THE VILLA AT TEXARKANA
For profit - Individual
106 Beds
CARING HEALTHCARE GROUP
Data: November 2025
2 Immediate Jeopardy citations
Trust Grade
51/100
#152 of 1168 in TX
Photo by The Villa @ Texarkana
Photo by The Villa @ Texarkana
Photo by The Villa @ Texarkana
1 / 10 photos
Last Inspection: December 2024
Within standard 12-15 month inspection cycle. Federal law requires annual inspections.
Overview
The Villa at Texarkana has a Trust Grade of C, indicating it is average and sits in the middle of the pack compared to other facilities. It ranks #152 out of 1,168 nursing homes in Texas, placing it in the top half, and it is the best option among the four facilities in Bowie County. The facility is improving, with issues dropping from 16 in 2023 to 8 in 2024, but there are still concerns. Staffing is rated at 3 out of 5 stars, with a turnover rate of 54%, which is average for Texas. Although there have been no fines, which is a positive sign, the facility has less RN coverage than 81% of Texas facilities, meaning residents might not receive the level of oversight they need. Specific incidents raised concerns about the care provided. For example, one resident experienced a deterioration in health due to the facility's failure to consult a physician about dangerous side effects from antipsychotic medications. Additionally, another incident involved a lack of adequate supervision for a resident with dementia, which put them at risk for falls. While the facility has strengths, including excellent overall and quality measure ratings, these weaknesses should be carefully considered by families looking for a nursing home.
- Trust Score
- C
- In Texas
- #152/1168
- Safety Record
- High Risk
- Inspections
- Getting Better
- Staff Stability ⚠ Watch
- 54% turnover. Above average. Higher turnover means staff may not know residents' routines.
- Penalties ✓ Good
- No fines on record. Clean compliance history, better than most Texas facilities.
- Skilled Nurses ⚠ Watch
- Each resident gets only 18 minutes of Registered Nurse (RN) attention daily — below average for Texas. Fewer RN minutes means fewer trained eyes watching for problems.
- Violations ⚠ Watch
- 31 deficiencies on record. Higher than average. Multiple issues found across inspections.
51/100
Top 13%
Review needed
16 → 8 violations
★★★★★
5.0
Overall Rating
★★★☆☆
3.0
Staff Levels
★★★★★
5.0
Care Quality
★★★★☆
4.0
Inspection Score
↔
Stable
2023: 16 issues
2024: 8 issues
The Good
-
5-Star Quality Measures · Strong clinical quality outcomes
-
Full Sprinkler Coverage · Fire safety systems throughout facility
-
No fines on record
Facility shows strength in quality measures, fire safety.
The Bad
Staff Turnover: 54%
Near Texas avg (46%)
Higher turnover may affect care consistency
Chain: CARING HEALTHCARE GROUP
Part of a multi-facility chain
Ask about local staffing decisions and management
The Ugly 31 deficiencies on record
2 life-threatening 1 actual harm
Dec 2024
8 deficiencies
CONCERN
(D)
📢 Someone Reported This
A family member, employee, or ombudsman was alarmed enough to file a formal complaint
Potential for Harm - no one hurt, but risky conditions existed
Resident Rights
(Tag F0550)
Could have caused harm · This affected 1 resident
**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observations, record reviews, and interviews, the facility failed to protect and promote the rights of the resident in ...
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**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observations, record reviews, and interviews, the facility failed to protect and promote the rights of the resident in an environment that promoted maintenance or enhancement of his or her quality of life for 2 of 18 residents (Resident #63, Resident #53) reviewed for resident rights.
The facility failed to protect and value Resident # 63's rights when the facility failed to allow Resident #63 call the police to report a potential crime.
The facility failed to protect and promote the rights of Resident #53 by not knocking on the door prior to entering the resident's room.
This failure could place residents at risk for decreased quality of life, increased anxiety, decreased privacy, and increased stress.
Findings included:
Record review of Resident #63's face sheet dated 10/24/22 indicated he was [AGE] years old and admitted to the facility on [DATE] with diagnoses including Muscle Wasting and Atrophy (the loss of muscle mass and strength, often caused by disuse, injury, malnutrition, or neurological conditions, resulting in a decrease in muscle size and function), Delusional Disorders (a mental illness that involves having fixed false beliefs, or delusions, that are not based in reality), Hypertensive Heart Disease (a group of heart problems that develop due to long-term high blood pressure).
Record review of Resident #63's quarterly MDS dated [DATE] indicated he was understood and understood others. The MDS indicated a BIMS score of 13 which indicated Resident #63 was cognitively intact. The MDS indicated Resident #63 did not reject care.
Record review of Resident #63's care plan dated 5/10/24 shows that Resident #63 has a history of being verbally aggressive at times. Shows that Resident #63 has a potential for side effects regarding his psychotropic medications.
During an interview on 12/10/24 at 11:00 a.m. Ombudsman A said she remembered the incident with Resident #63 and Resident #13 . She said that she does not know what to believe with the incident because both residents changed their story so much. She said that Resident #63 did complain to her after describing his side of the story that he wanted to call the police. She said the day she spoke to Resident #63 she also spoke to RN G who she educated that he needed to assist Resident #63 in calling the police. She said she educated the RN on duty as it was the weekend, and he was in charge. She said that she also educated him as Resident #63 said he was not able to call the police the day the incident occurred because he was told that only the Administrator was able to call the police.
During an interview on 12/10/24 at 12:40 p.m., Resident #63 said he was not afraid of Resident #13. He said he still leaves his room and goes to all his activities and eats in the dining room, but he will ignore Resident #13. He said he does not remember exactly what happened the day of the incident. He said he wants to call the police and has not been given the opportunity to do so.
During an interview on 12/10/24 at 2:55 p.m., RN G said he was working as the charge nurse on the day the incident occurred between Resident #13 and Resident #63. He said that he did hear something going on, but he did not see it. He said that he was told Resident #13 and Resident #63 got into an altercation after Resident #63 ran over the foot of Resident #13 on accident. He said he was told that Resident #13 either tripped and fell onto Resident #63 or Resident #13 slapped Resident #63 . He said he wasn't sure what was true. He said he wasn't sure if he spoke to Ombudsman A and B about the incident and calling the police.
During an interview on 12/10/24 at 3:12 p.m., Resident #13 said that she remembers the incident with Resident #63. She said she was shocked when Resident #63 ran over her foot. She said that she slapped Resident #63 in response. She said she felt really bad about it and wished she did not do that. She said she did not slap him hard and that she barely touched him. She said that she was happy Resident #63 was ok and she would never slap anyone again. She said this was the first time she every slapped anyone. She said now she has a sitter with her day and night watching her. She said that she regrets what happened and wants to stay clear of Resident #63 in the future. She said she feels safe at the facility and is not afraid of Resident #63.
During an interview on 12/11/24 at 9:13 a.m., with Ombudsman B she said she spoke with RN G with Ombudsman A and they called him into a room and interviewed him alone. She said he was the RN on duty at the time and he said he did not witness the incident. She said he assessed Resident #13's foot and she was unharmed, and it was determined that Resident #63 did not run over Resident #13's foot. She said they asked RN G if he called the police and he said he did not. They said they educated RN G that he was required to call the police if a resident asked to, and Resident #63 had requested to call the police. She said that they educated RN G that they must allow a resident to use the phone if they requested to.
During an interview on 12/11/24 at 12:44 p.m. the Director of Nurses said residents have the right to call outside the building to police or anyone else if they request to. She said that residents should be allowed to call the police to make a report whether their story is true or not as it is their right.
During an interview on 12/11/24 at 12:55 p.m., the Administrator said residents have the right to call the police if they so desire to do so. She said that if a resident comes to a staff and asks to use the phone to call the police the staff should direct the resident to a phone.
2. Record review of an undated face sheet revealed Resident #53 was a [AGE] year-old female admitted to the facility on [DATE] with the diagnoses of anxiety, Diabetes Mellitus Type II (prolonged high levels of glucose in the blood), and dementia (a group of symptoms affecting the memory).
Record review of an annual MDS assessment dated [DATE] revealed Resident #53 had a BIMS of 05 which indicated a severe cognitive impairment. Resident #53 was dependent for ADLs such as toileting, transfer, and bathing.
During a record review on 12/10/2024 at 10:10 a.m. of the facility Inservice binder, no Inservice was noted on knocking before entering a resident's room.
During an observation on 12/10/2024 at 8:20 a.m. CMA H entered Resident #53's room without knocking and Resident #53 was exposed during incontinent care. Resident #53 was facing the wall and the door was closed within 15 seconds. Resident #53 was not aware she was exposed to the hallway, medication aide, and surveyor.
During an interview on 12/11/2024 at 9:45 a.m., Resident #53's family member stated he had been a witness to the CNA and Medication Aides not knocking on the door several times. She stated luckily, she had never witnessed any unclothed residents as she walked by rooms. She stated Resident #53 was a private person and would not like knowing she was exposed to the hallway and staff members.
During an interview on 12/11/2024 at 10:00 a.m., CMA H stated she was aware she was supposed to knock on the resident's door prior to entering. She stated she accidentally forgot to knock before entering but quickly corrected herself once she saw Resident #53 was exposed. She stated it was not her intention to cause any embarrassment to Resident #53.
During an interview on 12/11/2024 at 11:00 a.m., the DON stated it was the resident's right to live in home that was as close to the home they lived in prior to coming to the facility. She stated that was why knocking before entering was important. She stated no one that worked there would enter someone's home without knocking first and it was the same concept at the nursing facility.
During an interview on 12/11/2024 at 2:00 p.m., the ADM stated she expected all staff to knock and provide care with dignity and respect for the elders of the community. She stated no one enters the staff's home without knocking and she wanted the staff to understand the correlation. She stated not knocking can make the resident feel less important and as if their privacy was unimportant to the facility.
Review of the facility 's policy titled Resident Rights with a revised date of December 2016 indicated, Employees shall treat all residents with kindness, respect, and dignity Federal and state laws guarantee certain basic rights to all residents of this facility. These rights include the resident's right to be free from abuse, neglect, misappropriation of property, and exploitation exercise his or her rights as a resident of the facility and as a resident or citizen of the United States communicate with outside agencies (e.g., local, state, or federal officials, state and federal surveyors, state long-term care ombudsman, protection or advocacy organizations, etc.) regarding any matter.
CONCERN
(D)
Potential for Harm - no one hurt, but risky conditions existed
Safe Environment
(Tag F0584)
Could have caused harm · This affected 1 resident
**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, interview, and record review, the facility failed to 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 2 of 23 residents reviewed for environment. (Resident #57 and Resident #72)
1. The facility failed to repair an electrical outlet in the room of Resident #57 a timely manner.
2. The facility failed to provide a functioning bed light pull string for Resident #72.
These failures placed residents at risk of injury of, living in an uncomfortable environment and a decrease in quality of life and self-worth.
Findings included:
1. Record review of the face sheet 12/10/24 indicated Resident #57 was [AGE] years old and was admitted on [DATE] with diagnoses including heart failure, dementia, and weakness.
Record review of a quarterly MDS assessment dated [DATE] indicated Resident #57 was sometimes understood and sometimes understood others. The MDS indicated a BIMS score of 07 indicating Resident #57 was severely cognitively impaired. The MDS indicated Resident #72 was dependent on staff for ADLs.
During an observation and interview on 12/09/24 at 10:04 a.m., near the head of the bed of Resident #57's bed was a red electrical outlet hanging out of the wall. The outlet was secured to the wall by metal brackets. The screw in the top bracket was completely out of the wall. The top part of the outlet was approximately 1 inch away from the wall exposing the entire length of the screw, the electrical conduit (a tube that protects and routes electrical wiring in a building or structure), and three holes in the wall. There were three electrical cords plugged into the outlet. Family Member A (family member of Resident #57) said the outlet had been hanging off the wall forever.
During an observation and interview on 12/10/24 at 8:12 a.m., Resident #57 was in bed. Approximately 3 feet away from Resident #57 was a red electrical outlet hanging out of the wall. The outlet was secured to the wall by metal brackets. The screw in the top bracket was completely out of the wall. The top part of the outlet was approximately 1 inch away from the wall exposing the entire length of the screw, the electrical conduit (a tube that protects and routes electrical wiring in a building or structure), and three holes in the wall. There were two electrical cords plugged into the outlet. Resident #57 said she did not know how long the outlet had been pulled away from the wall.
During an interview on 12/10/24 at 8:24 a.m., Family Member B (family member of Resident #57) said the outlet had been that way for several months. Family Member B said it had concerned them. Family Member B said there had been attempts made in the past to reattach the outlet to the wall, but it never stayed attached very long.
During an interview on 12/10/24 at 9:47 a.m., RN B said he had not noticed the outlet in Resident 57's room. He said all maintenance issues were entered into the maintenance log that was kept at the nurses' station. He said the log was then checked by Maintenance Director so the appropriate repairs could be made.
During an interview on 12/11/24 at 7:57 a.m., the Maintenance Director said maintenance issues were supposed to be put in service order books at each nurses' station. He said he had a huge problem with staff not doing this. He said staff just stop maintenance staff in the hall and verbally tell them. He said the outlet had been repaired several times. He said staff raising the head of the bed kept pulling the outlet out of the wall. He said he just found out on 12/10/24 that it was pulled out from the wall again. He said the wall itself and the outlet needed to be repaired and the power would have to be shut off in that room. He said this has been an ongoing issue for approximately 3 weeks. He said the box was originally` anchored to the wall but not anchored to a stud. He said now it was temporarily secured to the wall until the dry wall could be replaced.
During an interview on 12/11/24 at 8:11 a.m., CNA C said the outlet beside Resident #57's bed had been hanging out of the wall for months. She said she had verbally reported the outlet being out of the wall to maintenance when it was first pulled from the wall. She said, It's been a good minute.
During an interview on 12/11/24 at 8:15 a.m., CNA D said the outlet in Resident 57's room had been pulled out from the wall for months. She said when the bed was raised up it would hand on the outlet. She said she had reported to maintenance herself. She said she reported it to them verbally. She said she did not know if there had been previous attempts by maintenance to repair the outlet.
During an interview on 12/11/24 at 9:07 a.m., the DON said she would have expected for the outlet to have been repaired in a timely and appropriate manner. She said the outlet hanging out of the wall could be a fire hazard.
During an interview on 12/11/24 at 1:50 p.m., the Administrator said staff should put maintenance request on the log at each nurse's station. She said anything concerning electrical should be repaired immediately. She said would have expected the outlet to have been appropriately prepared and in a timely manner. She said an outlet not being repaired could potentially be a fire hazard or could fall and hit the resident.
Record review of an In-service Training Report dated 09/03/24 for All Staff and was titled Maintenance Logs indicated, All staff are required to complete a maintenance request when they observe repairs that are needed. Use the log books that are located at the nurse station. Do no assume the dept is aware. I would rather the request be made over and over other than not at all. The In-Service was conducted by the Administrator.
Record review of a Maintenance Repair Log that was in a binder at the nurses' station for Resident #57's hall did not indicate a repair request for the outlet in Resident #57's room .
2. Record review of the face sheet 01/31/24 indicated Resident #72 was [AGE] years old and was admitted on [DATE] with diagnoses including Muscle Weakness (occurs when your muscles are unable to contract properly, resulting in reduced strength), Abnormalities of Gait and Mobility (deviations from a normal walking pattern, including issues like limping, shuffling feet, dragging toes, difficulty with coordination, short steps, or an unsteady gait), Schizophrenia (a chronic mental illness that affects a person's thoughts, feelings, and behaviors).
Record review of a quarterly MDS assessment dated [DATE] indicated Resident #72 was understood and understood others. The MDS indicated a BIMS score of 15 indicating Resident #72 was cognitively intact. The MDS indicated Resident #72 required use a walker to ambulate and supervision for some ADLs.
During an interview and observation on 12/09/24 at 09:56 a.m., Resident # 72 said is that his only complaint was he wanted his light pull cord fixed. He said he tied his call light button cord to his light switch cord so he could turn his light on. He said he doesn't know if he has asked for it to be fixed. He said that he would prefer for the light above his bed to have a pull cord that was not torn off. It was observed that Resident #72's light above his bed had a frayed and torn pull cord. The cord turns the light on above his bed. It was approximately 75% torn off. Resident #72 said had tied his call light cord to the torn light pull string so he could reach it from his bed, so he didn't have to stand up.
During an interview on 12/11/24 at 09:42 a.m., the Maintenance Director said he did not know that resident #72 had a broken pull cord for his light. He said if he had known he would fix it as that was a simple problem. He said that he had issues with staff reporting in their maintenance log broken items that need fixed. He said that residents lived in the facility as their home and should have a comfortable and homelike environment.
Record review of facility Maintenance Log revealed that there was no report for Resident #72's light pull cord being frayed and torn.
During an interview on 12/11/24 at 12:52 p.m., the Administrator said the Maintenance Director was responsible for maintaining the building including bed light pull cords. She said that the Maintenance Director is required to do rounds in the facility and identify issues such as this. She said that this issue when found by staff should be reported in the maintenance log. She said that rigging up a self-fix so that Resident #72 could turn his light on was a quality-of-life issue that should be addressed immediately.
Record review of a facility policy revision date of May 2017 and titled, Quality of Life - Homelike Environment Indicated that, Residents are provided with a safe clean comfortable and homelike environment and encouraged to use their personal belongings to the extent possible Staff shall provide person-centered care that emphasizes the residents' comfort, independence and personal needs and preferences Comfortable and adequate lighting is provided in all areas of the facility to promote a safe, comfortable and homelike environment. The lighting design emphasizes sufficient general lighting in resident-use areas task lighting as needed.
Record review of a facility policy revision date of December 2009 and titled, Maintenance Service Indicated that, Maintenance service shall be provided to all areas of the building, grounds, and equipment The Maintenance Department is responsible for maintaining the buildings, grounds, and equipment in a safe and operable manner at all times Maintaining the building in compliance with current federal, state, and local laws, regulations, and guidelines Maintaining lighting levels that are comfortable, and assuring that exit lights are in good working order Maintenance personnel shall follow established safety regulations to ensure the safety and well-being of all concerned
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 that resident assessments accurately reflected the resident's...
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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 resident assessments accurately reflected the resident's status for 1 (Resident #20) of 12 residents reviewed for accuracy of resident assessments.
The facility failed to ensure that Resident #20's MDS quarterly assessment accurately reflected the resident had 5 injections of insulin and had no UTI (urinary tract infection).
This failure put residents at risk for not receiving care and services needed.
Findings included:
Record review of Resident #20's face sheet dated 12/09/2024 revealed she was a 77-years-old female, admitted to the facility on [DATE]. She had diagnoses of depression, obesity, glaucoma (a group of eye diseases that can lead to damage of the optic nerve)
Record review of the quarterly MDS assessment dated [DATE] indicated Resident #20 had a BIMS of 15, which indicated no cognitive impairment. The MDS also revealed Resident #20 received injections of insulin for 5 days in the prior 7 days. The MDS was not coded for UTI.
Record review of the consolidated orders dated 11/2024 indicated Resident #20 was started on Rocephin 1 gram intramuscularly daily on 11/15/2024. There were no orders for insulin.
Record review of Resident #20's MAR dated 11/2024 indicated Resident #20 received injections 11/15/2024 daily through 11/24/2024 of antibiotic medication. The MAR had no orders for insulin.
Record review of a urinalysis for Resident #20 indicated she had a UTI with 3 separate organisms cultured on 11/15/2024.
During an interview on 12/11/2024 at 10:20 a.m., the MDS Coordinator stated she made a mistake by claiming 5 days of injections of insulin for Resident #20. She stated most people that got injections received insulin and it was just an oversight. She stated she had not claimed UTI because she felt it did not meet criteria for a UTI. She stated Resident #20 only had one day of symptoms. She stated this failure would not affect the resident in a negative.
During an interview on 12/11/2024 at 2:00 p.m., the DON stated the MDS was important to be coded accurately because it was what was care planned about the resident and that was how the staff knew the individual needs of each resident. She stated Resident #20 was positive for a UTI in November 2024 because she complained of burning and itching with urination and tested positive for multiple bacteria. She stated that UTI should have been claimed as a diagnosis on the MDS. She stated not coding that or the antibiotics was not an accurate reflection of the resident because she was someone with frequent UTI's.
During an interview on 12/11/2024 at 2:15 p.m., the ADM stated she expected the MDS to be coded accurately so the staff new the correct way to care for each resident individually. She stated it was an oversight on the part of the MDS nurse and it was corrected before the interview. She stated the facility followed the RAI manual for their policy on accuracy of the MDS.
Review of an undated facility Minimum Data Set (MDS) Policy for MDS assessment Data Accuracy indicated, The purpose of the MDS policy is to ensure each resident receives an accurate assessment by qualified staff to address the needs of the resident .According to CMS's RAI Version 3.0 manual; the MDS is a core set of screening, clinical, and functional status elements .which forms the foundation of a comprehensive assessment for all residents of nursing homes .the items of the MDS standardize communication about resident problems and conditions with nursing homes, between nursing homes, and outside agencies .Federal regulations .require that .the assessment accurately reflects the resident's status .
CONCERN
(D)
Potential for Harm - no one hurt, but risky conditions existed
Accident Prevention
(Tag F0689)
Could have caused harm · This affected 1 resident
**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, interview, and record review the facility failed to ensure each resident received adequate supervision to ...
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**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, interview, and record review the facility failed to ensure each resident received adequate supervision to prevent accidents for 2 of 14 residents (Resident #66, Resident #72) reviewed for adequate supervision.
The facility failed to ensure that Resident #66 and Resident #72 did not have cigarette lighters in their room and in their personal possession.
This failure could place residents at risk for injury, harm, and impairment or death.
Findings included:
1. Record review of the face sheet 06/26/24 indicated Resident #66 was [AGE] years old and was admitted on [DATE] with diagnoses including Addisonian Crisis (Adrenal crisis, is a life-threatening medical emergency that requires immediate treatment), Hypoglycemia (occurs when your blood sugar level drops too low), Type 2 Diabetes (a condition that occurs when the body doesn't use insulin properly, leading to high blood sugar levels).
Record review of a quarterly MDS assessment dated [DATE] indicated Resident #66 was understood and understood others. The MDS indicated a BIMS score of 13 indicating Resident #66 was cognitively intact. The MDS indicated Resident #66 required use a walker to ambulate and supervision for some ADLs.
Record review of Resident #66's Care Plan dated 7/23/24, revealed a problem initiation on 7/23/2024 that Resident #66 was a smoker. Indicated that Resident #66 would keep his smoking materials at the nurse's station.
During interview and observation on 12/09/24 at 10:17 a.m., Resident #66 had a lighter on his bedside table. Surveyor asked if Resident #66's lighter worked as it was a type of metal collectable lighters. Resident #66 opened the top of the metal light struck the [NAME] which produced a fire. He said that he keeps his lighter on his bedside table so he can go out and smoke whenever he wants. No cigarettes were observed in the room.
2. Record review of the face sheet 01/31/24 indicated Resident #72 was [AGE] years old and was admitted on [DATE] with diagnoses including Muscle Weakness (occurs when your muscles are unable to contract properly, resulting in reduced strength), Abnormalities of Gait and Mobility (deviations from a normal walking pattern, including issues like limping, shuffling feet, dragging toes, difficulty with coordination, short steps, or an unsteady gait), Schizophrenia (a chronic mental illness that affects a person's thoughts, feelings, and behaviors).
Record review of a quarterly MDS assessment dated [DATE] indicated Resident #72 was understood and understood others. The MDS indicated a BIMS score of 15 indicating Resident #72 was cognitively intact. The MDS indicated Resident #72 required use a walker to ambulate and supervision for some ADLs.
Record review of Resident #72's Care Plan dated 1/09/23, revealed a problem initiation on 2/20/2024 that Resident #72 was non-compliant with facility smoking policies. Indicated that staff were to Instruct resident about the facility policy on smoking: locations, times, safety concerns.
During an interview and observation on 12/09/24 at 9:56 a.m., Resident #72 was observed to have two plastic lighters in his room on his walker in plain sight. He said that he always kept his lighters with him. Resident #72 began getting agitated that the surveyor was asking about his lighters and walked out of the room.
During an interview on 12/09/24 at 10:24 a.m., RN B said that Residents are not allows to keep their smoking materials on them or in their room. He said that they residents could start a fire if they are able to keep them. He said he would go confiscate the lighters. He said that it is the responsibility of any staff to confiscate lighters.
During an interview on 12/11/24 at 12:44 p.m., the Director of Nurses said it was the policy of the facility that residents cannot keep their lighters with them. She said that their policy says to take the lighters from residents. She said that residents could cause a fire if they have use of their lighters unsupervised .
During an interview on 12/11/24 at 12:47 p.m., the Administrator said their policy does not allow a resident to keep their lighters in their room. She said that residents cannot have smoking materials with them. She said that residents could start a fire in the facility if they have their lighters and are unsupervised.
Record review of an undated facility policy and titled, Smoking and Vaping Policy Indicated that, Policy: Smoking and/ or vaping is not allowed anywhere WITHIN this facility (by residents and/or staff). It is the policy of this facility to establish and maintain resident smoking and vaping policies. Smoking is not allowed in resident's rooms or inside the facility Materials are not to be carried by residents or allowed in resident rooms. They must be kept in the smoking box or stored in the Administrators office until use is needed.
CONCERN
(D)
Potential for Harm - no one hurt, but risky conditions existed
Deficiency F0700
(Tag F0700)
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 attempt to use alternatives prior to installing a sid...
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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 attempt to use alternatives prior to installing a side or bed rail, obtain informed consent prior to installation, ensure correct installation, use and maintenance of bedrails for 1 of 23 residents (Resident #30) reviewed for bedrails .
1. The facility failed to ensure informed consent for the use of Resident #30's bed rails were obtained prior to installation.
2. The facility failed to obtain a bed rail assessment to assess the risk of entrapment for Resident #30's bed rails.
These failures could place residents at risk of entrapment or injury.
Findings included:
Record review of Resident #30's face sheet, dated 12/11/24, indicated he was an [AGE] year-old male, admitted to the facility on [DATE]. His diagnoses included anxiety disorder (mental health conditions that cause uncontrollable and excessive feelings of fear or anxiety that can interfere with daily life), and myopathy (disease that affects the muscles and causes them to malfunction).
Record review of Resident #30's quarterly MDS assessment, dated 09/16/24, indicated he has a BIMS score of 13, which indicated intact cognition. He was able to make himself understood and he was able to understand others. He required substantial assistance with rolling left and right and sit to stand. He was completely dependent on staff for assistance for lying to sitting on side of bed, and chair/bed to chair transfers.
Record review of Resident #30's physician's orders, dated 12/11/24, did not indicate an order for bed rails.
Record review of Resident #30's care plan, last revised on 10/24/24, indicated a focus of resident is at risk for falls. This focus included a statement of: Assist rail to resident left side of bed. another focus indicated on the care plan was resident is at risk for pressure ulcers/skin breakdown. This focus included a statement of: 2 half rails for positioning.
During an observation and interview on 12/09/24 at 09:50 AM, Resident #30 was in his room lying in his bed. His bed had rails that were greater than one-quarter the length of his mattress. He said he used them to help move around in the bed. He said he had not had any issues with them.
During an interview on 12/10/24 at 12:52 PM, LVN E said she was responsible for care plans in the facility. She said that the bed rails were added to Resident #30's bed because he had a fall. She said they were for the resident to use to turn and assist for bed mobility.
During an observation on 12/10/24 at 1:00PM, Resident #30 was lying in his bed in his room. Corporate Nurse F was present and had a tape measure to measure the bed rails and mattress of Resident #30's bed. His mattress measured approximately 79 inches long and the bed rails were approximately 30.5 inches long.
During an interview on 12/10/24 at 01:05PM, the Administrator said they considered the rails on Resident #30's bed to be for mobility and for turn assist. She said they are not intended to keep him from falling or keep him in the bed. she said they did not do any informed consent or bed rail assessments. She said they did not do the assessments and informed consent because they did not consider the rails to be restraints.
During an interview on 12/11/24 at 12:47 PM, the DON said Resident #30 should have had the informed consent, assessments, and all the requirements completed for bed rails. She said they will change the rails to the proper turn assist rails. She said the risk to Resident #30 was there could be potential skin breakdown by the rails being too long.
Record review of the facility's policy, Proper Use of Side Rails, last revised December 2016, stated:
.The purposes of these guidelines are to ensure the safe use of side rails as resident mobility aids .
.General Guidelines .
.2. Side rails are only permissible if they are used to treat a resident's medical symptoms or to assist with
mobility and transfer of residents.
3. An assessment will be made to determine the resident's symptoms, risk of entrapment and reason for using
side rails. When used for mobility or transfer, an assessment will include a review of the resident's:
a. Bed mobility;
b. Ability to change positions, transfer to and from bed or chair, and to stand and toilet;
c. Risk of entrapment from the use of side rails; and
d. That the bed's dimensions are appropriate for the resident's size and weight.
4. The use of side rails as an assistive device will be addressed in the resident care plan .
. 9, Consent for side rail use will be obtained from the resident or legal representative, after presenting
potential benefits and risks .
CONCERN
(D)
Potential for Harm - no one hurt, but risky conditions existed
Medication Errors
(Tag F0758)
Could have caused harm · This affected 1 resident
**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on interview and record review, the facility failed to ensure residents who use psychotropic drugs receive gradual dose re...
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**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on interview and record review, the facility failed to ensure residents who use psychotropic drugs receive gradual dose reductions, and behavioral interventions, unless clinically contraindicated, in an effort to discontinue these drugs for 2 of 5 residents (Resident #8 and Resident #18) reviewed for unnecessary medications.
1. The facility failed to ensure Resident #8 had an appropriate rationale for declining a GDR for her Zyprexa medication (an antipsychotic medication used to treat bipolar disorder).
2. The facility failed to ensure Resident #18 had an appropriate diagnosis for her prescribed Trileptal (it can treat epileptic seizures).
This failure could put residents at risk of possible psychotropic medication side effects, adverse consequences, decreased quality of life, and dependence on unnecessary medications.
Findings included:
1. Record review of Resident #8's face sheet, dated [DATE], indicated she was a [AGE] year-old female, admitted to the facility on [DATE]. Her diagnoses included dementia (a decline in mental ability that affects thinking, memory, and behavior, and interferes with daily life), cerebral infarction (a serious condition that occurs when blood flow to the brain is blocked), bipolar disorder (a serious mental illness that causes extreme shifts in mood, energy, thinking, behavior, and sleep), and anxiety disorder (mental health conditions that cause uncontrollable and excessive feelings of fear or anxiety that can interfere with daily life).
Record review of Resident #8's annual MDS assessment, dated [DATE], indicated she had a BIMS score of 6, which indicated severe cognitive impairment. The MDS indicated that she received antipsychotic medication during her assessment window.
Record review of Resident #8's physician's orders, dated [DATE], indicated this order:
*Zyprexa Tablet 2.5 mg Give 1 tablet by mouth at bedtime related to bipolar disorder. The start date was [DATE].
Record review of Resident #8's consultant pharmacist / physician communication dated [DATE], indicated the consultant pharmacist communicated to the physician that the olanzapine (Zyprexa) medication was due for a GDR and recommended a change in the order to every other night for 14 days and then trial discontinue. The note further indicated If resident failed previous dose reduction attempt or is clinically contraindicated, please document clinical rationale below. The physician / prescriber response stated: hospice care.
During an interview on [DATE] at 12:47 PM, the DON said she expected the provider to provide an appropriate rationale for their decision regarding GDR's. She said the risk to the resident was that she could be potentially receiving unnecessary psychotropic medications.
During an interview on [DATE] at 01:10 PM, the Administrator said she expected the GDR to be justified. She said the risk to the resident was that it was possible that the resident could be on an unnecessary medication for longer than necessary.
2. Record review of Resident #18's face sheet dated [DATE] indicated an 83-years-old female admitted to the facility on [DATE]. Resident #18 had diagnoses including Alzheimer's disease (a progressive disease that destroys memory and other important mental functions) major depression disorder (a mental health disorder characterized by persistently depressed mood or loss of interest in activities, causing significant impairment in daily life) and anxiety disorder (a mental health disorder characterized by feelings of worry, anxiety, or fear that are strong enough to interfere with one's daily activities).
Record review of Resident #18's MDS assessment dated [DATE] indicated Resident #18 was usually understood and usually understood others. Resident #18's BIMS score was a 6. Resident #18 required moderate assistance with toileting and personal hygiene. Resident #18 MDS indicated she had major depression and anxiety disorder, unspecified.
Record review of Resident #18's care plan dated [DATE] indicated has impaired cognition diagnosis of Alzheimer's disease, anxiety. Resident #18 has inattention and disorganized thinking at times. Resident has delusional thoughts at times, such as she believes she is babysitting kids and waiting for her family member (who is deceased ) to pick her up.
Record review of Resident #18's Medication Summary Report dated [DATE] ordered and [DATE] started indicated Trileptal Oral Tablet 150 MG (Oxcarbazepine) Give 1 tablet by mouth three times a day related to anxiety disorder, unspecified.
During an interview on [DATE] at 9:44 A.M., RN B said ADON J was responsible for putting the medications in the system and making sure the medications match the diagnosis. He said a negative effect on the medication could not be ineffective if monitoring for the wrong diagnosis.
During an interview on [DATE] at 9:51 A.M., ADON J said the nurses were responsible to make sure the medications match the proper diagnosis. She said the doctor was responsible to ensure the medication match the diagnosis when he signed the orders. She said when the nurse gets the orders, they should make sure the orders match the diagnosis. She said the ADON's put the orders in and make sure the orders match the diagnosis. She said a negative effect of a medication with the wrong diagnosis could cause a different effect in the resident and staff would monitor for whatever the medication was used for.
During an interview on [DATE] at 10:09 A.M., LVN O said she wrote the orders on admission, but the ADON usually put in the orders in the system with the diagnosis. She said but if the ADON was busy or had not put the orders in the charge nurse would do it. She said a negative effect of a medication not having the correct diagnosis was a medication could not a positive outcome for a resident if staff monitored the resident for the incorrect diagnosis.
During an interview on [DATE] at 1:48 P.M., the DON said on admission ADON J normally did the admissions, but if she was not here one of the other ADON's put the orders and diagnosis in the system. She said expected the nurses to make sure the medications were with the correct diagnosis. She said negative effect of not having the correct diagnosis with the medication would be not checking the correct parameters for that medication.
During an interview on [DATE] at 2:07 P.M., the ADM said she expected the nurses to put the correct diagnosis with the appropriate medications. She said a negative effect of not having the correct diagnosis with the appropriate medication could cause medication errors and effect quality of care. She said the facility had corrected the issue with the medication.
Record review of the facility policy Medication Therapy revised 04/2007 indicated Each resident's medication regimen shall include only those medications necessary to treat existing conditions and address significant risks. Medication use shall be consistent with an individual's condition, prognosis, values, wishes and responses to such treatment.
Record review of the facility's undated policy, Behavior and Psychoactive Management Program, stated:
.Tapering and Gradual Dose Reduction (GDR) .
.3. After the first year, GDR or tapering should be attempted once a year.
4. GDR or tapering may be considered clinically contraindicated if the resident's
targeted symptoms worsened or returned during the reduction. If this occurs the
physician must document the clinical rationale why further GDR attempts should
not be done (further attempts may cause impairment of resident function,
increase distressed behavior(s), cause psychiatric instability by exacerbating an
underlying medical or psychiatric disorder
CONCERN
(D)
Potential for Harm - no one hurt, but risky conditions existed
Deficiency F0813
(Tag F0813)
Could have caused harm · This affected 1 resident
**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, interview, and record review, the facility failed to maintain and ensure safe and sanitary storage of resi...
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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 and ensure safe and sanitary storage of residents' food items for 1 of 12 resident personal refrigerators reviewed for food safety (Resident #75).
The facility failed to ensure the refrigerator for Resident #75 did not contain expired bologna and milk.
This failure could place resident at risk for food borne illnesses.
Findings include:
1. Record review of Resident #75's face sheet dated 01/3/24 indicated Resident #75 was [AGE] years old male and was admitted on [DATE] with diagnoses including Edema (a condition where fluid builds up in the body's tissues, causing swelling), Muscle Weakness (occurs when your muscles are unable to contract properly, resulting in reduced strength), and Cerebral Infarction (a serious condition that occurs when blood flow to the brain is blocked, resulting in brain tissue death).
Record review of a quarterly MDS assessment dated [DATE] indicated Resident #75 was understood and understood others. The MDS indicated a BIMS score of 12 indicating Resident #75 had mildly impaired cognition. The MDS indicated Resident #75 required supervision for some ADLs.
Record review of Resident #75's care plan dated 12/22/2023 revealed that Resident #75 required assistance with his activities of daily living.
During an observation and interview on 02/25/2024 at 10:24 a.m ., Resident #75's personal refrigerator had expired bologna (13th March 2024) and milk (October 14th 2024) He said that he will eat whatever is in his refrigerator. He said he does not look for expiration dates before eating food. He said he doesn't throw any of the food away. He said staff come every few months and cleans his refrigerator out.
During an interview on 12/11/2024 at 08:36 a.m., CNA A said that housekeeping and any staff that enters a resident room and saw that there was expired food in their refrigerator should throw that food away. She said that residents could be placed at risk of illness if they ate expired meat or expired milk.
During an interview on 12/11/2024 at 12:44 p.m. the Director of Nursing said housekeeping was responsible for ensuring that residents personal refrigerators were cleaned out and expired foods thrown away . She said non-clinical staff should also double check that housekeeping was removing expired items and cleaning. She said that residents could be placed at risk of foodborne illness eating expired meat and milk.
During an interview on 12/11/2024 at 12:55 p.m. the Administrator said resident's personal refrigerators should be cleaned out by any staff that recognizes there was spoiled food in their refrigerators. She said that it was primarily the responsibility of housekeeping. She said that residents would be put at risk for foodborne illness.
Record review of a facility policy revised July of 2014 titled, Food Receiving and Storage. Policy indicated, Foods shall be received and stored in a manner that complies with safe food handling practices Food items and snacks kept on the nursing units must be maintained as indicated. All food items to be kept below 41 °F must be placed in the refrigerator located at the nurses' station and labeled with a use by date. All foods belonging to residents must be labeled with the resident's name, the item and the use by date.
CONCERN
(D)
Potential for Harm - no one hurt, but risky conditions existed
Infection Control
(Tag F0880)
Could have caused harm · This affected 1 resident
**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observations, interviews, and record reviews the facility failed to ensure the hand hygiene procedures were followed by...
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**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observations, interviews, and record reviews the facility failed to ensure the hand hygiene procedures were followed by staff involved in direct resident contact for 1 of 5 residents (Resident #59) reviewed for infection control.
The facility failed to ensure Staffing Coordinator M performed appropriate hand washing after incontinent care was performed for Resident #59.
This failure could result an increase the infections, cross contamination and decrease quality of life.
Record review of face sheet date 12/10/2024 indicated Resident #59 was a [AGE] year old male initially admitted to the facility on [DATE] with a diagnoses which included unspecified dementia (a general term for dementia that doesn't have a specific diagnosis), anoxic brain damage (cerebral hypoxia occurs when the brain doesn't receive enough oxygen) and a personal history of urinary tract infections.
Record review of a quarterly MDS dated [DATE] revealed Resident #59 had a BIMS score of 12 and the resident was usually understood and usually understood others. The MDS indicated Resident #59 was dependent with toileting hygiene and required moderate assistance with personal hygiene.
Record review of Resident #59 care plan dated 02/21/2024 indicated Resident #59 was incontinent of bowel and bladder, due to diagnosis of neuromuscular dysfunction of bladder (a condition where the nerves controlling bladder function are damaged, leading to impaired bladder muscle activity and resulting in difficulty emptying the bladder or incontinence) and anoxic brain damage.
Record review of Staffing Coordinator M Proficiency checkoffs dated 09/16/2024 revealed Handwashing, and Perineal care was satisfactory.
During an observation of incontinent care performed on 12/10/24 at 1:50 PM by Staffing Coordinator M on Resident #59. Staffing Coordinator M did not wash her hands after she performed incontinent care on Resident #59 before she applied a clean brief and placed covers over the resident.
During an interview on 12/11/24 at 9:33 A.M., CNA I said after incontinent care was performed the CNA should wash their hands or sanitize, then applied clean gloves before a clean brief was placed on a resident and prior to covering the resident. She said improper hygiene could made the resident at risk for infections such as urinary tract infections.
During an interview on 12/11/24 at 9:38 A.M., CNA A said after she performed incontinent care she would wash or sanitize her hands then apply clean gloves, then apply a clean brief and apply the covers over the resident. She said she always washed her hands before and after incontinent care. She said the negative effects of improper hand hygiene was it could spread germs.
During an interview on 12/11/24 at 9:44 A.M., RN B said after peri care staff should wash their hands before applying a clean brief and applying covers over the resident. He said improper hand hygiene could cause infections.
During an interview on 12/11/24 at 9:51 A.M., ADON J said after peri care the aide should wash their hands and applied clean gloves before a clean brief and the covers were applied to the resident. She said negative effect of improper hygiene could cause infections and potentially cause other resident to get infections as well.
During an interview on 12/11/24 at 10:09 A.M., LVN O said after peri care was performed peri care the aide should have washed their hands or sanitize their hands then apply clean gloves. She said after the clean gloves were applied the aide could have applied a clean brief and the resident's covers. She said a negative effect of improper hand hygiene was cross contamination.
During an interview on 12/11/24 at 10:25 A.M., CNA L said she took her dirty gloves off and wash my hands before she touched anything after incontinent care. She said then she would have applied clean gloves then apply a clean brief and covered the resident. She said a negative effect of improper hygiene was infection.
During an interview on 12/11/24 at 10:30 A.M., Staffing Coordinator M said she should had washed her hands and changed her gloves before she grabbed the clean brief and pulled his covers over Resident #59. She said improper hand hygiene could cause cross contamination.
During an interview on 12/11/24 at 10:38 A.M., Restorative Aide K said after incontinent, or peri care the aide should most definitely wash their hands apply clean gloves before a clean brief and resident covers were placed on a resident. She said staff could transfer bacteria on the sheets and to the resident.
During an interview on 12/11/24 at 1:48 P.M., the DON said she expected the staff to wash their hands and change gloves after incontinent care or peri care was performed. She said after staff had washed their hands and apply clean gloves, then a clean brief and replaced resident covers for the resident should have been done. She said improper hand hygiene can cause cross contamination.
During an interview on 12/12/24 at 2:07 P.M., the ADM said she expected staff to perform proper hand hygiene during incontinent or peri care with residents. She said some of the risks with improper hand hygiene are infections and it could affect the resident's quality of life.
Record review of the facility Infection Control Policy, undated indicated all employees are required to wash their hands after each direct resident contact for which hand washing is indicated by accepted professional practice.
Record review of the facility policy Perineal Care revised 10/2010 indicated remove gloves and discard into designed container. Wash and dry your hands thoroughly. Reposition the bed covers. Make resident comfortable.
Record review of the facility policy Handwashing/ Hand Hygiene revised 08/2015 indicated all personnel shall be trained and regularly in-serviced on the importance of hand hygiene in preventing the transmission of healthcare-associated infections. All personnel shall follow the handwashing/hand hygiene procedures to help prevent the spread on infections to other personnel, residents, and visitors.
Nov 2023
7 deficiencies
CONCERN
(D)
Potential for Harm - no one hurt, but risky conditions existed
Deficiency F0657
(Tag F0657)
Could have caused harm · This affected 1 resident
**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, interview and record review, the facility failed to ensure each resident's person-centered comprehensive c...
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**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, interview and record review, the facility failed to ensure each resident's person-centered comprehensive care plan was reviewed and revised by the interdisciplinary team after each assessment for 2 of 21 residents (Residents #37, #78), reviewed for care plans.
The facility failed to revise and update Resident #37's comprehensive care plan with new enteral feeding orders.
The facility failed to revise and update Resident #78's comprehensive care plan for hospice services.
These failures could affect residents of the facility by not addressing their physical, mental, and psychosocial needs for each to attain or maintain their highest practicable physical, mental, and psychosocial outcome.
Findings included:
1. Record review of the undated face sheet indicated Resident #37 was a [AGE] year-old female that was admitted on [DATE].
Record review of the physician's orders dated 11/13/23 indicated Resident #37 had diagnoses that included: Major depression (persistently depressed mood or loss if interest in activities causing significant impairment in daily life), Diabetes Mellitus type 2 (a chronic condition that affects the way the body processes sugar), Gastro-Esophageal Reflux Disease (stomach content persistently and regularly flows up into the esophagus), Dysphagia (difficulty or discomfort in swallowing), and dementia (impairment of at least 2 brain functions, such as memory loss and judgement). The physician's orders indicated:
5/24/23 Glucerna 1.5 cal, 240 ml bolus (a single dose given all at once) three times a day for feeding. Flush with 60 ml water before and after bolus.
Record review of the quarterly MDS dated [DATE] indicated Resident #37 had no speech, rarely understood others, and was rarely understood by others. She had short and long-term memory problems with inattention, disorganized thinking, and an altered level of consciousness that was continuously present. The MDS indicated she had a feeding tube.
Record review of the care plan dated 6/1/23 indicated:
Resident #37 gets Glucerna 1.5 cal. Give 75 ml/hr via peg tube at night with 25cc/hr water flush.
The care plan indicated she required a peg tube due to dysphagia and had impaired cognition.
Record review on 11/14/23 at 11:30 AM, of Resident #37's care plan indicated she still received continuous feedings. The care plan did not indicate she was changed to bolus feedings on 5/24/23.
Record review of the MAR for Resident #37 dated 10/1/23-10/31/23 indicated:
Glucerna 1.5 cal 240 ml bolus three times a day for feeding. Flush with 60 ml water before and after bolus. The start date was 5/24/23.
Record review of the MAR for 11/1/23-11/30/23 indicated:
Glucerna 1.5 cal 240 ml bolus three times a day for feeding. Flush with 60 ml water before and after bolus. The start date was 5/24/23.
2. Record review of a face sheet dated 11/13/23 revealed Resident #78 was [AGE] years old and was admitted on [DATE] and was initially admitted on [DATE] with diagnoses including Alzheimer's Disease (a progressive disease beginning with mild memory loss and possibly leading to loss of the ability to carry on a conversation and respond to the environment), muscle weakness, and stroke.
Record review of a handwritten physician's order dated 09/05/23 indicated Resident #78 was admitted to hospice care with a diagnosis of vascular dementia (changes to memory, thinking, and behavior resulting from conditions that affect the blood vessels in the brain).
Record review of the most recent MDS dated [DATE] indicated Resident #78 was receiving hospice care while a resident in the facility.
Record review of a care plan last revised on 11/06/23 did not indicate Resident #78 was receiving hospice care.
During an interview on 11/14/23 at 12:20 PM, the Regional Nurse said Resident #37's care plan had not been updated to indicate she was currently on bolus feedings. She said Resident #37 was receiving the correct feedings ordered by the physician.
During an interview on 11/14/23 at 2:43 PM, the Regional Nurse looked at the care plan for Resident #37 and said she understood it had not been changed to bolus feedings (on 5/24/23) and still indicated a continuous feeding. The Regional Nurse and this surveyor compared the care plan to the physician's orders. She said the care plan did not reflect the current care of the resident. She said the care plan should have been updated with Resident #37's new orders for bolus feedings.
During an interview on 11/14/23 at 3:36 PM, RN C said care plans should be updated and accurate because they were the blueprint on how to care for the resident. He said Resident #37 used to be a continuous feeding at night, but he knew the order changed to bolus feedings, so he would not make a mistake even if the care plan was incorrect. He said the care plan should still be accurate. He said the person responsible for making sure the care plans were accurate was the CPC.
During an interview on 11/14/23 at 3:40 PM, LVN B said the care plans for residents should always be updated and accurate because that was how their care was dictated. She said if the care plans were wrong, they should be updated as soon as possible. LVN B said the CPC was responsible for making sure the care plans were correct and up to date. She said ultimately all nurses were responsible for making sure the care plans were correct.
During an interview on 11/14/23 at 3:44 p.m., a family member of Resident #78 said the resident was receiving hospice care. The family member said hospice was working on providing Resident #78 with a low floor bed.
During an interview on 11/14/23 at 3:45 PM, ADON A said the care plans being accurate was very important because that was how they knew how to take care of the resident. She said the person responsible for making sure the care plan was accurate was the CPC.
During an interview on 11/14/23 at 4:31 PM, the DON said the care plan for Resident #37 should have been correct and updated so they administered her feeding correctly. She said it was on the MAR correctly, so she believed that the feeding was being given correctly. She said the CPC was responsible for accuracy of the care plans and keeping them updated. She said the ADM had been checking the care plans since October of 2023, but she did not know if she had looked at that Resident #37's. She said moving forward from right now they will be bringing care plans to the morning meeting to go over them and make sure they were correct. She said beginning right now she would be checking all care plans for revisions and accuracy. She said the problem with the care plans being wrong was that the staff may not know to do the right things for the resident.
During an observation on 11/14/23 at 4:45 PM, Resident #37 was lying in her bed. Her eyes were open. The head of her bed was up approximately 35 degrees. She did not acknowledge this surveyor or respond to verbal stimulation.
During an interview on 11/14/23 04:57 PM, the DON said the Comprehensive Care Plan policy was the only one they had. She said they did not have a policy regarding updating or revising care plans.
During a phone interview on 11/14/23 at 5:44 PM, the CPC said Resident #78's care plan should have been updated to show he was on hospice care. She said Resident #37's care plan should have been updated to show she got bolus feedings through her peg tube and no longer got continuous feedings at night. She said it was important for the care plans to be correct because nurses looked at them to see how to care for a resident. She said she was responsible for making sure the care plans were correct. She said she had started checking care plans for accuracy recently, in the last 10 days or so. The CPC said no one was checking her care plans for accuracy but the ADM, DON, and ADON's were going to start checking them for accuracy during the care plan meetings.
During an interview on 11/15/23 at 8:10 AM, the DON said the process for updating changes on a care plan was they would take the triplicate for the new orders into the stand-up meeting and go over the new orders at that time. She said they would give the copy to the CPC. The DON said she could not provide the triplicates or the notes from the stand-up meeting because they had been shredded. She said she did not know how Resident 78's hospice order, or Resident #37's feeding change was missed.
During an interview on 11/15/23 08:15 AM, RN F said she had worked at the facility for 3 months and always worked PRN. She said Resident #37 had always gotten bolus feedings since she had worked. She said the physician's orders indicated she got bolus feedings. She said it was important for the care plan to be accurate to know how to properly care for the patient. She said she went by a resident's orders and double checked it on the MAR for accuracy. She said the MAR and physician's orders both indicated bolus feedings for Resident #37.
During an interview on 11/15/23 08:52 AM, the Regional Nurse provided the updated care plan for Resident #37 that indicated: Resident #37 requires Glucerna 1.5 calorie, 240 ml bolus three times a day for feeding. Flush with 60 ml water before and after bolus. The care plan revision was dated 11/14/23.
During an interview on 11/15/23 09:22 AM, the MDS nurse said she did not do anything regarding care plans. She said care plans were the responsibility of the CPC.
During an interview on 11/15/23 09:39 AM, the ADM said the new process for care plans as of 10/24/23 was to discuss any changes at the morning meetings with the ADON's, DON, and herself. She said the DON and ADON's were currently auditing care plans, but they had not gotten to Resident #37 or Resident #78's care plan yet. She said the new process was to compare the consolidated physician's orders with the care plans to make sure nothing was missed, and the care plan was correct. The ADM said the CPC was responsible for making sure the care plan was accurate but ultimately, as the ADM she was responsible.
Review of a Care Plans, Comprehensive Person-Centered facility policy dated December 2016 indicated, .A comprehensive, person-centered care plan that includes measurable objectives and timetables to meet the resident's physical, psychosocial and functional needs is developed and implemented for each resident .the care plan interventions are derived from a thorough analysis of the information gathered as part of the comprehensive assessment .The comprehensive, person-centered care plan will .Describe the services that are to be furnished to attain and maintain the resident's highest practicable physical, mental, and psychosocial well-being .Incorporate identified problem areas .Assessments of residents are on-going and care plans are revised as information about the residents and the resident's condition change .
CONCERN
(D)
Potential for Harm - no one hurt, but risky conditions existed
ADL Care
(Tag F0677)
Could have caused harm · This affected 1 resident
**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, interview, and record review, the facility failed to provide the necessary services to maintain personal h...
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**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, interview, and record review, the facility failed to provide the necessary services to maintain personal hygiene for 2 of 21 residents reviewed for ADLs. (Resident #3 and Resident #72)
The facility failed to remove facial hair from female Resident #3.
The facility failed to shave facial hair for male Resident #72.
These failures could place residents who required assistance from staff for ADLs at risk of not receiving care and services to meet their needs which could result in poor care, risk for skin breakdown, feelings of poor self-esteem, lack of dignity and health.
Findings included:
1. Record review of Resident #3's admission Record dated 03/15/23 indicated she was a [AGE] year-old female admitted to the facility on [DATE]. Her diagnoses included Dementia (impaired ability to remember, think, or make decisions that interferes with doing everyday activities), Physical Debility (General debility is a state of general weakness or feebleness that may be a result or an outcome of one or more medical conditions), Muscle Wasting and Atrophy (Muscular atrophy is the decrease in size and wasting of muscle tissue), and Anemia (a condition that develops when your blood produces a lower-than-normal amount of healthy red blood cells).
Record review of Resident #3 ' s Quarterly MDS dated [DATE] revealed a BIMS with a score of 5, which indicated resident #3 has severely impaired cognition. The MDS also revealed, Resident #3, required limited assistance with personal hygiene. Resident #3 required one-person physical assistance with personal hygiene, including shaving.
Record review of Resident #3's Care Plan dated 6/21/23, revealed a problem initiation on 3/31/23 resident requires assistance with ADL care related to diagnosis of Dementia. Resident #3 ' s care plan did not show that she refused care.
During an observation and interview on 11/13/23 at 10:16 a.m. Resident #3 was observed lying in her bed. She presented with 10 to 15 chin hairs and mustache hairs that were approximately one inch long. She stated that she does not remember the last time she was shaved. She stated that she does not shave herself. She stated that she would prefer to be shaved and not have any facial hair.
During an interview and observation on 11/14/23 at 8:30 a.m. Resident # 3 was observed with facial hair.
During an interview on 1/15/23 at 9:31 a.m. RN F, she stated the CNAs were responsible to shave residents. She stated CNAs can shave a resident when they give the resident a bath. She stated dependent residents were not able to shave themselves on their own, they require assistance. She stated that she thinks that it was reasonable for a female to want to be clean shaven. She stated that the resident however will need to allow the staff to shave them without refusing.
During an interview on 11/15/23 at 09:44 a.m. CNA G stated the CNAs and nurses were responsible for ADLs for dependent residents. She stated some residents refuse ADL care. She stated that if a resident refuses ADL care staff can encourage residents so that care can be provided. CNA G stated the names of resident ' s that refuse care. Resident #3 was not included. CNA G worked on Resident #3 ' s hall.
During an interview on 11/15/23 at 11:14 a.m. with the Administrator, she stated residents who were dependent for ADLs should have their facial hair shaved by staff. She stated it was staff ' s responsibility to ensure that residents who were dependent for ADLs were groomed. She stated unless a resident refuses staff should ensure residents were groomed properly and according to their care plan. She stated resident ' s care plans should reflect if they refuse care.
During an interview on 11/15/23 at 11:23 a.m. with the DON, she . She stated it was the responsibility of CNAs to shave residents that were/are dependent for care. She stated nurses should ensure that the CNAs were/are completing these tasks and they too are overseen by the ADONs. She stated it was reasonable that a female resident would not want facial hair.
2. Record review of a face sheet dated 11/15/23 revealed Resident #72 was a [AGE] year-old male and was admitted on [DATE] with diagnoses including muscle weakness, high blood pressure, and Parkinson ' s Disease (a progressive disorder that affects the nervous system and the parts of the body controlled by the nerves).
Record review of the most recent MDS dated [DATE] indicated Resident #72 was understood and understood others. The MDS indicated a BIMS score of 14 which indicated intact cognition. The MDS indicated Resident #72 was totally dependent on staff for personal hygiene.
Record review of a care plan last revised on 09/06/23 did not indicated Resident #72 ' s need for assistance with personal hygiene or shaving.
Record review on nurse ' s notes from 11/01/23 to 11/15/23 did not indicate Resident #72 had refused care.
Record review of CNA-ADL Tracking Form dated 11/2023 indicated Resident #72 had received total assistance with personal hygiene on 11/01/23 - 11/14/23.
During an observation and interview on 11/13/23 at 10:09 a.m., Resident #72 was in bed. The resident had unkept facial hair extending down onto his neck. He said staff did not shave him as often as he would like. He said he prefers a goatee and to clean shaven around the goatee.
During an observation on 11/14/23 at 10:06 a.m., Resident #72 was in bed. The hospice CNA and a facility CNA were assisting Resident #72 with dressing. The resident had unkept facial hair extending down onto his neck.
During an observation and interview on 11/15/23 at 8:06 a.m., Resident #72 said that staff never shave him. He said staff do not offer to shave him. He said he got a bath on 11/14/23 and still was not shaved. The resident had unkept facial hair extending down onto his neck. Resident #72 said to the surveyor, I thought you weren ' t going to come back to see about this.
During an interview on 11/15/23 at 9:07 a.m., CNA K said male residents were supposed to be shaved on shower days. She said Resident #72 was very picky about who shaved him. She said he would let her shave him. She said staff should offer for him to be shaved on his bath days. She said his bath days were Tuesdays, Thursdays, and Saturdays.
During an interview on 11/15/23 at 9:14 a.m., LPN L said staff should offer to shave male resident on their bath days and as needed.
During an interview on 11/15/23 at 10:19 a.m., the DON said she would have expected Resident #72 to have been shaved on his bath days and as needed. She said the hospice aide usually shaved him and she was not sure why he had not been shaved. She said not being shaved could be a dignity thing.
During an interview on 11/15/23 at 10:46 a.m., the Administrator said she would have expected Resident #72 to have been shaved. She said hospice was responsible for his baths. She said staff should have offered to shave him and shave him anytime he asked. She said she had visited with him, and he had asked to be shaved. She said Resident #72 not being shaved could make him uncomfortable. She said the beauty shop also provided shaves to the resident.
Review of a Quality of Life, Activities of Daily Living (ADLs)/Maintain Abilities facility policy dated 11/28/2017 indicated, .To appropriately address resident and facility practices that would affect the resident ' s ability to attain and maintain his/her practicable well-being .The facility must provide the necessary care and services, based on the comprehensive assessment of a resident and consistent with the resident ' s needs and choices, to ensure that a resident ' s abilities in activities of daily living do not diminish unless circumstances of the individual ' s clinical condition demonstrate that such diminution was unavoidable. This includes the facility ensuring that a resident is given the appropriate treatment and services to maintain or improve his or her ability to carry out the activities of daily living. The facility must provide care and services, in accordance with the previous paragraph, for the following activities of daily living .Hygiene .grooming .
CONCERN
(D)
Potential for Harm - no one hurt, but risky conditions existed
Respiratory Care
(Tag F0695)
Could have caused harm · This affected 1 resident
**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, interview, and record review the facility failed to ensure a resident who needed respiratory care was prov...
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**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, interview, and record review the facility failed to ensure a resident who needed respiratory care was provided such care, consistent with professional standards of practice, the comprehensive person-centered care plan, the residents' goals and preferences for 2 of 2 residents (Resident #24 and #55) reviewed for respiratory care and services.
The facility failed to ensure Resident #24's oxygen concentrator was set at 2 LPM, as ordered by the physician.
The facility failed to change the filters on oxygen concentrator machines that were in use for Resident #55.
This failure could place residents at risk for developing respiratory complications.
Findings included:
1. Record review of Resident #24's face sheet, dated 11/14/23, indicated she was a [AGE] year-old female, admitted to the facility 09/13/23. Her diagnoses included polycythemia vera (a rare blood disorder in which there is an increase in all blood cells, particularly red blood cells), and asthma (a disease in which the airways clog and narrow, making it hard to breathe).
Record review of Resident #24's admission MDS assessment , dated 09/20/23, indicated she had a BIMS score of 15, which indicated intact cognition. She was able to make herself understood and she was able to understand others. She did not exhibit behavior of rejection of care.
Record review of Resident #24's undated physician's orders indicated she had an order for oxygen via nasal cannula 2 L as needed. The start date was 09/28/23.
Record review of Resident #24's undated care plan indicated a focus of resident requires the use of oxygen as needed. The focus was last revised on 10/25/23. Interventions included oxygen as ordered.
During an observation on 11/14/23 at 04:20 PM, Resident #24 was in her room lying in her bed. She had oxygen in place via nasal cannula. The oxygen concentrator at her bedside was set to 3.5 LPM.
During an observation on 11/15/23 at 08:07 AM, Resident #24 was in her room lying in her bed. She had oxygen in place via nasal cannula. The oxygen concentrator at her bedside was set to 3.5 LPM.
During an interview on 11/15/23 at 09:25 AM, LVN H said she was assigned to Resident #24 on 11/15/23. She said Resident #24 had an order for oxygen as needed. She said the order indicated Resident #24's oxygen concentrator should have been set at 2 LPM. She said the concentrator should not have been set at 3.5 LPM. She said the oxygen concentrator should be set to the ordered rate. She said the resident could suffer CO2 overload and decreased respiratory drive. She said no one was responsible for ensuring the oxygen concentrators were set at the ordered rate other than the nurse.
During an observation on 11/15/23 at 09:33 AM, Resident #24 was lying in bed in her room. She had oxygen in place via nasal cannula. The concentrator at her bedside was set at 3.5 LPM.
During an interview on 11/15/23 at 9:52 AM, ADON J said she expected Resident #24's oxygen concentrator to be set at the ordered rate. She said if Resident #24's oxygen was set too high she could overexert herself and suffer complications. She said the nurse was responsible for ensuring the oxygen rate was set correctly throughout their shift. She said the ADONs and charge nurses were responsible for ensuring the oxygen rate was set correctly. She said all licensed personnel were responsible for ensuring the oxygen rate was set correctly.
During an interview on 11/15/23 at 09:55AM, the DON said she expected Resident #24's oxygen to be set at the ordered rate. She said Resident #24 could become dependent on the higher dose of oxygen. She said the nurse was responsible for ensuring the oxygen was set at the ordered rate. She said the ADONs were also responsible for checking the oxygen was set at the ordered rate.
During an interview on 11/15/23 at 09:57 AM, the Administrator said she expected Resident #24 to be given the ordered dose of oxygen. She said she expected the nurses to keep an eye on the oxygen rate. She said the resident could suffer a negative effect if the rate was set at the wrong rate.
2. Record review of an undated face sheet revealed Resident #55 was an [AGE] year-old, female, and admitted on [DATE] with diagnoses including Chronic Obtrusive Pulmonary Disease (a common lung disease causing restricted airflow and breathing problems), Palpitations (feelings or sensations that your heart is pounding or racing), Dyspnea (difficult or labored breathing).
Record review of the Quarterly MDS dated [DATE] revealed Resident #55 had a BIMS score of 7, which indicated Resident # 55 has severely impaired cognition. Resident #55 was coded as receiving oxygen therapy. Resident #55 required limited assistance with ADLs.
Record review of Resident #55 ' s care plan revised on 2/10/21 shows that she receives oxygen as ordered for PRN shortness of breath. Care plan stated that staff are to, Ensure oxygen concentrator is clean and in good working order.
During an observation and interview on 11/13/23 at 10:16 a.m. Resident #55 ' s oxygen concentrator external filter was obstructed with dust and debris. Resident #55 stated she used the oxygen concentrator. She stated she did not remember the last time someone cleaned the machine nor the filter on the machine. Resident #55 was observed with the nasal cannula attached to the concentrator on her bed indicating that she uses the device.
During an observation on 11/15/23 at 9:00 a.m. Resident #55 ' s oxygen concentrator external filter had yet to be cleaned or replaced. The filter was obstructed with dirt and debris.
During an interview on 11/15/23 at 9:31 a.m. with RN F, she stated that the night shift nurses were responsible to change out the oxygen concentrator filters but she wasn ' t sure. She stated she does not look at the concentrator filters.
During an interview on 11/15/23 at 9:44 a.m. with CNA G, she stated that it was not her responsibility or that of CNAs to clean or change the filters on oxygen concentrators. She stated she knows what the filter looks like and its location. She stated she was able to report if a filter was dirty to a nurse.
During an interview on 11/15/23 at 11:14 a.m. with the Administrator, she stated. She stated it wasis the nurse ' s responsibility to ensure that oxygen concentrator filters wereare cleaned and replaced when needed. She stated that there should not be a buildup of dust on the external filters. She stated that a resident could become ill if the filters wereare not kept clean and free from dust and particles.
During an interview on 11/15/23 at 11:23 a.m. with the Director of Nursing, she stated it was the nurse ' s responsibility to ensure that the external filter for the oxygen concentrator was free from dust and debris. She stated that residents were placed at risk for respiratory issues, and it could cause the machine to not work properly. She stated it was the facility ' s policy to ensure that respiratory equipment was in a good and working order.
Record review of facility policy titled Oxygen Administration revised in October of 2010 revealed that, The purpose of this procedure is to provide guidelines for safe oxygen administration Verify that there is a physician's order for this procedure. Review the physician's orders or facility protocol Review the resident's care plan to assess for any special needs of the resident Assemble the equipment and supplies as needed.
CONCERN
(D)
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 administering of all drugs and biologicals, to meet the needs of 1 of 21 residents reviewed for pharmacy services. (Resident # 73)
The facility failed to provide adequate supervision for Resident #73 during medication administration.
This failure could place residents at risk for inaccurate drug administration.
Findings included:
Record review of the face sheet 11/14/23 indicated Resident #73 was [AGE] years old and was admitted on [DATE] with diagnoses including high blood pressure, chronic obstructive pulmonary disease (chronic lung disease), and low back pain.
Record review of physician's orders dated 11/14/23 did not indicate Resident #73 could safely administer his own medications.
Record review of the MDS dated [DATE] indicated Resident #73 was understood and understood others. The MDS indicated a BIMS score of 15 indicating Resident #73 was cognitively intact. The MDS indicated Resident #73 was taking medications for depression and an opioid (pain medication).
Record review of a care plan revised on 10/24/23 indicated Resident #73 was at risk for side effects related to the use of analgesics (drug to relieve pain), sedatives/hypnotics, anti-hypertensive/cardiac medication, multivitamins, and respiratory drugs. The care plan indicated the resident had chronic pain. There was an intervention for medication as ordered. There was no indication that Resident #73 could safely administer his own medications.
Record review of a Resident #73's Medication Administration Record for November 2023 indicated on the morning of 11/13/23 Resident #73 was administered Tylenol #3 (pain medication), Amlodipine 10 milligram tablet (blood pressure medication), Folic Acid 1 milligram tablet (a vitamin used to treat anemia), Klor-Con 20 milliequivalent extended-release tablet (potassium), Loratadine 10 milligram tablet (allergy medication), Montelukast Sodium 10 milligram tablet (a respiratory medication), a multi-vitamin, Tamsolosin 0.4 milligram capsule (medication for an enlarged prostate), Thiamin 100 milligram tablet (vitamin B1), Depakote 250 milligram delayed release tablet for being verbally aggressive, Magnesium 400 milligram tablet (a mineral), Gabapentin 300 milligram capsule (medication for nerve pain), and Sodium Chloride 1 gram tablet (an electrolyte replenisher). There was an order on the record that indicated, May give AM meds at 9:30 a.m.
During an observation and interview on 11/13/23 at 10:11 a.m., Resident #73 was sitting in bed with his bedside table in front of him. There was no staff present in the room. There were 7 pills sitting on a napkin on the bedside table. The resident took one pill in front of the surveyor. One pill was pink, 4 were white, one was yellow and brown. The resident said the medication aide let him take them on his own. He said the staff had supervised him while he took his pain medication.
During an interview on 11/14/23 at 2:56 p.m., Mediation Aide D said she did leave the pills with Resident #73 on 11/13/23. She said he swallowed his medication real slow and so she went back and forth between residents to make sure he took his medicine. She said sometimes she saved him for last and she stood in the room to make sure he took the medications. She said she was not sure if he had a safe medications administration assessment. She said she did go back and check because she knew it was against state rules to leave medicines with residents.
During an interview on 11/15/23 at 10:19 a.m., the DON said she would have expected the medication aide to have stayed in Resident #73's room with him during medication administration. She said he had no safe self-medication administration assessment of any kind and medications were to be given by the medication aide or nurse. She said Resident #73 being left alone to self-administer his medications, he could throw them away or choke on them. She said since the administration was not observed by staff, they would not know if he even got his medications.
During an interview on 11/15/23 at 10:46 a.m., the Administrator said she would not have expected Resident #73 to have been self-administering his medications while staff were not in the room. She said the resident could take the medications wrong or not take them at all.
Review of a Administering Medications facility policy dated December 2012 indicated, .Medications shall be administered in a safe and timely manner .Only persons licensed or permitted by this state to prepare, administer, and document the administration of medications may do so .Residents may self-administer their own medications only if the Attending Physician, in conjunction with the Interdisciplinary Care Planning Team, has determined that they have the decision-making capacity to do so safely .
CONCERN
(D)
Potential for Harm - no one hurt, but risky conditions existed
Deficiency F0761
(Tag F0761)
Could have caused harm · This affected 1 resident
**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, record review and interview the facility failed to store all drugs and biologicals in locked compartments ...
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**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, record review and interview the facility failed to store all drugs and biologicals in locked compartments for 1 of 21 reviewed. (Resident #73)
The facility failed to securely store over the counter medications for Resident #73.
This failure could place residents at risk for adverse reactions.
Findings included:
Record review of the face sheet 11/14/23 indicated Resident #73 was [AGE] years old and was admitted on [DATE] with diagnoses including high blood pressure, chronic obstructive pulmonary disease (chronic lung disease), and low back pain.
Record review of physician's orders dated 11/14/23 for Resident #73 did not indicate an order for Flonase Nasal Spray. There was an order dated 09/07/23 for Symbicort Inhalation Aerosol 160-4.5 micrograms/actuations 2 puffs inhale orally two times a day related to chronic obstructive pulmonary disease.
Record review of the MDS dated [DATE] indicated Resident #73 was understood and understood others. The MDS indicated a BIMS score of 15 indicating Resident #73 was cognitively intact.
Record review of a care plan revised on 10/24/23 indicated Resident #73 was at risk for side effects related to the use of respiratory drugs. There was an intervention for medication as ordered.
During an observation and interview on 11/13/23 at 10:11 a.m., Resident #73 was sitting in bed. There was a bottle of Flonase nasal spray and an inhaler at bedside. The inhaler was white and orange. There was no label identifying to type of inhaler or resident identifying information. The Flonase did not have a resident identifying label. The resident said he kept the two medications on his bedside table so he could use them during the day when he needed them. The resident did have a roommate that was not in the room at this time.
During an observation on 11/14/23 at 8:26 a.m., Resident #73 was resting in bed. The bedside table was within reach of the resident. There was a bottle of Flonase nasal spray and an inhaler at bedside. The inhaler was white and orange. There was no label identifying to type of inhaler or resident identifying information. The Flonase did not have a resident identifying label. The resident did have a roommate that was not in the room at this time.
During an interview on 11/14/23 at 2:56 p.m., Medication Aide D said Resident #73 always had Flonase and an inhaler beside his bed. She said she had not reported this to the charge nurse.
During an interview on 11/14/23 at 3:44 p.m., the Administrator said 73's family member told her they had brought the Flonase and inhaler to the facility and did not think anything about it. She said if staff saw the medications in the room it would have been wise to have checked his care plan. But we should all know OTC (over the counter) medications were not allowed at bedside.
During an interview on 11/14/23 at 3:58 p.m., a family member of Resident #73 said they bought the Flonase and inhaler to Resident #73 a few months ago from home. He said the inhaler was just an over-the-counter inhaler that you get from the store. They said Resident #73 had asked them to leave them both because he used them several times a day. He said when he had visited over the last few months, they had been sitting on the bedside table so Resident #73 could reach them. He said when he brought them to the facility, he did not tell any staff and he said he did not know Resident #73 could not have them.
During an interview on 11/15/23 at 9:07 a.m., CNA K said she had never seen medications sitting on Resident #73 bedside table. She said any staff that saw medications on a bedside table should report it to the charge nurse.
During an interview on 11/15/23 at 9:14 a.m., LPN said she had not noticed any medications in Resident #73's room. She said if she saw any medications at bedside, she would collect them unless there was an order by a physician.
During an interview on 11/15/23 at 10:19 a.m., the DON said she would have expected over the counter medications to have been locked up and not left at the resident's bedside. She said she looked at the inhaler and it was not labeled, and she was not sure what kind of inhaler it was. She said the resident told her it was Symbicort, but a family member said it was an over-the-counter medication. She said the two medications were destroyed. She said over the counter medications could lead to the resident not taking the appropriate dose or another resident using the medications.
During an interview on 11/15/23 at 10:46 a.m., the Administrator said the medications left at the bedside of Resident #73 could have had a contraindication to the medications he was on and could cause illness.
Review of a Storage of Medications facility policy dated April 2007 indicated, .The facility shall store all drugs and biologicals in a safe, secure, and orderly manner .the nursing staff shall be responsible for maintaining medication storage .
CONCERN
(E)
Potential for Harm - no one hurt, but risky conditions existed
Safe Environment
(Tag F0584)
Could have caused harm · This affected multiple residents
**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, interview, and record review, the facility failed to 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 2 of 4 shower rooms reviewed for environment. (Shower # 1 and Shower # 4)
The facility failed to clean and repair tiles in the facility shower room [ROOM NUMBER] and 4.
These failures could place residents at risk of an unsafe or uncomfortable environment and a decrease in quality of life and self-worth.
Findings included:
During an interview on 11/14/23 at 3:30 p.m. with Resident # 82, she stated the showers in the shower rooms were bothering her. She said that there was mold growing on the tiles and the caulking was coming apart. She said that there were tiles that were broken and coming off the wall. She said the main reason why she was bothered by the showers was, there was mold or mildew on the tiles, in the broken tiles, and in the caulking on the floor and walls. She said that she wants the showers cleaned, the caulking restored, and the tiles replaced.
During an observation on 11/14/23 at 5:05 p.m. shower rooms 1, 2, 3 and 4 were inspected. Shower room [ROOM NUMBER] and 4 had broken tiles, caulking that was missing between the floor tile and the wall tile, and caulking that had worn down and needed replacement. It was observed that both showers 1 and 4 had broken tiles on the wall where it met the floor. It was observed a black substance on the caulking, shower tile grout lines, tiles, and behind the broken tiles. Caulk lines where the floor met the wall was no longer white but was now black in color presumably from mildew and mold.
During an interview on 11/15/23 at 10:20 a.m. with the Maintenance Supervisor, he stated he has a maintenance order book that he keeps at the nurse ' s station. He stated all facility staff had access to this book and were supposed to report damage to the building or any items that need fixed. He stated it was not written in the facility maintenance log that shower rooms [ROOM NUMBERS] needed repair to the tile and caulking. He stated it had not been reported to him that the caulking in the shower rooms needed repair and that it had turned black. He stated that the picture the surveyor showed him shows that there was mildew or mold in the shower room. He stated that over time the caulking wore down and would need to be replaced. He said the caulking has to be cut out in order for it to be replaced. He stated that it was also not reported to him that the shower tiles had started to detach from the walls and needed repair. He stated that he has already worked on the shower rooms [ROOM NUMBERS] and they were in good condition. He stated he will replace the caulking in shower rooms [ROOM NUMBERS] as well as replace the tile. He stated he has the tile that goes in the shower rooms, but he has not yet replaced them.
During an interview on 11/15/23 at 11:14 a.m. with the Administrator, she stated she expects staff keep the showers clean and free from mold or mildew. She stated she expects the Maintenance Supervisor to keep the shower room in good working condition which includes intact tile and caulking in the appropriate areas. She stated she wants residents to feel that they live in a clean and comfortable homelike environment and that includes the shower rooms.
During an interview on 11/15/23 at 11:23 a.m. with the Director of Nursing, she stated that she expects her staff to keep the shower rooms clean and working. She stated mold or mildew could pose a risk to residents in the form of infections.
Record review of the Maintenance Work Log dated from January 1, 2023 to Novemer 2023 revealed maintenance services. The Maintenance Work History Report did not reveal shower room work on the tile or the caulking.
Review of a Quality of Life - Homelike Environment facility policy dated May 2017 indicated, Residents are provided with a safe, clean, comfortable, homelike environment .staff shall provide person-centered care that emphasizes the residents ' comfort, independence, and personal needs and preferences .the facility staff and management shall maximize, to the extent possible, the characteristics of the facility that reflect a personalized homelike setting. These characteristics include clean, sanitary, and orderly environment . pleasant neutral scents.
CONCERN
(F)
Potential for Harm - no one hurt, but risky conditions existed
Food Safety
(Tag F0812)
Could have caused harm · This affected most or all residents
Based on observation, interview, and record review the facility failed to store, prepare, distribute, and serve food in accordance with professional standards in 1 of 1 kitchen reviewed for food servi...
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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 in 1 of 1 kitchen reviewed for food service safety.
The facility failed to ensure all food items were labeled and dated.
The facility failed to ensure a clean ice machine.
These failures could place residents at risk of foodborne illness and food contamination.
Findings include:
During an observation on 11/13/23 at 8:53 a.m., there were 14 bags of a light brown triangle shaped food item in the pantry with no date or label.
During an observation on 11/13/23 at 8:54 a.m., in the walk-in freezer there was 1 bag of round beige colored unknown food items on the floor with no label. There was 1 bag of square light brown unknown food items with no date or label. There were 2 bags round beige colored food item no date or label. There was 1 plastic bag of unknown frozen small round off white food items with no date or label.
During an observation on 11/13/23 at 8:56 a.m., in the walk-in cooler there were 6 bags of a yellow liquid with no label. There was 1 gallon of orange juice with a best by date of 10/28/23. There were 2 bags of whipped topping with no date. There were 2 bags of green leafy vegetables with no label.
During an observation on 11/13/23 at 9:00 a.m., there was a sign hanging on the refrigerator in the kitchen, Nothing goes in here without an in and out date and label. Dietary Supervisor.
During an observation on 11/13/23 at 9:01 a.m., the dishwasher testing strips had an expiration date of August 1, 2019.
During an observation on 11/13/23 at 9:03 a.m., in the ice machine there was a black substance, that flaked off when touched, in the seams of the metal pieces in the top of the ice machine over the ice.
During an interview on 11/15/23 at 8:55 a.m., the Dietary Manager said all kitchen staff were responsible for dating and labeling foods. She said everything was supposed to be first in and first out. She said as the food items were put away all foods should be dated and labeled. She said undated food could be expired or old. She said food that was too old could cause illness. She said the dishwasher testing strips expired before she became the dietary manager. She said she was not aware she was responsible for cleaning the ice machine. She thought maintenance was responsible.
During an interview on 11/15/23 at 9:20 a.m., the Maintenance Supervisor said he said he was responsible for cleaning the ice machine. He said he cleaned the ice machine once every 6 months. He said he did check the ice machine once a month. He said he did not have an ice machine check list. He said the cleaning of the ice machine was not documented. He said he thought he had last cleaned the ice machine in August or September when repairs were done on the machine. It said the previous Dietary Manager did clean the ice machine at times.
During an interview on 11/15/23 at 10:46 a.m., the Administrator said the dietary department was responsible for dating and labeling food items. She said anytime any food item was opened or removed from a box it should be dated and labeled. She said all foods received from a vendor should be dated. She said out of date foods could make a resident ill. She said the dietary department and maintenance were both responsible for keeping the ice machine clean. She said the ice machine not being kept clean could cause resident to receive contaminated/dirty ice.
Review of a Sanitization facility policy dated October 2008 indicated, .The food service area shall be maintained in a clean and sanitary manner .all utensils, counters, shelves and equipment shall be kept clean .Ice machines and ice storage containers will be drained, cleaned and sanitized .
Review of a Food Receiving and Storage facility policy dated July 2014 indicated, .Foods shall be received and stored in a manner that complies with safe food handling practices .Dry foods that are stored in bins will be removed from original packaging, labeled and dated. Such food will be rotated using a first in - first out system .All food stored in the refrigerator or freezer will be covered, labeled and dated .
Oct 2023
7 deficiencies
1 Harm
SERIOUS
(G)
📢 Someone Reported This
A family member, employee, or ombudsman was alarmed enough to file a formal complaint
Actual Harm - a resident was hurt due to facility failures
Accident Prevention
(Tag F0689)
A resident was harmed · This affected 1 resident
**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on interview and record review, the facility failed to ensure adequate supervision was provided to prevent accidents for 1...
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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 adequate supervision was provided to prevent accidents for 1 of 1 resident reviewed for accidents and supervision. (Resident #2)
The facility failed to provide appropriate supervision for Resident #2 to prevent falls with and without injury.
This failure places residents at risk for serious injury related to falls.
Findings included:
1.
Record review of an undated face sheet indicated Resident #2 was a [AGE] year-old male and admitted on [DATE] and readmitted on [DATE] with diagnoses including dementia (the loss of cognitive functioning - thinking, remembering, and reasoning - to such an extent that it interferes with a person's daily life and activities), Alzheimer's disease (a progressive disease beginning with mild memory loss and possibly leading to loss of the ability to carry on a conversation and respond to the environment) and repeated falls.
Record review of the MDS dated [DATE] indicated Resident #2 was sometimes understood but understood others. A BIMS score of 99 indicated Resident #2 was severely cognitively impaired. The MDS indicated Resident #2 required extensive assist of 2 staff for bed mobility and transfer and he was dependent for toileting. Resident #2 was coded as always being incontinent of bowel and bladder. Resident #2 had 2 or more falls with no injury coded.
Record review of incident reports for Resident #2 revealed the following:
09/07/2023- Resident #2 had a fall in his room on the secured unit at 7:15 a.m., all meds were on hold-intervention was urinalysis.
09/08/2023- Resident #2 had a fall in his room on the secured unit at 12:30 a.m., aides heard a big bang and found resident on the floor in room with a broken lamp on the floor beside him.- intervention turn and reposition bars added to bed.
09/13/2023- Resident #2 had a fall in his room on the secured unit at 2:11 a.m., nurse was out of unit on 200 hall, CNA H was on break in her car, CNA I was providing care to another resident when she heard a thud. Intervention CNAs working the unit at night could not leave the building for breaks.
09/30/2023-Resident #2 had a fall on the floor in unit at 3:35 p.m., fall mats in place- No intervention further intervention.
10/05/2023- Resident #2 had a fall in his new room on 400 hall at 8:30 p.m., slipped off bed onto floor. No Intervention further intervention.
10/07/2023- Resident #2 brought to nurses' station so staff could watch him. Resident #2 was noted to be on the floor by a nurse from another station that was passing by at 7:30 a.m.- Intervention was high back wheelchair.
10/10/2023-Resident #2 was found on the floor in room- Intervention- Inservice staff about working with agitated, impulsive residents and how to provide incontinent care to them.
10/13/2023-Resident #2 fell in his room and was found on the fall mat. No intervention.
10/16/2023- Resident #2 fell at 7:36 a.m. at the nurse's station. No witness. Laceration to eye requiring sutures. Noted on the floor by a nurse from another hall.- Sent to ER.
10/16/2023- Resident #2 fell at 11:45 a.m., at the nurse's station while 3 nurses sat at the station. Resident landed on his right arm.
10/17/2023- Resident #2 fell in room at 6:27 a.m., slipped off bed onto right knee and scooted on buttock across room. Intervention was frequent monitoring. No documentation of frequent monitoring was located.
10/20/2023- Resident #2 found sitting on floor in room. Resident had a skin tear to his right hand and complained of pain. Xray done and a fracture of indeterminate age was found to his ulnar bone.
During on observation on 10/18/2023 at 2:00 p.m., Resident #2 was up in his wheelchair in his room alone. Resident #2's room was noted to have fall mats on the floor on the right side of bed and foam wrapped around the transfer bar on his bed. Resident #2 remained in room alone for 15 minutes until CNA came to assist him to bed. Resident #2 was noted to have a large area of bruising to his left eye deep purple in color. Resident #2 had a laceration to his brow bone on the left side.
During an interview on 10/19/2023 at 10:02 a.m., CNA H stated she was working with Resident #2 on the night of 09/13/2023 when he fell. CNA H stated she went on her lunch break and when out to her car to talk on her cell phone. CNA H stated Resident #2 was up in his wheelchair in his room when she left CNA I alone on the unit while she went to break. CNA H explained the nurse for the secured unit was also the nurse for the 200 hall at night time and they stayed out on 200 hall unless they needed them to come back there for something. CNA H stated the nurse came outside and beat on her car hood and signaled for her to come back in the facility. CNA H stated the nurse informed her Resident #2 had fallen and she needed to come in from her break to assist the other aide in getting him up off the floor. CNA H stated Resident #2 had fallen over in the wheelchair because it was on its side when she arrived at the room. CNA H stated Resident #2 was not injured from the fall. CNA H stated the next day there was an in-service that said the staff on night shift had to stay in the building during break. CNA H stated with the nurse on 200 hall there was no way to keep an eye on all the residents if you are assisting another resident and no one else is on the hall.
During and observation on 10/19/2023 at 11:35 a.m., Resident #2 was sitting in a wheelchair at the nurse's station. No nurses or CNAs were noted to be at the station at the time. Resident #2 was unattended outside of nursesnurse's station for 10 minutes prior to the nurse returning to the nurses station.
During an interview on 10/19/2023 at 2:15 p.m., CNA I stated she recalled Resident #2 falling on 09/13/2023 because she was on the unit alone and she had opened the unit door and hollered for the nurse to come check on him. CNA I stated she was giving care to another resident when she heard Resident #2 fall. CNA I stated she had to finish the care she was doing before she could go see what occurred in Resident #2's room. CNA I stated Resident #2 has tipped his wheelchair over and was lying on his side on the floor. CNA I stated he had not appeared to be injured but she went and got the nurse to check him to make sure. CNA I stated there was no way to watch all the residents when they were caring for any resident that took 2 people to care for or if one of them was on break. CNA I stated they did their best and they had not had too many instances where they were left alone and something happened.
During an interview on 10/22/2023 at 10:00 a.m., LVN J stated she was the nurse that found Resident #2 on the floor in the 400 hallway on 10/07/2023. LVN J stated she was told by other nurses that Resident #2's family wanted him to be looked after more closely and the staff was to put him at the nurse's station when they got him up. LVN J said it was right after 7:00 a.m., when she was walking toward the nurse's station, she saw him down on the floor. She stated his wheelchair was few feet behind him and it appeared he had gotten up and took a few steps and fell. LVN J stated the CNAs were getting people ready for breakfast and his nurse was in a resident's room. There was no one at the nurse's station to keep an eye on him at that time of day. LVN J stated Resident #2 had to have constant eyes on him unless he was asleep.
During an interview on 10/22/2023 at 11:00 a.m., CNA F stated she had assisted Resident #2 many times with getting out of bed and bathing. CNA F stated on 10/16/2023 around 7:15 a.m., she was working on 300 because an aide called in and when she rounded the corner at the nurse's station, she found Resident #2 on the floor lying in a large puddle of blood. CNA F stated she looked for his nurse briefly and could not find her, so she notified the nurse working the 300 hall. CNA F stated LVN K came and assessed the resident and sent him to the hospital. CNA F stated Resident #2 did not need to be left at the nurse's station when no one was around to watch the resident. CNA F stated he was safer in his room if he was unattended because he had padded furniture and fall mats there.
During an observation on 10/22/2023 at 11:30 a.m., Resident #2 was sitting at the nurse's station in a wheelchair. Resident #2 had a splint/cast noted to his right arm at this time. No staff was at the nurse's station or in sight of Resident #2 for 20 minutes. The 300-hall nurse and 400- hall nurse that share the nurse's station were checking blood sugars on the hall and the 1 CNA was on break and 1 was providing care to another resident during this time.
During an interview on 10/22/2023 at 1:10 p.m., LVN K stated she was the nurse that sent Resident #2 out on 10/16/2023 at 7:40 a.m. LVN K stated she was not the nurse assigned to care for and monitor Resident #2 on 10/16/2023. LVN K stated she was familiar with Resident #2 because he had several falls prior to 10/16/2023 and his family was very vocal at the facility. LVN K stated she could not locate his nurse (RN L) after assessing him, so she continued with the process and sent him to the ER to be evaluated. LVN K stated she was unaware of the reason Resident #2 was left at the nurse's station unattended and his nurse was not in the building to ask who was supposed to be monitoring him. LVN K stated he returned around 2 hours later with some sutures to his eyebrow. LVN K stated later on 10/16/2023 at around 11:00 a.m., Resident #2 was at the nurses' station when he returned from the ER, and he fell again at the nurse's station. LVN K stated she and two other nurses were sitting at the nurses' station with their heads down and did not see what happened that made him fall.
Record review of the timesheet for RN L for 10/16/2023, showed she was clocked out from 7:12 a.m. to 7:42 a.m.
During an interview on 10/22/2023 at 1:25 p.m., RN L stated she was assigned to the care of Resident #2 as his charge nurse on 10/16/2023. RN L stated she was not available during his first fall at 7:15 or 7:30 a.m., but she was sitting across from him at the nurse's station when he fell for the second time that day just a few hours later. RN L stated Resident #2 moved quickly when he decided to get up. RN L stated she and the other nurse behind the nurse's station had their heads down and she did not know he had fallen until she heard him hit the floor.
During an interview on 10/23/2023 at 10:00 a.m., Resident #2's family stated they attempted to hire a sitter to come in at night and sit with Resident #2 until he became tired and was ready to go to bed in attempt to decrease his agitation and decrease his falls. Resident #2's family stated the approach of some of the staff to a man with dementia was what caused him to become upset and restless. Resident #2's family stated he did not do well with lots of noise or people grabbing him by the clothes to do care. Resident #2's family stated she made all this clear to the facility when he had an episode of being combative and injured his hand. Resident #2's family stated after a week and a half of the sitter coming into the building and helping Resident #2, the Administrator stated she could no longer come be the sitter for Resident #2 because she was employed by the facility prn. Resident #2's family stated the Administrator refused to provide extra supervision for Resident #2 stating this is not a facility that provides 24 hours a day sitters.
During an interview on 10/23/2023 at 11:45 a.m., the Administrator stated she did tell the family she could not use the CNA as the sitter for Resident #2 because in the facility handbook it stated no gifts could be received for care given for residents of the facility. The Administrator stated it was the facilities responsibility to come up with interventions for falls and to continue to update the interventions when they do not work to prevent accidents and injuries. The Administrator stated it was ultimately the facilities responsibility to provide adequate supervision to keep all the residents safe.
Record review of a policy dated July 2017 titled Safety and Supervision of Residents revealed that the facility strived to make resident safety and supervision and assistance to prevent accidents facility wide priorities. The individualized, resident-centered approach to safety .1. Our individualized resident-centered approach to safety addresses safety and accident hazards for individual residents.4. Implementing interventions to reduce accident risks and hazards shall include the following .communicating specific interventions to all relevant staff; assigning responsibility for carrying out interventions; providing training, as necessary; ensuring the interventions are implemented; and documenting interventions.
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
Grievances
(Tag F0585)
Could have caused harm · This affected 1 resident
**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on interview and record review, the facility failed to make prompt efforts to resolve grievances the resident may have 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 make prompt efforts to resolve grievances the resident may have for 1 of 28 residents (Resident #3) reviewed for grievances.
The facility failed to make prompt efforts to resolve a Grievance/concern report when Resident #3's Representative #1 reported being concerned that another family member may be giving Resident #3 medication, because she noticed Resident #3's speech being different after the other family member visited.
This deficient practice of not making prompt efforts to resolve grievances could place residents at risk for abuse, neglect, and not having their needs met.
Findings included:
Record review of Resident #3's face sheet dated 10/18/23 revealed Resident #3 was an [AGE] year-old male. Resident #3 was admitted to the facility initially on 3/20/23 and readmitted on [DATE] with diagnoses including Alzheimer's (progressive mental deterioration due to generalized degeneration of the brain), dementia (progressive or persistent loss of intellectual functioning with impairment of memory and thinking, and often with personality change), weakness, transient cerebral ischemic attack (brief stroke-like attack, usually resolves within minutes to hours, that could be a warning sign to a future stroke), depression (persistent sadness), anxiety (feeling of worry, nervousness, or unease), heart failure, and heart disease.
Record review of Resident #3's quarterly MDS assessment dated [DATE] indicated Resident #3 was understood and usually understood others. The MDS indicated a BIMS score of 01 which indicated Resident #3 had severe cognitive impairment. Resident #3 had disorganized thinking, delusions (false belief or judgement about external reality), and he rejected care 4-6 days a week. Resident #3 wandered daily. Resident #3 required extensive to total assistance of 1-2 persons for most ADLs, but he was able to self-propel himself in his wheelchair and feed himself. Resident #3 was always incontinent of bowel and bladder.
Record review of Resident #3's care plan dated 4/07/23 revealed he had Alzheimer's dementia, severe impaired cognition, and he needed a special care unit due to his elopement risk. There were no interventions related to increased monitoring of Resident #3 during the other family member's visits to ensure she was not administering him medications that were not prescribed.
Record review of a Concern Report dated 8/01/23 revealed Resident #3's Representative #1 reported being concerned about another family member may have been giving Resident #3 medications because she noticed Resident #3's speech being slurred after the other family member visited. The summary/findings section was not completed. The SW follow-up section was completed and dated 8/01/23 and said there was a legal guardian in place and the guardian could refuse visitation from anyone. Then it said the guardian was going to speak to the other family member about limiting visits with no concerns or guardian would prevent her from visiting at all. In the additional follow-up/notes section, it said family would notify the ADM with any ongoing concerns. There was no documentation of an investigation related to the concern of the other family member potentially giving Resident #3 medications that were not prescribed.
During an entrance conference interview on 10/18/23 at 8:56 AM related to a facility reported incident dated 10/05/23, the ADM said Resident #3's Representative #1 felt another family member may be administering non-ordered medications to Resident #3, such as Seroquel. The ADM said Resident #3's Representative #1 was upset that ADM had reported the incident to the state. The ADM said she told Resident #3's Representative #1, if she was going to accuse the family member of doing something like drugging Resident #3, she had to investigate it as an accusation of abuse. The ADM said she had to report it as abuse because giving a resident medication that was not prescribed to them was abuse.
During an interview on 10/19/23 at 2:51 PM, Resident #3's Representative #1 said she had talked to the facility in August 2023 when they first thought another family member might have been giving Resident #3 medications that were not ordered and the facility basically told her, since Representative #1 was the legal guardian, then she would have to be the one to tell the other family member that she could not visit and then the facility could put a sign up to not allow the other family member to visit. Representative #1 said so nothing was done by the facility about her concern in August 2023. Representative #1 said she felt the facility should have provided increased monitoring of Resident #3 during the other family member's visits to ensure she was not giving him medications that were not prescribed, but the facility said it was up to Representative #1 to prevent the other family member from visiting Resident #3. Representative #1 said she then texted the ADM on 9/22/23 and the ADM did not respond about continued concerns of the other family member could be giving Resident #3 medications that were not prescribed. Representative #1 said then on 10/04/23 she texted the ADM about wanting Resident #3 drug tested and told the ADM that she thought Resident #3 was being drugged due to Resident #3 would be more lethargic after the other family member visited. Representative #1 said Resident #3 ended up going to the hospital due to a UTI, and Representative #1 said she had him drug tested there, but it did not test for everything like Seroquel that she thought the other family member might have been giving Resident #3. Representative #1 said Resident #3 returned to the facility the same day, and then the facility tried to get a urine drug test and could not get the urine and ended up doing a blood test for Seroquel. Representative #1 said the drug test was negative, but she felt that it may have been too late to show if he had received any thing that was not ordered. Representative #1 said the other family member took Seroquel and that was why she thought the other family member may have given Resident #3 Seroquel.
During an interview on 10/19/23 at 3:35 PM, the ADM said the grievance/concern report filed on 8/01/23 said Representative #1 was concerned that another family member may be giving Resident #3 medication because Representative #1 noticed Resident #3's speech being different after the other family member visited. The ADM said Representative #1 was not that concerned at that time and was just mentioning it in passing. The ADM said she told Representative #1 that as the legal guardian, she could tell the other family member that she could not visit Resident #3, but Representative #1 did not want to do that at the time. The ADM said in hindsight, she probably should have reported it, but at the time she did not feel it rose to the point of needing to be reported as potential abuse. The ADM said in October 2023 when Representative #1 made the allegation of suspecting the other family member was giving Resident #3 some medications that were not ordered, she said Representative #1 said she was suspicious due to the other family member seemed to be hiding something from the camera in the resident's room and Representative #1 said Resident #3 would seem more lethargic after the other family member visited. The ADM said Representative #1 was much more concerned at that time, so she reported it as abuse and investigated.
During an interview on 10/19/23 at 4:22 PM, the SW and ADM said at the time of the Grievance/concern Report on 8/1/23, Resident #3's Representative #1 did not want anything done and just had a concern, and they did not feel it rose to the level of a reportable abuse. The ADM said when Resident #3's Representative #1 again brought it to their attention in October 2023 and said the other family member was also seen on camera hiding something but had not seen the other family member give him Resident #3 anything. They then felt it was reportable. The ADM said if the family felt the other family member was giving Resident #3 something then it was a type of abuse and had to be reported. The ADM said they investigated the 8/01/23 Grievance/concern report but was unable to provide documentation of the investigation or what interventions were put in place to ensure the resident was not given medications that were not prescribed by another family member.
During an interview on 10/23/23 at 4:58 PM, the SW said she was responsible for filling out the Grievance/concern Report when a resident or family member came to her with a concern or grievance, but any staff could initiate the report. The SW said she filled out the top concern portion and then handed it straight to the ADM, and the ADM gets with the concerned party to discuss and come to a resolution. The SW said after the ADM completed the concern, she then gives it back to the SW and a couple of weeks after it was closed/completed, the SW logs it in the concern/grievance log book; and then the SW would follow-up with the concerned party to see if there was any other concerns and documented it in the SW follow-up report section of the concern report. She said they also would discuss the concerns in their SOC meetings every Friday.
Record review of the facility's grievance policy titled Grievances/Complaints, Filing dated April 2017 revealed . any resident, family member, or appointed resident representative may file a grievance or complaint concerning care, treatment, behavior of other residents, staff members, theft of property, or any other concerns regarding his or her stay at the facility . all grievances, complaints or recommendations stemming from resident or family groups concerning issues of resident care in the facility would be considered . actions on such issues would be responded to in writing, including a rationale for the response . upon receipt of a grievance and/or complaint, the Grievance Officer will review and investigate the allegations and submit a written report of such findings to the Administrator within five working days of receiving the grievance and/or complaint . coordinate actions with the appropriate state and federal agencies . all alleged violations of neglect, abuse, and/or misappropriation of property would be reported and investigated under guidelines for reporting abuse, neglect, and misappropriation of property, as per state law . Grievance Officer, Administrator and Staff would take immediate action to prevent further potential violations of resident rights while alleged violations were being investigated . the resident, or person filing the grievance and/or complaint on behalf of the resident, would be informed (verbally and in writing) of the findings of the investigation and the actions that would be taken to correct any identified problems .
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
Free from Abuse/Neglect
(Tag F0600)
Could have caused harm · This affected 1 resident
**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on interviews and record reviews the facility failed to ensure each resident was free from abuse and neglect for 1 (Reside...
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**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on interviews and record reviews the facility failed to ensure each resident was free from abuse and neglect for 1 (Resident # 1) of 8 residents reviewed for abuse and neglect.
The facility failed to ensure Resident #1, was free from verbal abuse when he was cursed at by CNA E during care.
This failure could place residents at risk of serious harm from possible abuse and neglect.
Findings included:
Record review of the face sheet for Resident #1's dated 10/23/2023 revealed a [AGE] year-old male admitted to the facility on [DATE]. His diagnoses included Parkinson's Disease (brain disorder that causes unintended or uncontrollable movements, such as shaking, stiffness, and difficulty with balance and coordination), depression (mental health disorder characterized by persistently depressed mood or loss of interest in activities, causing significant impairment in daily life), and anxiety (a feeling of fear, dread, and uneasiness).
Record Review of Resident #1's MDS assessment dated [DATE] revealed a BIMS score of 13, which indicated no cognitive impairment. The MDS revealed Resident #1 was understood and understood others. Resident #1 required extensive assistance with toileting and dressing. Resident #1 was frequently incontinent of bowel and bladder.
Record Review of Resident #1's care plan dated 11/29/2022 revealed Resident #1 had a depression and anxiety. The intervention for the problem was to approach resident with warmth and positivity.
Record Review completed of the Facility Reported Intake dated 08/04/2023 reflected it alleged that Resident #1 was verbally abused by CNA E while providing care.
Record review of PIR dated 08/04/2023 reflected, per camera (observed by family, Administrator and Social Services) the aide was repeatedly telling Resident (#1) to pull his pants down for toileting, (CNA E) stated if he hit her, she would hit him back, and (CNA E) stated I don't give a fuck about your camera.
Review of video revealed a date and timed stamped video of Resident #1's private room:
08/03/2023 3:51 CNA E stated in a loud harsh tone pull your pants down [Resident #1]! CNA E repeated this 6 times and then said at 16:51:32 what, you don't speak English?
16:51:55-CNA E attempted to pull residents pants down for him and resident stated I am going to hit you if you do not stop. CNA E stated, Do it and I'll hit you back.
16:52:10 Resident #1 hollered [CNA E]! You see there is a camera rolling? CNA E stated, I don't care about those fucking cameras.
16:53:55-Resident #1 stated I've never seen anyone as ugly as you. CNA E responded, you're ugly shut up.
Record review of CNA E's employment record revealed she was terminated on 08/04/2023 prior to working another shift. CNA E had been educated on abuse and neglect on 07/21/2023 during an all staff Inservice.
Record review of Resident #1's social service notes dated 08/04/23 revealed no psychological harm from incident. Resident #1 was seen by counseling service monthly since incident with no harm noted.
Record review of Resident #1's PIR dated 08/04/2023 revealed local police were contacted on 08/04/2023. Review of PIR revealed safe surveys (interviewing other residents taken care of by CNA E) for 10 residents. All 10 residents stated they felt safe at the facility and had not experienced abuse or neglect of any kind.
Record review of staff training showed Abuse and Neglect training occurred on 08/04/2023 with 75% of staff completing the training.
Attempted contact with CNA E was unsuccessful x 3 attempts 10/23/2023 at 10:15 a.m., 10/23/2023 at 4:00 p.m., and 10/24/2023 at 12:05 p.m.
During an interview on 10/24/2023 at 9:30 a.m., the Administrator stated she had visited with Resident #1 several times since the incident, and he remembered the incident but was not affected by it. The Administrator stated that verbal abuse was still abuse and it was the policy of the facility that the residents live in an environment free from any type of abuse or neglect.
During an interview on 10/24/2023 at 10:00 a.m., Resident #1 stated he remembered CNA E being very rude to him and cursing at him. Resident #1 stated he knew she would not get away with it because his family watched the tape from his room every day. Resident #1 stated no one had been rude to him before that incident or since that incident.
Record review of the facility policy titled, Abuse and Neglect, with effective date October 2022 read in part, .It is the policy of the facility to administer care and services in an environment that is free from any type of abuse, corporal punishment, misappropriation of property, exploitation, neglect, or mistreatment.
CONCERN
(D)
📢 Someone Reported This
A family member, employee, or ombudsman was alarmed enough to file a formal complaint
Potential for Harm - no one hurt, but risky conditions existed
Report Alleged Abuse
(Tag F0609)
Could have caused harm · This affected 1 resident
**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on interviews and record review, the facility failed to ensure all alleged violations involving abuse, neglect, exploitati...
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**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on interviews and record review, the facility failed to ensure all alleged violations involving abuse, neglect, exploitation, or mistreatment, including injuries of unknown source and misappropriation of resident property, were reported immediately but not later than 2 hours after the allegation is made if the events that cause the allegation involve abuse to the state survey agency for 1 of 28 residents (Resident #3) reviewed for abuse, neglect, exploitation, and misappropriation of resident property.
The facility failed to report an allegation of abuse within 2 hours after Resident #3's Representative #1 filed a Grievance/concern report on 8/01/23 about being concerned that another family member may have been giving Resident #3 medications because Resident #3's speech was slurred after the other family member visited.
This deficient practice could place residents at risk for abuse, neglect, misappropriation of property, and not having their needs met.
Findings included:
Record review of Resident #3's face sheet dated 10/18/23 revealed Resident #3 was an [AGE] year-old male. Resident #3 was admitted to the facility initially on 3/20/23 and readmitted on [DATE] with diagnoses including Alzheimer's (progressive mental deterioration due to generalized degeneration of the brain), dementia (progressive or persistent loss of intellectual functioning with impairment of memory and thinking, and often with personality change), weakness, transient cerebral ischemic attack (brief stroke-like attack, usually resolves within minutes to hours, that could be a warning sign to a future stroke), depression (persistent sadness), anxiety (feeling of worry, nervousness, or unease), heart failure, and heart disease.
Record review of Resident #3's quarterly MDS assessment dated [DATE] indicated Resident #3 was understood and usually understood others. The MDS indicated a BIMS score of 01 which indicated Resident #3 had severe cognitive impairment. Resident #3 had disorganized thinking, delusions (false belief or judgement about external reality), and he rejected care 4-6 days a week. Resident #3 wandered daily. Resident #3 required extensive to total assistance of 1-2 persons for most ADLs, but he was able to self-propel himself in his wheelchair and feed himself. Resident #3 was always incontinent of bowel and bladder.
Record review of Resident #3's care plan dated 4/07/23 revealed he had Alzheimer's dementia, severe impaired cognition, and he needed a special care unit due to his elopement risk. There were no interventions related to increased monitoring of Resident #3 during the other family member's visits to ensure she was not administering him medications that were not prescribed.
Record review of a Concern Report dated 8/01/23 revealed Resident #3's Representative #1 reported being concerned about another family member may have been giving Resident #3 medications because she noticed Resident #3's speech being slurred after the other family member visited. The summary/findings section was not completed. The SW follow-up section was completed and dated 8/01/23 and said there was a legal guardian in place and the guardian could refuse visitation from anyone. Then it said the guardian was going to speak to the other family member about limiting visits with no concerns or guardian would prevent her from visiting at all. In the additional follow-up/notes section, it said family would notify the ADM with any ongoing concerns. There was no documentation of an investigation related to the concern of the other family member potentially giving Resident #3 medications that were not prescribed.
During an entrance conference interview on 10/18/23 at 8:56 AM related to a facility reported incident dated 10/05/23, the ADM said Resident #3's Representative #1 felt another family member may be administering non-ordered medications to Resident #3, such as Seroquel. The ADM said Resident #3's Representative #1 was upset that ADM had reported the incident to the state. The ADM said she told Resident #3's Representative #1, if she was going to accuse the family member of doing something like drugging Resident #3, she had to investigate it as an accusation of abuse. The ADM said she had to report it as abuse because giving a resident medication that was not prescribed to them was abuse.
During an interview on 10/19/23 at 2:51 PM, Resident #3's Representative #1 said she had talked to the facility in August 2023 when they first thought another family member might have been giving Resident #3 medications that were not ordered and the facility basically told her, since Representative #1 was the legal guardian, then she would have to be the one to tell the other family member that she could not visit and then the facility could put a sign up to not allow the other family member to visit. Representative #1 said so nothing was done by the facility about her concern in August. Representative #1 said she then texted the ADM on 9/22/23 and the ADM did not respond about continued concerns of the other family member could be giving Resident #3 medications that were not prescribed. Representative #1 said then on 10/04/23 she texted the ADM about wanting Resident #3 drug tested and told the ADM that she thought Resident #3 was being drugged due to Resident #3 would be more lethargic after the other family member visited. Representative #1 said Resident #3 ended up going to the hospital due to a UTI, and Representative #1 said she had him drugged tested there, but it did not test for everything like Seroquel that she thought the other family member might have been giving Resident #3. Representative #1 said Resident #3 returned to the facility the same day, and then the facility tried to get a urine drug test and could not get the urine and ended up doing a blood test for Seroquel. Representative #1 said she felt that it may have been too late to show if he had received any thing that was not ordered. Representative #1 said the other family member took Seroquel and that was why she thought the other family member may have given Resident #3 Seroquel.
During an interview on 10/19/23 at 3:35 PM, when the ADM was asked why she reported the incident in October 2023, but did not report the grievance/concern report filed on 8/01/23 where Resident #3's Representative #1 was concerned that another family member may be giving Resident #3 medication because Representative #1 noticed Resident #3's speech being different after the other family member visited. The ADM said Representative #1 was not that concerned at that time and was just mentioning it in passing. The ADM said she told Representative #1 that as the legal guardian, she could tell the other family member that she could not visit Resident #3, but Representative #1 did not want to do that. The ADM said in hindsight, she probably should have reported it, but at the time she did not feel it rose to the point of needing to be reported as potential abuse. The ADM said in October 2023 when Representative #1 made the allegation again of suspecting the other family member was giving Resident #3 some medications that were not ordered, she said Representative #1 said she was suspicious due to the other family member seemed to be hiding something from the camera in the resident's room and Representative #1 said Resident #3 would seem more lethargic after the other family member visited. The ADM said Representative #1 was much more concerned at that time, so she reported it as abuse to the state immediately.
During an interview on 10/24/23 at 11:12 PM, the ADM said at the time of the 8/01/23 Grievance/concern report, Resident #3's Representative was not that concerned, and the ADM did not feel that it rose to the point of abuse and did not feel it needed to be reported. The ADM said when Resident #3's Representative #1 reported the concern again in October 2023, there was reported suspicious activity on the video camera and Resident #3 was more lethargic per the Representative, therefore, the ADM said it had to be reported as abuse immediately.
Record review of the facility's policy titled Abuse Policy dated April 5, 2016, revealed . all allegations, no matter what types of incidents reported would be investigated fully . the ADM or designee would report this allegation of abuse immediately to state agency . and to the proper local authorities .
CONCERN
(D)
📢 Someone Reported This
A family member, employee, or ombudsman was alarmed enough to file a formal complaint
Potential for Harm - no one hurt, but risky conditions existed
Comprehensive Care Plan
(Tag F0656)
Could have caused harm · This affected 1 resident
**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on interview, and record review, the facility failed to develop and implement a comprehensive person-centered care plan to...
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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 to meet each resident's medical, nursing, mental and psychosocial needs for 2 of 10 residents reviewed for care plans. (Resident #5, and Resident #4)
1.The facility failed to develop a comprehensive person-centered care plan including interventions for falls for Resident #5.
2.The facility failed to develop a comprehensive person-centered care plan including interventions for pain and opioid use for Resident #4
These failures could place residents at risk of not having individual needs met, a decreased quality of life, and cause residents not to receive needed services.
Findings include:
1. Record review of a face sheet dated 10/23/2023 revealed Resident #5 was an 85- year-old male and was admitted on [DATE] with diagnoses including atrial fibrillation (an irregular and often very rapid heart rhythm), hypertension (elevated blood pressure), and weakness
Record review of the most recent MDS assessment dated [DATE] indicated Resident #5 was understood and understood others. The MDS indicated a BIMS score of 13 showing that Resident #5's cognition was intact. Resident #5 was noted to have a fall with no injury.
Record review of the incident report dated 08/19/2023 at 7:30 p.m., indicated Resident #5 had a fall in his bathroom resulting in an ER visit for syncopal (blood pressure drops rapidly) episode.
Record review of Resident # 5's care plan last updated 08/25/2023 by the Care Plan Coordinator indicated, no fall on 08/19/2023 and no intervention for fall were developed.
During an interview on 10/23/2023 at 2:20 p.m., the Care Plan Coordinator stated Resident #5's fall from 08/19/2023 should have been care planned with the intervention of sending him to the ER for testing and a diagnosis of syncope. The Care Plan Coordinator stated each fall with intervention should be care planned in attempt to decrease repeat falls for the same reasons.
2. Record review of a face sheet dated 10/23/2023 revealed Resident #4 was a 77- year-old female and was admitted on [DATE] with diagnoses including atrial fibrillation (an irregular and often very rapid heart rhythm), hemiplegia (Muscle weakness or partial paralysis on one side of the body that can affect the arms, legs, and facial muscles), and aphasia (loss of ability to understand or express speech, caused by brain damage).
Record review of the most recent MDS assessment dated [DATE] indicated Resident #4 was usually understood and usually understood others. The MDS indicated a BIMS score of 13 showing that Resident #4's cognition was intact. Resident #4 was noted to have unclear speech. Resident #4 had frequent pain that limited ADL function from day to day. Resident #4 ranked her pain a 10 on a scale of 1-10. Resident #4 received opioids daily.
Record review of the physician orders for Resident #4 indicated she had an order for Tramadol 50mg one tab every 6 hours as needed for pain with a start date of 11/29/2022.
Record review of the July 2023 and August 2023 MARs for Resident #4 indicated she received Tramadol 50mg daily from 07/29/2023 to 08/04/2023.
During an interview on 10/23/2023 at 10:00 a.m., Resident #4 indicated through unclear speech that she had pain daily in her right shoulder, arm, and hand. Resident #4 stated it hurt bad bad all the time. Resident #4 stated pain pill make it ok.
Record review of Resident # 4's comprehensive care plan last updated on 08/11/2022 revealed no care plan was developed for pain and no care plan was developed for opioid use.
During an interview on 10/23/2023 at 2:20 p.m., the Care Plan Coordinator stated Resident #4's pain and opioid use should have been care planned. The Care Plan Coordinator stated it was her job to make sure all areas of the MDS were care planned that affected the residents. The Care Plan Coordinator stated not care planning those areas could affect the type of care the resident received.
During an interview on 10/24/2023 at 11:50 a.m., the Administrator stated she expected all care plans to be updated to reflect the most accurate information possible for each resident. The Administrator stated the care plan should be used to guide the care of each resident and failure to update the care plan could result in a disruption of care.
Review of a facility policy titled Care Plans dated 11/2020 revealed the resident care plan was used to plan and assign care for all disciplines. The resident care plan must be kept current at all times.
CONCERN
(D)
📢 Someone Reported This
A family member, employee, or ombudsman was alarmed enough to file a formal complaint
Potential for Harm - no one hurt, but risky conditions existed
ADL Care
(Tag F0677)
Could have caused harm · This affected 1 resident
**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, interview, and record review, the facility failed to ensure residents who were unable to carry out activit...
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**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, interview, and record review, the facility failed to ensure residents who were unable to carry out activities of daily living received the necessary services to maintain personal hygiene for 2 of 12 residents reviewed for ADLs (Residents # 2 and Resident # 6)
1.The facility did not provide incontinent care for Resident #2 for 6-8 hours for 2 days
2. The facility did not provide scheduled showers for Resident #6.
These failures could place residents at risk of not receiving services/care and decreased quality of life.
Findings Include:
1.Record review of an undated face sheet indicated Resident #2 was a [AGE] year-old male and admitted on [DATE] and readmitted on [DATE] with diagnoses including dementia (the loss of cognitive functioning - thinking, remembering, and reasoning - to such an extent that it interferes with a person's daily life and activities), Alzheimer's disease (a progressive disease beginning with mild memory loss and possibly leading to loss of the ability to carry on a conversation and respond to the environment) and repeated falls.
Record review of the MDS assessment dated [DATE] indicated Resident #2 was sometimes understood but understood others. A BIMS score of 99 indicated Resident #2 was severely cognitively impaired. The MDS indicated Resident #2 required extensive assist of 2 staff for bed mobility and transfer and he was dependent for toileting. Resident #2 was coded as always being incontinent of bowel and bladder.
Record review of the care plan dated 09/11/2023 had no care plan for incontinence.
Record review of a facility grievance filed by Resident #2's family on 09/15/2023 indicated Resident #2 had a camera in his room that showed no one entered the room from 10 p.m. to 5:00 a.m. on 09/14/2023 to 09/15/2023. Resolution was noted to in-service staff on providing care by entering the room and physically checking for incontinence.
During an interview on 10/23/2023 at 9:20 a.m., LVN N stated she told the CNAs not to disturb Resident #2 on 09/14/2023 night if he was sleeping. LVN N stated he had been combative earlier in the night and had to be given Ativan 0.5mg to decrease his agitation. LVN N stated she felt if he was woken, he would start being combative again. LVN N stated she understood the importance of incontinent care for skin integrity but felt Resident #2 needed to rest. LVN N stated he was cleaned at 9:30 p.m. on 9/14/2023 and again at 5:00 a.m. on 9/15/2023.
During an interview on 10/23/2023 at 10:00 a.m., CNA I stated she had not provided incontinent care for Resident #2 on 09/14/2023 to 09/15/2023 from 10:00 p.m. until 5 a.m. at the instruction of LVN N.
During an interview on 10/23/2023 at 11:00 a.m., CNA F stated she had done incontinent care for Resident #2 many times because other aides do not like to work with him. CNA F stated he took extra time and a calm slow approach. CNA F stated people had to understand his disease to understand that he cannot help what he was doing or saying. CNA F stated she worked during the day and had come into the facility and found Resident #2 extremely wet, soaked through the sheets on several (4-5) occasions.
During an interview on 10/24/2023 at 10:30 a.m., Resident #2's family stated the incident on 09/15/2023 was only one grievance made by the family about the resident not getting incontinent care throughout the night. Resident #2's family stated they had reported Resident #2 not getting care throughout the night several times. Resident #2's family was unable to provide dates and times for these occurrences. Resident #2's family stated the facility was supposed to check the resident every 2 hours but twice a night would have been acceptable. Resident #2's family stated this was all discussed during a care the care plan meeting the day after Resident #2 readmitted .
During an interview on 10/24/2023 at 11:45 a.m., the Administrator said she had received concerns from the family that Resident #2 would go hours without anyone coming into his room. The Administrator stated they had in serviced the staff multiple times about providing care to difficult residents and she expected for all residents to get the care they need. The Administrator stated it was unacceptable to not provide incontinent care for an entire shift. The Administrator stated most residents were provided with at least 2 episodes of incontinent care throughout the night.
2. Record review of a face sheet dated 10/19/2023, indicated Resident #6 was an [AGE] year-old male admitted on [DATE] with the diagnoses of candidiasis of the skin (infection of the skin and nails caused by the candida fungus. Candida infections often occur in areas exposed to moisture for long periods of time), anxiety (feeling of fear, dread, and uneasiness), and cerebral infarction (occurs because of disrupted blood flow to the brain due to problems with the blood vessels that supply it).
Record review of the MDS assessment dated [DATE] indicated, Resident #6 had a BIMS of 13, which indicated no cognitive impairment. Resident #6 was coded as being understood and understanding others. Resident #6 required dependent assist with toileting and bathing. No refusal or rejection of care was noted on the MDS assessment.
Record review of the comprehensive care plan dated 08/22/2023 for Resident #6 indicated no refusal or rejection of care.
Record review of Completed ADL Documentation from August 2023 reflected Resident #6 was scheduled to have baths on 08/01/2023, 08/03/2023, 08/05/2023, 08/08/2023, 08/10/2023, 08/12/2023, 08/15/2023, 08/17/2023, 08/19/2023, 08/22/2023, 08/24/2023, 08/26/2023, and 08/29/2023. Resident #6 had recorded baths on 08/01/2023 only. Resident #6 received 1 out of 13 bathes scheduled for August 2023.
Record review of Completed ADL Documentation from September 2023 reflected Resident #6 was scheduled to have baths on 09/02/2023, 09/05/2023, 09/07/2023, 09/09/2023, 09/12/2023, 09/14/2023, 09/16/2023, 09/19/2023, 09/21/2023, 09/23/2023, 09/26/2023, 09/28/2023, and 09/30/2023. Resident #6 had recorded baths on 09/03/2023, 09/14/2023, 09/19/2023, 09/22/2023, and 09/29/2023. Resident #6 received 5 of the 13 bathes scheduled for September 2023.
During an observation and interview on 10/19/2023 at 9:20 a.m., Resident #6 had severely dry skin. He was wearing a navy-colored sweatshirt and it was covered in dead skin. Resident #6 had a rash to his face and smelled strongly of ammonia from urine. Resident #6 stated they had gotten better about bathing him, but they still were not bathing him as often as he needed. Resident #6 stated he itched horribly and it made him want to claw his skin off He stated his crotch itched the most because he sat in wet diapers all day. Resident #6 stated he had jock itch more than once since he came to the facility. Resident #6 said he needed a bath and some lotion, and he would be very content. Resident #6 stated he last received a bath 10/16/2023.
During an interview on 10/23/2023 at 1:10 p.m., CNA G stated Resident #6 was supposed to get a shower every Monday, Wednesday, and Friday. CNA G stated she attempted to give wash downs with a wipe when the facility was short staffed. CNA G stated Resident #6 was changed to a 2-10 bath in September after he made a complaint about not getting a bath. CNA G stated Resident #6's family member visits him during the day sometimes and when his family was here, he asked for his bath to be done later.
During an interview on 10/23/2023 at 11:30 a.m., the DON stated the CNAs performed showers on the residents, but any of the nursing staff could and should perform showers when needed. The DON stated she expected the CNAs to provide baths to the residents three days per week at minimum. The DON stated she was aware the facility had a few days when the hot water was not working and a bath or two may had been missed on those days.
During an interview on 10/24/2023 at 11:45 a.m., the Administrator stated it was the job of the nursing department to ensure all residents were bathed and personal hygiene was maintained. The administrator stated it was the facility's job to accommodate the residents schedule when giving care.
ADL policy was requested on 10/24/2023 from corporate nurse at 10:00 a.m. and 11:30 a.m. and was not received prior to exit.
CONCERN
(E)
📢 Someone Reported This
A family member, employee, or ombudsman was alarmed enough to file a formal complaint
Potential for Harm - no one hurt, but risky conditions existed
Infection Control
(Tag F0880)
Could have caused harm · This affected multiple residents
**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, interview, and record review the facility failed to establish and maintain an infection prevention and con...
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**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, interview, and record review the facility failed to establish and maintain an infection prevention and control program designed to provide a safe and sanitary environment and to help prevent the development and transmission of communicable diseases and infections for 1of 1 memory care unit reviewed for infection control and 6 of 24 residents observed during hydration pass. (Resident #6, Resident #7, Resident #8, Resident #9, Resident #10, and Resident #11)
The facility failed to ensure the ice scoop for the memory care unit was sanitarily stored while not in use.
The facility failed to ensure CNA A did not use a contaminated ice scoop to fill the memory care unit residents' cups with ice.
The facility failed to ensure HA C did not cross-contaminate each resident's cup while using an ice scoop to fill Resident #6, 7, 8, 9, 10, and 11's cups during hydration pass.
The facility failed to ensure HA C stored the ice scoop sanitarily while not in use during hydration pass.
These failures could place residents at risk for cross-contamination and the spread of infection.
Findings included:
1. Record review of Resident #6's face sheet dated 10/23/23 indicated Resident #6 was an [AGE] year-old male and admitted to the facility on [DATE] with diagnoses including myopathy (muscle disease), depression (persistent sadness), anxiety (feeling of worry, nervousness, or unease), weakness, hypertension (high blood pressure), cerebral infarction (disruption of blood flow to part of the brain that results in part of the brain dying, also called a stroke), lack of coordination, and repeated falls.
Record review of Resident #6's quarterly MDS assessment dated [DATE] indicated Resident #6 was understood and understood others. The MDS indicated a BIMS score of 13 which indicated Resident #6 had no cognitive impairment.
2. Record review of Resident #7's face sheet dated 10/23/23 indicated Resident #7 was a [AGE] year-old female and admitted to the facility on [DATE] and readmitted on [DATE] with diagnoses including dementia (progressive or persistent loss of intellectual functioning with impairment or memory and thinking and often with personality changes), neutropenia (abnormally low white blood cells, leading to increased susceptibility to infection), diabetes (high sugar level in the blood), hypertension, heart failure, weakness, and lack of coordination.
Record review of Resident #7's annual MDS assessment dated [DATE] indicated Resident #7 was understood and understood others. The MDS indicated a BIMS score of 15 which indicated Resident #7 had no cognitive impairment.
Record review of Resident #7's care plan dated 9/15/23 indicated Resident #7 had neutropenia and was at risk for infection with interventions to keep the environment clean and people with infection away.
3. Record review of Resident #8's face sheet dated 10/23/23 indicated Resident #8 was a [AGE] year-old female and admitted on [DATE] with diagnoses including weakness, abnormalities of gait, dementia, and malnutrition (lack of proper nutrition).
Record review of Resident #8's quarterly MDS assessment dated [DATE] indicated Resident #8 was understood and usually understood others. The MDS indicated a BIMS score of 09 which indicated Resident #8 had moderate cognitive impairment.
4. Record review of Resident #9's face sheet dated 10/23/23 indicated Resident #9 was a [AGE] year-old male and admitted to the facility on [DATE] with diagnoses including muscle wasting, weakness, abnormality of gait, malnutrition, Wernicke's encephalopathy (life threatening illness caused by a thiamine deficiency), hypertension, liver failure, alcohol abuse, and altered mental status.
Record review of Resident #9's annual MDS assessment dated [DATE] indicated Resident #9 was understood and understood others. The MDS indicated a BIMS score of 09 which indicated Resident #9 had moderate cognitive impairment.
5. Record review of Resident #10's face sheet dated 10/23/23 indicated Resident #10 was a [AGE] year-old female and admitted to the facility initially on 2/20/23 and readmitted on [DATE] with diagnoses including cerebral infarction, muscle wasting, aphasia (language disorder that affects a person's ability to communicate), right sided weakness after cerebral infarction, diabetes, hypertension, and kidney disease.
Record review of Resident #10's quarterly MDS assessment dated [DATE] indicated Resident #10 was usually understood and usually understood others. The MDS indicated a BIMS score of 13 which indicated Resident #10 had no cognitive impairment.
6. Record review of Resident #11's face sheet dated 10/23/23 indicated Resident #11 was an [AGE] year-old female and admitted to the facility on [DATE] with diagnoses including hypertension, muscle wasting, abnormality of gait, malnutrition, depression, anxiety, and Parkinson's (progressive disease of the nervous system marked by tremors and imprecise movements).
Record review of Resident #11's annual MDS assessment dated [DATE] indicated Resident #11 was understood and understood others. The MDS indicated a BIMS score of 15 which indicated Resident #11 had no cognitive impairment.
During an observation on 10/18/23 beginning at 11:40 AM, observed an ice chest in the memory care dining room and the ice scoop with water droplets on it was sitting in a side table drawer unbagged and sitting on top of a magazine with the drawer open.
During an observation on 10/19/23 beginning at 11:20 AM, observed in the Memory Care unit, CNA A fill approximately 10 cups with ice using the ice scoop from the side table drawer that was sitting on top of a magazine and the ice scoop was not in a bag. CNA A then replaced the ice scoop back into the side table drawer on top of the magazine and the ice scoop was not placed in a bag. CNA A then came back at 11:25 AM and removed the unbagged ice scoop from the side table drawer and resumed filling approximately 10 more cups with ice and placed the ice scoop back into the drawer on top of the magazine unbagged when she was finished.
During an observation on 10/19/23 beginning at 11:33 AM, observed HA C go into Resident #7's room and brought the resident's cup out to the ice chest cart, removed the lid, and filled the cup with ice while touching the ice scoop to the top of the cup, and then placed the ice scoop on a flat area of the cart, and returned cup to the resident. HA C then went into Resident #8's room and brought her water cup out to the ice chest cart, and placed three scoops of ice into cup, and touched the top of the cup each time. HA C then went to Resident #6's room and brought his water cup to ice chest cart, and placed three scoops of ice into his cup, and touched the top of the cup each time. HA C then went into Resident #9's room and brought a small cooler bag to the ice chest cart and filled it with ice and touched the inside of the cooler bag with the ice scoop, and then laid the ice scoop on the flat area of the cart. HA C then went to Resident #10's room and brought her cup to the ice chest cart and filled the cup with ice and put ½ the scoop into the cup and touched the inside of cup with the ice scoop. HA C then went and got Resident #11's cup and brought her cup to the ice chest cart and filled her cup with ice and put ½ the scoop into the cup and touched the inside of cup with the ice scoop. HA C placed the scoop on the flat area of the ice chest cart after filling each resident's cup and small ice bag, until she was at the end of the hall and then HA C placed the ice scoop in the covered scoop holder on the 2nd shelf of the ice chest cart.
During an interview on 10/19/23 at 11:42 AM, HA C said she had worked at the facility for almost a month. HA C said the ice chest, ice scoop, and the ice chest cart were cleaned twice daily. HA C said she did touch the tops and inside of the residents' cups and just did not think about it until surveyor asked her about it. HA C said it would be cross-contamination and could transfer germs to other residents and make them sick.
During an interview on 10/19/23 at 11:46 AM, CNA B said she had worked at the facility for 2 years. CNA B said she worked on the 400 Hall and now primarily works on the 100 Hall. CNA B said the ice scoop should be stored in a bag. CNA B said if it was not stored in a bag and laid on top of a magazine in a drawer then it would need to be cleaned and sanitized, preferably run through the dishwasher in the kitchen. CNA B said it would be cross-contamination and could make residents sick.
During an interview on 10/19/23 at 1:46 PM, ADON D said she was not aware the ice scoop was being stored in the side table drawer by the ice chest in the memory care dining room and it was not in a bag. ADON D said the ice scoop should be stored in a plastic bag when not in use. ADON D said when she realized the scoop was not being stored sanitarily, she sent it to the kitchen to be washed in the dishwasher. ADON D said she then made sure it was placed in a plastic bag when it was returned to the memory care unit. ADON D said the ice scoop being laid in the drawer on top of the magazine without a plastic bag, contaminated the ice scoop with who knows what germs or what else was in there. ADON D said using a contaminated ice scoop to scoop ice from the ice chest and fill the memory care unit residents' drink cups, was an infection control issue and could potentially make residents sick.
During an interview on 10/23/23 at 12:30 PM, CNA A said she had worked at the facility for a couple of weeks. CNA A said she usually worked the 6a-2p shift. CNA A said every morning she took the ice chest for the memory care unit to the kitchen and the kitchen staff washed it inside & out and they run the ice scoop through the dishwasher, and she said she wiped the ice chest cart down with disinfectant wipes. CNA A said the ice scoop should be stored in a plastic bag, so it does not become contaminated, and it keeps it clean. CNA A said on 10/19/23, she saw the ice scoop was in the drawer of the side table by the ice chest and it was not in a bag, and she used it anyway. CNA A said, I knew better; I have had been a CNA for 35 years. CNA A said she should have taken the scoop to the kitchen and had it cleaned and not used it to scoop ice with. CNA A said the drawer was nasty and anything could be on the ice scoop, and it could make residents sick.
During an interview on 10/24/23 at 10:30 AM, the DON said it was absolutely not appropriate to store or use an ice scoop that had been in a drawer on top of a magazine without being in a bag to fill ice cups for the residents. The DON said the ice scoop was contaminated and should have been taken to the kitchen to be cleaned/sanitized. The DON said it was not appropriate for HA C to touch the ice scoop to the tops or inside the residents' cups or touch the inside of a resident's ice bag or sit the ice scoop on top of the ice chest cart when not in use. The DON said HA C's actions contaminated the ice scoop and the ice and resulted in cross-contamination between the residents. The DON said it was an infection control issue.
During an interview on 10/24/23 at 11:12 AM, the ADM said the ice scoops should be stored in a bag or in an appropriate holder to keep clean. The ADM said if the ice scoops become contaminated then they should be sanitized prior to using. The ADM said storing the ice scoop in the drawer of the side table on top of a magazine unbagged was not sanitary and was an infection control issue. The ADM said the hydration aide touching the ice scoop to or inside each residents' cup while filling cups with ice, could spread infection, and was disgusting.
Record review of the facility's policy titled Ice Machines and Ice Chests dated January 2023 revealed . ice storage/distribution containers would be used and maintained to assure a safe and sanitary supply of ice . ice storage chests/containers, and ice could become contaminated by unsanitary manipulation by employees, residents, and visitors . improper storage or handling of ice . keep the ice scoop/bin in a covered container when not in use . clean and sanitize the tray and ice scoop daily .
Aug 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
Accident Prevention
(Tag F0689)
Could have caused harm · This affected 1 resident
**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, interview, and record review, the facility failed to ensure each resident's environment remained as free o...
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**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, interview, and record review, the facility failed to ensure each resident's environment remained as free of accident hazards as possible for 1 of 11 residents reviewed for accidents hazards (Resident #1).
1.The facility failed to ensure the television cable cord was secured and not laying in Resident #1's floor of her room.
This failure could place residents at an increased risk of injury.
Findings included:
1.Record review of Resident #1's face sheet dated 8/1/22 indicated she was [AGE] years old and admitted to the facility on initially on 5/31/22 with diagnoses including Alzheimer's (progressive mental deterioration that can occur in middle or old age due to degeneration of the brain), dementia (progressive loss of intellectual functioning with impairment of memory, thinking, and behaviors), anxiety (feeling of worry, nervousness, unease), and depression (persistent sadness).
Record review of Resident #1's quarterly MDS dated [DATE] indicated she was sometimes understood and sometimes understood others. The MDS indicated a Resident #1 was not able to complete BIMS due to severe cognitive impairment. The MDS indicated Resident #1 have severely impaired decision-making skills, continuous inattention and disorganized thinking. The MDS indicated Resident #1 transferred independently and ambulated under supervision. The MDS indicated Resident #1 was not steady but was able to stabilize without staff assistance when moving from a seated to standing position, walking, turning around, surface to surface transfers, and moving on and off the toilet. The MDS indicated Resident #1 had 2 previous falls without injury and 1 fall with injury.
Record review of Resident #1's care plan revealed a post fall care plan initiated 4/21/23. The post fall care plan indicated she had sustained falls on 4/21/23 and 4/22/23 with interventions of bed cord rearranged, staff in-serviced to be mindful of clutter. Resident #1's care plan initiated on 6/27/22 indicated: she had impaired cognitive function/dementia or impaired thought processes, potential for falls and injury related to cognitive deficits, and had an increased risk of bleeding related to the use of aspirin.
Record review of Resident #1's Incident Report dated 4/21/23 the resident was found on the room floor with the power remote cord to the bed stretched out beside her and it appeared Resident #1 got her feet tangled up in the cord.
During an observation of Resident #1's bedroom on 8/01/23 at 2:23 PM revealed approximately 6 to 7 feet of television cable cord laying on the floor approximately 8 inches from the wall at the widest point from the outer bathroom wall area and then going behind the personal refrigerator on the opposite side of the resident's bed. The television cable cord had a raised loop in it and curled where some areas were raised off the floor.
During an observation and interview on 8/02/23 at 9:35 AM, CNA A said she had worked at the facility for two years and had worked primarily in the memory care unit for two months. CNA A said Resident #1 was constantly walking in the memory care unit and would go in and out of all the rooms in the memory care unit. With surveyor intervention, CNA A entered Resident #1's room. CNA A said the television cord had probably been there for as long as she had been working in the unit. CNA A said there used to be a long dresser in the open area where the television cable cord was laying in the floor, but they moved the dresser and the extra bed out of the room a little while ago. CNA A said the extra bed and dresser were moved out of Resident #1's room, because they needed them somewhere else. CNA A said she had not noticed the television cable cord in the floor, because Resident #1 was seldomly in her room on CNA A's shift. CNA A said it should have been reported and secured, because it was a trip hazard for the resident.
During an observation and interview on 8/02/23 at beginning at 1:20 PM, LVN B said she had worked at the facility since December of 2022 and usually worked in the memory care unit. With surveyor intervention, LVN B entered Resident #1's room. LVN B said CNA A had told her about the television cable cord this morning after surveyor had interviewed CNA A. LVN B said she then notified the Maintenance Supervisor, and he came and secured the cord along the wall. LVN B said she had not previously noticed the television cable cord in Resident #1's floor until CNA A reported it to her on 8/02/23. LVN B said she seldomly goes into Resident #1's room, because Resident #1 was always ambulating all other the memory care unit and seldom in her room. LVN B said the extra bed and dresser had probably been gone about a month. LVN B said the television cable cord in Resident #1's floor could have caused the resident to fall.
During an interview on 8/02/23 at 1:28 PM, the Maintenance Supervisor said Resident #1's television cable cord should not have been in the floor, and it should have been secured. The Maintenance Supervisor said he was not notified until 8/02/23 about the cable cord needing secured. The Maintenance Supervisor said there was a maintenance logbook at each nurses' station and the staff should be writing any maintenance issues in the logbook. The Maintenance Supervisor said the logbooks were checked frequently and repairs were made timely. The Maintenance Supervisor said no one had reported the cable cord being in the floor in the logbook for the memory care unit. The Maintenance Supervisor said he secured the television cable cord as soon as he was notified. The Maintenance Supervisor said the maintenance department staff made weekly rounds throughout the facility and looked for needed repairs. The Maintenance Supervisor said he did not know when the last time the memory care unit rooms were checked due to, he had been off work.
During an interview on 8/02/23 beginning at 3:25 PM, the DON said Resident #1 was very active and continuously walked throughout the memory care unit. The DON said Resident #1 had a fall in April 2023 from getting her feet tangled in the bed remote cord. The DON said they rearranged the resident's furniture and in-serviced staff on being mindful of cords to ensure there were no tripping hazards in the residents' rooms. The DON said she was not aware of the television cable cord being in the floor and it could have caused a resident to trip and fall. The DON said she would be re-educating her staff to be checking the residents' rooms for trip hazards.
During an interview on 8/02/23 at 3:39 PM, the Administrator said Resident #1 was ambulatory and walked throughout the memory care unit. The Administrator said Resident #1 had a fall in April 2023, Resident #1 must have somehow knocked the bed remote cord in the floor and somehow got her feet tangled in it. The Administrator said they in-serviced staff to make rounds and be mindful of tripping hazards and to keep areas safe at all times. The Administrator said she was unaware of the television cable cord being in Resident #1's floor and it should have been secured.
Record review of an In-service Training Report dated 4/24/23 with the topic of Fall prevention to all staff, indicated When making rounds in resident rooms, always be mindful of any tripping hazards. If you observed any bed cords, oxygen cords or tubing, or any other items that may cause a resident to fall, remove or relocate the item immediately. Keep walkways free of clutter, furniture, or any other tripping hazards. We always want to be proactive and try to prevent a fall before it happens. It is ALL of our job to work together and keep our residents safe.
Record review of the facility's policy titled Quality of Life-Homelike Environment, with a revised date of May 2017, indicated . residents were provided with a safe, clean, comfortable, and homelike environment .
Jul 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
Accident Prevention
(Tag F0689)
Could have caused harm · This affected 1 resident
**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, interview, and record review the facility failed to ensure each resident receives adequate supervision and...
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**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, interview, and record review the facility failed to ensure each resident receives adequate supervision and assistance devices to prevent accidents for 1 of 3 residents reviewed for accident hazards (Resident #1).
The facility did not ensure the oxygen canister in Resident #1's room was secured/stored properly.
This failure could place residents at risk for injury.
Findings included:
Record review of the Resident #1's face sheet indicated Resident #1 was a [AGE] year-old and admitted to the facility on [DATE] with diagnoses including abnormalities of gait, weakness, Parkinson's disease, high blood pressure, centrilobular emphysema (characterized by damage to your respiratory passageways [known as bronchioles]) and other abnormal finding of the lung.
Record review of the MDS dated [DATE] indicated Resident #1 understood others and made himself understood. The MDS indicated Resident #1 had no cognitive impairment (BIMS of 15). The MDS indicated he required extensive assistance with bed mobility, dressing, and eating. The MDS indicated Resident #1 was totally dependent on staff for toilet use, personal hygiene, and bathing. The MDS indicated that during the 7 days look back period walking, transfers, and locomotion with an assistive device had not occurred. The MDS indicated he was always incontinent of bladder and bowel. The MDS indicated Resident #1 had shortness of breath, or trouble breathing with exertion, with sitting at rest and with lying flat. The MDS indicated the resident had not received oxygen therapy during the 14 day look back period.
Record review of the care plan revised on 1/6/23 indicated Resident #1 required the use of oxygen PRN (as needed) due to his history of nicotine dependence, centrilobular emphysema, and abnormal findings of the lung field. The care plan noted, efforts will be made to ensure oxygen is used in a safe manner .
The active physician's order with a start date of 11/10/22, reflected Resident #1 was to be administered oxygen at 2 liters per minute via nasal cannula as needed for shortness of breath.
During an observation on 7/7/23 at 12:40 p.m., Resident #1 was lying in his bed. There was a free standing oxygen canister (not secured to the wall or floor) sitting next to the head of his bed. The oxygen canister was not secured in any transport device or rack. Resident #1's bed was to the right of the oxygen canister, approximately 5-6 inches. His nightstand sat to the left of the oxygen canister, approximately 5-6 inches. The oxygen canister sat approximately 5-6 inches from the back of the wall (at the north of the canister). No items were to the south of the canister. Oxygen tubing was connected to the canister and was coiled to the top of the canister.
During an interview and observation on 7/7/23 at 2:08 p.m., revealed Resident #1 was lying in his bed. He said he had not used oxygen in months but sometimes needed it to help him breathe. The oxygen canister was still next to his bed, unsecured. Resident #1 said the oxygen canister had been right there, just like that in the room for at least 2 months.
During an interview on 7/7/23 at 3:10, CNA A said CNAs did not do anything with oxygen or oxygen equipment. CNA A said oxygen tanks were to be secured during transport and at all times because of the risk of explosion. CNA A said she regularly took care of Resident #1 but had not noticed the free standing oxygen tank in his room. CNA A said if she had noticed the oxygen tank in the room not secured, she would have gotten the nurse.
During an interview on 7/7/23 at 3:13 p.m., CNA B said CNAs did not do anything with oxygen or oxygen equipment. CNA B said oxygen tanks were to be secured during transport and at all times because of the risk of fire. CNA B said she regularly took care of Resident #1 but had not noticed the free standing oxygen tank in his room. CNA B said if she had noticed the oxygen tank in the room not secured, she would have gotten the nurse.
During an interview and observation on 7/7/23 at 3:30 p.m., revealed RN A stood in Resident #1's room. Resident #1 was lying in his bed. He said he had not used oxygen in months but sometimes needs to help him breathe. The oxygen canister was still next to his bed, unsecured. RN A said the oxygen canister should not be free- standing in the resident's room. RN A said she had not noticed the oxygen canister in the room earlier while providing care to the Resident #1 but would remove it immediately as it was a hazard. RN A said she regularly took care of Resident #1 but could not say exactly how long the canister had been in his room. RN A said it was possible someone from therapy left it there after he (Resident #1) was transported from therapy to his room. RN A said the free-standing canister was a hazard because it could easily fall over if Resident #1 attempted to get up or if staff were to bump it unintentionally while providing care. RN A said if the canister fell it could cause injury to staff or could cause a fire. RN A removed the canister out of Resident #1's room and placed it in the oxygen supply room. There was a note on the front of the oxygen supply room that read Attention!!! Place all O2 Cylinders in a rack or secure with a chain do not leave free standing.
During an interview on 7/7/23 at 3:45 p.m., OTA B said Resident #1 had not received therapy services since 6/12/23. OTA B said it was not safe to leave an oxygen canister unsecured and her technicians would know that. OTA B said oxygen was usually secured in a device that attached to the resident's wheelchair. OTA B said she did have a technician working in June 2023 that assisted with the transports to and from therapy, but currently she did not.
During an interview on 7/7/23 at 3:55 p.m. the DON said the risk of a free-standing oxygen cylinder was that the cylinder could easily be knocked over which could cause a fire or explosion. The DON said staff were to perform rounds every 2 hours and she expected nursing staff to look for hazards during those rounds. The DON said she would expect to identify a free-standing oxygen tank as a safety hazard.
During an interview on 7/7/23 at 4:05 p.m., the ADM said the facility performed weekly administrative rounds. The ADM said she was not sure if the rounding sheet used by the administrative staff specifically listed free standing oxygen canisters as something to look for but said she would expect every staff member to know that a free-standing oxygen canister was a safety hazard.
The facility policy and procedure titled, Safety and Supervision of Residents on Oxygen, dated 11/28/20, stated, To ensure sanitary, appropriate, use and storage of oxygen cylinders for the safety of all residents . (3) protected from abnormal mechanical shock, which is liable to damage the cylinder, valve, or safety device. (4) protected from tamper by unauthorized. (5) if not supported in a proper cart or stand, properly chained, or supported
Sept 2022
7 deficiencies
2 IJ
CRITICAL
(J)
Immediate Jeopardy (IJ) - the most serious Medicare violation
Notification of Changes
(Tag F0580)
Someone could have died · 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 consult the physician when there was a significant chang...
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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 consult the physician when there was a significant change in the resident's physical and mental status (that is, a deterioration in health, mental, or psychosocial status in either life-threatening conditions or clinical complications) for 1 of 6 Residents (Resident #19) whose records were reviewed for change in condition.
The facility failed to consult a physician or NP of Resident #19's signs and symptoms of extrapyramidal side effects (side effects of antipsychotic medicines. EPS can cause movement and muscle control problems throughout your body) after her return from a behavioral hospital.
An Immediate Jeopardy (IJ) situation was identified on 09/15/2022 at 7:40 PM. While the IJ was removed on 09/16/2022 at 5:00 PM, the facility remained out of compliance at a scope of isolated with a severity of actual harm, due to the facility's need evaluate the effectiveness of the corrective systems.
This failure could place residents at risk of not having their physician consulted of changes in condition timely, resulting in a delay in medical intervention, decline in health, possible worsening, or irreversible symptoms.
Findings included:
Record review of the face sheet dated 08/30/22 revealed Resident #19 was [AGE] years old, female, and admitted on [DATE] and readmitted on [DATE] with diagnoses including Alzheimer's disease, dementia without and with behavioral disturbance, depression, and anxiety.
Record review of the admission MDS dated [DATE] revealed Resident #19 was sometimes understood and sometimes understood others. The MDS revealed Resident #19 had a BIMS of 01 which indicated severe cognitive impairment. The MDS revealed Resident # 19 had evidence of inattention and disorganized thinking. The MDS revealed Resident #19 hallucinated, physical, verbal, and other behavioral symptoms directed towards others. The MDS revealed Resident #19 rejected care and wandered. The MDS revealed Resident #19 required limited assistance for dressing, toilet use, personal hygiene, and bathing but independent for transfers, walking, and eating. The MDS revealed Resident #19 had active diagnoses of Alzheimer's, Non-Alzheimer's dementia, anxiety, insomnia, and depression. The MDS revealed Resident #19 received antianxiety (reduces anxiety) and antidepressant (used to treat major depressive disorder).
Record review of the significant change MDS due to being placed on hospice dated 08/02/22 revealed Resident #19 was sometimes understood and sometimes understood others. The MDS revealed Resident #19 had a BIMS of 01 which indicated severe cognitive impairment. The MDS revealed Resident # 19 had evidence of inattention and disorganized thinking. The MDS revealed Resident #19 hallucinated, physical, verbal, and other behavioral symptoms directed towards others. The MDS revealed Resident #19 rejected care and wandered. The MDS revealed Resident #19 required extensive assistance for dressing, toilet use, personal hygiene, and bathing but independent for transfers, walk in room, and eating. The MDS revealed Resident #19 had active diagnoses of Alzheimer's, Non-Alzheimer's dementia, insomnia, mood affective disorder (as mood disorders, are mental disorders that primarily affect a person's emotional state) and depression. The MDS revealed Resident #19 received antipsychotic and antidepressant. The MDS revealed Resident #19 received antipsychotic on a routine basis, gradual reduction had not been attempted.
Record review of the undated care plan revealed Resident #19 required moderate assistance for ADL care and cues related to diagnosis of Alzheimer's initiated and revised on 06/27/22. The care plan revealed Resident #19 had episodes of physically and verbally abusive to staff and resident at times with difficult redirect, pace the hallways and go in and out of other residents' room at times, refuses care at times, impulsive related to diagnoses of Alzheimer's and dementia initiated on 06/27/22 and revised on 08/03/22. Interventions initiated on 06/27/22, included approach in calm manner, be firm, not forceful, redirect, medication as ordered, and monitor/document behaviors. The care plan revealed Resident #19 had impaired cognitive function/dementia or impaired thought process related to Alzheimer's and dementia, initiated, and revised on 06/27/22. The care plan revealed Resident #19 had potential for side effects related to psychotropic medication, initiated on 06/27/22. Interventions initiated on 06/27/22, included give medication as ordered and monitor for effectiveness, notify MD of any note side effects, or change in behavior, and set up psychological evaluation as needed.
Record review of the consolidated physician orders dated 07/28/22 revealed Resident #19 had orders for Depakote Sprinkles Capsule (to treat seizure disorders, mental/mood conditions (such as manic phase of bipolar disorder), and to prevent migraine headaches) 125 MG (500 MG) by mouth three times a day for mood stabilizer ordered on 07/19/22. The consolidated physician orders revealed Resident #19 had orders for Risperdal (antipsychotic; is a medication that works in the brain to treat schizophrenia) tablet 1MG 1 tablet by mouth a day and Risperdal 2MG, 1 tablet by mouth at bedtime for aggressive behaviors ordered on 07/19/22.
Record review of the MAR dated 07/01-07/31/22 revealed on 07/19/22 Resident #19 was given Risperdal tablet 1MG between 07/22/22-07/31/22, Risperdal 2MG was given 07/19/22-07/31/22 and Depakote Sprinkles Capsule 125 MG (500 MG) was given between 07/19/22-07/31/22.
Record review of the MAR dated 08/01/22-08/31/22 revealed Resident #19 on 08/01/22-08/17/22 was given Risperdal tablet 1MG and Risperdal 2MG on 08/01/22-08/16/22, Depakote Sprinkles Capsule 500 MG given on 08/01/22 - 08/15/22 and was modified 08/15/22 to twice a day.
Record review of the progress note dated 06/23/22 revealed resident being very aggressive with staff and other residents .started pulling on another resident who told her to stop .we attempted to redirect her .pushed nurse head .started yelling
Record review of the behavioral hospital paperwork written by NP Y dated 07/01/22 revealed admission date 06/24/22 .history of Alzheimer's dementia .behavioral disturbance and yelling, hitting, and throwing things at staff members and other residents .nursing home staff states that nothing makes symptoms any better or worse .tangential thoughts and loose speech .requires gerichair off and on due to pacing and difficult to redirect .will charge at staff .ongoing confusion .anxious with cognitive impairments/changes in evolving routine/environment .behaviors .mood instability .emotional instability .within normal limits muscle strength and tone, slow ambulation for gait and station, fair eye contact, restless/fidgety, confused, orientation to person only, and fluent speech .
Record review of the behavioral hospital paperwork written by MD Z dated 07/11/22 revealed .pleasant but continuously disoriented and confused .unsteady gait .no aggression noted .
Record review of the behavioral hospital discharge paperwork dated 07/19/22 revealed Resident #19 discharge diagnosis of acute Alzheimer's dementia with behavioral disturbance. The discharge medication list revealed Divalproex (Depakote) 500mg three times a day, Risperidone (Risperdal) 1mg oral daily, and Risperidone 2mg oral once at bedtime with no diagnosis or indication of use noted. The behavioral hospital paperwork revealed Resident #19 had a urinary tract infection upon admission and was treated with antibiotics.
Record review of the behavioral/intervention monthly flow record dated 07/22 revealed Resident #19 monitored behavior was hitting and kicking at staff and resident, psychoactive drug/dose: Depakote 500 mg, Diagnosis: Mood Stabilizer. No behaviors or side effects noted.
Record review of the behavioral/intervention monthly flow record dated 07/22 revealed Resident #19 monitored behavior was hitting and kicking at staff and resident, psychoactive drug/dose: Risperdal 1mg and 2mg, Diagnosis: Aggressive behaviors. One evening shift on 07/21/22, LVN AA noted two episodes of behaviors with intervention of redirect, 1 on 1, give food and fluids.
Record review of a physician's notes dated 08/16/22 revealed MD W stated .this patient was seen in my office having had a significant change in her condition .she went from an open unit with long hallways to a closed Alzheimer's dementia unit .she did not do well with the transition .she was psychiatrically hospitalized .while hospitalized placed on Depakote .Risperdal .the family member has become quite concerned since her return back .family member reports the patient is no longer walking .speech is garbled and nonsensical .no eye contact slumped posture noted . shuffling of gait noted .poor balance .cogwheeling of both upper extremities .clonus of the right hand .affect anxious but flattened .no violence towards the examiner .this patient symptoms are consistent with pseudo parkinsonism of Risperdal .this will be discontinued .obtain Depakote level today .repeat urinalysis for urinary tract infection .if return of aggression, Seroquel 25 milligrams may be used twice daily .continue Depakote .posture: rigid .eye contact: avoidant .activity: slowed .affect: flat .mood/affect: no significant change .thought process/functioning: notable change .behavior/functioning: notable change .medical condition: notable change .behavioral health diagnosis: neuroleptic induced parkinsonism .follow up in 1 month .
Record review of Resident #19's progress notes 07/19/22-08/30/22 did not revealed documentation of EPS sign and symptoms or notification of change in condition to MD W, MD X, NP E, or NP X.
During an observation on 08/29/22 at 10:55 a.m., Resident #19 wandered up and down the secured unit hallway. Resident #19's posture was slightly stooped with a shuffling gait. Resident #19 had mumbled speech with occasionally understood words and did not make eye contact.
During an observation on 08/30/22 at 8:39 a.m., Resident #19 wandered up and down the secured unit hallway. Resident #19's posture was slightly stooped with a shuffling gait. Resident #19 had mumbled speech with occasionally understood words and did not make eye contact.
During a phone interview on 08/30/22 at 9:04 a.m., the family members of Resident #19 said they felt Resident #19 was over medicated. They said before her admission to the facility, she was at an assisted living and only taking an antidepressant and something to help her sleep. They said within days of being admitted , they were getting phone calls of Resident #19 wandering and displaying aggressive behaviors. The family members said they felt the change in facilities and the constriction of the secured unit increased Resident #19's behaviors. They said Resident #19 was sent to a local behavioral hospital on [DATE], and during admission, lab results showed she had a urinary tract infection. They said UTIs could make any elderly person act out of character. The family members said when Resident #19 returned to the facility from the behavioral hospital, she was unrecognizable. They said she was stooped over when she walked, barely could feed herself, and drowsy. The family members said they had been pushing the facility to wean Resident #19 off some or lower the dosage of some medications.
During an observation on 08/30/22 at 1:51 p.m., Resident #19 was asleep in her bed.
During an observation on 08/30/22 at 3:07 p.m., Resident #19 was asleep in her bed.
During an observation on 08/30/22 at 5:16 p.m., Resident #19 was asleep in her bed.
During an interview on 08/31/22 at 3:12 p.m., the DON said she had been in the position for about 3 weeks but was the ADON for 6 years. She said Resident #19 did return to the facility with Risperdal and Depakote. She said Resident #19 posture had significantly improved over the last month. She said she returned from the behavioral hospital with a stooped posture.
On 08/31/22 at 4:58 p.m., call placed to NP E and left voice message. NP E did not return call prior to exit.
During an interview on 09/02/22 at 9:40 a.m., the pharmacy consultant said any medication was appropriate for use if it controlled the behaviors the resident was exhibiting even if they did not have the correct diagnosis. The PC said she did not know Resident #19 had a UTI when she went to the behavioral hospital which could have caused some of the extreme behaviors. She said she only went by the hospital paperwork which showed the extreme behaviors which a mood stabilizer would be appropriate to treat. The pharmacy consultant said she did not know Resident #19 came back from the facility with psychotropic med side effects like stooped walking and drowsiness, which could have indicated she did not have the right diagnosis to be prescribed Depakote and Risperdal. She said she could see why it would have been important for Resident #19 to have been seen by her primary doctor or psychiatrist to diagnosis her with an appropriate diagnosis before continuing Depakote and Risperdal after returning from the behavioral hospital.
During an observation on 09/15/22 at 6:14 p.m., Resident #19 was wandering the secured unit with one house slipper on her foot. Resident #19 had bruises noted to her face. Resident #19 responded to the Administrator when she addressed her but did not make eye contact with a flat affect. Resident #19 had improved but rigid posture and shuffled gait.
During an interview on 09/15/22 at 6:40 p.m., MD W said he has been providing medical management since 05/05/ 2020 to Resident #19 and was currently overseeing her care at the facility. He said the facility, nor the behavioral hospital notified him of Resident #19 admission in June and he should have been notified of her admission and discharge. He said learned of the psychiatric hospitalization from a family member after Resident #19 returned and the family member wanted to make an appointment. MD W said he did not know Resident #19 had urinary tract infection during her admission to the behavioral hospital. He said he expected the facility to inform him of important issues such as extrapyramidal symptoms (an inability to sit still, involuntary muscle contraction, tremors, stiff muscles, and involuntary facial movements; the symptoms of EPS are debilitating, interfering with social functioning and communication, motor tasks, and activities of daily living. This is often associated with poor quality of life and abandonment of therapy), falls, and behaviors since he does not round at the facility. He was never notified of signs or symptoms of EPS. He said Resident #19 had severe EPS when he assessed her on 08/16/22 and 09/14/22 she still had them but not as frequently. He said he discontinued Risperdal on 08/16/22 due to Resident #19's EPS and scheduled a follow up visit on 09/14/22 to ensure the facility followed his orders.
During an interview on 09/15/22 at 7:35 p.m., the Administrator said during the admission process Resident #19's family member preferred she continue using MD W as her primary care physician. She said the facility allowed MD W to continue overseeing Resident #19's care to appease the family.
The ADM and ADON were notified on 09/15/22 at 7:40 p.m., an Immediate Jeopardy situation was identified due to the above failures. The Administrator was provided with the IJ template on 9/15/2022 at 8:09 p.m.
The following plan of removal was submitted by the facility and was accepted on 9/16/2022 at 12:00 p.m.:
1. All nursing staff have been in serviced on 09/16/22 by DON the following:
-
Interventions documentation on behavioral monitoring record
-
Identify Extrapyramidal symptoms
-
Notifying Physicians when a resident has a significant change
-
Use of medication/documented justification from MD or NP for 14 days PRN psychotropic meds
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Assessing behaviors clinically (i.e., UTI, oxygen levels, sugar level, and type of possible infections)
2. All new nurses will be in serviced in orientation regarding facility policy and practice regarding psychotropic medications.
3. All residents were screened on 09/16/22 by DON and ADON for any EPS.
4. All admissions and readmissions will be reviewed for accurate diagnosis relevant to psychotropic medications by DON.
5. A Physician has been contacted to review psychotropic PRN medications on residents on Resident #19 and #77 immediately.
6. The DON and designee will follow up and continuously monitor to ensure compliance.
Monitoring of the POR included:
Record review of the in-service on 09/16/2022 at 2:30 p.m., provided to all nurses addressed intervention documentation on behavioral monitoring record, identifying extrapyramidal symptoms, notifying physician when a resident has a significant change, use of medication/justification for 14-day psychotropic meds, and behaviors clinical versus mental.
Content of summary of training session:
1. Documentation is required on each shift for any/all non-pharma logical interventions prior to administering PRN medication or any medication listed for psychotropic use on the behavioral monitoring record for each medication on each resident.
2. see attached EPS signs and symptoms.
3. MD must be notified with any resident change of condition and documented in the chart (i.e., behavior change, physical change, mental change) mental and physical decline must be reported to MD or NP.
4. All PRN psychotropic medications will only be ordered on a 14 day use and documentation should be provided by MD or NP prior to 14 days use of medication.
5. Behavior management must be approached from a clinical viewpoint prior to administering PRN psychotropic.
Record review of the educational handout on 09/16/22 at 2:30 p.m., provided to all nurses addressed, How do I recognize extrapyramidal symptoms?
Record review of the example of a behavioral monitoring flowsheet on 09/16/22 at 2:30 p.m., provided to all nurses addressed how to properly fill out and document on the flowsheet for psychotropic medications.
Record review of the post test on 09/16/22 at 2:30 p.m., revealed:
1. The licensed nursing staff should not first give a prn psychotropic medication when a resident became increasingly agitated.
2. Signs and symptoms of extrapyramidal effects included shuffled/unsteady gait, stooped over poor posture, and tremors.
3. An inability to sit still, involuntary muscle contraction, tremors, stiff muscles, and involuntary facial movement were symptoms of extrapyramidal effects.
4. After giving a PRN medication the nurse should reassess and document its effectiveness.
5. Notify the MD, NP, or supervisor if a resident is showing signs of EPS.
6. After a resident received a PRN medication, the nurse should document on the behavioral monitoring sheet and prn sheet.
7. Offering snacks and activities or walk away and provide safe space if necessary were good options of redirection for residents prior to admin prn psychotropic medications.
Interviews conducted on 09/16/22 at (2:39 p.m., LVN M who worked 6am-2pm shift) (2:56 p.m., RN N who worked 6am-2pm shift) (3:07 p.m., LVN C who worked 6am-2pm shift) (3:24 p.m., LVN O who worked 2pm-10pm shift) (3:36 p.m., LVN P who worked 2pm-10pm shift) (3:48 p.m., LVN S who worked 2pm-10pm shift) (3:53 p.m., LVN T who worked 10pm-2am shift) (3:55 p.m., LVN U who worked 10pm-2am shift) (4:20 p.m., LVN V who worked 10pm-2am shift) (4:33 p.m., DON) (4:41 p.m., RN Z (ADON)) revealed they had received education on alternative non-pharmalogical intervention to use before giving prn medication such as activities and snacks, side effects of psychotropic medications, proper documentation of prn administration which should include reason and effectiveness, interventions used and consider mental versus clinical behaviors when there is a change in condition, when and who to notify for change of condition and recognizing EPS side effects such as stooped posture, shuffling feet, and tremors.
During an interview on 09/16/22 at 3:07 p.m., LVN C said she took care of Resident #19 after her admission to the facility and since her return from the behavioral hospital. She said Resident #19 had a change of condition related to her shuffled gait and stooped posture. LVN C said she did not report or document the changes because NP X made rounds and should have seen the changes. She said she did not notify a MD either.
Record review of a resident roster dated 09/16/22 revealed the DON and ADON assessed all residents for any EPS.
Record review of a facility notifying the physician of significant change in status policy dated 03/11/13 revealed .the nurse will notify the physician immediately with significant change in status .the nurse will document signs and symptoms of significant change, time/date of call to physician, and interventions that were implemented in the resident's clinical record .if the resident remains in the facility and a significant change has occurred, update the care plan accordingly .
The Administrator was informed the Immediate Jeopardy was removed on 09/16/2022 at 5:00 p.m. The facility remained out of compliance at a severity level of actual harm that is not immediate jeopardy and a scope of isolated due to the facility's need to evaluate the effectiveness of the corrective systems that were put into place.
On 09/19/22 at 1:40 p.m., called NP E and left message to return phone at her earliest convenience. NP E did not return phone call prior to exit.
On 09/19/22 at 3:49 p.m., called NP X and unable to leave message due to full mailbox.
On 09/19/22 at 4:57 p.m., called MD X and left message to return phone when he was available. MD X did not return phone call prior to exit.
CRITICAL
(J)
Immediate Jeopardy (IJ) - the most serious Medicare violation
Medication Errors
(Tag F0758)
Someone could have died · This affected 1 resident
**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, interview and record review, the facility failed to ensure that resident prn orders for psychotropic drugs...
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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 resident prn orders for psychotropic drugs are limited to 14 days, and if prescribing practitioner believed it is appropriate for PRN order to be extended beyond 14 days, then document rationale in resident's medical record for 2 of 6 residents review for unnecessary medications (Resident #19 and Resident #77).
1. The facility failed to monitor and recognize serious side effects of a newly prescribed antipsychotic medication for Resident #19 resulting in the resident developing extrapyramidal symptoms (serious side effects that develop after taking antipsychotic medication), decreased activity of daily living capabilities and a decreased quality of life.
2. The facility failed to ensure after Resident #19 returned from a behavioral hospital admission, her diagnoses and behaviors were appropriate for continual use of Depakote Sprinkles and Risperdal.
3. The facility failed to use and document other interventions used before administering prn psychotropic medication per facility's policy for Resident #19 and Resident #77.
4. The facility failed to limit Resident #19 and Resident #77 psychotropic prn medications to 14 days and the prescribing practitioner did not provide rationale for extended use.
An Immediate Jeopardy (IJ) situation was identified on 09/15/2022 at 7:40 PM. While the IJ was removed on 09/16/2022 at 5:00 PM, the facility remained out of compliance at a scope of isolated with the severity of actual harm, due to the facility's need evaluate the effectiveness of the corrective systems.
These failures could place residents at risk for possible psychotropic medication side effects, adverse consequences, decreased quality of life and dependence on unnecessary medications.
Findings included:
1. Record review of the face sheet dated 08/30/22 revealed Resident #19 was [AGE] years old, female, and admitted on [DATE] and readmitted on [DATE] with diagnoses including Alzheimer's disease, dementia without and with behavioral disturbance, depression, and anxiety.
Record review of the admission MDS dated [DATE] revealed Resident #19 was sometimes understood and sometimes understood others. The MDS revealed Resident #19 had a BIMS of 01 which indicated severe cognitive impairment. The MDS revealed Resident # 19 had evidence of inattention and disorganized thinking. The MDS revealed Resident #19 hallucinated, physical, verbal, and other behavioral symptoms directed towards others. The MDS revealed Resident #19 rejected care and wandered. The MDS revealed Resident #19 required limited assistance for dressing, toilet use, personal hygiene, and bathing but independent for transfers, walking, and eating. The MDS revealed Resident #19 had active diagnoses of Alzheimer's, Non-Alzheimer's dementia, anxiety, insomnia, and depression. The MDS revealed Resident #19 received antianxiety (reduces anxiety) and antidepressant (used to treat major depressive disorder).
Record review of the significant change MDS due to being placed on hospice dated 08/02/22 revealed Resident #19 was sometimes understood and sometimes understood others. The MDS revealed Resident #19 had a BIMS of 01 which indicated severe cognitive impairment. The MDS revealed Resident # 19 had evidence of inattention and disorganized thinking. The MDS revealed Resident #19 hallucinated, physical, verbal, and other behavioral symptoms directed towards others. The MDS revealed Resident #19 rejected care and wandered. The MDS revealed Resident #19 required extensive assistance for dressing, toilet use, personal hygiene, and bathing but independent for transfers, walk in room, and eating. The MDS revealed Resident #19 had active diagnoses of Alzheimer's, Non-Alzheimer's dementia, insomnia, mood affective disorder (as mood disorders, are mental disorders that primarily affect a person's emotional state) and depression. The MDS revealed Resident #19 received antipsychotic and antidepressant. The MDS revealed Resident #19 received antipsychotic on a routine basis, gradual dose reduction had not been attempted.
Record review of the undated care plan revealed Resident #19 required moderate assistance for ADL care and cues related to diagnosis of Alzheimer's initiated and revised on 06/27/22. The care plan revealed Resident #19 had episodes of physically and verbally abusive to staff and resident at times with difficult redirect, pace the hallways and go in and out of other residents' room at times, refuses care at times, impulsive related to diagnoses of Alzheimer's and dementia initiated on 06/27/22 and revised on 08/03/22. Interventions initiated on 06/27/22, included approach in calm manner, be firm, not forceful, redirect, medication as ordered, and monitor/document behaviors. The care plan revealed Resident #19 had impaired cognitive function/dementia or impaired thought process related to Alzheimer's and dementia, initiated, and revised on 06/27/22. The care plan revealed Resident #19 had potential for side effects related to psychotropic medication, initiated on 06/27/22. Interventions initiated on 06/27/22, included give medication as ordered and monitor for effectiveness, notify MD of any note side effects, or change in behavior, and set up psychological evaluation as needed.
Record review of the consolidated physician order dated 05/31/22 revealed Resident #19 was ordered on 05/31/22 Alprazolam (is used to treat anxiety and panic disorders) tablet 0.25mg, 1 tablet by mouth as needed for anxiety for 14 days three times a day, as needed.
Record review of a handwritten medication record dated 05/31/22 revealed Resident #19 was prescribed Alprazolam (Xanax) 0.5mg PO TID PRN x 30 days with a started date of 06/09/22 related to diagnosis of anxiety but no rationale for 30 days. The MAR revealed Resident #19 received 1 dose on 06/12/22, 06/13/22, 06/15/22, 06/16/22, 06/21/22, 06/23/22 and 06/24/22. Resident #19 received 2 doses on 06/14/22, 06/18/22, 06/19/22, 06/20/22, 06/22/22, and 06/23/22. Resident #19 received 3 doses on 06/17/22.
Record review of the PRN sheet dated 05/31/22 revealed documentation of reason (anxiety) and effectiveness (effective) for doses given on 06/03/22, 06/14/22, 06/18/22, 06/19/22, 06/20/22, 06/24/22 at 7:00 a.m. completed by LVN C and dose on 06/07/22 at 8:00 a.m. completed by LVN D.
Record review of the medication administration record dated 06/01/22-06/30/22 revealed Resident #19 was prescribed Alprazolam (is used to treat anxiety and panic disorders) tablet 0.25mg, 1 tablet by mouth as needed for anxiety for 14 days three times a day, as needed with start date of 05/31/22 and discontinued dated of 06/09/22. The MAR revealed Resident #19 received 2 doses during 06/01/22-06/08/22 except received 3 doses on 06/06/22.
Record review of the consolidated physician order dated 06/27/22 revealed Resident #19 was ordered Alprazolam (Xanax) 0.5mg PO TID PRN for anxiety for 30 days with start date of 06/09/22.
Record review of the behavioral/intervention monthly flow record dated 06/2022 revealed for Resident #19 monitoring for Alprazolam with documentation of increased anxiety and heart rate behaviors with intervention of activity, redirect and one on one were on day shift for 06/03/22 by LVN C, 06/04/22 by LVN C, 06/05/22 by LVN C, 06/08/22 by LVN C, and 06/09/22. The behavioral intervention monthly flow record had no other days of documentation for alternative interventions attempted prior to administration of PRN psychotropic medication.
Record review of the consolidated physician orders dated 07/28/22 revealed Resident #19 had orders for Depakote Sprinkles Capsule (to treat seizure disorders, mental/mood conditions (such as manic phase of bipolar disorder), and to prevent migraine headaches) 125 MG (500 MG) by mouth three times a day for mood stabilizer ordered on 07/19/22. The consolidated physician orders revealed Resident #19 had orders for Risperdal (antipsychotic; is a medication that works in the brain to treat schizophrenia) tablet 1MG 1 tablet by mouth a day and Risperdal 2MG, 1 tablet by mouth at bedtime for aggressive behaviors ordered on 07/19/22.
Record review of the MAR dated 07/01-07/31/22 revealed on 07/19/22 Resident #19 was given Risperdal tablet 1MG between 07/22/22-07/31/22, Risperdal 2MG was given 07/19/22-07/31/22 and Depakote Sprinkles Capsule 125 MG (500 MG) was given between 07/19/22-07/31/22.
Record review of the MAR dated 08/01/22-08/31/22 revealed Resident #19 on 08/01/22-08/17/22 was given Risperdal tablet 1MG and Risperdal 2MG on 08/01/22-08/16/22, Depakote Sprinkles Capsule 500 MG given on 08/01/22 - 08/15/22 and was modified 08/15/22 to twice a day.
Record review of the progress note dated 06/23/22 revealed resident being very aggressive with staff and other residents .started pulling on another resident who told her to stop .we attempted to redirect her .pushed nurse head .started yelling
Record review of the behavioral hospital paperwork written by NP Y dated 07/01/22 revealed admission date 06/24/22 .history of Alzheimer's dementia .behavioral disturbance and yelling, hitting, and throwing things at staff members and other residents (reason for admission to behavioral hospital) .nursing home staff states that nothing makes symptoms any better or worse .tangential thoughts and loose speech .requires gerichair off and on due to pacing and difficult to redirect .will charge at staff .ongoing confusion .anxious with cognitive impairments/changes in evolving routine/environment .behaviors .mood instability .emotional instability .within normal limits muscle strength and tone, slow ambulation for gait and station, fair eye contact, restless/fidgety, confused, orientation to person only, and fluent speech .
Record review of the behavioral hospital paperwork written by MD Z dated 07/11/22 revealed .pleasant but continuously disoriented and confused .unsteady gait .no aggression noted .
Record review of the behavioral hospital discharge paperwork dated 07/19/22 revealed Resident #19 discharge diagnosis of acute Alzheimer's dementia with behavioral disturbance. The discharge medication list revealed Divalproex (Depakote) 500mg three times a day, Risperidone (Risperdal) 1mg oral daily, and Risperidone 2mg oral once at bedtime with no diagnosis or indication of use noted. The behavioral hospital paperwork revealed Resident #19 had a urinary tract infection upon admission and was treated with antibiotics.
Record review of the behavioral/intervention monthly flow record dated 07/22 revealed Resident #19 monitored behavior was hitting and kicking at staff and resident, psychoactive drug/dose: Depakote 500 mg, Diagnosis: Mood Stabilizer. No behaviors or side effects noted.
Record review of the behavioral/intervention monthly flow record dated 07/22 revealed Resident #19 monitored behavior was hitting and kicking at staff and resident, psychoactive drug/dose: Risperdal 1mg and 2mg, Diagnosis: Aggressive behaviors. One evening shift on 07/21/22, LVN AA noted two episodes of behaviors with intervention of redirect, 1 on 1, give food and fluids.
Record review of a physician's notes dated 08/16/22 revealed MD W stated .this patient was seen in my office having had a significant change in her condition .she went from an open unit with long hallways to a closed Alzheimer's dementia unit .she did not do well with the transition .she was psychiatrically hospitalized .while hospitalized placed on Depakote .Risperdal .the family member has become quite concerned since her return back .family member reports the patient is no longer walking .speech is garbled and nonsensical .no eye contact slumped posture noted . shuffling of gait noted .poor balance .cogwheeling of both upper extremities .clonus of the right hand .affect anxious but flattened .no violence towards the examiner .this patient symptoms are consistent with pseudo parkinsonism of Risperdal .this will be discontinued .obtain Depakote level today .repeat urinalysis for urinary tract infection .if return of aggression, Seroquel 25 milligrams may be used twice daily .continue Depakote .posture: rigid .eye contact: avoidant .activity: slowed .affect: flat .mood/affect: no significant change .thought process/functioning: notable change .behavior/functioning: notable change .medical condition: notable change .behavioral health diagnosis: neuroleptic induced parkinsonism .follow up in 1 month .
During an observation on 08/29/22 at 10:55 a.m., Resident #19 wandered up and down the secured unit hallway. Resident #19 posture was slightly stooped with a shuffling gait. Resident #19 had mumbled speech with occasionally understood words and did not make eye contact.
During an observation on 08/30/22 at 8:39 a.m., Resident #19 wandered up and down the secured unit hallway. Resident #19 posture was slightly stooped with a shuffling gait. Resident #19 had mumbled speech with occasionally understood words and did not make eye contact.
During a phone interview on 08/30/22 at 9:04 a.m., the family members of Resident #19 said they felt Resident #19 was over medicated. They said before her admission to the facility, she was at an assisted living and only taking an antidepressant and something to help her sleep. They said within days of being admitted , they were getting phone calls of Resident #19 wandering and displaying aggressive behaviors. The family members said they felt the change in facilities and the constriction of the secured unit increased Resident #19's behaviors. They said Resident #19 was sent to a local behavioral hospital on [DATE], and during admission, lab results showed she had a urinary tract infection. They said UTIs could make any elderly person act out of character. The family members said when Resident #19 returned to the facility from the behavioral hospital, she was unrecognizable. They said she was stooped over when she walked, barely could feed herself, and drowsy. The family members said they had been pushing the facility to wean Resident #19 off some or lower the dosage of some medications.
During an observation on 08/30/22 at 1:51 p.m., Resident #19 was asleep in her bed.
During an observation on 08/30/22 at 3:07 p.m., Resident #19 was asleep in her bed.
During an observation on 08/30/22 at 5:16 p.m., Resident #19 was asleep in her bed.
During an interview on 08/31/22 at 3:12 p.m., the DON said she had been in the position for about 3 weeks but was the ADON for 6 years. She said the ADON's monitor medications and appropriate diagnoses from admissions, MDs/NPs should be writing new medications orders with appropriate diagnoses, and the MDS coordinator puts in the diagnosis's codes. She said Resident #19 did return to the facility with Risperdal and Depakote. She said she did not know why the MDS nurse added mood affective disorder on the MDS diagnoses, but it was not showing on the face sheet. She said Resident #19 posture had significantly improved over the last month. She said she returned from the behavioral hospital with a stooped posture
During an interview on 08/31/22 at 4:00 p.m., the MDS nurse said she was responsible for diagnoses from hospital admissions. She said she added the mood affective disorder to the MDS because the Depakote use on the MAR said mood stabilizer.
During an interview on 08/31/22 at 04:36 p.m., the Regional DON and the DON said Resident #19's diagnosis of mood instability description came from the behavioral hospital paperwork. When this surveyor questioned on the clarification needed to place mood disorder or mood stabilizer diagnosis on the medication Depakote and aggressive behavior for Risperdal, they stated the physician, or rather NP E signed off on the medication order summary on 07/19/22 after the resident's hospitalization. They said NP E verified Resident #19 had correct diagnosis for Depakote and Risperdal. They said the physician/NP would have expected the diagnosis to be from the hospital paperwork, and we did not know we had to let them know mood stabilizer or aggressive behavior was incorrect diagnoses since Resident #19 did not have a history in her medical diagnosis of mood disorder, only Dementia and Alzheimer's. The DON said for Depakote usage, the facility always used mood instability as the use of or diagnosis reason, and no one had ever said it was wrong. When asked if the pharmacist had ever recommended on the monthly medication reviews about clarifying diagnosis for psychotropics they stated, no. They said they were unaware the facility needed to ask for diagnosis clarification from physicians.
On 08/31/22 at 4:58 p.m., called placed to NP E and left voice message.
During an interview on 09/02/22 at 9:40 a.m., the pharmacy consultant said any medication was appropriate for use if it controlled the behaviors the resident was exhibiting even if they did not have the correct diagnosis. The PC said she did not know Resident #19 had a UTI when she went to the behavioral hospital which could have caused some of the extreme behaviors. She said she only went by the hospital paperwork which showed the extreme behaviors which a mood stabilizer would be appropriate to treat. She said she did not know Resident #19 came back from the facility with psychotropic med side effects like stooped walking and drowsiness, which could have indicated she did not have the right diagnosis to be prescribed Depakote and Risperdal. She said she did not know why the MDS nurse changed her diagnosis to mood affective disorder since she was on a mood stabilizer because normally indication of use was what they normally used. She said she could see why it would have been important for Resident #19 to have been seen by her primary doctor or psychiatrist to diagnosis her with an appropriate diagnosis before continuing Depakote and Risperdal after returning from the behavioral hospital.
Record review of a physician order dated 09/4/22 written by LVN T revealed Resident #19 had a fall involving the head and body.
Record review of a hospice order dated 09/7/22 revealed Resident #19 experienced over sedation and increased fall risk with new orders to discontinue Depakote 125 mg 4 tabs BID to 125 mg 2 tabs BID.
During an observation on 09/15/22 at 6:14 p.m., Resident #19 was wandering the secured unit with one house slipper on her foot. Resident #19 had bruises noted to her face. Resident #19 responded to the Administrator when she addressed her but did not make eye contact with a flat affect. Resident #19 had improved but rigid posture and shuffled gait.
During an interview on 09/15/22 at 6:40 p.m., MD W said he has been providing medical management since 05/05/ 2020 to Resident #19 and was currently overseeing her care at the facility. He said the facility, nor the behavioral hospital notified him of Resident #19 admission in June and he should have been notified of her admission and discharge. He said learned of the psychiatric hospitalization from a family member after Resident #19 returned and the family member wanted to make an appointment. MD W said he did not know Resident #19 had urinary tract infection during her admission to the behavioral hospital. He said he expected the facility to inform him of important issues such as extrapyramidal symptoms (an inability to sit still, involuntary muscle contraction, tremors, stiff muscles, and involuntary facial movements; the symptoms of EPS are debilitating, interfering with social functioning and communication, motor tasks, and activities of daily living. This is often associated with poor quality of life and abandonment of therapy), falls, and behaviors since he does not round at the facility. He was never notified of signs or symptoms of EPS. He said Resident #19 had severe EPS when he assessed her on 08/16/22 and 09/14/22 she still had them but not as frequently. He said he discontinued Risperdal on 08/16/22 due to Resident #19's EPS and scheduled a follow up visit on 09/14/22 to ensure the facility followed his orders.
2. Record review of the face sheet dated 08/30/22 revealed Resident #77 was [AGE] years old, female, and admitted on [DATE] with readmission date of 07/07/22 with diagnoses including dementia with behavioral disturbance, bipolar disorder, anxiety, major depressive disorder, and insomnia.
Record review of the MDS dated [DATE] revealed Resident #77 was understood and usually understood others. The MDS revealed Resident #77 had a BIMS on 03 which indicated severe cognitive impairment and required extensive assistance for transfer, dressing, toilet use, personal hygiene, and bathing but independent for eating. The MDS revealed Resident #77 received antianxiety and antidepressant. The MDS revealed no issues were found during drug regimen review.
Record review of the undated care plan revealed Resident #77 had history of anxiety/agitation/irritability which required monitoring per staff initiated on 04/27/22. Interventions included administer meds as ordered, check resident frequently to assess needs, monitor behaviors and medication for effectiveness, redirect, reorient, and reassure as needed.
Record review of the consolidated physician order dated 07/28/22 revealed Resident #77 was ordered on 06/20/22 Ativan tablet 1MG, 1 tablet by mouth as needed for anxiety for 60 days BID PRN.
Record review of the MAR dated 06/01/22-06/30/22 revealed Resident #77 was prescribed Ativan tablet 1MG, 1 tablet by mouth as needed for anxiety for 60 days BID PRN with started dated of 04/14/22. Resident #77 received doses on 06/01/22 given by LVN D, 06/03/22 (2 doses), 06/06/22, 06/07/22, 06/11/22 given by LVN D and 06/12/22.
Record review of an undated handwritten medication record revealed on 06/20/22, Resident #77 was prescribed Ativan 1mg PO BID PRN x 60 days for diagnosis of anxiety. Resident #77 received doses on 06/20/22 given by LVN C, 06/21/22 given by LVN D, 06/23/22 given by LVN D, 06/24/22 given by LVN C, 06/25/22, 06/26/22 (2 doses), 06/28/22 (2 doses), and 06/29/22.
Record review of the PRN sheet dated 05/30/22 revealed documentation of reason and effectiveness for dose given on 06/03/22 (crying/anxiety; effective) by LVN C, 06/06/22 (verbal/agitation; effective), 06/19/22 (anxiety; effective) by LVN C, 06/22/22 (anxiety; effective) by LVN D, 06/24/22 (anxiety; effective) by LVN C.
Record review of the behavioral/intervention monthly flow record dated 06/2022 revealed Resident #77 had monitoring for Ativan 1MG/Diagnosis of anxiety. The flow record had no documentation of striking out, hitting staff and other resident behaviors to monitor. The behavioral intervention monthly flow had no documentation of alternative interventions attempted prior to administration of PRN psychotropic medication.
During an interview on 08/31/22 at 2:43 p.m., LVN C said she worked the secured unit once-twice a week. She said she knew Resident #19 and Resident #77. She said she could not remember prn medication administration for June 2022. She said to give prn psychotropic medications, the facility required nurses to document behaviors, interventions such as redirect, snacks, activities, taking them outside, and effectiveness. She said NPs and physicians ordered prn medications 14-60 days.
During an interview on 08/31/22 at 3:12 p.m., the DON said she had been in the position for about 3 weeks but was the ADON for 6 years. She said the pharmacy consultant recently told the facility PRN psychotropic medication could be longer than 14 days. She said she did not know where the PC received her information from. She said she did not know the prescribing practitioner had to provide a rationale for prn medication longer than 14 days. She said prn medication should be given after all other interventions were attempted. She said the behaviors and interventions and the effectiveness of the interventions needed to be charted. She said it was important to have documentation to provide to physicians and NPs for continuation, modification, or discontinuation of medications. She said LVN D was no longer employed by the facility to ask about prn administration.
During an interview on 08/31/22 at 04:36 p.m., the Regional DON and the DON said they did not know to ask for a reasoning on PRN psychotropics that were longer than 14 days. They said the pharmacist had not found issues on the monthly medication reviews with prn psychotropic being more than 14 days.
On 08/31/22 at 4:58 p.m., a call was placed to NP E to ask about Resident #19 and Resident #77's prn orders but was unable to reach her and left voice message.
During an interview on 08/31/22 at 5:00 p.m., the Administrator said she did not know the physician had to provide documentation or rationale for prn psychotropic use greater than 14 days. She said the facility would have to come up with a system to figure out the best way to accomplish this. She said the residents on the secured unit normally needed their prn for more than 14 days.
During an interview on 09/02/22 at 9:40 a.m., the pharmacy consultant said her understanding of prn usage was it could be longer than 14 days if there was an indication of use. She said she did not know there had to be a documented rationale for longer usage. She said she understood if a resident did not have a standing order for Ativan or Xanax, then having it prn x 14 days was important to monitor in case the resident needed it scheduled or other medications adjusted.
The ADM and ADON were notified on 09/15/22 at 7:40 p.m., an Immediate Jeopardy situation was identified due to the above failures. The administrator was provided with the IJ template on 9/15/2022 at 8:09 p.m.
The following plan of removal was submitted by the facility and was accepted on 9/16/2022 at 12:00 p.m.:
1. All nursing staff have been in serviced on 09/16/22 by DON the following:
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Interventions documentation on behavioral monitoring record
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Identify Extrapyramidal symptoms
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Notifying Physicians when a resident has a significant change
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Use of medication/documented justification from MD or NP for 14 days PRN psychotropic meds
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Assessing behaviors clinically (ie. UTI, oxygen levels, sugar level, and type of possible infections)
2. All new nurses will be in serviced in orientation regarding facility policy and practice regarding psychotropic medications.
3. All residents were screened on 09/16/22 by DON and ADON for any EPS.
4. All admissions and readmissions will be reviewed for accurate DX relevant to psychotropic medications by DON.
5. A Physician has been contacted to review psychotropic PRN medications on residents on resident #19 and #77 immediately.
6. The DON and designee will follow up and continuously monitor to ensure compliance.
Monitoring of the POR included:
Record review of the in-service on 09/16/2022 at 2:30 p.m., provided to all nurses addressed intervention documentation on behavioral monitoring record, identifying extrapyramidal symptoms, use of medication/justification for 14-day psychotropic meds, and behaviors clinical versus mental. Content of summary of training session:
1. Documentation is required on each shift for any/all non-pharma logical interventions prior to administering PRN medication or any medication listed for psychotropic use on the behavioral monitoring record for each medication on each resident.
2. see attached EPS signs and symptoms.
3. All PRN psychotropic medications will only be ordered on a 14 day use and documentation should be provided by MD or NP prior to 14 days use of medication.
4. Behavior management must be approached from a clinical viewpoint prior to administering PRN psychotropic.
Record review of the educational handout on 09/16/22 at 2:30 p.m., provided to all nurses addressed, How do I recognize extrapyramidal symptoms?
Record review of the example of a behavioral monitoring flowsheet on 09/16/22 at 2:30 p.m., provided to all nurses addressed how to properly fill out and document on the flowsheet for psychotropic medications.
Record review of the post test on 09/16/22 at 2:30 p.m., revealed:
1. The licensed nursing staff should not first give a prn psychotropic medication when a resident became increasingly agitated.
2. Signs and symptoms of extrapyramidal effects included shuffled/unsteady gait, stooped over poor posture, and tremors.
3. An inability to sit still, involuntary muscle contraction, tremors, stiff muscles, and involuntary facial movement were symptoms of extrapyramidal effects.
4. After giving a PRN medication the nurse should reassess and document its effectiveness.
5. After a resident received a PRN medication, the nurse should document on the behavioral monitoring sheet and prn sheet.
6. Offering snacks and activities or walk away and provide safe space if necessary were good options of redirection for residents prior to admin prn psychotropic medications.
Interviews conducted on 09/16/22 at (2:39 p.m., LVN M) (2:56 p.m., RN N) (3:07 p.m., LVN C) (3:24 p.m., LVN O) (3:36 p.m., LVN P) (3:48 p.m., LVN S) (3:53 p.m., LVN T) (3:55 p.m., LVN U) (4:20 p.m., LVN V) (4:33 p.m., DON) (4:41 p.m., RN Z) revealed they had received education on alternative non-pharmalogical intervention to use before giving prn medication such as activities and snacks, side effects of psychotropic medications, proper documentation of prn administration which should include reason and effectiveness, interventions used and consider mental versus clinical behaviors when there is a change in condition, and recognizing EPS side effects such as stooped posture, shuffling feet, and tremors. RN N said he worked on the secured unit a handful of times but did know Resident #19's stooped posture had recently improved since her return from the behavioral hospital.
During an interview on 09/16/22 at 3:07 p.m., LVN C said she took care of Resident #19 after her admission to the facility and since her return from the behavioral hospital. She said Resident #19 had a change of condition related to her shuffled gait and stooped posture. LVN C said she did not report or document the changes because NP X made rounds and should have seen the changes. She said she did not notify a MD either.
Record review of a resident roster dated 09/16/22 revealed the DON and ADON assessed all residents for any EPS.
Record review of an undated and unlabeled facility policy revealed .resident must be assessed to ensure that the behavior, agitation, etc. is not due to pain, needing to toilet, or other unmet need .always treat any agitation, aggressive behaviors, etc. as pain first .do the PAINAD and administer PRN pain meds BEFORE administering Ativan, or other psychoactive drug .document all efforts in the nurse's notes AND on the behavior monitoring sheets .document the prn medication on the PRN flow sheet and document whether or not the interventions are/were effective .document that you tried non-medication interventions prior to administering a prn anti-anxiety drugs .no order for prn anti-anxiety medications can be more than 14 days .
The Administrator was informed the Immediate Jeopardy was removed on 09/16/2022 at 5:00 p.m. The facility remained out of compliance at a severity level of actual harm that is not immediate jeopardy and a scope of isolated due to the facility's need to evaluate the effectiveness of the corrective systems that were put into place.
On 09/19/22 at 1:40 p.m., called NP E and left message to return phone at her earliest convenience. NP E did not return phone call prior to exit.
On 09/19[TRUNCATED]
CONCERN
(D)
Potential for Harm - no one hurt, but risky conditions existed
ADL Care
(Tag F0677)
Could have caused harm · This affected 1 resident
**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, interview and record review, the facility failed to ensure residents who were unable to carry out activiti...
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**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, interview and record review, the facility failed to ensure residents who were unable to carry out activities of daily living with the necessary services to maintain good personal hygiene and received such services for 2 (Resident #20 and Resident #36) of 18 residents reviewed for ADL care.
The facility failed to provide dependent Residents #20 and #36 with incontinent care every two hours at night which resulted in the residents waking up soaked with urine.
This failure could place residents who required assistance from staff for personal hygiene/toileting at risk of not receiving care and services to meet their needs and an increased risk for skin breakdown.
Findings included:
1. Record review of the face sheet dated 8/31/22 revealed Resident #20 was a [AGE] year old, female, and admitted on [DATE] with diagnoses including osteoarthritis (joint pain caused by the wearing down of the protective tissue at the ends of bones that occurs gradually and worsens over time), diabetes (disease of too much sugar in the blood), diabetic neuropathy (nerve damage that can occur with diabetes that most often affects the legs and feet), morbid obesity (more than 80 pounds over the person's ideal body weight), congestive heart failure (the heart does not pump blood as well as it should), depression (mood disorder that causes persistent feelings of sadness and loss of interest), bipolar (mood disorder with episodes of mood swings ranging from depressive lows to over the top levels of activity or energy, mood or behavior), anxiety (intense, excessive, and persistent worry and fear about everyday situations), history of a stroke with right sided weakness, COPD (chronic obstructive pulmonary disease- constriction of the airways and difficulty breathing), and had a rash with skin eruption (open skin areas).
Record review of the admission MDS dated [DATE] revealed Resident #20 had a BIMS of 13, which indicated she was cognitively intact. She was totally dependent and required two- person assistance with toilet use, bathing, and transfers. She required extensive assistance and required two persons for bed mobility, dressing, and required one person assistance for personal hygiene. She was always incontinent (having no control of urination or defecation) of urine and bowel.
Record review of the Resident #20's order summary report dated 8/31/22 revealed an order to clean the upper inner buttocks with normal saline, pat dry, and apply lantaseptic (skin protectant) once daily for rash.
During an interview on 8/29/22 at 2:27 PM, Resident #20 said there was a problem with the graveyard shift (night shift) not changing her and her roommate (Resident #36) at night. She said the staff would provide incontinent care for both herself and her roommate when staff came in and that was how she knew if her roommate had been changed during the night. She said she had woke up on multiple mornings and her entire bed was soaked in urine. She said she was not wakened or checked to see if she was wet during those nights. She said it was embarrassing and she did not like the strong smell of urine or being wet with urine. She said staff should be checking both her and her roommate for incontinence even if they are asleep. She said she should be woke up and changed at night and not wake up soaked in urine in the mornings.
During an interview and observation on 8/30/22 at 5:10 AM with Resident #20 revealed the resident was asleep and snoring loudly. Surveyor said Resident #20's name and she said yes?. She said she had been changed once during the night and was wet at that time. She pushed her call light for assistance .
During an observation on 8/30/22 at 5:23 AM, observed CNA K enter Resident #20 and Resident #36's room and incontinent care was provided.
During an interview on 8/31/22 at 2:24 PM with Resident #20 revealed her and her roommate's (Resident #36) care had been better the last couple of nights, since State had been in the building. She said prior to the State coming in, at least 2-3 times a week she nor her roommate (Resident #36) would not be changed during the night and would wake up soaked in urine in the mornings. She said her roommate (Resident #36) usually was changed at night at the same times she was if they got changed. She said her roommate (Resident #36) would be soaked in urine also. She said it was embarrassing and she did not like the strong smell of urine.
2. Record review of a face sheet revealed Resident #36 was a [AGE] year old, female, that admitted to the facility on [DATE] with the diagnoses including muscle wasting (loss of muscle decreasing strength and the ability to move), history of coronavirus 19 (infectious disease causing respiratory illness), diabetes, bladder cancer, vascular dementia (brain damage caused by multiple strokes resulting in memory loss), high blood pressure, congestive heart failure, and a history of stroke.
Record review of the Quarterly MDS dated [DATE] revealed Resident #36 was usually understood and understood others. Resident #36 had a BIMS of 11, which indicated moderate cognitive impairment. Resident #36 was totally dependent with toilet use and extensive assistance of one to two persons for bed mobility, transfers, dressing, bathing and personal hygiene. She was also always incontinent of urine and bowel.
Record review of a care plan dated 7/27/22 revealed Resident #36 required total assistance with ADL care with listed intervention to assist with turning and repositioning approximately every two hours and as needed and assist/provide incontinent care or toileting needs as needed. Resident #36 was at risk for developing pressure ulcers (skin breakdown) related to decreased mobility and incontinence with interventions to check for incontinence and turn/reposition the resident every two hours and as needed.
During an interview on 8/29/22 at 2:30 PM, Resident #36 said she was not changed at night. Resident #20 said if Resident #36 was her grandmother, she would not want her done that way. Resident #36 said she did not like being wet in urine.
During an observation and interview on 8/30/22 at 5:10 AM, Resident #36 was asleep, but woke up when her name was called. She said she was not wet and had not been changed last night.
During an interview with CNA K on 8/30/22 at 5:40 AM revealed she had been working at the facility for approximately one year. She said she usually worked the evening or night shifts. She said she made rounds on her residents at every two hours and tried to answer the call lights as soon as she could. She said she turned/repositioned residents and checked them to see if they were wet. She said she would let residents know she was there to check them, even when they were asleep. She said she would either talk to them and if they woke up that was great, but if they did not wake up, then she would just check to make sure they were dry by sliding a gloved hand under the resident. She said Resident #20 and Resident #36 were wet when she went in to answer the call light. She said she did not remember how many times Resident #20 or Resident #36 had been changed during the night, but she checked her residents every two hours.
During an interview with CNA F on 8/31/22 at 11:33 AM revealed she had worked at the facility for six months. She said she usually worked the 6AM-2PM shift and sometimes worked the 2PM-10PM shift. She said she tried to answer call lights as soon as they came on. She said some nurses would help answer call lights, but not all of them and it wore her out when she had to do everything herself. She said she felt she had time to complete her duties sometimes. She said they were short staffed at times, especially when someone called in. She said if residents are a two person assist, she would ask the nurse or another CNA to assist her. She said she had come in on the 6AM-2PM shift on numerous occasions and residents were soaked in urine, like they had not been changed in a long time. She said Resident #20 and Resident #36 were a couple of the residents she had found soaked in urine when she came in on the 6AM-2PM shift, like they had not been changed in a while. She said she had reported those occasions to the charge nurse. She said she had multiple residents tell her about being left wet all night. She said it was not the same residents that were soaked in urine in the mornings. She said residents that are left in urine for a long time could have skin breakdown.
During an interview with CNA G on 8/31/22 at 12:09 PM revealed she had worked at the facility for eight months. She said she usually worked the 6AM-2PM or 2PM-10PM shifts. She said she answered call lights as soon as she could, and the nurses and medication aides also helped answer the call lights. She said the CNAs were told they could sit in the chairs in the hallways to monitor the lights. She said she had come in on the 6AM-2PM shift multiple times and multiple residents would be soaked in urine. She said it would not be the same residents every time, but she had seen Resident #20 and Resident #36 soaked with urine like they had not been changed in a long time. She said she reported to the charge nurse every time she found residents soaked in urine when she was coming in on the 6AM-2PM shift. She said residents could feel neglected if they were not kept clean and dry or could have skin breakdown.
During an interview with LVN H on 8/31/22 at 2:15 PM revealed she was responsible for scheduling the nurses, CNAs, and medication aides. She said she usually worked the 8AM-5PM shift and occasionally she might have to work a shift on the floor if there was a call in. She said she constantly was reminding staff to not be sitting in the hallways and to make sure they were rounding on residents at least every two hours to turn residents, provide incontinent care, to do their menus with the residents, to do hydration rounds, and to not be on their cell phones unless they were off the floor on a break. She said residents should have their needs met timely, so they do not feel forgotten. She said if a staff member reported an issue with another staff member, she would address the issue. She said if the staff member that reported the issue to her was not satisfied with how she handled the issue, then they could go to the DON and/or the Administrator.
During an interview with the DON on 8/31/22 at 3:55 PM revealed she had been the DON for three weeks. She said staff should be providing incontinent care and turning/repositioning dependent residents at least every two hours. She said residents should not be left soaked in urine for extended periods of time because it could lead to skin breakdown.
During an interview with the Administrator on 8/31/22 at 4:12 PM revealed she wanted staff members to be in the hallways to monitor the call lights and help prevent falls. She said she allowed staff members to sit in chairs in the hallways for that reason, only if they were caught up with their rounds. She said residents should be checked for incontinence and turned at least every two hours. She said residents should be kept clean and dry to prevent skin breakdown. She said she had not received any complaints of residents not being clean and dry. She said she had a hard time believing that residents were being left wet because the facility had a very low number of two pressure ulcers/skin breakdown and those residents were admitted to the facility with the pressure ulcer/skin breakdown. She said residents being left soaked in urine was unacceptable.
Record review of the facility's Concern Report dated 3/15/22 revealed . Resident #36's responsible party reported the resident was found soaked in urine and all over the mattress and sheets two days in a row . DON in-serviced staff on providing incontinent care every two hours .
Record review of the facility's In-service Training Report dated 3/16/22 titled Incontinent Care, revealed . incontinent care/peri care would be provided to all dependent residents the minimum of at least every two hours .
Record review of the facility's Urinary Incontinence-Assessment and Management policy not dated revealed . staff will appropriately screen for and manage individuals with urinary incontinence . management of incontinence will follow relevant clinical guidelines . incontinence care should be provided when making rounds as needed in order to maintain comfort and skin integrity . primary goals are to maintain dignity and comfort and to protect the skin .
CONCERN
(D)
Potential for Harm - no one hurt, but risky conditions existed
Deficiency F0692
(Tag F0692)
Could have caused harm · This affected 1 resident
**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, interview, and record review, the facility failed to ensure residents maintained acceptable parameters of ...
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**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, interview, and record review, the facility failed to ensure residents maintained acceptable parameters of nutritional status when there was a nutritional problem for 1 of 6 residents (Resident #77) reviewed for unplanned weight loss.
1. The facility failed to ensure variance was addressed with documentation to ensure accuracy of weights for Resident #77.
2. The facility failed to notify the dietician in a timely manner for interventions to address Resident #77's significant weight loss.
These failures could place residents at risk for undetectable weight loss, malnutrition, and poor quality of life.
Findings included:
Record review of the face sheet dated 08/30/22 revealed Resident #77 was [AGE] years old, female, and admitted on [DATE] with readmission date of 07/07/22 with diagnoses including dementia with behavioral disturbance, anorexia (an abnormally low body weight; initiated on 07/07/22), and nutritional deficiency (A disorder resulting due to not receiving or absorbing adequate nutrient/s from the diet; initiated on 07/07/22).
Record review of the MAR dated 08/01/22-08/31/22 revealed Resident #77 was prescribed on 01/14/22 Lasix (diuretic that causes increased passing of urine) tablet 20 mg, 1 tablet by mouth, 1 time a day related to chronic obstructive pulmonary disease (block airflow and make it difficult to breathe).
Record review of the MDS dated [DATE] revealed Resident #77 was understood and usually understood others. The MDS revealed Resident #77 had a BIMS on 03 which indicated severe cognitive impairment and required extensive assistance for transfer, dressing, toilet use, personal hygiene, and bathing but independent for eating. The MDS revealed Resident #77 experienced coughing or choking during meals or when swallowing medications. The MDS revealed Resident #77 had gained 5% or more in the last month and was not on physician prescribed weight-gain regimen. The MDS revealed Resident #77 had a mechanically altered and therapeutic diet.
Record review of the undated care plan revealed Resident #77 had a potential for nutritional problems initiated on 09/15/16. The care plan revealed on 02/11/22 med pass 1.7, 4oz by mouth, three times a day for low sodium level in the blood. Intervention initiated on 01/21/19 revealed explain and reinforce the importance of maintaining the diet ordered and provide/serve diet as ordered, encourage regular diet with special preference. Resident #77 requested ½ portions with meal. The care plan did not address weight gain coded on 07/14/22 MDS or the recent weight loss with dietary interventions/recommendations on 08/18/22.
Record review of the monthly weights report dated 01/2022-08/2022 revealed on 07/01/2022, Resident #77 weighed 182 lbs. On 08/01/2022, the resident weighed 166.4 pounds which is a -8.57 % Loss.
Record review of the dietary progress note dated 08/18/22 revealed weight loss 8.6% in 30 days, weight at 166.4 lbs. Intervention med pass 1.7-4oz TID, BMI 26.1, Reg diet. Rec: Double portion at breakfast. Will monitor for weight changes.
Record review of the dietary recommendations dated 08/18/22 revealed the dietitian's recommendations of double portions at breakfast for Resident #77 was approved by a physician on 08/22/22.
Record review of the ADL eating tracking form dated 08/2022 revealed Resident #77 had:
-4 out of 31 (08/18, 08/19, 08/20, 08/31) breakfast meals with no intake documented.
-9 out of 31 (08/13, 08/14, 08/15, 08/16, 08/17, 08/18, 08/19, 08/30, 08/31) lunch meals with no intake documented.
- 22 out of 30 (08/01, 08/02,08/05,08/08, 08/09, 08/10, 08/11, 08/12, 08/14, 08/15, 08/16, 08/17, 08/18, 08/21, 08/22, 08/23, 08/24, 08/25, 08/26, 08/28, 08/29, 08/30) dinner meals
with no intake documented.
No dietary substitutes were offered on the days of missed meals.
Record review of the lab dated 07/21/22 revealed Resident #77 total protein level (measures the amount of protein in your blood. Proteins are important for the health and growth of the body's cells and tissues) was 5.6 which was considered low with a reference range of 6.2-8.0. The labs revealed Resident #77 prealbumin (test helps your doctor determine if you're getting enough nutrients -- namely, protein -- in your diet) was 19 which was considered low with a reference range of 20-40.
During an observation on 08/29/22 at 11:56 a.m., Resident #77 was in her wheelchair in the common area. Resident #77's lunch tray was placed in front of her, and she did not eat it. She kept saying, I want to go home.
During an observation on 08/30/22 at 12 p.m., Resident #77 was asleep in her room and missed lunch.
During an interview on 08/30/22 at 3:15 p.m., the DON said weights were done by the 8th of each month. She said the DON was responsible for checking the accuracy of the weights. She said Resident #77 weight was a -8% difference and she emailed the dietician for recommendations 9 days later (08/17/22). She said it should have been sooner, but she was just taking over the position and catching up. She said the dietician sent back recommendation the next day (08/18/22) for double portions for breakfast. She said the order was approved by the physician on 08/24/22.
During an observation on 08/30/22 at 5:16 p.m., Resident #77 was asleep in her room and missed dinner.
During an observation and interview on 08/31/22 at 10:50 a.m., Resident #77 was wheeled into a shower by RA B to be weighed. RA A and RA B attempted to coax Resident #77 to stand on the scale, but she said her legs hurt. After the second failed attempt to weigh Resident #77 standing up, RA A placed her on scale in her wheelchair. RA B held Resident #77's feet off the scale. RA A manipulated the dials then said Resident #77 weighed 148lbs. RA A and RA B did not know Resident #77's previous weight. RAs were told Resident #77 was 166.4lbs at the beginning of the month, RA B said they could weigh Resident #77 with the lift since she would not stand. Resident #77 was weighed by a lift and weighed 161.3lbs. On 08/31/2022, Resident #77 weighed 161.3 pounds which was a -3.06 % loss from 08/08/22 weight of 166.4 lbs.
During an interview on 08/31/22 at 3:12 p.m., the DON said she had been in her position for 3 weeks but was the ADON for 6 years. She said restorative aides did the resident's weights. She said she did not know who taught them the proper technique, but she thought it was therapy. She said she did not know when the last time the Restorative Aides were checked off for accuracy. She said it was concerning the aides lifted Resident #77's feet probably making her weigh less. She said it was important residents had accurate weights and the staff doing the weights be competent. Inaccurate weights could delay treatment or cause treatment to be started that may not be needed which could cause inadequate nutrition. She said she did not know why Resident #77's care plan said the med pass supplement was for treating low sodium in the blood. She said she thought it was inaccurate information.
On 08/31/22 at 5:00 p.m., called Dietician and left voicemail to return phone call.
During an interview on 08/31/22 at 5:04 p.m., RA A said she weighed Resident #77 every month but did not remember if she obtained her weight this July. She said Resident #77 normally stands for her weights but since her fall this month, she has not been standing up. She said the RAs obtain the weights, give the weights to the DON or a nurse who checks for accuracy. She said one of the therapists trained her on weighing residents probably a year ago. She said she was [NAME]-serviced today on obtaining weights and felt it was a more in-depth training than before. She said they were taught to weigh resident in the wheelchair, then when the resident went to sleep or got out of the wheelchair then subtract the wheelchair. She said she knew how important it was to obtain accurate weights.
During an interview on 08/31/22 at 5:45 p.m., the Regional nurse said she did not believe Resident #77 had significant weight loss. She said the 182lbs weight came from the hospital records. She said Resident #77 went to the hospital for 3 days for IV antibiotics and was probably pumped with fluids. She said the weight fluctuation being addressed on the care plan would provide a better picture of Resident #77. She said she did not know how the DON configured Resident #77 had a -8.06% weight loss and would need some more education. She said Resident #77 was prescribed Lasix which could contribute to her weight/water loss. This surveyor informed the Regional nurse, Resident #77 had been prescribed the same dosage of Lasix since 01/14/22 which should not have a huge impact on her weight fluctuations. Policies regarding nutrition and weight loss management were requested from the Regional nurse. A policy addressing Resident Hydration and Prevention of Dehydration was given instead.
On 08/31/22 at 5:45 p.m., policies regarding nutrition and weight loss management were requested from the Regional nurse. A policy addressing Resident Hydration and Prevention of Dehydration was given instead.
On 09/01/22 at 3:09 p.m., called Dietician and left voicemail to return phone call at her earliest convenience.
CONCERN
(E)
Potential for Harm - no one hurt, but risky conditions existed
Grievances
(Tag F0585)
Could have caused harm · This affected multiple residents
Based on interview, and record review, the facility failed to promptly resolve grievances for 10 of 10 residents in a group meeting (Anonymous Resident (AR) 1 Anonymous Resident (AR) 10) reviewed for ...
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Based on interview, and record review, the facility failed to promptly resolve grievances for 10 of 10 residents in a group meeting (Anonymous Resident (AR) 1 Anonymous Resident (AR) 10) reviewed for grievances.
The facility failed to ensure AR1-AR10's grievances of staff constantly on cell phones and not answering call lights timely were promptly resolved as evidenced by not following up to ensure the issue was resolved.
This deficient practice could place the residents at risk for decreased quality of life and feelings of neglect.
Findings included:
Record review of the Resident Council Minutes dated 1/6/22 revealed .CNA phone usage still as bad as before .
Record review of the Resident Council Minutes dated 3/3/22 revealed CNAs spend too much time having gab sessions and not doing their jobs . call lights not answered timely .
Record review of the Resident Council Minutes dated 4/5/22 revealed .CNAs on phone talking and eating food . currently too many lazy aides .
Record review of the Resident Council Minutes dated 5/5/22 revealed . lazy CNAs sit around and constantly on phones . cannot find the CNAs most times . the CNAs do not pay attention to call lights . CNAs do not check residents in between rounds to make sure no falls . CNAs should be in the hallways watching for lights .
Record review of the Resident Council Minutes dated 6/1/22 revealed . CNAs still had a cell phone usage problem, not paying attention to needs of the residents, and disappeared for long periods of time .
Record review of the facility's concern report dated 7/7/22 revealed resident council members had reported . residents on the 300 hall said the CNAs were meeting in the hallway, talking, and using their cell phones . and in-serviced staff on staying off cell phones . there was no documented resolution .
Record review of the Resident Council Minutes dated 8/4/22 revealed . residents having to wait extended time for call lights to be answered and CNAs still spending too much time on cell phones and on breaks .
During a confidential resident group meeting on 8/30/22 at 10:05 AM, AR1 AR10 were in attendance and all 10 residents wished to remain anonymous. Residents in the confidential group meeting said there was an ongoing issue with the CNAs standing in the hallways talking on their cell phones and not answering the call lights timely mainly on the evening and night shifts. They said the issue had been reported to the Administrator multiple times both verbally and in writing by the President of Resident Council. They said a fellow resident documented the Resident Counsel minutes and the Resident Counsel President would discuss the concerns from the meeting with the Administrator monthly. They said the Administrator and/or the DON had talked to the CNAs multiple times, but they did not follow up to make sure the issues had been resolved. They said it had been a continuous problem for well over six months. They said there had been multiple times where it would take an hour or more to have their call lights answered on the evening and night shifts and had seen the CNAs in the hallways on their phones and not answering the call lights. They said no one should have to wait over an hour to have their call light answered because the CNA staff were lazy and would rather talk on their cell phones.
During an interview with CNA F on 8/31/22 at 11:33 AM revealed she had worked at the facility for six months. She said she usually worked the 6AM-2PM shift and sometimes worked the 2PM-10PM shift. She said she tried to answer call lights as soon as they came on. She said some nurses would help answer call lights, but not all of them and it wore her out when she had to do everything herself. She said she had seen other staff members sitting in the hallways talking on their cell phones and eating. She said multiple residents had told her about other CNAs staying on their cell phones and did not answer call lights timely. She said she had reported the residents' comments to the Charge Nurse that was working but did not remember who it was. She said residents could feel that they were not being cared for if their call lights were not answered timely.
During an interview with LVN H on 8/31/22 at 2:15 PM revealed she was responsible for scheduling the nurses, CNAs, and medication aides. She said she usually worked the 8AM-5PM shift and occasionally she might have to work a shift on the floor if there was a call in. She said she constantly was reminding staff to not be sitting in the hallways and to make sure they were rounding on residents at least every two hours to turn residents, to do their menus with the residents, to do hydration rounds, and to not be on their cell phones unless they were off the floor on a break. She said residents should have their needs met timely, so they do not feel forgotten.
During an interview with the DON on 8/31/22 at 3:55 PM revealed she had been the DON for three weeks. She said anyone could report a grievance to any staff member and they would initiate the grievance form. Then the form would be given to the appropriate department head to address the issue. If staff members were involved, then they would in-service the staff member and/or write up the staff member if needed. She said there was a cell phone policy that all new staff members sign upon hire. She said staff members should not be on their cell phones unless they were on break and off the floor. The grievance form would be given to the social worker, after the grievance had been addressed. She said once the grievance was addressed with staff then they would file the form in the Grievance book. She said they did not have any particular follow up policy. She said she had been the DON for three weeks and had not seen any grievances related to cell phone use or residents' call lights not being answered timely. She said residents' call lights should be answered timely.
During an interview with the Social Worker on 8/31/22 at 4:07 PM revealed if a resident voiced a grievance to her, she would initiate the Grievance form and then would give the form to the appropriate department head to address the issue. She said after the department head addressed the issue, the form would come back to her, and she would log it in the Grievance book and then give the form to the Administrator. The Administrator would make sure the issue was resolved and then would give the form back to her to file in the Grievance book. She said the resident could come back to her office if the issue continued and she would start the Grievance process over by starting a new form. She said she personally had not taken a grievance related CNAs being on their phones or not answering there call lights timely.
During an interview with the Administrator on 8/31/22 at 4:12 PM revealed any resident/family member could file a grievance with any staff member and the forms were located in all departments and at the nurses' station. Once the grievance form was initiated, then it would be given to the appropriate department head to be addressed/handled. She said she did a Chat with (Administrator's name) monthly in the dining room where anyone that wanted to attend could come and voice any issues and her door was always open to the residents if they needed to discuss any issues. She said the Resident Counsel President would discuss any concerns the counsel had with her after their meeting. She said she had received verbal report from him about cell phone use on the floor and call lights in the past, but not lately. She said staff members should not be on their phones on the floor and they all knew it. She said if she saw staff members on their phones, they were told to put the phone up and she had even taken some phones from employees and/or terminated employees for continued use. She said they have had multiple staff meetings and in-services related to cell phone use in the facility related to resident/staff reports. She said she had told the charge nurses to hold staff accountable and to not allow cell phone use on the floors. She said the Charge Nurse was responsible to ensure the CNA staff were performing timely care and should address any issues immediately. She said the Charge Nurse should report any continued issues to the DON. She said she had made night visits periodically in the past to follow up on the issues, but she could not be at the facility all the time. She said she may need to do some night visits again. She said she wanted staff members to be in the hallways to monitor the call lights and help prevent falls. She said she did allow staff members to sit in chairs in the hallways for that reason if they were caught up with their rounds. She said residents having to wait over an hour to have their call light answered was unacceptable, but she had a hard time believing residents had to wait that long.
Record review of the facility's Cell Phone Use policy not dated revealed . that if employees are on their phone's in the halls or in a resident's room or anywhere in a resident area the administration would take their phone and hold until the end of their shift or their next break . cell phones should be left in employee cars and used outside of the building or in the break room only . failure to adhere to the policy could lead to employment termination .
Record review of the facility's Grievance policy and procedure policy not dated revealed .may voice grievances with respect to treatment or care that is, or fails to be furnished, without fear of reprisal or discrimination for voicing the grievance . facility will make prompt efforts to resolve the grievances . the Administrator and Department Heads will take necessary action to correct the situation .
CONCERN
(E)
Potential for Harm - no one hurt, but risky conditions existed
Comprehensive Care Plan
(Tag F0656)
Could have caused harm · This affected multiple residents
**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, interview, and record review, the facility failed to develop and implement a comprehensive person-centered...
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**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, interview, and record review, the facility failed to develop and implement a comprehensive person-centered care plan for each resident, consistent with the resident rights, that includes measurable objectives and timeframes to meet a resident's medical, nursing, mental and psychosocial needs that are identified in the comprehensive assessment for 4 of 13 residents (Resident #73, Resident #64, Resident #81, and Resident #77) reviewed for comprehensive person-centered care plans.
The facility failed to develop and implement care plans for Resident #73, #64, and #81 for the triggered care area of falls.
The facility failed to care plan Resident #77 weight fluctuations and intervention on the comprehensive care plan.
These failures could affect residents by placing them at risk for not receiving care and services to meet their needs.
Findings included:
1.
Review of Resident #73's face sheet dated August 2022 indicated Resident #73 was a [AGE] year-old male who admitted to the facility on [DATE] with diagnoses including dementia with behavioral disturbance (Behavioral disturbances in dementia are often globally described as agitation including verbal and physical aggression, wandering, and hoarding.), Alzheimer's disease, and sepsis (A life-threatening complication of an infection).
Review of Resident #73's annual MDS assessment dated [DATE] indicated Resident #73 had a BIMS (brief interview of mental status) score of 00, which indicated a severe cognitive impairment. The MDS indicated Resident #73 was sometimes understood and sometimes understood others. Resident #73 required extensive assistance with bed mobility and transfer.
Review of the CAAs (Care Area Assessment) dated 05/25/2022 indicated Resident #73 triggered for the care area of falls. The care area assessment for falls indicated a care plan would be created for the potential for falls related to difficulty maintain sitting balance, impaired balance during transition, antidepressant use, diuretic use, and opioid use.
Review of the comprehensive care plan dated 06/24/2022 revealed no care plan for the potential for falls for Resident #73.
2.
Review of Resident #64's face sheet dated August 2022 indicated Resident #64 was a [AGE] year-old female who admitted to the facility on [DATE] with diagnoses including dementia, Alzheimer's disease, and fracture of the left femur.
Review of Resident #64's admission MDS assessment dated [DATE] indicated Resident #64 had a BIMS (brief interview of mental status) score of 07, which indicated a moderate cognitive impairment. The MDS indicated Resident #64 was understood and understood others. Resident #64 required extensive assistance with bed mobility and transfer. Resident #64 was noted to have imbalance during transition and was not steady during transfer. Resident #64 was only able to stabilize with staff assistance. Resident #64 had a history of falls and was admitted to the facility with a fractured femur related to a fall.
Review of the CAAs (Care Area Assessment) dated 07/22/2022 indicated Resident #64 triggered for the care area of falls. The care area assessment for falls indicated a care plan would be created for the potential for falls related to difficulty maintain sitting balance, impaired balance during transition, internal factors of incontinence, and history of falls.
Review of the comprehensive care plan dated 07/07/2022 revealed no care plan for the potential for falls for Resident #64.
3.
Review of Resident #81's face sheet dated August 2022 indicated Resident #81 was a [AGE] year-old female who admitted to the facility on [DATE] with diagnoses including cerebral infarction ( occurs as a result of disrupted blood flow to the brain due to problems with the blood vessels that supply it), hemiplegia (Muscle weakness or partial paralysis on one side of the body that can affect the arms, legs, and facial muscles.), and unspecified injury of head (a hard blow to the head from striking an object).
Review of Resident #81's admission MDS assessment dated [DATE] indicated Resident #81 had a BIMS (brief interview of mental status) score of 11, which indicated a mild cognitive impairment. The MDS indicated Resident #81 was understood and understood others. Resident #81 required supervision assistance with bed mobility and transfer. Resident #81's MDS revealed she was noted to have imbalance during transition and was not steady during transfer. Resident #81 was only able to stabilize with staff assistance during transition. Resident #81 had a history of falls in the last 30 days and in the last 2-6 months prior to admission. Resident #81 took daily opioids (fall-risk-increasing adverse effects of opioids are caused by sedation, dizziness and cognitive impairment).
Review of the CAAs (Care Area Assessment) dated 08/03/2022 indicated Resident #81 triggered for the care area of falls. The care area assessment for falls indicated a care plan would be created for the potential for falls related to difficulty maintain sitting balance, impaired balance during transition, daily opioid use, and history of falls.
Review of the comprehensive care plan dated 08/03/2022 revealed no care plan for the potential for falls for Resident #64.
During an interview on 08/30/2022 at 3:30 p.m. RN Z stated she was the care plan coordinator for 3-4 weeks about 1 month ago. RN Z stated the facility hired a new care plan coordinator, but she had not started yet. RN Z stated the facility has had 3-4 care plan coordinators over the last 1 year. RN Z stated when she was the care plan coordinator, she was responsible for creating and updating all care plans. RN Z stated she would care plan medications and diagnosis of each resident. RN Z stated she did not look at the MDS to determine what needed to be care planned. RN Z stated she knew what CAAs were and to look at them. RN Z was stated Resident #73, #64, and #81 should have had a potential for fall care plan because it was triggered in their CAA. RN Z was not sure how the care plans were missed but it was more than likely due to the turnover in that position.
During an interview on 08/30/2022 at 3:40 pm the DON stated it was the care plan coordinators duty to ensure all care plans were completed in a timely manner. The DON stated care plans were used as guides to ensure the residents were having all their needs met. The DON agreed that Resident #73, #64, and #81 should have been care planned for the potential or falls related to their history and triggering for falls on the CAA.
During an interview on 08/31/2022 at 2:15 pm the Administrator stated the facility had several different care plan coordinators over the course of the last 1-2 years. The Administrator stated the care plan coordinator was responsible for all care planning related to the MDS, diagnosis, medications, and acute changes. The Administrator stated that the care plan is a guide the staff to know each residents' individual needs. The Administrator stated she expected the care plan coordinator to make sure each resident was care planned for all triggered care area assessments.
4.
Record review of the face sheet dated 08/30/22 revealed Resident #77 was [AGE] years old, female, and admitted on [DATE] with readmission date of 07/07/22 with diagnoses including dementia with behavioral disturbance, anorexia (an abnormally low body weight; initiated on 07/07/22), and nutritional deficiency (A disorder resulting due to not receiving or absorbing adequate nutrient/s from the diet; initiated on 07/07/22).
Record review of the MAR dated 08/01/22-08/31/22 revealed on 02/11/22, Med Pass (nutritional supplement) 1.7 three times a day for decreased appetite 4oz.
Record review of the MDS dated [DATE] revealed Resident #77 was understood and usually understood others. The MDS revealed Resident #77 had a BIMS on 03 which indicated severe cognitive impairment and required extensive assistance for transfer, dressing, toilet use, personal hygiene, and bathing but independent for eating. The MDS revealed Resident #77 experienced coughing or choking during meals or when swallowing medications. The MDS revealed Resident #77 had gained 5% or more in the last month and was not on physician prescribed weight-gain regimen. The MDS revealed Resident #77 had a mechanically altered and therapeutic diet.
Record review of the monthly weights report dated 01/2022-08/2022 revealed on 07/01/2022, Resident #77 weighed 182 lbs. On 08/01/2022, the resident weighed 166.4 pounds which was a -8.57 % Loss.
Record review of the dietary progress note dated 08/18/22 revealed the dietician stated weight loss 8.6% in 30 days, weight at 166.4lbs. Intervention med pass 1.7-4oz TID, BMI 26.1, Reg diet. Rec: Double portion at breakfast. Will monitor for weight changes.
Record review of the dietary recommendations dated 08/18/22 revealed the dietitian's recommendations of double portions at breakfast for Resident #77 was approved by a physician on 08/22/22.
Record review of the undated care plan revealed Resident #77 had a potential for nutritional problems initiated on 09/15/16. The care plan revealed on 02/11/22 med pass 1.7, 4oz by mouth, three times a day for low sodium level in the blood. Intervention initiated on 01/21/19 revealed explain and reinforce the importance of maintaining the diet ordered and provide/serve diet as ordered, encourage regular diet with special preference. Resident #77 requested ½ portions with meal. The care plan did not address weight gain coded on 07/14/22 MDS or the recent weight loss with dietary interventions/recommendations on 08/18/22.
During an observation and record review on 08/31/22 at 10:50 a.m., Resident #77 was weighed by a lift and weighed 161.3lbs. On 08/08/2022, the resident weighed 166.4 lbs. On 08/31/2022, the resident weighed 161.3 pounds which is a -3.06 % Loss.
During an interview on 08/31/22 at 3:12 p.m., the DON said she had been in her position for 3 weeks but was the ADON for 6 years. She said the DON was responsible for weight loss care plans. She said the care plan should have weights, percentage of loss, dietician recommendations/interventions, and physician orders. She said the care plan should be updated as soon as possible with new interventions or orders. She said she was still trying to sort through the paperwork and Resident #77 probably had a care plan. The weight loss care plan for Resident #77 was not provided.
During an interview on 08/31/22 at 5:45 p.m., the regional nurse said she did not believe Resident #77 had significant weight loss. She said the 182lbs weight came from the hospital records. She said Resident #77 went to the hospital for 3 days for IV antibiotics and was probably pumped with fluids. She said the weight fluctuation being addressed on the care plan would provide a better picture of Resident #77.
An undated policy titled Care Plans- Comprehensive indicated, the comprehensive care plan has been designed to: Incorporate identified problem areas , incorporate risk factors associated with identified problems and to prevent declines in the resident's functional status.
CONCERN
(E)
Potential for Harm - no one hurt, but risky conditions existed
Infection Control
(Tag F0880)
Could have caused harm · This affected multiple residents
**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, interview, and record review the facility failed to ensure an infection prevention and control program des...
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**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, interview, and record review the facility failed to ensure an infection prevention and control program designed to provide a safe and sanitary environment and to help prevent the development and transmission of communicable diseases and infections for 1 of 1 resident reviewed for transmission-based precautions. (Resident #235)
The facility failed to maintain isolation status of COVID positive Resident #235.
The facility failed to ensure all staff were wearing PPE when entering the room of COVID positive Resident #235.
These failures could place residents at risk for being exposed to health complications and infectious diseases.
Findings included:
1. Record review of a face sheet dated August 2022 revealed Resident #235 was a [AGE] year-old female that originally admitted on [DATE] and readmitted on [DATE], with the diagnoses of Alzheimer's (A progressive disease that destroys memory and other important mental functions), dementia (a chronic or persistent disorder of the mental processes caused by brain disease or injury and marked by memory disorders, personality changes, and impaired reasoning), and atrial fibrillation (An irregular, often rapid heart rate that commonly causes poor blood flow). Resident #235 was diagnosed with COVID- 19 (an acute respiratory illness in humans caused by a coronavirus, capable of producing severe symptoms and in some cases death, especially in older people and those with underlying health conditions) on 08/22/2022.
Record review of an admission MDS dated [DATE] indicated Resident #235 was usually understood and sometimes understood others. Resident #235 was had a BIMS of 02, which indicated a severe cognitive impairment. Resident #235 was independent and required supervision for walking and limited assistance for toileting. Resident #235 was frequently incontinent (unable to control) of bowel and frequently incontinent of bladder. Resident #235 resided on the secured unit related to delusions and daily wandering.
Record review of Resident #235's care plan dated 08/12/2022 revealed it did not address the diagnosis of COVID-19 or interventions to assist Resident #235 to prevent the spread of COVID-19 on the secured unit.
Record review of Resident 235's physician order report titled Active orders as of 08/29/2022 did not indicate any orders related to COVID-19. No order for isolation was noted.
During an observation on 08/29/2022 at 9:12am, an isolation set up was located outside of Resident #235's room. The isolation set up included N-95 masks, goggles, gowns, and gloves. Resident #235's door had a sign on it that read: HOT ROOM. Resident #235 was walking in the hallway with no mask on. Resident #235 was noted to have a cough and was not shielding the cough. No staff attempted to redirect Resident #235 or provide Resident #235 with a mask. Resident #235 encountered 4 other wandering residents in the hallway. Resident #235 then sat in the common area that had 3 other residents present less than 6 feet apart for about 15 minutes.
During an observation on 08/29/2022 at 10:03am CNA D was noted to be in Resident #235's room with her. CNA D had no gown, gloves, or goggles on while touching Resident #235. CNA D then came into the dining room and assisted other residents with snacks. CNA D was unavailable for interview.
During an observation on 08/29/2022 at 11:19am LVN R was noted attempting to redirect Resident #235 by walking hand in hand with Resident #235 down the hallway and into her room with no gloves, no gown, and no goggles. Resident #235 was in the hallway looking for her truck and was wearing no mask outside of her room.
During an interview on 08/29/2022 at 11:28am LVN R stated she was educated that it was the right of Resident #235 to come out of her room when she wanted to. LVN R stated Resident #235 had not stayed in her room any of the days she had worked with her since she was diagnosed on [DATE]. LVN R stated there was not really a point to gown up when going into her room if she could walk around the secured unit when she wanted to. LVN R stated she had not attempted to put a mask on Resident #235 because she would not remember to wear it.
During an observation on 08/29/2022 at 12:45 pm, Activity Aide Q was noted to enter the room of Resident #235 without donning any PPE to bring in and set up Resident #235's lunch tray. Resident #235 had no mask on and was actively coughing. Activity Aide Q came out of Resident #235's room and began to assist another resident with eating lunch in the same scrubs she was in Resident 235's room in.
During an interview on 08/31/2022 at 9:30 am Activity Aide Q stated the staff had been educated that it was the right of Resident #235 to come out of her room. Activity Aide Q stated she knew she was supposed to put full PPE on when going into the room of someone with COVID-19. Activity Aide Q stated she was given misinformation by a CNA and entered Resident #235's room unprotected. Activity Aide Q stated later that day an in service went around about encouraging Resident #235 to wear a mask and putting on full PPE when going into her room.
During an interview on 08/31/2022 at 2:30 pm the DON (also the infection preventionist) stated the staff had been in serviced on donning and doffing PPE when dealing with different transmission-based illnesses. The DON stated Resident #235 was a tricky situation. She stated that because Resident #235 wandered all day long, the staff could only encourage her to stay in her room and wear a mask. The staff should have been wearing full PPE when going into Resident #235's room to care for her. Not wearing full PPE when caring for a resident with a communicable disease could cause spread of the disease and an outbreak of COVID -19 in the secured unit. The DON stated it was the facilities policy to isolate any COVID-19 positive residents for 10 days. The staff is tested twice weekly because the county is high and the residents once weekly.
During an interview on 08/31/2022 at 2:45 pm the Administrator stated it was the right of Resident #235 to come out of her room when she wanted to. The Administrator agreed that it was the responsibility of the staff to protect Resident #235 and the other residents on the secured unit by attempting to redirect Resident #235 in coming out of the room frequently and wearing a mask when she came out of the room. The Administrator stated the staff was never told not to attempt to protect the residents because they were being exposed by Resident #235 when she came out of the room anyway. The Administrator stated negative outcomes to not having worn the proper PPE during care for Resident #235 could be the spread of COVID-19 in the secured unit.
An undated policy titled Pandemic Infection, Control Measures During stated,1. Due to the increased risk of mortality from infectious agents in the frail elderly and others with comorbidities which affect the immune system, infection control measures will be implemented to prevent the introduction or spread of the virus/agent is a priority. 5. Early prevention of infectious outbreak may include the following measures: Training of clinical staff in the modes of transmission of the agent and recognition of signs and symptoms, isolation of infected residents in private rooms or cohort units, use of barrier precautions during resident care and, if necessary, throughout the facility during conduct of normal operations.
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
- • No fines on record. Clean compliance history, better than most Texas facilities.
Concerns
- • Multiple safety concerns identified: 2 life-threatening violation(s), 1 harm violation(s). Review inspection reports carefully.
- • 31 deficiencies on record, including 2 critical (life-threatening) violations. These warrant careful review before choosing this facility.
- • Grade C (51/100). Below average facility with significant concerns.
Bottom line: Mixed indicators with Trust Score of 51/100. Visit in person and ask pointed questions.
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About This Facility
What is The Villa At Texarkana's CMS Rating?
CMS assigns THE VILLA AT TEXARKANA an overall rating of 5 out of 5 stars, which is considered much 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 The Villa At Texarkana Staffed?
CMS rates THE VILLA AT TEXARKANA's staffing level at 3 out of 5 stars, which is average compared to other nursing homes. Staff turnover is 54%, compared to the Texas average of 46%.
What Have Inspectors Found at The Villa At Texarkana?
State health inspectors documented 31 deficiencies at THE VILLA AT TEXARKANA during 2022 to 2024. These included: 2 Immediate Jeopardy (the most serious level, indicating potential for serious harm or death), 1 that caused actual resident harm, and 28 with potential for harm. Immediate Jeopardy findings are rare and represent the most serious regulatory concerns. They require immediate corrective action.
Who Owns and Operates The Villa At Texarkana?
THE VILLA AT TEXARKANA is owned by a for-profit company. For-profit facilities operate as businesses with obligations to shareholders or private owners. The facility is operated by CARING HEALTHCARE GROUP, a chain that manages multiple nursing homes. With 106 certified beds and approximately 90 residents (about 85% occupancy), it is a mid-sized facility located in TEXARKANA, Texas.
How Does The Villa At Texarkana Compare to Other Texas Nursing Homes?
Compared to the 100 nursing homes in Texas, THE VILLA AT TEXARKANA's overall rating (5 stars) is above the state average of 2.8, staff turnover (54%) is near the state average of 46%, and health inspection rating (4 stars) is above the national benchmark.
What Should Families Ask When Visiting The Villa At Texarkana?
Based on this facility's data, families visiting should ask: "What changes have been made since the serious inspection findings, and how are you preventing similar issues?" "Can I visit during a mealtime to observe dining assistance and food quality?" "How do you handle medical emergencies, and what is your hospital transfer rate?" "Can I speak with family members of current residents about their experience?" These questions are particularly relevant given the facility's Immediate Jeopardy citations.
Is The Villa At Texarkana Safe?
Based on CMS inspection data, THE VILLA AT TEXARKANA has documented safety concerns. Inspectors have issued 2 Immediate Jeopardy citations (the most serious violation level indicating risk of serious injury or death). The facility has a 5-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 The Villa At Texarkana Stick Around?
THE VILLA AT TEXARKANA has a staff turnover rate of 54%, which is 8 percentage points above the Texas average of 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 The Villa At Texarkana Ever Fined?
THE VILLA AT TEXARKANA has no federal fines on record. CMS issues fines when nursing homes fail to meet care standards or don't correct problems found during inspections. The absence of fines suggests the facility has either maintained compliance or corrected any issues before penalties were assessed. This is a positive indicator, though families should still review recent inspection reports for the full picture.
Is The Villa At Texarkana on Any Federal Watch List?
THE VILLA AT TEXARKANA 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.