LAKESIDE NURSING AND REHABILITATION CENTER
Government - Hospital district
118 Beds
THE ENSIGN GROUP
Data: November 2025
3 Immediate Jeopardy citations
Trust Grade
32/100
#270 of 1168 in TX
Photo by Lakeside Nursing and Rehabilitation Center
Photo by Lakeside Nursing and Rehabilitation Center
Photo by Lakeside Nursing and Rehabilitation Center
1 / 10 photos
Last Inspection: July 2025
Inspected within the last 6 months. Data reflects current conditions.
Overview
Lakeside Nursing and Rehabilitation Center has received a Trust Grade of F, indicating significant concerns about the facility. It ranks #270 out of 1168 facilities in Texas, placing it in the top half, but the poor trust grade raises red flags. The facility is currently improving, with issues decreasing from 12 in 2024 to 4 in 2025, but there are still serious deficiencies, including multiple critical incidents involving staff sharing inappropriate images of residents. Staffing is a weakness here, with a rating of 2 out of 5 stars and a turnover rate of 44%, which is lower than the Texas average. Additionally, the facility has incurred fines of $14,611, which is concerning but not excessive compared to other facilities.
- Trust Score
- F
- In Texas
- #270/1168
- Safety Record
- High Risk
- Inspections
- Getting Better
- Staff Stability ○ Average
- 44% turnover. Near Texas's 48% average. Typical for the industry.
- Penalties ⚠ Watch
- $14,611 in fines. Higher than 85% of Texas facilities, suggesting repeated compliance issues.
- Skilled Nurses ⚠ Watch
- Each resident gets only 29 minutes of Registered Nurse (RN) attention daily — below average for Texas. Fewer RN minutes means fewer trained eyes watching for problems.
- Violations ⚠ Watch
- 24 deficiencies on record. Higher than average. Multiple issues found across inspections.
32/100
Top 23%
Review needed
12 → 4 violations
★★★★☆
4.0
Overall Rating
★★☆☆☆
2.0
Staff Levels
★★★★☆
4.0
Care Quality
★★★★☆
4.0
Inspection Score
↔
Stable
2024: 12 issues
2025: 4 issues
The Good
-
4-Star Quality Measures · Strong clinical quality outcomes
-
Full Sprinkler Coverage · Fire safety systems throughout facility
-
No fines on record
-
Staff turnover below average (44%)
4 points below Texas average of 48%
Facility shows strength in quality measures, fire safety.
The Bad
Staff Turnover: 44%
Near Texas avg (46%)
Typical for the industry
Federal Fines: $14,611
Below median ($33,413)
Minor penalties assessed
Chain: THE ENSIGN GROUP
Part of a multi-facility chain
Ask about local staffing decisions and management
The Ugly 24 deficiencies on record
3 life-threatening
Jul 2025
4 deficiencies
CONCERN
(D)
Potential for Harm - no one hurt, but risky conditions existed
Deficiency F0583
(Tag F0583)
Could have caused harm · This affected 1 resident
Based on observation, interview, and record review, the facility failed to ensure residents have a right to personal privacy for 1 of 6 residents (Resident #89) reviewed for privacy, in that: The faci...
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Based on observation, interview, and record review, the facility failed to ensure residents have a right to personal privacy for 1 of 6 residents (Resident #89) reviewed for privacy, in that: The facility failed on 7/30/2025 when CNA A and RA B did not completely close Resident #89's privacy curtain while providing incontinent care. This deficient practice could place residents at-risk of loss of dignity due to lack of privacy. The findings include: Record review of Resident #89's face sheet, dated 07/30/2025, revealed an admission date of 12/09/2023 and, a readmission date of 10/03/2024, with diagnoses which included: Dementia (decline in cognitive abilities), Type 2 diabetes mellitus (high level of sugar in the blood), Hyperlipidemia (Elevated level of any or all lipids(fat) in the blood),Dysphagia (Difficulty swallowing), Schizoaffective disorder (mental disorder characterized by abnormal thought processes and an unstable mood). Record review of Resident #89's Quarterly MDS assessment, dated 04/25/2025, revealed the resident had a BIMS score of 09, indicating she was moderately cognitively impaired. Resident #89 was always incontinent of bladder and frequently incontinent of bowel and, required total assistance with her ADLs. Record review of Resident #89's care plan, dated 12/20/2023, revealed a problem of has bowel and bladder incontinence r/t Activity Intolerance, Dementia, Disease Process, Impaired Mobility, w/c bound, and Overactive Bladder., with an intervention of TOILET USE: The resident requires extensive assist from (2) staff for toileting. Observation on 07/30/2025 at 10:20 a.m. revealed CNA A and RA B did not completely close the privacy curtains while they provided incontinent care for Resident #89, exposing the resident who could be seen if somebody entered the room. Further observation revealed Resident #89's roommate was in the room. The privacy curtain was folded on itself on one end and was too short to be completely closed. During an interview with CNA A and RA B on 07/30/2025 at 11:11 a.m., when CNA A stated the privacy curtains was not completely closed while they provided care for Resident #89 but it should have been to protect the resident privacy. Neither CNA had noticed the privacy curtain was too short to completely close and were going to notify Maintenance. They stated they received resident rights training within the last year. During an interview with the DON on 07/30/2025 at 3:55 p.m., when DON stated privacy must be provided during nursing care and Resident #89's privacy curtains should have been closed completely. DON stated the staff had received training on resident rights within the year and the training was provided by the ADONs and herself. The DON stated they also check the staff skills annually and as needed. Review of Facility's policy, titled Resident Rights, undated, revealed They also will have the right to privacy, maintain privacy curtains for dressing and when providing care.
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 and record review the facility failed to ensure the resident Minimum Data Set (MDS) assessment accurately ref...
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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 resident Minimum Data Set (MDS) assessment accurately reflected the resident's status for 2 (Resident #48 and Resident #84) of 5 residents reviewed for accuracy of assessments. 1.The facility failed to ensure Resident #48 was coded on his annual MDS assessment dated [DATE] as receiving an antipsychotic medication. 2.The facility failed to ensure Resident #84 was coded on his quarterly MDS assessment dated [DATE] as receiving an antipsychotic medication. This failure could place residents at risk for improper or incorrect care and services necessary for their physical, mental, and psychosocial well-being. The findings included: 1.Review of Resident #48's admission sheet with an original admission date of 8/31/24 and a re-admission date of 7/16/25, showed a [AGE] year-old male resident with diagnoses including Dementia, Depression, Anxiety, Post Traumatic Stress Disorder, Cholecystitis (inflammation of the gallbladder, often caused by gallstones), Parkinson's Disease (a movement disorder of the nervous system), and Hypertension (high blood pressure). Review of Resident #48's order summary included an order for Nuplazid (Pimavanserin) 34 MG dated 8/30/24, with directions to give 34 MG one time a day for hallucinations. Nuplazid is an atypical antipsychotic indicated for the treatment of hallucinations and delusions associated with Parkinson's disease psychosis. Review of Resident #48's annual MDS assessment dated [DATE] documented the resident with a BIMS of 11, indicating moderate cognitive impairment. Further review of the assessment showed in Section N - Medications, N0415. High-Risk Drug Classes: Use and Indication 1. Is taking Check if the resident is taking any medications by pharmacological classification, not how it is used, during the last 7 days or since admission/entry or reentry if less than 7 days A. Antipsychotic, a blank box under the Is taking column for antipsychotic medication. Review of Resident #48's care plan with a revision date of 9/2/24, documented the resident is on antipsychotic medication use r/t hallucinations with interventions/tasks including Document episodes of behavior; Document non-pharmacological interventions; Pimavanserin as ordered per Medical Doctor (MD); and Quarterly Abnormal Involuntary Movement Scale (AIMS) assessment to be completed. 2.Review of Resident #84's admission sheet with an original admission date of 1/17/23 and a re-admission date of 10/3/23, showed a [AGE] year-old male with diagnoses including Type 2 Diabetes Mellitus, Hypertension, Anxiety, Bipolar Disorder, and Benign Prostatic Hyperplasia (enlarged prostate). Review of Resident #84's order summary included an order for Latuda (Lurasidone) 40 MG dated 4/10/25, with directions to give 1 tablet by mouth one time a day for Bipolar. Latuda is an atypical antipsychotic indicated for the treatment of schizophrenia and bipolar depression. Review of Resident #84's quarterly MDS assessment dated [DATE] documented the resident with a BIMS of 14, indicating intact cognition. Further review of the assessment showed in Section N - Medications, N0415. High-Risk Drug Classes: Use and Indication 1. Is taking Check if the resident is taking any medications by pharmacological classification, not how it is used, during the last 7 days or since admission/entry or reentry if less than 7 days A. Antipsychotic, a blank box under the Is taking column for antipsychotic medication. Review of Resident #84's care plan with a revision date of 5/20/24, documented the resident receives Lurasidone Psychotropic medication r/t Bipolar disorder with interventions/tasks including Administer medications (Latuda) as ordered. Monitor/document for side effects and effectiveness. During an interview with the MDS Coordinator on 7/30/25 at 2:24 PM, the MDS Coordinator stated she opens the MDS assessment in the scheduled time frame and the interdisciplinary team reviews the medical record and completes their portion of the assessment. The MDS Coordinator stated when the assessment was complete, a registered nurse with Resource Utilization Group (RUG) training will sign the assessment. The MDS Coordinator stated after the assessment has been signed, she will lock and transmit it. The MDS Coordinator stated it was important for the MDS to be accurate, because they use the assessment for quality measures, to perform the care of the patient, and to revise the care plan. During an interview with the DON on 7/30/25 at 4:00 PM, the DON stated her expectation for the MDS assessments is that they are accurate, and if they are inaccurate, her expectation was that they be fixed. During an interview with the DON on 7/31/25 at 9:08 AM, the DON stated they use the Resident Assessment Instrument (RAI) Manual as a reference for the MDS assessments. Review of the RAI Manual (Resident Assessment Instrument) dated October 2024, documented in section N0450: Antipsychotic Medication Review Coding Tips and Special Populations, Any medication that has a pharmacological classification or therapeutic category of antipsychotic medication must be recorded in this section, regardless of why the medication is being used.Review of the facility policy titled Resident Assessment, undated, documented It is the policy of this facility to complete a comprehensive assessment of the resident's needs which are based on the State's specific Resident Assessment Instrument (RAI) and the facility's interdepartmental assessment forms.
CONCERN
(D)
Potential for Harm - no one hurt, but risky conditions existed
Infection Control
(Tag F0880)
Could have caused harm · This affected 1 resident
**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, interviews, and record reviews, the facility failed to maintain an infection prevention and control progra...
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**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, interviews, and record reviews, the facility failed to maintain an infection prevention and control program designed to provide a safe, sanitary, and comfortable environment and to help prevent the development and transmission of communicable disease and infection for 1 of 6 residents (Resident #86) reviewed for infection control, in that: While providing colostomy care for Resident #86, LVN C failed to use proper infection control. These deficient practices could place residents at-risk for infection due to improper care practices. The findings included: Record review of Resident #86's face sheet, dated 07/30/2025, revealed an admission date of 02/05/2025, and a readmission date of 05/01/2025, with diagnoses which included: Dementia (decline in cognitive abilities), Type 2 diabetes mellitus(high level of sugar in the blood),Dysphagia (Difficulty swallowing), Depression (mood disorder that causes a persistent feeling of sadness and loss of interest), Hypothyroidism (under active thyroid), Hypertension (high blood pressure), Ileostomy status(opening in the abdominal wall allowing for elimination of feces). Record review of Resident #86's Significant Change MDS, dated [DATE], revealed the resident had a BIMS score of 15 indicating no cognitive impairment. Resident #86 required total assistance with her ADLs, was always incontinent of bladder and, had a ostomy. Review of Resident #86's care plan, dated 02/06/2025, revealed a problem of Has an alteration in gastro-intestinal status r/t Diverticulitis withperforation and Ileostomy status. and an intervention of Provide ileostomy care and change bag as needed. Observation on 07/30/2025 at 12:05 p.m. revealed while providing Ileostomy (opening in the abdomen allowing waste to exit the body) care for Resident #86, LVN C, use sanitizer between change of gloves after removing the collection bag and after cleaning the stoma, however LVN C did not sanitize between her fingers. During an interview with LVN C, on 07/30/2025 at 12:25 p.m., she stated she did not realize she did not correctly sanitize her hands but confirmed she should sanitize between her fingers to prevent cross contamination and put the resident at risk for infection. She confirmed receiving infection control training within the year. During an interview with the DON on 07/30/2025 at 3:55 p.m., she stated staff had to sanitize between their fingers while sanitizing to prevent risk of infection for the residents. She confirmed training was provided for the staff at least annually and their skills were check at least annually Review of facility policy, titled Hand Hygiene, dated 10/2022, revealed Using alcohol-based hand rubs. Apply generous amount of product to palm of hands and rub hands together. Cover all surfaces of hands and fingers until hands are dry.
CONCERN
(E)
Potential for Harm - no one hurt, but risky conditions existed
Food Safety
(Tag F0812)
Could have caused harm · This affected multiple residents
Based on observation, interviews and record review, the facility failed to store, prepare, distribute, and serve food in accordance with professional standards for food service safety for 1 of 1 kitch...
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Based on observation, interviews and record review, the facility failed to store, prepare, distribute, and serve food in accordance with professional standards for food service safety for 1 of 1 kitchen reviewed for kitchen sanitation. 1. 1 container of an orange juice cup was sitting on top of a box of orange juice and was partially opened. 2. A box of graham cracker tart shells was open and the individual shells were not covered. 3. A box of vanilla ice cream cups was open, not dated and contained cups that had opened and spilled out into the cardboard box. 4. A box of strawberries in the freezer was open and the plastic wrap around the strawberries was torn, exposing the strawberries to the air. 5. An individually wrapped glazed donut was in a plastic baggie with smeared marks at the top where the Date and Contents line was located. 6. An undated and unlabeled bag of red juice was located under the juice dispenser and was not connected to the dispenser. 7. The facility failed to store a mop in the proper position in the utility closet. These deficient practices could place residents who received meals and snacks from the kitchen at risk for food borne illness. The findings were: 1. Observation on 07/28/25 at 9:12 am in the kitchen revealed a small container of orange juice sitting on top of a cardboard box of orange juice that had the cardboard lid partially opened and juice had leaked out onto the side of the container. 2. Observation on 07/28/25 at 9:12 am in the kitchen revealed a box of graham cracker crust tart shells that was open, not dated and exposed to the air.3. Observation on 07/28/25 at 9:12 am in the kitchen freezer revealed a box of vanilla ice cream cups that was open, not dated and contained cups that had opened and spilled out into the cardboard box. This appeared to indicate that at some point the containers were not kept frozen and melted so that the contents spilled out. 4. Observation on 07/28/25 at 9:12 am in the kitchen, revealed a box of strawberries in the freezer that was open and the plastic wrap around the strawberries was torn, exposing the strawberries to the air.5. Observation on 07/28/25 at 9:12 am in the kitchen, revealed a baggie of an individually wrapped glazed donut with illegible ink smears on the label part of the bag for date and contents.6. Observation on 07/28/25 at 9:12 am in the kitchen, revealed an undated and unlabeled open bag of red juice located under the juice dispenser laying on a shelf that was not connected to the dispenser. A kitchen employee grabbed the container off the shelf when she noted surveyor was looking at it and said she was going to take it to the trash. 7. Observation of the utility closet in the kitchen on 07/29/25 at 10:00 am revealed a mop stored head-side down in the drain compartment of a mop- bucket. The mop was not in use at the time of the observation. The Dietary Manager was asked if that is where the mop is usually stored he said, ‘No, it should be hung up. He then proceeded to try and hang the handle of the mop on a wall mounted mop and broom holder. The holder would not hold the handle so he just took the mop head off, put it in a plastic bag and had one of his employees take it to the laundry. On 07/31/25 at 1:00 pm, a follow-up observation of the closet revealed a mop with the mop head up leaning against the wall of the closet. When asked if this was the proper way to store the mop, the Dietary Manager stated that it should probably be stored with mop head down which was also incorrect. Record review of an undated Policy/Procedure for Dietary Services revealed It is the policy of this facility that the facility shall have an organized food service, appropriately planning, equipped, and staffed to prepare and serve the number of meals created in the kitchen. Under the Procedures, #7 stated All cleaning equipment must be stored in designated area when not in use. Record review of the Food Code, U.S. Public Health Service, U.S. FDA, 2022, U.S. Department of H&HS, revealed: 6-501.16 Drying Mops. After use, mops shall be placed in a position that allows them to air-dry without soiling walls, equipment, or supplies.
Jun 2024
9 deficiencies
CONCERN
(D)
📢 Someone Reported This
A family member, employee, or ombudsman was alarmed enough to file a formal complaint
Potential for Harm - no one hurt, but risky conditions existed
Deficiency F0558
(Tag F0558)
Could have caused harm · This affected 1 resident
**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observations, interview and record review, the facility failed to ensure residents had the right to reside and receive ...
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**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observations, interview and record review, the facility failed to ensure residents had the right to reside and receive services in the facility with reasonable accommodation of resident needs and preferences except when to do so would endanger the health or safety of the residents for 1 of 3 residents (Resident # 15) reviewed for call light.
The facility failed to ensure. Resident # 15's call light was within reach.
This failure could place residents at risk of achieving independent functioning, dignity, and wellbeing.
Findings include:
Record review of Resident 15's face sheet dated 6/18/24, reflected a [AGE] year-old male who was admitted to the facility on [DATE]. Resident # 15 had diagoses which included: Guillain-Barré syndrome, (is a rare neurological disorder that occurs when the body's immune system attacks the peripheral nervous system), Paraplegia (is a specific pattern in which you can't deliberately control or move your muscles) and Pulmonary hypertension (condition that occurs when blood pressure in the lungs is higher than normal).
Record review of Resident # 15's Quarterly MDS, dated [DATE], reflected a BIMS score of 13, which indicated cognition was intact.
Record review of Resident # 15 Quarterly MDS, dated [DATE], reflected under section G, 0130, option # 1 which stated, the patient required assistance X 2.
Record review of Resident # 15 care plan dated 1/11/23, revised 5/4/24 revealed that Resident # 15 had an alteration in muscle function related to Guillain [NAME] Syndrome, intervention Be sure call light is with in reach.
Observation on 6/18/24 at 10:15 a.m. revealed the call light was not visible for Resident # 15. Resident #15's call light was located inside the nightstand drawer.
In an interview with Resident # 15 on 6/18/24 at 10:35 a.m., he stated, I don't like to bother the CNA's .
During an interview on 6/18/24, at 10:18 am, LVN B stated that she was the assigned nurse for Resident #15 and mentioned that the call light was located inside the nightstand drawer. She noted that the lack of accessibility of a call light could possibly have a negative impact if Resident # 15 required assistance.
During an interview with the DON on June 21, 2024, at 9:05 a.m., she expressed that it was her expectation for call lights to be within arm's length of all residents. She emphasized that the absence of a call light could result in a fall if a resident required assistance. The DON was unaware that Resident #15's call light was not visible. She mentioned that her ADON's were responsible for ensuring that all residents' call lights were within reach, and she monitors this randomly.
Record review of the facility's policy titled Call Light/Bell , undated, reflected Place call light with in residents reach.
CONCERN
(D)
Potential for Harm - no one hurt, but risky conditions existed
Deficiency F0559
(Tag F0559)
Could have caused harm · This affected 1 resident
**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on record review and interview, the facility failed to ensure the right to receive written notice of a room change before ...
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**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on record review and interview, the facility failed to ensure the right to receive written notice of a room change before the change was made for 2 of 2 resident (Resident #41 & Resident #80) reviewed for resident room changes.
The facility did not provide evidence that Resident #41 and Resident #80 was given a written notice of a room change before the resident was moved.
This deficient practice could affect residents in the facility that are moved without required notification.
The findings included:
Record review of Resident #41's comprehensive MDS assessment, dated 06/14/2024 reflected a [AGE] year-old female admitted on [DATE] a primary diagnosis of Other encephalopathy (damage or disease that affects the brain) and assessed to have severe cognitive impairment.
Record review of Resident #41's face sheet, dated 06/21/2024 listed Resident #41's RP as Resident #41's primary contact.
Record review of Resident #80's quarterly MDS assessment, dated 06/03/2024, reflected a [AGE] year-old female admitted on [DATE] with a primary diagnosis of Acute and chronic respiratory failure with hypoxia (not getting enough oxygen into your blood) and was assessed to not have cognitive impairment.
Record review of Resident #80's progress notes, dated 05/20/2024 at 11:27 AM, authored by ADON C, reflected Spoke w/ resident about room change. Resident acknowledged understanding and agreed.
Interview on 06/18/2024 at 11:40 AM, Resident #41's RP stated she was the primary responsible party for Resident #41 and stated in the last month (May 2024) the facility moved both Resident #41 and her roommate, Resident #80 from room [ROOM NUMBER] to their current room at the end of the hall. Resident #41's RP stated she was not notified of this room change prior to when the change was made and was later notified this communication was made to Resident #41's other family who was not listed as the RP. Resident #41's RP stated had she been notified of the room change then it would have been rejected outright. Resident #41's RP stated she became aware of Resident #41's room change when she visited and could not find Resident #41. Resident #41's RP stated she never received a written notification of the room change and was informed after the room change was made by the DON that the change was made to accommodate a different resident in a different room who would be better equipped in room [ROOM NUMBER] due to its proximity to the nurse's station and a recent fall incident.
Interview on 06/18/2024 at 11:54 PM, Resident #80 stated she was requested to move to her current room from room [ROOM NUMBER] approximately 1 month ago (May 2024) to which she initially declined as the DON stated Resident #41 was not going to be transferring with her. Resident #80 stated after her initial declination to move rooms, the DON then returned to request her to move to room [ROOM NUMBER] but then stated Resident #41 was going with her. Resident #80 stated at no point was she provided a written notification of the room change. Resident #80 stated she was requested to move to her current room to accommodate a different resident who recently experienced a fall and was requiring more direct nursing care based on the proximity of room [ROOM NUMBER] to the nurse's station.
Interview on 06/20/2024 at 9:52 AM, ADON C stated she was the assigned ADON for Resident #80 and Resident #41's hall. ADON C stated she completed the notification of the room change to Resident #80 and Resident #41 verbally, during which neither disagreed. ADON C stated she did not provide a written notification as she was not instructed to, and only made the room change notification to Resident #80 and Resident #41 based on the instruction provided that day from the DON. ADON C stated she was not familiar with why Resident #80 and Resident #41 were being moved and was only told by the DON of the need to move them.
Interview on 06/20/2024 at 10:07 AM, the SW stated she was not part of the room change for Resident #80 and Resident #41. The SW stated the facility protocol during room changes was to verbally request the room change, and if the resident was to refuse, then a 5-day written notification was to be issued, however this was never needed to be utilized as a resident had never refused before. The SW confirmed the staff who made the verbal notification to Resident #80 and Resident #41 was ADON C.
Interview on 06/20/2024 at 10:40 AM, the DON stated she and the ADM were both present when the notification of the room change was made to Resident #41 and Resident #80 and stated Resident #80 did not disagree and that was evidenced by the fact that the room change was inevitably made. The DON stated there was no record of the DON and ADM being present for the verbal notification and stated written notifications of room changes were not part of facility protocol as they were only used when a resident was to disagree to the room change. The DON stated the SW would primarily be the one to provide the written notification of the room change but during the room change with Resident #41 and Resident #80 a verbal notification was instead made by herself and the ADM.
Interview on 06/20/2024 at 10:54 AM, the ADM stated he did not have record of a written notification of the room change for Resident #41 and Resident #80 due to both residents not objecting to the room change and the room change was made the same day when both he and the DON made a verbal request for Resident #41 and Resident #80 to move from #101. The ADM stated he did not see a potential concern with not providing a written notification because he did not see a potential abusive scenario where a resident would be moved without their consent. The ADM stated his facility protocol regarding room changes was only to issue written 5-day notifications was when a resident was to disagree and stated Resident #80 never disagreed to the room change and further stated Resident #41's RP never complained of the room change to any staff at any time. A request for a facility policy was requested at this time.
Facility policy specific to room changes was not provided prior to exit. A request was made to the ADM on 06/20/2024 at 10:54 AM.
CONCERN
(D)
Potential for Harm - no one hurt, but risky conditions existed
Deficiency F0565
(Tag F0565)
Could have caused harm · This affected 1 resident
Based on interview and record review, the facility failed to demonstrate their response and rationale regarding the resident's council's grievances after group meetings concerning issues of resident c...
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Based on interview and record review, the facility failed to demonstrate their response and rationale regarding the resident's council's grievances after group meetings concerning issues of resident care and life in the facility and provide a private space for residents' monthly council meetings for 1 of 1 resident council, in that:
The facility failed to demonstrate their response and rationale for such response to the resident council's grievances.
The facility failed to provide the resident council with a private space for their monthly meetings.
This failure could place residents that participate in a resident council at risk of not having the right to their concerns and grievances followed through with.
The findings included:
During confidential interviews on 06/19/24 at 02:02 PM, residents stated grievances were not always followed up on and they were concerned the grievances they wrote were not being addressed. They stated they felt they could not make grievances without being reprimanded by staff. They expressed they were not aware they could have resident council meetings without staff.
During an interview 06/20/24 on 03:01 PM, the AD revealed she has had meetings for resident council with staff members. She further revealed it was the president's preference to have AD present at all meetings, but other residents did not request the AD to be present at all meetings. She further revealed the resident council meeting was held in the dining room or the conference room.
During an interview on 06/21/24 at 10:30 AM, the Activities Director revealed they have had resident council meetings in the dining room due to growing numbers of resident council members. The AD further revealed she put signs up for staff to not walk by the resident council meeting, but it did not stop staff from walking by. She pointed out the nurse's station was near the dining room, and they could not control nurses being present at the nurse's station while the resident council meeting was going on.
During an interview on 06/21/24 at 10:56 AM, the ombudsman revealed staff members have always been present at the resident council meetings and she did not know if residents were aware they could have resident council meetings without staff members. She suggested that the AD put signs up to let staff members know to not walk into the dining room to provide privacy to the resident council meeting. She further revealed the facility's grievance system was broken and needed work. She had received complaints from residents about grievances not going anywhere and not being addressed.
During an interview on 06/21/24 11:18 AM, the AD revealed sometimes old business and old grievances that have been resolved were not discussed. She further revealed she asked residents if they wanted to discuss old grievances being resolved and some residents in the resident council said no. She revealed it may be important to discuss when grievances had been resolved so residents knew grievances had been addressed. She assumed residents would speak up if they wanted to hear the grievance solutions and did not consider the residents may stay quiet and still want to hear the solutions.
Attempts to interview the resident council president were not successful as she was at medical appointments per facility staff.
Record review of the facility's Grievance Log for the last 6 months revealed April 2024 was the only one that had Resident Council for 4 out of 6 grievances, reported on 04/17/24 and resolved 04/17/24 with resolution noted to be satisfactory.
Record review of the facility's Complaint/Grievance Follow-up Report for these 4 grievances, dated 04/17/24, revealed the person notified of resolution for these complaints was the [resident council president].
Record review of the facility's policy titled Grievances, revised 12.2023, reflected, It is the policy of this facility to establish a grievance process that allows the resident(s) a way to execute their right to voice concerns or grievances to the facility or other agency/entity without fear of discrimination or reprisal. And The Grievance Official or designee responds to the individual expressing the concern within (3) three working days of the initial concerns to acknowledge receipt and describe steps taken toward resolution.
There were no policies about resident council.
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 interviews and record reviews, the facility failed to develop a baseline care plan for each resident that includes the ...
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**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on interviews and record reviews, the facility failed to develop a baseline care plan for each resident that includes the instructions needed to provide effective and person-centered care of the resident that meet professional standards of quality for 1 (Residents #451) of 8 residents reviewed for baseline care plans.
Resident #451's baseline care plan, dated 06/18/24, did not reflect any interventions for focus of at risk for falls.
This deficient practice could affect residents admitted to the facility and result in missed or inadequate care.
The findings included:
Record Review of Resident #451's admission Record, dated 06/18/24, reflected a [AGE] year-old male admitted [DATE] with diagnoses to include fracture of left femur, difficulty in walking, abnormalities of gait and mobility, cognitive communication deficit, and need for assistance with personal care.
Record Review of Resident #451's admission MDS assessment, dated 06/12/24, reflected a BIMS score of 13 out of 15, indicating cognitively intact. His MDS assessment further reflected all questions pertaining falls in section J were not answered.
Record Review of Resident #451's care plan, dated 06/18/2024, revealed no interventions for problem At risk for falls r/t (SPECIFY), initiated 06/09/2024, and for problem Has acute/chronic pain r/t, initiated 06/09/2024.
Record Review of Resident #451's Fall Risk Evaluation, dated 06/08/24, Resident had 1-2 falls in the last 3 months with a medium risk for falls.
Record Review of Resident #451's hospital records, dated 06/05/24, revealed resident was admitted for left femur fracture and left hip contusion following a fall from a previous group home.
During an interview on 06/20/24 at 05:00 PM the DON revealed any new admission will have fall interventions in place and staff knew to do this. The DON would not confirm there were no fall interventions on Resident #451's care plan when showed the electronic copy of Resident #451's care plan.
Interview and observation of Resident #451 on 06/18/24 at 04:29 PM revealed some fall interventions in place to include: call light within reach, bed in lowest position, room was free from clutter. Resident #451 revealed he has not fallen while in the facility and the staff checked in on him regularly.
Record Review of the facility's policy Fall Management System, undated, reflected, Residents with high risk factors identified on the Fall Risk Evaluation will have an individualized care plan developed that includes measurable objectives and timeframes.
Record Review of the facility's policy Care Planning, undated, reflected nothing about the baseline care plans.
A policy for baseline care plans was requested from the DON on 06/21/24 at 10:27 AM and on 06/22/24 at 10:17 AM. There was not a policy available.
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
Pharmacy Services
(Tag F0755)
Could have caused harm · This affected 1 resident
**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, interview, and record review the facility failed to provide pharmaceutical services (including procedures ...
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**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, interview, and record review the facility failed to provide pharmaceutical services (including procedures that assure the accurate acquiring, receiving, dispensing, and administering of all drugs and biologicals) to meet the needs of each resident for 1 of 3 residents (Resident #28) reviewed for pharmacy services.
Resident #28 was provided a medication, Prilosec, outside of the ordered time range.
This failure could place residents at risk of not receiving the therapeutic effects of their prescribed medications.
The findings included:
Record review of Resident #28's face sheet, dated 6/20/24, reflected a [AGE] year-old female with an initial admission date of 10/28/19 and diagnoses including: Acute Pancreatitis ( condition where the pancreas becomes inflamed (swollen) over a short period of time, Cirrhosis of the Liver ( a type of liver damage where healthy cells are replaced by scar tissue) and Hepatic Failure ( loss of liver function ).
Record review of Resident # 28's Quarterly MDS assessment, dated 1/3/24, revealed Resident # 28 was assessed with a BIMS score of 15 which indicated intact cognition.
Record review of resident #28's Care Plan dated 8/12/23 revealed the resident had GERD (Gastroesophageal Reflux Disease) with interventions give the resident their medications as ordered.
Record review of Resident # 28's Physician orders for June 2023 revealed that Resident # 28 was prescribed Prilosec 20 mg daily at 0630 for GERD (Gastroesophageal Reflux Disease).
Record review of medication administration history for Resident # 28, dated 6/20/24, revealed that Prilosec was administered on 6/20/24 at 810 a.m.
Observation on 6/20/24 at 915 a.m. revealed that Resident # 28's medication order for Prilosec 20 mg on the electronic medication administration record was red, indicating that the medication was not given as ordered.
Interview with CMA A on 6/20/24 at 8:05 am, revealed that medication Prilosec 20 mg for Resident # 28 was scheduled at 6:30 a.m. but adminstered at 810 a.m because , Resident # 28 does not like to take medication before eating breakfast.
Interview with Resident # 28 on 6/20/24 at 10:00 a.m. revealed she has told all nurses that she does not want any medications before breakfast.
During an interview on 06/20/2024 at 10:45 AM, the DON stated that the expectation for certified medication assistants was to administer medications per physician orders and notify the charge nurse of any deviation.
The DON stated if a nurse makes a medication error, such as providing medications out of a one-hour window when scheduled, they should inform the DON, physician, and RP. The DON stated the risk of the resident receiving medications outside of physician orders could cause possible side effects. She stated her ADONs currently monitor this task at random, and she oversees this task.
A record review of the facility's Policy Medication Administration , dated May 2007, revealed, Any irregularly in pouring or administrating must be reported to the physician .
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 observation, interview, and record review, the facility failed to ensure drugs and biologicals were stored in accordance with currently accepted professional principles for, 1 of 4 medication...
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Based on observation, interview, and record review, the facility failed to ensure drugs and biologicals were stored in accordance with currently accepted professional principles for, 1 of 4 medication carts observed, in that:
The Nurse Medication Cart in the 300 hall contained eleven loose medication pills.
This failure could place residents who receive medications at risk for not receiving the intended therapeutic effects of medications.
The findings were:
Observation on 06/19/2024 at 9:57 a.m. of the 300 Hall Nurse Medication Cart revealed there were eleven loose medication pills inside one of the drawers.
During an interview with Nurse E on 06/19/2024 at 9:57 a.m., Nurse E confirmed there were eleven loose medication pills inside a drawer of the Nurse Medication Cart.
During an interview with the DON on 06/19/2024 @ 10:27 a.m., she stated medication carts should not have loose medications. They were the responsibility of the nurse that accepted responsibility for the cart, also the medications carts were supposed to be checked bi-weekly by the ADON's and any loose medications were to be identified, followed by a medication count then cross-checked by residents, then disposed of per facility policy.
Record review of the facility policy titled Medication Access and Storage revealed, Policy Statement: Medication storage areas are kept clean, well lit, and free of clutter.
CONCERN
(D)
Potential for Harm - no one hurt, but risky conditions existed
Deficiency F0804
(Tag F0804)
Could have caused harm · This affected 1 resident
Based on observations, interviews, and record review, the facility failed to prepare puree food by methods that conserve nutritive value, flavor, and appearance for 1 of 1 kitchen observed for puree p...
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Based on observations, interviews, and record review, the facility failed to prepare puree food by methods that conserve nutritive value, flavor, and appearance for 1 of 1 kitchen observed for puree preparation.
The facility failed to follow the puree diet recipe for Pureed Buttered [NAME] Bread for 06/20/24 lunch.
This failure could affect residents on puree diet at risk of receiving inadequate diet that could affect their health.
Findings included:
Record Review of Week At a Glance week 2 revealed Pureed Buttered [NAME] Bread to be served for pureed diets.
Record Review of recipe Pureed Buttered [NAME] Bread, Copyright 2024, reflected Ingredients: white sliced bread, melted margarine, and milk and instructions to add an appropriate amount of liquid (NOT WATER) to achieve a smooth, pudding or soft mashed potato consistency.
During an observation, interview, and record review on 06/20/24 at 10:11 AM, [NAME] F prepared Pureed Buttered [NAME] Bread not according to the recipe. The recipe was not present while [NAME] F was preparing this recipe. Observation revealed [NAME] F did not add margarine or milk during this preparation. [NAME] F revealed she added chicken broth and water to the pureed white bread menu item. She further revealed the product was not a mashed potato consistency because the foods became hardened when on the steam table due to the liquids evaporating by the time foods were served.
During an observation and interview on 06/20/24 at 11:48 AM, the CDM revealed they did not use the Pureed Buttered [NAME] Bread that was made during the pureed foods observation. The CDM further revealed the Pureed Bread that was going to be served for 06/20/24 lunch had ingredients to include bread, margarine, and broth. The CDM stated he would contact the RD to see if broth was okay to use instead of the milk.
During an interview on 06/20/24 at 02:06 PM, the CDM revealed the RD stated it was okay to use broth or a liquid with nutritive value instead of milk in pureed recipes due to some residents having an allergy to milk. He further revealed the kitchen did not use the prepared pureed bread that was observed by this surveyor for 06/20/24 lunch.
A policy for following recipes was requested from the DON on 06/21/24 at 10:27 AM. There was not a policy available.
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
Safe Environment
(Tag F0921)
Could have caused harm · This affected 1 resident
**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, interview, and record review the facility failed to provide a safe, functional, sanitary, and comfortable ...
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**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, interview, and record review the facility failed to provide a safe, functional, sanitary, and comfortable environment for residents, staff, and the public for 1 of 32 residents (Resident #50) reviewed for safe comfortable environment.
The facility failed to ensure Resident #50's room was free of two cracks in the floor, running the length of the room.
This deficient practice could place residents at risk of falling due to a tripping hazard created from the floor crack.
The findings included:
Observation and interview on 06/18/2024 at 12:13 PM, Resident #50's room was revealed to contain two cracks, each measuring approximately 1.5 millimeters in width or slightly larger than the thickness of pencil lead and measuring approximately 12 feet long of one crack and the other measuring approximately 8 feet long. Resident #50 stated she has had this crack in her room for as long as she had been in the room and did not prefer to have the crack in the floor. Resident #50 stated she has expressed the concern to her nursing staff but could not identify individual staff and stated she had not seen maintenance in her room since she had been in this room. Resident #50 stated she has never tripped on the crack and did not believe the crack had grown. Resident #50 stated the crack went underneath her roommate's bed as well but was only visible on her side of the room in front of her bed.
Record review of Resident #50's comprehensive MDS assessment, dated 06/14/2024, reflected an [AGE] year-old female admitted on [DATE] with a primary diagnosis of Unspecified dementia, unspecified severity, without behavioral disturbance, psychotic disturbance, mood disturbance, and anxiety (A group of thinking and social symptoms that interferes with daily functioning), and was assessed to have severe cognitive impairment.
Interview on 06/20/2024 at 9:30 AM, LVN D stated she has worked at the facility for a few weeks as a medication aide and has never observed the crack in Resident #50's room.
Interview on 06/20/2024 at 9:36 AM, LVN E stated she was the charge nurse for Resident #50's hall and had never seen a crack in Resident #50's room at any time.
Interview on 06/20/2024 at 9:52 AM, ADON C stated she was the ADON assigned to Resident #50's hall and had never observed a crack in the room and stated if any staff member had observed it, it was facility protocol to submit a work order request in their digital work order logbook.
Interview on 06/20/2024 at 10:07 AM, the SW stated she had never received a concern from Resident #50 regarding broken flooring but also that she had never observed it in her room during her routine visits to Resident #50.
Observation and interview on 06/20/2024 at 10:33 AM, the MS stated he has not received work orders related to Resident #50's room related to floor repair or cracks in the floor. The MS stated he last visited Resident #50's room on 04/12/2024 for a telephone repair and during that visit he did not observe any floor cracks. The MS stated any staff who visit the room could submit a work order. During observation of the crack in Resident #50's room, the MS stated the floor crack was significant and required it to be submitted as an outside vendor request.
Observation and interview on 06/20/2024 at 11:42 AM, the ADM stated he was not familiar with any cracks in Resident #50's room and stated he had not received any concerns from Resident #50 related to the state of the bedroom floor. During observation of Resident #50's floor, he stated this was the first time he had observed it before and stated he believed the crack in the floor to not have been observed previously as the bed was potentially rotated in a position that obscured the full length of the crack. The ADM stated even in a 90-degree rotation of the bed, he did not believe staff would have noticed the crack even as the crack was observed to extend past where the bed had covered or would have covered in a 90 degree rotation. The ADM stated the risk of the broken floor to be a potential tripping hazard along with a potential infection control concern as water or contaminates could be harbored in the crack. Policy specific to physical environment and building upkeep was requested at this time.
Facility policy specific to physical environment and building upkeep was not provided prior to exit. A request was made to the ADM on 06/20/2024 at 11:42 AM.
CONCERN
(D)
Potential for Harm - no one hurt, but risky conditions existed
Deficiency F0925
(Tag F0925)
Could have caused harm · This affected 1 resident
Based on observations, interviews, and record reviews, the facility failed to maintain an effective pest control program for 1 of 1 dining room for pests, in that:
An unknown number of gnats were surr...
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Based on observations, interviews, and record reviews, the facility failed to maintain an effective pest control program for 1 of 1 dining room for pests, in that:
An unknown number of gnats were surrounding the beverage station (to include cranberry juice, water, coffee, mugs, and glasses) in the dining room for 06/18/24 lunch.
This deficient practice could place residents at risk of residing in an environment with pests.
Findings included:
Observation on 06/18/24 at 11:59 AM revealed an unknown number of flying black living things, surrounding mugs and glasses that were upside down and present in the beverage station. It was further revealed the residents were getting their beverages from this station for 06/18/24 lunch.
Observation and interview 06/18/24 12:09 PM with the Activities Director revealed there were bugs around the beverage station. She stated she would get the maintenance director or the dietary department to clean the beverage area.
Observation on 06/18/24 at 12:16 PM revealed 8 residents received mugs or glasses from the beverage station that had these black flying bugs around their respective glass and mugs. These glasses and mugs were observed to not be sent to the kitchen for cleaning.
Interview on 06/18/24 at 12:16 PM with the Activities Director revealed kitchen was bringing out cleaned mugs and glasses.
Interview and observation on 06/18/24 at 12:16 PM with the Housekeeping Supervisor revealed the pest control company came to the facility earlier in the day to clean the area where containers of liquids were available to residents. The Housekeeping Supervisor was observed waving a towel as to try to hit these bugs away from this area.
Interview on 06/18/24 at 12:17 PM, Resident #24 and Resident #24's POA revealed there were gnats around the dining room a lot and unaware of why. They expressed dislike when gnats were surrounding them when they were in the dining room.
Interview on 06/20/24 at 09:29 AM, the CDM revealed housekeeping oversaw making sure the beverage station was cleaned. Housekeeping were supposed to let them know when anything kitchen related like cups need to be cleaned. He further revealed the kitchen washed all the glasses and mugs from the drink station on 06/18/24.
Interview on 06/21/24 at 10:54 AM, the Maintenance Director revealed there were problems with gnats in the dining room and the pest control company targeted this area along with other areas in the facility.
Record Review of [Pest Control Company] service log reflected service date of 06/18/24 for general type of pest to service locations to include the dining area. This was confirmed by the Maintenance Director.
Record Review of the facility's policy on section: Physical Environment with a subject of Maintains Effective Pest Control Program, undated, reflected An effective pest control program is defined as measures to eradicate and contain common household pests .
Feb 2024
3 deficiencies
3 IJ (3 affecting multiple)
CRITICAL
(K)
📢 Someone Reported This
A family member, employee, or ombudsman was alarmed enough to file a formal complaint
Immediate Jeopardy (IJ) - the most serious Medicare violation
Free from Abuse/Neglect
(Tag F0600)
Someone could have died · This affected multiple residents
**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on interview and record review the facility failed to ensure the resident's right to be free from abuse for 3 of 5 residen...
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**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on interview and record review the facility failed to ensure the resident's right to be free from abuse for 3 of 5 residents (Resident #1, #2 and #3) reviewed for abuse:
CNA A, as part of a CNA chat group, took a video recording of Resident #1, naked, in the shower having a bowel movement, with a close-up view of her exposed bottom with feces on it and he shared it with the chat group.
CNA B, as part of a CNA chat group, took a digital picture of Resident #2, naked, in the shower with her back toward the camera and not aware of the photo and she shared it with the chat group.
CNA C as part of a CNA chat group, took a photo of Resident #3 after he had fallen on the floor without pants on, and shared it with the chat group.
The noncompliance was identified as PNC. The IJ began on February 5th and ended on February 6th 2024. The facility had corrected the noncompliance before the survey began.
This deficient practice could affect residents who require assistance with ADL's and result in emotional abuse and exploitation.
The findings included:
1. Record review of Resident #1's electronic face sheet dated 02/14/2024 reflected she was admitted to the facility on [DATE]. Her diagnoses included: weakness (lacking strength), contracture of muscle, left hand (tissues tighten or shorten causing a deformity, pain, and loss of function), cognitive communication deficit (difficulty with thinking and how someone uses language) and hemiplegia (paralysis of one side of body), and hemiparesis (one sided weakness) following unspecified cerebrovascular disease ( a group of conditions that affect blood flow and the blood vessels of the brain) affecting left non-dominant side.
Record review of Resident #1's quarterly MDS with an ARD of 05/02/2023 reflected she scored a 99 on her BIMS assessment which signified the resident had 4 or more items coded 0 because she chose not to answer or game a nonsensical response. She sometimes could understand and sometimes be understood. Resident #1 required extensive assistance with ADL's.
Record review of Resident #1's comprehensive person-centered care plan revised 09/28/2023 reflected Focus .has ADL self-care performance deficit r/t limited mobility, CVA, hemiplegia, contractions, muscle wasting and atrophy (decrease in size and wasting of muscle tissue), lack of coordination and pain .Interventions/Tasks .converse with resident while providing care .explain all procedures and tasks before starting .BATHING .requires total assistance.
Further review of Resident #1's comprehensive person-centered care plan revised 02/07/2024 reflected Focus .is at risk for communication problem r/t hearing deficit, stroke, confusion .Interventions/Tasks .ensure/provide a safe environment .anticipate and meet needs.
Review of a video of Resident #1 taken by CNA A, who admitted to taking the video (unknown date) revealed a picture of a buttock with feces covered on it hanging through the seat hole of a shower chair. A white trash can with a plastic liner was positioned below the shower chair. A close up of the feces coming out of the buttocks was then seen. The video then zooming out and back up to Resident #1's face with an anguished expression and her naked upper half of body exposed as she looked directly at CNA A. The camera zooms out and focuses on Resident #1's anguished face and naked torso with her breast exposed and a partial gown draped over her bottom half sitting in the shower chair. The camera zooms back down to the buttocks with feces coming out positioned over a white plastic lined trash can. As the camera zooms back out to the shower chair legs and trash can the video ends.
Observation on 02/14/2024 at 2:40 p.m. of Resident #1 lying in her bed revealed she was quiet, appeared withdrawn and when asked how she was, she responded OK. She did not respond to any other questions.
Record review of Resident #1's Active Orders as of: 02/14/2024 reflected Refer to psychiatric services to evaluate and treat .Active as of 02/06/2024.
Record review of Resident #1's psychiatric services note dated 02/06/2024 reflected Visit Note-Initial Psychiatric Diagnostic Interview .seen today for depression/sadness .patient is evaluated laying in her bed .is pleasantly confused and does not appear to be in any emotional or psychosocial distress. Patient states she is not well as she is sick .Mental Status Exam: Behavior was withdrawn and hypoactive .speech was mumbling, slow and soft .attention span and concentration was poor .oriented to person .recent memory severely impaired .severe dementia .Diagnosis-Major depressive disorder .Treatment Plan of Care: Future visits are recommended once a week for 12 months.
Interview on 02/15/2024 at 08:50 a.m. with CNA B who admitted to being part of the of the CNA chat group , she stated she saw the video of Resident #1 and did not know why she did not report it. She stated she was trained on abuse and neglect.
Interview on 02/16/2024 at 08:20 a.m. with CNA A who admitted to being part of the CNA chat group and who took the video of Resident #1, he stated he did not know what he was thinking when he videotaped Resident #1 naked in the shower room having a bowel movement. He stated he violated Resident #1's rights, privacy, disrespected and abused her. He stated now, he realized how serious it was. He stated he was trained on abuse and neglect.
2. Record review of Resident #2's electronic face sheet dated 02/14/2024 reflected she was originally admitted to the facility on [DATE]. Her diagnoses included: chronic obstructive pulmonary disease (a group of diseases that cause airflow blockage and breathing-related problems), cognitive communication deficit (difficulty with thinking and how someone uses language), bipolar disorder (a mental illness that causes unusual shifts in a person's mood, energy, activity levels, and concentration), need for assistance with personal care and major depressive disorder (feeling of sadness and loss of interest and can interfere with activities of daily living).
Record review of Resident #2's quarterly MDS assessment with an ARD of 01/06/2024 reflected she scored a 14/15 on her BIMS which signified she was cognitively intact. She required assistance with her ADLs to include bathing.
Record review of Resident #2's comprehensive person-centered care plan revised 01/11/2023 reflected Focus .has ADL self-care deficit performance r/t shortness of breath .Interventions/Tasks .Requires staff participation with bathing.
Record review of a photo on a phone with the chat group titled Bitches [facility name] and a phone number with pluses to indicate other contact numbers reflected a photo (undated) time stamped 06:31 a.m. of Resident #2 sitting in a shower chair naked with her back toward the camera. Under the photo in Spanish was Anexo prubas hahaha which interpreted in English Attached Evidence hahaha. A responding comment from (unknown) in Spanish jajajaja te la banos translated in English hahaha we wash you.
Record review of Resident #2's Active Orders as of: 02/14/2024 reflected Refer to psychiatric services to evaluate and treat .Active as of 02/06/2024.
Record review of Resident #2's psychiatric services note dated 02/06/2024 reflected Visit Note-Subsequent Evaluation/Management Visit .seen today for depression/sadness, high risk behavior, psychosis (a collection of symptoms that affect the mind, where there has been some loss of contact with reality) and restlessness .patient is seen sitting on bed eating a snack and watching TV .Patient states I'm good .Diagnoses: Bipolar II disorder (a pattern of depressive episodes and hypomanic episodes) and major depressive disorder .Treatment Plan .future visits recommended once a week for 6 months.
Observation on 02/15/2024 at 4:00 p.m. of Resident #2 revealed she was lying on her bed watching television.
In an interview on 02/15/2024 at 4:05 p.m. with Resident #2, after being informed of the picture, which she was unaware was taken and what was in the photo, she stated she always trusted CNA B and really liked her. She stated she felt like her rights and privacy were violated .
Interview on 02/15/2024 at 07:50 a.m. with CNA F who admitted to being part of the CNA chat group, she stated she saw the photo that CNA B posted of Resident #2 in the shower naked, but she did not report it at that time because she was afraid of retaliation, and she didn't want to get anyone in trouble. She stated she knew taking photos and videos of residents violated their rights and could be considered abuse. She stated she was trained about abuse and neglect.
Interview on 02/15/2024 at 08:00 a.m. with CNA D who admitted to being part of the CNA chat group, she stated she did not know how long the group was active. She stated that CNA C started the group and that CNA E posted the first picture . She stated that CNA A posted the video of Resident #1 and she knew it was wrong. She stated she knew better; had training and she did not report and did not know why she did not. She admitted that the resident rights were violated.
Interview on 02/15/2024 at 08:50 a.m. with CNA B who admitted to being part of the CNA chat group , she stated she took the picture of Resident #2, naked in the shower chair to show the others in the group she was busy. She stated she knew she violated Resident #2's rights and it was not ok. She stated she knew it could be considered abuse, but she did it anyway .
3. Record review of Resident #3's electronic face sheet dated 02/14/2024 reflected he was initially admitted to the facility on [DATE] and readmitted on [DATE]. His diagnoses included: unspecified dementia (condition characterized by progressive or persistent loss of intellectual functioning, especially with impairment of memory and abstract thinking, and often with personality change, resulting from organic disease of the brain), anxiety disorder (persistent and excessive worry that interferes with daily activities), diabetes (body doesn't make enough insulin or doesn't use it well), chronic pain (pain that lasts for over 3 months), overactive bladder (causes a frequent and sudden urge to urinate), difficulty walking (problems with joints, bones and circulation) and need for assistance with personal care.
Record review of Resident #3's quarterly MDS assessment with an ARD of 02/05/2024 reflected he scored a 09/15 on his BIMS which signified he was moderately cognitively impaired. He was able to understand and be understood. He required total assistance with ADL's.
Record review of Resident #3's comprehensive person-centered care plan revised 01/16/2023 reflected Focus .is at risk for impaired cognitive function or impaired thought processes .Interventions/Tasks .keep routine consistent and try to provide consistent care givers as much as possible to avoid confusion.
Further record review of Resident #3's comprehensive person-centered care plan revised 01/16/2023 reflected Focus .has an ADL self-care performance deficit r/t limited mobility .Interventions/Tasks .Promote dignity by ensuring privacy.
Further record review of Resident #3's comprehensive person-centered care plan revised 01/24/2024 reflected Focus .is at risk for falls r/t unsteady gait and poor safety awareness .Interventions/Tasks .Anticipate and meet needs .follow facility fall protocol.
Record review of a photo taken by CNA C (who admitted to taking the photo), (undated, time stamped 11:30 a.m.) reflected Resident #3 sitting on the floor (right side angle looking down), he was naked from the waist down and his legs were spread apart on the floor. Under the photo was an emoji (a small digital image or icon used to express and idea or emotion) laughing so hard there were flooding tears and 2 hearts which indicated others viewing the posting and reacting to the emoji. Underneath the photo was a comment by CNA C in Spanish, Un soldado caido which interprets in English as A fallen soldier.
Observation on 02/15/2024 of Resident #3 revealed he was sitting on the side of his bed, and when asked about someone taking a picture of him sitting on the floor when he fell, he stated I don't like it .
Record review of Resident #3's Active Orders as of: 02/14/2024 reflected Refer to psychiatric services to evaluate and treat .Active as of 02/06/2024.
Record review of Resident #3's psychiatric services note dated 02/06/2024 reflected Visit Note-Subsequent Evaluation/Management Visit .seen today for anxiety, dementia and depression/sadness .patient is evaluated in his wheelchair completing a word search. is calm and maintains good eye contact with provider .patient states he is not too good as he has chest congestion and reports he has pain in his left hand .Diagnoses: Major depressive disorder, anxiety and dementia .Treatment Plan .see once a week for 6 months.
Record review of Resident #3's Active Orders as of: 02/14/2024 reflected Refer to psychiatric services to evaluate and treat .Active as of 02/06/2024.
Record review of Resident #3's psychiatric services note dated 02/06/2024 reflected Visit Note-Subsequent Evaluation/Management Visit .seen today for anxiety, dementia and depression/sadness .patient is evaluated in his wheelchair completing a word search. is calm and maintains good eye contact with provider .patient states he is not too good as he has chest congestion and reports he has pain in his left hand .Diagnoses: Major depressive disorder, anxiety and dementia .Treatment Plan .see once a week for 6 months.
Interview on 02/14/2024 at 4:10 p.m. with CNA H, she stated that she received training on abuse and neglect and reporting of violations. She stated that she worked the evening shift on 02/04/2024 with CNA E, and CNA E wanted to show her something that had bothered her. She stated it was the photos of Residents #2 and #3 and the video of Resident #1. She stated CNA E stated she was afraid that she did not know how to report it to the Administrator. CNA H stated she planned to report the incidents in the morning, but she was so disturbed by what she had seen that she reported it at 06:00 a.m. instead of 08:00 a.m. as she had planned. She stated she knew she should have reported the violations immediately and she had other things she had to do, so she waited.
Interview on 02/15/2024 at 09:40 a.m. with CNA C who admitted to being part of the CNA chat group, she stated she started the group as an intent to talk and mingle as friends. She stated she started the chat group in November of 2023. She stated she saw the video of Resident #1, but did not open it, but commented on it. She stated she realized the pictures could harm the residents by violating their rights and privacy. She stated she could not recall any other photos or videos and said she was sorry for what happened. She stated she was trained on abuse and neglect.
Interview on 02/16/2024 at 09:00 a.m. with the DON, she stated she did not know why staff did not report the photos or video immediately. She stated that training on abuse and neglect was ongoing. She stated she had no idea how it happened. She stated she and the Administrator found out about the chat group and the activities when CNA H reported to them on February 5th. She stated she and the Administrator were accountable for staff actions. She stated there was zero tolerance for abuse and neglect at the facility.
Interview on 02/16/2024 at 09:20 a.m. with the Administrator, he stated he received a call from CNA H the morning of February 5th, 2023, and he stated when they figured out who participated in the chat group, all 7 of them were terminated. He reported it and started an investigation immediately. He stated he had no idea why it happened, but that it was unacceptable. He stated he reported the incident as soon as possible and he started an investigation.
Interview on 02/16/2024 at 09:35 a.m. with the SW, she stated that she met with Resident's #1, #2 and #3 and she spoke with them about the incident, and Residents #2 and #3 had adapted and felt safe at the facility. She stated she did not think that Resident #1 was aware of what was going on.
Record review of the facility Access and Confidentiality Agreements which stipulated confidentiality reflected you will not record or take pictures of anyone or anything in our workplace for your own use without the written permission of the Administrator. Further review reflected CNA A signed on 10/21/2022, CNA B signed on 10/21/2022, CNA C signed on 06/26/23, CNA D signed on 04/12/2023, CNA E signed on 04/12/2023, CNA F signed on 04/12/2023 and CNA G signed on 04/12/2023.
The facility course of action prior to surveyor entrance included:
Record review revealed : All required notifications were made: the Medical Director, Responsible Party, Physician, Nurse Practitioner, HHS, and to the local police department. Case #24028379.
Record review revealed : Initially the 3 CNAs involved in the photo taking and video were terminated and the other 4 suspended. All 7 CNAs (CNA A, CNA B, CNA C, CNA D, CNA E, CNA F and CNA G) were eventually terminated by the time the surveyor exited the facility.
Record review of the CNA's personnel folders reflected suspension and termination dates as follow: CNA A, Terminated 02/06/2024, CNA B, Terminated 02/06/2024, CNA C, Suspended 02/06/2024, Terminated 02/07/2024, CNA D, Suspended 02/06/2024, Terminated 02/07/2024, CNA E, Terminated 02/06/2024, CNA F, Suspended 02/06/2024, Terminated 02/07/2024, CNA G, Suspended 02/06/2024, Terminated 02/07/2024.
Record review dated : 02/06/2024-Head to toe assessment completed on all residents. The SW evaluated the 3 residents.
Record review dated: 02/06/2024- In-serviced 131 staff, all staff, using a staff roster were checked off and signed for In-services titled:
Record review in-services dated 02/06/2024, titled: Abuse/Neglect, Dignity, Privacy and Hipaa and Phone Use-Do not take pics or videos of residents.
02/06/2024-Orders and consults for and completed by Psychiatric Services to see all 3 residents.
Record review of an in-service titled Reporting Abuse/Neglect Right Away dated 02/14/2024 revealed it was provided for CNA H by the DON.
STAFF INTERVIEWS ON TRAINING: 02/15/2024 from 1:10 p.m. to 3:00 p.m.
On 02/15/2024 interviewed 8 staff on day shift, 3 CNA's, 2 COTA's, 1 Physical Therapy Assistant, and 2 LVNs revealed they received training on abuse/neglect, reporting, dignity, resident rights, privacy and HIPAA, and phone use to include pictures and videos.
On 02/15/2024 interviewed 5 staff on evening shift, 3 CNAs, and 1 LVN and one RN revealed they received training on abuse/neglect, reporting, dignity, resident rights, privacy and HIPAA, and phone use to include pictures and videos.
On 02/15/2024 interviewed 4 staff on night shift, 2 LVN's 1, CNA and one 1 MA revealed they received training on abuse/neglect, reporting, dignity, resident rights, privacy and HIPAA, and phone use to include pictures and videos.
The noncompliance was identified as past noncompliance IJ. The noncompliance began on 02/05/2024 and ended on 02/06/2024 when all staff had been in-serviced on abuse/neglect, reporting, dignity, resident rights, privacy and HIPAA, and phone use to include pictures and videos. The 7 CNAs were either terminated or suspended before the surveyor entrance.
CRITICAL
(K)
📢 Someone Reported This
A family member, employee, or ombudsman was alarmed enough to file a formal complaint
Immediate Jeopardy (IJ) - the most serious Medicare violation
Abuse Prevention Policies
(Tag F0607)
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 develop and implement written policies and procedures to prohibit...
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**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on interviews and record reviews, The facility failed to develop and implement written policies and procedures to prohibit and prevent abuse, neglect and exploitation of residents and misappropriation of residents property for 3 residents (Residents #1, #2 and #3) out of 5 residents reviewed for abuse and neglect in that:
CNA A, as part of a CNA chat group, took a video recording of Resident #1, naked, in the shower having a bowel movement, with a close-up view of her exposed bottom with feces on it and he shared it with the chat group.
CNA B, as part of a CNA chat group, took a digital picture of Resident #2, naked, in the shower with her back toward the camera and not aware of the photo and she shared it with the chat group.
CNA C as part of a CNA chat group, took a photo of Resident #3 after he had fallen on the floor without pants on, and shared it with the chat group.
CNA D as part of a CNA chat group, failed to report the video of Resident #1.
CNA E as part of the CNA chat group, failed to report the photos of Resident #2 and Resident #3.
CNA F, as part of the CNA chat group, failed to report the photo of Resident #2.
The noncompliance was identified as PNC. The IJ began on February 5th and ended on February 6th 2024. The facility had corrected the noncompliance before the survey began.
This deficient practice could affect residents who require assistance with ADL's and result in emotional abuse and exploitation.
The findings included:
1. Record review of Resident #1's electronic face sheet dated 02/14/2024 reflected she was admitted to the facility on [DATE]. Her diagnoses included: weakness (lacking strength), contracture of muscle, left hand (tissues tighten or shorten causing a deformity, pain, and loss of function), cognitive communication deficit (difficulty with thinking and how someone uses language) and hemiplegia (paralysis of one side of body), and hemiparesis (one sided weakness) following unspecified cerebrovascular disease ( a group of conditions that affect blood flow and the blood vessels of the brain) affecting left non-dominant side.
Record review of Resident #1's quarterly MDS with an ARD of 05/02/2023 reflected she scored a 99 on her BIMS assessment which signified the resident had 4 or more items coded 0 because she chose not to answer or game a nonsensical response. She sometimes could understand and sometimes be understood. Resident #1 required extensive assistance with ADL's.
Record review of Resident #1's comprehensive person-centered care plan revised 09/28/2023 reflected Focus .has ADL self-care performance deficit r/t limited mobility, CVA, hemiplegia, contractions, muscle wasting and atrophy (decrease in size and wasting of muscle tissue), lack of coordination and pain .Interventions/Tasks .converse with resident while providing care .explain all procedures and tasks before starting .BATHING .requires total assistance.
Further review of Resident #1's comprehensive person-centered care plan revised 02/07/2024 reflected Focus .is at risk for communication problem r/t hearing deficit, stroke, confusion .Interventions/Tasks .ensure/provide a safe environment .anticipate and meet needs.
Review of a video of Resident #1 taken by CNA A, who admitted to taking the video (unknown date) revealed a picture of a buttock with feces covered on it hanging through the seat hole of a shower chair. A white trash can with a plastic liner was positioned below the shower chair. A close up of the feces coming out of the buttocks was then seen. The video then zooming out and back up to Resident #1's face with an anguished expression and her naked upper half of body exposed as she looked directly at CNA A. The camera zooms out and focuses on Resident #1's anguished face and naked torso with her breast exposed and a partial gown draped over her bottom half sitting in the shower chair. The camera zooms back down to the buttocks with feces coming out positioned over a white plastic lined trash can. As the camera zooms back out to the shower chair legs and trash can the video ends.
Observation on 02/14/2024 at 2:40 p.m. of Resident #1 lying in her bed revealed she was quiet, appeared withdrawn and when asked how she was, she responded OK. She did not respond to any other questions.
Record review of Resident #1's Active Orders as of: 02/14/2024 reflected Refer to psychiatric services to evaluate and treat .Active as of 02/06/2024.
Record review of Resident #1's psychiatric services note dated 02/06/2024 reflected Visit Note-Initial Psychiatric Diagnostic Interview .seen today for depression/sadness .patient is evaluated laying in her bed .is pleasantly confused and does not appear to be in any emotional or psychosocial distress. Patient states she is not well as she is sick .Mental Status Exam: Behavior was withdrawn and hypoactive .speech was mumbling, slow and soft .attention span and concentration was poor .oriented to person .recent memory severely impaired .severe dementia .Diagnosis-Major depressive disorder .Treatment Plan of Care: Future visits are recommended once a week for 12 months.
Interview on 02/15/2024 at 08:50 a.m. with CNA B who admitted to being part of the of the CNA chat group , she stated she saw the video of Resident #1 and did not know why she did not report it. She stated she was trained on abuse and neglect.
Interview on 02/16/2024 at 08:20 a.m. with CNA A who admitted to being part of the CNA chat group and who took the video of Resident #1, he stated he did not know what he was thinking when he videotaped Resident #1 naked in the shower room having a bowel movement. He stated he violated Resident #1's rights, privacy, disrespected and abused her. He stated now, he realized how serious it was. He stated he was trained on abuse and neglect.
2. Record review of Resident #2's electronic face sheet dated 02/14/2024 reflected she was originally admitted to the facility on [DATE]. Her diagnoses included: chronic obstructive pulmonary disease (a group of diseases that cause airflow blockage and breathing-related problems), cognitive communication deficit (difficulty with thinking and how someone uses language), bipolar disorder (a mental illness that causes unusual shifts in a person's mood, energy, activity levels, and concentration), need for assistance with personal care and major depressive disorder (feeling of sadness and loss of interest and can interfere with activities of daily living).
Record review of Resident #2's quarterly MDS assessment with an ARD of 01/06/2024 reflected she scored a 14/15 on her BIMS which signified she was cognitively intact. She required assistance with her ADLs to include bathing.
Record review of Resident #2's comprehensive person-centered care plan revised 01/11/2023 reflected Focus .has ADL self-care deficit performance r/t shortness of breath .Interventions/Tasks .Requires staff participation with bathing.
Record review of a photo on a phone with the chat group titled Bitches [facility name] and a phone number with pluses to indicate other contact numbers reflected a photo (undated) time stamped 06:31 a.m. of Resident #2 sitting in a shower chair naked with her back toward the camera. Under the photo in Spanish was Anexo prubas hahaha which interpreted in English Attached Evidence hahaha. A responding comment from (unknown) in Spanish jajajaja te la banos translated in English hahaha we wash you.
Record review of Resident #2's Active Orders as of: 02/14/2024 reflected Refer to psychiatric services to evaluate and treat .Active as of 02/06/2024.
Record review of Resident #2's psychiatric services note dated 02/06/2024 reflected Visit Note-Subsequent Evaluation/Management Visit .seen today for depression/sadness, high risk behavior, psychosis (a collection of symptoms that affect the mind, where there has been some loss of contact with reality) and restlessness .patient is seen sitting on bed eating a snack and watching TV .Patient states I'm good .Diagnoses: Bipolar II disorder (a pattern of depressive episodes and hypomanic episodes) and major depressive disorder .Treatment Plan .future visits recommended once a week for 6 months.
Observation on 02/15/2024 at 4:00 p.m. of Resident #2 revealed she was lying on her bed watching television.
In an interview on 02/15/2024 at 4:05 p.m. with Resident #2, after being informed of the picture, which she was unaware was taken and what was in the photo, she stated she always trusted CNA B and really liked her. She stated she felt like her rights and privacy were violated .
Interview on 02/15/2024 at 07:50 a.m. with CNA F who admitted to being part of the CNA chat group, she stated she saw the photo that CNA B posted of Resident #2 in the shower naked, but she did not report it at that time because she was afraid of retaliation, and she didn't want to get anyone in trouble. She stated she knew taking photos and videos of residents violated their rights and could be considered abuse. She stated she was trained about abuse and neglect.
Interview on 02/15/2024 at 08:00 a.m. with CNA D who admitted to being part of the CNA chat group, she stated she did not know how long the group was active. She stated that CNA C started the group and that CNA E posted the first picture . She stated that CNA A posted the video of Resident #1 and she knew it was wrong. She stated she knew better; had training and she did not report and did not know why she did not. She admitted that the resident rights were violated.
Interview on 02/15/2024 at 08:50 a.m. with CNA B who admitted to being part of the CNA chat group, she stated she took the picture of Resident #2, naked in the shower chair to show the others in the group she was busy. She stated she knew she violated Resident #2's rights and it was not ok. She stated she knew it could be considered abuse, but she did it anyway .
3. Record review of Resident #3's electronic face sheet dated 02/14/2024 reflected he was initially admitted to the facility on [DATE] and readmitted on [DATE]. His diagnoses included: unspecified dementia (condition characterized by progressive or persistent loss of intellectual functioning, especially with impairment of memory and abstract thinking, and often with personality change, resulting from organic disease of the brain), anxiety disorder (persistent and excessive worry that interferes with daily activities), diabetes (body doesn't make enough insulin or doesn't use it well), chronic pain (pain that lasts for over 3 months), overactive bladder (causes a frequent and sudden urge to urinate), difficulty walking (problems with joints, bones and circulation) and need for assistance with personal care.
Record review of Resident #3's quarterly MDS assessment with an ARD of 02/05/2024 reflected he scored a 09/15 on his BIMS which signified he was moderately cognitively impaired. He was able to understand and be understood. He required total assistance with ADL's.
Record review of Resident #3's comprehensive person-centered care plan revised 01/16/2023 reflected Focus .is at risk for impaired cognitive function or impaired thought processes .Interventions/Tasks .keep routine consistent and try to provide consistent care givers as much as possible to avoid confusion.
Further record review of Resident #3's comprehensive person-centered care plan revised 01/16/2023 reflected Focus .has an ADL self-care performance deficit r/t limited mobility .Interventions/Tasks .Promote dignity by ensuring privacy.
Further record review of Resident #3's comprehensive person-centered care plan revised 01/24/2024 reflected Focus .is at risk for falls r/t unsteady gait and poor safety awareness .Interventions/Tasks .Anticipate and meet needs .follow facility fall protocol.
Record review of a photo taken by CNA C (who admitted to taking the photo), (undated, time stamped 11:30 a.m.) reflected Resident #3 sitting on the floor (right side angle looking down), he was naked from the waist down and his legs were spread apart on the floor. Under the photo was an emoji (a small digital image or icon used to express and idea or emotion) laughing so hard there were flooding tears and 2 hearts which indicated others viewing the posting and reacting to the emoji. Underneath the photo was a comment by CNA C in Spanish, Un soldado caido which interprets in English as A fallen soldier.
Observation on 02/15/2024 of Resident #3 revealed he was sitting on the side of his bed, and when asked about someone taking a picture of him sitting on the floor when he fell, he stated I don't like it .
Record review of Resident #3's Active Orders as of: 02/14/2024 reflected Refer to psychiatric services to evaluate and treat .Active as of 02/06/2024.
Record review of Resident #3's psychiatric services note dated 02/06/2024 reflected Visit Note-Subsequent Evaluation/Management Visit .seen today for anxiety, dementia and depression/sadness .patient is evaluated in his wheelchair completing a word search. is calm and maintains good eye contact with provider .patient states he is not too good as he has chest congestion and reports he has pain in his left hand .Diagnoses: Major depressive disorder, anxiety and dementia .Treatment Plan .see once a week for 6 months.
Record review of Resident #3's Active Orders as of: 02/14/2024 reflected Refer to psychiatric services to evaluate and treat .Active as of 02/06/2024.
Record review of Resident #3's psychiatric services note dated 02/06/2024 reflected Visit Note-Subsequent Evaluation/Management Visit .seen today for anxiety, dementia and depression/sadness .patient is evaluated in his wheelchair completing a word search. is calm and maintains good eye contact with provider .patient states he is not too good as he has chest congestion and reports he has pain in his left hand .Diagnoses: Major depressive disorder, anxiety and dementia .Treatment Plan .see once a week for 6 months.
Interview on 02/14/2024 at 4:10 p.m. with CNA H, she stated that she received training on abuse and neglect and reporting of violations. She stated that she worked the evening shift on 02/04/2024 with CNA E, and CNA E wanted to show her something that had bothered her. She stated it was the photos of Residents #2 and #3 and the video of Resident #1. She stated CNA E stated she was afraid that she did not know how to report it to the Administrator. CNA H stated she planned to report the incidents in the morning, but she was so disturbed by what she had seen that she reported it at 06:00 a.m. instead of 08:00 a.m. as she had planned. She stated she knew she should have reported the violations immediately and she had other things she had to do, so she waited.
Interview on 02/15/2024 at 09:40 a.m. with CNA C who admitted to being part of the CNA chat group, she stated she started the group as an intent to talk and mingle as friends. She stated she saw the video of Resident #1, but did not open it, but commented on it. She stated she realized the pictures could harm the residents by violating their rights and privacy. She stated she could not recall any other photos or videos and said she was sorry for what happened. She stated she was trained on abuse and neglect.
Interview on 02/16/2024 at 09:00 a.m. with the DON, she stated she did not know why staff did not report the photos or video immediately. She stated that training on abuse and neglect was ongoing. She stated she had no idea how it happened. She stated she and the Administrator found out about the chat group and the activities when CNA H reported to them on February 5th. She stated she and the Administrator were accountable for staff actions. She stated there was zero tolerance for abuse and neglect at the facility.
Interview on 02/16/2024 at 09:20 a.m. with the Administrator, he stated he received a call from CNA H the morning of February 5th, 2023, and he stated when they figured out who participated in the chat group, all 7 of them were terminated. He reported it and started an investigation immediately. He stated he had no idea why it happened, but that it was unacceptable. He stated he reported the incident as soon as possible and he started an investigation.
Interview on 02/16/2024 at 09:35 a.m. with the SW, she stated that she met with Resident's #1, #2 and #3 and she spoke with them about the incident, and Residents #2 and #3 had adapted and felt safe at the facility. She stated she did not think that Resident #1 was aware of what was going on.
Record review of the facility Access and Confidentiality Agreements which stipulated confidentiality reflected you will not record or take pictures of anyone or anything in our workplace for your own use without the written permission of the Administrator. Further review reflected CNA A signed on 10/21/2022, CNA B signed on 10/21/2022, CNA C signed on 06/26/23, CNA D signed on 04/12/2023, CNA E signed on 04/12/2023, CNA F signed on 04/12/2023 and CNA G signed on 04/12/2023.
The facility course of action prior to surveyor entrance included:
Record review revealed : All required notifications were made: the Medical Director, Responsible Party, Physician, Nurse Practitioner, HHS, and to the local police department. Case #24028379.
Record review of the CNA's personnel folders reflected suspension and termination dates as follow: CNA A, Terminated 02/06/2024, CNA B, Terminated 02/06/2024, CNA C, Suspended 02/06/2024, Terminated 02/07/2024, CNA D, Suspended 02/06/2024, Terminated 02/07/2024, CNA E, Terminated 02/06/2024, CNA F, Suspended 02/06/2024, Terminated 02/07/2024, CNA G, Suspended 02/06/2024, Terminated 02/07/2024.
Record review dated : 02/06/2024-Head to toe assessment completed on all residents. The SW evaluated the 3 residents.
Record review dated: 02/06/2024- In-serviced 131 staff, all staff, using a staff roster were checked off and signed for In-services titled:
Record review in-services dated 02/06/2024, titled: Abuse/Neglect, Dignity, Privacy and Hipaa and Phone Use-Do not take pics or videos of residents.
02/06/2024-Orders and consults for and completed by Psychiatric Services to see all 3 residents.
Record review of an in-service titled Reporting Abuse/Neglect Right Away dated 02/14/2024 revealed it was provided for CNA H by the DON.
STAFF INTERVIEWS ON TRAINING: 02/15/2024 from 1:10 p.m. to 3:00 p.m.
On 02/15/2024 interviewed 8 staff on day shift, 3 CNA's, 2 COTA's, 1 Physical Therapy Assistant, and 2 LVNs revealed they received training on abuse/neglect, reporting, dignity, resident rights, privacy and HIPAA, and phone use to include pictures and videos.
On 02/15/2024 interviewed 5 staff on evening shift, 3 CNAs, and 1 LVN and one RN revealed they received training on abuse/neglect, reporting, dignity, resident rights, privacy and HIPAA, and phone use to include pictures and videos.
On 02/15/2024 interviewed 4 staff on night shift, 2 LVN's 1, CNA and one 1 MA revealed they received training on abuse/neglect, reporting, dignity, resident rights, privacy and HIPAA, and phone use to include pictures and videos.
The noncompliance was identified as past noncompliance IJ. The noncompliance began on 02/05/2024 and ended on 02/06/2024 when all staff had been in-serviced on abuse/neglect, reporting, dignity, resident rights, privacy and HIPAA, and phone use to include pictures and videos. The 7 CNAs were either terminated or suspended before the surveyor entrance.
CRITICAL
(K)
📢 Someone Reported This
A family member, employee, or ombudsman was alarmed enough to file a formal complaint
Immediate Jeopardy (IJ) - the most serious Medicare violation
Report Alleged Abuse
(Tag F0609)
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 report abuse immediately but no later than 2 hours after the inc...
Read full inspector narrative →
**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on interviews, and record reviews, the facility failed to report abuse immediately but no later than 2 hours after the incident for 3 of 3 residents (Residents #1, #2, and #3) reviewed for reporting abuse and neglect in that:
CNA H was informed about the abuse of Residents #1, #2 and #3 by CNA F of text chat group and did not report it to the Administrator until February 5th at 06:00 a.m. (8 hours later).
CNA F, as part of the CNA chat group, failed to report the phone of Resident #2.
CNA D, as part of the CNA chat group, failed to report the video of Resident #1.
CNA E, as part of the CNA chat group, failed to report the photos of Resident #2 and Resident #3.
The noncompliance was identified as PNC. The IJ began on February 5th and ended on February 6th 2024. The facility had corrected the noncompliance before the survey began.
This failure could place the residents at further risk of abuse and neglect due to lack of reporting of incidents.
The findings included :
1. Record review of Resident #1's electronic face sheet dated 02/14/2024 reflected she was admitted to the facility on [DATE]. Her diagnoses included: weakness (lacking strength), contracture of muscle, left hand (tissues tighten or shorten causing a deformity, pain, and loss of function), cognitive communication deficit (difficulty with thinking and how someone uses language) and hemiplegia (paralysis of one side of body), and hemiparesis (one sided weakness) following unspecified cerebrovascular disease ( a group of conditions that affect blood flow and the blood vessels of the brain) affecting left non-dominant side.
Record review of Resident #1's quarterly MDS with an ARD of 05/02/2023 reflected she scored a 99 on her BIMS assessment which signified the resident had 4 or more items coded 0 because she chose not to answer or game a nonsensical response. She sometimes could understand and sometimes be understood. Resident #1 required extensive assistance with ADL's.
Record review of Resident #1's comprehensive person-centered care plan revised 09/28/2023 reflected Focus .has ADL self-care performance deficit r/t limited mobility, CVA, hemiplegia, contractions, muscle wasting and atrophy (decrease in size and wasting of muscle tissue), lack of coordination and pain .Interventions/Tasks .converse with resident while providing care .explain all procedures and tasks before starting .BATHING .requires total assistance.
Further review of Resident #1's comprehensive person-centered care plan revised 02/07/2024 reflected Focus .is at risk for communication problem r/t hearing deficit, stroke, confusion .Interventions/Tasks .ensure/provide a safe environment .anticipate and meet needs.
Review of a video of Resident #1 taken by CNA A, who admitted to taking the video (unknown date) revealed a picture of a buttock with feces covered on it hanging through the seat hole of a shower chair. A white trash can with a plastic liner was positioned below the shower chair. A close up of the feces coming out of the buttocks was then seen. The video then zooming out and back up to Resident #1's face with an anguished expression and her naked upper half of body exposed as she looked directly at CNA A. The camera zooms out and focuses on Resident #1's anguished face and naked torso with her breast exposed and a partial gown draped over her bottom half sitting in the shower chair. The camera zooms back down to the buttocks with feces coming out positioned over a white plastic lined trash can. As the camera zooms back out to the shower chair legs and trash can the video ends.
Observation on 02/14/2024 at 2:40 p.m. of Resident #1 laying in her bed revealed she was quiet, appeared withdrawn and when asked how she was, she responded OK. She did not respond to any other questions.
Record review of Resident #1's Active Orders as of: 02/14/2024 reflected Refer to psychiatric services to evaluate and treat .Active as of 02/06/2024.
Record review of Resident #1's psychiatric services note dated 02/06/2024 reflected Visit Note-Initial Psychiatric Diagnostic Interview .seen today for depression/sadness .patient is evaluated laying in her bed .is pleasantly confused and does not appear to be in any emotional or psychosocial distress. Patient states she is not well as she is sick .Mental Status Exam: Behavior was withdrawn and hypoactive .speech was mumbling, slow and soft .attention span and concentration was poor .oriented to person .recent memory severely impaired .severe dementia .Diagnosis-Major depressive disorder .Treatment Plan of Care: Future visits are recommended once a week for 12 months.
Interview on 02/15/2024 at 08:00 a.m. with CNA D who admitted to being part of the CNA chat group, she stated she did not know how long the group was active. She stated that CNA C started the group and that CNA E posted the first picture . She stated that CNA A posted the video of Resident #1 and she knew it was wrong. She stated she knew better; had training and she did not report and did not know why she did not. She admitted that the resident rights were violated.
Record review of Resident #2's electronic face sheet dated 02/14/2024 reflected she was originally admitted to the facility on [DATE]. Her diagnoses included: chronic obstructive pulmonary disease (a group of diseases that cause airflow blockage and breathing-related problems), cognitive communication deficit (difficulty with thinking and how someone uses language), bipolar disorder (a mental illness that causes unusual shifts in a person's mood, energy, activity levels, and concentration), need for assistance with personal care and major depressive disorder (feeling of sadness and loss of interest and can interfere with activities of daily living).
Record review of Resident #2's quarterly MDS assessment with an ARD of 01/06/2024 reflected she scored a 14/15 on her BIMS which signified she was cognitively intact. She required assistance with her ADLs to include bathing.
Record review of Resident #2's comprehensive person-centered care plan revised 01/11/2023 reflected Focus .has ADL self-care deficit performance r/t shortness of breath .Interventions/Tasks .Requires staff participation with bathing.
Record review of a photo on a phone with the chat group titled Bitches [facility name] and a phone number with pluses to indicate other contact numbers reflected a photo (undated) time stamped 06:31 a.m. of Resident #2 sitting in a shower chair naked with her back toward the camera. Under the photo in Spanish was Anexo prubas hahaha which interpreted in English Attached Evidence hahaha. A responding comment from (unknown) in Spanish jajajaja te la banos translated in English hahaha we wash you.
Record review of Resident #2's Active Orders as of: 02/14/2024 reflected Refer to psychiatric services to evaluate and treat .Active as of 02/06/2024.
Record review of Resident #2's psychiatric services note dated 02/06/2024 reflected Visit Note-Subsequent Evaluation/Management Visit .seen today for depression/sadness, high risk behavior, psychosis (a collection of symptoms that affect the mind, where there has been some loss of contact with reality) and restlessness .patient is seen sitting on bed eating a snack and watching TV .Patient states I'm good .Diagnoses: Bipolar II disorder (a pattern of depressive episodes and hypomanic episodes) and major depressive disorder .Treatment Plan .future visits recommended once a week for 6 months.
Observation on 02/15/2024 at 4:00 p.m. of Resident #2 revealed she was lying on her bed watching television.
In an interview on 02/15/2024 at 4:05 p.m. with Resident #2, after being informed of the picture, which she was unaware was taken and what was in the photo, she stated she always trusted CNA B and really liked her. She stated she felt like her rights and privacy were violated.
Interview on 02/15/2024 at 07:50 a.m. with CNA F who admitted to being part of the CNA chat group, she stated she saw the photo that CNA B posted of Resident #2 in the shower naked, but she did not report it at that time because she was afraid of retaliation, and she didn't want to get anyone in trouble. She stated she knew taking photos and videos of residents violated their rights and could be considered abuse. She stated she was trained about abuse and neglect.
Record review of Resident #3's electronic face sheet dated 02/14/2024 reflected he was initially admitted to the facility on [DATE] and readmitted on [DATE]. His diagnoses included: unspecified dementia (condition characterized by progressive or persistent loss of intellectual functioning, especially with impairment of memory and abstract thinking, and often with personality change, resulting from organic disease of the brain), anxiety disorder (persistent and excessive worry that interferes with daily activities), diabetes (body doesn't make enough insulin or doesn't use it well), chronic pain (pain that lasts for over 3 months), overactive bladder (causes a frequent and sudden urge to urinate), difficulty walking (problems with joints, bones and circulation) and need for assistance with personal care.
Record review of Resident #3's quarterly MDS assessment with an ARD of 02/05/2024 reflected he scored a 09/15 on his BIMS which signified he was moderately cognitively impaired. He was able to understand and be understood. He required total assistance with ADL's.
Record review of Resident #3's comprehensive person-centered care plan revised 01/16/2023 reflected Focus .is at risk for impaired cognitive function or impaired thought processes .Interventions/Tasks .keep routine consistent and try to provide consistent care givers as much as possible to avoid confusion.
Further record review of Resident #3's comprehensive person-centered care plan revised 01/24/2024 reflected Focus .is at risk for falls r/t unsteady gait and poor safety awareness .Interventions/Tasks .Anticipate and meet needs .follow facility fall protocol.
Record review of a photo taken by CNA C (undated, time stamped 11:30 a.m.) reflected Resident #3 sitting on the floor (right side angle looking down), he was naked from the waist down and legs were spread apart on the floor. He was not aware of the photo being taken. Under the photo was an emoji (a small digital image or icon used to express and idea or emotion) laughing so hard there were flooding tears and 2 hearts which indicated others viewing the posting and reacting to an emoji. Underneath the photo was a comment by CNA C in Spanish Un soldado caido which interprets in English as A fallen soldier.
Interview on 02/14/2024 at 4:10 p.m. with CNA H, she stated that she received training on abuse and neglect and reporting of violations. She stated that she worked the evening shift on 02/04/2024 with CNA E, and CNA E wanted to show her something that had bothered her. She stated it was the photos of Residents #2 and #3 and the video of Resident #1. She stated CNA E stated she was afraid that she did not know how to report it to the Administrator. CNA H stated she planned to report the incidents in the morning, but she was so disturbed by what she had seen that she reported it at 06:00 a.m. instead of 08:00 a.m. as she had planned. She stated she knew she should have reported the violations immediately and she had other things she had to do, so she waited.
Interview on 02/15/2024 at 09:15 a.m. with CNA E who admitted to being part of the CNA chat group, she stated she was not part of the group conversation, but was at CNA F's house when she saw the photos (unknown date and time) and the video. She stated that she made a wrong decision and did not report it right away. She stated she showed CNA H and she was aware that she reported the incidents to the Administrator.
Interview on 02/16/2024 at 09:00 a.m. with the DON, she stated she did not know why staff did not report the photos or video immediately. She stated that training on abuse and neglect was ongoing. She stated she had no idea how it happened. She stated she and the Administrator were accountable for staff actions. She stated there was zero tolerance for abuse and neglect at the facility. She stated she had no idea that CNA H did not report the violations immediately to the Administrator.
Interview on 02/16/2024 at 09:20 a.m. with the Administrator, he stated he received a call from CNA H on February 5th at 06:00 a.m., and he stated when they figured out who participated in the chat group, all 7 (CNA A, CNA B, CNA C, CNA D, CNA E, CNA F and CNA G) of them were terminated. He stated he was told CNA H reported immediately and was not aware she did not.
Record review of the facility policy and procedure titled Abuse, Prevention of and Prohibition Against revised 10/2022 reflected H. Reporting/Response .all allegations of abuse, neglect, misappropriation of resident property, or exploitation will be reported immediately to the Administrator.
The facility course of action prior to surveyor entrance included:
Record review revealed : All required notifications were made: the Medical Director, Responsible Party, Physician, Nurse Practitioner, HHS, and to the local police department. Case #24028379.
Record review of the CNA's personnel folders reflected suspension and termination dates as follow: CNA A, Terminated 02/06/2024, CNA B, Terminated 02/06/2024, CNA C, Suspended 02/06/2024, Terminated 02/07/2024, CNA D, Suspended 02/06/2024, Terminated 02/07/2024, CNA E, Terminated 02/06/2024, CNA F, Suspended 02/06/2024, Terminated 02/07/2024, CNA G, Suspended 02/06/2024, Terminated 02/07/2024.
Record review dated : 02/06/2024-Head to toe assessment completed on all residents. The SW evaluated the 3 residents.
Record review dated: 02/06/2024- In-serviced 131 staff, all staff, using a staff roster were checked off and signed for In-services titled:
Record review in-services dated 02/06/2024, titled: Abuse/Neglect, Dignity, Privacy and Hipaa and Phone Use-Do not take pics or videos of residents.
02/06/2024-Orders and consults for and completed by Psychiatric Services to see all 3 residents.
Record review of an in-service titled Reporting Abuse/Neglect Right Away dated 02/14/2024 revealed it was provided for CNA H by the DON.
STAFF INTERVIEWS ON TRAINING: 02/15/2024 from 1:10 p.m. to 3:00 p.m.
On 02/15/2024 interviewed 8 staff on day shift, 3 CNA's, 2 COTA's, 1 Physical Therapy Assistant, and 2 LVNs revealed they received training on abuse/neglect, reporting, dignity, resident rights, privacy and HIPAA, and phone use to include pictures and videos.
On 02/15/2024 interviewed 5 staff on evening shift, 3 CNAs, and 1 LVN and one RN revealed they received training on abuse/neglect, reporting, dignity, resident rights, privacy and HIPAA, and phone use to include pictures and videos.
On 02/15/2024 interviewed 4 staff on night shift, 2 LVN's 1, CNA and one 1 MA revealed they received training on abuse/neglect, reporting, dignity, resident rights, privacy and HIPAA, and phone use to include pictures and videos.
The noncompliance was identified as past noncompliance IJ. The noncompliance began on 02/05/2024 and ended on 02/06/2024 when all staff had been in-serviced on abuse/neglect, reporting, dignity, resident rights, privacy and HIPAA, and phone use to include pictures and videos. The 7 CNAs were either terminated or suspended before the surveyor entrance.
Sept 2023
1 deficiency
CONCERN
(D)
📢 Someone Reported This
A family member, employee, or ombudsman was alarmed enough to file a formal complaint
Potential for Harm - no one hurt, but risky conditions existed
Deficiency F0551
(Tag F0551)
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 obtain documentation that the resident's representativ...
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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 obtain documentation that the resident's representative has been delegated the necessary authority to exercise the resident's rights and must verify that a court-appointed representative has the necessary authority for the decision-making at issue as determined by the court. For example, a court-appointed representative might have the power to make financial decisions, but not health care decisions. Additionally, the facility must make reasonable efforts to ensure that it has access to documentation of any change related to the delegation of rights, including a resident's revocation of delegated rights, to ensure that the resident's preferences, are being upheld for 1 of 5 residents (Resident #1) reviewed for resident representative rights.
The facility failed to ensure Resident #1, who was cognitively impaired when admitted to the facility, had
had a representative who had the authority to make decisions on his behalf.
This failure could lead to the facility making decisions without the resident's right to designate a surrogate or representative to make treatment or transfer decisions for the resident; and could deny the resident through the resident representative their wishes and preferences.
The findings included:
Record review of Resident#1's face sheet, dated 09/12/23, and EMR (electronic medical record) revealed, the resident was re-admitted on [DATE] with diagnoses that included: anoxic brain damage (not enough oxygen to the brain causing brain damage), seizures, cerebral infarction (destructive blood flow in the brain) and PEG (Resident was a Male age [AGE]. RP (responsible party) was listed as the resident per the face sheet.
Record review of Resident# 1's Care Plan, dated 02/08/23, revealed goals and interventions that included: ADL care, medications as ordered, Code status DNR, at risk for infection, cognitive deficits, and behaviors.
Record review of Resident#1's MDS (minimum data set), dated 8/8/23 revealed: BIMS (brief interview of mental status) Score was zero (severely impaired in cognition).
During an interview on 09/12/23 at 8:55 AM, Resident#1's family member stated there was no documented POA or guardianship. The family member stated that a family attorney informed the family a POA was not required because a family member signed the admission for the resident to the facility. The family member stated the facility refused to provide documents involving a resident fall (Resident#1) on 9/8/23. The facility requested that the family member provide written documentation of POA which the family member did not possess before medical files could be released to the family member. The family member expressed the opinion that it was not right for the facility to insist on written documents when the family member signed the admissions packet.
Observation and interview on 09/12/23 at 11:00 AM revealed Resident #1 was in bed; TV was on; alert and not oriented. Communication cues card were not visible at the time of the observation. [in interview with SP on 9/12/23 at 5:10 PM below the SP stated cue cards were provided to the resident.] The Resident could not answer any direct questions; or follow simple cues. The surveyor pointed to Resident#1's blue shirt and asked the resident whether the color of the shirt was red and the resident did not provide a response. The surveyor attempted to cue the resident by using the thumb technique; that was, thumb up meant yes and thumb down meant no. The resident did not provide a thumb response to the color of the shirt. The DON was present during the attempted interview with the resident.
During a joint interview on 09/12/23 at 4:00 PM with the DON and the ADON, the DON stated Resident #1's family member was denied medical records because the family member was not the RP or the Guardian; the family member was only an emergency contact person. The DON stated on 09/11/23- Resident #1's family member- as requested to provide proof of POA or guardianship because during the weekend the family member wanted medical records concerning Resident #1's fall on 09/08/23. Resident #1's family member was denied the medical records involving the fall on 09/08/23. The DON and the ADON both recognized that on admission [DATE]) the admissions office failed to establish who was the RP and by default Resident #1 who was cognitively impaired was listed as the RP. This failure prevented the resident designating an RP at admissions; and given the resident could not provide consent the facility failed to encourage the family member to seek guardianship at admissions.
During observation and interview on 09/12/23 at 5:10 PM, with the DON and SP A present, the surveyor asked Resident #1 by use of communications cards provided by SP A as to whether the color of the Resident#1's shirt was black [actual color was blue], the resident pointed to yes the color was black.
During an interview on 09/12/23 at 5:15 PM, the Administrator stated: Resident#1's family member was denied the medical records involving labs and we identified that the family member was not the RP, POA or guardian. The Administrator stated Resident #1's family member would be encouraged to get guardianship if they want to get the medical records or if they wanted to make medical decisions. The Administrator recognized that Resident #1 who was cognitively impaired was admitted to the facility without an RP being designated. Policy on admission process was requested on 9/12/23 from the Administrator but none was provided at exit on 9/12/23.
Record review of facility's Resident Rights policy dated revised 05/2007 read: The Resident has the right: .to have a legal representative .
Apr 2023
4 deficiencies
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 review, the facility failed to develop and implement a comprehensive person-centered care plan for...
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**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on interview and record review, the facility failed to develop and implement a comprehensive person-centered care plan for each resident that included measurable objectives and timeframes to meet a resident's medical, nursing, mental and psychosocial needs for 1 of 5 residents (Resident #45) reviewed for care plans in that:
Resident #45's comprehensive person-centered care plan indicated the resident was treated with medications for seizures when the resident was not
This failure could place residents at risk of receiving inadequate interventions not individualized to their care needs.
The findings were:
Record review of Resident #45's face sheet, dated 4/25/23 revealed a [AGE] year-old female admitted on [DATE] with diagnoses that included dementia (impaired ability to remember, think, or make decisions that interferes with doing everyday activities), epileptic seizures (disorder of the brain characterized by repeated seizures; a temporary change in the electrical functioning of the brain), bipolar disorder (a disorder associated with episodes of mood swings ranging from depressive lows to manic highs) and lack of coordination.
Record review of Resident #45's most recent quarterly MDS assessment, dated 3/31/23 revealed the resident was cognitively intact for daily decision-making skills, was diagnosed with a seizure disorder, bipolar disorder and was treated with an antipsychotic and an antidepressant.
Record review of Resident #45's Order Summary Report, dated 4/25/23 revealed the following:
-Benztropine Mesylate tablet 0.5 mg, give 1 tablet by mouth at bedtime for tremors, with order date 9/29/22 and no end date
-Depakote Sprinkles 125 mg, give 4 capsules by mouth one time a day for bipolar disorder, with order date 2/14/23 and no end date.
-Depakote Sprinkles 125 mg, give 6 capsules by mouth at bedtime for bipolar disorder, with order date 2/14/23 and no end date
Record review of Resident #45's comprehensive care plan, revision date 12/16/22 revealed the resident had a diagnosis of epilepsy and was at risk for side effects and ineffectiveness of medications with interventions that included to give seizure medications as ordered by doctor. Monitor/document side effects and effectiveness. Further review of the comprehensive care plan, under the same epilepsy focus category revealed Resident #45 received Benztropine Mesylate per the physician's orders. Resident #45's comprehensive care plan revealed the resident received antipsychotic medications related to bipolar disorder with interventions that included to administer medications as ordered, monitor/document for side effects and effectiveness and the resident received Depakote Sprinkles as per the physician orders.
During an interview on 4/25/23 at 4:41 p.m., Resident #45 revealed she did not have a seizure disorder. Resident #45 stated, I have dementia and I'm bipolar.
During an interview on 4/25/23 at 5:21 p.m., the DON revealed Resident #45 had been diagnosed with bipolar disorder and a seizure disorder. The DON revealed Resident #45 had not had any seizures since the DON had been employed at the facility since 10/24/22. The DON, after reviewing Resident #45's Order Summary Report revealed Resident #45 did not have an active order for medications to treat seizures. The DON stated, the MDS Coordinator oversaw revising and updating the comprehensive care plans.
During an interview on 4/25/23 at 5:44 p.m. the LVN MDS Coordinator revealed, the comprehensive care plan was generated by an RN and the LVN MDS Coordinator, under the direction of the RN, revised the care plan, as necessary. The LVN MDS Coordinator stated, I know Resident #45 has a seizure disorder diagnosis. We (MDS Coordinator) rely on the orders and the nurse practitioner's notes to help develop and revise the comprehensive care plan, as necessary. The LVN MDS Coordinator revealed, the purpose of the care plan was to set goals and had to be measurable and used as a guide to know how to provide care to the resident. The LVN MDS Coordinator stated, regardless of the use, Resident #45 was on Depakote, so was still on a seizure medication even though it was prescribed for mood. We are just not being specific to the medication, and I believe there is a fine line. I think the care plan is accurate.
During a follow up interview on 4/25/23 at 6:38 p.m., the DON revealed, the purpose of the comprehensive care plan was to provide information on the care and treatment for the residents. The DON stated, even though the Depakote (for resident #45) was care planned for bipolar disorder, the Depakote could be prescribed for seizure disorder and the care plan is accurate. The DON further revealed, Resident #45 was treated with Benztropine Mesylate and was indicated on the care plan as an intervention for the treatment of seizures. The DON then revealed, Resident #45's care plan was inaccurate because Benztropine Mesylate was a medication that would not be prescribed for seizures. The DON revealed she did not believe the inaccuracy of the care plan would cause Resident #45 to have a negative outcome.
Record review of the facility policy and procedure titled, Comprehensive Person-Centered Care Planning, undated, revealed in part, .It is the policy of this facility that the interdisciplinary team (IDT) shall develop a comprehensive person-centered care plan for each resident that includes measurable objectives and timeframes to meet a resident's medical, nursing, mental and psychosocial needs that are identified in the comprehensive assessment .5. The resident's comprehensive plan of care will be reviewed and/or revised by the IDT after each assessment and as needed. Interventions put in place are to (be) followed as the plan of care for the resident. These interventions may be adjusted or resolved as needed to facilitate resident needs .
CONCERN
(D)
Potential for Harm - no one hurt, but risky conditions existed
Food Safety
(Tag F0812)
Could have caused harm · This affected 1 resident
Based on observation, interview, and record review, the facility failed to store, prepare, distribute and serve food in accordance with professional standards for food service safety for 1 of 1 kitche...
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Based on observation, interview, and record review, the facility failed to store, prepare, distribute and serve food in accordance with professional standards for food service safety for 1 of 1 kitchen reviewed for kitchen sanitation in that:
The facility failed to remove expired thickening liquid found within 1 of 1 kitchen dry food storage and 1 of 1 nutrition room.
This failure could place residents at risk for cross-contamination and foodborne illnesses.
The findings included:
Observation on 4/25/23 beginning at 11:53 AM revealed 6 quarts of liquid thickener all dated EXP 3/5/23 within the dry food storage in the kitchen.
Interview on 4/25/2022 at 2:31 PM, the DM stated he did not recall the liquid thickener and only saw the unexpired liquid thickener in the dry food storage. The DM stated anyone who entered the dry food storage was meant to remove any expired food, but he completed an unrecorded audit daily of the food in addition to when food delivery are made. The DM stated the risks associated with having food in the dry food storage was it may be served to residents and cause foodborne illness. The DM stated the facility nutrition room was stocked by the dietary department but was fully maintained by the nursing department.
Observation on 4/25/23 at 5:36 PM, 2 units of liquid thickener dated 2/14/23 and 3/5/23 within the reach-in refrigerator in nutrition room.
Interview on 4/25/23 at 5:46 PM, the DON stated the facility had 1 total nutrition room and it was maintained by the nursing department with the food supplies provided by the dietary department. The DON stated the dietary department affirmed the quality of the food when it was provided but the nursing department was intended to evaluate all items when providing it to residents. She stated the ADON's have the sole responsibility of auditing the nutrition room fridge. She stated when she evaluated the nutrition room yesterday, the thickening liquid was not there. She stated the risk associated with having expired food in the nutrition room refrigerator was that it may be served to residents and cause foodborne illness.
Interview on 4/25/23 at 5:57 PM, the Infection Preventionist/ADON stated he was the sole ADON responsible for auditing the nutrition room and completed a daily audit. He stated this morning, the expired thickening liquid was not in the reach-in refrigerator. He stated the risk with having expired food in the nutrition room refrigerator had the potential of serving the food to residents and causing foodborne illness.
Record review of the facility nutritional policy titled Food Storage, dated 8/2007, revealed It is the policy of this facility that food storage areas shall be maintained in a clean, safe, and sanitary manner.
Record review of US Food Code, dated 2017, revealed (F) MEAT and POULTRY that is not a READY-TO-EAT FOOD and is in a PACKAGED form when it is offered for sale or otherwise offered for consumption, shall be labeled to include safe handling instructions as specified in LAW, including 9 CFR 317.2(l) and 9 CFR 381.125(b).
Record review of US Food Code, dated 2017, revealed The shelf life of ROP foods is based on storage temperature for a certain time and other intrinsic factors of the food (pH, aw, cured with salt and nitrite, high levels of competing organisms, organic acids, natural antibiotics or bacteriocins, salt, preservatives, etc.). Each package of food in ROP must bear a use-by date. In some cases such as cook chill or sous vide processing when none of these intrinsic factors are present, a temperature lower than 3ºC (38ºF) must be the controlling factor for C. botulinum and L. monocytogenes growth and/or toxin formation. This use by date cannot exceed the number of days specified in one of the ROP methods in Section 3-502.12 or must be based on laboratory inoculation studies. The date assigned by a retail repacker cannot extend beyond the manufacturer's recommended expiration or pull date for the food. The use-by date must be listed on the principal display panel in bold type on a contrasting background for any product sold to consumers. Any label on packages intended for consumer sale must contain a combination of a sell-by date and use-by instructions which makes it clear that the product must be consumed within the number of days determined to be safe as specified under Section 3-502.12 of the Food Code. Foods, especially fish, that are frozen before or immediately after packaging and remain frozen until use should bear a label statement, Important, keep frozen until used, thaw under refrigeration immediately before use. Raw meat and poultry packaged using ROP methods must be labeled with safe handling instructions found in 9 CFR 317.2(l) and 9 CFR 381.125(b)
CONCERN
(D)
Potential for Harm - no one hurt, but risky conditions existed
Infection Control
(Tag F0880)
Could have caused harm · This affected 1 resident
**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, interview and record review, the facility failed to maintain an Infection Control Program designed to help...
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**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, interview and record review, the facility failed to maintain an Infection Control Program designed to help prevent the development and transmission of disease and infection to include sanitizing of medical equipment for 3 of 3 Residents (#64, #57, and #60) reviewed in that:
1.
The MA did not sanitize the blood pressure cuff before or after use with Resident #64.
2.
The MA did not sanitize the blood pressure cuff before or after use with Resident #57.
3.
The MA did not sanitize the blood pressure cuff before or after use with Resident #60.
The failure could affect residents who had their blood pressure taken in the facility and placed the residents at risk for cross-contamination and the spread of infection.
Findings included:
Record Review of Resident #64 face sheet dated 04/26/2023, revealed the Resident was admitted to the facility on [DATE] with diagnoses that included essential primary hypertension (high blood pressure), glaucoma (causes problems with vision), neuropathy ( nerve damage), muscle wasting, major depressive disorder (causes feelings of lessened self- worth as well as feelings of sadness and loneliness), and age related cognitive decline (causes difficulty in through processing and ability to process information taken in by the brain).
Record Review of Resident #57 face sheet dated 04/26/2023, revealed the Resident was admitted to the facility on [DATE] with diagnoses that included contracture of muscle multiple sites, cognitive communication deficit, muscle weakness, muscle wasting, acute respiratory failure, kidney failure, aphasia ( language disorder that affects a person's ability to communicate), epilepsy (seizure disorder), essential hypertension (high blood pressure), pruritus (itching), disorder of the skin and subcutaneous tissue, unspecified.
Record Review of Resident #60 face sheet dated 04/26/2023, revealed the Resident was admitted to the facility on [DATE] with diagnoses that included hemiplegia and hemiparesis following a stroke (weakness and paralysis) of left non-dominate side, difficulty walking, dysphagia (difficulty swallowing), reduced mobility, atrial fibrillation (irregular heartbeat at times), and major depressive disorder (causes feelings of lessened self- worth as well as feelings of sadness and loneliness).
Observation on 04/25/2023 at 2:39 p.m. of the MA taking Resident #64's blood pressure, revealed the MA did not sanitize the blood pressure cuff before or after taking Resident #64's blood pressure.
Observation on 04/25/2023 at 2:41 p.m. of MA taking Resident #57's blood pressure, revealed the MA did not sanitize the blood pressure cuff before or after taking Resident #57's blood pressure.
Observation on 04/25/2023 at 2:44 p.m. of MA taking Resident #60's blood pressure, revealed MA did not sanitize the blood pressure cuff before or after taking Resident #60's blood pressure.
During an interview with MA on 04/25/2023 at 2:50 p.m., MA stated she did not know that she should sanitize the blood pressure cuff before and after use with each resident. She further stated she was required to bring her own blood pressure cuffs to work from her home to utilized with the residents. When asked if she sanitized the blood pressure cuff utilized with Resident #57, Resident #60, or Resident #64 the MA stated she had never been taught in school or in the facility that she needed to sanitize the blood pressure cuff before or after use with each Resident, so she did not sanitize the blood pressure cuff before or after use with any of the resident's during the observations.
During an interview with the ADON on 04/25/2023 at 3:31 p.m., the ADON stated the blood pressure cuff should be sanitized prior to and after use with each resident. She stated it was important to sanitize the equipment because it was unknown of what organism such as COVID-19, C. diff (clostridium difficile which was bacterium that can infect the bowel and cause diarrhea) ,or anything that could get on the cuff. The ADON went on to state, it might or might not have an effect on the resident, but it could because they could possibly get an infection, depending if anything got on the blood pressure cuff or not.
During an interview with the DON on 04/25/2023 at 3:46 p.m. the DON stated, When taking blood pressures staff should make sure their equipment was clean by wiping it down, we provide specific wipes for equipment that all staff are trained to use. The DON further stated it was important to clean all equipment used with residents to prevent cross contamination.
Policy provided by the facility on 4/26/2023 titled, Sanitation Services, Cleaning & Disinfection Resident Care Items & Equipment revealed the following:
1.
Reusable resident items are cleaned and disinfected between residents.
2.
Single use items are disposed of after a single use.
3.
Durable medical equipment must be cleansed and disinfected before reuse by another resident.
4.
Intermediate and low-level disinfectants will be utilized for non-critical items include: stethoscope,
blood pressure machines etc.
MINOR
(C)
Minor Issue - procedural, no safety impact
Deficiency F0848
(Tag F0848)
Minor procedural issue · This affected most or all residents
**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on interview and record review the facility failed to ensure that the binding arbitration agreement provided for the selec...
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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 the binding arbitration agreement provided for the selection of a venue that is convenient to both parties for three of three residents (Residents #45, #53, and #57) reviewed for facility compliance with requirements for binding arbitration agreements.
The facility failed to ensure that its arbitration agreement provided for the selection of a venue that is convenient for both parties for Residents #45, #53, #57.
These failures put residents and their representatives at risk of being uninformed about their rights regarding binding arbitration and less able to defend their rights related to disputes, controversy or claims arising out of or related to the services to be performed by the nursing facility.
The findings included:
Record review of Resident #45's face sheet, dated 4/25/23 revealed a [AGE] year-old female admitted on [DATE] with diagnoses that included dementia (impaired ability to remember, think, or make decisions that interferes with doing everyday activities), epileptic seizures (disorder of the brain characterized by repeated seizures; a temporary change in the electrical functioning of the brain), bipolar disorder (a disorder associated with episodes of mood swings ranging from depressive lows to manic highs) and lack of coordination.
Record review of Resident #45's Arbitration Agreement dated 2/28/22 did not provide for the selection of a venue that was convenient for both parties and stated arbitration will take place in the county that the facility is located in without any additional corollary or area of venue or setting changes.
Record review of Resident #53's Face Sheet dated 4/25/23 reflected a [AGE] year-old male with an admission date of 5/13/22 and a primary diagnosis of dementia (A decrease in cognitive abilities or mental decline.)
Record review of Resident #53's Arbitration Agreement dated 5/13/22 did not provide for the selection of a venue that was convenient for both parties and stated arbitration will take place in the county that the facility is located in without any additional corollary or area of venue or setting changes.
Record review of Resident #57's Face Sheet dated 4/25/23 reflected a [AGE] year-old male with an admission date of 12/10/19 and a primary diagnosis of hemiplegia and hemiparesis follow cerebral infarction (partial paralysis after a
heart attack.)
Record review of Resident #57's Arbitration Agreement dated 12/10/19 did not provide for the selection of venue that was convenient for both parties and stated arbitration will take place in the county that the facility is located in without any additional corollary or area of venue or setting changes.
Interview on 4/25/23 at 6:09 PM, the Business Office Manager stated she assisted with the arbitration agreements but the primary contact for residents and prospects would be the Admissions Coordinator or the Operations Manager. She stated when potential residents have additional questions during the admissions process, those are posed to the Operations Manager.
Interview on 4/25/23 at 6:25 PM, the Admissions Coordinator stated she had only recently been in the role as an admissions coordinator and was not very familiar with the arbitration component of the admissions packet. The Admissions Coordinator stated during admissions she provided the packet to the potential resident or the family but will read parts of the packet to them. She stated when potential residents have additional questions, she directed them to the Operations Manager. She stated in reviewing the arbitration agreement, she only identified within the agreement describing the venue for a potential arbitration would be the sentence describing [it] will take place in the county that the facility was located in.
Interview on 4/25/23 at 6:36 PM, the Operations Manager stated the Arbitration Agreement contained in the admission packet provided to the survey team on 4/23/23 was the Arbitration Agreement currently used by the facility, and that to his knowledge it was the document that had been in use since the facility changed ownership in October of 2022. The Operations Manager stated he received the arbitration agreement from corporate to provide during admissions and potential changes would need to be submitted to his corporate structure and reviewed by legal. The Operations Manager stated the only area within the arbitration agreement that references the venue was the sentence describing that it would take place in the county of the facility. The Operations Manager stated additional questions about arbitration during admissions are posed to him and he assures potential residents that assistance was provided to residents in travel accommodations such as during potential arbitration, however that this was not stated within the arbitration agreement. The Operations Manager stated the facility did not have a policy for arbitration agreements or admissions as the admissions packet was their policy.
Record review of the admission packet reflected the arbitration agreement that stated arbitration will take place in the county that the facility is located in.
Mar 2023
1 deficiency
CONCERN
(D)
📢 Someone Reported This
A family member, employee, or ombudsman was alarmed enough to file a formal complaint
Potential for Harm - no one hurt, but risky conditions existed
Notification of Changes
(Tag F0580)
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 immediately inform the resident's physician when there was a signif...
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**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on interview and record review, the facility failed to immediately inform the resident's physician when there was a significant change in the resident's physical, mental, or psychosocial status for 1 of 5 residents (Resident #5) reviewed for notification of changes in that:
The facility did not notify Resident #5's physician when Resident #5 presented with redness to her left arm on 12/27/22.
This deficient practice could place residents at risk of not having their physician informed when there was a change in condition resulting in a delay in medical intervention and decline in health.
The findings were:
Record review of Resident #5's face sheet, dated 3/14/23, revealed Resident #5 was admitted to the facility on [DATE], with diagnoses of Alzheimer's Disease [a progressive disease that affects memory and other important mental functions], major depressive disorder, single episode, unspecified, anxiety disorder, unspecified, insomnia, unspecified, and Gastro-Esophageal Reflux Disease [also known as acid-reflux disease or GERD] without esophagitis [inflammation of the esophagus.]
Record review of Resident #5's Annual MDS, dated [DATE], revealed Resident #5 had a BIMS score of 0, signifying severe cognitive impairment. Further record review of this document revealed for the section item M1040: Other Ulcers, Wounds and Skin Problems, it was marked None of the above were present.
Record review of Resident #5's care plan, obtained 3/14/23, revealed the following focus area dated 1/8/23: [Resident #5] has potential impairment to skin integrity r/t contractures, incontinence, limited mobility, fragile skin. Interventions implemented for this Focus area included the following intervention dated 1/8/23: Report abnormal findings to skin integrity or skin breakdown to MD/RP.
Record review of Resident #5's Skin Evaluation, dated 12/27/22 signed by Wound Care LVN C, revealed the following: red discoloration to left arm. There was no documentation that showed a physician was notified.
Record review of Resident #5's assessments revealed there was no Change of Condition form completed on or after Resident #5's Skin Evaluation dated 12/27/22.
Record review of Resident #5's progress notes from 12/1/2022 to 12/31/2022 revealed no documentation that the physician was notified of Resident #5's red discoloration to left arm.
During an interview and record review on 3/16/23 at 9:02 a.m., Wound Care LVN C stated if a resident had a new wound or pressure ulcer, she would go assess it, then notify the doctor for treatment orders, then document the skin issue. Wound Care LVN C stated she performed the skin assessment on 12/27/22. Wound Care LVN C stated she would document physician notification in a change of condition form or in a progress note. A review of Resident #5's progress notes and assessments was done with Wound Care LVN C at this point in the interview. Wound Care LVN C stated she did not complete a change of condition form, or a progress note about the skin discoloration. Wound Care LVN C stated she should have contacted the physician about Resident #5's skin discoloration.
An attempted telephone interview on 3/16/23 at 9:43 a.m., with Resident #5's primary care physician, Physician D, was made; however no call-back was received prior to exit.
During an interview on 3/16/23 at 9:51 a.m., NP E stated the facility did not notify her of Resident #5's left arm redness back in December 2022 NP E stated she would prefer to be notified if a resident had arm redness. NP E stated, they're supposed to notify if anything different happened with the patient.
During an interview on 3/16/23 at 10:41 a.m., the DON stated when a resident presented with a new injury or a wound the staff should complete a change of condition report, which had a section regarding physician notification. The DON stated one of her ADONs also helped to follow-up on incidents with the family or the resident. The DON stated it was important for the physician to be promptly notified because we get the orders from there. And then they [the physician] knows what's going on with the patient.
During an interview on 3/16/23 at 11:28 a.m., Wound Care Physician F stated Resident #5 had an open record, but due to a lack of physician notes in Resident #5's record, it did not appear she (Wound Care Physician F) had seen Resident #5 yet. Wound Care Physician F stated, I think just redness in and of itself could be anything . Unless there's a wound, I don't really treat the infection. It might be a primary care doctor's treatment plan.
Record review of the facility's policy titled, Care of Condition Reporting, undated, revealed the following, it is the policy of this facility that all changes in resident condition will be accessed and communicated to the physician . All symptoms and unusual signs will be communicated to the physician promptly.
Mar 2023
2 deficiencies
CONCERN
(E)
📢 Someone Reported This
A family member, employee, or ombudsman was alarmed enough to file a formal complaint
Potential for Harm - no one hurt, but risky conditions existed
Deficiency F0685
(Tag F0685)
Could have caused harm · This affected multiple residents
**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, interview and record review the facility failed to ensure that residents received proper treatment and ass...
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**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, interview and record review the facility failed to ensure that residents received proper treatment and assist the resident in making appointments for 1 of 1 Resident (Resident #1) whose records were reviewed for vision services.
Nursing staff failed to ensure that Resident #1 was scheduled for an optometry appointment since August 2022.
This deficient practice could affect residents and contribute to a decline in vision.
The findings were:
Review of Resident #1's face sheet, dated 3/2/23, revealed she was initially admitted to the facility on [DATE] with diagnosis to include legal blindness.
Review of Resident #1's nurse's note, dated 9/2/22, read in part, informed RP social worker will follow up with eye appt. RP verbalized understanding with agreement.
Review of Resident #1's Care Plan note, dated 9/7/22, read in part, IDT met to conduct care plan with RP via telephone. IDT reviewed meds, weight, code status, diet, ancillary services, and rehab services. Resident and RP requested referral for optometry. SW will complete referral.
Review of Resident' #1's progress notes from 9/8/22 to 9/30/22 did not reveal any entries that the SW had completed an optometry referral for Resident #1.
Review of Resident #1's quarterly MDS, darted 2/7/23, revealed her BIMS was 14 (out of 15) indicating intact cognitive functioning, her vision was highly impaired and it confirmed she had a diagnosis of legal blindness.
Review of Resident 1's Care Plan, revised on 1/7/23, revealed Resident #1 is at risk for impaired visual function related to diagnosis of Legal Blindness. One of the interventions included Arrange consultation with eye care practitioner as required.
Review of Resident #1's consolidated physician orders for March 2023 revealed an order for Tylenol with Codeine #3 Tablet 300-30 MG, give 1 tablet by mouth every 12 hours for PAIN.
Review of nurses progress notes from 2/5/23 to 3/1/23 did not reveal any entries indicating that Resident #1 complained of pain or that she received Tylenol with Codeine #3 for any reason. Further review did not reveal any entries regarding an optometry apt.
Interview on 3/1/23 at 9:57 AM with the SW revealed she had worked in the facility for almost 2 years. She stated Resident #1 was alert resident The SW stated she would help with scheduling podiatry, optometry and dental appointments. She stated she was not aware if Resident #1 was referred to the ophthalmologist. She stated they changed optometrist in [DATE]. The facility was using another provider and she completed her initial visit during November 2022. The provider made another visit during January or February 2023 but was not sure if Resident #1 was seen because she had not received documentation on who was seen during the appointment dates. The SW stated she had not called the provider to inquire about obtaining a list of residents who were seen and who still needed to be seen.
Interview on 3/1/23 at 2:03 PM with LVN A revealed she was the charge nurse on 100 hall from May 2021 to July 2022. LVN A stated she remembered Resident #1 complained of pain to one of her eyes and she had the SW schedule Resident #1 for an optometry appointment. The optometrist would refer Resident #1 to an Ophthalmologist as needed.
Observation and interview on 3/2/23 at 10:05 AM with Resident #1 revealed she was lying in bed. Her right eye was grayed over. Resident #1 stated she had talked with the SW off and on and then again about 1 month ago about seeing the eye doctor because her right eye hurt. She stated she had also told at least two nurse's about wanting to see the eye doctor but could not remember their names because there was often different staff. Resident #1 stated she had almost given up on it and became tearful. Resident #1 stated her right eye still hurt and stated she could not see out of it because she had glaucoma.
Interview on 3/2/23 at 10:33 AM the SW revealed Resident #1 had not said anything to her about wanting to see the optometrist until January 2023. She referred Resident #1 for the appointment scheduled in house on 2/6/23. She stated she had not had any communication with the provider's office except about who should be added to the list for the next scheduled appointment. The SW stated she did not know if the optometrist actually saw Resident #1 on 2/6/23 because she had not received the list of residents who were seen. The SW stated she called the provider's office on this date (3/2/23) and was waiting for a fax from the provider.
Interview on 3/2/23 at 2:45 PM the SW revealed the provider told her she did not see Resident #1 during the November 2022 or February 2023 in-house visits.
Interview on 3/2/23 at 3:04 PM Resident #1's RP confirmed Resident #1 had complained to him about lack of follow up by nursing staff. He stated Resident #1 was concerned about her functional eye because she was blind from her right eye. He stated staff said they would schedule Resident #1 to see their in-house eye doctor. He was not sure if this was done.
Interview on 3/2/23 at 2:35 PM with the DON revealed the SW made her aware about the situation with Resident #1. The DON stated it was ultimately the SW's responsibility to ensure Resident #1 was referred and scheduled for an optometry appointment as needed. She would expect the SW to follow up with the provider office to ensure the optometrist saw her during the scheduled in-house appointment. The DON confirmed the SW told her the optometrist had not seen Resident #1. She further stated it was the facilities responsibility to ensure Resident #1 received the necessary services to help Resident #1 maintain optimal eyesight. The DON expected the SW to follow up on ensuring the optometrist saw Resident #1 on the scheduled in house visit and it should not take the SW since November 2022 to request documentation from the provider.
Interview on 3/2/23 with the ADM and DON at 5PM revealed they did not have a policy for vision services.
CONCERN
(F)
📢 Someone Reported This
A family member, employee, or ombudsman was alarmed enough to file a formal complaint
Potential for Harm - no one hurt, but risky conditions existed
Deficiency F0837
(Tag F0837)
Could have caused harm · This affected most or all residents
**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on interview and record review, the facility failed to ensure the governing body appointed an administrator who was licens...
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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 governing body appointed an administrator who was licensed by the State, where licensing is required; responsible for management of the facility; and reports to and is accountable to the governing body for 1 of 1 facility reviewed for the governing body, in that:
The governing body did not appoint an administrator who was licensed by the state.
This deficient practice could result in the facility not being managed in a responsible manner, which could affect the health and safety of all residents.
The findings include:
On 2/28/23 at 9:15 am, survey team conducted an entrance conference by interviewing the Operations Manager (Ops Mgr) and the DON. The Ops Mgr was asked if he was a licensed administrator and he stated he was nationally certified since he had taken the [NAME] (National Association of Long-Term Care Administrator Boards) exam. The Ops Mgr stated there was a licensed administrator who was serving as his preceptor but he only came to the facility about once a week. The Ops Mgr confirmed the licensed administrator did not work 40 hours per week in the facility as required by statute.
During an interview with DON on 02/28/23 at 9:30 am, DON confirmed the administrator/preceptor came to the facility about once a week.
Record review of the state online self-reporting website, revealed the administrator who was named as the preceptor was listed as the administrator of record for this facility.
During confidential interviews with direct care and administrative staff on 03/02/23 between 10:50 am and 11:14 am regarding their knowledge of the Abuse Coordinator and Administrator, it was revealed that staff identified current Ops Mgr as the administrator and abuse coordinator. Only the ICP nurse was familiar with the preceptor and stated he was in the facility about once a week. The other staff interviewed were not aware of the name of the preceptor.
During an interview on 03/02/23 at 2:55 pm, the Ops Mgr confirmed the administrator and he were both hired upon the transition to the current management company on 10/01/22. Ops Mgr stated he was in the process of getting his administrator's license in Utah which does not require a State exam. He stated he had completed a 6-month Administrator in Training program in Utah and had taken the [NAME] exam but had not finished getting his license when he was offered the position at this facility in Texas. When he contacted the Texas Licensure Board for Administrators, he learned he had to complete additional coursework and take the exam for administrators in Texas. The Ops Mgr stated he was currently enrolled in the [Name of College] program for licensed administrators so was taking coursework online. When the Ops Mgr was asked how the preceptor was overseeing the Ops Mgr's work, he stated, He is part of my support staff - we discuss all allegations and reportables; financial and management decisions, and generally discuss things going on in facility. The Ops Mgr confirmed the preceptor/administrator was not in the facility for 40 hours per week.
A search on the Texas HHSC credentialing website confirmed his nursing home administrator license status as Prospective which means he has not been granted a license. After fulfilling the requirements of licensing, this will change to Active.
On 03/02/23 at 3:30 pm, Ops Mgr was asked to provide documentation for the number of hours that administrator/preceptor was in the facility. Ops Mgr stated the company did not keep any time sheet records on the administrator. Ops Mgr was also asked for any written documentation on the arrangement the company had between the Ops Mgr and the preceptor/administrator but none was provided by the time of exit except for a letter from the corporate office.
The letter from [CORP] dated 10/01/22 stated: To Whom It May Concern: This letter is to acknowledge that [NAME - Ops Mgr], as the Operations Manager of the above Facility, is authorized to represent the Facility, shall conduct business and/or services on behalf of the Facility and shall have general supervisory responsibilities over the business operation. [Ops Mgr]'s responsibilities shall include, but are not limited to, having the authority to carry out the policies of the Facility.
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
- • 44% turnover. Below Texas's 48% average. Good staff retention means consistent care.
Concerns
- • Multiple safety concerns identified: 3 life-threatening violation(s). Review inspection reports carefully.
- • 24 deficiencies on record, including 3 critical (life-threatening) violations. These warrant careful review before choosing this facility.
- • $14,611 in fines. Above average for Texas. Some compliance problems on record.
- • Grade F (32/100). 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 Lakeside's CMS Rating?
CMS assigns LAKESIDE NURSING AND REHABILITATION CENTER an overall rating of 4 out of 5 stars, which is considered above average nationally. Within Texas, this rating places the facility higher than 99% of the state's 100 nursing homes. This rating reflects solid performance across the metrics CMS uses to evaluate nursing home quality.
How is Lakeside Staffed?
CMS rates LAKESIDE NURSING AND REHABILITATION CENTER's staffing level at 2 out of 5 stars, which is below average compared to other nursing homes. Staff turnover is 44%, compared to the Texas average of 46%. This relatively stable workforce can support continuity of care.
What Have Inspectors Found at Lakeside?
State health inspectors documented 24 deficiencies at LAKESIDE NURSING AND REHABILITATION CENTER during 2023 to 2025. These included: 3 Immediate Jeopardy (the most serious level, indicating potential for serious harm or death), 20 with potential for harm, and 1 minor or isolated issues. Immediate Jeopardy findings are rare and represent the most serious regulatory concerns. They require immediate corrective action.
Who Owns and Operates Lakeside?
LAKESIDE NURSING AND REHABILITATION CENTER is owned by a government entity. Government-operated facilities are typically run by state, county, or municipal agencies. The facility is operated by THE ENSIGN GROUP, a chain that manages multiple nursing homes. With 118 certified beds and approximately 112 residents (about 95% occupancy), it is a mid-sized facility located in SAN ANTONIO, Texas.
How Does Lakeside Compare to Other Texas Nursing Homes?
Compared to the 100 nursing homes in Texas, LAKESIDE NURSING AND REHABILITATION CENTER's overall rating (4 stars) is above the state average of 2.8, staff turnover (44%) is near the state average of 46%, and health inspection rating (4 stars) is above the national benchmark.
What Should Families Ask When Visiting Lakeside?
Based on this facility's data, families visiting should ask: "What changes have been made since the serious inspection findings, and how are you preventing similar issues?" "Can you walk me through typical staffing levels on day, evening, and night shifts?" "Can I visit during a mealtime to observe dining assistance and food quality?" "How do you handle medical emergencies, and what is your hospital transfer rate?" These questions are particularly relevant given the facility's Immediate Jeopardy citations and the below-average staffing rating.
Is Lakeside Safe?
Based on CMS inspection data, LAKESIDE NURSING AND 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 4-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 Lakeside Stick Around?
LAKESIDE NURSING AND REHABILITATION CENTER has a staff turnover rate of 44%, 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 Lakeside Ever Fined?
LAKESIDE NURSING AND REHABILITATION CENTER has been fined $14,611 across 1 penalty action. This is below the Texas average of $33,225. While any fine indicates a compliance issue, fines under $50,000 are relatively common and typically reflect isolated problems that were subsequently corrected. Families should ask what specific issues led to these fines and confirm they've been resolved.
Is Lakeside on Any Federal Watch List?
LAKESIDE NURSING AND 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.