gabapentin 300 mg capsules (medication used for neuropathy pain), MiraLAX (stool softener), Sani wipes (product used to disinfect equipment)
4.
Drawer 4: Cups, straws
During an observation on 4/17/2024 at 11:10 a.m., medication cart for hall 2 observed to have following:
1.
Drawer 1: eye drops (eye lubricant), insulin pens (decrease blood sugar), nitroglycerin (used to treat chest pains)
2.
Drawer 2: Amlodipine 5 mg (blood pressure medication), Sertraline 50 mg (antidepressant), OTC Melatonin (sleep aid), Pepcid (stomach acid reducer), Colace (stool softener)
3.
Drawer 3 Breathing treatments Bromide/Albuterol (breathing treatment), Nyamyc (medication used to treat fungal infections)
4.
Drawer 4: Overflow, cups, feeding, gloves, gowns and overflow and a prescription drug Cyclobenzaprine (muscle relaxer).
During an interview on 4/17/2024 at 9:00 a.m., CMA C said she was responsible for her medication cart. CMA C said anyone passing by could get in an unlocked medication cart. CMA C said she was concerned there was an emergency with a resident and went in the room. CMA C said the resident had a question about her medications and her voice did not sound like an emergency. CMA C said if a resident went to an unlocked medication cart, they could take medications not prescribed. CMA C said medications could cause nausea, vomiting, increased sickness, or their blood pressure could drop.
During an interview on 4/17/2024 at 10:05 a.m., LVN E said medication carts should always be locked when not in use. LVN E said there were medications and things residents, visitors or other staff members could get out of the medication cart and could cause a drug diversion. The LVN said the nurse or CMA who was scheduled to the cart was responsible for the medication cart and should lock the medication cart when not being used.
During an interview on 4/17/2024 at 11:13 a.m., LVN D said the medication cart should always be locked while not in use. LVN D said it could put the residents and visitors at risk if they get into the medication cart. LVN D said a resident could have an adverse reaction to a medication if it was not prescribed to them. LVN D said the medication cart should be locked even if your back was turned against the medication cart.
During an interview on 4/17/2024 at 11:45 a.m., ADON P said she expected the medication carts to be always locked while not in use. ADON P said a resident passing, staff or visitors could get in the medication cart and take something they did not need without staff aware and have an adverse reaction to a medication not prescribed to them. ADON P said it could include death if resulted in a reaction or insulin not prescribed.
During an interview on 4/17/2024 at 12:08 p.m., the DON said she expected the nurses and CMA assigned to the cart to keep them locked when not in use. The DON said if the cart was within eye site, it could be unlocked, and she said it was acceptable for the cart to be unlocked if the cart was facing inside the resident room even if they turned their back. The DON said no one could get past the medication to get in the drawer if the cart was turned inside the doorway of the resident's room and said it was acceptable.
During an interview on 4/17/2024 at 1:12 p.m., the ADM said the medication carts were to be locked and the CMA or nurse assigned were responsible for the medication carts. The ADM said if the cart was within the nurse's eye site, it was okay for the cart to be unlocked if they had eye site on the cart. The ADM said if it was out of eye site, the cart should be locked. The ADM stated she expected the carts to be locked if unattended on the hall.
Record review of the facility's policy, dated 1/20/2021, titled Medication Storage indicated it was the policy of this facility to ensure all medications housed on our premises will be stored, dated, and labeled according to the manufacturer's recommendations and sufficient to ensure proper sanitation, temperature, light ventilation, moisture control, segregation, and security . General guidelines . All drugs and biologicals will be stored in locked compartments (i.e., medication carts, cabinets, drawers, refrigerators, medication rooms) .Only authorized personnel will have access to the keys to locked compartments .during medication pass, medications must be under the direct observation of the person administering the medications or locked in the medication storage area/cart
CONCERN
(E)
📢 Someone Reported This
A family member, employee, or ombudsman was alarmed enough to file a formal complaint
Potential for Harm - no one hurt, but risky conditions existed
Infection Control
(Tag F0880)
Could have caused harm · This affected multiple residents
**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, interview, and record review, the facility failed to establish and maintain an infection prevention and co...
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**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, interview, and record review, the facility failed to establish and maintain an infection prevention and control program designed to provide a safe, sanitary, and comfortable environment, and to help prevent the development and transmission of communicable diseases and infections for 2 of 4 residents (Residents # 20 and #52) reviewed for infection control practices.
1.LVN T failed to change her gloves after performing foley care on Resident #20 and touched clean surfaces.
2.CNA K failed to wash or sanitize her hands when changing gloves while performing foley catheter care for Resident #52.
3. CNA J and CNA K failed to wash or sanitize their hands after performing foley catheter care for Resident #52.
These failures could place residents at risk of exposure to communicable diseases, cross-contamination and infections.
1. Record review of Resident #20's, undated, face sheet indicated an [AGE] year-old male who was admitted to the facility on 3/15/24.
Record review of Resident #20's physician's orders, dated 4/16/24 , indicated Resident #20 had diagnoses which included: Parkinson's Disease (a disorder of the nervous system that affects movement, often including tremors), Cerebrovascular Disease (affects blood flow to the brain), flaccid neuropathic bladder (hyperstimulation of the nerves and muscles leading to urinary retention and the inability to fully empty the bladder) and Stage 3 pressure ulcer to the sacrum (an injury that breaks down the skin and underlying tissue).
Record review of Resident #20's physician's order, dated 3/18/24, indicated:
Urinary catheter 16 FR, 10cc, bulb to gravity.
Record review of the admission MDS, dated [DATE], indicated Resident #20 had clear speech, was sometimes understood by others, and sometimes understood others. Resident #20 had a BIMS score of 6, which indicated severe cognitive impairment. The MDS indicated under H0300, Urinary Continence 9. Not rated, resident had a catheter (indwelling, condom), urinary ostomy, or no urine output for the entire 7 days.
Record review of the care plan, dated 3/21/24, indicated Resident #20 had impaired cognition with a risk for further decline. Resident #20 had a urinary catheter and was at risk for urinary tract infections and injury. Urinary catheter care was to be provided per facility practice.
During an observation on 4/16/24 at 1:28 PM, LVN T and CNA V donned gowns and after washing their hands, donned gloves. LVN T performed foley care for Resident #20. CNA V assisted LVN T. LVN T performed foley care and did not change her gloves. She touched Resident #20's brief, blanket and bed side table with the same gloves. After covering Resident #20 and adjusting the bed side table she took off her gloves and washed her hands.
During an interview on 04/16/24 01:38 PM, LVN T said she should have changed her gloves after the foley care when her gloves were dirty and before touching the resident's brief, blanket and bed side table. She said she was trained to change her gloves and clean her hands after foley care, and she did not because she was nervous. She said what she did was an infection control issue and could spread infection.
During an interview on 4/17/24 at 12:02 PM, CNA W said it was important to take dirty gloves off before touching anything clean to prevent spreading germs. She said staff had to take off their dirty gloves, wash their hands and re-glove, if needed. She said it was an infection control issue to touch items or residents with dirty gloves. She said she was trained to remove her dirty gloves before touching anything clean and washing her hands to prevent infection.
During an interview on 04/17/24 at 12:07 PM, LVN R said when doing foley or incontinent care it was an infection control issue to touch clean items when gloves were dirty. She said dirty gloves should be taken off immediately and hands washed before touching anything clean. She said anything could be spread by contact and could make the resident sick or sicker.
During an interview on 4/17/24 at 12:14 PM, LVN S said dirty gloves should not touch clean items because that would be cross-contamination and could cause infection to the resident. She said dirty gloves should be swapped out for clean gloves, after hand washing during foley care.
During an interview on 4/17/24 at 12:23 PM, ADON P said touching clean surfaces with dirty gloves could cause cross contamination of the clean area especially if someone else touched the dirty area with clean gloves or hands. She said the danger to the resident was infection, weight loss and an infection could require the resident to be on antibiotics. She said touching clean surfaces with dirty gloves was bad all the way around.
During an interview on 4/17/24 at 1:11 PM, the DON said regarding foley care, a staff should never touch resident's items with dirty gloves. She said to do that was cross-contamination which could spread infection or cause infection. She said she expected staff to go by their training and change their gloves after a dirty procedure and perform hand hygiene. She said dirty gloves should be changed and hand hygiene performed before going to a clean area.
During an interview on 4/17/24 at 1:41 PM, the ADM said she expected staff to follow best practices learned when obtaining their licensure. She said if a staff had dirty gloves on and touched a clean area it was cross-contamination and could cause infection. She said it was definitely an infection control issue and could cause a resident to become sick.
Record review of a skills check off entitled Nursing Hand Hygiene, dated 10/16/23, indicated LVN T was competent in hand hygiene.
Record review of a skills check off entitled Provides Catheter Care for Female, dated 8/8/23, indicated LVN T was competent in catheter care.
2. Record review of Resident #52's face sheet, dated 4/17/2024, indicated a [AGE] year-old male who was admitted to the facility on [DATE]. His diagnoses included hemiplegia and hemiparesis following cerebral infarction affecting left non-dominant side (unable to move the left side of his body), type 2 diabetes mellitus with hyperglycemia (high blood sugar) and obstructive and reflux uropathy (urine cannot drain through the urinary tract).
Record review of Resident #52's care plan, dated 11/10/2021, indicated he had a urinary catheter related to obstructive uropathy with interventions to provide urinary catheter care per facility practice and to position the catheter bag and tubing below the level of the bladder.
Record review of Resident #52's annual MDS, dated [DATE], indicated he was rarely/never understood, and a BIMS score that was not able to be obtained. He required total dependence with one-person physical assist with bed mobility, dressing, toilet use and personal hygiene. He was always incontinent of bowel. Bladder was not rated due to having a foley catheter in place.
During an observation on 4/16/2024 at 3:12 PM in Resident #52's room revealed, CNA J and CNA K were present to provide foley catheter care. Both staff washed their hands in the assisted dining room before entering Resident #52's room. CNA J and CNA K stopped at linen cart in the hallway and applied gowns 2 doors down from Resident #52's room. CNA J and CNA K both knocked on the resident's door and entered the room. CNA J and CNA K sanitized their hands and donned gloves at the bedside. CNA J and CNA K positioned Resident #52 in supine position to perform his foley catheter care. CNA J doffed gloves and sanitized hands, CNA K doffed gloves and did not sanitize her hands and donned new gloves. CNA J removed the blanket from Resident #52 and placed the foley catheter bag and tubing on the bed next to his leg. CNA K placed a trash bag at the end of the bed. CNA J removed a wipe from the over the bed table and began cleaning around the foley catheter insertion site working in a downward motion. LVN E placed the wipes in the trash bag at the end of the bed. After CNA J completed the foley catheter care, CNA K repositioned Resident #52. CNA J, without changing gloves, took the foley catheter bag off the bed and positioned it under the mattress below bladder level. CNA J and CNA K pulled the resident up in bed without changing gloves, sanitizing or washing hands. CNA J and CNA K both doffed gloves and said skill complete without washing or sanitizing hands. CNA J then removed the trash bag at the end of the bed and placed it in the trash can in the resident's room. Both CNA J and CNA K stopped before exiting residents' room and doffed gowns then exited the room. Once in the hallway CNA J and CNA K said skill not complete we forgot to wash our hands and went over to the hand sanitizer station in the hallway and sanitized their hands. CNA J doffed clean gloves and re-entered residents' room and retrieved the trash bag from the trash can and walked down the hallway and disposed the trash bag in trash barrel.
During an interview on 4/17/2024 at 3:31 PM, CNA K said she had been employed at the facility for about 1 year and 5 months., CAN K said she should have sanitized her hands when she doffed her gloves after positioning the resident. She said both CNA J and CNA K should have washed their hands after doffing gloves before they said, skill complete. She said residents could be at risk of an infection if they did not wash or sanitize their hands when changing their gloves.
During an interview on 4/17/2024 at 3:34 PM, CNA J said she had been employed at the facility for about 2 years. CNA J said she should not have gone back into the resident's room to retrieve the trash bag after she doffed her gown. She said CNA K should have sanitized her hands between glove changes after repositioning Resident #52. She said it was not the proper procedure for CNA K to have placed the trash bag on the end of the bed. She said residents could be at risk of an infection if they did not wash or sanitize their hands when changing their gloves.
Record review of the Validation Checklist, dated 5/20/2023, for CNA K indicated she was trained and had demonstrated hand hygiene procedure in accordance with the facility's standard of practice.
Record review of the Nursing Assistant Clinical Skills Checklist and Competency Evaluation, dated 8/16/2023, for CNA J indicated she was trained and had demonstrated hand hygiene procedure in accordance with the facility's standard of practice.
Record review of the facility's policy titled Indwelling Foley Catheter Guidelines, dated 5/23/2014 and reviewed on 2/10/20, indicated: The facility shall identify and assess patients with an indwelling catheter or at risk for catheterization, provide appropriate treatment and services to prevent urinary tract infections and to achieve or maintain as much normal bladder function as possible, and ensure that indwelling catheters are medically necessary .Perform hand hygiene immediately before and after insertion or any manipulation of the catheter .Keep the collecting bag below the level of the bladder at all times.
Record review of the facility's policy titled Hand Hygiene, dated 2/20/20, with a revised date of 2/11/2022, indicated: All staff will perform proper hand hygiene procedures to prevent the spread of infection to other personnel, residents, and visitors. This applies to all staff working in all locations within the facility .The use of gloves does not replace hand hygiene. If your task requires gloves, perform hand hygiene prior to donning gloves, and immediately after removing gloves.
Record review of the facility's policy titled Infection Control Guidelines dated 2/2007 with a revised date of 9/22/2015, indicated: The purpose for this policy is to reduce and prevent the spread of infections by the use of evidenced based techniques established infection control policies and procedures .Staff shall use hand hygiene when coming on duty, between patient contacts, after handling contaminated objects, after PPE removal, and before going off duty .Staff shall wash their hands with an antiseptic preparation before performing patient care procedures and when providing care to patients in isolation.
Record Review of the facility's policy titled Infection Prevention and Control Program, dated 10/24/2022 and revised on 4/12/2023, indicated: This facility has established and maintains an infection prevention and control program designed to provide a safe, sanitary, and comfortable environment and to help prevent the development and transmission of communicable diseases and infections as per accepted national standards and guidelines .Hand hygiene shall be performed in accordance with out facility's established hand hygiene procedures .All staff are expected to provide care consistent with infection control practices.
Mar 2023
13 deficiencies
3 IJ (1 facility-wide)
CRITICAL
(K)
Immediate Jeopardy (IJ) - the most serious Medicare violation
Notification of Changes
(Tag F0580)
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 immediately consult with the resident's physician when...
Read full inspector narrative →
**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, interview, and record review the facility failed to immediately consult with the resident's physician when there was significant change in the resident's physical, mental, or psychosocial status for 2 of 6 residents reviewed for notification of changes. (Resident #'s 45 and 74)
The facility failed to notify the resident's physician when Resident #45 had worsening symptomatic shingles (painful rash with blisters) covering his right eye lid.
The facility failed to notify the resident's physician when Resident #74 had diarrhea since admission on [DATE].
An Immediate Jeopardy (IJ) situation was identified on 02/28/2023 at 4:47 p.m. While the IJ was removed on the 03/03/2023 at 1:21 p.m., the facility remained out of compliance at an actual harm with a scope of pattern with a potential for more than minimal harm, due to the facility's need to evaluate the effectiveness of the corrective systems.
These failures could place residents at risk of their physicians not being aware of the resident conditions and delay treatments for the residents' conditions of loss of vision and/or loss of life.
Findings included:
1)Record review of a face sheet dated 03/02/2023 indicated Resident #45 was an [AGE] year-old male who admitted on [DATE] and readmitted on [DATE] with the diagnoses of heart failure, depression, malnutrition, and high blood pressure.
Record review of the most recent Significant change MDS dated [DATE] indicated Resident #45 was usually understood and usually understood others. The MDS indicated Resident #45's BIMS score was 11 indicating he had moderately impaired cognition. The MDS indicated during the assessment period Resident #45 did not reject care. The MDS indicated Resident #45 required extensive assistance of one staff with bed mobility, dressing, toilet use, personal hygiene, and with bathing Resident #45 required total assistance of one staff member.
Record review of the consolidated physician's orders dated 03/01/2023 indicated Resident #45 had Acyclovir 800 milligrams 5 times daily for 5 days for possible shingles(painful rash with blisters) started on 03/01/2023. Resident #45 had Clindamycin 300 milligrams three times a day for cellulitis (potentially serious bacterial skin infection) x 7 days started on 02/28/2023 and Doxycycline Monohydrate 100 mg twice a day for cellulitis until 03/07/2023. Resident #45 was also ordered Gentamicin Sulfate Ophthalmic ointment 0.3% 1 application in right eye two times a day for infection x 7 days to start on 02/28/2023.
Record review of the comprehensive care plan dated 11/09/2022 revealed it did not address that Resident #45 had shingles involving his face and right eye. The comprehensive care plan did not address isolation precautions.
Record review of Resident #45's February 2023 electronic medication administration record indicated these medications were ordered and administered medications: Acyclovir 800 milligrams one tablet three times a day for shingles for 7 days started on 02/20/2023 and completed on 02/27/2023. Resident #45 was ordered Ofloxacin Ophthalmic Solution 0.3% one drop to the right eye 4 times daily for 5 days starting on 02/20/2023. Acyclovir 800 milligrams was restarted on 02/28/2023, Ofloxacin Ophthalmic Solution 0.3% instill one drop in right eye at bedtime for 7 days started on 2/27/2023, and Doxycycline 100 milligram give one tablet twice daily for 7 days started on 02/28/2023.
Record review of Resident #45's March 2023 electronic medication record indicated these medications were ordered and administered: Gentamicin Sulfate Ophthalmic Ointment 0.3% instill one application in the right eye two times a day for 7 days starting on 03/01/2023, Ofloxacin Ophthalmic Solution 0.3% instill one drop in right eye at bedtime for 7 days starting on 02/27/2023; Doxycycline monohydrate 100 milligrams one capsule twice daily for cellulitis until 03/07/2023; and Clindamycin 300 mg one capsule by moth three times a day for cellulitis for 7 days; and Acyclovir 800 milligrams one tablet by mouth 5 times a day for 5 days for possible shingles starting on 03/01/2023.
Record review of a nursing note dated 02/20/2023 at 10:12 a.m., indicated LVN G wrote the physician was notified regarding Resident #45's redness, swelling, and matter to his right eye.
Record review of a nursing note dated 02/20/2023 at 10:54 a.m., indicated LVN G wrote he received new orders for Acyclovir 800 milligrams three times a day for 7 days, ofloxacin 0.3% one drop in right eye four times a day for 5 days, appointment with an ophthalmologist and to check a HSV ig M level (anti-body test to indicate a current or recent infection).
Record review of a nursing note dated 02/20/2023 at 8:34 p.m., indicated LVN M wrote monitoring for edema (swelling) every day and night shift, with the right side of Resident #45's face/eye with edema with the MD aware with laboratory test ordered.
Record review of a nursing note dated 02/21/2023 at 1:03 a.m., indicated LVN M wrote that the right side of Resident #45's face/eye continued with edema and redness, and Resident #45 denied pain. LVN M noted Resident #45's family member would like to see if the facility ophthalmologist could see Resident #45 instead of having to be transferred out of the facility.
Record review of a nursing note dated 02/22/2023 at 9:08 a.m., indicated LVN O wrote that Resident #45 continued the Acyclovir eye drops to his eye every night, continued to assess for pain, discomfort, and changes.
During an observation on 02/27/2023 at 12:17 p.m. revealed, Resident #45 was lying in his bed. He had scabbing appearing areas to his right eye and forehead. Resident #45's right eye was scabbed closed, and he could not open it when requested Resident #45 said he did not know what was on his face and eye.
During an interview on 02/27/2023 at 12:26 p.m., CNA N said she was told Resident #45 had shingles (painful rash with blisters) and not been on any isolation precautions. CNA N said she regularly careds for Resident #45 and had floated to other halls to help. CNA N said she had questioned the DON today as to why Resident #45 was not on any type of isolation because she said shingles were contagious. CNA N said Resident #45 did not eat his noon meal because he was hurting from the shingles.
During an interview on 02/27/2023 at 8:55 a.m., the DON said the nurses had not realized Resident #45 required isolation due to shingles being a contagious communicable disease. The DON said the nurses did not make her aware of Resident #45 having shingles when the symptoms started. The DON said Resident #45 should have been placed on contact isolation. The DON said the risk for unvaccinated and residents who had not had chicken pox as a child were at risk of having shingles. The DON said she was unaware Resident #45 had an order to see an ophthalmologist related to his right eye. The DON said they facility's eye physician had already made rounds around February 9th or the 10th 2023. The DON said she had not contacted the mobile eye physician or the family member with a plan to have Resident #45's right eye examined. The DON said shingles in the eye could result in vision loss for Resident #45. The DON said she was the infection preventionist for the building. The DON said she was unsure how Resident #45's infection of the shingles was missed because she said the nurse managers log the infections and review the orders in morning meeting. The DON said the physician should be notified immediately when symptoms occur or worsen.
Record review of a nurses note written by LVN P dated 02/28/2023 at 12:57 p.m., revealed Resident #45 had an appointment scheduled for March 2, 2023, at 3:15 p.m. The note indicated Resident #45's family member was notified of the appointment related to shingles to the right eye.
Record review of a nurse note dated 02/28/2023 at 1:06 p.m., indicated Resident #45 was administered a Tramadol 50 milligram tablet for pain to his right eye.
During an interview on 02/28/2023 at 3:11 p.m., LVN P said she had worked February 19, 2023, through February 23, 2023 and had observed Resident #45 during that time period. LVN P said Resident #45's eye was much worse than when she last saw the eye on February 23, 2023. LVN P said the medical record did not indicate any one had contacted the physician for Resident #45's worsening shingles.
During an interview on 02/28/2023 at 3:26 p.m., the Medical Director said she was #45's physician and she said she was unaware of Resident #45's right eye condition with shingles covering the entire eye lid and the right eye would not open. The Medical Director said she was unaware Resident #45 had not seen an eye specialist related to the shingles to the right side of the face and eye. The Medical Director said she expected the facility to obtain an appointment promptly due to the risk of blindness with ocular shingles.
During an observation and interview on 02/28/2023 at 3:45 p.m., revealed LVN P applied a warm compress to Resident #45's right eye. LVN P asked Resident #45 to open his right eye, and he could not open the eye at all. Resident #45 said his right eye was hurting and LVN P immediately stopped and said she would administer a pain medication. LVN P said she would notify the physician.
Record review of a nurse note dated 02/28/2023 at 8:03 p.m., indicated the ADON wrote Resident #45's family was notified of the lab results of the Herpes Simplex IgM (antibody test of recent or current infection) result of 0.66 and a new order was received from the physician for Clindamycin 300 mg one three times and day and discontinue the Acyclovir.
Record review of a medication administration record dated February 2023 indicated Clindamycin 300 mg was administered on 02/28/2023.
During an interview on 02/28/2023 9:57 a.m., the responsible party for Resident #45 said he was never told officially Resident #45 had shingles (painful rash with blisters). Resident #45's responsible party said he asked if the mobile eye doctor could see Resident #45 but he definitely would have had him sent to another local eye physician if Resident #45 needed to go.
Record review of a nurse note dated 02/28/2022 at 8:21 p.m., indicated the DON wrote Resident #45's isolation was discontinued for shingle precautions and indicated Resident #45 had a new diagnosis of cellulitis and with a new medication ordered. The new order was Clindamycin 300 mg one capsule three times a day for 7 days.
Record review of a nurse note dated 02/28/2023 at 11:08 p.m., indicated LVN B wrote Resident #45 was administered gentamycin eye drops. LVN B wrote Resident #45 face was red and swollen with blisters and scabs.
During an interview on 02/28/2023 at 10:07 a.m., the Interim Administrator said she was unaware of Resident #45 having shingles.
Record review of a nurse note dated 03/01/2023 at 1:24 a.m., indicated LVN B documented Resident #45 had a diagnosis of cellulitis, day 2 of isolation, acyclovir was discontinued, day 2 of 7 on Ofloxacin and G entamicin eye drops, day 3 of 7 on doxycycline with no adverse reactions. The note indicated Resident #45 had redness, swelling, and scabs to his face and a warm compress was used.
During an interview on 03/01/2023 at 8:34 a.m., the Regional Corporate Nurse said after digging deeper the lab result for an IgM level (antibody level detecting recent or new infection) was 0.66 which was negative. The Regional Corporate Nurse said Resident #45 was negative for shingles but was being treated for cellulitis.
During an observation and interview on 03/01/2023 at 9:18 a.m., Resident #45 said his right eye was hurting. Resident #45 had a very minimal opening between his eye lids and there was yellow stingy material in the opening.
During an interview on 03/01/2023 at 2:57 p.m., the Medical Director indicated initially Resident #45's rash appeared to be shingles. The medical director indicated the IgM test was negative for antibodies.
On 02/20/2023. The medical director said she would complete a PCR HSV and VSV (recommended testing for diagnosing of shingles), and place Resident #45 back on isolation. The medical director said she would order a PCR HSV and VSV because the test would be the most accurate test for diagnosing shingles according to CDC recommendation.
Record review of a nurses note dated 03/01/2023 at 6:24 p.m., indicated the ADON wrote she notified the Resident #45's family member on of the new orders to restart Acyclovir 800 milligrams five times daily x 5 days, PCR HSV and VZV lab, and reinstate the isolation precautions.
Record review of an incident report dated 03/02/2023 at 3:30 p.m., indicated Resident #45 slid from his wheelchair to the floor. The ADON wrote there were no injuries noted but Resident #45 was sent to the emergency room.
Record review of an After Visit Summary dated 03/02/2023 indicated Resident #45 was provided instructions related to shingles and minor head injury. The summary indicated his diagnoses included an unspecified fall, facial contusion, and herpes zoster (shingles). The educational material included in the Visit Summary report indicated:
*If the shingles affects your eye the doctor may cover your eye with a bandage
*Infections of the eye and the skin around the eye were other health problems to treat
*To prevent the shingles do not share towels, go swimming, or play contact sports with people who have shingles if you never had chicken pox.
*Do not touch or scratch your rashes, if you do wash your hand afterwards.
2) Record review of a face sheet dated 03/02/2023 indicated Resident #74 was an [AGE] year-old female who admitted on [DATE] with the diagnoses of spondylolisthesis (disorder of which a bone vertebra slips forward onto the bone below), eating disorder, and high blood pressure.
Record review of an admission MDS dated [DATE] indicated Resident #74 was usually understood and usually understood others. The MDS indicated Resident #74 BIMS score was a 13 indicating she was cognitively intact. The MDS indicated Resident #74 required extensive assistance of one staff with bed mobility, transfers, locomotion, toilet use, personal hygiene, and bathing. The MDS indicated Resident #74 was frequently incontinent of bowel and was not on a toileting plan.
Record review of a Baseline care plan dated 01/24/2023 at 8:39 a.m., indicated the ADON did not document Resident #74 had a recent history of Clostridium Difficile from the physicians history and physical (inflammation of the colon cause by bacteria), diarrhea, or isolation precautions needed for on-going symptoms.
Record review of the comprehensive care plan dated 02/07/2023 indicated Resident #74 was at risk for Covid 19 infection but the care plan did not mention Clostridium Difficile or the need for isolation precautions.
Record review of the February 2023 electronic medication record indicated Resident #74 received Colestipol 1 gram twice daily for treating diarrhea since 01/24/2023, lactobacillus capsule one capsule by mouth twice daily, and Lomotil 2.5-0.025 milligrams one tablet every 6 hours as needed for diarrhea since 01/24/2023. The electronic medication record indicated Resident #74 had 8 doses in the month of February and two doses were unknown if effective.
Record review of a nursing progress note dated 01/24/2023 documented by LVN T indicated Resident #74 was post C-diff.
Record review of a nursing progress note dated 01/31/2023 at 1:22 a.m., indicated LVN V administered Lomotil for diarrhea, but the medication was ineffective. The note did not indicate the physician was notified.
Record review of a nursing progress note dated 01/31/2023 at 12:24 p.m., indicated LVN F documented Resident #74 was administered Lomotil for diarrhea.
Record review of a skilled nurses note dated 02/01/2023 at 12:48 a.m., indicated LVN T documented Resident #74 was post C-diff.
Record review of a progress note dated 02/01/2023 at 1:30 a.m., indicated Resident #74 was administered Lomotil for diarrhea by LVN M.
Record review of a nursing note dated 02/03/2023 at 5:40 a.m., LVN T documented an administration of Lomotil for diarrhea was provided to Resident #74.
Record review of a nurses note dated 02/04/2023 at 3:32 a.m., indicated LVN R documented Resident #74 was post C-diff.
Record review of a nurses note dated 02/04/2023 at 3:32 a.m., indicated LVN R documented Resident #74 was post C-diff.
Record review of a nurses note dated 02/06/2023 at 8:37 a.m., indicated LVN S documented Resident #74 was post C-diff.
Record review of a nurses note dated 02/06/2023 at 11:18 p.m., LVN T documented Resident #74 required the administration of Lomotil for diarrhea.
Record review of a nurses note dated 02/07/2023 at 11:40 p.m., LVN T documented Resident #74 required Lomotil administration related to diarrhea.
Record review of a nurses note dated 02/15/2023 at 9:42 p.m., LVN T documented Resident #74 required administration of Lomotil for diarrhea.
Record review of a nurses note dated 02/24/2023 at 12:54 a.m., indicated LVN PP documented Resident #74 continued to have been monitored for diarrhea none on this shift. The note failed to indicate the physician was notified.
Record review of a nurses note dated 02/25/2023 at 6:41 a.m., indicated LVN T documented that Resident #74 had 3 diarrhea bowel movements with Lomotil given and effective at present. The note indicated Resident #74's peri area was very red. LVN T indicated she notified the physician and was waiting on orders.
Record review of a nurses note dated 02/25/2023 at 8:59 a.m., indicated LVN D apply Nystatin ointment to Resident #74's inner thighs and buttocks for redness.
Record review of a nurses note dated 02/25/2023 at 6:41 a.m., indicated LVN D received a new order for Nystatin ointment and zinc oxide twice daily for 30 days.
Record review of a nurses note dated 02/25/2023 at 6:43 p.m., indicated LVN B documented Resident #74 required Lomotil for diarrhea and the medication was effective. The note did not reflect LVN B notified the physician.
During an interview an observation on 02/27/2023 at 10:08 a.m., Resident #74 said her brief needed changing due to having a very large diarrhea bowel movement. Resident #74 said she thought she should return to the hospital due to her continuous diarrhea since she left the hospital. Resident #74 was assisted to activate her call light for assistance. CNA C answered the call light and left the room. CNA C returned with bed linen and incontinent care supplies. CNA C washed her hands then initiated care to Resident #74. LVN F said Resident #74 has had diarrhea since admission. LVN F said he had been trying to obtain a stool sample but the stool was so loose the bowel movement absorbed in the brief.
Record review of the physician's orders dated February 2023 did not reveal a stool specimen was ordered by the physician.
Record review of a nurses note dated 02/27/2023 at 5:55 p.m., indicated LVN F documented Resident #74 made the statement she thought she needed to return to the hospital due to the ongoing diarrhea. LVN F documented he informed Resident #74 he had a stool sample waiting for pickup.
During an interview on 02/28/2023 at 7:51 a.m., the Housekeeping Supervisor said she was unaware there were residents with possible Clostridium Difficile. The Housekeeping Supervisor said for Clostridium Difficile there was a special tablet to add to the water for cleaning of these rooms. The housekeeping supervisor said she was also unaware of Resident #74 or Resident #45 having communicable disease processes requiring special laundry procedures. The housekeeping supervisor said when the laundry receives linen in the yellow bags the laundry personnel would be alerted to wash this linen separate from the general linen.
During an interview on 02/28/2023 at 3:26 p.m., the physician for Resident #74 said Resident #74 had Clostridium Difficile in the recent past. The physician said she was not notified Resident #74 had on-going diarrhea since admission. The physician said Resident #74 could be a carrier of Clostridium Difficile.
Record review of a hydration assessment completed by the DON dated 02/28/2023 indicated Resident #74 had poor skin turgor, had more than a 3-pound weight loss in a month, and was at risk due to diarrhea/vomiting occurred in the last 7 days.
Record review of a Notification Policy dated 07/13/2015 and revised on 02/12/2023 indicated the policy was to provide guidance on when to communicate acute changes in status to MD, NP, and responsible party. The facility will immediately inform the resident; consult with the resident's physician; and if known, the resident's legal representative or appropriate family members of the following:
1.
An accident resulting in injury to the resident that potentially requires physician's intervention
2.
An emergency response situation that requires EMS involvement
3.
A significant change in the physical, mental, or psychosocial status of the resident.
4.
The need to significantly alter the resident's treatment.
5.
A decision to transfer or discharge the resident to another facility.
6.
A change in room or roommate assignment.
7.
A change in resident rights under Federal or State law, including changes to items and services included under State plans.
8.
The facility's Medical Director will be contacted if the attending or admitting physician can not be contacted and/or does not respond timely.
This was determined to be an Immediate Jeopardy (IJ) situation on 02/28/2023 at 4:47 p.m. The Interim Administrator and the Regional Corporate Nurse was notified. The Administrator was provided with the IJ template on 02/28/2023 at 4:58 p.m. and requested a Plan of Removal (POR).
The Plan of Removal (POR) was accepted on 03/02/2023 at 4:22 p.m. and indicated the following:
Immediate action:
*On 02/28/2023 the physician was notified of Resident #74's on-going diarrhea
*On 02/28/2023 the physician was notified of Resident #45's worsening symptoms of shingles.
Facilities plan to ensure compliance quickly:
*On 02/28/2023 DON/designee began training on notification of change in condition policy which provides guidance on when to communicate acute changes in status to physician and the need to significantly alter the resident's treatment with all licensed nurses on duty to include post-tests. This education was completed on 02/28/2023 at 10:00 p.m. with 11 of 34 licensed nurses trained. No licensed nurse will be allowed to work until this education is completed.
*On 03/01/2023 an additional 6 of 34 (total 17) licensed nurses were trained prior to working.
*Again, no licensed nurse will be allowed to work until this education has been completed
*On 03/01/2023 DON/designee began training on Clinical Documentation Guidelines which provides direction to the healthcare team on documentation and communication with the resident's progress and current treatment with all licensed nurse on duty. This education was completed on 03/01/2023 at 2:00 p.m. with 7 of 34 licensed nurses trained. No licensed nurse will be allowed to work until this education is completed.
*On 03/01/2023 an additional 6 of 34 (13 total) licensed nurses were trained prior to working
*Again, no licensed nurse will be allowed to work until this education has been completed.
Quality Assurance
*The Medical Director was notified on 02/28/2023 at 08:00 p.m., of the Immediate Jeopardies.
On 03/01/2023 An Ad Hoc QAPI meeting was conducted to discuss identified issues, and to develop plan for sustaining compliance
Monitoring included:
During Interviews on 03/03/2023 from 3:08 p.m. until 1:21 p.m., the surveyors confirmed the facility implemented their plan of removal sufficiently to remove the IJ by:
Interview with the DON stated she was in-serviced on her role as Director of Nurses and Infection Preventionist. She was in-serviced on documentation of changes of condition requirements, notification of the responsible party and physicians, and following up on changes of condition to ensure all care needs were met.
Interviews with 2 RNs: DON and RN KK (6am-6pm); 4 nurses LVN L (6a-6p), LVN A (6a-6p), LVN F (6a-6p), LVN B (6p-6a), ADON (all shifts), Tx nurse (all shifts) in-serviced on transmission-based precautions, notification of the physician and family of acute changes such as accidents, illness, transfers, emergencies, and injuries.
Record review of Resident #74's laboratory PCR HSV and VSV pending taking 5-7 days for return.
Record review of Resident #74's stool culture dated 2/27/2023 indicated a negative result for C-diff.
Record review of Resident #45's ophthalmologist appointment dated 03/02/2023 at 3:15 p.m. but he slid from his wheelchair preparing to leave the facility. The facility working with a local EMS ambulance to take Resident #45 to the ophthalmologist on a stretcher.
In-services:
Record review of an in-service dated 03/03/3023 used the Notification of Changes policy with a revision date of 02/12/2021 indicated the policy was to provide guidance on when to communicate acute changes in status to MD, NP and /responsible party. The facility will immediately inform the resident: consult with the resident's physician; and if known, notify the resident's legal representative or appropriate family member(s) of the following:
3. A significant change in the physical, mental, or psychosocial status of the resident.
5. The facility documents resident assessment (s), interventions, physician and family notification (s) on SBAR, Nurse Progress Notes or Telephone Order Form (physician /family notice) as appropriate.
During an interview on 03/03/2023 at 11:15 a.m., the Interim Administrator said she expected the physician to be notified off all changes of condition.
On 03/03/2023 at 5:22 p.m. the Interim Administrator was informed the IJ was removed: however, the facility remained out of compliance at a severity level of potential for more than minimal harm that is not immediate jeopardy with a scope identified as isolated due to the facility's need to complete in-service training and evaluate the effectiveness of the corrective systems.
CRITICAL
(K)
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 interviews and record reviews, the facility failed to ensure that residents receive treatment and care in accordance wi...
Read full inspector narrative →
**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on interviews and record reviews, the facility failed to ensure that residents receive treatment and care in accordance with professional standards of practice, the comprehensive person-centered care plan, and the residents' choices for 3 of 6 residents reviewed changes of condition. (Resident #'s 41, 45 and 74)
The facility failed to obtain a PCR HSV and VZV lab when Resident #45 had worsening symptomatic shingles (painful rash with blisters) covering his right eye lid.
The facility failed to obtain a stool culture when Resident #74 had on-going diarrhea since admission on [DATE].
An Immediate Jeopardy (IJ) situation was identified on 02/28/2023 at 4:47 p.m. While the IJ was removed on the 03/03/2023 at 1:21 p.m., the facility remained out of compliance at an actual harm with a scope pattern with a potential for more than minimal harm, due to the facility's need to evaluate the effectiveness of the corrective systems.
These failures could place residents at risk of their physicians not being aware of the resident conditions and delay treatments for the residents' conditions of loss of vision, dehydration, and/or loss of life.
Findings included:
1)Record review of a face sheet dated 03/02/2023 indicated Resident #45 was an [AGE] year-old male who admitted on [DATE] and readmitted on [DATE] with the diagnoses of heart failure, depression, malnutrition, and high blood pressure.
Record review of the most recent Significant change MDS dated [DATE] indicated Resident #45 was usually understood and usually understood others. The MDS indicated Resident #45's BIMS score was 11 indicating he had moderately impaired cognition. The MDS indicated during the assessment period Resident #45 did not reject care. The MDS indicated Resident #45 required extensive assistance of one staff with bed mobility, dressing, toilet use, personal hygiene, and with bathing Resident #45 required total assistance of one staff member.
Record review of the consolidated physician's orders dated 03/01/2023 indicated Resident #45 had Acyclovir 800 milligrams 5 times daily for 5 days for possible shingles(painful rash with blisters) started on 03/01/2023. Resident #45 had Clindamycin 300 milligrams three times a day for cellulitis (potentially serious bacterial skin infection) x 7 days started on 02/28/2023 and Doxycycline Monohydrate 100 mg twice a day for cellulitis until 03/07/2023. Resident #45 was also ordered Gentamicin Sulfate Ophthalmic ointment 0.3% 1 application in right eye two times a day for infection x 7 days to start on 02/28/2023.
Record review of the comprehensive care plan dated 11/09/2022 revealed it did not address that Resident #45 had shingles involving his face and right eye. The comprehensive care plan did not address isolation precautions.
Record review of Resident #45's February 2023 electronic medication administration record indicated these medications were ordered and administered medications: Acyclovir 800 milligrams one tablet three times a day for shingles for 7 days started on 02/20/2023 and completed on 02/27/2023. Resident #45 was ordered Ofloxacin Ophthalmic Solution 0.3% one drop to the right eye 4 times daily for 5 days starting on 02/20/2023. Acyclovir 800 milligrams was restarted on 02/28/2023, Ofloxacin Ophthalmic Solution 0.3% instill one drop in right eye at bedtime for 7 days started on 2/27/2022, and Doxycycline 100 milligram give one tablet twice daily for 7 days started on 02/28/2023.
Record review of Resident #45's March 2023 electronic medication record indicated these medications were ordered and administered: Gentamicin Sulfate Ophthalmic Ointment 0.3% instill one application in the right eye two times a day for 7 days starting on 03/01/2023, Ofloxacin Ophthalmic Solution 0.3% instill one drop in right eye at bedtime for 7 days starting on 02/27/2023; Doxycycline monohydrate 100 milligrams one capsule twice daily for cellulitis until 03/07/2023; and Clindamycin 300 mg one capsule by moth three times a day for cellulitis for 7 days; and Acyclovir 800 milligrams one tablet by mouth 5 times a day for 5 days for possible shingles starting on 03/01/2023.
Record review of a nursing note dated 02/20/2023 at 10:12 a.m., indicated LVN G wrote the physician was notified regarding Resident #45's redness, swelling, and matter to his right eye.
Record review of a nursing note dated 02/20/2023 at 10:54 a.m., indicated LVN G wrote he received new orders for Acyclovir 800 milligrams three times a day for 7 days, ofloxacin 0.3% one drop in right eye four times a day for 5 days, appointment with an ophthalmologist and to check a HSV ig M level (anti-body test to indicate a current or recent infection).
Record review of a nursing note dated 02/20/2023 at 8:34 p.m., indicated LVN M wrote monitoring for edema (swelling) every day and night shift, with the right side of Resident #45's face/eye with edema with the MD aware with laboratory test ordered.
Record review of a nursing note dated 02/21/2023 at 1:03 a.m., indicated LVN M wrote that the right side of Resident #45's face/eye continued with edema and redness, and Resident #45 denied pain. LVN M noted Resident #45's family member would like to see if the facility ophthalmologist could see Resident #45 instead of having to be transferred out of the facility.
Record review of a nursing note dated 02/22/2023 at 9:08 a.m., indicated LVN O wrote that Resident #45 continued the Acyclovir eye drops to his eye every night, continued to assess for pain, discomfort, and changes.
During an observation on 02/27/2023 at 12:17 p.m. revealed, Resident #45 was lying in his bed. He had scabbing appearing areas to his right eye and forehead. Resident #45's right eye was scabbed closed, and he could not open it when requested Resident #45 said he did not know what was on his face and eye.
During an interview on 02/27/2023 at 12:26 p.m., CNA N said she was told Resident #45 had shingles (painful rash with blisters) and not been on any isolation precautions. CNA N said she regularly careds for Resident #45 and had floated to other halls to help. CNA N said she had questioned the DON today as to why Resident #45 was not on any type of isolation because she said shingles were contagious. CNA N said Resident #45 did not eat his noon meal because he was hurting from the shingles.
During an interview on 02/27/2023 at 8:55 a.m., the DON said the nurses had not realized Resident #45 required isolation due to shingles being a contagious communicable disease. The DON said the nurses did not make her aware of Resident #45 having shingles when the symptoms started. The DON said Resident #45 should have been placed on contact isolation. The DON said the risk for unvaccinated and residents who had not had chicken pox as a child were at risk of having shingles. The DON said she was unaware Resident #45 had an order to see an ophthalmologist related to his right eye. The DON said they facility's eye physician had already made rounds around February 9th or the 10th 2023. The DON said she had not contacted the mobile eye physician or the family member with a plan to have Resident #45's right eye examined. The DON said shingles in the eye could result in vision loss for Resident #45. The DON said she was the infection preventionist for the building. The DON said she was unsure how Resident #45's infection of the shingles was missed because she said the nurse managers log the infections and review the orders in morning meeting. The DON said the physician should be notified immediately when symptoms occur or worsen.
Record review of a nurses note written by LVN P dated 02/28/2023 at 12:57 p.m., revealed Resident #45 had an appointment scheduled for March 2, 2023, at 3:15 p.m. The note indicated Resident #45's family member was notified of the appointment related to shingles to the right eye.
Record review of a nurse note dated 02/28/2023 at 1:06 p.m., indicated Resident #45 was administered a Tramadol 50 milligram tablet for pain to his right eye.
During an interview on 02/28/2023 at 3:11 p.m., LVN P said she had worked February 19, 2023, through February 23, 2023 and had observed Resident #45 during that time period. LVN P said Resident #45's eye was much worse than when she last saw the eye on February 23, 2023. LVN P said the medical record did not indicate any one had contacted the physician for Resident #45's worsening shingles.
During an interview on 02/28/2023 at 3:26 p.m., the Medical Director said she was #45's physician and she said she was unaware of Resident #45's right eye condition with shingles covering the entire eye lid and the right eye would not open. The Medical Director said she was unaware Resident #45 had not seen an eye specialist related to the shingles to the right side of the face and eye. The Medical Director said she expected the facility to obtain an appointment promptly due to the risk of blindness with ocular shingles.
During an observation and interview on 02/28/2023 at 3:45 p.m., revealed LVN P applied a warm compress to Resident #45's right eye. LVN P asked Resident #45 to open his right eye, and he could not open the eye at all. Resident #45 said his right eye was hurting and LVN P immediately stopped and said she would administer a pain medication. LVN P said she would notify the physician.
Record review of a nurse note dated 02/28/2023 at 8:03 p.m., indicated the ADON wrote Resident #45's family was notified of the lab results of the Herpes Simplex IgM (antibody test of recent or current infection) result of 0.66 and a new order was received from the physician for Clindamycin 300 mg one three times and day and discontinue the Acyclovir.
Record review of a medication administration record dated February 2023 indicated Clindamycin 300 mg was administered on 02/28/2023.
During an interview on 02/28/2023 9:57 a.m., the responsible party for Resident #45 said he was never told officially Resident #45 had shingles (painful rash with blisters). Resident #45's responsible party said he asked if the mobile eye doctor could see Resident #45 but he definitely would have had him sent to another local eye physician if Resident #45 needed to go.
Record review of a nurse note dated 02/28/2022 at 8:21 p.m., indicated the DON wrote Resident #45's isolation was discontinued for shingle precautions and indicated Resident #45 had a new diagnosis of cellulitis and with a new medication ordered. The new order was Clindamycin 300 mg one capsule three times a day for 7 days.
Record review of a nurse note dated 02/28/2023 at 11:08 p.m., indicated LVN B wrote Resident #45 was administered gentamycin eye drops. LVN B wrote Resident #45 face was red and swollen with blisters and scabs.
During an interview on 02/28/2023 at 10:07 a.m., the Interim Administrator said she was unaware of Resident #45 having shingles.
Record review of a nurse note dated 03/01/2023 at 1:24 a.m., indicated LVN B documented Resident #45 had a diagnosis of cellulitis, day 2 of isolation, acyclovir was discontinued, day 2 of 7 on Ofloxacin and G entamicin eye drops, day 3 of 7 on doxycycline with no adverse reactions. The note indicated Resident #45 had redness, swelling, and scabs to his face and a warm compress was used.
During an interview on 03/01/2023 at 8:34 a.m., the Regional Corporate Nurse said after digging deeper the lab result for an IgM level (antibody level detecting recent or new infection) was 0.66 which was negative. The Regional Corporate Nurse said Resident #45 was negative for shingles but was being treated for cellulitis.
During an observation and interview on 03/01/2023 at 9:18 a.m., Resident #45 said his right eye was hurting. Resident #45 had a very minimal opening between his eye lids and there was yellow stingy material in the opening.
During an interview on 03/01/2023 at 2:57 p.m., the Medical Director indicated initially Resident #45's rash appeared to be shingles. The medical director indicated the IgM test was negative for antibodies.
On 02/20/2023. The medical director said she would complete a PCR HSV and VSV (recommended testing for diagnosing of shingles), and place Resident #45 back on isolation. The medical director said she would order a PCR HSV and VSV because the test would be the most accurate test for diagnosing shingles according to CDC recommendation.
Record review of a nurses note dated 03/01/2023 at 6:24 p.m., indicated the ADON wrote she notified the Resident #45's family member on of the new orders to restart Acyclovir 800 milligrams five times daily x 5 days, PCR HSV and VZV lab, and reinstate the isolation precautions.
Record review of an incident report dated 03/02/2023 at 3:30 p.m., indicated Resident #45 slid from his wheelchair to the floor. The ADON wrote there were no injuries noted but Resident #45 was sent to the emergency room.
Record review of an After Visit Summary dated 03/02/2023 indicated Resident #45 was provided instructions related to shingles and minor head injury. The summary indicated his diagnoses included an unspecified fall, facial contusion, and herpes zoster (shingles). The educational material included in the Visit Summary report indicated:
*If the shingles affects your eye the doctor may cover your eye with a bandage
*Infections of the eye and the skin around the eye were other health problems to treat
*To prevent the shingles do not share towels, go swimming, or play contact sports with people who have shingles if you never had chicken pox.
*Do not touch or scratch your rashes, if you do wash your hand afterwards.
2) Record review of a face sheet dated 03/02/2023 indicated Resident #74 was an [AGE] year-old female who admitted on [DATE] with the diagnoses of spondylolisthesis (disorder of which a bone vertebra slips forward onto the bone below), eating disorder, and high blood pressure.
Record review of an admission MDS dated [DATE] indicated Resident #74 was usually understood and usually understood others. The MDS indicated Resident #74 BIMS score was a 13 indicating she was cognitively intact. The MDS indicated Resident #74 required extensive assistance of one staff with bed mobility, transfers, locomotion, toilet use, personal hygiene, and bathing. The MDS indicated Resident #74 was frequently incontinent of bowel and was not on a toileting plan.
Record review of a Baseline care plan dated 01/24/2023 at 8:39 a.m., indicated the ADON did not document Resident #74 had a recent history of Clostridium Difficile from the physicians history and physical (inflammation of the colon cause by bacteria), diarrhea, or isolation precautions needed for on-going symptoms.
Record review of the comprehensive care plan dated 02/07/2023 indicated Resident #74 was at risk for Covid 19 infection but the care plan did not mention Clostridium Difficile or the need for isolation precautions.
Record review of the February 2023 electronic medication record indicated Resident #74 received Colestipol 1 gram twice daily for treating diarrhea since 01/24/2023, lactobacillus capsule one capsule by mouth twice daily, and Lomotil 2.5-0.025 milligrams one tablet every 6 hours as needed for diarrhea since 01/24/2023. The electronic medication record indicated Resident #74 had 8 doses in the month of February and two doses were unknown if effective.
Record review of a nursing progress note dated 01/24/2023 documented by LVN T indicated Resident #74 was post C-diff.
Record review of a nursing progress note dated 01/31/2023 at 1:22 a.m., indicated LVN V administered Lomotil for diarrhea, but the medication was ineffective. The note did not indicate the physician was notified.
Record review of a nursing progress note dated 01/31/2023 at 12:24 p.m., indicated LVN F documented Resident #74 was administered Lomotil for diarrhea.
Record review of a skilled nurses note dated 02/01/2023 at 12:48 a.m., indicated LVN T documented Resident #74 was post C-diff.
Record review of a progress note dated 02/01/2023 at 1:30 a.m., indicated Resident #74 was administered Lomotil for diarrhea by LVN M.
Record review of a nursing note dated 02/03/2023 at 5:40 a.m., LVN T documented an administration of Lomotil for diarrhea was provided to Resident #74.
Record review of a nurses note dated 02/04/2023 at 3:32 a.m., indicated LVN R documented Resident #74 was post C-diff.
Record review of a nurses note dated 02/04/2023 at 3:32 a.m., indicated LVN R documented Resident #74 was post C-diff.
Record review of a nurses note dated 02/06/2023 at 8:37 a.m., indicated LVN S documented Resident #74 was post C-diff.
Record review of a nurses note dated 02/06/2023 at 11:18 p.m., LVN T documented Resident #74 required the administration of Lomotil for diarrhea.
Record review of a nurses note dated 02/07/2023 at 11:40 p.m., LVN T documented Resident #74 required Lomotil administration related to diarrhea.
Record review of a nurses note dated 02/15/2023 at 9:42 p.m., LVN T documented Resident #74 required administration of Lomotil for diarrhea.
Record review of a nurses note dated 02/24/2023 at 12:54 a.m., indicated LVN PP documented Resident #74 continued to have been monitored for diarrhea none on this shift. The note failed to indicate the physician was notified.
Record review of a nurses note dated 02/25/2023 at 6:41 a.m., indicated LVN T documented that Resident #74 had 3 diarrhea bowel movements with Lomotil given and effective at present. The note indicated Resident #74's peri area was very red. LVN T indicated she notified the physician and was waiting on orders.
Record review of a nurses note dated 02/25/2023 at 8:59 a.m., indicated LVN D apply Nystatin ointment to Resident #74's inner thighs and buttocks for redness.
Record review of a nurses note dated 02/25/2023 at 6:41 a.m., indicated LVN D received a new order for Nystatin ointment and zinc oxide twice daily for 30 days.
Record review of a nurses note dated 02/25/2023 at 6:43 p.m., indicated LVN B documented Resident #74 required Lomotil for diarrhea and the medication was effective. The note did not reflect LVN B notified the physician.
During an interview an observation on 02/27/2023 at 10:08 a.m., Resident #74 said her brief needed changing due to having a very large diarrhea bowel movement. Resident #74 said she thought she should return to the hospital due to her continuous diarrhea since she left the hospital. Resident #74 was assisted to activate her call light for assistance. CNA C answered the call light and left the room. CNA C returned with bed linen and incontinent care supplies. CNA C washed her hands then initiated care to Resident #74. LVN F said Resident #74 has had diarrhea since admission. LVN F said he had been trying to obtain a stool sample but the stool was so loose the bowel movement absorbed in the brief.
Record review of the physician's orders dated February 2023 did not reveal a stool specimen was ordered by the physician.
Record review of a nurses note dated 02/27/2023 at 5:55 p.m., indicated LVN F documented Resident #74 made the statement she thought she needed to return to the hospital due to the ongoing diarrhea. LVN F documented he informed Resident #74 he had a stool sample waiting for pickup.
During an interview on 02/28/2023 at 7:51 a.m., the Housekeeping Supervisor said she was unaware there were residents with possible Clostridium Difficile. The Housekeeping Supervisor said for Clostridium Difficile there was a special tablet to add to the water for cleaning of these rooms. The housekeeping supervisor said she was also unaware of Resident #74 or Resident #45 having communicable disease processes requiring special laundry procedures. The housekeeping supervisor said when the laundry receives linen in the yellow bags the laundry personnel would be alerted to wash this linen separate from the general linen.
During an interview on 02/28/2023 at 3:26 p.m., the physician for Resident #74 said Resident #74 had Clostridium Difficile in the recent past. The physician said she was not notified Resident #74 had on-going diarrhea since admission. The physician said Resident #74 could be a carrier of Clostridium Difficile.
Record review of a hydration assessment completed by the DON dated 02/28/2023 indicated Resident #74 had poor skin turgor, had more than a 3-pound weight loss in a month, and was at risk due to diarrhea/vomiting occurred in the last 7 days.
Record review of a Notification Policy dated 07/13/2015 and revised on 02/12/2023 indicated the policy was to provide guidance on when to communicate acute changes in status to MD, NP, and responsible party. The facility will immediately inform the resident; consult with the resident's physician; and if known, the resident's legal representative or appropriate family members of the following:
9.
An accident resulting in injury to the resident that potentially requires physician's intervention
10.
An emergency response situation that requires EMS involvement
11.
A significant change in the physical, mental, or psychosocial status of the resident.
12.
The need to significantly alter the resident's treatment.
13.
A decision to transfer or discharge the resident to another facility.
14.
A change in room or roommate assignment.
15.
A change in resident rights under Federal or State law, including changes to items and services included under State plans.
16.
The facility's Medical Director will be contacted if the attending or admitting physician cannot be contacted and/or does not respond timely.
Record review of a Provision of Quality-of-Care policy dated 01/24/2023 indicated based on comprehensive assessments, the facility will ensure that residents receive treatments and care by qualified persons in accordance with professional standards of practice, the comprehensive person-centered care plans, and the residents' choices. 1. Each resident will be provided care and services to attain or maintain his/her highest practicable physical, mental, and psychosocial well-being. 4. Qualified persons will provide the care and treatment in accordance with professional standards of practice, the resident's care plan and the resident's choices. 6. Policies and procedures will reflect current professional standards of practice. a. All employees are responsible for following established policies and procedures. B. Violations of policies and procedures will result in disciplinary action up to and including termination.
This was determined to be an Immediate Jeopardy (IJ) situation on 02/28/2023 at 4:47 p.m. The Interim Administrator and the Regional Corporate Nurse was notified. The Administrator was provided with the IJ template on 02/28/2023 at 4:58 p.m. and requested a Plan of Removal (POR).
The Plan of Removal (POR) was accepted on 03/03/2023 at 1:21 p.m. and indicated the following:
Immediate action:
On 02/27/2023 Stool culture was obtained and sent to lab for Resident #74.
On 02/28/2023 DON RN completed a Hydration assessment on Resident #74.
On 03/01/2023 Regional Registered Dietician completed a Nutritional assessment on Resident #74 with no new recommendations.
On 02/28/2023 Social Services/Designee obtained an Ophthalmology consult for Resident #45 for 03/03/23 related to worsening symptomatic Shingles.
On 02/28/2023 ADON LVN completed rounds and identified 1 other resident with diarrhea who is in a private room and was placed on isolation precautions on 02/28/2023. DON RN completed a hydration assessment on this resident and notified the Physician 02/28/2023 regarding on-going diarrhea and hydration assessment.
On 02/28/2023 stool culture was obtained and sent to lab for the one other identified resident.
On 03/01/2023 Regional Registered Dietician completed a review on the 1 other resident in the center who was experiencing diarrhea, an identified as having the potential to be affected by this alleged practice with no recommendations.
Facilities plan to ensure compliance quickly
On 03/03/2023 DON Designee began training on Provision of Quality of Care to ensure that residents receive treatment and care by qualified persons in accordance with professional standards of practice. This education will be completed on 03/03/2023. No staff will be allowed to work until this education is completed.
Quality Assurance
Medical Director was notified on 02/28/2023 at 08:00 p.m., of the Immediate Jeopardies.
On 03/01/2023 An Ad Hoc QAPI meeting was conducted to discuss identified issues, and to develop plan for sustaining compliance
In-services:
*Provision of Quality Care:
The facility will ensure that residents receive treatment and care by qualified persons in accordance with professional standards of practice, the comprehensive person-centered care plans, and the resident's choice.
During an interview on 03/03/2023 at 11:15 a.m., the Interim Administrator said she expected the physician to be notified off all changes of condition.
Interviews with 2 RNs: DON and RN KK (6am-6pm); 4 nurses LVN L (6a-6p), LVN A (6a-6p), LVN F (6a-6p), LVN B (6p-6a), ADON (all shifts), Tx nurse (all shifts) in-serviced on transmission-based precautions, notification of the physician and family of acute changes such as accidents, illness, transfers, emergencies, and injuries.
Record review of Resident #74's laboratory PCR HSV and VSV pending taking 5-7 days for return.
Record review of Resident #74's stool culture dated 2/27/2023 indicated a negative result for C-diff.
Record review of Resident #45's ophthalmologist appointment dated 03/02/2023 at 3:15 p.m. but he slid from his wheelchair preparing to leave the facility. The facility working with a local EMS ambulance to take Resident #45 to the ophthalmologist on a stretcher.
During an interview on 03/03/2023 at 11:00 a.m., the DON said she expected nurses to monitor for changes of condition and then act on the physician's orders. The DON said a resident could have their needs not met.
On 03/03/2023 at 5:22 p.m. the Interim Administrator was informed the IJ was removed: however, the facility remained out of compliance at a severity level of potential for more than minimal harm that is not immediate threat with a scope identified as isolated due to the facility's need to complete in-service training and evaluate the effectiveness of the corrective systems.
CRITICAL
(L)
Immediate Jeopardy (IJ) - the most serious Medicare violation
Infection Control
(Tag F0880)
Someone could have died · This affected most or all residents
⚠️ Facility-wide issue
**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** 6. Record review of Resident #54's facesheet, dated 03/01/23, indicated he was a [AGE] year-old male, admitted on [DATE]. He had...
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**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** 6. Record review of Resident #54's facesheet, dated 03/01/23, indicated he was a [AGE] year-old male, admitted on [DATE]. He had diagnoses which included hemiplegia (paralysis of one side of the body) and hemiparesis (weakness that affects one side of the body) following cerebral infarction (a pathologic process that results in an area of dead tissue in the brain, caused by disrupted blood supply), Obstructive and reflux uropathy (a condition where the urine cannot flow through the urinary system, and the urine backs up, or refluxes, into the kidneys).
Record review of Resident #54's quarterly MDS, dated [DATE], indicated he was sometimes able to make himself understood, and sometimes understands others. He had a BIMS score of 2 which indicated severely impaired cognition. Resident #54 did not exhibit behaviors of rejection of care or wandering. Resident #54 required extensive assistance with bed mobility, transfers, locomotion on and off unit, dressing, and personal hygiene. He was totally dependent on staff for eating and toileting. Resident #54 was marked for having an indwelling catheter.
Record review of Resident #54's physician's orders reflected an order for change foley catheter drainage bag every shift on the 8th of the month. Change foley catheter with 18fr 30mL bulb every month on the 8th in the morning. The order start date was 10/08/22. Further review reflected an order for foley catheter care, clean foley catheter every shift with soap and water. This order start date was 09/13/22.
Record review of Resident #54's care plan for foley catheter, dated 11/10/21, and revised on 08/01/22, indicated a focus of resident has a urinary catheter and is at risk for urinary tract infections and injury. Urinary catheter related to obstructive uropathy. The goals included encourage resident to use leg bag, and the resident will be/remain free from catheter-related trauma and complications through next review date. Interventions included enhanced barrier precautions, resident refuses to wear leg bag, monitor for and report to the physician any signs or symptoms of a urinary tract infection, monitor for pain and discomfort due to the presence of a urinary catheter, change urinary catheter per routine schedule, if leaking, or if a blockage is present as ordered by the physician, and provide urinary catheter care per facility practice.
During an observation and interview on 03/01/23 at 10:29 AM LVN D performed catheter care on Resident #54. Two instances were observed where LVN D wiped two times with the same cloth before folding the washcloth and wiping again. LVN D said she should have folded the washcloth before wiping with the dirty part of the cloth. She said wiping the same area with the dirty part of the washcloth could cause an UTI.
During an interview on 03/02/23 at 10:25 AM the ADON said she would not expect a nurse to wipe with the same area of a washcloth. She said it is normally one wipe per swipe. She said the risk to the resident could be an infection.
During an interview on 03/02/23 at 10:29 AM the DON said she would expect a new wipe per each pass. She would not expect the nurse to use the same area of the washcloth for a clean area and a dirty area. She said the risk to the residents could be infection.
During an interview on 03/02/23 at 10:35 AM the Interim Administrator said her expectation is for the nurse to follow the facility policy for catheter care. She said the risk to the resident for wiping in the same place with the same washcloth would be possible infection.
During an interview on 03/02/23 at 10:48 AM the Interim Administrator said it was the DON's responsibility to ensure catheter care is being performed correctly. She said the DON reports to the Administrator, so it is ultimately the Administrator's responsibility to ensure catheter care was performed correctly.
During an interview on 03/02/23 at 12:02 PM the DON said the charge nurse and ultimately the DON was responsible for ensuring catheter care was performed correctly.
Record review of facility policy Indwelling Foley Catheter Guidelines, dated 02/10/2020, stated:
.Anticipated Outcome .
.The facility shall identify and assess patients with an indwelling catheter or at risk for catheterization, provide appropriate treatment and services to prevent urinary tract infections and to achieve or maintain as much normal bladder function as possible, and ensure that indwelling catheters are medically necessary .
The policy did not address catheter care.
Record review of facility policy Incontinence Care, dated 04-17-14, and reviewed 04-10-17, indicated the policy did not address catheter care.
7) During an observation and interview on 03/02/2023 at 9:00 a.m., RN G was standing in a resident's doorway. RN G had his N95 face mask down with a piece of tissue hanging out of his right nostril and RN G's face was flushed. RN G said he was sick, he had a fever of 102.2, coughing and nasal drainage. RN G revealed on his cell phone where he had texted the ADON a picture of the thermometer reading of 102.2. The ADON's response on RN G's cell phone read tell the DON. RN G revealed his text the DON. The text was a picture of the thermometer reading 102.2 and his symptoms. The cell phone had no response from the DON to RN G's cell phone. The DON said she did not have RN G's Coronavirus test to verify he was not Covid 19 positive.
During interviews on 03/02/2023 at 9:15 a.m., the Interim Administrator and the DON said they were unaware RN G had symptoms. The DON said she had not received a text from RN G indicating he was ill. The DON said the employee's self-screen. The Interim Administrator said RN G should have not started working with the residents when he had symptoms. The DON said she was the infection preventionist.
During an interview with the DON on 03/03/2023 at 11:00 a.m., the DON said she had not been in-serviced or trained on her role as the DON or the infection preventionist. The DON said the ADON works on the floor numerous times per week because of staffing issues and the corporation denies any use of agency to replace the floor staff therefore there was no time to work the systems correctly.
During an interview on 03/03/2023 at 11:15 a.m., the Interim Administrator said she had been in the building one week. The Interim Administrator said she was not responsible for these findings, but the prior administrator would have been. The Interim Administrator said the corporation had systems, but the prior administrator was not using the corporate forms to work through the processes. The Interim Administrator said the DON should have been aware of all these issues as she was a regional consultant. The Interim Administrator said the ADON had said she just did not think to isolate the residents with communicable diseases. The Administrator said she expected the staff to perform incontinent care correctly, she expected the physician to be notified off all changes of condition, she expected staff to stay home when they were ill and pass the screening for Covid 19, and she expected isolation precautions to be in place to prevent further spread of communicable diseases.
Record review of the facility's policy, Hand Hygiene, dated 02/20/20 and revised on 02/11/22, indicated .All staff will perform proper hand hygiene procedures to prevent the spread of infection to other personnel, residents and visitors .Hand hygiene is indicated and will be performed under the conditions listed in, but not limited to the attached hand hygiene table .before applying and after removing personal equipment, including gloves .after handling items potentially contaminated with blood, body fluids, secretions, or excretions .The use of gloves does not replace hand hygiene. If your task requires gloves, perform hand hygiene prior to donning gloves, and immediately after removing gloves .
Record review of an Antibiotic Stewardship Policy - Infection Control Program dated 2/12/20 was provided by the regional nurse on 03/02/23 at 10:11 AM and indicated:
Policy
It is the policy of tis facility to follow an Antibiotic Stewardship process that promotes the appropriate use of antibiotics and includes a system of monitoring to improve resident outcomes and reduce antibiotic resistance.
Commitment - Facility leadership (Administrator, Director of Nursing (Infection Control Preventionist) and Medical Director) and Consultant Pharmacist are committed to safe and appropriate antibiotic use that includes .
.Tracking - Track measures of antibiotic use in the facility (i.e., process and outcome measures) .
Process:
.b.The facility will track outcome measures of antibiotic usage i. e. Pharmacy data, Lab data
Record review of the Transmission-Based Precautions policy dated 10/24/2022 indicated the policy was to take appropriate precautions to prevent transmission of pathogens, based on the pathogens' mode of transmission. 1. Facility staff will apply Transmission-Based Precautions, in addition to standard precautions to residents who are known or suspected to be infected or colonized with certain infectious or colonized with certain infectious agents requiring additional controls to prevent transmission. 4. Residents on transmission-based precautions should remain in their rooms except for medically necessary care. 7. Initiation of Transmission-Based Precautions a. Nursing staff may place residents with suspected or confirmed infectious diarrhea, influenza, or symptoms consistent with a communicable disease on transmission-based precautions/isolation empirically while awaiting confirmation. 8. Contact Precautions- a. Intended to prevent transmission of pathogens that are spread by direct or indirect contact with the resident or the resident's environment. C. Healthcare personnel caring for residents on Contact Precautions wear a gown and gloves for all interactions that may involve contact with resident or potentially contaminated areas in the resident's environment. 11. Discontinuation of Transmission-Based Precautions c. Strategies for determining to discontinue precautions, organism specific, is summarized in the table .i. Consider the known pattern of persistence and shedding of infectious agents associated with natural history of the infectious process and its treatment. ii. Symptoms of disease is resolved. Table reference: Clostridioides difficile formerly Clostridium difficile requires contact isolation for the duration of the illness and Herpes zoster (shingles) require contact isolation until lesions were dry and crusted.
https://www.cdc.gov/cdiff/clinicians/resources.html accessed on 03/06/2023
. diff (also known as Clostridioides difficile or C. difficile) is a germ (bacterium) that causes diarrhea and colitis (an inflammation of the colon).
It's estimated to cause almost half a million infections in the United States each year.
About 1 in 6 patients who get C. diff will get it again in the subsequent 2-8 weeks.
One in 11 people over age [AGE] diagnosed with a healthcare-associated C. diff infection die within one month.
Risk Factors for C. diff
C. diff can affect anyone. Most cases of C. diff occur when you've been taking antibiotics or not long after you've finished taking antibiotics.
There are other risk factors:
Being 65 or older
Recent stay at a hospital or nursing home
A weakened immune system, such as people with HIV/AIDS, cancer, or organ transplant patients taking immunosuppressive drugs
Previous infection with C. diff or known exposure to the germs
Symptoms of C. diff
Symptoms might develop within a few days after you begin taking antibiotics.
Diarrhea
Fever
Stomach tenderness or pain
Loss of appetite
Nausea
What if I have symptoms?
If you have been taking antibiotics recently and have symptoms of C. diff, you should see a healthcare professional.
Developing diarrhea is fairly common while on, or after taking, antibiotics, but in only a few cases will that diarrhea be caused by C. diff. If your diarrhea is severe, do not delay getting medical care.
Your healthcare professional will review your symptoms and order a lab test of a stool (poop) sample.
If the test is positive, you'll take a specific antibiotic (e.g. vancomycin or fidaxomicin) for at least 10 days. If you were already taking an antibiotic for another infection, your healthcare professional might ask you to stop taking it if they think it's safe to do so.
Your healthcare team might decide to admit you to the hospital, in which case they will use certain precautions, such as wearing gowns and gloves, to prevent the spread of C. diff to themselves and to other patients.
Is C. diff contagious?
Yes. To keep from spreading C. diff to others:
Wash hands with soap and water every time you use the bathroom and always before you eat.
Try to use a separate bathroom if you have diarrhea.
Take showers and wash with soap.
Can I get C. diff again?
Some people get C. diff over and over again.
One in 6 people who've had C. diff will get it again in the subsequent 2-8 weeks.
If you start having symptoms again, seek medical care.
For those with repeat infections, innovative treatments, including fecal microbiota transplants, have shown promising results (see the Life After C. diff page).PCR is the most useful test
https://www.cdc.gov/shingles/hcp/diagnosis-testing.html accessed on 03/07/2023
Laboratory testing may be useful in cases with less typical clinical presentations, such as in people with suppressed immune systems who may have disseminated herpes zoster (defined as appearance of lesions outside the primary or adjacent dermatomes). Polymerase chain reaction (PCR) is the most useful test for confirming cases of suspected zoster sine herpete (herpes zoster-type pain that occurs without a rash).
PCR can be used to detect VZV DNA rapidly and sensitively and is now widely available. The ideal samples are swabs of unroofed vesicular lesions and scabs from crusted lesions; you may also detect viral DNA in saliva during acute disease, but salvia samples are less reliable for herpes zoster than they are for varicella. Biopsy samples are also useful test samples in cases of disseminated disease. It is also possible to use PCR to distinguish between wild-type and vaccine strains of VZV.
Direct fluorescent antibody (DFA) and Tzanck smear are not recommended due to limited sensitivity. These methods have a rapid turnaround time, but DFA is substantially less sensitive than PCR, and Tzanck is not specific for VZV. Moreover, real-time PCR protocols can be completed within one day.
Serologic methods have limited use for laboratory confirmation of herpes zoster and should only be used when suitable specimens for PCR testing are not available. Patients with herpes zoster may mount a transient IgM response and would be expected to mount a memory IgG response. However, a positive IgM [NAME] result could indicate primary VZV infection, re-infection, or re-activation. Primary infection can be distinguished from reactivation or reinfection with VZV IgG avidity testing. High avidity IgG in the context of VZV IgM is indicative of a remote infection; low avidity IgG indicates a primary infection. Measuring acute and convalescent [NAME] also has limited value, since it is difficult to detect an increase in IgG for laboratory diagnosis of herpes zoster.
In people with compromised immune systems, it may be difficult to distinguish between varicella and disseminated herpes zoster by physical examination or serological testing. In these instances, to help with diagnosis, consider if the patient has a history of VZV exposure or of a rash that began with a dermatomal pattern, along with results of VZV antibody testing during or before the time of rash.
https://www.cdc.gov/infectioncontrol/guidelines/hand-hygiene/index.html accessed on 03/06/2023
The Guideline for Hand Hygiene in Health-Care Settings provides health-care workers (HCWs) with a review of data regarding handwashing and hand antisepsis in health-care settings. In addition, it provides specific recommendations to promote improved hand-hygiene practices and reduce transmission of pathogenic microorganisms to patients and personnel in health-care settings. This report reviews studies published since the 1985 CDC guideline ([NAME] JS, [NAME] MS. CDC guideline for handwashing and hospital environmental control, 1985. Infect Control 1986; 7:231-43) and the 1995 APIC guideline ([NAME] EL, APIC Guidelines Committee. APIC guideline for handwashing and hand antisepsis in health care settings. Am J Infect Control 1995; 23:251-69) were issued and provides an in-depth review of hand-hygiene practices of HCWs, levels of adherence of personnel to recommended handwashing practices, and factors adversely affecting adherence. New studies of the in [NAME] efficacy of alcohol-based hand rubs and the low incidence of dermatitis associated with their use are reviewed. Recent studies demonstrating the value of multidisciplinary hand-hygiene promotion programs and the potential role of alcohol-based hand rubs in improving hand-hygiene practices are summarized. Recommendations concerning related issues (e.g., the use of surgical hand antiseptics, hand lotions or creams, and wearing of artificial fingernails) are also included.
5. Record review of Resident #50's face sheet, dated 03/02/23, indicated a [AGE] year-old female who admitted to the facility on [DATE] with diagnoses which included type 2 diabetes mellites (condition that affects the way the body processes blood sugar), high blood pressure, dysphagia (difficulty swallowing), and metabolic encephalopathy (a problem in the brain caused by a chemical imbalance in the blood).
Record review of Resident #50's comprehensive care plan dated 02/27/23 indicated she had a diagnosis of diabetes and was at risk for unstable blood sugars and abnormal lab results. The care plan interventions included to monitor blood sugar as ordered by the physician and administer sliding scale insulin if ordered.
Record review of the quarterly MDS, dated [DATE], indicated Resident #50 was usually understood and usually understood others. The MDS indicated Resident #50's BIMS score of 8, which indicated she had moderately impaired cognition. Resident #50 required extensive assistance with bed mobility, transfers, toileting, and personal hygiene and she was totally dependent on staff on bathing. Section N, Medications, indicated Resident #50 had received insulin 5 days within the last 7 days of the look back period.
Record review of Resident #50's order summary report, dated 03/02/23, indicated she had an order for Humalog Kwik Pen Solution Pen-Injector 100 unit/ml inject per sliding scale before meals and at bedtime for diabetes.
During an observation on medication pass and interview on 02/28/23 at 11:15 a.m., LVN F performed hand hygiene, donned gloves, and obtained Resident #50's fingerstick blood sugar. LVN F went to nurse cart, unlocked the cart, touched the laptop, and removed Resident #50's Humalog insulin pen from the cart all while using the same gloves he used to obtained Resident #50's blood sugar. LVN F proceeded to administer the one unit of Humalog insulin to Resident #50. LVN F removed gloves and donned new gloves. LVN F did not perform hand hygiene in between glove changes. LVN F said by not removing the gloves after obtaining Resident #50's blood sugar and performing hand hygiene after removing gloves, placed the resident at risk for cross contamination and possible infection. LVN F said he had been checked on insulin administration and hygiene verbally but not by demonstration.
Record review of LVN F's Administration of subcutaneous insulin via insulin pen check off, dated 6/29/22, indicated skill being met.
During an interview on 03/02/23 at 10:28 a.m., the ADON said she expected gloves to be removed after obtaining blood sugar and hand hygiene to be performed before donning clean gloves. The ADON said by not removing gloves or performing hand hygiene could place residents at risk for cross contamination and cause infections. The ADON said they had completed hand hygiene check offs in December 2022 by demonstration.
During an interview on 03/02/23 at 10:50 a.m., the DON said she expected hand hygiene to be performed for all encounters. The DON said she expected gloves to be removed after obtaining blood sugar and hand hygiene be performed after removing gloves and donning clean gloves. The DON said it was her responsibility to ensure hand hygiene was being performed by staff. The DON said by not performing hand hygiene or removing gloves after obtaining blood sugar, placed the residents at risk for infections and cross contamination. The DON said staff check offs for all skills and procedures should be performed yearly.
During an interview on 03/03/23 at 11:05 a.m., the Interim Administrator said she expected the nurse to perform hand hygiene in between glove changes. The Interim Administrator said by not doing so could cause infections to spread.
Non-Immediate Jeopardy Information
3. A record review of the physician's orders dated March 2023 indicated Resident #41 admitted [DATE], and was [AGE] years old with diagnoses that included: Type 1 diabetes (the pancreas does not make insulin or does not make enough) , Type 2 diabetes (an impairment in the way the body regulates and uses sugar/glucose), end stage renal disease (the kidneys cease functioning on a permanent basis leading to the need for long term dialysis or a kidney transplant), and dependence on renal dialysis (an ongoing treatment that removes extra fluid and waste products when the kidneys are not able).
A record review of the MDS dated [DATE] indicated Resident #41 had clear speech, usually understood others, and was usually understood by others. The MDS indicated he was cognitively intact. The MDS indicated he was occasionally incontinent of urine and bowel. The MDS indicated Resident #41 required the supervision of one person for bed mobility and supervision and set up assistance for transfer.
A record review of the undated care plan indicated Resident #41 required the assistance of 1 staff for bed mobility and transfer and was incontinent of bowel and bladder. The care plan indicated he had a diagnosis of diabetes and ESRD (End Stage Renal Disease) requiring dialysis.
During an observation and interview on 2/27/23 at 10:36 AM Resident #41 said he was [AGE] years old. He was in his room in his wheelchair. He said he went to dialysis on Tuesday, Thursday, and Saturday's.
During an observation on 2/28/23 at 11:47 AM, Resident #41 was in the dining room at a table by himself. He had a surgical mask pulled down to eat and was wearing isolation gown.
During an observation and interview on 3/01/23 at 8:28 AM, Resident #41 had PPE (isolation gowns, gloves, face shields, N95 masks) outside of his room in a container. He was not in his room. He was observed eating breakfast in the dining room at a table alone. He had on an isolation gown and a surgical mask pulled down to eat. LVN A said Resident #41 was in a gown and mask because she was told people with diarrhea had to be in isolation. She said she believed Resident #41's diarrhea was from his dialysis medication, but they had to do what they were told. She said he was in isolation until his Clostridium Difficile (a bacteria that can cause colitis, a serious inflammation of the colon) C-diff test came back.
A record review of a lab collected 2/28/23 for Resident #41 indicated he was positive for C-diff and the result was called in to LVN B on 3/2/23 at 4:06 p.m.
A record review of the progress notes on 3/3/23 indicated Resident #41 was positive for C-diff on 3/2/23, at 4:36 p.m. The progress notes indicated they had received orders for Vancomycin 125 mg by mouth every 6 hours.
During an interview on 3/03/23 at 9:40 AM, the DON said she did not notify the Dialysis Center that Resident #41 was positive for C-diff.
During an interview on 3/03/23 at 9:47 AM, the administrator at [name] Dialysis Center said she had not been notified by the facility Resident #41 was positive for C-diff. She said it was very important for infection control purposes for the facility to have let them know as soon as possible that Resident #41 was positive for C-diff. She said there was a risk of infection to residents and staff if they were not aware.
During an interview and record review on 3/03/23 at 10:05 AM, LVN A said she had worked at the facility for 2 months. She said Resident #41 had diarrhea the whole time she had been at the facility. She said the Medical Director was aware of his chronic diarrhea. She showed this surveyor progress notes indicating:
A record review of the progress notes dated 2/28/23 indicated the DON notified the MD of ongoing diarrhea for Resident #41 and indicated no new orders were received.
A record review of the progress notes dated 2/1/23 indicated the MD documented Resident #41 had chronic diarrhea and refused colonoscopy . continue current treatment.
LVN A said she could not find where she documented she had called the MD regarding Resident #41's diarrhea. She said she should have documented it. She said as a nurse if it was not documented it was not done. She said Resident #41 used a bed side commode in his room or his brief to have a bowel movement
A record review on 3/3/23 indicated on 1/12/23 Resident #41 had an order to test stool for ova and parasite (checking for parasites and eggs of parasites), C&S (test that checks for bacteria, viruses or other germs), C-diff, Calprotectin (testing for irritable bowel syndrome), and Giardia (a parasite that can live in intestines).
A record review of an MD note, on 1/16/23 indicated:
Resident #41 had diarrhea for quite some time and it was no longer well controlled with antidiarrheals. Patient complained of cramping and loose stools. A stool sample was ordered to be tested for C-diff, O&P culture, Giardia, and calprotectin. Awaiting results.
A record review of labs obtained on 1/17/23 indicated Resident #41 was negative for Ova (reproductive cell), Parasites (organism that lives in or on an organism of another species deriving its nutrients at the other's expense), and Giardia (an intestinal infection caused by a parasite). The lab indicated he had a high Calprotectin which was an indicator of neutrophils (white blood cells) in stool and not specific for inflammatory bowel disease. Other conditions including infections, diverticular disease (spasms in intestines causing pain and disturbance of bowel function without inflammation), proton pump inhibitors (medication that causes a profound and prolonged reduction of stomach acid production), and neoplasm (abnormal growth, can be a characteristic of cancer), among others, can result in elevated calprotectin (measurement of inflammation)
The lab indicated the Clostridium difficile (C-diff) test was cancelled indicating C-diff was not run at this time. Recollect for new test if needed. The lab indicated a fecal calprotectin of over 120 was suggestive of Inflammatory Bowel Disease.
During an interview on 3/03/23 at 10:47 AM, the ADON said Resident #41 had diarrhea off and on for about a year. She said he had end stage renal disease and she believed the phosphate binders (from a medication given for dialysis residents) caused his diarrhea.
During an interview on 3/03/23 at 11:55 PM, the DON said Resident #41 had diarrhea since she had been at the facility (1/31/23). She said she should have gotten a C-diff test on him once she realized he had chronic diarrhea which would have been 1-2 weeks after she had begun working at the facility. She said not doing that put other residents and staff at risk of serious injury for the risk of catching C-diff. She said LVN B called the dialysis center yesterday evening about 6:00 p.m. and let them know Resident #41 was positive for C-diff. She said LVN B documented she called the family and the MD but did not document she called the dialysis center.
During an interview on 3/03/23 at 12:05 PM, LVN B said she did not call the dialysis center to let them know Resident #41 was positive for C-diff. She said she should have let the dialysis center know, but she forgot. She said she did not find out he was positive until he was back from his dialysis treatment on Tuesday 3/2/23. She said he went to dialysis Tuesday, Thursday, and Saturdays. She said it was her responsibility to call the dialysis center.
During an interview on 3/03/23 at 12:09 PM, the DON said she would call dialysis and let them know Resident #41 was positive for C-diff.
During an interview on 3/03/23 at 12:18 PM, the ADON said she did not know why the C-diff lab for Resident #41 was not redrawn after 1/17/23. She said it might have fallen through the cracks.
During an interview on 3/03/23 at 1:55 PM, the Regional Nurse said the C-diff lab on 1/17/23 for Resident #41 was not warranted because the other labs taken were negative so there was no indication for the C-diff lab to be drawn. She said after the other labs were negative there was no reason to run that test. She said she did not know if Resident #41 had constant diarrhea or how long he had it. She said if the MD saw him on 2/1/23 and indicated he still had diarrhea a nurse should have followed up within 2 weeks. She said the problem was communication between the nurses and the MD. She said Resident #41 should not have been in the dining room even if he was in a gown and mask because he was pending a C-diff test. She said he should have been in isolation in his room pending his C-diff. She said the risk of him not having the C-diff test until after surveyor intervention was a risk of infection to other residents and staff that could be serious. She said the risk of staff not notifying the dialysis center that Resident #41 was positive for C-diff was a risk of infection to the other dialysis patients or dialysis staff that could be serious.
4. A record review indicated there was no tracking and trending for antibiotics and infections for January 2023.
During an interview on 2/28/23 at 1:55 PM, the DON said she was looking for the tracking and trending for antibiotics for January 2023. She said she thought the Regional Nurse had it and was getting it together. She said she would bring it soon.
During an interview on 3/1/23 at 8:54 AM, the DON said she was still waiting for the tracking and trending for antibiotics for January 2023 from the Regional Nurse.
During an interview on 3/01/23 at 11:36 AM, the DON said the Regional Nurse had the tracking and trending for antibiotics for January 2023 or was still looking for it. She said the Regional Nurse was busy and she would ask her about it.
During an interview on 3/01/23 at 1:41 PM, The Regional Nurse said she could not find the tracking and trending for January 2023. She said it was after the prior DON left and
CONCERN
(D)
Potential for Harm - no one hurt, but risky conditions existed
Deficiency F0635
(Tag F0635)
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, at the time each resident was admitted , there...
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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, at the time each resident was admitted , there were physician orders for the resident's immediate care for 1 of 3 (Resident #131) reviewed for admission physician orders.
The facility failed to ensure Resident #131 had a physician's order for the use of oxygen.
This failure could place residents at risk of not receiving appropriate care, treatment services, and at risk for low oxygen and/or high oxygen levels.
Findings included:
Record review of Resident #131's face sheet dated 03/02/2023 indicated she was an [AGE] year-old female who admitted on [DATE] with the diagnoses of respiratory failure, Chronic Obstructive Pulmonary Disease (a group of lung diseases that block airflow and make it difficult to breath), Covid-19, and pneumonia due to Coronavirus-19.
Record review of Resident #131's electronic medical record on 02/28/2023 revealed the MDS assessment was not completed.
Record review of the baseline care plan dated 02/27/2023 indicated Resident #131 did not use any special treatments such as oxygen.
Record review of the consolidated physician's orders dated 03/02/2023 created by the ADON indicated Resident #131 had a new order dated 03/02/2023 for oxygen 2-4 liters per minute per a nasal cannula as needed for shortness of breath.
During an observation on 02/27/2023 at 3:00 p.m. revealed , Resident #131 was sitting on the edge of her bed. She had oxygen infusing at 3 liters per minute via the nasal cannula. Resident #131 said she had never used her oxygen set at 3 liters and she stated she would like the nurse to lower the administration.
Record review of the EMR indicated on 03/02/2023 the ADON documented Resident #131 was having shortness of breath lying flat.
During an observation and interview on 03/02/2023 at 10:19 a.m. revealed, Resident #131 had oxygen infusing from an oxygen concentrator via a nasal cannula at 3.5 liters per minute. The oxygen cylinder on her wheelchair was set on 3 liters per minute. The ADON said she was unaware of Resident #131's current order for oxygen. The ADON, after reviewing the physician's orders, said Resident #131 did not have an order for oxygen. The ADON said the admitting nurse was responsible for ensuring Resident #131 had an order for oxygen upon admission. The ADON said there were risk of having low oxygen levels or too much oxygen.
Record review of a Transcribing or Noting and Discontinuing Orders policy with a review date of 02/10/2021 indicated the purpose was to provide a guideline for the process of physician order management for transcribing or noting and discontinuing orders.
During an interview on 03/03/2023 the Regional Corporate Nurse was asked to provide an admission policy and one was not provided at the time of the exit.
CONCERN
(D)
Potential for Harm - no one hurt, but risky conditions existed
Deficiency F0645
(Tag F0645)
Could have caused harm · This affected 1 resident
**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on interview and record review, the facility failed to ensure the Pre-admission Screening and Resident Review (PASRR) Leve...
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**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on interview and record review, the facility failed to ensure the Pre-admission Screening and Resident Review (PASRR) Level I assessment accurately reflected the resident's status for 1 of 7 resident (Resident #131) reviewed for PASRR Level I screenings.
The facility failed to ensure the accruecy of the PASRR Level 1 screening for Resident #131. The PASRR 1 Level screening did not indicate a diagnosis of mental illness, although the diagnosis was present upon admission.
This failure could place residents who had a mental illness at risk of not receiving a needed assessment (PASRR Evaluation), individualized care, or specialized services to meet their needs.
Findings included:
Record review of a face sheet dated 03/02/2023 indicated Resident #131 was an [AGE] year-old female who admitted to the facility on [DATE] with the diagnoses of respiratory failure, pneumonia related to Covid-19, Covid-19 virus, and major depressive disorder.
Record review of Resident #131's electronic medical record indicated on 03/03/2023 the admission MDS and comprehensive care plan was not completed.
Record review of the consolidated physician's orders dated 02/25/2023 indicated Resident #131 was administered Remeron 15 milligrams every evening for major depressive disorder.
Record review of a PASRR Level 1 Screening dated 02/23/2023 indicated in Section C0100 there was not any evidence, or an indicator Resident #131 had a mental illness.
During an interview on 03/03/3023 at 10:45 a.m., the Social Worker indicated she should have indicated Resident #131 had a mental illness. The Social Worker indicated she believed she had to indicate the same answers as the discharging facility. The Social Worker stated she resubmitted a corrected PASRR for Resident #131 indicating she had a mental illness of major depressive Disorder on 03/03/2023.
During an interview on 03/03/2023 at 11:00 a.m., the DON said the Social worker was responsible for the PASRR being accurate. The DON said the Resident #131 could miss out on services from the local authority. The Social Worker said she had been completing PASRR screening for years and was provided PASRR education.
During an interview on 03/03/2023 at 11:15 a.m., the Interim Administrator said the Social Worker was responsible for the PASRR screens. The Interim Administrator indicated major depression was a mental illness and if the PASRR was not correct Resident #131 could miss out on services.
Record review of Preadmission and Screening Resident Review (PASRR) Rules and Guidelines, dated 04/26/16, and last revised on 06/03/20, indicated:
Guideline
It is the intent of facility to meet and abide by all State and Federal regulations that pertain to resident Preadmission and Screening Resident Review (PASRR) Rules .
.Procedure
Referring Entity completes a PL1 .
.If Positive:
.AND admission is NOT Exempted Hospital Discharge or Expedited . The PL1 is faxed to LIDDA/LMHA prior to admission
CONCERN
(D)
Potential for Harm - no one hurt, but risky conditions existed
Deficiency F0655
(Tag F0655)
Could have caused harm · This affected 1 resident
**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on interview, and record review the facility failed to develop and implement a baseline care plan for each resident that i...
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**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on interview, and record review the facility failed to develop and implement a baseline care plan for each resident that included the instructions needed to provide effective and person-centered care of the resident that met professional standards of quality care for 1 of 4 residents reviewed for baseline care plans. (Resident # 131)
The facility failed to address Resident #131's communication, daily preferences, ADLs, devices, health conditions, medical conditions, safety risks/falls, skin, smoking, dietary, and therapy on the computerized base-line care plan.
This deficient practice could place residents at risk for missed care.
Findings included:
Record review of a face sheet dated 03/02/2023 indicated Resident #131 was an [AGE] year-old female who admitted to the facility on [DATE] with the diagnoses of respiratory failure, pneumonia related to Covid-19, Covid-19 virus, and major depressive disorder.
Record review of Resident #131's electronic medical record on 02/28/2023 revealed the MDS assessment was not completed.
Record review of the Baseline Care Plan dated 02/27/2023 at 10:56 a.m., indicated Resident #131's care plan was blank in all the sections except the area of Section C: Social Services completed by the Social Worker.
Record review of Resident #131's electronic medical record on 02/28/2023 revealed the comprehensive care plan was not completed in place of the baseline care plan.
During an interview on 03/03/2023 at 11:00 a.m., the DON said ultimately, she was responsible for the baseline care plan. The DON said a baseline care plan was needed to properly care for the resident. The DON said she had not had the time to document on the baseline care plan due to the survey process. The DON said Resident #131 admitted over the weekend and she had not had time to review her admission.
During an interview on 03/03/2023 at 11:15 a.m., the Interim Administrator said she believed the ADON was completing the baseline care plans. The Interim Administrator said a baseline care plan was needed to know the care needs of the resident.
Record review of a Baseline Care Plans policy with a revised date of 05/13/2021 indicated the purpose was to provide a person-centered baseline care plan developed and implemented for new admission and readmission residents. Baseline care plans are developed and implemented within 48 hours of a resident new admission and /or readmission. Baseline care plans are developed by Registered Nurses and other healthcare team members. The LVNs and other healthcare team members execute baseline care plans. The overall care coordination of the resident is evaluated by the DON/designee.
CONCERN
(D)
Potential for Harm - no one hurt, but risky conditions existed
Comprehensive Care Plan
(Tag F0656)
Could have caused harm · This affected 1 resident
**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on interview, and record reviews, the facility failed to review and revise by the interdisciplinary team after each assess...
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**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on interview, and record reviews, the facility failed to review and revise by the interdisciplinary team after each assessment, including both the comprehensive and quarterly review assessment for 1 of 1 (Resident #45) reviewed for comprehensive person-centered care plans.
The facility failed to revise Resident #45's care plan when he was receiving treatment for shingles (painful rash with blisters).
This failure could place residents at risk of not having their individualized needs met in a timely manner and communicated to providers and could result in a decline in physical well-being and care needs not being addressed.
Findings included:
1)Record review of a face sheet dated 03/02/2023 indicated Resident #45 was an [AGE] year-old male who admitted to the facility on [DATE] and readmitted on [DATE] with the diagnoses of heart failure, depression, malnutrition, and high blood pressure.
Record review of the most recent Significant change MDS dated [DATE] indicated Resident #45 was usually understood and usually understands. Resident #45 required large print to read. The MDS indicated Resident #45's BIMS score was 11 indicating he had moderately impaired cognition. The MDS indicated during the assessment period Resident #45 did not reject care. The MDS indicated Resident #45 required extensive assistance of one staff with bed mobility, dressing, toilet use, personal hygiene, and with bathing Resident #45 required total assistance of one staff member. Resident #45 was incontinent of bowel and bladder.
Record review of the consolidated physician's orders dated 03/01/2023 indicated Resident #45 had Acyclovir 800 milligrams 5 times daily for 5 days for possible shingles started on 03/01/2023. Resident #45 had Clindamycin 300 milligrams three times a day for cellulitis x 7 days started on 02/28/2023 and Doxycycline Monohydrate 100 mg twice a day for cellulitis until 03/07/2023. Resident #45 was also ordered Gentamicin Sulfate Ophthalmic ointment 0.3% 1 application in right eye two times a day for infection x 7 days to start on 02/28/2023.
Record review of the February 2023 and March 2023 medication administration record indicated Resident #45 was receiving Acyclovir, Clindamycin, Doxycycline, and Gentamicin eye drops.
Record review of the comprehensive care plan dated 11/09/2022 revealed it did not address that Resident #45 had shingles involving his face, and right eye. The comprehensive care plan did not address isolation precautions.
During an interview on 03/01/2023 at 11:01 a.m., the MDS nurse NN said the residents''s comprehensive care plans were updated during the interdisciplinary team meetings in the mornings. The MDS nurse indicated the nurse managers were responsible for updating the care plans with acute infections.
During an interview on 03/03/2023 at 11:00 a.m., the DON said the nurse management team, and the MDS nurses should update the care plan. The DON said she was unsure how the charge nurses got away from documenting on the care plan. The DON said the care planning needs were reviewed in the morning meeting. The DON said Resident #45's care plan should have been updated by the nurse managers and herself included.
During an interview on 03/03/2023 at 11:15 a.m., the Interim Administrator said she was not sure who updated the care plans and she said that was a problem. The Interim Administrator said not updating the care plan could cause a resident to have missed care needs and services.
Record review of a Care Plans and Care Area Assessment Policy dated 01/21/2015 indicated the intent was to meet and abide by all State and Federal regulations that pertain to resident care plans and subsequent Care Area Assessments completion. The purpose of this guide was to ensure that an interdisciplinary approach was utilized in addressing the Care Area Triggers that were generated by the completion of the MDS to effectively address the Care Area Assessments and ultimately achieve the completion of an effective comprehensive plan of care for each resident. Acute Care Plans: As acute problems or changes to intervention or goals were identified, an appropriate care plan would be developed or modified by a nursing staff member.
CONCERN
(D)
Potential for Harm - no one hurt, but risky conditions existed
ADL Care
(Tag F0677)
Could have caused harm · This affected 1 resident
**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, interview, and record review the facility failed to ensure a resident who was unable to carry out activiti...
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**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, interview, and record review the facility failed to ensure a resident who was unable to carry out activities of daily living received the necessary services to maintain good nutrition, grooming, and personal and oral hygiene were provided for 3 of 4 residents (Residents #280, #74 and #131) reviewed for ADL care.
The facility failed to ensure Resident #280 was routinely showered/bathed.
The facility failed to ensure Resident #131 was routinely showered/bathed.
The facility failed to ensure Resident #74's brief with bowel incontience was changed prior to her morning meal.
These failures could place residents at risk of not receiving care/services, decreased quality of life impacting their loss of dignity.
Findings included:
1. Record review of Resident #280's face sheet, dated 03/02/23, indicated an [AGE] year-old female who was admitted to the facility on [DATE]. Her diagnoses included fracture of right femur, history of falling, asthma, anxiety, and osteoporosis (condition in which bones become weak and brittle).
Record review of Resident #280's comprehensive care plan, dated 02/28/23, indicated she had an ADL self-care performance deficit and was at risk for not having her needs met in a timely manner. The care plan interventions included to provide shower, shave, oral care, hair care, and nail care per schedule and when needed.
Record review of the admission MDS, dated [DATE], indicated Resident #280 was usually understood and usually understood others. The MDS revealed Resident #280 had a BIMS score of 10, which indicated she had moderately impaired cognition. Resident #280 required limited assistance with transfers, dressing, toileting, and personal hygiene. Resident #280 required extensive assistance with bed mobility and locomotion. She was totally dependent on staff for bathing.
During an interview on 02/27/23 at 10:12 a.m., Resident #280 was in her room with family member present at bedside. Resident #280 said she had only received one shower since she admitted on [DATE]. Resident #280's family member agreed with Resident #280's statement and indicated that was correct.
During an interview on 03/01/23 at 08:11 a.m., Resident #280 said had not received another shower since the one she received Sunday (02/26/23).
Record review of Resident #280's ADL flow sheets did not reveal any refused bathing or showering.
During an interview on 03/01/23 at 10:32 a.m., CNA U said the showers were completed as per the shower sheet that was posted at the nurse's station. CNA U said shower schedule was as follows:
Monday, Wednesday, Friday- Morning shift women on A beds.
Monday, Wednesday, Friday- Evening shift women on B beds.
Tuesday, Thursday, Saturday- Morning shift men on A beds.
Tuesday, Thursday, Saturday- Evening shift men on B beds.
CNA U said they do not have shower sheets that they complete. CNA U said they document on the POC where they indicate if the resident received a shower. CNA U said there was not a place in the POC to indicate if a resident did not receive a shower or bath. CNA U said she would notify the charge nurse for any resident refusals. CNA U said she did not care for Resident #280.
During an interview on 03/01/23 at 10:40 a.m., RN G said the showers were done as per the schedule that was posted at the nurse's station. RN G said Resident #280 had indicated to him that she had been having problems receiving a bath. RN G said he instructed the nurse aide to give Resident #280 a shower on Sunday (02/26/23). RN G said he had notified the ADON regarding the issues Resident #280 was having receiving her showers or baths. RN G said there was usually only one aide on that hall and that there needed to be at least two aides for residents to receive the care they needed.
During an interview on 03/01/23 at 10:57 a.m., the ADON said they were in the middle of implementing the shower sheets again. The ADON said she was not aware of Resident #280 issues receiving a shower.
During an interview on 03/02/23 at 10:14 a.m., CNA H said the bath schedule was done by room numbers. CNA H said if a resident was in the room by themselves then they were considered being in the A bed. CNA H said she had given Resident #280 a bed bath one time. CNA H said the reason Resident #280 did not receive a shower was because when Resident #280 admitted to the facility, she had a wound thing on her hip and Resident #280 did not want to get the wound wet. CNA H said if a resident did not receive a bath or shower, N/A was checked on the POC.
During an interview on 03/02/23 at 10:28 a.m., the ADON said she expected showers or baths to be done according to the shower schedule unless the resident refuses. The ADON said if a resident refuses their shower, the aide was responsible for notifying the charge nurse. The ADON said the charge nurse was responsible of charting the refusal, notifying the family and physician if necessary. The ADON said the charge nurses were responsible of ensuring the baths were being completed as scheduled. The ADON said by not providing the showers as scheduled the resident was at risk for skin breakdown, dignity issue, or infection.
During an interview on 03/02/23 at 11:34 a.m., Resident #280 said she had not received a bed bath. Resident #280 said when she had the wound vac to her right hip the aides said they could give her a bed bath, but one was never provided. Resident #280 said the only shower she had received was the one that was provided to her on Sunday (02/26/23).
During an interview on 03/03/23 at 10:50 a.m., the DON said she expected the aides to follow the shower schedule and expected all the residents to be provided with a shower or bath depending on their preference. The DON said if a resident was to refuse their shower or bath, the aide was to notify the charge nurse so they could go talk to the resident as to why they refused. The DON said by not receiving a bath as scheduled the resident was at risk for skin problems, increased infection, and poor hygiene. The DON said she was responsible, as well as the charge nurse, to ensure the showers or baths were being completed as scheduled.
During an interview on 03/03/23 at 11:05 a.m., the Interim Administrator said she expected the showers or baths to be completed as scheduled. The Interim Administrator said by not receiving showers or baths the resident was at risk for not feeling well and a risk for infection. The Interim Administrator said the DON was responsible for ensuring the baths or showers were completed.
2. Record review of a face sheet dated 03/02/2023 indicated Resident #131 was an [AGE] year-old female who admitted on [DATE] with the diagnoses of respiratory failure, pneumonia, related to Covid 19, Covid 19 virus, and major depressive disorder.
Record review of Resident #131's electronic medical record on 02/28/2023 revealed the MDS assessment, the comprehensive care plan, and the baseline care plan were not completed.
During an interview and observation on 03/02/2023 at 8:51 a.m., the ADON was the nurse for Resident #131. The ADON was informed by Resident #131 that she had not been bathed since she admitted on [DATE]. The ADON said Resident #131 would have a bath/shower today. The ADON said the nurses were responsible for ensuring the baths were completed. The ADON said the bath sheets were removed from use when the facility went to all electronic. The ADON said they no longer used the paper bath sheets and the computer documentation did not indicate a resident had a bath only the assistance required for bathing.
During an interview on 03/02/23 at 10:14 a.m., CNA H said the bath schedule was done by room numbers. CNA H said if a resident was in the room by themselves then they were considered being in the A bed. CNA H said Resident #131 had refused her shower today but was given a bed bath. CNA H said Resident #131 received her bath on the 2:00 p.m. - 10:00 p.m. shift.
Record review of an undated bath sheet provided by the ADON on 03/02/2023 indicated Resident #131 would receive her showers on Monday-Wednesday-Friday on the 2:00 p.m. to 10:00 p.m. shift.
Record review of Resident #131's ADL flow sheets did not reveal any refused bathing or showering.
3)Record review of a face sheet dated 03/02/2023 indicated Resident #74 was an [AGE] year-old female who admitted on [DATE] with the diagnoses of spondylolisthesis (disorder of which a bone vertebra slips forward onto the bone below), eating disorder, and high blood pressure.
Record review of an admission MDS dated [DATE] indicated Resident #74 was usually understood and usually understood others. The MDS indicated Resident #74 BIMS score was a 13 indicating she was cognitively intact. The MDS indicated Resident #74 required extensive assistance of one staff with bed mobility, transfers, locomotion, toilet use, personal hygiene, and bathing. The MDS indicated Resident #74 was frequently incontinent of bowel and was not on a toileting plan.
During an observation and interview on 02/27/2023 at 10:08 a.m., revealed Resident #74 was lying in her bed leaning to the left side. Resident #74's room smelled of foul-smelling bowel movement at the doorway. Resident #74 said she had been incontinent of bowel since right before breakfast. Resident #74 said she was still lying-in bed with an incontinent episode at this time. Resident #74 said she refused therapy because she was waiting to be changed. Resident #74 said she had to eat with bowel movement in her brief and bed.
During an observation on 02/27/2023 at 10:16 a.m., revealed CNA C entered Resident #74's room and answered the call light. Resident #74 made CNA C aware she needed her brief changed. CNA C left the room and obtained the needed supplies. During the incontinent care Resident #74's brief had overflowed with liquid bowel movement. Resident #74 had liquid stool was up her abdomen past her umbilicus (belly button) and up her low back. Resident #74's back of her shirt was saturated with liquid stool as well.
During an interview on 03/03/2023 at 2:30 p.m., CNA OO said on 02/27/2023 Resident #74 activated her call light during breakfast. CNA OO said she did not change Resident #74 because the regulation (state regulation) said changing of briefs during breakfast was cross contamination. CNA OO said she was aware Resident #74 had a bowel movement.
During an interview on 03/03/2023 at 11:00 a.m., the DON said no one should eat their meal with an incontinent episode. The DON said it was a dignity issue. The DON said Resident #74 should have been changed prior to her having her breakfast.
During an interview on 03/03/2023 at 11:15 a.m., the Interim Administrator said she did not expect anyone to eat their meals with soiling in their briefs. The Interim Administrator said leaving someone with a soiled brief on could cause skin problems, loss of dignity, and make a resident not want to eat.
During an interview on 03/03/2023 at 11:00 a.m., the DON said the CNAs were responsible for the bathing and the nurses for ensuring the baths were completed.
During an interview on 03/03/2023 at 11:15 a.m., the Interim Administrator said the baths/showers should be monitored using the electronic computer system. The Interim Administrator said again this was monitored in the morning meetings with the corporate tools (morning meeting tool used to audit). The Interim Administrator said the previous administrator failed to implement the tools the corporate tools. The Interim Administrator said not bathing could make a resident feel good because they may not smell good.
Record review of the facility's policy, Resident Showers, dated 02/11/2022, indicated .the practice of this facility to assist residents with bathing to maintain proper hygiene, stimulate circulation, and help prevent skin issues as per current standards of practice . 1. Residents will be provided showers as per request or as per shower schedule .
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 an environment that was free of accident hazar...
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**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, interview, and record review, the facility failed to ensure an environment that was free of accident hazards for 1 of 6 residents reviewed for accidents hazards. (Resident #130)
The facility failed to implement a fall intervention when Resident #130 said he fell on [DATE] to prevent Resident #130 from falling on 02/27/2023.
These failures could place residents at risk for falls and falls with serious injury.
Findings included:
Record review of a face sheet dated 03/02/2023 indicated Resident #130 was an [AGE] year-old male who admitted on [DATE] with the diagnoses of stroke, heart attack, heart failure, and diabetes.
Record review of a baseline care plan dated 02/23/2023 documented by the ADON indicated Resident #130 had self-care performance with personal hygiene, toileting, dressing and bathing. The base line care plan indicated Resident #130 was alert but cognitively impaired. The base line care plan indicated Resident #130 was at risk to fall with the goal will not sustain a fall related injury by utilizing fall precautions through next review date. The Fall care plan indicated an intervention would be to provide assistance to transfer and ambulate as needed.
Record review of a comprehensive care plan dated 02/23/2023 and revised on 03/01/2023 indicated Resident #130 had a potential to falls related to high blood pressure medications, gait problems, and incontinence. The goal was he would not sustain a fall related injury by utilizing the fall precautions. The interventions included anticipate his needs, educate resident/family/caregivers on safety reminders, encourage socialization, encourage activities, anticipate needs by placing items close to him, and attempt to determine cause of past falls. The comprehensive care plan did not address a bed alarm.
Record review of the most recent MDS dated [DATE] indicated Resident #130 usually understands and was usually understood. Resident #130 BIMS score was 12 but he required cueing to recall. The MDs indicated Resident #130 had difficulty focusing his attention and was easily distracted. The MDS indicated Resident #130 required limited assistance of one staff with bed mobility, transfers, walking, locomotion, dressing, toileting, personal hygiene, and extensive assistance of one staff for bathing. The MDS indicated Resident #130 was incontinent occasionally of bladder and frequently of bowel. The MDS indicated Resident #130 had one fall with an injury.
Record review of a fall risk dated 02/23/2023 indicated Resident #130 scored a 14 indicating he was at moderate risk to fall. The fall risk indicated Resident #130 had a history of multiple falls in the last six months. The fall risk assessment indicated Resident #130 could not recall the season, where he was, the location of his room or the names of the staff. The assessment failed to assess his gait.
Record review of a nurse's note dated 02/26/2023 at 11:30 a.m., RN G wrote Resident #130's family was visiting today and informed the RN supervisor and staff nurse of Resident #130 reporting he had a fall last night and got himself back to bed and did not report to anyone. RN G documented there was new discoloration around the right eye of Resident #130.
Record review of an incident report dated 02/26/2023 indicated Resident #130 reported a fall last night. The daughter's statement indicated she reported Resident #130 said he fell against his wheelchair. The immediate action taken on the incident report indicated a head-to-toe assessment was completed with noted old bruises to trunk with yellow discoloration. Slight bruising noted to the right peri-orbital area (surrounding the eye).
Record review of a progress note documented by LVN V dated 02/27/2023 at 9:59 p.m., indicated Resident #130 was found on his buttocks on the floor between the bed and wheelchair. LVN V documented Resident #130 said he was trying to get in his chair. LVN V documented there were no injuries. LVN V indicated the bed was in low position and he had his call light in his hand. LVN V indicated she provided re-education.
Record review of the consolidated physician's orders indicated Resident #130 had a bed alarm ordered on 02/28/2023 two days after he reported to his family, he fell and sustained bruising to his right eye.
Record review of the electronic medical record dated February 2023 indicated Resident #130 had a physician's order for a bed alarm when in bed, monitor every shift for falls beginning on 02/28/2023 at 6:00 p.m. The medical record did not indicate a nurse completed this task; the space was blank.
During an observation and interview on 03/01/2023 at 4:10 p.m., Resident #130 was lying in bed. Resident #130 had deep purple peri-orbital (around the eye) bruising. Resident #130 said he did not know he had bruising to his right eye. Resident #130 denied falling.
During an interview on 03/03/2023 at 11:00 a.m., the DON said the care plan should be updated with fall interventions as they occur to prevent another fall or risk for injuries. The DON said the nursing team was responsible for putting interventions in place.
During an interview on 03/03/2023 at 11:30 a.m., the Interim Administrator said interventions should be put in place with each fall to prevent the next fall. The Interim Administrator said not putting an intervention in place could result in a serious injury.
Record review of an Investigation of Incidents and Accidents policy dated 12/03/2020 indicated the resident environment will remain s free of accident hazards as possible. Each resident will receive adequate supervision and assistive devices to prevent accidents. This included: identifying hazards and risks, evaluating, and analyzing hazards and risk, implementing interventions to reduce hazards and risks, and monitoring for effectiveness and modifying interventions when necessary. Implementation of Interventions-using specific interventions to try to reduce a resident's risk from hazards in the environment. This process included: Ensuring interventions were put into action.
CONCERN
(D)
Potential for Harm - no one hurt, but risky conditions existed
Deficiency F0692
(Tag F0692)
Could have caused harm · This affected 1 resident
**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based interview, and record review, the facility failed to ensure residents maintained acceptable parameters of nutritional stat...
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**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based interview, and record review, the facility failed to ensure residents maintained acceptable parameters of nutritional status when there was a nutrition a problem for 2 of 6 residents reviewed for unplanned weight loss. (Resident #'s 74 and 130)
The facility failed to ensure a weight variance was addressed and documented to ensure management of weight loss for Resident #'s 74 and 130.
These failures could place residents at risk for undetectable weight loss, malnutrition, and poor quality of life.
Findings included:
1. Record review of a face sheet dated 03/02/2023 indicated Resident #74 was an [AGE] year-old female who admitted on [DATE] with the diagnoses of spondylolisthesis (disorder of which a bone vertebra slips forward onto the bone below), eating disorder, and high blood pressure.
Record review of a Baseline care plan dated 01/24/2023 at 8:39 a.m., the ADON did not document Resident #74 had a recent history of Clostridium Difficile, and current diarrhea having an increased risk of weight loss.
Record review of an admission MDS dated [DATE] indicated Resident #74 was usually understood and usually understands. The MDS indicated Resident #74 BIMS score was a 13 indicating cognitively intact. The MDS indicated Resident #74 required extensive assistance of one staff with bed mobility, transfers, locomotion, toilet use, personal hygiene, and bathing. The MDS indicated Resident #74 was frequently incontinent of bowel and was not on a toileting plan.
Record review of the electronic weight summary dated 01/24/2023 indicated Resident #74's weight was 96.0 pounds. The electronic medical record did not reveal a weight for the month of February.
Record review of the comprehensive care plan dated 02/07/2023 indicated Resident #74 was at risk for Covid 19 infection but did not mention Clostridium Difficile (inflammation of the colon caused by bacteria causing diarrhea) or the need for isolation precautions.
During an interview on 02/28/2023 at 5:00 p.m., the DON said Resident #74's current weight was 87.4 pounds. The DON said she was unaware of this weight indicated Resident #74 had weight loss.
Record review dietician note dated 03/01/2023 indicated Resident #74's weight was 87.5 pounds. The dietician note indicated Resident #74's consumed of meals but still had unintended weight loss. The Dietician recommended to reweigh to confirm actual weight loss, weekly weights for 4 weeks, try super cereal at breakfast, start Prostat 30 milliliters twice daily (protein supplement), and offer beverage of choice and house snacks between meals.
2). Record review of a face sheet dated 03/02/2023 indicated Resident #130 was an [AGE] year-old male who admitted on [DATE] with the diagnoses of stroke, heart attack, heart failure, and diabetes.
Record review of a baseline care plan dated 02/23/2023 documented by the ADON indicated Resident #130 had self-care performance with personal hygiene, toileting, dressing and bathing. The base line care plan indicated Resident #130 was alert but cognitively impaired.
Record review of a comprehensive care plan dated 03/01/2023 indicated Resident #130 had a self-care deficit and was at risk of not having his needs met. The goal was to participate to be best of their ability and maintain current level of function with ADLs. The intervention included to provide supervision and set up help with eating. The comprehensive care plan indicated Resident #130 had a nutritional status deficit, and he would receive a mechanical soft diet with thin liquids due to complaints of difficulty swallowing. The goal was to maintain adequate nutritional and hydration status as evidenced by weight stable with no signs or symptoms of malnutrition or dehydration with the interventions to provide and serve diet as ordered and speech therapy to evaluate. The care plan interventions failed to indicate monitoring Resident #130's weight.
Record review of the most recent MDS dated [DATE] indicated Resident #130 usually understands and was usually understood. Resident #130 BIMS score was 12 but he required cueing to recall. The MDs indicated Resident #130 had difficulty focusing his attention and was easily distracted. The MDS indicated Resident #130 required limited assistance of one staff with bed mobility, transfers, walking, locomotion, dressing, toileting, personal hygiene, and extensive assistance of one staff for bathing. The MDS indicated Resident #130 was incontinent occasionally of bladder and frequently of bowel. The MDS indicated Resident #130 had one fall with an injury.
Record review of the hospital records indicated Resident #130 weight on 02/19/2023 was 206 pounds.
Record review of the electronic medical record on 02/28/2023 indicated Resident #130 failed to have an admission with for February 2023.
During an interview on 03/02/2023 at 4:10 p.m., the DON said Resident #130's current weight was 194.6. The DON said Resident #130 should have had a weight on his admission, but she could not provide one.
During an interview on 03/02/2023 at 11:00 a.m., the DON said she expected the admitting nurse to input a completed assessment including the weight. The DON said she expected the Resident #74 and #130 to have weekly weights for 4 weeks to ensure no weight loss was occurring. The DON said she was unaware Resident #74 had an eating disorder. The DON said she would have reviewed Resident #74 differently with the knowledge of the eating disorder. The DON said she would have provided psychological therapy, smaller meals, and more protein.
During an interview on 03/02/2023 at 11:30 a.m., the Interim Administrator said she the DON was responsible for weight management. The Interim Administrator said Resident #'s 74 and #130 should have had weekly weights.
Record review of the facility's policy, Weight Management, dated 01/2005 and revised on 04/23/2014, indicated .The facility management/clinical team will know the weight status of their residents, including the number of residents who have had a significant and insidious weight loss. Resident weights will be recorded in each resident's medical record monthly, using the Monthly Weight Report. Residents will maintain an acceptable weight unless clinically unavoidable, it is a planned weight change, or it is against the resident wishes. The parameters for significance of unplanned and undesired weight loss are: 1 month -Significant Loss- 5%, Severe loss- greater than 5% It is also important that all residents weights are accurately recorded in the individual resident's clinical record in a timely manner 1. All weights (admission, weekly and monthly) are to be entered into the Point Click Care weight system .All residents should be weighed on admission, readmission and monthly, unless more frequent weights are deemed necessary by the clinical team
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 observations, interviews, and record review, the facility failed to ensure drugs and biologicals used in the facility w...
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**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observations, interviews, and record review, the facility failed to ensure drugs and biologicals used in the facility were labeled in accordance with currently accepted professional principles, included the appropriate accessory and cautionary instructions, and the expiration date when applicable for 1 of the 5 medication carts reviewed for medications storage. (Station #2's nurse's cart)
The facility failed to ensure Resident #27's Basaglar (long-acting insulin to control high blood sugar) insulin pen was dated when opened on station #2's nurse's cart.
This failure could place residents at risk for not receiving the therapeutic benefit of medications, adverse reactions to medications, or harm by indigestion.
Findings included:
During an observation and interview on [DATE] at 09:01 a.m, station #2's nurse's cart revealed Resident #27's Basaglar insulin pen was opened and not dated. LVN F said the insulin pen should have had a date on it when they first opened it. LVN F said by not having an opened date on the insulin pen they could go past the 30-day expiration date. LVN F said the nurse who first opened the insulin pen was responsible of dating the insulin. LVN F said he was unsure of what could happen to the resident if they received an undated insulin. LVN F said the nurses check the medication carts weekly.
During an interview on [DATE] at 09:30 a.m., the ADON said she expected the insulin pens to be dated when opened. The ADON said the nurse who opens the insulin pen was responsible for dating it. The ADON said by not dating the insulin when opened the staff will be unaware of when the insulin expires. The ADON said the resident was at risk for the medications not to work properly. The ADON said the carts were to be checked daily.
During an interview on [DATE] at 10:50 a.m., the DON said she expected the insulin to be dated when opened and the nurse who first opens it was responsible for dating it. The DON said it was her responsibility to oversee that was being done. The DON said the residents were at risk for medications to be ineffective.
During an interview on [DATE] at 11:05 a.m., the Interim Administrator said she expected the insulin pens to be dated when opened and by not doing so, the staff would be unaware of when it expired. The Interim Administrator said the carts were checked by the pharmacist consultant and the nurse managers. The Interim Administrator said the resident was at risk for receiving an expired medication that could be ineffective.
Record review of the facility's policy, Medications Storage in the Facility, dated [DATE], indicated .Medications and biologicals are stored safely, securely, and properly, following manufacturer's recommendations or those of the supplier . Outdated, contaminated, or deteriorated medications and those in containers that are cracked, soiled, or without secure closures are immediately removed from stock, disposed of according to procedures for medication disposal and reordered from the pharmacy if a current order exists .
CONCERN
(D)
Potential for Harm - no one hurt, but risky conditions existed
Laboratory Services
(Tag F0770)
Could have caused harm · This affected 1 resident
**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** 2. Record review of Resident # 77's face sheet, dated 03/02/23, indicated a [AGE] year-old female who was admitted to the facili...
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**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** 2. Record review of Resident # 77's face sheet, dated 03/02/23, indicated a [AGE] year-old female who was admitted to the facility on [DATE] with diagnoses which included right femur (thigh bone) fracture, muscle weakness, high blood pressure, and depression (persistent feeling of sadness).
Record review of Resident #77's admission MDS, dated [DATE], indicated she was understood and understood others. The MDS revealed Resident #77 had a BIMS score of 15 which indicated her cognition was intact. Resident #77 required limited assistance with dressing and extensive assistance with bathing. She was independent with transfers, locomotion, eating and toileting.
Record review of Resident #77's comprehensive care plan did not address lab orders.
Record review of Resident #77's order summary report, dated 03/02/23, indicated she had the following order: CBC, CMP, and Mg every 3 months with an order date of 01/30/23 and a start date of 02/28/23.
During an interview on 03/02/23 at 02:34 p.m., the ADON said she had looked in Resident #77's records and her labs for CBC, CMP, and Mg could not be found. The ADON also reviewed the laboratory book, and she indicated the labs were not completed. The ADON said the labs for CBC, CMP, and MG were done on admission as standard orders for labs. The ADON said the charge nurse was responsible for ensuring the lab requisitions were completed and she was unsure as to why Resident #77 labs were not completed. The ADON said it was her responsibility to check the orders the next day and to ensure the lab requisition were completed for all lab orders. The ADON said by no completing the labs as order placed the resident at risk for harm.
During an interview on 03/03/23 at 10:23 a.m., the DON said she expected the labs to be completed as ordered. The DON said the nurse that obtained the lab order was responsible for ensuring the lab requisition was completed and placed in the lab book. The DON said she was ultimately responsible for ensuring the labs were completed and was unsure as to of why Resident #77 had missed labs. The DON said the clinical team reviews orders the next day during the morning meeting or the following Monday. The DON said they ensure the orders are correct and the lab requisitions were completed. The DON said by the obtaining the labs as ordered the resident was at risk for not receiving the care they need.
During an interview on 03/03/23 at 11:05 a.m., the Interim Administrator said she expected labs to be completed as ordered. The Interim Administrator said the DON was responsible for ensuring the labs were completed as ordered. The Interim Administrator said by not obtaining the labs as ordered the resident was at risk for being sick or having nontherapeutic medication levels.
A record review of the Lab Tracking Documentation Clinical Practice Guidelines dated 8/2015 indicated:
Anticipated Outcome
Lab documentation provides a record of the ordered lab test, including a system to monitor timely completion of ordered lab test and serves as a primary document describing lab services provided to the patient.
Fundamental Information
Lab tracking tools are used by healthcare team to track and record timely completion of ordered lab tests.
Procedure
Only physician ordered laboratory tests are completed .
Lab requisition form will be completed and placed under appropriate date in the lab notebook.
Individual tests are recorded on separate lines in the lab notebook and on the appropriate (Lab Tracking Tool or PT/INR Lab tracking tool) in the facility lab tracking notebook.
The new order is then recorded in facility's lab tracking notebook on appropriate tracking form (Lab Tracking Tool or PT/INR Lab tracking tool)
A Following Physician's Orders policy dated 9/28/21 provided by the Regional Nurse did not address orders for labs.
Based on interview and record review, the facility failed to ensure laboratory services were obtained to meet the needs of 2 of 22 residents reviewed for laboratory services (Residents #20 and 77).
The facility failed to obtain ordered CBC (Complete Blood Count), CMP (Complete Metabolic Panel, and Mg (Magnesium) levels for Resident #20.
The facility failed to obtain ordered CBC, CMP and Mg levels for Resident #77.
These failures could place residents at risk of not receiving timely diagnoses, treatment, and services to meet their needs.
This failure could place residents at risk of not receiving the care required to meet their physical, mental, and psychosocial needs for each to attain or maintain their highest practicable physical, mental, and psychosocial outcome.
Findings included:
1. A record review of the physician's orders dated March 2023 indicated Resident #20 admitted t the facility on 4/13/22, was [AGE] years old, with diagnoses that included: recurrent depressive disorders (lowering of mood), hypertension (high blood pressure), Alzheimer's Disease (progressive mental deterioration), pain, generalized anxiety disorder (a mental condition characterized by unrealistic anxiety about two or more aspects of life), unspecified mood affective disorder (a disorder affecting a person's emotional state, most commonly sadness), and seizures (uncontrolled burst of electrical activity in the brain). The physician's orders indicated: 12/20/22, CBC, CMP, Mg every 3 months.
A record review of the MDS dated [DATE] indicated Resident #20 had severe cognitive impairment, clear speech, usually understood others and was usually understood by others. The MDS indicated she had inattention that was continuously present. The MDS indicated she required supervision with no set up or physical help from staff for bed mobility and transfer.
A record review of the Care Plan dated 6/23/22 indicated Resident #20 required supervision for bed mobility and transfer and was able to effectively communicate when she had pain.
During an interview on 3/01/23 at 9:10 AM, LVN J said she could not find the labs (CBC, CMP, Mg) ordered for Resident #20 in December 2022. She said she looked yesterday and could not find them then either. She said it appeared they had not been done.
During an interview on 3/01/23 at 9:15 AM, the ADON said she could not find the labs were done for Resident #20 that were ordered in December of 2022. She said she called the lab provider and they could not find them either. She said the procedure for orders for labs was the nurse took the order, wrote the order, filled out the pharmacy recommendation and then would put the pharmacy recommendation in the lab book. She said the lab provider came in Monday through Friday, got the recommendations from the book, then took the labs per the orders. She said when the results were back the lab would fax the results. She said if the results were critical the lab would also call them. She said she did not know who missed the labs for Resident #20 but not getting her labs could cause serious harm, injury, or death. She said it was important to get all the labs.
During an interview on 3/01/23 at 9:46 AM, the DON said the risks of Resident #20 not getting her ordered labs on 12/20/22 was that they or the MD would not know her baseline. She said not having the labs would mean they could miss an infection, or a heart problem. She said they would not know if there was a shift in one of her labs. She said there was a danger of serious harm, injury, or death. She said the process for ordering labs was the nurse would take the order, then put the order in the computer. She said then the nurse would fill out a lab requisition, fax it to the lab and then put it into the lab book. She said the lab provider would then collect it and fax the results. She said the lab would stay on the 24-hour report until it was completed. She said she was not here at the time that lab was ordered.
A record review on 3/01/23 of the progress notes for Resident #20 from 12/19/22 - 12/21/22 did not address the labs ordered on 12/20/22.
During an interview and record review on 3/01/23 at 11:04 AM, RN K said she took the order for Resident #20 on 12/20/22 for a CBC, CMP, and MG. She said she probably did not put it on the 24-hour report because that was up to the charge nurse. She said her responsibility was to tell the charge nurse and the charge nurse would put that information on the 24-hour report. She showed this surveyor her work schedule for 12/20/22 and 12/21/22. The schedule indicated she had worked 12/20/22 and 12/21/22. RN K agreed she had worked 12/20/22 and 12/21/22. RN K said she did not follow up on the order for Resident #20's labs. She said it was not her responsibility to follow up on the orders. She said it was the charge nurse's responsibility to follow up on the new orders. She said she did not remember who the charge nurse was at that time. She said at that time (12/20/22) she took the order for the labs and made out the lab requisition. She said she did not fax it to the lab because it was not a STAT lab. She said she put the lab requisition for Resident #20 in the lab book. She said there was no written procedure for the particular way to go about getting labs for residents. She said the lab did an audit of the labs for the facility in November of 2022. She said she reviewed the lab audit that showed many labs were missed so she had done her own audit. She said she missed Resident #20's labs in the audit she did. She said she just realized the labs were missed. She said Resident #20 did not get the labs that were ordered 12/20/22.
During a interview and record review on 3/01/23 at 11:36 AM, the DON showed this surveyor the 24-hour reports dated 12/19/22 - 12/22/22. She said the 24-hour reports did not indicate any new orders for Resident #20.
During an interview on 3/01/23 at 3:02 PM, the Medical Director for Resident #20 said there should not be any problems with Resident #20 not getting her CBC, CMP or Mg labs. She said the CBC, CMP, and Mg labs were something they were required to do every so often and that was why they were ordered. She said she had taken care of Resident #20 since 2021 and she had not had a seizure. She said the labs were something that they did every so often and not related to seizures.
During an interview on 3/02/23 at 8:11 AM, the ADON said following MD orders was important regarding labs. She said Resident #20 could have had an infection that they missed. She said labs were important to see if anything had changed from her last labs. The ADON said they would want to catch anything abnormal. She said not having her labs could cause serious injury, or illness. She said depending on what labs, if she had elevated bloodwork of some type, it could potentially be very bad to not know what the labs were.
During an interview on 3/02/23 at 8:22 AM, the DON said physician's orders should have been followed for Resident #20 for patient safety, positive outcomes, and maintenance of health status. She said she was not at the facility in December 2022, but with the current process the nurse would take the order, put it in the computer, complete the lab requisition and put it in the doctor's lab book. She said the lab provider would come around Monday through Friday and get the order. She said on weekends if it was a timed lab (a lab that had to be done in a certain time frame), they had to call the lab, the same as with a STAT (as soon as possible) lab. She said the charge nurse for that unit would put it on the 24-hour report until they got the results. She said the charge nurse was the actual nurse so she should have known to put it on the 24-hour report. She said RN K was working PRN (as needed) at the time and was not the charge nurse at the time. She said RN K was at the facility helping but the charge nurse at the station should have put the new orders on the 24-hour report. She said she would look and see who that was.
During an interview on 3/02/23 at 8:29 AM, the Interim Administrator said labs were important no matter what they were. She said if they did not know what the labs were, there were all kinds of things that could go wrong with the resident. She said Resident #20 not getting her labs could have caused them to miss an infection or an illness. She said missing the labs could cause serious injury to the resident. The Interim Administrator said she was not a nurse or a MD so she did not know if it could cause death.
During a phone interview on 3/02/23 at 10:54 AM, LVN L said she was the charge nurse on 12/20/22 (at the time when Resident #20 got the lab orders). She said if RN K took the order, it was up to her to get that order on the 24-hour report so that the order could be followed through. She said that was so long ago she did not remember if RN K told her about the new lab orders for Resident #20. She said if RN K did not put the new orders on the 24-hour report she should have told her about the new orders so she could have put them on the 24-hour report. She said the information on the 24-hour report was how the nurses followed up and made sure the labs were completed.
CONCERN
(E)
📢 Someone Reported This
A family member, employee, or ombudsman was alarmed enough to file a formal complaint
Potential for Harm - no one hurt, but risky conditions existed
Pharmacy Services
(Tag F0755)
Could have caused harm · This affected multiple residents
**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, interview and record review, the facility failed to establish a system of receipt and disposition of all c...
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**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, interview and record review, the facility failed to establish a system of receipt and disposition of all controlled drugs in sufficient detail to enable accurate reconciliation and determine that drug records are in order and that an account of all controlled drugs are maintained and periodically reconciled for 1 of 22 residents (Resident #59) and 1 of 5 medications carts. (Station #2 medication aide cart).
The facility failed to remove expired prostat liquid (concentrated liquid protein), expired melatonin, and 3 bottles of expired eye drops from station #2's medication aide cart.
The facility failed to keep a record of receipt of controlled medications awaiting disposition to allow accurate and periodic reconciliation.
The facility failed to ensure the security of Resident #59's Haldol medication upon delivery of medications on 02/06/23.
These failures could put residents at risk for misappropriation of medication, drug diversion, not receiving the therapeutic benefit of medications, adverse reactions to medications, or harm by indigestion.
Findings included:
1. During an observation on 02/28/23 beginning at 09:10 a.m., the station #2 medication aide cart revealed the following expired medications:
*Two OTC lubricant eye drops with an expiration dates of 11/22
*One OTC artificial tears eye drops with an expiration date of 09/22.
*One bottle of OTC melatonin 3mg with an expiration date of 01/23.
*One bottle of OTC Prostat liquid with an expiration date of 02/25/23.
During an interview on 02/28/23 at 09:19 a.m., CMA E said the nurses and medication aides were responsible of ensuring the carts are checked for expired medications a least daily. CMA E said the resident was a risk for receiving an expired medication and could cause them to become sick or the medication could not work as intended.
During an interview on 02/28/23 at 09:30 a.m., the ADON said she expected the expired medications be pulled off the cart as soon as it was noticed the medication was expired. The ADON said the resident was at risk for the medications not to work properly. The ADON said the nurses and medication aides were responsible for removing expired medications from the carts. The ADON said the carts were to be checked daily. The ADON said the DON and herself were responsible for overseeing there were no expired medications on the carts.
During an interview on 03/02/23 at 10:50 a.m., the DON said she expected the nurses and medication aides to audit their carts at least monthly to check for expired medications. The DON said it was her responsibility to oversee that was being done. The DON said the residents were at risk for medications to be ineffective.
During an interview on 03/03/23 at 11:05 a.m., the Interim Administrator said she expected for the medication carts to not have any expired medications. The Interim Administrator said the carts were checked by the pharmacist consultant and the nurse managers. The Interim Administrator said the resident was at risk for receiving an expired medication that could be ineffective.
2. During an observation and interview on 03/01/23 beginning at 1:33 p.m., the DON showed this surveyor where she stored controlled medications awaiting disposal, and inside the storage appeared to be at least 100 different medications including medication cards, medication bottles and narcotic medications. The DON said some of the medication was already there when she started on 01/31/23. When asked how she reconciled medication brought to her to be disposed, the DON said she did not have a log. The DON said the nurse and herself signed off on the narcotic sheet how much medication was left and placed with the medication in the locked cabinet until the pharmacist told her how they would want it done at the facility. The DON said the pharmacist had not been there since she started.
Record review of the facility's pharmacy medication destruction form indicated last medication destruction was completed on 01/23/23.
During an interview on 03/01/23 at 02:59 p.m., the DON said the facility does not keep a log here for expired or discontinued narcotics. The DON said they use a scanning system to log the narcotic medications but does not have access to that system and the corporate nurse does not know how to access the system either. The DON said she does not have access to her policies and procedures and was not allowed by the corporate nurse to access those policies.
During an interview on 03/02/23 at 10:50 a.m., the DON said her expectations for narcotic reconciliation was for the nurses to pull the expired or discontinued narcotic medications off the cart and be given to her so she could log and lock them until the pharmacist came for drug destruction. The DON said there was a risk drug diversion or abuse for not logging the narcotic medications. The DON said it was her responsibility to ensure the narcotic medications were logged and locked.
During an interview on 03/03/23 at 11:05 a.m., the Interim Administrator said she expected the discontinued narcotics to be double locked and logged. The Interim Administrator said by not logging the narcotic medications, some medications could end up missing. The Interim Administrator said it was the DON's responsibility to ensure that narcotic medications were kept logged until she gained access to the scanning system.
2.Record review of Resident #59's admission record dated 03/02/23 indicated the resident was a 94year old female who admitted to the facility on [DATE] with the diagnosis of dementia, anxiety, mood disorder, diabetes, high blood pressure, and kidney disorder.
Record review of Resident #59's annual MDS dated [DATE] indicated under Section B, Hearing, Speech, and Vision, B0700 was coded as a 2 indicating she sometimes understood and B0800 was coded as a 2 indicating she was sometimes understood by others. Section C, Cognitive Patterns, under section C0500 Brief Interview for Mental Status, which indicated a score of 02 for severe cognitive impairment. Section G, Function Status, under section G0110 indicated she needed extensive assistance with toileting, personal hygiene, and bathing, limited assistance with bed mobility and dressing, supervision with transfers, and independent with eating.
Record review of Resident # 59's medication administration record dated 3/2/23 indicated that for the month of February 2023 Resident #59 had an order for Haldol Injection 5MG/ML (Haldol lactate) Inject 2.5mg intramuscularly every 8 hours as needed for agitation for 12 days that started 02/08/23 at 1230 (12:30 p.m.) and discontinued 02/08/23 at 1234 (12:34 p.m.) with no administration. It also indicated Resident #59 had an order for Haldol Injection 5MG/ML (Haldol lactate) Inject 2.5mg intramuscularly every 8 hours as needed for agitation that started on 02/06/23 at 1700 (5:00 p.m.) and discontinued on 02/08/23 at 1218 (12:18 p.m.) with no administration.
Record review of the facility's patient dispense history dated 03/01/23 for dates 02/01/23-02/28/23 indicated Resident #59 had Haloperidol Lac 5MG/ML 1ML with quantity of 5 dispensed to the facility on [DATE].
Record review of Resident #59's Order Summary Report dated 03/14/23 indicated that resident had an order for Haldol Injection 5MG/ML (Haldol lactate) Inject 2.5mg intramuscularly every 8 hours as needed for agitation that started on 02/06/23 and discontinued, and Resident # 59 had order for Haldol Injection 5MG/ML (Haldol lactate) Inject 2.5mg intramuscularly every 8 hours as needed for agitation for 12 days that started 02/08/23 and ended on 02/20/23.
During an interview on 03/02/23 at 01:32p.m. CNA LL said she had been working for the facility for 30 years. She said she had never known Resident #59 to be given any injections.
During an interview on 03/02/23 at 01:34p.m. LVN MM said she was never aware of Resident #59 having an injection given. She said she never knew the resident had an order for Haldol at all. She said she thought Haldol injections should have been in the narcotic lock box on the cart and counted daily. LVN MM said she would have reported to the DON if the medication had been removed or missing from the cart.
During an interview on 03/03/23 at 10:08a.m. LVN L said she knew Resident #59 had an order for Haldol, but never knew of the resident being administered Haldol because it was discontinued soon after it was ordered. LVN L said Resident #59 never had any anxiety or agitation noted.
During an interview on 03/03/23 at 11:02 a.m. the DON said she could not locate the Haldol medication that was sent to the facility. She said she had looked through her closets and all discontinued medications. The DON said she had notified the police on 03/01/23 to report the Haldol medication as missing. The DON said her, and the floor nurses had completed a search through all medication carts, as well as the medication rooms on 03/01/23. She said the charge nurses were responsible for removing discontinued medications from the cart and giving the narcotic medications to her or placing regular medications in the medication room's discontinued medication box. The DON said she was responsible for monitoring and logging the medications, as well as ensuring the medications were in the correct place. The DON said the risk to Resident #59 medication being misplaced was the medication being abused or the resident not getting the medication administered as needed. The DON said the missing medication was considered to be misappropriation or resident property.
During an interview on 03/03/23 at 04:58 p.m. the Interim Administrator said the Haldol medication was missing. She said her, nor the DON had been able to determine who had taken the medication nor where it was located. The Interim Administrator said she had confirmed that the medication was delivered on 02/06/23, and it was discontinued on 02/08/23. She said the DON was responsible for ensuring all medications were received and discarded in the proper locations. The Interim Administrator said the Haldol missing could have placed Resident #59 at risk for not receiving the proper medication if needed.
A record review of the facility's Abuse policy, originally dated 02/2005, reviewed 02/01/2021, indicated, Residents have the right to be free of abuse, neglect, misappropriation of resident property, and exploitation, physical and chemical restraint not required to treat the resident's symptoms, involuntary seclusion and corporal punishment.
A record review of the facility's Drug Diversion policy, dated 02/23/2017, indicated, The following recommendations are designed to reduce and limit drug diversions:
1.
Do not sign for receipt of controlled substances until you have inspected the delivery from the pharmacy that all ordered medications have arrived.
2.
The narcotic count sheet should be signed and quantity received should be indicated.
3.
Medications should be put in storage areas immediately and not left at nurses station or on medication room counters.
4.
Controlled substances should be stored in a double locked compartment at times including discontinued and overstocked medications.
5.
A drug count must be done at each shift change and should be done whenever the keys to the narcotic storage areas are exchanged from one staff to another. ALL controlled substances should be counted including those in the lock box in the refrigerator and overstock narcotics in medication room.
6.
Access to refrigerator lock box and overstock narcotics in medication room should be limited.
7.
Signing the narcotic shift count sheet means you are accepting responsibility for the controlled substances. Therefore, do not sign unless you are certain that all of the controlled substances are present and have not been adulterated/tampered with or altered in any way.
8.
Document usage both on MARs and narcotic count sheet as soon as possible after administration of medication.
9.
Document administration of PRNs controlled substances on the MARs including dose, date, time, route and effectiveness of medication.
1O. Do not return capsule or tablet to a container or a medication card once it has been removed. NEVER USE TAPE ON A MEDICATION CONTAINER OR
BLISTER PACK.
o
Do not use white-out or obliterate an entry if you make an error. Draw one line thru the error and provide an explanation with your signature.
o
Do not use the double locked storage areas to store personal items (keys, cash, resident/personal property, etc ).
o
Check medication containers and cards for signs of tampering or drug substitution (ie. tape on back of blister cards)
o
Check ampules to make certain they have not been opened and glued back together.
Record review of the facility's policy, Narcotic Reconciliation, dated 08/2014, indicated .Medications included in the state and federal Drug Enforcement Administration classification as controlled substances are subject to special handling, storage, disposal, and record keeping in the nursing care center in accordance with federal, state, and other applicable laws and regulations . 1. The director of nursing and the consultant pharmacist monitor for compliance with federal and state laws and regulations in the handling of controlled medications .
Record review of the facility's policy, Medications Storage in the Facility, dated March 2011, indicated .Medications and biologicals are stored safely, securely, and properly, following manufacturer's recommendations or those of the supplier . Outdated, contaminated, or deteriorated medications and those in containers that are cracked, soiled, or without secure closures are immediately removed from stock, disposed of according to procedures for medication disposal and reordered from the pharmacy if a current order exists .
Feb 2023
2 deficiencies
CONCERN
(D)
📢 Someone Reported This
A family member, employee, or ombudsman was alarmed enough to file a formal complaint
Potential for Harm - no one hurt, but risky conditions existed
Report Alleged Abuse
(Tag F0609)
Could have caused harm · This affected 1 resident
**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on interview and record review, the facility failed to ensure that all alleged violations involving abuse, neglect, exploi...
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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 all alleged violations involving abuse, neglect, exploitation, or mistreatment, including injuries of unknown source and misappropriation of resident property, were reported no later than 24 hours as required for two of 10 reviewed for abuse, neglect, and exploitation (Resident #1 and Resident #2).
The facility did not report an incident of drug diversion and of misappropriation of drug medication to state agency.
This failure could place residents at risk of drug diversion and misuse of medication
Findings included:
Record Review of the facility investigation report indicated the incident was reported on 12/12/2023 at 10:27 PM. The report indicated on 12/9/22, the medication aide discovered potassium pills in the hydrocodone card for Resident #1. The report indicated the card was almost empty and only had a few pills remaining. The card had no obvious signs of tampering, and the pharmacy was notified. The report indicated the next day 4 more cards were found to be affected. The report indicated on 12/12/22, evidence of an empty potassium card was found, and it was concluded to have been the card of pills that were switched with the narcotic card. The report indicated audits revealed no further evidence. The pharmacy audit had no evidence of foul play. The report indicated staff who had access to the medications were drug tested and none tested positive. Staff were questioned and none reported knowledge of foul play amongst staff members. The report indicated the investigation indicated no evidence of who was responsible nor where the tampering took place.
During an interview on 02/01/2023 at 1:09 PM, LVN E said he worked 6:00 PM to 6:00 AM shift on 12/09/22. LVN E said around 6:30 PM, just after he started his shift, LVN C told him that Resident 1's Norco was really Potassium. LVN E said he assumed that LVN C had already reported it to the ADON. LVN E said he thought LVN C was just sharing information with him, and he did not think to report it at that time. LVN E said later that evening when he was passing medication around midnight, became curious, and looked at Resident #2's Norco. He said there were 4 cards. LVN E said the first 2 cards were Norco. LVN E said the first card had about 20 pills in the blister pack and the second card was full and there were 30 pills. LVN E said cards 3 and 4, were both full. LVN E said there were a total of 60 pills (30 in each pack) but the pills inside the pack were Potassium and not Norco. LVN E said the pills look a lot alike. LVN E said he called the ADON to report the Norco were Potassium and not Norco as it showed on the card. LVN E said he did an audit of other medications and did not find any other Norco that had been replaced.
During an interview on 02/01/2023 at 12:58 PM, the ADON said she first learned of Norco being replaced with Potassium around midnight on 12/09/22. The ADON said LVN E, called her and said two full cards of Norco had been replaced with potassium tablets.
During an interview on 02/02/2023 at 10:10 AM, The ADON said the drug diversion was reported to the previous Administrator of the facility on 12/10/22.
During Record Review of a written statement signed and dated 12/12/2022 by LVN E indicated, On 12/09/22, I was told that the [Resident #1's], Norco 10 mg were Potassium. Later that shift, I was just curious and looked at [Resident #2's] Norco 10 mg. That is when I noticed they were Potassium pills instead of Norco like the package says. I could tell it was Potassium due to how the pill looked. It was grainy/spotted looking, plus it has KCM10 which is Potassium 10 mg. That's when I decided to look at the new card sent that was delivered on 12/07/22. The first two partial cards were Norco 10 mg, the last 2 cards were Potassium. 60 in total. I checked to see if the package was tampered with, not marks were found. The foil was intact, the clear bubble and card was intact. The cards looked just like a new card from the Pharmacy. I then notified the Nurse Practitioner and ADON.
During Record Review of a letter dated 12/15/22 from Pharmacy Tech, and Customer Success Representative for the pharmacy company indicated, On Monday, December 13th, 2022, I performed a full audit of all medications stored in the medication carts throughout the facility. I verified the contents of each blister card to confirm the medication on the label matched the entire contents of each blister card. During my audit, there were no discrepancies in the medications located.
During Record Review of a witness statement dated 12/12/22 at 4:25 PM, signed by LVN F indicated, I found out about the narcotics being potassium on 12/09 from LVN E
During an interview on 02/02/2023 at 10:20 AM, with LVN F. LVN F said he worked on 12/09/22. LVN F said on 12/09/22 he heard LVN C telling LVN E, that a resident's Norco was really Potassium.
During an interview on 02/02/2023 at 10:33 AM, LVN E said the first time he heard of medication being switched from Norco to Potassium was from LVN C when he started his shift at 6:00 PM on 12/09/22.
During an interview on 02/02/2023 at 12:26 PM, the ADM said the incident of the missing medication was not reported within 24-hours because they thought it was a pharmacy error and did not know the packets had been tampered with at the time. The ADM said they discussed it and did not feel it was a reportable incident when they first heard about the wrong medications. The ADM said the incident should have been reported before 12/12/22 according to facility policy.
During Record Review of a Face Sheet, Resident #2 was a [AGE] year-old male admitted [DATE] with diagnoses of Chronic Pain. Consolidated Orders for January 2023 showed Resident #1 was prescribed Hydrocodone-Acetaminophen Tablet 10-325 MG give 1 tablet by mouth every 8 hours related to Chronic Pain Syndrome. Resident is given Tylenol #3 and Mobic to help manage pain. Order dated 01/28/2023 include Tylenol with Codeine#3 oral tablet 300-30MG, give 1 tablet by mouth every 6 hours as needed for moderate pain 4-6 for 14 days. Laboratory report dated 12/10/23 showed Resident #1's Potassium leve1 as 4.0, which was in the normal limits of 3.5 and 5.1. Review of Medication Administration Records (MAR) for January 2023, showed Medications were given as prescribed.
Record review of the Abuse Policy dated 01/01/2021 revealed . a.Shall report to the state agency and one or more law enforcement entities . any responsible suspicion of a crime against any individual who is a resident of or receiving care from the facility B.Shall report immediately, but no later than 2 hours after forming the suspicion .result in serious bodily injury, or not later than 24 hours if the events causing the suspicion do not result in serious bodily injury.
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 F0761
(Tag F0761)
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 secure all drugs and biologicals in locked compartmen...
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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 secure all drugs and biologicals in locked compartments, including the storage of schedule II-V medications in separately locked, permanently affixed compartments, permitting only authorized personnel to have access for 4 of 6 medication carts. (Stations #1, #2, #3, and #4)
The facility failed to ensure only authorized personnel had access to the facility's medication carts containing narcotics.
The facility failed to ensure medication carts with narcotics, were kept double locked.
These failures could place residents at risk of drug diversion and misuse of medication.
Findings included:
During an observation on 01/31/23 at 05:02 AM, two medication carts located near Nurse's station 1 were unattended and the outer lock was open.
During an interview on 01/31/23 at 5:02 AM, LVN A said both carts should be locked because they contained narcotics and should be under double lock.
During an observation on 01/31/23 at 5:13 AM, a medication cart located near Nurse's station 3 was unattended and unlocked.
During an interview on 01/31/23 at 5:15 AM, LVN B said the cart should be always locked because there were narcotics in the cart. LVN B said during the night shift LVN B and LVN A share the keys to the medication cart because not all the medications were in each cart.
During an observation and interview on 01/31/23 at 5:20 AM, the cart 3 was locked. When asked to open the cart, LVN B said she did not have the key and used her hand to pat the top of the notebook on top of the cart looking for the keys. LVN B said she must have left them in her jacket and walked toward Station 3. LVN A walked toward the cart and said she had the keys. LVN A handed the keys to LVN B. LVN B unlocked the cart showing narcotics inside the cart.
During an interview on 01/31/23 at 5:21 AM, LVN A said she normally left the keys inside the narcotic count book on top of the medication cart. LVN B said she sometimes left the keys in the book.
During an interview on 01/31/23 at 6:20 AM, the ADON said all narcotics should be stored under double lock according to facility policy. The ADON said carts should be secured any time they were unattended, and keys should never be left on top of the cart. The ADON said the facility had some recent drug diversions.
During an observation 02/02/23 at 5:11 AM, Station 4 medication cart was locked. Two sets of keys were on top of the cart in plain view. Surveyor approached the cart, NA A, looked at Surveyor, reached for the keys and pulled her hand back rapidly. Surveyor walked to station 3, the cart was locked. Surveyor turned around and went back to the cart on station 4 the keys were no longer on the cart.
During an interview on 02/02/23 at 5:14 AM, NA A said LVN C motioned for her to get the keys when she saw the surveyor coming. When asked how she knew LVN wanted her to get the keys, NA said, Because she was standing down the hall in front of room [ROOM NUMBER] and pointed to the cart and felt of her pockets. NA A said she should not have keys to the medication cart.
During an interview on 02/02/23 at 5:15 AM, LVN C said it was a mistake to leave the keys on top of the cart. LVN C said normally she does not leave the keys. LVN C said the keys on top of the cart were for the medication cart and the nursing cart for Hall 1. LVN C said she motioned for NA to move her cart.
During an observation and interview on 02/02/23 at 5:15 AM, Surveyor asked LVN C to unlock the nursing cart on Station 1. LVN C felt her pockets and said, I don't have the keys. NA A must have them. LVN C asked NA A for the keys. LVN C got the keys from NA A, opened the Nurse's cart on Station 1 revealing 20 containers of narcotics in the cart.
During an observation on 02/02/23 at 5:25 AM, station 2 medication cart was unlocked inside a room next to the nurses' station. LVN D walked into the unlocked room.
During an interview on 02/02/23 at 5:26 AM, LVN D said she was just around the corner restocking the other cart. LVN D said she left the cart unlocked when she took supplies to the other cart that was in the hallway, just around the corner.
During an observation on 02/02/23 at 5:26 AM, LVN D opened the Narcotic lock box for station 2 and seven cards of narcotics were inside the box.
Record review of a policy titled medication storage dated 01/20/21 showed .1. All drugs and biologicals will be stored in locked compartments (i.e., medication carts, cabinets, drawers, refrigerators, medication room) under proper temperature controls. B. Only authorized personnel will have access to the keys to locked compartments . 2. Narcotics and Controlled Substances: a. Scheduled II drugs and back-up stock of Schedule III, IV and V medications are stored under double-lock and key.
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
- • 39% turnover. Below Texas's 48% average. Good staff retention means consistent care.
Concerns
- • Multiple safety concerns identified: 3 life-threatening violation(s), 1 harm violation(s), $366,445 in fines. Review inspection reports carefully.
- • 32 deficiencies on record, including 3 critical (life-threatening) violations. These warrant careful review before choosing this facility.
- • $366,445 in fines. Extremely high, among the most fined facilities in Texas. Major compliance failures.
- • Grade F (4/100). Below average facility with significant concerns.
Bottom line: This facility has 3 Immediate Jeopardy findings. Serious concerns require careful evaluation.
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About This Facility
What is Henderson Health & Rehabilitation Center's CMS Rating?
CMS assigns HENDERSON HEALTH & REHABILITATION CENTER an overall rating of 3 out of 5 stars, which is considered average nationally. Within Texas, this rating places the facility higher than 99% of the state's 100 nursing homes. This mid-range rating indicates the facility meets federal standards but may have areas for improvement.
How is Henderson Health & Rehabilitation Center Staffed?
CMS rates HENDERSON HEALTH & REHABILITATION CENTER's staffing level at 4 out of 5 stars, which is above average compared to other nursing homes. Staff turnover is 39%, compared to the Texas average of 46%. This relatively stable workforce can support continuity of care.
What Have Inspectors Found at Henderson Health & Rehabilitation Center?
State health inspectors documented 32 deficiencies at HENDERSON HEALTH & REHABILITATION CENTER during 2023 to 2025. These included: 3 Immediate Jeopardy (the most serious level, indicating potential for serious harm or death), 1 that caused actual resident harm, and 28 with potential for harm. Immediate Jeopardy findings are rare and represent the most serious regulatory concerns. They require immediate corrective action.
Who Owns and Operates Henderson Health & Rehabilitation Center?
HENDERSON HEALTH & REHABILITATION CENTER is owned by a for-profit company. For-profit facilities operate as businesses with obligations to shareholders or private owners. The facility is operated by ADVANCED HEALTHCARE SOLUTIONS, a chain that manages multiple nursing homes. With 173 certified beds and approximately 74 residents (about 43% occupancy), it is a mid-sized facility located in HENDERSON, Texas.
How Does Henderson Health & Rehabilitation Center Compare to Other Texas Nursing Homes?
Compared to the 100 nursing homes in Texas, HENDERSON HEALTH & REHABILITATION CENTER's overall rating (3 stars) is above the state average of 2.8, staff turnover (39%) is near the state average of 46%, and health inspection rating (3 stars) is at the national benchmark.
What Should Families Ask When Visiting Henderson Health & Rehabilitation 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 I visit during a mealtime to observe dining assistance and food quality?" "How do you handle medical emergencies, and what is your hospital transfer rate?" "Can I speak with family members of current residents about their experience?" These questions are particularly relevant given the facility's Immediate Jeopardy citations.
Is Henderson Health & Rehabilitation Center Safe?
Based on CMS inspection data, HENDERSON HEALTH & REHABILITATION CENTER has documented safety concerns. Inspectors have issued 3 Immediate Jeopardy citations (the most serious violation level indicating risk of serious injury or death). The facility has a 3-star overall rating and ranks #1 of 100 nursing homes in Texas. Families considering this facility should ask detailed questions about what corrective actions have been taken since these incidents.
Do Nurses at Henderson Health & Rehabilitation Center Stick Around?
HENDERSON HEALTH & REHABILITATION CENTER has a staff turnover rate of 39%, which is about average for Texas nursing homes (state average: 46%). Moderate turnover is common in nursing homes, but families should still ask about staff tenure and how the facility maintains care continuity when employees leave.
Was Henderson Health & Rehabilitation Center Ever Fined?
HENDERSON HEALTH & REHABILITATION CENTER has been fined $366,445 across 1 penalty action. This is 10.0x the Texas average of $36,743. Fines at this level are uncommon and typically indicate a pattern of serious deficiencies, repeated violations, or failure to correct problems promptly. CMS reserves penalties of this magnitude for facilities that pose significant, documented risk to resident health or safety. Families should request specific documentation of what issues led to these fines and what systemic changes have been implemented.
Is Henderson Health & Rehabilitation Center on Any Federal Watch List?
HENDERSON HEALTH & REHABILITATION 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.